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Home My WebLink AboutTR-7472E Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Bredemeyer Town Hall Annex 54375 Main Road 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.: 7472E Date of Receipt of Application: January 26, 2011 Applicant: Cynthia Kaminsky SCTM#: 106-4-3 Project Location: 80 East Mill Rd., Mattituck Date of Issuance: January 28, 2011 Date of Expiration: N/A Reviewed by: Board of Trustees Project Description: To remove remains of fire damaged building and related debris. 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 in the application received on January 26, 2011. Special Conditions: The installation of staked hay bales along the seaward side of the damaged building. This is not a determination from any other agency. Doherty, PF~§identz of Trustees "k. it, SOUTHOLD Jill M. Doherty, Pres/dent James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only --C°astal Erosion Permit Application __Wet/and Permit Application ./ a : -. -- '~"~"7 , ..,~ --AmendmentFfransfer/Extensio~-- ye rermtt ' ~eceived Application~ "~eceived Fee:$~'.lD - · ~mpleted Appli-catio~ __Incomplete __SEQRA Classification: Type I Type II Unlisted --Coor~nation:(dat~-ssent)~ __LWRP Consistency Assessment Form __CAC Referral Sent: __Date of Inspection: ~ __Receipt of CAC Re~ __Lead Agency Determination: __Technical Review: __Public Hearing Held: __Resolution: Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY I1971 Telephone (631) 765-1892 Fax (631) 765-6641 Name of Applicant q"trl~'l' ' 6k' K~ Phone Number:( Suffolk County Tax Map Number: 1000 - ~ ~ Dr_- ~ Property Location:~ (provide LILCO Pole #, distance to cross streets, and location) AGENT: (Ifapplicable) Address: Phone: Board of Trustees Appllcation Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property:. Covenants and Restrictions: If "Yes", please provide copy. GENERAL DATA Yes / No Does this project require a variance from the Zoning Board of Appeals __ If "Yes", please provide copy of decision. Prior permits/approvals for site improvements: Agency Date Yes lJ No __ 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): Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: 0 .square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge ofwetlands~ ~O feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? '-x / 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 ef[ec[~ if any, 0_n ~he wetlands and.tidal_ wa_ters of th~ town that may_ r_¢_591[by reason of such proposed operations (use attachments if appropriate): PROJECT ID NUMBER PART 'I - PROJECT INFORMATION 1. APPLICANT / SPONSOR 3.PROJECT LOCATION: STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. PROJECT NAME 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map 5. IS PROPOSED ACTION: [] New E~Expansion i----~Modiflcation/alteration 6. DESCRIBE PROJECT BRIEFLY: SEQR 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WIL 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.) E~ Residenflal E~] Industrial E~ Commercial E~]Agriculture [] Park / Forest / Open Space ~'Other (describe) 10.'DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) []Yes ~-~No Ifyes, list agency name and permit / approval: 11.U~E5 ANY A~SPECT~ IH[: ACTION HAVE A CURRENTLY V~ I~ERMIT OR APPROVAL? E~Yes [~o If yes, list agency name and permit / approval: ~2. AS A RESULT OF PROPOSED ACT~O. WILL EX~ST,.G PERM~T~ APPROVA. REOUIRE MOD,FICA~ON? I~e. FINe I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE sponsor Name __. . Date: Signature %If thee a~<Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To be completed I~ Lead AgenCy). A. ~ ACTION EXCEE"D ANY TYPE, '~-IRESHC)LD ,N e NYCRR, PART e17.47 . yes, coamlnate the ra~ew pmoess and use the FULL EAF. B. WILL ACTION R~C~IYE (X)ORDINATED REVIEW A8 PROVIDED FOR UNUSTED ACTIONS IN 6 NYCRR, PART 617.67 If NO, a negative C. COULD ~C. ~- --~i4 RESULT IN ANY ADV-r_~ EFFECTS ASSOCIA'I'ED WTH ~ FOCLOWING: (Answera amy be han0~it~, ff legible) O1. ~ ak quash-, ~u~mce or groundwater qual#y or quar,~iy, ~¥,e teve~, e~tng tmflin paifam, ~kl wa~e ixodue~on or disposal, No F- I~ ~ |E,~F.., ON 18 I¥1ERE UKELY TO BEt CONTROVERsy RELA'I'~D TO'POu=NTIAJ. ~ ENVIRC~,;~,~AL IMPACTS? F-I¥' INSll~UCTIONS: F~each adverse effect identified above, determine whether I~ Is sub~antlal, large, Importantorothenvise slgnifiCanL Each e,".=~ ~hould be assessed In conne<~on with its (a) ~etting (i.e. urban m rural); (b) probability of ocountng; (C) duration; (d) Irreversl~, (e) geogmp~k~ aoage; and (0 magnitude. If necessmy, add atta~ or refemnoe suppo~ng mate~mls. Eneure that explanations contain euffi(dent detail, to show that all relevant adverse impacts have been ident#led a~ ~ ~. If quesllon d of pet # was checked FAF end/(x prepare a posi6vedeclaratlen' WILL NOT result In .Beard of Trustees Name of Lead Agency Date Jill M. Doherty President print or Type Name of Respeas;ble Officer In Lead Agency Ti~e of Responsible Officer · Sigeature of Resp<~s~ble Officer in Lead Agency .Signature of F*,=V,=,~' (If dliferant from respondbte officer) Board of Trustees ~tion County of Suffolk State of New York ~¥t4 TH, ~ ~ ! A],SK / 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 I-lIS/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. SWORN TO BEFORE ME THIS DAY OF~~2.3~,20 [[ "~I~otary Public LAUR[N M. STANDISH Nota~, Public, State of New York No. 01ST6164008 Quali[i~d in Suffoii County Commis,~ioa Expires APril 9, APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics orohibits conflicts of interest on the part of town officers and emolovees. The oumose of this form is to nrovide information which can alert the town of~ossible conflicts ofinmrest and allow it to take whatever action is necessary to avoid same. {Last name, first t{ame, ~iddle initial', u~lass you are applying ia the name of someone else or other entity, such as a company. If so, indica/e 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 (I f"Other", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a mlationshlp 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 corporation 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 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 llne 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) tbe owner of greater than 5% of the shares of the corporate stock of the applic0nt (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 Signature Print Name