HomeMy WebLinkAboutTR-6355A
.
.
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
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
CERTIFICATE OF COMPLIANCE
# 0187C
Date: Januarv 12, 2007
THIS CERTIFIES that the chain link fence
At 13457 Oregon Road, Cutchogue
Suffolk Couuty Tax Map # 83-2-10.13
Conforms to the application for a Trustees Permit heretofore filed in this office
Dated 11/3/06 pursuant to which Trustees Permit # 6486A Dated November 15,2006
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 chain link fence at the base of the erosion control embankment to enclose the pool
area.
The certificate is issued to Martin Soia
owner of the
aforesaid property.
r07~
Authorized Signature
.
t
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
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
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
15t day of construction
v
Yo constructed
Project complete, compliance inspection. 1/11/01 0 }<..;J~
.
.
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
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.: 6486A
Date of Receipt of Application: November 3,2006
Applicant: Martin Soja
SCTM#: 83-2-10.13
Project Location: 13457 Oregon Road, Cutchogue
Date of Resolution/Issuance: November 15, 2006
Date of Expiration: November 15, 2008
Reviewed by: Jim King
Project Description: Install a chain link fence at the base of the base of the
erosion control embankment to provide additional support to entire erosion
control system by linking all parts together and to provide additional protection
against any potential run-off from the embankment, and to enclose the pool area,
and all as depicted on the plan prepared by Young and Young received by the
Board of Trustees November 3, 2006.
Findings: The project meets all the requirements for issuance of an
Administrative Permit set forth by the Board of Trustees.
Special Conditions: Final inspection.
If the proposed activities do not meet the requirements for issuance of an
Administrative Permit set forth by the Board of Trustees, a Wetland Permit will be
required.
This is not a determination from any other agency.
r074
- - --------------------
James F. King, President
Board of Tru~lee~
.
.
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-6641
TO:
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
\J\ OV---\-' () So.1"'\
Please be advised that your application dated
reviewed by this Board at the regular meeting of
following action was taken:
/1/3/ob
11/15/06
,
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 Chapfer 97 of the Southold Town
Code.
The following fee must be paid within 90 days or re-application fees will be necessary.
COMPUTATION OF PERMIT FEES: Al.sb hnutl In.srCc.-t.~rV
S <R
TOTAL FEES DUE: $ 0,':;,
BY: Jamesj=._fSing, President_____.
Board of Trustees
.
,
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
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
Southold Town Board of Trustees
Field InspectionlW orksession Report
Date/Time: /J / /.3 ) (' (,., - /1:/tJ
Name of Applicant: JJ fJRT/;J .5 (' J 1-1
Name of Agent:
Property Location: SCTM# & Street
Brief Description of proposed action:
F€..ucP.c lIt!cv~'P 1P4rE
5kJTR/L
"F Bti? tf!.1V1
(ffl.~tP L../I'-'/C
Type of area to be impacted:
Saltwater WetIand Freshwater WetIand
,
~undFront _BayFront
c~/t? 7<',0 dF ;3{ uFF (A/'i"..eiJie'.')
Distance of proposed work to edge of above:
Parp of Town Code proposed work falls under:
~hapt.97 _Chapt. 37 _other
Type of Application: _ W etland _Coastal Erosion _Amendment ~inistrative
_Emergency
Info needed:
Modifications:
Conditions:
Present were:v1"King J.Doherty P.Dickerson D. Bergen
- -- - ~
Other:
MailedIFaxed to:
Date:
Comments of Environmental Technician:
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Office Use Only
_Coastal Erosion PeIIDit Application
_Wetland Pennlt Application ~ Administrative Permit
Amendment!T ransferlExtension
--.::Reeclved Application:--'.'l31 OJ.
--=-Received Fee:$ ~'
-,,=Completed ApplieatiorJ.1l0/1:J-6
_Incomplete
SEQRA ClaSSlflCatlOn
Type I_Type lI_Unlisted_
_Coordination:(datc sent)
CAC Referral Sent:
~ateof]nspection: 11110/'01"
_Receipt of CAC Report:
_Lead Agency Detcnnination:_
Technical Review:
_--1'nblicHearingHeld: 1111,5)(")(
Resolution:
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Name of Applicant
Martin Soja
Address
62 The Waterway. Manhasset, NY 11030
Phone Number: ( ) 516 627-5223
Suffolk County Tax Map Number: 1000 -01\1-007-01 0.011
Property Location: 13457 Oregon Road, Cutchogue, NY
(provide LILCO Pole #, distance to cross streets, and location)
AGENT:
(If applicable)
Address:
Phone:
.
.
Board of Trustees Application
GENERAL DATA
Land Area (in square feet):
Approximately
~8'<'!"
I
Area Zoning:
f'P"( J.e>\-\.\ '" ~
Previous use of property:
Rpc::irl"",nt";:ql
Intended use of property:
Residential
Prior permits/approvals for site improvements:
Agency
Building Permit
Date
2/8/05
Pool Permit
10/14/05
Erosion Control Permit
5/17/06
_ No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?
~No_ Yes
If yes, provide explanation:
Project Description (use attachments if necessary): Install chainlink fence
at base of erosion control embankment to provide additional support
to entire erosion control system bv linking all parts together and
to provinp. RdditionRl protection a~ainst any Dotential runoff from
embankment! 01'1.\ -\", O1"d.,~ ~ ~tJO \ l:\1rl'.....
.
.
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
To provide additional support to
existing rock wall erosion control system with a fence that is
linking parts together and vroviding additional protection against
potential runoff.
Area of wetlands on lot:
square feet
Percent coverage oflot:_
%
Closest distance between nearest existing structure and upland
edge of wetlands: 100+ feet
Closest distance between nearest proposed structure and upland
edge of wetlands: approx. 50 feet
Does the project involve excavation or filling?
x
No
Yes
If yes, how much material will be excavated?
cubic yards
How much material will be filled?
cubic yards
Depth of which material will be removed or deposited:
feet
Proposed slope throughout the area of operations:
Manner in which material will be removed or deposited: Chain link fence to be
installed by means of steel poles mounted into soil/rock approximately
ten feet apart along base of embankment.
Statement of the effect, if ,my, on the wetlands and tidal waters of the town that may result by
reason of such proposed operations (use attachments if appropriate):
Fence to provide added protection against any possible runoff
from embankment.
.
.
Board of Trustees Application
COWlty of Suffolk
State of New York
(fv\ A (L \l JJ ;;. CT.:>A BEING DULY SWORN
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), 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.
/2Ut~~~ ~~'--'
Signatu e
SWORN TO BEFORE ME THIS ;) NO)
DAY OF H('II(>~ i,<-v
.200 (0
~.J/;~, ~ CC<> /<~~
Notary P Ii (
HEAl HEh AI~GU~ BENNETT
NOTARY PUBLIC, State of New Yorl<.
No. 01 BE61 03824
Qualified in Nassau County
Commission ExpIres I - I;). - oS
rl AAO~C; '" ","'C, '!
PART 1 - PROJECT INFORMATION
617.20 .
APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLISTED ACTIONS Only
( To be completed by Applicant or Project Sponsor)
SEQR
1 APPLICANT/SPONSOR , 2 PROJECT NAME
IV\qV'i\~ 5oJt<..- R~s \ J-e ""Ce.
3.PROJECT LOCATION
Municipality ,S<;v-\ \.., 0 'd County Su +fa \ k.
4. PRECISE LOCATION Street Addess and Road Intersections. Prominent landmarks ete - or provide map
{";.<fSl o Y"e"4 D" R..o",-J. / C.oX L..a "'-E
5. IS PROPOSED ACTION: [RI New o Expansion o Modification / alteration
6. DESCRIBE PROJECT BRIEFLY:
1:'~..~ l \" -\,~ Clt f-e VI u...
7. AMOUNT OF LAND AFFECTED
Initially .0" S acres Ultimately ,01$"" acres
B. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
~Yes o No If no, describe briefly: ,
/
I
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.)
~ Residential o Industrial o Commercial DAgriculture o Park / Forest I Open Space o Other (describe)
10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
AGENCY (Federal, Slate or Local)
DYes IXI No If yes, list agency name and permit / approval:
11 DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
DYes IZINO If yes, list agency name and permit I approval.
12. AS A ~ULT OF PROPOSED ACTION WILL EXISTING PERMIT! APPROVAL REQUIRE MODIFICATION?
DYes No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant ! Sponsor Name /V\ ~R.T \ Ul2: 'S.D.::J'" Dale f/1-z.../oCo
flA ~,hA .A
Signature ._~v _
~
If the action is a Costal Area, and you are a state agency,
complete the Coastal Assessment Form before proceeding with this assessment
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MAY 1
~ 2005
.
James F. King, President
Jill M. Doherty, Vice-President
Peggy A, Dickerson
Dave Bergen
John Holzapfel
.
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
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
1 sl day of construction
Y, constructed
~ Project complete, compliance inspection.
.
.
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Joho Holzapfel
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.: 6355A
Date of Receipt of Application: May 12, 2006
Applicant: Martin Soja c/o Oregon Cliffs, LLC
SCTM#: 83-2-10.13
Project Location: 13457 Oregon Rd., Cutchogue
Date of Resolution/Issuance: May 17, 2006
Date of Expiration: May 17, 2008
Reviewed by: Board of Trustees
Project Description: To provide erosion control to the side of the property
including the addition of erosion control blanket, boulders and ground cover, hay
bale berm and directing water run-off landward.
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
plans received on May 12, 2006.
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.
Jam!:J~~g,~:Z
Board of Trustees
\ '" 1
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NTS
.
.
NATURAl BOULDER
RET A1NtNG
fiEAVIL Y PL.ANTED
GROUNDCOVER , SHRUBS~,
~ND PERENNIALS TO "
PREVENT EROSION "'-,
"'-
\
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PRDVIDE MICRO-FILAMENT
MESH OR POLYMERIC
EROSION BUIHKET
(ENKAM~TOR EQIML)-'
BEFORE PlACING BOUlDERS
TO PREVENT EROSION
(AS REOUIRED . V.lr.)
NOTE:
NOTE:
. BOUlDER RETAINING
TO BE Ir,tPI..EMENTeD
INTO NEWt Y DlSlURSED
SlOPES (VERtFY NFIElD)
t,
fiEAVIl Y PLANTED
GROUNOCOVER I SHRUBS
rAND PERENNIALS TO
/ PREVENT EROSION
C}~~T~~DER PLACEMENT WITH EROSION CONTROL D6J~1
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Page
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<I: DeB! UJuv. - NoCu$tody UArrest-Juv. LJ Offender Dead :J Extrad. Deelin. DUnknown Pages
DCJS-3205 (10103)
'FALSE STATEMENTS ARE PUNISHABLE AS A CRIME, PURSUANT TO THE NEW YORK STATE PENAL LAW.
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Albert J. Krupski, PreSid"
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
Office Use Only
Coastal Erosion Pennit Application
Wetland Pennit Application """"'-::\'dministrative Pennit
AmendmentITransfer/Extension
_'1teceived Applicatio~(.,
...-'Received Fee:$ 5D
==.Completed Application '5]1 ~ ~
_Incomplete
_SEQRA Classification:
Type I_Type II_ Unlisted_
_ Coordination:( date sent)
_ L WRP Consistency Assessment Form
CAC Referral Sent: ~
..Bate of Inspection: Ii),
_Receipt ofCAC Report:
_Lead Agency Detennination:_
Technical Review:
v1>ublic Hearing He~l'l/~
_Resolution:
MAY 1 2 2006
Name of Applicant
M~r~;n ~nj~ ~/n Orpgon r.liff~r TTr.
Address
62 The Waterway, Manhasset, NY 11030
Phone Number:~l6) 627-5223
Suffolk County Tax Map Number: lOOO-Section 830.00; Block 2; Lot 10.013
Property Location:
13~57 Oregon Road, Cutchogue, NY 11935
._-----LProyjdeLlLCDl'Qle #,J:!istance tocross.streets, and location) .
AGENT:
(If applicable)
Address:
Phone:
~oard of Trustees APPlica~on
GENERAL DATA
Land Area (in square feet):
3.825
Area Zoning:
RpR;npnr;;:!l
Previous use of property:
Rj:H::irl,:>nt";~l
Intended use of property:
Rp.:Hinpntial
Prior permits/approvals for site improvements:
Agency
Date
7/R/700'i
Rllilrling npp~rt"mpn'"
Building Department
10/18/2005
_ No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?
y No_ Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
Provide erosion cont~ol to side of property including the
;:ulrii t"; on of prn!=d on C"nnt"rnl h 1 ::tnkpt" hrml rlpr~ ;::ann grollnn rovpr,
hale hay herm and direc..t:in~ WRtPT Tllnnd'fl;:mowHrd- ::iR shown on
on attached drawings.
~Board of Trustees APPliClIfon
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
Provide erosion control to side
of property by adding erosion control blanket, boulders and groundcover.
Area of wetlands on lot: 3.825
square feet
Percent coyerage oflot:
I. 75 %
Closest distance between nearest existing structure and upland
edge of wetlands: 101 feet
Closest distance between nearest proposed structure and upland
edge of wetlands: 'i'i feet
Does the project involve excavation or filling?
No
x
Yes
If yes, how much material will be excavated?
cubic yards
How much material will be filled?
300
cubic yards
Depth of which material will be removed or deposited:
14
feet
Proposed slope throughout the area of operations: 2: 1
Manner in which material will be removed or deposited:
Put in place with l2-inch lift and compacted
1:itatement of the (lffect, if any,onthe we!l~!isand tidll! waters ()fthe. tOWl1~thatm~ rtl.s_u!t by__
reason of such proposed operations (use attachments if appropriate):
None to the best of mv knowledge
617.20 .
PROJECT 10 NUMBER APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLISTED ACTIONS Only
PART 1 - PROJECT INFORMATION (To be completed by Applicant or Project Sponsor)
SEQR
1. APPLICANT/SPONSOR 2. PROJECT NAME
Martin Soja Residence
3.PROJECT LOCATION:
Municipality Southold County Suffolk
4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks ate - or provide map
13457 Oregon Road / Cox Lane
5. IS PROPOSED ACTION: W New D Expansion D Modification I alteration
6. DESCRIBE PROJECT BRIEFLY:
7. AMOUNT OF LAND AFFECTED:
Initially .075 acres Ultimately .075 acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
~Yes o No If no, describe briefly:
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.)
[i] Residential o Industrial D Commercial DAgriculture D Park I Forest I Open Space OOther (describe)
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMA TEL Y FROM ANY OTHER GOVERNMENTAL
AGENCV (Federal, State or Local)
OVes GJNO If yes, list agency name and permit I approval:
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
DYes GJNO If yes, list agency name and permit J approval:
~_....__._..,- --------- - . ..
1H~ A ~ULT OF PROPOSED ACTION WILL EXISTING PERMIT / APPROVAL REQUIRE MODIFICATION?
as No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant I Sponsor Name Martin Soja Date: 4/12/06
---;;Jt, / A"'- 2"
Signature . -Lj
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 Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes. coordinate the review process and use the FULL EAF.
DYes DNo
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative
declaration may be superseded by another involved agency.
DYes DNo
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be han~written, if legible)
C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal,
potential for erosion, drainage or floodIng problems? Explain briefly: I
I
C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly:
I I
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
I 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 . . I
C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly:
I 1
C6. Long term, short term, cumulative, or other effects not identified in C1-C5? Explain briefly:
I I
C7. Other impacts lincludina chanaesin use of either Quantity or type of enerov? Explain brieflv:
I I
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL
ENVIRONMENTAL AREA (CEA)? (If yes, explain briefly: I
DYes D No I
E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain:
DYes DNo I I
PART III- 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 <aJ 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 FUL
EAFandJor prepare a positive declaration.
-. Checkthis"boxffyou-fiavedei'errriTned~-base(ro'ilTtie I"nforinatio'n and analysj's above and- any supportlng- documentation, fhifthe-proposed i:iaio-
WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi
detennination.
Name of Lead Agency
Date
Print or Type Name of Responsible Officer In Lead Agency
TiUe of Responsible Officer
Signature of Responsible Officer In Lead Agency
Signature of Preparer (If different from responsible officer)
~ Board of Trustees APPli~ion
County of Suffolk
State of New York
Martin Soja BEING DULY SWORN
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 FORTHIN 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.
~)Wu~~
Signature
SWORN TO BEFORE ME THIS
j.;L-u. DAY OF
/nj
,200(.,
~~ ~ ;:S~t:t
Notary Ptiblic I
HEATHER ANGUS BENNEIT
NOTARY PUBLIC, Slate of New Yolk
No. 01 BE61 03824
Qualified in N_u County
Commission Expires I - ';:J.. - 0 15
.
.
APPLICANT/AGENTIREPRESEN'tATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold?s Code of Ethics orohibits conflicts ofinterest on the Dart aflOW" officers and emolovees. The numose of
this (onn is to orovide information which can alert the town ofoossibJe conflicts of interest and allow it to take whatever action is
necessarY to avoid same. '
YOUR NAME:
Soja, Martin
(Last name, ftrst name, Jl1iddle initial, unless you are applying in the name of
someone else or other entity, such as a company. Ifso, indicate the ather
person's or company's name.) ,
NAME OF APPLICATION: (Check all that apply.)
Tax grievance
Variance
Change of Zone
Approval of plat
Exemption from plat or official map
Other
(If "Other", 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 the town officer or employee owns more than 5% of the shares.
Building
Trustee
Coastal Erosion
Mooring
Planning
x
YES
NO
x
If you answered "YES", complete the balance of this form and date and sign where indicated.
Name ofperspn employed by the Town of South old
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% ofthe shares of the corporate stock of the appliC\U1t
(when the applicant is a corporation); .
_B) the legal or beneftcial 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
_D) the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this ~ of 111+0/
Signature ~ +
Print Name Martin Soja-
200~
Fonn TS I