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Home My WebLink AboutTR-6252AAlbert 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 1631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD 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 1st 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 (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 6252A Date of Receipt of Application: December 2, 2005 Applicant: Roberta F. Jaklevic SCTM#: 117-5-21.2 Project Location: 900 Old Harbor Rd., New Suffolk Date of Resolution/Issuance: December 21, 2005 Date of Expiration: December 21, 2007 Reviewed by: Trustee Peggy Dickerson Project Description: To install a split-rail fence along the east side of the property. 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 an Administrative Permit allows for the operations as indicated on the survey prepared by Stanley J. Isaksen, Jr. last amended on December 2, 2005. Special Conditions: Final inspection. 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 Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated reviewed by this Board at the regular meeting of following action was taken: has been and the ~/) 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: SIGNED: PRESIDENT, BOARD OF TRUSTEES Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson To~ Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone~631) 765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only __Coastal Erosion Permit Application _ Wetland Permit Application .--"~AdminisU'ative perrmt Amendment/Trans fer/Exte~asion A~eceiv~ ed Application: '~eceived Fee:$ ~ ~' -"L~ompleted Application lc) Incomplete SEQRA Classification: Type I Type II Unlisted CoordJnation:(date sent) __LWRP Consistency Assessment Form CAC Referral Sent: ~ate of Inspection: ~) __Receipt of CAC Report: __Lead Agency Determination:__ Technical Review: -~P~dblic Hearing Held: __Resolution: t//~?~-'~ Phone Number:((,O/) 7~- ~, D~ Suffolk County Tax Map Number: 1000 - //7 - ,~- ~ o?/ ,2. Property Location: ~,~,-o_~;t~:~/.~ ,,~'~..,',/~ ~ /~.~d~o~--~'~/le~'r~../ (provide LILCO Pole #, d~stanc¢ to cros~ streets, and location) AGENT: (If applicable) Address: Phone: of Trustees Applica~n GENERAL DATA Land Area (in square feet): Area Zoning: _~.r ,' 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 suspended by a governmental agency? .,i' No Yes If yes, provide explanation: Project Description (use attachments if necessary): I ~/7 ~ .,~r,~,</ of Trustees Applica~n WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ~'~"c-.7' .~/ :~_/~"~g,/t~;' Area of wetlands on lot: ~,".~.~ ~. square feet Percent coverage of lot:...(/~, Closest distance between nearest existing structure and upland edge o f wetlands: feet Closest distance between nearest proposed structure and upland edge o f wetlands: feet Does the project involve excavation or filling? ~ No Yes If yes, hoxv much material will be excavated? How much material xvill be filled? Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: Manner in which material xvill be removed or deposited: cubic yards cubic yards feet Statement of the effect, if any, on the wetlands and tidal xvaters 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 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor} 2. PROJECTj~_.~,~.,.NAME County ,~i'~'~ SEQR 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map 5. IS PROPOSED ACTION ' C~"New [] Expansion [] Modification / alteration 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8 WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? r~Yes [] No It no, describe briefly: 9 WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) E~Re$,dential E~lndustdal E~Commercial r--]Agriculture ["-] ParklForestl Open Space []Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) r-~Yes []No If yes, list agency name and permit / approval: lt. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ]Yes []No If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EX~STING PERMIT/ APPROVAL REQUIRE MODIFICATION? E es I No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/Sp°~~~'Z~'¢Signature Date: ~/~.~ .~'"' t / ItllT'6'action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes, coordinate the review process and use the FULL EAr. [--~ Yes r~No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR. PART 617.67 I¢ No, a negative declaration may be superseded by another involved agency C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1 Existingairqua~ity'surface~rgr~undwaterqua~ity~rquantity'n~ise~eve~s~existingtra~cpa~tern~s~lidwastepr~duc~n~rdisp~sa~ potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3~ Vegetation or fauna, fish, shellfish or wildli[e species, signiflcent habitats, or threatened or endangered species? Explain bdefly: C4. A communi¥s e×i$fing plans or goals oo officially adopted, or a change in uso or intensity et use ol land or olhor natural ro$oumes? Explain briefly: C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Longterm. shortterm, cumulative, or other effects not identifled in Cl-C5? Explain briefly: C7. O her'mpac s t'nc ud n~ chan~es in use of either c}uantlt~ or t;/p e of ener~l¥ ? Ex plain bfiefl ~,. ]- ....... D WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA ICEAI? (If yes, explain brief/),: E. IS[_.~ YesTHERE' OR[~NojIS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes ex,)lain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadvemee~ectidenti~edab~ve~determinewhetheritissubstantia~~~arge~important~r~therwisesigni~cant~ 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 (0 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 potenlially large or significant adverse impacts which MAY occur. Then proceed directly to the FUL[ EAr and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentaflon, that the proposed actior WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi.· determination Name of Lead Agency Date Title of Responsible Officer Print or Type Name el~ Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) Board of Trustees Application County of Suffolk State of New York DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE 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 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), 11: 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 BEFOKE ME THIS 2"'9 DAYOF r3e_¢et,-.b~.. ,20 oa- John M. judqe NOTARY PUBLIC, State of New York No. 01JU6059400 Qualified In Suffolk Ceuntv Commission Expires M&y 29, 20 O']. Board of Trustees Applicton (where AUTHORIZATION the applicant is not the owner) (print owner of property) residing at (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics nrohibits conflicts of interest on thc oat of town officers and emolovees. The ourvose of thi~ form is to orovide information which can alert the town of oossible conflicts of interest and allow it to rake whatever action is (Last name, first nal~, mid(tie ihitlal, unless 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 Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Otber", name the activity.) 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 thc town officer or employee owns more than 5% of the sha~s. YES NO ~ If)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 applicanffagcntJrepresentative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (chcck all that apply): __A) the owner of greater than 5% of the shares of the corporate stock oftbe applicsnt (when the applicant is a co~oration); 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, parmer, or employee of the applicant; or __D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I Submitted this J,'~d day of ~)~'¢~"~'~_~__., 200,,~'~ 0 0 0