The URL can be used to link to this page

Home My WebLink AboutTR-6128AAlbert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson To~m Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (63D 765-1892 Fax (631) 765-6641 # 0047C At BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE Date July 20, 2005 THIS CERTIFIES that the storage shed on a rock foundation 310 Ackerly Pond Lane, Southoid Suffolk County Tax Map # 70-5-5 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 4/19/05 pursuant to which Trustees Permit # 6128A Dated 5/18/05 Was issued, and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for a storage shed on a rock foundation The certificate is issued to aforesaid properS'. Gary Laube owner of the Authorized Signature Albert J. Krupski, 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 OFTOWNTRUSTEES TOWN OFSOUTHOLD 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 lS~ day of construction ½ constructed Project complete, compliance inspection. 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 (6311765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 6128A Date of Receipt of Application: April 19, 2005 Applicant: Gary Laube SCTM#: 70-5-5 Project Location: 310 Ackerly Pond Lane, Southold Date of Resolution/Issuance: May 18, 2005 Date of Expiration: May 18, 2007 Reviewed by: Trustee Peggy Dickerson Project Description: To construct al0'× 16.5' storage shed with four stanchions and a rock foundation. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 97 of the Southold Town Code. The issuance of the Administrative Permit allows for the operations as indicated on the survey prepared by Nathan Taft Corwin III last dated April 3, 2005. Special Conditions: None If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 97 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Albert J. Krupski, Jr., President Board of Trustees Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Pegg5r A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: ~2J'~UI ~"~Lt.cl~ Please be advised that your application dated q I I ~ ]O~- reviewed by this Board at the regular meeting of ~'] J~ lO~- following action was taken: has been and the v/~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: TOTAL FEES DUE: $ ,~'0, (_'~O SIGNED: PRESIDENT, BOARD OF TRUSTEES 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 t631) 765-1892 Fax ~ 631) 765-'14~q BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application ~Wetland Permit Application '~'~Adininistrative Permit Ame ndment]Trans £er/E,x]~ensio n -4~eceived Application: ~--Rece~ved Fee: $~"~'~0''' ~Completed Application Incomplete __SEQIL~. Classification: Type I Type II Unlisted Coordination:(date sent) ~AC Referral Sent:~ ~Date of Inspection: ~70'/0 __Receipt of CAC Report: __ __Lead Agency Determination:__ Technical Review: ~--'Fublic Hearing Held:~]-0 Resolution: Bear~l of Trustees NalneofApplicant C.~CK.'~ LClx~x~:9~ Phone Number:( ) Suffolk County Tax Map Number: 1000- ') O - O ~ eropertyLocation:-~i[3 ('~C~/'~-°-T'/~ 9bl'-~L ~0~. ,Q~thx~.~'h~\ ~6_ (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: ard of Trustees ApplicatiOn Land .&rea (in square feet): Area Zoning: GENERAL DATA Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency Date __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspe%ded by a governmental agency? No Yes If yes, provide explanation: of Trustees ApplicatiOn WETL' N ' T.,. STEE L',N 'S',PPL.CAT.ON.AT Purpose ofthe proposed operations:k Area of wetlands on lot: /0~ ~,30 square feet Percent coverage of lot: x/) % Closest distance between nearest existing structure and upland edge of wetlands: ~3. ~ feet Closest distance between nearest proposed structure and upland edge of wetlands: .~ ? · [.. feet Does the p~'ect involve excavation or filling? '~ No Yes If yes, ho~v much material will be excavated7 cubic yards How much material will be filled? kl/f{ cubic yards Depth of which material will be removed or deposited: Io [oq feet Proposed slope throughout the area of operations: ~o~ ~ I), ~ [- 3]14 Manner 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 (use attachments if appropriate): PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 1. APPLICANT ~ SPONSOR 3.PROJEC LO~ATION: Municipality PRECISE LOCATION' Street Addess and Road Intersection., APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) PROJECT NAME Prominent landmtar~s etc-or prowde mad SEQR PROPOSED ACT'ION: E~ New ' E~] Expansion ~ 5. IS [] Modification ,¢ alteration AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8 WILL/PROPOSED ACTION COMPLY WlTH EXISTING ZONING OR OTHER RESTRICTIONS? ~i'Yes [] No If no, describe briefly: 9. W IS PRESENT LAND USE IN VICINITY OF PROJECT? (Chooseasmanyasapply.) ~dential E~lndustrial ~lcommorcial ~]Agriculture E~ Park / Forest / Open Space E~Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) E~es [] NO If yes. list agency name and permit / approval: 11 DOES ANY,~,~PECT OF THE A)CTION~HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [~Yes L__~No If yes, list agency name and permit / approval: 12.~esA A RESULTr~No OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS FRUE TO THE BEST OF MY KNOWLEDGE Signature ~- J ~ - O 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 (To be completed by Lead A~lenc¥) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes, coordinate the review process and use the FULL EAF B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If NO, a negative declaration may be superseded by another involved agency. r-]Yes F"INo C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, ii legible) C1 Existing air quality, surface or groundwater qualgy or quantity, noise levels, existing traffic pattern, solid waste producbon or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2 Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats or threatened or endangered species? Explain briefly: I C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly I C5 Growth. subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1-C57 Explain bdefly: C70!her impacts (including changes in use of either quantit~ or t¥e of ener~ '~ Ex lain briefl · O. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA ICEA~? fir },es. explain bfiefl},: [Z] Yes r--IN°I E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If }'es ex~olain: i-lYes INoI PART fit - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur Then proceed directly to the FULl EAF and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed actior WILL NOT result in any significant adverse en.,ironmental impacts AND provide, on attachments as necessary, the reasons supporting thi.~ determination. Name of Lead Agency Date Title of Responsible O~ficer Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) ~rd of Trustees Application County of Suffolk State of New York Q~c>.-~ ~-,~(~L~55~ j BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED H~REIN 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. '~ ,~gnature /q of Trustees ApplicatiO AUTHORIZATION (where the applicant is not the owner) (prin~ o~er o~ property~ (mailing addr%ss) ~ ~ ~. // do hereby a~thorize / ( Agent ) to apply for pe~it(s) from the Southold Boa~of gown Trustees on ~ behalf. (Owner's signature) 8 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of SouthoId's ~'ode of Ethics nrohibits conflicts of interest on the hart of town officers and emnloyees. The n~so of thi5 form i_s to provide information which can alert the town of possible conflict.5 of interest and allow it to take whatever action is necessary to avoid same. (Last name, first name, mid'~e inifia~ tmles~ 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.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance v7 Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (lf"Other", name the activibQ if Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, marriage, or business interest_ "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of (or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO I~ lf)ou answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) andlor describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): A) the owner of greater than 5% of the shares of the coq~orate stock of the applic0nt (when the applicant is a corporation); ____B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a corporation); __~C) an officer, director, partner, or employee of the applicant; or __rD) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Submitted th(s Signature Pr nt Name 200.5_ *1 5 O' X 8,6'20,', )"W ~/0/? THE EXISTENCE OF RIGHTS OF WAY AND/OR EASEMENTS OF RECORD, IF ANY, NOT SHOWN ARE NOr GUARANTEED ,~b 257.52' -2227 - ~__ - Lio No 50467 URYE'~ OF PROPERTY ,qI2 (,X TF~D AT SOU'I't TOWN OF SOUTNOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-70-05-05 SCALE 1"=50' MAY 6, 2000 AREA = 50,885.85 sq. fl 0 709 ac. Nathan Taft Corw,n III Land Surveyor 992 Roanoke Avenue Riverhead, New York 11901 PHONE (651)569-5475