HomeMy WebLinkAboutBriarcliff Landscape12/84/2886 14:12 7656641 BOARD OF TRUSTEES PAGE 81
James F. King, President
Jill M. Doherty, Viee-Pr6sident.
Peggy A. Dickerson
Dave Bergen
John Holzap£el
Town Hall
53096 Route 25
P.O. Box 1179
$outhold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
Coastal Erosion Permit Application
~Wetland Permit Application
~Amendmen~fr~$ fer/Ext~nsion
~Rec~ivzd Applica~on:
Received Fee:$~
__Comploted Application
~Ineomplete
__SEQI~, Classification:
Type I, Type II Unlisted,__
Coordinatiom(d~-te sent)__.__
LWRP Conslsteney Assessment Form
CAC Referral Sent:
__Date of Inspection: ,__
__Receipt of CAC Report:__ ,_
__Lead Agency Determination:
Technical Review',
~Pubtic Hearing Held:
__Resolution;
Admin/~t~ative permit
Suffolk County Tax Map Number: I000 -
(provide LILCO Pole ~, distance to ~oss s~ets, and location)
(If applicable)
Ad~s:
12/04/2806 14:i2
7656641 BOARD OF TRUSTEES
Bo&r~ of Tru~tee~ A1~Pl~cat~-°n
GEI~ERAL DATA
Axea Zor~g:~
previous use of property:~~--~ -"----- '
Intended use of propertY:----~eslA~-rnt~ i ~~
PAGE
02
prior permits/approvals for site improvements:
D ate
No prior pcrmitslapprovals for site improvements,
Has any permit/approval ever been revoked or suspended by a governmental agency?
.,~ No Yes
l£)'es~ provide ex?lanation:_
Project Description (use attachments if necessary): ~-X 4~rt~ [~ von
PART II. IMPACT ASSE-~-,MENT 0'0 be com. pleled by Le~_~ Agency) .,
"~ ~;S A~QN ~GEED ANy ~p; l ~ESHOLD I~ 6 ~CRR, PA~ 617,47 ~ yes. ~lnate t~ ~ew p~ss and u=e ~e FULL ~.
B, WILL ACT}ON ~EIV~ COO~DI~A~D R~I~ A8 p~OVIDED FO~ UNUSED AGTION~ ~N ~ ~C~R, PART 617,6? ff No, a
de~tata~on ~ay~ ~upe~ded by ano~er i~vo~ ~ge~,
~Yes ~No
C. COULD ACTION RESULT IN ~ ADVERSE EFFE~S ASSOC~D W~TH THE FOLLOWING: (Answers may be han~wHEen, ie legible)
Ct. ~lsting air quall~, suda~ Or gmu~ater quali~ ~ quanU~, noise levels. ~isflng ~ffic paffem, solid waste p~ucflon or disposal.
~mn~a f~ erosion, drainage er fl~lng problems? ~plain briery:
C2, Ae.the~, agrlcul~ml, archaeol~l~l, hlo~dg, or other natural or cultural ms.roes; or mmmun ~ or ne~ghb~h~d chamcte~ ~plaiq
I ' - '" C L.
J
.... ~ :_.~ ........ ~ .....
C5. GmS, ~'~uent deve~p~'~t, or rela~ activities likely lo be indued by ~e proposed a~tion? Explain
O. ~LL THE PRDJE~ ~VE AN IMPACT ON ~E ~NVIRONMENTAk CHARACTERISTICS T~T CAUSED ~E ESTABLISHMENT OF A CRITICAL
E~ RONMENTAL AR~ {C~?, (If yes explain
E. IS THERE. OR IS THERE LIKELY TO BE. CONTROVERSY RELATED TO POTE~IAL ADVERSE ENVIRONMENTAL IMPACTS?' If
PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTI~UC"rlOIN$; F~ each adverse effect identified above, determine wl~etl~er It is sabsLant~al, large, ~mportant or otrrerw~se s~gn~h~nL ~-ecn
effect should be assessed ti1 connection with its (a) setting (La. urbeo or rural); (b) probability of occurring; (c) dumt. ion; (d) irreva~ibility;
, g.eographi¢ soope; and (~) magnitude. If necessary, adcl attachments or reterence supporting materials. Ensure that explanations contaifl
e~Jfl~cAeNt detail to show that all relevant adverse, impac, ts have been identttied and adequately addressed. If question d of part ii was che~l(e(:l
¥ es.rLbe, deter mina Ue~q e f =!g ~ ~c= ~-'...34a=~et evelua~ L~,= pc ',~. 2. ~c.~ !,mp=etefths prepesee'-act~c,~, o,'~-~,; c.~.'~r-eflmental-ohamcte~. ~;c.. ~,;'~,e CF.A.
Check this box if you have identified 0~e or more potentially ts~ge or significant adveme impacfs which MAY o~rr. jr. Then proceed clire ~ly b~ Ule FUL
EAF and/or prepsre a positt~e deeleratton.
WILL NOT result In any significant sever'se environmental ImpacL~ AND provide, on attachments es necessary, the reasons supporting
detelwtinstion,
Name of Lead Agency
Print 0¢ Type Name of Responsible r.~llcef In LearJ Agency
Eil!tnature of Responsible ~t in Leati Agenu"J
Oat~
Title of Responsible Officer
signature et Preparer (it air. rent Item responsible omoer)
12/84/2886
14:12 '7656641 BOARD OF TRUSTEES PAGE
Board of Trustees ApplicatiOn
County of Suffolk
State of N~w York
~ q~ ~-(~,'~i,~ BEmGDU,YSWO~
DEPOSES ~ AFFIRMS T}:iAT lIE/SHE IS T~ffi ~PLIC~T FOR T~ ~O~
D~SCm~D.V~mmS) ~D ~T ~[ ST~mS CO~D maEm ~
TR~ TO ~ BEST OF ~S~R ~O~EDOE A~ BEL~F, AND ~T ~L WORK
~L BE DO~ ~ ~ ~R SET FORTH ~ T~S ~PLICATION ~ AS MAY
BE ~PROVED BY T~ SOUTHOLD TO~ BOARD OF TRUSSES. ~ ~PLICANT
AG~ES TO HOLD ~ TO~ OF SOUTHOLD A~ ~ TO~ ~US~S
~ESS ~ ~E ~OM ANY ~ ALL D~AOES ~ CL~S ~S~G
~DER OR BY ~ OF S~ PE~T(S), ~ Oll~D. ~ CO~LET~G ~S
~PLICATiON, I ~BY AU~ORIZE T~ ~US~ES, ~IEI_R AGENT(S) OR
REP~SE~ATI~S(S), TO E~R O~O ~ PROPERTY TO ~SPEC . T~
P~MISES ~ CONJ~CTION ~TH ~VIEW OF ~S APPLICATION.
-~ ~ ~ Signature
Notary Public, State of New York
No. 4863757
Qualified ?,,Suffolk Goun~ .~
Comrrlission Expires.October 20,. ~
12/84/2886 14:12 7656641 BOARD OF TRUSTEES PAGE
APPLICA_NT/AGENT/REPRES~A~
TRANSACTIONAL DISCLOSURE, FORM
0B
The ?ov~ of Southold'~ Code ofEthlc~ nrohthtts conflLc~ of lnte~ on tM ~ of m~ offi~m ~d emo]o~ ~ ~m of
~o~ h m p~de info~ation which c~ alcn ~ ~wn of ~ible ~fli~ o~ ~ ~d ~low it to ~e ~st~ ~ion Is
(L~ n~e, fi~ n~o, ~ dd o initial, ~less yo~u ~ ~plying i~ ~e ~a,i~o or
~meO~ :lse or ~er enfi% such ~ a ~mp~y. If so, indi:am ~.v~er
NAME OF APFLICA~ON: (Ch:ck all ~at apply,) "
Tax griev~n~c Building
Verianve
Changc of Zon~ ~ , Coastal Erosion "
Approval of plat Mooring
F. xamption ~TOm plat or otllcial map . Planoing
O~hcr
Do you p~r~oally (or through your compmsy~ s poo_~,e, s[blin&, par~L or child) havc a relationship ~vi~ any el~icer or cmployce
of'the Town o[ ~o~thold? "Relat]onsh¥' ~noludes by blood, man,age, or bu~incs.s int.=resL ~'~usine~ interest'~ ~ ~ busine~
including a p~melshi~, in which th~ tow~ o ~r or employ~ h~ even ~ panial owlmmhip or (or cmploymcnt by) a ~om~on
in which the t~n o~ or omploy~: own~ more g~ 5% or~c
lryou ~wc~d "YES", complete ~h~ balan~ or ~(s fo~ ~d d~te ~d si~ wl~ i~dicut~d.
N~e of ~on employed by ~e Tox~ Of ~uthold
Titlc Vr ~sition orthat ~n ~
~scH~ the ~lation~hip ~tw~;m you.ll (the appli~ag~nC~pm~n~tlve) ~d the town o.ffi~r
thc appropriate lin~ A) through D) ~d/or dcscd~ i~ thc sp~ pm~i&d.
~e m~ o~cer or cmploy~ or his or her s~u~, siblin~ pamn~ or child is (~h~ck all that ~pply):
_A) tho owner ofgmat~ fl~ 5% orthe sh~ms of~c ~m~ stock of~v apPlicont
(whon the applicant is a m~tion);
~B) t~ Icg~ or ~mficial own~ of~ inlem~ in a non-co.rote emi~ (wh~ ~
a~licnnt is not ~ co.ration); '
~) an offi~r, di~or, p~, o~ ~ploy~ of~ appli~ng or
__.D) ~ s~ual eppll~nt
DE$CR,IPTION OF RELATIONSHIP
Form T~ 1
Submi'ttod this .... day of ,, 200
Signature
Print Name
A T ORIENT
TOWN OF .SOUTHOLD
SUFFOLK COUNTY; N Y.
,.~ ,~,~ Scale, I"
Mar. 27, 1997
~¢ " ~ EI~ t997 (adoltions)
11/20/2006
1B:i9 B31?B50015 BRIARCLIE PAGE 01
www.brlar¢llfflnfld$oalme.com
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~ Route'~,~
11/28/2006
15:41 6317650015 BRIARCLIE PAGE
01
I c~ b,~,~3 ~l pbr~ ~h~. oZ-fic~ ~,tci,
Office.' A~,l 7~5-1220
-~>~-~ I o-f ~
PO Sox ~ Peconlc, NY 119Jll fax: &31
-~'~ . ~UFFOLK COUNTY, N Y.
~ c3 ~' . ~, TOWN OF-$OUTHOLD
' .,,~' ~c~e, 1" =. 80'
M~ 2~ ~97
1998 (
. ~ ~.