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Home My WebLink AboutTR-5175Albert O. I{a~ap.~ki, President James [{Jug, Vice-President Henry Smlfk Artie Foster Ken Polio; o(la Town Hall 53095 Main Road P.O. Box 1179 S(mthold, New York 11971 Telephone (516) 765-18.~)2 Fax (516) 765-1823 BOARD OF TOWN 'rRUSTEES TO~VN OF SOUTHOLD Office Use Only ~.~__Coastal Erosion Permit Application We~-..l. and Permit Application Grandfather Permit Application .Waiver/Amendment/Chooge~ Received A ]~cation- Received,Fee:$ ___Comp].eteo App lication_..~/[ ~,/ ~ _Incomplete Type I___~.Type ~I Unlisted Coor.:lirtz{t:itJn: (date sent) CAC ~e~erral :gent: Date of Inspection: ___.Receipq: of CAC Report: Lead Agency Dele.rmination: Technical RevJ_ew: Public Hearing Held: ---Resolution: Name ¢;f Applicant \/, ~_~_~_____.~_~_0.. Phone Number: ( ~( ) _/J:J=. /~ ~ 't.~ Suffolk Couury Tax Map NuJr, ber: 1000 - _c~0- ~ - ~. Property Location: g~% Cc,k.~.r Po~F.~7,~ ~t~-, ~o,,&~l~ (provide LSLCO Pole #, distance to cross streets, and location AGENT: (If · appl~_able) Address: Phone: FAX#: Albert J. Krupski, President James FAng, Vice-President Henry Smith .~-*t ie Fester Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18~ Fax (516) 765-1823 BOARD OF TOWN BOARD OF TRUSTEES: TO~ OF SOUTHOLD In the Matter of the Application STATE OF NEW YORK) AFFIDAVIT OF POSTING I, ~IVJ~ CCC) , residing at 7 ~9[~ ~,~ ~. being duly sw6rn, ~epose and say: That on the /~-day of /~ , ~ , 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 seven days prior to the date of &t~e public hearing. (date of hearing noted thereon to be held~ · Dated: ( signature ) Sworn to before me this cf TLu:~tees ~ENERAL DATA Land Area fin square feet): Area Zoning: Previous use of property: Intended use of property:__. 15_,j 7& ....... Prior permits/approvals for site Agency improvements: Date No pi. lot permits/approvals for site Has any permit/approval ever been revoked governn~entai agency? j No If yes, pro~/ide explanation: suspended by a ~es Project. Description (use attachments if necessa3'v): of 'Cru~tees ~ppli~atio~ Purpose of WETLAND/TRUSTEE LANDS APPLICATION DATA the proposed operations: ~,~ zt~, Area of wetlands on lot:_ ~'Cff ~u~ ~ .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 ~ N0~ ~,~ If yes, how much material wi.l] be excavated?__..~.~____cubic yards How much mate.rial will be filled? ~i% titbit yards of which material will be removed or deposited: Depth feet Proposed slope throughout the area of operations: NO Manner in which material will be removed or deposited: Statement of tile effect, if any, on the wetlands and tidal waters o~ the town that may result by reason of such proposed operations (use attachments if appropriate): 617.£1 Appendix C State Epvironrnentai Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be completed by ..~pticant or P,'oject .~or)nsor) SEQ §, tS PROPOSED ACTION' ~New ~ ¢-xoanslon b~ MoodicadonlaJteration 6. GESC~IEE PROJECT 8RIE.--LY: If the action is in the Coas.*a[ Area. and ¢ou are a state ~GenDy, complete the Coas[si ,Assessmer~t Form before proceeding with this assessment OVER I PROOF OF MAIf,ING OF HOT!CE ATTACH CERTIFIED ~'D%IL RECE1PTS Name: Address: U.S. Posta~ Service CERTIFIED MAIL RECEIPT ~Domestic Mail Only; No Insurance Coverage Provided) Name (Please Print Clearly) (To be completed ...... ~ ~..E~L~ .~ .... STATE OF NEW YORK COUNTY OF SUFFOLK Town of Southold; that States Pest Office at were mailed to each of mail. ~{VI~ 500 , residing at .... , being duly sworn, deposes and says that on the ._.!~__ day of P~r~[ ._~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 of~osite 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 said Notices were mailed at the United that said Notices said persons by (ce~tifled) (registered) Sworn tQ before me this day of Notary ~ublic HELENE D. HORNE Nota~ Public, State of New York No. 4951364 ' Qualified in Suffolk County Commission Expires May 22, .~ ceca/ 6 i~rd of Trustees County of Suifolk State of New York BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS '~E APPLIC~qT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STA~EMF~TS 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 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, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. swoRN TO XE THIS Dm Nota_t y PLtblic HELENE D. HORNE Public. State of New Yin'ii No. 4951364 QUalified in Suffolk County ~ml~ion Expires May 22, ~ FORM The Town of $ouLhold'e Code o£ EM11ce prohibit8 conflicts of tnterea~ on the par~ o£ town o~---~'ers _and ~mpluye~s. The purpose of this form ts co provide information which can alert ~he town of poss[~ie conflicts of ~-~-~-emt and allow i~ to take whatever action i~ necessary to avoid same. you are applying in Lh~, ,am~ obher enLtby, such as a company. th~ other p~r~on'~ or eompnny'~ (Ch~ck all that Tax grievance Variance change of zone- hpp~l~vai of plat , E~emption from plat or official map other (If "other," n~m- the activity,) _J~Je~' ,~ parent, or child) hav~ a relatlon~ltip with any ~:[ffieer or ~mployee of the Town of Soutbold? interest" m~an. a buuinen., including a partneruh[p, In which the ~o~n ~EEleer or employee ha. even a par~lai u~neruhip o[ (or employment by) a uorporag{oM !n ~hicb th~ town officer or employe, own. more tha{i 5% n~ the uhateu. NO date and uigfl where indicated. and Name of pereo,t employed by the Town of Southold -- ~- Title or po~{.tirJn of that pereon ~' Describe the relationship between youteeti' (th~ applicant) and the town officer er employee. Either check appropriate line A) through D) and/or describe in the ~pace provided. The town officer or employee or hi. ct b~r epo[l.~, sibling, parent~ or child ia (check all. that apply), A} the owne~ of greater than ~% of the share~ o~ the corporate stock of the applic~.t (when the applicaat is a corporation}I __B) the legal or b~neficial owner of any tntere0t in a noncnrporate'entity (when the applicant [~ not a corporation); C) an officer, director, partner, ~r emploT~e of the applicant; or D) the actual applicant. UESCRIPTION OF NIrLATIONSHIP