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HomeMy WebLinkAboutTR-5395Board Of $outhold Town Trustees SOUTHOLD, NEW YORK PERMIT NO... 'k~s,~.C~k,~. .... DATE: ..S...e.p.~....4,....,~.gl ISSUED TO EDWIN & GRACE BERNHARDT ut'ttarizatian PurSuant to the provisions of Chapter 615 of the .Laws of' the State of New York, 1893~ and Chapter 404 of the ,L~. ws of the · State of New York 1952; and the Southeld ToWn Ordinance en- titled ."REGULATING AND THE PLAC:ING OF OBSTRUC:TIONS 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 wlth the Resolution of The B6ard adopted at a meetlncj held on _.A,.y~g...:....~9~.L. ~00~ ........... . and In consideration of the sum of $...?.L.0...0.. .......... paid by Edwin & Grace Bernhardt of Southold N. Y, and subject to the Terms and Conditions listed on the reverse side .hereof, of Southold Town TruStees authorizes and permits the following: Wetland Permit to replace rotted deck and ~ncrease size of w~dth of deck by 4' for a s~ze of 15'X lZ'. all in accordance with the detai~ed Specifications as presented in · the orkjinaflng application. IN WITNESS WHEREOF, The said Board of Trustees here- by causes its C:orporate Seal to be at, xed, end these [p.resen~ to be subscribed by a'majorify of the smd Board as of thts dat~. TER~S end C. ONDITIONS Edwin & Grace Bernhardt 500 Koke Dr., Southold N.¥. ~ part. of the consideration for the i.~,~:e of the P'~t does undetstmd and pn~:tibe to the ~oI- · ,~L teapot thereto, to the complete';-.-:~ulon of the B~u,d of Tmseees of d~e Town o~ 8~&oid for an ,-~mm4on may be made to the Bo~d at · ~___~ ~. 'that thLs p~r,~;¢ should be ~*'~,,,d inde['mi~ety, or as long as d~e said Peantaee wishes to maintain the structure or pt'oject Involved, to provide evidence to anyone concerned dm aud~ 4. That d~e wock involved will be subject to d~e in~ and spprav~ of the Baaed agents, and non-mm~;;,~ with.the ptovislons of tee ot~,~-~ apldicndon, m~be ,----,. revocation of this I['~t by r"-~oi~don of d~e sa~d ~ 7. That if ~x~e operstiom of the Town of Soutbold require dM femoul and/o~ aleeradom fnthe 14~:~on o~ the work herein ~ or 1~, ia the ol~a~ou o~ the Bomii ot lmsm~ the. woek ~h,l! c~use un_,~sooable obsta~uon to free naviga~a~ the ~ pt.~d,ee will be .aeq~ ulxm due no~ to remove or alee~ this work ot project bete~ s~.t~l withou~ ezpemes to the Town 8. That the said Board will be notified by the Petmittee ot the c.,~,~4eekm0~ ~he work mtd~- odzed. 9. That the Permiteee will e~ln aH other i~m;t- and ~on~~ ~t snay ~e ~ s~ plem~*-! m m~ pennlt which nuy be subject to sevoke upon f,n~e to oixsln sam~ Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda September 4, 2001 Mr. & Mrs. Edwin Bernhardt 500 Koke Dr. Southold~ NY 11971 RE: 500 Koke Dr., Southold SCTM#87-5-4 Dear Mr. & Mrs. Bernhardt: 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 The Board of Town Trustees took the following action during its regular meeting held on Wednesday, August 29, 2001 regarding the above matter: WHEREAS, EDVON & GRACE BERNHARDT applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated August 1, 2001, 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 August 29, 2001, 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 EDWIN & GRACE BERNHARDT to replace rotted deck and increase size of width of deck by 4' wide for a size of 15'X 12'. 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: Non~ Ve~ truly yours, Albert J. Krups'ki, Jr. President, Board of Trustees AJK/lms DEC Bldg. Dept. Zoco //o/7 Telephone i631) 765-1892 Town Hall. 5309.~ Ma/n Road P,O. Box 11'/9 Southold. New Y~xk 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Monday, August 20, 2001, the following recommendation was made: EDWIN & GRACE BERNHARDT to rep ace. rotted deck and increase size of width of deck by 4' wide for a size of 15'X 12'. 500 Koke Dr., Southold. SCTM#87-5-4 The CAC did not make an inspection, therefore no recommendation was made. Albert J. Krupski, President James tLing, 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 Coastal Erosion Permit Application ~"Wetland Permit Application __ Major Waiver/Amendment/Changes ..R:eceived Application: ~/~ ,,,~Received Fee:$ ~ ~ ~'Completed Application Incomplete SEQRA Classification: Type I Type II Unlisted__ ~Coordination:(date sent) . ~'CAC Referral Sent: g~ I~ ,~rate of Inspection: Receipt of C AC Report: Lead Agency Determination:__ Technical Review: ,~Public Hearing Held: Resolution: Minor Phone Number:(l) (~'~ t'~ "1'6 ~'-~' I '7 ~.. Suffolk County Tax Map Number: 1000 - Property Location: ~'C3E5 ~(c:Sk~ '-~ (provide LILCO Pole ~, distance to cross stre~s, and loc~tion) AGENT (If applicable) Address: Phone: Board of Trustees Application GENERAL DATA Land Area (in square feet):. AreaZoning:'-~ ~:~ ~ cl evx2~ ~L. Previous use of prope~y: % ~ O_ O~ ~ ~ ~ Imend~ use of prope~y: Prior permits/approvals for site improvements: 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 neces~ry): -x~ ~D~ ~ ~. Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: ~ ~:~::> ~_~.~ ~_ ~,c~"~ ~ ~ Area of wetlands on lot: square feet Percept coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands:~feet Closest distance bet,ween nearest proposed edge of wetlands '~.:.".~ ,~j' 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: Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: structure and upland cubic yards cubic yards feet Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: AUg - 2 2001 STATE OF NEW YORK COUNTY OF SUFFOLK .~o,'w ~tv~~- , residing at <x~%~ ~. %~q]l , being duly sworn, deposes and says that on the ~h day of ~ ,~O~ , 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 sai~ Notices were mailed at the United States Post Office at ~U~d , that said Notices were mailed to each of said persons by (certified) (registered) mail. LYNDA Mm BOHN NOTARY PUBLIC, State of New Yo~k No. 01 BO6020932 (~ualified in Suffolk Cour~.~ Term Expires March 8, 20(~,,~ Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall .53095 Route 25 P.O. Box 1179 Southold, NewYork 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF $OUTHOLD In the Matter of the Application of COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I,~u~iv%~~~ , residing at ~ ~\<~ ~ ~ being duly sworn, oepose and say: That on the day of //~ , 200 , I personally posted the property known as 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 the public hearing. Date of hearing noted thereon to be held Dated: Sworl~ to be~e~.m_e .~his ~C~Vday of~ 200 % Nota~ Public LYNDA M. BOHN NOTARY PUBLIC, State of ,~lew York No. 01806020932 Qualified in Suffolk Counly..~ Term E~pires r~,;~mh 3.20~.~ (signature) Board of Trustees Application County of Suffolk State of New York DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH 1N THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT 'AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. SWORN TO BEFORE ME THIS Signature DAY OF~ ~_~ ,2oC \ LYNDA M. BOHN NOTARY PUBLIC, State of New York No. 01 BO6020932 Qualified in Suffolk Coun_ty. Term Expires March 8, 20(~ NEU' DEPARTNENT OF ENVIRONNENTAL CONSERV/0 PERMIT U~der the Envirmmontat ConServation LaM EFFECTIVE DATE Jury 26, 1995 EXPLRATION DATE(S) Jury ~0, 2000 D Modification O Permit to Construct O Permit to Operate O O O 0 0 O Article 15, Title 5: Protection of Waters Article 15, Title 15: ~ater Supply Article 15, TitZe 15: Uater Transport Article 15, Title 15: Long Island ~etts Article 15, Title 27: Wild, Scenic and Recreationsl Rivers Other: 6NYCRR 608: Dater Quality O Article 27, Title 7; 6NYCRR 360: Certification Solid Waste Management Article 17, Titles 7, 8: SPDES D Article 27, Title 9; 6NYCRR 3T5: Hazardous~aste Management Article 19: Air Pollution Control 0 Artic(e 34: Coastal Erosion Mansge~ent Article Z~, Title 27: Mined Land Reclamation D Article 36: FLoodplain PERMIT LSSUED TO I TELEPHONE NL~IBER Edein J. Bernhardt I (516) 765-517~ ADDRESS OF PERMITTEE 500 Koke Drive Southotd, NY 11971 CONTACT PERSON FOR PERNITTED t/ORK Same es Per~ittee NAME AND ADDRESS OF PROJECT/FACILITY Bernhardt Property 500 Koke Drive LOCATION OF PROJECT/FACiLITY Sou(hold COUNTY I TO~N ~ATERCOURSE NYTM COORDINATES SuffoLk I Southo[d Corey Creek Rep[ace approximte(y 77 Linear feet of tiaber bulkhead 18" seeHard of existing bulkhead on Hest side and tampering to O' on east side; reconstruction of a 29'x 4' fixed pier, Mx 13~ ramp and 20~x 8' flat; construction of a neH 29'x ~ "L" pier; ~'x 1~' ramp and 8' x 23~ float uith iud pi[es. ALt ~ork shall be done in accordance Hith plans prepared by Ec~in Bernhardt dated 4/17/95 (tHo sheets) and starRoed NySOEC Approved on 7/26/95. Ali uork Land~ard of~ouLkheacl~s not uithin the jurisdiction of the NYSDEC. Dy acceptance of this pemit, the permtttee agrees that the permit is contingent upon striCt compliance ~Lth the ECL, all applicable regulations, the General Conditions specified (see page 2) and any special Conditions inctoded as part of this permit. PERMIT ADMINISTRATOR: ADDRESS Charles T. Hamilton BLdg. 40, SUNY, Room 219, Stony Brook, NY 11790-2356 AUTHORIZED SIGNATURE DATE ~~. ~ July 26, 1995 Page 1of 5 95-20~ba (7/921- 25c ADDITIONAL GENERAL CONDITIONS FOR ARTICLES 15 (Title 51, 24, 25, 34 and 6 NYCRR Part 608 ( Tidal Wetlands 9 That if future operations by the State of New York require an al- teration in the position of the structure or work herein authorized, or ~f. in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural resources of the State, the owner may be ordered by the Department to remove or alter the structural work, obstructions, or hazards caused thereby w~thout expense to the State. and if, upon the expiration or revocation of this permit, the structure, fdl, excavation, or other modification of the watercourse hereby authorized shall not be com- p[eted, the owners, shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or flu and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall be made against the State of New York on account of any. such removal or alteration. 10 That the State of New York shaU in'no case be liable for any damage or injury to the structure or work herein authorized which may be caused by or result from future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no claim or right to compensation shall accrue from any such damage 11 Granting of this permit does not relieve the apphcant of the responsi- bdity of obtaining any other permission, consent or approval from the U.S. Army Corps of Engineers. U.S. Coast Guard. New York State Office of General Services or local government which may be required. 12 Ali necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any ) other environmentally deleterious materials associate~l with the proiect 13 Any material dredged in the prosecution of the work herein permitted shall be removed evenly, without leaving large refuse piles, ridges across the bed of a waterway or floodplain or deep holes that may have a tendency to cause damage to navigable channels or to the banks of a waterway. 14 There shall be no unreasonable interference with navigation by the work herein authorized. 15 If upon the expiration or revocation of this permit, the project hereby authorized has not been completed, the applicant shall, without expense to the State. and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fdl and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. 16 If granted under 6 NYCRR Part 608. the NYS Department of Environ- mental Conservation hereby certifies that the subject project will not contravene effluent limitations or other limitations or standards under Sections 301, 302. 303. 306 and 307 of the Clean Water Act of 1977 (PL 95-217) provided that all of the conditions listed herein are met 17 All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or his agent as part of the permit application. Such approved plans were prepared by on SPECIALCONDITIONS 1. Any debris or excess material from construction of this project shall be completely removed from the adjacent area (upland) and removed to an approved upland area for disposal. debris is permitted in tidal wetlands and or protected buffer areas. No 2. There shall be no disturbance to vegetated tidal wetlands or protected buffer areas as a result of the permitted activity. 3. Ail fill shall consist of "clean" gravel and soil (not asphalt, slag, flyash, broken concrete or demolition debris). 4. 'No excavation of the beach is authorized for the purpose Of obtaining fill or stone materials. 5. Ail peripheral berms, cofferdams, rock revetments, seawalls, gabions, bulkheads etc. shall be completed prior to placement of any fill material behind suoh structures. 6. Equipment operation below apparent high water is strictly prohibited. 7. The new bulkhead shall be constructed within a maximum of 18" seaward of the structure, measured from face of old sheathing to face of new sheathing (as shown on the approved x-section). 1-4738-01051/00001-0 Page 3 of 5 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION SPECIAL CONDITIONS 25 Tidal Wetlands For Article (_ 8. Bulkhead constructed directly adjacent to vegetated tidal wetlands shall be jetted in with no disturbance to the tidal. wetland. Trenching is strictly prohibited. 9. There shall be no discharge of runoff or other effluent over or through any bulkhead or shoreline stabilization structure or into any tidal wetland or adjacent area. 10. Dock or timber catwalk shall not exceed 4 feet in width and shall be a minimum of 3'½" feet above grade* over tidal wetland areas (* as measured from ground to bottom of dock sheathing). 11. Floats and ramps may not rest on or be stored in any vegetated tidal wetland. 12. No permanent structures may be installed on dock/catwalk/float without first obtaining written Department approval (permit, modification or amendment). 13. Docks/catwalks/floats may not (a) extend laterally beyond property lines, (b) be placed so that docked boats extend over adjacent property line, (c) interfere with navigation, (d) interfere with other landowners riparian rights. Supplementary Special Conditions (A) through (F) attached. DEC PERMIT NUMBER 1-4738-01051/00001-0 l IPROGRAM NUMBER IPage 4 of 5 The following conditions apply to all Tidal Wetlands; Freshwater wetlands; Coastal Erosion Management; and Wild, Scenic, and Recreational Rivers Permits~ Ae DJ A copy of this permit, including all conditions and approved plans, shall be available at the project site whenever authorized work is in progress. The permit sign enclosed with the permit shall be protected from the weather and posted in a conspicuous location at the work site until all authorized work has been completed. The permittee shall require that any contractor, project engineer, or other person responsible for the overall supervision of this project reads, understands, and complies with this permit and all its general, special, and supplementary special conditions. Any failure to comply precisely with all of the terms and conditions of this permit, unless authorized in writing, shall be treated as a violation of the Environmental Conservation Law. If any of the permit conditions are unclear, the permittee shall contact the Division of Regulatory Affairs at the address on page one or telephone (516) 444-0365. If project design modifications become necessary after permit issuance, the permittee shall submit the appropriate plan changes for approval by the Regional Permit Administrator prior to undertaking any such modifications. The permittee is advised that substantial modification may require submission of a new application for permit. At least 48 hours prior to commencement of the project, the permittee and contractor shall sign and return the top portion of the enclosed notification form certifying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion of the permitted work, the bottom portion of that form shall also be signed and returned, along with photographs of the completed work and, if required, a survey. For projects involving activities to be undertaken in phases over a period of more than one year, the permittee shall notify the Regional Permit Administrator in writing at least 48 hours prior to recommencing work in subsequent years. The granting of this permit does not relieve the permittee of the responsibility of obtaining a grant, easement, or other necessary approval from the Division of Land '" Utilization, Office of General Services, Tower Building, Empire State Plaza, Albany, NY 12242 {516) 474-2195, which may be required for any encroachment upon State-owned lands underwater. DEC Permit No.1-4738-01051/00001-0 Page 5 of 5 · ; ~ ([tOITl(]q~ - , Inspections 1. The pem~itted site or facility, including relevant records, is subject to in- spection at reasonable hours and intervals by an authorized representative of the Deparb~=nt of Envirc,'nuntal Conservation (the Depar~=~t) to determine whether the permittee is c~plying with this permit and the R'~. Such represen- tat ire tray order the work suspended pursuant to r~ 71-0301 and S~PA 401 (3). A copy of this permit, including all referenced rmps, draNings and special conditions, rmst be available for inspection by the Cepar~.3a3t at all times at the project site. Failure to produce a copy of the permit upon request by Deparb¥ent representative is a violation of this permit. Permit (3~anges and I:isn~ls 2. The Depar~,,=nt reserves the right to rrodify, suspend or revoke this permit when a) the scope of the permitted acti.vi.ty is exceeded or a violation of ar~ condition of the permit or provisions of the ~ and pertinent regula- tions is found; b) the permit v~s obtained by misrepresentation or failure to disclose relevant facts; c) ne~vrmterial info.~'ution is discovered; or d) envir(~.=~tal conditions, relevant technology, or applicable lan or regulation have rmterial Iy changed since the permit v~s issued. ~ permittee rrust su~rnit a separate written application to the Deparln'ant for rene~H, nodification or transfer of this pe.~nit. Such application mJSt ir~lude any fo.~, fees or supplu~cntal info~¥~tlon the Deper~=nt requires. ~ny renenal, rmdification or transfer granted by the Deparb~=nt rrust be in writing. The permittee rrust sub. it a renenal appl ication at least: a) 180 days before expiration of permits for State Pollutant Discharge El imination Syst~n (SFCES), Hazardous W~ste Manag~rmnt Facilities (RN~F), rmjor Air Pollution Control (A.=C) and SolidW~ste IVenacje~nt Facilities (~/f~F); and b) 30 days before expi rat ion of al I other permit types. Unless expressly provided for by the Deperb~.qt, issuance of this permit does not rrodify, supersede or rescind any order or determina, tion perviously issued by the Deparb~=nt or any of the te.)u, conditions or requ.re~ents contained in such order or determinat ion. Other Legal C!31 igations of Pen~ittee 6. The permittee has accepted expressly, by the execution of the application, the full legal responsibility for all d¢=.uges, direct or indirect, of v~atever nature and by ~ver suffered, .arising out of the project described in thisj permit and has agreed to indu[.lfy and save harmless the State fr~ suits, actions, du[.ges and costs of avery na[. and description resulting frcm this project. This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted v~3rk ncr does it authorize the irrpai.¥ent of any rights, title, or interest in real or personal property held or vested in a person not a par~y to the permit. 8. The permittee is responsible for obtaining any other permits, approvals, lands easu[ents and rights-of-v~y that may be required for this project. Pa~e 2 of 5 PROJECT I.D. NUMBSR 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 sponsor) SEQ 1. APPLICANT ~SPONSO~ 2. 3. PROJECT LOCATION: 4. PREC',SE LOCATION (Street a~3oress am: roaci intersections, prominent landmass, etc., or p~ov~oe mao) 5, IS PROPOSED ACTION: [] New [] Exc)ansion '~.MoOif[cation/alteration 6. 0ESCRIBE PROJECT SRIEFLY: 7. AMOUNT OF ~ND AFFECTED: Initially ~ ~ 7 ~ ~ I acres L~ Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY %FSDERAL. STATE OR LOCAL)? [] Yes ]~:~.No If yes, Jist agency{s) and permit/aoorovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAL]O PERMIT OR APPROVAL? [] Yes' '~I, No If ,/es, list agency name and perm~tlaooroval 12. AS A RESULT OF PROPOSED ACTION '&'ILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? E~] Yes []No i CERTIFY THAT THE INFORMATION PRO~ISED ABOVE IS TRUE TO THE SEST OF MY KNOWLEDGE ]f the action is in the Coostal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this as_s, essment OVER ! pART I1--ENVIRCNMENTA' [SSMEHT,To be cQmcie!eg ~'' *":" · 2ART ilI--0~TERMINATICN OF SIGNIFICANCE ~To be comoleted by Agency) Check ;his box if you have identifieo one or more ;o[en[ially large or significant adverse ;moac:s which MA':' occur. Then orcceed airec:ly ~o :ne PULL EAF ~nolor procare a positive' declara'.Jcn. Checx :his box :f you ;~ave de,.ermined, based on the information and analysis above and any suooortip, c_ documenJa[~cn. :ha[ ;he arooosed ac;ion WILL ,',tOT resul£ in_~?¢y s~gnificant adverse env)rcnmental imcac:2 AND 3rowce gn a;:acnmen[s as necsssary.~. [he reasons sugcor;ing mis determination: