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Home My WebLink AboutTR-5423Albeffc J. Krupski, President James tGng, Vice-President A.r tie 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' TEUSTEES TOWN OF SOtTT'KOLD June 1.8, 2003 Mr. ~rm~k Notaro Arcl:itecnologies 13405 Main Rd. Matfituck, NY 11.952 P.E: ROBERT & CELIA SWING 445 ISLAND VIEW DR.~ CREENPORT scl M~>7-,-., Dear Mr. Notaro: The following .xcfien ... ra[:e~ ._ ._,~ ooar,.Au T:~wn Board of Trustees at their Regular ~Ce[lll~. hetu,:n "~ 5a;;~'sd~x'. .'..lll.~* :~. :;~:'~,.~ ~', RESGL V:ED. -h:~, :k.~ '" .o'.t".=,o,c .'.;w~ :3c. ard oi Trustees APPROVE the .~endment to Pe~it ~5423 t,) tncmce :tO ,o '_,.., .). Or =a ._._.iuO O[ AI~ to .:o~er the >amtao, system, as depicted on the site plan prepateo ;.y x:-chirecuologics last dated June 18. 2003, and a One-Year Extension If you have any questions, please call our ofrice at (631) 765-1892. Sincerely, .k[bem J. [~x~pski. rt. President. Board of Trustees AJK:!ms John T. Metzger, L.S. Pt.2CONIC 8UP, VEYORS, ~ P.O. Box909 1230Tm~LER STREET SOUTHOLD, N.Y. 11971 631-765-5020 ' F,&x 631-765-1797 June 18.20C3 Southold Town Board of Trustees Southold. N.Y. 11971 RE' Robert & Celia Swing 445 Island View Drive Greenport, N.Y. Suffolk County Tax Parcel- 1000 - 57 - 02 - 27 TO Whom It [day Concern Please be advised that as per our review of the site we are certifyiqg that the proposed storm drains are located nc less than 20' away ;roq] :he proposed leaching pools, ar'd will meet and or exceet~ the drainage reou,rements of the si:e. ( Ref: Site Plan ) We also certify that lhe site will be protected wit': & line of staked out ha,,, oa~es a~ound the perimeter cf the proposeo '~rfl. Drainage Criteria: Tne total gu. yards of fill requ~'e,:J = 530 cd yards. 1,214x 0.17x q = 206 cult Area of fill = .~,56 sq.ft. 3.564x0.17x 0.4 =242cu.'t. total runoff = 448 c.u b .~o~rd of Trustees Prov'de 3 drains 6' x ~' de6p - Thank you for your t:me arid Cor~s'derat[orl Sincereiy ¥o:~rs, New York State Department of Environmental Conservation Division of Environmental Permits, Region One Building 40 - SUNY, Stony Brook, New York 11790-2356 Phone: (631)444-0365 · FAX: (631) ~.d~.-0360 Website: www.dec.state.ny, us Erin M. Crotty Commissioner Amendment to Permit Robert and Celia Swing 28 Dyke Road Setauket NY 11733 June 2, 2003 NYSDEC #1-4738-00278/00003 Swing Property 445 Island View Lane Greenport NY SCTM #1000-57-2-27 Dear Permittees: Your recent request to modify the above pemait has been reviewed pursuant to 6 NYCRR, Part 621. It has been determined that the proposed modification will not substantially change the scope of the permitted actions or permit conditions. Therefore, the permit is amended to authorize: The placement of 530 cubic yards of clean fill, an increase to the existing grade, and a redesign of the northern covered porch. Ail work shall be performed in accordance with the plans prepared by Architecnologies dated 5/21/03, and stamped NYSDEC approved on 5/30/03. This letter is an amendment to the original permit and, as such, shall be available at the job site whenever authorized work is in progress. Ali other terms and conditions remain as ~rittenin/the/v . original oer~it. CC: Architecnologies BMHP File ter~ truly your,, [o~m A. Wiela~ ;$eputy Permit ~oai~istrator JUN 7 8 ~:003 $outhold Town Board of Trustees d 85°40'30 0 >-- "- :z: ,0 ~ gUZ New York State Department of Environmental Conservation Division of Environmental Permits, Region One Building 40 - SUNY, Stony Brook, New York 11790-2356 Phone: (631)444-0365 · FAX: (631) 444-0360 Website: www.dec.state.ny, us Erin M. Crotty Commissione~ Amendment to Permit Robert and Celia Swing 28 Dyke Road Setauket NY 11733 Dear Permittees: June 2, 2003 NYSDEC #1-4738-0027: Swing Property 445 Island View Lane Greenport NY SCTM #1000-57~2-27 JUN 1 8 2003 Southnld Town Board of Trustees Your recent request to modify the above permit has been reviewed pursuant to 6 NYCRR, Part 621. It has been determined that the proposed modification will not substantially change the scope of the permitted actions or permit conditions. Therefore, the permit is amended to authorize: The placement of 530 cubic yards of clean fill, an increase to the existing grade, and a redesign of the northern covered porch. All work shall be performed in accordance with the plans prepared by Architecnologies dated 5/21/03, and stamped NYSDEC approved on 5/30/03. This letter is an amendment to the original permit and, as such, shall be available at the job site whenever authorized work is in progress. /-~ -- All other terms and conditions remain as~rittetin the [ Y~'ery:trul youn olin A. Wiela~ ~eputy Permit ~ai~istrator CC: Architecnologies BMHP File S. 85':'40'30" E. O' ~ 0,.-', Z Ou~ ,~d Telephone (631) 765-1892 Town Hall. 511095 Main Roa<l 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, June16, 2003, the following recommendation was made: Moved by Drew Dillingham, seconded by BOb Ghosio, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the Amendment application of ROBERT & CELIA SWING to Amend Permit #5423 to include 530 cy. of fill, and as needed to cover the sanitary system and a One-Year Extension to Permit #5423. Located: 445 Island View Dr., Greenport. SCTM#57-2-27 Vote of Council: Ayes: All Motion Carried Board Of $outhold Town Trustees PERMIT NO.. SOUTHOLD, NEW YORK Z9.,..2001 ISSUED TO ................ BO'B"~' 'C:EL]:A' SW~'NG ................................ Antharizatiou 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 PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;'~. and in accordance with the Resolution of The B6ard adopted at a meeting held on ..Sept.....Lg... -20~t----, and in consideration of the sum of $ -..200-,-00 .- paid by Architec-netogies.- on--beh-al-E- o~" Bob' "~"'Gelia'"'Swin'~ .......................... of ...... Ma.e~tu.¢k ...-.--:.: ...... :...... : ............. N. Y. and subject to the Terms and C~bnd,hons hsted on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: Wetland Permit for an addition to 'a second floor to an existing residence. Replace septic system to the road side of house, stake row of haybales during construction. all in accordance with the detailed specification~ as presented in · the or;gineting appficetion. IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these presents to be subscribed by ~ majority of the said Board as of this date. TERMS end C~NDmONS The Permlctee Bob & C~-lia 8W~nC ~dl.g ~t 445 T:l:~,-1 1/'~ .... T~--4..~, t~ ......... N.Y.~ Is pan of the com~leratloa for the ~,.,z of ~he Pem~t does uudersumd smd ptgscdbe to the fol- losd~: 1. That the said Boax'd o~ Trustees and the Town o~ Southold ate released ft~n any nad all ~ or ,4,1.,~ fo~ a,,~e~ of miu tdsing dimxly o~ indire~y ~s · t~ult of any opet- ~i~a l~ffoa~d pummat m riffs p---,dt~ m~d d~e saki ~ ~f, ac bis or Is~ own ex:peme, with n~pect thereto, m the eamplete ,~,ssioa of the Bocci of Trustees e~ the Town o~ Sea~bold 2. That tl~ Pem~ Is' valid for a period of 21 mos. whkh js comideged to be dsc e~imated gme'required to compleee the wof~ involved, but should for an ~.~dofl may be made to the Bo~'d at m !-~r date. 3. That this Permit should be retained iaddinlte/y, or as loa~ ~s the s~d p~,~inee ~bes to aufi.,~, the structure or project involved, to provide evidence to anyone concerned that ot'ization was originally obtained. 4. That the work involved will be subject to the impectlon and approval of ~ ~ et Its agents, and non-compliance with the provisions of the ori~fl,g appficatlo~ troy be _~e for tevocatloa of this Pesmlt by moludon of the said Board. 5. That dw. re will be no um'easonable interference with mvlgad~ ~s · result of the ~ ~ sffthodzed. 6. ~ there shall be ~o imerfere~ce v~4fl~ the dgbt of the ~ to pes~ ~ ~ ~ the beach between high and low w~t~ marks. 7. Th~ if future opemiom o[ the Town of SouthoM require the removal ~l,/at work ~ cause unre~tsotzablc obstmcnon to free nav~ the ssld Penntttee will be tequlted~ upon due notice, to remove or tlter ~ wo& or project bemln mtecl ~Itbout e~l~mes to the To~n 8. That the said Board will be notified by the Pemfittee ot the cmntx~tion O~ the wo~ auth- orized. 9. That the Permit~e will obtain all other permits and commu dutt plemental to this petxnit which may be subject to revoke upon flllme to Albert J. Krupski, President James King, Vice-President Henry Smith Attic Foster Ken Poliwoda BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 September 28, 2001 Architecnologies PO Box 93 Mattituck, NY 11952 Bob & Celia Swing 445 Island View Drive Greenport, NY SCTM#57-02-27 Gentlemen: The following action was taken by the Board of Town Trustees during a Regular Meeting, held on September 19, 2001, regarding the above matter. WHEREAS, Architecnologies on behalf of BOB & CELIA SWING applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated August 23,200 l WHEREAS, said application was referred to the Southold Toxvn Conservation Advisory Council for their findings and recommendations, and WHEREAS, a Public Heating was held by the Town Trustees with respect to said application on September 19, 2001 at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar w~th the premises ~n ' 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 of the Southold Town Code. WHEREAS, the Board has determined that the project as proposed will not affect the health, 2 Safety and general welfare of the people of the town, NOW THEREFORE BE IT. RESOLVED, that the Board of Trustees approved the application of Architecnolgies on behalf of BOB & CELIA SWING for an addition to a second floor to the existing residence. Replace septic system to the road side of house, stake row 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. Permit to construct project will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified when project is started and on completion of said project. FEES: NONE Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees Tdcjc cc: Building Department ITECNOLOGIES Transmittal: FROM: ~bO~i ~--~. CC: SEP { 8 200{ DEREK MOR( O~! BE, .~g~ I~lalld Viex* £,al~e, Greelxporl, N.Y ! Iq44 DER£K MOR£'O'~BE~ 7.~ IMand VJex~ Lane. Greenporl. N.Y. 11944 ~elephoae (631) 765-1892 Tow~ Hall. 5309,~ Ma/n Road P.O. Box 117~ ~outh~Id, Ne; ~ork ~1971 SOUT~OLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Tuesday, September 11, 2001, the following recommendation was made: BOB & CELIA SWING to add a second fl.oor to the existing residen'c~. 445 Island View Lane, Greenport. SCTM#57-2-27 The CAC did not make an inspection, therefore no recommendation was made. · Albert J. Krupski, President James King, Vic~Pre~ident Artie Foster Ken Poliwoda Peggy A. Dickerson To~m Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 DATE APPLICATION FOR AN ~ BOARD OF TOWN TI~USTEES TOWN OF $OUTHOLD TAX MAP NO. I000' ~ ? · 0~. ' ~9 request an Amendment to Permit # ¥ ~:0s ~, EICEIVE-~ MAY 2 8 2'0~3 .~ Board of Trustee~ PATRICIA C. MOORE Attorney at Law Main Road 51020 Main Road Southoid, New York 11971 Tel: (63l) 765-4330 Fax: (631) 765-4643 June 17, 2003 BY HAIqD Board of Trustees Town of Southold 53095 Main Road P.O. Box 1179 Southold, NY 11971 Re: Premises: SCTM g: Robert ~. Swing and Celia"S~ing 445 Island View Lane, Greenport, NY 1000-057.00-02.00-027.000 Dear Ladies/Gentlemen: Enclosed please find two Return Receipt cards for the above referenced matter. Very truly yours, Patricia C. Moore PCM/mr Encls. Name: PROOF OF M~ILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Address: John Mulholland Robert Needham and Ruth Lee Catherine Jarres 725 Island View Lane Greenport, NY 11944 24 Monroe Street Port Washington~ NY 64-4! 74th Avenue Glendale, NY 11385 11050 STATE OF NEW YORK COUNTY OF SUFFOLK States Post office at were mailed to each of mail. Melissa McGowan , residing at 555 Marlene Lane, Mattituck~ New York , being duly sworn, deposes and says that on the 2nd day of 3une ,~) 2003, 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 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 Southold~ New York , that said Notices said persons by (certified) Melissa McGowan Sworn to before me this 2nd day of June ,~ 2003 Notary Public MARGARET C. RUTKOW~ Notary PuDlic, State ot No. 49825211 Qualified in Suffoll~ ,b% - 6.~ 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 I,~tF_~:~_~ ;T)e_rx;~x~CD~esidingat I,~bO~ f~A-qt'3 F---~. being duly sworn, depose and say: That on the ~V"day of ~m~.~ , 200 , I personally posted the property known as /-lq ~ ~t.-~rto~ 12t~/x3 'Z;>~ tjX, · by placing thc Board of Trustees official poster where it can easily be seen, and that I have checked to bc sure the poster has remained in place for eight days prior to thc date .of the ~_ublic hearing. Date of hearing noted thereon to be held b !l~ 1{5~ ~ 5f' O.[h~Ot~ ? .t'Y~ ~ Dated: (~ /~; /03 Swom to before me this day of ~o,,~200 .} Notary Public Monica CeriS~e. ,,.- ~mm ot Now YOlk NOTARY P U ~,? ~ ~, ..... No 0~CE60.v,4O ,_ ~ount~ ~ (sil nature) PATRICIA C. MOORE Attorney at Law 51020 Main Road Southold, NewYork 11971 Tel: (631) 765-4330 Fax:: (631) 765-4643 June 5, 2003 Board of Trustees Town of Southold P.O. Box 1179 Southold, NY 11971 RE: Robert J. Swing and Celia Swing Premises: 445 Island View Lane, Greenport, SCTM: 1000-057.00-02.00-027.000 NY Dear Sir or Madam: Enclosed please Posting and three (3) referenced matter. We will forward the our receipt of same. /mm Enclosures find the Affidavit of Mailing, Affidavit of Certified Mail Receipts for the above signed Return Receipt Cards to you upon Very truly yours, Patricia C. Moore By: Melissa McGowan, Secretary May 22, 2003 Southold Town Trustees P.O.Box 1179 Southold Town Hall Main Road, Southold, NY 11971 PATRICIA C. MOORE Attorney at Law 51020 Main Road Southold, New York 11971 ~.. ' '~eh (63l) 765-4330 Board ot ln~stees -- Re: Swing Residence Greenport Margaret Rutkowski Secretary Dear President Krupski and Board: Enclosed please find my check in the amount of for the amendment to the existing permit. The amendment will not adversely impact the environment. Clean fill is required because the house had to be raised one foot to comply with FEMA regulations. The land will be graded and water retention basins are proposed to retain any rain water runoff. Also under the original permit, the Trustees requested that we relocate the sanitary system to the landward side of the house. To comply with your request, and the Health Department regulations, clean sand is required to cover the rings. The amendment has been submitted to the DEC and a permit amendment is anticipated shortly. Please send the notices to me for certified mail and posting. Very truly yours, Patricia C. Moore ITEC OLOGIES May 15, 2003 New York State Department of Environmental Conservation Building 40 SUNY Room 219, Stony Brook, N.Y. 11794 RE: Request for Amendment to a recent D.E.C Permit. Swing Property Southold, Suffolk County, New York. Suffolk County Tax Parcel: 1000 ~ 57 - 02 - 27 NYSDEC # 1-4738-0027/00003 A~q-N: Ma~hew R. Penski: Dear Mr. Penski: Per review from the Southold Town Building Department the property mentioned above had to be brought up to code to comply with Flood Zone AlE (el.8'). Additional 530 cu. yards of fill will have to brought in to site to cover the proposed septic system. The slab of the existing house has to be placed at 8' el. or 1 '-0" below (as proposed) the flood elevation with in-flow out-flow valves placed in the foundation wall. a) b) Location of additional fill to be brought to site = 530 cu.yards. Grade Elevation Section. Other information requested by your department is as follows: 1. OWNER: Bob & Celia Swing 28 Dyke Road Setauket, N.Y. 11733 2. EXHIBITS: Recent Survey (2 copies) Please contact .our office with any questions or comments at 631-298-1129. Please send all correspondences to our Architect, Frank Notaro, at his Mattituck office C/O: Architecnologies (Architects and Planners) P.O.Box 93 Mattituck, New York 11952 Tel. (516) 298-1129 Thank you for your time and consideration. Sincerely yours, Frank Notaro James King, Vice-President Henry Smith Artie Fosl;er Ken Poliwoda BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office UseOnly Coastal Erosion Permit Application Wetland Permit Application __ Major __v' Minor Waiver/Amendm~tl~¥nges q~[ Received Applica~on: ~/~' ~ " - t Received Fee:$ t/l~-~~ o~ ¢ / Completed Application ~yt / Incomplete SEQRA Classification: Type I Type 1I Unlisted Coordination:(date sent_)~_t_ CAC Referral Sent: ~[,~/p[ Date of Inspection: '~/('~0 t Receipt of C AC Report: Lead Agency Determination:__ Technical Review: Public Hearing Held: ltqlot Resolution: Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 NameofAvplicant 30~3 ~- ~bl'A ~iNJ~ Phone Number:( ) Suffolk County Tax Map Number: 1000 - Property Location: { CL~~'''') f') ¥ i' ~.~.J (provide LILCO Pole ~, distance to cross stree[s, ~d location) ~f applicable) Phone: Board of Trustees A~plication Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property: GENERAL DATA Prior permits/approvals for site improvements: Agency Date ~)No prior, permits/approvals for site improvements. Has any permit/approval ever been revoked or susp~nd~ed by a governmental agency? b(JNo Yes If yes, provide explanation: Project Description (use attachments if necessary):. Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: ~J~ ~ltLO~3C~C, [0 ,A~,r') /% Area of wetlands on lot: z~ ~OC) square feet Percent coverage of lot: ~] % Closest distance between nearest existing structure and upland edge of wetlands: "~ feet Closest distance between nearest proposed structure and upland edge of wetlands: 45 feet Does the project involve excavation or filling? ~ No Yes If yes, how much material will be excavated? How much material will be filled? Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: cubic yards cubic yards feet 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): Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: t~ · ~"" Are wetlands present within 100 feet of the proposed activity? No Yes 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? p(cubic yards) Manner in which material will be 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) NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES~ TOWN OF SOUTHOLD In the matter of applicant: ~"iO~-~ ~ ~i ~9~L~ SCTM#1000- YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: co fsl cT A 2. That the property which is the subject of Environmental Review-is located adjacent to your property and is described as 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 on: 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: MA~LIN~ ADDRESS,: PHON~ ¢: ' ' Enc.: Copy of sketch or plan showing proposal for your convenience. Board of Trustees Application County of Suffolk State of New York DEpOsES AI~ AFFIRMS THAT H~/gF[E 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 REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. swoRN TO BEFO~ ~ THIS ~73~ DAY OF ~ ,20m_ 0 "~ No~Public LYNDA M. BOHN ~OT/~ PUBLIC, State of Ne~ York No. 01BO6020932 ~)ualified in Suffolk County Term Expires March 8, 2~ AU~ORI ZA~IO~ (where the applicant is not the owner) (print owner of property) residing at d/Z~ J'-)~'llL~ ~¢~dd) ( mailing' address ) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner ' s signa 8 I Albert J. K~upski, Presiden~ 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 'A . ~ 'of · . COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, At-JC~ k · residing at 0~ being ~ul'y sworn, depose and say: That on the da~ of ~c~[~, 2Q0 , I personally posted the property known as ~,~3~--~~ 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 ghe public hearing. Date of hearing noted thereon to be held ;~/~ Dated: Sworn to before me this /~?~/~day of ~S'~/o~. 200/. ( s lgnature: I ~ PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK · residing at , being duly sworn, deposes and says that on the __ day of ,19 , 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 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 $outhold; that said Notices were mailed at the United States Post Office at , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to before me this day of ,19__ Notary Public 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION O-o be completed by Appticant or Project sponsor} SEQ PROJECT LOCATION; 5. iS PROPOSED ACTION: [] New [] ExpanSion ~ModifJcadon/alteration 5, OESCRIBE PROJECT BRIEFLY: 1-o 7, AMOUNT QF LAND AFFECTED; ~ Rar~/Foresb'Ooen space L~ Other 10. DOES ACTION tNVOLVE A PERMIT APPROVAL_ OR F-UNDING, NOW OR ULTIMATELY FROM ANY OTHE~ GOVERNMENTAL AGENCY (FEDERAL. STATE OR LOCAL)? [] NO If yes, Iisi agency~s~ and permmt/approva, lS 11. DOES ANY AS E~T OF TH~ ACTION NAVE A CURRENTL~ VALID PERMIT OR .APPROVAL? ~ Yes ~o ff ye., list agency name and permd/apDroval 12, AS A RESULT OF PROPOSED ACTION WILL SXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? the action is in the Coastal Area, and you are a state ac. ency, complete the Coastal Assessment Form before proceeding with this a~S, essment OVER PART III--OETE.RMINATION ,OF SIGNIFICANCE ~To 3e comole[eo by Agency) Print.or Type: Joffi. ce use onlyI File #: Permit #: TOWN OF SOUTHOLD HIGHWAY DEPARTMENT PECONIC LANE PECONIC, NEW YORK 11958 PERMIT & BOND APPLICATION FOR ACCESS THROUGH TOWN OWNED PROPERTY l) 2) (Name of Applicant) (Address) (Name & Address of Contractor Involved) 3) 4) : 1000- - - (P'roject Location) (S.C.T.M. #) 5) (Name of Road or Town Property Involved) (Hamlet) (Brie~ Job Description) 6) 7) 8) Starting Date: Completion Date: Estimated Cost of Proposed Work: 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 # D. Policy # : E. State whether policy or certification is on file with the Highway Department: (If no, Provide a copy with Application) (yes/no) (Signature of Applicant) (Date) To be completed by the Bond Amount Required: Superintendent of Highways: (Signature) Print 1) or Type: ACCESS CONSENT FORM FOR ACCESS THROUGH PRIVATE PROPERTY JOffice use Only File #: Permit #: 2) (Name of Applicant) (Address) (Name & Address of Contractor Involved) 4) 5) (Project Location) (Name of Road or Private Prop'erty 1000- - - (S.C.T.M. #) Involved) (Hamlet) 6) (Name & Address of Homeowners Association / Property Owner) (Brief Job Description) 7) Starting Date: Completion Date: s) e) Estimated Cost of Proposed Work: Insurance Coverage: A. The coverage required to be extended to the Property Owner: Bodily injury & Property Damage; $300,000/$500,000 Bodily Injury & $50,000 Property Damage. 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. (Signature of the Property ~ner orduly authorized representative) APPLICANT TRANSACTIONAL DISCLOSURE FORM The Town o~ Southold's code of Etilics prokibits con~licts of interest on the part of town officers and employees. The pgrpoee 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. ·OUR N~JiR! (Last' namb, first ~ame, m~d~le '~n~tial, unless - you are applying in the name of someoue else or other entity, such as s company. I~ so, indicate th~ othor p~rson'~ or ~ompany~s name.) NATURE OF APP~ICATION~ (Check all that apply.) Tax grievance Variance Change o~ zone Approval of plat Exemption from plat or o~ficial map Other {ti "other," name the activity,). CO Po ~ou personallt (or through ~our ~ompa~y~ epouee~ ~ibllng, parent, or child) have a relationship ~lth any o~fl~er or employee o[ the Town og 5outhold? 'Relationship' l~lcludee by blood, marriage, or business interest. 'Business inter,et" moans a business, includin~ a partnership, in which the to~n officer or empl. oye~ has even a partial ovnernhip of (or employment by} a corporation in which the town officer or employee owns more than 5% of the shares. YES NO ~ It you answered "YES," complete the balance ct ~his form and date and sign wher~ indicated. Name o~ person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicant) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the apace provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check ail that apply)l A) the owner of greater than 5% of the shares el the corporate stock of the applicant (when the applicant is a corporation)~ B) the legal or b~neficial owner o~ any interest in a noncorporate'entity (when the applicant is not a corporatton)t _ C) an o~ficer, director, partner, or employee o£ the applicantl or D) the actual applicant. DESCRIPTION OF RELATIONSIIIP