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HomeMy WebLinkAboutBurns, Arthur r- James F. King, President *0f SUUryo Town Hall Jill M. Doherty,Vice-President 53095 Route 25 P.O.Box 1179 Peggy A. Dickerson Southold,New York 11971-0959 Dave Bergen CA Bob unusio, Jr. �� Telephone(631)765-1892 ly�,oUNTY,� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application _Wetland Permit Application �ZAdrmmstrative Permit Amendment/Transfe /Ex ension eceived Application: 0� (/Received Fee:$ 'Q _Completed Application ® tS p _Incomplete _SEQRA Classification: Type I Type II Unlisted IVAY 2 —Coordination:(date sent) 3 2®®� _LWRP Consistency Assessment Form CAC Referral Sent: g p outhhold Tory Date of Inspection: 10 // or and of Tr n _Receipt of CAC Report: usfoes _Lead Agency Determination: _Technical Review: _,Public Hearing Held: a Resolution: Name of ApplicantWA , /�i !=�� x Address 0? Phone Number:(6-3/) Suffolk County Tax Map Number: 1000 - a Property Location: (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: Lrd of Trustees Applicatii GENERAL DATA Land Area(in square feet): Area Zoning: Previous use of property: / P&V&� Intended use of propert Covenants and Restrictions: Yes ✓ No If"Yes", please provide copy. Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? ✓ No Yes If yes,provide explanation: Project Description (use attachments if necessary): X17 o ��� A i����✓G� �s/�� �� (Ad a^ard of Trustees Applicata —, WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: Zex �&, ACfJsquare feet Percent coverage of lot: % Closest distance betweenne est existing structure and upland edge of wetlands: %0 feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: �Ijh,12j. - Statement of the effect, if any, on the wetlands and tidal waters of the_town that may result by reason of such proposed operations (use attachments if appropriate): PROJECT ID NUMBER SEQR APPPENDIEND/X C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1 APPLICANT/SPONSOR 2 PROJECT NAME 3 PROJECT LOCATION' Municipality ZAT3 lbe , V t).511U6 0"") County 4 PRECISE LOCATION* Street Addess and Road Intersections, Prominent landmarks etc -or provide map Lolu" 5 IS PROPOSED ACTION ❑ New ❑Expansion 10 Modification/alteration 6 DESCRIBE PROJECT BRIEFLY L✓I ✓✓�'eP79)_7 i) /4/1)4) /-/S, // //xy!l�/ �i���G' f /ll/l /,�e 7 AMOUNT OF LAND AFFECTED. Initially acres Ultimately acres 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? MYes ❑ No If no,describe briefly. 9 WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply) ❑Residential ❑Industrial ❑Commercial ❑Agriculture ❑Park/Forest/Open Space ❑Other (describe) 10 'DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ElYes M No If yes, list agency name and permit / approval- 11 CURRENTLY VALID PERMIT OR APPROVAL? F1Yes ©No If yes, list agency name and permit / approval 12 AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? Dyes ❑No I CERTIFY kHE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sip ,sor N Da Signature -1 ` If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT(To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL EAF. Yes 0 No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617 6? If No,a negative declaration may be superseded by another involved agency ❑ Yes [—] No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,if legible) C1 Existing air quality,surface or groundwater quality or quantity,noise levels,existing traffic pattern,solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly C2 Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly. C3 Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly C4 A community's existing plans or goals as officially adopted,or a change in use or intensity of use of land or other natural resources?Explain briefly C5 Growth,subsequent development,or related activities likely to be induced by the proposed action?Explain briefly C6 Long term, short term,cumulative,or other effects not identified in C1-05? Explain briefly F- C7 Other impacts(including changes in use of either quantity or type of energy? Explain briefly D WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA CEA)? If es,ex Iain briefl : F] Yes F-�No E IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If es ex lam 1-1 Yes 1-1 No PART 111-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether It Is substantial,large,important or otherwise significant. Each effect should be assessed in connection with its(a)setting(i.e urban or rural); (b)probability of occurring;(c)duration; (d)irreversibility;(e) geographic scope;and (f) magnitude. If necessary,add attachments or reference supporting materials Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been Identified and adequately addressed. If question d of part ii was checked —kgs;tf&dgterrniaatisRefSig aifisaflse-Ott►st-evaluate4he-petentiaHmpac4efth"Fepesedaotien-enthe-envlronmentaf-eharacteristicsoftheC� — Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur Then proceed directly to the FULL EAF and/or prepare a positive declaration. Check this boxif you have determined,based on the information and analysis above and any supporting documentation,that the proposed actio WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from responsible officer) Board of Trustees Application County of Suffolk State of New York �UCJ� BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/I ER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PR PERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH O/F� HIS APPLICATION Signatur SWORN TO BEFORE ME THIS a` DAY OF fl-ey1 t I 120 0 N ary Pub c JAY E.SC 4Y Notary Public,state of New York No.31-4986609 Qualified in Nassau County __ -- - - -----Cpmmfssion Expires Dec.1A i5i=p-a-0� ' Pard of Trustees- Applicat L i . AUTHORIZATION (where the applicant is not the owner) I► residing at (print owner of property) (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. Owner' gnature) 8 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOURNAME: � ' (Last name,first name,middle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest_"Business interest"means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%%of the shares. YES NO t/ If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this j of 200_ Signature (�� Form TS 1 f Print Name /V 2y7Vp4 r/,� SUFFOLK COUNTY TAX MAP NUMBER FIRST HALF - SOUTHOLD TAX LEVY 0.2007-2008 473889 126.-2-15.1 DE TACH S-1 U6 FOR FIRST HALF PAYP41ENT-RETURN BOTH STUBS FOR I - 1, " PAYMENTCF-TOTA"LTAX,MAKE CHECK PAYABLE TO GEORGE R.'SULLIVAN, AMCUNTDUE BILL ES RECEIVER OF TAXAND*BITE BILL NO.AND TAX MAP NO.ON FACE OF THE CHECK. 7 16107 �67 h�IrTA_N�U_rCHEM_ I�E - FIRST-HALF ONLY 0 T9T IJA)� Burns Arthur FULLAYMP- EW ❑, r- k _14,979.355 (INCLUDE BOTH STUBS) ;accept payments during-regular business'hours: es located within the Town of Southold The following bank branch Bridqehampton National Bank, Bank of America, North Fork Bank, Suffolk Cbuntv National Bank., 4738890000126XZ2Zl5X1016lO7D7DO74896700000000014979350 S Bill M r I •� e c t•�� �; � ::'� fit. �. � " �{ �. : ,. �'Fa.Z�` �� ;;"s 4 J z low Lir �`N,,,3 ,?C!: �;,��"��n,►=.,!Y' �;`�� o�•� ��s '�•: 7��� • r 04/08/2009 •� i i H p � ',/ r a � 04108/20`09 14 42 ",tet LI 1 i 04/0812009 •1.4 : 42 04/08/2009 1442 s w 04110812009 14`12" 15 r. 17- 4' CID IC 130 o-, 7,-2, W 27 '44 co 'a Ck 0 5: nPOOL Z;, Cli 4.7 METER cz::Z:z tck) q 0 7S- F LA rn 0 OS 2.2.4 CE APRO 4 C, C) 14 Ile Oh 4 ' o I�c 4 16 1 OC6, 4 001, ----------------------- I NerveLINE NE n S. sax xu.No 11 ?• s' $ 0\' Oil 0000 .y- ]Eve 00 0 ` / �b� •t611c�O O t iiIUC,xs MA- 6 a6r ¢ L] u21v0 •SOT x.iva cmuxv.:c. �J` tM •s7c o 5 0 �• n + Se Ho/fon Creek 7 ate/• —N— °a\,`+ oi,N ,e '�`•-,C, � O / t�-a° �1\�' EE sec w.,s. � \ \ 4 rax ^• SEF 6EC.N0. \�• 3 ' g '�` S'T' ,zs-w-624:a 'r ,§ J � t, �.�• ,p a ,S-i ate: e 1• / '4` sEE sic w\• 1 i F. 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