HomeMy WebLinkAboutReeve, Helen
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Phone Number:( ) 'i?feD - S? t -:213'" N'-.
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Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
_Coastal Erosion Permit Application
~etland Permit Application ~ Major - Minor
WaiVer/Amen~S
r ReceIved Application:
A:e;,eivedFee:$~ ~~ i: Ii:! WJ I:W
...-completed Application
_Incomplete AUG 1 8 2004 0
_ SEQRA Classification:
Type I_Type "_Unlisted_
_Coordination:(date __
-CAC Referral Sent:
~ate of Inspection: Southold Town
_Receipt ofCAC Report: Board of Trustees
_Lead Agency Detennination:_
_TeChniCa1ReView:~
~lic Hearing Held:
Resolution:
Name of Applicant
Address
c2 I.f 5
t1 f/-TTl mC-l!
Suffolk County Tax Map Number: 1000-
/4o.{-8
Property Location: d-ljS- fJ1 fflJ:>W LffiJi?, m f'r7'Tlruci( I AJ . Y
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
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(111' ("lVJ) or /J1/rre>eL&vF, or/'- <$- 12-72 'If - H61O,1r;:; o.uf11;'tmi/Aq(<"(2.Etc~
(provide LILCO Pole #, distance to cross streets, and location)
AGENT: C {.HfLf} iTA) 1J f<(-TIJE
(If applicable)
Address: d ~ n-ffffJ'It'5 sT
/!JEW Lo/V\JQ /..J C. T
Phone: (,0 '2 () lone.:>
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Board of Trustees Application
Previous use of property:
r-e51 iZl2-~
Intended use of property: riG5! ~~
Prior permits/approvals for site improvements:
Agency
Date
II
if
t;/;/n ~r /'jfoJ
I ' P
5 /1/73 /kA~ +- 93()
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5/;210 1::>0 ~~ 1fr-. y.3
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80fH2-1)~~NI! T~(~-QS
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L No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?
_No_ Yesz: 1>>fJ'1' W/IJI'- SO -
If yes, provide explanation:
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SeE 4-TTlkdt:r> j)/2/1<<-,{,uGS
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Board of Trustees Application
WETLANDffRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: 1+ Tioc-\,,- !D f,<? LcS ~'l) ();,'f
/-fvyvIc<>w~er...5 ~ T/1-E7fL fe-i-Yo/V4L- t3 0/1-7'-
Area of wetlands on lot:
lL?oU
square feet ft-f f.~?' -
Percent coverage oflot:
Ii) %
Closest distance between nearest existing structure and upland
edge of wetlands: @c) feet
Closest distance between nearest proposed structure and upland
edge of wetlands: I Cc) 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:
.",.;
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):
NO t.:ffec:r /f;v7? C/fJ#TEU
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Board of Trustees Application
COASTAL EROSION APPLICATION DATA
Purposes of proposed activity: 7)0 CJ!.- IJ If!) f)-,TIKtI-&'V> {-Loti,
/-vf-- P r:fL So !J fU-- l(S (;""" 0 '1 jf-6w, r;;-O {p IJ ~-{J- ,
Are wetlands present within 100 feet of the proposed activity?
No ..........--Yes
Does the project involve excavation or filling?
k No Yes
If Yes, how much material will be excavated?
(cubic yards)
How much material will be filled?
(cubic yards)
Manner in which material will be removed or deposited:
Describe the nature and extent of the environmental impacts reasonably anticipated resulting
from implementation of the project as proposed. (Use attachments if necessary)
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I PROJECT 10 NUMBER
PART 1 - PROJECT INFORMATION
617.20
APPENDIX C
STATE ENVIRONMENTAL QUALllY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNUSTED ACTIONS Only
( To be completed by Applicant or Project Sponsor)
SEQR
1 . APPLICANT I SPONSOR
HtIEtJ P-bt:Vt"
3.PROJECT LOCATION:
f~ Jt Ir"! TZ1 CK "
Municipality W j.J oF-- 56!.L COUnty .5'ct F- F- oL~
4. PRECISE LOCATION: Suest Addess and Road Intersections. Prominent landmarks ate. or provide map
:2. '-/S ;J]/iIz>EAJ L/tNC, f'> +"I7rlrvC.g,/V<( - ~rd} fu~ '""' )Ii1/ITTiJ74C{"L ()f2.,C'c.-I<-.
2. PROJECT NAME
"bOC(L 1fT :;). <{ 5"
(Vi !T17)/::7J LlfflJt
5. IS PROPOSED ACTION:
New D Expansion 0 Modification J alteration
6. DESCRIBE PROJECT BRIEFLY:
l)OqL VIT[t f1-7ffkti"e'P f"'LOl'1t Ff!Jh.'7 jJf'..o('E/Lr'( OIXT //J7'o
fJ1 It I'll T7A C[( Q ,€.t:E"J<'" -
7. AMOUNT OF LAND AFFECTED: I
Initially acres ~ ~ Ultimately ~ tJ...., acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
~es 0 No If no, describe briefly:
~.WHAT IS PRESENT LAND USE IN VICINllY OF PROJECT? (Choose as many as apply.)
~ Residential D Industrial Deornmerclal DAgriculture D Park I Forest I Open Space
DOther (describe)
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
AGENCY (Federal, State or Local)
~s 0 No If yes, list agency name and permit I approval:
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
~Yes D No If yes, list agency name and pennit I approval:
(3ofJ'P,D 00 St/IA.ZJl.m-D]1WIJ 7P-4~a-'<'"s.., (/C1'-fJJ(i# Nb3j ZJo, '-1..3
S A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION?
No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF
Si ature
MY KNOWLEDGE
Date: 3j 1<O/U'/
Applicant
.
If the action Is a Costal Area, and you are a,s.te agency,
complete the Coastal Assessment Form before proceedIng with this assessment
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PART n. IMPACT ASSESSMENT 0 be Ieted Lead
A. DOES ACTION EXCEED ANY lYPE I THRESHOlD IN 8 NYCRR. PART 817.47 llyes, coonIInal8\he _process and use \he FUll. EAf.
Dyes DNo
B. WlU.ACTION RECElVECOORIlINATED REVIEW ASPROIIIDED FOR UNUSTEDACTIONS 1N8 NYCRR. PART 817.87 II No. . ~
__lIl8Ybe__Ilv--_.
Yes 0 No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOlLOWING: (AnoMrs IIl8Y be ...._.11 1IlgIbIe)
C1. EldolIng _quoIty. __ ...__quoIty ...~, _ _. exIsIklg _ paII8m, soIcI_ producIan ...dIsposa/,
...,...ror-. __"'~"-"7 ExpIBIn brt8IIy:
I I
C2. -. ogrlcuIIuraI. ....._glc... -.... __..._ _;... communIIy... nBlgI-.ood c:h8I8clor7 ExpIBIn brt8IIy:
I . 'I
C3. VBgBlalloo....faun8,..... _..._ opec:les, 1lQ.__. ..._18d ....lId.llg.....1p8C1es7 ExpIBInbrt8lly:
I
C4. i lXIIIllllUllIly 0IdItIng plono...go8Io.. oIIIcl8Iy 8dopIed, or. cII8ngB In ... or Int8noiIy 01 use 01_ or - - _7 ExpIoIn briotIy:
C5. G<owIh. subsequent clewIopI......... _ -'1I<BIy II> belnduc8d by \he proposed _7 ExpIBIn bolofty:
I
C8. i....... short....... -....- - nalldentlll8d In C1-c57 ExpIBIn bolofty:
C7. 0Ul8r In... of_
D. WLL TIE PROJECT HAVEAN IMPACT ON THE ENVIRONMENTAl CHARAClERISl1CS THAT CAUSED THE ESTABliSHMENT OF A CRITICAl
ENVIRONMENTAL AREA (CEA)? (If yes. explain brI8IIy:
Dyes ONo I I
E. D~ OI!.~ ~ UI<ELY TO BE. CONTROVERSY RElATED TO POTENTIAL ADVERSE ElMRONMENTAlIMPACTS? llyeselClllBln: I
PART.. DETERIII<lATlON OF 1IIGNFlCANCE (To be oompIeIlld Ilv Agency)
INS1RUCT1ONS: F...eechadverse elrect identified above. delennlnewhether ftls substantlal.Iarge.lmportanl...oIherwIse sIgnificanI. Each
elrect should be ass"",,'" In connedlon with Its (a) selling (1.8. urban ... rural); (b) probability of oa:urrtng; (e) duration; (d) iTevelslbIlIy; (e)
geographic; scope; and (I) magnilude. If necessary, add attachments... refeoellC8 supporting ma-.s. Ensure thai explanations contain
aullIclenI cIetaR lD show IhaI aI relevant adverse Impacts have been identified and adequately addle" e d. If qwstion d of part i was checked
yes. the dele...lilallonofsignlllconcemJStevalualelhe potentlallmpactoftha proposed action on lheenvfronmental CharaclarlsllcsofthaCEA.
Chacltthlaboxllyou_~one"'I1IOI8~Iarge...sIgnIIlc;ant-"'ImpKbwhlc:hIlAY occur. Thenprooaeddlredlyll> Ihe F
oEAf -... __ a poaIIlile cIBCIintion.
Chaclt thIa box II you _ _18d. based on lhelnlonnatlon and analysis -... and _ -'">9 _lion, Ihe. Ihe proposed
WILL NOT ....... In _ "",oIIc.i -... _ ImpKb AND provide, on __ .. neceslI8IY. the ........ -'">9
......lalloo.
Name 01 Lead Agef"'f
Dale
PrInt or Type Name or ResponsI)I8 omcer i'l Lead AgenCy
Tille 01 flespoI..- 0IIk:er
Slgnature of flespoI..- 0lIIcer In Lead Agef"'f
Signature of Preparer {If dltIerenI from responsible o~
eard of Trustees APPlicati.
I,
AU'l'HORIZATrON
(where the applicant is not the owner)
. _ . - Y2.~ j)/!.o2DycJ( D;</jE3
HcLt;:-/V Z. ;( E E \JCresiding at Gi<oTbAJ. C-(- c)(o"S<f U
(print owner of property) (mailing address)
~
do hereby authorize
(l i-ffI2-,4 /)).1 AI /? C EI/I=--
(Agent)
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
-JAw ia.~
(OWner I s si ture)
I
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APPLICANT/AGENTIREPRESENTATIVE
TRANSAcrIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics orohibits conflicts ofintcrCst on the Dart oftoWo o~ and eI1lolovees. The DUI'DOSC of
thk fonn is to nrovide information which can alert the town ofnossib1e conflicts of interest IU1d allow it to take whatever action is
__rv to avoid same. .
YOUR NAME:
liD-EN KCEVC
(Last name, first name"l/liddlelnitiaJ, un1ess yoU are applying in the name of
someone else or other entity, such as a company. If so, indi""",. the other
person's or company's name.) .,. .
NAME OF APPLlCA nON: (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.) /3 '^ 11..0
Building
Trustee
Coastal Erosion
Mooring
Planning
fuQL ItIJ/U rr/fTTI(2{o"-.. c;2-f'l?fL.-
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, 1Qlll1"iage, 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 S% of the shares.
YES
NO
x
If you 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 applicantlagent/represenlalive) 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 a1I'that apply):
A) the owner of greater than 5% of the shares of the corporate stock of the applicant
- (when the applicant is a corporation); ,
_B) the legal or beneficial owner of any interest in a nOIH:Orporate 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
S~bmitted this I ~ ~ ~ of f!;:-!;J- 200 1.
SIgnature (.I' 4 .L~
Print Name OLM-It /J-tf)iJ I<teVe-
Form TS I
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