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Home My WebLink About34081-Z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY Date: OS/07/0S No: Z-33199 THIS CERTIFIES that the building AS BUILT ALTERATION Location of Property: 3575 WELLS (HOUSE NO.) County Tax Map No. 473SS9 Section S6 RD (STREET) Block 2 PECONIC (HAMLET) Lot 10 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in tbis office dated JULY lS, 200S pursuant to whicb Building Permit No. 340S1-Z dated JULY 30, 200S 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 AS BUILT GARAGE ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR. TRUSTEES CERTIFICATE OF COMPLIANCE NOT REQUIRED FOR THIS PROJECT. The certificate is issued to JOSEPH & SHERRI MELCHIONE (OWNER) of the aforesaid building. N/A SUFFOLK COUNTY DBPARTMKIlT OF HEALTH APPROVAL OS/22/0S KLBCTRICAL CERTIFICATE 110. 3060611 PLUMBERS CERTIFICATION DATED OS/05/0S MELCHIONE ~ /piD_ Aut r1zed S1gnature Rev. l/Sl -..--.. ('AV < ~/ '"...~.I j 10" /,/ - / j 7 J J , L___.. .., I ,J6 -::"7 ./ TOWN HALL '. J/ 765-1802 - '-~TION FOR CERTIFICATE OF OCCUPANCY Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. 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 2/10 of 1 % 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 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 Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. 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 & /31,,8 Date. Old or Pre-existing Building: .1.5 'IS ~ u.. t ...e....,. House No. Street Owner or Owners of Property: :::T"t!J!;G.I'N,. g~,e.e I B6 .,/' (check one) ;:>~~NIC: Hamlet New Construction: Location of Property: Suffolk County Tax Map No 1000, Section ,tl(€ 'C#'leJ~ '::>"1-- Block Lot ID Health Dept. Approval: Planning Board Approval: Request for: Date of Permit. ,I.J/A ~/I. 1 13~ jtJK . Filed Map. Applicant: Lot: Subdivision Permit No. ~4f)r/ l. Fee Submitted: $ Temporary Certificate lS.." Final Certificate: / /'tG.~CHI.""~ (!.v F 1t4 1 ?{)(.~{,/I- " ''J/ ..r -</./ -o..fJ 7/v~ ,/J..r'~ /'?.r4('.. ~-v-,fY (check one) Underwriters Approval: -- ~ Applicant Signature eo.zYJ/~;P fr '- ~ ~ij' 7 J,{2, 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. 34081 Z Date JULY 30, 2008 Permission is hereby granted to: MELCHIONE 3575 WELLS ROAD PECONIC,NY 11958 for : AS BUILT ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR PER TRUSTEE APPROVAL. at premises located at 3575 WELLS RD PECONIC County Tax Map No. 473889 Section 086 Block 0002 Lot No. 010 pursuant to application dated JULY 18, 2008 and approved by the Building Inspector to expire on JANUARY 30, 2010. Fee $ 400.00 ORIGINAL Rev. 5/8/02 TOWN OF SOOmOLD BUlLDINGDE\tARTMENT TOWN HALL SOUmOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www. Dordtfork.netfSoutboldl r BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the foll~. before appl,ying? i : ,Board ofHealth N I fT _ , 4 sets of Building Plans V Planning Board approvllI IJ I k SllIVey V , Check ./ , Septic Forr:'r~ ~;:';~'7~ Contad: Mail to; Examined Approved Disapproved ale Phone; Expiration ,20_ APPLICA nON FOR BUILDING PERMIT Date J(/ '- ~ / 17 ,,200,$ INSTRUCTIONS a. This application MUST be completely ftlled 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 $lreets or areas, and waterways. ' c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Pemtitto the applican:t. Such a permit shall be kept on the premises availahle for inspection throughout the work. e. No building shall be occupied' or used in whole or in part for any purpose what so ever uiltiI the Building Inspector issues a Certificate of Occupancy. f. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of ' issuance or has not been completed within 18 months from such date. Ifno zoning amendments or other regulations affecting the property have been enacted in the in~ the Building Inspector DIllY authorize, in writing, the extension of the pemtitfor an addition six months. Thereafter, a new permit shall be required. " " APPLICA nON IS HEREBytdADE to the Building Department for dte issuance of a euiJding Pemtit P~t to the Building Zone Ordinance of dte Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction ofbuildi.ngs, additions, or alterations or for removal or demolition as hereip described. The _..........,., ................:., ..........'"""'. ~" housing code an,', d re,gulatio~, IUl:d t611flm,', iL , authorized mspectors on preuuses and m building for necessary mspecuons. ','. .~ . //~I ~. (Signature of applicant or name, if a corpomtion) . " . . ~/l/ht-.~rr -4 .5T,I!A"'4/ /JA-?# Ir~a:;r-- V.po.G 1412.- 5'adT/M.-f;, -try //9'7/ . (Mailing address 0 applicant) ,'... . . State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder //1' 1P"-UT / A -f-t/bI"/"-er Nameofownerofprenlises --.JtJ5/if',ij- 1T' <f:H'$~~; .41e:Cc:-/..// C>l.(T r _' " (As on the tax roll or latest deed) If applicant is a corporation, sign e of duly authorized officer ';;(/ (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. :tlI~ ~ " JRl ,..... , ,. AP/a 1. Location ofIand on which proposed work will r7 r- t.-V L.. House Number '. Street COWlty Tax Map No. 1000 Section Subdivision 8& Block C) 2- Filed Map No. Lot Lot /0 (Name) f 2. State existing use and occupancy of premises and intended use and occupancy of proposed constructi6n:... 4 a Existing use and occupancy 5//V<t:t.'-of:.- ,t::;O_'c.- 0/" p~.,._a/~. / b. Intended use and occupancy :>-(j P7 €- 3. Nature of work (check which applicable): New Building Repair Removal Demolition 4. Estimated Cost ; Z ~ ?'rt> Addition Other Work /?I/~O'f-.. / Alteration V VfC;4<11& Iff-...€-V-r: f' ?!v-t/c (Description) Fee (To be paid on filing this application) 5. If dwelling, number of dwelling units .1/lJ f!C- 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 3 {, (f.17 orad Rear 3 b (+- /717"""\ Depth Z y-(;"'4 ,.,',m'.tj Height 2- J ' Number of Stories 6P /lJ e:- Dimensions of same structure with alterations or additions: Front :> -(/ "'" L Depth -;5:.?l ""~ _ Height :'5 Xl ;M C Number of Stories Rear 54' PI C. 54~C 8. Dimensions of entire new construction: Front Height Number of Stories Rear Depth r ' , 9. Sizeoflot: Front 79 Rear 127' r Depth 15-9 tf 16'$ 10. Date of Purchase 6/&'/0? Name of Former Owner C.4 '5 Ie- Ct':. f' 11. Zone or use district in which premises are situated .;p - 4-0 t; S:M'~.nI/ 12. Does proposed construction violate any zoning law, ordinance or regulation? YES_NO_ 13. Will lot be re-graded? YES~NO ~l excess fill be removed from premises? YES_ NO ~. 14. Narnes of Owner of premises fJ1el-c+llo-t./JE:.-- Address f7; ~'n">Y':D PhoneNo. ,5"/6-$tP?-S.$z/, Name of Architect :5 ,/"t..-1/i/&:;. Address ?Cd yprot-fi':> PhoneNo 7~r>-"'-4-6-~ Name of Contractor ,4/ ~ Addfess Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES ' ~O _ * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITSJ-fA Y BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES ~ NO_ * IF YES, D.E.C. 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) o SS' COUNTYOFuvfhiL) . ril/ U{:11 I. [;7../1 JJ& being duly sworn, deposes and says that (s)oo is the applicant (Name of individual signing contract) above named, (S)He is the A lZuu -r (Contractor, Agent, C of said owner or owners, and is duly authorized to perform or have performed the said work and to make and me 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. Sworn to before me this 17r1/ day of .JelL Y -..tf~~. / Notaly Public 20t) ? ,4=y Signature of pplicant Barbara A. Strang NOTARY PUBLIC, New York No. 4730095 1"", 1i1fied . Suffolk County C'".".., o;.;xpires July 31, "J-OIIJ CERTIFICATION Date: vir(~ Building Permit No. 3 4- c> 8 I a Owner: Jt>,fs,/J?' lL1e(c (( r't\o/l-€- I (please print) Plumber: IJ<.,S~'" ;\..{.fl ked D....e (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. Sworn to before me this S-;-{ r~ . (plumbers Signature) day of /ft'Gc<.si, 20-'2f:l ....... FRED J. KUNZ -,Publrc._ol_'lbrlr #5074821 Com Ouollllod In SuIIolk Count" "7 rj / / minion Elcplroo .....,.. If, ~/ / Notary Public, County I' fl 70- .0 ;J - fZ) lID.lID ~. BY THIS CERTIFICATE OF COMPLIANCE THE ~ ~ NEW YORK BOARD OF FIRE UNDERWRITERS ~ ~ BUREAU OF ELECTRICITY C Ov..V~~_Li ~ ~ 40 FULTON STREET - NEW YORK, NY 1 0038 ~ ~ CERTIFIES THAT ~ ~ ~ ~ Upon the application of upon premises owned by ~ ~ JOStph}rlf.,LGfI/O,ut- ~ ~ REP ELECTRIC JOE & SHERRIE MELCHIONE ~ ~ PO BOX 635 3575 WELLS RD ~ ~ MATTlTUCK, NY 11952, PECONIC, NY 11958 ~ ~ ~ ~ Located at 3575 WELLS RD PECONIC, NY 11958 ~ ~ . ~ ~ Application Number: 3060611' Certificate Number: 3060611 ~ I Section: Block: Lot: Building Permit: 0 BDC: n511 I ~ Described as a Residential occupancy, wherein the premises electrical system consisting of ~ ~ electrical devices and wiring, described below, located in/on the premises at: ~ = Basement, First Floor, Outside, Attic, ~ ~ 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 22nd Day of May, 2008. ~ ~ Name OTY Rate Rating Circuits ~ ~ ~ Alarm and emergency equipment ~ ~ Sensor 1 0 0 CarMon/Smoke ~ ~ Sensor 3 0 0 Smoke ~ ~ Appliances and Accessories ~ ~ Dish Washer 1 0 1.2 KW ~ ~ Exhaust Fan 2 0 F.H.P ~ ~ Furnace 1 0 Oil ~ ~ Range 1 0 50 Amps ~ ~~~~ ~ ~ ~ Dimmer 5 0 120V ~ ~ Fixture 2 0 Flouresent ~ ~ Fixture 21 0 Incandescent ~ rnJ Outlet 23 0 Fixture rnJ ~ ~~::~e Fan ~15 f\;" Gen, Purpose ~ ~~- ~ ~ ~ ~ Receptacle 4 0 i? GFClseal ~ ~ Receptacle 35 O!"-, Gen, Purpose ~ ~ Continued on Next Page 1 of 2 ~ 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 lID.lID @].@] ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ Located at ~ ~ Application Number: 3060611 I Section: ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ I @]~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ .@] BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET - NEW YORK, NY 10038 CERTIFIES THAT Upon the application of upon premises owned by REP ELECTRIC PO BOX 635 MATTITUCK, NY 11952, JOE & SHERRIE MELCHIONE 3575 WELLS RD PECONIC, NY 11958 3575 WELLS RD PECONIC, NY 11958 Certificate Number: 3060611 Block: Building Permit: 0 BDC: ns11 Lot: Described as a Residential occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located inion the premises at: Basement, First Floor, Outside, Attic, 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 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 22nd Day of May, 2008. Name OTY Rate Rating Circuits IYill< Switch 26 0 Gen, Purpose seal 2 of 2 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 6684A Date of Receipt of Application: August 10, 2007 Applicant: Joseph & Sherri Melchione SCTM#: 86-2-10 Project Location: 3575 Wells Road, Peconic Date of Resolution/Issuance: August 22, 2007 Date of Expiration: August 22, 2009 Reviewed by: Trustee Peggy Dickerson Project Description: Remove dead shrubs, dead oak tree, and replace with native plants, prune existing plantings, and to replace the shingles, windows, siding and insulation on the existing dwelling and replace the garage door. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the application prepared by Joseph & Sherri Melchione, received on August 10, 2007. Special Conditions: Replace the trees with native species and the addition of a 10' non-turf buffer along the bulkhead. Inspections: Final inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set fo~h in Chapter 275 of the South old Town Code, a Wetland Permit will be required. This is not a determination from any other agency. ~~~ James F. King, President Board of Trustees JFK:eac .?fo~ I z- TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING I STRAPPING ~ FINAL [ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION REMARKS: ~ ' k of( f 6~ rI- l~jJ~ () ()^ j-;,/Lt ~ \ II ~~o....l A~~~~ r DATE Y-'f.-tJ K INSPECTOR~~ ~ . FIELD INdECTION REPORT I DATE I - : ! , FODNbATION (1ST) ! COl\1MENTS ~~"" .t"l ~~ ~: I , FOUN~ATION (2ND) , i ~~ " .' c:: \~ .t' \ ~6 ~. , ----- - -- -- - - - -,- - - - - - - -- --- - - --------- ROUG~ FRAMING & PrlUMBING CI:l >-:l ~1:l '01?l 'S..\>-:l 0: --1-- "- '" <:) I. : INSULATION PER N. Y STATE ENERGY CODE --------f- -_..~-----_._'- ------- --I :I: ~~', ~ t"l <:.: >-:l C (' . . IiIN AL '{'-Lf-,..f ~ A~~~ ~ - .L ,:.. l..., 0 (\ Ji:-.t?,.~., rf: ~ V , V.' ,., ,,1 --;t- ~ ^A\J f/ TTiJ. ~V..::1'- ^~\of1 .' V "'-./5,. '..17// 0 . . . ADDITIONAL COMMENTS ~ \'-..0 " ::E ~. z m '1\ ;U ~s ~~ . >-:l ~O . ~ Z . . '\ [;J . ~ g:; . >-:l :I: , '=' , I?l i '-;;l 1 i , .. "-'H 'E '" vv J-tIT :::' I I I ,- , " II" If\~ 'I \'" I" I ~ ! l. M. Bldg. .) )1.340 - ?~ S so :;lo:' Foundotion C. liS- Both / - Extension Basement .,IL L..-- Floors '" tI-' k'- I . Extension Ext. Walls sB Interior Finish W. L- t. i;$j) ._- Extension Fire Place E.s. Hem l..> --- ------- 3:. :;.:s K Porch Attic Porch Rooms 1st Floor Breezeway Patio Rooms 2nd Floor Garage Driveway -- O. B.~>t\ l'f '- ':'0 "''' ---------- 3 .t3 Q/5:J- ",' ;;. -/0 TOWN OF SOUTHOLD PROPERTY RECORD CARD ~~. t i,' I tl'.? . ~ OWNER STREET --:;>'5 7.5 ~ VI Li.,AGE DISTRICT SUB. LOT . ...)QSMhJ\ ~~r-; .// , 7 l"~ ~ "rmP Vi! /(.,. RJ.. //-..__--l r..i-'-,J FORMER OWNER N ) E ?:?_I!. AC~~GE '1/ , C. 'Vi 1 , nA " -;/' /~ 11 ....? Il S f W TYPE OF BUILDING w- ~04<k.. (I/Jslell/Ifr.U~ Md.~0t,o lJe/i.J, ki RESo<' I ~ IA{ SEAS. VL. FARM COMM. I IND. I CB. I MISC. I LAND IMP. TOTAL DATE REMARKS v' J- 2- .. I J'O () 3080 4j()~ /~Jq/.SA Lf?-~/480()~ 9/42- A /71:' !V",)M.rIfP", EfT.JT; - ::r('/ls'l;//'~.w'.t ~t'9(){) ~ OO() JUO[)\ / /1.. / .... i.J/ gf07-L eJC'i If [) )/q7 J &skltt ~.f;o.>f -In IY/e {(');, "oYle. "r.uF 't.2~OOO S;;.ooJ /~~2;;~ , / 2-000 ?:Z-<>j) / () /1 v AGE BUILDING CONDITION NEW . NORMAL BELOW ABOVE - Farm . Acre Value Per Acre Value Tillable 1 I Tillable 2 PiA 7.,,. /'ii'd )(.;9,. - /C2.j-" {J 16 ~ = 2 60C, ~ Tillable. , 3 Woodland Swampland Brushland House Plot Total . .... ...... -- Soutbold Town Board of Trustees Survey of Property SUrveyed: ..line 5, 2001 SGT# 1000-86-2-10 Situate: Paconlc. TOi'ln: Southold SUffolk Gounty, NY I l' = 30' I ~+E s 159057' II ~Ij ?i . ;; ..... 1. -t> f7 f / a~J- :;;;:c en 0 >- w ..... a:l w 0 l- X C en l- f'. ::;) ::> 'l;:) ~I w 0:: 0 > I- .... en 0 0 .... ~ 0::: 0 , 0 ;II a.. 0:: Z \\:) a.. -c( 5 <( 0 0 a:l ..... W ..... -c( 0 .-J 63> L -~- l Old' If. iJ~J: .-B~ -:F(.:J:' .. ... ;:::.IJ .{' ~ 'a J i# -' "- I ~)~- 1~' ~~i --< c:: ~ -. '0 c 8" ~ ' ~ -, L_~ . lJ'J'1J :-'.- Certified to, Joseph Mek;hlone Sherrl Melc.hlone Bethpage Federal Credit Union Landamerlc.a Commoni"lealth '" Jh Jh j, (7 \ / , ; , ' , ! ROBERT H. FOX NYS PLS# 501f11 POBOX#538 RlVERHEAD NY119ll1 631.722-3390 6/1912001 Jl:51,2bAM c,.\Sl...J-f\c.O&tlll.pl"o ~hor"edDII"ratlDnor<>o;Jdlllonloo"""'''~ mop bear-Ing " Ir~ere.ed r"r,d 5v,,,.,ep''' se,,1 l~ " vl,,'<"I,,~ of ~"dIO" 12~, 5Lb-dtvl~i<m 2, of t~ Ne", Yoe<. 5'''18 EdlJa.l~lDn 1-""" 'Onl~ copl". /rom the or]g"":" of tit.. ~"r",,~ marked "lIT> on "rig"",1 cllh.. lard 5""""'Pr'~ ~l"mp..d ....", 5~1I be ~onsld"r"d to be valid Ir"" ~op'e" "c.erJlflcQtlor15 Irrdic",,,,, nereO>1 s.",.f~ ~hat thl~ ~tlrv..~ """" pr"p"reClln ",,~O>"dar..e ",Ith the ax- ""ingc..od"ofPrOGt;c"forL"r1o<:l~e-...adop~e-d ~1he.~..Yor..S1"'""^"socIat1aoc'Prc;"'~ICCQI Land ~p~. SaId c"rtlllcol:,,~~ ~""'II .""'.0 O~h; to t"" f"<'N><>'\ for ><ham the ~.........~ b; p.-ep.:red, ~"~hlobe/"lalltothetllle';:"""f'an~.l:Jov"rnm..n ~I ~~';:e~"~~ ~I~:~ ~~~~K>~c"'c:.~a_ tl~Pr'"noItraw.lerGlbi<!ltoaddlt""",lirlOliW"""", , -----.-,---- Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M. #: THE FOLLOWING ACTIONS I\!AY REQUIRE THE SlIBMISSION OF A STORM-WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. District Section EiiOCj( ~ ---------------------------------------------------- Item Number: (NOTE: A Check Mark (J ) for each Question is Required for a Complete Application) l:!2. Ves -----------------------------------------------~--- 1 Will this Project Retain All Storm.Water Run.Off Generated by a Two (2") Inch Rainfall on Site? tI [J (This item 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.) Does the Site Plan and/or Survey Show All Proposed Drainage Structures Indicating Size & Location? J [J This Item shall Include all Proposed Grade Changes and Slopes Controlling Surface WaterFlow! r&~t' 'f/N'5 - t?A.J 7'/7v 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? 2 [Jv [J~ [J~ [J/ [J~ [JJ [J/ 3 4 Will this Application Require land Disturbing Activities Encompassing an Area in Excess of Five Thousand (5,000) Square Feet of Ground Surface? 5 Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction or within One Hundred (100') feet of a Wetland or Beach? 6 Will there be Site preparation on Existing Grade Slopes which Exceed Fifteen (15) feet of Vertical Rise to One Hundred (100') of Horizontal Distance? 7 Will Driveways, Parking Areas or other Impervious Surfaces be Sloped to Direct Storm-Water Run-Off into and/or in the direction of a Tawn right-af-way? 8 Will this Project 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 will NOT Include the Installation of Driveway Aprons.) 9 Will this Project Require Site Preparation within the One Hundred (100) Year Floodplain of any Watercourse? NOTE: If Any Answer to Questions One through Nine 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 Permltl ---------------------------------------------------- EXEMPTION: Ves 1 Does this project meet the minimum standards for classification as an Agricultural Project? Note: If You Answered Yes to this Question, a Storm-Water, Grading, Drainage & Erosion Control Plan Is NOT Required! ---------------------------------------------------- STATE OF NEW YORK, COUNTY OF ........................................... SS 111at!, ...~4!:(6.~....4.;:..5.r.k/f./v...L. ....... being duly SWOIll, deposes and says that he/she is tl1e appliGUlt for Permit, (Name of individual signing Document) And that he/she is the ...........4&.Cdl:l.,7Xk.T,/A.,~(f:,t!.,L..<t.'4'!~...c::?~:'Cf,:1,.,.......,......,",.................'.."..... (Owner, Contractor, Agent, Corporate Officer, etc.) Owner and/or representative of the O,vner of Owner's, and is duly authorized to perform or have pelformed the said work and to make ,md 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 fortl1 in tlle application filed herewitll. Sworn to before me tllis; J. /. ~ ...".......!~.'T..I!..".."..../" d~bar~.A.,8tr8r.l~~t 20,i.>.8' NOTARY PUBLIC, NElW ~k Notary Public: ..,."......................Q~aiifi~$":~.fuW~~~iitY.........,.. ./~~......=-"..".- (Signat of Applicant) FORM - 06/07