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TR-1527
Glenn Goldsmith, President ®��®� S® Town Hall Annex Ur�®� 54375 Route 25 A. Nicholas Krupski,Vice President ® P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly Telephone (631) 765-1892 Elizabeth Peeples � �� Fax(631) 765-6641 C®UNv,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 st day.of construction % constructed When project complete, call for compliance inspection; Glenn Goldsmith,President ®r- so�fy Town Hall Annex A. Nicholas Krupski,Vice President ®� ®e® 54375 Route 25 P.O. Box 1179 Eric Sepenoskif Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples a® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES May 9, 2024 TOWN OF SOUTHOLD David Bergen P.O. Box 1008 Cutchogue, NY 11935 RE: JAMES & PAMELA LUBIN 2765 WELLS ROAD, PECONIC SCTM#: 1000-86-2-2 Dear Mr. Bergen: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, February 14, 2024. RESOLVED that the Southold Town Board of Trustees APPROVE the Administrative Amendment to Wetland Permit#1527 to construct a 4'x24' ramp with short stairs to ground off of current landward end of catwalk using 4"x4" posts and thru flow grating; new ramp to be maintained 3' above wetlands as per NYDEC.; and to add water and electricity to landward end of catwalk; with the condition of the use of dark sky compliant lighting; and as depicted on the site plan prepared by David Bergen & Ken Quigley, dated February 6, 2024, and stamped approved on February 14, 2024. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, -�V— 4" Glenn Goldsmith President, Board of Trustees GG/dd 4 LOCATION PLAN Dock water and elec to terminate Al 4'-0° Continuous Handrail R at landward end of walkway 4"x4"Post ' Existing Stair to be Removed NEW RAMP EXISTING CATWALK Flow-Thru Decking p�°$ 'r HOGS NECK 4T 24'-0"+/- TO REMAIN EXISTING FLOATER TO REMAIN New Steps o . ; ih r t, 1 n� AHW_ _ �, +; 2765WELLS,ROAD -- — - -- --- - ----- ---------- --------- ----- ALW --- o PEGONIC, '. - - _ T'E W Z ; le-- Q.= Q a i ..J > _ • U c� W LITTL•E IStarkin Point of Wettarids' _ NASSAU — — P PECONIG Bounda ry _ — ! olNr —� a —I�� —i�—�!- t ',Z� _ BAY —_I — _ —I-1 -=_ _I 1. E —I 41 Fk, I— I I — — 1 Walkwa E v 4 RamSection , NEW SUFFOLK,.NY x- Al sp 2' Scale: Al Scale: PROJECT DESCRIPTION 0' 5' 10' 20' 0' 2' 4' MODIFY EXISTING PERMITTED RAMP,CATWALK AND DOCK BY:REMOVING NON-FUNCTIONAL STAIR AND CONNECTING A .• �..__t I NEW 24'X 4'RAMP AND SHORT STAIRS TO THE LANDWARD SIDE / DISTANCE TO OF EXISTING CATWALK. NEAREST STRUCTURE .' NEW RAMP EXISTING CATWALK NEW RAMP TO MAINTAIN 3'-0"ABOVE WETLANDS AS PER NYSDEC / 68'-0"+/- 24'-0" 1 TO REMAIN EXISTING FLOATER TO REMAIN CREATE/MAINTAIN A 16-0"NATURALLY VEGETATED NON-DISTURBANCE BUFFER. / / J.. . / Ramp to be supported by 4"x 4"posts. b Ramp surface to be flow-thru decking. / Water and electricity to be added to seaward end of ramp. \ I WETLANDS DEMARCATION LINE ALL AS PER PLANS DATED:FEBRUARY 6,2024 �— DENOTES 15'-0" - NATURALLY VEGETATED . . 1 NON-DISTURBANCE BUFFER APPRO ♦- LD BY. NOTES 2 Walkwa n 1. MEAN LOW WATER-MLW IS DEFINED TO BE 0,0 AS INDICATED ON SITE Al Scale:1"=10'-0" ?" `OF'TRUSTEES SURVEY DRAWINGS BY PECONIC SURVEYORS,P.C. 0' 5' 10' 20' Q ` .. 'n LANDWARD END OF PROPOSED CATWALK TO NEAREST STRUCTURE IS •OF-.SOU I HOLE/ 70,_0+/_ m 2, EXISTING CATWALK,RAMP,AND FLOAT(S)PERMITTED SOUTHOLD TRUSTEE PERMIT TR-1527 r 189.40' DATE DEC PERMIT - TW15273-0090 SEPT 19,1977 qv N85 '50"E " IiN Cli CW ------- ICHMOND CREEK 46 %,Z I TlE LINE ALONG MNWM Z Z / I %! ' / / 000c nmtnxa oo� fY rrt o J0.B' t I / / r a z DUCK \' 1 1 < }' LANDWARD EDGE OF WEFLANDS Q O I aX 2 STY.FIR f 1 , {.'. m ti I , m OELIN&iTEO BY SUFFOLK C 19 F OUg 9 1\ I t 11 \\ \` `� .;;� _ ENVIRONMENTAL CONSUL7ING, n INC. ON AUGUST 17, 2018 DENOTES 15'-0" NATURALLY VEGETATED Z L Lubin - Applicant LL m I NON-DISTURBANCE BUFFER FR PROPOSED RAMP FM _•` T I I ! \ �° �� \ �:•.-:'�:. s `=' 2765 Wells Road, Peconic, NY 11958 SCTM - 1000-086-002-002 LL FEB - 6 2024 Prepared by: David Bergen and Ken Quigley S84 56'50"W U. I U. Southold Town Construction Scope Plans Board of Trustees Date-FEBRUARY 6,2024 Drawing: _ 3 ' Al Scale:1"=20'-0" Scale:As Noted Al 0' 10' 20' 40' Tt a C r< Cantrell, Elizabeth From: Dave Bergen <davebergen78@gmail.com> Sent: Tuesday, February 6, 2024 3:10 PM To: Cantrell, Elizabeth Subject: Lubin Amendment Project Description Modify existing permitted ramp, catwalk and dock by removing non-functional stairs and connecting a new 24" X 4" ramp and short stairs to the landward side of the existing catwalk. New ramp to maintain an,elevation of 3 feet above wetlands as per NYDEC. All per plans dated February 6, 2024. ATTENTION: This email came from an'external source. Do not open attachments or click on links from unknown senders or unexpected emails. i NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Division of Environmental Permits,Region 1 SUNY caStony Brook.50 Circle Road.Stony Brook,NY 11790 P:(631)444-03651 P(631)444,0360 www.dec.nygov February 2, 202 E C E � �n David Bergen ® U Box 1008 Cutchogue, NY,11935 FEB - 6 2024 Re: Application#1-4738-04823/00002 Lubin Property:2765 Wells Rd Southold Town SCTM#1000-86=2-2 Board of Trustees Dear David Bergen, The Department of Environmental Conservation (DEC) has completed a-review of your client's request to install a ramp connecting to the existing catwalk and we have the following comments. men as na a 'ectio , in enera, o re However, technical staff indicate:the following changes to the project plans are require for to permit issuance. 1. The proposed buffer must extend no farther seaward of the tidal wetland flagging. You must resubmit the plans showing a buffer beginning at the flagging as depicted. on the submitted plans.The resubmitted plans must note that this area.is to be a "vegetated, non-disturbance buffer"as opposed to°non4urf. Please.be:advised gravel will not be permitted in this area. 2. In order to avoid further vegetation disturbance,the ramp must be elevated 3'-4' above grade to allow for light penetration and growth of native vegetation. Please revise the project plans as indicated above and submit two copies of revised plans.to my attention. Please call Jennifer Burton of the Marine Habitat Protection unit at 631-444-0295 with any technical questions, or you can.contact me via email at heather.leonard@dec.ny.gov with any procedural questions. Sincerely, Heather Leonard Environmental Analyst cc: Lubin JF Living Trust BEH File ry wt Department of Environmental Conseivatlon Glenn Go1L°._o,.h,President �0 COGy Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 0 Eric Sepenoski . ,? P.O.Box 1179 Liz Gillooly �y • ��� Southold,NY 11971 Elizabeth Peeples �Cl �a Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 2 1211 24 Completed infield by: E��4W-k fee t��eJ David Bergen on behalf of JAMES & PAMELA LUBIN requests an Administrative Amendment to Wetland Permit#1527 to construct a 4'x25' ramp from current landward end of catwalk using 4"x4" posts and thru flow grating; add water and electricity to landward end of catwalk. Located: 2765 Wells Road, Peconic. SCTM: 1000-86-2-2 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: /Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info need ed/ModilIfications/Conditions/Etc.: cn di-�D n S iCS coyWoli galk Ii i�- 1VI&-billej Present Were: G. Goldsmith N. Krypski E. Sepenoski L. Gillooly E. Peeples J if ECG N MAIN ROAD (S.R.25) JAN 17 2024 VEY OF PROPERTY ' AT PECONIC ` T N OF SOUTHOLD s01�1fT COUNTY, N.Y. N/o/F °frr�TI 1000-88-02-02 DEBORAHJOHN SDEAVER i SCALE. 1'--20 SEPTUM 19, 2018 N 189.40' FENCE I I I 5B 50°E N84 v'C0 I I o.e x' c . 'ter ".- _,:__---- �,�\ �,/ �,/�,�', � �� RICHMOND CREEK _ M r ca O /' ,� � , /' I WLF �d TIE LINE ALONG MHWM m CK� l ,/ ' f/' d 2 oomw cN ooac cn o � °ttK LANDWARD EDGE OF W971ANDS P 2 FR U on DELINEATED BY SUFFOLK HOUSE to �1 1 ` ��\ �1 EAMRONMENTAL CONSUL77NG, yp FF-9.9' oo c INC. ON AUGUST 17, 2018 \ sWE I \ STY FR 10AW5 r \\ �'08.7 'ao�'t� \ I \ \WtF KEY @ a RE84R Itm Proe SEOF NOW 9 o TEST HOLE S8r}56'SO"W � y, • a PIPE r �N �4P 'T.IMe ■ a MONUMENT N/O/F K7LAND FLAG WILLIAM & VI T RIA GORDO ZEUATIONS REFERENCED 7V NAIAD 88 JUL -2 2021 W ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 72090E ` Southold 7bWt1 I S UQ NO. 48818 HE NEW YORK STATE EDUCATION LAW. EXCEPT AS PER SECTION 7200—SUBOMSION 2. Board o Trustees PBCO RS, P.C. AID LL MAPOR COPIES BEAR THE IMPRESSED SEAL OFF TAP HE SURVEYYOR ES w�E ONLY IF (631) 765-5020 FAX(631) 765-1797 IIONATURE APPEARS HEREON. A= 18,913 so, F?: P.O. BOX 908 s MHOOLLD,N Y s� 18 163 I 4 LOCATION PLAN Existing Ramp to be Removed Al 4'-0" Continuous Handrail a =• Dock water and elec to terminate 4"x4"Post A$ HOGS NECK at landward end of walkway NEW RAMP EXISTING CATWALK Flow-Thru Decking p� _ New Ramp to Terminate where 25'-0" TO REMAIN EXISTING FLOATER TO REMAIN Ramp Meets Grade b q -- -- ---- ----- --- - ---- ---------- --------- ----- AHW 2765 WELLS ROAD �. . _ ALW ° �� PECONIC,NY - ASS AU PECONIC 4.` v POINT BAY - - NEW 1 WalwElevation4 Ramp Section SUFFOL Scale: K NY o' 5' 10, 20' Al Scale: PROJECT DESCRIPTION 0' 2' a' / Add a 25'X 4'ramp landward from end of existing catwalk onto permitted catwalk,ramp and dock. / + ) Ramp to be supported by 4"x 4"posts. / DISTANCE TO Ramp surface to be flow-thru decking. NEAREST STRUCTURE NEW RAMP EXISTING CATWALK Water and electricity to be added to seaward end of ramp. i4 70'-0"+/- 25'4" TO REMAIN EXISTING FLOATER TO REMAIN / ALL AS PER PLANS DATED:JANUARY 16,2024 J I NOTES 2 Walk a n 1. MEAN LOW WATER-MLW IS DEFINED TO BE 0,0 AS INDICATED ON SITE SURVEY DRAWINGS BY PECONIC SURVEYORS,P.C. Al Scale:1"=10'-0" 0' 5' 10, 20' LANDWARD END OF PROPOSED CATWALK TO NEAREST STRUCTURE IS 70'-0„+1- m 2, EXISTING CATWALK,RAMP,AND FLOAT(S)PERMITTED N SOUTHOLD TRUSTEE PERMIT TR-1527 N DEC PERMIT - TW15273-0090 SEPT 19,1977 189.40' N845V50'E — / /1 1 Iv, —————— /'/' iO RICHMOND CREEK ® i' O / o� x \ 70A"+/- t WLF I— T/E LINE ALONG MHWM m °EX \ Ij 1 1 1 LANDWARD EDGE OF WETLANDS O 1 / °1 2 STY- FFt 1 \ 1 1 m DELINEATED BY SUFFOLK i 1 ' FF HOUSE99' \ 1, 11 1 1 I ENVIRONMENTAL CONSULTING, LL v \ 1 1 \ 1 i INC. ON AUGUST 17, 2018 11 \ 1 z Lubin - Applicant LL m m s E �i I V PROPOSED RAMP cl k 11cr \\ cl =G7 a r I I ��\ �� �\ �� ? r I.� ` C \ I 1 \ s , 2765 Wells Road, Peconic, NY 11958 'oo zea / I \WLF�\ \\ \ \a- g ��0. 1 �AN 1 7 2024SCTM - 1000-086-002-002 R _ € La \ — / �� 1 \ 3 Prepared b David Bergen and Ken Quigley / P Y� 9LL FlPE Sg4 56'S0'W i U. Southold fTnistees Construction Scope Plans z 3 Date-JANUARY 16, 2024 Drawing: a 3 S° le:, Al Sca °=zo'-o" ey Scale:As Noted u 0' 10' 20' ao a c u x�. Address Ro� Pe ' CL` THIS. NOTICE MUST RE DISPLAYED DURING CONSTltUCTlOId SOU' TH' OLD T' '- ' ' USTEES lcgq TOWN TRUSTEES OFFICEeTO:WN OF SO.UTHOLD SOUTHOtDI N.Y. 11971 .. TEL.: J65-1892 ; . L � I y .�a �c lf• _� Vr�d I r e, t v� ti ems_ 5 .� t� '�� �"► � � \ 1 J _ s tiiv ~ +R� , i} � S�.I �"K►��'"'•-n��' _ -erg �� *.VA4 it ":Al -Vil��.�..��..�E �..r gyp v.. � .. _ ;�� 77�1►� f l v :ter• ,�f�.i9C` w r 1 ?f; i i -• � � � e T �_ �YaN Li po ,+ f WIM Sag, , __ �� tt'�sL'„_r.-� _ - �����Z�,} ^.�e� �: �J!' �� �.` _``.s•-'�::-'e^i:Vz.r+'�.�' _.�•`„�9;y ` :��.'���������"'r"�'- •'s A' :��'ter'. '��+E;. W .mac �• 7�`+,f• -�+. c yua wcus mu-uuugie(naps Go gle Maps 2765 Wells Rd j port ua.Ocr Y �aril enstavra�a 9 Southold Menel Southdd Police oepartmerrt Scott OeSimone ?he H., .� pnn�ma�s away `Pr fi. G ('� o ` Ie Map data©2024 200 ft 2765 Wells Rd Building Directions Save Nearby Send to Share phone Glenn Goldsmith,PresidentJ� + f Town Hall Annex A.Nicholas Krupski,Vice President ��+ �� �,� 54375 Route 25p.0.Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly CIO Telephone 631 765-1892 Elizabeth Peeples .-� �Sz p ( ) � t Fax(631)765-6641 BOARD.OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For'Office Use Only 3.. Coastal Erosion Permit Application E Wetland Permit Application Administrative Peimit JAN 17 2024 —k-_Amendment/Transfer/Extension 9 X Received Application: Received Fee:S 100. so of Trustees holdTown Completed Application: Incomplete: SEORA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): x LWRP Consistency Assessment Form Sent: CAC Referral Sent: Date of Inspection: Receipt of CAC Report: _Technical Review: _Public Hearing Held Resolution: Owner(s)Legal Name of Property(as shown on Deed): Lubin JF Uvinq Trust, Lubin PM Living Trust Mailing Address: 24 Tower Ct, Syosset, NY 11791 Phone Number: 201-452-7595 Suffolk County Tax Map Number. 1000-86.-2-2 Property Location: 2765 Wells Rd, , Peconic NY 11958 (If necessary,provide LILCO Pole 4, distance to cross streets,and location) AGENT(If applicable):David Bergen Mailing Address:Box 1008 Cutchogue NY 11935 Phone Number: 516-848-6438 Email:davebeMen78@gmaii.com Board of Trustees Application GENERAL DATA Land Area(in square feet): 18,913 Area Zoning:R-40 Previous use of property:residential = . Intended use of property: residenttial Covenants and Restrictions on property? —aYes _IZI_No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? _aYes ✓�No If"Yes",be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? J:LYes _21TNo If"Yes",please provide copy of decision. s project any demolition as per Town Code or as determined by the Building Dept.? re Yes u✓ No Does the structure(s)on property have a valid Certificate of Occupancy? Yes_O_No Prior permits/approvals for site improvements: Agency Date Trustees#1527;9983 3/30/82 transferred 2021;9/15/21 NYDECTW15273-0090 Trustee 1341 and 1025 11/1/78 and 613/74 ❑ No prior permitstapprovals for site improvements. Has any permittapproval ever been revoked or suspended by a governmental agency? _a No_D Yes If yes,provide explanation: Project Description(use attachments if necessary):construct a ramp from current landward end of catwalk 25 feet landward (4' X 25) using 4" X 4" posts and flow thru grating. Water and electrical included at landward end of catwalk. Maintain 15 ft non turf buffer 'Board of .Trustees: Appiica.._ n: AFFIDAVIT:. j vl �._..._..:p4�*P � :.';BEIN.G DUi:Y SWORN. - DEPOSES AND AFFIRMS THAT HE/e.�SHE IS THE'APPLICANTFOR THE.ABOVE DESCRIBED PERMITS)AND THAT'ALL`.STATEMENTS CONTAINED HEREIN . ARE TRUE.TO THE BEST OF.-'-HIS/HER KNOWLEDGE:AND BELIEF;AND.THAT . ...- . ALL WORK.WILL BE DONE IN..THE:MANNER SET FORTH.IN.THIS APPLICATION-. AND AS MAY.BEAPPROVED BY THE;SOUTHOLD,TOWN BOARD.OF:TRUST.EES: THE.APPLICANT AGREES TO-HOLD.THE TOWN:OYSOUTHOLD AND:THE: . ..: . . BOARD OF 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 iikliEBY AUTHORIZE THE TRUSTEES;-THEIR AGENT(.)S 'OR REPRESENTATIVES .INCLUDING THE CONSERVATION ADVISORY COUNCIL;TO ENTERONTO.:MY PROPERTY TO . :.-INSPECT THE PREMISES lNiCONJUNCTIONWITH,.THIS.APPLICATIO%N, . INCLUDING:A FINAL:INSPECTION.:LFURTHER�AUTHORIZE THE BOARD OF TRUSTEES:.TO:-ENTER ONTO MY .:PROPERTY AND REQUIRED TO:INSURE COMPLIANCE WITHANV CONDITION OF ANY WETLAND OR.COASTAL EROSION PERMIT ISSUED BY-THE BOARD:OF TRUSTEES;DURING THE TERM OF THE PERMIT. i afore;of Property:Owner. Signature of Property-Owner SWORN TO:BEFORE ME.THIS: 3 DAYOF. L):ec JOHN.OLSZEWSKI � NOTARY PUBLIC,'State of New York.- tary.Public No.:4898051 Qualified iri Suffolk County Commission Expires.July 13, Paz. Board of Trustees Applica—in AUTHORIZATION (Where the applicant is not the owner) I/We, Z;0 ES. . F- A-'etS owners of the property identified as SCTM# 1000-. Z �` n� in the town of New York, hereby authorizes �✓4 L)f i> e2 a 64 to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. Pr p Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS . ,3'4_ DAY OF Q�_�,,�,�g Q 2 20:23 Nolblic JOHN OLSZEWSKI NOTARY PUBLIC, State of New York No.4898051 ' Qualified in Suffolk County Commission Expires July 13, I APPLICANUAGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM -The-Town ofSouthold's Code.of Ethics prohibits•coriflicts.of interestjn the part oftown�oflicers'and-emoloyee§:The pumose of ;this form•is=to-brovideinfoiindtion which canialert the town,of possilite conflicts:ofiritetr st en-d allow:it tb take whatever action is necessaiv to avoid//same. ,p YOUR NAME: (Last e,first name,jpiddle initial,uoless.you area lyingimthe 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;orthild)have a:relationship with any officer-or employee. of the Town of Southold? "Relationship"includes by blood;:marriage;of business interest:"Easiness interes>"'meansabusigess, including a partnership.-'in.Which the townoffceror etnployce has even.a partidl ownership.of(or employment liy).°a corporation in which the town officer or empoyee.ow ns,more than:5%o o€3he shares. nYES n NO _ . 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): EIA)the owner of greater than 5%ofthc:shares of the corporatc;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 thq d 20 2 3 Signature Print Name Fonn TS 1 APPLICANUAGENUREPRESENrATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Souttiold's.Code.of Ethics prohibits conflicts.ofintereston the trait<oftown oflicets and emofoyees The aumose of this forth is b arovide information whichcan alert the town of trossible conflicts of interest and allow it io take whatever action is necessary to id name. yOURNAME: David Bergen (Last name,first name,griddle 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 ofplat Mooring Exemption from plat or official map Planning Other (If"Other",name the activity.) D the Town ofSouthothr Reyour-sbmpany,spouse,sibling,parent,or child)have a-relationship;with any officer or,employee Do you personally(or through your-company, " ip"includesby blood,.inwriage,or business;➢nterex"Business inteiest"means a;business. including a partnership,in which the town officer or employee has evert a partial ownership of(or cmplo' ."'by)a corporation in which the town officer or employee owns more than 50/0of the shares. YES NO 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 S%of the shares of the corporate stock of the applicant (when the applicant is a corporation); E-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 day of 20 Signature I Print Name DaV Bergen Form IS I '� Box 1008 Cutchogue, NY. 11935 January 17, 2024 Southold Town Trustees Southold Town Annex 54375 Rt 25 Southold, NY. 11971 Trustees, We are requesting an amendment to Southold Town Trustee Permit#1527 to modify the permitted dock structure to include a 25 ft. ramp for Lubin JF and PM Living Trust located at 2765 Wells Rd, Peconic, NY. .You will find an original packet with one copy of the following: -Color pictures -Property Survey -Property Site/Construction Plan -Copy of location map -Application fee check for$100 This projects purpose is to provide protection to the intertidal wetlands with the addition of a ramp landward of the catwalk. The ramp's surface will consist of flow through decking to support the habitat in the intertidal zone. Please let me know if you require any additional information. Sincerely, 0, David Be 6� E C E I V y' Agent for Lubin JAN 17 2024 Southold Town —oerd of Trustees Glenn Goldsmith,President �QF so(/l Town Hall Annex A.Nicholas Krupski,Vice President O y�lO 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold, New York 11971 Michael J. Domino G Q Telephone(631) 765-1892 Greg Williams �O �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD May 20, 2021 David Bergen P.O. Box 1008 Cutchogue, NY -11935 RE: JAMES &,PAMELA LUBIN 2765 WELLS AVENUE, PECONIC SCTM# 1000-86-2-2 - Dear Mr. Bergen: The following action was takenby the,Southold Town Board of Trustees at their Regular Meeting held on Wednesday, May-19, 2021: RESOLVED, that the Southold Town Board of Trustees APPROVE the request for a Transfer of Wetland Permit#1527 from Ralph Condit to James & Pamela Lubin, as issued on March 30, 1982. .Any other activity within 100' of the wetland boundary requires a permit from this office. This is not'a determination from any other agency. If you have any questions, please contact our office at (631) 765-1892. Sincerely, Glenn Goldsmith, President Board of Trustees GG/dd Glenn Goldsmith, Pi,` -1-,lent ��511FF0(�-Cp Town Hall Annex A. Nicholas Krug;.,.::,^Vice-President ,��� Gy�q 54375 Route 25 John M. Bredemeyer, III y P.O. Box 1179 Michael J. Domino o Southold, NY 11971 Greg Williams y�o 0- Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES Date/Time: TOWN OF SOUTHOLD ���:?Oz1 rJ '` �Z Completed in field by: / 1✓e � ` c.— David Bergen on behalf of JAMES & PAMELA LUBIN requests a Transfer of Wetland Permit#1527 from Ralph Condit to James & Pamela Lubin, as issued on March 30, 1982. Located: 2765 Wells Avenue, Peconic. SCTM#: 1000-86-2-2 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=� Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: I II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey :5 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: s' �nc v-11, C; A�f 1_e LC " -I ra., I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other J Box 1008 Cutchogue, NY. 11935 April 21,2021 Southold Town Board of Trustees Q � +� Southold Town Hall Annex Box 1179 ` APR l .I 2021 Southold, NY. 11971 Southold Town Dear Trustees, Board of Trustees As the agent for James and Pamela Lubin, we are applying for a transfer of Trustee permit #1527 dated March 30, 1982 from Ralph Condit to James and Pamela Lubin for catwalk, ramp and floats located at 2765 Wells Ave, Peconic NY 11958. Enclosed please find: Completed Applicant/Agent Representative Transactional Disclosure Form Completed Affidavit to allow Trustees to enter the property Trustee Agent Authorization Form Copy of Deed Transfer of property from Condit to Lubins Copy of Permit#1527 along with application and plans associated with permit#1527. A check to cover application fee of$50.00 made out to Town of Southold. Please let me know if there is any additional information required. I can be reached at 516-848-6438. Respectfully, David Berg Agent for James and Pamela Lubin AppLICANTIAGENUREPRESlEN'I'ATM TRANSACTIONAL,DISCLOSE FORM The Town of Southold's Code of Ethics Qrohr-its conflicts of interest on the part of town officers and emnlovees,_The putuose of this form is to rovide inforination which can alert the town of nnssrble conflicts of tnternst and allow tt to take whatever action is necesM to avoid same. _ YOUR NAME: .s G d t (Last name,first name,jpiddle initial,unless you are applying m the name of someone else or other entity,such as a company.If so,indicate thb.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,sibI"ing parent,or child)have a relationship--with any officer or employee of the Town of Southold? "Relationship' includes by blood,rgarriage,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 inore than 5%ofthe shares. YES NO Ifydu answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title br 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); - : I 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 i1 6ERANN R, MARINO Submitted this a� day of 1 20 NOTARY RUDLIC•6TATE OF NEW YORK Signature No 01 MAG147276 Print Name 0uAli#i@d in Suffolk County May 09iffIRA Expires 06-30-AaZ Board of Trustees Appli4 ion AFFIDAVIT J PAR eS ' L) Z� BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER 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 BOARD OF 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,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. r Si ature of Property Owner Signature of Property Owner &A SWORN TO BEFORE ME THIS \` DAY OF r, ' 520 a—�-- Notary Public 140,fAgy PU6LIM R,TE RI�O Y 110,01MAe147276 CRK �Uallfl®d In Suffolk County lvly Commission Expires 06-30--L0-a4 Board of Trustees Appli< ' 'ion AUTHORIZATION (Where the applicant is not the owner) V. owners of the property identified as SCTM# 1000- 0 in the town of R S New York,hereby authorizes ` to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. Pro erty Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS a DAY OF 20D_ Notary Public LL99A N R. MARINO WMV PUSU.PC-STATE OF NEW VQJJ4 N0,01 MA6147275 NflIlfled In Suffolk County MV COMMISGIon Expires 05-30-a0da CONSULT YOUR LAWYER BEFORE SIGNING THIS INSTRUMENT-THIS INSTRUMENT SHOULD BE USED BY LAWYERS ONLY THIS INDENTURE,madetthe day ofi=R,2016 BETWEEN THOMAS M. CONDIT, residing at 214 Four Knot Lane, Osprey, FL 34229; SHARON J. GRASSO, residing at 2765 Wells Road, Peconic, NY 11958; and CATHLEEN HARRISON, residing at 36 Baiting Drive, Calverton, NY 11933; as successor co-trustees of the Joan M.Condit Revocable Trust party of the first part, and JAMES F. LUBIN and PAMELA M. LUBIN, husband and wife, both residing at 24 Tower Court, Syosset, NY 11791 party of the second part, WITNESSETH, that the party of the first part, in consideration of EIGHT HUNDRED FORTY-NINE THOUSAND and no/100ths ($849,000.00)dollars paid by the party of the second part, does hereby grant and release unto the party of the second part, the heirs or successors and assigns of the party of the second part forever, SEE SCHEDULE "A"ANNEXED HERETO AND MADE A PART HEREOF BEING AND INTENDED TO BE the same premises conveyed to Joan M. Condit, as trustee of the Joan M. Condit Revocable Trust by deed dated September 8, 2008 and recorded in the Suffolk County Clerk's Office on September 25, 2008 in Liber 12566 Page 215 made by Joan M. Condit. TOGETHER with all right, title and interest, if an of the art of the first art in y, party p and to any streets and roads ,,, abutting the above described premises to the center lines thereof; TOGETHER with the appurtenances and all the estate and rights of the party of the first part in and to said premises; TO HAVE AND TO HOLD the premises herein granted unto the party of the second part, the heirs or successors and assigns of the party of the second part forever. AND the party of the first part covenants that the party of the first part has not done or suffered anything whereby the said premises have been encumbered in any way whatever, except as aforesaid. AND the party of the first part, in compliance with Section 13 of the Lien Law, covenants that the party of the first part will receive the consideration for this conveyance and will hold the right to receive such consideration j( as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same o bU first to the payment of the cost of the improvement before using any part of the total of the same for any other purpose. The word "party" shall be construed as if it read "parties" whenever the sense of this indenture so requires. IN WITNESS WHEREOF, the party of the first part has duly executed this deed the day and year first above written. TO BE USED ONLY WHEN THE ACKNOWLEDGMENT IS MADE IN NEW YORK STATE State of New York,County ofSuffolk ss: State of New York,County uffolk ss: On the (/day of M crf in the year 2016 On the day of in the year 2016 before me, the undersigned, personally appeared SHARON J. Before me, the undersigned, personally appeared CATHLEEN GRASSO HARRISON personally known to me or proved to me on the basis of personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is satisfactory evidence to be the individual(s) whose name(s) is fare)subscribed to the within instrument and acknowledged to (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the capacity(ies), and that by his/her/their signature(s) on the instrument,theandividual(s),or the person upon behalf of which instrument,the individual(s),or the person upon behalf of which the indiyi�(s}acted,a cecuted the instrument. the individuals) xecuted the instrument. signatur`and office ly_w[a t q acknowledgment) (s gnat a fin Ivid owledgment) NOTARY PUBLIC NOTARY PUBLIC MATTHEW SCHOENFELD _ MATTHEW OENFELD Notary Public, State of New York Notary Publ' , State of New York No_OISC6013498 No.OISC6013498 Qualified in Suffolk County Qualified in Suffolk County Commission Expires September 21,2018 Commission Expires September 21,2018 TO BE USED ONLY WHEN THE ACKNOWLEDGMENT IS MADE OUTSIDE NEW YORK STATE State(or District of Columbia,Territory,or Foreign Country)of Florida i SS: On the '�I l) day of March in the year 2016 before me,the undersigned,personally appeared THOMAS M.CONDIT personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies),and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument,and that such individual made such appearance before the undersigned in the 4Cin S�� in Florida rt the City or other political ubdivision) (and insert the tate or Country or other place the acknowledgment was taken) �t'� Y` (signature and office of indigidual taking acknowledgment) T=AENEE VXH1EL . . tlfoCerl►P�1��StFef OH ff�Bl�i ALL COUNTY ABSTRACT INC. My Cam•WresA W 24.2017 87 COVERTAVENllE '••,,;;;�?•r C�las�lon 0 FP 113,13Y 11 , FLORAL PARK,NY 11001 (718)470-9250f(516)352-7353 BARGAIN AND SALE DEED DISTRICT 1000 WITH COVENANT AGAINST GRANTOR'S ACTS SECTION 086.00 BLOCK 02.00 Title No. „�t"Cy LOT 002.000 COUNTY OR TOWN THOMAS M. CONDIT, SHARON J. GRASSO & STREET ADDRESS CATHLEEN HARRISON, as successor co-Trustees TO Recorded at Request of JAMES F. LUBIN & PAMELA M. LUBIN COMMONWEALTH LAND TITLE INSURANCE COMPANY RETURN BY MAIL TO: STANDARD FORM OF NEW YORK BOARD OF TITLE UNDERWRITERS Distributed by ARCHIE T. CHENG, ESQ. 87 Covert Avenue I* A Commonwealth Floral Park, NY 11001 LA,,DAmERica couP.Am Comm NWEALTIi LAND TITLE INSURANCE COMPANY w I' 1 a a ti t - Schedule A Description.Underwriter No. 575S9438 Title Number BAC-22667-5 Page 1 ALL that certain plot, piece, or parcel of land with the buildings and improvements thereon erected, situate, lying, and being in the Town of Southold, County of Suffolk, and State of New York, being bounded and described as follows: , BEGINNING at an iron pipe on the Easterly side of Wells Road, distant 2721.88 feet Southerly, as measured along the Easterly side of Wells Road, from the corner formed by the intersection of the Easterly side of Wells Road and the Southerly side of Main Road; RUNNING THENCE North 84 degrees 56 minutes 50 seconds East, through an iron pipe, 194.00 feet, to a point in the ordinary high'water mark of Richmond Creek; THENCE along said ordinary high water mark on a tie line course of South 05 degrees 03-minutes 10 seconds East, 100.00 feet, to the Northerly line of the land now or formerly of Berg; THENCE along the land now or formerly of Berg, South 84 degrees 56 minutes 50 seconds West, through an iron pipe, 194.00 feet, to the Easterly side of Wells Road; THENCE along the Easterly side of Wells Road, North 05 degrees 03 minutes 10 seconds West, 100.00 feet, to the point or place of BEGINNING. TOGETHER with all the right, title, and interest, if any, of the party of the first part to the beach, waters, and land under water of Richmond Creek, in front of and abutting said premises to the center line thereof. TOGETHER with Beach Rights in Liber 6381 Page 532, repeated in Liber 7559 Page 1, repeated in Liber 11091 Page 475. Said premises known as: 2765 Wells Road, Peconic, NY Q i - �+ _ owc� cc�., cn.�hli_.��-.c,.�.l.,��'/o�..� �'p�•�►���'/�;�__Q„�(_/s,�s� m�F'�f d�!c j�r'lfsn�s �visfr..p rawp n,e�.gt PAP-z — I� �0-new-feet�.f r'ow i'�o Pm la.p ° ° b�x2h' t3'e q,-I• -��•--- //u I V -FL,q IV 'VIEW, ,j p°�°ta aatale ia% Pita !! ;l • `�' � �� fi 1� ,1° "^'^^-�...`"...`�".'°""" a �"-'--•--�-....._..__ � , l/ 7 1 1 ropa,s� Red It II Saes/� �gk;�r 1 4; � � .,, .. _._.._ ..,... ^� ._ �� Ord H•�a...r H,�4�Ja�®r�»�� — __.. _.. ._.— _ _• •- �_�-� ..__ .. _ y _ �;+vnY��3' %k'yP'�j:_y�"(7r,.�.'PSM�',-..r _ ...su+...n.�.+� f' 1 1 9 6 -x 01!15160!�I� "I 51 n am Zia V "WE Q ME— MAI ist board Of Southold Town Trustees Ni SOUTHOLD, NEW YORK PERMIT NO. 1527 DATE: March 3Q 1982 ISSUED TO 'Ralph Condit a _ u#F ri a#tit Jz Z.. Pursuant to the provisions of Chapter 615 of the Laws of the State of New York, 1893; and Chapter 404 of the Laws of the State of New York 1952; and the Southold Town Ordinance en. titled "REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;" and in accordance with the Resolution of The Board adopted at a meeting held on March 2' ill 19 82 and in consideration of the sum of $ 15 .00 paid 6y Ralph Condit ..� 6,; of Pec.onic, N. Y. and su6jecf to the C Terms and Conditions listed on the reverse side hereof, 'gi, of Southold Town Trustees authorizes and permits the following: to remove exi sting isting catwalk and replace with 20 ft section of floating dock to be attached to existi;gl'�: floating dock. all in accordance with the detailed specifications as presented in the originating application. IN WITNESS WHEREOF, The said Board of Trustees here- 6y causes its, Corporate Seal to be affixed, and these presents to be subscribed by a majority of An ,"a*d Board as off-this date. 30J LIM Tiustees .110 MzF7 .5 'A Board Of Southold Town Trustees SOUTHOLD, NEW YORK MOORING NO. N/A PERMIT NO. 1527 DATE: ../44 7 ISSUED TO Ralph Condit certify that the work as authorized-' in thisp-�mit has been completed and is now ready for your inspe� tion. Also, the number required on this project is clearly visible. I further understand this permit is not valid until this tear sheetr,, is returp-ed to the Trustees. d Sifned - Owner Signed ntractor i - r TERMS and CONDITIONS The Permittee Ralph Condit residing at RD 3, 2765 Wells Road, Peconic, N. y,, as part of the consideration for the issuance of the Permit does understand and prescribe to the fol- lwin 1. That the Southold Trustees Permit must be prominently dis- p�ay�d on the premises effected thereby during the period of work under the permit. 2. That the said Board of Trustees and the Town of Southold are released from any and all damages, or claims for damages, of suits arising directly or indirectly as a result of any oper- ation performed pursuant to this permit, and the said Permit-tee will, at his or her own expense, , defend any and all such suits initiated by third parties, and the said Permittee assumes full liability with respect thereto, to the complete exclusion of the Board of Trustees of the Town of Southold 3. That this Permit is valid for a period of 12 mos. which is considered to be sufficient time required to complete the work involved, but should circumstances warrant, request for an extension may be made to the Board at a later date. 4. That this Permit should be retained indefinitely, or as long as the said Permittee wishes to maintain the structure or project involved, to provide evidence to anyone concerned that auth- orization was originally obtained. _ 5• That the work involved will be subject to the inspection and- approval of the Board or its agents, and non-compliance with the provisions of the originating application, may be cause for revocation of this Permit by resolution of the said Board. 6. That there will be no unreasonable interference with navigation as a result of the work herein authorized. " 7. That there shall be no interference with the right of the public to pass and repass along the:beach.between,high,and low water marks. F 8. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstruction to free navigation, the said Permittee will be required, upon due notice, to remove or alter this work or project herein stated without expenses to the Town of Southold. 9. That the said Board will be notified by the Permittee or the completion of the work auth- orized. (See attached sheet) . 10. That the Permittee will' obtain all other permits and consents that may be required sup- plemental to this permit which may be subject to revoke upon failure to obtain same. i I Y•`rx� Amok SOUT mm HULU I HEa U S I Em'm too S No. s' 't t` -r Issued T iq 4- p pq o N i r Date .. _ a Address E N JC- Al. THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE, TOWN OF SOUTHOLD SOUTHQLD. N. Y. 11971 sA+ TEL.: 765-1801 Y ....— . _.., :. 1. . .. . ... r \�~��a �� r .Jlr , u..h ri ..H .lna � � .. • .. i.�rr.._. .. �. tL.,v. >Ia.+•14 . r P/1 Rev/6,72 BOARD OF TOWN TRUSTEES Town of Southold Main Road Southold, New York 11971 To: ................................................R;A1P.h... .,...COI? .7, .................................................................... 1. Your application, dated ........Februarx 5 1982 ••••••r...•...••••••••.••••••••.•............ has been reviewed by this Board, of a meeting of the Trustees held on .......March 2, 1982. . ................. .... ....................................................... and resulting in the action, as indicated below: Application approved. (............) Application denied. (............) Application tabled. 2. Comments and remarks: 3. If your application is approved above, A Permit Fee is now due, and should be made payable to the order of the Board of Southold Town Trustees. This fee is computed below according to the Schedule of Rates as set forth in the Instruction Sheet (Form 1/1). If the Permit Fee is paid in person to the Secretary of the Board, The Permit will be obtainable at the same time. If the fee is paid by mail, the permit will be mailed in reply. Computation of Permit Fee: Vie) Rio, ao --00' x 20 of floating dock — -1:&$ sq. ft. C $.25 per sq. ft. 1 spile 5 . 00 - i�� 0 e�Total Fee for this application ...........................,................................. $ ........................................ Signed .. ..`.�:�:u::t.... ......}�...."...�.. :���. . .... -Board of Southold Town Trus e`� e ::'ti - - r =`r'u it crio3�3 a'-:�-" - ���, - � � - •- °- _� - .' - _ - N Alt - Rev. 6/72 in BOARD OF TOWN TRUSTEES Town Of Southold Main Road Southold, New York 11971 APPLICATION FOR FIXED and/or FLOATING DOCKS 1. Applicant's name and address: . .L O ! ..C C®A( �1. ..................................... �.. ...... �n..... �tJECC........�`...�:.....�."Cr®..`......`..�.....:�..C.............................................r 2. Contractor's name and address A ....�.� .................................................................................................................................................................. 3. Briefly explain the purpose of this application: ...�Xr a"l..C4.7.4. .��.=r.u,� 1©Za...��./.7 . csc.�.... o2L3 .5 cc.................................................. y nn j �z+iC' /6 to L'�a?ttzas4 ditLA ee�r� . t"n ..... .. ...... �... ...... .......................... y. ..... Y` ........................ CscL da.S If , 4. After issuance of a Permit, I expect to: (mark by an X) (a) Commence work — AT ONCE ............: ASAP X......; UNKNOWN ............. (b) Complete work in — 1 DAY ............: 1 MO. ..X......; 1 YR. ............; FUTURE ............. 5. Secure the correct Area Map from the Secretary of this Board, and by using an X WITHIN A CIRCLE indicate as closely as possible the location of this dock. On the reverse side of this map, provide a SCALE DRAWING which will show Ordinary High Water Mark, the shape and size of the dock and any supplemental pilings which are needed to hold a floating dock or tie-up a boat. Give all dimensions necessary to determine the area of the dock surface which extends offshore from the O. H. W. M. 6 Will any portion of this construction extend offshore into Town Waters beyond on imaginary line or boundary formed by other similar structures along the area's shoreline? YES oi-- . If it does extend beyond this so-called dock line indicate by how far, approximately,../� ...ft. 7. Provide the following documents: (a) A Licensed Engineer's Survey of the property involved. (b) A copy of the Contractor's Plans and Specifications. 8. Will this construction require the Filling of any land offshore of the Ordinary High Water Mark or the Dredging of any material from Town Lands under water? for NO. If it does, Form A/4 (Application for Dredging/Filling) must be completed and attached as part of this application. 9. In requesting approval of this application, I submit that: the information presented herein is true and correct to the best of my knowledge and belief; I am the person accountable for the performance of the work in accordance with the plans and specifications attached; I have read or am familiar with the provisions of any Southold Town Ordinance pertinent to the work involved; and further, I intend to adhere to and abide by the Terms and Conditions of the Permit, when and if issued to me. L. S. ........... .............................................. .Accepted by: Dated: r `_ �` 9, c a2 C- / a Cj �, G��3�•L��/�2C�cc% c�j- J a,vT Gt.�v°� ! v'•c, � � 'C��lJ�a-w: e.�cl t�i.�e^(`�',c,� G�c�,rcC��� ��—� -. , t/ �D tr i'1� a U�`[ T!D C2.4 '�D �J" e h`��/_VJ�/KLc3st�+��G �U•:e� +�' r.��t�l.L� ' TOWN OF SOUTHOLD SHORT ENVIRONMENTAL ASSESSMENT ' FORM INSTRUCTIONS : a In order, to answer the questions in this short EAF it is assumed that the preparer will use currently available information concerning the' project and the likely. impacts ,of the action . It is not expected that additional studies, - research o'r other investigations will be undertaken . (b) If any 'question has been answered Yes the project may be significant and- a completed Environmental Assessment Form is necessary . (c) If- all questions have been answered No it is likely that this project is not significant . (d) Environmental Assessment 1 . Will project result in a large physical ,change -to the project site or physically al-ter more than 10 acres of land? . Yes ,C No 2 . Will there be a major change to, any unique or unusual land form - found on the site? . . . . . . . . . . Yes No 3 . Will project alter or have a large effect on existing body of water? . . . . . . . . . . . . . . . . . . . . . . Yes X No 4. Will project have a potentially large impact , on groundwater quality? . . . . . . . . . . . . . . Yes V No 5. Will project significantly effect drainage flow on adjacent sites? . . . . ... . . . . . . . . . . . . . . . . Yes X No 6 . Will project affect any threatened or endangered plant or animal species? . . . . . . . . . . . Yes )( No 7. Will project result in a' major adverse effect on air quality? . . . . . . . . . . . . . . . . Yes X No 8 . Will project have a major effect on visual character of the community or scenic ,views or vistas known to be important to the communit-y? Yes )' No 9 . Will project adversely impact any site or structure of historic, prehistoric or paleontological -importance or any site designated as a critical ' environmental area by a local agency? . . . Yes )( No 10 . Will project have amajor effect on existing or future recreational opportunities? . . . . . . . ... Yes )( No 11 . Will project result in major traffic problems or cause a major effect to existing transportation systems? . . . . . . . . . . . . . . . . . . . . . . Yes No 12 . Will project regularly cause objectionable odors, noise, glare, vibration, or electrical disturbance as a result of the project ' s operation? . . . . . . . . . . . . ... . . . . . . . . Yes )j No 13 . Will project have any impact ,on public health or .safety? . . . . . Yes 1C No 14. Will project affect the existing community by directly causing a growth in permanent population of more than ,5 percent over a one year period ,or have a major negative effect on 'the character of the community or neighborhood? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .—Yes X No 15. Is there public controversy concerning the 'project? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X No PREPARER ' S SIGNATURE_ REPRESENTING DATE )C;:/, I/2 Rev/6/72 BOARD OF TOWN TRUSTEES Town of Southold Main Road Southold, New York 11971 INSTRUCTIONS PERTINENT TO THE FILING OF AN APPLICATION 1. All applicants should read and become familiar with the Town Ordinances which govern the use of WETLANDS or PUBLIC LANDS OF THE TOWN. Extracts and complete Ordinances are available from the Secretary of this Board or from the Town Clerk's Office. 2. A completed application will normally require a SINGLE COPY of each of the following items: (a) An application FORM A/1, A/2, A/3, A/4, or A/5) with all the questions answered. (b) An Area Map to show location of project. (supplied by Secretary). (c) A Licensed Engineer's Survey of the property involved. (d) A copy of the Contractor's Plans & Specifications. This may be supplied after approval of the application but a Permit will not be issued until the Secretary of this Board receives this item. (e) An applicant's diagram drawn to SCALE or the reverse side of the Area Map, showing the size, shape, and overall dimensions of the structure or work as well as its relation to Ordinary High Water Mark. 3. A completed application must be filed with the Secretary of this Board, before it can be reviewed by the Board at the earliest meeting after its date of filing. 4. In complicated cases, or at the request ofthe Secretary, it may be necessary for the applicant to present the completed application in person in order to supply additional or more complete in- formation than the Forms provide for. 5. After review by the Board, the applicant will be notified of the action taken, and if approved, such notice will also include the amount of the Fee required for the issuance of the Permit. 6. The following schedule of charges will apply: (a) A minimum fee of $5.00 will be charged against all applications Was- i;ie '-- - AA___ wog. This fee is payable at time of filing and is not returnable regardless of action taken. (b) Fee for Mooring (Form A/1) — at the rate of $1.00 per piling, stake, or other anchor- ing device. (c) Fee for Docks (Form A/2) — at the rate of 10c per Sq. Ft. of dock surface offshore of Ordinary High Water Mark plus $1.00 per piling used to,secure a. float or boat. (d) Fee for Bulkheads (Form A/3) — at the rare of $1,00 per lineal foot of construction offshore of Ordinary High Water Mark. (e) Fee for Dredging/Filling (Form A/4) — at the rate of 10c per cu. yd. based on the estimated maximum from computing the application. (f) Fees for Special Purposes (Form A/51) —at a rate depending on the type of work. 7. The Permit Fee, made payable to the Board of Southold Town Trustees, must be paid either in person or by mail prior to the issuance of the Permit. IF PAID IN PERSON, THE PERMIT IS OB- TAINABLE AT THE TIME PAYMENT IS MADE. 8. NOTIFICATION OF APPROVAL of an application is NOT a, PERMIT. 9. A Permit is usually issued for a period of construction to cover 12 mos., but may be for a shorter or a longer period of time as the case may warrant. The Permit should be retained, however, for as long as the construction will be maintained, as a proof of original authorization. 10. 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