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Home My WebLink AboutTR-6684A James F.King, President �tf SU!/rTown Hall Annex V� 54375 Main Road Bob Ghosio,Jr.,Vice-President h0 l0 P.O.Box 1179 Dave Bergen Southold, New York 11971-0959 John Bredemeyer G e Telephone(631) 765-1892 Michael J. Domino Q a COMM Fax(631) 765-6641 �y �� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD C CERTIFICATE OF COMPLIANCE #0842C Date: March 4, 2013 THIS CERTIFIES that the removal of dead scrubs dead oak tree and replacement with native plants prune existing plantings and replacement of the shingles windows, siding and insulation on the existing dwellingand nd replacement of garage door, 10' non-turf buffer along bulkhead At 3575 Wells Road, Peconic,New York Suffolk County Tax Map# 86-2-10 Conforms to the application for a'Trustees Permit heretofore filed in this office Dated August 10, 2007 pursuant to which Trustees Administrative Permit#6684A Dated August 22, 2009, 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 removal of dead scrubs, dead oak tree and replacement with native plants,prune existing plantings, and replacement of the shingles, windows, siding and insulation on the existing dwellin and nd replacement of garage door, 10' non-turf buffer along bulkhead. The certificate is issued to JOSEPH MELCHIONE owner of the aforesaid property. uthorized Signa re Jill M.Doherty,President SO(/Ty Town Hall Annex James F.King,Vice-President ,`O l 54375 Main Road G P.O. Box 1179 Dave Bergen Southold,New York 11971-0959 Bob Ghosio,Jr. G John Bredemeyer O Telephone(631) 765-1892 Fax(631) 765-6641 COUNT`1,0 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE F INSPECTION: T Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 st day of construction 2 constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: e. -5 C� CERTIFICATE OF COMPLIANCE: i r Jill M.Doherty,President QF SU!/ry Town Hall Annex James F. King,Vice-President ,`O� ��® 54375 Main Road P.O. Box 1179 Dave Bergen t Southold,New York 11971-0959 Bob Ghosio,Jr. G Telephone(631) 765-1892 John Bredemeyer 'Q Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE F INSPECTION: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 st day of construction '/2 constructed Project complete, compliance inspection. INSPECTED BY: ` COMMENTS: /9 CERTIFICATE OF COMPLIANCE: " Survey of Properly W E _ Surve��{{ed: June 5, 200-7 s 5LT# 1000-8(9-2-10 Situate: F'econic N 't a o Town: Southold �a 5uffolk County, NY m � Josed nd� or For rner�y ofE c E U pa S69029�4o► ormeAy6 Krr,9e�p�er 11F _ 30' Cf, JAN 2 2 2007 �.s,- � �gsoy j5 ��a•. Pen I�r along Fac Southold Town Board of Trus#ees Q tt__ d e � eau ��►__ � a o � Q UVU LU ® s gioh r L/o. 8 Acres- Itz __-_ 1 LU IX CIN ® i9, nrL ® ® C') i CL z 0C--j m C--ILMI I L f g Pobq,,q, geon^ ® eoIv 4 0 masonry 4; � �^ryj�r� � Gertifled to: Joseph Melchlone Sherri Melchlone g Beth age Federal Gredit Union r Landamerica Commonwealth bp p t� 'Unauthorized alteratbn or adtlitlon to a survey �i , be\ mop b.-L lg O ILe�,ed Ionil 55fvByOr5 Seal 15 O 'x '�� vblatlor of SBLtIOn-1209,Sub-divl5bn 2,OF the tt New York State Education Law 'Only copies From the orlglnal of this survey marked Y� tt with an origlnal of thB gond surveyor's stomped ROBERT H.FOX seal shall fie considered e,be valkt true copl.5" 3',t NYS PLS#50197 "GertiFiLations Indicated hereon signify that this 9 t survey was prepared h accordance with the ex- \', S ti ' P 0 BOX#538 (sting God.of P—tice for Land Surveys adopted v� t RIVERHEAD f the Naw York State A55oLlOLlan of Professional ' Land Surveyors Sold certifications shall run only t NY 11901 to th.parson for whom the survey Is pr.p.%', i an on Ls a al to the title company,l�overrvn.n- pq /�/�qq(]/� tol ag.ncy and lending Institution hsted hereon,and 831-722 390 to the asSlgnees of the lending I tltutlon Gertlfl— tiore are not transferonl.w add¢m�l—tit�tiore 6/15/200 11.51 25AM GASLKcastelll pro . 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 _~nstructed L Project complete, compliance 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 SOUTH OLD Permit No.: 6684A Date of Receipt of Application: August 10, 2007 Applicant: Joseph & Sherri Melchione SCTM#: 86-2-10 Project Location: 3575 Wells Road, Peconic Date of Resolution/Issuance: August 22, 2007 Date of Expiration: August 22, 2009 Reviewed by: Trustee Peggy Dickerson Project Description: Remove dead shrubs, dead oak tree, and replace with native plants, prune existing plantings, and to replace the shingles, windows, siding and insulation on the existing dwelling and replace the garage door. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the South old Town Code, The issuance of an Administrative Permit allows for the operations as indicated on the application prepared by Joseph & Sherri Melchione, received on August 10, 2007. Special Conditions: Replace the trees with native species and the addition of a 10' non-turf buffer along the bulkhead. Inspections: Final 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. ~G<~ James F. King, President Board of Trustees JFK:eac . . 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: S~ ~ Sherr,' aJcJ,,'or.€- Please be advised that your application dated ~'1(J...""'+/O)~CXJ '/ has been reviewed by this Board at the regular meeting'ef ~ { . <0;}- c::')O}, c;;2a::J /> and your application has been approved pending the com etion of the following items checked off below. Revised Plans for proposed project Pre-Construction Hay Bale Line Inspection Fee ($50.00) 1st Day of Construction ($50.00) Yo Constructed ($50.00) ~allnspection Fee ($50.00) Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: E7)~ TOTAL FEES DUE: $ -./V 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 July 24, 2007 Mr. Joseph Melchione 4 Mountain View Court Fort Salonga, NY 11768 RE: 3575 WELLS RD., PECONIC SCTM#86-2-10 Dear Mr. Melchione: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Tues., July 24, 2007: RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to Permit #4707 to include the existing 4 Y>' wide steps and place approx. 5 cy. of clean fill behind the bulkhead to replace lost fill, and to Transfer Permit #4707 from Joseph Castelli to Joseph Melchione, as issued on February 25,1997. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765-1892. Sincerely, Ja};;;in;< ~ President, Board of Trustees JFK:lms Telephone'(631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES j /:3/07 ad ~ TOWN OF SOUTHOLD g. M. ~ <9, Ii . Mr..-i- 'f ~ W~::o;g~ ~ Date/Time: 7 1 tJ7 ~: 36 ~ ~d ~. f'~ JOSEPH M LCHIONE requests a Transfer of Permit #4707 from Joseph ~ Castelli to Joseph Melchione, as issued on February 25, 1997, and to Amend f 4'/ e 7 Permit #4704 to include the existing 3' wide steps and place approx. 5 cy. of '( clean fill b.ehind the bulkhead, to replace the lost fill from the 4/15/07 storm(,l. . A IJ _ /I Located: 3575 Wells Rd., Peconic. SCTM#86-2-10 ' "CJ ~tv TypeM area t~be impacted: j . -'"u( . tJ- JJ ~1twaterWetland _Freshwater Wetland _Sound _Bay . t?f:~ -b~.. Distance of proposed work to edge of above: 10 . i. ~. . ~~l a./l.--. Iln. paz{ of Town Code proposed work falls under: 0 ^ .. / C ('" ~Chapt.275 _Chapt.111_other .t;./.~.f . d-, ~ ~~ Type of Application: _ W etland _Coastal Erosion _Amendment _ AdmiI~tive t2.+- _Emergency _Pre_Submission_Violation -"/"f'r.~ .J-- Info needed: ~4-- . James F. King, President Jill M. Doherty, Vice-President Peggy A Dickerson Dave Bergen Bob Ghosio, Jr. Southold Town Board of Trustees Field Inspection/Work session Report . . Town Hall 53095 Route 25 P.O. Box 1179 SouthDld, New York 11971-0959 , Modifications: ~ ~ '-I ~z ~ Conditions: I tD Ih- ~~ '#0 Present Were: _J.King _J.Doherty A.Dickerson _D. Bergen_ B. Ghosio, Jr _H. Cusack_D. Dzenkowski _Mark Terry_other Form filled out in the field by Cc>n J.. ,~,)n oL-k<.. (It.. h...t...J W..r f I~-, \,J(.l.l~. -\- ~~c.?- ~ ~ vtk-4 ~ b.r-7.~ (f MailedIFaxed to: Date: Enviromnental Technician ^ Review r::! :tJ! w~ "". A'\ 1:5 tAT ""-~,,,..~ "".t.. ..1_ ~ ~ ~ ~ _ Det.. "v.r ~,...4.& ~.j-'S4 v" 1>~ t>~ ~ . , *' ~~ J-k ~_t7 ~ ~ 7"> ,. ~ ... (9 '" l ..... ;~ ) " ~ j } -- ~ w '" .,j '1 ~ ,. V1 - - T-' p- r ~ ~ r ~ ~ ~0 W r- C/~ rvff' p-9 '\ j~ ~-J IF ,~ I:;' ,-1 n . Dc; L Z lor Rf1 Wt~ ~ ~ ~ ~ 3J(QJ ~ to :? to ~ j ~ r - - 1" 1J ,.~ i t ... l" Pfl T . ~ r p ... ~ " ~ I-, ~ ~ f?- T ,.' ~ 1 ~ ~ to r -- o ;. ~ iF .... ~ ~ ~ ,;\!i ,. ~ ~ 1" I-, ,...... .... -bt.4 l , r> ..... " p.. ~ It ~. , ~ J i~~ F~ i w+E 5 I \. \l.,,--~ ~r - -'to .'"_ t; l}".. ..J.... .... .... ., f..; ,. 'j [, .1 C_'.;- /-:. ^ - . t~j l< "<;~ ,,,,,.",:; - --. .~ <::;:.t '-r.~_1 (. (::>~,~; ;"r ~11 ,-.~,""':\ C,e" ,) <' -7 ~-:_~ ,;, . . i / / / ~ ~~l io. ~ I.~":I eo' "5-~ / 'tj -9 PI- I() /~ oo..K_~- / l'/.ry , ... "I. II' ~ Certified to- ~ Mel~hlone Be Melc.hlone L~I~~edlt Union I -., ealth ""'Pbooa--e OII"r"tlOt\~' vlolatlDningOIk;...-d Oi:Idltlonto Ne... T""l:of~ctlon 120<lland~,;;",..p,~a=y :::::" _~ ,,:"':;:"''; u....~~ 'm ,': 0 M"I~~l'l<llof It,e ~l'lI:Ilor thIS ~...'" "Geo"U'lGall r.or'l!o1der5dta"':e>te1JO,"'~t~7k.8d _ ~lnd"'CJt.ed volI<ltrue ::;'''9"o'::'~'::;''"~. ::::",,;?"".~ ";:::'. L::" \'"....10 ~~~.. far" L.<ncl';'" ..Ilh l~ ",,- tall\oo""'P'"S'$c:II<1As5oGlatio:,"o~ocIopUld aid p.o'''''''' for """",,"""'~I'I"""lans 01""91"",,1 LQ1c>nh"'beholfIO the......... ohollrvnonly lo;:""y""""...~tltl,,<-~ISF"""P<>r"d tlOMar":'r"'"of tM~I::::1<7> I"'~~rrvr,;,"- Ic""",lerabl<! to ~tt,~~", ~I~O- II"&tllvti<>r<l tJ Ilfi2_~8 1 if{ l:r2 Survey of Property Surveyed. SGT# '1~_~~001 Situate' p 2-10 To . ec.onlc. SuffOI~n;"o50UthOld v unty. NY I 111 =301 I L C't J Ond ...,69 oSe,f;h n~", Or f ~9'An arm Alb arm ~"b er/y e~;q ~21j of .c Ueg Iil.Jpl er er , " " " " ''',~0Q '^" S ~If,., C "<':~~ oc,?~~Q// C,., ~ ~L ~ ~~ "~- q., ~~. /1.- -............' " fenc 159057' e 01 On 9 Iline ry, ry. ",,6,. 1 (J / I 6,3:- Area o.Be kres 1 ^ // / / r:\J1g r~' u~" oJ! ~ "!!Jj'~~(f' .' S- f: ..,.- "fIV' ~ ~ e I , l!J /,i ~ ~ ! , , , I I ~s;o I 4:1__ '\ \ '"'if" \ \ q, \ \ .\?O~00q "~ ",'; " :2't 00 ' &0501 " o <1 ~ (~' &Q",.,!:I""............ ~"'"i:;~o~'" '~' ,^:;~ ---;-:-mo~~NO\k- D t~ ,,~ SL J' 1'-- 0"5 Sc:;' 0 - I, ~"'Q' '~ +" 0'J:, ~ ", ' ~ I,,~ ,3 --~-..- o ~~.;:", ~tv%'" ,;If )1. ROBERT H. FOX NYS PLS" 50197 POBOX" 538 RlVERHEAD 631~11901 6/13/200, -3390 G,\SLM~I,:n,31Ai'1 Do;telli.prD p j.J... ~. " y" .k . . Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Joseph Castelli 36 Massapequa Ave. Massapequa, NY 11758 Re: Trustee Wetland Permit # 4707 SCTM# 86-2-10 Bulkhead, dock, planting Dear Mr. Castelli, This letter is to inform you that while you may rebuild your dock that was damaged, with the above referenced permit, a condition ofthe permit is the plantings of the Spartina alterniflora in the 3'x 100' area in front of the bulkhead. Please refer to the attached permit. Please notify this office when the dock and the plantings are complete for a final inspection. Very Truly Yours, t1L&c- I 9. ~ <r Albert J. Krupski, President Board of Town Trustees Attachment Cc: Rob Herrmann En-Consultants .','~ '.' .;-. " " . . . ~......... ., ....,,-; . Town Hall 53095 Main Road P.O. Box 1179 Southoll!. New York 1197 Telephone (516) 765-189: Fax (516) 765-1823 I . Albert J. Krupski, President John Holzapfel, Vice President .Jim King.. Manln H. Gan:ell Peter Wenczel BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD February 25. 1997 oJ.H. Geideman P.O. Box 416 East Marion, NY 11939 Re: . Joseph Castelli SCTM 186-2-10 Dear Mr. Gein...,.""r> : '1he fol:towing action was taken by the Board of Town Trustees durin1J its regular: meeting hel.d on Februa.:l:y 19, 1997 regarcli.i1g. the above matt:er:: WHEREAS, J.B. Gei"-tt OIl. 'b<>b"lf of JOSEPH CASTRT.T.T applied to the Southol.d ':Eawn Tl:'uS.tees :fox a pemit 'I~d"r the provisiCIDS of. the Wet1.aDd Or,H n..nt'!e of the Town of Southold., appll~",H nn n"'~ed January 13,1997, and, WHEaEAS, scdd appU.cation was referred to the SQuthold. 'fawn Conse:r:vation AdviSorY Council for t'h..h- fiTunn<J$ and . reconmendations, and WHEaEAS,. a Public Hear~ was held by the Town Tl:u.stees wi~ respect t:.o said application. on i'ebruaJ:y 19, 1.991, a.t wh-l...b. time all interested persons Were given an uA'!'U..lunity to be heard,. .' and, . '. '. .... <.' . . WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the sUrrounding area, and, . WR'R'In1.lo~, the Board has.cnn~MA-r::ed all the t.estimOny and . documentation s.ubmi.tted conce:ming this appllcat1.on,.and,. WHEREAS, the sb:uc.tw:e complies with the s~"'nn"T1:l set forth in Chapter 37-18 of the Southold. Town Code, WHEREAS, the Board bas determln~ that the project as proposed wi1.1 not affect the hea.l.th, safety and gAn.....al. welfare of. the people of the town, . . " NOW THEREFORE BE IT,. RESOLVED, that the Board of Trustees. grant a WetlaDd PEU:mi.t to constl:uct a 130' btll1<'hPild w~thin 18" of old btll1<h~..n and. in front 'of existi.ng slip, then fill i.n slip withapprax..S,O. c.y. of fi.ll, a1sa a 3' X 24' dock, a l' X 100 'area i.n front. of bulkhead will ~ rep1.aD.ted with. spartina,and., . . . '. BE 1'1' FURTHER ~R-c:nT,VEJ) that thi.s det:",,..,,nn<rti.on..sbou.ld. not .~. considered a. dete......i-natian. madefoJ: a:rqother ~t or> Agency which may alSO bavean' appli.caticJJi p.-iH'nqmri"'h..' sim!e or . sindlar project.' .... . .' . . . . . Permit tocions.t.ruct project will. "''lIpiz:e two~s;;rcmt:he.da.te it is signed... Fees mus.t be paid,. if. .appli.c..bl-,.-,'and. pe,J:mi.t' issued within siX months of the' date of tlrl;S;.IiOtificati.on. . . Two i.nSpectiouS. arer~;redand the '.rl:uSteeStteto benot.ified upon c~of. ....~(t pz:ojed:.~ . '. '. '. .'. FEES: None.. Very truly yours,n ~f..II1. I~' 9, A :r:t J. ~, Jr. President, . Board of TrUstees AJKI jmd '. r . . I ,/ -<::>--z ____________ ,~5i I /~~~ AYe ;! ,~ , :~, d~ 1 ----...., 0""0"<:/" ~J , " .. '. , '; e ! I . ~ : . I ' ~---- -~j[-~ ----+ ., " . ~i g ~ ~: ~~i .,: " I!, i= ~.' !f ~~i rr hi Iljll ~ i!'1l1 ~!j1j1 j.lm "Ii III, ini 1,,1 III jj I"" .11 !1 iiiii 1,'JI i Illl JilU 1@lj I II !, 'I " f" . l 1'5. 'Ii , I' 'I · illlli /J,:/ '1'1,'; III, d, ,i 'I >l i Iii i "'''''''''ZQ . James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob \7nosio, 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 _Coastal Erosion Permit Application ~ _Wetland Permit Application L Administrative Permit Amendment/Transfer/Extension _Received Application: _Received Fee:$ _Completed Application _Incomplete _SEQRA Classification: Type I_Type II_UnIisted_ _ Coordination:( date sent) _LWRP Consistency Assessment Form _ CAC Referral Sent: _Date of Inspection: _Receipt of CAC Report: _Lead Agency Deterrnination:_ _'!$chnical Review: :::21>ublic Hearing He~ _Resolution: Office Use Only rD) [E ~ ~ ~ WI [E ,rm IJ11 AUG 1 0 2007 ,D Southold Town Board at Trustees Name of Applicant Address '} ... - r Joe. '.J" I 't - . ""./tIck ~OA~ PM_l ~ /3At..rd I fvJe Ie h lone. Phone Number:Crtbl If Alov....I-o,... v,'~w ('0",.1- Forr ~(o"" AlV (17'" f.9.s SI.?~ (tell) ~~ *~; i)..,,"I 1,..3 ft.t --.'\ Suffolk County Tax Map Number: 1000.. Property Location: 'JS7r Wl/ \\1 /to....d ~/H..ttM~f:.- (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: ~ Board of Trustees APPlic~on GENERAL DATA Land Area (in square feet): . '('0 Q~''''~ Area Zoning: Previous use of property: v(J.c.....h.,.....~ V...~... fi~ ~..NL Intended use of property: Covenants and Restrictions: Yes ~o If "Yes", please provide copy. Prior permits/approvals for site improvements: Agency Date _ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspe~d by a governmental agency? No Yes If yes, provide explanation: Project Description (use attachments ifnecessary): ,:y! !..t:-.e_ I ot J4!o.o.f Se..,..t.( I .t..e..-l ..,. k "~e. , /^""'~ 1(_ ....''1 .r ~~/c...~ sl. ,~I'.J; c.J/4owJ I .rl~/'j .. r....ru..l..-k......, "1tv..,.. .tOI!>r /116 1'w,""S'P "" Aa~r~ of- /....tJ./.4!.. ,;., ~ ~ I(.......jot:.., 6': ......f-.A.,,(......~ 0.1 ' PROJECT ID 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 1. APPLICANT I SPONSOR 2. PROJECT NAME Joe Me Ic~ I O^~ 3.PROJECT LOCATION: JS 7r "'t \(~ ~cl Municipality 't<<t>t",c. .1\0{' County StJ#-ll:... 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks ete - or Drovide maD S.e 0. '0... ~ 5. IS PROPOSED ACTION: D New D Expansion ~djflcatjon I alteration 6. DESCRIBE PROJECT BRIEFLY: - Il~....o".(. Jf*'D/ SI"'''''J I d~ 0"'('- "'of. .. , /,v..-. ~ ,I (,... +-. ~J" I<er ~e (1.,'''3 (f J' ... .....,'.....0./0""'"' , .r;oI.'-; , I.....t:..""h~ I :> --,.s -e. ~ I'-.....~,~ . f(y.~ "J- 1- , vi 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS7 ~s DNa If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) ~Sidential o Industrial o Commercial DAgricu,ture D Park I Forest I 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) [3Yes DNa If yes, list agency name and permit I approval: .s~.. K. let .,.""'^ .,-......, ........) 1kI... .'~ IJ ;,-. f-t.~ ,P~r.....,'r- 11. UUe~ ANY ur 'ne A""UN HAVe A VALIU pERMIT OR APPROVAL7 DYes [?Ia If yes, list agency name and permit I approval: -- -_.,- _n..__.__ 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION? Ges DNa I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE ~~ant I Sponsor Nama Date: Signature /'\- ~ A, . , /t.. ,~ ~ , 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 ITa be completed by Lead Aaencvl 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. Dves DNo C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be han~written, if legible) C1. Existing air quality, sulface 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 ;'V~ 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 N~ - I C4. A community's existing plans or goals as officially adopted, or a change in use or inlensity of use of land or other natural resources? Explain briefly: I ,IV.... I C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly; L .-v"" . J ..-. - C6. Long term, short term, ~~;:;{~i'~tive, or other effects not identified in C1-C5? Explain briefly: I ,1/-> I C7. Other impacts (including changes in use of either quantity or ty~e of energy? 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: I DVes ~I E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSV RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes expiain: I Dves 0NO 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 (1) 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, thedsterrnin3tisn Qfsignific3noe must evaluate thepeteR-tial-impaetofthc pre19ssod aetiof'! GR the Cflyireflff1Cfltal chalaetcri:stk...lofU,e OCA. 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 andlor prepare a positive declaration. CheCidtlTs..bOxTfyoufiave determmecf,bas8crorl'the Tnfor-i-riation and analysis above and" 'any supporting- documentiitlon,. fhafthepropos-ediiCtio- WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thf detennination. 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) . . Board of Trustees Applioation County of Suffolk State of New York SJ, e. y r I' fV1 e. , c h ,. 0 1'1 ~ BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBEDPERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF illS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN TillS 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 TillS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENT ATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF TillS APPLICATION. ~ Signature SWORN TO BEFORE ME THIS /0 DAYOF t2u.ry. ,20Q2 ~ Lu..n "'irt, ~fldW... otary PublIc ~\r~ ~r,pJl~=rltwk CommlsiiOn'E1iPif8S Apf1?r.~ 4- ,. . . APPLlCANT/AGENTIREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of South old's Code of Ethics nrohibits conflicts of interest on the Dart aflOW" officers and emolovees. The DUmose of this fonn is to orovide information which can alert the town of nossibl6 conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: M~k("."o,.t. ...6,- (Last name, first name, .t;niddle initial. unless yo.u 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 (If "Other", name the activity.) Building Trustee Coastal Erosion Mooring Planning v- 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~ld? "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. YES NO Y"" lfyou answered "YES", complete the balance of this fonn 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 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 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 this ~ day of (l ~ ~l ~ 200 "7 Signature -fJ=2 . ./l- . . Print Name -:1.,.., - ~ # r....".. D ~... Fonn TS 1 r . James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen John Holzapfel . Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD APPLICATION FOR AN AMENDMENT TO A WETLAND PERMIT DATE ~',-,-\.., OWNERj,SI2f~ M.Q.\.<:.!"..,'",,^-€ PHONE ~3(- 'L~(---rl<:d AD'''''-'Dt,;''SS lili "'\Mcv^~~^ \.J:e.~ (ovr-\-, hr+- ~"\"'^je. /"vy /11 b '-i AGENT PHONE ADDRESS PROPERTY LOCATION :]S7 S w~ \\S R.."od, TAX MAP NO. 8Co- 'L- \<) p~,-""^\c.. IIWe rJ.. ~o ./ to I~"-\."'~ ~ request an Amendment to Permit # ,+7'0 { ( ~\~t-I"": 5'tc<\f-S QAA""-I..:1 U,d~ ,SS~bJ J /1 (-J a..-/.. t, ,file p ~~r1r")C S ""..."r'c.. '-(orcl.t Clf' d~ !:( I bA~ ~ ,,~( t.t..~-I ( r. "'lb.=.. ("Jf- ~ ~ fN Afr:/ r') ,'l=". .Jh7r.-v-.. 4-d fu ~s?tr jle"-"",Ir # <{707 ~ Signed By: r " liD Joj"f ~ IV e(tc..4,'",,,.e.... (: JUN L 2 ?0n7 j!.I L___~_ ...----.J'- " .sOt! ,fl~id TO',','i] h'-'^i;{j ':'; Tn:,tl;,:~ - ----~--__.__ I . . Board of Trustees Application County of Suffolk State of New York ~Jkf' t., j\;f f k"- ,'0'" <L BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. -F ~o <'5I'gnature c1,M SWORN TO BEFORE ME THIS o-U DAY OF ~v..t\.L ,2007 ~"l vrn . ~nd.J.!J.. otary Public LAUREN M. STANDISr Nolary Public, State of Nell 'fori No.OIST6164008 Q\I8IIfied In Suffolk CoUflh CommIssion Expires April', ;Jo II . . . APPLICANT/AGENTIREPRESENtATlVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics Drohibits conflicts of interest on the oart of town officers and emplovees, The DUrDOse of this form is to orovide information which can alert the town of nos sible conflicts of interest and allow it to take whatever action is necessarv to avoid same, . ,J,S-:'f"'- /'--\.'- ~t \"":."..0.- (Last name, fIrst name, J)1iddle initial, unless you are applying in the name of someone else or other entity, such as a company. Ifso, indicatetheother person's or company's name.) -, YOUR NAME: NAME OF APPLICATION: (Check all that apply.) Tax grievance Variance Change of Zone Approval of plat Exemption from plat or official map Other (If "Other", name lhe 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 Southold? "Relationship" includes by blood, marriage, or bus"iness interest "Business interesf~ 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. YES NO v 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 TitleoC-Positiori-cifffia( per~f6n -- 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% ofthe shares nfthe corporate stock of the applicant (when the applicant is a corporation); . _B) the legal or beneficial owner of any interest in a non-<: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 Fonn TS 1 Submitted this )... "- day of J ~~ <<- 200 '( Signature ~./Vv' , PrintName~"r-<,~L.. N. ~ h.!.l. ,'~" e... ~+e s Sclothold Town Board of Trustees V) Cl >- w ..... CO w 0 I- :E: C V) I- :::l :::l ~II w 0=: 0 > l- V) &L 0 0 &L DI::: 0 0.. Cl z JlI 0=: 0.. <( ~ <( 0 0 a:a I- w I- <( Cl ,~ Certified to. ~ Meldllone 5her+1 Meidl/one Bethpage Federal Credit Union Landam8rI<;a GornmonHealth ~IzedClIUlral;\ofloroddltlont<><>......-vey mopbourr.g"Ilc._ac..d~'5..."I15" vIolallonof ~~t"",12O<l.&ub-c:llv15lon2,<>ftho> Ne...Yorl<5l:al"~oUonLQ.<. -onl~ c:opr..s Fr""" Ih9 orlgW:l! of this ~ mer....d "'lhQ'\Of"1c3Ir1aI<>fth9I~_!P"'$&t""'F'."" ....alsnollbec.orl6!dooroUltobevoll<ltrU<lo:.cp"'". .c.e.-j:)f":'(JtlO~\"IdIUlt8clIle"""""~~Ulc:ltth15 ........eyo<>!loP'""pcr<!ld"'a:"c:>rd:>n""w~h_.."- IStlngCDdoJ off'r'oo:tl"-8 lor L<>nc::lS0.0-vsy5oc1opl<od b:jthe Ne..Torl;.5tat,oAs.!IO(.lallonof F'I'-cl_1o<Io1 La-dSo.rvooyor5. 5oId<.8t1;ltlc.aUo....,;M1I rvrloniy to_~'''''-....tIw~''!ll5-pr6po2"..d. a-d""hl!;betlajfto_tltkoC"""f'<3"II:j'3<"'"""",,n_ ~I~~~..~~ ~~~ V:~I~r~~_t~,,_ t~or.,not....~....ab"'toadc::llllon:>lretltut'''"''' 159057' Fenc e 01 0"'911ine Survey of Property SUrveyed. ...iIne 5, 2001 SCTII 1000-86-2-10 Situate. pEl(;OO/c. TOHn. Sovthold SUffolk County, NY I l' = 30' ill ~~ ?i . !! .... 1. ""b ~t t . v 6:j;- Ol~ If. oh N~ '::;;:t..::t:" i!l.. .f ~ tl",~ Jl r 6/~ \\ Jl Jl Jl ~~\ \\ 9,\ \ k J1. ~\ k 'k / J*'"~ o cr, ~ ~: c ~ =;:., s.~, ! 2:: ~~ ~- .. ~ ~. ~ ~ a .$ ;# l__ " I: -- 1 l[fij'"' ",'~ r-:-;'1 Iw .~ ROBERT H. FOX NYS PLS# 50197 POBOX#538 RIVERHEAD NY 11901 631-722-3390 6/1312001 U,5,,28AM c,,\SLM'.:;os.teltl.pro ~~E 5 I I Land ..JOSe h nol-V Or r S69~n'4() fPor':'e~~~~~~~:~ of, ;, ''8 ",ruegerUPler JUN 2 2 2007 Soulhold Town Board of Trustees 6.=3;' He" o3e />Qe. Certified to, Joseph MeIGh\onEl Sherrl MeIGhlone 13e~ Federal c.redlt I.k1lon Lclrldcrri6rIUl c.onmonl'l8alth ...vs./o <1.t~. "'o~"q ~ /""t'b ~o ~ ~ 0 :-->0 ~/i "/'. e,....;,<Q6 q.., '1/.- DSff;0e"j, O"SL"i:';;: of. "e 'Lp . r Ie,.... ~\U!ld"lu"..""loflar~U""to"~ mopboocrln9ali<._d1and..........-p'"'fi..-oI.... vIOlauonofMdIOn12O'1,SLC>-""""lOn2,oftN """,,,Yon<.5tottI&iI<.ouonl.cM." "On1~"opl8&fromtt>oo","I9l'l<:llofthl&~rnc:r""'d "llh""or19WJ1ofth9Ia1d~'fi&~ ~1""",lIb1tGO'l!!olc:l91"...:ltobooVO\ld-G.Op"'&" ~ift<:.otlOr6lr>do:.at.codholr.on6Ign1F~tMtthl& ~_pr-ep.:r""'l'l<X.c.or<\(lr\G"...ItI'lth8..,,- ~~~:on:.~::~=Xof~1 1-i:lnd5u-ve~.5aldo.MtlffG.al:\OI'l5"""II""'on"l to_peM<>"laro<tlOmth8~...pr"f'U..d. .,.,.;onh...betlal!to_tltl"C.~~r"""'n- ~IZ':;~,,~~ ~::~ ':~~~t~o- t~ ar" not vlrll>l""- to ac::IdIll""'" ~t!h4I""" , '" Jic Jic Jic Survey of Property ~rveued' ..iIne 5. 2001 sCTllIOOO-e6-2-IO Situate, Pe<;.onlC. To....n, Southold ~ffolk Gounty, NY I l' = 30' I p'~ S}O o;f~: N~ ~,-::t:' i!J.. .[ ~ 1 o 'a I iU JL ROBERT H. FOX NYS P\..S# 50197 PO BOX # 538 RIVERHEAD NY 11901 631-722-3390 6/1312001 1l,51,2BAM c;.,\,SLM\(..Q$>te:III.pI"o ---