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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
~~
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ro
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~~~
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/
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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.
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