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Home My WebLink AboutTR-5661 James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # OI72C Date December 7. 2006 THIS CERTIFIES that the second-story addition, front porch, rear patio. garage, retaining wall. and sanitary system At R.O.W offViIlage Lane. Orient Suffolk County Tax Map # 24-2-11 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 10/1 0102 pursuant to which Trustees Permit # 5661 Dated 11/20102. Was issued, and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for a second-story addition, front porch. rear patio. garage, retaining wall and sanitary system. The certificate is issued to ANN MARIE KELLY owner of the aforesaid property. ~c7~ Authorized Signature Board Of Southold Town Trustees SOUTH OLD, NEW YORK PERMIT NO. . .5"&1 DATE: ·Nov·,·zOth;····zooz ISSUED TO.n......ANJ:LMARIEnKELLY ...................... ...... ...........n ^ut~nrii!ntin" Pursuant to the provisions of Chapter 615 of the Law¡ of the State of New York, 1893: and Chapter 404 of the Law¡ of the State of New York 1952: and the Southold Town Ordinançe 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 accordançe with the Resolution of The BOard adopted at a meeting held on .nN.o.y.,.?Q.tb . ZO.O.~m' and in consideration of the sum of $.200..0Q. m paid by . ::;ûff"lkl'l'lVi~Orl~",r)J..I1Çonl.iuJ,t~Ilj¡Q11'frehal£.o£A=.Marie Kelly .' . of onnnBl'idgehamp.ton ... .... .....oooo N. Y. and subject to the Terms and Conditionš listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the foHowinq: Weuana Pennit io construct a 1.075 sq. ft. second story addition, a 205 sq. ft. front porch extension a 96 sq. ft. rear patio, deposit 575 +/- cu. yd. of clean fill from an up~and source, relocate the existing garage to the eastern comer of subject property and construct a J 5 ft. long retair.iPg wall off the southern corner of same, abandon the existing sanitary structure and consttUct upgraded system and relocate private well - roof gutters and dryweUs for roof lWl-off also a tine ofbaybalcs during construction. as per plans stamped dated May 8. 2003. the originating application. IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these presents to be subscribed by a' majority of the said Board as of this dat.e. Trust... TERMS and CONDITIONS ~ ~~ ð. The Permittee Ann Marie Ke]]y residing at "illÂge l.aae., OlivuL N. Y., as put of the cooside<atioo for me isSuaøœ of the Permit does ~\1Iod IIDCI pœscribe to the fo¡- 1owÜIg: 1. That the said Board of Trusteeo IIDCI the TO'II'D of Soud1oId aœ ftlased from my IIDCI .u .wn.ges, ex claims fIX .wn.ges, of suIø arisiDg cIúecdy or inditecdy .. . RIUh of my o~· adoo pedom>ed pUnumt to dùs pemùt. IIDCI the aid 1\. ¡..... wiJJ, lit his ex her owø. upc_. defend my IIDCI .u such 1Ul1S'lodtI.-I by tbIrd parties, IIDCI the said F I...." .-- ... fall JIahIUq with RSpect thereto, to the ~ 'exdasIoa of the Board of n- of 1be TO'II'D of So ..1-.L1 24 2. That dùs PermIt is..w for . period of mas. ..tdch is (DV-wow,d to be the ecri.......d time' requited to œmpJae the ..uk 1a'fOhoed, but shoaJd CÚèaIiISUDCCS warnar, request for an exœasion may be .,..de to the Board at a later dace. ~. That dùs Penult should be RraIoed ladef"mitely. or as loag .. the said PermIttee wishes 10 m.i....in the sttuctUte or project lavolved, to provide evidenœ to anyoae ~ that amh- orizatioo was origlaa11y obtaIaed. 4. That the work Ia-rolved wi11 be subject to the ~ IIDCI appron1 of the Boerd oc iu agents, IIDCI 1101HOIII(>1iaoce with the provisåoos of the or'gi-,;"g epplicatioa. -y be cause for rewcatioo of this Permit by resolution of the said Board. 5. That there wi11 be no uareasooable interfereoœ with oavigatioo .. a RIUh of the wodo: be<ein aåthorlzed. 6. That there shall be 110 Interference willl the right of the pobIIc to ..... IIDCI repus aloøg the beach between high IIDCI low walet marks. 7. That if future operatioos of the Town of Southold œqaIte the taI1OftlllDCl/oc aIœradoas in the JocatIoo of the ..uk heteIa ...._.hd. or If. Ia the opùùoo of the Board of TrusteeS, the wock shall cause _""Ie obstrucÞOl1 to free oavigatioa. the said p.o. IJI~ wi11 be nqaired, upon due aodœ, to remove or alter this work ex project hereIa stated wicbout -J. CI'''' to the TO'II'D of SoutholcL 8. That the said Board will be notified by the Permittee 011be ..""['ktl"Ø of the WO<k audi· orlzed. 9. That the Permittee wiU obtain aU other permits IIDCI coaseoCI that ØJItf be requûed ...... plemental to this permit which ØJItf be subject to revoke upoa failure to obcaIa same. Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A Dickerson . Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTH OLD December 11, 2002 Mr. Bruce Anderson Suffolk Environmental Consulting. Inc. PO Box 2003 Bridgehampton, NY 11932-2003 RE: SCTM# 24-2-11 Ann Marie Kelly Village Lane Orient, NY Dear Mr. Anderson: The following action was taken by the Board of Town Trustees during a Regular Meeting, held on November 20th, 2002 regarding the above matter. WHEREAS. Suffolk Environmental Consulting, Inc. on behalf of Ann Marie Kelly applied to the Southold Town Trustees for a permit under the provisions ofthe Wetland Ordinance of the Town of South old, application dated October 10, 2002 WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on November 20th 2002 at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS. the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standard set forth in Chapter 97-18 ofthe Southold 2 Town Code. WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town. NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approved the application of Ann Marie Kelly for a Wetland Permit to construct a 1,075 sq. ft. second story addition, a 205 sq. ft. front porch extension a 96 sq. ft. rear patio, deposit 575 +/- cu. yd. of clean fill rrom an upland source, relocate the existing garage to the eastern comer of subject property and construct a 35 ft. long retaining wall off the southern comer of same, abandon the existing sanitary structure and construct upgraded system and relocate private well - roof gutters and drywells for roof run-off also a line of haybales during construction. BE IT FURTHER RESOLVED that this determination should not be considered a determination made for any other Department or Agency, which may also have an application pending for the same or similar project. Fee must be paid, if applicable and permit issued within six months of the date of this notification. Ifinspections are required, at a fee of$5.00 per inspection (See attached schedule). FEES: None Very truly yours, a~t ¿ ·1 ~ /&"-f"-vl' ~ Albert J. Krupski, Jr. President, Board of Trustees AJK/cjc cc DEC Building epartment SDt.k EDviroDmeDtaI COUSUltiD~ IDe. Newman Village. Main Street. P.O. Box 2003. Bridgehampton. New York 11932-2003 (6311537-5160 Fax: (6311537-5198 Bruce Anderson. M.s.. President Mr. Albert J. Krupski, President Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971 US) ,IE ~\rn MAY - 5 2003 EIH U May 2, 2003 ~-- ..... II TllsIIII SCTM #: KELL Y property R.O.W. off Village Lane Orient; Town of Southold, NY 1000-024-02-011 Re: Situate: Dear Mr. Krupski, Concerning the above referenced property, please find enclosed: (I) Survey of subject property, prepared by FOX LAND SURVEYING, (three [3] copies) indicating the requested information, including: I) Relocation of the existing garage to the eastern comer of subject property; 2) Indication of a retaining wall from the southern comer of subject garage and running 35.0' southwest along the southeastern property boundary; and 3) Indication that the existing sanitary system will be removed. By way of this correspondence, and on behalf of Mr. and Mrs. Kelly, kindly issue the requested approval at your earliest opportunity. Should you have any questions concerning this matter, please feel free to contact this office at any time. Thank you in advance for your attention and consideration. . Hammarth/ S;k Matt D. Ivans enc. . . 2 · Telephone (631) 765-1892 Town Hall. 53095 Main Road P.O. Box 1179 Southold. New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town ConserVation Advisory Council held Monday, November 18, 2002, the following recommendation was made: ANN MARIE KELLY to construct a 1,075 sq.ft second-story addition, a 205 sq.ft. front porch extension, a 96 sq.ft. rear patio, deposit 575 cy. of clean fill from an upland source, relocate the existing garage to the eastern corner of the subject property and construct a 35' long retaining wall off the southern corner of same, abandon the existing sanitary system and construct upgraded system, and relocated private well. Located: R.OW. off Village lane, Orient SCTM#24-2-11 The CAC did not make an inspection, therefore no recommendation was made. Suffolk Environmental Consulting, Inc. Newman Village. Main Street. p.o. Box 2003, Bridgehampton. Ne\\ York 11932-2003 16311537-5160 Fax: 16311537-5198 Bruce Anderson, M.s., President '- October 9,2002 Mr. Albert J. Krupski, President Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971 SCTM #: Kelly property R.O.W. off Village Lane Orient; Town of Southold, NY 1000-024-02-011 f.:-- rf \ ' . 'M_. -~ , ' .c' c' r-' ..' .' .. JI : r' l8 ï a tWl .;:; _n___. Re: Situate: , ~- Dear Mr. Krupski, This Firm represents Mrs. Kelly who is seeking improvements to the above referenced property. In order to do so, a Wetland Permit from your Board is required. Enclosed herewith please find a completed Wetland Permit Application. Application contents are as follows: (1) Town of South old Trustees Wetlands Permit Application; (2) Short Environmental Assessment Form; (3) Location Map of subject property (two [2] copies); (4) Survey of the property, prepared by Fox Land Surveying indicating both existing and proposed structures (two [2] copies); and (5) Check made payable to the Town of South old in the amount of $200.00 covering the requisite application fee. HammarthI 2 By way of this correspondence, and on behalf ofMes. Kelly, I request that you commence review of this application. Should you have any questions or require additional information, please feel tree to contact this office at any time. Thank you in advance for your cooperation. SinCer~e~IY' //4 / ~' // IJ' 27--------- /; Matt D. Ivans enc. cc: A. Kelly · . LOCATION MAP for KELLY Property Situate: R.O.W. off Village Lane; Orient; Town of South old, NY r",pooed c....b""dud A..... Route I o R I E· N T HARBOR HAGSTROM StreetAtlas (page 32) ~, CD '--, ...-,-: ----/ ----.. ---- %_'> SŒSlic.-.o.UZ ~, SCTM #: 1000-024-02-011 SITE · . LOCATION MAP for KELLY Property Situate: R.O.W. off Village Lane; Orient; Town ofSoutbold, NY Pro--'C_ Acœa Route "...", , ORIENT HARBOR SITE HAGSTROM StreetAtlas (page 32) .. ~" ~ % ~.. 'U5(o.NO.'~ ~... "" SCTM #: 1000-024-02-011 . / / . / /) ( . .\ ( , .~J) l f ~ ~ o ~ ~. / - ~'< 'I>~ 7-- ì ----- ff'···' " ,.... ' ",,": -x.?' ø' The now or formerly Oyster Ponds Historicol (VACANT) Society -.,~, ,.. "'- ",<=r:>." -~~ .~~~,~"j;; 1.'1 "Il!! ... ,: " ~( "':~~_~::>"'4,¿~ -- ---- ,-, I Cp \ -----~..:-....-',- 157' ) / "" TO WELb --f:------t- (I " ~ QJ ; , " l.. C' ;' "" ClJ -I-J 1 , r- "- "" E 0 ôQ "-', ~ "- C/), o .:J "" ~ 0 o:J:: c: tV :£ UT'L POLE ..:Q:---- 'ü,S"FLgJtt,-L ·:n FRAME GARAGE TO BE RELOCATED __ 546"48'30"E " J.D· - '" ~ -, I Pt I cp \ -, ^" y ........ ::0.(1 cp \ cp \ / \ , Cb\ J--""¡ Dr:;. \ 0-.... -.....F " y"' Op _....[ ""[ \ \CP,\_-<\'! '_ / ~ \ I PfT~ rf \ 4 \1 SA OSEO ,I /"' frAFi'r .... I Sr \ S'r¡1tA.f \..,.....' I I ;'rÿ I ! 0) /. )- ¿ ß" ¡g~ Q~::f o~~ ff'" ,'" ~ tV ·ù o C/J ,;r ~. ;:,,-:¡: ~ .::, .41 o ,0 " :-- i8 ZONE: ~ -:--;: .~'" ZOivE:~'a) (E:, 11) 1'.7F?"" fO. ~ -!.!:!Cf : , - ~ ,,0 -::::"CJ "- "- tV "- E.2 ¥! l....f/) .:: J?::i '< l... C/J 0 ObS c: § ~ 0 ~ oQ c: "- tV ~ g; o ...,-", ;~ f~ s' , , , )".'" '::' ;; --- tV " '0 OR/~Nr H ARBOR '7 ;r~ f:o/.R/ y 3!VO a10H!nOS ~o NMO! S33!Sm.u ~o a~Vog AS 03AO'ddd\f ......... ¿, - ,;Ç- ~~ Z'rf\ <J'I ~r- ~~ ../f1'\ , I i I I ! I ~/ ~, 1 ! < .I 8 I I g /' I f I / / I 1 ! I I i ; / I 1,1 /1/ /21 If¡ / ' I I / I ¡J Ti.- 4þ.o,~~~f ~(0',- .. .~'/.,¡u ~ ~ '1-'&. " ,OS, , <"0 00_ ",,9&. I/' ......... ......... ......... I I I 95.09' TEST HOLE DATA MAY 01. 2002 EL=4.1 I DARK BROWN i 0.0 SIL TY LOAM 2.0 BROWN SILT J.9 WA TER IN BROWN SILT 4.5 WA TER IN PALE BROWN : FINE TO I COARSE SAND Survey for: JOHN F. KELLY & ANN MARIE KELLY At Orient Town of Southold Suffolk County, New York s.c. T,M,: 1DOO-024.00-02.00-Dl1.DDO SEPT 06, 2002 IN(JICHEC, ~R0" _úCln,~,r', MAY 06, 2002 INGICq[[, rEr H':UO: DA TE: MAR. 13, 2002 JOB ND: 2DD2-D87 CERTIFIED TO: JDHN F. KELLY & ANN MARIE KELLY " ~'J 3(J )J)( '1.0 SCALE: 1 "=30' HOUSE FF-9.5 C,r, COVER TO CRADE CRAWL SPACE ELz8'; EKIST1NG GRADE EL_~.J ..... ,":.~ ....-"2"¡"'E".-- EL_5." "," r. " I NDTES: 1. AREA = 17,350 S.F. 2. . ~ MONUMENT FOUND. 3. REFERENCE DEED L. 11626 CPo 129 4. ELEVATIONS SHOWN HEREON ARE REFERENCED TO N.G.V. DATUM (MSL 1929). 5. NORTH EASTERLY SIDE OF RIGHT DF WAY AS SHOWN ON SURVEY BY ANTHDNY W. LEWANDOWSKI LAST DATED MAR. 19, 1993. 6. FIRM BDUNDARY LINE SHOWN HEREON IS FROM FLODO INSURANCE RATE MAP NO. 36103C0068 G LAST DATED MAY 04. 1998. DAVID H. FDX N.Y.S.L.S. #50234 FOX LAND SURVEYING PO BOX 224 SPEONK, N.Y. 11972 (631) 325- 2902 ~L_t e [,_,0 +~ FI""SHED GRADE I':~Ô 5 ,E_Ef ,[-õ, SEASONAL HIGH GROU"'O WATER EL"'2.0 l:''''NI , --'" ^." -"ùP':':EC, '_ TE~~ T,:', ÙP _'-"-"'.', - T~" ,', " _'G_~""' t:J,':^T,c". L·..· ,~E L~"C 'õ_'>< S"'''LL'._'Tt'E f'-- , " >~ ./:ð- - '\ SEPTIC TANK 1000 CAL. CESSPDDL =E""",:~T<', ''''L ~^-EC ~E~~,-_·. '~^LL >i'_~ _,'._ "'EP';',"" ~~,>< ...H~,'., -"E ';L'¡:".F" " ""~"^><>::' ^, L 5e:"~LF ~~ hE ,'LtO: _~'-_'.'o~", '~(."õ:,,,,,_.é.'.,__ ~:t·. ~,.~, LE',¡;.,,,:; ,,,",,,_ "'~" Uot:é. ...E~õ.=,·, ~,.,__,- ,,,,c..ChEE': :,f' ,~Õ _~,.~ '.; ''''', T_''':'' ,... ."''0: N ~ T iF' ^'. ."0." ":LL - ^[ [ 'J ^ ,'''''' ~L,'_ :p 'õ'-"j:;E~wE'.- .'''-,0 OWG: 2002-087 . . Albert J Krupski, President John Holzapfel, Vice President Jim King Martin H. Garrell Peter Wenczel Town Hall 53095 Main Road P. O. Box 1179 Southold, New York 11971 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Telephone (631) 765-1892 Fax (631) 765-1823 Office Use only Coastal Erosion Permit Application X Wetland Permit Application Grandfather Permit Application WaiVer/Amendment~h"ngeS i Received Application: ;0 {o t>V Recei ved Fee: $.9.rv -- ,/ Completed Application IOltV/Ö v Incomplete I I SEQRA Classification: Type I Type II Unlisted - Coordination: (date slntl / CAC Referral Sent: I () I~ t>~ I Date of Inspection: III /tJ ~ Receipt of CAC Report: , Lead Agency Determination: Technical Review: , , ~ Public Hearing Held: II /7-p/ö Ý Resolution: I I Name of Applicant Ann Marie Kelly Address 8 Sears Road; Southborough, Massachusetts 01772 Phone Number ( 508 481-7026 Suffolk County Tax Map Number: 1000-024-02-011 Property Location: R.O.W. off Village Lane; Orient, NY provide LILCO Pole #, distance to cross streets, and location) AGENT: Suffolk Environmental Consulting, Inc. Phone Number: (631) 537-5160 Fax: (631) 537-5198 :( /;Ý.¡ rfAo~O \' Address: P.O. Box 2003 Bridgehampton, NY 11932 Albert J. Krupski, President James King, Vice· President Henry Smith Artie Foster Ken Poliwoda /- , Town Hall . 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 . Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD ----------------------------------- In the Matter of the Application /J . of ~~~~----------- STATE OF NEW YORK) AFFIDAVIT OF POSTING , residing at ~I'\A..J V;Ú/! OC- G'...IDð tI vi rJ bei g du depose and say: That on the 1'1(1( day of Mv. ,200, I personally posted the property known as r¡q¿ by placing the Board of Tr stees official poster where it can easily be seen, and that I have checked to be sure the poster has remained in place for eight days prior to the date of the 2ublic hearing, Date of hearing noted thereon to be held~~ Zð~ '-j£]:J.. N t-v a.~ 70 fcb-d...(l' IÎ1 Dated: No..;. It 2m?. Sworn to befoFe me this [o-rv- day of J/ol/~,200Z-- /k-/ Not¡try Public ~ ----- ------ Matthew D. Ivans Notary Public of New Volt No. 011V6053859 Ouzllfled in Suffolk County Comm¡~s,or, Ex.oires January 22, 200.> . . Board of Trustees Application COASTAL EROSION APPLICATION DATA N/A Purpose of Proposed Activity: Are wetlands present within 75 feet of the proposed activity? No Yes If Yes, how much material will be excavated? (cubic yards) How much material will be filled? (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from the implementation of the project as proposed. (Use attachments if necessary) 4 . . NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: Ann Marie Kelly SCTM# : 1000-024-02-011 YOU ARE HEREBY GIVEN NOTICE: 1. That is the intention of the undersigned to request a Permit from the Board of Trustees to: Applicant proposes to construct a 1,075 sq. ft. second-story addition, a 205 sq. ft. front porch extension, a 96 sq. ft. rear patio, deposit 575 cu. yds. ± of clean fill from an upland source, relocate the existing garage to the eastern corner of subject property and construct a 35 ft. long retaining wall off the southern corner of same, abandon the existing sanitary system and construct upgraded system, and relocate private well. 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: R.O.W. off Village Lane; Orient; Town of Southold, NY 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. OWNERS NAME: MAILiNG ADDRESS: Ann Marie Kelly 8 Sears Road; Southboro, Mass. 01772 PHONE # : (5081481-7026 Ene.: Copy of sketch or plan showing proposal for your convenience. UL. . 5 .. . . ATTACHED ADDENDUM for KELLY Property Adjacents SCTM #: 1000-024-02-011 WEE HOUSE PARTNERS: 26 Lefurgy Avenue; Hastings On Hudson, NY 10706 SCTM #: 1000-024-02-010 OYSTERPOND HISTORICAL SOCIETY: P.O. Box 844 Orient, NY 11957 SCTM #: 1000-024-02-013.1 . . Board of Trustees Application County of Suffolk State of New York Bruce A. Anderson 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/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 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 REPRESENTATIVE(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. ignature ff'1 DAY OF SWORN BEFORE ME THIS .À,jVl7fi'L-2002 ~_// Z /. ,t- Ndtary Pub ic D \'Ians MattheW', New 'ork lIo\ary pUo~\~6~53859 NO. " II<. counlY 0 't. Qualified \n ~~S °Januaf)' n. 20 " CommisSIon Exp' 7 . . OWNER'S ENDORSEMENT (TO BE SIGNED IF APPLICANT IS NOT OWNER) STATE OF NEW YORK) COUNTY OF SUFFOLK) SS: Ann Kellv , being duly sworn, deposes and says; I reside at 8 Sears Road: Southboroul!h In the County of , and the state of Massachusetts, and I am the (owner in fee) (officer of the Corporation which is owner in fee) of the premises described in the foregoing application and that I have authorized Suffolk Environmental Consultinl!. Ine, to make the foregoing application as described herein. ~ o/¿.~ fd- Signature If Corporation. name of corporation and Officers Title ~«,ø«~ ðbady tp /ý . Before me, this It ~ay of ...-;;' . I Officer's Title -7 c.__ NlaryPubliè ,JANE R. DELANEY Notary Public MY.. Ç:ommlssion Expires Jun. 10. 2005 . . . 14-16-4 (Q'95)-Taxt 12 I PROJECT I.D. NUMBER 617.20 ¡ Appendix C Slate Environmental Qual~y Review SHO T ENVIRONMENTAL ASSESSMENT FORM For UNUSTED ACTIONS Only SEQR PART 1- PROJECT INFORMATION 1. APPLlCANTISPONSOR Suffolk Environmental Consulting, Inc. 3. PROJECT LOCATION: Mun' IU Southold Coon Suffolk 4. PRECISE LOCATION (Street Iddress Ind road Intersections, prominent Ilndmlrks, etc. or provide mlp) RD. W. off Village Lane; Orient; Town of Southold, NY 5. IS PROPOSED ACTION: New a~on 6. DESCRIBE PROJECT BRIEFLY: o ModiftcltionlaUerltion Please refer to the attached Projec1 Description. 7. AMOUNT OF LAND EFFECTED: Inftl8/1 < 0 1 ocres Ultlmltel < 0.01 ocres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? 181 Ves 0 No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? I8IResldantil1 Olndustrial OCommerclal OAgr1cuUure Describe: OPlrkIForestlOpen space OOther Private single family residences with related appurtenances. 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENT, AGENCY (FEDERAL, STATE OR LOCAL)? 181 Yes ONo If yes, list Igency(s) and permlt/approvlis Town of Southold Trustees approval; Town of Southold Building Department approval 1 L DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? o Ves 181 No II yes, list Igency(s) and permlt/lpprovais 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? Yes No I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE TO THE BEST OF MY KNOWLEDGE Appllclntlsponsor name: Ik Environm Inc. Dote: 04/05/02 Signature: - If the action la In the Coastal Area, and you are a stste agency, complete the Coastal Aaaeaament Form before proceeding with thla as..aament OVER 1 , . . . PROJECT DESCRIPTION for KELL Y Property Situate: R.O.W. off Village Lane; Orient, NY SCTM #: 1000-024-02-011 Applicant proposes to construct a 1, 075 square foot second-story addition, a 205 square foot front porch extension and a 96 square foot rear patio off the existing dwelling. In addition, applicant proposes to relocate the existing frame garage forty feet (40.0') southeast to the eastern corner of subject property, construct a 35.0' long retaining wall extending from the southern comer of subject garage and extending southwest and bring in 575 cubic yards of clean fill from an upland source to elevate the proposed sanitary system. . . , I PART 11- ENVIRONMENTAL ASSESSMENT (To be comal.ted bv Ag.ncvl A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.127 If yes, coordinate the review process and n use the FU L'JAF. Yes No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative declaration may be superseded by another Involved agency. o Yes 0 No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answel'1l m.y be h.ndwritten, ff legibl.) C1. Existing air quality, surface or groundwater quality, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archeological, historical or other natural or cultural resources; or community or neighborhood ch.racter? Expl.in brleny: C3. Vegetation or fauna, fISh, shelfflSh or wildlife species, signifICant habitat, or threatened or endangered species? Explain brleny: C4. A community's existing plans or goals as officially adopted, or change in use or intensity of use of land or natural resources? Expl.ln brleny: CS. Growth, subsequent development, or related activities likely to be induced by the proposed action? Expl.ln brleny: C6. long term, short term, cumulative, or other effects not Identified in C1-C5? Explain briefly: C7. Other Impacts (including changes in use of either quantity or type of energy)? Explain brieny: D. Wl2ï~ THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? Yes ONo D. IS THERE. OR IS THERE LIKELY TO BE. CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? DYes ONo If yes, explain brieny PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Ag.ncy) INSTRUCTIONS: For e.ch .dv.rse effect Id.ntlfied ebov., det.rmine wh.ther ft is subst.ntlel, I.rg., Import.nt, or otherwise slgnlllc.nl. Each .ffect should be .ss....d in conn.ctlon with Its (.) setting (I.e. urb.n or rur.Q; (b) probability of occurring; (c) dur.tlon; (d) Irrev.rsibillty: (.) geographic scope; and (I) m.gnftude. If nec.ssary, .dd .ttachments or refer.nc. supporting m.t.rI.ls. Ensure th.t explanations contain sufllcl.nt d.tail to ahow that .11 rel.vant adverse Impacta have been Identlfl.d and adequately addr...ed. If question D of P.rt II was checked Y.s, the determln.tton and signlllcance must ev.lu.te the pot.nti.llmpact of the proposed .ction on the environmental characteristics of the CEA. ÇJ Check this box if you have klentified 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. o Check this box If you have determined, based on the information and analysis above and any supporting documentation, that the proposed action Will NOT result in any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: - Name of lead Agency Print or Type Name of Responsible Officer Tftle of Responsibi. Ofllcer Signature of Responsible Offœr In lead Agency Signature of Preparer (if different From responsible officer) 2