HomeMy WebLinkAboutTR-5227
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Board Of Southold Town Trustees
SOUTH OLD, NEW YORK
PERMIT No.Set.~I....
ISSUED TO .........~.1'.:!..~P?9APP..r.?..............
DATE: ... Q!;to):)l~r..~6.J
1\ut~nrizatin1t
Punuant to the provisions of Chapter 615 of the Laws of
the State of New Yon:. 1893: and Chapter 404 of the Laws of the
State of New York 1952: and the Southold Town Ordinance en-
titled "REGULATING AND THE PLACING OF OBSTRUCTIONS
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 with the
Resolution of The Board adopted at a meeting held on .?~~..~....2.S..!......
2000....... and in consideration of the sum of $.....~5.O'.,..O'o.. .... paid by
Astrid Gad dis
of ...............~~':l.r..~.l........................ ............. N. Y. and subject to the
Terms and Conditions listed on the revene side hereof,
...r ~.....+I...IA Town T....m-s autharixes and P41rmm +hA following:
Wetla"fiaPermil 0 bUIld-two bulRheaas "Tandwara 'or eXIstmg
secondary bulkheads to terrace bluff in levels. Return walls to be
built on east and west side connecting new walk to north and sou
~ All material will be 1.5 CCA lumber. A set of stairs will be pla.eed
in t~gu~K~~cWr'l-JdgR- 'wRWtl1e aaiMIJif Jpiclfi-e4il8Rs llt~ri&~ ~nass . .
. the origineting lipplication. ,," .." ..'
Montauk d~~eWITN'k~oWH~RIOF.'The':id Board;f'Trust~ here- .
. . by 'cauSe_1ts Corporafe Seal to.be affIXed, and these presents to
be subscr!bed bye' majority of the said Board as of this date..
..... ._, ~ .. -..
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Henry.Smith -.Absent
TrwsiHs
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TERMS end CONOmONS
The Permittee
NSidIag at 7020 Great Peconic" Bay Blvd. Laurel N. Y., lIS
put of the coasideratioa for the m-~ of che Permit does uaden~-' and p.-rlIle to the fol-
1owlag:
Astrid Gaddis
1. That the said !loud of Trustees and che Towa of Southold _ mased &om my -
all damages, or daims for damages, of lUlls uisiag cIirecdy or IacIitecdy . . lSIk oE my opec-
atiOll perfoaaecl punumt to tbls permit, and che said P-i_ wi1I, at bls or bet - ......-.
defend my and all IUCb 1lli1l"1aldauod by tbl1'll p.me., aad the said P '" 1..- .- fall u..bDIq
with respect theteto, to the complete --'-'na of che Boud of Traorees of che T_ oE Soachold
2. That tbls Peualt Is ~ for . period of 24 _ whkhls DDrul~ .d to be che
esdmated time required to aJlIlp1ete che WOlf< invol~ but shoald c:i1camslaaces wmaar, request
for an exteaSion may be made to the Boud at a later cIale.
3. That tbls Permit should be retained indefmilely, or .. loog .. che aid P......iuee wishes
to maintain che structUre or project invol~ to provide evidence to aayoae toDCerneCI that aach-
orization was originally obtained.
4. That che work involftd will be subject to che inspection and apptonl oE che Jloud or
fa ap>ts, and DOD-alGIpllanao with che provisioas of che otigiaadag application, may be cause fex
te't'Oation of tbls Permit by resolutioa of che said Board.
5. That there will be no uareuoaable Interference with tI&Yiptioa u a ~t of che wod<
beRia uithorized.
6. That chere shall be DO interference with the right of che pahIIc to put and rep.- alnag
che beach benveeo blsb and low _let marka.
7. That if future opendoos of cheTowa. of Souehold recpdre che-.l U1II1/or al~
la che locatinG oE che WOlf< heceIa .""., "e ~. or If; in che or''''- of che Bod of T~ che "
wo.tk shall cause IItIteUtIUbIe obsttacbOO to free ...~ che said P-i- will be reqaIlW,
apoa due ootice, to remove or alter tbls work or project herein stated widlout ap , .. to che T_
of Southold.
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8. That the said Boatd will be notified by the Permitcee or 1he --.pI"""" of the work auth-
orized.
9. That the Permittee will obtain all other permits aad ~1lI chat may be nquited sap-
plemental to tbls permit which may be subject to revoke upon failure to obcalo -.
~.,.,.
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.
~bert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poiiwoda
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
October 26, 2000
Mr. Ed Goodwin
P.O. Box 541
Cutchogue, NY 11935
Re: ASTRID GADDIS
SCTMU26-11-6
Dear Mr. Goodwin:
The following action was taken by the Board of Town Trustees
during its regular meeting held on October 25, 2000 regarding
the above matter:
WHEREAS, Ed Goodwin on behalf of ASTRID GADDIS applied to the
Southold Town Trustees for a permit under the provisions of the
Wetland Ordinance of the Town of Southold, application dated
August 31, 2000, 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 October 25, 2000 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 standard set forth in
Chapter 97 of the Southold Town Code,
.
.
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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
ASTRID GADDIS to build two bulkheads landward of existing
secondary bulkheads to terrace bluff in levels. Return walls to
be built on east and west side connecting new walk to north and
south. All material will be 1.5 CCA lumber. A set of stairs
will be placed in the same location. Sand areas to be planted
with beach grass, Montauk daisies and Rosa Rugosa.
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 sa~e
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: None
Very truly yours,
tltt,.19. /4-~~'~.
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/lms
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AREA: 19,227 S.F. = 0.441 AC.
CERTIFIED TO: o,sf.".,'d 9/tddi 5
;0:;'1:> ~f1JqA p.t>c.ot.....'( i5~i?1
Lftu r ~
JOB NO. F2754
REVISIONS:
ADD G<RAGE '" srAKE 6/23/2000
GAR. U/e '" P.OL'S 8/25/2000
f"ASDIEN1S AND/OR SUBSURFACE 5TRUCTlJRES RECORDED OR UNRECaROED
ARC NOT GU4IMN1EED UMESS PHrSICALLY ElfOfNT ON THE: PREJIISES AT
1HC 1ME OF THE: SUIM;Y.
GUoWW1EES INDICATED HEREON SHALl.~ONLY THE PERSON(S) FOR
JllHQVTlESLfMYISPI'iEPARfl), . 1DTHC111lECOItI-
PANY, ~ N;ENC'f AND LENDINC USTFD HERCON.
AND ro nE ASSIGIEES or THE LENDING INS1T1IJ11ON. Gl.WMN1ElS' ARC
NOT TI6WSff1WlLE 10 ~ INS1T1U11OItS OR SUBSEQUENT OIINERS.
THE 0FFSEr5 (at 0IIIEN5IDNS) SHOWN HERElJN FROM THE srRUCnJRES ro
THE PROPERrr UNES ARE FOR A SPECIRC PURPOSe AND use AND 1HERC-
FORe ARC NOT 1NTlNDED TO GUIDC THE: EREaION OF ~ RCrAININC
RLS;. POOlS. PA~ I'WITING ARE"AS, ADarIONS 1D 8UI.DINGS MID
ANY arI/ER CONS7RlIC1lO/(
LINE OF SHRUBS
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DIVISION LINE BETWEEN THE LANDS NOW OR FORMERLY
THOMAS H. HARPER AND OF CHARLES E. LEWIS.
license no. 050149
SURVEY OF
DESCRIBED PROPERTY
fA!l~
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SITUA TE AT
LAUREL
TOWN OF SOUTHOLO
SUFFOLK COUNTY. NEW YORK
SCALE: 1"=40'
Mtm: E CIr<Irnt, L.s.
SUcU"Ma to
Paul T. Canalizo, L.s. Robert A Kart. LS.
_ Gmund ~ P.c.
DATE: APRIL 3, 2000
S.C. T.II. OIST. 1000 SEC. 125 BU<. 11 LOT 5
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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) 765-18.'12
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
/Coastal Erosion Permit Application
~Wetland Permit Application
---Grandfather Permit Application
.i waiver/Amendment~C ng s .'.
Received Applica 'on:
Received Fee:$ S;U--
Completed Application
Incomplete
SEQRA Classification:
Type I Type II Unlisted
Coordination: (date t) -
CAC Referral Sent:
Date of Inspection~
Receipt of CAC Report: rI
Lead Agency Determination.
Technical Review: I (
Public Hearing Held: ? lUll Ofl
Resolution: f
r~ rn @ rn 0 ~J rn fn)
IL~[~;'~J~
L, '. : c.. "funl"
ll~_;~~:;.~::: " t 1 j,~_.:~~
Name of Applicant r\~rlcl
Address / 0 ~O Gr QD.t1
Phone Number: (~3) ;l, (O(q - ......, 50S
Suffolk County Tax Map Number: 1000 - I c:l. ~ ~ II - ,
Property Location: 10 J.o GfeA+ -?ec,ClI'-~<" i?, ~
LAvreL B~!:1 Ave.
(provide LILCO Pole #, distande to cross streets, and location)
AGENT: ~i GoOd4J/1V
(If applicab e)
Address:Y' 0 (f!>t:>" ~'II
c; A-dd;s
?Ivd.
CvJdt 0' "-'e
/Iff ({ cr ~ 5
Phone: fs:,~ J - '76{~/fW7
FAX#:
1
B~d of Trustees APplicatio~
GENERAL DATA
Land Area (in square feet):
1..9 , fJ.J.)
Area Zoning:
it~_ ')' __/"",,-h' ",L
Previous use of property:
Intended use of property:
Agency
improvementf'::\ l'~ ~ r. n ,;j rn F0
"I ' ". "'~. '~'"I'
, '" r~~'''''-'''''''-'''' ., /,- ':
I' " ' i, Ii
Date i." AUG 3 I 2000 Ii!'
Prior permits/approvals for site
;J
No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a
governmental agency? /
V No Yes
If yes, provide explanation:
Project Description (use attachments if necessary): J 0 Q,\JI-td
-two bu(l{l~l'Il.Js L/'JNdl..Jc.rd o-f -e,v.isl,~ S~~
bvl~"-M..ctr iu krro.re hI,,;! 'iN Le..lWI<: f'~jV
W~,\ -Iv ~ bu;U. O'N es..$-I- c..tvt:i \J.Je<;.f S,-d-e CG-t-~
JJ CLv we: I/~ ~ ~ <;,~ So Y"c.lbor:t-.r p~-Hc.f
~Cl~ /Jo erO('~,J f.c--a~. aU ~~~.l wlll be.. 1.5c~
L..- k- Q.. c:'?J- of 'S~:("r wfll h< ~ I)\J ~....~
Lf>cl'ti,.;".... S 4Nl U/l!AL(' ~ b-c pl~d w: -H,... betl..d.. <t~~s
f'r\0IVf.....A< ch:.s ie5' , Ro ~~ R~fl.(",-
2
B. of Trustees APplication.
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: eR- O~ /(J^" b ~R.
,_ _..T' '.._.,~___~_..,_~^"
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Area of wetlands on lot:
square :l;eet
L_~"._____
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
If yes, how much material will be excavated?
50
cubic yards
How much material will be filled?
60
cubic yards
lj ~f-.
Depth of which material will be removed or deposited:
feet
Proposed slope throughout the area of operations: NO cho.N9~
Manner in which material will be removed or deposited:
e...Ul'rvoJ/:Jt. <://9 bluff' ~ IN~-4.11 'ilv{j(~ f4Jto..cc /Nt
n, ~.:""L cu-<J. bv I-t:~ ~IA j ~ ( -k b4. :ref />.) IN i1-~ p~p)
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):
3
-
..,rd of Trustees APP1icati~
County of Suffo1k
State of New York
o. #ii.mtJ.dl> Gl'9lJ/){~ BEI~G DULY SWORN
D'bOS 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), IF GRlINTED. IN
COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,
THEIR AGENT (S) ORitiREPRESENTATlVES (S), TO ENTER ONTO MY PROPERTY
TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
~~4'
Signature
SWORN TO BEFORE ME THIS 9fhJ
DAY OF c5.f'.pternber ~~O
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TERRI L. NULL RUOT
NOTARY PU~C
My CGmm. EIjI. 8- I -2fnl../
7
~ of Trustees APPlication.
...
AUTHORIZATION
(where the applicant is not the owner)
I,
Ck ":>-1< ,d G.1-\ElO is
(print owner of property)
residing at to 2.0 G~ ~;<
(mailing address)
~ ~ g (\Jc\. LfIJ~L
c..~...rlW;,,, CI&5-l./~f7)
do hereby authorize
p. ().B~ 541 (Agent)
C.J \-d.-o<t.,.(. f.../V (/1 %
to apply for permit(s) from the
t:d
Southold Board of Town Trustees on my behalf.
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b":,.il,_ '1.00, 3 I 2000
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NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
~~~.4 GaJdiS SCTMHOOO- I ]..(q-I/ - (,
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a
Permit from the Board o.f Trustees to: ~v"L~ J.. B....~a..c!f tMtvcnJ1
.e:y:;~ 4e'c-cl~1 .. f~r "ft;kfY<J.c..~ b/uPf' ,r- L~"~r (pj'. ~rrJ IA..d ~
-to ~ bLl,-Lf (;.f'V E()-5+ ! f!.;cKfc;.'-dQ ~'-(~';"'f fIJ'flN /,.JaR MrA f fwlt, S"~. ~
"''e.-~~ f~( hew... ""', flt;.uv fH~/i:/I1 ~.j,;.!:l e. plOt~ "-I:U- bl4c1.c;faf{ ~of"l ~:~ ,
2. That the property which is the subject o.f Environmental ~ON~ ~'~9
Review.-is located adjacent to your property and is described as
fOllOWS:/Od.O 9r<vJ- p-aOf'nt ~ 81wi L.a.vrd_
\
3. That the project which is subject to Enviro.nmental ReJiew
under Chapters 32, 7, or 97 of the To.wn Co.de is open to. public
comment o.n: S j.O t:_ You may contact the Trustees Office at
765-1892 or in wri ing.
The above referenced proposal is under review o.f the Board of
Trustees of the Town of Southold and does not reference any
other agency that might have to review same pro.Posal.
OWNERS NAME: A(-fR.id G~)
MA~~r:tDR~~S: :02-0 ::te- i1~Vf~
PHONE it: !l S - ,1 - l/ sn. .
Ene.: Copy of sketch or plan showing proposal for your
convenience.
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PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Name:
Address:
.
e t>!<:.S!ctV) IJ ~ i{~~a. < Vuh.
(0 '1 ~ 0 ~(o^"'"C.. b/97 ~/ l./cf
g, "" g '7 ( ,t. ". :- L.r>de.( NY / ('14 i
:rC>~N f S~rJNO#
70 ~ pewv ~c ~tlV(/
3 SPfjrl( ftu~ rJ/ /V,Y
/oo/(p
f:/Iet0 /--I-,~ ~~
G'1oZ5' fhoN1C ~ 5/uc(
3 35' t: Lf ~ 'IJ.. C::;-I
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NY NY
JO()()
STATE OF NEW YORK
COUNTY OF SUFFOLK
e: w-~ 'i2. ~1X9t> lJJ \ ~
oodw;1\3
t 1<. <.:i
c." "-,,,,~ ( , being duly sworn, deposes and says
that on the day of Sf2(kAReI.. ,""~, deponent
mailed a true copy of the Notice set forth in the Board of
Trustees Application, directed to each of the above named
persorrs 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 said Notices were mailed at
the United States Post Office at . 'So,,~ft(cl , that
said Notices were mailed to each of said persons by (certified)
(registered) mail.
, residing at
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I. SCOTT. JR.
State crI New VCIfll
Suffolk County
1SC47215OBL
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CERTIFIED MAIL RECEIPT
(DomestIc Mail Only; No Insurance Coverage Provided)
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ToteJ Postage & Fees
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Postage $
Certified Fee
Return Receipt Fee
(Endorsement Required)
Restricted Delivery Fee
(Endorsement Required)
Total Postage & Fees
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617.21
Appendix C
State Environmental Quality Review
SHORTEN~RONMENTALASSESSMENTFORM
For UNLISTED ACTIONS Only
PART I-PROJECT INFORMATiON (To be completed by Applicant or Project sponsor)
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1.'.1&-,4 {218n- Text 12
I PR~JECT 1.0. NUMBER
SEC
1. APPLICANT I$PONSOA 2. PROJECi" NAME
o...<;w,;,
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3. PROJECT LOCATION: L .
MuniCipality ~12-tL CounlY ~ JffiL
... PREClse lOCATION (Street address and road intersections, prominent landmarks. etc., or proviae map)
76 J-o Gr 6>.,f- pectJ/'V,'c ~~ Blvd l/Tvret..
Ce-Of.~ %u:f B.r ftv-e..,
5. IS P~OSED ACTION:
r!J New 0 Expansion 0 MocIificatlonJalteration
6. DESCRISE PROJECT BRIEFLY: ~S'fq/I iwb BvLt(~5' f.c, hf'O..("'< 6rvff'
7. AMOUNT OF LAND AF;:eCTED:
InWally acres Ultimately acres
a. WILL FROPOSEO ACTION COMPLY WITH €<ISilNG ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
o Ves 0 No If No. describe briefly
9. W!ifA/ IS, PRESENT LAND uSe IN VICINITY OF PROJECT'?
N Residential O.lndustrial 0 C.,mmercial
Oescrlbe:
o Agriculture
[] Park/For,sUCoen space
OOlner
10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL.
STATE On LOCAl)?
DYes 0 No If yes. list agency(s) and permlUapprovals
(.
11. DOES ANY ASPECT OF THE ACTlOI' HAVE A CURRENTLY VAUD PERMIT OR APPROVA ?
o Yes. ~NO It yes, list agency name and permiuapproval '
AUG312000
1..:
.
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12. AS A RESULT OF PROPOS eo ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
OYas NO
AppllcanUsponsor
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE 15 TRUe TO THE aEST OF MY KNOWLEOGE
name: ~l(r7) f ~
f:'~ ~:N
Dale:
~/gllO()
Signa lure:
If the action' is in the CODstal Area, and you are a state agency. complete the
Coastal Assessment Form before proceeding with this a.~essment
OVER
1
.... OCE.S ..l.C7;C:-.l =;(C2.=.::: :":-.lY
"f~S C:-.lO
3. WILL .~C7:CN ~eC2:VE:::Cfl.OINA,c::l ~e"IE'N':'S ??C'JIOE:J .=,:r:; UI'lL:Sr::n ,.:.C7iCNS:N 3 .\lYC::::R. ,:::IAAT .;i7.57
:nay be $ucerSedec ~y l.nclf'1er ;nvolveo agency.
'.SSMENT ,-:-0 J:Je r::Or7::ietec:y .4.genc' It
.)C' -'=E:;:"OL."N . "".--;::- :J' -- .'7 ."., :, .,.. "^ c,nal' n. r"V'Il!W rcces~ anc
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PAriT 1I_=NVIRONMEN7A'
'J$e ~r.e .=lJL:.. ~F
it ,'~o. 3. ;'e~3tl"'e :ec:ar
; Yes roo: ~O
C. C::ULO ..:..C7tCN ~eSUL7 ;N ANY ).QVERSE ~~;:;:C7S ).SSCC:..:. TEa ',vlrH '7"-:-:= .='JU..CWING: (,Answers .-nay :.e 1ancwntten. d ;eQlctel
C1. ::.'Cisting air Quality. surface or 'Jrol.mowarer ;;:ualily ~r :::uanClty, i'101Se ;e',els, ~x:sllnq :rattic ::arterns. sOlia .....asie ;:lrcCt.:c:i~n,Jr JJs.:
~Otentlal ror erOSion, ::ralnac;e or :looC!.inq oroolems? ::."l.Qlaln :Jrieily:
C2. ..l.esthetlc. ac;ric~ltural. 1tcl1aeological, histonc. Jr other ,at~ral Jr cuitural ;esources: or communIty or .,etqnocrnood e~arac:er1 :.:cclaln
W. 'Ie1;etaUon or tauna. tlsn. sr..uflsn or 'Nllallle scecies. significant ~acitals. or :nreatened or ~nC!.angerea :scecles? Exclaln '::Irlelly:
CJ. A c~mmunit.,'s e"istin9 j)lans or ;oals as otftc:aily acJooted. or a cnange in use or intensity ot use of lancl or olner natural resources? E;c:plaJn
CS. Growl". subseQuent -:evelooment. or relateCl ac:iviUes likelY to oe induceCl oy !ne Qrcco5ea ac:ion7 ExOlaln onefly.
CS. ~ong :erm, snort ,erm. C:Jmuialive. or Other ~rfects not iaentiflea in Ci-CS1 :XC lain :Jrletly.
....... Ctr:er imoac:::s iinc:ucinc; ::,an1;es In ~.se at ~!ther quantity or :y~e ot ~ner9YJ? :.xolam ::riefly.
i ~
oJ. :5 i'He~e. eft is ""e~E WKS!..Y 70 aE. CONTROVE~SY =IEUie:O ';'0 ~OTENTIAL AOV5.?ISe :NVIRONMENT;'L ;MP.o.C7S?
.-
~ Yes l-i No :1 Yes. -!xclain ~ri.tly
?ART 1II-0ETE;;MINATION OF SIGNIFlCANCE (1;'0 ~e Cl.lmpletedby Agency) ,
INSTRUCTIONS: For eaC:1 adverse effect identified acove. determine whether it is substantiat. large. iml:)ortanr or otherwiSe signi
E.ach effec,: snouJd be assessed in connection with its (a) setting (I.e. urban or rural); (b) .probatlility of occ~: (C) duratlc
irreversibility: (e, geOCjlraanic Jcape: and (I) ma9nitude. If necessary, add attacnments or r.terence sUPJJontng mar.rials. a.,sur
SXDlanalions contain sufficient delall 10 snow that aU .refevant adverse impacts have been identiflea and adequately addresse.
C C~eck this box if you have identified one or more potentially large or Significant adverse imoacts whichM.
occur. Then proceed direc:ly 10 the FULL =..." 3M/or prepare a positive- declaraticn. .
'-' Clleci< this ~ox it you have determined, ~ased on the information and analysis above and any supoort!
documentation. :hat :he prooosea action I,VILL NOT result in...:;.l.ny significant adverse environmental imoa(
AND proviae on altacnments as necessary, the reasons supporting this determination:
......'"~ ru ...~"u A\;~"('1
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f,u. Of ,.(",.oon"OIC vlfle~r
J.\;n"'Ufe'" -(fI!'~con\iOI~ .';r:'(~r ,n l.t'.lG '''l;~ev
.,"cn...cur~ .)f i"r~.a"f' tlf :JIHeft!n1 :rom ,~sOon\lO'~ "f1,eUI
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2
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.brPi cc;,L No. \J 1 b vL/( he.o.d
AUG 3 I 2000
0.. S ~;d. ~ o.tIc::/oS
/D)..O PeGC)<^liC 1~ MoJJ
~i'(.L t0Y
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APPt.t~AN'r
TRANSACTIONAL DISCLOSURE FORM
The Town of
interest on
u .
. ~h
t to hlte
Sou\;hOldls
the art 0
. m
W Oil
whatever act
~tohlbits conllicts ot
and em e
on w an
n~.r'lb an allow
!;o avo d same.
TOUR N/\HBt
c; , td I ',. ,..' ,.,,'~~.,(....;." '.
J . ", J. . """"'.' ;,,"" ',..,"....'.''11,' ,
00 aWfN "V0l(C1' """ ".,.,.,.1'
(Las!; name, firs!; name, mldd~e Ini!;l~i:-~nless
you are applying in !;he name of someone else or
o!;her en!;i!;y, such as a company. If so, indica!;e
!;he o!;her person's or company's name.)
...
"., .
NATURE 0' APPLI~ATIONI (CheCk all I;hal; applY.)
.;:' ;':~ i.,:~)::~.> .-':.:::..: t. .::~;i/.,.:,~~".:i'
Tax grievance
Variance
change of zone
Ap'p~pval of plab .
Exe~ption from pla!; or official map
"other
(If "other," name bhe ac!;ivity.)
,~.:~~
We..+I~ perm;,+:-
Do you pe~eonallr (o~ th~ough rour co.panr, ep6uee, sibling,
pa~ent, o~ child) have a ~elablonshlp vlth any officer or
employee of the Town of Southold7 -Relabionship- includes
by blood, marriage, or business interesb. -Duslnesa
intereat- means a business, including a partnership, in
vhich bhe town officer or employee has even a partial
ovnership of (or employment by) a corp,oratlon in which
the tovn offlce~ or employee ovns more than 5% of the
sha~es.
YES
NO ':+-
~: :.i!/ ..
If you anevered MTRS,-. complete the balance of ~htl form and
date aDd sign vhe~e Indicated.
Name of person employed by the Town of Soul:hold
Title or position of thab person
Describe the relationship bebween yourself (l:h8 applicanl:)
and the tovn officer er employee. Eil:her check bhe
approprlabe line A) bhrough D) and/or describe in bhe space
provided.
The tovn officer or employee or his or her spousei sibling,
parenb, or child Ie (check all bha!; apply).
A) bhe ovner of greaber !;han 5% of !;he shares of !;he
corpora!;e s!;ock of !;he applican!; (vhen the applicant'
is a corporation),
B) the legal or beneficial owner of any in~re.t in a
noncorporate'enbity (when the app11canb is not a
corporation),
C) an officer, director, parl:her, or employee ot the
applicanb t or
D) the acbual applicanb.
f""..,.-, ....
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A&.3 12000:"
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;. ..t:~~t:.'~.,:~.....~~.~- :~_(,,'l' ";.. .... ,'.
DBSCRIPTION OF ItBLATIONSIIIP
._'..-
'print: name
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