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Home My WebLink AboutTR-6603 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 # 0245C Date September 7,2007 THIS CERTIFIES that the upper timber retaining wall and lO'non-turfbuffer landward of the retaining wall At 8180 Peconic Bav Blvd. Laurel, Suffolk County Tax Map # 126-11-18 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 4/23/07 pursuant to which Trustees Permit #6603Dated 5/16/07 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 the upper timber retaining wall and 10' non-turf buffer landward of the retaining wall. The certificate is issued to GUIDO & MARGUERITE DOSSENA owner of the aforesaid property. r07~ Authorized Signature ---- \....._" TERMS AND CONDITIONS The Permittee Guido & Marguerite Dossena, residing at 8180 Peconic Bav Blvd" Laurel, as part of the consideration for the issuance of the Permit does understand and prescribe to the following: 1. That the said Board of Trustees and the Town of Southold are released from any and all damages, or claims for damages, of suits arising directly or indirectly as a result of any operation performed pursuant to this permit, and the said Permittee will, at his or her own expense, defend any and all such suits initiated by third parties, and the said Permittee assumes full liability with respect thereto, to the complete exclusion of the Board of Trustees of the Town of Southo1d. 2. That this Permit is valid for a period of 24 months, which is considered to be the estimated time required to complete the work involved, but should circumstances warrant, request for an extension may be made to the Board at a later date. 3. That this Permit should be retained indefinitely, or as long as the said Permittee wishes to maintain the structure or project involved, to provide evidence to anyone concerned that authorization was originally obtained. 4. That the work involved will be subject to the inspection and approval of the Board or its agents, and non-compliance with the provisions of the originating application may be cause for revocation of this Permit by resolution of the said Board. 5. That there will be no unreasonable interference with navigation as a result of the work herein authorized. 6. That there shall be no interference with the right of the public to pass and repass along the beach between high and low water marks. 7. That iffuture operations of the Town of South old require the removal and/or alterations in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstruction to free navigation, the said Permittee will be required, upon due notice, to remove or alter this work project herein stated without expenses to the Town of Southo1d. 8. The Permittee is required to provide evidence that a copy of this Trustee permit has been recorded with the Suffolk County Department of Real Properties Office as a notice covenant and deed restriction to the deed of the subject parcel. Such evidence shall be provided within ninety (90) calendar days of issuance of this permit. 9. That the said Board will be notified by the Permittee of the completion of the work authorized. 10. That the Permittee will obtain all other permits and consents that may be required supplemental to this permit, which may be subject to revoke upon failure to obtain same. . . 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 May 16, 2007 Mr. & Mrs. Guido Dossena 8180 Peconic Bay Blvd. Laurel, NY 11948 RE: 8180 PECONIC BAY BLVD., LAUREL SCTM#126-11-18 Dear Mr. & Mrs. Dossena: The Board of Town Trustees took the following action during its regular meeting held on Wed., May 16, 2007 regarding the above matter: WHEREAS, GUIDO & MARGUERITE DOSSENA applied to the Southold Town Trustees for a permit under the provisions of Chapter 275 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated April 23, 2007, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator for their findings and recommendations, and, WHEREAS, in accordance with Chapter 268, said application was found to be Exempt from the Local Waterfront Revitalization Program policy standards, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on May 16, 2007, 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, 2 . . WHEREAS, the structure complies with the standards set forth in Chapter 275 of the Southold Town Code, 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 GUIDO & MARGUERITE DOSSENA to remove and replace the existing upper retaining wall using timber, and backfill, with the condition a 10' non-turf buffer is installed landward of the retaining wall, and as depicted on the plan received on April 23, 2007. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of $50.00 per inspection. (See attached schedule.) Fees: $50.00 Very truly yours, Jamek 57 ~ President, Board of Trustees JFKllms . . ,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 TO:~d & 'V- Yvlt'lJ) ~ l , n" 1-0 tDo~f1Q Please be advised that your application dated '1/ JJJ 07 reviewed by this Board at the regular meeting of 57/hlo7 following action was taken: has been and the ( ...../..) Application Approved (see below) (_) Application Denied (see below) L-) 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 Chapter 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: '1t naJI (~~ -.q S1J. OU TOTAL FEES DUE: $ S'b/(Xj BY: James F. King, President Board of Trustees . . 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 Inspection/Work session Report Date/Time: GUIDO & MARGUERITE DOSSENA request a Wetland Permit to remove and replace the existing upper bulkhead using timber, and backfill. Located: 8180 Peconic Bay Blvd., Laurel. SCTM#126-11-18 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound ~ _Bay Distance of proposed work to edge of above: P~ofTown Code proposed work falls under: _Chapt.275 _Chap/I_other Type of Application: _ Wetland _Coastal Erosion _Amendment _Administrative _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'lWl 1w-,.(:' J.,,~ No (C f\ -fr s h..t..1h (~ Tn (I ~u . . Telephone (631) 765-1892 Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Wed., May 9 2007, the following recommendation was made: Moved by Don Wilder, seconded by James Eckert, it was RESOLVED to SUPPORT the Wetland Permit application of GUIDO & MARGUERITE DOSSENA to remove and replace the existing upper bulkhead using timber, and backfill. Located: 8180 Peconic Bay Blvd., Laurel. SCTM#126-11-18 Inspected by: Don Wilder The CAC Supports the application with the Condition of a 15' non-turf buffer and no treated lumber is used. Vote of Council: Ayes: All Motion Carried New York State Department of Environmental Conservation Division of EnviiOnmental Permits, Region One Building 40 - SUNY, Stor~y BmoK, t-JeV'l York. ."! 1790-235G Phone: (63"1) 444-0365 . FAX: (631) 444-0360 Website: www.dec.state.ny.u3 ~ ..... ~ Erin M. Crolty Commissioner j..etter of Non-Jur1?cjiction - Tid"IV>,ietlands Act January 31, 2002 Guido and Margaret Dossena 70 Magnolia Avenue (,arden City, NY 11530 Dear Mr & Mrs. Dossena: Re: Dossena Property, 8180 Peconic Bay Boulevard, Laurel SCTM: 1000-126-11-18 DEe No. 1-4738-01477/00005 Based on H',e information you !lave submitted, the New York State Department of Environmental Conservation has determined that the property th"t Is landward of the pre- existing (prior to 8/20/77) bulkhead. which is rnore li'lall 100 feet ill length, as shown on the Infrared photograph. No. 323, maintained by NYS DEC Bureau of Marine Habitat Protection at Stony Brook, is beyond the jurisdiction Of Article 25 (Tidal WetlandS) Therefore, in accordance with the current Tidal Wetlands Land Use Regulations (6 NYCRR Part 661), no permit is required under the Tidal Wetlands Act. Please be advised, however, that no construction, sedimentation, or cilsturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundary, as indicated above, without a permit. It is your responsibility to ensure that all necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within tidai wetlands jurisdiction which may result from your project. Such precautions may inciude maintaining 8n adequate work area between the tidal wetland jurlsdiclional boundary and your project (i.e., a 15 to 20 feet wide construction area) or erecling a temporary fence, barrier, or hay baie berm. Please be further advised that this letter does not relieve you of tile responsibility of obtaining any necessary permits or approvais from other agencies. Very truly yours, _ i /;~'i ~; (,~'/ If _'~ -w _ . ,.~'c':;',?-.l,j-. f " t~'VV. '\.?~ - - George W. Hamma!ih Deputy Permit Administrator cc Bureau of Marine Habitat Protection . . 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 EMERGENCY WETLANDS PERMIT Permit No.: 6564E Date of Receipt of Application: April 18, 2007 Applicant: Guido & Marguerite Dossena SCTM#: 1000.126.11.18 Project Location: 8180 Peconic Bay Boulevard, Laurel Date of Resolution/Issuance: April 18, 2007 Date of Expiration: N/A Reviewed by: Trustee James King Project Description: A temporary patch to the upper retaining wall. Findings: The project meets all the requirements for issuance of an Emergency Wetlands Permit as determined by the Board of Trustees. The issuance of the Emergency Wetlands Permit allows for the operations as indicated on the application received on April 18, 2007. Special Conditions: A full Wetland Permit must be obtained in order to conduct any further activity on the bulkhead and/or other shoreline structures. This is not a determination from any other agency. Jal:::in::::2t Board of Trustees -r-' .~'r~ 7f:C.ON {c.. .,1 _ r - ~. 2.3*" ;"ll<1lN T" """"N 85":!-' 1'0("<1, I. lB 'P '" <:! ~ r - >.>-\ ~'(o.fF' J.;sr' EX_ HOLlSe L.. ~:l t.' , . ~ t: -'d.s. .. ...'r ;-~~ ~ :;. :ll~~ _:.~ .. , -...~ u. 1=' ~h 'Z . ~ - () ... - ".Ii "!r.l ~~ FEEr o ZJ:> 'iD ~\c.. '7t:.lO -J>~b -VOv.\...e. 0):-\ ~ ~ ., p ~ ~ I j;:. - l . t 't . . f '. "'--1- ,,- , \[.; - - - I L ~. I c- ck Y.C I '30" 1-' r--- e! r-__I 5l.tFFOLr: [.0. H...{G,STl2.on n.A1> Z~ I" -::. .3000' 'r o ~ ~;} ~I;; "'z .J"~ "II> NOTES: I. ))ftUK, ....LW 2.. Plo\1tPo~,,> E"12oSION (.~L. 3...AL.L-TI>-\Bell n I3s c:.c.:..0I. TJZ.Il.A'TEl> 4. 'PlZ.OZet-T /..DU ..o-N Pete,..,!: ~'/ BL.\It> h..4 'TT1 TU.(I(, N,-/ I 1 'is'''' ScrM.# /000- /zt. -1/-/8 5.,'Il'~,UENT ~"'e~s I.II.)1Z.( 11 P'uAl I 2. . 05 LER. CI. 11 C.'i. C-L.E.AN .:s....Nl:> TO Be- ~UUCE"t> IN Fl<.<l1-1 ..4"l Lc.PL...AI'oIt> So.U>c.Er ... :, "'~..a ~-\)- =N \- '0 -5 ~3 ~ti: ..a ;j .. '" ~~ ::s... ",-=- " 1: - .s'-' 3 ,H i=~ ~~ -'<, \-..J ",/4 ..,w \r;r.L 1'KO:PO.5Eb BUI..XtfE:..4)) 12.E:f:'>LAc.E;Mf:.NI [IIC/If') FoR. [.VE-L'fN STe;W..A i2.T ON J:>C:CONIC. !5.4'1IN f-1 ..ATT ITU('( J S 1..1 FFOLi( (.0., N' Sf-IE:8T lOFI IIf'51'tt, .. . '. . Board Of Southold Town Trustees SOUTH OLD, NEW YORK PERMIT NO. '. 4ft:> B':y ISSUED TO ....EVELYNSTEWART 1\utl1nriluttnn DATE: ..11125J96. Pursuant to the provisions of Chapter 615 of the Laws of the State of New York, 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 .JJ/4419..6. i 1996, and in consideration of the sum of. $1.00.00 paid by .. .....En:::Cons.u1:t.an.t.s....Inc.........fQr ..EVELYN ..STEWART of....Ma.t.tituck.. . ....... ... ................... N. Y. and subject to the Terms and Conditions listed on the reverse side hereof, of South old Town Trustees authorizes and permits the following: Grandfather Permit to remove and replace inkind/inplace 95' . , of existing bulkhead. baakfill with 17 c.y. of sand to be truckedi~ .', in from upland source. : all in accordance with the detailed specifications as presented in the originating application. IN WITNESS WHEREOF, The said Board of Trustees '-re- by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date. ~?:/~f{ .,.~..,~." .,m."~7..=~ e. . "'. e,-. fD) IHCl m 0 WI m fn1 lJl1 DEe I 6 1996 ~ TOWN OF SOUTHO~..R! December 13, 1996 George E. Pataki Governor Alexander F. Treadwell Secl'etary of State Albert J. Krupski, Jr. Trustee, Town of Southold 53095 Main Street P.O. Box 1179 Southold, NY 11971 Re: F-96-706 U.S. Army Corps of EngineerslNew York District Permit Application - Evelyn Stewart, Peconic Bay Dear Mr. Krupski: Enclosed is a copy of the information submitted to the Department of State for review of the above-referenced project with respect to its consistency with the Coastal Management Program for your information and preliminary review. Please contact William Feldhusen, the DOS reviewer assigned to this project, at (518) 474--6000 to discuss your concerns, and any additional information which may be necessary to assist you in reviewing this project. Any comments you may have will assist the Department in reaching a decision as to the. consistency of the proposed action with the approved NYS Coastal Management Program. Please note, however, that if we do not hear from you within 45 days of the date of this letter, we will presume that you have no objections to the prOP.OSed project. ~. ~At:.\' Cl [, j1lI""" \j. '! \. ~jf !dJJ William F. Barton Chief, Project Review and Analysis Bureau Enclosures WFB:dlb NYS DEPARTMENT OF ST....TE DifJision of Coastal /hsOllrcu and wllterfront Revitalization Albany. NY 12231-0001 Voice: (518) 474-6000 Fax: (518) 473-2464 .. e: December 18, 1996 NYS\\,/h'ljJ ()tl!~ George E. Pataki GO'tJeTnor Alexander F. Treadwell Secretary of State Roy L. Haje, President En-Consultants, mc. 1329 North Sea Road Southampton, NY 11968 Re: F-96-706 U.S. Army Corps of EngineerslNew York District Permit Application #96-13650- L2 Evelyn Stewart, Peconic Bay Town of Southold, Suffolk County Dear Mr. Haje: The Department of State has received the information you provided on November 25, 1996 describing the above proposed project. We have been informed by the U.S. Army Corps of Engineers that your project was authorized under an existing Nationwide Permit. Therefore, no further review is required by this Department. We appreciate your referring this information to the Department of State for review. Sin~J ~ 'illiam F. Barton fA Chief, Project Review and Analysis Bureau WFB:WF:dlb cc: COElNew York District - Denise Butts DEClRegion 1 - Regional Permit Administrator Town of Southold - Albert J. Krupski, Jr. NYS DEPAKTMENT OF STATE DioisiOll of 0JitstAl.R.smm:a ad WlUtfront Reuu.Jizati1lll AllNny,NY 12231-0001 Voice (518) 474-6000 Fax:: (JI8) 473-2464 liL i i.1 Ig I ",.,:1 #' ; I )' 0/ ..' t ~~~:. e ~ ;1 lljl ~H ;11.1 ~ ~ ~ ~ i Ii i ie. .. ~..;~ d Ill:; " ~*il. i' , I , I I I I ; ~ ! n! ~ l } I Ii i ii ! , ~ IJf -. ',. ~ ~ J:' .'1 " i , , " I' ., 1 !~ '. !i< ,1 . . ~~ ~~ I ~"J-Z ~ I . ~ ~ w i -+~ N . rl , ~ i~ i ~ . . I I ~ ' . 8j~ ~.~h ~~ji i!5- . ~-"'Jj ~~ ~d::~ uJ1.! e ~Ifi ;~ ~~ ~ 11m \i' ~ ~ ~ ~: I,!ii ~In~ !!jIIIJ ~HiH~ 1;lj11 . J" :!1' i ~d~g!i i i ii! iliii ! . ; ~ ~ i:tq 'I" !I,ll 'II i i i ~ " . " . ~ i i i Ii i ~~.~!~~ l~nH LH!J Ie!!! I! I Iii , !,; I, j id " ~ : !a'Jp 1 . .t .ti l jl , ~~1~. '! 'i ~ ] I J II :' ~ I,' r..: Ii d. ii!" " : ji! ~~i . ~lii'i! H!!l -'WU...Jzc -11~ , , i . ,~- ~~~ ijl~:!: B'i! --2'--- t.W;;:~ " . . '% ~ - ~~~ ,~\ ~~* ~!lIt. --------.om;- l!!il~ -----.,.,---- ~d ~t!l; -z --- . . OFFICE WCATION: Tawn Hall Annex 54375 State Route 25 (car. Main Rd. & Yaungs Ave.) Sauthald, NY MAIUNG ADDRESS: P.O. Bax 1179 Sauthald, NY 11971 Telephone: 631 765.1938 Fax: 631 765.3136 LOCAL WATERFRONT REVITALIZATION PROGRAM COORDINATOR TOWN OF SOUTHOLD MEMORANDUM To: PI: I: 1(.... !~ r !l.:I,"c, .", b '_ :l i ~ Ii" MAY L (r' ., ,~! ! Jim King, President ~ Town of South old Board of Trustees From: Mark Terry, Principal Planner L WRP Coordinator j0n7 .uu ,~- / ~(jI;JIGI(/ I(h.-- '___ >-.'::~~,:, "f r"I),;k Date: May 2, 2007 Re: Request for Wetland Permit for Guido and Marguerite Dossena SCTM#126-11-l8 GUIDO & MARGUERITE DOSSENA request a Wetland Permit to remove and replace the existing upper bulkhead using timber, and backfill. Located: 8180 Peconic Bay Blvd., Laurel. SCTM#126-ll-18 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of South old Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is exempt from review pnrsuant to Chapter 268-3, Exempt Minor Actions, item B which states: "Replacement, rehabilitation or reconstruction of a structure or facility, in kind, on the same site, including upgrading buildings to meet building or fire codes, except for structures in areas designated by the Coastal Erosion Hazard Area (CEHA) law where structures may not be replaced, rehabilitated or reconstructed without a permit". Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. e . James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Joho Holzapfel Town Hal! 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 AP'. 3 2007 D _Coastal Erosion Permit Application ;;;;;Wetland Permit Application _ Administrative Permit AmendmentfTransfer/Extension ~eceived Application: f.//J."Vo) ____ Received Fee:$ .2'\tY _ ~mpleted Application 1f/:k7:JlrsJ _Incomplete _SEQRA Classification: Type I_Type II_Unlisted_ Coordination:( date sent) ---- LWRP Consistency A~~essment Form If/J.i3/()7 _-€"AC Referral Sent: '/JiL~07 ~te ofInspection: 5J9/w _Receipt ofCAC Report: _Lead Agency Determination:_ _Technical Review: ~lic Hearing Held: 'ill ~I 01 _Resolution: Southhold Tow. Board ot Trustees ~ $1(, ~%r') -D~'/'I Name of Applicant (17\..l ide> ... J-.-\ev-o' ut'(';\c. ~S:eY\a ~ Address ~l80 Pert"'lV'tc. B2>~ ~\~ l:orove..\ ,Uy \~ Phone Number:~\) ~e \ <tB~ Suffolk County Tax Map Number: 1000 - \~ 1\ Ie Property Location: L\Lr (') \>v\c.. ~~ \ -) sou\l.....lde.. o~ V"1.e '"'~ f e... e LILCO Pole #, distance to cross streets, and locat on) .,., ~,..""^ \ (" AGENT: (If applicable) ~~-61 LJ ~'f Address: Phone: "'ard of Trustees APPlicat~ GENERAL DATA Land Area (in square feet): 30 I O~4 . '3Q SC{' t + Area Zoning: ~ - 40 Previous use of property: S\~ eo ):ar>\; \ ~ ~eS\Qe~~ \ Intended use of property: 100 ~"'a~Q Covenants and Restrictions: Yes If "Yes", please provide copy. No 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? ~No_ Yes If yes, provide explanation: Project Description (use attachments if necessary): ....f;'I"c.... \o",\\.b:rl (..t..\~\,^I"~ '"'~\~) ~'N1a~ a~ ~~~1'JC.t'. el<l<;:,..\.'lV\6. ~alM.=lr~~ J' a.M 'o::!r\.S.\\. l b \'Io,.~ CCAAc::...~~~~O". "'ard of Trustees APPlicat~ WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: H.lI"..p65e \<. ex'o<;\ 0(\ r(')V\~'("d\ 0\'\ V>1tr\V\ \a'V\~ 6~. Area of wetlands on lot: o o square feet Percent coverage oflot: % Closest distance between nearest existing structure and upland edge of wetlands: I-J A feet Closest distance between nearest proposed structure and upland edge of wetlands: )..:)A feet Does the project involve excavation or filling? No Xl Yes If yes, how much material will be excavated? How much material will be filled? \ "::<0 cubic yards cubic yards I Depth of which material will be removed or deposited:~ .... - feet Proposed slope throughout the area of operations: }jo CVu,Wl e- o Manner in which material will be removed or deposited: ~a\t."'\e\ \.1..1;\\ '0(.. A"'r-\\d ~ ~ tN"J~. 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): "'ard of Trustees APPlicat~ COASTAL EROSION APPLICATION DATA Purposes of proposed activity: \>l.JvVX'c;.e C;>V) Wtz \ If\ \ d \l\C\ )'S eOCOS\(",Vl ec,,,,-;~o , o'<'€< Are wetlands present within 100 feet of the proposed activity? ~ No Yes Does the project involve excavation or filling? No)( Yes If Yes, how much material will be excavated? 0 (cubic vards) \20 (cubic vards) - ~ How much material will be filled? Manner in which material will be removed or deposited: }-\Zl-k'l'le\ W\\\ 'oe. ~~s~U ~~ ~uc\... Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) . . PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS US Postal Service, , CERTIFIED MAIL" RECEIPT (Domestic Mall Only; No Insurance Coverage Provided) <0 <0 "" ru -II ..0 lJ1 CJ U.S. Postal Service '" CERTIFIED MAIL" RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) 0019 01 lr ddr~ "" -II -II lJ1 CJ Certified Fee ltlO Iii if 1i9i: iAihlit 1M 1'- SentTo,^f\b: 0 _ ~ Sireer.ApTN~--- - .....h:;.l.\e.:___n___... m..__n_____..__._______________.__. 1'- 0' PO Box No :G.,,), a}:t c1t.Y:srate,"Zi;;"4U_' _". n_ _n ". n..........___n._._n...UU__U.....nhn_. Postage $ $0.39 S2.~ $0.00 SO.OO S2.79 Certilied Fef' rn o Return Receipt Fee ~ (Endorsement Required) I Restncled Delivery Fee o (Endorsement Required) ! ru ru Total Postage & Fees $ CJ Postage $ 0019 01 Postmark H,~ Postmark Here rrl Return Receipt Fee g (Endorsement Required) o Restricted Delivery Fee (Endorsement Required) 04/19/2007 CJ ru ru CJ 1'- CJ CJ 1'- ent 0 Total Postage & Fees $ STATE OF NEW YORK COUNTY OF SUFFOLK &'dl..? ~~W- ~",I/'t.\ ,U"t ~ day of ,II" "', / , 200;>., deponent mailed a true copy of the Notice set forth in the Board of Trustees Application, directed to each of the above named persons 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 South old; that said Notices were mailed at the United States Post Office at , that said Notices were mailed to each of said persons by (certified) (registered) mail. , residing at 9\80 ~coV\tv Ba~ \S\v~ , being duly sworn, deposes and says th on the .)C"'':'1>''''I~ Sworn to before me this ~ f Day of # 0 ,201'r? rrv-^~ Not PublIc L" ..J. I' MILAGROS HILt~~~ York Notary Public,State 0 13 No 01HI60B40 n\ Qua1i1i~d In l(mgs $~~k toun~ Certifi,ca,te fElIed'r~~ ~~:ember 25, 2D CommIssion Xpl "'-.J . James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, JI. . 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 BOARD OF TRUSTEES: TOWN OF SOUTHOLD --------------------------------------------------------------- In the Matter of the Application of ---~Lti:_~---~~tt.._~rzq COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, G vi 1,-, 1)05S€Vla..,residingat g/ go "Pe(!'Orllt" 1/9L/? Pw. 1/ , RIve! i.au~ei J,.) y being duly sworn, de'pose and say: That on the;;l '1 day of lirA; I , 200'Z I personally posted the property known as 1?1;?O Pe(!o.-fic 134-V ,fJ/..,J ,,"11.)/1,*-1 NY //530 by placing the Board of Trustees official poster where it can easily be seen, and that I have checked to be sure the poster has remained in place for eight days prior to the date of the public hearing, Date of hearing noted thereon to be held Wt:d, /n(J{ I J /~, an)? - m ~l I o.Oov:t-~:30 ffll Dated: (JIJ 0. '/ /0 I ~ 0 0 Q Sworn to before me this I ti"'\Iay of m'j 200 q. ~99~- N tary Publi 4~~.> tJ(~ ( signature) KATHLEEN A. DUNBAR NaIIry Public. State of New YorII No. 01 DU6087782 Qualllled In Nueau County. /0 CocnmIeelCln ExpIr.. Oat. 28, I PROJECT ID NUMBER . I . 1. APPLICANT I 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. PROJECT NAME SEQR PART 1 - PROJECT INFORMATION 3.PROJECT LOCATION: Municipality Ha\\.;\u~ county$LJt=c>\\<. 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks ate _ or provide map Sc."\1-\ ~ lOO-\U.-IHi. 8\eO ?ec.onk.. E 5. IS PROPOSED ACTION: 6. DESCRiBE PROJECT BRIEFLY: 'R.e-~".. ~ 're-..p\cce... "'-"'<;'\''''<<:' \co rool" ... \"e>\u,<,\'\.. \Sac\):'~ \\ .....~ \\... <!..\e.c", '5;1"'.;'\. J..;.'Ma~e.\ b...\k~d 7. AMOUNT OF LAND AFFECTED: Initially . ~ acres Ultimately . eo acres 6.:::>;L PROPOSEO ACTION COMPLY WITH EXISTING ZONING OR OTHER pYas 0 No If no, describe briefly: RESTRICTIONS? 9. WHAT is PRESENT LAND USE IN VICINITY Residential D Industrial 0 Commercial OF PROJECT? (Choose as many as apply.) DAgriculture 0 Park f Forest I Open Space D Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR UL TIMATEL Y FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ~Yes 0 No If yes, list agency name and permit I approval: 11. DOES DYes ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ~o If yes, list agency name and pannit J approval: PROPOSED ACTION WILL EXISTING PERMIT / APPROVAL REQUIRE MODIFICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF ~. Applicant I Sponsor Name ~ 0 Sc:..~ MY KNOWLEDGE Date L\/ I <:tIC 7- Signature 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 lTo be completed by Lead Aoencvl A. I;>ol\s ACTIQN IlJ;CEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.41 If yes, coordinate the review process and use the FULL EAF. Yes No B. WILL ACTlcfj 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 DNa C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, 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 neighbomood 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 I C6. Long term, short term, cumulative, or other effects not identified in C1~C5? Explain briefly: I I C7. Other impacts (including chanQes in use of either auantitv or e of ener ? Explain brieflY: 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 brieflv: I DYes 0 No I E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If ves explain: DYes DNo I I PART 111- 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 (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 determination of significance must evaluate the potential impactofthe 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 EAF and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation. that the proposed actio 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 Pnnt or I ype 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) . . Board of Trustees Application County of Suffolk State of New York <::,;",\ ~<;'">E''''-'''' BEING DULY SWORN DEPOSES 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/HERKNOWLEDGE 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. - ~C;$clc Signature SWORN TO BEFORE ME THIS 1) Cf DAY OF g.o ,20V ~ ~/~ , Notary Pub . ~ I MllAGROS HilARIO . f New York Notary Publlc,State 0 No. 01HI6084013 Qualified iii ,Zings County Certificate filed_ In New York Co~ntYa:J Commission Expires November 25. ;:.OrV . . APPLICANT/AGENTIREPRESENT ATIVE TRANSACTIONAL DISCLOSURE FORM The ~o~sOfS;~th~~'~ c:e of Ethics Drohibits conflicts of interest on the Dart of town offieers and emolovees The DUroose of this fi nn' to vi i fo alien which can alert the town of oossible conflicts of interest and allow it to take whatever action is necessarY to avoid same. YOUR NAME: (Last name, first name, J,TIiddle initial, unless you are applying in the name of someone else crother entity, such as a company. Ifso, indicate the other person's accompany'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 (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 of South old? "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. X YES NO If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person 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) and/or 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% of the shares of the corporate stock of the applicant (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 a corporation); _C) an officer. director. partner, or employee of the applicant; or _D) the actual applicant. DESCRIPTION OF RELA TlONSHlP Submitted this ~ day of ~{i'/' \ \ S. t --- l~na ure .....J.:=..D....-7 ~ ~v~ Prmt Name 200 "l. Form TS I Town of South old . . LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS I. All applicants for permits. including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of South old Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. · Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area (which includes all of South old Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the L WRP policy standards and conditions contained in the consistency review law. Thus. each answer must be eXDlained in detail. listinl! both sUDDortinl! and non- sUDDortinl! facts. If an action cannot be certified as consistent with the L WRP policy standards and conditions, it shall not be undertaken. A copy of the L WRP is available in the following places: onl' website (southoldtown.northfork.net), the Board ofT -- M, \lie I" I local libraries and the Town Clerk's office. \' -' .. \~ ,\ :TM:~ION\~F SfIE; PROPOSED ACTION L ;::;~~l J \ Board olllU~.__," ,. ," PROJECTNAME &<do ~~U4."t<Z 'boS.s2nq -----.~-. d's ent, all The Application has been submitted to (check appropriate response): Town Board D PlanningBoardD BuildingDept. D Board of Trustees LjI I. Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g. capital construction, planning activity, agency regulation, land transaction) D D (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: 0/ Nature and extent of action: mn'G.)Q.\rQP\Qc.. .e.,\Xs.~~ b\l\t~. . . Location of action: 9\~ '?ecUI'\\C ~j '\s\"J -':> Uf~f ~\~\vd\llJ \.,..>~\\ Site acreage: 3(j O<;;,LI ~~ 'Sa .S;-\.. I ' Present land use: S\\r1~e'. 't='a~\\~ ~<;; ~e-0 ~ ~ \ Present zoning classification: R - L\ 0 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Narneofapplicant: C,-l'ido ~ N~v~"'e<;\e.. '\:)e><;.:Se\tlo (b) Mailing address: 8~FS{) \>ef DIj\\(, '6?'~ .)?...\"d t 3u\{"e \ U'i (c) Telephone number: Area Code ( ) 03\ 24..<6 \qg ~ (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes D NO~ If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See L WRP Section III - Policies; Page 2 for evaluation criteria. DYes D No ~NotAPPlicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See L WRP Section III - Policies Pages 3 through 6 for evaluation criteria DYes D No ~ Not Applicable . . Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See L WRP Section III - Policies Pages 6 through 7 for evaluation criteria DYes D No ~ Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III - Policies Pages 8 through 16 for evaluation criteria ~ Yes D No D Not Applicable ...- '\ '\ \Z\'ld ~ c."".,......:,; \ \. . C\h. ..... Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See L WRP Section III - Policies Pages 16 through 21 for evaluation criteria o V.. 0 No ~ot AppH"bl. Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See L WRP Section III - Policies; Pages 22 through 32 for evaluation criteria. D D 'r;tJ Yes No Not llicable . Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies Pages 32 through 34 for evaluation criteria. DYes D No ~ Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See L WRP Section III - Policies; Pages 34 through 38 for evaluation criteria. DYes D No 'fl'Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. D YeD NO~ Not Applicable Attach additional sheets if necessary . WORKING COAST pouls . Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria. DYes 0 No P Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See L WRP Section III - Policies; Pages 57 through 62 for evaluation criteria. DYes 0 NO? Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages 62 through 65 for evaluation criteria. DYes 0 NoFf Not Applicable r Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III - Policies; Pages 65 through 68 for evaluation criteria. DYes 0 No f Not Applicable PREPARED BY TITLE DATE~ . . James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob LTnosio, 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 Pennit Application / '" ll" r..Y.- _Wetland Pennit Application _ Administrative Pennit .. ~nlt.\. f"ov .,~ _ Amendment/Transfer/Extension ~ceived Application: _ ~eceived Fee:$ ~1J ~'~ ~...eompleted Application J J I; _Incomplete _ SEQRA Classification: Type I_Type II_Uniisted_ f>,PR 1 8 2C07 _ Coordination:( date sent) _ L WRP Consistency Assessment Form CAC Referral Sent: -Date ofInspection: Lllrn _Receipt ofCAC Report: _Lead Agency Deterrnination:_ Technical Review: -Public Hearing HeW:3J IK/in Resolution: Name of Applicant Crt/ide.> ...r\2V"~e(';\e. \bsse.1'\d Address 8\~ '?eccnk... 'R:J~ ts\\ld Lau~e\ Dl..( /194'6 Phone Number:(~) ;2Q$'l, \ Ci9~ /51&1 S1-7 03J~ I Suffolk County Tax Map Number: 1000 - /2/0 -1/- JR Property Location: on lie- SOu I-f, sid~ on fe.OOi1/c- 13<1" Bkal, .:J.. v .n'7/k~ e.:J~f- or &~ AI/eI1l~ - l/L({') ~.k w-- 31 (provide LILCO Pole #, distan e to cross streets, and location) AGENT: (If applicable) Address: Phone: ~ard of Trustees APPlicat~ GENERAL DATA Land Area (in square feet): '3() () <at..L.39 Sq, f-t J. , Area Zoning: Previous use of property: \;e<;, \~..~; ".\ Intended use of property: ~e.~1 de....0-;.. \ Covenants and Restrictions: Yes If "Yes", please provide copy. f3 No Prior permits/approvals for site improvements: Agency Date _ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or susp~ed by a governmental agency? No Yes If yes, provide explanation: Project Description (use attachments if necessary): ~e?:;\\V'" c~t'l.n-."c~r ~\, e"r;:>.'<)<;iGIr1 ".... ~''';'''''' l...>o\\. ::, ckn~ *l"' bu\~ \nl~ ",,1.OC'rn. C'l''i\''''\.'('l .r~'c.....~ \>2.\.c..\. LJ('f"-'" '"'Ol.o...... 4Ifoard of Trustees APPlicallJn WETLANDITRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: square feet Percent coverage oflot: % 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? 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 wetl~cls andtidal waters of the town that may resultlJ)' reason of such proposed operations (use attachments if appropriate): PROJECT 10 NUMBER 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only . SEQR PART 1 - PROJECT INFORMATION (To be completed by A pllcant or Project Sponsor) 1. APPLICANT I SPONSOR 2. PROJECT NAME ~icb-4. }--\-'3rooe\l';~c.. ",",OS5e\'1a 3.PROJECT lOCATION: " Municipality County 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks ate - or Drovide map 8\m~V\\c ~~ ~'vd -) <;o,-,""'S\d~ ~~ ~~, .:1 -v>>; \e-s eC35\. a.~ 'C('~ Avenve. 5. IS PROPOSED ACTION: D New o Expansion D Modification I alteration 6. DESCRIBE PROJECT BRIEFLY: "R€.f>a\'I'" ~an>~e.d \'u\"''n~d . I-J" eV(? 3v'\':i ,cll\ . <,r ~ w""\""'uv\",,,,,,,_ 7. AMOUNT OF lAND AFFECTED: Initially acres Ultimately 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.) ~ Residential D Industrial 0 Commercial DAgricu,ture D Park I Forest / Open Space D Other (describe) 10" DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMA TEL Y FROM ANY OTHER GOVERNMENTAL AGENCY (Federal. State or local) DYes DNO If yes, list agency name and permit I approval: rr:-uoE0 ANY A::lPe(.; I Ut-. I He At; liON HAVt. A (.;URREN I L Y VAllO PERMIT OR APPROVAL? ~~- DYes flI No If yes, list agency name and permit I approval: ---. - 12. AS A ritfUlT OF PROPOSED ACTION Will EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION? []ves No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant I Sp~sor Name Date tV /01 - '" <!J<..SeW>. Signature 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 ITo 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 hanQwritten, 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 ^^^-~ I C6. Long term, short term, cumulative, or other effects not identified in C1MC5? Explain briefly. I I C7. Other impacts (including changes in use of either ouantity or type of energv? Explain briefly: 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: 1 DYes 0 No I E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: j DYes ONo I PART 11I- 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 (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 _._--YSE:, the determinatisn Qf si€lniflsam:e mlJst-evaklate-lAe-t3eteA-tial iFRpoet of tMe prepese6~ireftmental chal actcrlsUcs of II 16 aCA. 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 EAF and/or prepare a positive declaration. CheckTflfs"fiox""if you}lave"determTiiecf; bas8cfon"itie)nfor'mation and analysis above and-any supportinii documentation,' that" the-propos-ed a-cUe) 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 Title of Responsible Officer Signature of Responsible Officer 10 Lead Agency Signature of Preparer (If different from responsible officer) ~ Board of Trustees APPli~ion County of Suffolk State of New York Sa\v"e.\c.~ ~~s~r.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, THEIRAGENT(S) OR REPRESENT ATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. --- ~c. ':."'!>~_ Signature SWORN TO BEFORE ME THIS /8~ DAY OF r ,20 f!1 ~{'(}Jaiw _...1. C.... IlOtMY ..-.c.... _ .w VORIC - --No. Ol....~ --- Quol"" ...... County -~ --...,...... ---..._~ --------- : . . APPLICANT/AGENTIREPRESENtATlVE TRANSACTIONAL DISCLOSURE. FORM The Town of South oJ d's Code of Ethics orohibits conflictq of interest on the Dart arroW" officers and emolovees. The ouroose of this fonn is to nrovide information which can alert the town of DOssible conflicts of interest and allow it to take whatever action is necessarv to avoid same. . YOUR NAME: c:"(..>~....H.,,~,,\k ~e~;;! (Last name, first nar6e, .lpiddle initial, ~less you are applying :10 the name of someone else or other entity, such as a company. Ifso, indicatethe 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 Of official map Other (If "Other", name the activity.) re.~2-\"'" Building Trustee Coastal Erosion Mooring Planning ~ d2-,",,~...d \'"\\..\"",,J 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 bus'iness 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. ~ ~ ~ If you answered "YES'" complete the balance ofthis form and date and sign where indicated. Name of person 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% of the shares of the corporate stock of the applic~nt (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 a corporation); ~ C) an officer. director, partner, or employee of the applicant; or _D) the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted t~ _day of A('l'; \ Slgnatufvo- "--o.~a Print Name 200~ Form TS 1 , .. - Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson . . Town Hsll 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 OTHER POSSIBLE AGENCIES YOH MIGHT HAVE TO APPLY TO N.Y.S. Dept. of Environmental Conservation (DEC) SUNY,Bldg.40 Stony Brook, NY 11790-2356 (631) 444-0355 Mon., Wed., Fri., 8:00 AM-3:00 PM Suffolk County Dept. of Health Services County Center Riverhead, NY 11901 852-2100 U.S. Army Corp. of Engineers New York District 26 Federal Plaza New York, NY 10278 212-264-3912 N.Y.S. Dept. of State Coastal Management 162 Washington Ave. Alb~___m 518-474-6000 · t:I J 'w \v.Ja"Y' · J.-{UjeJ , ,4",.1 PeL~... c:~ \ ~~S .:2. 60 a> . k C~Jy (; 3/ ~ /17;2 6~ \ '-('if 'l:i.;L~ SIlo 7ft) f3JS r-:' , ,--./ ,~ 1'6[.0 N I c." "J.. J ,...-' , '- / 1 t~--::::-' - J. cIIC ~,~~ "'1Fn, i \' I lO'. - I It.; .' I I " l i \ ;(- \r.1 r' I i:!'.- , V,(G I '3a' rl I e- I , ..., - - - -- (.2,Jl' ;"n<lIH 'JlI !rlAl1ol &st' 1\ -PO/'e'" Ell, HOl.(Se SLj,f' FOL.t: CD. I-/Ar"STJ2.D11 t1.A'P Z~ I" ... .3000' \ . ~"""''l''>Se: e,("OS\o,<\ 1:0\'\\\('0\ ~. )..\\ ~~",,\e.. .\."Q,I.e~ ~. ~vc,\U.\ LCJca~i'c.'" ~ 8\~~..~c- ~'-\ ~\".:\ Hz\\:l.,\:.. 1--1,<' \\ "\S:< sc:.;n...... lace - \.24- II - \~ 4.AJ\~~c~ ~~~~\O~s . Po\"'.. . Os.\<t..- ~ S. c.~ +:\\ ~ \,e,. ~ ~ t"'....c\c..J;'" C'/!P' ,.. ~i ~.APPROVEDBY '" BOARD OF TRUSTEES TOWN OF SOUTHOLC DATE cV'~7 # z.. lt1~, ~ 0$ ~ ,. ("I .- "i - l!! '. 'Q~ "f . " .:.cf- .J ~ J.- ,;~ ~l r.g, \ -"J ~ 1 - $:" "'-..'".Q ~-<l +1 " ~ J~ .A'''j .jy Fe:er o ~ 'lO ~~ A~R : :G7~ ~ VY'~~o~ec\ bu\ \\te.a~ Y'~\a<:.eW\e~ ~'("' , ll.v,do ... )..jl!o'\rJV_;~L ~O'Sc;~V1~ 0(\ ~\eC) ~e.c:!..oV\\(!' '~3':) \S\~ South Id Town 8<l8rd Trustees ~-J).~ 'DOvJ... (, ~).--\ '7tlOtl-\ ~ ~ Cl