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' fFOL `` Town of Southold Annex 10/21/2014 P.O.Box 1179 54375 Main Road ' ► W. Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 37219 Date: 10/21/2014 THIS CERTIFIES that the building IN GROUND POOL Location of Property: 175 Burtis Pl, Pecomc, SCTM#: 473889 Sec/Block/Lot: 67.4-15.1 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 3/18/2013 pursuant to which Building Permit No. 37887 dated 3/26/2013 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: ACCESSORY IN-GROUND SWIMMING POOL FENCED TO CODE PER NYS PETITION#2014-0379 AS APPLIED FOR The certificate is issued to Slavin,Eileen (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 37887 08-13-2014 PLUMBERS CERTIFICATION DATED A ed ignature � F0yr p TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#: 37887 Date: 3/26/2013 Permission is hereby granted to: Slavin, Eileen 175 Burtis PI Peconic, NY 11958 To: construct an In-Ground Swimming Pool, fenced to code At premises located at: 175 Burtis PI, Peconic SCTM # 473889 Sec/Block/Lot# 67.-4-15.1 Pursuant to application dated 3/18/2013 and approved by the Building Inspector. To expire on 9/25/2014. Fees: SWIMMING POOLS -IN-GROUND WITH FENCE ENCLOSURE $250.00 CO - SWIMMING POOL $50.00 Total: $300.00 ZA.AA 0� Building Inspector 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 G Date. New Construction: v� Old or..Pre-existing Building: (check one) Location of Property: Ur'J '\� (� ��C_'n,(l l 1 House No. Street Hamlet 11 1 Owner or Owners of Property: _ � 1 t�� L(�;'1�l (� Suffolk County Tax Map No 1000, Section tJ �0 d Block 0 • 0 U Lot O l S D Subdivision Filed Map. (1 b Lot: q g + �. Permit No. Date of Permit. Applicant: �ll hen �l Q ✓I'� Health Dept.Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: (check one) Fee Submitted: $ Applicant Signature o��OF SO�ryol. � of Town Hall Annex Telephone(631)765-1802 54375 Main Road cn Fax(631)765-9502 P.O.Box 1179 COQ roger.riche rt(a-)-town.southoId.ny.us Southold,NY 11971-0959 Q 'yl4UNTY,� BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Eileen Slavin Address: 175 Burtis PI City: Peconic St: NY Zip: 11958 Building Permit#: 37887 Section: 67 Block: 4 Lot: 15.1 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: DBA: VMB Electric License No: 2526-e SITE DETAILS Office Use Only Residential X Indoor Basement Service Only Commerical Outdoor X 1st Floor Pool X New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 1 ph Heat Duplec Recpt Ceiling Fixtures HID Fixtures Service 3 ph Hot Water GFCI Recpt 1 Wall Fixtures Smoke Detectors Main Panel A/C Condenser Single Recpt Recessed Fixtures CO Detectors Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps 1 Transformer Appliances Dryer Recpt Emergency FixtureTime Clocks 1 Disconnect Switches 1 Twist Lock Exit Fixtures TVSS Other Equipment: in ground swimming pool to include, bonding, 1-pool light, 1-heat pump Notes: Inspector Signature: Date: Aug 13 2014 81-Cert Electrical Compliance Form.xls r4F sOVlyO� i TOWN OF SOUTHOLD BUILDING DEPT. / 765.1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLEIG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING /STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: s 6 / !—o Zy ,. /j-&vo-k 1�&r,,A �Jco-c- �UL�i &,hhe DATE INSPECTOR 3� 8g� o��Of SOUIyo TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ]�IULATION [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOL ATI N [ ] CAULKING Jol DATE �� �� INSPECTOR OF SO(/l�o� Q coOlm,` TOWN OF SOUTHOLD BUILDING DEPT. 7654 802 �j INSPECTION [ J FOUNDATION IST [ ] ROUGH PLUMBING [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) KELECTRICAL (FINAL) [ ] CODE VIOLATION [ J CAULKING REMARKS: DATE �3 INSPECTOR-( OF SOUTyolo TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECT19N [ } FOUNDATION 1ST [ ] PLUMBING [ ] FOUNDATION 2ND [ ] SOLATION [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION ( ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) [ ] CODE VIOLATION [ ] CAULKING REMARKS: DATE �� t INSPECTOR FIELD ORT DATE COMMENTS FOUNDATION(1ST) pp FOUNDATION(2ND) z � O ROUGH FRAAMNG& y PLUMBING -40U Cq WUL•ATION PER N.Y. H STATE ENERGY CODE --lb FINAL , ADDITIONAL COMMENTS 3c� / — ac �, t�-�- �Vy7t�Cs ' Gtr �- ••� ------------ ot �� t3— 1 ZZ _ 21i 0 z e TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health 'SOUTHOLD,NY 11971 4 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 /� Survey SoutholdTown.NorthFork.net PERMIT NO.✓ Check Septic Form N.Y.S.D.E.C. Trustees 3�� 20 / Flood Permit Examined _ _ Storm-Water Assessment Form I -� Contact: I_� I Approved 20 _ Mail to: Disapproved a/c MAR 18 2013 ' Phone: � � C_2 Y Expiration ,20 — Building Inspector APPLICATION FOR BUILDING PERMIT INSTRUCTIONS /� p Date( ��,�� 0 , 20 13 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 buildirfgs 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. iii�; 6►� (Signature of applic t o name,if a corporation) ENCLOSE 1uOL TO CODE 1 UPON C " ON �ur�1S . Lon C ►'y ��� BEFORE "WATER" (Mailing address of applicant) AMC` State whether applicant is owner, lessee, agent, architect, engineer, general contractor,electr4Cn, plumber or builder DATE Name of owner of premises / Q 1/r r NOTIFY i (As on the tax roll or lately , � If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) ER RUNOFF G PURSUANT TO CHAPTER, X36 TR i .4 N Q,�., � Builders License No. OF THE TOWN CODE. ti Plumbers License No. WRT SF COMnI_€Tr Electricians License No. ,41 R1,_jQ1, 'TIT Other Trade's License No. 1 QUIREMENTS OF 1 tii ,_ 7 fat n Y,_!RK STATE, NOT RESPO,;,'.. 't. AOR 1. Loc a ' o nil on w ' h proposed wo will be done: � L 10N ORCONSTRUCT1QNtKKOR5.. L//—,�j�s t) 11 House Number Street Hamlet County Tax Map No. 1000 Section ()�O . 0 t) Block 04 , b Lot Subdivision Filed Map No. '_` 2. State existing use and occupancy of premises and intended use apd occupancy of proposed construction: a. Existing use and occupancy �jc,�1�-y U.r->� b. Intended use and occupancy b QC Y-1 0..r"C( tAA 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work 4. Estimated Cost �S, a Fee (Description) (To be paid on filing this application) 5. 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. 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories 9. Size of lot: Front Rear Depth V 10. Date of Purchase '0 A_ ► y 'Name of Former Owner 3 ,�,y,-), 0�, 4—W�✓� 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 premises 'LAef(\ %k\jk;, AddressMV-1 Is XI,h\1'Phone Nolko 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_7,)C, * 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 N04 * 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 signing 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 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. Sworn to before me this _day of j� 20 13 Notary Public v —COf�NI D. 1311Signature f Notary Public;, State of New York g o A 1►cant No. 01€UG185060 Ot :-iified in Suffolk County T UXAL STATE OF NEW YORK DEPARTMENT OF STATE �' �(,i SEP 2 g 2014 ONE COMMERCE PLAZA ANDREW M. CUOMO 99 WASHINGTON AVENUE ESAR� GOVERNOR ALBANY, NY 12231-0001 ! Ec rn(rx`.bF11� STATE OF NEW YORK—DEPARTMENT OF STATE In the Matter of the Petition of: DECISION Eileen Slavin For a Variance to the New York State PETITION NO. 2014-0379 Uniform Fire Prevention and Building Code Upon the application of Eileen Slavin, filed pursuant to 19 NYCRR 1205 on July 18, 2014 and upon all other papers in this matter, the Department makes the following determination: NATURE OF GRIEVANCE AND RELIEF SOUGHT The petition pertains to the installation of an in-ground swimming pool for a one-family dwelling, located at 175 Burtis Place, Peconic, Town of Southold, County of Suffolk, State of New York. The petitioner is seeking relief from: 19 NYCRR 1220, The Residential Code of New York State,(2010)Section AG105.3, part 8.2,which requires, in part, that.. all gates shall be self-latching, with the latch handle located within the pool enclosure(i.e., on the pool side of the enclosure)and at least 40 inches above grade. In addition if the latch handle is located less than 54 inches from the bottom of the gate, the latch handle shall be located at least 3 inches below the top of the gate. [ The Petitioner request permission to permit latch handles for two pedestrian gates as a part of a pool enclosure, located 54 inches above the bottom of the gate, to be located on the outside of the pool enclosure. FINDINGS OF FACT 1. An in-ground swimming pool was installed at the subject premises. In doing so an enclosure was provided around the pool with two pedestrian access gates. 2. The two pedestrian access gates swing outward from the pool and have latch handles that are located at least 54 inches above the bottom of the gate. However the latch handles have been located on the outside of the gate. 3. The previous, 2003 and 2007, Residential Codes of New York State allowed the latch handle to be placed on the outside of the pool enclosure as long as the handle was located a minimum of 54 inches above the bottom of the gate. The current 2010 Residential Code of New York State requires that even if the latch handle is 54 inches above the bottom of the gate that it must be located on the pool side of the enclosure. WWW.DOS.NY.GOV E-MAIL:INFO@DOS.NY.GOV Petition No 2014-0379 Page 2 4. The provisions for barriers around swimming pools are to protect young children, less than 5 years of age, according to the International Residential Code Commentary. 5. The 2006 International Residential Code, on which the 2010 New York State Residential Code is based, allows a latch that is 54 inches above the bottom of the gate to be located on the outside of the enclosure. 6. The commentary for the International Codes states that the"54 inch latch height requirement limits the potential for small children to reach and activate the latch." If the latch is located lower than 54 inches then the Code requires that the latch be located 3 inches below the gate on the inside of the enclosure. 7. Section 303.2, Part 8,of the current, 2010, Property Maintenance Code of New York State has retained the language pertaining to pool latches that was in the previous Residential Codes of New York State and still allows a latch that is located 54 inches above the gate to be located on the outside of the enclosure. 8. Based on the above findings, it is the assumption that the 54 inch height of the latch above the bottom of the gate is adequate to protect the children that the Code has identified from reaching the latch and gaining entrance to the swimming pool regardless on which side of the enclosure the latch is located. CONCLUSIONS OF LAW Strict compliance with the provisions of the Uniform Fire Prevention and Building Code would be unnecessary in light of the fact that the latches as configured will be a minimum of 54 inches above the bottom of the gate and should be out of reach of the children that the Code provisions are trying to protect and would ensure the achievement of the Code's intended objectives more efficiently, effectively or economically such that granting a variance would not substantially adversely affect the Uniform Code's provision for health, safety and security DETERMINATION WHEREFORE IT IS DETERMINED that the application for a variance from 19 NYCRR Part 1220, Section AG105.3, Part 8.2, to permit latch handles for pedestrian gates as a part of a pool enclosure, located 54 inches above the bottom of the gates, to be located on the outside of the pool enclosure; be and is hereby PROPOSED TO BE GRANTED with the following condition(s): 1. That the latch handles be located a minimum of 54 inches above the bottom of the pedestrian gates. 2. That the entire pool enclosure and pedestrian gates will be in compliance with all other applicable provisions of Appendix G of the Residential Code of New York State including that the pedestrian gates be free from obstructions and are easily able to self-close and latch. Petition#20140379 Page 3 This DECISION is issued under 19 NYCRR 1205.6 unless obiected to by the petitioner in a writing received by the Department, the decision shall become FINAL after fifteen days of receipt of the decision by the parties. This decision is limited to the specific building and application before it, as contained within the petition, and should not be interpreted to give implied approval of any general plans or specifications presented in support of this application. Ronald E.�Piester,AIA, Director Division of Building/Standards and Codes. DATE:,<� • �7 RAS: sg VWWV.DOS.NY.GOV E-MAIL:INFO@DOS.NY.GOV NYS DEPARTMENT OF STATE DIVISION OF CODE ENFORCEMENT AND ADMINISTRATION Variance Attest List Petition No: 2014-0379 The persons below are advised to TAKE NOTICE of the attached document. The attached document pertains to a petition for relief related to code requirements. If there are any questions,call(518)474-4073 and ask for the Variance Unit. Please refer to the petition number in all related conversations or correspondence with us. MICHAEL VERITY/ TOWN OF SOUTHOLD BLDG DEPT 53095 MAIN ROAD PO BOX 1179 SOUTHOLD, NY 11971 EILEEN SLAVIN 175 BURTIS PLACE PECONIC, NY 11958 07/25/2014 Page 1 of 1 F. Town of Southold - Chapter 236 - Stormwater Management t� SWPPP - Storm Water Pollution Prevention Plan Assessment Form GENERAL INFORMATION: (All Requested Information is Required for a Complete Application) APPLICANT NAME; er- ant-Consultant-Contractor or Other(Circle One) Property OWNER:(If Different then Applicant) SIT Address: - Telephone#: ( F l Telephone#: Fax# zvv11 E-1911 ee�1 � QrJ\n Q: �1ril�n .IVt�C" E-Mag: i r r�77 t� �fy i Property Address:, •3l J f•)tS Q PeCU+�i e- N 1 I Ct S a Brief Description of Construction Activity,Proposed Swichu-0 BMPs,Soil Stabalization Bli4Ps,Project Scope and/or Sequence of Construction I S.C.T-M.#: 1000 (O 1 e (Provide AddWonal Papas as Needed) ��t3' i Th-Nd 8eelion Block Lot I i Nemo ofi Contractor andfor ContsW Person Responsble for Implementatfon of SwPPP: ------------------------- .-......-------.__._....-..-. I Address: (c3 1 \ S�'. Lt�nderth , N %IS7 ------------......_..._.._._.--------..---------------- phonq L 14q, �srk I Tele '311 2" 0 Fax#: __-_-----.--_-.._----_-----. --------------------- E-Moll: -_---_....,___--..__--_-E-beg: oc.>\S b liCC_ietrJ I (� tv►ct\1. � -------------------------------------•------- I I� -___------------------------------_.--_.__----- maotpersonsRes ponalbfe for Installation 8 Maintenance of Erosion Control Practice: -_-^--------------------------------•-------- I. I ase: --•--------------------------------------..___ Telephone#; I E-Mall: ------------------------------------------- ------------------------------------------ Total ------------•----------------------- ------------Taal Area of Al 0;Z3 Ckcres Total Area of land clearing Protect Parcels: andlor Growd Dlsksbance: ----------------------------- (SF./Awe) fS.F.l Awe) ........_.........._,....._..- Project Duration: Start End ----------------------------------------- i (Antidpated) /q -t... 3() 13 Dm-: r i WIIlthis Pro)ectDisttabefive(5)orMore Acres at Q _._---__.__-_----.--------- AnyOne Time During the ProposWDevelopment? Yes o ----------_--.------_-.--__-_-_.---------------- I If YES:PlsseAmtwnthe FoIWMngl ---------------.............__.._:---------------------- Does - ..---------------Does the Applicant have a Qualified Inspector On Staff To Conduct the Required Inspections? Yes No b. Does the SWPPP Indicate How Frequently the Site Q 0 List the NAMES"description of all Potenttely impacted Waterbodies and/or Watlends: l Inspections will Occur and for What Period of Time? Yes No c. Does the SWPPP Adequately Identify All Temporary Q C] and/or Permanent Soil Sfabaifzatfort Measures? Yes No d. Does the SWPPP Adequately Identify a Complete 0 Q ._..__......._._._. ........_._...__....._....................._.___. .._ .._.....__..__.._ 1 Project Phasing Pian? Yes No Status of Impacted Waterbody:(og.TMDL,3e3(d)Listed,knpairod...) i e. Does the SWPPP Indicate Additional Site Specific = Practices that Will be Utilized to Protect Water Quality? Yes No L Has the Applicant Submitted a Completed DEC Notice Typo of Impacted Waterbody:(eg.Lake,Creek,Say,Pond,Sound,Fmshwolw Wetland„.) Of Intent and SWPPP Acceptance Form for Review Q I by the Town of Southold? Yes No STATE OF NEW YORK, COUNTY OF................ ....... .................SS That I �l...il.p—ein......-�..'�-(/�.�.being duly sworn,deposes and says that he/she is die applicant for Permit, f (Name of Individual signing Doosnent) Andthat he/she is the ......................................... 1 "................................................................................ (Owner, . Contractor,Agent,corporate Officer.etc.) Owner and/or representative of the 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 Erle 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. Swom to be�rune this i .e .............................. .... .:......day of ...: .... ..... .....................,20".13CV Notary Public: .............. �,t!IA............ .......... . il�t tFTOTH ... . ....... ............ . ...... .. ... .... War of N York (stgnakxe of A I) I SWPPP Assessment FORM: 03-12 au8MW in Suffolk County COrtImission Exnif kth�9R �f �� Town of Southold - Chapter 236 - Stormwater Management CONTRACTOR CERTIFICATION STATEMENT Prior to the commencement of construction activity,the owner or operator must identify ALL contractor(s)and sub-contractors)that will be responsible for Installing,constructing,repairing,replacing,inspecting and maintaining the erosion and sediment control practices Included In the SWPPP;and the contractors)and i sub-contractors)that will be responsible for constructing the post-construction stormwater management practices included in the SWPPP. The owner and/or operator shall have each of the contractors and/or sub-contractors Identify at least one person from their company that will be responsible for Implementation of the SWPPP.This person shall be known as the trained contractor.The owner and/or operator shall ensure that at least one trained contractor is on site on a daily basis when soil disturbance activities are being performed. The owner and/or operator shall have each of the contractors and subcontractors identified above sign a copy of the following certification statement below before they commence any construction activity: CERTIFICATION "I hereby certify that I understand and agree to comply with the teens and conditions of the SWPPP and agree to r implement any corrective actions identified by the qualified inspector during a site inspection.l also understand that the owner or operator must comply with the terms and conditions of the most current version of the New York State Pollutant Discharge Elimination System("SPDES")general permit for stormwater discharges from construction activities and that it is unlawful for any person to cause or contribute to a violation of water quality standards.Furthermore,l understand that certifying false,incorrect or Inaccurate information is a violation of the referenced permit and the laws of the State of New York and could subject me to criminal,civil and/or administrative proceedings." l 2Q11 ,) l� i/cn NAME TtN: Oab: I In addition to providing the certification statement above,this page must also identify the specific elements of the SWPPP that each contractor and/or sub-contractor will be responsible for: Specific SWPPP Element: (Please Describe Here) _........_........... ,....---------- I i NAME and TITLE of the Trained Contractor(s) responsible for SWPPP Implementation; MAUL'. Title: Dete: j NAME,address and telephone number of the Contracting Firm; _ �4L i rJ�C ,_ar._ anS --.o3__ �.._. ree ��,C,n �i S�-_N 11757 ---------------- 44 Property Address and 1 Suffolk County Tax Map Number of the site; 11_Ii i S.C.T.M.P 1000 -- ------ - --------------------- -- - _ .._.. . ____ I DlsMct Section BlockL' of' i The owner and/or operator shall attach All certification statement(s)to the copy of the SWPPP that is maintained at the construction site.If new or additional contractors are hired to implement measures Identified in the j SWPPP after construction has commenced,they must also sign the certification statement and provide the Information listed above. For projects where the Department of Environmental Conservation requests a copy of the SWPPP or inspection reports,the owner and/or operator shall submit the documents in both electronic(PDF only)and paper format within five(5)business days,unless otherwise notified by the Department. SWPPP Certification Statement FORM: 03-12 T.O.S. "SWPPP" Preparation - Chapter 236 For Department Use Only: Storm Water Pollution Prevention Plan S.C.T'M. PropertyAddresa:t04(u�, Review Checklist Checklist # 1 1 -9-ewo-n r REQUIRED PLAN INFORMATION AND IMPLEMENTATION DETAILS: + i i i Plan Sheet Explanation for NO or N.A. (Does the SWPPP Adequate) = , ,Provide for and/or Indicate the Foliowin ,YES, NO ,N,A., Location(pg 1. Drainage Calculations&Stormwater 5MPs Designed to contain a Two Inch Rainfall On-Site. 1 , 2. Construction Phastn Plan indica! Se encs of P Construction Activities. ----- ----.$.-- ---....- -qu"of ed Construction 3,_GeneralLocation_MaP.:.._-_._•_-.________._ ..._.__. - _.. - ---j r + r - - --- .._.... __. .. .... 4.-Draiange Site Plan brawn to Scale at Six�r(80')test to the Inch or la%er Ind cgting the F-ollowing_ ,Q 1 Q,Q, a_ Location and Description of Pro party Boundaries;_..-_.-_._. _ ... .. _._.._._..._ Acreao C,_ All Existing Natural and/or Man Made Features Olt and within 50'of the Property Boundary d, Test Hole Data Indl2jtin$Soil Charade----s&Depth to Seasonal High Wafer Table; _+D 1 Q i©, e. Contours Indicating Property t,atwns(Min_2ng ar_), ^Spo - -._osed 3.-_. __ + + i f. t Grade&Ftntsh Floor Elevations for Existiuf Proptrudures; Q (� [� g. ocaUon o Wood as Isolated uses with a Minimummension of 18'Diameter; Q 101 Q, h:" Soii�anservaifon __._._.__._. 5. Back round Information about the S g cope of the Project,Location&Description of the Site, Proposed Changes to the Site and All Existing Development on the site Including the Following. _ At.._All tmpryyerp@Rt,4)A dip9 Tgtal.Area_pf LAAndM#.0 tang&7$ .ta11$ite.Area, b. All Excavation.Filling,Stripping&Grading Proposed and Identified as to depth,Volume ' & Nature of Materials tnvolved +Q'Q° C. -All Areas Rgg9 ring Clearing andlor Grubbfng�__ ._ _.__-._.-.---_--__.__.__-_ ._.__-_._+Q r Q s Q r _. .._--....-_---- - - .... _ _._.-- d. AO Areas Where Topsoil is to be Removed.Stockpiled and where Topsoil will ultimately i0 E 0 iQ; beaced; - ---- --- i r e. All Temporary&Permanent Vegelatron to be Placed on Site f. All Temporary&Permanent Storm Water Rurroff „g.^ The An4cipated Patter of Surface Drainage During,Periods of Peak Runoff h The Location of all Roads Dnveways Sidewalks Patios Structures Utilities&Other r 1 _ vements,Including'Temporary Access h Constnidion Staging 6. A Schedule of the Sequence for the installation of All Planned Soil Erosion,Sedimentation &Stormwater Runoff Control Measures. 7. DescriQtionofPollutionPreventionMeasures that will beImplemented. ___________.____.-._.';D;Q;Q� _....------_-._. __._......... 8. A Description of the Minimum Erosion&Sediment Control Practices to be Installed and/or + + + �rQ+Q Impjemerrted for Each Construction Activity That will result in Soil Disturbance._______..__• .__; , , 9. Desai tion of Construction&Waste materials CVWed to be Stored On-She ,_---•----------__,_...-__.^ _.__-.__"_--•_--____.-.»._....._._.__.__.___jQi©iQi_._._..._._._._....,..»..........-................._..__.,_..._.,__..._......_.___._._....._,...................... 10. Temporary&Permanent Soil Stabilization Plan that meets the Current Version of the New York State Storm Water Design Manual Technical Standard. + + H. General Site Pian and Construction Drawings for the Projects 12. Dimensions,Material SQeoifications&inst�Ia60n D_stalla for AI Erosion&Sediment Control Practices. ,Q,Q: ----------------- -----------------------------------------____. 13__Temporary Practices that will be Converted to Permanent control Measures. U i D;Q ------ ---- -------_.---------•----------_......_ 14.._implementation Schedule for Staging Temporary Erosion_Control Practice or BMP_. _ ----i Q [�F Q --..._..._.____.__._.........__. .---._._ ------, 15. Maintenanch ce Sedule to Ensure Carni-nuous&Effective Operation of E-roeion& -- - + , Sediment Control Practices. 1 B.-Wames of Potential Surface Waters of the§Wt i of New fc W and/or we that may tie Impacted by Development :17 17. Dahneatron of Sloan Water Control Pian Implementation Resporusiblltties for Each part of the__a Q ©+Q r__ __ _ --- -------------------------- - -- _ __ __......_._...._- - _........._._.... _._......._........_.._....._.. Pro ect Construction Site. 18. All other Existing Data that Describes Storm Water Runoff and/or Natural Drainage Sxrales_ 18. Iderlpfication of All Contractor(s)/Sub-Contractor(s) Responsible for Installing,Constructing, Repairing,Replacing,Inspecting and MaIntainin g the Erosion&Sediment Control Practices. Storm Water Management Control Plan Checklist 9 1 : 03-12 sum DEC "SWPPP" Preparation - .Chapter 236-19 For Department Use Only: Storm Water Pollution Prevention Plan S.C.T.M.M Property Address: +-, Review Checklist Checklist # 2 1000 (Additional Items to be Included with Checklist#1 when Article III is trigered.) oretw 9.odoe ewer+ REQUIRED PLAN INFORMATION AND IMPLEMENTATION DETAILS: ii n i Plan Sheet (Does the SWPPP Ade untel Provide for and/or Indicate the Followin .) ,YES, NO,N A ,Explanation for NO or N.A.Must be Approved by SMO Location(pg.# Indicate an or ow a Items Requl __ _ ._ �__1_in this Packet? - 2. Does the Plan Indicate and/or Show a Description of Each Post-Construction stormwater __Management_Practice? 3. Does the Site PlanlConstruction Drawing(s)Indicate and/or Show the Location&Size of U 0 _Each Post-Construction Stormwater Management Practice? _.__..-._._._..-.--.--.._._E I + r.___..._...._... ..... . _...__._..____._.._._._.._.._.. .........................._ _._._..._...... 4. De S oes thite Plan/ConsLuctlon Drawings)Indicate and/or Show Hydrologic&Hydraulic Analysis For All Structural Components of the Stormwater Management System for Applicable Storms? I 5. Does the She PianlConstruction Drawing(s)Indicate andlor Provide a Comparison of Post- Develo ment Stormwater Runoff Conditions with Pre-Development Conditions? 6. Does the Site Plan/Construction Drawing(s)Indicate and/or Show Atl Dimensions,Material Specifications&Installation Details for Each Post Construction Stormwater Practice? i 0 7. Does the Site Plan/Construction Drawings}Indicate a Maintenance Sctxedule Provided by the Constractor(s)to Ensure Continuous&Effective Operation of Each Post-Constructiorl Stormwater Management Practice? 8. Does the Site Plan/Constructlon Drawing(s)Indicate and/or Show Maintenance Easements to Ensure Access to All Stormwater Management Practices at the Site for the Purpose of Inspection +Q+Q+Q! and Repair? ------------------ ---------- -- -- ---------- -- 9. Does the Site Plan/Construction Drawing(s)Indicate and/or Show Inspection and Maintenance , , , + Agreements) that are Binding on AN Subsequent Landowners? 10. For All Activities meeting the Threshold in 236-19(B)(1),the SWPPP shall be Prepared&Signed t i E By a Professional in the Principles and Practices of Stormwater Management&Treatment Who r Q s Q E Q+ Who Shap Certify thatt he Design Meets the Requirements of Chapter236_-_ ........... 1 i. Does the Plan Indicate andlor Identify AIi Potential Sources of Pollution which may affect the Quality of Stormwater Discharges? _ 12. Does the Plan Provide Dcu omnt eation 3upporting the Determination of Approval with Regard i 0 0 to Historic Places or Archeological Resources that Includes the Followirn ______ _._.._-_•---------------- -- ___ ____..___ a Information whether the stormwater discharge or land development activities would have an effect on a property that is listed or eligible for fisting or eligible for listing on the 17-1:r__1 i State or National Re aster of Historic Places_____ _ ---•---------------_s_____________J ___________-______----__ b. The kiii- of Historic Resources Screening Determinations that have been Conducted; 10+Q s Q r c. Description oT Measures Necessary to Kv&a or Minimize Adverse impacts W PlacesListed, _ or Eli ible for LiS6 on the State or National Register of Historic Places;and �- d. Where Adverse Effects May Occur,Any Written Agreements in Place with the NYS Office of Parks,Recreation and Historic Places(OPRHP)or other Governmental Agency to Mitigate Those Effects. _________.__... _________ _____._____ ___ ____--_.--_-.__ _, , r---------------------------_.._._-_____.-_-----.__---_-.._ 13. A Desorption of the Soil{s)Present at the Site,Including an Iderxtification of the ,(�, , , H dreulic Soil Grou . 14. Identification of Any Elements of the Design that are not in Conformance with the Design manual,Including Reasons for the Deviation or Alternative Design and a Description ___of the EguNalency with technical Standar-----------------------------------------------. s i -----------------------------.--_._.----------- ._____..__.__ 15. A Hydrologic and Hydraulic Analysis for All Structural Components of the Stormwater Management Control System___ ____________Wt ____ _ ___ ___, , , _____---_-_--_ 16. :!.Detailed Summary,with Cala,tatt';' of the Sizing Crlterla that was Used to Design , 1 , , -._ All Post-Constrvctlon Stormwater Management Practices. I�I i _..-._..---"'----- '- — ... ._ ........,. ...__. ._..... ................_---._....._...__7 I r r`------ ------------------_.---..__.---..._-- ------....__...._...... 17. An Operations a—nd—Maintenance----- _ Plan_ that_Includ_ es_Inspec--tio—n"and-- Maintenance 1 Schedules and Action to Ensure Continuous and Effective Operation of Each Post-Construction Stone Water management Practice. ! + + + Storm Water Management Control Plan Checklist#2: 03-12 - OF s�lyo Town Hall Amex >� �( Telephone(631)765-1802 54375 Main Road R7Y ) P.O.Box 1179 roger-dcheft(CUi0 n. 0U 5 �.ny.us Southold,NY 11971-0959 �i�'� BUIMING DEPARTMEW TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: Date: Company Name: ('Y) d L le Name: , \;�� ?. Cci��Lt�o License No.: 5 a E S Address: S K o R c L o... E Phone No.: I -G 12.-�B S 17 JOBSITE INFORMATION: (*Indicates required information) *Name: 'Address: 6�S '6a 2-rtS l (aS .. *Cross Street; *Phone No.: Permit No.: Tax-Map District: 1000 Section: Block: _ Lot: . *BRIEF DESCRIPTION OF WORK(Please Print Clearly) _E�2 a-sem (-a (Please Circle Ali That Apply) *Is job ready for inspection: YES/ NO. Rough In Final * -you need a Temp Certificate: YES l(NO.� Temp Information(if needed) *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION z 82=Request for Inspection Fon I�, Eileen Slavin September 18, 2014 Mr. Michael J Verity Town of Southold Building Department PO Box 1179 Southold, NY 11971 Re: Permit#37887 Request for 6-Month Extension Dear Mr.Verity, We would like to request a 6-month extension for our Permit#37887.We are still awaiting approval from New York State for the fence variance. We spoke with your office and they informed us a letter requesting the extension would be sufficient. Please let us know if you require anything else. Thank you for all your help in this matter. Sincerely, 1 Eileen Slavin ! SEP -�2 2014 ' BLDG.DEPT. 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