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HomeMy WebLinkAboutMoyle, Donald Southhold Town inc. (Y?b� Jill M.Doherty,President C► - James F.King,Vice-President OD _ ( Dave Bergen , ' Bob Ghosio,Jr. / John Bredemeyer 6�1�z � r BOARD OF TOWN TRUST TOWN OF SOUTHOL)0 Office Use Only /GTS 5A, _�r-e- a,e,4, _ Po Coastal Erosion Permit Application �S kt� (• 0- Wetland Wetland Permit Application Administrative Permit _Amendment/Transfer/Extension _Received Application: _Received Fee:$ - Completed Application _--_----; ----- - Incomplete i - _SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) ` qR 15 2010 LWRP Consistency Assessment Form j _CAC Referral Sent: _Date of Inspection: ^� ; _Receipt of CAC Report: . a-c` = cT;d'_'-i ___)Lead _Lead Agency Determination: _Technical Review: _Public Hearing Held: Resolution: Name of Applicant®1,/4 L7 /V0 YAC Address l Y,2 � r �,r�/ L/ � Phone Numbe / 7/ O _ Suffolk County Tax Map Number: 1000 - Property Location: A?2— /,(/,{/� /�j�} � (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: K� Board of Trustees Application GENERAL DATA Land Area(in square feet): o lac- Area CArea Zoning: Previous use of property: Intended use of property: X-114 Covenants and Restrictions: Yes No If"Yes",please provide copy. Prior permits/approvals for site improvements: l Agency Date 2601 2)EP <0C/ No prior permits/approvals for site improvements. Has zny permit/approval ever been revoked or suspen ed by a governmental agency? No Yes If yes,provide explanation: Project Description(use attachments if necessary): 4 F Board of� Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: )J ec ,o Area of wetlands on lot: square feet Percent coverage of lot: - % Closest distance between nearest existing structure and upland edge of wetlands: 20 feet Closest distance between nearest proposed structure and upland edge of wetlands: 0 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: 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 617.20 SEAR APPENDIX 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 A6P6Pd3-(!7R 2.PROJECT NAME &PROJECT LOCATION, Municipality S4 VL County�C �d L 4.PRECISE,, LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map ?z-u) , A-gwc-c—a----r 5.IS PROPOSED ACTION: New ❑Expansion ❑Modification/alteration 6.DESCRIBE PROJECT BRIEFLY: Z-f- 7, -/,C7� 7.AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? 1-1 Yes ❑ 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) ❑Yes �No If yes, list agency name and permit / approval. A A CURRENTLY VALID PERMIT OR APPROVAL? ElYes /9No If yes, list agency name and permit / approval, 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? []Yes nNo I CERTIFY THAT THE INFORMATION PRO ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor / Date: Signature 5 If the actin ' a Costal Area,and you are a state agency, complete the CoastalAssessment Form before proceeding with this assessment 1 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 [:] 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. 0 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 [--------­-—_­­ ___ —1 C6. Longterm,short term,cumulative,or other effects not identified in C1-05? Explain briefly: 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 Yes No F E IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes exIain• F] Yes F—I No PART III-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 ye ,+hedeter,,,inatien o€ i^g iea nsa,rustevatuate4hepetentiakmpaet of the proposed ashen on the environ . 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 box if 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) I Board of Trustees Application IPJ-0;40 Rove its County of Smf 4k State ofNFLor(DW i ono 'A o BEING DULY SWORN DEPOSESAND ir HRMS 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/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY I 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 PROPERTY TO INSPECT T PREMISES IN CONJUNCTION WITH RE OF THIS APPLICATION. Signatu e SWORN TO BEFORE ME THIS J2 ,1A. DAY OF a rch -)20 /0 KIMBERLY E.MASSUNG z Commission DD 688757 Notary ub11cA' "`` Bond dTh.Ttoyiresjul , Fain Insu20cesoa3esao1e I APPLICANUAGENT/REPR.ESENTATIVE 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. �1 YOUR NAME: v (Last name,first nam ., riddle 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 platMooring Exemption from plat or official map Planning Other (If"Other",name the activity.) �C�E� �f✓C� 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 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 day of 2040 Signature Print Name Form TS l P y OTHER POSSIBLE AGENCIES YOU MIGHT HAVE TO APPLY TO N.Y.S. Dept. of Environmental Conservation (DEC) SUNY, Bldg. 40 Stony Brook, NY 11790-2356 (631) 444-0355 Mon., Wed., Fri., 8:00 AM-3:00 PM Suffolk County Dept. of Health Services 360 Yaphank Ave., Suite C Yaphank, NY 11980 852-5700 U.S. Army Corp. of Engineers New York District 26 Federal Plaza New York, NY 10278 917-790-8007 N.Y.S. Dept. of State Coastal Management 99 Washington Ave. Albany, NY 12231 518-474-6000 I BVI650M15 ra� 5 I>a 2+01 0 x.�x 00 H.0 \ � SaS EAYit O5M K. v \' i u ♦ �) ' 1•I4v 3L 3L1 �4, •„� tourxan. saEld a n x L.11 oao u i� •p ty F .$0 A — � 0,0' ' S ° � . W fta IIi1S L3•-::: F 1 41 114 G , S SEF SEC.qI tl�y x p.x ly `.Y •J L!!' ii4 ,/ M fp[.T sauncxD 311 O tS.f — a 1 a SIC Is i° SO�x�MOLD _ ..x1 yL S_ � '•S yb y Sf r Da*mcr G.D.2B L.D.43 � io P.D•la xF m R wylX333[/�� \ �WTS=COKFXYj hVG NECK �0 BAY c COUNTY OF SUFFOLK © SOUTHOLD Property . ,Agency m Q2 ^^ Red Pr Tax Service d. ..W.s 0087