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Home My WebLink AboutTR-5962 Michael J. Domino, President o�pSUFFO(,��oG Town Hall Annex John M. Bredemeyer, III, Vice-President 54375 Route 25 Charles J. Sanders H P.O. Box 1179 Glenn Goldsmith o • Southold, NY 11971 A. Nicholas Krupski y�o� , �aTelephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES January 18, 2017 Patricia C. Moore, Esq. 51020 Main Road Southold, NY 11971 RE: DOUGLAS A. GEROWSKI, MICHELLE'GEROWSKI & DOUGLAS J. GEROWSKI 2570 CLEARVIEW AVENUE, SOUTHOLD SCTM# 1000-70-10-29.2 Dear Mrs. Moore: The following action was taken at the Southold Town Board of Trustees regular meeting held on Wednesday, January 18, 2017: RESOLVED, that the'Southold Town Board of Trustees APPROVE the request for a Transfer of Wetland Permit#5962 from Robert and Cheryl Scheidet to Douglas A. Gerowski, Michelle Gerowski & Douglas J. Gerowski, as issued on July 21, 2004, and Amended on March 23, 2005. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. If you have any questions, please contact our office at(631) 765-1892. Sincerely, Michael J. Domino, President Board of Trustees MJD/dd f New York State Department of Environmental Conservation Division of Environmental Permits, Region One AM Building 40-SUNY, Stony Brook, New York 11790-2356 Phone: (631)444-0365 - FAX: (631)444-0360 Website:www.dec.state.ny.us _ Denise Sheehan Acting Commissioner PERMIT MODIFICATION Robert and Cheryl Scheidet April 5, 2005 2570 Clearview Avenue Southold NY 11971 NYSDEC #1-4738-02769/00002 - Scheidet Property 2570 Clearview Avenue Southold NY Permit Expiration: 10/12/14 Dear Permittees: Your recent request to modify the above permit has been reviewed pursuant to 6 NYCRR Part 621 (Uniform Procedures Regulations). It has been determined that the proposed modifications will not substantially change the scope of the permitted actions. Therefore, the permit is modified to authorize: Construction of the 4 foot by 4 foot platform using fiberglass grid panel decking a minimum of 1%2 feet above grade as shown on the plans prepared by Robert and Cheryl Scheidet last revised on 3/26/05, and stamped NYSDEC approved on 4/5/05. Special condition number 1 is revised as follows: 1. The platform shall be constructed of fiberglass grid panel decking not to exceed 4 feet in width and a minimum of 1 Meet above grade* over tidal wetland areas (* as measured from ground to bottom of platform decking). This letter is a modification 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 written in t o iginal p mit. Sin ere r A. Wieland Deputy Permit Administrator cc: Marine Habitat Protection file Site Pi:ilt -f 37 BEET ,� Y \ ,® SoundingLocations Under Dock at I1ILW "/CON Mh1ts*,/ \ 91 HILIV rA �Jr �1 Adv/OvSk r °M W wADe PMTPORH Jo RAMP xad ° FG ®AT 7,vn lam! I �r ! V_ { � 9 .w Al� kta '� w Ir 14A R Scale: 1"=5 feet `X, DSA• Proiect SI►ecifi 9ations: �•� Robert anal Cheryl Scheidet 1. Aluminum 4 XiP platform 6ND E bw. 765-9419 2. Alumiuum TX Ill' rump ASProperty Location: 2570 Clearview Ave. FIN� 3. Plastic floating l dock Southold, N.V. 11971 4. Platform & duck anchored with late flans Prepared: July 9, 2004 0 2 '/2" X 12' aluminum piping N Y S D E O %- 7 APPROVED AS PER TERMS a/�/cD�G �'� f-V 7jg-� 70 /y J AND CfJNDITIONS OF PEZ,1tIT NO.1473J Q_,�761 ODOQ�- DATE- 1 Cross View Diagram 1 . 3 7 FEE Y - ® Sounding Locations Under Dock at 1VfLW t t J* y )</ORAM,o GRADE F1�ATl�M F4M7 L L v4/3 MNI�i 1g�r y'8��14LW �'!1 MLw S•z•, Mtw t Scale: 1"=5 feet Pro'ect Specifications: yJX� &RID 1. Aluminum 4' Xf platform R�. A8 00 Z �A ��D1�, Robert incl Clceryl Selceiclet 2. Aluminum 3' X 10' ramp PANE�� G� POST 765-9419 3. Plastic floating clockL Property Location: 2570 0earview Ave. 4. Platform & clock anchored with Southold, N.Y. 11971 2 '/:" X 12' aluminum piping j N Y s n E C �' IDaie flans Prepared: July 9,20'04 t' P (, A_PPROVED AS PER TERms ,./- -7+/Q AND CONDITIONS OF N ysJ» -W-1-41739p— _W C - 1_4173 —0j� !2 / DAodsz PH-NUT ItiO.�`�7�✓�'6a��7�/�OOOZ DATE D ' r N O O 4 3 2 1 8 9 81 318 80114 O 4 O U H h � co eta A A oR 7701V 737-6,9,t 7 w METALLIC LADDER MFG. CORP. amm ftoddet Pls toren OUB MMtellicepic Ladder Mfg,Corp. DATE om 0201ARP 2r1 ooa MA ERIAL: SHEET 1 OF 2 a a 2 11 o , N o ' 1 � C-1 O O 4 a 2 , marican Recreetlonal Products W supply fiberglass grate In thess arem • B 8 62 314 q 61 318 O H 0 24- -24- 43 UA 2443114 48 m 60114 -a CIO 1 1 W x 4'Aluminum Drive Pipe 4 Required a A �+ A t` METALLIC LA DDERMG, CORP �7 8cheldst Pleftm Cl1BTOMER: ,y Mbtollio Ladder Mfg.Corp, SIZE- T,REV WRI UT RATE Bom 10201ARP 211005 MATERIAL: 3 SHEET 2 OF 2 2 1 on 0 C4 o ISO 9001:2000 Square Product Details Certified Rectangular ,:,:e<m,ze`n..ff. $m r.bStr1. r,...�'t� ..;1.a',��°4S'a'G .sl3.`i3�^,>s...•). .f',..:.'aU..�. _ �,_r-, • Corrosion resistant • Easy to install • Non-conductive MW j `� • • Uniform appearance��,--: P- Fire retardant pp • Bidirectional ' • Lightweight • Easy fabrication load bearing >t, �'g • Maintenance free • Impact resistant • Cost effective Molded Grating y -FS i• .'t i _ Of{+^. Wit,y Jy!_R -, vi_' _ _ _ S: w.: s ji`. y _lam Z.�57 70 s. � +` E �40 `I. " s �t 'lank , s � � WELL - TEST HOLE DATA - - (ICT HOLO 0100 rN9MWC't•'OSC!£kj ON JUNE 15,2000) SURVEY OF- PROPERTY ,may a• yy O CESSPOOL D#c M"LOAM OL SITUAT,UD A7' PINE NECK exon+LLOWSan mt)�+ Ct Q a Q = TOWN OF SOUTHOLD � PAM°1°'"FM To OGAIM&Ms" SUFFOLK COUNTY, NEW YORK ' z S.C. TAX No. 1000-70'-10-20,2 O SCALE 1"=50` CL.&i ALR�I AEsPJUNE 13, 2000 AS 1A7 PER�OWNER TO COLVISE SavsW OU AUGUST 29, 2000 ADDED-PROPOSED HSE_ P y A j j SEPTEMBER 28, 2000 REVISED PROP, SEPTIC 57(STEM I V J r o RNO wt11� 3 rr OCTOBER 1. 2000 ADDED LOT COVERAGE NOTE I p i NOVEMBER 1, 2000 REVISED PLOT PLAN t4 airDECEMBER 8. 2000 REVISED PATH i JANUARY 26, 2001 LOCATED TEST WELL Uj I APRIL 25, 2001 REVISED $ S PER F. S. KEITH, P.E, tI �N OP 4 O m,, I 1� APRIL 25, 200 r S Ik s st�L1s'se� C I S - 00` I 1.06�3ph� I S \ P. - � AREA = 29 7 T. V E #� h i ® OU' 'off D �V (TO TIE UNE) 0. a L 2' FOUND a � a ��p = �i _ i•� – �,o—i CERTIFIED TO: �=, f✓ s ��\ . e,n1 t �Z In � CR Aa I PECONIC ABSTRACT, Inc. SON 3 0 2004 `� i = ° FIDELITY NATIONAL TITLE I (SURA CE COMPANY OF NEW K $ I • '_ MARC CLEJAN ANNA CLEJAN -7 A z Cj�\� ;� , I – .9! Southold Town �X ab �, Board of Trustees ' C;" o b aLn = Ig 1. ELEVATIONS ARE REFERENCED TO N.O.V.D. 1929 DATUM/.6 C y�* i C,! 1 EXISTING ELEVATIONS ARE SHOWN THUS:12O EXISTING CONTOUR LINES ARE SHOWN THUS:----8---- / I,I COPROPOSED CONTOUR LINES ARE SHOWN THUS: --�— FOUNDam_ J -O - LOCATION FOR EXPANSION OF LEACHING POOL CAPACITY.'. NE.YON. A 1!I! 1 =Fe1�4M16f1•)E EXSLINO WELL .�{- ® 2�DEFP,NR HDIME�FLAT Su0RECAST (D"R�ULREO Nc POOL[OrKi N // ®PROPOSED 10DO GALLON PRECAST CONCRETE SEPTIC TAHX ER 15 ' OSU 0CESSPOOLS AS 7 / I,I i� ON SEPTEMBER 6. L 1973 43'1 O 2 THE LOCATION-OF WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD `\UlkY or 0.0 / � � !!___.,...0 �.y OBSERVATIONS AND/OR DATA OBTAINED FROM OTHERS. fo IV 511AW MATH HAY M5&5Lf Mla MEM��T"• G / 3. THIS PROPERTY IS IN FLOOD ZONE AE (EL 8) AS SHOWN-ON / OEPI.,MnWVMAWW01°NATN -WN'RDZfL��r FLOOD INSURANCE RATE YAP COMMUNITY-PANEL No. 38903C0166G mom SHFw5(t3'ON aW=MWf 4. COASTAL BARRIER LEGEND 11-16-90 COASTAL BARRIER FLOOD INSURANCE NOT AVAAA&.E FOR NEW CONSTRUCTION i OR SUBSTANTIALLY IMPROVED STRUCTURES ON OR AFTER y /��`�a r NovEYBER 16, 1990.IN DESIGNATED COASTAL BARRIERS. q!? 7 P)T1F1 5. 2001 cu. rda. OF CLEAN FILL WILL BE NEEDED FOR THE SEPTIC SYSTEM. ONLY Soul cu. a. YST OF FILL WOULD BE NEEDED IF THE EXISTING MOUND IN THE y S - R / EDGE OF WETLANDS FLAGGED O I +w• /3/ S CENTER OF THJtT IS OF ACCEPTABLE MATERIAL TO BACK FILL THE SEPTIC SEM. BY EN-CONSULTANTS. `7 INC. `1: 7La _ IF THE MOUND IS OF UNACCEPTABLE MATERIAL TO EtACK FILL THE SEPTIC SYSTEM, 1 ,Td �• - -- F�Cy THE MATERIAL FROM THE MOUND IS TO BE REGRADED OVER THE PORTION OF THE i�D FLAG /�� FLAG Fl.AO Z \` `G/may LAT NOT CONTAINING THE SEPTIC. ft. SYSTEM. _ �( 4I 8. UPLAND AREA = 16.207 a ft. S O 4 20 WETLAND AREA = 13,480 sq. ft. \_ sp 2 ! L IMPERVIOUS LOT COVERAGE HOUSE. PORCH & DECK) OVER UPLAND LAT AREA �.� N -� FLAG / n \ i IS 2,515 aq. ft. OR 15.52% z � rrlr.��//�fsj�ru?� I i'E�,si�/CGZ Jl�.rtJ/2�OCr� PREPARED DDS IN ACCORDANCE C RDRDANCE WITH THE UE S HFD PRop�SaD AL m G/ /A5�. i I. F�oR sEuai t11 N YOR 1 P,104 iVc / G'� - ! t i Vie/7-: - TITLE /- . �- / /Q ice! r �i�"� I I� `� IQ ��@�v � •Ac ,U COASTAL BARRIER IDENTIFIED 11-16-90 wCY) NA 09154 r AL R \ D UNAUTHORIZED ALTERATION OR ADDITION 4 TO THIS SURVEY IS-A VIOLATION OF W / // / / \ \ /nv�� •`� SECTION 7209 OF THE NEW YORK STATE cQ �IIIL ' / I \ I�Y ZI .Z' COPIES ON LAW. Jose h A. Ingeg■ ■® "ME LA OF THIS SURVEY MAP NOT BEARING 3 THE LAND SURVEYOR'S ID®SEAL OR 174E174E _ / ` / �_ SEWAGE DI'SPOSfAL SYSTEM BY: EMBOSSED SEAL SHALL NOT BE CONSIDERED La d Survey®r [T"F.Atp / TO BE A VALID TRUE COPY. H1p"W,� o SAG HARBOR ENGINEERING CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY.TO THE PERSON FOR WHOM THE SURVEY N v 381 Town Line Road, Sag Harbor, New York s PREPARED.AND ON HIS BEHALF TO THE 74• `\ / N p' TITLE COMPANY,GOVERNMENTAL-AGENCY AND Title Surveys - Subdivisions - Site Plans - Conabuctfon Layout GO 3z>>S„ n.e M Frederick S. 'Keith, P.E. LENDITO NG INSTITUTION LISTED HEREON, , (�s W T1maN. CERTIFICATIONS ARE NOT TRANSFERABLE. PHONE (631)727-2090 Fax (631)727-1727 �P�i L7T 85-17- THE EXISTENCE OF RIGHT OF WAYS OFFICES LOCATED AT M41L M ADDRESS L!I AND/OR EASEMENTS OF RECORD. IF 1380 ROANOKE AVENUE P.O. Box 1931 ANY, NOT SHOWN ARE NOT GUARANTEED. RIVERHEAD, New York 11901 Riverhead, New York 11901-0965 h - J PATRICIA C. MOORE Attorney at Law 51020 Main Road Southold,New York 11971 Tel: (631) 765-4330 Fax: (631) 765-4643 www.mooreattvs.com email: pcmoore ,mooreatts betsy@mooreattys.com V D August 19, 2016 Board of Trustees Town of Southold Main Road(Town Hall Annex) AUG ] 9 2016 Southold NY 11971 hand delivered fT RE: Douglas A. Gerowski, Michelle Gerowski&Douglas J. Gerowski ,PREMISES: 2570 Clearview Avenue, Southold SCTM: 1000-70-10-29.2 Dear President and Board members: Please Transfer the following permits to the new owners: Douglas A. Gerowski, Michelle Gerowski&Douglas J. Gerowski...permit#541,permit#5962, and 6952A. 5244 The proposed elevated patio is set back from the side yard at the existing setback of the house and because of the encroaching wetlands a 2.6% lot coverage variance is required. The Zoning Board of Appeals held the public hearing and because of the wetlands, requested that we make the application to the Trustees first. The proposed patio is elevated approximately 4' (48") above natural grade and the swimming pool will be inside the retaining walls of the patio. Enclosed is the cross section of the concrete wall provided by North Fork Pool Care. With reference to the above, enclosed please find an original and 3 copies of- 1. f1. Application for Wetland Permit signed and notarized,by owner together with authorization from owner 2. Transactional Disclosure signed by agent and owner 3. LWRP 4. Short EAF I have also enclosed four sets of the survey prepared by Peconic Surveyors and last dated together with my client's check for the filing fee. Please place this matter on your next available calendar. Thank you and please call should you have any questions. ery tr ours, atricica C. Moore encls. / Board of Trustees Application County of Suffolk State of New York DOUGLAS A.GEROWSKI, MICHELE GEROWSKI and DOUGLAS J.GEROWSKI, BEING DULY SWORN DEPOSITS AND AFFIRMS 'THAT HE/SI IE IS THE APPLICANTFOR THE ABOVE. DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO TILE BEST OF HIS;I1ER KNOWLEDGE, AND BELIEF. AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROV-Ff) BY TI 117, SOIJTHOI.D TOWN BOARD OF TRUSTEES. THE APPLICANTAGREES TO HOLD'I'H1 TOWN OF SOUTHOLD AND TIIE 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 I{EREBY AUTHORIZE THE TRUSTEES.THEIR AGENT(S) OR REPRESF'.NTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT"1 If F PREMISES IN CONJITNCTION WITII REVIEW OF THIS APPLICATION. t Do gigs A. Ge owski Michele Gero% .•ki Douglas J. Gerowski Sworn W before me this { day of . 2016 1 BETSY A.PERKINS otary Pub ' Notary Public,State,of New York No.01PE6130636 Qualified in Suffolk Coun,�M"). Commission Expires July 18, L I I Board of Trustees Application AUTHORIZATION (where the applicant is not the owner) DOUGLAS A.GEROWSKI AND MICHELE GEROWSKI and DOUGLAS 1 GEROWSKI. as owners of premises 2570 Clearview Avenuse. Southold.NY (sctin: 1000-70-10-29.2) do hereby authorize our attorney. Patricia C. Moore. to apply for permit(s) and appear before the Southold Board of Toy+n Trustees On our behalf. .--(Owner's signature) Douglas A. Gcrowski (owner's signature) Michele Gerowski � V^z (owner's signature) Douglas J. Gerowski 4 APPLIC AN I TRANSAC IIU\A1.DISCLOSURI IORM WOR SI;B\gltiSION, BY 0 NLR cmdONNFR'S GEN 1) The I(mil of Southold'z.Code of l.thics prohibith conflict,of interest un the part of I wast orf icer,,and emplovees I he purpose of this form is to protide infiirmation. ..hlch can alert the Tmmi of-possihle conlircta of interest and •allot% it to take%%hateacr action is necessm to a.oid same Y(WR NAME: DOUGLAS A. GEROWSM, MICHELE GEROWW , DOUGLAS .). GEROWSKi AND MOORL. PA 1 RIC'[A C (Last name.first name.muddle initial.unless you are app F.in_u1 the name of someone else or other enirt%,such as a compan. It :o.it dreate the other person or compam name.) NA R;Rr OF APPI i('ATION•(Clieck all that apply I lit\Grie.ance _ Variance _ Special L\ception I f"Other". name t}tc acti.it.- Change of/one Apptoval offlat Exemption from I'lat or Official Map Other Trustees X Do you petsonalh.for through\our eotnpam spouse. sibling, parent,or child)have a relationship.tith an} officer or employer of the 1 o..n of Southold? -Relationship" includes b% blond. marriage. or business interest. "llusmcss interest' mean, a busmcs,, including a partnership, in which the lotto officer or employee has e.en a partial oWnership of (or enaplo}mint b\)a corporation in .Ahich the I(mn officer or emplo.ee otuts more than P-0 of the shares 1 ES _ NO X _ Complete the balance of this form and date and sign belo....hcre indicated Name of'person emplo�cd by the"town ol'Southold. 1 isle or position of that person: _ Describe that relationship hett.ecn yourself(the applicant) and the '1'()%%n officer or entplo%ee Either check the appropriate line A through 1)(bclo%%)andlor describe the relationship in the space pro.ided I'he fo..n officer or rmplo%ce or his of her spouse,sibling.parent.or child is(chief.all(11,11 apph). A)the owner of greater than 5%of the shares of the corporate.tool, of the applicant(when the applicant is a corporation): 11)the legaf or beneficial o%%ner of an; interest in a non-corporate entit; (..hen the applicant is not a corporation): _ C)an officer.director.partner.or eny>lmce of the applicant:or D)the actual applicant. DESCRIPTION OF RLLA HONSLI1P Submitted this IT da}ofa Signature: Doul s r Gero%\skt -— .Michele Ger(mski Douglas J 'cro..ski rici:tC.M1loore 1 John M. Bredemeyer III, President �6,�p5�FF0(,� elk Town Hall Annex Michael J. Domino, Vice-Preside n`r' r��o y 54375 Route 25 Glenn Goldsmith o ` P.O. Box 1179 A. Nicholas Krupski o A Southold, NY 11971 Charles J. Sanders '!,fj o`� Telephone (631) 765-1892 Fax 631 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 12 Completed in field by: Patricia C. Moore, Esq. on behalf of DOUGLAS A. GEROWSKI, MICHELLE GEROWSKI & DOUGLAS J. GEROWSKI request a Transfer of Wetland Permit#5962 from Robert & Cheryl Scheidet to Douglas A. Gerowski, Michelle Gerowski & Douglas J. Gerowski, as issued on July 21, 2004, and Amended on March 23, 2005. Located: 2570 Clearview Avenue, Southold. SCTM# 1000- 70-10-29.2 CH. 275-3,- SETBACKS WETLAND BOUNDARY: Actual Footage or OK=� Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic,Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100-feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of He- ng Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: I II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: c)2 ,lJ Present were: (,"J. Bredemeyer . Domino . Goldsmith �. Krupski VC. Sanders Other Page 1 of 2 John M. Bredemeyer III, President 4� j'aFotK4"n Town Hall Annex Michael J. Domino, Vice-President ;A G�;Aq 54375 Route 25 Glenn Goldsmith o - - P.O. Box 1179 A. Nicholas Krupski ��, Southold, NY 11971 Charles J Sanders yy pati Telephone (631) 765-1892 o� oaf ' Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD o . Date/Time: ,fir (," �� Completed in Work Session by: o d 1 � Patricia C. Moore, Esq. on behalf of DOUGLAS A. GEROWSKI, MICHELLE GEROWSKI & DOUGLAS J. GEROWSKI request a Transfer of Wetland Permit #5241 from Robert A. and Cheryl Scheidet to Douglas A. Gerowski, Michelle Gerowski & Douglas J. Gerowski, as issued on November 15, 2000. Located: 2570 Clearview Avenue, Southold. SCTM# 1000-70-10-29.2 Ch. 275-12 - STANDARDS FOR ISSUANCE OF PERMIT MET=X or Comment=* A. Adversely affect the wetlands of the Town: B. Cause damage from erosion, turbidity or siltation: C. Cause saltwater intrusion in the fresh water recourses of the Town: D. Adversely affect fish, shellfish or other beneficial marine organisms, aquatic wildlife & vegetation or the natural habitat thereof: E. Increase the danger of flood and storm-tide damage: F. Adversely affect navigation tidal waters or the tidal flow of the tidal waters of the Town: G. Change the course of any channel or the natural movement or flow of any waters: H. Weaken or undermine the lateral support of other lands in the vicinity: I. Otherwise adversely affect the health, safety and general welfare of the people of the Town: J. Adversely affect the aesthetic value of the wetland and adjacent areas: Ch. 111-9 - ISSUANCE OF PERMIT MET=X or Comment=* A. Is reasonable and necessary, considering reasonable alternatives to the proposed activity and the extent to which the proposed activity requires a shoreline location: B. Is not likely to cause a measurable increase in erosion at the proposed site and at other locations: C. Prevents, if possible, or minimizes adverse effects on natural protective features and their functions and protective values, existing erosion protection structures and natural resources: D. :525% Expansion/Calculation Work Session Notes Application Complete SEQRA Classification Confirmed Coordinated Review Y/N Pos/Neg Declaration CAC: LWRP: Additional information on comments/to be discussed/Public Hearing: Date: / Completed By: Present: 1/ . Bredemeyer LfGl. Domino Goldsmith N. Krupski Sanders E. Cantrell D. Di Salvo Other Page 2 of 2 OgUFFO(� Albert J. Krupaki, President ��. CQG Town Hall James King,Vice-President h� T�� 53095 Route 25 Artie Foster C P.O. Box 1179 Ken Poliwoda Z Southold, New York 11971-0959 Peggy A. Dickerson '1ifJQ y aQ`' Telephone(631) 765-1892 1 T Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0036C Date May 3, 2005 THIS CERTIFIES that the dock, ramp and floating dock At 2570 Clearview Ave. , Southold Suffolk County Tax Map # 70-10-29.2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 6/30/04 pursuant to which Trustees Permit# 5962 Dated 7/21/04 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 dock, ramp, and floating dock The certificate is issued to ROBERT & CHERYL SCHEIDET owner of the aforesaid property. Authorized Signature Albert J. Krupski, President , + • Town Hall James King,Vice-President �gUFF0j/( 53095 Route 25 Artie Foster, �� /i P.O. Box 1179 Ken Poliwoda p Southold,New York 11971-0959 Peggy A. Dickerson y i Telephone 1631) 765-1892 P Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD 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 '/2 constructed �//Project complete, compliance inspection. Alhert J. Krupski, President Og�FF014,0 O Town Hall James King,Vice-President = Gy53095 Route 25 Artie Foster H P.O. Box 1179 Ken Poliwoda Z Southold, New York 11971-0959 Peggy A. Dickerson 'yif�o QQt' Telephone 1631) 765-1892 •� `ll. Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD March 23, 2005 Mr. & Mrs. Robert Scheidet 2570 Clearview Ave. Southold, NY 11971 RE: 2570 CLEARVIEW AVE., SOUTHOLD SCTM#70-10-29.2 Dear Mr. & Mrs. Scheidet: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wed., March 23, 2005: RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to Permit #5962 to construct a docking facility with an open fiberglass grid panel platform 1.5' above grade. If you have any questions, please call our office at (631) 765-1892. Sincerely, l A] rtt J K upski,'Jr� President, Board of Trustees AJK:Ims � .� >(t t } r �t,., i .L .� � .a..lr,, fi..., � w . .., � � . .! f:-..:Cr•.1 i '�. C> v • - � • 7 !� • • : e 1 ,3/•tea � � � � • � '{_. \\ •[`a�e � �� 11•' •1. 11 � r ��/ � 1r ��J/J � 'I• I I' I I r1 I I• ' I r I rl A_�� - Alt ( `.�tl - � I I I ' II I rI I r I ' I r . r • r I . I 'r � r• i �¢..� 1 . 11 • I I rI rI I • II II ' 11 • 40, `I .�, • a fff !'��( .y r �r.�';'irr` .ry>a✓tr Y_r v ✓s r.v r'. � f �V +1.-.•i!' t.�.�„ `•••...r'`'te `ti.r'' `•.✓� 1,,�..•,,.^�i'�.� �.,,,r•� �.,,,? TERMS and COADMONS Property located at: 2570 Clearview Ave. , Southold. SCTM#70-10-29.2 1w Pamittx Robert & Cheryl Scheidet residinB at 560 Water Terrace, Southold N Y as Y., Vw of the consideration for the issuance of the Permit does understand and prescribe to the fol- towing: I. That the acid Boned of Trustees amid the Town of Southold aur released from any amid all damages, or dAm for damages, of suits arisingditeedy or ladirady as a result of any oper- tuba performed pursuant.-0 6is paa0.k and the Ladd Permittee will, at his or her own expense, defend any and all such adts'ialdated by thitd parties, and the odd Permhtte asuman fall 11dMty with respect thereto, ta-dwAmplete eulusion of the Board of Trustees of the Town of Southold _-- I That this Penhtk is valid for a period of mos. whkh is dthddabd to be the estimated time required to complete the wort involved, but should drdrmsamra warn*, regaw for an extension may be made to the Board at a later date. 3. That this Permit should be retained indefinitely, or as long as the said Permittee wishes to maintain the sttacoM or, project involved, to provide evidence to anyone concerned that auth- orization was originally obtained 4. That the wort involved will be subject to the inspection amid approval of the Board at In agents, and noacompllance with the provisions of the originating application, may be cause for revocation of this Permit by resoludon of the said Board. 5. That there will be no unreasonable interference with navigation as a result of the work herein tuid►orlmd. 6. Thu theft stall be no interference with the right of the public to pass and ttgamt along the bath between high and low water markt 7. That if future operations of the Town of Southold zegWm the,removal and/or altaadoos in the location of the work fiaein assibad:ed, or If, is the opinion of the Bard of Tmsow% the. vvotic ahall rause tmcaaoable obstrtscuoa to free navigation, the said Pemdctee will be tagtditk upon due node,to remove or alter dtis wodk or project herein stated without acpm+a to the Town' of Southold. a. That the said Board wlll be notified by the Permittee of the completion,of the week sit&- odw& g. That the 'Permittee will attain all other pewits and cottseaii 6m may be required sop• plemental to this pewit wlddr my-be subject to revoke upon fauna to obtain same. — �1 • • oS�FFo��, Albert J. Krupski, President ��. Q Town Hall James King,Vice-President 53095 Route 25 Artie Fostery P.O.Box 1179 Ken Poliwoda y. • Z Southold, New York 11971-0959 Peggy A. Dickerson Gy�o Telephone (63 1) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD July 21, 2004 Mr. & Mrs. Robert Scheidet 560 Water Terrace Southold, NY 11971 RE: 2570 CLEARVIEW AVE., SOUTHOLD SCTM#70-10-29.2 Dear Mr. & Mrs. Scheidet: The Board of Town Trustees took the following action during its regular meeting held on Thursday, July 21, 2004 regarding the above matter: WHEREAS, ROBERT & CHERYL SCHEIDET 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 June 30, 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 July 21, 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, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approve the application of ROBERT & CHERYL SCHEIDET to construct a docking facility consisting of a 4'X 5' platform, stairway to grade, 3'X 10' seasonal ramp, and a 5'X 20' seasonal floating dock, and all as depicted on the plan prepared by Robert & Cheryl Scheidet dated July 9, 2004. 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.) Fees: $440.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/Ims 0 0 Albert J. K.rupski,President 0�%gUFFQ4r CO Town Hall James King, Vice-President ppti'Z' °y� 53095 Route 25 Artie Foster p P.O. Box 1179 Ken Poliwoda �r at Southold, New York 11971-0959 Peggy A. Dickerson Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES [� TOWN OF SOUTHOLD TO: Am(t `E- chowl Scho(ta Please be advised that your application dated CI 04 has been reviewed by this Board at the regular meeting of 2 0 and the following action was taken: ( ✓) 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: -hmk •- -13p,co Scat- MoF Ht - 3 ><la rc�m� �Z03-Mj-fit. = gb,Uo ildo' = I-)O' A � 3.1 � p TOTAL FEES D $ '�I �) 0 , 0� I b ty C)gA341 ' SIGNED: PRESIDENT, BOARD OF TRUSTEES ��O��gpFFO(,�coGy Telephone p Town Hall (631)765-1892 H 53095 Route 25 Oy� W P.O.Box 1179 Southold,New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Tuesday, July 13, 2004, the following recommendation was made: Moved by Don Wilder, seconded by Bill Cook, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A CONDITION of the Wetland Permit application of ROBERT & CHERYL SCHEIDET to construct a 5'X 20' dock, 10' ramp, and 4'X 5' platform. Located: 2570 Clearview Ave., Southold. SCTM#70-10-29.2 The CAC recommends Approval of the application with the Condition no treated lumber is used. Vote of Council: Ayes: All Motion Carried New York State Department of Environmental Conservation AM of Environmental Permits, Region One Building 40 - SUNY, Stony Brook, New York 11790-2356 imbom Phone: (631)444-0365 • FAX: (631)444-0360 - Website: www.dec.state.ny.us Erin M.Crotty Commissioner PERMIT MODIFICATION Robert Scheidet April 21, 2004 560 Water Terrace Southold, NY 11971 D E C IS U IS Re: Permit # 1-4738-02769/00001 JUN C 2U04 D Dear Mr. Scheidet: Southold Town Board of Trustees Your recent request to modify the above permit has been reviewed pursuant to 6NYCRR Part 621 (Uniform Procedures Regulations). It has been determined that the proposed modifications will not substantially change the scope of the permitted actions or the existing permit conditions. Therefore, the permit is modified to authorize: Reconfiguration of septic system and extension of 4' wide path, as shown on plans prepared by Joseph Ingegno, dated 6/13/00, last revised 4/25/01, stamped NYSDEC approved on 4/21/04 and subject to the following additional speciai condition. 13. Path through vegetated wetland shall only involve trimming of vegetation. No ground disturbance is authorized by this permit. This letter is a modification 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 written in the original permit. Sincerely, '004 Mark C. Carrara Permit Administrator cc: MHP P. Moore File NEW STATE DEPARTMENT OF ENVIRONMENTAL CONSOION DEC PERMIT NUMBER EFFECTIVE DATE 1-4758-02769/00001 December 26 2000 FACILITY/PROGRAM NUMBER(S) PERMIT EXPIRATION DATES) Under the Environmental Conservation Law December 26, 2004 TYPE OF PERMIT ■ New ❑ Renewal ❑ Modification ■ Permit to Construct ❑ Permit to Operate ❑ Article 15, Title 5: Protection ❑ 6NYCRR 608: Water Quality ❑ Article 27, Title 7; 6NYCRR of Waters Certification 360: Solid Waste Management ❑ Article 15, Title 15: Water ❑ Article 17, Titles 7, 8: SPDES ❑ Article 27, Title 9; 6NYCRR Supply 373: Hazardous Waste Management ❑ Article 19: Air Pollution ❑ Article 15, Title 15: Water Control ❑ Article 34: Coastal Erosion Transport Management ❑ Article 23, Title 27: Mined ❑ Article 15, Title 15: Long Land Reclamation ❑ Article 36: Floodplain Island Welts Management ❑ Article 24: Freshwater Wetlands ❑ Article 15, Title 27: Wild, ❑ Articles 1, 3, 17, 19, 27, 37; Scenic and Recreational Rivers ■ Article 25: Tidal Wetlands 6NYCRR 380: Radiation Control PERMIT ISSUED TO TELSP40NE NUMBER Thomas Meyer (631) 427-1040 ADDRESS OF PERMITTEE 8 Notch Court Dix Hills NY 11746 CONTACT PERSON FOR PERMITTED WORK TELEPHONE NUMBER EnConsuttants, Inc. 1329 North Sea Road Southampton, NY 11968 (631) 283-6360 NAME AND ADDRESS OF PROJECT/FACILITY Meyer property, 2570 Ctearview Avenue, Southold LOCATION OF PROJECT/FACILITY SCTM #1000-70-10-29.2 COUNTY TOWN WATERCOURSE NYTM COORDINATES Suffolk Southold Goose Creek DESCRIPTION OF AUTHORIZED ACTIVITY: Construct single family dwelling with deck, septic system,pervious drive and 4'wide access path. All work is to be done in accordance with the attached plans stamped NYSDEC approved. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, the General Conditions specified (see page 2 8 3) and any Special Conditions included as part of this permit. PERMIT ADMINISTRATOR: ADDRESS Mark C. Carrara (CKW) Bldg. #40 SUNY, Stony Brook, NY 11790-2356 AUTHORIZED SIGNATURE DATE December 26, 2000 Page 1 of 4 NEJ%K STATE DEPARTMENT OF ENVIRONMENTAL CONS&ON { NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee expressly agrees to indemnify and hold harmless the Department of Environmental Conservation of the State of New York, its representatives, employees, agents, and assigns for all claims, suits, actions, damages, and costs of every name and description, arising out of or resulting from the permittee's undertaking of activities or operation and maintenance of the facility or facilities authorized by the permit in compliance or non-compliance with the terms and conditions of the permit. Item B: Permittee's Contractors to Comply with Permit The permittee is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit, including all special conditions while acting as the permittee's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee. Item C: Permittee Responsible for Obtaining Other Required Permits The permittee is responsible forobtaining any other permits, approvals, lands,easements and rights-of-way that may be required to carry out the activities that are authorized by this permit. Item D: No Right to Trespass or Interfere with Riparian Rights This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or Personal property held or vested in a person not a party to the permit. GENERAL CONDITIONS General Condition 1: Facility Inspection by the Department The permitted site or facility,including relevant records,is subjectto inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Department) to determine whetherthe permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71-0301 and SAPA 401(3). The permittee shall provide a person to accompany the Department's representative during an inspection to the permit area when requested by the Department. A copy of this permit, including all referenced maps, drawings and special conditions, must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. General Condition 2: Relationship of this Permit to Other Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Department or any of the terms, conditions or requirements contained in such order or determination. General Condition 3: Applications for Permit Renewals or Modifications The permittee must submit a separate written application to the Department for renewal, modification or transfer of this permit. Such application must include any forms or supplemental information the Department requires. Any renewal, modification or transfer granted by the Department must be in writing. The permittee must submit a renewal application at least: a) 180 days before expiration of permits for State Pollutant Discharge Elimination System (SPDES), Hazardous Waste Management Facilities (HWMF), major Air Pollution Control (APC) and Solid Waste Management Facilities (SWMF); and b) 30 days before expiration of all other permit types. Submission of applications for permit renewal or modification are to be submitted to: NYSDEC Regional Permit Administrator, Region 1, SUNY Bldg#40, Stony Brook, NY 11790-2356 General Condition 4: Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to modify, suspend or revoke this permit. The grounds for modification, suspension or revocation include: a) the scope of the permitted activity is exceeded or a violation of any condition of the permit or provisions of the ECL and pertinent regulations is found; b) the permit was obtained by misrepresentation or failure to disclose relevant facts; c) new material information is discovered; or d) environmental conditions, relevant technology, or applicable law or regulation have materially changed since the permit was issued. D 1-4738-02769/00001 EC PERMIT NUMBER PAGE Z OF 4 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION C ADDITIONAL GENERAL CONDITIONS FOR ARTICLES 15 (TITLES), 24, 25, 34 AND 6NYCRR PART 608 ( TIDAL VVETLAINDS) 1. If future operations by the State of New York require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural resources of the State, the owner may be ordered by the Department to remove or alterthe structural work,obstructions,or hazards caused thereby without expense to the State, and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other modification of the watercourse hereby authorized shall not be completed, the owners, shall, without expense to the State,and to such extentand in such time and manneras the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall be made against the State of New York on account of any such removal or alteration. 2. The State of New York shall in no case be liable for any damage or injury to the structure or work herein authorized which may be caused by or result from future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes,and no claim or right to compensation shall accrue from any such damage. 3. Granting of this permit does not relieve the applicant of the responsibility of obtaining any other permission, consent or approval from the U.S.Army Corps of Engineers, U.S.Coast Guard, New York State Office of General Services or local government which may be required. 4. All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project. 5. Any material dredged in the conduct of the work herein permitted shall be removed evenly,without leaving large refuse piles, ridges across the bed of a waterway or floodplain or deep holes that may have a tendency to cause damage to navigable channels or to the banks of a waterway. 6. There shall be no unreasonable interference with navigation by the work herein authorized. 7. If upon the expiration or revocation of this permit, the project hereby authorized has not been completed, the applicant shall,without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York an account of any such removal or alteration. 8. If granted under 6NYCRR Part 608,the NYS Department of Environmental Conservation hereby certifies that the subject project will not contravene effluent limitations or other limitations or standards under Sections 301, 302, 303, 306 and 307 of the Clean Water Act of 1977(PL 95-217) provided that all of the conditions listed herein are met. 9. At least 48 hours prior to commencement of the project,the permittee and contractor shall sign and return the top portion of the enclosed notification form certifying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion of project, the bottom portion of the form must also be signed and returned, along with photographs of the completed work and, if required, a survey. 10. All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or his agent as part of the permit application. Such approved plans were prepared by: Joseph A. Inoeano dated 6/13/00 last revised 12/8/00 DEC PERMIT NUMBER PAGE 3 OF 4 1-4738-02769/00001 • NEARK STATE DEPARTMENT OF ENVIRONMENTAL CONSIIRTION SPECIAL CONDITIONS 1. During construction, concrete or leachate shall not escape or be discharged, nor shall washings from transit mix trucks, mixers, or other devices enter tidal wetlands and or protected buffer areas. 2. Any debris or excess material from construction of this project shall be completely removed from the adjacent area (upland) and removed to an approved upland area for disposal. No debris is permitted in tidal wetlands and or protected buffer areas. 3. There shall be no disturbance to vegetated tidal wetlands or protected buffer areas as a result of the permitted activity. 4. All areas of soil disturbance resulting from this project shall be stabilized immediately following project completion or prior to permit expiration, whichever comes first. The approved methodologies are as follows: a. Stabilization of the entire disturbed area with appropriate vegetation (grasses, etc.), 5. The storage of construction equipment and materials shall be confined to within the project work site and or upland areas greater than 75 linear feet from the tidal wetland boundary. 6. All fill shall consist of"clean"sand, gravel, or soil (not asphalt, fiyash, broken concrete or demolition debris). 7. To protect the values of the tidal wetlands, a permanent vegetated buffer zone shall be established. There shall be no disturbance to the natural vegetation ortopography within an area extending 50 linearfeet landward of the tidal wetland boundary. 8. A row of staked hay bales or approvable erosion control devices shall be placed at the landward edge of the buffer area or 50 linear feet from the tidal wetland boundary, or as per NYSDEC approved plan, at commencement of regulated activities and remain in place until project is completed and all disturbed areas stabilized with vegetation. 9. Roof runoff shall be directed to drywells a minimum of 75 feet landward of the tidal wetland boundary for immediate on-site recharge. 10. Driveways and parking areas shall be constructed of pervious material. 11. Sanitary system (bottom of tank and leaching pools) shall be located a minimum of 2' above seasonal high groundwater. 12. The permittee shall incorporate the following language as a notice covenant to the deed: "Regulated tidal wetiarids associated with Goose Creek are located at Suffolk County Tax Map Number:District 1000, Section 70, Block 10, Lot 29.2, otherwise known as the properties of Thomas Meyer and his heirs, assigns, or successors. This property is subject to the provisions of New York State Environmental Conservation Law (ECL) Article 25 or its successor, and the conduct of regulated activities may occur only pursuant to ECL Article 25 if prior approval is given by the New York State Department of Environmental Conservation (NYSDEC) or its successor. Regulated activities include, but are not limited to the erection of any structure(s); excavation; dredging grading and filling; clearing of vegetation; and application of chemicals.° This deed covenant shall be recorded with the Clerk of Suffolk County within 90 days of the issuance of this permit. A copy of the covenanted deed or other acceptable proof of record, along with the number assigned to this permit, shall be sent within one calendaryear of the issuance of this permit to: NYSDEC, Regional Manager, Bureau of Marine Habitat Protection, SUNY Building 40, Stony Brook, New York 11790-2356. DEC PERMIT NUMBER PAGE 4 OF 4 1-4738-02769/00001 P.E. gangway to 8 at kit, w/stainless steel hdwe. 4004 ^.' 197 f,77 f,11777,77717511 ffjf.(T'q'f 17 7-21111111 ;PART A"106.M'Pir.100$40 of 100600:i _`} PART 0.'Wi00 j Galvanized steel hinge aK - - bracket and hardware, for wood walkways 24" 71 161cmi, 34" 186cm1, or 60" �- n 11.5mi wide. Kits include hardware connectors with nuts, hinge-to-float bracket, Hinged polyethyler hinge-to-plank bracket and 2 gangplank stiffeners with carriage smooth transition br bolts, nuts, and washers. Lumber not included. and deck surface. _ WIDTH _FITS FLOAT WIDTH PART# 24 j6icm} -.:$OAx 60•z�80 Float Z pocket cnonedion _100240 24" 161cml w/Stainless steel hardware �100240SS ' I I. r- 3-.19ipma 40 x6Q x 10' ; " ket conned_ion "}00340 PART#:30501SS or 5, 34" (91 cm) w/Stainless steel hardware v 10034055 601.6 1 :, 0 F�nf3 cbrReetan ' 100600 60" i1.5m1 w,/ Stainless steel hardware 10060OSS • �0 jt,Sm}_�v^�80��trd pcl�et.�onnedion �_a ��680�; 60 p.5mi w/ Rainless steel hardware 1006805S DA Kit for 34" 1.9m1 gangway 1503.10 K t for60:. t' m MM ai 150400 i Kit for 34"1.9m)gangway abutment w/ railer 140340 Bracket attachesto mnngwaynbutinent.w�roller f40400� ---\ 191cm1 and 5' 11.5m1 c I , bolting to shoreline 6a c. ,.. t WIDTH ,:PARC/:30031010 500530 1-' Gan ay has welded cons uction with slip- ' 't l resi ant walkway, side NU 100650SSor il cur and rails. Lengths IMSr., fr 10'-30' 13m-9.Imi, and laths frcm 3'-5' I1m-1sm1. WIDTH LENGTH PART # `4 _ ,: X15 er ithraifm � x.;300310 :;: { r with railing 300314 - !'c_ '—_�_ ,� nfmng� _3_ 00320 7- 3' 25' with railing 300325 Hinged bracket witf 30 `x`*_ awl 'tar in �' 30033� � gangway to dock. A 5' 10' with railing' 500510 and 80" =m1 widths. - . „ _ '' 60514..:;: POCKETS 1 i ra r. 5 20' with railing 500520 - •+•.+3��5y+;3-TC ti_.5, r: s ,:25�-fa "r w h railing LL; 500525_ _. "3 1 e EZ Dock Prod d Guide DOCK TM 01101104 -0000 DOCK SECTIONS The Right Dock For Every Application. Uff 2211111111111 Rugged, adaptable, reliable, safe—the EZ Dock system has it all Our low-density polyethylene docks, boat lifts, and PWC lifts hr i 4 4L 4l 4r ^ rte a unique design that delivers outstanding load capacity, functior A6y and safety. A variety of dock sections and lifts, plus an ext afku- � selection of anchoring systems and accessories, make it • to Is 4„ ,, '_': � ,• s, customize the system. For private, commercial, or public 6 the EZ Dock system is a low-maintenance,versatile design that It FM4 e years of convenient,dependable use. EZ Dock's patented one Liu'�'TrI self-floating design is fast and easy to install. Sections come in sizes with evenly spaced coupler, hardware, and anchor pcIII � You choose the configuration that suits your application. •�I e I r i, A. B. Y Features & Benefits: • Low maintenance • Beige color The New Half-Hexa �7 7 - - •• • Variety of anchoring options y� -. • Convenient accessories Adds Versatility. ' • Versatile modular design is Secure connection couplers Imagine the configurations now made possible by _ VA • Strength and flexibility this unique dock design. Combine modular half- - Safe, slip-resistant surface hexagon sections for a platform of almost any size, is Four-season accessibility or as a starting point for unusual dock angles. - r SIZE WEIGHT FLOTATION PART# CAPACITY A. - 40'x 5'x 15” 10016S. _ 1000 lbs. 204060 In tl5mx 38cm 454 kg 453.6 kg Y S :40"x 10'x 15" 190 lbs. _20001bs. 204010 v�§R x-x } -'.- _ " �_ Imx71mx38cm 86.2kg 90'2kg 60'x 10'x 15' 285 lbs. 3000 lbs 206010 1.5m x 3.1 m x 38cm 129.3 kg 1360.8 kg x 10'x 15" - 385 lbs. 4000 be. 208010 Special connection couplers are designed to 2m x 3 1 m x 38cm 175 kg 1814 4 kg allow sections to move independently under high-stress conditions, yet provide unified E.. . 60"x 10'x 15" _ 210 lbs. 20001bs. 260120 stability. Made with recycled material, the 1.5m x 3.It,,38cm 95 3 kg 9017 2 kg couplers are compounded to prevent fatigue problems. The composite coupler bolt and U.S.Potent#5,281,055 nut eliminate rusting;n all water conditions. NOTE.Because of she rolumidding process,w.gMs and dimemione mov vary U.S.Patent#5,281,055 DESCIIIPTIOH'".' —,_PAAtfj Couple set Ibdk pack)./hord-ore 301100 ""caylrr;iRpo;rlwAndwen:` ' JU12a0.`] (v 00) 654 -8168 Coupler set 13parlw,}ardsmre ` 301300 DOCK www.ez-dock.com I J 2004 EZ Dock,Inc. nCr•.,or®PLAYPOwa,INC New York State Department of Environmental Conservation Am Division of Environmental Permits, Region One Building 40 -SUNY, Stony Brook, New York 11790-2356 _ Main Phone: (631)444-0365 Matt Penski Phone: (631)444-0358 Denise Sheehan `'Website: Nvwxv.dec.state.ny.us Fax: (631) 444-0360 Acting Commissioner Request for Additional Information March 22, 2005 Mr. Robert Scheidet 2570 Clearview Avenue Southold NY 11971 Re: NYSDEC #1-4738-02769/00602 Permit Modification Dear Mr. Scheidet: The Department's technical staff reviewed your requested modification and provided the following comments Simple revisions to the plans and proposal are necessary. Please change project specification number 1 on your plans to state: 444' x 4' fiberglass grid panel platform 1.5' above grade." Please also revise the cross view diagram to show and label the platform to be 1.5 feet above grade. Please include the revision date on the plans. Please provide three (3) copies of the revised plans showing the requested changes. Thank you. Sincerely. QQ // /T �. 1 Matthew R. Penski Env. Analyst Tr.l cc: file Site Plan � 37 fEET - - Y \ 0 Sounding Locations Under Dock at MLW HIGH MARSH Y 3.2��\ \ A„MLW V 47 MLW yea 1,14.k N 5� '�H�W Y Y Y Y Ntct+ � �►'iovSr,Y ' ' N P TFOIRN � 3x/oRAMP 6xzD �FLoAT V � Y 1sM• � 9i t.w y,� ,�MLw S,.N/7�Cw 5 �"Mew f1j N f � MARSff Y ?l Y Y Y �, x ALt, roses �}R6 Y Scale: 1” =5 feet ;z lOV D/A. ro'eet S cifications: Robert and Cheryl Scheidet 1 Aluminum 4' X ' platform 765-9419 2.Aluminum Y X 10' ramp Property Location: 2570 Clearview Ave. 3. Plastic floating dock Southold, N.Y. 11971 4. Platform & dock anchored with Date Plans Prepared: July 9, 2004 / 2 '/z" X 12' aluminum piping I C' e IVy5p= , /--738-0.2789 qv.;d past plw��n� tQEvts�d ; ts� ubo�� 9Pude. _Cross View Dig ram I . 37 FEET Uove 9-P4& ® Sounding Locations Under Dock at NMW i 9 r �77rAeM 3 k!o RAMA H 18 rr POSTS 9�'Ml.w � t y'8"MLW � H'11�MLW it S'2" MLW t Scale: 1"=5 feet PrMect S ecifications: L luminum 4' Xplatform .2 �R 'r�f/} Robert and Cheryl Scheidet .A Uminum X X 10' ramp POSTS 765-9419 I Plastic floating dock Property Location: 2570 Clearview Ave. 4. Platform & dock anchored with Southold, N.Y. 11971 2 '1/2" X 12' aluminum piping Date Plans Prepared: July 9,2004 ?' , N YSJDEC y (x y ' k r(--ort" - te47/i ss yvi'd Pie l �e�SPc� • March 7, 2005 To Whom it May Concern; Chuck Hamilton from the NYS Dept of Environmental Conservation has been working with the Trustees of Southold Town to move from a 3 '/2 ft. high platform that connects the dock ramp to a 1 ft. high platform. This new design has been approved by the Trustees of Southold and Chuck Hamilton. I have been asked by Mr. Hamilton to re- submit my approved plans(NYSDEC 91-4738-02769/00002)to allow for this new structure. I have included revised drawings(both views), the spec sheets for the platform from Metallic Ladder Mfg. Corp, and the spec sheets for the fiberglass top grating from McNichols Co. I will be utilizing the MS S-150 grit mesh. For any questions you can contact Mr. Hamilton or myself at 631875-8445. We have moved to the new location: 2570 Clearview Ave Southold, N.Y. 11971 Thank you, Robert Scheidet MAR 1 0 2005 D' Zj Southold Town Board of Trustees Site Ph 3�: Y A Sounding Locations Under Dock at NILW HIGH MARSH �/,9iimw y�. L "144W 5. q 4'MW 1� V 3 aM \� - - r v�ovs�t' y X H" Lj Wipe PIATFORH 3XIO' AAMP � F40AT rR/Nrz�M1Pl I H�H y -3 f / 9'"MI.W y AI MA.W $ Np1 W 5'�.rMIW MARE ti f Z' Y V Y Y y i/ z AIJ. rows ARE Y � Scale: 1" = 5 feet 0040 DSA' Project Snerifications: Robert and Cheryl Schcidet 1. Aluminum VX 5' platform 765-9419 2. Aluminum Y X 111' ramp Properly Location: 2570 Clearview Ave. 3. I'las(ic floating dock Southold, N.Y. 11971 4. Platform & dock anchored with Date flans Prepared: .luly 9, 2004 2 '/:" X 12' ahnninum piping /61�OZ �Y$DEn :;Pt /-41738-cz27 ` Ilxsuea //�_ SAPPROVIA) AS 1'17t '1'1'It AIS ANIIt'J),"JI)Il1t 11:;i tw PI ur. 4 rlrr NO. I- ' 7 W-C074'1 VOODa uA l r: — /°/1 3/0` e Cross View DiaLram -z 1411111 I . 37 FEer Sounding Locations Under Dock at 11fLM 106 rTM 3 kIo RAMA 5 � 20 FLOAT MHW ,I I LW psrsA' N 11 MLw `mil . •. � s z Moly t Scale: 1"=5 feet Project Snecifications: Robert and Cheryl Scheidet 1. Aluminum 4' X 5' platform '2 /'� 765-9419 2. Aluminum 3' X 10' ramp POST'S 3. Plastic floating dock Propert}, Location: 2570 Clearview Ave. 4. Platform & dock anchored with Southold, N.Y. 11971 2 '/:" X 12' aluminum piping Date Plans Prepared: July 9, 2004 t nrriuweu ns r(:u rr:onis /V ys��c #-l_ tf73�^aZ76�/O�OD� Atli) ('.Ip7111'1'I�f,�j „�. i;.MIt 1444,/-`173�f 0-M170000i a n � ie /u r3/o� env w e 0 LIP a a 2 1 e e 61 Sb gp 1µ W 0 O O U UR ti a n METALLIC LADDER MFG. CORP. Mig NAM SCnidolPwwm Loddw Mt.Corp. NoB a^ 0261ARP 2n� F mAnu : lg#T 1 op 2 4 8 2 N G H O w ' o � 1 n 0 0 4 2 L Y*ApplY ftergim Wole 1n Ia!uw 8 0 y 62 914 q 61 3M o V 24 24 0 ■ 49 LF6 ma Li n 60116 a 1 NC x V Mmkwm GNve Pkw n 4 RMOM m A n m METALLIC LADDER MFG. CORP, !llWn • INIC BtlMIa4t Phtbn� A4�IW61Adit C" MIT Dal B O1" MIARP 9 ' IIHW 2 of o , ti 0 O w •o Molded Square Fiberglass Grating-Integral Git Page 1 of 1 4,1 Go Back http://www.mcnichols.com/products/fiberglass/molded/square/fg_sq_integral_cu.htm 7/26/2004 New York State Department of Environmental Conservation Division of Environmental Permits Rm 121, Building 40-SUNY Am Stony Brook, New York 11790-2356 Telephone (631) 444-0365 Facsimile (631) 444-0360 - Erin M.Crotty Commissioner October 13, 2004 Robert and Cheryl Scheidet X60 Nater Terrace Southold NY 11971 RE: Pen-nit # 1-4738-027691100002 Dear Permittees: In conformance with the requirements of the State Uniform Procedures Act (Article 70, ECL) and its implementing regulations (6 NYCRR, Part 62)1) we are enclosing your permit. Please read all conditions carefully. If you are unable to comply with any conditions, please contact us at the above address. Also enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather. Very truly yours, Matthew R. Penski ECPA N-IRP Enclosure NEW YORK. STATE DEPARTMENT OF ENVIRONMEIITAL COIISERVATION DEC PERMIT NUMBER EFFECTIVE DATE 1-4738-02769100002 October 13, 2004 FACILITYIPROGRAM NUMBER(S) PERMIT EXPIRATION DATE(S) Under the Environmental Conservation Law October 12,2014 TYPE OF PERMIT ■New ❑Renewal ❑ Modification ❑ Permit to Construct ❑ Permit to Operate ❑ Article 15,Title 5: Protection of Waters ■ 6NYCRR 608:Water Quality ❑ Article 27,Title 7;6NYCRR Certification 360: Solid Waste Management ❑ Article 15,Title 15:Water Supply ❑ Article 17,Titles 7,8:SPDES ❑ Article 27,Title 9;6NYCRR 373: Hazardous Waste Management ❑ Article 15,Title 15:Water ❑ Article 19:Air Pollution Transport Control ❑ Article 34:Coastal Erosion Management ❑ Article 15,Title 15: Long ❑ Article 23,Title 27: Mined Land Island Wells Reclamation ❑ Article 36:Floodplain Management ❑ Article 15,Title 27:Wild, ❑ Article 24: Freshwater Wetlands Scenic and Recreational Rivers ❑ Articles 1,3, 17, 19,27,37; ■ Article 25:Tidal Wetlands 6NYCRR 380:Radiation Control PERMIT ISSUED TO TELEPHONE NUMBER Robert and Cheryl Scheidet (631)765-9419 ADDRESS OF PERMITTEE 560 Water Terrace, Southold NY 11971 CONTACT PERSON FOR PERMITTED WORK TELEPHONE NUMBER NAME AND ADDRESS OF PROJECT/FACILITY Scheidet Property, 2570 Clearview Avenue, Southold NY LOCATION OF PROJECT/FACILITY SCTM#1000-70-10-29.2 COUNTY TOWN WATERCOURSE NYTM COORDINATES Suffolk Southold Goose Creek E:716.6 N:4547.4 Description of Authorized Activity Construct a 4-foot by 5-foot platform, stairway to grade, a 3-foot by 10-foot seasonal ramp, and a 5 foot by 20 foot seasonal float as shown on the plans prepared by Robert and Cheryl Scheidet on 7/9/04, and stamped NYSDEC approved on 10/13/04. By acceptance of this permit,the permittee agrees that the permit is contingent upon strict compliance with the ECL,all applicable regulations,the General Conditicns specified(see pa s 2-4)a any Special Conditions included as part of this permit. PERMIT ADM ISTRATOR: ADDRESS Bldg.#40.SUNY,Sony Brook, NY 11790-2356 John .Wi and (MRP) A H RI ED IGNATURE DATE II ( Page 1 of 4 October 13, 2004 l - NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL COI'ISERVATION SPECIAL CONDITIONS 1. Dock or platform shall not exceed 4 feet in width and shall be a minimum of 3Y�feet above grade` over tidal wetland areas (' as measured from ground to bottom of dock sheathing). 2. Platform/ramp/float may not(a)extend laterally beyond property lines, (b)be placed so that docked boats extend over adjacent property line, (c) interfere with navigation, (d) interfere with other landowners riparian rights. 3. No permanent structures may be installed on platform/ramp/float without first obtaining written Department approval (permit, modification, or amendment). 4. The ramp and float shall be installed and removed on a seasonal basis. The ramp and float shall be installed on or after April 1"of each calendar year and must be removed by December 1s'of each calendar year. 5. Floats and ramps may not rest on or be stored in any vegetated tidal wetland. 6. Platform/ramp/Float reconstruction or replacement or seasonal installation shall not involve expansion or substantial modification of existing structures or facilities. 7. The storage of construction equipment and materials shall be confined to within the project work site and or upland areas greater than 50 linear feet from the tidal wetland boundary. 8. No dredging, excavating or other alteration of shoreline or underwater areas is authorized by this permit, nor shall issuance of this permit be construed to suggest that the Department will issue a permit for such activities in the future. 9. The use of wood treated with pentachlorophenol in the construction of structures that will be in contact with tidal waters is strictly prohibited. 10. Any debris or excess material from construction of this project shall be completely removed from the adjacent area (upland)and removed to an approved upland area for disposal. No debris is permitted in tidal wetlands and or protected buffer areas. DEC PERMIT NUMBER PAGE 2 OF 4 1-4738-02769/00002 NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee expressly agrees to indemnify and hold harmless the Department of Environmental Conservation of the State of New York, its representatives, employees, and agents ("DEC")for all claims, suits, actions, and damages, to the extent attributable to the permittee's acts or omissions in connection with the permittee's undertaking of activities in connection with, or operation and maintenance of, the facility or facilities authorized by the permit whether in compliance or not in compliance with the terms and conditions of the permit. This indemnification does not extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or intentional acts or omissions,or to any claims, suits,or actions naming the DEC and arising under article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision under federal or state laws. Item B: Permittee's Contractors to Comply with Permit The permittee is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit, including all special conditions while acting as the permittee's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee. Item C: Permittee Responsible for Obtaining Other Required Permits The permittee is responsible for obtaining any other permits, approvals, lands,easements and rights-of-way that may be required to carry out the activities that are authorized by this permit. Item D: No Right to Trespass or Interfere with Riparian Rights This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. GENERAL CONDITIONS General Condition 1: Facility Inspection by the Department The permitted site or facility,including relevant records, is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Department)to determine whether the permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71-0301 and SAPA 401(3). The permittee shall provide a person to accompany the Department's representative during an inspection to the permit area when requested by the Department. A copy of this permit, including all referenced maps, drawings and special conditions, must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. General Condition 2: Relationship of this Permit to Other Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Department or any of the terms, conditions or requirements contained in such order or determination. General Condition 3: Applications for Permit Renewals or Modifications The permittee must submit a separate written application to the Department for renewal, modification or transfer of this permit. Such application must include any forms or supplemental information the Department requires. Any renewal, modification or transfer granted by the Department must be in writing. The permittee must submit a renewal application at least: a) 180 days before expiration of permits for State Pollutant Discharge Elimination System (SPDES), Hazardous Waste Management Facilities(HW MF),major Air Pollution Control(APC)and Solid Waste Management Facilities(SW MF);and b) 30 days before expiration of all other permit types. Submission of applications for permit renewal or modification are to be submitted to: NYSDEC Regional Permit Administrator, Region 1, SUNY Bldg#40, Stony Brook NY 11790-2356 General Condition 4: Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to modify, suspend or revoke this permit in accordance with 6 NYCRR Part 621. The grounds for modification, suspension or revocation include: a) materially false or inaccurate statements in the permit application or supporting papers; b) failure by the permittee to comply with any terms or conditions of the permit; c) exceeding the scope of the project as described in the permit application; d) newly discovered material information or a material change in environmental conditions, relevant technology or applicable law or regulations since the issuance of the existing permit; e) noncompliance with previously issued permit conditions, orders of the commissioner, any provisions of the Environmental Conservation Law or regulations of the Department related to the permitted activity. GEC PERldIT NUA7BER PAGE 3 OF 4 1-4738-02769/00002 ' NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION ADDITIONAL GENERAL CONDITIONS FOR ARTICLES 15 (TITLE 5), 24, 25, 34 AND 6NYCRR PART 608 ( TIDAL WETLANDS ) 1. If future operations by the State of New York require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural resources of the State, the owner may be ordered by the Department to remove or alter the structural work, obstructions, or hazards caused thereby without expense to the State, and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other modification of the watercourse hereby authorized shall not be completed, the owners, shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall be made against the State of New York on account of any such removal or alteration. 2. The State of New York shall in no case be liable for any damage or injury to the structure or work herein authorized which may be caused by or result from future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no claim or right to compensation shall accrue from any such damage. 3. Granting of this permit does not relieve the applicant of the responsibility of obtaining any other permission,consent or approval from the U.S. Army Corps of Engineers, U.S. Coast Guard, New York State Office of General Services or local government which may be required. 4. All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project. 5. Any material dredged in the conduct of the work herein permitted shall be removed evenly,without leaving large refuse piles, ridges across the bed of a waterway or floodplain or deep holes that may have a tendency to cause damage to navigable channels or to the banks of a waterway. 6. There shall be no unreasonable interference with navigation by the work herein authorized. 7. If upon the expiration or revocation of this permit,the project hereby authorized has not been completed,the applicant shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require,remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. 8. If granted under 6NYCRR Part 608, the NYS Department of Environmental Conservation hereby certifies that the subject project will not contravene effluent limitations or other limitations or standards under Sections 301, 302, 303, 306 and 307 of the Clean Water Act of 1977 (PL 95-217) provided that all of the conditions listed herein are met. 9. At least 48 hours prior to commencement of the project, the permittee and contractor shall sign and return the top portion of the enclosed notification form certifying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion of project, the bottom portion of the form must also be signed and returned, along with photographs of the completed work and, if required, a survey. 10. All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or his agent as part of the permit application. Such approved plans were prepared by Robert and Cheryl Scheidet on 7/9/04. DEC PERMIT NUMBER PAGE 4 OF 4 1-4738-02769/00002 NOTICE OF COMMENCEMENT OF CONSTRUCTION AmRETURN THIS FORM TO: COMPLIANCE OR FAX TO: 631-444-0297 V Marine Habitat Protection NYSDEC - Building 40-SUNY PERMIT NUMBER: Stony Brook N 11790-2351; ISSUED TO: oo0Da Rode.t4.�c( Clfery/ SCKeicQ�� PROJECT LOCATION/ADDRESS: CONTRACTOR NAME: ADDRESS: TELEPHONE: Dear Sir: Pursuant to General Condition#9 of the referenced permit,you are hereby notified that the authorized activity shall commence on . We certify that we have read the referenced permit and approved plans and fully understand the authorized project and all permit conditions.We have inspected the project site and can complete the project as described in the permit and as depicted on the approved plans. We can do so in full compliance with all plan notes and permit conditions.The permit sign, permit and approved plans will :e available at the site for inspection in accordance with general Condition No. 1. (Both signatures required) PERMITEE DATE CONTRACTOR DATE THIS NOTICE MUST BE SENT TO THE ABOVE ADDRESS AT LEAST TWO DAYS PRIOR TO COMMENCEMENT OF THE PROJECT AND IDR ANYASSOCIATED REGULATED ACTIVITIES. FAILURE TO RETURN THIS NOTICE, POST THE PERMIT SIGN, OR HAVE THE PERMIT AND APPROVED PLANS AVAILABLE AT THE WORK SITE FOR THE DURATION OF THE PROJECT MAY SUBJECT THE PERMITTEE ANDiOR CONTRACTOR TO APPLICABLE SANCTIONS AND PENALTIES FOR NON-COMPLIANCE IMTH PERMIT CONDITIONS. Cutalong this line x..........................?` .}`.... .................._?`.........................._}`........ ...............}`...........................}` ......................... NOTICE OF COMPLETION OF CONSTRUCTION Am THIS FORM TO: COMPLIANCE OR FAX TO: 631-444-0297 Am Marine Habitat Protection NYSDEC - Building 40-SUNY Stony Brook, NY 11790-2356 PERMIT NUMBER: ISSUED TO: PROJECT LOCATION/ADDRESS: CONTRACTOR NAME: ADDRESS: TELEPHONE: Dear Sir: Pursuant to General Condition#9 of the referenced permit,you are hereby notified that the authorized activity was completed on .We have fully complied with the terns and conditions of the permit and approved plans. (Both signatures required) PERMITEE DATE CONTRACTOR DATE THIS NOTICE, WITH PHOTO MPLETED SURVEY,AS APPROPRIATE, MUST BE SENT TO THE ABOVE ADDRESS WITHIN 30 DAYS OF COMPLETION OF THE PROJECT. Site Plan : - f 37 AMM Y Y ` A Sounding Locations Under Dock at MLW N/GN MAasH Y �� X V #9"M�w y�io'�McW 5 yMt w Y 1 A A Y Y .. v PO&I ar VIM yt X Jr� 40, WIAe fa PMTFORH 1 3 xlOO RAhfP 640 FL 0AT Am 9,t w y'�"Mtw 5'/ now gay•'Mtw MARSff � Y /� , Y �r Y Y Y �/ Z A" POs -$ ARE Scale: 1"= 5 feet l �lo DSA. Proiect Specifications: Robert and Cheryl Scheidet 1. Aluminum 4' X 5' platform 765-9419 2. Aluminum 3' X 10' ramp Property Location: 2570 Clearview Ave. 3. Plastic floating dock Southold, N.Y. 11971 4. Platform & dock anchored with Date Plans Prepared: July 9, 2004 2 '/z" X 12' aluminum pipingQewOZ NySDEc /-4 738-x2709 NTS DEC APPROVED AS PER TERMS AND CONI11T1ON3 OF b PERMI'C NO./-y73$=002769/°000c9I DATE /0/13 0 z Cross View Diaerram I . 3 7 FEET J 5 tpXg79gDR/9 ` Sounding Locations Under Dock at MLW �x ' 3�b� /GN .3Xio" N� 5 ' 20' FLAAT H 1"R-W Iger MLW3 PW739 A• 9q�"►�w L Scale: 1"=5 feet Proiect Snecifications: 11 Robert and Cheryl Scheidet 1. Aluminum 41 X 5 platform 765-9419 2.Aluminum 3' X 10' ramp PO Property Location: 2570 Clearview Ave. 3. Plastic floating dock Southold, N.Y. 11971 4. Platform & dock anchored with o7/A Date Plans Prepared: July 9,2004 2 '/:" X 12' aluminum piping ArPROVED 4s PEn Tr:RMSOZ76��a �/ysD�c w-/-if73�- AND C+1Nn1'1'h)NS OF PLUMIT NO'/473�-oa76700091, nA ra /0 95-20-1 (11/03)-9d New York State Department of Environmental Conservation �afto NOTICE low v The Department of Environmental Conservation (DEC) has issued permit(s) pursuant to the Environmental Conservation Law for work being conducted at this site. For further information regarding the nature and extent of the approved work and any Department conditions applied to the approval, contact the Regional Permit Administrator listed below. Please refer to th60i mber howwn w Ojtacting the DEC. 900 Regional Permit Administrator Permit Number Expiration Date NOTE: This notice is NOT a permit A 1 STATE OF NEW YORK DEPARTMENT OF STATE 4 1 STATE STREET ALBANY, NY 1223 1-0001 GEORGE E. PATAKI RANDY A. DANIELS GOVERNOR October 15, 2004 SECRETARY OF STATE Robert A. Scheidet 560 Water Terrace Southold, NY 11971 Re: F-2004-0815 U.S. Army Corps of Engineers/New York District Permit Application -Robert Scheidet- Install 4'x 5'platform; a Y x 10' ramp; and a 5' x 20' float Goose Creek,Town of Southold, Suffolk County General Concurrence Dear Mr. Scheidet: On October 11, 2004 the Department of State received your response to our September 27, 2004 request for information. The Department of State has determined that this proposal meets the Department's general consistency concurrence criteria. Therefore, further review of the proposed activity by the Department of State,and the Department's concurrence with an individual consistency certification, are not required. When communicating with us regarding this matter, please contact us at(518)474-6000 and refer to our file #F-2004-0815. Sincerely, QJetf�ppfe�ril� Supervisor of Consistency Review and Analysis Division of Coastal Resources sm cc: COE/New York District-Michael Vissichelli NYS DEC Region 1-John Pavacic N^MY.DOS.STATE.NY.US • E-MAIL: INFO@DOS.STATE.NY.US Cross View Diagram ji 37 FEET �jt9� 7, /� A Sounding Locations Under Dock at MI f 0 "X 20r FL447 M"Ll w3�g�r i Paws ra y 8 A.w i H'llyMtw ;` • y S z 14L Scale: 1"=5 feet Proiect Specifications: Robert and Cheryl Scheidet 1. Aluminum 4 X 51 platform POSTS 765-9419 2. Aluminum Y X 10' ramp Property Location: 2570 Clearview Ave. 3. Plastic floating dock Southold, N.Y. 11971 4.Platform & dock anchored with Date Plans Prepared: July 9,2 2%"X 12' aluminum piping N YsAEc 4;t-/-1173, ® °� " JUL u Southold Town 3 %� a - CE qlc � o� � I N It- 4 � ■ �� to } C4 $ 3 3 on .4 ■ ] ■ `2 f 2 E % m $ & � . � IJL�L �� ! � } f k § ) « � n . ■ � � a � � D6 n IN & : t o O = y 3 O m V ^ �� o 1- 0 CD 01 101. fi III C, 00 zz Do 11 LL 6 g u 0J n y( sit 1 g■r 6 y� 41 V 6E eb try' N 14 cl on > i w m o z W Z oFav 1z `1 ✓ In Wsa V) _`_ A j W Ole 1A E� ` c C O d' V1 PARK WAY -.... LI) e t xr I W � . + a I 31n `s SUMVI3fON MAP OF �) W o nID M MOIIr[OMnIRdR Y - j` or IeronDl m. Iw u nc r. 2141001� oD c LOT Lor(s)f 0 � � •{� �� Q I I o N/0/F' s � . ANN 0DAYAALA i 6 / Z TROY , BAYAALA I .. NANCYN V " ; � DWE .WNHOEWlq Bf LHlG 306.10• 01 50_ II � mst� OF` s [N11G 11111YN 346.73• ti N 01'34.40 ! VCM t�- Q N/0/f.srAMSY CIfASd GAGEN'9 LANDING ROAD " f,�c Irlw r fuer L_// — GAGEN'S LANDING ROAD Albert J. Krupski, President O-pSVFFO��CO • Town Hall James King,Vice-President /'1` 53095 Route 25 Artie Foster .�! P.O.Box 1179 Ken Poliwoda o Southold, New York 11971-0959 Peggy A. Dickerson G.j Telephone(631) 765-1892 ��l �a Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only - Co tal Erosion Permit Application etland Permit Application _Major Minor _WaiveriAmendm nt/ han es Aeceived Application: Oil AWceived Fee:$ completed Application rCE _Incomplete D_SEQRA Classification:Type IType IIUnlisted Coordination:(date sent QAC Referral Sent/hate of Inspection:Receipt of CAC Report:Lead Agency Detennination: _Technical Review: _/Public Hearing Held: Resolution: Name of Applicant dfoxe 7- 7' erWeeYL -5c. 7- Address Address Jr-6O b✓197ZW 7X 4CoF SD!/Tfld�� A •/ . Phone Number:( 763-9�/9Ur o� Suffolk County Tax Map Number: 1000 - SEC. 740 jK4C/( /Q A07-,2?.A, Property Location: ,ZS70 Cj•EA/Pl7/�W AIDE. -,FASTd/V,?>OF CA.69R11Ew Ave, 9n .XWT'MS;7-0 -G-„%FN A4YA & (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: Board of Trustees Application GENERAL DATA Land Area (in square feet): -�Z 9 6 S-7, 5:!;- Area SArea Zoning: Previous use of property: V,4C41Y7— Intended use of property: AF571 SENT//9 L Prior permits/approvals for site improvements: Agency ate _Po' 3o,Z6,0 SMAMP FWIP/Ads AFrT z S� AEC y Zi o #/- Y757-41Z 76q1a000 No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspenl{ed �y a governmental agency? ✓✓ No Yes If yes, provide explanation: Project Description(use attachments if necessary): S /X.241 pOC& U-yST OF h//7-X/ SfJwCE , CSEE ATTACrS(FD P44 Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: 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: feet 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? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 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): 0 Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: 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? (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) • • PROJECT ID NUMBER 61720 SEQR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART t -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1.APPLICANT L£P9NB6R 2.PROJECT NAME KT g n 5CHE/AET 'PeCk 3.PROJECT LOCATION:,,?f—m ( 46K✓w� A(/ [+U'J F,F03� �j Municipality Q(/Tfjd,(j� County .S 4.PRECISE LOCATION: Street Access and Road Intersections. Prominent landmarks etc -or P" a m" As720 vE - ,9D ,Wr ,l,©T; -1127 AdrrX10 J`0r-&,Z— .SA%r ATlACH6b /!AP 5. IS PROPOSED ACTION: New ❑Expansion ❑Modification/alteration 6.DESCRIBE PROJECT BRIEFLY: .5- / / �� TvS+T oFF SHGKEL./x/E � xzo v V P,* p 97->' 0117W /2A,AlP AND ,Z FODT fj�KN ixI1 TF�'�'P�1 ON s'Ho e1. CSEE ATTAc'HEA AKAN) 7.AMOUNT OF LANL❑ AFFECTED: te�aw// Initially ♦Op"3cres Ultimately Ow�p acres 8.WILL OPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? Yes ❑ No If no,describe briefly: g.WH4 IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) Residential ❑Industrial ❑Commercial Agriculture ❑Park/Forest/Open Space ❑Olher (describe) 1o. DOES TION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGEN (Federal, Stateor Local) es ❑No If yes, list agency name and permit / approval: 11.DO S ANY A CT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes o If yes, list agenc name and A,16=6 a r v ��owwN o,�'f ,�/,�rA,16,�fi9l p�sr�ir 3 R6�2 -D� /6;W17_ MGW,r1CAT/o/V Y/-V/ .� 12 AS A RES OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? ❑Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE / Applicant / Spo Date: ��j-� Signature If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment 10 PART II - IMPACT ASSESSMENT o be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL EAF. 0 Yes E] 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. 0 Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,if legible) C1. Existing air quality,surface or groundwater quality or quantity,noise levels,existing traffic pattern,solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly. C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly: C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly: 04. A community's existing plans or goals as officially adopted.or a change in use or intensity of use of land or other 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 C1-05? Explain briefly: C7. Other impacts(includingthan es in use of either quantity or type of energy? Ex lain brieFl : D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA CEA? If yes,explain briefly: E] Yes ❑No THERE,OR IS THERE LIKELY TO BE CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain I Yes 0 No F— I PART III-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it is substantial,large,important or otherwise significant. Each effect should be assessed in connection with its(a)setting(i.e.urban or rural);(b)probability of occurring;(c)duration;(d)irreversibility;(e) geographic scope; and (f)magnitude. If necessary,add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes,the determination of significance must evaluate the potential impact of the proposed 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 information and analysis above and any supporting documentation,that the proposed actio WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting IN! determination. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from responsible officer) • � • Albert J. Krupski, President gpFFO(,�O 4449, Town Hall James King,Vice-President may` 53095 Route 25 Artie Foster p P.O. Box 1179 Ken Poliwoda ca Southold, New York 11971-0959 W Nf Peggy A. Dickerson �,f. �� 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 iQO�ERT 9-�iCYL I, SCfiSE/ 1 residing at SfO W*M< �[,E st�G;Ti F.Y,D . Y //97/ being duly sworn, depose and say: That on thea dayoftVLY , 200V I personally posted the property known as ,Z -70 CA64GW45'w Av-f A rW MD 4/.X 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_� JV�U 121 pna— ^,. /`V . / , YM Dated: � Y (signal) Sworn to before met s 34d yofJuly 2004 offi"&4�_ Notary Public ftb7z;100 r PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: !�1/P• �/`�RS. HE/S.NE� /700 /r1R P- r � /6n % 7 lf/15 . BAYAAtA ORX / / .,AIR t- M�2S BcGt/oN 7PE/YJYY .cA�F 117"80 9- MRS MESS✓NA /p 7WOMB4Y,4ye NX /0306 STATE OF NEW YORK COUNTY OF SUFFOLK RWX7-7'CX&M- SCHE/IST residing at 360 AOP72C 72POW-c' S7J!/Tf ' /. Y, //97/ being duly swom, deposes and says that on the ��day of 7V.4 y 20 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 States Post Office at that said Notices were mailed to each of said persons by (certified)(registered)mail. r Swom to bgfore me this Day of 20_LL Notary Public KATHLEEN M.SANTORO E Notary Public.Stsre of Now Yak No.4882427 3 Qualified in Nassau County {_ Commission Expires May 11,�pG NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES,TOWN OF SOUTHOLD In the matter of applicant: ROAgEe'T7"Cf/ErCY4 SCTM# 09 "�� `�Z 9•.Z YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the oard of Trustees to: caw 9 7;file T �9 FLoA T/NG D�C�" x 10 .) /O �RAMP� hAP y X .r 1LATF40VW ort/ Sr�!LPEl✓NE OF PkApERTY. 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: # 6 9 AGCE /?ES/DF.v7741_ foeapeleTY 1.49v//M.. A ovE FAMILY //pME W1771 //.f FG`ET OF Sfl�CE1/NE' dV G��C.4EE.�. 3. That the project which is subject to Environmental Review under Chapters 32, 37, and/or 97 of the Town Code is open to public comment on: cT!/,CY.Z/, .ZDOjV 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: A0Xk Z- 9—C,AfoeYL- SChE/laET MAILING ADDRESS: WA CF v / PHONE #: Enc: Copy of sketch or plan showing proposal for your convenience. NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: SCTM# YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: 3. That the project which is subject to Environmental Review under Chapters 32, 37, and/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: MAILING ADDRESS: PHONE #: Enc: Copy of sketch or plan showing proposal for your convenience. Board of Trustees Application County of Suffolk State of New York Z-4,;,; j i X/ ir'f/�/AE7 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 REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. ,Si atureJ / �G SWORN TO BEFORE ME THIS Z DAY OF 200� Notary Public PATRICIA COMIN Notary Public,State of New Yak No.01C05017352 Cuakhed in Suffolk Cowdy CC-1m,,i09 ExplRf Sept U, APPLICANUAGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this forth 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. YOURNAME: Jc �iEIIT�QOBERTA. SGSL��yci/ G�iL�/QYL E, (Last name,fust 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.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other DOCK (If"Other",name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of 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!eyca a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of ares. YES NO If you answered"YES".complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)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%of the 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 noncorporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this d y T7! E 00 Signature Print Name / Form TS 1