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HomeMy WebLinkAboutTurchiano, JosephAlbert 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) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only __Coastal Erosion Permit Applicat~ __Wetland Permit Application Administrative Permit __Amendment/Frans fer/Egtension *'l~eceived Applica~ ~Received Fee:$~~j_J~ fd~ ~Completed Applicatmn __Incomplete __SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) LWRP Consistency Assessment Form CAC Referral Sent: -'Date of Inspection:~ __Receipt of CAC Report: __Lead Agency Determination: __Technical Review: ~-~t~blic Hearing He~ __Resolution: Name of Applicant Address Phone Numbcr: i_ - Z Suffolk County Tax Map Number: 1000 - lift' - /2 -,.5'~ PropertyLocation: ti:fo Oee~/4~ie ]~..a,~,v_> - (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: ~oard of Trustees Appiica~ Land Area (in square feet): .,M'e a Zoning: Previous use of property: Intended use of property: GENERAL DATA Prior pemfits/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 Has any permit/approval ever been revoked or suspended by a governmental agency? x/ No Yes If yes, provide explanation: Project Description (use attachments if necessary):. Board of Trustees ApplicOon WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: O .square feet Percent coverage of lot: 6:> % 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? fi( No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? t~ cubic yards Depth of which material will be removed or deposited: 0 feet Proposed slope throughout the area of operations: D Manner in which material will be removed or deposited: ---"--' Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 1 APPLICANT / SPONSOR 3 PROJECT LOCATION: Municipality /~/'~' 7/~"'~C' ~-- 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 County ~'~'/'Z/'~o J- K SEQR 4. PRECISE LOCATION: Street Addess and Road Intersection.~ Prominent landmarks etc-or provide map ,or o 5.1S PROPOSED ACTION: r~ New [~Expansion [~]Moaification/alteration 6. 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.) r~Residential ~]lndustrial r---lcommercial ZAgdculture r-lPark/Forest/OpenSpace [---1Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ~----]Yes r~No If yes, list agency name and permit / approval: 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? E~]Yes ~lNo If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? E~]Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 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~lenc¥) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes, coordinate the review process and use the FULL EAF. E~Yes r-'-i No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative declaration may be superseded by another involved agency. [] Yes [] 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, Aaethefic, agricultural, archaeological, historic, or erbar natural or cultural raeources; or community or neighborhood characte~ Explain C3. Vegetation or fauna, fish, she fish or w d fo spec es, s gn ficant hab tats, or hraa ened or endangered species? Explain briefly: I C4, A community's existing plans or goals aa officialty adopted, or a change in uso or intensity of use of land or other natural resources? Explain bdofl¥ C5. Growth, subsequent development, or related activities likely to be indu'~ed by the prop0s0d a~tion~ Explain briefly: C6. Long term, shor~ term, cumulative, or other effects not ide~ti~a~ [~ CIRCE? Explain briefly: C7. Other impacts (i~cluding changes in use ot either quantit~ or t¥~e of energy? ~xplain D WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (C~AI? f~f yes, exJ)lain briefly: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If }/es explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadVersee~ectidenti~edab~ve~determinewhetheritissubstantia~~~arge'imp~rtant~r~therwisesignificant~ 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 ali 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 impact of the 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 FULL 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 actior WILL NOT resLgt in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi.< determination. Name of Lead Agency Date Title of Responsible Officer Pdnt 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 ~/e*,_-- ,,~ L. ~c~5~ O 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 1N THE MANNER SET FORTH 1N 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. SWORN TO BEFORE ME THIS DAYOF lr~,z~?] ,20~ g Notary Public, State of New York No. 24-4994448 Qualified in Kings County ~ Commission Expires April 6, 2~__ APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics orohibits conflicts of interest on the part of town officem and emalovees. The pumose of this form is to provide information which can alert the town of ~ossible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: '7~_ r' ~O/t' ,~ ~ o do S"Cr'/d ~, (I~ast name, first name, gaiddle initial, tmless 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 Exemption from plat or official map Planning Other (lf"Other", name the activity.) ~'~ ~ ~D' el Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee &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 corporation in which the town officer or employee owns more than 5% of the shares. YES NO ~ If you answered "YES", complete the balance of this form and date and sign where indicated. Name 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% oftbe shares of the corporate stock of the applic0,nt (when the applicant is a corporation); __B) the legal or beneficial owner 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 Form TS 1 Submitted thi~/~2~day of Signature Print Name~,~ I.."hc m ©! i James F. King, President J/ll M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen John ttolzapfel 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 Inspectionffforksession Report Name of Applicant: '~ o, r o~ ? ~-,~o Name of Agent: ~ Property Location: SCTM# & Street Brief Description of proposed action: T~Se of area to be impacted: altwater Wetland Freshwater Wetland Sound Front Bay Front Distance of proposed work to edge of above: P~CC of Town Code proposed work falls under: hapt.97 Chapt 37 other Typeof Application: \/'"'Wetland__CoastalErosion~Amendment__Administrative __Emergency Info needed: Conditions: P~esent Were: _fi. King L/f"J.Doherty __P.Dickerson __ M/Other: D. Bergen__J.Holzapfel ~4 Mailed/Faxed to:' Date: zuu~-u~ Page 1 of i 2004-04 (April) \PICTURES\IM_A0024.JPG Image 24 of 31 file://D:\MEMDISC\ALBUM A\VIEW~SHOW\HTML\SSL 0023.HTM 3/10/2006 2'9 -i