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Home My WebLink AboutTR-6537A . . James F. King, President Jill 1\1, 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 # 0190C Date: March 27,2007 THIS CERTIFIES that the restoration of the buffer within 100' of the wetlands and existing hay bales to permanently remain in place along the 50'non-disturbace buffer line, At 570 Maple Lane, Mattituck, New York Suffolk County Tax Map #107-3-3.1 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 02/21/07 pursuant to which Trustees Permit # 6537A Dated 03/21/07. 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 restoration of the buffer within 100' of the wetlands and existing hay bales to permanently remain in place along the 50' non-disturbance buffer line, The certificate is issued to Scott Edgett owner of the aforesaid property. r~~ Authorized Signature . James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. TO: Building Dept. FROM: James King, Presid Board of Trustees DATE: March 23, 2007 RE: . . 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 SCOTT EDGETT 570 MAPLE LANE, MATTITUCK SCTM#1 07 -3-3.1 Please be advised that the Board of Trustees has issued an Administrative Permit to Scott Edgett to replant the buffer within 100' of the wetlands, and Mr. Edgett has agreed to plant the area on Tues., March 27, 2007. Our department has no objection with your department proceeding with the issuance a Certificate of Occupancy. Please contact our office if you have any questions. ~ . . 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 1 st day of construction Yo constructed ;/ Project complete, compliance inspection. ~ One-Year Plant Survivability inspection. . . 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.: 6537A Date of Receipt of Application: February 21, 2007 Applicant: Scott Edgett SCTM#: 107-3-3.1 Project Location: 570 Maple Lane, Mattituck Date of Resolution/Issuance: March 21, 2007 Date of Expiration: March 21, 2009 Reviewed by: Board of Trustees Project Description: To restore a buffer within 100' of the wetlands. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the plan prepared by Scott F. Kruk dated March 22, 2007. Special Conditions: The placement of a hay bale line along the 50' non- disturbance buffer and a One-year plant survivability inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. ~~~ Board of Trustees I I I , t5&-O; --- -- --- j Ii APPI!9Y ..--B'OAiD OF TR TEES ~ TOWN OF SOU HOLD DATE ,~ - . MAR 2 2 2ea S'. ':: ",< I'}' ~ -- -- -- .-- ~ ..--=.,~ ';0 ~''\. t::lZ~~ "'- is::. 0 ..!> <" o~ '~.".. t"-< ~ -r.... ~ '.l> '>- ~ Co ~'<"' .. . '" 2~ SlOIf'( FIWotE a MIlAGE 47$ \ IV ... '" ~ ..... , \ ~ ~ $- . 7- , ...-- , 50 W"" ~b<., L;..e IE y.* ,$A _-- 10 -BY"" ..0.1[ lEL -- -- -- ~)L"""~v:,t\ 'i!.\--e 'oe....~ o ('1 ;;l CJ &of - ~ - ~ \~),~<a'idf ~?A\ (s)<;t~ ~ ~.. ./i' ~ ,,~ , ~ ,/,_J ,,', .,,:>~ r;y;j~ ' " /- .,').. ~ " ;tj 'c ' , :/.' "',,:>~.l>i ElAs\> '\ - " "./' -' ~ S c.e.~rsJ' ~ ) ~';/ .')..4 Jf. Ci ....::: ..' . s,$ z ..' :1'~ ~ "E", ::"/--:;.-- S .. ~,Jl _ "../ A." ~ ~Q'l!!;;~/ ~~,_ ~ ~ / / .~, 'lib " ~'Sl, .. ....,. ~!f //1' S ~ f?rfJ 1 ! ~ ~& /1:0 ~~ Ill:'" -~ ato (~.s / / [:i II&, /" ; h/: ~.i ~ //,. .,. '/ . ,?OJ OlD t\. /IV / .6 "'~ NATIVE GRASSES SPECIAl. ORDER UTnEEIUJESlBI-GS-LB BIG Bl.lJESTEM - GS-BB BUFFALOGRASS - TEXOIQA - GS-8U GRAIIA, SlDEOATS - GS-SG INDIANGRASS - GSm _ pJ\NCGRASS - GS-PA_ LOVEGRASS. WEEPING - GS-LG , , -, -~ Ced"''' ~ 5"',,' ce.c!."'''''S ., II '0 \6 -~ Do..'t Ben') :;u. \~,..\ L.d", ~4-, l!.\--e be ~ 4'-' , -." S'v..o. '=>\0..:.0 +\,c.'t..cx-j ,-,,,<.4... ~~r~, seeded ......0\'" ~'\\ ~..c\<;s Se-ed 5 5 ~ . . ~ NATURAL IMAGES -lANDSCAPING- Estimate for: Dated: Februarv 14. 2007 ~! >,f, (;Jr,IL - I !~07 Scott Edgett 570 Maple Lane Mattituck, NY 11952 1-631-255-4028 Wetland Restoration All Remaining Cut Brush, Logs, & Branches in Disturbed Area Removed from Site $900.00 +Dump Fees Area Replanted at 50' Non-disturbance line with (5) 7'.{I' Eastern Red Cedar (5) 6'-7' Eastern Red Cedar (9) 18"-24" Bayberry (26) 19a1 Highbush Blue Berry (3) 4'-5' Shadblow Hickory Under-story Seeded with Native Grass Seed Total Cost: $5013.50 (Work to Be PeTjormd Between 3/15/07 & 4/15/07 Depending on Weather) 50% Deposit Required l Jpon acceptance of Propo8al .long with compl"tl~l Certificate 0/ CapitRllmprovement Form ",hen Necessary Balance Due upon Completion of Work C~mnerS~tuTe: ~ a{1 /' J>r.pared BJ: Date: --2f~---- .~ This estimate is good for 30 days following issuance. This estimate is a general calculation of the size and cost of the above said undertaking. While Natural Images Landscaping makes every effort to minimize cost & maximize quality, we cannot be held responsible for increased costs due to unforeseen circumstances beyond our controls (I.e., Acts of God, Market Fluctuations, etc...) ... 34990 NORTH ROAD, PECONIC, NEW YORK 11958 PHONE: 631.734.6279- FAX: 631.734.2674 . EMAIl: NATURALlMAGES@OPTONLlNE.NET " f[J 1 5 ?007 -------- .----- -- ---- ---- -- \:%j t:l ~ ';l:> -. ';tl CiZ ~6 ()~ t-'>--r1 ';>> c. n .. _. ." '!OI. . . - - s" """'" - i , ! i i 51'6' __- ./--- ---.. 1 i N . '" !!Iii "0 ;go ~ ~ '" <D_ ::os:.-. 17..... 2-1/2 STORY fRAME HOUSE a: GARAGE 41.5~ n..n "''''~ ~;;l, ~;g", ~a~ " .. \ '" '" '" ~ ~- , \ \ \ \ \ / \ -- -------\ , --- ~. ..->' - , ---- ' 7- . ---- ~)( --------- 1-....'::- - - - ,,* - ~" , 50 W"", ~~b:..... L;"e \ (:,)~~~ ~ " ~\C:_ 't-o" ') ~ :S)--':B' ~ - 'Sf \ c"do.r , '(el) ~1?~" .... i$~ ~ ~ \ ", . (j, 0"" J '7~r< ~ ____ . ~ ~, p \";l.)l~'" ~."r-'J1\. I. (~) o;~~~,. ~ /' ceCGV",- ;.( i" I :7:/", ..-t\ ~ ,z-.~/ ~ ,;r~ d i":l~' f:\l~~ ,~-/ I>'~'b.~ E><\~"3 ~~" ~) fiI.'......' / ;/ -t\ S ~ c.e.do,,.,,,,j,,, '~"':";'%" "'0 ' .'J,':. '" '" ",'\ . .. itJ 1>' b.() ~ ~z c.. ",1.' ,!/:o.'" ' ...'J ff~ /'Y~ Ao(> " $",.y;'/ ,~: ~~ (// b.'~:lE>" ~~ ,ff ? ~ - ~ 1" ,f51 ill!.x 'i"d /11 ~ lr$ 1.1;:;:.. -J}2 010 ;.., i". "::::'.l.. ,. - (~ /!",C'J~ , , // ///' ~ '/' ~ ,,?OJ '" . , .0,"" /lV"'- ,..~ "". )l* z()tl:. _ _ _ ____ ~ ~ (S..1t) --- -- - l,?Io) LO<A)\?'~ \!.\...e. 'oe""'~ € NATIVE GRASSES SPECIAL ORDER UTTLE BWESTEM" GS-I.B BIG Bl.UESTEM .. GS-BB BUFFALOGRASS - TEXOKJA - GS-BU GRAMA, SIDEOATS .. GS..sG INDlANGRASS" GS-IN .. PANlCGRASS .. GS-PA_ LOVEGRASS, WEEPING" GS-LG 5 " 1-% Ce..!",,, ~ 5 5'-(/ Ce. eOl'i"S 1 41' II 'Q \u - a... Do..'j"Ben j :;}.,(, \ !?l"'\ Lc..... ~~ ~\o...e be....- ~ 4.!S' """"'-0. \:'\0"';" {.\,c>Lo"'j U"c.~'i" s-\ov- :J ~e.e.Je<i ,--",\-'" l'\q-\-, ~..~SS Se-ed. . . 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 Southold Town Board of Trustees Field InspectionlWark session Report Date/Time: SCOTT EDGETT requests an Administrative Permit to restore a buffer within 100' of the wetlands. Located: 570 Maple Lane, Mattituck. SCTM#1 07 -3-3.1 Type of area to be impacted: ~altwater Wetland Freshwater Wetland Sound _Bay Distance of proposed work to edge of above: P~ of Town Code proposed work falls under: ~Chapt.275 _Chapt. Ill_other Type of Application: _ Wetland _Coastal Erosion _Amendment ~dministrative _Emergency _Pre-Submission _Violation Info needed: Modifications: Conditions: Present Were: _J.King _J.Doherty _P.Dickerson _D. Bergen_ B. Ghosio, Jr _H. Cusack_ D. Dzenkowski _Mark Terry_other MailedlFaxed to: Date: Environmental Technician Review i. R" ~",'n:: S""vw<<l"l.y ,.:J ~ '7 Insf~(.-hons - c:J1\.Q C<.F-/0- 1f'1c;at>'!5 / 01>e. J') 1 _ rlo VI. j>:"<:' "'....~ e.'f9l..\ ifn.,^ t O<'1e ' .... 5 ~ fAG N"-r m<1" h . ~ NATURAL IMAGES -lANDSCAPING- . j..L. ""'~~ AcH'-\ sro ~"1-a Estimate for: Dated: Februarv 14. 2007 Scott Edgett 570 Maple Lane Mattituck, NY 11952 1-631-255-4028 Wetland Restoration All Remaining Cut Brush, Logs, & Branches in Disturbed Area Removed from Site (Except Large Tree an West Side of Disturbed Area) $900.00 +Dump Fees , " FE3 1 5 ?C07 Area Replanted at 50' Non-disturbance line with (5) 7'-8' Eastern Red Cedar (5) 6'-7' Eastern Red Cedar (9) 18"-24" Bayberry (26) 19a1 Lowbush Blue Berry (3) 4'-5' Shadblow Hickory Under-story Seeded with Native Grass Seed Total Cost: $5013.50 (Work to Be Per/ormed Between 3/20/07 & 4/20/07 Depending an Weather) SO{Yo Df'pnRir Required Upon acceptance of Proposal along v..i.th cllmpktcd Certificate of Capital Improvement Form when Necessary' Balance DuC' upon Completion of Work Prepared By: Customer Signature: Date: 34990 NORTH ROAD. PECONIC, NEW YORK 11958 PHONE: 631.734.6279 FAX. 631.734,2674. EMAIL NATURALIMAGE5@OPTONLINE,NET 1:( I...., . '. ..' ~I IS sEPTIC T"'~ 32,6' ... ~~ ...~ /i<'" ~dIl ... ""Ill '8 IX "" 2:15.44' WINDOW WEUS ~ ' !~ --- --- 24,3' \ \ \ ",\ :l\\ 1-, I \ \ ICE --- . .-- \ ' .-- \;!~ .--f'" \ \ \ \ \ \ \ \ \ 9661 . \ . \e \ \ ",(\~ .*)( \'~ )(\~ \\ \\~ \ , .- .- .- f I '. \ ~ \ .- .- .- ,- .- --- 2 -1'1 . .~-, i::J (.)'1 '" C:> !03 . ~'*' :UI ~~. ~ .~~ \ ."'4 ~I ';-i'/1. \~ Ii' M ,,<'SIO'It. O-i'tvllf:-i'/lO"", "~~ --___,8t..t.o S '..;>'/':10 "0 S.J >._____... _____ ., S" Ji/i:!..lSI'I<J.l "'-~ <:~ A_ '" /i" 0101{ ~ "" '" ~ ' ~"411t ~f)os '>,> ~6'.("".(' I 011{ O"'o~~ "'410.l '" '>" '.90.r... ""'/7 ,"'e ; '" '" - '<c- ' .1/1-...-., " oS' " 'l :>7\,59' \ \ \ \ \ \ \ \ \ \ N/O/F UCHLIN MeLA WARD ED I . . 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 InspectionIWorksession Report Date/Time: ;)-1 ~ -0-' SotJ- {) p+ rJcm.rz4 ~3'- Name of Applicant: Name of Agent: .Property Location: SCTM# & Street Brief Description of proposed action: lvef1c:..J.. /.:"...+kc (' c.f VrO 1&1-hrd - -(O, ".t.vJ Atr.~ , , Type of area to be impacted: i/Saltwater Wetland _Freshwater Wetland _Sound Front _Baj Front Distance of proposed work to edge of above: ~ofTown Code proposed work falls under: _Chapt.97 _Chapt. 37 _other Type of Application: _ W etland _Coastal Erosion _Amendment _Administrative _Emergency Info needed: ~ ! PI"" Y' -t<<e) b /Ce./GI..., c:2o'" . evil .tOl.J... : / ce.,J'(" ~ / CJ <\11""" -5~J 4e ;) S""..II v\,.., L-. ,'"'" ck&lr'<-~ .....,( u.~ be':) "',/~ .." ~ I I'\..t Ll . -\-''''Iu I ,)'<-IL ;;""1' j";v!,.\-, 17J 1,- A I I I Modifications: ~'v<.. (...~ L k le,- 5-fuMf +' \., ~1 \,..1.<- Conditions: V ././ .-/ Present Were: _J.King _J.Doherty y.Dickerson _D. Bergen Other: (j)",... ..D . F>~ u: 1-'~i7}..r C . MailedIFaxed to: Date: Comments of Environmental Technician: --- \ \ ~ \..9 '" -l- .,...- . . . . . . . EJ Jdl- S,l. 5<--\-1- . fj.~"'tv- . "" ;;;; -;r "'t- " .' .. - - '- (","!:!' .,. ,.. "'- ~' . 1~ 't . ~ ~. ~~ l~ i " . ~ ~ ~x . . . . James F. King, President Jill M. Doherty, Vice-President . pe~ Dickerson Dave Bergen/ . __.~ Holz~ifel 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 InspectionIW orksession Report , DatelTirne: <(lll.c - Name of Applicant: ~oH UjJct Name of Agent: Property Location: SCTM# & Street S 7 a fY1 qy Ie L"-II-€ Brief Description of proposed action: Vlo (",,+,..,. . ~~ . 0(' (N,.J..v. J., ~ . fVWlj;;J- J OZ ~. d-f5/.'"':.J Tv.ie of area to be impacted: ":2:'S~twater Wetland _Freshwater Wetland _Sourid Front _Bay Front Distance of proposed work to edge of above: ~fTown Code proposed work falls under: _Chapt97 _Chapt. 37 _other (// tJ I-r+-. n.--J Type of Application: _ Wetland _Coastal Erosion _Amendment _Administrative _Emergency. Info needed: /V-:r l-d4-er p~ Sr<..c,~ .~ 0< 1=h'J Modifications: Conditions: r..)~\- .\-o'~ uSe ~~O\LP1-i<YV\ , -"Present Were: 0King ~Doherty ~ickerson~ ~ergen CA:Holzapfel Other: . .. MailedIFaxed to: Date: {U .. "--/- L htM^A I I ,.. r -'-".1--" _.--n. M Gu.J.Orn dc,' . fjU'-mll1'~ Ire",,' Wki 5e..-.+ '"T" .~ n.."".,..,. {V,'""". I" IU' 'I 1. Agency _;oo/P,oc;oot New York State 13 ORI __ 14. -"C";g ~~se No. 16. Incident No. ,..- J'/' i rI ~.4' , _ ,~A . 01 INCIDENT REPORT N\O<;""/<, DSupp '-f,'Nli' 7. Report Day bZ ~<;;-' lo( I~~~~' Occurred ..to_::1.::11.Date, ~2.Time Oc~rred V3. Day "'1..14. Date _ [,15. Time f,-J.....,/ OOIFmm':vi - 1.1.'i<"'k ~ ~ ,< 0"').;' nl:; 00 To. ~ '.J~,/ 010 I~ loc, /3</9 >- 16. Inciden1 Type 17. Business Name 16.Weapon(s) A. Z bo';, ,i"'- ~ t>-k v,~/ql':l"'-' w C U 19. Incident Address (Slreet No., Street Name, Bldg. No., Apt. No.) \20. City, Slate, Zip (0 C ~ D V) 1...21. LocaHon Code B. ~ I~o /'-10 '.4-_ k~ H41(J. . ." ,lc.<..-q 22. OFF. NO. LAW SECTION SUB CL CAT DEG ATT NAME OF OFFENSE CTS 23. No. 01 Victims C. 1 2 24. No. of Suspects D. 3 l/:? 25. Person Type: CO_Complainant OT _01her PI"Person Interviewed PR " Person Reporting WI "Witness Nl=Notlnlerviewed VI"Vic1im 126 Vic1im also complainant 0 Y ON E rn lYPE/NO NAME (LAST, FIRST, MIDDLE, TITLE) Dale 01 STREET NO., STREET NAME, BLDG. NO., APT. NO., CllY, nATE, ZIP Telephone No. Z Birth 0 ~ F. rn or ~da ~..,/ <,....;./. /] h /7Q r~~/" __ 'f";..j. ~4 // ~ a: ~;;-;::> r/ji~f-jtfc ;! w ,- a. I G. C .' W 1-"-'-. >- .. " ,.. H. U 0 i:X:' .. rn rn ~:~:,;,r-; _ I. .. '" 27. Date 01 Birth 26. Age 29. Sex 130. Race I :1. Ethnic 132. Handicap I r3. Residence Status D Temp Res. - Foreign Nat. J. ti .. I I OM OF o White DBlack o Other 0 Hispanic 0 Unk. DYes D Resident 0 Tourist 0 Student 0 Other ;; DU o Indian D Asian DUnk. D Non-Hispanic o No 0 Commuter 0 Military D Homeless 0 Unk. Z ~:;~~~;'~0.13S. Name (Last, First, Middle) 36. Alias/Nickname/Maiden Name (Last, First, Middle) I :7. Apparent Condition K. 0 o Impaired Drugs 0 Mental Dis. DUnk. rn o Impaired A1co D [oj/III 0 App Norm a: W 38. Address (Street No., Street Name, Bldg. No., Apt. No., City, State, Zip) 139 Phone No. 40. Social Securlty No. e. .. o Home 1-0 DWor1c: O~ 41. Date 01 Birth 42. Age 43. Sex 1 r. Race I:S.EthniC I f6. S~n 147 Occupation M. wrn o..W I OM OF OWhite DBlack o Other D Hispanic DUnk. OUght D Dar1c: DUnk. .l.:' rna: o U 0 Indian 0 Asian o Unk. 0 Non-Hispanic D Medium 0 Other ",a: rn" ... Height 49. Weight 150_ Hair \51 Eyes 52. Glasses \53. Build 154. Employer/School \55. Address N. ;;1 I ' ," D Yes 0 Contacts 0 Small 0 Large Z o No D Medium '" 56, Scars/Mar1c:s/Tattoos (Describe) 157 Misc. r=] '" :E ~S~mN~~ Property P~:erty Quantity! D~ok~~~ Model Serial No. Description Value 0 Status Measure 1.:'''.1 :.. ,,".;',t;T ;\[1!, L " 0 >- [] >- a: 59. Vehicle 60. License Plate No. \61 State 62. Exp. Yr. 63. Plata Type 164 Value . W Status FunD GJ 0.. 0 W '.':If Partial 0 a: .... 65. Veh. Yr. 66. Make \67. Model 168. Style 169. VIN. GJ Q. 0 ;: W > 70. Color(s) I" \72. Vehicle Notes D Towed By: To: GJ 73. 4/~ /-. _. { I '7' ~, L" ./ r/. / L/_ A _.~, GJ "/# <.. , A ;)71 r :.", J._ dd' - - / 4.-- G . ~ 'S"oS- ~ . W ~ --" / > . G ;:: .. a: G a: .. z G' W 74. Inquiries (Check all that apply) 175. NYSPIN Message No. 176. Complainant Signature B t > DDMV OWantfWarrant DScoffiaw use cover ~ OCrim.History o Stolen Properly DOther sheet a: 77!72cerjCC~/anL 17';~3 79. Supervisor's Signature (Include Rank) 180.10 No. 84, >- g, I rn Page Z ~ ~Stalus D1r;'1 .~r~ed (If Closed, check box below) DUnfoundud I;Z;~O~ loG I BJ. No"",dITOT ;01 C o Viet. Refused to Coop. Arrest 0 Pros. Declined DWarrantAdvised .. DCBI D Juv. - No Custody DArrest-Juv. DOflenderDead DExtrad.Declin. o Unknown ' Pages DCJS-3205 (10/03) 'FALSE STATEMENTS ARE PUNISHABLE AS A CRIME, PURSUANT TO THE NEW YORK STATE PENAL LAW, . . ~1"" ~~. m ~. I !hi ;i. ~ .-. I ~::l- I Ir. I -<>-Z I ~:Hl__-----i'-_ 9~:l ~ ~ ~ ~t:l! Y~il ~~* ~5t;; I I 'I e U ; I I 11 ::;~ -~ . II I o;..J ~ ~ ~ 'f "j~1 "~', ,,., ;'i '" """....A'" II~\\ ~ -----.wiil . , . . 8) ~~ ~i ~v ~J 0, ~~ 6. uj , . , ~i " " Iii 'III ;;j1 i,1. '<<f.:- iii 'Ow iil !d Ij! Il I" .!! iii '" Ijl Jd i Ie, I I ) I! jl ] 15'1 , ,/ "II If I J '[Iii 'tf.:' Iii d, "J'! fi Ii , . /ir.N.,rtJ ,,,tr.. ~'IE . 1"'<,rl'\.'+- 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 Office Use Only _Coastal Erosion Permit Application _Wetland Permit Application ~Administrative Permit Amendment/Transfer/Extension ~Received Application: J..IJ-;(r) 1 ~Received Fee:$ :'>\J _Completed Application _Incomplete _ SEQRA Classification: Type I_Type II_Unlisted_ _Coordination:(date sent) _ L WRP Consistency Assessment Form CAC Referral Sent: f\~ ~Date of Inspection: ,3 lll01 _Receipt ofCAC Report: _Lead Agency Determination:~ Technical Review: -,LPnblic Hearing HelcC:3J;) ({()1 _Resolution: .~ r ~ :~j , Name of Applicant Sc Dft- Ed Cf tf- Address SID M."'rlE" 1t\I"lE M.ft\4.~L\( Phone Number:(b ~O 2. <:;: c; <-/.c:J"L ~ Suffolk County Tax Map Number: 1000- Property Location: S", b tv\ ~~ IE: CrOse;. ';)-1- G,"I\Nd f\v~ ~Pf61-- (provide LILCO Pole #, distance to cross streets, and location) ! ME N\l\-1-\.:-\-6\:C '( y~ Md":;- - --AGENT-: - (If applicable) Address: Phone: j' 4IJoard of Trustees APPlicallln GENERAL DATA Land Area (in square feet): Area Zoning: K 0 Previous use of property: J ~tP<:t-l+ Intended use of property: \<'e.,:d...N+''O..:, 8D,ooo "'::" 1- \-\-0 ME:: ~P,-M'"\ ~ 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:6:0_No_ Yes If yes, provide explanation: Project Description (use altaclunents if necessary): W~t-\"'t-i c) ~<;-h> r~ i, 'ON nUI\~["Ofd''N~ +0 0~~ld -\.lA.SUtfus ~C1 v..~S+':- . t'\""~ , , ...Board of Trustees APPliClllon WETLANDITRUSTEE LANDS APPLICATION DATA \Suf'rc\ \' ,j ~ IOD' \2e~6r~ v-J e.. t \ ""t-l~ SE+blll..d::_ Purpose of the proposed operations: \ <' Area of wetlands on lot: Z B / D DO square feet Percent coverage of lot: '2-<; % Closest distance between nearest existing structure and upland edge of wetlands: \ ,'1 ' feet Closest distance between nearest proposed structure and upland edge of wetlands: \ \ 7 I feet Does tlle project involve excavation or filling? 1>< No Yes If yes, how much material will be excavated? ~UbiC 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: ~'-- N\ ,...-\-t,. ().., \...- WI-I' 'of. ~i"\(lV~~ 1'0 ~ dtJ"D M<ul\-~~~ tk~ fOo' B",p~u--,/ h(4Jcl ('i)'j <Lll ? \ &.-~ ~7/ ~ (' I? Q,~ f, 1.J'1-\.'N' ~l{,: ~lll ? Statement of the effect, if any, on the wetlands and tidal waters ofthe town that may result by ureason of sudiproposed operatlonsCuse ilttachllents It'appropnate): - . --- . -..- -- -- ---- - -- U --. hl...~~t-\";> ,:)0 "B...\/)F~ C>I U):,I ~ ~t':' 4e-~JLe- cl..~s"+ IN -tl, w~+-I~ D~ M-tj ~..I~~ (IFf'.A..Jr ,....L ~ v-:.;LL ";0 Un (;....Ee, c~j(1 (b(. CA S€' OQ QEM..\ L.\o,l. --I--t> \kc,-t-. r '( 4-r, ~ ts~..t vJf-k'tWd~ PROJECT 10 NUMBER 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 PART 1 . PROJECT INFORMATION APPLICANT I SPONSOR St..O 2. PROJECT NAME lJ0-tC+ I~~d. 'Q.e~-h,ro-..A~' 3.PROJECT LOCATION: Y'"70 M t- 111\,.11: Mt.::\-h'L.-L Municipality ~p \::.. -, l...\... County 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks ete - or provide maD 5. IS PROPOSED ACTION: New o Expansion D Modification I alteration 6. DESCRIBE PROJECT BRIEFLY: t)......P(:..e, t:4.~~r",-~", N v-:>ku--c.. -H'ces d B('~ WI\-s, CIA+- KeCy-~ <-h :P/l\').)-\--'"l'tJ ? 1f\-r-1 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? DYes ~NO If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY rzrReSidentia, D Industrial D Commercial OF PROJECT? (Choose as many as apply.) DAgriculture D Park I Forest J Open Space D Other (describe) 10.'DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) 0~~s _ 0 No If yes, list agency name and permit I approval: 5'"~<Jt,,l,{ICW,.( *\Jl-1>te . ANY A::iPI:.(.;1 01- IHI:. ACtlUN HAV!:: A (.;URRENTLY VALID PERMIT OR APPROVAL? DYes 0NO If yes, list agency name and permit I approval: 1 .. 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION? es DNa I CERTIFY THAT FORMATION PROVIDED ABOVE IS TRUE TO T[lE BEST OF C>L011 ~~-tT MY KNOWLEDGE Date: _ 0"'" 'l--U , Applicant I Sponsor Name Signature If the action is a Costal Area, and you are a state agency, plete the Coastal Assessment Form before proceeding with this assessment ? . . PART II - IMPACT ASSESSMENT (To be comDlete~ead A~ A_ DOES ACTION EXCEED ANY TYPE !THRESHOLD IN 6 NYCRR, PAR, 011.", If yes, coordinate the review process and use the FULL EAF. OVes ONo 8. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NVCRR, PART 617.6? If No. a negative declaration may be superseded by another involved agency. o Ves ONo C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be han~wrjtten, 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 ~--^ -- .-0- u --.-....- .---. ----. _n .- ----- I C4. A community's existing plans or goals as offidatfy adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly: I C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: I C6_ Long term, short term, cumulative, or other effects not identified in C1-C5? Explain briefly: I I C7. Other impacts (including changes in use of either quantity or type of energy? Explain briefly: I ] D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA fCEA)? . {If ~es, eX~lain briefly: I o Ves D No I E. IS THERE, OR IS THERE LIKELY TO BE. CONTROVERSV RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Ifyesex~lain DVes DNO In I . PART III. DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whetheril is substantial, large, important or otherwise significant. 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 (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-d-etemlfAatiQA-E>f-si9Aif~AGe-must-evaluate-the-peteAtial-imFl8et--eHhfrpfepes-efr-aetiefl--e-fHh-e-eftvircflFfle.ntaf-eha-raeteristies-o-tttte-eEA. Check this box if you have identified one or more potentially large or significant adverse Impacts which MAYoccur. Then proceed direclty to the FUL EAF and/or prepare a positive declaration. - ~ - Ched<ThTsbox if you'have-'d'etermmec( ba-sedon the }nformation an(f~n:;alysls -above and-any supporting do-cumenta:tlon, fhaTthe proposeda'Ctlo- 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 Print or Type Name of Responsible Officer In Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) j. ~ Board of Trustees APPliC~ion County of Suffolk State of New York 5co-rt Ed~ -Jt- BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEIvffiNTS 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 PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REV. OF THIS APPLICATION. ~W ~ Signature SWORN TO BEFORE ME THIS ;}Ili!- DAYOF id.n'""J20d7- , MElANIE DDRDSKI "OTARY PUB L1C, State of New M No. 01004634870 . Qualifleef.iii E~ffelk ceunrc~, \ "- CofllllllSseon Exjllres September O.~ '-' ;.,,,,,. I eeoard of Trustees APPlic.n AUTHORIZATION (where the applicant is not the owner) ~ I, SLo1t ~d~+T- (print owner of property) residing at ~ Yu k 11.1..4 \V\~th.~t.( (mailing address) Sc"f/- ccl~ do hereby authorize~c>"~^lll.-l 't."\A-~~ (Agent) to apply for permit(s) from the d of Town Trustees on my behalf. 8 ; . . , APPLICANT! AGENTIREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The TOVrll of South old's Code of Ethics Drohibits conflicts of interest on the Dart of town officers and emolovees. The Durnase of this form is to orovide information which can alert the town of oossib16 conflicts of interest and allow it to take whatever action is necessary to avoid same. ' YOUR NAME: (Last name, first name, JTliddle initial, u~less 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 Variance Change of Zone Approval of plat Exemption from plat or official map Other (Jf"Other", name the activity,) Building Trustee Coastal Erosion Mooring Planning Do you personally (or through your company. spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town oJ South~ld? "Relationship" includes by blood, marriage, or bus"iness interesl "Business interest" means a business, including a p:lrtnership, in which the town officer or employee has even a partial ownership of (or employment by) a corporation in which the lawn officer or employee owns more than 5% of the shares. YES NO If you answered "YES", complete the balance of this form and date and sign where indicated. Name ofpers.on employed by the Town of South old Title or position ofrhat person Describe the relationship between yourself(the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or descf!be in the space provided. The to\vn officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): _A) the o.wner of greater than 5% of the shares of the corporate stock of the applici;lnt (when the applicant is a corporation); _B) the legal or .beneficial own~r of any interest in a non-corporate entity (when the applicant is not 3 corporation); " _C) an officer, director, partner, or employee of the applicant; Of _D) the actual applicant. DESCRIPTION Of RELATIONSHIP Submitted this _day of Signature Print Name 200 Form TS ] , " \. ---- --._-- - 1-1- B- 0<,0 --:r-- S'co1f €dr-tt ~ 'V-G)"+- ().{' ~ t c..- 70 o ~ . Mj r ' c fkr . 0 a. J ~A-H, ~ck ,,-,I y If'j')/- f [~5 E ChAt><cJ pi./( ~ ~ CJc<-~ k'('J . [<=] 200 lp ~ - --~~ . '" ~,,-<;-kes r',..;spe(f,q ~A-P [c L A:-.v "'~ . ~~l 'L'))" tfD"L8 nr:-Jh/ ~ /