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HomeMy WebLinkAboutTR-5593Albert J. Krupski, James King, Vice-President Artie Foster Ken Poliwoda Pegg5~ A. D[ckerson BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone(631) 765-1892 Fax(631) 765-1366 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 ,11"1} 1st day of construction ½ constructed /Project complete, compliance inspection. Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson To~m Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD April 20, 2005 Ms. Linda Sanford 5 Mountain Peak Rd. Chappaqua, NY 10514 RE: 780 PRIVATE RD. #17, SOUTHOLD SCTM#81-3-27.1 Dear Ms. Sanford: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wed., April 20, 2005: RESOLVED that the Southold Town Board of Trustees grants the last One-Year Extension to Permit #5593 to demolish the existing dwelling and construct a new dwelling and renovate the existing garage, with the condition drywells and gutters are installed to contain the roof run-off and a staked row of hay bales is installed along the top of the bank before any activity begins. 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. ICrupski, 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 May 26, 2004 BOARD OF TOWN TRUSTEES TOWN OFSOUTHOLD Ms. Linda S. Sanford 5 Mountain Peak Rd. Chappaqua, NY 10514 RE: 780 PRIVATE RD. 17, SOUTHOLD SCTM#81-3-27.1 Dear Ms. Sanford: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, May 26, 2004: RESOLVED that the Southold Town Board of Trustees grants a One-Year Extension to Permit #5593 to demolish the existing dwelling and construct a new dwelling and renovate the existing garage, with the condition drywells and gutters are installed to contain the roof run-off and a staked row of hay bales is installed on the top of the bank before any activity begins. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, President, Board of Trustees AJK:lms ~!bert J. Kcupski, President James King, Vice-President .M't ie 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 August 1, 2002 Eva M. Szabat PO Box 133 2057 Main Road Laurel, NY 11948 RE: SCTM#81-03-27.1 Linda S. Sanford 780 Private Road 17 Southold, NY Dear Ms. Szabat: .The following action as taken by the Board of Town Trustees during a Regular Meeting, held on July 24, 2002, regarding the above matter. WItEREAS, Eva M. Szabat on behalf of Linda S. Sanford applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated July 1, 2002. WHEREAS, said application was referred to the Southold Town Conservation Advisory Com~cil for their findings and recommendations, and WHEREAS, a Public Heating xvas held by the Town Trustees with respect to said application on July 24, 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, the structure complies with the standard set forth in Chapter 97-18 of the Southold 2 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 approved the application of Linda S. Sanford for a Wetland Permit to demolish existing residence construct new residence renovation of existing garage with the stipulation that drywells and gutters for the new house to contain roof run-off- stake row of haybales on top of bank during demolish and construction. BE IT FURTHER RESOLVED that this determination should not be considered a determination made for any other Department or Agency, which may also have an application pending for the same or similar project. Fee must be paid, if applicable and permit issued within six months of the date of this notification. If inspections are required, at a fee of $5.00 per inspection (See attached schedule). FEES: None Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJKYcjc cc DEC Building Department Board Of $outhold Town Trustees SOUTHOLD, NEW YORK ISSUED TO .............. ~./~A...8..,... $.~N1]..ORD ................................. Pursuant to the provisions of Chapter 615 of the Laws of the State of New York, 1893; and Chapter ~ of the Laws of the State of New Yore 1952: and the Southold Town Ordinance en- titled "REGULATING AND THE PLAGING OF OBSTRUGTIONS IN AND ON TOWN WATERS AND PUBLIG LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;~?. and in accordance with the Resolution of The Board adopted at a meeting held on .....0~.~L¥. ;~4 .... · :>00.2..., and in consideration of the sum of $ ...... ~O0..0~ paid by 'I~ir~da S ;" San£oFi:l ...................................... : ................. of . . Chappagua...; .......... N. Y. and subiect to the Terms and Condit,ons listed on the reverse side hereof, of Southold Town Trustees authorizes end permits the following: Wetland Permit to demolish existing residence construct new residence reno~'ation of existing garage wilh the stipulation that ciD"wells and gutters for the new house to contain roof nih-off- stake row of haybales on top of bank during demolish and construction all in accordance with the eleta~ed specifications e~pre~ented in the originating appllcbfign, IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these presents to be subscribed by e'majodfy of the said Board as of this dat~. TER~S ,and C, ONDmONS Liud~ $. g~nferd t~iding st 780 P,-i,,a~.e P. oad 1.7t. S,..,u. tl.tuld ..... N. Y., ts ~ of the coosidera~ion foe ~he is~manc~ o~ me l~em, t ~ Uaoetata~t m~ pt~crme to the fol- lowlag: L That the said ]km_~cl of Tn~stees mM the Town a/ ,Soutbold ~ ~ f~ ~ ~ ~&~ ~o,m~~of~T~T~d~ 2. ~t ~P~'~ ~ · ~ of ~4 ~h~~ for ~ ~don my ~ ~ ~ ~ ~ at a ~ ~ 3. That this Permit should be retained indefinitely, or as long as the ~iA Pemalttee wls~es to maintain the stzucmxe or project involved, to provide evlcleac~ to anyone concerned that od~6c~ w,s orig~ly obtained. 4. That the wodc involved will be subject to ~ ~ and approval of the Boaed ot its agen~ and non-compliance with the provisions of the otlglaa6ng appficatkm, may be ,',,,~, fo~ revocation of this Permit by ~esolution of tl~ said ltoetck 5. That there will be no unreasonable interference with ua~4g~ ~ a result of the hesein a~thorized. 7. That if ftmtze ope~'atloas of the Town of Soutbold te~ire t~e tetnoval and/at in the loc~tion of the work herein authotlzed, or if, in the oplnlon ¢~ the ]k~vd ¢~ Trustees, the. ~ shall cause unreasoaable obstzuctto~ to free navigation, the said Petmittee will be upon due notice, to remove or alter this work oc project herein stated without expense~ to the Town 8. That the said Board will be notified by the Pennittee ot ~he c~ 0~ the wodc auth- ot4zed. 9. That the Permittee will obtain nH other pe~mlcs ~nd consents that may be tequlred plemental to this pesmlt which may be subject to revoke upon failm~ to obtain same. To: Town Trustees, Town of Southold, Southold, New York Army Corps. Of Engineers New York State Department of Environmental Conservation Suffolk County Department of Health Services, Office of Wastewater Management Zoning Board, Planning Board and Building Department, Town of Southold From: Linda S. Sanford Date: May 28, 2002 RE: Property at North Bayview Road and Paradise Point Road SC Tax Map # 1000-81-03-27.1 I, Linda Sanford, as owner of the above referenced property do authorize Chuck Napoli, Architect Eva Szabat, Environmental Consultant Joseph Ingegno, Surveyor To act on my behalf and to submit, as necessary, any and all documents required to obtain the permits needed for the demolition of the existing and construction of the new private residence at the said property. Notary PAMELA C. McMINN Notary Put3#c - State of New York No. 01MC.,,8046719 '~.ty Comrniealon Exptre~ August 21, ~002 Town Trustees, To~vn of Southold, Southold, New York Army Corps. Of Engineers New York State Department of Environmental Conservation Suffolk County Department of Health Services, Office of Wastewater Management Zoning Board, Planning Board and Building Department, Town of Southold From: Linda S. Sanford Date: May 28, 2002 RE: Property at North Bayview Road and Paradise Point Road SC Tax Map # 1000-81-03-27.1 I, Linda Sanford, as owner of the above referenced property do authorize Chuck Napoli, Architect Eva Szabat, Environmental Consultant Joseph lngegno, Surveyor To act on my behalf and to submit, as necessary, any and all documents required to obtain the permits needed for the demolition of the existing and construction of the new private residence at the said property. Notary PAMELA C. McMINN No{my Pu~Ic - ~tate of New York No. 01~719 Qual~ied in We~chester County Commi~ion Expires August 21, 2002 To: Town Trustees, Town of Soutbold, Southold, New York Army Corps. Of Engineers New York State Department of Environmental Conservation Suffolk Comity Department of Health Services, Office of Wastewater Management Zoning Board, Planning Board and Building Department, Town of Southold From: Date: RE. Linda S. Sanford May 28, 2002 Property at North Bayview Road and Paradise Point Road SC Tax Map # 1000-81-03-27.1 I, Linda Sanford, as owner of the above referenced property do authorize Chuck Napoli, Architect Eva Szabat, Environmental Consultant Joseph Ingegno, Surveyor To act on my behalf and to submit, as necessary, any and all documents required to obtain the permits needed for the demolition of the existing and construction of the new private residence at the said property. Notary PAMELA C. McMINN No,my Pub~ - 8tare of New York NO. 01MC6046719 Quailed in Weetoheeter County ~.~/Comrni~Y~on Expires A ,ugust 21. 2002 TRANSACTIONAL DISCLOSURE FO~H The Teen o], $ou[heid's Code o[ £tbice_prehibite conflicts o£ interest on the part pi town officers and employees. The purpose of this [orm ia to prpvide in:ormatlon vh[ch can alert the town of possible conflicts o£ interest and allow YOUR NA]41~! (Last name, first name, mi~d.le initial, unless NATURE OF APP~ICAT~.0N~ (Check ali fha{ apply,) Tax grievance Variance Chauge of zone App[~al of plat Exemption ~rom plat o~ o~fiofal map (~ "Othe. r," name the activ[tr.) interest' senna a bun[nest, including a pa~tnereh[p~ ~hfch ~he to~n off,esr or employee hat even a partial ovnereh~p of (or employment by) a corporation ia which date and sign where indicated. Name o~ person employed by the Town of Southold Title or position of that person Describe tho relationship between yourself (the 'applicant) The town officer or employee or hie or her spouse~ sibling, parent, or child is (check all that apply), A) the owne~ o[ greeter than 5% of the shares of the corporate stock of the applicant (wile. the applicant' . ia a corporat[oe)~ g) the legal or beneficial owner of ~y ~ntereat in a noecorpora~e~entit¥ (rhea the applicant ie not s _C} an off[csr~ eirector~ partner, or emplOyee. Of the appliosnt~ or ~ D) the ~tUel applicant. APPLICANT TRANSACTIONAL DISCLOSUR~ FORH i The To_~n o~ $~ubhold's Code of Ethics ptohibit~ conf.li~te o£ inteceat on the part of town..off, icere and..emplo eeee~ The ~urpeee of this ~orm is to pr~¥ide information which can alert the ~own of peesibi~ conflicbe of interest and allow ~ -- c~ ~__~.{.. · ~ :,.~,{{~:.,(~J~.! .' ... · " ~ .....:- .':::'-~...:~'~.'?-h-,'-.- ARp{~sl of plst Interest' mean~ ~ business, including ~ partner~h{p, fn vhich ~he torn officer or employee has ~ven ~ partial o~nersh~p of (or emploFme~t b~) a corporation i~ I~ ~ou angver~d 'XgS,".complete ~he b~ian~ u[ ~hi. [orm and date aug sign vhere indicatmd. Name o~ p~r.~n employed by 5h~ TOWn of ~oU~hold Title or position of 5hat p~rson Describe the r~latlon~hip between yourmeif (5he 'applicant) provided. The %own o~fieer or employee or hi~ or her ~pouee~ sibL[ng, parent, or child is (check all that apply), corporate s~ock of the applicon% (~]le~ th~ applicant . is a corporation)~ . B) the legal or b~neficial owner o~ any ~nter~et in a C) an officer, director~ partner, or ~mplOye~ of the applicmnb; or . , . . ..', . . {l.',' 3UN 29 2002 12:28 .... " The Town o~ $ou~hold's cods of £thica_prohibitB coa~liota interest on the pa_ri of town officers ~n~ ~mplo~eee. The purpose of this ~o~m is to provide in~ormatio~ ~hl~b. other ~n%ity, such ~a a companF. It so, indicate the ~her person's ot company's NATURE ~F APPLXeATXON~ (che~K ali hha~ apply.) Tax grievance ~hang~ of zone ARp~al of plat ,.~, Exe~pt~o~ ~rom pla~ or' o~fic~al map (If "other," name ~he activity,) <~S~S. employee o~ ~h~ Town o~ Southold? 'Re~at~on~hip~ include~ ~hfch ~he fo~n officer o~ ~plo~ee has ~v~ a partial o~nership of (or employment by) a corpocatfon ia ~hich the town officer o~ ~mploy~e o~n~ mor~ than 5~ o~ th~ date and sign ~here indicated. Name o~ parson employed by the Town of Sou~hold ~ Title or position o~ ~h~t per,on Describe tho relationship between yoursel~ (~he applicant) apptopt{ate line ~) through D) and/or d~e=r~be in ~he specs provided. The %own of[i~er ~c employee or his dc her spouse~ sibling, parent, or child is (check all that apply), . A) the owner og greater than 5% of %he shares oE the corporate stock of the applic~n% (~hen the applicant . is a corpocntion)~ B) the legal or beneficial owner o~ any i~are~ i~ a noncorporate'entity (~hen the applicant la not _ .C) an officer, director, part,er, or employee, o~ tho appll~ant~ or .~ P) the ~tual applicant. .' ..__:..~ :~ ..... . -., ..D?... ; :. submitted bhie",.[a 'dar Tetephone (631) 765-1892 Towa Hall 5309,5 Ms, in Road P.0. Box 1179 ~uthold. New. York 11971 SOUTHOLD TOWN CONSERVATION' ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Wednesday, July 17, 2002, the following recommendation was made: Moved by Drew Dillingham, seconded by Jason Petrucci, it was ' ' RESOLVED to recommend to the Southold Town Board of Trustees i;It&A~I, of the Wetland Permit Application of LINDA ~.~NE. OIi~t to demolish the existing residence and construction a new reSi~en;ce, and to renovate the existing garage. Located: 7'80 Private Rd. #17, Southold. SCTM#81-3-27.1 The CAC recommends Disapproval of the application because the project required a 100' setback. Vote of Council: Ayes: All Motion Carried Mep 20 05 07:49p Ber~eni Builders March 17, 2.005 Mn AIl~ert Krupsl~, President Soulh~cl Town E~ard of Tru~ P.O. Box 1179 Southold, NY 11971 Dea~ Mr. Krur~ki= I am r_~ _ _,et~'lg a one year pe,,,~ extension for parmit # 5321 f~r Lir,~da S Sanlord, 780 Private Road 17. Southold, SCTM~ 81-3-27.1 which ex~ on May 26, 2005. Enclosed is my check for $50.00. Thank you Sincerely, Linda $. Sanford ~ Owner 5 Mountan Peak Road Chappaq[~ NY 10514 ~Ibert J. Krupski, Presidbnt James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone(631) 765-1892 Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF $OUTHOLD Office Use Only Coastal Erosion Permit Applicatio~/'''-h Wetland Permit Application / Major Waiver/Amendmep~Eh~nge~s Received Application: 7/[/{9 --Received Fee:$ ~ ~ t Completed Application '7[[/0 Incomplete __SEQRA Classification: Type I Type II Unlisted Coordination:(date sent)L._/~_~, CAC Referral Sent: ~ [J ! 0'. r , ~Date of Inspection: 7//~,/V'''-'/ Receipt ofCAC Repo~: ' t Lead Agency Determination:__ __Technical Review: ! / Public Hearing Held: Resolution: · t - Minor Name of Applicant L. i/K/D/~- ~. ' ' --' I Phone Number:( ) q/d Suffolk County T~ Map Number: 1000- ~l -- ~ ~ - ~7 ~ / (provide LILCO Pole ~, dist~ce to cr&s stre~s, a~ location)' 2~ ~ Oa ~l~ ~Mr (If applicable) Address: Board of Trustees Application GENERAL DATA Land Area (in square feet): q3, 663. ~3 Previous use ofproperty: ~j~/l/n~. rer,~,o//2_ Intended use of property: pl"' V~iL~. Y'e&ld ~/1~.~. Prior permits/approvals for site improvements: Agency Date ~ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspe, nd_.gd by a governmental agency? ..-'K No Yes If yes, provide explanation: Project Description (use attachments if necessary): Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ~'-Xl:53LI}q(/ · ) ', ~ - II Area of wetlands on lot: {~ square feet Percent coverage of lot: ~) % Closest distance between nearest existing structure and upland edge of wetlands: _0'7 t _ ~ tt feet Closest distance between nearest proposed structure and upland edge of wetlands: fir] t ~. {a # feet Does the project involve excavation or filling? No Y Yes If yes, how much material will be excavated? ~ ~00 cubic yards How much material will be filled? IqA cubic yards Depth of which material will be removed or deposited: .n/ q feet Proposed slope throughout the area of operations: .~'t 7 7° Manner in which material will be removed or depos~ted.~.~ .~ . . . . ~ ,~ ~ Statement of the effect, if any, on the wetlands and tidal waters of the tom that may result by rmson of such proposed operations (use attachments if appropriate): Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity:. No Does the project No within 100 feet of the proposed activity? Yes ~n or filling? If Yes, how much material How much material will be Manner in which material will excavated? yards) (cubic yards) Describe the nature and extent oft impacts reasonably anticipated resulting from implementation of the proj as proposed, attachments if necessary) Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall · 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In,he Matter of the Application ......... STATE OF NEW YORK) AFFIDAVIT OF POSTING I, L/~b~ ~. ~F~, residing at ~ ~~/~ ~/ 4 bein%/du~ Sw6rn,,~ ~epose and say. That on the /~day ofJ~, 200~ I personally posted ~he property known as ~ ~/V~ ~ ]~ 3~f~. ~ . by placing the Boar,-of Trus'te~s o'fficial poster wherW 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 ~the Rublic hearing. Dage of hearing ngted thereon to be hel~/ Dated: Sworn to before me this ~rLday of ~J-~/~ 200~7~ N~r~ Pubii~ - - IP,R~)JECT I.D. NUMBER 617.2.1 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only SEQ PART I--PROJECT INFORMATION (To be coml31eted by Applicant or Project soonsor) 7. AMOUNT OF LAN~AFFEj;TED: If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this a.s_,sessment OVER ! PART II--ENVIRO;,!MENT SSMENT ~'o be cemc,eted 2y Agend PART III--OETERMINATION OF SIGNIFICANCE ~To ~e comole~ed by Agency) INSTRUCTIONS; For e3c~ adverse effect identified at:cve, determine whether it is substsntiai, farge, fmcoc[ant or ot~e~'wise signific. Ezcn affect Should be assessed in connec:ion ,#~:i3 rts la) setting li.e. urban or rural); (b} pr(3ba~3Hit¥ of occa=%qg; (cl duratJort- irrevers~bHity; (el geograon~c ~c=ce: an~3 (t) magnitude. If necessary, add attachments or reference supDcr~ing materials. Ensure · e×131anadons ccn~aln sutfic:ent deJali (o $~,ow iI3a[ all relevant edverse imeac~s nave been identified and adequately acdressec. IP~JECT I.O. NUMBER 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be compfe[ed by Applicant or Project sponsor) APPL, A T ,PON* ,ROJEC'LOCATION= $ olrJ Municipality (~ '~ County PROP SED ACTION: ~w ~ Exoansion ~ Modificallon/alteratlon ~x~ Vl~W Xt/~i~~¢ SEQ DEECRleE PROJECT ERIEFLY: 7. AMOUNT OF ~N~AFF~TED:~ Ipi~ialry ~ · ~ acres Ultimately acres [1. OOES ANY A~P~OF THE A~I~N HAVE A CURRENTLY VALID P~RMIT OR APPROVAL. ~ Yes' ~No it yes. list agency name and permitfa~proval If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this as~,sessment OVER .CART II--ENVI~O,~IMENT,~ SSMENT ,TO be comcie!eo PART III--OETE~MINATION OF SIGNIFICANCE iTc ~e comoleted by Agency) INSTRUCTIONS; For each adverse eifect identified acove, determine wt3etne¢ it is substantial, large, imconan[ or otl~ec,vise signific -:3ch affect should be assessed in connection w~li3 ~fs (a) setting (La. urban or rural); (b) probaDHity of OccO~"'~rlg; (Cl duration. irreverslbHi[y; ~e) gecgraonic scoce; and (f) magmtude, if necessary, acid attachments or relerence supoorHng materfals. Ensure exotanations contain sufficient detail :o snow that all relevant aciveree impacts have been identtlied and adequately aCdressec. Check this Sox !f you have de:ermined, based on (he information and analysis above and any suooortinc~ PROJECT I.D. NUMBER J 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be coml31e[ed by ApDlican/ or Project sponsor) ! 6, DESCRIBE PROJECT ERIEFLY: Imlially ~ · I~ acres Ultimately acres SEQ If the action is in the Coastal Area, an[ you are a state agency, complete the Coastal Assessment Form before ~roceeding with this as.~essment PART II--EbWIRC~'I~,~E?IT;: S,~,tEblT ,To be ,;o~,,sleteo o'/ Agaric PART III--0ETE.~MINATION OF $1GN[FJCANCE (To be completed by Agency) [NSTFJUCTION$; For _=aCh &ciYetse etfec! Jdemilied al:)ove, determine whether Jt is sul:)sJ;~ntial, large, Jmeor~.~l[ or otJler, vJse sJgn~tic Ezch =-tree: should be assessed in connection wJJi~ its (a) setting ti..=. urban or rural); th) probaDilit¥ of occ=-~ag; (ct d~JratJol'l' irrevers~bility: (e} geograenic $cace: an(] ti} magmtuee. If necessary, aed attachments or reference supporting male/ires. ~nsure =_xolana[ions contain sufficient aetaii Io $l~ow iha[ all re;event adverse impacts nave been idealifJecl and adequately addressee. Chec,~ ~his box ~f you have identified one or more cotentiall? large or significsnt zoverse impacts which ;,'JAY occur. Then oroceea ,~irec:l'/ ~o H~e F;JLL --.A~ eno/or prepare ,~ positive-declaration. Check( this box ~f you have de[ermined, ~ased on Ihe information ;[nd analysis ~bove ;~nd ~lny suooortJnc_ documentation. :i~a[ :he ~roDoseo action WILL HOT result in -..~..~y significant adverse envJronmemal [meac:~ ANO 3rov~ce on a[;,Bcnmen;s :~s necsssarv, the reasons StlgCOr'(Jng (his determination: NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEESt TOWN OF SOUTHOLD In the matter of applicant: setup1000- 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 Environmen~a± Review-is located adjacent to your property and is described as 3. That the project which i~ subject ~o Environmental ~eview under Chapter~ 32, 37, or 97 of the Town Code is open to public on:~'~~You may contact the Trustees Office at 765-1892 or inlwriting. The above referenced proposal is under review of the Board of Trustees of the Town of $outhold and does not reference any other agency that might have to review same proposal. MAI.~ING ADDRESS,.' ~ H~l'al~ ~ ~ Enc.: Copy of sketch or plan showing proposal for your ' { convenience. ~k ~ ~/ ~ 9~-~ PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: STATE OF ~W YO~ CO~Y OF S~FOLK ~DOLc_.~-Tx30.30~ , residing at c90~7 0qc-~a,t~ ~-~:~/ ~ , being duly sworn, deposes and says that on the ) 5' day of ~ ~_~, 200:;L. 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 aL La. fei N-xJ_ ~(reglstered) mall. ' , that said Notices were mailed to each of said persons by Sworn tt~ before me this Day of,./{Ache: ,20 Not,~.[] ublic ~mm~ Board of Trustees Ap~lica~i,on County of' Suffolk State of New York DAYOr 4U~/~ JOYCE A. BERGMAN '©TARY PUBLIC, STATE OF NEW YORk NO. ,S942285 't, LIFIED IN WESTCHESTER COUNTY · gJON EXPIRES SEPTEMBER 19 200~ I /UN 23 2002 18:56 4109649893 PAGE.0~ ~rd of Trustees Applicati~ A UTHORI ZATION (where the applicant is not the owner) I. ~/~ ~. ~FO~ residing at (print owner of property) (mailing ad, ess) /~/~/~,~ /~,~/~ d° hereby auth°rize (Agent) ~V~ ~, ~~ to apply for ~e~it(s) fro~ the Southold Board of Town Trustees on my behalf.