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HomeMy WebLinkAbout33659-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. OF OCCUPANCY No• Z-33149 Date: 07/14/08 THIS CBRTIFIES that the building ACCESSORY Location Of Property: 22950 MAIN RD ORIENT (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 18 Block 5 Lot 10 Subdivision Filed Nap No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JANUARY 24, 2008 pursuant to which Building Permit No. 33659-Z dated JANUARY 29, 2008 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ACCESSORY IN GROUND SWIMMING POOL WITH FENCE TO CODE AS APPLIED FOR. The certificate is issued to JOSE & IVONNE HERNANDEZ (OWNER) of the aforesaid building. SDFFOLR CODNTY DEPARTMHN'P OF HEALTH APPROVAL N/A HLECTRICAL CERTIFICATE NO. 3066098 05/07/08 PLDI~ffiSRS CERTIFICATION DATED N/A thorized Signature Rev. 1/81 ~• FonnNo.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT I ~ TOWN HALL I 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY l~ - Tlus application must be f lled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: I . Pinar survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Corrunercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. _~ B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic ~ features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building hrspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate ofOccupancy -New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swinuning pool $25.00, Accessory building $25.00, Additions to accessory building $25.00, Businesses $50.00. 2 Certificate of Occupancy on Pre-existing Building - $100.00 3- Copy of Certificate of Occupancy - $.25 4- Updated Certificate aCOccupaney - $50.00 ~. Temporary Certificate of Occupancy -Residential $15.00, Commercial $15.00 Dafe- _ New Construction- _ Old or Pre-existing Building: (check one) Location efProperty: 02 a 9 so /~'~", ,, House No. Street ~. - Owner or Owners of Property: ~_S___ 1/O {~ nP Suffolk County Tax (\4ap No 1000, Section ~~ Brock ----~---_ Lot I -- Subdir.isioit Piled Map. Lot. -- -- - - _ Permit No ~ ~ 6 ~ Date of Permit ~ d ---- ~-~~' ~_ Applicant SoS2 ~'~ /b'i Y1 C Z Health De~ri- Approval- _ Underwriters Approval: ~_ Plamring [3oard Approval. ~- Request Cor Temporary Certificate Fee Submil[ed. S _ ~,S__,_~~-. ~~331`1~1 ~~ ~ ~ ~. a~ Final Certificate: _ _ (check one) Applicant Signature BY THIS CERTIFICATE NEW YORK BOARD OF OF COMPLIANCE THE FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET - NEW YORK, NY 10038 CERTIFIES THAT ~Si - S - ~d Upon the application of upon premises owned by JIM SAGE ELEC. INC. PO BOX 38 GREENPORT, NY 11944-0038, Located at 22950 MAIN RD ORIENT, NY 11957 Application Number: 3066098 JOSE HERNANADEZ 22950 MAIN RD ORIENT, NY 11957 Certificate Number: 3066098 Section: Block: Lot: Building Permit: , BDC: ns11 33 6 s9 Described as a occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: Outside, PooVSpa, A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed herein, was conducted in accordance with the requirements of the applicable code and/or standard promulgated by the State of New York, Department of State Code Enforcement and Administration, or other authority having jurisdiction, and found to be in compliance therewith on the 7th Day of May, 2008. Name QTY Rate Ra[ine Circuit Tv e Appliances and Accessories PooV Spa Bonding Wiring and Devices Receptacle Switch Receptacle Fixture 1 0 1 0 20a PooU Spa 1 0 General Purpose 1 0 GFCI 1 0 ~ PooU Spa (Swimming Pool): This certificate covers compliance at the date of inspection only. Because of unusual environments it is advisable to have frequent test and/or repairs made by a qualified person. seal 1 of 1 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 33659 Z Date JANUARY 29, 2008 Permission is hereby granted to: JOSE & IVONNE HERNANDEZ 22950 MAIN RD ORIENT,NY 11957 for CONSTRUCTION OF AN IN-GROUND SWIMMING POOL IN THE REQUIRED REAR AS APPLIED FOR at premises located at 22950 MAIN RD ORIENT County Tax Map No. 473889 Section 018 Block 0005 Lot No. 010 pursuant to application dated JANUARY 24, 2008 and approved by the Building Inspector to expire on JULY 29, 2009. Fee $ 250.00 ~~ ~ ized Sianature ORIGINAL Rev. 5/8/02 N YS ROUTE 25 S 86' S4' 20" E AE= 146.11 39.51 ' N 89' 07' 40 E 1 ~ I / FD O ~ i l STONE O 3 I ; MON ~. /W N i T/ ~ ~ a ~r 75'R/W i i ° 8602 p 550 15 I ; 0 282. 60.5' I /i m ~ / N ' ~ 7 s roR PAPANTON'lO W ~ ~O zo.5' I / ti 3.7' ,v ~ r ,, ~ ~w 7. a' RES O IP = Q a /1 Rh n Q C]P 56.3' I fl2. .84.4 'S .4 3' 7 / i coN ' taut: srooP / I ~~ ~ CHAI INK FENCF 1 ENO FENCE IO' I , S 89 ° 53' 20 " W S CCKAOE FENCE - PRdP I'f'x24' POOL N/F TABOR N o o I N ORIENT CEMETERY O "~ N N ~ ~ FENCE CDR. 213.45' S 1.4. N/F LA THAM SURVEYED 19 JULY, 2007 SCALE 1 ""=40' AREA= 26, 251.424 SF OR 0.603 ACRES NTEES INDICATED HERE ON SHALL RUN TO THE PERSON FOR WHOM THE SURVEY PARED. ANO OT4 HlS BEHALF TO THE :O.NPANY, C04ERNMENTAL AGENCY, 'C /NSnTUnON, /F USIEO HEREON, ANO ASSIGNEES OF THE LENDING INSTINnaV. NTEES ARE NOT 1RANSFERABLE TO 7NAL lNSnn/nONS OR SUBSEQUENT OWNERS ROR/ZED AL 7ERADON OR ADD/T10N TO n1/5 i r is a hounoN of sECnoN 7zos of ' EW YORK STATE EOUCA nON CAW. ~ OF THIS SUR4EY MAP NOT BEARING INO SDRVEYORS EMBOSSED SEAL SHALL E CCWSIOERED TO 8f A VAUO TRUE SURVEY OF DESCRIBED PROPERTY SITUATE ORIENT, TOWN OF SOUTHOLD SUFFOLK COUNTY, N. Y. SURVEYED FOR JOSE HERNANDEZ IVONNE HERNANDEZ JR. 956 'EYOR 01R1047 SURVEYED BY 33~sq z TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPECTION ] FOUNDATION 1ST [ ]ROUGH PLBG. ] FOUNDATION 2ND [ ]INSULATION ] FRAMING /STRAPPING [~ FINAL ] FIREPLACE A CHIMNEY [ ]FIRE SAFETY INSPECTION ] FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION REMARKS: ~~ ~~ DATE 7~ 3 ~ g INSPECTOR 33~~~~ TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ]FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING /STRAPPING FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUC710N [ ]FIRE RESISTANT PENETRATION ~~ REMARKS: DATE 6 ~ ~7~ G ~ INSPECTOR ' ~f'`~-~ ` '~ FI~,LD INSPECTION REPORT DATE ~ COMMENTS ~~~ ~~ FOUNDATION (1ST) lI\ ~~y x \~ ~ FOUNDATION (2ND) py s z 0 ~ ~ ROUGH FRAMING & ~' " PLUMBING H l/ ~ -- - r_ ---- - ~ x - --- --- LNSULATION PER N. Y. - -- _ _ „~ STATE ENERGY CODE AAA. ILJ n ~, FINAL ~ s G/~'~ ~ ~ Q ~ • ~ ~ ~ -r- 1 ADDITIONAL COMMENT ~# I O z A , ~ ;i !~ ~~ H l p ~~ z `~ - ~ _ y x c ~, b y TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 119'31 TEL: 765-1802 BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying ? Boazd of Heal[h PERMIT NO. ~ ~ ~ ~ Examined / ~ , 20 Approved ,20~ Disapproved a/c 3 sets of Building Survey _ Check Septic Form N.Y.S.D.E.C._ Trustees Contact: Vail tn• 1 <' `- APPLICATION FOR BUILDING PERMIT aU ~~N 2 ~ ~ , Date l ' ~ Z - , 20 (~ ~. _ INSTRUCTIONS ~, . a. Thistapplieation MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or azeas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Pernut to the applicant. Such a pemut shall be kept on the premises available for inspection throughqut the work. e. No building shall be occupied or used in whole or in part for any purpose what-so-ever until a Certificate of Occupancy is issued by the Building Inspector. APPLICgTION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordirtartces or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. /I (Signature of applic~tt or name, if a corporation) ~tZ~ Rr asp ~~![~>< ~1~D ~~~e~ (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate Builders License No. ~~~o- ~ T Plumbers License No. Electricians License No. ~ I ~- !1"~ C Other Trade's License N 1. Location of land. on which proposed work will be done: ~„ „ ~.. - House Number Street Hamlet p ~*~ A'~~nr : ~:~~q County Tax Map No. 1000 Section ~ 0 Block tJ~ " ' ~"~~;pt, ~ ~N Subdivision Filed Map No. xl;, ~,:: Lot . . (Name) ---s _ „ 2. State existing use and occupancy of premises and a. Existing use and occupancy ~ .S~pe. b. Intended use and ~SlAenmrz ,Su~mmml9 i~~ Nature of work (check which applicable): New Buildi~ Repair Removal Demolition 4. Estimated Cost ~ Z, ~t7~ ' Fee Other Work Alteration (Description) (to be paid on filing this application) 5. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Sto 8. Dimensions of entire new construction: Front ~~ ~ x zµ Rear Depth Height Number of Stories 9. Size of lot: Front ~'1\ Rear .~1,3 Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated l ?.~ 12. Does proposed construction violate any zoning law, ordinance or regulation: 13. Will lot be re-graded ~pp~ -~Qk (7Nt.~J Will excess fill be removed from premises: YES 14. Names of Owner c Name of Architect Name-of Contracts NO No. 3 Z3- 4~~f No '7Z~t-78$Fr No. `T~d~t-~14S 15. Is this property within 100 feet of a tidal wetland? *YES NO • IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. STATE OF NEW YORK) SS: COUNTY OF ) y .QS being duly sworn, deposes and says that (s)he is the applicant (Name of in 'vidual signing contract) above named, (S)He is the (~(JN1Y~T1)2 . (Contractor, Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Swom to before me t 0~"9 day of ~ ~ ~ 20Q~_ a. ~~, ~~tary Public MARGARET A. KIDNEY Notary Public -State of New York No. 01 K16021 1 Yl Qualified in Suffolk County My Commission Expires March 8, 2011 use and occupancy of proposed construction: Signatur of Applicant !" Suffolk Couraty Executive s Office of Consumer Affairs VETERANS MEMORIAL HIGHWAY HAUPPAUGE, NEW YORK 11788 DATE ISSUED: 5/1/80 No. 2740-ME SUFFOLK COUNTY Master Electrician License This is to certify that EDWARD S REIFF doing business as UNDERGROUND SPECIALTIES INC having given satisfactory evidence of competency, is hereby licensed as MASTER ELECTRICIAN in accordance with and subject to the provisions of applicable laws, rules and regulations of the County of Suffolk, State of New York. This certifes that the bearer is duly licensed by the County of Suffolk L~keNlr>>4. ~Grm SUFFOLK COUNTY EXECUTIVE'S OFFICE OF CONSUMER AFFAIRS MASTER ELECTRICIAN EDWARD S REIFF :s ~.,E UNDERGROUND SPECIALTIES INC 2740-ME ~os/otnsso °~°'"1gry p"'~ 05/01/2008 Additional Businesses f~.~iLt~X~C ~.~~C~~ih~°L._. 7'hlx cad8cate ip an original. 9TATP. OF NEW yORK WORKLR9' COtvIPEN3ATION BOARD CERTIFICATE OF P.A~tTIC~PATION IN WORKERS' COMPENSATION GROUP SEIr~'-INSURANCE 1a. Lo(al Nano and Addreu efBndnva Pnrtldppaop In Cropp td. BoefxoN 7elephopo Number of Bmipcxp tMmneW b box "ln" Sdf•tamnove oleo Sheet Addraa l)nlvt Arthurd. l=ttwanla Adason Contractor, Inc. 16317447185 DBA; Arthur Edwartls Paol & Spa Cenv+a 929 Route 26 A Miller Piece, NY 11764 le. NYS Unempivyhnent Innoraacv tmplvyer Re(htratiop Nnmbor of avalme nkrnad ip Box "lA". t0. fitfaeva Dak ofManbanpln M alp Grvap n412dJ2nn2 24108715 taxno Date 5/30/2007 a:pinden Dpk 6/29/2(x)9 1L FNVrY ICmplovcr Ideparivptkn Npmppr of R~wk W9 )t The Propriaror. Parpwn or F,xatativv O~cap prc ~rn~ b Box "ta^ (~ kclndad (ONI' Ciaok pox Hall parmOrYMfaeorA 1nCloeed) 111277925 ^ nil exdnded or eertaln wrinerv/oaleera exelddN. 7. Name pod Addreea of fps spaty RaQpada(ProotolCovtta(c a Nnmd end Addrvu of tk pra f6:ntth Bekn I.Ytcd Y Cerafeate Rolda~l Town of 6outhold 6padal Tratlea, Contracting And Construcaon TrWI Town HaA 8250 South Bay Road PO Box 728 PO Bax 3880 Southold, New Yodt 11971 Syracuse, NY 13220 Policy: VV521504 This mortifies that tho business roferenced abavo {n box "I a" {s complying with the tnendatory coverage requiremems of the New York State Workers' Compensation Law as a participating manber of the Group Self-insurer listed above in box "3" and Participation in each group self-insurance is still in force. The QroupBelf-Insurer's Administraor will sand this Certificate of Participation to the entity listed above as the certificate hvldcr in box "Z". The Group Sel£ insurer's Administrator will notify the above mortificate holder within 10 days IF the membership of the Participant listed in box ^ la" is termivatod. (These><totieesrray be soot by rcgular.mail.) Otherwise, this Ctatificato is valid for a maximum of one year Hrom the date mollified by the Yroup self-insuror. If this certtficare is no longer valid according to the above guidelines and the business referenced Jn box "la " condt:ues to be nmrted on a permit, license or contract issued by the certiJtcare holder, the business must provide the cert~cate holder either with a new eert~cate nr other authorised proof the business is complying with the mandatory coverage requirements of the Certified by: David ahedmnmd.grtownwuro ^rdm nreigr $elfiina~v) Certified by: Title: 6/3012007 ~r Telephone Number: (315) B99-6476 t3SI-105.2 (2-02) WORKERS' COMPENSATION LAW WORKERS' COMPENSA'fl[ON LAW Section 57 Restriction on issue of permits cod the entering into contracts anless compensation is secnrcd. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits. shall not issue such permit unless proof duty subscribed by an insurance carrier is produced in a form satisfactory to the chair, that componsation for alI employees has been secured as provided by this chapter. Nothing herein,. however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. Tho head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or spacial statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Ploasa Note: Thla CerttAcaW Is valid only through the policy dates Indicated above, OR a maximum of one year otter this form is approved by the authonzed reprasantatlvea of the Group Self-insurer, At the expiration of those dates, 'rf the business wntinuas to be named on a pemllt or contract Issued by the above govemm~nt amity, the buaineas mutt provide that government entHy with a now CertHfoate. The buslneas must also provide a new Certificate upon notke of cancellation or change In statue of the policy. GSI-105.2 (2-02) Reverse TOWN OF SOUTHOLD PROPERTY RECORD CARD / ~~~ - /~- a y~ --~~~ OWNER STREET ~ ~~~,~ -,, VILLAGE DIST. SUB. LOT `e $ /VOnne ~~i/la~'z "~:,,>, l~~ ~ ~~ ~'J..-~.~-L~ ~ .Dcsc , ORMER OWN R / ~ ' ~ , E Cam e e -/9N6 ACR. 603 ~-) ~ -tea ~,~r h` ~~ /~_). la bar ~ ~~ S ~ C. ir~/3a ~w1= W .u aN`~'o .p TYPE OF BUILDING RES. O SEAS. VL. FARM COMM. CB. MICS. Mkt . Value LAND IMP. TOTAL DATE REMARKS ~' ~ L F--d ~ / ~ v ~ ~/~ , ~, ,~ ,~ E ~' ~' ' ni 2 8 c. O o E~ boa ., 5 a / o v ~ U ~ ~ z 3 o/d r ._ S src~ e/ ~ ~~' ~ `~ v°'C ~ ~ ~~ ~0 a ~ p -~ :a~4 '~ ct+sSC~vY S~C4o. -~w.uce ,G. ~, 1?„=00 ~®pQ~'~ Co3oo 2 2eo '2007.- / ~ '~Q~ y - 4-J ~oa~sf' ftGCeS<'~v~ ,g~c^>-„r.:• ~i~t' ~C ~tl -- 130 7 d3~ ~3 ~ _ 9' d.f'!~/Sa~i .__ ?~ cfssa- vee ~ouse ~G'rl,$nE~ ~~' ~ 5 7 5 - !~ • 3 - r ~ ~-L/Zl~ z~ 87 /-~SDG~ pl ~ ~Pin~hdez ~L AGE BUILDING CONDITION .~ I7 ~_&P#_ a _ ~ ~ "~ NEW NCRMAL BELOW ABOVE \_ _ FARM Acre Value Per Acre Value Tillable FRONTAGE ON WATER Woodland ~ FRONTAGE ON ROAD ,~1 _ _ Meadowland DEPTH ~ ~ House Plot ~ ~ ~~ ~~ O BULKHEAD Total'"" ~°' ~' 2 ~~~ DOCK 18-5-10 01/03 ... `; x a ~z3v ExterFSion _ i_ /3 ~ ~S ~vs' Extension ' Extension ~ 'zf~ ~~ (Foundation orch ~ Basement .PoreFr $Y ~ 2'3 +~ Ext. Walls ~~~ `~ ~~ 3 ' © ~ Fire Place Garage ~ v~ `f l(~ l ,~ 0 `~~ a-0 ~SO Type Roof Petro ~ ~ 6 Ph+BV~~ >~~^ ' I Recreation Room 0. B. ~ ~1eei1 _ °a,..a.,Fr Donner Total i 3 z~i~z ,:~ r tr2co3~ `~ ~'~ Floors ~': "e` ~'~vi f° Interior Finish "~„A ' Heat ~ =~;~~X~ Rooms 1st Floor Rooms 2nd Floor Driveway // L Dinette ~~ IC 5 /~' '-v j DR. B R. FIN. B - -- - - -. _ - - - ~- - ~ 4 ~ i _ ~ H ~~ - - _ __ Bldg M . . i y~,~ a, ~~ /.2 3'~ Extension ~ \ I I ' ~ ~ ~ i ~ ? ~ ~ ~ - ~ l ' 17 X .t O= /~ /: ~; J 4~ 4 S~ ~ I i i Extension I _ I i j i ~-~ ~! _ ~ ~ ~ ~ _ ~ i~ I ~ I I I A--I r FEET Ff. FT. F T. F T. Ff . F T. F T. FT. SQ.FT. GAL. IOz32' 16' 32' 0' 14' 0' 4' 4' 8' 512 19,000 ~~Z~d,(~tdfaA 16'z36' 10' 36' 12' 14' 6' 4' 4' 0' 576 21,600 POOL & SPA CENTRE PERMACRETE WALL SYSTEM 10'z3B' 1s' 3s' 12' 14' 0' 4' 5' 0' s48 24,300 929 Route 25A Miller Place NY 11764 20'z40' 20' 40' i6' 14' 0' 4' 6' 8' 000 30,000 (631) 744-7185 FAX (631) 744-0174 24'z44' 24' 44' 18' 14' 8' 4' 6' 10' 798 30,000 Suffolk License #4436-HI 24'z48' 24' 48' 20' 16' B' 4' 6' 10' 900 30000 Nassau License #HI74450000 !DIATELY~ LOSE POOL TO CODE UPON COMPLETION BEFORE"WATER" Files f~/~Jy1 F9ESr k Pump ~ ~,~/ PTO Re4m~ ry Wtll Optlnoh From iping Arrangement >a 0 _~ P~6k . ,,uVT A.T 765-1802 8 A'~i , . t FOR THE F t ~` ?„ i < ~,. ~ yes ~nF~ . _ .~ , ~_~ =~~~.u s. IrISULRTIG'J BE ~n.,_, ~. C +.'~ _ __ „EET THE _. ~;~ r. 'EBOFNE'~V YGFr' C. ~ '." _ .,.;BIBLE FOR ~~' t -.n A^ I~4T ATE: z B.P.# ~36. Erosion, Sedimentation and Storm-water Run-off Control Plan ASSESSMENT FORM Yes EXEMPTIONS:. No A. Does this project meet the minimum standazds for classification as an Agricultural Project ~ . Note; If you. answered. Yes. to any. of the above, a Storm•water, Grading, Drainage 8 Erosion Control. Plan is not required. ------------------------------------- _ ------------------------------ ACTIONS. REQUIRING THE. SUBMISSION OF A STORM-WATER GRADING DRAINAGE & EROSION CONTROL. PLAN. CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK.. Item Number:. (A Check Mark (/) for each question is required for complete application) Yes. No 1. Will this. project retain all Storm-Water Run-off generated on Site? (This: will include. all run-off created by site clearing,and/or construction activities. as well as all ~ Site Improvements and the ermanent creati f i i f . p on o mperv ous sur aces.). ^ 2. Will this project require any ]and filling, grading or excavation where there is a change to the ^ natural existing grade involving more than 200. cubic yazds of material within any parcel? 3. Will this application require land disturbing activities encompassing an area ^ of five thousand (5,000). square feet of ground surface or more? 4. Is there a Natural Water course running through the site or is this project within ^ One hundred (100) feet of wetlands or a beach? ~ 5. Will there be site preparation on slopes which exceed fifteen (15) feet of vertical rise to One hundred (100). feet of horizontal distance? ^ / -~C.- 6. Will driveways,. pazking azeas or other impervious. surfaces direct Storm-Water Run-off into and/or in the direction of a Town Ri ht-of--Wa ? . g y 7. Will this application require the placement of material, removal of vegetation and/or the ^ construction of any item within the Town Right-of--Way or road shoulder azea? (This. item. does. not include. the installation. of driveway. aprons.) 8. .Will there be site preparation within the one hundred (100) year floodplain of any watercourse? ^ .~ Note: If any answer to questions one through. eight is answered. with. a check mark in the Box,. a Storm•water, Grading, Drainage $ Erosion Control. Plan is required and must be submitted for review prlorto issuance o[ any building. permit. STATE OF NEW YORK, ~ F ~~~ CO OF.........._ .................................. ss That I . ...................1,fF.:~;~l~.rJ.•,.,~Qblhtl(~~.,......,,,...,, being duly sworn, deposes and says that he/she is the applicant for Permit, (Name of individual signing Document) And that He/She is the ..........................................~~/f~lbt~.............................................................................................. (Owner, Contractor, Agent, Corporate Off cer, etc.) Owner and/or representative of the Owner or Owner's, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are tme to the best of his knowledge and belier; and that the work sill be performed in the manner set forth in the application filed herewith. Swom to before me this; ufl ..................~ .....//.ll''..~'..~n.,.day of/~.. Notary Public:...... ~~~.ta:. V...... 20 f?. 7. MARGARET A. KIDNEY K~...~44-Y Pudlk:.-.State. of New York No. OI KIG021 I YI t]ualified in Suffolk County My Commission Expires March 8, ZOJ„~, (Sig afore of Applicant)