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Home My WebLink AboutTR-6041Albert J. Krupski, James K/ng, Vice-President Artie Foster Ken Poliwoda P~gy A. Dickerson BOARD OF TOV~N TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (031) 765-1892 Fa_,: (t331) 765-1366 YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE __ Pre-construction, hay bale line __ 1st day of construction ¼ constructed '~/' Project complete, compliance inspection. Board Of $outhold Town Trustees '- ~ SOUTHOLD, NEW YORK PERMIT NO, .. ~.Q.~.. J ..... DATE: .D.,e..~.: ..~q.~,.,..~.qo4 ISSUED TO _ ~.~r,_EEN ZUAR ................... Pursuant to the provisions of Chapter 615 of the I.~ws of the Sfe~ of New Yor~ 1893; end ~apfer ~ of the ~ws of fha State of New Yor~ 19~2~ and the Southold Tokn Ordinan~ eh- IN AND ON TOWN WA~RS AND PUBLIC ~NDS and f~ REMOVAL OF SAND, ~VEL O~ O~ER MATERIALS.~M ~NDS .UNDER TOWN 'WA~RS:~.]. end in acc~den~ wlfh 'the Resol~ion of The Board adopted al a meeting held on .~.%~......~?'~ ..... 2q~!..., and in consideration of the sum of $2.IQ..DD ......... paid by Of Greenport c-' N.Y. and subletto the Te~s end ~.difirJ'ns listed on ~e ~ve~e ride ~f, of Southold Town' Tr~ees *uthorlzes end permlh the follo~ng:. IN W~S WHERe, ~e sdd ~ 0f T~tees by ~uses ~s ~r~rele ~el to be ~xed, en~ ~e~p~sen~ to ~ subscribed by ~ 'mai~ of ~ said ~rd as of ~s date. ~rt~e Foste~ -' Tr~ices Kathleen Zu~r ~ ~¢ Gr~nport ..... N. ¥~ '~, ~ Wodc _~h,l! cause um~son~ble obs~ to free navit~ t~e said IF~ml~ee will ~e .teq~ ogzed. f~_.~t,~ m ~ permit ~ ,..,y'be subject to t~xd~ upon f,l~.,,~ to ot~.. ,nm Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda PegK~' 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 SOUTHOLD December 20, 2004 Suffolk Environmental Consulting, Inc. P.O. Box 2003 Bridgehampton, NY 11932 RE: KATHLEEN ZUAR 1905 BAYSHORE ROAD, GREENPORT SCTM# 53-4-9 Dear Mr. Anderson: The Board of Town Trustees took the following action during its regular meeting held on Monday December 20, 2004 regarding the above matter: WHEREAS Suffolk Environmental Consulting, Inc. as agent for KATHLEEN ZUAR applied to the Southold Town Trustees for a permit under the provisions of Chapter 97 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated November 5, 2004, 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 20, 2004 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 standards set forth in Chapter 97 of the Southold 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, RESOLVED, that the Board of Trustees approve the application of KATHLEEN ZUAR to construct a front entrance arbor off the southwestern corner of the existing dwelling 80 sq. feet; remove existing rear wood deck 85.6 sq. foot; construct a rear screened in porch off the north western corner of the dwelling 192 sq. feet; construct a rear deck off the northeastern side of the dwelling 540 sq. feet; remove an existing stone driveway from within the western corner of the property 880 sq. feet; construct a driveway within the southwestern section of subject property 2,100 sq. feet; remove only the Black locust trees in the beach area and plant beach grass (Ammophila breviligulata) and beach rose (Rosa rugosa)with the condition that no other natural vegetation be removed, remove turf under the deck when rebuilding, and gutters into drywells to contain all roof runoff and all as depicted in the plan surveyed by Hillebrand Land Surveying and updated February 14, 2005. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of $50.00 per inspection. (See attached schedule.) This is not a determination from any other agency. Fees: Final inspection $50.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/hct Al. bert J, Kcupski, President Jaznes King, Vice-President Artie Foste~ Ken Poliwoda Peggs' A. Dicl~erson Town Hall 53095 Route 25 P,O, Box 1179 Southold, New York 119,,7,1-0959 Telephone (631~ 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated I I / ~'/O reviewed by this Board at the regular meeting of_ I following action was taken: has been and the ,...- ( v )Application Approved (see below) ( ) Application Denied (see below) ( )Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees. The fee is computed below according to the schedule of rates as set forth in the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $ _~C~ , o o SIGNED: PRESIDENT, BOARD OF TRUSTEES RESOLUTION RESOLVED that the Board of Trustees of the Town of Southold hereby finds that the application of KATHLEEN ZUAR more fully described in the public hearing item #1~of the Trustee agenda dated Monday December 20, 2004, is classified as a Type II Action pursuant to SEQRA Rules and Regulations, and is not subject to review under SEQRA. Telephone (631) 765-1892 Town Ha~l 53095 Route 25 P.O. Box 1 !79 Southold, New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Tues., December 7, 2004, the following recommendation was made: Moved by William Cook, seconded by Don Wilder, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A CONDITION of the Wetland Permit application of KATHLEEN ZUAR to construct a front-entrance arbor off the southwestern corner of the existing dwelling (80 sq.ft.); remove an existing rear wood deck (85.6 sq.ft.); construct a rear screened-in porch off the northwestern corner of the dwelling (192 sq.ft.); construct a rear deck off the northeastern side of the existing dwelling (540 sq.ft.); remove an existing stone driveway from within the western corner of the subject property (880 sq.ft.); construct a driveway within the southwestern section of subject property (2,100 sq.ft.); construct a wood walkway off the existing rear retaining wall measuring 4'X 35' (w/steps) and supported with ten (10) posts; and remove any and all invasive and/or non-native vegetation within the area situated from the existing rear retaining wall 35' seaward (2,600 sq.ft.) and re-vegetate with Rugosa Rose and American Beach Grass. Located: 1905 Bay Shore Rd., Greenport. SCTM#53-4-9 The CAC recommends Approval of the application with the Condition of a 10' non-turf buffer. Vote of Council: Ayes: All Motion Carried ZUAR Pro-; er.ty Situate: 1905 Bayshore Road; Greenport; Town of Southold, NY Proposed Construction Access Route SITE SCTM #: 1000 - 053 - 04 - 009 SURVEY OF LOT51 AND SOUTH 1/2 LOT JO. AMENDED MAP 'A~ PECONIC BAY ESTATES FILED MA Y Ig. I~ FILE NO. #24 SITUA TED A T ARSHAMONAOUE. TOWN OF SOUTHOLD . SUFFOLK COUNT~ NEW YORK SCALE · I' - 40' SURVEYED: AUGUST 24. 2004 ~SE~E~rS ~/o~ SU~SU~F~CS structures ~ECO~m O~ U~ECO~ED ~E PL 0 T PLAN REVISED: FEBRUARY 14. OFFSETS OR DIMENSIONS SHOWN HEREON FRO~ THE PROPERTY LINES TO ~ ~ ~ ~u~v~r ~ ~ ~ r~ ~ ~u~v~r~'~ ~m /. SUFFOL~ COUNTY TAX MAP o~ ~ss~ s~ s~a~ ~r ~ c~s~E~m r~ ~ ~ w~ ~u~ c~ D/STRICT SECTION BLOCK LOT ,u,,~o,,~TO,~,,. '?~~,... ,~..~., ~ HILLEBRAND LAND SURVEYING. P.C. · ~? . I I CHURCHILL LANE. S~1THTO~N. NE~ YORK ~.,,o TP~ (6~1) q4~-~l~ Suffolk Environmental Consulting, Inc. Newman Village, Main Street, P.O. Box 2003, Bridgehampton, New York 11932-2003 (631) 537-5160 Fax: (631) 537-5198 Bruce Anderson, M.S., President March 1, 2005 Albert Krupski, Jr., President Southold Town Trustees P. O. Box 1179 Southold, NY 11971 Re: Zuar Situate: Bay Shore, Southold SCTM # 1000-53-4-9 Dear Mr. Kruspski, MAR - 4 2005 iL.~.~ $0uta01fl Town Board of Trustees Enclosed herewith please find three copies of the revised survey prepared Hillebrand Surveyor last dated February 14, 2005 along with a check made payable to the Town of Southold in the amount of $50.00 You will note that the revisions to the survey include a slightly larger porch and deck addition which are beyond the jurisdiction of your Board along with the removal of the walkway as required. In addition, the required $50.00 inspection fee is enclosed herewith. Kindly forward the requested approval. Thank you in advance for your cooperation. Bruce A. Anderson Cc. K. Zuhar Albert J. Krupski, President John Holzapfel, Vice President Jim King Martin H. Garrell Peter Wenczel BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Main Road P. O. Box I 179 Southold, New York 11971 Telephone (631) 765-1892 Fax (631) 765-1823 Office Use only Coastal Erosion Permit Application X Wetland Permit Application Grandfather Permit Application -/~Re Waiver/Amendment/Changes c--~-~d Application: ---Received Fee: $ ---Completed Application Incomplete SEQRA Classification: Type I Type II__Unlisted__ Coordination: (date sent) a.C-i~C Referral Sent: ~Date of Inspection: Receipt of CAC Report: Lead Agency Determination: Technical Review: ~/'Public Hearing Held: I~/[~/O~ Resolution: So u~tl,~id [own Bosrd of Tm:,tees Name of Applicant Kathleen Zuar Address 28 Willets Lane; _14--hassettt N~ Phone Number( 516 ) 627 - 7780 Suffolk County Tax Map Number: Property Location: provide LILCO Pole 11030 1000-053-04-009 1905 Ba~shore Road; Green~ort; Southoldr NY #, distance to cross streets, and location) AGENT: Suffolk Environmental Consultingt Inc. Address: P.O. Box 2003 Bridgeham~tonr NY 11932 Phone Number: (631) 537-5160 Fax: (631) 537-5198 Board of Trustees Application GENERAL DATA Land Area(in square feet): 29~ 550 sc~u&re £eet Area Zoning: Previous use of property: Intended use of property: Improved lot Same w/additional ~.rov~ments Prior permits/approvals for site improvements: Agency Date X No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? X No Yes If yes, provide explanation: Project Description (use attachments if necessary) : Applicant wishes to perform the following: (1) (2) (3) (4) (6) (?) (8) Construct a Front. Entrance Arbor off the southwastenl comer of the existing dwelling (80.0 square feet +); Remove an existing rear Wood Deck (85.6 square feet +); Construct s rear Screeneckln Porch off the northeastern corner of the existing dwelling (192.0 square feet ~); Construct s rear Deck off the northeastern side of the existing dwelling (540 square feet ~:); Remove an existing Stone Dr/ye from within the wes~rn corner of subject property (880 square feet ~:); Constnlct a Dr/veway within the southwastem section of subject property (2, 100 square feet :~); Construct a Wood Walkway off the existing rear r~;~ining well measuring 4.0' W x 35.0'L (w/steps) and supported with ten (10) po~s; and Remove any & all invasive and/or non-nstive vegetation within the area situated from the existing rear retaining well 35.0' seaward (2,600 sq. ft. +) and re-veg~a~, with Rugoas Rose (Rosa rugosa) and American Beach Gras~ (Ammophila breviligulata). Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Improve the existing dwelling with typical and reasonable minor appurtenances common within the surrounding neighborhood (i.e. arbor, porch, deck, driveway); provide safe & practical access to the shoreline of Pipes Cove (i.e. walkway); and return an area of shoreline to a more native character (i.e. m-vegetation). Area of wetlands on lot: 6~ 735 · (Aug. 24r 2004) * square feet · Including section of property within surface waters of Pipes Cove. Percent coverage of lot: 22.8 ± % Closest distance between nearest existing structure and upland edge of wetlands: 86.0 ~ feet (Existing Wood S~eps) Closest distance between nearest proposed structure and upland edge of wetlands: 56.0 · feet (Proposed Wood Walkw&y) Does the project involve excavation or filling: X No Yes If yes, how much material will be excavated? N/A cubic yards How much material will be filled? N/A cubic yards Depth of which material will be removed/deposited: N/A · feet Proposed slope throughout the area of operations: N/A · Manner in which material will be removed or deposited: N/A 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): No impact ~ the wetlands am anticipated due ~ the location and minor nature of the proposed appurtenances (i.e. arbor. ~o~h, deck, drivewa~ walkway, as well as the dwelling i~elf exi~inR ~r yearn in this location witho~ msultinR in any neg~ive environmental impacts ~ the surrounding ama. 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? How much material will be filled? (cubic yards) (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) NOTI~TO ADJACENT PROPERTY BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: Kathleen Zuar SCTM# 1000-053-04-009 YOU ARE HEREBY GIVEN NOTICE: 1. That is the intention of the undersigned to request a Permit from the Board of Trustees to: (1) Construct a Front-Entrance Arbor off the southwestern center of the existing dwelling (80.0 square feet ~:); (2) Remove en existing rear Wood Deck (85.6 square teet *); (3) Construct a rear Screened-In Po~.h off the northeastern corner of the existing dwelling (192.0 square feet t); (4)Construct a rear Deck off the northeastern side of the existing dwelling (5,10 square feet ~:); (5)Remove an existing Stone Dr/ye from within the western conter of subject properbj (880 square feet ~); (6) Construct a Dr/vewaywflhin the southwestern section of subject property (2, 100 square feet t); (7) Construct a Wood Walkway off the existing rear retaining wall measuring 4.0' W x 35.0'L (w/steps) and supported with ten (10) posts; and (8) Remove any & all Invasive and/or non-native vegetation within the area situated from the existing rear retaining wall 35.0' seaward (2,600 sq. fL :l:) end m-veg~a;~ with Rugo~a Rose (Rosa rugosa) and American Beach Gras~ (Ammophila brew'ligulata). Review ±$ located adjacent to your property and is descr±bed as follows: 1905 Ba~shore Road; Greenport; Town of Southold~ NZ 3. That the project which is subject to Environmental Review under Chapters 32, 37, or 97 of the Town Code is open to public cormment. 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: Kathleen Zuar 28 Willets Lane; Manhassett~ NY 11030 PHONE # : (516) 627 - 7780 Enc.: Copy of sketch or plan showing proposal for your convenience. Suffolk Environmental Consulting, Inc. Newman Village, Main Street. EO. Box 2003, Bridgehampton. New York 11932-2003 (631 ~ 537-516(I Fax: (631 } 537-5 198 Bruce Anderson, M.S., President December g, 2004 Mr. Albert J. Krupski, President Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971 Re.- Situate: SCTM #: ZU.4R Property 1905 Bayshore Road Greenport; Town of Southold, NY 1000 - 053 - 04 - 009 Dear Mr. Krupski, As you know, this Firm represents the owners of the property referenced above who are s~king regulatory approval to improve thereon. In accordance with Chapter 58 of the Southold Town Code, enclosed herewith please find: (l) Affidavit of Mailing stating notification of Public Hearing was mailed to adjacent property owners via certified mail on December 7, 2004; and (2) Original Certified Mailing Receipt~ for adjacent property owners along with the corresponding SCTM No. for each lot. Kindly include same into our file and maintain the pubic hearing of Decembor 20, 2004 concerning this matter. Should you have any questions concerning this matter, please feel free to contac! this office at any time. Thank you as always for your attention and consideration. Sincerely, Diane K. Wassick cc: K. Zuar 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 SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of .............................. COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING being duly sworn, depose and say: That on the Id~day of r~[(- ~0~nally posted the propelty 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 (q'D(')D.. ~'. ,-~: c~(3~/- Dated:'T'~C. ~0, ~0'4. Sworn to before me this ~. day of'l~'.,(..2004 Not~ry 45ublic Matthew D. Ivans Notary Public of New Yoilt No. 011v6053859 Qualified in Suffolk County {~ommissior~ Expires January 22, 2~ ,o '7 OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF NEW YORK I, Diane K. W~s~ickr residing at Suffolk Znvizg~mental Consultin Inc.; Newman Vi11& e; Main S~t; Bri e ton N~., being duly sworn deposes and says that on the 7~ day of December, 2004, 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 their respective names; that the addresses set opposite the names of said persons 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 Bridgehampton, that said Notices were mailed to each of said persons by (certified) (registered) mail. K. WASSICK Sworn to before me this day of ~cw- .~ 2004 M~tthew D, Ivans Not~ry P~D[~c ol New York No. 01iV6053859 Qualified in Suffolk County Cornrmsslon Expires January 22, 20o -7 Board of Trustees Application County of Suffolk ) State of New York ) Kathleen Zuar 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 MJkNNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOABD 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. x_ Sign~ure SWORN BEFORE ME THIS b~J_c GREGORY J. DALIA Notary Public, State of New York #01 DA6090267 Qualified in Queens County Commission Expires 4/7/2007 DAY OF m~ 2004 Board of Trustees Application AUTHORIZATION (where applicant is not the owner) Kathleen Zuar residing at do hereby authorize Suffolk Environmental Consulting, Inc. to apply for (Agent) permit(s) from the Southold Board of Trustees on my behalf. (0~her $ ~gnature) 14-16-4 (9195)-Text 12 617.20 i PROJECT I.D. NUMBER I Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNUSTED ACTIONS Only PART 1- PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT/SPONSOR 2. PROJECT NAME Suffolk Environmental Consulting, Inc. ZUAR SEQR 3. PROJECT LOCATION: Municipality Town of Southold County Suffolk 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc. or provide map) 1905 Bayshore Road (SCTM #: 1000-053-04-009); Greenport; Town of Southold, NY 5. IS PROPOSED ACTION: [] New [~ Expansion [] Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: (1) C~os~ructaFr~nt-Entr~nceArb~r~thes~uthwostemcorner~ftheexistingd~elling(8~squarefeet~);(2) Removean existing rear WcodDeck(85.6squam feet ±); (3) Construct a mar Scraeneddn Porch off the northeastern comer of the existing dwelling (192.0 square feet ±); (4) Construct a rear Deck off the noriheastem s~de of the existing dwelling (540 square feet ±); (5) Remove an existing Stone D~ve Eom withi~ the wesfem comer of subject property (880 square feet ±); (0) Construct a Driveway within the southwestern sec{ion of subject property (2, 100 square feet :~); (7) Cons~ct a Wood Walkway off the existing rear retaining wall measuring 4.0' W x 35.0'L (w/steps) and snpperied with ten (10) posts; and (8) Remove any & all invasive and/or non-native vegetalion within the area situated Eom the existing rear retaining wall 35.0' seaward (2,&~0 sq. It. ±) and re-vegetate with Ru~losa Rose (Rose ~ose) and American Beach Grass {Arnmophile brevil~ulata). 7. AMOUNT OF LAND EFFECTED: Inltally < 0,3 acres Ultimately <0,3acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? [] Yes [] No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? []Residential []industrial []Commercial r-lAgricutiure Describe: []Park/Forest/Open space [~Other Private single family residences with related appurtenances. I0. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENT AGENCY (FEDERAL, STATE OR LOCAL)? [] Yes [-]No If yes, list agency(e) and permit/approvals New York State Department of Environmental Conservation approval; Town of Southold Building Department approval. I1. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [] Yes [] No If yes, list agency(s) and permit/approvals l?. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? [] Yes [] No I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: Matt D,v~ans - Suffolk Environmental Consulting, Inc. Date: Nov. 2,2004 If the action is in the Coastal Ama, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER PART II- ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.'127 use the FULL EAF. -I Yes [] No If yes, coordinate the review process and WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If NO, a negative doclaratdon may be superseded by another involved agency. Yes [] No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C 1. Existing air quality, sudece or groundwater quatlty, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, ngriculturel, 8rcheoicginal, historical or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitat, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or change in use or intensity of use of land or natural resources? Explain briefly: C5, Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1-C57 Explain briefly: C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly: D. WILL THE PRO.IECT HAVE AN IMPACT ON THE ENV~ONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? i--lyas r-INo D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? [] Yes [] No If yea, explain briefly PART III - DE'rERilINATION OF 51GNIFICA#CE (To be completed by Agency) INSTRUCTIONS: F~' each advorse effect ident~ed above, determine whether it is substantial, large, important, or ethenvise significant. Each effect should be assessed in cennectJon with its (a) seffing (i.e. urban or rural); (b) probability of occuniog; (c) duration; (d) in'eversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient de*ail to chew that all rMevont adverse impacts have been identified and adequately eddrassed. If question D of Part II wes checked yes, the determination and significance must evaluate the pnteniml impact of the propasnd action on the environmental characteristics of the CEA. [] 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 infermation and analysis abovo and any supporting documentation, that the proposed ac6on WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necassary, the reasons supporting this determination: Name of Lead Agency Print or T~e Name of Responsible Officer Signature of Responsible Offic~ in Lead Agency Title of Responsible Officer Signature of Preparer (if different From responsible officer) 2