The URL can be used to link to this page

Home My WebLink AboutTR-5837 - Board Of Southold Town Trustees SOUTHOLD, NEW YORK PERMIT NO.. 5837 DATE: .:D..e.c. 17,..2º03 ISSUED TO .....nJ:'!'.~I.'~'~~.);:.ç~.n!\§§ºC;I1\TIºN .... ..n..···..·· Aut~nrilntin" 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 PUBUC LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWNWATERS:!~; and in accordance with the Resolution of The BOard adopted at a meeting held on nJ:>."~.~nJ.?'n.. .2QO.3..n, and in consideration of the sum. of $..2.ºº..,.º.º n· paid by .. ge()r~en~,.~atl1"l11....J t:'nfornPe.t~~' ¡;.~"'f~n.A§§ºç.'.nnnn._.". of ...n..()r.i~':':~........n... .. . .n. ....m· N. Y. and subject to the Terms and Conditions listed on the reverse slcle hereof. of Southold Town Trustees aut~orizes and permits the foRowing: WetlanáFermi1 to replace. in-kmd. approx. 560 linear ft. of old 1 and decayed wood bulkheading on 'both sides. on a raised access . road. Fi~l on each side of roadway to be removed,stored on site, " then re-mstalled, and as depicted on the plan prepared by . aU in accordance with the detailed specifications as presented in . the originating aDDlication. George R. Latham,' :Jr. dated December 6. 2003. IN WITNESS WHEREOF. The said Board of Trustees høre- by causes its Corporate Seal to be affixed, and these prewnts to be subscn"bed by it· majority of the said Board as of this dat.e. fÔ4J 1- ~ :,dE Trusi... ..'~..~_...!-~-"'_--!_. '~~_.~~--'~_. '--" -- . , '-.! .' ,., >. ' . TERMS and CONDft1ONS The I'etmII:œe Peter's Neck AS50C. residiag at c/o George R. Latham, Jr.. PO Box 576. Orient N. y~ as pan. of the ~raâoo for !he sSm",ce of die PCrmlt does uøderscaød and prescribe to the fa!· ~I 1. That the said Board of Trustees and the TOWD of SontJ1oId _ released from IJJy and all damages, oc claims fIX damages, of saJa adsiøg directly or Iadåecdy as a RSUh of IJJy opec- adoa perfom>ed punuaøt (0 chis pamIt. and the raid Po. ¡'~o. wID. at bJs eN: .. _ ~ø,... delead aoy aDd alllUCh IUIa ·..M.-I·IIT !bird parda, and Che saW f\ . 1..- d- .... f'!II ¡w,mq wIIh reipea thereto, to Che comp'ek --'-Ino. of the &ard cI. T-œe. Of the Town cI. ~ 2. That Chis Pemdt Is· wIid lex ..period of 24 mos. wfdch Is CXlasliWt~ to be the wI....~ed time· required fO ~'Ote the 'I9Od: ,iawlwd. bat·ihoaId å-.nseonc- -. røpoeIt for an eDemiOQ may be made to the Board at a bier date. 3. That this Permil should be retaiaed indefanlte1y, or as loag as die said ~ wiII>Cs to m.;....in die sttuaure or project involved, to provide evideaœ to anyone c:oacemed chat aath- .orizatioo was originally obtaiaed. 4. That die work åm>lved will be subject to the inspectIoo and approval of the Board (It iu agents, and œn-œmpUaoœ with. the prcnisioas of the ~-""s appIicadoø. ø.y be cause for revocadOQ of Chis Pamit by reso1udoo of die said Baud. 5. That there will be no ua.reaSO<'f"'~ iatedereoce with aa..;pâoo as a result of the 'I9Od: beteia uitborized. 6. That there sbaIl be DO imerfereoœ with the righl of the public to pass and repass aIœg the beach between high and low .....ter marks. . 7. That if future operaâoos of the Town of Sootbo'd req,aire die ftIDOftI -.1/IX allUadoa.s in the Iocatioa of the 'I9Od: beteia ..tJ.otI-"", or ill In the opIøIoa of cbe Board cI. n-. the. work IbaII ca_ uørellSOO"ble obstrucÞO<1 to free aa~ the said ~-- will be required, upoo due ac>tiœ. to remove or alter Chis 'I9Od: or project beteia stated wi~ eq>MIU to the T_ . of Southold. 8. That the said Board will be notified by the PermIttee at Che CCCI,ok~ Of the 'I9Od: auth- orized. 9. ThaI the Permittee will obcain all other pemWs and c:oøeais d1at ø.y be required lap- plemeotal to this penult wbL:b _y be IlUbject to reYOIœ upoa faJlare to obcaia -. . ." . . Albert J, Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A, Dickerson Town Hall 53095 Route 25 P,Q. Box 1179 Southold, N ew York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD December 17, 2003 Mr. George R. Latham, Jr. P,O, Box 576 Orient, NY 11957 RE: PETER'S NECK ASSOC. PETER'S NECK RD., ORIENT SCTM#32--3 Dear Mr. Latham: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, December 17,2003 regarding the above matter: WHEREAS, George R, Latham, Jr. on behalf of PETER'S NECK ASSOC. applied to the Southold Town Trustees for a pennit under the provisions of Chapter 97 of the Southold Town Code, the Wetland Ordinance ofthe Town of South old, application dated November 24, 2003, and, 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 December 17, 2003, 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 sWTounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, 2 . . WHEREAS, the structure complies with the standards set forth in Chapter 97 of the Southold Town Code, WHEREAS, the Board has detennined that the project as proposed will not affect the health, safety and general welfare of the people ofthe town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approve the application of PETER'S NECK ASSOCIATION to replace, in-kind, approx, 560 linear ft, of old and decayed wood bulkheading on both sides, on a raised access road, Fill on each side of roadway to be removed, stored on site, then re-installed, and as depicted on the plan prepared by George R. Latham, Jr. dated December 6,2003, Pennit to construct and complete project will expire two years from the date the pennit is signed. Fees must be paid, if applicable, and pennit issued within six months of the date of this notification, Inspections are required at a fee of$5,OO per inspection. (See attached schedule,) Fees: None Very truly yours, ~. $ 17. ~. SG-J..· 17_ . (, 7 7' Albert J, Krupski, Jr. President, Board of Trustees AJK/lms . . GEORGE R. LATHAM, JR. PETERS NECK, BOX 576 ORIENT, NEW YORK 1.1.957 Dlrc. ~ ð " ~ ])r;;-Itlt.. A-L-I JII>f, A/>.Tle, kEN ,.AI;J> P6/Þ~/; ílhf,,;k 7 OK nlC. {thr <!P....tc..f;./ ?O>t"TtVf AC.T;oN tA5í WE'p",e:>Z>7 8y .+u.. of /.t.~ tAl A-L.so LA"'~EN AA5 1/ N/t;;IIT. (T W.l9~ /Yl lAc-ii Af>I'~Ct"T~.Þ Tik P¡;--T6J(.'~ A/ec.Jc Æ-S5ocUt7iølll, G'lèEIIT I-I-t!!'Lp To WI_ WI T/I -ri-k II-ffl-iCJ- Tt'ON I Æ VIFR'! ¡.I-,,1}1.-7#¡ 'I-- rt?rj>jJ,7 ¡'¡"¿'tD7 S~.s"A..I T", Þu....~ (<>",-, ý~;f.1T~71>-t<.~1 f?~ ;( tCt:L__ EIV D nEC 2 3 2.003 Soiltllokl TIWI Boanl øI TlUs\III - ~ ~ 'j... \l¡ <t: "- ,...:¡ Q.~\-..~ \"t~~ ~ <..> .. \-- ~~<J'- <:.)'-S:\ '-..s ~ ~\ .;. '" s ~ t-I\ ~ ~ ¡v II t ~ ~ ~ 'è ~ ~ J\ ~ <J " <:t: ,$ s - \Jì ~ ~ Bì' ~ ~ ~ ~ .. ~ >-- N\ ~ ~ ~ I ~ ' ~ l- ~ ~~!~ rf\ <:C ~s;. ;:::; ~ = ""'.......- ~ .... c-!' ~ A <;t .... ~ - Q . ':l~ ~~ ~'\ '?~ .. ..:;. ~ t ,~ -t ~ ~ ~ ~ ~ - ~ \ÎI ><- ~ = ('-! X ~ '" ?i ~ . ~ 'i;) '-SI N .J ~ '§ 1::1 » -I m -I o c:> .... ~ 0 }> tv Z·»"" ¡¡o .." ':::--Ol::l:::c ... -n 0 0 eft "T1 .........0-1< C> C ~ m II- -I è;:; (7 :x: -I o fll c::J ,..... r, -< 1::1 cr_ I- ~ <:::> '-.S\ N -.I ~ :> ~ ~ ,~ -.. ï~ ~ ~!~~ ~ ~&:t ~ ~ ~~~ cs:::... ~ ~ ~-~ þ... ~ .<;J -I c..... ~ <:t.. t;-- . . Telephone (631) 765-1892 Town Hall 53095 Route 25 P.O. Box 1179 Soulbold, New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Monday, December 8, 2003, the following recommendation was made: Moved by Don Wilder, seconded by Tom Schlichter, it was RESOLVED to recommend to the Southold Town Board ofTrustees APPROVAL WITH A STIPULATION of the Wetland Permit application of PETER'S NECK ASSOCIATION to replace, in-kind, approx, 560 linear ft, of old and decayed wood bulkheading on both sides, on a raised access road, Fill on each side of roadway to be removed, stored on site, then re-installed, Located: Peter's Neck Rd" Orient. SCTM#32-1-3 The CAC recommends Approval of the application with the Stipulation no treated wood is used. Vote of Council: Ayes: All Motion Carried -z.. - o -::;.., ~~ \. "f- ... -J.. SURVEY OF RIGHT OF WAY A T ORIENT TOWN OF SOUTHOLD SUFFOLK COUNTY, N. y: 1000-32-01- SCALE- 1"= OCTOBER 6. 2003 N -z.. - o -::;.., ~ ~ ~ ~ ~ ~ ~ ... -J.. ... ... ... -¡.. IJ>f-"" sI'" -¡.. ,¡.. -J. -¡.. -J.- IJ~# <;1-'-' ,~-J.- ", -¡.. :I-- -J.- ø (j tt~ pETE HECK cREEK -¡.. I OJ ;0 -<' ~ g " S Q; -J. ~ ~?- -¡.. ç¡." -¡.. ~ ~ J. ...~ >f-'" ,'" s'" -J.- J .. .. :I-- /// / ,I.. ,IJØ' s'" -J.. -¡. -z.. (3 -;:¡;, -0 -a 'ß ~ ~ \'" 'Y~ ~ .. <-- ~ ~ ~ [õ),n; !: lU U IÚì ,tnl NOV ¿ 't ,",J Q Southold Town Board of Trustees NO. 49618 ANY AL TERA nON OR ADOIT/ON TO THIS SURVEY IS A VIOLA nON OF SECTION 7209 OF THE NEW YORI<' STATE mUCAnON LAW EXCEPT AS PO? SECTION 7209-SUFJOlVlSlON 2. ALL CER77FICA TlONS HEREON ARE VALID FOR THIS MAP ANO COPIES THEREOF ONL Y IF SAID MAP OR COPIES BEAR THE IliPRESSED SEAL OF THE SURVEYOR 765-1797 n"1_ 91-';.9 · ., , .n, - ..~ '..... . -z- - o -=<0. ~~ ~ '\. ... ... SURVEY OF RIGHT OF WAY A T ORIENT TOWN OF SOUTHOLD SUFFOLK COUNTY, NY: 1000-32-01- SCALE: 1·- OCTOBER 6. 2003 -z- - o -=«. "- ~ ..(. \, ~ (' ... ... ... ... .. t c ... » --J.- ,/ -f m -f 03 <;t!- O 0 » ~ ..... » "'U ... Z ~ ... Iv C "'U 0 0 ;::c ... ." 0 ... -0 ,.., en < 0 .. ........ '<1 Q C ì -f Vv :J: 0 roo C N ~ ~ "F- --J.- ,1-9'- ,II ,¡.. s"- -----........... ~ ,¡.. :I- --J.- --J.- #"- rf ~~ pEtE HBCK cRBEK , ~ " ~ ~ -¡. ~ S .,..~ ... 'À ~ ,¡.. I "'- ,¡. ..(. .,1. ~ ,/ <;t!- --J.- ,¡.. ,¡.. ~ --J.- ... ,¡. ... .¡I-Ø' s»-' -z- - o -=«. -<:) ~ ~ ~ ("" .,..~ ~ ,¡..... c.-- ~ ~ ~ rö), ~ ~ ~ ~ WJ ~ n ~' NOV 2 4 2003 U SoutholdTon lIÐanl of Trustees NO. 49618 ANY AL rE:RA nON OR AoomON TO THIS SUR'ÆY IS A VIOLA nON OF SEcnON 7209 OF THE NEW YORK STArE: Eouc....nON LAW. EXCEPT ....S ÆR SECTION 7209-SUBD/lASlON 2. ALL CERTIFICATIONS HEREON ARE V....LlO FOR THIS MAP AND COPIES THEREOF ONL Y IF SAID MAP OR COPIES BE....R THE IMPRESSED SE....L OF THE SUR'ÆYOR 65-1797 I....~,..,r-r r"",,,........ n.nr ..nnr..nr"" '_'rnr......' 0J::0 . Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A, Dickerson BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Pennit Application ,-'Wetland Pennil Application ". Major Waiver/AmendmentlCha,IJ!Ie~ ..LReceived Application: I j /__I//Q.J .A(eceived Fee:$ ~OO . ~mpleted Application 1118.1/10:> _Incomplete _SEQRA Classification: Type I_Type II_Unlisted_ Coordination:( date S"1ßnt ...eAC Referral Sent: 1 ¡¡.I/jl'l?J _~ of InspectIOn: --11oID _Receipt ofCAC Report: _Lead Agency Determination:_ _ Te.s}mical Review: ,~ htn\ ~blic Hearing Held: ...., ~ _Resolution: Minor NOV 2 4 2~:2 Soulhokl Town Roan! of Trustees Name of Applicant P{T~'€'5 J-J~c.k. rt SSoc JItTJ DN Address ~ G,~ L;+-TH¡tI\I, JR... , f/1'1- 3'V'3 17:J 1- 01 Phone Number:( ) 3.... 30 35"1 ( . Town Hall 53095 Route 25 P,O, Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 ~ Suffolk County Tax Map Number: 1000 - 3¡.. - 1- 3 /VIA-P -:tt 4 '13' B 'j , Property Location: ~ hills Souµ'" I:)¡.~T Dr NAIe.'L"'''' R/~1f? !èDA-» t:W I . D~ I E'~T N / / f 5 7 '/WIII'í" R&1t (provide LILCO Pole AGENT: (If applicable) Address: Phone: ~~./ ~ \&"~\O \\\ .' . . Board of Trustees Application GENERAL DATA () P t?A'St]) Previous use of property: Intended use of property: prior permits/approvals for site improvements: Agency Date _ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? -Ä-No_ Yes If yes, provide explanation: Project Description (use attachments if necessary): To P¡rp!...4c e. , /1'1/ klN'þ O¿Þ , " .AAI'l> þE(:,~yø Woo Þ 'buLk..~'1>I"¡(; Ð"" 730 1# S/~S ..J I't RAIS;Þ Æ-ccefS Ro.'C). ¡Qrf'h)L4/t1ll7Fly Sbð ilNnL¡:-r. of lJ,..L)::1ItirlIÞ1.N~. fiU oM' (¡¡teH S/~ of rc"AÞ""7 T", lJt; ìÔ;l'/')ølJrlÞ, S'7ð~liX> 41£ $/T,/ TIhJ iIi-IN$7Þl.l.-et:>. T#tE S"'lI'rl.A- 'B1C1:t>G-~ ð 1I'e..~ CR/!'wl< WI LL- NoT ß e IN Yol.-VE'þ, . Board of Trustees . Application WETLANDffRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 'To 7?epUlce- /!) ¿'þ hA/þ J)ECAyeJ> , . 13WJ<./J-r;-A.ÞS Ivl (If AfIf'W mFtT~Iù",,-.(~£Pl.4cIf'r(""" IAI kINÞ) " , --n-k- Bu,Lk. Høtt>IN r. S"'-ff6lf¿T$ It ~/l151f}) l(o,<Û> W~7 II#Þ IS -rlltr MIL¡ AcceS$ TIS riff ¡'¡-.s~ ON ?,~d Nti7cl::. Area of wetlands on lot: square feet Percent coverage oflot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No X Yes rfyes, 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: No 5LoJ>1! Manner in which material will be removed or deposited: A-N'I filL k. rhl ,,~p'þ "",fA... Be S-r.lt.t;> ()~ S,TE AN}) bt.SE'b AtÞJt/1V -ÐNCE TNI:' NFJt) B""-krhF/l-p/lÚ(; 15 I^' p¿".c. . 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): S!-fn.tþ ~K A ht/N/4IIt'L errÉcT oN Skle..f!o...,Þ/N6 fA} £TÚM/D,5 ¡q 5 A-U.- wo~ w. u- 'ðé ])oAle.. Fk sit¡ ~Al> 19,e¡;;-A. No '{'F'C} (þ AI 11])1'1-1- ¿,vfl-TiF~S . . Albert J, Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P,Q. 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 of __e~(s..J)/.d~--a~~~ç~~OO----------- COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING rÆ~ ~- 'õ( ~eSiding at ..ieí~M AI e-c-k ~/.!./aJT /J'I P()Bø~S7(. , being duly sworn, depose and say: That on the if day of.D e.c... , 200.3, I personally posted the property known as 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 eight days prior to the date of the public hearing, Date of hearing noted thereon to be held ~~t'<2.r'" ~ ;.001> - , C)(\ or 0. \3..l t ')' ,CO rn , Dated: 1i~~ ~~ Sworn to before me this f ¡yOday of./).¡¡L 2003 ~--Jf (7 ~'f1J4 Notary ublic L¡;,\\)P, J. r."):::':'~3 N0.tP!r~' p! !h1jc, State of Np.w V("..l. r." ...".,..... --: ~") VIr¡. 1. ~ '. .,' ".- :. ;".,. S!,.~~I):¡.:: Cr·unty '-11..,,- '--.,-- __-" y-;.J........... -·.-·-·-~·~'.:;·-.."...:··"",~6 · . Board of Trustees Application County of Suffolk State of New York ~ It, X .d...~1 BEING DULY SWORN DEP ES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMlT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HISIHER 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 PERMlT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATlVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. A~tf- S~::~ SWORN TO BEFORE ME THIS / / 'f-l<- DAY OF ~ 200 " '- ~~~ Notary Public LINDA J. Ç00~ ~.';' Notary Public. State of N~w York No, 4e22563. Scllcl' CumIV Ti.rm Ehpkes (re{.&iì'lilt;; ;..1 . ..,..:0200,.c 1-(-!6-oi (2/87)- Tf!xt '2 I PROJECT I.D. NUMBER . . 617,21 Appendix C State Environmental Quality Review SHORTEN~RONMENTALASSESSMENTFORM For UNLISïED ACTIONS Only PART I-PROJECT INFORMAïlON (To be completed by ADplicant or Project sponsor) SEa ICANT ¡SPONSOR TFm,S N frvk A 5$0 Ctl1-711J ,.¡ ! 2. PROJEC7 NAME J. P OJECT LOCATION: Munlclpallty.o I 4. PREC:SE LOCATION (Street addres and road rntersectlons. prominenl landmarks. e!c_. or provloe map) o mll..e S0'l-H...~sT NE'c.K. !eoItÞlPIe/Ylti) 5tc.F: () L.Ic. 'P. T llTU , F AlA 1e;U <0 I::., 'Ie te. I? 0 1/-.1> 0 ¡¡/ ;4:. h1'U¡ ~A$7 Dr 1<11#(; STIt.~-eT. 5. IS PROPOSED ACTION: o New 0 Expansion Moaification/allera¡ion õ.DESCRI8EPROJECTBRIEFLY: /6 72EfLAce :P.CJflYG'J:, B~~'þs dn.J E'»cN ÐF It /(AI.5C> KOJl/-ÞIAIA:!, WITH NtF,J mAT¡;~IIiL - fJ¿P h'RTE~.JU... R.1!7116r1,g) F¡e'hI SITE. S¡Þe wlui3rJ 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimate IV acres 3. \J'JlL~ ?~O?lJSED ÀCT!ON COMPLY WITH EXISTING ZONING OR OTHER E..':(ISTlNG '-AND USE ::1E57¡::¡JC710NS" ~ Yes (J No If No. describe brleflv 9_ V/HAT IS ?RE3ENT LANO lI::¡::!N VICINITY OF ?ROJECT? ~;:¡eSdenta U.!nau3ItrS C CùmmerCléi.l Describe: o AgricUlture ~ Pan</ForesUOoen space L1 Other 10. DOES ACTION rNVOLVE A PERMIT APPROVAL OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNME!'-ITAL AGENCY \F::DERAL. STATE GM LOCAL)? ~es 0 No If yes. list agency{s) and permit/approvalS N 5 ])Cp-¡; of CONSEAVA-TJfJAI .:;'- 11. DOES ANY ASPECT OF THE AGnor"! HAVE A CURRENTLY VALID PERMIT OR APPROVAL? o Yes' ~o It Yp.s, Iisl agency name and permiuapproval 12. AS A RESULT OF PROPOSED ACTION WILL S<JSTlNG PERMITIAPP!=IOVAL REQUIRE '..-IODIF!C..\7ICN? DYes 0 I CERTIFY THAT THE INFORMATION PROVIDED Ae~E IS TRUE -;"Q THE 3ESï OF M'f KNQWL'::OGE G..,RGç R, tJ,-rHII/If..Je, r.A. r.7it,t¡s tJ.cl( A35ØCJ"Tïøol . /11'0 Ir, 7.-"1 name~ Delte: ÀppjcanVsponsor Slgnalure:¿ 03 "e, ~. If the action is in the Co<:!stal Area, and you are a state agency, complete the Coastal Assessment Form beiore proceeding with this a'i..~essment OV!::R PAí1ï 1I_=N'JIRO~JMËNï..l' '.SMENT \-:":):J~ t:::H7".:::te~e'J ':.y -\ç;enc .... :JCES ,2,.C7;C:-.l ::':\C2'=:~ ':'N'f ".::':, \ 7H¡:::.E3¡-.GLJ!N -) .'~~Cr¡:;. :>:.,--:; 517.';:, ]"l·~~S r ;-.10 :!. 'NIL!... .:..C":'ICN ~E':::':'C:= :::::CPDIN,2,.,;"'2J .=!E'/IEW AS ?RC'JIQE:J .--:.:;:; U/'IL:S":''S:J ..:.C7iCNS iN 5 :-.!',<;:?A. ~ð,¡::;7 5iT.5Î may be sucerse~e-: :)y :!.notr.er ;nvolved <I¡;enc·,. L.; 'fes L-: ~o II ïtf!5. ::JcrolnaI9 :ne r!!Vf~W :::rQcess ana 'JS8 ~ne .=IJL:.. .::..",..... Jþ il .'~Q. 1 .,e(p,(:ve -:::!!c:,u.;. C. C':ULD ACTICN :I.ESUL7":N M~Y AOVe;:15E. 'S~;:'SG';"5 ASSGC:;.7:;;::J ',vlïH -;-.!: ;:·:JLL":WING. ~~""s"llers ""av -:::e unawrlllen. " :e~lclel C1. =-"Clsllng ,ur Quality. surtac!! ,r ~rounowaler cualily .,r ,:canlltv, .'0158 ;e'/els. o!XIS:lng :,alllc ::allerns, sOlid N3s:e :arcc\.:c:;=n :ar ,]15'::: ?Q!enual for :!rQSlon, :ratnaçe or ~Iooalng JroOlems?' S-:.olam :Jtlp.lly: cz. ).estnetlc. ,u;ric:JUural. trc:1aeologlcal. :"us:onc, :lr :Hner .,at:.¡ral Jr cullural ~esourc.!s: or .:ommunlty ::Ir "ell;:1ccrnOoa c::arac:er1 Stolaln :::r Cl. I/eqelat10n or ~auna. ~Isn. 5nellflsn or 'HllalHe 'oecies. slgmiicanl ~aClla!s, ~r :/,ue3tened or !ncam;erea !cec:es? Stclam Jrlðlly: ç~. ..\ c~mmuml'''s existing ;)Iaml or ~oals as offlc:all'f adoo1ed. ar a cnange in use or intensity oi use 01 land or otner na1ural resources? E;c:plaln :::r cs. Growtn, subseauen! :::e"elocmenl, ::Ir related .1c:lvlt!es likelY !o ~e Induceo 'JY !ne ::Irooosp.a ac:lon7 ::xOlaln ;)(lelly. CS. I_ong :erm, snort :erm. ::JmulallvP', or ·:)Iner '!Ifec:s not IcenlitleO in C~-C51 =xOlam :)fletl'l. :Ir.'!~ :moac:s .jnc:.,Jci....g ::-:aot;'!!S ,n 'Jse 01 ~!tner ~uan.tiIY "r :yçe or !nerq'''? ~"C'Jlaln :;rlefly. oJ. .5 Ti-IE::'E.::R:5 7"¡..,E:=IE :_:!<¡:!.:~ 7"0 3E, ':;~NT;:¡GVe?S" =!E!..AT¿:J :-0 ~OTË~IT1;'L ADV::=!SE =NVIFìONME~fí;'L :f,1P4.C73? " :- '~es ,_,'AO :1 ·~es. o!xclaln 'Jf1erlv P"'RT III_OETE"MINATION OF SiGNIFICANCS ¡To ~e comoleled ~y Agenq) INSïRUC110NS: ror !3C:1 adverse 2ifect identified atove. aetermine whether it is substantial. large, [mcortant or otherwise signific. :3ch ~lfec~ snould be assessed in connection wiln its (a) 3ettlng (I.e. urban or rural); (b) ;Jrobability of occ~q; (C) duration' irreversibility; fel geograonic .;coce: and (I) magnitude. If nl!cessary, add altachmenls or reference suppon'ng materials. =~sure !!xClanatlons contain sufficient detail to snow thai all rl!le'lant adverse impactS have been identifieCl and adequately acdresseC. >-..; C:'eck ¡his box if you have identified ene or íT10re ootentially large or significant ao'¡erse imoac:s whic:1 MA'f oc::ur. Then :Jroceed direc:ly to ~t!e rULL :Ai= anaJor prepare a positive' declaration, I C:'ec:< ~his ~ox if you have defermined, ~asèd on the information and analysis above and any suooortinc doc:Jmenta[lon. :hat :he :JrocoSea ac:ion WILL ~JOT result in","*0Y significant adverse environmental imcac::; ).NO :Hovlce ·::m 3.itac:lments as necessary, the reasons supcortlng this determination: I I ! ! i i ......'11... '11 ~o::.,U "\;~"e" "'''"1 031 . ~Ct: --=..,n.. .JI <~"con~'o"~ ''';Ulc':!r n ·.~·...a ....:0::,,0:;., "lle ':II -I.o::.oans.Olo:! WII.err ;'1(n"':UI~ .)f r',~~.,r~r ~II ';11:r,~n( ¡rom resao""OI~ ",rICill :1I.:nJII.I~ )J <e\con\lQle ':1:'(8 n "'~..Ia ....>:~nCv .)...11:' 2 . . APPLICANT/AGENTIREPRESENT ATIVE TRANSACTIONAL DISCLOSURE FORM The TOy..11 of South old's Code of Ethics Drohibits conflicts of interest on the Dart of town officers and emolovees. The Durnase of this Conn is to orovide information which can alert the town of Dossible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME; (!eoR. irE (Last name, first name, middle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) ~ LI! TH/7J11 . v.R.. NAME OF APPLICATION: (Check all that apply.) Tax grievance Variance Change of Zone Approval of plat Exemption from plat or official map Other (If "Other", name the activity.) /.AI~7 ¿ÆÞf/J rElMII Î Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town or 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 x Iryou answered "YES", complete the balance or this rorm and date and sign where indicated. Name of person employed by the Town of Southold Title or position or that person Describe the relationship between yourselr(the applicantlagenUrepresentative) 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% orthe 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 or the applicant; or _D) the actual applicant. DESCRIPTION OF RELATIONSHIP ~~~::ed ~~d;LO~~ 1;0 3 PrintNarhe ~GE. n HA,;¡'æ..