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Home My WebLink About36037-ZTown of Southoid Annex 54375 Main Road Southold, New York 11971 11/30/2011 CERTIFICATE OF OCCUPANCY No: 35311 Date: 11/30/2011 THIS CERTIFIES that the building DECK 705 LONGV1EW LA SOUTHOLD, N.Y. 11971, Location of Property: SCTM #: 473889 Subdivision: Sec/Block/Lot: 88.-5-8 Filed Map No. conforms substantially to the Application for Building Permit heretofore Lot No. filed in this officed dated 11/12/2010 pursuant to which Building Permit No. 36037 dated 11/19/2010 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: 16'X 24' DECK ADDITION TO AN EXISTING DWELL1NG AS APPLIED FOR. The certificate is issued to Simon, Joan&Simon, Paul (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUII~ING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 36037 Z Date NOVEMBER 19, 2010 Permission is hereby granted to: P & J SIMON 705 LONGVIEW LANE SOUTHOLD,NY 11971 for : CONSTRUCTION OF A 16'X 24' DECK ADDITION TO AN EXISTING DWELLING AS APPLIED FOR at premises located at County Tax Map No. 473889 Section 088 pursuant to application dated NOVEMBER Building Inspector to expire on MAY 705 LONGVIEW LA SOUTHOLD Block 0005 Lot No. 008 12, 2010 and approved by the 19, 2012. Fee $ 353.60 Authorized Signature ORIGINAL Rev. 5/8/02 Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be filled in by typewriter or ink and submitted to the Building Department with the following: A. For new building or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. 'For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $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 New Construction: Location of Property: Date. II- Iq - I 0 d Old or Pre-existing Building: (check one) House No. Strict Hamlet Owner or Owne~ of Prope~y: ~Q~ ~~ Suffolk County T~ Map No i000, Section ~ Block Subdivision Date of permit. Health Dept. Approval: Filed Map. Lot: Applicant: ./~ A~)IJ~-- Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ Final Certificate: (check one) Appli~nt Signature TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]F~UNDATION 1ST [ ]~R~HPLBG. [ ]//KOUNDATION 2ND ~TION [ ~J FRAMING/STRAPPING [~NAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAd-,-, ~r INSPECTION [ ] FI"EREmTANTCONSl~UCTION [ /\ REMARKS: ~/£/'7/ ~ ] FIRE RESISTANT PENETRATION DATE ~ INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION FOUNDATION 1ST //~IL', [ [ j'FOUNDATION 2ND [ ] ROUGH PLBG. ] INSULATION ] FINAL ] FIRE SA~.', 1' INSPECTION ] FIRE RESISTANT PENETRATION [ ] FRAMING / STRAPPING [ [ ] FIREPLACE & CHIMNEY [ [ ]FIRERESISTANTC0flSTRUCTI0fl [ REMARKS: DATE TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULIN [ ] FRAMING / STRAPPING [~].,tqNAL [ ] FIREPLACE & CHIMNEY [ [ ] FIRE RESISTANT CONSTRUCTION [ [ ] ELECTRICAL (ROUGH) [ REMARKS: FIRE SAFETY INSPECTION FIRE RESISTANT PENETRATION ELECTRICAL (FINAL) DATE TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ~ SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net Examined Approved Disapproved a/c ,/'If! ~, 20 ,,, ? Expiration (/[~. 20 /ox PERMIT NO. ~(~ 0 NOV 1 2 2810 Building Inspector 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 x/~' Septic Form N.Y.S.D.E.C. Trustees Flood Permit Storm-Water Assessment Form Contact: Mail to: L/_ v/q?- APPLICATION FOR BUILDING PERMIT Date ,20 INSTRUCTIONS 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. <'~ (S~_,na xr'g tue o}f~me, ifa corporation) (Mailing address o~f applicant) I/qT/ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Nameofownerofpremises (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. Plumbers License No. Electricians License No. Other Trade's License No. Location of land on which proposed work will be done: Hous~ Number Street / J Hamlet County Tax Map No. 1000 Section ~> Block ~" Lot Subdivision Filed Map No. Lot State existing use and occupancy of premises and intended use and occupancy of proposed ~°,onstruction: a. Existing use and occupancy ~o6~.~ FP~, t~-~ t)~o~cctt,.~ ~ b. Intended use and occupancy. Nature of work (check which applicable): New Building Repair Removal Demolition Estimated Cost If dwelling, number of dwelling units If garage, number of cars Fee Addition Alteration Other Work ~d~tq~?> (Description) (To be paid on filing this application) Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. ?. Dimensions of existing structures, if any: Front ~'[, ~( Rear Height. ~- ?~ ~'/~' Number of Stories -Thro _Depth 9. 10. Date of Purchase Dimensions of same structure with alterations or additions: Front Depth. '~l. '~ Height_ Dimensions of entire new construction: Front 2-"'] ~- 6- r, Height $~d' Numberof Stories 5"/, ,./r Rear Number of Stories Rear 2-~-0 Size oflot: Front [150. C/O · Rear /Il, ~0 Depth %/gt-jto c/lbjl°NameofFormerOwner 145~e- I oo Depth / 6 t.. O" 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 g Will excess fill be removed from premises? YES__ NO ~ 5rv~,c. ~ '3o/10 7oS~'L.otoCV't£~O ~ 14. Names of Owner of premises ~1~ Address ~ Phone No~t ~O~-Z~ Name of Architect Address Phone No Name of Contractor Address Phone No. 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 fbundation 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 OF ,~q~. ) ~ 1~'"~. ~ [~ O~ being duly swom, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the ~/x/~ (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. Sworn to before me this / [0t'~' 4ayof ~//o//eg~ep- 20 Notary Publi~c ,fi' loft TILL^H JR. NO'FARY PUBLIC, STATE OF NEW YORK Registration No, 01TI6135995 Qualified in Suffo!k County ,...., Commission Expires October 31, 20L.5 ~ure of Applicant Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M. ih, THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM-WATER~ GRADING; DRAINAGE AND EROSION CONTROL pi&lq Cl=~,,rlED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. Item Number:. (NOTE: A Check Mark (~) for eaoh Question is Required for a Complele Application) Yes No 1 2 3 4 5 6 7 8 9 Will this Project Retain All Storm-Water Run-Off Generated by a Two (2") Inch Rainfall on Site? (This item will include all mn-off created by site cleadng and/or construction activities as well as all Site Improvements and the permanent creation of impervious surfaces.) Does the Site Plan and/or Survey Show All Proposed Drainage Structures Indicating Size & Location? This Item shall include all Proposed Grade Changes and Slopes Controlling Surface WatenClowl Will this Project Require any Land Filling, Grading or ExcavaUon where there is a change to the Natural Existing Grade Involving more than 200 Cub c Yards of Material within any Parcel? Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five Thousand (5,000) Square Feet of Ground Sudace? Is there a Natural Water Coume Running through the Site? Is this Project within the Trustees jurisdiction or within One Hundred (100') feet of a Wetland or Beach? Will there be Site preparation on Existing Grade Slopes which Exceed Fifteen (15)feel of Vertical Rise to One Hundred (100') of Horizontal Distance? Will Driveways, Parking Areas or other Impervious Surfaces be Sloped to Direct Stom~Water Run-Off into and/or in the direction ora Town right-of*way? Will this Project Require the Placement of Material, Removal of Vegetation and/or the Construction of any Item Within the Town Right.of. Way or Road Shoulder Area? {This Item will NOT Include the Installation of Driveway Aprons.) Will this Project Require Site Preparation within the One Hundred (100) Year Floodplain of any Watemourse? ~ NOTE: If Any Answer to Questions One through Nine Is Answered with a Cheek Mark In the Box, a Storm-Water, Grading, Drainage & Erosion Control Plan Is Required and Must be Submitted for Review Prior to Issuance of Any Building Permftl EXEMPTION: Yes No Does this project meet the minimum standards for classification as an Agricultural Project? Note: If You Answered Yes to this Question, a Stoma-Water, Grading, Drainage & Erosion Control Plan is NOT Requiredl STATE OF NEW YORK, COUNTY OF .....~.L).?'7...~...o.~ ................ SS 5' ' That I ................ ~ ........ .... 1 ............................being duly sworn, deposes and says that he/she is the applicant for Penni[ (Name of individual s~gning Document) Sd that he/she is thc .............. ,0.,.C~,.~.~..~. .................................................................................................................................... (Owner, Contractor, Agent, Corporate O/ricer, etc.) 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 tree to the best of his knowledge and belief; and that the work will be peffomaed in the manner set forth in the application filed herewith. Sworn to before me this; ......... f/~..~.... ....................... d ay Of .& ~ .~....~...//..~....~/~..~.. ....... gO~..~) .......................... NOTARY PUBLIC, STATE OF NEW YORK (Signatu~ of Applicant) FORM - 06/07 "~i~'~'~'n' §-~ff'o'~'~'fi~i',7~ Commission Expires October 3;I, 20.L.~ Suf~lk County Water Authority 40'~0 Sunrise Hwy Oakdale, NY 11769 Al-tN: New Service (631) 218-1148 PRICE EFFECTIVE UNTIL November 5. 2010 SUFFOLK COUNTY WATER AUTHORITY SERVICE APPLICATION and AGREEMENT for SUPPLEMENTAL/DELIMITED AREA Telephone .o. ~j Driver's License No. '~-7 Social Security No. Premlsee Address: 788 LONGVIEW LN SOUTHOLD, NEW YORK Tax Map No. 1000 088.00 88.00 008.500 New Home: Costs District Section Yea No /~ Block Lot quarterly payment, upon sale of the premi~'~"~nation of sevice. NOTES:. Repayment terms up to 10 (ten) years are available up0~n request. Your property is located in an area where there is a charge to cover a portion of the water main installation cost. Payment of this charge as well as the standard connection fees are a condition of receiving water service. This water main charge can be paid over a period of five years.* There is also a water Tapping Fee of $950.00. This includes the installation of a meter vault. The fee rn~ be paid in full with this application, or the residential applicant may pay one half of the Tapping Fee ($475.00) with this application and pay the remaining balance plus interest over the surcharge repayment period. Main extension costs will be billed commencing from the project in service date or the customer's service tap date, whichever is earlier. Total Costs may be paid at any time in full to terminate interest charges. New homes are required to pay key money fees in full 'in addition to the main extension costs. These fees start at $3000.00 for a one-inch service and increase with the size of the service. - --~,'~ ~ r~ ~ ~y~,~m~-~ Breakdown of Costs {~ E ! (1-in service) Applies to new homes only $ 3000.00 (must be paid in full) =ee (1 inch service connection) $ 950.00 in Installation Charge $ 3018.00 rte $ 3968.00 ** Financed Pavmenta (Reeidentlal Customers Only) ~ 0t'~a~ll'~Mn ;~t,~n~, Costs - Quarterly payment for 5 Years (excluding $475 tap fee balance) (@ 5% annual interest rate) $171.48 *** Total Main Extension Costs - Quarterly payment for 5 Years (including $475 tap fee balance) (@ 5% annual interest rate) $198.47 *** ***Billed quarterly in addition to the service charge and commodity charge portion of your water bill I hereby apply to become a customer of the Authority at the premises indicated above. Enclosed is a check made payable to "SCW^" for Tapping Fees in the amount of $475.00/$950.00 (cimle one). I have read and agree to the terms and conditions on the back of this Agreement. I agree to connect to SCWA service and to disconnect domestic service from the private well currently used at the premises. I agree to pay the Total Costs indicated above over the period selected, unless the costs are paid in full prior thereto. I agree to pay the Total Costs still unpaid, whether or not due as a if the total amount to be financed is $2000 or less, the finance agreement will not exceed five years. If the total amount to be financed is $1200 or less, the finance agreement will not exceed two years. ** If local highway officials require additional road restoration, you will be charged your proportional share of these added costs above those included in your surcharge. PLEASE NOTE THIS WE MUST RECEIVE BOTH THE FRONT AND BACK OF THIS AGREEMENT Supplemental - delimited area - 5% - Southhold Montauk.doc Revised May 2006 .' , ' PLEASE NOTE THIS WE MUST RECEIVE BOTH THE FRONT AND BACK OF THIS AGREEMENT TERMS AND CONDITIONS 1. Water service shall be provided and the customer agrees to comply with the rules and regulations of the Authority, including the rates and charges established therein, as the same may be modified from time to time. 2. The customer will be required to mark out any underground facilities the customer owns that will be in the area where the water mains are to be installed under this agreement. This requirement applies whether the facility is located on public or private property. If unmarked facilities are damaged by the contractor, it is the customer's responsibility to effect any necessary repairs. If a marked out facility is damaged by the contractor, it will be the contractor's responsibility to effect the necessary repairs. 3. Mains under this Agreement shall be and remain the property of the Authority, its successors and assigns, and the Authority retains and shall have the right to extend any main installed by it pursuant to the terms of this Agreement in or to other lands, streets, and avenues, and to hook up new premises or customers to said main, but the customer shall not by reason thereof be entitled to any repayments or refunds. 4. The Authority shall use its best effort to install the water mains or connect the Applicant. In no event shall performance under this Agreement by the Authority be required or continued when circumstances beyond its control prevent, prohibit, or interfere with such performance. Such circumstances include, but shall not be limited tO, delays in delivery of materials, weather conditions, strikes, or other labor difficulties, causes commonly referred to as "Acts of God", acts or omissions attributable to the customer and other conditions not reasonably foreseeable. 5. In the event the customer fails to take water service, the Authority shall have the right to charge and collect a service charge bill as set forth under the appropriate classificatiOn in the Authority rules and regulations, as the santa, may be modified from time to time, in addition ~to the charges for the costs described herein. In the event that the customer fails to take water service within one year from the date of this agreement, the Tapping Fees paid herewith shall be retained as liquidated damages, it being agreed that the Authority's damages might be impossible to ascertain and that the Tapping Fees paid herewith constitute a fair and reasonable amount of damages under the circumstances and is not a penalty. If the customer requires water service after such retention, the customer shall be required to pay the Tapping Fees in addition to other fees and penalties as set forth in the rules and regulations of the Authority at the time of application for water service or as the same is amended from time to time. 6. Each customer is responsible for the cost to have the water service line installed (i.e. the service line from the property line to the premise). A licensed plumber, experienced in water service installations, should perform this. The Authority must inspect the service line before the trench is beck'filled to ensure proper installation. Water service lines should be installed prior to the main installation. In the event you are unable to have your service line installed prior to the SCWA tapping your service, please place a blue stake at the location where you would like your service installed. If you do not know the location, SCWA will select your service location at our discretion. PLEASE NOTE THIS WE MUST RECEIVE BOTH THE FRONT AND SACK (DF THIS Supplemental - d¢limi~l ~a ~ 5% - Southhold Momauk.doc Revised May 2006 Form 133B ..v. o7,o7 31185 SUFFOLK COUNTY WATER AUTHORITY 4060 Sunrise Highway Oakdale, NY 11769 Rec'd from//:; ¢ , ,, ,; BP Number CA Number Check Number Amount Cash Q Check,~l KREIGER WELL & PUMP CORP. P.O. Box 101 MATTITUCK, NEW YORK 11952-0101 ILL TO: (631) 298-4141 (631) 283-1390 PAUL ~IMON 17 ROYCE ROAD DIXBIIIS, N. y. 11746 INVOICE INVOICE NO. 35915 6[25/2010 SHIP TO: SDVIO~ 705 LONG'VIEW LANE SOUTHOLD, N. Y. 11971 455-2348 INVOICE DATE OUR ORDER NO. YOUR ORDER NO. TERMS SALESPERSON QUANTITY DESCRIPTION UNIT PRICE AMOUNT 1) INSTATI.kYO APPROXIMATELY 45 FEET 1" K COFFER 1,275.00 WATERLINE FROM PROPERTY LINE INTO BA~BMEKr OF HOUSE 2) INSTAT.T.t~ i"BALL VALVE ONIffNEIMiW~IATELY AFI~R ENTERING BA~]~iEKF. 3) PROVIDED DISCONNECTION OF WEll. SYSTEM AND CO~"~ON OF NEW WATERLINE WIlH PRESSURE 1~ k-n3UCING VALVE. **CONTRACT PRICE DOES NOT INCLUDE ANW S.C.W.A_ CRAR~** 6/22/2010 DEPOSrI' -6_50.00 6/25/2010 PAID INFUIL -625.00 NOTE,: PLE&SE SIGN AND RETURN TIlE ENCLOSED CERTIFICATE OF CAPITAL IMPROVEMENT WITH PA'~. NON TAXABLE, 0.00 i I 'l--'nmk__y~u £or yom' business. ST-!24 (?89) New York State and Local Sales and Use Tax Certificate of Capital Improvement ~ Ts~fion ~ end Rnsnca After this certificate is completed and signed by both the customer and the contractor padorming the capital improvement, it rnu~t be kept by the contractor. Read this form completely before making any entries. This certificate is not valid unless all entries ere compJ'eted Name ol customer (print or type) PAUL SIMON 17 ROYC~ ROAD City state ZIP code D~x ~tt.t..~ ~,~ 11746-5401 Certificate of Authority number 0f any) '- Name of eontmgtor (print or type) KREIGER WELL & PUMP CORP. MATTITUCK, Ny 11.952'-O101 Cib/ State ZiP code Ce~llflcete of Authority number (if any) To be completed by customer: Tl:e nature of the work is as follows (give description of capital improvement to be performed): 1" [ COPPER WATF~.LINE Project name SIMON Street address (where Ihs work is to be performed) 705 LONGV'[Kt,/ T~ANI~. City State ZIP code SOuTuOLD ~ 11971 certify that: · I am the [~/owner, ['~ tenant of the real property identified on this form, and · The work described above will result in a capital Improvement to the real property within the guidelines set forth above, and · This contract [] includes, J~I'does not include the sale of tangible personal property which/when installed, retains its identity as tangible personal property and does not become a permanent par of the real property.' understand that: · I will be responsible for any sales tax, interest end penalty due on the contractor's total charge for langible personal property and for labor if it is determined that this work does not qualify es a capital improvement, * I am required to pay the contractor the appropriate sales tax on tangible personal property (and any associated services) transferred to me pursuant to Ibis contract, when the property is not Installed by the contractor as a permanent part of the real property, and · I will be subject to civil or criminal penalties or both under the Tax Law for issuing a ~alee or fraudulent certificate. Signature of customer Title Date To be completed by contractor: i, ll~e Contractor, certify that I have entered into a contract to perform the work described by the customer named above. (A copy ol the writl~n cOntrsc~ if any, is attached.) I undemtand that my failure to collect tax aa a result of accepting improperly completed certificate wll~ make me personally liable for the tax ctb~.~Wise due p ua penalties end ntereal., an S;~,~"""'; ~! contract r o car Date Town of Southold Erosion, Sedan & ASSESSMENT FOR."," PROPERTY L~OC/~ATIOH. /~5.C.T.M.,~ .TILE FOLLOWING ACTIONS MAy REQUIRE THE SU_m_.~".!_~SION OF Jt ulstrict Section Block Lot GI:KTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. Item Number: (NOTE: A Check Mark (~) for each Question is Required for a Complete Application) Yes No Will this Project Retain All Storm-Water Run-Off Generated by a Two (2") Inch Rainfall on Site? V/ (This item will include all mn-off created by site cieadng end/or construction activities as well as all Site Improvements and tile permanent creagon of impervious sudacas.) Does the Site Plan and/or Survey Show All Proposed Drainage Structures Indicating Size & Location? This item shall include all Proposed Grade Changes and Slopes Controlling Surface Watee=lowi Will this Project Require any Land Filling, Grading or Excavation wbem them is a change to the Natural r~ Existing Grade Involving mom than 200 Cubic Yards of Matedai within any Parcel? Will this Application Require Land Dislurbing Activities Encompassing an Area in Excess of Five Thousand (5,000) Square Feet of Ground Surface? Is them a Natural Water Course Running through the Site? r~ Is this Project within the Trustees jurisdiction or within One Hundred (100') feet of a Wetland or Beach? Will there be Site pmparaben on Existing Grade Slopes which Exceed Fifteen (15) feet of Vedical Rise to One Hundred (100')of Horizontal Distance? Will Driveways, Parking Areas or other Impervious Surfaces be Sloped to Direct Storm-Water Run-Off into and/or in the direction cfa Town right-of-way? Will this Project Require the Placement of Material, Removal of Vegetation and/or the Coustruction of r~ any Item Within the Town Right-of-Way or Road Shoulder Area? (This Item will NOT Include the Installation of Driveway Aprons.) Will this Project Require Site Preparation within the One Hundred (100) Year F,'<x)dplain of any Watercourse? NOTE: If Any Answer to Questions One through Nine is Answered with a Check Mark In the Box, a Storm-Water, Grading, Drainage & Erosion Control Plan Is Required and Must be Submlffed for Review Prior to Issuance of Any Building Penaltl EXEMPTION: Yes No Does this project meet the minimum standards for classification as an Agricultural Project? Note: If You Answered Yes to this Questtan, a Storm-Water, Grading, Drainage & Erosion Control Plan is NOT Requiredl STATE OF NEW YORK, COUNTY OF ....................................... ing duly sworn, deposes and says that he/she is the applicant for Permit, (Name of individual s[gnlflg Docurr~nti And that he/she is the 0(,¢~...~. (Owner, Contractor, AgenL Corpcmte Officer. e~c.) Owner and/or representative of the Owner of Owner's, and is duly authorized to perform or have perforn~ed 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 rne this; 0 ......... ~ .................................. day oje .g~../<~.~.....~...'~...e...~....... , 20~..~ NOTAEY PUBLIC, STATE O~ NEW YORK (Signatu/Ib of Applicant) ................ FORM- 06/07 Commission Expires October 31, 20.}.~ \ \ \ SURVEY OF LOT 45 ~'IAP OF TERRY WATERS SITUATED AT BAYVIEW TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-.88-05-08 $¢AL~ 1 "=30' OCTOn£R ?, 1998 , ...... _.-..:: ........ ~.~._~g__~¢_ JoSePh A. Ingegno "¢' Land Surveyor ,! -T-I APPROVED AS NOTED/ USE iS UNLAWFUL ' VF~[-IOt]T CERTIFICATE / ¢~e~,¢ /or- /