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Home My WebLink About33426-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEP~kRTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-33694 Date: 05/07/09 T}{IS c~KTIFIES that the building ADDITIONS & ALTERATIONS Location of Property: 555 RED FOX RD LAUREL (HOUSE NO.) (STREET) (HAMLET) County T~ t4ap No. 473889 Section 125 Block 2 Lot 1.22 Subdivision Filed Map NO. Lot NO. conforms substantially to the Application for Building Permit heretofore filed in this office dated JUNE 17, 2007 pursuant to which Building Pe~it No. 33426-Z dated SEPTE~BER 26, 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 ADDITIONS AND ALTERATIONS TO AN EXISITNG ONE FAMILY DWELLING AS APPLIED FOR. The. certificate is issued to ANDREW C & DEBORAH M HICKOX (OWNER) of the aforesaid building. SUFFOLK COUNTYDEPART~ENT OF HEALT~APPROVAL N/A Er.cCLi-KIC~kL C]~TIFIf3%l~ NO. 3060414 10/09/08 PL~ C~KTIFICATION DA'£H43 0~/28/09 CUTCHOGUE EAST PLUMBING Rev. 1/81 TOWN OF SOUTHOLD 765-1802 APPLICATION FOR CERTIFICATE OF OCC This applicatiou mu~t be fflled in by typewnter or ink and ~ubmitted to the Buildin~l[. [ ' rtm~with~the~nfo~llo~: For new building or new use. 1. Final survey of property with accurate locatioa of all buildings, property l~nea, ~ or topographic features. 2. Final Approval fi-om Health Dept. of water supply and sewerage-disposal 3. Approval of electrical installation from Board of Fire Underwriters. 4. Swora statement from plumber certifying that the solder used in system contains le~s than 2/10 of 1% lead. 5. Commeroial building, industrial building, multiple x~sidcnee~ and similar buildings and installations, a certificate of Code Compliance from architect or engin~r respousible for the building. 6. Submit Planuing Board Approval of completed site plan requiremeats~ 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, streeta, building andanusual, natural or topographic features. 2. A properly completed application and conseat to inspcct signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicam. C. Fees 1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelllng $25.00, Alterations to dweiling $25.00, 3. 4. 5. New Construction: Location of Property: Swimming pool $25.00, Accessory building $25.00, Additions to accessory buildihg $25.00, Businesses $50.00. Certificate of Occupancy on Pro-existing Building - $100.00 Copy of Certificate of Occupancy- $.25 Updated Certificate of Occupancy - $50.00 Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Date./f k~o~ne~/O ~ Old or Pre-existing Building: /// (ehec Owner or Owners of Property: [:},.t~ t-,..-~ ¢. Suffolk County Tax Map No 1000, Scction House No. Street Hamlet Subdivision Ver it $ a-6 Health Dept. Approval: Planning Board Approval: Date of Permit. Request for: Temporary Certificate Fee Submitted: $ ~ 5-/9 ~ ~r~ ~'- Block ~ Lot Filed Map. Lot: Applicant: Underwriters Approval: Final Certificate: /~(check one) Applicant Signature 53095 ~ Read O ~1%7g Te{e~ (516) 765-~ 8~? OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD CERTIFICATION Plumber <please pri~t) T certl[¥ that the solder used in the water Supply system contains less than 2/10 Of t% lead. NO. 0iB~6099317 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 DANIEL WILCENSKI ELEC. CONTR. PO BOX 319 SOUTHOLD, NY 11971, MR & MRS HICKOX 555 RED FOX RD LAUREL, NY 11948 Located at 555 RED FOX RD LAUREL, NY 11948 Application Number: Certificate Number: 3060414 3060414 Section: Block: Lot: Building Permit: BDC: BP33426 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, Second 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 9th Day of October, 2Oos. Name OTY Rate Rating Circuits Twe Alarm and emergency equipment Sensor I 0 0 CaYoon Monoxide Sensor 2 0 0 Smoke Appliances and Accessories Dish Washer 1 0 1.2 KW Exhaust Fan 1 0 F.H.P Oven 2 0 9.0 KVV Wiring And Devices Dimmer 8 0 120 V Fixture 28 0 Incandescent Outlet 28 0 Fixture Outlet 45 0 Gen, Purpose Paddle Fan 2 0 Receptacle 2 0 20a-laundry Appliance Receptacle 4 0 GFCl Receptacle 25 0 Gert, Purpose Switch 26 0 Gert, Purpose seal ConfinuedonNextPage 1 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. BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STRE~I ~ NEW YORK, NY 10038 CERTIFIES THAT Upon the application of upon premises owned by DANIEL WlLCENSKI ELEC. CONTR. MR & MRS HICKOX pO BOX 319 555 RED FOX RD SOUTHOLD, NY 11971, LAUREL, NY 11948 Located at 555 RED FOX RD LAUREL, NY 11948 Certificate Number: Application Number: 3060414 3060414 BDC: Section: Block: Lot: Building Permit: BP33426 ns11 Described as a Residential occupancy, premises system consisting wherein the electrical of electrical devices and wiring, described below, located in/on the premises at: First Floor, Second 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 9th Day of October, 2008, Name OTY Rate Rating Cir~uit~ Typ~ 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. 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. 33426 Z Date SEPTEMBER 26, 2007 Permission is hereby granted to: for : ANDREW C HICKOX 555 RED FOX ROAD LAUREL,NY 11948 ADDITIONS & ALTERATIONS TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR at premises located at County Tax Map No. 473889 Section 125 pursuant to application dated JUNE Building Inspector to expire on MARCH 555 RED FOX RD LAUREL Block 0002 Lot No. 001.022 17, 2007 and approved by the 26, 2009. Fee $ 526.40 Authorized Signature ORIGINAL Rev. 5/8/02 TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ]FIRE RESISTANT CONSTRUCTION [ ] ROUGH PLBG. [ ] INSULATION [/~J~INAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT PENETRATION REMARKS: DATE INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ]RRE RESISTANT CONSTRUCTION ROUGH PLBG. ~/~ INSULATION ( ] FINAL [ ] FIRE SAFETY INSPECTION [ ) FIRE RESISTANT PENETRATION REMARKS: DATE INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ~.~OUNDATION 1ST ~ROUGH PLBG. [ ] FOUNDATIO~N 2ND [ ] INSULATION ~ [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION DATE ~ *" ~-~'~ ~ ~ INSPECTOR ~~, ~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ~/FOUNDATION 1ST [ ~,,~OUNDATION 2ND ] ROUGH PLBG. [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT PENETRATION [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ]FIRE RESISTANT CONSTRUCTION REMARKS: DATE / ~) -- / '~- 0 7 INSPECTOR CHRISTOPHER R. STRESS, R.A. ARCHITECTURE AND PLANNING P.O. BOX 821 JAMESPORT, NY 11947 PHONE/FAX (631)722-7865 runbout@optonlinenet 20 Feb. 2008 Southold Building Department Via Hand delivery RE: Hickox Residence As Architect of record, Please be advised that we have seen and approve the following work a completed on the above referenced residence: l. Installation of all strapping relative to the new work that has been completed. 2. Installation of micro lam / flitch plate beams as installed in lieu of lighter steel beams per original drawings. The above work meets or exceeds the NYS Code and as such is approved by this office. Should you have any questions on the above or stares of the project, kindly contact this office. Regards, Christopher ~.t~¢~ ss ~R,A. NYS Lic. 02~3~39 : ' ru~ ~s~'~c'no~ u.~OUT ...................................... FO~DATION (2ND) ~S~ATION PER N. Y. STATE E~RGY CODE TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www. nor th fork.net/Southold/ ExpirationS, :Ofl~ PERMIT NO. [Buhding Inspector BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? APPLICATION FOR BUILDING PERMIT i Date ~x~ r~ ,20(~'~ JDN ~ '~ 7 ~ ~STRUCTIONS a. ~is application ~ST be completely filled ~ by ~ewfiter or ~ i~ ~d subm~ed to ~e Buil~g ~spector wi~ 3 b Plot pl~ s~aaon of lot ~d of bml~gs on pm~s. mlation~ip W ~jo~g p~ises or pubfic s~ or c. ~e ~ ~ by ~s ~fi~fi~ may not ~ ~enc~ ~fo~ i~ of Bml~g Pe~t shall be kept on ~e presses av~lable for ~spcction ~ou~out ~e work. c. No baling shall be o~upied or us~ ~ w~le or ~ p~ for ~y p~sc what ~ ~ ~1 ~c Buil~g ~p~r f. Ev~ b~g ~t ~1 ~xp~ if~e ~ ~o~ ~ not co~c~ wi~ 12 mon~ ~r ~e ~te of prop~ have be~ ~ac~d in ~e ~fim, ~e Buil~g ~p~r ~y au~o~, ~ ~t~g, ~e extension of~e ~it for ~ ad~fion s~ ~n~s. ~er~r, a new pe~t ~all ~ ~q~. applic~t a~s to comply wi~ ~1 appli~ble laws, ordln~nc~s, b~l~g code, hous~g code, ~d re~lafiom, ~d ~ a~t au~oHz~ ~speclom on p~mises ~d ~ buil~g for ncc~ ~specgons. State whe~ appli~t is o~, l~, ~¢n~ ~M~g en~r, ~n~ con~r, ¢l~Mcm, plm~r or b~ld~ (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. ~A / Plumbers License No. '~' Electricians Licease No: Other Tmde's License No. 1. Location of land, on which proposed work will be done: House Nu~nber Street Hamlet Co=vT, pNo.,0oo Subdivision /1/~,4/~- Filed Map No. (Name) Lzz Lot 2. State existing use and occupancy of pt~rnises and intended use and occupancy of~proposed consU'uction: a. Existing use and occupancy ~)~J~5 , ..~....J14 b. Intended useandoccupancy /~[~/~:' /t~Ad y~' 3. Nature of work (check which applicable): New Building diti Altemtinn Repair Removal Demolition Other Work (Description) (To be paid on tiling this application) J. 5, If~welling, number ofdwalling units 'ii ]/-~- Number of dwalling units on each Iloor If garage, number of cars ~ -/' ~ 6, If business, comma[rial or mixed occupancy, specify nature and extent o£ each type o£us¢, 7. Dim,n,io2 of existing ,tmctur~, if any: Front q t/~ ~f'~ Rear ~(~ ~t~' D~pth Height '~'fi_'~'~4- Number of Stories ' ' Dimensions of same strui:ture with alterations or additions: Front "7~ ~- Rear Depth "~/~,d- Height Number of Stories 8. Dimensions of enth'e new construction; Front Rear Depth Height /7~"~-~ Number of Stories 11, Zone or use distriql in which premises are situated 12. Does ,proposed ¢omction violate any zoning lav~, ordinance or regulation? YES 14. Names of Owner of promises ~'~c~.~ ~' Address Z~/eO~, Name ofArchitectdme~'~ ~.~'*~K ~ Address~Phone No Name of Contractor Address .... ~ ~' ,"~Phone No. 15 a, Is this property within 100 feet of a tidal wet and 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 wetiand? * YES 'NQ/,~. * IF YES, D,E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances tu property lines. / 17. If elevation at any point on property is at 10 f~et or below, must provide topographiCal data on survey.~/ STATE OF ~ YORK) SS: COUNTY OF ~a~O~,-~ ~r~x. ~ being duly swom, deposes and says that (s)be is thc applicant (Name of ththvklmd signing contract) above ~amed. (S)He is the (ConU'actor, Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the sa/d work and to make and file this application; flint all sta~nems contained in this application are true to the best of his knowledge and belieq and that the work will be performed in the manner set forth in the application filed therewith. Signature of .~pplicant ' TARA T. ROCHE NOTARY PUBLIC, STATE OF NEW YORK No 01R06112443 QUALIFIED IN SUFFOLK COUNTY MY COMMISSION EXPIRES ,JULY 6, 2008 CHRISTOPHER R. STRESS, R.A. ARCHITECTURE AND PLANNING P.O. BOX 821 JAMESPORT, NY 11947 PHONE/FAX (631)722-7865 runbout@optonline.net REScheck Software Version 4.0.1 Compliance Certificate Project Title: Hickox Residence Report Date: 06/19/07 Data filename: C:\PROGRA~I\Check~REScheck\HtCKOX~I.RCK ~10 · DEP~. ~p~¥N QF Sr~?HO' L Energy Code: New York State Energy Conservation Construction Code Location: Suffolk County, New York Construction Type: Detached 1 or 2 Family Heating Type; Non-Electric Glazing Ares Percentage: 13% Heating Degree Days: 5750 Construction Site: Owner/Agent: Andrew and Debra HIckox Laurer, NY Designer/Contractor: Christopher Stress PO Box 821 Jameaport, NY 631-722-7865 runbout~optonline.net Ceiling 1: Flat Ceiling or Scissor Truss: Wall 1: Wood Frame, 16" o.c.: Window 1: Metal Frame:Double Pane with Low-E: Door 1: Glass: Floor 1: Ail-Wood Joist/Truss:Over Unconditioned Space: Fumace 1: Forced Hot Air: 78 AFUE Air Conditioner 1: Electric Central Air: 13 SEER 440 30.0 0.0 15 1143 19.0 010 60 88 0.320 28 60 0.320 19 440 30.0 0.0 15 The proposed building represented In this document is consistent wi. tJ=~J'~136~g plans, spec~J~i~, and other calculations submitted with this permit application. The proposed systems have been des~ned to meet't/j~H~ York~State E~j~rgy Conservation Construction Code requirements. When a Registered Design Professional has,stamped and~'lJned//this ~JJ~r'e~e attesting that to the best of Name - Title Signature Date / / Hickox Residence Page I of 4 REScheck Software Version 4.0.1 Inspection Checklist Date: OGIlg/07 Ceilings: [] Ceiling 1: Flat Ceiling or Scissor Truss, R-30.0 cavity insulation Above-Grade Walls: Wall 1: Wood Frame, 16" o.c., R-19.0 cavity insulation Comments: Windows: [] Window 1: Metal Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: #Panes Frame Type Thermal Break? Comments: Yes __ No Doors: Door 1: Glass, U-factor: 0.320 Comments: Floors: Floor 1: Ali-Wood Joist~Truss:Over Unconditioned Space, R-30.0 cavity insulation Comments: Heating and Cooling Equipment: [] Furnace t: Forced Hot Air: 78 AFUE or higher Make and Model Number: [] Air Conditioner 1: Electric Central Air: 13 SEER or higher Make and Model Number: Air Leakage: [] Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage are seared. Recessed lights are 1 ) Type lC rated, or 2) installed inside an appropriate air-tight assembly with a 0.5' clearance from combustible materials. If non-lC rated, fixtures are installed with a 3" crearance from insulation. Vapor R~arder: [] Installed on the warm-in-winter side of al~ non-vented framed ceilings, walls, and floors. Materials Identification: [] Materials and equipment are instslled in accordance with the manufacturer"s installation instructions. [] Matsrials and equipment are identified so that compliance can be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. [] Insulation R-values and glazing U-factors ara cleady marked on the building plans or specifications. [] insulation is installed according to manufacturar's instructions, in substantial contact with the surface being insulated, and in a manner that achieves the rated R-value without compressing the insulation. Duct Insulation: [] Supply ducts in unconditioned attics or outside the building are insulated to R-8, Hickox Residence Page 2 of 4 [] Return ducts in unconditioned attics or outside the building are insulated to R-4. Supply ducts in unconditioned spaces are insulated to R-8, Return ducts in unconditioned spaces (except basements) are insulated to R-2. thsu~ation is not required on return ducts in Duct Construction: AI~ joints, seams, and connections ara securely fastened with welds, gaskets, mastic~ (adhesives), mastic-plus-empadded-te bric, or tapes. Tapes and mastics are rated UL 181A or UL 181B. Exespt~3ns: Continuously welded and locking-type lengitudina~ joints and seams on duc~s operating at less than 2 in. w.g. (500 Pa). I~ The HVAC system provides a means for balancing air and water systems. Temperature Controls: [] Each dwelling unit has at least one thermostat capable of autornatical~y adjusting the space temperature set point of the largest Elec{Hc Systems: [] Separate electric meters exist for each dwelling unit. Fireplaces: [] Fireplaces ara installed with tight fitting no~-combustible fireplace doors. [] Firepfaces have a somce of oombust]on air, as required by the Fireplace constnictJon provisions of the Bu/iding Code of New York State, the Residential Code of New York State or the New York City Building Code, as applicable. Sewlce Water Heating: [] Water heaters with vertical pipe rtsecs have a heat trap o~3 both the inlet aod outlet unless the water hester has an inta(jml heat trap or is part of a circulating system. [] Circulating hot water pipes are insulated to the levels in Table 1. Circulating Hot Water Systems: [] Circulating hot water pipes are insulated to the levels in Table 1. Swimming Pools: AJI heated smmming pools have an on/off heater switch aad a cover unless over 20% of the haati~g energy is f~om no,n-depleteble soumes. Peel pumps have a time clock. Heating and Cooling Piping Insulation: [] HVAC piping conveying fluids above 105 degrees F or chiiled fluids below 55 degrees F are insulated to the levels in Table 2. Hickox Residence Page 3 of 4 Table 1: Minimum Insulation Thickness for Circulating Hot Water Pipes Insulation Thickness in Inches by Pipe Sizes Non-Circulating Runouts Circulating Mainl and Runouts Heated Water Up to 1' Up to 1.25' 1.5' fl32.0' Over 2" Temperature (°F) 170-180 0.5 1.0 1.5 2.0 140-169 0.5 0.5 1.0 1.5 100-139 0.5 0.5 0.5 1.0 Table 2: Minimum Insulation Thickness for HVAC Pipes Insulation Thickness in Inches by Pipe Sizes Fluid Temp. Piping System Types Range(OF) 2" Runouts 1" and Less 1.25" to 2.0" 2.5" to 4' L~w Pressure/Temperature 201-250 1.0 1.5 1.5 2.0 Low Temperature 120-200 0.5 1.0 1.0 1.5 Steam Condensate (for feed water) Any 1,0 1.0 1,5 2.0 Cooling Systems Chilled Water, Refrigerant and 40-55 0.5 0.5 0.75 1.0 Brine Below 40 1.0 1.0 1.5 1.5 NOTES TO FIELD: (Building Department Use Only) HJckox Residence Page 4 of 4 ioo~.l~_.e...~.~.a:TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER STREET ('~i~/'i VILLAGE DIST. SUB. LOT E ACR. (~ FORMER OWNER N ~'~ ( ~ ~'~-J~-(c~:~ ~', ~ I ~~. S W '/ ~PE OF BUILDING RES.,; ~ S~S. VLsi" FARM COMM. CB. MICS. Mkt. Value ~ND IMP. TOTAL DATE R~RKS Tillable I, ~ [ ~ '~O~3 ~ FRONTAGE ON WATER W~land FRONTAGE ON ROAD Mead~ ~ ~ ~ ~ ~ ~ DEPTH H~ P~ ~ ~ ~ .~ BULKH~D Total ~ ~ ~ ~ ~ ixtension Extension Extension Deck Garage Foundation ~,C, Bath Basement -~o~ Floors ~,~ Ext. Walls Interior Finish Fire Place ' Pool Patio Heat Attic Rooms 1st Floor O riveway Rooms 2nd FIoor Suffolk County Department of Health Services Health Reference Number Office of Wastewater Management 360 Yaphank Avenue, Suite 2C - Yaphank, NY 11980 (631) 852-5700 - Certification of Existing Subsurface Sewage Disposal And Water Supply Facilities For A Single Family Residence A. Property Information l) Address of Residence: Street /~'~' ~ ~)X ~ Hamlet ~L~,IP~'~ 2) T~ Map Num~n Dbtdct~ Se~ion BIo~ 3) O~efs Name~~ 4) Client's Na~ (if different than ~er) ~ · Lot(s) Phone 5) Proposed changes in use (e.g., addition of apartment, J;~dmoms, office, etc.). B. Sanitary System Evaluation: ** Sanitary System(s) must be pumped out and physically examined by the certifying design professional. 1) Type of VVater Supply: [] Public Water ~ Pdvate Well- Provide copy of water analysis dated within one calendar year 2) Date of sanitary system pumping "'-'-- total gallons removed 3) Materials of construction of sanitary system '~Precast [] Block* *NOTE: Block pools are no longer accepted - sanitary s~'stem must be replaced 4) Size of Sanitary components*: Septic tank ~'E~) gallons ~____,~'az~ate~, or dimensions if rectangular effective depth Leaching Pools ~ I diameter ./~.. I' effective depth _{__~.~ total number of pools *NOTE: Sanitary components must meet current standards for proposed use or upgrading will be required. 5) Overall condition of sanitary components: ~acceptable [] unacceptable (waste lines, drop tees, baffle walls, covers, septic tank, leacl~ing pools) Certification: The results and recommendations found in this report a/m--ba,~upon my evaluation and inspection of the above//~efere~tc~d)l~-ope~a, nd pumped out sanitary system: Name{of Arch~t~l~l~r License Number ~f~'~'~! Signat~ Date(~--'~'r'(~'/'Phone ~{ ,?¢~.~--.r~ ~)5 Mailing Address: pD _~ ~i~g,/ l / H;ml;t ~"'""~YI~T¥ ' ', State ~ Zip WWM-072 (Rev. 08/06) Page 1 of 2 C. Recommendations And Results (Check applicable items): :!stem em(s) functioned properly at time of inspection and is adequate for the proposed b. __ System(s) is not adequate for the proposed use (explain and make recommendations in Section D below or attach a separate report). c. Other 2. Water Supply a. ~ Water supply is adequate for proposed use (E' __ Water supply is not adequate for proposed use (explain and make recommendations in Section D below or attach a separate report). c, Other D. Other Comments/Recommendations: AFFIX DESIGN PROFESSIONAL'S SEAL HERE Disclaimer: This inspection report indicates the present condition of the private on-site subsurface sewage disposal system and water supply based on recommended inspection procedures. The results of this inspection do not guarantee or warranty future ~rformance. The recipient of this report should discuss any deficiencies found by this inspection with the individual who prepared the report. , WWM~072 (Rev. 08/06) Page 2 of 2 mo~ucl~ B3t-722,.41~0 GEORGE FORMES 111E MAIN ROAD SUITE A2 P.O. BOX 2336 AQUEBOGUE, NY 1t9~1 I.EADEN 0ON~rRUCTION LLC 9;~i FAIRWAY DRIVE PO BOX 1038 CUTCHOGUE, NY 11935 CERTIFICATE OF LIABILITY INSURANCE I · ..,,,, ~,,~,~.^TH. ,.u.D ^. ^ ,,A'm. o, ONLY AND GONFIB~ NO RIGHTH UPON THE HOLDER, THIS CERTIFIGATH OO~$ NOT AL11R THE COVERAGE AFFORDED BY 'I1RE POLIGI~a BELOW. / IHSUREI~ AI~ORI~IG COVERAGE . .*~L~--.~-~- .... ,,~.i~m.~ FARM FAMILY CA~UAL'I'~ INS. CO. 3152)(3935 09/27/07 1t52W8230 CARPENTRY- RESIDENTIAL PROPER'fY ~ERTIFI,GATE HOLDER TOWN OF SOUTHOLD TOWN HALL 53095 ROUTE 25 PO BOX 1179 ~OUTHOLD, NY 1 Ig71 CA. N~L:~L&TiON : STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la. Legal Name & Address of Insured (Use street address only) Work ~tion of i~d to ce~a~ locations ~ N~ Yor& ~ate, ~, a Wr~Up Poilu) 2. Name and Address of the Entity Requesting Proof of Coverage (Entity Being Listed as the Certificate Holder) I b. Business Telephone Number of Insured lc. NYS Unemployment Insurance Employer Registration Number of Insured ld. Federal Employer Identification Number of Insured or Social Security Number 3a. Name of Insurance Carrier 3b. Policy Number of entity listed in box "la" 3c. Policy effective period 3d. The Proprietor, Partners or Executive Officers are included. (Only ch~k box if all partnerdofficera iaclltded) all excluded or certain partners/officers excluded. This certifies that the insurance carder indicated above in box "3" insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' enmpeusatinn insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box "2". The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the Insurance carrier or its licensed agent, or until the policy e.q~ieatinn date listed in box "3c", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: ~ (Print name .of ~uthorized representative or licensed agent of insurance carfior) Title: /~9~5~''-'- Telephone Number of authorized representative or licensed agent of insurance carrier: Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. c-105.2 9-07) www.wcb.state.ny.us Erosion, Sedimentation and Storm-water Run-off Control Plan ASSESSMENT FORM EXEMPTIONS: Yes No A, Does this project meet the minimum standards for classification as an Agricultural Project. -4~ ~ Note: If you answered Yes to any of the above, a Storm-water, Grading, Drainage & Erosion Control Plan is not required. .ACTIONS REQUIRING THE SUBMISSION OF A STORM-WATER~ GRADING~ DRAINAGE & EROSION CONTROL PLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. .Item Number 1. (A Check Mark (,/) for each question is required for complete application) Yes No Will this project retain all Storm-Water Run-off generated on Site? (This will include all mn-off created by site clearing and/or co.traction activities as well as all Site Improvements and the permanent creation of impervious surfaces.) P'/r~ 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 ~ncompassing an area of five thousand (5,000) square feet of ground surface or more? r~ 4. is there a Natural Water course running through the site or is this project within One hundred (100) feet 'of wetlands or a beach? 5. Will there be site preparation on slopes which exceed fifteen (15) feet of vertical rise to One hundred (100) feet of horizontal distance? 6. Will driveways, parking areas or other impervious surfaces direct Storm-Water Run-off into and/or in the direction of a 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? {lhis 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? r-~ v/' Note: if any answer to questions ~ne through eight is answered with a check mark in the I~ox, a Storm-water, Grading, Drainage & Erosion Control Plan is required and must be submitted for review prior to issuance of any building permit. STATE OF NEW YORK, COUNTY OF ....... .-~w' fFe~ ! ~ ............ ss That I .......~/~.0.~-Q.../~...../~l,: f: ~:~? 4~ ........................being duly sworn, (i~poses and says that he/she is the applicant for Permit, (Name of individual signing Document) And that He/She is the ~ ~ ~ontractor, Agent, Corporate Officer, etc.) ~:~wn~ and/or representative of the Oxw~er or Owner's, and is duly authorized to perform or have erformed the said work and to make · . p _ s apphcatmn; that all statements contained in tlfis application are true to the best of his knowledge and belier; and that the ~'6~l~i[Ilae performed in the manner set forih in the application filed herewith (Signature of Applicant) ~. A ~\~ 'o ANDREW C, HICKOX ~ DEBO~A~ M HI.OX eC~IES ~ ~s ~v~Y ~T ~e TNE L~HO D~R~ M. HICKOX FIDELI~ NATI~AL ~TLE HE~ ~MENT.~TA ~ ~ ~ C~STR~CT ~ ~ ~aw~ ~Y ~ ~ . ~F ~. ~ ~ ~ ~C~ ~ ~ ~ LOT ~. ~, ~O ~ ~ ~s OF ~ LE~I~ _ .,.._-.,...,-__ '- " ' UNG,.8 Y~ ~E= I ~ M~UMENT F~O ~ =~.~10 ACRES LOT) moa SUKIVISION ~ ~ RIC~RD & O~NALEE RELYEA" PLUMBING ALL PLUMBING WASTE & WATER LINES NEED TESTING BEFORE COVERING PL UMBER CER, TIFICA TION ON LEAD CONTENT BEFORE CERTIFICATE OF OCCUPANCY SOLDER USED.IN WATER SUPPLY SYSTEM EXOC~ED 2/?n,''~F ~°/- LE4D. CERn'FtC,CT'ON OF NA~L'r t"3NNECTIONS nL~IRED. ALL COU¢'''' ,C '1¢ 'ME~' THE HEQUiaECv~&N ~S OF THE CODES OF NEW YORK STATE. UNDERWRffERS CERTIFICATE REQUIRED OCCl ~,NCY OR USE i~PNLAWFUL WlTH~)I[IT CERTIFICATE OF( AP D AS NOTED FEE. FOR POU Er TF 2. ROUGH - F ' -, PLUMBING ~-FINAL - C-~'~,' -"H MUST BE COMPLE u' O, ALL CONSTRUCT,r % SHALL MEET THE REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. RETAIN STORM WATER RUNOFF PURSUANT TO CHAPTER 236 OF THE TOWN CODE. ! ,I C~NI~ ?.lmphflecJ Wa / ~oof' J ZONBI ZONB2 ZONBD I I PI~I.P 4" O,C, I ~" O,C, 12" O,d, ~P¢i~ D" 0,¢, 4" O,C, 6" O,C, dI.AZIN~ PP. OI~CqON WlNI:2 BOI~N~ P~P~I5 FA51~!~R5 A5 NO1~P IN I~YWOOP 5'FOP. M ~HUI'I~R !2~rAL ~' 16" 0£, Prcvi~ ~/&" O~X Wa/I 5F~h~t R~ I~ ~ N ~, ~ 2"C)" ,N,. f'rm ~,~f~dl, Na~ pl~d L~ A 21 16-10J ,U