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Home My WebLink AboutTR-6589A James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD CERTIFICATE OF COMPLIANCE # 0454C Date: Au~009 THIS CERTIFIES that the trimming of the phragmites to a height not less than 12" and mow a 25' area on the southwest comer on an as needed basis At 2125 Grathwohl Road, New Suffolk, New York Suffolk County Tax Map # 117-1-7 Conforms to the applications for a Trustees Permit heretofore filed in this office Dated 3/23/07 pursuant to which Trustees Administrative Permit # 6589A Dated 4/18/07 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 trirnminq of the phragmites to a height not less than 12" and mow a 25' area on the southwest corner on an as needed basis The certificate is issued to El.lZABETH CANTRELL owner of the aforesaid property. Authorized Signature James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 Telephone (63 I) 765-1892 Fax (631) 765-6641 DATE ~ INSPECTION: //' Ch. 275 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Ch. 111 INSPECTION SCHEDULE __ Pre-construction, hay bale line/silt boom/silt curtain 1 ~ day of construction ¼ constructed '~Project complete, compliance inspection. INSPECTED BY: COMMENTS: CERTIFICATE OF COMPLIANCE: James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall Annex 54375 Main Road P.O. Box 1179 Southeld, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD April 22, 2009 Mrs. Elizabeth Cantrell P.O. Box 128 New Suffolk, NY 11956 RE: 2515 GRATHWOHL RD., NEWSUFFOLK SCTM#117-1-7 Dear Mrs. Cantrell: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wed., April 22, 2009: RESOLVED, that the Southold Town BOard of Trustees grants a One-Year Extension to Permit #6589A, as issued on April 18, 2007. This is not an approval from any other agency. Sincerely, President, Board of Trustees JFK:lms Elizabeth Cantrell P.O. Box 128 New Suftblk, NY 11956 April 2, 2009 Re: 2125 Grathwohl Road, New Suffolk SCTM: 117-1-7 Dear Board of Trustees: I am requesting a one year extension to Permit # 6589A. I am still working with the DEC on getting a permit to trim the phragrnites. Thank you, Elizabeth Cantrell New York State Department of Environmental Conservation Division of Environmental Permits SUNY @ Stony Brook, 50 Circle Road, Stony Brook, NY 11790-3409 Telephone (631) 444-0352 Facsimile (631) 444-0360 May 6, 2009 Alexander B. Grannis Commissioner Mrs. Elizabeth Cantrell P.O. Box 128 New Suffolk, NY 11956 RE: 1-4738-03829/00001 Dear Permittee: In conformance with the requirements of the State Uniform Procedures Act (Article 70, ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit. Please carefully read all permit conditions and special conditions contained in the permit to ensure compliance during the term of the permit. If you are unable to comply with any conditions, please contact us at the above address. Also enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather. JRP/ls En¢logure Sincerely, e R. Pasquini Environmental Analyst NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Facility DEC ID 1--4738-03829 PERMIT Under the Environmental Conservation Law (ECL) Permittee and Facility Information Permit Issued To: ELIZABETH ANN CANTRELL PO BOX 128 NEW SUFFOLK, NY 11956 (631) 734-5924 Facility: CA~NTRELL PROPERTY 2125 GRATHWOI-J.L RDISCTM#1000-117-1-7 NEW SUFFOLK, ~ 11956 Facility Loc~on. in SOUTHOLD in SUFFOLK COUNTY Village: New Suffolk Facility Principal Reference Point: NYTM-E: 712.068 NYTM-N: 4541.491 Latitude: 41°59'49.4" Longitude: 72°28'43.2" Project Location: 2125 Grathwohl Road - Watercourse - West Creek Authored Activity: Trim a 10' x 115' area ofphragmites and mow a 25 foot area on an as need~ basis. All work must be in accordance with the attached plans stamped NYSDEC approved on 5/659. Permit Authorizations Tidal Wetlands - Under Article 25 Permit ID 1-4738-03829/00001 New Permit Effective Date: 5/6/2009 NYSDEC Approval Expiration Date: 5/31/2014 By ac~ptance of this permit, the permittee agrees that the permit is contingent upon strict compli~ce with the ECL, all applicableregulations,and all conditions incguded as part of this permit. Permit Administrator: MARK CARRARA, Deputy Regional Permit Administrator Address: NYSDEC REGION 1 HEADQUARTERS SUNY ~ STONY BROOK150 CIRCLE RD STONY BROOK, NY 11790 -3409 Authorized Signature: ~ Date ~ Distributi°n List Marine Habitat Protection JACQUEL1NE R PASQUINI Page 1 of 4 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Facifity DEC ID 1-4738-03829 Permit Components NATURAL RESOURCE PERMIT CONDITIONS GENERAL CONDITIONS, APPLY TO ALL AUTHORIZED PERMITS NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS NATURAL ~SOURCE PERMIT CONDITIONS - Apply to the Following Permits: TIDAL WETLANDS 1. State Not Liable for Damage The State of New York shall in no case be liable for any damage or injury to the structure or work herein authorized which may be caused by or result from future operations undertak~'n by the State for the conservation or improvement of navigation, or for other purpose~ and no claim or right to compensation shall accrue from any such damage. 2. NOtice of Commencement At least 48 hours prior to commencement of the project, the permittee and e°ntractor shall sign and return the top portion of the enclosed notification form certifying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion of project, the bottom portion of the form must also be signed and returned, along with photographs of the completed work. 3. PHRAGMiTES Phragmites may be hand cut to a height of 12". 4. Conformance With Plans All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or applicant's agent as part of the permit application. Such approved plans were prepared by JMO Environmental Consulting dated 2/20/08. 5. State May Order Removal or Alteration of Work If future operations by the State of New YOrk require an alteration in the position of the sh'ucture or work herein authorized, or if, in the opinion of the Department o~' Envir°nmental ConS~ation it ~ ~u~e unr~aS~abie ~bStructi0n to the free navigation of said waters or flood flows or endanger the health; ~afetyor w~lfaf6 of flie~p~0ple of ~e State, or cause loss or destroction of the natural resources of thc State, the owner may be ordered by thc D~ent to remove or alt~ the structural work, obstructions, or hazards caused thereby without expev~ to the State, and if, upon thc expiration or revocation of this permit, thc structure, fill, excavation, or other modification of the watercourse hereby authorized shall not be completed, the own~ shall, without expense to the State, and to such extent and in such time and manner as the Depasiis~ent of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore to its former condition thc navigable and flood capacity of thc watercourse. No claim shall be made against the State of New York on account of any sudl removal or alteration. 6. Precautions Against Contamination of Waters All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project. Page 2 of 4 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Facility DEC m 1-4738-03829 7. State May Require Site Restoration If upon the expiration or revocation of this permit, the project hereby authorized has not been completed, the applicant shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill'and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. GENERAL CONDITIONS. Apply to ALL Authorized Permits: 1. Facility Inspection by The Department The permitted site or facility, including te!evant records, is subject to inspeotion at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Department) to determine whether the permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71- 0301 and SAPA 401(3). The permittee shall provide a person to accompany the Department's representative during an inspection to the~ermit area when requested by the Department. A copy of this permit, including all referenced maps, drawings and special conditions, must be available for inspection by the Depa~hnent at all times at the project site or facility. Failure to produce a copy Of the penmt upon reqUest by a Dep~erit tepr~tative i~ x/i61~ti6~ of~§ permit. 2. Relationship °~ this Permit to O/her Department Orders and Determinations Unless eXpressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Department ~aay of the terms, conditions or requirements contained in such order or determination. 3. Applications For Permit Renewals, Modifications or Transfers The permittee must submit a separate written application to the Depa~hnent for permit renewal, modification or transfer of this permit. Such application must include any forms or supplemental information the Department reqaires. Any renewal, modlfieati6h or h'~'f~i~ graf621 b~ ~41t ifiUS~ b~ in ~ting~ ~ubmission of applications for permit renewal, modification or transfer are to be submitted to: Regional Permit Administrator NYSDEC REGION 1 HEADQUARTERS S~ @ STONY BROOKIS0 CIRCLE RD STONY BROOK, NY11790 -3409 4. Submission of Renewal Apph'..c~ation The permittee must submit a r~ewal application at least 30 days before permit expiration for the follo~ng permit authorizations! Tidal Wetlands. 5. Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to modify, suspend or revoke this permit. The grounds for modification, suspension or revocation include: a. materially false or inaccurate statements in the permit application or supporting papers; Page 3 of 4 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Facility DEC ID 1-4738-03829 b. failure by the permittee to comply with any terms or conditions of the permit; c. exceeding the scope of the project as described in the permit application; d. newly discovered material information or a material change in environmental conditions, relevant technology or applicable law or regulations since the issuance of the existing permit; e. noncompliance with previously issued permit conditions, orders of the commissioner, any provisions of the Environmental Conservation Law or regulations of the Department related to the permitted activity. 6. Permit Transfer Permits are transferrable unless specifically prohibited by statute, regulation or another permit condition. Applications for permit transfer should be submitted prior ~o actual transfer of ownership. NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The pormittee, excepting state or federal agencies,'expressly agrees to indemnify and hold harmless the Department of Environmental Conservation of the State of New York, its representatives, employees, and agents ("DEC") for all claims, suits, actions, and damages, to the extent attributable to the permittee's acts or omissions in connection with the permittee's undertaking of activities in connection with, or operation and maintenance Of, the facility or facilities authorized by the permit whether in compliance or not in compliance with the terms and conditions of the permit. This indemnification does not extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or intentional acts or omissions, or to any claims, suits, Or actions naming the DEC and arising under Article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision under federal or state laws. Item B: Permittee's Contractors to Comply with Permit The pormittee is responsible for informing its independent contractors, employees, agents and assigns of their respunaibility to comply with this permit, including all special conditions while acting as the permittee's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those Prescribed for thepermittee. Item C: Permittee Responsible for Obtaining Other Required Permits The permittee is ~ponsible for obtaining any other permits, approvals, lands, easements and rights-of- way that may be req~red to carry out the activities that are authorized by this permit, Item D: No Right to Trespass or Interfere with Riparian Rights This permit doe~ not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. Page 4 of 4 RETURN THIS FORM TO: PERMIT NUMBER: PROJECT LOCATION/ADDRESS: CONTRACTOR NAME: NOTICEOFCOMMENCEMENTOFCONSTRUCTION COMPLIANCE Marine Habitat Protection NYSDEC 50 Circle Road - SUNY Stony Brook, NY 11790-3409 OR FAX TO: 631-444-0297 ISSUED TO: ADDRESS: TELEPHONE: Dear Sir: Pumuant to General Condition of the referenced permit, you are hereby notified that the authorized activity shall commence on · We certify that we have read the referenced permit and appmvad plans and fully understand the authorized project and all Peri-it conditions. We have inspected the project site and can complete the project as described in the permit and as depicted on the approved plans. We can do so in full compliance with all plan notes and permit conditions. The permit sign, permit and approved plans will be available at the site for inspection in accordance with general Condition No. 1. (Both signatures required) PERMITEE DATE CONTRACTOR DATE THIS NOTICE MUST BE SENT TO THE ABOVE ADDRESS AT LEAST TWO DA YS PRIOR TO COMMENCEMENT OF THE PROJECT AND /OR ANY ASSOClA TED REGULA TED ACTIVITIES. FAILURE TO RETURN THIS NOTICE, POST THE PERMIT SIGN, OR HAVE THE PERMIT AND APPROVED PLANS AVAILABLE A T THE WORK SITE FOR THE DURATION OF THE PROJECT MA Y SUBJECT THE PERMITTEE AND/OR CONTRACTOR TO APPLICABLE SANCTIONS AND PENAL TIES FOR NON-COMPLIANCE WITH PERMIT CONDITIONS. Cut along this line ~.~ ~ ~< ~ NOTICE OF COMPLETION OF CONSTRU~:i:i~i~' ................................................ RETURN THIS FORM TO: COMPLIANCE OR FAX TO: 631-444-0297 Marine Habitat Protection NYSDEC 50 Circle Road - SUNY Stony Brook, NY 11790-3409 PERMIT NUMBER: PROJECT LOCATION/ADDRESS: ISSUED TO: CONTRACTOR NAME: ADDRESS: TELEPHONE: Dear Sir: Pursuant to General Condition of the referenced permit, you are hereby notified that the authorized activity was completed on · We have fully complied with the terms and conditions of the permit and approved plans. (Both signatures required) PERMITEE DATE CONTRACTOR DATE THIS NOTICE, WITH PHOTOGRAPHS OF THE COMPLETED WORK AND/OR A COMPLETED SURVEY, AS APPROPRIATE, MUST BE SENT TO THE ABOVE ADDRESS WITHIN 3O DA YS OF COMPLETiON OF THE PROJECT. gS-20-1(11/O3)-gd New York State Department of Environmental Conservation NOTICE The Department of Environmental Conservation (DEC) has issued permit(s) pursuant to the Environmental Conservation Law for work being conducted at this site. For further information regarding the nature and extent of the approved work and any Department conditions applied to the approval, contact the Regional Permit Administrator listed below. Please refer to the permit number shown when contacting the DEC. Permit Number Expiration Date Regional Permit Administrator ROGER EVANS NOTE: This notice is NOT a permit SFD I toDEC APPROVED AS PER TERMS AND CONDITIONS OF PERMIT DATE ,.G/(~ ~ / /'//,4 'AREA TO ON WEST CREEK TWL, AHW &ALW located by G Just 20 Feb '08 SCALE 1~40' · Applicant: Elizabeth Ann Cantrell Location: 2070 Grathwohl Road, ' New Suffolk Datum: Apparent Low Water Locus: 40~59' 72o28' ./~trpose: Phr ~agmite control . S.C.TM.No. 1000-117-1-7 SHEET J.M.O. Environmental Consulting Services Quogue, New York I OF James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob GhosJ_o, 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 __ 1st day of construction /roj~nstructed ct complete, compliance inspection. James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hail 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.: 6589A Date of Receipt of Application: March 23, 2007 Applicant: Elizabeth Cantrell SCTM#: 117-1-7 Project Location: 2125 Grathwohl Road, New Suffolk Date of Resolution/Issuance: April 18, 2007 Date of Expiration: April 18, 2009 Reviewed by: Board of Trustees Project Description: Trim the phragmities to a height of no less than 12 inches on an as needed basis and mow the phragmites in a 25 foot area on the Southwest corner of the property on an as needed basis. 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 survey prepared by Van Tuyl & Sons, received on March 23, 2007 and approved on April 18, 2007. Special Conditions: No Bakaris bushes or Cedar trees to be removed. 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 $outhold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. King, ident Board of Trustees JFK:eac James F. K/ng~ President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. ' Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone~(631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Southold Town Board of Trustees Field Inspection/Work session Report Date/Time: /4" I/~ 0 ~ ELIZABETH CANTRELL requests an Administrative Permit to trim the phragmites to 12", as needed. Located: 2125 Grathwohl Rd., New Suffolk. SCTM#117-1-7 Type of area to be impacted: V/Saltwater Wetland Freshwater Wetland Sound Bay Distance of proposed work to edge of above: Pv~t~ of Town Code proposed work falls under: __Chapt.275 Chapt. 111 other Type of Application: L/Wetland __Coastal Erosion__Amendment __~/Administrative __Emergency Pre-Submission Violation Info needed: Modifications: Conditions: Present Were: '~.King /J.Doherty P.Dickerson ~/~. Bergen B. Ghosio, Jr H. Cusack D. Dz-~-nkowski ~Mark Terry other -- Mailed/Faxed to: Date: Environmental Technician Review !/'~ ~¢ ~r~ ex/M_.x MAP QF LAb-!f) BAY James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob ~nosio, Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application Wetland Permit Application J Administrative Permit Amendmcnt/Trans let/Extension ~Received Application: ,~oq~0'~ ,.,q~eceived Fee:$ ~SL)r .~ompleted Application,5/Ocy ~/ Incomplete SEQRA Classification: Type I Type II Unlisted __Coordination:(date sent) __LWRP Consistency Assessment Form ___--C~AC Referral Sent: t~]& ...~ate of Inspection: ~.flt [ ~ __Receipt of CAC Report: __Lead Agency Determination: __Technical Review: __P-~lic Hearing Held: ~['l~]O'~ __Resolution: Name ofApplicant ~ ](Z..<:k[~'l ~(9¢(C]] Address c~C-PTO t'~c'vc~-v'zoc)~/ ~. Suffolk County T~ Map Nmber: 1000- /] ~ mrope~y Location: ~] ~ ~ ~F~(~] (provide LILCO Pole ~, dist~ce to cross streets, AGENT: (If applicable) Address: Phone: OBoard of Trustees ApplicOon GENERAL DATA Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency Date '~No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspende~d~o~y a governmental agency? ~ No Yes If yes, provide explanation: Project Description (use attachments if necessary): Cc.x'~ &e-.0r3 3 O Board of Trustees ApplicOon WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: .square feet Percent coverage of lot: % 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? b/'"/~-No Yes If yes, how much material will be excavated? How much material will be filled? Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: cubic yards cubic yards feet Statement of the effect, if any, 0_n the wetlands and tidal waters of the town that may res_ult ~y reason of such proposed operations (use attachments if appropriate): 617.20 PROJECT 10 NUMBER APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 - PROJECT INFORMATION ( To be completed by Applicant or Project Sponsor) 1. APPLICANT / SPONSOR Z PROJECT NAME ~ PROJECT LOCATION: PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map SEQR DESCRIBE PROJECT BRIEFLY: 7 AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~Yes [] No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) [~]Residentia, []Industrial I--'lcommercial E~]Agriculture E~] Park / Forest / Open Space F--1Other (describe) 10.' DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ~'jYes I~lNo If yes, list agency name and permit / approval: 11, UU~::~ ANY A~Hb(~l OF T~E ACIION HA~7~A C~RREN~i'[~[~E'~'MIT OR APPROVAL? E~Yes ~--"~No If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? [~]Yes I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicantsignature 1S(~2;~ ~/,~~.~/ Date; If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To be completed by Lead A~enc)/) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 6t 7.47 If yes, coordinate the review process and use the FULL EAF. S. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS N 6 NYCRR, PART 617.67 If No, a negative declaration may be superseded by another involved agency. E~TM E~]No 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: C2. Aesthehc agr cu ural archaeological, h~stonc or other natural or cultural resources or commumty or neighborhood character? Explain bnefiy Vegeta on or fauna fish shellfish or wildlife species, s~gmficant habdats or threatened or endangered species? Explain b'nefly C4. A community s existing plans or goa s as offlc~aHg adop ad or a change m use or ~ntensdy of uso of land or other ~a u ~!.resources* Explain C5. Growth subsequent development or related act*wbes l~kely to be ~nduced by he proposed achon9 Explain bnefiy C6. Long term, shod term, cumulative, or other effects not identified th Ct-CS? Explain bdetly: C7 Other impacts {including changes in uso o(either quantity or [yp'~ Of energy? Explain bdo[IV: I D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA/CEAI? (If yes, explain bdefl~: ~lYes I~lNo E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (0 magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that ali relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked :,,es, the determinath:~ef eignifi6~nce must cvs!ustc thc pctcntiaHml~ct cf thc propcscd actle~o~the ec~vi ' 'c~ of ~he C~ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULl EAF and/or prepare a positive declaration. Che(~k lhis ~x J(you'l~ave cl~r~nedl b~sed on'the information a~d ~aly~Js ~b0ve and any ~uppoding document~ti0n, that ~h~ pr0p(~s~ ~ctti~i WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thh determination. Name of Lead Agency Date Title of Responsible Officer Print or Type Name of Responsible Officer in Lead Agency 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 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), Hr GRANTED. 1N COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CON/UNCTION WITH REVIEW OF THIS APPLICATION. ~ S~g[ature SWORN TO BEFORE ME THIS__ ~..~,_d DAYOF ~Aflu/'~L Notary Publ~) MELANIE OORO$~ IIOTARY PUBLIC, State of New Ye~ No. 01D04634870 Qualified in Suffolk County ~ommission E.xoires September 30d APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town Officers and emnlovees. The nuroose of this form is to twovidc information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. (Last name, first name, x~iddle initial, unless you are applying in the name of someone else or other entity, such as a company. I f so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring n from plat or official map 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 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 corpomtlon in which the town officer or employee owns more than 5% of the shares. YES ~ _____ NO lfyou answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Tow~of ~outhold ~'1; z~ Title Or position of that person ~'-(-O.E~'~ff_~5 '~?. Geck Describe the relationship between yourself(the applicanffagen~/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 oftbe applicant; or ~;~"~D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Submitted this~laT, of .~C~ Signature t'a-ff'~ tfJ~stZ~J~ Print Name ~'~I;~C,~I 200? I ~ ~ ? --~ MAP C'F LA~4F~ --