HomeMy WebLinkAboutTR-5760Board Of $outhold Town Trustees
ISSUED TO ................... CAbl~AC.F....M.,..-GO[.I,~;.TT ...................................
Pursuant to the provis;ons of Chapter 615 of the Laws of
the State of New York, 1893; and Chapter 40~ of the Laws of the
· State of New York 1952; and the Soufhold Town Ordinance
titled ."REGULATING AND THE PLACING OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS and the
REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM
LANDS UNDER TOWN WATERS;'-.~. and in accordance with the
Reselu~ion of The B~ard adopted at a meeting held on ........ ~.y..~.1.~
.ZC~0.~..., and' in consideration of the sum of $--?.00-,O0 paid by
· gar~...H., .. C~le~.t ........................................................... : ..................
of .....~.~.s~,~ ................... N. Y. and subject to the
Terms and Conditions listed on the reverse dde hereof,
of SoufhoJd Towa Trmfees authorizes and ~ermits the
Wetland Permit to construct extensions and addit/ons [o ma existing single farmjy residence a
603.5 s.£ +/- covered porch is proposed with a new eatS, on the front of the existing residence a
745 */- addition is proposed on the north and east side of the existing residence 768 +/- s.f. of
deck area is proposed on the east side of the residence a 216 +/- s.f. screened porch is proposed
on the south side of the realdenee a 31'x22' (682 s.f.) detached garage is proposed south of the
existing residence. Pervious earth driveway in front of residence and to access proposed detached
garage- proposed structure to the wetlands line is the proposed deck, which is proposed to be
setback 86 feet. With the stipulation of a hay bale line dining eonetrucfion at fifty foot back
from the wetland line - drywells and gutters on the house on all of the extensions.
IN WITNESS wl-lt:K~-, i~- ;a,a t~oera ot ,rusteos mr.-
by causes ifs Corporate Seal to be affixed, end these present~ fo
be subserved by a majority of the said Board es of this date.
TERMS and C. ONDfflONS
Candace M. Corlett
n~ arview Southold,
v~ .. ~ Road,
part of the coosidea'ation for the issuance of ~e P,"~m~t does tmderstand and pvescrlbe to the fol-
lowing:
1. That the sald Boaz'd of T~ and the Town ot 8a~thotd a~e released from any amd
all damage& oc ~-~,,~ for damageq o~ mia ~sing dim:dy et indimaty as · result of my opet-
wltb req~ecx thereto, .to the complete ezdmion of the Board o~' T~.~_ a~ the Tmvn a~ 8o~daold
2. That d,;, permit is valid for ·pedod of ;>4 m~_ wk~4~ b o0ix~qbJeted to be the
estimated dme'tequlred to c~nplete the wotlc involved, but daould circumstances wartxm, request
for an ~on may be made to ~e ~ at a later ~
3. That this Permit d~ould be tx.~ined inde~inltely, or as long as the said P~ ~d=sbes
to maie~, the structure or project involved, to provide evidence to anyone concerned chat tuth-
o~__-tloo was odginaHy obtained.
4. That the work involved will be subject to the in~ and approval of the Board
agents, and non-mmp~i,~e with. the provisions tff the ori~n-~.,g appficatlon, may be cause
revocation of this l~!~ by r-'~ohdon of the said Boa_,d.
5. Thac them will be tm unteasomble iflterfe~ence with nivig~ti,~ iLS ·rcsult of thc wm:k
~ -'..~ f~thodzed.
6. That there shah be no interfereace with the tight of the puidk eo ~ mad ~ sloag
the beach between high and low water m~ks.
8. That the s~id Board will be notified by the Pesmittee ot d~e o0n2j~d~ O~ ~ work such-
orlzed.
9. That the Petmittee will obtain all ol~e£ permits and conse~b dutt m~y ~e ~ ~
plemental to this permit which may be subject to revoke upoa f, ll,,,~, to obCdn _-,~
Albert J. Krupski, President
James K/ng, 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 27, 2003
BOARD OF TOWN TRUSTEES
TOWN OFSOUTHOLD
Mr. Dan Hall
Land Use Ecological Services, Inc.
2576 Sound Avenue
Baiting Hollow, NY 11933
SCTM#90-4-8.1 & 8.2
Candace M. Corlett
300 Clearvi~w Road
Southold, NY
Dear Mr. Hall:
The Board of Town Trustees took the following action during a Regular Meeting, held on May
21, 2003 regarding the above matter
WHEREAS, Land Use Ecological Services, Inc. on behalf of Candace M. Corlett applied to
the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the
Town of Southold, application dated April 7, 2003
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
May 21, 2003 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 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 Land Use Ecological
Services, Inc. on behalf of CANDACE M. CORLETT for a Wetland Permit to construct
extensions and additions to an existing single family residence a 603.5 s.f. +/- covered pomh is
proposed with a new entry on the front of the existing residence a 745 +/- addition is proposed on
the north and east side of the existing residence 768 +/- s.fi of deck area is proposed on the east
side of the residence a 2 l 6 +/- s.fi screened pomh is proposed on the south side of the residence a
31'x22' (682 s.fi) detached garage is proposed south of the existing residence. Pervious earth
driveway in front of residence and to access proposed detached garage- proposed structure to the
wetlands line is the proposed deck, which is proposed to be setback 86 feet. With the stipulation
of a hay bale line during construction at fifty foot back from the wetland line - drywells and
gutters on the house on all of the extensions.
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.
Inspections are required at a fee of $5.00 per inspection. (See attached schedule).
FEES: $5.00
Very truly yours,
President, Board of Trustees
AJK/cjc
cc DEC
Building Department
Albert J. Krupski, President'~'
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwocla
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1892
Fax (516) 7654823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
TO:
Land Use Ecological Services on behalf of CQNDACE CORLETT
Please be advised that your application, dated April 7. 2003
has been reviewed by this Board, at the regular meeting of
~.~.~_y 2!, 2993 and the following action was taken:
( X ) 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:
One Inspection @$5.00 each
TOTAL FEES DUE: $
SIGNED:
BY:
PRESIDENT, BOARD OF TRUSTEES
4/98
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
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.
CANDACE CORLETT
INSPECTION SCHEDULE
__ Pre-construction, hay bale line
__ 1st day of construction
% constructed
__ Project complete, compliance inspection.
X DRYWELLS
Albert J. Krupski, President
James KJ. ng, 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
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
st
1 day of construction
¼ constructed
,./Project complete, compliance inspection.
Te].ephone
(631) 765-1892
Town Hall. 53095 Main Road
P.O. Box 11')9
Southokl. New Yo~k 11971
SOUTHOLD TO~VIq
CONSERVATION ADVISORY COUNCIL
At the meeting of the Southold Town Conservation Advisory Council held Tuesday, May
13, 2003, 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 CANDAOE M. OORLETT to
construct additions to an existing single-family dwelling. A 603.5 sf. covered porch with
a new entry on the front of the residence, a 745 sf. addition on the north side and east
side of the residence, 768 sf. of deck area on the east side of the residence, a 216 sr.
screened porch south of the residence, and a pervious earth driveway in front of the
residence and to access the proposed detached garage.
Located: 300 Clearview Rd., Southold. SCTM#90-4-8.1&8.2
The CAC recommends Approval with the Condition that hay bales are placed down
before construction.
Vote of Council: Ayes: All
Motion Carried
CANDACE CORLE'Fr
84-3.3 KENDRICK PLACE
JAMAICA ESTATES, NY ! 1432
May 12, 2003
Board of Trustees
Southold Town
Southold, NY 11971
To Whom It May Concern:
Please give Walter Corlett the copy of the cover page for the submission to the
Board of Trustees for the permit application for the house renovation. This
should show the date when the application was submitted to the Board.
Thank you.
.Candace Co/dett
LandUse
April 4, 2003
Town of Southold
Board of Town Trustees
P.O. Box 1179
Southold, N.Y. 11971
Re: Corlett - Southold
Proposed House Extension / Additions
To whom it may concern:
Enclosed please find an application package whicl
APR - 7
Seuthoid Town
Board ot T~'ustees
~.;ud~ the TOIIOWlng:
- (1) original, (2) copies of the completed application form.
- (1) original, (2) copies of a Short Environmental Assessment Form
- (3) sets of Plans.
- Application fee ($200.00).
If there are any questions, or if you require additional information please don't
hesitate to contact this office.
DH
Enc.
Express Mail
Sincerely,
Land Use Ecological Services, Inc.
25.76 Sound,-.~nu~ .... · Baiting Hollow Ne.',, "&srk · 119'3.3
63 i 7'27 2400 · -" ~
h,~x 6J1 7272605
Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
.~oastal Erosion Permit Application
~;etland Permit Application Major
Waiver/Amendmen. t/(~hapge.s
Received Application: ?~ ~0 ..5
Received Fce:$
Completed Application
Incomplete '' ''
SEQRA Classification:
Type I Type II Unlisted
__Coordination :(date
CAC Referral Sent: t't'l...I T~ ! ~. ~
Date of Inspection:
Receipt of CAC Report: J ' t -
Lead Agency Determination:__
Technical Review: ~'.
Public Hearing Held:
Resolution:
Minor
APR 7 200
$outhotd Town
Board of Trustees
Name of Applicant Candace M. Corlett
Address 84-35 Kendrick Place Jamaica Estates, NY 11432
Phone Number:( ) 212-924-7780
Suffolk County Tax Map Number: 1000- 90-4- 8.1 & 8.2
Property Location: 300 Clearview Road Southold, NY
Northeast corner of Clearview Road and Docjwood Drive
(provide LILCO Pole #, distance to cross streets, and location)
AGENT: Dan Hall/Land Use Ecological Services, Inc.
(If applicable)
Address: 2576 Sound Avenue Baiting Hollow, NY 11933
Phone: 631-727-2400
Board of Trustees Applioation
GENERAL DATA
Land Area (in square feet): ~.8,793.49 s.f.
ArQ Zoning: Residential
Previous use of property:.
Intended use of'property:_
Residential
Residential
Prior permits/approvals for site improvements:
Agency Date
N.Y.S.D.E.C~ (dock)
Southold Trustees (dock)
3/12/03
11/20/02
__ No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?
x No Yes
If yes, provide explanation:
Project Description (use attachments if necessary):__
Please see attached oroject description.
Corlett- Southold
Project Description:
Applicam proposes extensions and additions to an existing single family residence. A
603.5 s.f. +/-covered porch is proposed with a new entry on the fi'ont of the existing residence. A
745+/- addition is proposed on the north and east side of the existing residence. 768+/- s.f. of
deck area is proposed on the east side of the residence. A 216+/- s.f. screened porch is proposed
on the south side of the residence. A 31' x 22' (682s.f.) detached garage is proposed south of the
existing residence. A pervious earth driveway is proposed in t?ont of the residence and to access
the proposed detached garage. The nearest proposed structure to the wetlands line is the
proposed deck which is proposed to be setback 86'.
Board of Trustees ApplicatiOn
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: House Expansion / additions.
Area of wetlands on lot: 1,450 +/- square feet
Percent coverageoflot: 3.6 +/- %
Closest distance between nearest existing structure and upland
edge of wetlands: 90 +/- feet
Closest distance between nearest proposed structure and uplfind
edge of wetlands: 86+/- feet
Does the project involve excavation or filling?
X No Yes
I£yes, how much material will be excavated? n/a cubic yards
How much material will be filled? n/a cubic yards
Depth of which material will be removed or deposited: n/a feet
Proposed slope throughout the area of operations: n/a
Manner in which material will be removed or deposited: n/a
Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by
reason of such proposed operations (use attachments if appropriate):
This project will not have any negative affect on the adjacent
wetland areas.
Board of Trustees Application
County of Suffolk
State of New York
Dan Hall/Land Use Ecological Services, Inc.
BErNG DULY SWORN
DEPOSES AND AFFIRMS THAT HE/SHE IS TH~ APPLICANT FOR THE ABOVE
DESCFJBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRUE TO THE BEST OF H/S/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, TItEIR AGENT(S) OR
REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CON/UNCTION WITH REVIEW OF THIS APPLICATION.
SWORN TO BEFORE ME THIS
/'" Slgnatur6t ~vt ' ~
7 /'~ DAYOF
CYNTHIA ALVAREZ
NOTARY PUBUC, STATE OF NEW YORK
No. 01 AL6080878
{IUAUFIE0 IN SUFFOLK C0Urfh'
MY COMMISSION EXPIRES SEPT.
Name:
Joseph Monaco Jr.
Robert & Gurly Maus
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Address:
595 Oakwood Ct.,P.O. Box742 Sou~old, N.Y. l1971
450 Clearview Rd. Southold, NY 11971
STATE OF NEW YORK
COUNTY OF SUFFOLK
'~ ~" , residing at
~;c~ D."C, I{q6l , being duly swprn, deposes and Says
that o~ the ~w~ day of kY ,~ZooS, 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 sa~d persons as shown on the current assessment
roll of the Town of Southold; that s~d Ngtices were mailed at
the United States Post Office at ~n~ , that
said Notices were ma~led to each of said persons by ,(certified)
(registered) mail. -~~ ff~
/ ' 6YNTH~A ALVA~E~
I NOTARY PU.LIC, STATE OF N~ ~RK
/ Nm 01AL6080878
~-, ~/ ~ I Q~LIFIED IN SUFFOLK COU~
S~O~ Co~e~o~e me Ibis ~/ I ~COMMISSlON~IRESSE~23,2~'
~/ --Not~ Publ~ /
/
~bert J. Krupski,
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
Town Hall
.53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In the Matter of the Application
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
I,.~--~( ~ t~ , residing at
bein~ dul~ sworn, depose and say:
Tha~ on hhe ~ day of ~0~ 200~ I pe:sonally posted ~e~
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~)~
publ%c heari~ Date ~f he~rigg noted thereon to be held ~
Dated:
Sworn to before me this
Notar~ Public
[ NOTARY PUBLIC, STATE OF NEW YORK
J No. 01AL6080878
[ MY QUALIFIEOINSUFFOLKCOUN~ .
EM COMMISSION EXPIRES SEP'I:. 23, 20~.~
72~2805 L:L%'D USE ECOLOGICAL
~k~ard of T~stee~ Apl):L~oati
AUTHOR~ATIO~
(where the appltcan= iR not the owner)
I, Candace M. Oorlett
"'(D~nt owner 6f property)
residing at 84-35 Kendriok Place
(mailing ad,tess }
Jamaica Estates, NY
do hereby authorize.
(Agent)
Land
Use
Ecological
Serviees'_t~%' apply for ~ermit(s} from the
Southold Boar~ of Tow~ Trus~ee~ on my beh&lf.
/(Ow~e~' s eiemature) /
PROJECT ID NUMBER
PART 1 - PROJEGT INFORMATION
1. APPLICANT / SPONSOR
D Hall/Land Use for Candace M. Corlett
3,PROJECT LOCATION:
Soua]old
Municipality
617.20
APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNUSIED ACTIONS Only
( To be comple(ed by ,~ pplioant or Project Sponsor)
' 2. PROJECT NAME
Codett - Southold
Surf(Ak
County
4, PRECISE LOCATION: Street Adders and Road Intersections. Pmmlneet landmarks eL -or I~oV~le m~o
300 Cleanaew Rd. Sot;thoM, NY 1197'1
SCTM# 1000-90-4-8.2
SEQR
5. IS PROPOSED ACTION; [] New [] F-xpan~lan r'~ Modillcatlon I alteration
6. DESCRIBE PROJECT BRIEFLY:
7. AMOUNT OF LAND AFFECTED:
Initially .89+/~ sores Ultlmatef/ .89+1- acres
8. WILL PROPOSEO ACTION COMPLY ~ EXISTING ZONING OR OTHER RESTRICTIONS?
[]YES [] NO If no, desatbebnie~:
g. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.)
I--lO.er (de~)
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FRObl ANY OTHER GOVERNMENTAL
AOENGY (Federal, Slate or I.o~al)
[]Yes ~lNo If yes, list agescy name-,.and penttlt I
appmvet:
USACOE, NYSDOS, & SOUTHOLD TOWN
11.DOES ANY AEPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL*;'
r~lYee ~-"lNo II yes, list agency name ~ pemllt I approval:
1jL. ~esAjaY RESULT~..1No OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION?
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
A~plicant. S/~.sor Name Dan H$11 I~/~tdd Use, E/o~g~l Services, Inc. Date: L~ - ~--¢3~
If the actlo~ Is a Costal Area, and you am a state agency,
complete the Coastal Assessmont Form before proceeding with this assessment
IPROJECT ID NUMBER
PART 1 - PROJECT INFORMATION
1. APPLICANT / SPONSOR
D Hall/Land Use for Candace M. Codett
3.PROJECT LOCATION:
Southold
Municipality
617.20
APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
fo~ UNLISTED ACTIONS Only
( To be completed by A ~licant or Project Sponsor)
2. PROJECT NAME
Codett - Southold
Suffolk
4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or ix~ovlde map
300 Clearview Rd. Southold, NY 11971
$CTIvI~ 1000-90-4-8.2
5.1s PROPOSED ACTION: [] New [~F. xpanNan [~Modiflnet~an/alteration
SEQR
6. DESCRIBE PROJECT BRIEFLY:
7. AMOUNT OF LAND AFFECTED:
In;~#y .89+/- acre~ ~timate!y .89+/- acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
[]Yes [] No ff no, de~crl~bdefly:
9. WHAT 18 PRESENT LAND USE IN VICINITY OF PROJECT? (Chanseasrnenyasap~ly.)
[:~]Of~er (desce'be)
10. DOES ACTION INVOLVE A PERMIT N=PROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
AOENCY (Federal, stere m' Lo~l)
[]Yes r~No ff yes, list agancy name-and pmmlt I appro~ll:
USACOE, NYSDOS, & SOUTHOLD TOWN
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
~]Yes F~INo If yes, list agency name and permit I approval:
lr~A.S A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
rites [] No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Appl~t .J._Sponeor Name Dan H~II/[/)arid Use E,~:)l~)g'!~l Services, Inc. Date: t~ - .~
If the action Is a Costal Area, and you are a state agency,
complete the Coastal Assessment Form before proceeding with this assessment
PART II - IMPACT ASSESSMENT (1'o be completed by Lead Agency)
^. DOES ACTION EXCEED ANY TYPE ~ THRESHOLD IN 6 NYCRR, PART 617A? If yes, coordiuate the review proc~ a~d use the FULL EAF.
B. WlLLACTION "ECEIVECOORDINATEDREVI~N',~'.~I~ROVIDED F(~R'UNM~TEDAC'i'IObiSI~61'~YcR"R, PART'617.67 If~.a regative
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. F_xl~ng ;air quality, surtaca or ~'sunckvater quality or quantity, noise levels, e~dsting traffic paifem, solid waste pro~uctics or disposal,
I,
C5. [Grov~h, ~3~quent ~va~ or rdiate~ a<~vNe~ ~ely io I~ k~uced'by the 'pml~xl ~lca? F.~n Ixk~
C6. Longterm,~ttem%cun~aitve, cxob~ereffastsn~idm~iedinCt-CS? E~brlefly:
,
E. IS THERE OR IS THERE LIKELy TO BE CONTROVERSY RE[J~TED TO POI~ITIAL ADVER,~E EN~, RONME,NTAL IMPACTS? If ~ explain:
PART Ill - DETERMINATION OF ,~IGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effas~tde~tified above, detem~ine whether it is substantial, large, important or o~erMse significant. Each
effec~ should be assessed In eonneofic~ with its (a) setting (La. urban or rural); (b) probability of occuntng; (c) duration; (d) irreverslbility; (e)
geographic scope; and (t) magnitude, ff necessary, add attachments or reference supporting materials. Ensure that explanations contain
sufficient detail ta show f~at all relevant adverea Impacts have bea~ Iden~fed and ad~taly ~ms~. ff question d of part ii wes checked
yes, the detarmination of slgr~canca must evaluata the potential impact of the proposed action on Ihe environmental charactertstics of the CEA.
Check this box If you have Ideflffiecl oee or more pofentially large or aignlflcant adv~ I~ ~ ~Y ~r. 'fhen proceed directly to the FUU
EAF end/or prepare a pca!tive dedm'aifca.
WILL NOT result in any d, gntilca~ adverse envlroemental Impae~ AND provide, o~ attadnments as necassary, the masons supporting thi:
Date
T~tle of Responsible Officer
print or T~tpe Name ~ Respor~ible Officer in Lead Agency
Signature of ReSl~onsible Officer in Lead Agency ~ignature of Preparer (If different kom responsible officer)
PART II - IMPACT ASSESSMENT (To be oompleted by Lead Agency)
A. DO~S ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 ff yes, coordinate the renew process and use the FULL EAF.
B. WILL ACTION RECEIVE CO~)RDINATED REVIEW A~ PRC)~D~ FOR'UNLISTED' ACTI(~,I~ IN 8 NYCRR. PART el?.e? if No, a negative
r-lw,
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legit~e) Cl. Exl~ng air quality, a~face (x g~oundwatar quality o~ quantity, noise levels, exisling traffic gattem, ~31id waste productioe or ~sposal,
E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVE.R_SY RELATED TO POTENTIAL ADVERSE..ENVOI. RONMENTAL IMPACTS? ff yes explain:
PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: F~re~chadvemeeffeeUde~edab~e~detsrm~newhatheririssubatan~a~arge~imp(~1ant~r~theP~v~seatgn~c~nt` Each
effec~ should be assessed tn co~necao~ with Its (a) setting (i.e. urban ~ mrat); (b) probability of occurflng; (c) d~; (d) irrevemibaity;, (e)
geographic scope; and (f) magnitude. If necessary, add attachments or reference suppor~ng materials. Ensure thai explanalions contain
suffietsnt detatl to show f~lat all relevant edveme Impacts have been Idenlif~ed and adequataty addressed. If question d of part II was checked
Check thle box if ~u have Identified ene or more potentially larga or sigaificant adveme Impacts which MAY occur. '13~e~ proceed directly to ff~e F UL
Cbee~ this bex If you hase detsrmlned, based en Ibe InfamYaion aed enalysis abeve and asy euppo~ng doc, ume~aflon, Ibet the proposed aerie
WILL NOT result in any ~ adverse envlrenmer~al Irnpa~ AND ixovlde, on attachrsenls as neoessae/, the reason~ eupp(xting thl:
Nmne c~ Lead Aganey Date
Print or T~tpe Name of Responsible O~ce~ in L~:I Agency
T~e of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer)