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HomeMy WebLinkAbout33700-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY NO: Z-33248 Date- 08/27/08 THIS CERTIFIES that the building ADDITION Location of Property: 1775 MILL CREEK DR SOUTHOLD (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 51 Block 6 Lot 33 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated FEBRUARY 8, 2008 pursuant to which Building Permit No. 33700-Z dated FEBRUARY 21, 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 UNHEATED SUNROOM ADDITION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED The Cert].fiCate iS issued t0 CHARLOTTE M (OWNER) of the aforesaid building. SIIFFOLR CODNTY DEPARTMENT OF HEALTH APPROVAI, N/A ELECTRICAL CERTIFICATE NO. 4004574 06/18/08 PLDI+IBSRS CERTIFICATION DATED A on ed S'gnature Rev. 1/81 dorm No. 6 TOWN OF SOUTHOLD BUILDINGDEPARTMENT ' r_ - - ----- To6s Iso ~ IG ~ ~ ~ f~ MI APPLICATION FOR CERTIFICATE OF OCCUPANCY I BUG 2 7 ~ I U This application must be filled in by typewriter or ink and submitted to the Building A. For new building or new use: 1. Final survey of property with accurate Location of all buildings, property lines, streets, and unusual naturalor 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 Pire Underwriters. 4. Sworn statement from plumber certifying drat the solder used in system contains less than 2/10 of 1% lead. 5. Coimnercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Cmnpliance from architect or engineer responsible for the building. 6. Submit PLanniug Board Approval of completed site plan requirements. B. For existing buildings (prior to April 9, 1957) uou-conforming uses, or buildings and "pre-existing" land uses: 1 . Accurate survey of property showing al l propert~~ lines, streets, building and unusual natural or topographic features. A properly completed application and consent to inspect si6nred b}' the app(icant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons drerefor in writing to the applicant. C. Fees 1 . Certificate ofOccupancy -New duelling $25.OQ, Additions to chvelling $25.00, Alterations to dwelling $25.00, Swimming pool $25.00; Accessory building. $25.00. ?,dditions to accesson~ building $25.00, Businesses $50.00. 2. CerlificateofOccupancyonPre-existingl3uildin~.-.Ri00.00 3. Copy of Certi&cate of Occupancy -3;25 4 Updated Certificate of Occupancy $50.00 5. Temporary Certificate of Ocarpancy -Residential $I5-00, Commercial $15.00 Date. 2S O~ New Construplion: Old~~or>>Pre-existing Building, / (check one) Location of Property: /7~S /'~il~ L i~re~ _ ~o ~~~ House No. Street Harrilet Owner or Owners of Property: ~'~ f_~~~ee~%- - Suffolk County Tax Map No 1000, Section .S/rr~o Block ~~ Lot ~ 33 Subdivision Filed Map. _ Lot: Petmi[ No. 3.37d-D Date of Pemsit. 11~Zoa~~gpplicant__~o-+-l ~r /3fu ~~,~- Health Dept. Approval: ~ Underu~rilers Approval: Planning Board Approval: Request for'. Temporary Certificate Fee Submitted: $ LS. `'° ~ ~33a ti$ ~~ 1~~~~ Final Certificate: ~ (check one) ,~~~~~- Applicant Signature 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 PAUL R. BURNS PO BOX 1061 SOUTHOLD, NY 11971-0932, Located at 1775 MILL CREEK DRIVE SOUTHOLD, NY 11971 Application Number: 4004574 Section: Block: Lot: RICHARD MULEN 1775 MILL CREEK DRIVE SOUTHOLD,NY11971 Certificate Number: 4004574 Building Permit: BDC: ns11 Described as a Residential occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: First Floor, Outside, 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 Lath Day of August, zoos. Name 4L Rate Ratios ircui Typg AdditionalCharges sun room Wiring And Devices Fixture 1 0 Incandescent Outlet t p Fixture Ousel t2 0 Gen, Purpose Receptacle 2 0 GFCI Receptacle 9 0 Gen, Purpose Switch 2 0 Gen, Purpose 1 of I seal 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 J. DEERKOSKI, P.E. 260 Deer Drive Mattituck, N.Y. 11952 (631) 298-7116 Date: June 5, 2008 To: Town of Southold Building Dept. Re: Strapping/Framing Inspections Mullen 1775 Mill Creek Southold, NY Permit# 33700 To Whom It May Concern: This letter certifies that all wind strapping on the above mentioned project is in tact, and meets all state and local building codes. A Framing Inspection was also Performed on this Structure, and all frazning was done correctly and also meets all state and local building codes. Any questions please feel free to call. P.E. James F. King, President ~~F ~DUjy Town Hall Jill M. Doherty, Vice-President ,~0~ ~~ 53095 Route 25 Pe A. Dickerson gam' ~ # P.O. Box 1179 Southold, New York 11971-0959 Dave Bergen Bob Ghosio Jr G Q '.cn ~ ~~ Telephone (631) 765-1892 , . 1~C0~~ ~~ Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0357C Date Aueust 22, 2008 THIS CERTIFIES that the extension of the existin¢ sunroom 4'X 20' and conversion into a four (41 season room At 1775 Mill Creek Dr.. Southold Suffolk County Tax Map #51-6-33 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 1/11/OS pursuant to which Trustees Wetland Permit #6793A Dated 1/23/08 was issued, and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the extension of the existin@ sunroom 4'X 20' and conversion into a four (4) season room. The certificate is issued to CHARLOTTE MULLEN owner of the aforesaid property. ~-- ~~ Authorized Signature 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. 33700 Z Date FEBRUARY 21, 2008 Permission is hereby granted to: CHARLOTTE M MULLEN PO BOX 1408 SOUTHOLD,NY 11971 for CONSTRUCTION OF AN UNHEATED SUNROOM AS APPLIED FOR PER TRUSTEES APPROVAL at premises located at 1775 MILL CREEK DR SOUTHOLD County Tax Map No. 473889 Section 051 Block 0006 Lot No. 033 pursuant to application dated FEBRUARY 8, 2008 and approved hl' the Building Inspector to expire on AUGUST 21, 2009. Fee $ 200.00 ,~ ~ ~~ thoriz~ nature ORIGINAL Rev. 5/8/02 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ' BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health SOUTHOLD, NY I1971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net PERMIT NO. 3 ~ 76~ Examined"( , 20Q~ Approved/jj~` '~, , 20p~ Disapproved a/c 4 sets of Building Plans Planning Board approval Check Septic Form N.Y.S.D.E.C Storm-Water Assessment Form Contact: Mail to: Expiration________ "/ , 20~ //~~ //// p// ~L/~CX~- i Building Inspector Phone: Ili .r- `~Z /y ~ APPLICATION FOR BUILDING PERMIT :.1: `... FEB $ `' Date ia//5' , zo © ~ ~~~ d INSTRUCTIONS ~ a. Thins appffcation MUST b'e completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of pldusraecus•ate 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. £ 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. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in wasting, 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 authorized inspectors on premises and in building for necessary inspections. (Signature of applicant or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder ~~~^ Name of owner of premises If annlicr3a tt is a (As on the tax roll or latest of dyly authorized officer (Name and title of corporate officer) Builders License No. 2 ~ 7S.Z - /><I Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be don ~G~~~~ / ~ ~r 7~i~ G~P~" a House Number Street Hamlet County Tax Map No. 1000 Section S , Subdivision Block !F Lot .~ 3 _ Filed Map No. Lot (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy /~ r•~c•, ~ t b. Intended use and occupancy 3. Nature of work (check which applicable): New Building Addition~Alteration >/~ Repair Removal Demolition Other Work (Description) 4. Estimated Cost Z 2, s°'a Fee (To be paid on filing this application) 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. r r ~ ~. 7. Dimensions of existing structures, if any: Front ,3~Rear 3 6 Depth ~' ~ Height Z/ ~ Number of Stories ~/ Dimensions of same structure with alterations or additions: Front .3 d' Rear -~~ Depth reG ~G ~ Height zl ~ Number of Stories ~ 8. Dimensions of entire new construction: Front Rear Zo ~T ~~ Depth Height ~ 9 z Number of Stories i 9. Size of lot: Front q3 ~ S 7 Rear y7 ~y~ Depth ~~ /. %2 10. Date of Purchase Name of Former 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_ NO Will excess fill be removed from premises? YES NO / 14. Names of Owner of r~1.//G~~ Phone No. 7Gr- 2970 Name of Architect off-. ~' r+'<< Address ~i~~i~~~ one No S'77-0~°-° Name of Contractor ~c~ ~~s Address ~~s ~o~~ Ctr~vCPhone No. 765-9-z/~ 15 a. Is this property within 100 feet of a 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. 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. 18. Are there any covenants and restrictions with respect to this property? *YES NO * IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OFS~ ~~ ,/Jets Gr/P~~ being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)Heisthe ~onT~~,%~- (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. Swomttokl~fore me 's da of 20~ ~~ ~. 4 ~ Notary Public 8111 Nohuy Signature of Applicant No.4555ilU5 Qualified in Sutfolk Counly CommUUOn Eapln~Aprll t4,(~D James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. ~o~~pF SOUryo~ ~~~QUI11 1 i~~,t1r BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 6793A Date of Receipt of Application: January 11, 2008 Applicant: Charlotte Mullen SCTM#: 51-6-33 Project Location: 1775 Mill Creek Dr., Southold Date of Resolution/Issuance: January 23, 2008 Date of Expiration: January 23, 2010 Reviewed by: Trustee Peggy Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631)765-6641 Project Description: To extend the middle of the existing sunroom 4'X 20' and convert into a four (4) season room. 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 survey prepared by John T. Metzger last dated January 10, 2008 and site plan prepared by North Fork Drafting & Design last dated November 26, 2007. Conditions: Drainage plan to comply with Chapter 236-Stormwater Management, of the Town Code. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, Wetland Permit will be required. This is not a determination from any other agency. Jam F. King, Presi t Board of Trustees iW!'f »' e. p,~n~f 7r,~~ ~ ; 1 ,"h,~{te SYt~ +'h e ..(%k ~~If`J x q`~ h,t~f.d,,~it~t' ~ i~il'~rr~ ~i`p . New Yor ~a~A ~ep¢rtnlerit bt'~nulronn'i~ttt~t)f~:.,~~~ •~i'tH; ~;•. • ,,4. ,, ,~~~;~, ,, 6ulidin~~t G l~Yi~lP~~~riSok, Naw Vork 11794 $358, • '#~;, .. R,I:~NRRI~`7 cN//JdLaITF ~-,uc[.F,~l ®: :: v .<. • Thomas C.'Jodlnp Date: Commissloner.~,;' ~' 0 2 - 2~- yy . , Re: ~- L/ j3~-oo~ycs /ovc,ul GoL' (n1FJT r,/zc c~z~.~rc:`:'~irr~~=~. • ' , S' a ~. T/-I u C.I~ IV y! /1.`9.7 / • Dear C'7~.. ~ a'v ~/Z.f'FI~C`i o M u G 4 /_ I'a:v ~~ T~ill.S• Cyit/LLF_./ Sc r~ O/uu.u-'ot/ x;'06'-:ci~J _r Based on the information you have submitted, the NeW:'York• State •• DepaYtment oP Environmental conservation hag ctef:esynined that :~ • .:~~~ivFy~ ~ Y J ~/~,~ T;, e~,rT~G%IZ~ i?-9ri~'/~ ,, ' i .vc~v,/L /y`9~ Z'S ; TJ/i Y r/-v r0 ~H/1 : ,~ .v /1 t s , ~ / c /' r v ,.i o'!~ 4 , , ~ ' °!rtld~efore; in accordance with the burreh£ R~idal Wetlands Land Use Regulations (6NYCRR Part 651j,ho permit is `required-under the Tidal ~, :~Tetilgnds: Act .-please be advised "11bwaV~Y~,:that no construction, =~:eedi~entation~ or disturbance of any kind they tiake place seaward of • ,~~;,tha • tidal wetlands jurisdictions) <botfrldary~' as indicated above, '~ y~,`Y~witihdut a'permit. °It is your res~ibhgibility to ensure. that;.all.,:~'• y heFiessafy,. precautions are takeH td ~ prtlV&i~t .any., s;edimentatior~," or , ;, 'othe'r alteration or disturbance t8 t21A +~rdttR/i surface or vegetation '' ' ,gt/ithin" 'pidal, Wetlands ~ jurisditlt~on'<~GrHi~t1'?"shay. ~Ygsult :from: your ,~ pro j edtr'~" Such precautions mad incliidA , ma~ntaiiiin Y~~grea"bettieen the tidal wetland .jurisdibtidrial. boundarYuand wour -~, prdjdet• (ire, a 15 to 20 hide Const~lictinfi area) or erecting a ;'~ 't •~; temporary Eende,. barrier, or hay•bale )9etiri;a o ~ .... ,` ., Please be further advised that this letter does. not relieve you: of ~r !~tl'tg responsibility of obtaining any neoe5saty permits or approvals '~.;fram other agencies. 5` .. ~ "•`~ ~ ~tery truly.; yours, ;. ;. ,. ~,;~ "_ ". Kati,., • . '=.i Deputy Regional Permit Administrator . .cct CaJTF!(o cti-4il~iv,E- ca-vr/l~4ctf~vG 1~~1///~/ /~ u T101 s • ' ~.' CJ a'^'b ~,.m~rw wwr NM~Lrrr~W.u•MI~1~•~n.......~.w.':.r..~...v..r.•r..u... m.~...vv •ih ~...n. +wn-~-n~r .~ '.~ . I!1\T11~~M.YlYryn W,IA!~An~TTF~~1M~ 33 ~e~ TOWN OF SOUTNOLD BUILDING DEPT. 765.1802 INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING /STRAPPING [ ]FIREPLACE 8~ CHIMNEY [ ]ROUGH PLBG. [ ]INSULATION [ NAL [ ]FIRE SAFETY DATE YY ~ ~ INSPECTOR [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION 33~~a~ TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPECTION [ ]FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [INSULATION [ ]FRAMING /STRAPPING [ ]FINAL [ ]FIREPLACE & CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION REMARKS: Oil, / - /~~-~ ~~ -~~.~ ~ 7_ D 8 DATE ~ _ ~ INSPECTOR /~~ `' ~~~°°~ TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPECTION [ FOUNDATION iST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]FRAMING /STRAPPING [ ]FIREPLACE 8~ CHIMNEY [ ]INSULATION [ ]FINAL [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION REMARKS: c~ . DATE INSPECTOR 3370~~ TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION ~] FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING /STRAPPING [ ]FINAL [ ]FIREPLACE 8~ CHIMNEY [ ]FIRE SAFETY INSPECTION [ ] RRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION ~~ ~ ~ Q r r DATE INSPECTOR V~ Frt.r.n INSPECTION REPORT DATE I COht14& , ~~ i ~ ~ ~ FOiINDATION(IST) ~~r': ~A, ~ ~'Y ----------------------------------- .. t~ FOUNDATION (2ND) z G ~c . ~ G~ „~ ~, ~ ~ ~ ROUGH FRANIING & "~ PLUMEING _- x _ _ >"-. ~ y INSULATION PER N. Y. STATE ENERGY CODE V1 O _ •, FINAL - ~ ~` C `' // // / ~ l~~/ ,~~J (/i ~ ADDI7 .+ Q f C We 11Pp rt. f (~ ~?~MYrc, s ~2 0 z m z ~~ P~ d ro H ~~~ S/- - ,~,~ TOWN OF SOUTHOLD PROPERTY RECORD CARD /'~- '3 OWNER STREET ~ T 7 VILLAGE DIST. SUB. LOT R C~ ,~,Colrc. M. , .,', ;~" ~ ~s-,tr <'~~Er~~ / e_/~,c_G~-?!.t<~, ::~' ..3_" `~Es~ , FORMER OWNER , E ~ ACR. ' S i, l W - /-~ (//~/ TYPE OF BUILDING RES.~v/'~Q ~ SEAS. VL. FARM COMM. CB. MICS. Mkt. Value LAND IMP.. TOTAL DATE REMARKS ,~,~ ;'~=>'~%~J ~'~~' ^^,, Yom' (~'D f G-d "S o2 O O. a5 ~ ~'~ 9 7 ~ c`.,s ~.. ~ t ~f. ~'"'~ '. ( J .-~ . oO (Qpo o p O_._ i/sG L~ ~1~ SAIe'~ _~ 2 ~r ~. ~ ~;~, f~~~ ~D 0 ~o / ~~o t~ `/ /at rf~ /y~~Q.~ /5~o fr. o%cE o ~ o~ O 1 loo (ozoo 7300 ~ 2 a ~ l81 ~ I -(~ ~ -r, ,' ~% _ Il oa ~.9~00 760 i '- ~ - 8P a - _~ s ~ r ~, „ !, Ta ~W~=(~~^~f ~ o-o ~ 9~ _ - / ~ os c -- AGE BUILDING CONDITION NEW NORMAL BELOW ABOVE FARM Acre Value Per Acre Value Tillobie FRONTAGE ON WATER 7~' ' ~ ~5-- ~ ~ _ /~ ~ ~ Woodland FRONTAGE ON ROAD Meadowland DEPTH .House Plot BULKHEAD Total d ~ DOCK f i~k'~,~i ~ I I ~I I I COLOR a~Ui..Q-~L. TRIM '' ~ - Q ~~,a a ' 9 - - - - i i~ ~ 6 M. Bldg: 3 3 2 6 8 Extension &, X Z / = / {• ~ 95 ~~ X /3 _ /3v 95 .Jr`7 Extensio y K G ~ .2 ~ 330 i ~ I ~ ~/ Extension '~p \.0_1 So Foundation ~ ~ , Bath Dinette Porch Basement ~'~t`" Floors K. arc ~ u IP' ~~ 2~{O ,gip l2r? Ext. Walls ~/~~, ,', Interior Finish ~ ~u!` LR. e /,~ tj Fire Place Heat ~ j DR. Garage ~ .2o Jc,2Q = ,~ 6 r' S6o T e Roof ~ Raorims 1st Floor BR. Retie ~~ ~a D . ZJ~ '~ZJ .Recreation. Room Rooms 2nd Floor FIN. B O. B. ~ K ~ X ,~; ~~{ _ Dormer Driveway " Total ~ I '~_ ~> ~ ~ Town of Southold Erosion, Sedimentation 8 Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: a.C.T.M. p: District Section Block Lot Item Number: (NOTE: A Check Mark (~) for each Question is Required for a Complete Application) OF A Yes No ----------------------------------------- ------- Will this Project Retain All Storm-Water Run-Off Generated by a Two (2") Inch Rainfall on SIte7 ~ ^ (This item will include all mn-off created by site clearing andlor conslmction activities as well as all Site Improvements and the permanent creation of Impervious surfaces.) 2 Does the Sile Plan end/or Survey Show All Proposed Drainage Structures Indicating Size & Location? ~ ^ This Item shall include all Proposed Grade Changes and Slopes Controlling Sudace WaterFlowl - Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Naturel ^ Existing Gmde Involving more than 200 Cubic Yards of Material within any Parcel? - 4 Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of ^ / Five Thousand (5,000) Square Feet of Ground Surface? - 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 8each7 - s Will there be Site preparetion on Existing Grede Slopes which Exceed Fifteen (15) feet of Vertical Rise to ^ ,j One Hundred (100') of Horizontal Distance? - 7 Wiil Driveways, Parking Areas or other Impervious Surfaces be Sloped to Direct Storm-Water Run-OK ^ / into and/or in the direction of a Town right-of-way? - 8 Will this Project Require the Placement of Matedal, Removal of Vegetation and/or the Construction of ^ any Item Within the Town Rightof-Way or Road ShoulderAreal - (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 Cheek Mark in the Box, aStorm-Water, Grading, Drainage 8 Erosion Control Plan Is Required and Must be Submitted for Review Prior to Issuance of Any Building Permltl ---------------------------------------------------- EXEMPTION: Yes No Does this project meet the minimum standards for classl(cation as an Agdculturel Project? Note: If You Answered Yes to this question, aStorm-Water, Grading, Drainage & Erosion Control Plan is NOT Requiredl - STATE OF NEW YORK, (~-~,~ ~~COUN~TY/OF 5,,~~p..l.k...r.......... SS That I, ....:/~~ w" ~ t ........................................ Ueing duly sworn, deposes and says that he/she is the applicant for Permit, ....................... (Name of intlivitlual signing Dacum¢nt) ~! And d~a[ he/shc is thc . ...............~'~~''~`~c( "Y ................................................................................................................................................. (Owner, Contractor, Agent, Corporate Officer, ¢tcJ Owner and/or representative of the Owner of 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 belief; and that the work will be performed in the manner set forth in the application filed herewith. Sworn to// before me this; ...................1.~.................... day of ...~~.lal-~.(,~....... , 20. Notary Public ..... ~.C~. _..... ~ ..' MICHELLE L MARTDCCNIA (Signature of ApplicanQ ~' V Rltl - V O/ V / N0.07MA9156871 CUALIFIED IN SUFFOLK COIIINTY MY COMMISSION EXPIRES NOV. 27, 20~ 5~ ~~ SURVEY FOR CHARLOTTE M. MULLEN A T ARSHAMOMOQUE TOWN OF SOUTHOLD SUFFOLK COUNTY, N. Y. 1000-51-06-33 Scale: 1" . 30' June 29, 1993 Sept. 22, 1993 (additions ) Sept. 28,1993 (e%vatlorls) Nov 12, 1993 (10 contour ) `/p~E OF NEp~r ,~~taT. MFp~ O~ ~~. 'Rn.~ ~n fr I ~' IC NO. 496/8 C. (5/ 61 765 - 5029-=--~' P. O. BOX 909 MAIN ROAD SOUTHOLD, N. Y. l197/ ~~~~ AREA =19,312 sq.ft. to tie lines Prepared in accordance with the minimum standards /or lit/e surveys os established by the L.I.A.L.S. and approved and adopted /or such use by The New York Stale Land TI//e Associallon. ~~J~ 0 ~'F-~ ~o~ ELEVATIONS 8 CONTOUR LINE ARE REFERENCED TO N.G.V. DATUM. ~/ no nn~