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Home My WebLink AboutTR-5255Board Of Southold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. 30~~''~'' DATE: ~.~em. be~....Z?.' ISSUED TO LOUISE MOYLE Pursuant +o the provisions of Chapter 615 of the Laws of the State of New York, 1893: and Chapter 40~ of the Laws of the State of New Yo~ 1952: and the Southold Town Ordinance en- 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 Resolution of The Board adopted at a meeting held on ...~.~......~9.,... 20.~.., and in consideration of the sum of $ .!~9.~.~ ...... paid by .. Louis~ ..~lOy~e ............................................................... of ............... ~h~ .................................. N. Y. and subject to the Terms and Conditions listed on the reverse side hereof, of Soufhold Town Trustees authorizes and permits the following: Wetland Permit to expand the existing one-car garage to a two-car garage and add a family room/studio with bath and deck above garage, with the condition that drywells be installed to contain the roof run-off. all in accordance with the detailed specifications es presented in i the originating eppl'mafion. . IN WITNESS WHEREOF, The seld Board of Trustees here- by 'cau*se~ ifs ~orp°rete Seal to be affixed, end these p.resenfs .to be subscribed by a 'majority of the seld Board-as of ~h,s date. TERMS and CONDITIONS The Pe~mlt'~e Louise Moyle tesidlng at 1920 Minnehaha Blvd., Southold N. ¥. ~ part of the co~ide~ation fo~ ~he k~,-,~_ of the Permit do~ trade, rand and pt~n'be to the fol- lowing: t. That the said Board of Trustees ~nd the Town of So~thold ate rdeased from say and all d~mages, or ~t.i,,~ fo~ ,l,,~es, of mits ~ising dite~ ~ Indirectly a~ · re, It of any ope~- with t'e~pect thereto, to the mmplete exdusion of the Bo~d of Trustees of ~ Town of .~athold 2. That d~s Permit Is valld for a period of 24 ~o~. which t~ mmide~l to be fl~e for an extension may be n~de to the Bo~ttd at a Iate~ da~. 3. 'lliat this Permit should be retained indefinleely, or ns long as the nld Permlttee ~ishes maintain the structure or project involved, to provide evidence to smyone concerned that anth- orlzation w~ originally obtained. 4. That d~e wo~ involved will be mbject to the inspection and approval of the Board agents, and non-compliance with the provisions of the otigim~ng applka0on, may be ~-~e t~vocatlon of this Petmlt by t'esolutlon of the said Board. 5. That there will be no tmte~.~mable intetfei'ence with nsvigagon ss · tesdt of the herein a~/thotlzed. 6. That there shall ~e no interference wkh the right of the pul~c to [~ss nad repass dong the beach ~tween high and low water m~rks. 7. That if fume opet~ions of the Town of So.hold requi~ ~he zemo~l snd/ol' alt~'attoas in the locstlon of d~ w~k herein md~ot~n~[~ or if, in the opinion of d~e wo~ shall cause tmt'essonable obstmcuon to free n~vigatlon, the said Pennlh'ee will be tequt~d~ upon due notice, to remove or alter this work or proiect hetvln stated wig~t expenses to the Town of Southold. 8. That the said Board will be notified by the Petmittee ot the ~et~n of the ~0rk anth- oriel 9. That the Petmittee will obtain all other permits and coot, eaU d~t m~' be ~e~uited plemental to this permit which may be subject to revolm upon failure to obtain same. 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 December 27, 2000 BOARI) OFTOWNTRUSTEES TOWN OFSOUTHOLD Mr. Donald M. Moyle 14 Partrick Lane ~Wilton, CT 06897 Re: 1920 MinnehahaBlvd, Southold SCTM#87-3-63.1 Dear Mr. Moyle: The following action was taken by the Board of Town Trustees during its regular meeting held on Wednesday, December 20, 2000 regarding the above matter: WHEREAS, Donald M. Moyle on behalf of LOUISE MOYLE applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated November 27, 2000, 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 December 20, 2000 at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standards set forth in Chapter 97 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approve the application of LOUISE MO YLE to expand the existing one-car garage to a two-car garage and add a family room/studio with bath and deck above garage, with the condition that drywells be installed to contain the roof run-offi 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. Two inspections are required and the Trustees are to be notified upon completion of said project. Fees: None Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/Ims cc. Building Dept. DEC Telephone ('631) 765-1892 Tovm H'~. 53{~9.5 Main P.O. Bo,* SouChold. Ne~w SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At.the meeting of the Southold Town Conservation Advisory Council held Thursday December 14, 2000, the l-bllowing recommendation was made: LOUISE MOYLE 87-$-63.1 to expand the existing one-car garage to a two-ca~' garage and add a family roonv'studio with bath and deck above garages. 1920 Minnehaha Blvd., Soutbold The CAC did not make an inspeclion, therefore no recommendation was made ,A/Io y'u~' 7~ /'4kp ~7 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 March 8, 2004 Mr. & Mrs. Don Moyle 1920 Minnehaha Blvd. Southold, NY 11971 Dear Mr. & Mrs. Moyle: In response to your letter received on February 27, 2004, please be advised that in accordance with the adoption of the revisions to Chapter 97, you are required to obtain a permit for your existing dock. Enclosed is an application for a Wetland Permit and a copy of Chapter 97 for your reference. If you have any further questions, please don't hesitate to contact our office. Very truly yours, Albert J. Krupski, Jr., President Board of Trustees AJK:lms F~b ~8 04 ll:07a ~L and Don Mosle [~031 834-37~4 p.1 Southold Town Trustees Southold, NY 11971 BL and Don Moyle 1920 Minnehaha Blvd Southold, NY 11971 FEB 2 7 Seuttteid Town ' B~srd of Trustees Having attended thc public hearing and read the revised Chapter 97 Wetlands and Shoreline Code I have the following questions and would appreciate a response as to how to proceed. Our docks have beeu ~h~aged thi~ winter by the ice and ~ require repair if not replacement. They were built around 1968 and qualify as '~re-existing and non cor~forming' and seem to be eoverefl under 9%i3 A. 5 aa ~u exception to requir~g a permit. My questions are: A--If rcpairefl ca~ decking materials be 5/4 ceflaf?. What would be alternative? B--Can poles be re-set without permit? C-If replacement ofexaot size is necessary will a permit be required7 Please send me an et~eial resporme so I can proceed with the project. (772) 234-2345 or 765-3013 27, 2004 T00[~ 3~la-urno:a;aV "-~-'~ :~l~r'I3 iq?A0.L (YIORT10S ~T, T9 ~9L TC9 X~A' 6T:~T I~.:[ T'0, ~O/L~ ~-~6-t~- 13:~2 JOHN3TON LAW OFFICE ID=1631734-5891 p.~i Sotithold CFo~'R $oh-thold. ~ 11971 FEB 2 7 have I~etl ~m.g~ tlfi~ ~t~ by ~g i~ ~ ~ t~e re~ ~ not rgpl~ ~y w~e ~flt ~o'm~ lg~ ~d tu~ ~ '~rc-~ ~ non replac~t of ~gt ~ is n~ ~ a pe~t ~ r~? ~ ~nd me ~ n~ re~o~e so I c~ ~o~ w~ ~t ~. (772) 23~-2345 or 765--~013 ~0o34,00' £' - Z 't111 7 ~ Iz'Al tYl-.I..,-71VtViNit ~', , Albert J. Krupski, President Jam. es 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 JanuaryS, 2001 Thomas C. Catalano, Jr. Attorney at Law Martin, VandeWalle, Donohue, McGahan & Catalano 555 North Broadway P.O. Box 350 Jericho, NY 11753-0350 Re: LOUISE MOYLE 1920 Minnehaha Blvd., Southold SCTM#87-3-63.1 Dear Mr. Catalano: In accordance with the above-referenced, enclosed is a copy of the Minutes from the Public Hearing held on December 20, 2000. If you have any questions, please don't hesitate to give our office a call. Very truly yours, Lauren M. Standish, Clerk Board of Trustees enc. CHARLES R VAN DE WAI. LE NICHOLAS J DONOHUE JAMES M Mc~AHAN' THOMAS C CATALANO, JR MICHAEL BELITSIS ' RANDI M SEIDNER HELEN VOUTSINASq MARTIN, VAN de WALLE, DONOHUE, McGAHAN & CATALANO ATTORNEYS AT LAW 555 NORTH BROADWAY P.O. BOX 350 JERICHO, N.Y, 11753-0350 516 681-3100 FAX: 516 681-5357 JULES MARTIN (1995) JOSEPH A GUARINO 119911 January5, 2001 Honorable, Albert J. Kmpski, President and Honorable Members of the Board of Trustees, Town of Southold PO Box 1179 Southold, New York 11971 Honorable, Albert J. Krupski, President and Honorable Members of the Board of Trustees, Iown of Southold Town Hall 53095 Main Road Southold, New York 1197l JAN - 8 2001 Re: SCTM#1000- Dear Members of the Board of Trustees, Town of Southold: By our letter of December 14, 2000, we opposed the granting of the permit on the above- referenced matter, on behalf of our client, Pauline Rafkin, property owner of premises 1715 Minnehaha Blvd., Southold, New York, across the street from the subject property. Please advise us as to the result of the permit Hearing, and thank you for your cooperation. Very truly yours, TCC/jc MARTIN, VAN de WALLE, DONOHUE, McGAHAN & CATALANO CHARLES R VAN DE WALLE NICHOLAS J. DONOHUE JAMES M. McO,~,HAN' TNOMA$ C CATALANO. JR MICHAEL BELITSIS * flANDI M. SEIDNER HELEN VOUTSINAS' MARTIN, VAN de WALLE, DONOHUE, McGAHAN & CATALANO ATTORNEYS AT LAW 555 NORTH BROADWAY P.O. BOX 350 JERICHO, N.Y. 11753-0350 516 681-3100 FAX: 516 681-5357 JULES MARTIN 11995) JOSEPH A OUARINO (199~ January 5, 2001 Honorable, Albert J. Krupski, President and Honorable Members of the Board of Trustees, Town of Southold PO Box 1179 Southold, New York 11971 Honorable, Albert J. Krupski, President and Honorable Members of the Board of Trustees, Town of Southold Town Hall 53095 Main Road Southold, New York 11971 8 2001 Re: SCTM#1000- Dear Members of the Board of Trustees, Town of Southold: By our letter of December 14, 2000, we opposed the granting of the permit on the above- referenced matter, on behalf of our client, Pauline Rafkin, prope~y owner of premises 1715 Minnehaha Blvd., Southold, New York, across the street from the subject property. Please advise us as to the result of the permit Hearing, and thank you for your cooperation. Very truly yours, TCC/jc MARTIN, VAN de WALLE, DONOHUE, McGAHAN & CATALANO By: ~ ....... CHARLES R. VAN DE WALLE NICHOLAS J DONOHU£ JAMES M McGAHAN' THOMAS C. CATALAN0, JR SCOTT FAIRGRIEVE MICHAEL SELITSIS ' RAND1 M SEIDNER HELEN VOUTSINAS ' MARTIN, VAN de WALLE, DONOHUE, McGAHAN, CATALANO & FAIRGRIEVE ATTORNEYS AT LAW 555 NORTH BROADWAY P.O. BOX 350 JERICHO, N.Y. 11753-O350 516 681-3100 FAX: 516 681-5357 Honorable, Albert J. Kmpski, President and Honorable Members of the Board of Trustees, Town of Southold PO Box 1179 Southold, New York 11971 December 15, 2000 JULES MARTIN (1995) JOSEPH A OUARINO (1991) Honorable, Albert J. Krupski, President and Honorable Members of the Board of Trustees, Town of Southold Town Hail 53095 Main Road Southold, New York 11971 Re: SCTM#1000- Dear Members of the Board of Trustees, Town of Southold: Pauline Rafkin, the owner of premises, 1715 Minnehaha Blvd., Southold, New York, described as District 1000, Section 08700, Block 0300, Lot 052000, has retained me to submit this formal letter of objection to the permit requested from the Board of Trustees, as applied for by Louise Moyle, 1920 Minnehaha Blvd., Southold, New York. We understand that the above-mentioned project is subject to Environmental Review and open to public comment on December 20, 2000, and that written objections can be made to the application mentioned above. We enclose, for your review, pertinent portions of the Title Insurance Policy and a copy of the Deed for the Rafkin premises. Pauline Rafkin now owns the premises as sole surviving spouse. We also annex, for your review and consideration copies of the Covenants and Restrictions in Liber 2185 cp. 426, as referenced in the Ralkin Title Policy, and which were contained in an Indenture dated August 30, 1941, which was the Deed for the premises now owned by Louise Moyle as evidenced by the drawing on the third page thereof, which comports with the survey annexed to Board of Trustees December 14; 2000 Page 2 the "Notice to Adjacent Property Owner" furnished to Pauline Rafkin, a copy of which is annexed hereto. You will note that the Restrictions as set forth in Deed 2185, page 426, and specifically on page 427, restrict construction to "only or one and one-half story house with garage attached shall be built on this plot". We also enclose, for your review, as recorded in the Suffolk County Clerk's Office, Liber 6908, page 288 through 290, a document entitled Modification of Covenants and Restrictions, effecting the Moyle property, and staling, on page 289 thereof, that the earlier-mentioned Restriction is modified as follows: "only one or one and one-half story house with garage attached or detached shall be built on this plot". A review of the Notice to Adjacent Property Owner enclosed herewith indicates an intention to request a permit fi-om the Board of Trustees to "expand present garage to two car garage and add a family room above garages", clearly indicating the creation of a two story structure, and not a one and one-half story dwelling, clearly in violation of the Covenants and Restrictions, and the modifications of Covenants and Restrictions, and set forth in the documents annexed hereto. This objection is further stated to be for reason that the additional structure, at a two story height, will now eliminate the water view previously enjoyed by Mrs. Rafkin since the purchase of herMinnehaha Boulevard propertyin 1979. TheRafldns decided to purchase their property based upon its proximity to the water, and its clear, unimpeded water view. Permitting the proposed structure on the Moyle property will create a two story eyesore, blocking the water view on the Ratkin property, and accordingly decreasing the value of that property by eliminating the enjoyment of the water view by any future potential purchasers. If the Moyle application is granted, the Moyle property will be overbuilt, and will violate the Covenants and Restrictions set forth in the Deed recorded on Liber 2185, page 426, particulary on 427 thereof, which contains the additional restriction that "no house or any portion thereof shall be built closer to the highway than twenty feet", which will also be clearly violated as evidenced on the copy of the Moyle-provided property Survey annexed to the Notice to Adjacent Property Owner earlier referred to and annexed hereto. Environmentally speaking, the over-building of the Moyle property will adversely impact the environment and the neighbors, both waterside and across Minnehaha Boulevard, by restricting natural vegetative growth, cau£mg additional erosion potentials, and will effect surface water mn-off Mrs. Ratkin has asked us to formally request a denial of the permit for the Moyle expansion, expressing extreme dismay at the impact of the new construction on her enjoyment of the water view, the natural habit and environment, the calm and quiet of the neighborhood, and has asked us to indicate that it will severely impact, not only on her property values, but also on her ability to enjoy the use of her property during her senior years. Board of Trustees December 14~ 2000 Page 2 On behalf of Pauline Rafkin, we hereby formally object to the Moyle application under SCTM#10000-, for a permit to expand and to create a second stow, and respectfully point out that not only will the Covenants and Restrictions earlier referred to be violated by the proposed structural expansion, but also that property values and the use and enjoyment of the Rafldn property will be severely impacted should the permit application be granted. Should you have any questions regarding the foregoing, please do not hesitate to contact me. Vew truly yours, MARTIN, VANdeWALLE, DONOHUE McGAHAN, CATALANO & FAIRGRIEVE TCC/jc cc.: Mrs. Pauline Rafkin IRVi~ DAVID RAFKIN & Policy No_ 1206396 PAULI~ ~ PD. FKIN Amoun, Of Insurance $ 72,000.00 Da.'l'e of ksue 6/28/79 The esfefe or inferesf bsure~ by fhb policy is fee simple '~sf~d ;n fhe insured by means of D. -~.din Coz's:in & .z~geline D. ¢orwin,' his w±'Fe to the I~SUDRD dated 6/28/79, recorded 7/5/79. a deed made by SCHEDULE B Telephone Agreement in Liber 1977 cp 478. survey by Otto w. van Tuyl dated 5/8/64 shows a one story frame house a_nd a detached garage; I) variation between fences an~ record lines of title. No other variations. Any state of facts an accurate survey of t4he premises might show since date of said su~rvey. C. Any state of facts an inspection of the premises might show. Covenants & Restrictions in Liar 2185 cp 426, which restrictions have not been violated by the existing improvements. There is no condition Or right of re-entry, or other provision for forfeiture under which the insured can be cut-off, subordinated, or otherwise disturbed. A mortgage made by Irwin David Rafkin & Pauline Ann Rafkin, his wife to Southold Savings Bank dated 6/28/79, recorded 7~/79 in the amount of $50,000.00 and interest. Policy No. 1206396 SCHEDULE A AL~ that certain plot, piece or parcel of land, with the buildings thereon erected, situate, lying and being at Bayview, TOW~% of Southold, County of Suffolk and State of New york, bounded and described as follows: BEGINNING at the corner formed by the intersection of the southerly side of wabun Street and the easterly side of Minnehaha Boulevard; RUNNING THENCE North 87 degrees 26 minutes 00 seconds East along the southerly side of Wabun Street, 75.00 feet to land now or formerly of Yarc; TmSNCE South 10 degrees 34 minutes 00 seconds East along said last mentioned land 150.72 feet to the northerly si~e of Minnehaha Boulevard; THENCE North 70 degrees 07 minutes 00 seconds West along the northerly side of Minnehaha Boulevard, 86.15 feet to the easterly side of Minnehaha Boulevard; T~FR. NCE North 10 degrees 34 minutes 00 easterly sade of M~nnehaha Boulevard, or place of BEGINNING. seconds West along the 117.'50 feet to ~he point T-4413 BETW~[~ D. ALDEN CORWIN a.~d ~ D. C0~, his ~fe, bo~ resid~ at (no ~er) ~h~ha B~lev~d, S~hold, N~ Yore 11971 [206396 ~both r~i~ at 110-20 21st E~d, For~t ~lls, New York 11375, ~y ~ ~ ~d ~ ........ ~ ~ O0/lO0 (*lO.O0) ........... ~ ~ of~ U~ $m~ and oc~ g~d ~d v~bla c~sidera~i~ l~g mad ~ at Ba~iew, T~ oE S~chold, C~ty of Sufffolk ~d S~te of ~ York, ~dad ~ d~c~d ~ follY: B~G at ~e corer ~d by t~ ~C~s~ti~ of R~O ~E No~h 87 dag~s 26 m~s ~ s~ E~t ~e s~erly side of Wa~ S~eet 75.~ f~t to ]~8 n~ or of Yaro; ~CE S~ 10 de~ees ~ m~tes 00 sects ~st al w ~st ~ti~d ~d ~0.72 f~t to t~e no~erl7 side of B~l~rd; ~E No~h 70 de~rees 07 m{~Ces 00 sec~ds West al~ no=~ side o~ ~.~ ~lev~d 86.~ feet to the ~st~ly ~ide e~terlI s~de of M{~ha B~a~, 117.50 f~t to ~e ~. 03~ ~G ~ ~ T0 B~ ~ s-~ pr~,es c~eE~ b7 W. P~I ~(,): 05~ Allen ~d Cl~a T. ~1~, his ~e ~ D. A[4~ Co~ ~d ~e[~ D. .... ~ his ~fe, ~e ~les-of ~ fi~c ~ ~e~ by de~ ~ced July ~ 1975 ~d recked ~ ~ S~folk C~ Clerk's Office ~July 16, 1975 ~ L~er 7875 of ~e~ at ~Ee 175. 36938 JUL 0 5 IgTg T~W/N DAVID KA~'[t~l and pAl.rr_.]]~ ~ ]IA~g~M, h:[s -~ife NL=~VYORK smao~ 087 s~oc3~ 003 u~ 052 com~r~ o~ row~ Suffolk~ Sou~.old. TAX BILLING ADDP.~S$ 5L, HJ ~ Zi ~ W (D. Alden Co. ri.n) (L.S.) .. (a~e,Vl~ o. Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-1872 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application ~ Wetland Permit Application Grandfather Permit Application ~ Waiver/Amendment/Changes ec~ved applicat~n~ ~Received Fee:$ /KO ~-Completed Application Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) w~CAC Referral Sent:~ -"Date of Inspection: Receipt of CAC Report: Lead Agency Determination: Technical Review: w~ublic Hearing Held:~ Resolution: NOV 2 7 Name of Applicant~ Address /~$-0 Suffolk County Tax Map Nualber: 1000 - F~,D~ ~4~6~7'~ Property Location: ~ A' ' -F~ (provide LILCO Pole #, distance to cross streets, and location) AGENT:p~~ (If ap ) Address: ~ ~ ~ ~rd of Trustees Applicatio~ GENERAL DATA Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property: Prior permits/approvals for site improvements: ~(;~/A/~Agency Date __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? ~ No__Yes If yes, provide explanation: Project Description (use attachments if necessary): / ~rd of Trustees Applicatio~ Purpose of WETLAND/TRUSTEE LANDS APPLICATION DATA the proposed operations: ~·~ t, ~/~/A/ Area of wetlands on lot:~square feet Percent coverage of lot:~'~-'~.WJ6~ % 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 ~/~ ~ ~/A/~ ~ If yes, how much material will be excavated?~~ ~O~rds How much material will be filled?~ ~o7~W'W~ cubic yards Depth of which material will be removed or deposited:_~O@~ feet ~F~ '~0.~. Proposed slope throughout the area of operations: Manner in which material will be r~oved or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): ~ard of Trustees Applicat] County of Suffolk State of New York BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR TW~ ABOVE DESCRIBED PERMIT(S) AND THAT ALL STAT~NTS CONTAINED ~IN 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 APPRO~mD BY '£r~ SOU'£~OLD TOWN BOARD OF TRUST~S. THE APPLICANT AGHEES TO HOLD THE TOWN OF SOUTHOLD AND '£'n~ 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 HEPHESENTATIVES(S), TO E~T~R ONTO MY PROPERTY TO INSPECT THE PRE~4ISES IN CONJUNCTION WITH REVIEW OF THIS /~ Signature / / ,~No%ary XSublic EU~AB~ A ~I'AT~ NOTARY PUSI.IC. Ho. 01STGO0817~. Suffom C,o~w~4y Oard of Trustees ApplicatiO AUTHORIZATION (where the applicant is not the owner) I, ~ residing at~~~z~ (print owner of property) (mailing' address) do hereby authorize~~A~ (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. ( O~n%~' s si~natur/) - ~=ROJECT i.D. NUMBER 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 Project sDonsor) SEC 1. ApPLICANT~SPONBOR i 2. PROJECT NAME 3. PROJECT LOCATION: [] New [] Expansion [] Mocdficatlo~alteratlon BEBCRIBE PROJECT BRIEFLY: AMOUNT OF ~ND AFFECTED: Initially acres Ultimately acres WILL FROPOSED ACTION COMPLY WITH ~JSTING ZONING OR OTHER ~IST~NG ~ND US~ ~ESTRICTIQNS? ~ Yes ~ NO If No, ~escnbe briefly WHAT IS PRESENT ~0 US~ iN VIOINI~ OF ~ROJEOT? STATE OR LOCAL)? ~ Yes ~ No If yes. llst agency(si and permiUapprovals 11. DOES ANY ASPECT OF THE ACTIOt4 HAVE A CURRENTLY VAMD PERMIT OR APPROVAL? [] Yes' ~ NO f yes. st aaer~cy name and permit/a¢laroval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MOOIFICATION? I']Yes ~'NO ::' [ CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE // 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, essment OVER ! PART III~OETERMINATIQN OF SIGNIFICANCE (To ~e com01eted by Agency) INSTRUC,~ON$: For earn aoverse offer! identified a{3ove, delermine wJletrler it is substantial, large, important or otherwise signi ~ac,~ ei~fec: should be assessed in connection with its (al setting (i.e. urban or rural); (b).rArobaDility of occ~--i.~lg; (ri dura. tic irrevers~3~lity;, (el geograonic 3coca: and (f) magmtuc~e. Il' necessar,f., aod attacttments or reference suplAor~lng materials. Ensur excAlanations ccntain sufficient de, ail lo sr2ow lllat all relevant adverse impacts ;~ave been iQentifieo anQ adequately aC:resse Chec,~ this ~3ox if you have identifiect one or more potentially larcje or significant a(Averse imoacts which .M. occur. ~en orocaad directly to :~e ~LL ~F anclor pre,are a positlv~declaraticn. Chert< :his ~ox ~f you ~ave determiner, ~ase~ on the information ~nd analysis ~ove &nd any documen[s~lcn, :ha~ :he pro,osco ac:ion WILL ~lOT result in.ny significant aeverse environmental imcs~ AND ~rov~e on A;;~cnmen~s ~s necessary, [he reasons supporting ~is determination: TRAN~ACT~ON~ D~O~UR~ FO~H The Town, of Sou~hold!s Code o£ E~hice prohibits con£11cts of interest on the.par~ of town officers and employees° The p~rpose of. this form is to_provide information which can alert ~he ~own of possible_conflicts of interes~ and allow it to take whatever action is necessary to avoid same, (Cast name, [irst name, midd.le initial, Unless you are applying in ~he name o~ someone else or o~hsr entity~ such as a company. If so~ indicate the other person~s or company's name.) · . 'it..~.~ · · NATURE OF APP~XCATIoN~ (Check all thee apply.) Tax grievance Variance change of zone A~p[l~al of plat . , Exemption from p~ab or o~icial map .~ (If ',other," name the'activity.) Do ~ou personally (o~ bh£ough ~our ~ompeny~ spouse, elbllng~ parent, or ~hlld) have a relationship ~lth any of[ioer or employee o~ the Town of Sou~hold? 'Relationship" includes by blood, marriage, or business interest. 'Business interest# means a business, inuluding a partnership~ in which the town officer or employee has even a pattie! ownership of (or empioym~nt by) a corporation in which the town officer or employee owns more than 5% of the NO >~, da~e and sign vhere indica~ed. Name of person employed by the Town of Southold Title or position of that person., Describe ~he relationship between yourself (the applicant) and the town officer or employee, Either cheek the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or Ilia or her spouse, sibling, 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 applic~nt (when the applicant is a corpora~lon)~ ~he legal or b~neficial ownsr of any interest in a noncorpora~e'entity (when the applicant ia not a corpora~ion)t __,C) an officer, director, applicant/ or __.D) the actual applicant. DESCRIPTION OF ~ELATIONSIIZP partner, or employee of the