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HomeMy WebLinkAbout33577-Z -----T- FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY NO: Z-33168 Date: 07/22/08 THIS CERTIFIES that the building ACCESSORY Location of Property: 290 (HOUSE NO.) County Tax Map No. 473889 Section 86 RICHMOND LA (STREET) Block 1 PECONIC (HAMLET) Lot 4.8 subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated NOVEMBER 29, 2007 pursuant to which Building Permit No. 33577-Z dated DECEMBER 11, 2007 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 JASON & ELISE BRETT (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPAR'l'MEIlT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. 3059228 03/13/08 N/A PLUMBERS CERTIFICATION DATED ~i~ Rev. 1/81 ...... Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 JJI_ I 6 ) .;\P~L1CATION FOR CERTIFICATE OF OCCUPANCY I ThIs ap/l':~~~,~:~P~E!~~~ in y typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: I. Final 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 2/1 0 of I % lead. 5. Commercial 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 nses: I. 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 sigued by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees I. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swimming 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 of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 ,,7/ 10 (08' Date. New Construction: Old or Pre-existing Building: /' (check one) Location of Property: 2 '1 () House No. JL, c t.. lit 0 ^.1 L "^ c... Street Hamlet Owner or Owners of Property: E/I~e.. d-J4sol1 13rcf+ Suffolk County Tax Map No 1000, Section _ ?f.c Subdivision Block I Lot _ 0/; ~ Filed Map. Lot: Permit No. 3 '3> S I '7 Date of Permit. Ii / II /0'1 Applicant: Health Dept. Approval: Planning Board Approval: Underwriters Approval: Request for: Temporary Certificate Final Certificate: t/' (check one) Fee Submitted: $ ~). D 0 GJo -Z- 3'Vllo ~ ~ t- 1 L(lolo~ ~(7~ Applicant Siguature - j [!J.[!J i BY THIS CERTIFICATE OF COMPLIANCE THE i ~ NEW YORK BOARD OF FIRE UNDERWRITERS ~ ~ BUREAU OF ELECTRICITY (6 . - \ - '-/.( ~ ~ 40 FULTON STREET - NEW YORK, NY 1 0038 ~ ~ CERTIFIES THAT ~ ~ ~ ~ Upon the application of upon premises owned by ~ ~ ~ ~ R.J. CORAllINI ELECTRIC JASON BRENT ~ ~ 320 RICHMOND LANE 290 RICHMOND'S LN ~ I PECONIC, NY 11958, PECONIC, NY:J19;8Si"l I ~ Located at 290 RICHMOND'S LN PECONIC, NY 11958 ~ I Application Number: 3059228 Certificate Number: 3059228 I ~ Section: Block: Lot: Building Permit: BDC: n511 ~ ~ ~ ~ Described as a occupancy, wherein the premises electrical system consisting of ~ ~ electrical devices and wiring, described below, located inion the premises at: ~ ~ Outside, PoollSpa, ~ ~ A visual inspection of the premises electrical system, limited to electrical devices and winng to the extent detailed ~ ~ herein, was conducted in accordance with the requirements of the applicable code andlor 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 13th Day of March, 2008. ~ ~ Name OTY Rate Ratin. Circuit ~ ~ ~~~ ~ ~ Jandy control panel ~ ~~~~~ ~ ffil Paoli Spa Bonding I 0 ffil ~ Pool Heater I 0 Gas ~ ~ Panels ~ ~ I 30 6 ~ ~ ~~:: and Devices 2 0 Paoli Spa ~ ~ Receptacle I 0 20a Paoli 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 ~ ~ ~ ~ I of I ~ ~ ~ I This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. I [!J~.[!J PERMIT NO. 3 ~\7 7 c: BUILDING PbKMlT AJ:'J:'L1CAIIUl~ LnCL"'-L101 Do you have or need the following, before applying? Board of Health 4 sets of Building Plans .;/ Planning Board approval Survey . i Check j 5 g- ~ Septic Fonn NY.SD.B.C. Trustees Contact: Mailto S10ltY1 K\1t Pocts 411 ~-\~ '2-'51'\ cc.lu.-t P+-Wi Phone 144-'3106 ll,.8 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www.northfork.net/Southold/ Examined t y/, \ 1,20 01 f '0-.D, 20 Dl Approved Disapproved ale Expiration r.,(l( ,2021- , i.....~ r:: r~' I" n .cr i i r, LS \'1 'T'j \,,' " U r---- \lJ1 ~J 29, It." j 't-""''''! ( ~~---~.~- i II . :-I .~ _.'~0.! '"' I "~ APPLlCA TION FOR BUILDING PERMIT Date ~-'{28 ,20.QL INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 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 areas, 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 Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f. Every building permit shall expire if the work authoriied has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafter, a new permit shall be required. APPLICATION 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, Ordinances 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 authonzed lllspectors on premises and in bUlldmg for necessary inspections. "IMMEDIATELY" ~r t2Qh~ EN~~~~E 6g~iLl~,g~DE UNQERWRITERS CERTIFICATE (Signature of applIcant or name, if a corporation) BEFORE "WATER" REOUIRED 41\ (2t..e.. '2!5l'T l3c..ic.-yP-t-tv-( In7B . ALL COi~.j . 1C,:'j u ,j S;<4l i.. MEET THE REO liVeN un ci ltlt State whether applicant is owner, less~~bw~l)ite?h~gW~o/e:general contractor, electrician, plumber or builder (Mailing address of applicant) [')\u'llW" Name of own: of premises Ja on ~ t: list'.. (Sf ~-tt- AI:"; ~~;EI~jl:;, t~.;)~~~ 7 ? .' .' (As on the tax roll or lates~fEee .?If! ' __~ i..:f{~F If apphcant IS a corporatlOn, SIgnature C{)@~~fb~rtlfl NOTIFY BUll.D1~ '.r', .":T:AENT AT (Name and title of corporate of~A WFU L ~~5:~;~~'U~~:ASI;2>~c':\ FOR THE Builders License No. J)... 14-\ :;)....1-+ WITHOUT CERTIFICA F Plumbers License No, ~ OF OCCII~ Electricians License No, .C:; \ L.\-I i:::: Other Trade's License No. County Tax Map No. 1000 Section Subdivision ~\d\monri Sho(~S (Name) 0f0 Block b I * (le con lc Filed Map No. 1. FOUt<OATION - 1";0 R~C\";ED FOH POUR:=D C~:;:CRETc 2. ROUCH - FRAMiNG & PLUI;,BING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL COi'ISTFiun:"J ~W,1l. :'~rr THE HEQUIREHENTS (J n'E C0liES OFNEW YORK STATE. NOT Rl,SPONSIBLE FOR HaJ~nrs~~ff~~uWORRS. PtlR6UANT.m.TO: ~236 CHilE ' . ,.,. .Lo. t. ',' . A.. ,', .'-,.'_ ,'_ ".'." . z::;> J. Location of land on which proposed work will be done: c!J,qo (.<lCi1m.Mo... Lo..... . House Number Street '.,' ": --.,:' ",""~' 2. State existing use and occupancy of premises ard inte ed use and occupaI<CY of proposed construction: a. Existing use and occupancy S\t'\ c.... \ l (.t.s'\o..W b. Intended use and occupancy S\~.:Y~~\.)14.. fts;tienCQ W I \V\3i"DW'\?.. ~O J 3. Nature of work (check which applicable): New Building Repair Removal Demolition Addition Other WorV-:Pool...- Alteration ,:l \olL o..f~ ~ (Description) L . 4. Estimated CostjtlS,ooo -' Fee 5. If dwelling, number of dwelling units If garage, number of cars (To be paid on filing this application) Number of dwelling units on each floor 6. Ifbusiness, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Height Number of Stories Rear Depth Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Height Number of Stories Rear Depth 9. Size oflot: Front_ Rear Depth 10. Date of Purchase Name of Fonner Owner 11. Zone or use district in which premises are situated . 12. Does proposed construction violate any zoning law, ordinance or regulation? YES_NO_ 13. Will lot be re-graded? YES v-No _ Will excess fill be removed from premises? YES_NO ~ Address ,;?qo i2d1h'lt\l1ti /..p... Address I \ I) U t.:>e<-tL1 i4"~ Address 1.\:1\ ~ '26f\-vo- L~A- 15 a. Is this property within 100 feet ofa tidal wetland or a freshwater wetland? *YES_NO_ * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO <../ -- * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 14. Names of Owner ofpremises.\o.~<\ &e.f\ Name of Architect ~J()~ Name ofContracto nd 2oJ<<be.f Phone No. Phone No Phone No. .;l '~-144-loq4 ( 33\-~to 5 "144.- it 0 0 1,,~. 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 ) rt<Md l{T eoc\ec\[~ being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the cvnMltc~ (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 knowledgeand belief; and that the work will be performed in the manner set forth in the application filed therewith. . Sworn to before me this o<~ d of 200+ ~ T&dW-. Signature of Applicant r 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. 33577 Z Date DECEMBER 11, 2007 permission is hereby granted to: J & E BRETT 290 RICHMOND LA PECONIC,NY for : CONSTRUCTION OF AN INGROUND SWIMMING POOL AS APPLIED FOR, FENCED TO CODE at premises located at 290 RICHMOND LA PECONIC County Tax Map No. 473889 Section 086 Block 0001 Lot No. 004.008 pursuant to application dated NOVEMBER 29, 2007 and approved by the Building Inspector to expire on JUNE 11, 2009. Fee $ 250.00 ~ C-ft Authorized Signature ORIGINAL Rev. 5/8/02 Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971-0959 Fax (631) 765-9502 Telephone (631) 765-1802 BUILDING DEPARTMENT TOWN OF SOUTHOLD July 3,2008 Swim King Pools 471 Rte 25A Rocky Point N.Y. 11778 Re: Brett: 290 Riclunond Lane, Peconic To Whom It May Concern: Weare unable to complete your Certificate of Occupancy because of the following reasons: ~An application for Certificate of Occupancy is not on file. (Enclosed) No Electrical Certificate on file. ~Check is not on file -$25.00 No Health Department Approval on file. No final inspection has been made. No Plumber Solder Certificate on file. (All permits involving plumbing being issued after April], ] 984) Certificate of Compliance from Southold Town Trustees. Approval of the Zoning Board of Appeals* Final Planning Board Approval. BP #33577 Inground Swimming Pool 33577:L. TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1 ST [ ] FOUNDATION 2ND [ ] FRAMING I STRAPPING [ ] FIREPLACE & CHIMNEY [ ] FIRE RESISTANT CONSTRUCTION ~ REMARKS: DATE 1;L~f [ ] ROUGH PLBG. [ ] INSULATION Oc(FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT PENETRATION ~ -- - L4- C) C V, INSPECTOR A-: ~ - I . FIELD INSPECTION REPORT DATE COMMENTS ~;g . . . ~~ FOUNDATION (1ST) ~.., . ~'l> ------------------------------------ FOUNDATION (2ND) ~~ 2: 9 3;", 0 >-3 ~ ROUGH FRAMING & ~~ PLUMBING '> l.,- "" ~ S ~-- -~ ", ~ ~ _._--_..,~ .--- ~.------~------ il:: - f~ INSULATION PER N. Y. - STATE ENERGY CODE . . r .// '/1 -1..... ::J..-t ~ P~I L...- ok . ~ .A V , (' FINAL . - [ ADDITIONAL COMMENTS ~ y~ 't~ ('" , ~'" , e;; ::::~ ~g 2: . t:..s:i "-~ j> il:: I::l i'j "" ~ Joon- 8G-{-4.e OWNER TOWN OF SOUTHOLD PROPERTY RECORD CARD icl.." , ,~<-( 1 .!:; VILLAGE PIi? -,,;:>~: DIST. SUB. Map l~ LOT STREET '2 q 0 FORMER OWNER N E 5 .., ',' ~ ~~. \ ~ t -l ~'""\' ACR. 14- TYPE OF BUILDING :-- fj.... ,. I A- -S . m .. Y'I 5 S W RES. SEAS. ' VL. -J II FARM COMM. CB. MICS. Mkt. Value LAND IMP. TOTAL DATE REMARKS .. , ..:5.1 D .s-/N'I 1~..zh9 1;//0/'17- Li/~1 o~cr-eE...r_75::"k, Co. -+v ~r-~/VIc..- dq!DI- LI 'AntJ,,:; /1/1--,'1) .(1" ~_. '" <:. ..j" <YJ,~ hV1 ~, r:...f.<:;'.~ 1I11U ~~ I , , 'F .. Tillable FRONTAGE ON WATER Woodland FRONTAGE ON ROAD Meadowland DEPTH Hause Plot BULKHEAD Total FORr1 110. 4 TOWN OF SOUTHOLD BUILDIlIG DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. COpy fOR YOUR INfORMATION CERTIFICATE OF OCCUP.~ICY No, 2-30548 Date: 11,'12/04 THIS CERTIFIES that the building NEW DWELLING Location of Property: 290 (HOUSE NO.) County Tax Map No. 473889 Section 86 RICHMOND LA (STREET) Block 1.- PECOIIIC I HJl.MLET) Lot 4.8 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building permit heretofore filed in this office dated DECEMBER 31, 2002 pursuant to which Building Permit No. 29097-Z dated JANUARY 13, 2003 was issuedl and conforms to all of the requirements of the applicable pro7isions of the law. The occupancj.' for which this certificate is issued is SINGLE FAMILY DWELLING WITH ATTACHED TWO CAR GARAGE, COVERED FRONT PORCH & REAR WOOD DECK AS APPLIED FOR. The certificate is issued to SCHEMBRI HOMES, INC. fONNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF IlBALTH APPROVAL RI0-00-0B7 02/23/04 ELECTRICAL CERTIFICATE NO. 3572 05/12/04 PLUMBERS CERTIFICATION DATED 02/09/04 CHARLES SAlIBERI Re',. 1/81 / / / / ./ / / ,{-' I' R=-25.00' r---lc:39.27' -\' -<,rn -Jr. ./",J ( ./" /> ; \ \ \ I i /~--------------- / I / -"-----~~-------._~--_.- / / / / //// '. \ / / I i \ \ , \ \ \ J / // -.)~. cc:s. / / // / / / / / / / V' '" /. '0' "'. '" o G 1-- "a. oS>- 00__ It- o ,.", .~. .1'. ",-G ""c. ~ :.0-, .p" ~Cf Sf N OFO' / .. '''1 1 f/ uV Y\.. t1 I , 'Irf/j~ ~.. l/// / / ///"--~ '. ~ LOT :.~ " " ".'-.....-....~ -.'......~ ". '------ SURVEY OF LOT 8 MAP OF RICHMOND SHORES AT PECONIC FILE No. 6873 FlLEO--NOVEMBER 20, 1979 SITUATED AT PECONIC TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-86-01-4.8 SCALf 1 "=40' MAY 24, 2000 JULY 24. 2000 REVISED WATER SERVICE DECEMBER 30. 2002 ADDED PROPOSED HOUSE ~ARCH 6. 2003 FOUNDATION LOCATION FEBRUARY 3, 2004 FINAL SURVEY AUGUST 19. 2004 ADDED PROPOSED POOL SEPTEMBER 23. 2004 UPDATE SURVEY FOR DECK AREA = 22.391.28 sq. It. 0.514 ae. CERTIFIED TO. UNITED GENERAL TITLE INSURANCE COMPANY CITIMORJGAGE, Inc. ISAOA JASON BRETT ELSIE BRETT ut.WJlHQRlZffi ALlEAATION 00 JlDDmOtl TO THIS SURVEY IS A VIOlATION OF" SfCllCN 7209 or THE NEW YOflK STATE EOUCATIOt1 Lo\W. N;Y.S Lie. No. 49668 IN -'CCORDHa WITH THE UINlt.IUM fOR mu: SUI'MYS AS ESTABUSHED ALS. MlO ~ N<<l ADOPTED 1JS[B'!'TH[N['W't'ORl{Sli\TELANO noN COPIES OF lHIS SlJRVEY WAf' I<1T BEARING THE LAND s~ INKED SEAl. OR EUBOSSrn 'XAl SHAU N01 BE CONsI[lf:RED TO BE A VAllO lRUE COPY seph A. Ingegno Land Surveyor eElmFlCAl10NS INOICATID HEREON Sl-t.oJ...l. RUN ONLY TO THE PERSON !COR WHOU TI:iE suRVE"f IS PREPARED. N<<J ON HIS E:lOWF TO THE TITU: COl.IPANY, ~TAl AGOlcr ,o,HO Lf},IDlNG lNsnTI,ITX)N USTED HEREON. .-.NO TO TH[ ASSIGNEES Of THE: l..ENl>><<: INST!:" lVTlON CERTIFICATIONS AAE NOT TRANsffil.'\Bli fHE EXISTENCE OF RIGHI Of WA ~s AND/OR EASEWENTS or RECORD, If ANY, NOT SHOWN ARE NOT GUARMITfEC TItle Surveys -' 5.JbdMsjQM _ "lite ,Pjons _ CQflstrvGtion Layout PHONE (631)727-2090 Fax (6.31)727-1727 IMJUNG A[){}RE5S P.O. Box 1931 Riverheod. New York 11901-0965 OFFICES LOCAT[D AT 322 ROANOKE AV;;:NU[ Rr>'tRHEAD, Ne,. Yor\<. . :90. GU-~jb91 ~ ~ Co t-- N N 101 Q "? N Q 46'-11" IU" PlAN 26 X 46 MOUNfNN em t '" ~ ;,- 2" to 4" SAN? WHOM POURW CONe. WPlXS AN? S1CPS SECTION A VAIloS S' d '? I--- SECTION B 'd !!Q1!2 1. SI1lIJCIllIE!S IIESIGNED RIR USE BB.OWGRADeAHD ONLY IN I19S \\lfIIE1lIE00IND WAlBl TAiL! !SA I4INIMI-" Of f~BB.OWl1E_fINISIIII)~ 2.1I!OOlU. WITH Qf.\H I:M1H, flIfE Of ROOTS AND DEBRIS. 00 NllTIlli1//1lIEHElGfTOf!lllllfW.lllElllEEll'llE IlEIGHTOf'llE WAlBlIN 1lIE POOL BY MORE THAN 8', 1ll'llE WAlBllll EI<<lED BIOOIll BY MORE THAN 8', ;. WAlJCSlllIE9l:lOTH,NONSKlD11PE.Sl.OFBlAWAYRlCIHOOL 4. WAlBlDlSPllill.SI\\lLIE LOOTIDlllOWlfRSPROPfIm'TOsurr LOC\I. RfQJlATIONS ~\ 04. '15-", PLUMBING SOiEMAl1C froMS!JIM'tR rr fIL~}wPll.l' ro WI81f fO IW% WAfl'RlI-I, 10" Ft Cl1At1' ReHW fom t31'lVIl',N lIN,R AND CONCRC!!' . .! . f(J(Mfi,S 4 . . :q. ?SOO PSI POURW CONCRC!!' . VIN\1-lIN,R V'\ . -IV OZ '-0 o cL ~ ~ ~ ;= t..J ~ Z Z a. f-- _~ <(Z :::l . l{) 0 f- N Cl.. ~~ ~Q ::;; Z ~V :::> <!' 0 0 V'\ cZ. cL cL <lJ ...:::L. ("Q" -I C '- ("Q" -fJ C ::s o :E '-0 -.q- X '-0 N 6-24-03 Erosion. Sedimentation and Storm.water Run-off Control Plan ASSESSMENT FORM Yes No EXEMPTIONS: A. Does this project meet the minimum standards for classification as an Agricultural Project. _,. Note: If you answered Yes to any olthe. above, a Storm-water, Grading, Drainage & Erosion Control Plan Is not required. ------------------------------------------------------------------- ACTIONS REOUlRlNG 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 (J) for each question is required for complete application) 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 permanent creation of impervious surfaces.) Yes No B Cd!/" , B' GJV [dL B GJ Cd \/" v ./ 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 prior to Issuance of any building permit. 2. Will this project require any land filling, grading or excavation where there is a change to the natural existing grade involving more than 200 cubic yards 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? ... being duly sworn, deposes and says that he/she is the applicant for Permit, Sworn to before me this; ..~'( .....20()"t 4. Is there a Natural Water course running through the site or is this project within One hundred (lOO) feet of wetlands or a beach? (Owner, Contractor, Agent, Corporate Officer, 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 true 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. ~1JC~.. (Signature of Applicant) 5. Will there be site preparation on slopes which exceed fifteen (15) feet of vertical rise to One hundred (100) feet of horizontal distance? 6. Will driveways, parking areas or other impervious surfaces direct Storm-Water Run-off into and/or in the direction ofa Town Right-of-Way? 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 area? (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? STATE OF NEW YORK, r rn COUNTY OF u~,v;>\\L That I. 20J'0.l{f.. Qpd<<=te.v-:- (Name of individual signing Document) .... ...... .. ss And that He/She is the .........HH.... ..C'uN1~.~...