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Home My WebLink AboutTR-5572 James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0182C Date J anuarv 8. 2007 THIS CERTIFIES that the two-story dwelling, attached garage & pervious driyeway At 1680 Brigantine Dr., Southold , Suffolk County Tax Map # 79-4-25 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 2/14/02 pursuant to which Trustees Permit # 5572 Dated 6/26/02 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 two-stOry dwelling, attached garage & pervious driyeway. The certificate is issued to RICHARD OLIVO owner of the aforesaid property. ~o<~ Authorized Signature Albert J. Krupski, President James King, Vice-President Artie Fester Ken Poliwoda Peg~' A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York~'~ 1971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 June 24, 2004 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Robert E. Herrmann En-Consultants, Inc. 1319 North Sea Rd. Southampton, NY 11968 RE: THOMAS JORDAN 1680 BRIGANTINE DR., SOUTHOLD SCTM#79-4-25 Dear Mr. Herrmann: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Thursday, June 24, 2004: RESOLVED that the Southold Town Board of Trustees grants a One-Year Extension to Permit #5572, as issued on June 26, 2002, and amended on June 24, 2004. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees AJK:lms 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 June 24,2004 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Robert E. Herrmann Eh-Consultants, Inc. 1319 North Sea Rd. Southampton, NY 11968 RE: THOMAS JORDAN 1680 BRIGANTINE DR., SOUTHOLD SCTM#79-4-25 Dear Mr. Herrmann: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Thursday, June 24, 2004: RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to Permit #5572 to construct a two-story dwelling and attached garage; install a pervious driveway, sanitary system, and public water service; and establish a 42' non- disturbance/non-fertilization buffer adjacent to the freshwater wetland boundary, with the condition the three (3) oak trees on the northeast corner of the property are left in place, drywells and gutters are installed to contain the roof run-off, and all as depicted on the survey prepared by Joseph A. Ingegno last dated June 28, 2004. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765-1892. Sincerely, Albert J. Krupski, Jr. President, Board of Trustee,~ .... AJK:lms Telephone (631) 765-1892 Town Hall 53095 Route 25 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, June 15, 2004, the following recommendation was made: Moved by Doris McGreevy, seconded by Don Wilder, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the Amendment application THOMAS JORDAN to Amend Permit #5572 to construct a two- story dwelling and attached garage; install a pervious driveway, sanitary system, and public water service; and establish a 42' non-disturbance/non-fertilization buffer adjacent to the freshwater wetland boundary. Located: 1680 Brigantine Dr., Southold. SCTM#79-4-25 Vote of Council: Ayes: All Motion Carried Albert J. Krupski, President James King, ¥ice-President Artie Foster Ken Poliweda 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 May 1, 2003 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. & Mrs. Thomas P. Jordan 1550 Brigantine Dr. Southold, NY 11971 RE: 1680 BRIGANTINE DR., SOUTHOLD SCTM#79-4-25 Dear Mr. & Mrs. Jordan: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, April 30, 2003: RESOLVED, that the Southold Town Board of Trustees APPROVE the Transfer of Perrn'lt #5572 from Gary Gems (as Contract Vendee) to Thomas & Annette Jordan. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765-1892. Sincerely, President, Board of Trustees AJK:lms Telephone (631) 765-189Z Town Hall. 5309.5 Maia Road P.O. Box 11'/9 Southold. New York ~197~. SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Consergation Advisory Council held Wednesday, February 19, 2003, the following recommendation was made: GARY GERNS to Amend Permit #5572 to 'construct a single-family dwelling with a 40' front yard setback. Located: 1680 Brigantine Dr., Southold. SCTM#79-4-25 The CAC did not make an inspection, therefore no recommendation was made. Alber~ 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 $OUTHOLD 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 1 st day of construction % constructed Project complete, compliance inspection. Board Of $outhold Town Trustees SOUTHOLD. NEW YORK DATE: ....... ~U~ ..~!.?....2002 Pursuant to the provisions of Chapter 615 of the Laws of the StMe of New Yor~, le93; and Chapter of State of New York 19~12; and ~heSo,hold ToWn Ordinance en- tiffed ."REGULATING AND THE PLAC;ING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND' PUBLIC; LANDS and the REMOVAL OF SAND, GRAVEL.OR OTHER IdATERIALS FROId LANDS UNDER TOWN'WATERS;~.!. and in accordance with Yne Resolution of The B~erd adopted at a meeting held on ..~.z~...~.: .... . 37..0..~.., and In consideration of Yne sum of $...~.g.gh~.g.~ ...... paid by Gar~ Gerns ............................................ of ........... ~.s..l.~p...~r.~ ...................................... N. Y. and ~ubiecS to the Terms and Conditions lis~ed on Yne reverse side hereof, W' .of .So,hold .T9wn Tr .~es .aufhorlze.s enid .~prm'.ds ~ following: e~lancl rerml~ ~o cons~ru¢~ a single-zamily clWelling with the conditions that hay bales are installed prior to construction with 10~ relief during construction but area must be re-vegetated after the const, is complete and drywells and gutters installed conta~i~ the ropf runT~fi~ all as~ d~D~cte~l cl~ survey dated . a# m accoraa~ce w,m ~ne ae~a~ma specmca~mn$ es presemea m · fha odglrmfing eppl~on. August 14, 1989 and last revised Julll~ 17, 2002. IN WITNESS WHEREOF, The said Board of Trustees here- ~2~ causes ifs Corporate Seal fo be aff'~ced, and fhese presents to subscr~ed by a'maiorlty of fhe sa;d Board as of this dat~. Tm#ecs TERMS GONDmONS Gery Gems ze~l~az 36 Irving St., Islip Terrace, NY 11752 lq. Y~ as wit~ t~spect thetet~ to the ~lete ~ of die Jk~td o~ Ttum~ ~ the Town o~ SoadaoM 2. That this Pennk h' valid Sot x period of' 24 mos. ~lch b comld~ed to be the [or aa _ _,?,~aon may be made to the lkam:l at a ~ a-re. ~ this P~t should be retained indeirmitefy, or as long ts the Mid Petmlttee wishes the stx~cm~ or project invotve~ to provide ~ ~o anyooe ~ d~ auth- temcaticm of d~ p.~m~¢ by resohtion of the said BomxL woek dxdl cause uflflmomble ebsmsmon to free mvipfio~ the aid Petmi~e will be Miub~ o~ S(mthol& 9. Tht the ~tmlttee witt ol~(, ~li edger l~; ~d comems d~t fray be zequired mP- piementnf to tf~ ~t ~ Jx~y IX~ ~u~joct tO revol~ upon f't~Jn~ to ~ same. Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 June 27, 2002 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Gary Gems 36 lrdng Place Islip Terrance, NY 11752 RE: 1680 BRIGANTINE DR., SOUTHOLD SCTM#79-4-25 Dear Mr. Gems: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, June 26, 2002 regarding the above matter: WHEREAS, GARY GERNS, as contract vendee applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated February 14, 2002, 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 June 26, 2002, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, thc 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 GARY GERNS, as contract vendee, to construct a single-family dwelling with the conditions that hay bales are installed prior to construction with 10' relief during construction but must be re-vegetated after the construction is complete, and drywells and gutters installed to contain the roof nm-off, all as depicted on survey dated August 14, 1989 and last revised June 17, 2002. 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 and complete 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. Inspections are required at a fee of $5.00 per inspection. (See attached schedule.) Fees: $10.00 Very truly yours, Albert J. Krups~, Jr. President, Board of Trustees AJKfLrns Albert J. Krupsld, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town HaH 53095 Main Road Ii P.O. Box 1179 Southold. New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TKUSTEES TOWN OF SOUTHOLD Please be advised that your application, dated has bean reviewed by this Board, at the regular ~eetlng of ~/9}~') 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: TOTAL FEES DUE: S.IGNED: PRESIDENT, BOARD OF TRUSTEES BY: CL~ERK~ BOARD OF TRUSTEES 4~98 Telephone (631) 765-1892 Town F_*~L 53095 Main Road P.O. Box Southold, New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At th~ meeting of the Southold Town Conservation Advisory Council held Monday, March 18, 2002, the following recommendation was made: Moved by Scott Hilary, seconded by Nicholas Dickerson, it was RESOLVED to recommend to the $outhold Town Board of Trustees DISAPPROVAL of the Wetland Permit Application of GARY GERNS (CONTRACT VENDEE) to construct a single-family residence. Located: 1680 Brigantine Drive, Southold. SCTM#79-4-25 The CAC recommendd Disapproval of the application for the following reasons: The project requires a 100' setback from the wetlands. There are concerns with the grade and potential alteration in the grade causing run-off. A building envelope appears to be impossible to achieve. Vote of Council: Ayes: All Motion Carried Albert J. Krupski, President James King, Vice-President Henry Smith Attic 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 November 15, 2001 Gerard P. Gochringer Chairman Zoning Board of Appeals Town of Southold Town Hall PO Box 1179 Southold, NY 11971 Dear Board Members: Upon review of the property located on Brigantine Drive in Southold (74-4-25&26) owned by Jordan, T&A. The Southold Town Board of Trustees request you to deny the applicant's request to unmerge lots 25 & 26 for the following environmental reasons: 1. The property contains an active wetland. 2. Concern about development without meeting the Southold Town Board of Trustees setback of 100 feet for septic system. 3. Concern about development without meeting the Southold Town Board of Trustees setback of 50 feet of no disturbance upland of the wetland delimitation line. 4. This is a substandard lot. If you have any questions. Please contact the Southold Town Trustee office. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees AJK:cjc Albert J. Krupski, Presider~ ' 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 (63 I) 765-1892 FAx (631) 765-1366 DATE MAY 26, 2004 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD LETTER OF REQUES~ OWNER THOMAS JORDAN PHONE 631-765-522 I ADDRESS 1550 BRIGANTINE DRIVE, SOUTHOLD, NY 11971 AGENT EN-CONSULTANTS, INC. PHONE 631-283-6360 ADDRESS 1319 NORTH SEA ROAD, SOUTHAMPTON, NY 11968 PROPERTY LOCATION 18680 BRIGANTINE DRIVE, SOUTHOLD TAX MAP NO. 1000-79-4-25 I/We EN-CONSULTANTS, INC. request an Amendment to Pemit # 5572 TO CONSTRUCT A TWO-STORY HOUSE AND ATTACHED GARAGE; INSTALL A PERVIOUS DRIVEWAY, SANITARY SYSTEM, AND PUBLIC WATER SERVICE; AND ESTABLISH A 42-FOOT NON-DISTURBANCEINON-FERTILLZATION BUFFER ADJACENT TO THE FRESHWATER WETLANDS BOUNDARY, ALL AS DEPICTED ON THE SITE PLAN PREPARED BY JOSEPH A. INGEGNO, LAST DATED DECEMBER 1, 2003. EXTEND PERMIT FOR A PERMIT OF ONE YEAR. Signed By: ~ ROBERT E. HERRMANN, COASTAL MGMT. SPECIALIST NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEESr TOWN OF SOUTHOLD In the matter of applicant:T~OMASJO~DAN SCTM#1000- 79~-25 YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the Permit from the Board of Trustees to: undersigned to request a TO CONSTRUCT A TWO-STORY HOUSE AND ATI~ACHED GARAGE; INSTALL A PERVIOUS DRIVEWAY, SANITARY SYSTEM, AND PUBLIC WATER SERVICE; AND ESTABLISH A 42-FOOT NON-DISTURBANCE/NON-FERTILIZATION BUFFER ADJACENT TO THE FRESHWATER WETLANDS BOUNDARY, ALL AS DEPICTED ON THE SITE PLAN PREPARED BY JOSEPH A. INGEGNO, LAST DATED DECEMBER 1, 2003. 2. That the property which is the subject of Environmental Review-is located adjacent to your property and is described as follows: 1680 BRIGANTINE DRIVE, SOUTHOLD 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: 6/24/04 ~7P.Nt 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 THOMAS JORDAN 1550 BRIGANTINE DRIVE SOUTHOLD, NY 11971 631-765-5221 Enc.: Copy of sketch or plan showing proposal for your convenience. 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) being duly sworn, depose and say: AFFIDAVIT OF POSTING That on the day of ~ , 20(]'/, I personally~ost~d the p[operty known as by placing the Board of T~ustees 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 (signature) Dated: Sworn to before me this day orca2005L PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: ANNE'I'I g & THOMAS JORDAN Address: 1550 BRIGANTINE DRIVE SOUTHOLD, NY 11971 SANDRA SIKOWSKI & WILLIAM KELLY P.O. BOX 1680 SOUTHOLD, NY 11971 STATE OF NEW YORK COUNTY OF SUFFOLK ROBERT E. HERRMANN 1319 NORTH SEA ROAD SOUTHAMPTON, NY 11968 doing business atEN~ONSuLTANTS,~qC' · being duly sworn, deposes and says that on the. 27th day ofMAY ,2o ~ , 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 addressesset 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 SOUTHA/~PTON said Notices were mailed to each of said persons by ~X~X~) mail. Sworn to before me this 27th day ofMAY ,2o04 , that (certified) ROBERT E. HERRMANN COASTAL MANAGEMENT SPECIALIST ~rd of Trustees Appl±cati~ AU'£~ORIZATION (where the applicant is not the owner) (print owner of property) residing at I,.~0 ~Rf6-~DN~ (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner' s ~nature) 8 06/24/2004 14:50 FAX 631283 EN-CONSULT.~IT$,INC. ~004 Albert J. Krupraki, President James King, Vice~Preoident Attic Fozter Ken Poliwoda Peb~' A. Dicker~on To~ra Hall 53095 Route 25 P.O. Box 1t79 Sauthold, New York 11971-0959 Telephone (63 D 765.1892 F~x (631.) 765-1366 BOARD OF TOWN 'L'I~USTEES TOWN OF $OUTHOLD BOAKD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING SOUItL Iq'; N.Y. 11968 being duly sworn, depoae and say: That on thc day of ~ , 20Or'/, I personally posted the pt'operty known as by placing the Board of T~ustec.,s 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 heanng. Date of hearing noted thereon to be held "~fg, ,,~kl_lflp ~,~, ~" Dated; Sworn to before me this day o£(~006L OBoard of Trustees Application County of Suffolk State of New York /~tAt~. t ~ ~R ~ BErG D~Y SWO~ DEPOSES ~ ~F~S THAT ~/S~ IS T~ ~PLIC~ FOR ~ ~O~ DESC~ED PE~T(S) ~ T~T ~L STA~S CONT~D ~ ~ ~ TO T~ BEST OF ~S~R ~O~EDGE ~ BEL~F, ~ T~T ~L WO~ ~LL BE DO~ ~ T~ ~R SET FORTH ~ ~S ~PLICATION ~ AS MAY BE ~PRO~D BY T~ SOUTHOLD TO~ BO~ OF TRUSTEES. ~ ~PLIC~ AG~ES TO HOLD T~ TO~ OF SOUTHOLD ~ ~ TO~ TRUSSES ~ESS ~ F~E ~OM ~ ~ ~L D~AGES ~ CL~S ~S~G ~ER OR BY ~T~ OF S~ PE~T(S), ~ G~D. ~ CO~LET~G T~S ~PLICATION, I ~BY A~HO~E T~ ~US~ES, T~ AGENT(S) OR ~P~SE~ATI~S(S), TO EN~R ONTO ~ PROPERTY TO ~SPECT T~ P~SES ~ CON~CTION ~ ~W OF ~S ~PLICATION. -- S~na~e SWORN TO BEFORE ME THIS DAY OF ~ Notary Public BARBARA ANN RUDDER Nol~ry Publlo, State of New York No. 4855805 Qualified in Suffolk County - Commission Explrel April 14, The Town of Southold'a Code of Ethics prohibits conflicts of interest on the psrL of town officers and employees. The purpose of this form.is to provide lnf6rmation which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. (Last name, firs~ name, middle initial, unleNs other entity, such as a company, l[ so, indicate NATURE OF APPL%CATIONt (Check ali that apply.) Tax grievanoe Approval o~ plat , interest' meanl a businele, including a partnecnhip, in oanerehip of (or employment b~) a corporation in vhich the tovn of£icer or employee dyne more titan 5~ of the YRE y NO -- If you anevered 'YES,' complete the balance of this form and date and sign vhere indicated. Name of person employed by the Town of Southold Title or position of that peraon .,4~bU~- Describe the ~elatio~ehip between youreelE (the applicant) and the town o~[ice~ or employee. Either check the appropriate line A) through D) and/or describe in ~he space p~ovided. Tbs town officer or employee o~ his or her spouse, s~blfng, parent, or child is (check all that apply). __A) the owner of grea~er than 5~ of the shares of the corporate stock of the applicant (when the applicant Is a corporation); __8) the legal or beneficial owner of any noncorp~rate'entity (when the applicant Is not a corporat{on)~ C} an officer, director, p~rtner, or employee of the applicant; or ~ D) the actual applicant. DESCRIPTION OF RELATIONSIIIP Submitted this I0 da~fOu' t~ Signature ~ ~ Albert J. Krupsk], President James King, Vice-President Artie Foster Ken Poliweda 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 APPLICATION FOR AN EXEMPTION FROM THE MORATORIUM ADDRESS AGENT/ATTORNEY PHONE ADDRESS CORRESPONDENCE SHOULD BE SENT TO: PROPERTYLOCATION /f~O ~..'dc~,q~7-r~v~ ~tge._tue~ 0oc~4~0~° , T~M~ NO. 77 - q -~ PLEASE ATTACH A LETTER EXPLAINING WHY YOU QUALIFY FOR THE EXEMPTION TO THE MORATORIUM--BE SPECIFIC REGARDING YOUR PROPOSED CHANGES. Signed By: Print Name: FORM NUMBER 97-1000 Albert J. Krupski, President James King, Vice~President Hemy 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 of COUNTY OF SUFFOLK) STATE OF NEW YORK) I, , residing at ~ ~/~c/,'~/~ being ~uly sworn, depose and say: That on the day,o~, 200~, I personally po~ted the property known as_~ ~ /~/~/~/3~. ~ ~OU~/~ by placing the Board of Trustees official p~ter where ~t can easily be seen, and that I have checked to be sure the poster publichas remained hearing,in place for hearing eight days prior to the date of;/~ Date of noted thereon to be held;~ ~~_. Dated: Sworn to befQ];e me this 11 day of ~U~200~ LYNDA M. BOHN NOTARY PUBLIC, State of New No. 01 BO6020932 Qualified in Suffolk Count~ _ Term Expires March 8, ( signature ) Albert J. Krupski, President James K~ng, Vice-Pres/dent Henry Smith Artle 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 SOUTHOLE Office Use Only Coastal Erosion Permit Application Wetland Permit Application ~' Major Waiver/Amend men.t/Ch.anges ___~eceived Application: ~]l~ /o ~ Received Fee:$ ~'-~ ¢¢r(0.~ Completed Application .Incomplete __SEQRA Classification: Type I_ Type II Unlisted Coordination:(date sent) __CAC Referral Sero: Date of Inspection:_.~(~t0 Receipt of CAC Repor~ __Lead Agency Determination: __Technical __Public Hearing Resolution: Name of Applicant Address ~} ~ Suffolk County Tax Map Number: 1000- _~_.q 7' (-~ q' o) x%~' (provide LII~CO ~o~o~s s~re~s, and location) (If applicable) Address: Phone: Board of Trustees Applica¢ion Land Area (in square feet): Area Zoning: GENERAL DATA Previous use of property: .. Intended use of property: Prior permits/approvals for site improvements: Agency Date ,~o prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? Yes If yes, provide explanation: Project Description (use attachments if necessary):. ~,O~ ~-~Ot" ~'O ~ Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ('[0/9 $7"/~J(77'c)~nJ D~ ! Area of wetlands on lot: square feet Percent coverage of lot: ,Of~''- % Closest distance between nearest existing structure and upland edge of wetlands: ~=~" ~) feet Closest distance between nearest proposed structure and upland edge of wetlands: / ~ , feet Does the project involve excavation or filling? No b,~ Yes If yes, how much material will be excavated?/~r~er, nA,..cubic yards How much material will be filled? ~"~,',~-ecf cubic yards Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: feet Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): PR~JECTLD. NUMEER 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be completed by Applicant or Proiect sponsor) SEQ APPLICANT ~SPONSO R PROFO$ ACTION: 5. IS ~ [] Ex0ansion [] Modification/alteration 5. DESCRIEE PROJECT BRIEFLY: 2. WILL PROPOSED ACTION COMPL,VWITH EXISTING ZONING OR OTHER EXISTING L-~ND USE RESTRICTIONS? '3. WHAT IS PRESENT LA~'~'~ bE;: IN ViCINiTY OF PROJECT? ~s~dentlal [],!nOustnal C Commercial 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING. NOW OR ULTIMATELY' PROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE CR LOCAL)? [] Yes ~o If yes, Ils! agency(s) and oermitlaooroval$ DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [] Yes ~ 1! yes. list aQency name and permrtlaoproval AS A RESULT OF P POSED ACTION WILL EXISTING PERMIT/APPROVAL aEQUIRE MODIFICATION? the action is in the Coastal Area, and you are a state aqency, complete the Coastal Assessment Form before proceeding with this a~s, essment OVER ! ~ :t Yes. ~.x:lam =r~eIly PART III--OETERMINATICN CF S~GNIFICANCE [To De comole[ed by Agency) Oheax ~Di= ;ox if 7au have identified one ar more potentially large or significant Acverse imosc:s whit2 ~,~'f ac=ur. Then oroc~ed direc:l'/ ~o ;ne FULL E.~F ~nalor preo~re ~ pasidv~oeclar~dcn. Checx :his box :¢ you aave oe[ermined, ~ased on the information &nd ~nalysis above an~ ~ny suooor:J2~ cocumen[a[~cn. :ns~ :he 2roooseo ~c~Jon WiLL ~OT result in.ny signific2nt adverse envlrcnmen~sl imcac:z AND orov~ce ~n ~:~cnmen[s as necassarv, the reasons suocor[ing t~lS determinsdofl: AUTHORIZATION (where the applicant is not the owner) (print owner of property) residing at /~O ~/~X)7-//~ (mailing address) Southold Board of Town Trustees on my behalf. tu~e ) do hereby authorize (Agent) to apply for permit(s) from the Albert J, Krupski, President James King, Vice-President Henry Smith Attic Foster Ken Poliwcda 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 COUNT OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING being duly sworn, depose and say: That on the / day of~d~ 200~ I ~ersonatly posted the by placing the Board of TrusteesWofficial poster ~here it can easily be seen, and that I have checked to be sure the poster has romained in place for eight days prior to the date of~the p~blic hearing. Date of hearing noted thereon to be held (signa%ure) Sworn to before me this day of t.4a, c.d 2oo THERESA V. MILLER NOTARY PUBLIC, STATE OF NEW YORK QUALIFIED IN S' ':":C" 7'~07,~'~ ~ PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Nar[lC: Address: STATE OF NEW YORK COUNTY OF SUFFOLK .~.f~,,l PoernZ , residing at --~, Z~-~U//.) ~ ~L ~C~, ~fp~f~/~//7~ , being duly swom, d~oses ~d sa~ ~at o~e G ~ ~yof ~ ,20~L,d~onentm~l~a~ecopyoftheNotice · set fo~.in ~e Bo~d of T~tees Application, ~rected to each of~e above n~ed pe~o~ at ~e ad~esses set opposite ~ere resp~tive ~es; ~at ~e ad&esses set opposite ~e n~es of s~d p~so~ ~e ~e ~ess of s~d persons ~ sho~ on ~e c~ent ~sessment roll of the To~ of Southold; ~at said Notices were m~led at the U~ted States Post Office at ~L~ , that s~d Notices w~e mailed to each of said pe~ons by (ceaified) (regisfered) m~l. ~ .~ ?.[~,/ / Sworn to~effire me ~s J~ Dayof~ ,200& ~ Not~ Public THERESA V. MILLER NOTARY PUBLIC, STATE OF NEW YORK NO. OIMI4953715 QUALIFIED IN SUFr:OLt~.C(~IT~ COMMISSION EXPIRES ! Board of Trustees Applicati¢ County of Suffolk State of New York BEING SWOR 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. / §ignature SWORN TO BEFORE ME THIS ~-"-lqo-tary Public THERESA ~/. ~ILLER NOTARY PUBLIC, STATE OF NEW YORK NO. O1MI4953715 QUALIFIED N SUFFQ.I,J(/C.O T The Town o~ S~u~hold's Cods of Ethics prshibits c0n~lfcts.o~ interest on the part of town officers and employees. The purposs of this form is to provide information which can alert the town of possible conflicts of interest and allow YOUR HAHRt (Last name, first name, you are applying in the other entity, such ~a a it to take whatever action is nscessary to avoid same. name oE somsone else or company. If so, indicate ths other person's or company's name.) NATURE OF APPLICATION~ (Check all the apply ) Tax grievance Variance Changs of zone A~p~val of plat Exemption from plat o~ o~ficial map other (If "other," name the activity.) , . Do you personall~ (or thcough your company~ spouse, sibling, parent, or child) have a relationship with any o{£1cer or ~mployee o~ the Town of Southold? "Relationship' includes by blood, marriage, or business interest. "Business interest' means a business, inclndin~ a partnership, in which ~he town officer or employee has even a partial ownership of (or employment by) a corporation in which the town officer or employee owns more than 5% oE the NO If you answered "YES,". complete the balance el ~h{, ~orm and date and nign vhere indicated. Name of person employed by the Town of Bout}told Titls or position of that psrson Describe the rslationship between yourself (the applicant) and the town officer ~r smployse. Either check the approprtats lins A) through D) and/or describe in ths specs providsd. The town psrentt c) o~fieer or employes or his or her ~pouss,' sibling, or child is (chsck all that apply)~ ths owner of greater than 5% of the shares o~ the corporate stock of tbs applicant (when the applicant' is a corporation)~ tbs lega1 or beneficial owner of any interest in a noncorporate'sntity (when the applicant is not a oorporation)~ an o~lcer, director~ pa~tner~ or employee oE the applicantl or ths a~tual applicant. DESCRIPTION OF RELATIONSIlIP