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HomeMy WebLinkAbout35980-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-34664 Date: 11/08/10 THIS C~KTIFIES that the building GREENHOUSE Location of Property: 2050 MAIN RD L~UREL (HOUSE NO.) (STREET) (HAMLET) Co%u~ty Tax Map No. 473889 Section 125 Block 3 Lot 2.3 Subdivision Filed Map No. Lot NO. conforms substantially to the Application for Building Permit heretofore filed in this office dated OCTOBER 28, 2010 purs,,~mt to which Building Permit No. 35980-Z dated OCTOBER 28, 2010 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 AGRICULTURAL GREENHOUSE AS APPLIED FOR. The certificate is issued to GIAN M MANGIERI (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH A~PRO~-AL ~.Rt-£KICAL C~TIFICATE NO. PLiErS CERTIFICATION DA'r~ N/A N/A N/A ~./t h~z ed Signature Rev. 1/81 FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-34665 Date: 11/08/10 THIS u~KTIFIES that the building GREENHOUSE Location of Property: 2050 MAIN RD LAUREL (HOUSE NO.) (STREET) (HAMLET) County Tax Map NO. 473889 Section 125 Block 3 Lot 2.3 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated OCTOBER 28, 2010 pursuant to which Building Permit NO. 35980-Z dated OCTOBER 28, 2010 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 AGRICULTURAL GREENHOUSE AS APPLIED FOR. The certificate is issued to GIAN M MANGIERI (OWNER) of the aforesaid building. ~u~.b'O~ CO~ DEPARTMENT OF HEALTH A~PRO%rAL RT.R~Jr~ICAL CERTIFICATE NO. PLI]~ERS U~KTIFICATION DA-i-~ Rev. 1/81 N/A N?A N/A 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) PERi, IT NO. 35980 Z Date OCTOBER 28, 2010 Permission is hereby granted to: GIAN MARIO MAIgGIERI PO BOX 368 LAUREL,NY 11948 for : INSTALLATION OF TWO GREENHOUSES AS APPLIED FOR PER PLANNING BOARD CONDITIONS. AMENDED FROM FOUR GREENHOUSES.REPLACES EXPIRED BP # 33842 at premises located at County Tax Map No. 473889 Section 125 pursuant to application dated OCTOBER Building Inspector to expire on APRIL 2050 MAIN RD LAUREL Block 0003 Lot No. 002.003 28, 2010 and approved by the 28, 2012. Fee $ 300.00 ORIGINAL Rev. 5/8/02 FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL COMPLETION OF THE WORK AUTHORIZED) FULL PERMIT NO. 33842 Z Date APRIL 23, 2008 Permission is hereby granted to: GIAN MARIO MANGIERI PO BOX 368 LAUREL,NY 11948 for : INSTALLATION OF FOUR AGRICULTURAL GREENHOUSES AS APPLIED FOR PER PLANNING BOARD CONDITIONS at premises located at 2050 MAIN RD County Tax Map No. 473889 Section 125 pursuant to application dated APRIL Building Inspector to expire on OCTOBER LAUREL Block 0003 Lot No. 002.003 14, 2008 and approved by the 23, 2009. Fee $ 600.00 / -~v Authorized ~ignature ORIGINAL Rev. 5/8/02 Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOW~ HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUF This application must be filled in by typewriter or ink and submitted to the Building D A. For new building or new use: 1. Final survey of property with accurate location of all buildings, property lines 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 amhitect 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 featums. 2. A properly completed application and cot/sent 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 $50.00, Additions to dwelling $50.00, Alterations to dwelling $50.00, Swimming pool $50.00, Accessory building $50.00, Additions to accessory building $50.00, 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 Date. ~ Old or Pre-existing Building: House No~ Street New Construction: (check one) Location of Property: Owner or Owners of Property: ~ ( ~..x,,~ Suffolk County Tax Map No 1000, Section Subdivision Permit No. '~/~] Health Dept. Approval: Date of Permit. Filed Map. Applicant: Underwriters Approval: Hamlet Lot: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ ~pp' ant Signature t/ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] I~SUI~ATION [ ] FRAMING / STRAPPING [//] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ]I:IHEREmTAH'rc0flSTRUCTKX4 [ ]F~REI~ESlSTANTPE.ETRA'n0N REMARKS:/~//~ ~.~~._ C~/2 DATE COM2ViENTS FEELI) J~NSPECTION RE]PORT [ DATE FOLrNI)ATION (1ST) ' ROUGH FRAMING & PLUTVlZBIN G O LNS1FYI~ATION PER N. Y, STATE ENERGY CODE ~DITION TOWN OF SOUTHOLD BUILDING.DEPARTMENT TOWN H.~LL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www. northfork.net/Southold/ Examined Approved Disapproved a/c Expiration PERMIT NO. ~'~ ~ ~ ~ BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health 4 sets of Building Plans Planning Board approval Survey. Check Septic Form N.Y.S.D.E.C. Trustees Contact: APPLICATION FOR BUILDING PERMIT Date INSTRUCTIONS Mail to: Phone: a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f. Every building permit shall expire if the work 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 writing, the extension of the permit for an addition six months. Thereafter, a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit 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, plmnber or builder If applicant is a corporation, signature of duly authorized officer Name of owner of premises (As on the tax ro'l-[ or latest deB. ( t ~) , ?Z ~/ 765-18~2 ' ~ ~ (Name and t~tle of corporate officetg) ~, L~ U ~/'~ I~ (,.,; Y /~ Builders License No. ~t//~?E IS UNLAW PlumbersLicenseNo. j~.;' %,ITHOUI CERq ',riC,,:-- Electhci~s License No. /%.¢¢, Other Trade's License No. FOLLOWING I,~,'S;,E:: ,:¢3: 1. FOr,.,';,JDATiON . T .L.) ;;:QU!q~3 FOR POURED C'/ :CR£T2 2. ROUGH - FRA~,I;;,4G & PLU:dZI~4G 3. INSULATION 4. FINAL . CONS1RUCTDN MUST BE COMPLETE FO.'l C.O. Location of land on which proposed work wig be done: HouSe N~mber Street - County Tax Map No. 1000 Section Subdivision .r.3 FO ~ (Name) A'L CONSTRUCTION ATE. PURSUA TO CHAP 'd~ ~ --- 2. State existing use and occupancy of premises and intended use and occup.ancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy 3. Nature of work (check which applicable): New Building ~ Addition Alteration Repair Removal Demolition Other Work 4. Estimated Cost q ~00, OG2 5. If dwelling, number of dwelling units If garage, number of cars (:~ Fee (Description) (To be paid on filing this application) Number of dwelling units on each floor O 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Height Number of Stories Rear Depth Dimensions of same structure with alterations or additions: Front Depth. Height Number of Stories 8. Dimensions of entire new construction: Front / q / Rear / I~ */ Height ~ / Number of Stories ~ 9. Size oflot: Front ~ ~o~f~ Rear 10. Date of Purchase ! q ?.~" Name of Former Owner Rear Depth Depth 11. Zone or use district in which premises are situated ,/~ r.,~/ ~r~ 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO ,~ 13. Will lot be re-graded? YES y NO Will excess fill be removed from premises? YES .7~ NO - , . 14. Names of Owner ofpremises(~-,~,"Zo4 j~'b,,,~,~e¢'. Address ~). ~'/ neMo. aqcr-yc()3 Name of Architect C~-,.,~..t ' ~d Address ..... Phone No Name of Contractor ~'_C'~..~,,,~.~_ Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO e'~ * 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 o.r below, m.u§t prqvide [opographidal data on survey. 18. Are there any covenants and restrictions with respect to this property? * YES__ NO t'~ · IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY oF~~~'~ being duly sworn, deposes and says that (s)he is the applicant (Name of individual sigrfing contract) above named, (S)He is the (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 tree 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. Swom to before me this l/ ~~...~ ,dayo . ~~ ~ Signatu~ of Applicant FOR INTERNAL USE ONLY SITE PLAN USE DETERMINATION Initial Determination Date: ~ /'zJ/' / ¼ Project Name: Project Address:oqO%-'o Date Sent: ~, /~b~_/~ Suffolk County Tax Map No.:1000- ('~,'~ - Request: 'h/OOP (Note: Copy of Building Permit Application and supporting documentation as to proposed use or uses should be submitted.) Initial Determination as to whether use is permitted: Initial Determination as to whether site plan is required: Planning Department (P.D.) Referral: P.D. Date Received: / / Date of Comment: Comments: Final Determination Date: / / Decision: Signature of Planning Dept. Staff Reviewer Signature of Building Inspector FOR INTERNAL USE ONLy SITE PLAN USE DETERMINATION Date Sent: ~, /_L~_/~ Initial Determination Date: g /d- Project Name: ~-~,_'7~. Project Add ress:,--~0%-'~ Suffolk County Tax Map No.:1000, [~,~- - ? -.2.-~ Zoning District: Request:-Ff/OO~ ,~/0 HS~._ (Note: Copy of Building Permit Application and supporting documentation as to proposed use or uses should be submitted.) Initial Determination as to whether use is permitted: Initial Determination as to whether site plan is required: Planning Department (P.D.) Referral: P.D. Date Reoeived: L~ / iq / 07 Date of Comment: ¸Si ~vlewer Final Determination Date: / / Decision: Siqnature of Building Inspector FORM NO. 3 NOTICE OF DISAPPROVAL DATE: June 21, 2007 AMENDED: December 3, 2007 TO: Gian N. Mangieri PO Box 368 Laurel, NY 11948 Please take notice that your application dated June 4, 2007 For permit for an four hoop houses at Location of property: 2050 Main Road, Laurel County Tax Map No. 1000 - Section 125 Block 3 Lot 2.3 Is returned herewith and disapproved on the following grounds: The proposed construction, on this conforming lot in the AC Zone, requires site plan approval from the a~.~i~d, pursuant to Article III, Section 280-127. '" om nP, Note to Applicant: Any change or deviation to the above referenced application, may require further review by the $outhold Town Building Department. CC: file, Planning Board PLANNING BOARD MEMBERS JERILYN B. WOODHOUSE Chair KENNETH L. EDWARDS MARTIN H. SIDOR GEORGE D. SOLOMON JOSEPH L. TOWIgS~ND A~iil 15, 2008 PLANNING BOARD OFFICE TOWN OF SOUTHOLD MAILING ADDRESS: P.O. Box 1179 Southold, NrY 11971 OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY Telephone: 631 765-1938 Fax: 631 765-3136 Mr. Gian Mangieri c/o Laurel Creek Nursery P.O. Box 368 Laurel, NY 11948 Re: Proposed Site Plan for Laurel Creek Nursery Located at 1900 & 2050 NYS Rt. 25, Laurel SCTM#1000-125-3-2.3 Zoning District: Agricultural-Conservation (AC) Dear Mr. Mangieri: The Southold Town Planning Board, at a meeting held on Monday, April 14, 2008, adopted the following resolutions: WHEREAS, the applicant, Gian Mangieri, submitted a formal site plan for approval on December 4, 2007 for the construction off.~ hoop house type greenhouses, two of which are.J,,4' wide by 10ff long, and two of which are 25' wide by 100' long. The site contains an existing w'h"b'l~le agricultural container ~"~'~ration wit'F~-'~e 14' x 120' hoop houses totaling 5,040 sq. ft. and several other buildings already existing. The existing buildings cover 10,800 sq. ft., and the new greenhouses add ~,800_~sq. ft. for a total of 18,600 sq. ft. of lot coverage on 12 acres; and WHEREAS, Gian Mangieri is also the owner of the property, located on the south side of SR 25, approximately 50 ft. west of Franklinville Rd in Laurel; and WHEREAS, on February 4, 2008, the Planning Board accepted the application after receiving all requested information; and WHEREAS, in February, 2008, the Planning Board, pursuant to Southold Town Code §280-131 C., distributed the application to agencies having jurisdiction for their comments, and the following agencies responded: NYS Department of Transportation, Town Engineer, Architectural Review Committee, SC Planning Commission, and the Mattituck Fire District; and WHEREAS, the comments from those agencies referenced above were received and accepted by the Planning Board, discussed with the applicant, and incorporated into the site plan to the satisfaction of the Planning Board; and Laurel Creek Nursery PaRe Two April 15, 2008 WHEREAS, on April 4, 2008, the Southold Town Building Inspector reviewed the plan and certified that "the proposed use greenhouse is permitted in this A-C District"; and WHEREAS, the Southold Town Planning Board, pursuant to §280-133 C. of Southold Town Code, has the discretion to waive any or all of the requirements in §280-133 for those applications involving uses strictly related to agriculture; and WHEREAS, the Southold Town Planning Board, pursuant to Southold Town Code §280-131 B.(5), has the discretion to vary or waive parking requirements; and WHEREAS, the Southold Town Planning Board, pursuant to §280-131 H. of Southold Town Code, has the discretion to waive the public hearing requirement for those applications involving uses strictly related to agriculture; therefore, be it RESOLVED, that on April 14, 2008, the Southold Town Planning Board, pursuant to State Environmental Quality Review (SEQR) (6 NYCRR, Part 617.5 (c) (3), has determined that the proposed action is a Type II Action, and not subject to review under SEQR; and be it further RESOLVED, that pursuant to Southold Town Code §280-133 C, the Planning Board has found that requiring the entire set of site plan application requirements for this site is not necessary to further the objectives set forth in Town Code §280-129, and maintain public health, safety, and welfare for the following reasons: the application is for an agricultural use, and the parcel is large in size relative to the proposed and existing structures. The Planning Board hereby waives the site plan application requirements, except for the following items: §280-133 A. (1), (2), (4), and (5), B. (1)(a)-(f), B. (2)(a), (b), B. (3)(a)(partial), (b), (c) (partial), (4) (a),(c),(e),(f), and (g). Pursuant to Southold Town Code §280-131 B.(5), the Planning Board has found that waiving the parking requirements on this application by allowing the existing parking area to serve the additional greenhouses will not have a detrimental effect on the public health, safety, or general welfare, and will not have the effect of nullifying the intent and provision of the site plan requirements chapter in the Town Code. The Board has found that this application is eligible for the waiver due to the large size of the property relative to the size of the proposed and existing structures, the proposed structures being an addition to an existing business where a parking area exists, and the site being not open to the public. The Planning Board hereby waives the parking requirements for this application. Pursuant to Southold Town Code §280-131 H., the Planning Board has found that the public hearing for this application may be waived for the following reasons: the application is for an agricultural use, the parcel is large in size relative to the proposed structures, the new structures will add 1.5 percent of lot coverage for a total of 4.6 percent; will be unheated (little noise), and will be situated in such a way as to be unobtrusive to the public view and neighboring residence - located 42 feet from the property line, nine feet lower in elevation, and screened by evergreen trees. The Laurel Creek Nursery Page Three April 15, 2008 Planning Board hereby waives the public hearing requirement for this application; and be it further RESOLVED, that the Southold Town Planning Board has reviewed the proposed action under the policies of the Town of Southold Local Waterfront Revitalization Program and determined that the action is consistent as outlined in the April 10, 2008 memo prepared by the LWRP Coordinator; and be it further RESOLVED, that the Southold Town Planning Board grant approval with conditions, listed below, and authorizes the Chairperson to endorse the site plan entitled "Survey of Property", prepared by David L. Saskas, last revised April 7, 2008. Conditions: Run-off and drainage from the new greenhouses shall be managed as described below: a. Construct a swale, located as shown on the site plan, to be an average of 2 feet deep, in the shape of an oval approximately 75 feet long and 35 feet wide. b. Install a grass filter strip, at least 15 feet wide, at the southerly end of the greenhouses, and running along the entire length of the greenhouse operation. 2. All storm water run-off from grading, driveways and gravel areas must be contained on site. 3. The top of the slope must be no closer than 20 feet to the property line, and the slope must be no steeper than a 1:3 ratio, as depicted on the site plan. The applicant must meet the requirements as directed in the Highway Work Permit application process, if required by the New York State Department of Transportation (NYSDOT) for this site plan. If a Highway Work Permit is required by the NYSDOT, the applicant must submit a copy of the approved plan and permit from the NYSDOT to the Planning Board for review. If the approved plan submitted to NYSDOT varies from the site plan approved by the Planning Board, the Planning Board reserves the right to review the changes as an amended site plan application. Please also note the following required by Town Code: Any outdoor lighting shall be shielded so the light source is not visible from adjacent properties and roadways. Lighting fixtures shall focus and direct the light in such a manner as to contain the light and glare within property boundaries. Laurel Creek Nursery Pa.qe Four April 15, 2008 2. Approved site plans are valid for three years from the date of approval, within which time all proposed work must be completed, unless an extension is granted by the Planning Board. 3. Any changes from the approved site plan shall require Planning Board approval. 4. Prior to the issuance of a Certificate of Occupancy, the Planning Board must inspect the site to ensure it is in conformity with the approved site plan and issue a final site inspection approval letter. Should the site be found not in conformance with the approved site plan, no Certificate of Occupancy may be issued unless the Planning Board approves the changes to the plan. Copies of the approved site plan are enclosed for your records. One copy will also be sent to the Building Department and the Town Engineer/Highway Department. If you have any questions regarding the above, please contact this office. Very truly yours, ~Jerilyn B. Woodhouse Chairperson encl. cc: Southold Town Building Department w/map Southold Town Engineer w/map By signing this letter, the applicant acknowledges that there are mandatory conditions, listed above, that must be satisfied prior to the issuance of a Certificate of Occupancy. Gia~nt PLANNING BOARD MEMBERS MARTIN H. SIDOR Chair WILLIAM J. CREMERS KENNETH L. EDWARDS JOSEPH L. TOWNSEND DONALD J. WILCENSKI July 12, 2010 PLANNING BOARD OFFICE TOWN OF SOUTHOLD MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971 OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY Telephone: 631 765-1938 Fax: 631 765-3136 Mr. Gian Mangieri P.O. Box 368 Laurel, NY 11948 Re: Site Plan Application - Laurel Creek Nursery Greenhouses SCTM# 125-3-2.3 Dear Mr. Mangieri: The Planning Board is in receipt of your request for final inspection received June 21, 2010 for the above referenced application. As per your request, the Town Engineer and staff conducted a site visit on June 24, 2010 and discussed with the Planning Board at their July 12, 2010 work session. It was determined that the work done to date was completed as per the approved site plan and mitigation outlined in correspondences dated April 30, 2009 and June 21, 2010 (attached). It should be noted that it is the property owner's responsibility for the continuous maintenance of the slope area for the management and protection of the slope. If you have any questions regarding this inspection, please contact Jamie Richter or myself. Sincerely, Kristy Win~r Cc: Planning Board Jamie Richter, Town Engineer Michael Verity, Chief Building Inspector Erosion, Sedimentation and Storm-water Run-off Control Plan ASSESSMENT FORM Yes .EXEMPTIONS: / A. Does this project meet the minimum standards for classification as an Agricultural Project. 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 STORMrWATER, GRADING, DRAINAGE & EROSION CONTROL PLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. Item Number: (A Check Mark (,/) for each question is required for complete application) Will this project retain all Storm-Water Run-off generated on Site? (This will include all mn-off created by site clearing and/or construction activities as well as all Site Improvements and the permanent creation of impervious surfaces.) 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? Will this application require land disturbing activities encompassing an area of five thousand (5,000) square feet of ground surface or more? Is there a Natural Water course running through the site or is this project within One hundred (100) feet'of wetlands or a beach? Will there be site preparation on slopes which exceed fifteen (15) feet of vertical rise to One hundred (100) feet of horizontal distance? 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? Will this application require the placement of material, removal of vegetation and/or the .construction of any item within the Town Right-of-Way or road shoulder area? (This item does not include the installation of driveway aprons.) Yes No 8. Will there be site preparation within the one hundred (100) year floodplain of any watercourse? Note: If any answer to questions~ne through eight is answered with a check mark in the Box, a Storm-water, Grading, Drainage & Erosion Control Plan is required and must be submiffed for review prior to issuance of any building permit. STATE OF NEW YORK, ./} j j . / COUN~/T OF .~~.,~... ss That I .............................................................................. being duly sworn, ~eposes and says that he/she is the applicant for Permit, (Name of individual signing Document) /had that He/She is the (Owner, Contlactor, Agent, Corporate Officer, etc.) Owner and/or representative of the Owner or Owner's, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belier; and that the work sill be performed in the manner set fomh in the application filed herewith. Sworn to before me this; ~ I~la~ll~l ~ I~t~ (Signature of~pplicant) ._ .... TOWN OF SOUTHOLD PROPERTY RECORD CARD. OWNER STREET ) ,"'~ ,: '~ , VILLAGE DIST SUB. ,, ~es. ~/o s~s. VL. FARM COMM. CB. MISC. Mkt. Value ~ND IMP. TOTAL DATE REMARKS ~. NORMAL BE~, t ABOVE 1~/~0]~ FARM~ ~ ~cr~ , Valu~ ~er ~lu~ wampland ~,~ ~ j~ FRONTAGE ON WATER ,ushlond ~ ~C ~ ~ ~ OO ~ ~OO FRONTAGE ON ROAD louse Plot :/~, ~/~/ ~'4 ~t ~ ~ ~ BULKH~D 'ot~ , /~ DOCK OLOR RIM 125.-3-2.3 3/06 Bldg. xtension xtension xtension 'arch 'arch ~rage Ioob 'otio ). B. '~ ~ ' ; rotal Foundation Basement Ext. Walls Fire Place Type Roof Recreation Roorr Dormer Driveway Bath :loors nterior Finish 4eot Rooms 1st Floor Rooms 2nd Floor i nette LR. FHxl. B. 125-3'~'2.3 12/00 COLOR ,,, ~, 1~ l~k-.~, I I dl I D_I,,~I~,~ I!1 //I I il ~ ! . !/~, il / M. Bldg. Extension Extension ~ Foundation Floors ~/~: Interior Finish COLOR TRIM M. B!dg. Extensinn 125-3-2.3 12/00 Foundafi~n I r~ _ COLOR TRIM Foundation Bath Z4 of p (,;>0 Certified only to Glan N Man~ler~ /i o% i i / / .( °/ '* ..?f,' "': , vd' o\ S FLOW k © 0 'x k k 'x x, x, x, ¥o~,6 Cor %~ e