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Home My WebLink AboutZimmer, Frank & Virginia Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18.~2 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application /Wetland Permit Application Grandfather Permit Application Waiver/Amendment/Changes ~Received Application: //~/~ ~/Received Fee:$ /b-O ~ ~/Completed Application . Incomplete . SEQRA Classification: Type I Type II Unlisted . Coordination:(date sent) ~/CAC Referral Sent: /Date of Inspection: Receipt of CAC Report% ' ' Lead Agency Determination: ~TTechnieal Review: Public Hearing Held: A~/q9 Resolution: SOUm LDJ Name of Applicant~< /~, ~ b//gg~n//~ ~, Address D;81~3 (~.0, -- ~,0, ~X ~J~ D(~': ~,~, 1~3'-~ Phone Number: (ST&) Suffolk County Ta.x~ap Number: 1000 Property Looation:~,tt0~ ~,~,-OF.,£~f(';/~,}', ~.3,~,~ (provide LILCO Pole #, distance to cross streets, and location) AGENT: O&,..,,,,u~F.. (If applicable) Address: Phone: FAX#: of Trustees Applicati~ COASTAL EROSION APPLICATION DATA Purposes of proposed Are wetlands present within 75 feet of the proposed activity? No ~ Yes Does the project involve excavation or filling? / No Yes If Yes, how much material will be excavated? How much material will be filled? - Manner in which material will be (cubic yards) (cubic yards) removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) 517.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be comDleted by ADDlicant or Proiec= sDonsor) SEC 3. PROJECT LOCATION: 4. PREC:SE LOCATION (S/reel address ~n~ road ,ntefsec~ions. ~rominenl lan~marAs, etc., 5. IS PROPOSE~ ~ New ~ Exoansion ~ Mooificationlalterazion ?. AMOUNT QF L.ANO AFFECTED: Initially 7'~ '~ acres Ultimately ~ ~ ~ acres ~ Yes [] No If No. descr~Oe brletly ~j:je$`~el~`I:l ~]'!~1~['ISti~']l J'~ Commercial '~ Agrlc~mJre 7'q Rar~/Fores:;Ooen soace ~ Omer STATE O;R LOCAL1? ~ Yes ~ No If yes, llst agency(s) and permstla~provals 11. DOES ANY ASPECT OF THE ACTtOt,I HAVE A CURRENTLY VALID PERMIT OR APPROVAL? If the action Ss in the Coastal Area, and you are a stab Coasts( Assessment Form before proceeding witl' OVER 1 Print or Type: ACCESS CONSENT FORM Office use Only FOR ACCESS File #: THROUGH PRIVATE PROPERTY Permit ~' (Name of Applicant) (Address) 2 ) zPu.~.r,..~. /d~,~T(z~ croft (Name & Address of Contractor Involved) (Project Location) (S.C.T,~. g) (Name of Road or Private Property Involved) (Hamlet) 5 ) ~ ~ (Hame & Address of Homeowners Association / Property Owner) (Brief Job Description) 7) 8) 9) Startin9 Date: ./5~-~c//~ Completion Estimated Cost of Proposed Work: F~£ ~uw~_~ Insurance Coverage: A. The coverage required to be extended to the Property Owner: Bodily injury & Property Damage; $300,000/$500,000 Bodily Injury & $50,00~ B. Insurance Company: C. Insurance Agent Name & Telephone # D. Policy ~ : E. State whether policy or certification is on file with the Trustees Office: (If no, Provide a copy with Application) (yes/no) (Signature of Applicant~) (Date) To be completed by the Property Owner: I/We the undersigned, fully understand the nature of the Proposed Work referenced above and have no objection to allowing the Applicant to cross My/Our Property to do the work. (~gnature of the~roPer~y Owner ordulyauthorized representative) Print.or Type: IOffi. ce use only File #:__ Permit #: TOWN OF SOUTHOLD HIGHWAY DEPARTMENT PECONIC LANE PECONIC, NEW YORK 11958 PERMIT & BOND APPLICATION FOR ACCESS THROUGH TO~N OWNED PROPERTY (Name of Applicant) (Address) (Name & Address of Contractor Involved) ,, -/- ~ ~ ~ o~,~ a~ ~ ~ ) : 1000- - - (Project Location) (S.C.T.M. ~) (Name of Road or Town Property Involved) (H~let) · 0~-'-- f'~,v~l~ ~oc~ i~ ~E Ou~-F ~£~tsT-~m~ oF ?? /~c~iF (Brief Job Description) 6) 7) 8) Starting Date: Completion Date: Estimated Cost of Proposed Work: ~ ~gm~ Do~-v~ Insurance Coverage: A. The coverage required to be extended to the Town: Bodily injury & Property Damage; $300,000/$500,000 Bodily Injury & $50,000 Property Damage Insurance Company: Insurance Agent Name & Telephone # : Policy # : State whether policy or certific&ti is on file with the Highway Departm (If no, Provide a copy with Application) Da (yes/no) (Signature ot'0 Applicant ) (Date) To be completed by the Superintendent Bond Amount Required: of Highways: (Signature) APPLICANT TRANSACTIONAL DISCLOSURR FORH The Town of Sou~holdts Code of Ethics prohibits c0n~Xic~s in~erest on the part of town o~ficers and employees. The purpose of this form is to provide information which can a~ert the town of po8sib~e con~lict8 el interest and it ~o take whatever action ts necessary ~o avoid same. YOUR NAHBt ~/~/~ ~/~"'~'~4~K ~/ ~ ~¢/,,,..,/~ ~,, .' .~ ' ~'~'~ (~aet name, ~lrsb name, m[d~.le you are applyin~ in bhe name sE somoono else o~her enbiby, ~uuh as a company. IE so; bhe o~hec pec~on'8 oF oompany'~ name,) NATURR OF APP~I~ATIONt (Check all ~h ; Tax grievance Variance change of App~9~a! of Exetp~ion from pl~t o~ o~ficial map other Do you personally (or ~hrough your ~Ompafly. spouse, sibling, paren~ or ~hi~d) have a relationship vl~h any offluer or employee o~ ~he Toss o~ Sou~hold? 'Rela~lonship~ in~ludee by blood, marriage, or business ln~eres~. 'BusLnees interest" means a business, including a pa£tnerehlp, in which the teen officer or employee has even a partial ownership o~ (or employmen~ by) a corporation in ehich the town of£i~er or employee owns more than 5~ of ~he shares. · NO ., you answered "YRS,#.oomplete ~he balance da~e and sign where indicated. Name of person employed by ~he Town oE Southold Title or position of ~hat person ..... Describe the relationship between yourself (the applicant) and the 2own offiuer or empioyee. Either cheek the appropriate line A) through D) and/or desoribe in ~he apace provided. The town officer or employee o~ his or her spouse; sibling, parent, or child is (check all tha~ apply)~ A) the owner of greater than 5% of ~he shares sE the corporate stock of the applicint (when the applican~' is a corporation)~ __.B) ~he legal or b~neficial owner sE any interest in a noncorporate'en~i~y (when ~he applioant is no~ s corporation)~ C) an oE~icer~ direc~or, pact,er, or employee ot the applicant; or __~) ~he aotual applicant. DESCRIPTION OF -. ',:'~'"'- ' RELATIONSIIZP "" Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hail 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18~2 Fax (516) 765-1823 BOARD OFTOWNT~USTEES TOV~NOFSO~HOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of COUNTY OF SUFFOLK) STATE OF NEW YORK) FEB 16 1999 AFFIDAVIT OF POSTING I. F%~- ~-%~x~ , residing at ~,-J ED. -~.otJ~o~ 33~ being duly'sworn, depose and say: That on the ~ day of~-C~ . 199 .. I persona%ly posted the property known as ~1~ ~ [~ by placing the Board of Trustees Official poster where it can easily be seen. and that I have checked to be sure the poster has remained in place for seven days prior to the date of public ~earing. (date of hearing noted thereon to be held Dated: ~-~5 ~, /§~/~ Sworn to before me this ~ day of ~d-~ 199~ -/ ( signature ) KENNETI4 J- MOLLO¥ Notary publiC, f~t~te ot New ¥o1~ No 4955512 Qualified in Sutteik County ~'~ Commission Expires September 5, County of Suffolk State of New York ~ 6, ~V/Rc~,~ ~, ~4Knr~ BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR TN 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 BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND T~U~ 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 HE~RRY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO E~T~LR ONTO MY PROPERTY TO XNSPE~ THE P~XSES IN CON=~CT~ON WI~ ~I~ OF THIS APPLICATION. ~.,,~~ OSignature6 SWORN TO BEFORE ME THIS DAY OF J~ ,1~¢~ KSNNSI~ 3. ~lOttO¥ No, 4995522 Co~mission Expires September 5, [OWN NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEESw TOWN OF SOUTHOLD In the matter of applicant: YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: 3. That the project which is subject to Environmental Review under Chapters 32, 37, or 97 of the Town Code is open to public comment. You may contact the Trustees Office at 765-1892 or in writing. The above referenced proposal is under review of the Board of Trustees of the Town of Southold and does not reference any other agency that might have to review same proposal. Enc.: Copy of sketch or plan showing proposal for your convenience. PROOF OF MKILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK , residing at ~/tq~D, ~r,~,¥, Itqr7 , being duly sworn, deposes and says that on the 4~-~day of mM, ,1997 , deponent mailed a true copy of the Notice set forth in the Board of Trustees Application, directed to each of the above named persons at the addresses set opposite there res~ctive .n~es; t~t the addresses set opposite the n~es of said perso~ are the address of said persons as shown on the current assessment roll of the Town of Southold; that said Notices were mailed at the United States Post Office at D~f~/~F~ , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to before me this day of ~7~ ~ ,199~ / / ' ' No/ary ~bl~ KENNETH J. MOLLOY Notary Public, Sta!e of New ~ No. 4955522 Qualified in Suffolk Coun~ ~mmi~ion E~ires September 5, ~d of Trustees Applicatio~ AUT~O~ON (where the applic~t is not~ I, resid~ at (print o~er of proper~// i ~aiiingad~ess) / do hereby authorize (Agent) to apply for pe~it(s) / Southold B~d of Town Trustees on ~ behalf. from the (Owner' s signature) New York State Department of Envird~-mental Conservation Division of Environmental Permits Rm 121, Building 40-SUNY Stony Brook, New York 11790-2356 Telephone (516) 444-0365 Facsimile {516) 444-0360 John P. Cahill Commissioner March 5, 1999 Frank B. Zimmer P.O. Box 355 Orient, N.Y. 11957 RE: Dockapp~cafion# 1-4738-02153/0000! Dear Mr. Zimmer: A person called fxom Sou[hold and pointed out to me that your property is landlocked attd ends at [he dike (berm). I checked [he tax maps and yo, ur survey one more time and this appears to be tree. Tiffs person also hfformed ~ne [hat you wereo t supposed to build on [he property due to some agreement wi[h [he county. I'm not sure what he was talking about. It doesn't look good for · the placement of a dock outside of the property lines. We can stillreview your ap. Dlication for tiffs dock. I spoke with [he teclmical staff person and we'll review any and all possibilities wi[h [he site. Please remember if you wish to continue [he apphcation process we need the scaled drawings and water dep[h information. A 2.5' dep[h Is a minimum for the issuance ora dock permit. When I visitedthe site on February 12, 1999, I reached a dep[h of approxhnatel¥ 2' at [he 100' distance from shore. You may stdl need to £md ano[her locatim'~ with a'2'.5 dep[h dm'it~g apparent low water within a reasonable distance from shore. Please call me if you have any questions. Thank you. Sincerely, Matthew R. Penski . Environmental Perutits