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HomeMy WebLinkAboutTR-2256Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwods Peggy A. Dickerson Town Hall 53095Route 25 P.O. Box 1179 Southold, New Yorkl1971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD January 23, 2003 Mr. & Mrs. Richard Miltner 3100 Deep Hole Drive Mattituck, NY 11952 RE: SCTM#115-17-13 Dear Mr. & Mrs. Miltner The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, January 22, 2003. RESOLVED, that the Southold Town Board of Trustees Approve an Amendment to Permit #2256 from 28"wide on ground walkway 30' now to elevated 48" wide walkway and 50 feet long. If you have any questions, please call our office at 765-1892. Albert J. Krupski, Jr. President, Board of Trustees cc: Building Department AJK:cjc Field Inspection 1/20/03 TelephOne (631) 765-1892 Town Hall. 53095 Main Road P.O. Box 11'79 Sour. hold. New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Wednesday, January 15, 2003, the following recommendation was made: RICHARD & MARILYN MILTNER to Amer~d Permit #2258 to include an elevated wa kway 48"X 50'. Located: 3100 Deep Hole Dr., Mattituck. SCTM#115-17-13 The CAC did not make an inspection, therefore no recommendation was made. 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 OFTOWNTRUSTEES TOWN OFSOUTHOLD APPLICATION FOR AN AMENDMENT TO A PERMIT DATE }'~ a~/) %1 ) 0_3 OWNER ?HONE ADDRESS 3/ OO D,"~--~fl'/°de D£ AGENT pl$g~ ]'l)ll~'[.- PHONE_ PROPERTY LOCATION ..q/O~ ,~t,'-p J--~Je~a. /~at/'~,½t~ /'vf TAXMAPNO. .~'C'bb",, ddL /000- i1-~- 19~12 request an Amendment to Permit #_3..D.,~ Signed By: ~l,lO ~5t~~ 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 January 23, 2003 Mr. & Mrs. Richard Miltner 3100 Deep Hole Drive Mattituck, NY 11952 RE: SCTM#115-17-13 Dear Mr. & Mrs. Miltncr The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, January 22, 2003. RESOLVED, that thc Southold Town Board of Trustees Approve an Amendment to Pemfit #2256 from 28"wide on ground walkway 30' now to elevated 48" wide walkway and 50 feet long. If you have any questions, please call our office at 765-1892, ~c~er~lly, ~ Albe~ J. Kmpski, Jr. President, Board of Trustees cc: Building Department AJK:cjc 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) 765-1892 Fax(516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD LETTER OF REQUEST FOR AN AMENDMENT '4 ,~DlmSS .WOo />c~' ~ /)O~vk AGENT PHONE ADDRESS PROPERTY LOCATION ~/a~ 0~:> //745,~q_ ~el;e ~e ~~ ~ ,~Y~ request ~ ~cndment to P~t ~ SignedBy: ~ ~ 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 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In/~he Matter of the Application 'COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, f~a4~ f~ ~'~ , residing at ~ / ~ D~-~9 ~ ~. r'9 being duly sworn, ~epose and say: That on the ~ day of ~ , 200~ ~ personally posted the property known as 3/oo ~-~ ~ ~ · 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 ~the ~ublic hearing. Date of ~earing noted thereon to be held~2~/ Dated: Sworn to before me this ~ ~ day of Richard & Marilyn M,tner 3100 Deep Hole Drive Mattituck, NY 11952 Pursuanf to the prov;s;on~ of Chaplet 6IS of the Laws of fha Sfafe of New York, 189]: and Chapter 404 of the Laws of the State of New Yor~ 1952: and the Southold Town Ordinance en- titled "RE~U~TIN~ ~ND THE PLACIN~ OF OBSTRUCTIONS IN AND ON TOWN W~TERS AND PUBLIC ~NDS and the REMOVAL OF SAND, ~RAVEL OR 'OTHER MATERIALS FRO~' LANDS UNDER TOWN WATERS;" and in accordance with the Resolution of The Board adopted af · meeting held on 19.~ ....... an~ ;n cons;deraf;on of the sum of $..~.~.~ ............. paid by ................................................... ~....~ ......................................................................... of ....~.~.~.~.~.~.~.~. ........................................................ N. Y. and subiecf fo the Terms and Cond~flons fisted on fha reverse side hereof,. of Soufhold Town Trusfees authorizes and permits the following: Application ~pproved un~e~ ~e Cran~a~he~ C~au~e ~ecu~e a pe~m~ ~ a carva~E on p~ope~y Zoca~ed ~uck ~ per sketch subm~e~. '(30~ x 2~ ag in accord,hCa w;fh the detailed specifications as presented the orig;nef~ng application. IN WITNESS WHEREOF, The said Board of Trusfees ~re- by causes ;ts Corporate Seal to be affixed, and these p~esenfs fo be lubscrlbed by · majority of the said Board of Board of Trustees Application County of Suffolk State of New York JE'S~D I~ BEING ~D~LY SWORN DE AFF T HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT{S) AND THAT ALL STA'£~ENTS 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 T~USTEES HAI~..~.SS AND FBRR FRO~ ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY V~IRTUE OF sAID PERMIT(S)., IF GRA~'r~D. IN COMPLETING THIS APPLICATION, I HEI?W. Ry AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO EN'~'~R ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLI CATION. SWOR. TO_aE OR THis NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN 'OF sOUTHOLD In the matter of applicant: sc #looo- ff£ -f7 -/J YOU ARE HEREBY GIVEN NOTICE: I. That it is the intention of the undersigned to recg/est a Permit from the Board of Trustees to: ;/ 2. That the property which is the subject of Environmental Review is located adjacent to your property~nd is described as follows: 3. That the project which is subject to Environmental Review ~nder Chapters 32, 37, or 97 of t~e Town Code is open to public comment on: ~' ~W You ~ay contact the Trustees Office at 76~-18~2 or in t~Titing. The above refe=~nced proposal is under review cf the Board of Trustees of the ~own of $outhotd and does not reference any other agent! that might have to review same proposal. MAILING ADDRESS: .2/~0 /%~'F ~ 4 ~'~-- Enc.: Copy of sketch or plan showing proposal for your cenvenience. PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Add]ess ~."~. I~ostal Service ~0~7~C 7~'~ CERTIFIED MAIL RECEIPT ff/~ ~ , residing at ~/'~ ~*~ //~S ~ , bei~ duly sworn, d~s~ ~d sa~ that on the ~ q day of ~c -~ ~ , 20 0~ d~onent mhl~ a me ropy of~e Notice set loCh. in ~e Bo~d of Tm~s Application, direct~ to e~h of ~e above rimed pe~ at the ~&esses set op~site there ~p~tive nm~; ~at ~e ad~sses set op~site the nines ofs~d pe~ons ~e ~e ~ess ofs~d p~ns ~ shorn on ~e c~t ~sessment roll of ~e To~ of Sou~old; ~at s~d Notices were mailed at the Unit~ States Post Officcat dgO JqB~ ,~ats~dNoticeswe~m~ledtoe~hofs~dp~o~by (ce~ifl~) (reCster~) m~l. Sworn to before me this ,,~ '4 Day of ~'~e~er,,ge~- , 20 Notary Public (/ 4t~E E. PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK J] O Restd*ted De very Fee 'Total Po~t.ge & Fees $ %42 i2/ ~.,~o~ ~,~ , residing at ~q. //~f~ , berg duly sworn, dq ~ ~r~7--r ..........~Lk- ~1~ ......... ~ ................................ pe~ons at the ad~esses set op~site op~site the n~es of s~d pe~ons ~s~sment roll of~e To~ of Sou~old; ~at s~d Notices w~e m~led at the Unit~ States Post Office at ~e~ ~ , t~t s~d Notic~ w~ m~lM to each ofs~d pe~om by (ce~ifi~) (registerS) m~l. Sworn to before mc this Dayof PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK U.S. Postal Service CERTIFIED MAIL RECEIPT (Domestic Moil Only; No Insut;tnce Cover,tge Prov dod) Postage $ m ,~?, ~t:'~ ................... ~- ........... , residing at set forth, in ~e Bo~d of Trainees Application, ~r~ted to pe~ at the ad~esses s~t op~site there r~p~tive n~es; ~at ~e ad~sses set opposite ~e n~es of said pe~ons ~e ~e ad.ess ofs~d p~sons ~ sho~ on ~e cu~ent ~seament roll of ~e To~ of Soutold; ~t said Notices w~e mail¢ at ~e gnit~ States Post Office at ff6t. J ~q ~ab4 , that s~d Notic~ were m~l~ to each of s~d p~ons by (ce~ifi~) (regist~) m~l. Sworn to before me this Day of ~"~ece~er ,20 Not~u~y Publi~ · "JHE E. ,~Y~ No, 4~ :' / :/ .. Q New York State Department of Environmental Conservation Division of Environmental Permits Building 40 - SUNY, Stony Brook, NY 11790-2356 Telephone (631) 444-0365 Facsimile (631) 444-0360 Erin M. Crotty Commissioner May 7, 2003 Mr. Richard Miltner 3100 Deep Hole Road Mattituck, NY 11952 RE: 1-4738-01205/00003 Dear Permittee: In conformance with the requirements of the State Uniform Procedures Act (Article 70, ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit. Please read all conditions carefully. If you are unable to comply with any conditions, please contact us at the above address. Also enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather. Sincerely, Claire K. Wemer Environmental Analyst CKW/Is Enclosure NEW YORK STATE DEPARTMENT OF ENViRONMENTAL CONSERVATION SPECIAL CONDITIONS 1. All components of old walkway shall be completely removed from the project site and disposed of at an approved upland Iocation, 2. No debds is permitted in the tidal wetlands or protected area. 3. The storage of construction equipment and materials shall be confined to landward of the house. 4. Dock or timber catwalk shall not exceed 4 feet in width and shall be a minimum of 3½ feet above grade* over tidal wetland areas (* as measured from ground to bottom of dock sheathing) as per the approved plan. 5. The use of wood treated with pentachlorophenol in the construction of structures that will be in contact with tidal waters is strictly prohibited. 6. Proposed elevated walkway shall be supported by 4" x 4" posts. DECPERMITNUMBER I [ PAGE 2 of 4 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION DEC PERMIT NUMBER 1-4738-01205/00003 FACILITY/PROGRAM NUMBER(S) PERMIT Under the Environmental Conservation Law EFFECTIVE DATE May 8, 2003 EXPIRATION DATE(S) May 8, 2008 TYPE OF PERMIT · New [] Renewal [] Modification · Permit to Construct [] Permit to Operate [] Article 15, Title 5: Protection of Watem [] Article 17, Titles 7, 8: SPDES E3 Artiole 27, Title 9; [] Article `15, Title 15: Water Supply [] Article '15, Title 15: Water Transport Q Article `15, Title 15: Long Island Wells [] Article t5, Title 27: Wild, Scenic and Recreational Rivers [] Article 19: Air Pollution Control E3 Article 23, Title 27: Mined Land Reclamation [] Article 24: Freshwater Wetlands · Article 25; Tidal Wetlands [3 Article 34: Coastal Erosion Management [3 Article 36: Floodplain Management [] Articles 1, 3, 17, 19, 27, 37; 6NYCRR 380: Radiation Control [] 6NYCRR 608: Water Quality Certifica- tion PERMIT ISSUED TO Richard Miltner ADDRESS OF PERMI 11'~_E Article 27, Title 7; 6NYCRR 360: Solid Waste Management TELEPHONE NUMBER (631)298-3528 3100 Deep Hole Road, Mattituck, NY 11952 CONTACT PERSON FOR PERMITi'ED WORK TELEPHONE NUMBER NAME AND ADDRESS OF PROJECT/FACILITY Miltner property, 3100 Deep Hole Road, Mattituck COUNTY TOWN Suffolk Southold DESCRIPTION OF AUTHORIZED ACTIVITY: SCTM #1000-115-17-13 WATERCOURSE Willis Creek NYTM COORDINATES Remove existing boardwalk on grade and construct new elevated 4' x 53' walkway. All work must be done in accordance with the attached plans stamped NYSDEC approved on 5/7/03. PERMIT ADMINISTRATOR: Mark C. Carrara (CKVV) By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, the General Conditions specified (see page 2 & 3) and any Special Conditions included as part of this permit. ADDRESS Region 1 Headquarters, Bldg. #40, SUNY, Stony Brook, NY 11790-2356 NEVi/YORK STATE DEPAR1MENT OF ENVIRONMENTAL CONSERVATION ADDITIONAL GENERAL CONDITIONS FOR ARTICLES '15 (TITLE 5), 24, 26, 34 AND 6NYCRR PART 6fl8 ( TIDAL WETLANDS) If future operations by the State of New York require an alteration in the position of the structure or work herein authorized, or if, 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 without expense to the State, and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other modification of the watercourse hereby authorized shall not be completed, 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 fill 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. The State of New York shall 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 rig ht to compensation shall accrue from any such damage. Granting of this permit does not relieve the applicant of the responsibility 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. All 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 associated with the project. Any material dredged in the conduct of the work herein permitted shall be removed evenly, without leaving large refuse piles, ddges 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. 6. There shall be no unreasonable interference with navigation by the work herein authorized. 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 fill 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. 8. If granted under 6NYCRR Part 608, the NYS Department of Environmental 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. 9. At least 48 hours pdor to commencament 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 project, the bottom portion of the form must also be signed and returned, along with photographs of the completed work and, if required, a survey. 10. 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 erePared by Richard Miltner, stamped NYSDEC approved on 5/7/03. ~/~/~ NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee expressly agrees to indemnify and hold harmless the Department of Environ mental Conservation of the State of New York, its representatives, employees, and agents ("DEC") for all claims, suits, actions, and damages, to the extent attributable to the permittee's acts or omissions in connection with the permittee's undertaking of activities in connection with, or operation and maintenance of, the facility or facilities authorized by the permit whether in compliance or not in compliance with the terms and conditions of the permit. This indemnification does not extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or intentional acts or omissions, or to any claims, suits, or actions naming the DEC and adsing under article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision under federal or state laws. Item B: Permittee's Contractors to Comply with Permit The permittee is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit, including all special conditions while acting as the permittee's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee. Item C: Permittee Responsible for Obtaining Other Required Permits The permittee is responsible for obtaining any other permits, approvals, lands, easements and rights-of-way that may be required to carry out the activities that are authorized by this permit. Item D: No Right to Trespass or Interfere with Riparian Rights This permit does not convey to the pem~ittee any right to trespass upon the lands or interfere with the dparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. GENERAL CONDITIONS General Condition 1: Facility Inspection by the Department The permitted site or facility, including relevant records, is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Department) to determine whether the permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71-0301 and SAPA 401(3). The permittee shall provide a person to accompany the Department's representative dudng an inspection to the permit area when requested by the Department. A copy of this permit, including all referenced maps, drawings and special conditions, must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. General Condition 2: Relationship of this Permit to Other Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Department or any of the terms, conditions or requirements contained in such order or determination. General Condition 3: Applications for Permit Renewals or Modifications The permittee must submit a separate written application to the Department for renewal, modification or transfer of this permit. Such application must include any forms or supplemental information the Department requires. Any renewal, modification or transfer granted by the Department must be in writing. The permittee must submit a renewal application at least: a) 180 days before expiration of permits for State Pollutant Discharge Elimination System (SPDES), Hazardous Waste Management Facilities (HWMF), major Air Pollution Control iAPC) and Solid Waste Management Facilities (SWMF); and b) 30 days before expiration of al~ other permit types. Submission of applications for permit renewal or modification are to be submitted to: NYSDEC Regional Permit Administrator, Region 1, SUNY Bldg ~40, Stony Brook NY 11790-2356 General Condition 4: Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to modify, suspend or revoke this permit in accordance with 6 NYCRR Part 621. The grounds for modification, suspension or revocation include: a) materially false or inaccurate statements in the permit application or supporting papers; b) failure by the permittee to comply with any terms or conditions of the permit; c) exceeding the scope of the project as described in the permit application; d) newly discovered material information or a material change in environmental conditions, relevant technology or applicable law or regulations since the issuance of the existing permit; e) noncompliance with previously issued permit conditions, orders of the commissioner, any provisions of the Environmenta~ Conservation Law or regulations of the Department related to the permitted activity. RETURN THIS FORM TO: NOTICE OF COMMENCEMENT OF CONSTRUCTION COMPLIANCE Marine Habitat Protection NYSDEC Building 40 - SUNY Stony Brook, NY 11790-2356 PERM,T NUMBER: li/q31 ' 01 6/ocoo3 PROJECT LOCATION/ADDRESS: CONTRACTOR NAME: ADDRESS: TELEPHONE' Dear Sir: Pursuant to Supplementary Special Condition D of tire referenced permit, you are hereby notified that the authorized activity shall commence on . We certify that we have read the referenced permit and approved plans and fully understand the authorized project and all permit conditions. We have inspected the project site and can complete the project as described in the permit and as depicted on the approved plans. We can do so in full compliance with all plan notes and permit conditions. The permit sign, permit and approved plans will be available at the site for inspection in accordance with general Condition No. 1. (Both signatures required) PERMITEE DATE IOR FAX TO: (631) 444-0297 ,SSUEDTO CONTRACTOR DATE THIS NOTICE MUST BE SENT TO THE ABOVE ADDRESS A T LEAST TWO DAYS PRIOR TO COMMENCEMENT OF TI IE PROJECT AND /OR ANY ASSOCIATED REGULATED ACTIVITIES. FAILURE TO RETURN THIS NOTICE, POST THE PERMIT SIGN, OR HA VE THE PERMIT AND APPROVED PLANS AVAILABLE A T THE WORK SITE FOR THE DURA T/ON OF THE PROJECT MA Y SUBJECT THE PERMITTEE AND/OR CONTRACTOR TO APPLICABLE SANCTIONS AND PENAL TIES FOR NON- COMPLIANCE WITH PERMIT CONDITIONS. .~ Cut alon~ lhis line. :'< ~ ~ ~ ~ ...a~l~ , ~.. ............................................................... fi8 ............................... COMPLIANCE RETURN THIS FORM TO: Marine Habitat Protection NYSDEC Building 40 - SUNY Stony Brook, NY 11790-2356 PERMIT NUMBER: PROJECTLOCATION/ADDRESS: CONTRACTOR NAME: ADDRESS: TELEPHONE' ISSUED TO: FAX TO: (631) 444-0297 Dear Sir: Pursuant to Supplementary Special Condition D of the referenced permit, you arb hereby notified that the authorized activity was completed on We have fully complied with the terms and conditions of the permit and approved plans. (Both signatures required) PERMITEE DATE CONTRACTOR DATE THIS NOTICE, WiTH PHOTOGRAPHS OF THE COMPLETED WORK AND/OR A COMPLETED SURVEY, AS APPROPRIATE, MU$' BE SENT TO THE ABOVE ADDRESS WITHIN 30 DAYS OF COMPLETION OF THE PROJECT.