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Home My WebLink AboutSchupler, RobertAlber~ J. Krupski, President james King, Vice-President Henry Smith :k.,-tie Foster Ken poliwoda Tower Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18,~2 Fax (516) 765-1823 BOARD OF TOWN TKUSTEES TOWN OF $OUTHOLD Office Use Only Coastal Erosion Permit Application 7Wetland Permit Application Grandfather Permit Application Waiver/Amendment/Ckanqe-s /Received Appl' '~ ~ReceivedFee:~ ~Completed Appl Incomplete SEQRA Classification: Type I Type II Unlisted__ Coordination:(date sent) ~'CAC Referral Sent: /Date of Inspection: ~ Receipt of CAC Report: Lead Agency Determination:__ Technical Review: /Public Hearing Held:_~e~_~ ---Resolution: S[ 2ooo TCL,'.i ' Suffolk County Tax Map Number: 1000 - Property Location: (provide LILCO Pole ~, distance ~o cross streets, and location) AGENT: (If applicable) Address' Phone: F~X$: MRY-1G-O0 TUE 04:30 PR FJ & ~ 05/16~Q0 TUE 13:-11 FAX ~16 78~66 FAX NO. 212 B97 2737 $oushold To~n AccounrinO ?, 02 GEN]~U%L DATA Land Area {in square feet): Ar~a Zonings__ Previou~ use of pIo]p~rty: Intendsd use o~ property: ~rior permits/appr¢~vals for site improvements: Agency Date wk/No prior pemt~its/approvals for site improv~mentm. any Dermit/approval ever bee~ revoked or s:sDande~ by a ~ov~nmental agenc!~'? If yes, provide explanatien~ p~oJect Description (use attae~4-~ents if necessary): ~ · - /- ~. - . " Board of Trustees Application W~'rI~/qD/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? How much material will be filled? Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner cubic yards cubic yards 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 (~se attachments if/appropriate)h ~ q~, , c.4, " ' Board of Trustees Application COASTAL EROSION APPLICATION DATA Are wetlands pre~nt within 75 feet of ~he proposed activity? ./ No v 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 na=ure and extent of the environmental impacts reasonably anticipated resulting from impler~entation of the project as proposed. (Use attachments if necessary) 4 NOTICE TO ADJACENT PROPERTY OW/qER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: p~/ SCT 000- YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to Permit f~om the Board of zTrus,~e~ to; / /1. /. request a 2. That the property which is the subject of Environmental Review.~is located adjacent to your property and is described as 3. That the project which is subject to Environmental Review under Chapters 32, 37, or 97 of the Town Code is open to public comment on: You may contact the Trustees Cffice at 765-1892 or in wriuLng. The above referenced proposal is under review of the Board of Trustees of the Town ef Southold and does not reference any other agency that might have to review same propcsal. PHONE la- Enc.: Copy of sketch or plan showing proposal for your convenience. PROOF OF M~ILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS STATE OF NEW YORK COUNTY_ OF SUFFOLK .~CC~ ~ [~9S~ , being duly sworn, deposes and says that on ~he day of ,19. ,, deponent mailed a true copy of the Notice set forth in the Board of Tr,]stees Applicationr 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. Sworn to before me this day of ,19__ Notary Public Board of Trustees Application County of Suffolk State of New York DEPOSES AND AF /SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PErMIT(S) AB-D THAT ALL STATEMENTS CONTAINED ~2<EIN ARE TRUE TO THE BEST OF HIS/H~RK~OWLEDGE AND BELIE~, AND THAT ALL WORK WILL BE DONE IN T~E MANUreR SET FORT~t IN THIS APPLICATION AND AS MAY BE APPROVED BY T~ SObT~OLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SObT~OLD AND TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PE~/HIT(S), IF GRAb~fED. IN COMPLETING THIS APPLICATION, I HEREBY Ab'raORIZE THE TRUST~, TREIR AGEnT(S) OR REPRESEnTATIVES(S), TO E~V~ER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS SWOP~N TO BEFORE ME THIS DAY OF ,19 Notary Public ~oard of Trustees Application Ab'£~OP~IZATTON (where the applicant is not the owner) (print owner of property) residing at (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) Print or Type: 1) 2) ACCESS CONSENT FORM FOR ACCESS ~_~ THROUGH~,~/~PRIVATE PROPERTY~ ~-~ (N~me- of Applicant) J, IOffice use Only File ~: Permit (Address) (Name & Address of Contractor Involved) (~rojec~ Loc~ti~n) (S,C.T.M, ¢) (Name of Road or P~ivate ~rooerty Involved) (H~let) 5) 6) (Name & Address of Homeowners Association / Property Owner) (Brief Job Description) ~ ~ 7 Starting Date: Completion Date: Estimated Cost of Proposea Wcrk; ~ J (~ Insurance Coverage: A. The coverage required to ~e extended to the Proper~y Owner: Bodily injury & Property Damage; $300,000/$§00,000 Bodily Injury & $50:Q00 Property Damage. B. Insurance Company: C. Insurance Agent Name & Telephone # : o. Pol oy,: osoqq t ~s on fJle ~h ~he Trus~e~s Office: (If no, ProvJde ~~h ApplJ~on) (yes/no) To be completed by the Property Owner: I/We the undersigned, fully understand the nature of the Proposed Work referenced above and have no objection to a]lowing the Applicant to cross My/Our Property to do the work. (Signature of the Property Owner or dulyauthorizedrepresentative) $1T.2~ Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFCRMATICN (To be commie:ed by Ao~:licant or Project soonsor) SEG Coas:sl .~$$a$$ment :rcrm ~efore proc~e~imG ',vi:h this a$~s, essmen: OVER Print.or Type: Iff$ce use only ile #: ermit ~: TOWN OF BOUTHOLD HIGHWAY DEPARTMENT PECONIC LANE PECONIC, NEW YORK 11958 PERMIT & BOND APPLICATION FOR ACCESS THROUGH TOWN OWNED PROPERTY 1) 2) (Name of Applicant) (Address) (Name & Address of Contractor Involved) : 1000- - (Project Location) (S.C.T.M. : (Name of Road or Town Property Involved) (Hamlet) (Brief Job Description) 3) S) 7) s) Starting Date: Completion Date: Estimated Cost of Proposed Work: Insurance Coverage: A, The coverage required to be extended to ~he Tcwn: Bodily injury & Property DamAge; $300,000/$500,000 Bodily Injury & $50,000 Promerty Damage Insurance Company: Insurance Agent Name & Telephone · : D. Policy # : E. State whether policy or certification is on file with the HighwAy DepArtment: (If no, Provide A COpy with Application) (yes/no) (Signature of ApplicAnt) (Date) To be completed Bond Amount Required: by the Superintendent of HighwAys: (SignAture) TI1AN.~ACTIONRb DISCLOSURE FORH The Town of Sou~hold's Code o£ Rthic~ pro|tib[~s con~tJ, cta o~ ~nee:es~ on ~he pa:~ oE ~o~n o~[~ce~e and emp~oge~e. The Purpose og Ltl8 germ i~ ~o provide ingormablOn which can aler~ the town of possible conliic~s of inberes~ and allow it to take whatever action is necessary to avoid same. ~he o~her person's or oompany~e name.) NATURE OF ~PPBI~ATIuN~ (check ail ~hak apply.) Variance Change of zone App~9.val of plat , Other _~ valet the town officer or employee has even a per,iai ovner~hip cE (or employmenb by) a corpocabion in wlmich date and eign where lndiuated. Name of person employed by the Town of Bouthuld Deeoribe the relationship between yourself (the applicant) and the town officer er employee. Either uheck the appropriate line A) through D) and/or deecribe in the space provided. The town officer or employee or his or her ,puuee, eibllng, parent, or child is (check all that apply)~ corporate stock of the applicant (when the appliean~ ia a eorporabion)l nonco~pora~e'en~i~y (when the appli~an~ la no~ a DESCRIPTION OF RELATIONSIIIP TRANSACTIONAL DI:{CLOSURR DORM -- The Town of Sou~hold's Code of Ethic~ pcohibits conflic~a of interest on the part of town officer~ ~d employees. The ~urpose of tills form Is to provide information which can aler~ ~he ~ow~ of possible conflicts o~ i~terest and allow it to take wl~atever action is neceesar~ to avoid same. ¥OUH NAMR~ (Last name, first name, middle init[~i, 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.) NATURE OF APPLICATIOII= (Check ail that apply.) Tax grievance Variance %/ Change of zone Approval of plat Exe.Rotion from plat or official map Other (If "Other," name the activity.) Do you per~onally (or through your company, ~ponee, sibling, parent, or ~hlld) hav~ a relationship ~ith ~ny officer or employee of tile Town off Southold? "R~lation~hip" lecludee by blood, marriage, or business interest. interest' meane a business, including a partner.hip, which the tow~ officer or employee ha. even a partial ownernhip of (or employment by) a corporation in which the town offioer or employee owns more titan 5~ of bite YER __%/ NO If you answered 'YES," complete the balance cE 51tie form and date and sign where indicated. of pe eo, employed by the of southold , itle cc position of that pe.o. Describe the relationship between yourself (ti)e applicant) and the town officer or employee. Either check tile appropriate line A) through D) and/or describe in the ,pace provided. The town officer or employee or hJ.a or her ~pouee, sibling, parent, or ch[id ie (check all. that apply)~ __A) the owner of greater than 5% of the shares cf the corporate stock of the applicant (when tile appilcant' is a corporation); __~) the legal or beneficial owner of any interest in a noncorporats mntlty (when the applicant is not a corporation)~ C) aa officer, director, partner, or employee of tile applicant: or D) the actual applicant. DESCRIPTION OF RELATIONSHIP O~ Pe.c~ b~ § 58-1 NOTICE OF PUBI,IC HEARING § 58-I Chapter 58 NOTICE OF PUBLIC IlEARING § 58-1. Providing notice of public hearings. [HISTORY.' Adopted by the Town Board of the Town of Southoid 12-27-1995 as L.L. No. 25-1995. Atnendments noted where applicable.] § 58-1. Providing notice of public hearings. Whenever the Code calls ~'or a public hearing, this section shall apply. Upon determining tha~ an application is complete, the board or commission reviewing the same shall fix a tiros as~d place for a public hearing thereon. The board or commission reviewing an application shall provide for thc giving of notice: A. By causing a notice giving the time, date, p~ace and nature of the hearing to be published [n the official. newspaper within the period prescribed by law. B. By requiring the applicant to erect the sign provided by the town, which shall be prominently displayed on the premises facing each public or privata street which the property involved in the application abuts, giving notice of the application, the nature of the approval sougi~t thereby and the time and place of the public hearing thereon. Thc sign shall be set back not more than ten (10) feet from the property line. The sign shall be displayed for a period of not less than seven (7) days immediately preceding the date of the public hearing. The applicant or his/her agent shall file an affidavit that s/he has complied with this provision. C. By requiring the applicant to send notice to the owners of record of every property which abuts and every property which is across from any public or private street § 58-1 SOUTHOLD CODF, § 58-1 from the property included in the application. Such notice shall be made by certified mail, return receipt requested, posted at least seven (7) days prior to the date of the initial pubne hearing on the .qpplication and addressed to the own°-rs at tho addresses listed for them on the local assessment roll. The applicant or agent shall file an affidavit that a/he has complied with this prov~sion I I ~' I SUFFOLK COUNTY LAND & TAX