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HomeMy WebLinkAboutTR-7509 James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino 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 CERTIFICATE OF COMPLIANCE # 0725C Date February 13, 2012 THIS CERTIFIES that the existing dwelling, deck ,in-ground swimming pool, replacement of fence around swimming pool and installation of drywells At 5705 Stillwater Ave., Cutchogue Suffolk County Tax Map # 137-4-4 Conforms to the application for Trustees Permit heretofore filed in this office Dated 3/I/1 l_pursuant to which Trustees Wetland Permit #7509dated 3/23/11 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 existing dwelling, deck, in-ground swimming pool, replacement of fence around swimming pool and installation of drgwells. The certificate is issued to DOUG GEROWSKI owner of the Aforesaid property. Authorized Signature James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631 ) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: ,//"~:~h. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1st day of construction ½ constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: CERTIFICATE OF COMPLIANCE: 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 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 % constructed .~ Project complete, compliance inspection BOARD OF SOUTHOLD TOWN TRUSTEES SOUTHOLD, NEW YORK PERMIT NO. 7509 DATE: MARCH 23~ 2011 ISSUED TO: DOUGLAS GEROWSKI PROPERTY ADDRESS: 5705 STILLWATER AVE.~ CUTCHOGUE SCTM#127-4-4 AUTHORIZATION Pursuant to the provisions of Chapter 275 and/or Chapter 111 of the Town Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted at the meeting held on March 23~ 2011 in consideration of application fee in the sum of $250.00 paid by Douglas Gerowski and subject the Terms and Conditions as stated in the Resolution, the Southold Town Board of Trustees authorizes and the following: Wetland Permit for the existing dwelling, deck (without shed), in-ground swimming pool and fence, and to replace the deck and fence around the swimming pool, with the condition drywells are installed to contain roof run-off in accordance with Chapter 236-Stormwater Management of the Town Code, and as depicted on the survey stamped approved on March 23, 2011. IN WITNESS WHEREOF, the said Board of Trustees hereby causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date. TERMS AND CONDITIONS The Permittee, Douglas Gerowski, residing at 89 Brook Court South, New Hyde Park, NY 11040, as part of the consideration for the issuance of the Permit does understand and prescribe to the following: That the said Board of Trustees and the Town of Southold are released from any and all damages, or claims for damages, of suits arising directly or indirectly as a result of any operation performed pursuant to this permit, and the said Permittee will, at his or her own expense, defend any and all such suits initiated by third parties, and the said Permittee assumes full liability with respect thereto, to the complete exclusion of the Board of Trustees oftbe Town of Southold. That this Permit is valid for a period of 24 months, which is considered to be the estimated time required to complete the work involved, but should circumstances warrant, request for un extension may be made to the Board at a later date. That this Permit should be retained indefmitely, or as long as the said Permittee wishes to maintain the structure or project involved, to provide evidence to anyone concerned that authorization was originally obtained. That the work involved will be subject to the inspection and approval of the Board or its agents, and non-compliance with the provisions of the originating application may be cause for revocation of this Permit by resolution of the said Board. That there will be no unreasonable interference with navigation as a result of the work herein authorized. That there shall be no interference with the right of the public to pass and repass along the beach between high and low water marks. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the work shall eanse unreasonable obstruction to free navigation, the said Permittee will be required, upon due notice, to remove or alter this work project herein stated without expenses to the Town of Southold. That the said Board will be notified by the Permittee of the completion of the work authorized. That the Permittee will obtain all other permits and consents that may be required supplemental to this permit, which may be subject to revoke upon failure to obtain same. Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Bredemeyer Town Hall Annex 54375Main Road P.O. Box 1179 Southold, NewYork11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 March 23, 2011 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Douglas Gerowski 89 Brook Court South New Hyde Park, NY 11040 RE: 5705 STILLWATER AVE., CUTCHOGUE SCTM#127-4-4 Dear Mr. Gerowski: The Board of Town Trustees took the following action during its regular meeting held on Wed., March 23, 2011 regarding the above matter: WHEREAS, DOUGLAS GEROWSKI applied to the Southold Town Trustees for a permit under the provisions of Chapter 275 of the Southold Town Code, the Wetland Ordinance, application dated March 1,2011, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator for their findings and recommendations, and, WHEREAS, the LWRP Coordinator recommended that the proposed application be found Inconsistent with the LWRP, specifically with Policy Standard 6.3 - Protect and restore tidal and freshwater wetlands, and, WHEREAS, the Board of Trustees has furthered Policy 6.3 of the Local Waterfront Revitalization Program to the greatest extent practical through the imposition of the following Best Management Practice requirements: the installation of drywells to contain roof run-off in accordance with Chapter 236-Stormwater Management of the Town Code, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on March 23, 2011, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standards set forth in Chapter 275 of the Southold Town Code, and, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that for the mitigating factors and based upon the Best Management Practice requirements imposed above, the Board of Trustees deems the action to be Consistent with the Local Waterfront Revitalization Program pursuant to Chapter 268-5 of the Southold Town Code, and, RESOLVED, that the Board of Trustees approves the application of DOUGLAS GEROWSKI for the existing dwelling, deck (without shed), in-ground swimming pool and fence, and to replace the deck and fence around the swimming pool, with the condition drywells are installed to contain roof run-off in accordance with Chapter 236- Stormwater Management of the 'Town Code, and as depicted on the survey stamped approved on March 23, 2011. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections a~e required at a fee of $50.00 per inspection. (See attached schedule.) Fees: $50.00 Very truly yours, Jill IV~.jDoherty Presider~ Board of Trustees JMD:lms 03/30/2011 15:11 710047~ O6 ORI PAGE ?.03 02 ~G - 03/30/2011 15:11 ?188474~ ORI PAGE 01 March 30,: 2011 TO: Town of Southold ATTN: Lauren email: Doug Gerowski 89 Brook Court South Manhasset Hills, NY 11040 phone: (516) 437-8311 cell: (516) 650-4058 Gcrowski~optonlin¢.net Drywell location Lauren, Attached is an updated copy of the plans showing where I will be installing the drywel~J. Hopefully we can get the permit approved with this inforrnatie.~. Please let me know if you need the original and I will overnight it to you. If possible, I would also like to have the permit sent overnight 5:o my office when approved. I will provide you with my FedEx number for that. Thank yorl for all your help in this process! Doug Gerowski Peter Young, Chairman Lauren Standish, Secretary Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631) 765-6641 Conservation Advisory Council Town of Southold At the meeting of the Southold Town Conservation Advisory Council held Wed., March 16, 2011, the following recommendation was made: Moved by Doug Hardy, seconded by Derek Bossen, it was RESOLVED to NOT SUPPORT the Wetland Permit application of DOUGLAS GEROWSKI for the existing dwelling, deck (without shed),in-greund swimming pool and fence, and to replace the deck and fence around the swimming pool. Located: 5705 Stillwater Ave., Cutchogue. SCTM#127-4-4 Inspected by: Doug Hardy, Derek Bossen The CAC does Not Support the application because the structures are in violation of the Town Code. Vote of Council: Ayes: All Motion Carried Jill M. Doherty, President Bob Ghosio. Jr., Vice-Pmsidem James F. King Dave Bergen John Bredemeyer P.O. Box 1179 Southold, NY 11971 Telephone (631 765-1892 Fax (631 ) 765-6641 Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: DOUGLAS GEROWSKI requests a Wetland Permit for the existing dwelling, deck (without shed) and in-ground swimming pool, and to replace the deck and fence around the swimming pool. Located: 5705 Stillwater Ave., Cutchogue. SCTM#127-4-4 Type of area to be impacted: Wetland ~. Freshwater Wetland / Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: __Chapt.275 Chapt. 111 other Sound Bay Type of Application: __ Wetland __Coastal Erosion __Amendment ~Ad ministrative__Emergency Pre-Submission __Violation Info needed: Modifications: Present Were: ~.King ?'J.Doherty ~J. Bredemeyer ,X D. Bergen~/x'- B.Ghosio, D. Dzenkowski other Form filled o~,i,n, the field by Mailed/Faxed to: Date: Jill M Doherty, President Bob Ghosio, Jr., Vice-President James F. Krug Dave Bergen JO]ill Bredemeyer P.O Box 1179 Southold, NY 11971 Telephone {631 765-1892 Fax (631) 765-6641 Southold Town Board of Trustees Field InspectionNVorksession Report Date/Time: DOUGLAS GEROWSKI requests an Administrative Permit to remove and replace the existing deck and fence around the in-ground swimming pool, Located: 5705 Stillwater Ave,, Cutchogue, SCTM#137-4-4 :pe of area to be impacted: Saltwater Wetland Freshwater Wetland Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: '~Chapt.275 Chapt. 111 other Sound Bay Type of Application: __ Wetland __Coastal Erosion --Amendment ]5_Administrative__Emergency __Pre-Submission __Violation Info needed: Modifications: (,,.,.,,_ Present Were: __&King __J.Doherty __J. Bredemeyer )~-O. Bergen__ B.Ghosio, __ D. Dzenkowski other Form filled ou~n. th.~ field by Mailed/Faxed to: Date: Doug Gerowski 89 Brook Court South Manhasset Hills, NY 11040 phone: (516) 437-8311 cell: (516) 650-4058 email: Gerowski~optonline.net TO: Town of Southold ATTN: Lauren Lauren, Enclosed is a check for the final inspection related to the permit that is being issued next week. Thanks again for all your help in this process! S~lY'~"/~ ~ Doug Gerowski OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY 11971 MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971 Telephone: 631 765-1938 Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: MEMORANDUM Jill Doherty, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: March 21, 2011 Re: Proposed Wetland Permit for DOUGLAS GEROWSKI SCTM#1000-1~7-4-4 DOUGLAS GEROWSKI requests a Wetland Permit for the existing dwelling, deck (without shed), in- to replace ground swimming pool and fence, and the deck and fence around the swimming pool. Located: 5705 Stillwater Ave., Cutchogue. SCTM#1~7-4-4 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is INCONSISTENT with the denoted following Policy Standards and therefore is INCONSISTENT with the LWRP: Policy 6. Protect and restore the quality and function of the Town of Southold ecosystem 6.3 Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction 1. Comply with Trustee regulations and recommendations as set forth in Trustee permit conditions The structures were constructed without a permit pursuant to Chapter 275 Wetlands and Shorelines of the Southold Town Code. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631 ) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only ~,(,Qoastal Erosion Permit Application ~'~Vetland Permit Application Administrative Permit Amendment/Transfer/Extension "~Received Application:. }~Lkk~ ,.~.eceived Fee:$ ~,'~'X.~ . ~ompleted Appli~'~tion ,_o~J I J JJ Incomplete __SEQRA Classification: Type I Type Il Unlisted ~,~' __Coordination: (date sent) ~WRP Consistency .&ss~essment Form ,./"CAC Referral Sent: '~-~1 q ~Date of Inspection: e~] __Receipt of CAC Report: Lead Agency Determination: Technical Review: ~ublic Hearing Held: __Resolution: Name of Applicant Address Sufiblk County Tax Map Number: Prope~y Location: (provide LILCO Pole #, distance to cross streets, and location) AGENT: t,,J/~k (If applicable) Address: Phone: of Trustees Applicati¢ GENERAL DATA Land Area (in square feet): ~ z~ ~ 0 C~ ~ Area Zoning: ~ 5 ~D~ M-Ti I~ L_ Previous use of property:. Intended use of property: Covenants and Restrictions: Yes t,-"' No If "Yes", please provide copy. 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 ,%o-rlefob~ .Px2m~ o[7 -Tk.r;Tc--,~'7 Yes 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: M /~ -- Project Description (use attachments if necessary): of Trustees Applicati¢ WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: ~Pc.~q~ff>~ $~E [¥.cx3~_~ [~c~4197(0A) Area of wetlands on lot: ~ square feet Percent coverage of lot: .---/~ % Closest distance between nearest existing structure and upland edge of wetlands: [ Q') feet Closest distance between nearest proposed structure and upland edge of wetlands: [ C) feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? M//lff cubic yards Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: /'J/~ Manner in which material will be removed or deposited: M//~ feet 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): Ad of Trustees Applicatio~ COASTAL EROSION APPLICATION DATA Purposes of proposed activity: ~(~3~ ~)~-tL~['-( ~[~)Q_ Are wetlands present within 100 feet of the proposed activity? No / Yes Does the project involve excavation or filling? / No Yes If Yes, how much material will be excavated? AJ/~ How much material will be filled? ?',J/tar Manner in which material will be removed or deposited: (cubic yards) (cubic yards) Describe the nature and extent of the environmental impacts to the subject property or neighboring properties reasonably anticipated resulting from implementation of the project as proposed, including erosion increase or adverse effects on natural protective features. (Use attachments if necessary) PROJECT iD NUMBER ~ART 1 - PROJECT INFORMATION 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 ~ - ~ SEQR 1. APPLICANT / SPONSOR 3.PROJECT LOCATION: Municipality ~tO~-1 '('~ 0 Cb 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide mad 9705- 5- tLc O c . llq 5' IS PROPOSED ACTION: [] New [~Expansion [~l~lodification/alteraflon DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially 2000-'~ acres Ultimately ~- acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~es [] No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) [~esidential [~lndustdal r'~commercial ~]Agriculture r--l 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) I~lYes I'-~o If yes, list agency name and permit / approval: 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? r~Yes [~.No If yes, list agency name and permit / approval: 12. AS A REF.~T OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? E~Yes I~1 No Applicant / Signature I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE OhS r Na ~~ 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 Agent)') · A. C~OF-~ AC~iO~ EXCEED ANY TYPE I THRESHOLD IN 6 NYCP~ PART 617A? ff yes. coofdlnale the renfrew process and L~e the R~LL EAF. B. W~U-ACTION~VECOORDIHATEOREV~EWAS PROVIDEDFORUNUSTEDACTK)f~IN6 NYCRR, PART6~7.~. ffNo, a neg~ C. COUt'D ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Ailswe~ et~y be hal~wlffi~efl, if leg~) or fauna, fish, .,,=,,~ o~ wiMlife spe~es, 8i~-,;.,,~,,, ,..,,~-w., o~ threatened or e(~tangm'ed species? F .,ff,~n briefly:. C6. Le~g~efm. sh~te~m, cumulaflve, orothereffec{snotklenlifiedlnCl.C5? F%ff~L~!~br[elTy: I I-1 - IZ]NeI '-- ' ! IS ~ |-'-~ OR I$ ~ ~ LIKELY TO BE? coNTROVERSy RELATED TO POTENTI/U~ ADVERSE ENVIRC~, ;;,;~,';T/U. IMPACTS? If yes p.4J~l' Ig. ~=, ~i~A~TION OF SmNFICJUdCE (To be o~pleted by ,~enc~) JNS~UCIlON$; F~reachadver~ee~ect~den6~ed~b~ve~d~ewhe~her~t~s~ub~tanb~arge~imPmtanL~t~e~sesig~ant~ Each ~".~ should be assessed in connection ~th ~ (a) seffing (i.e~ urban or mraO; (b) probabllll~ of oc~urriflg; (~) dmatlo,~; (d) Irreversa)illty;, (e) )'es, the,determlnatio~ (~slgnfficar~e mustevaluatelfle pote~tiallmpa(~ofthe proposed ac(kin ofllheenvflonrnen~chara(~edstlcs or,he CEA WILL NOT result M an~ dgnlflcant advesse er~onmenlal Impam ANO provide, o~ altKhmenls as necessary, the reas~na .Board of Trustees Name of Lead Aoency Jill M; Doherty - Prlrtt or Type Name of Responsible Officer In Lead Agency ?~ ~rla~re of R~'~ble OfiT/er I~ Lead Agency Da(e President T~e of Responsible Officer Signature of P,,~,~,,~' (ff different from responsible officer) Town of Southold  Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A 10~) ~'7 z~ ~ STORM-WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN Distact Section Block Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUc'rlON ~1~ ~ / WO~ ~S~SM~ Yes No a. What is the Total Area of the Project Parcels? I Will this Project Retain All Storm-Water Run-Off (Include Total Area of all Parcels located within I[~ Generated by a Two (2")inch Rainfall on Site? A.,/~ the Scope of Work for Proposed Construction) (This item will include all run-oft created by site U b. What is the Total Area of Land Cleadng (S.F. / At=es) clearing and/or construction activities as wed as all and/or Ground Disturbance for the proposed bJID tk) ~ Site improvements and the permanent creation of construction activity? impervious surfaces.) (s.~.,^~t 2 DoestbeSitaPlanand/orSurveyShowAiIProposed ~//~/~ D PROVIDE BRIEF PROJECT DESCRIPTION iP~ov~,, Additional pages as Needed) Drainage Structures Indicating Size & Location? This Item shall include all Proposed Grade Changes and -- h~. (~0 [ {)._~-' P(~/V~ ['~- ~,,~-)~-~ ~--~ 1 5~( J~J (..~ Slopes controlling surface water Flcw. ~ b~v---'~ ~.~ ~',,.~ D ~. ~.._ (PJ k'i'Pf c_.~ ~ ~=~) 3 D°es the Site Plan and/°r Survey describe the erosi°n ~'~gD and sediment control practices that will be used to I control site erosion and storm water discharges. This ~J~) ~])(~- Dx~.c~OV'~' ~ ~---~(./~_~ item must be maintained throughout the Entire Constr~ction Pedod. ~-~l~J~ DWc,~ ,~c&~D /'~Td~ ~ 4 Will this Project Require any Land Filling, Gradingor Excavation where there is a change to the Natural [ [ Existing Grade Involving more than 200 Cubic YardsL.7.,J -- of Matedal within any Parcel? 5 Will this Application Require Land Disturbing Activities ~ Encompassing an Area in Excess of Five Thousand (5,000 S.F.) Square Feet of Ground Surface? -- 6 is there a Natural Water Course Running through the[~ Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Requirementh: or within One Hundred (100') feet of a Wetland orI~1 Submission of a SWPPP Is required for all ConstnJcfion activi§es involving soil Beach? disturbances of one (1) of mere acres; including disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes~ are pad; of a larger common plan that will ultimately disturb one or mom acres of land; which Exceed Fifteen (15) feet of Vertical Rise to iocludtng Construction activities involving soil disturbances of less than one (1) acre where One Hundred (100') of Horizontal Distance?~ -- the DEC has delermined that a SPDES permit is required for storm water discharges. SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit 8 Will Driveways, Parking Areas or other Impervious r~ for Storm Water Discharges fr~ Constnictthn activity. Permit No. GP-O.10-001.) Surfaces be Sloped to Direct Storm-Water Run-Off U 1. The SWPPP shell be prepared prior to the submittal of the NOI. The NOI shall be into and/or in the direction of a Town right-of-way? submitted to the Depaamenl pdor to the commencement of construction activity. 2. The SWPPP shell descdbe the erosion and sediment control practices aed where 9 Will this Project Require the Placement of Material, required, post~onseuction stotra water management practices that will be used and/or Removal of Vegetation and/or the Construction of any ~ i constructed to reduce the pctlutaMs in storm water discharges and to assure item Within the Town Right-of-Way or Road Shoulder compliance with the terms and cendgions of this permit. In addition, the SWPPP shaft Area? {lh~ item will NOg include the Ir~t~llatlon of O~vewa¥ idenlify potential sources of pollution which may reasonably b~ expected to affect the quality ct storm water discharges. NOTE: ff Any Answer to Queedon$ One tsrough Ntoe is Aa~weteO wi~ a Check Ma~ 3. All SWPPPs that require the post-construstion storm water management prastJce in a Box and the censt~uoflon site disturbance k~ beiween 5,0~0 S.F. & 1 Acm in area, component shall be prepared by a qualifled Design Professional Licensed in New York a Storm-Water, Grading, Drainage & Erosion Control Plan is Required by the Town et Southold and Must be Submitted far Review Prior to Issuance of Any eugdl~g Pei'miL thatisknow/edgeableinthep,~ncip[esandpracticesofStorrnWaterM, anagement. (NOTE: ACheckMark(~) and/ot~,nsw~'foreachQuestivnlsRequiredforaCom~eteApplication) STATE OF NEW YORK, ~'x , c, cou~'y o~..(~..~./~ ......................x ss That 1, ....~..~..0..~.~.......~...~..~....~....~...! ..................... being duly swbm, deposes and says ti,at he/she is the applicant for Permit, (Name of individust signing Document) And that he/she is the .................................................................................................................................................................... Owner and/or representative of the Owner or Owners, and is duly authorized to perform or have performed the said work ;md to make and file this application; that all statements contained in this application are true to the best of his lutowledge and belief; and that the work will be performed in the maamer set fo~flt io the applicadon fried he~ce~th. Sworn to before me this; ~- / I .¢ / ......... ...................... .................. Notary Public~..~ ........ ~ ........................ ~__ .f~,(__ .~', __ .~..,..~...~_:...~./ Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box l 179 Southold, NY 11971 Telephone (63 I) 765-1892 Fax (631 ) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of DOUGLAS GEROWSKI COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, ~C[J~ 5~-~0LL)~} .residingat/dl~ ~)6~_ ~I2DO~Z.. ff o: P,, az_ 1104o being duly sworn, depose and say: That on the ~day of ~4~--~ ,201 ~, I personally posted the property known as 5705- 5~_~,~-'le~Z_ ~ ~ d~O~ ~ ttfl~ by placing the Bo~d of Trustees official poster wh~e it c~ easily be seen, ~d that I have checked to be sure the poster has r~ned in place for ei~t days prior to the date of the public hemng. Date ofhe~ng noted ther~n to be held Wed~ March 23~ 2011 on or about 6:00 PM. Dated: ~ ~ff / (s Sworn to before me this day of/~a r~k20 ti JAY N'.., RUGGIERE NOTARY PUBLIC, STATE OF NEW YORK NO. 01RUS~27~'5 QUALIFIED IN N,:,SS ,U CC'!j,/FT PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Address: STATE OF NEW YORK cotmz¥ OE S FOLK ~(3.~Cf~ ~3~1 , residing at ,~ ~)O6( C0,A~] ~L)2~ 6/e'u~ ~9C DW~V__ /~ I to4o , being duly sworn, deposes and says that on the q~ day of 34&q2c~ ,201 \ , deponent mailed a true copy of the Notice set forth, in the Board of Trustees Application, directed to each of the above named persons at the addresses set opposite there respective names; that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment roll of the Town of Southold; thal said Notices were mailed at the United States Post Office at bdO~ , that said N/gfi6~werT?/ailed to es. ch of said pg~sons by ~'%,' }.; ' / Swom tO before me this Day of i~I~LGt¢- ,20 · Nonpublic JAY I~ RUGGIERE NOTARY PUBLIC, STATE OF NEW YORK NO. 01RU~062795 QUALIFIED Iil NA$S,~U COUN/T~' COMMISSION E,,P,RES (~ OlolO i~> of Trustees Applicat~ County of Suffolk State of New York ~J.~c~? ~¢~o~5 ~ ~ BEING DU~v SWOlm 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 1N CONJUNCTION WlT/J:/F~ O~F THI~tAPPLICAT~SN. Signature SWORN TO BEFORE ME THIS DAY OF 0 ~, c.:4 JAY N. RUGGI~ NOTARY PUBLIC, ST" - NO. 01 ',',. QUALIFIED IN NAS..?, COMMISSION EXPh~::-S JAY I~ RUGGIERE NOTARY PUBUC', STATE OF NEW YORK NO. 01 RU6062795 QUALIFIED IN NA~AU COUJ~"/( COMM,SSION EXPIRE~ {Z.~o ~ APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics omhibits conflicts of interest on the oat of town Officers and emnlovees. The ~uroose of this form is to t~rovide information which can alert the town of oossible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOURN B: '&X36 OC5 (Last name, first name, ~aiddle initial, unless you 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 Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If "Other', name the activity.) 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 corporation in which the town officer or employee owns more than 5% of the shares. YES NO t~ 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. Thc 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 owr~r of any interest in a non-corporate entity (when the applicant is not a corporation); C) an officer, director, parmer, or employee of the applicant; or __D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 To~n of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area (which includes all of Southold Town). If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail~ listing both supporting and non- sum~ortin~ facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold ' s website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# ]~f'l c{ _ q PROJECT NAME SI ~/C~ ~('~L3~' The Application has been submitted to (check appropriate response): TownBoard [] PlanniagBoard~ BuildiagDept. ~-~ BoaraofTrustees Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g. capital construction, planning activity, agency regulation, land transaction) (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nature and extent of action: Locafionofacfion: 5ff{t~t-O,/l¥lL-~P~ ,~v'~ CC2L(4~II~,~ /k~ [{~3~ Site acreage: ~[% ~ Present l~d use: ~c~ ~ ~ ( ~'~ Pre~nt zo~g cl~sification: (~ ( D~D ( ~ If ~ application for ~e proposed action h~ been filed M~ ~e Tom of Sou~old agency, ~e following i~o~afion shill be prohded: (a) Name of applicant: (b) Mailing address: (c) Telephone number: Area Code (). (d) Application number if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes [-~ No ~-~ If yes, which state or federal agency?. C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III - Policies; Page 2 for evaluation criteria. Yes [] No ~ot Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section II1 - Policies Pages 3 through 6 for evaluation criteria Yes [] NO ~"No' Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout thc Town of Southold. See LWRP Section III - Policies Pages 6 through 7 for evaluation criteria [] Yes ~ No ~'~ot Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III - Policies Pages 8 through 16 for evaluation criteria Yes ~ No [~Not Applicable Attach additional sheets if necessary Policy 5. P~otect and improve water quality and supply in the Town of Southold. See LWRP Section III - Policies Pages 16 through 21 for evaluation criteria ~ Yes ~-~ No ~Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. · 'X2es No Not ApI~ble Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies Pages 32 through 34 for evaluation criteria. [--] Yes ~] No ~'~Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. 73 Yes No Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. ~ Yes[-'] No ~-~Not Applicable Attach additional sheets if necessary W(~R~NG COAST POLICIEO Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria. [] Yes [~ No ~Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. [] Yes ~ No ~-~Not Applicable ARach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages 62 through 65 for evaluation criteria. ~ Yes ~-~ No ~Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III - Policies; Pages 65 through 68 for evaluation criteria. ~-] Yes [] No ~/Not Applicable PREPAREDB¥ ~'~0,~L/~ ~Oot)~\ TITLE O~j~i'~.~ DATE~-2-~-~ Town of Southold Board of Trustees Application Office Use Only (,oastal Erosion Permit Application Wetland Permit Application L~/Administrative A mendment/Trans fcr/l~xtension z/t~eceived Application', '~1 t../Received Fee:$ ~3~7, J~ompleted ApplicatiorC,)_! Incomplete SEQRA Classification: Type I Type I1 Unlisted Coordination:(datc sent) ~'T,wRP Consislency Assessment Form ('AC Refkrral Sent: ~4)alc of inspection: ~k-t Receipt of CAC Report: Lead Agency Determination: Address Technical Review: t/~ublic Ilearing HeI& ..~.~ II - Resolution: Name of Applicant ~'~')£:'L; {_a L~ ~C;~ ~ I 5 Phone Number:( Suftblk County Tax Map Number: 1000 - PropcrtyLocation: 5-~0~- ~ ltl--L_%.t~--/~F- (provide LILCO Pole #, distancc to cross strccts, and location) AGENT: K~ / h (If applicable) Address: Phone: of Trustees Applicati0 GENERAL DATA Land Area (in square feet): '[~l DOC) a Area Zoning: ~xC::~ ~ DOO"~( k~ Previous use of property: Intended use of property: ~-,C-~ { 'D~-3-~ Covenants and Restrictions: Yes If "Yes", please provide copy. Does this project require a variance from the Zoning Board of Appeals lf"Yes", please provide copy of decision. Prior permits/approvals for site improvements: Agency Yes 'v-/No Date No prior permits/approvals for site improvements. [las any permit/approval ever been revoked or suspende_..cLby a governmental agency? ~," NI' No Yes If yes, provide explanation: Project Description (use attachments if necessary): ard of Trustees Applicati0 WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ~g'~}qqDt/~7'_~ ~ 4q-~OC~' Area of wetlands on lot: ,.-4~-- _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? ~ No Yes lfyes, how much material will be excavated? /w/A cubic yards How much material will be filled? /J/~ cubic yards Depth of which material will be removed or deposited: /O/,~ Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: feet 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): of Trustees Applicati~ COASTAL EROSION APPLICATION DATA Purposes of proposed activity: Are wetlands present within 100 feet of the proposed activity? No ~'"~-Yes Does the project involve excavation or filling? ~ No Yes If Yes, how much material will be excavated? How much material will be filled? ~/~ Manner in which material will be removed or deposited: (cubic yards) (cubic yards) Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) Oard of Trustees Applicati0 County of Suffolk State of New York ~L/~ ~2ql) U3~ } 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 TIIIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR pRl~ MR~i sSEEsNiT~ ~)VNEJ~ ~iOo~4NwT 7~WY oPFRCTt~ sRz~pTLO i Jfi~ NC.T THE SWORN TO BEFORE ME THIS 3T~ DAY ,20 I{ JAY N,. RUGGIERE NOTARY PUBLIC, STATE OF NEW YORK NO. 01RU~062795 QUALIFIED IN NASSAU COUNTY ard of Trustees Applicati0 (print owner~o/prope~rty) AUTHORIZATION (where the applicant is not the owner) residing at_ (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) " Town of Southold I Erosion, & Storm-Water Run-off ASSESSMENT FORM Sedimentation PROPERTY LOCATION: $..C.T.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A t O00 ~ 3'7 ~L'~ot STORM-WATr~ GRADING, DRAINAGE AND EROSION CONTROL PLAN olatrlct .ecuon ItlOCl~ CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPEOFWORK - PROPOSED CONSTRUCTION ITEM# / WORK.aSSESSMENT I Yes No a. Wha s the Total Area of the Project Parcels? Will this Project Retain All Storm-Water Run-Off (Include Total Area of all Parcels located wtihin ~ /~ ~.~_~- 1 Generated by a Two (2"} Inch Rainfall on Site? the Sc°pe °f W°rk for Prop°set C°nstruction) (This item will include all .ri.off created by site Ii/ b. What is the Total Area of Land Cleating {S.F. / AG'OS) cleadng and/or construction acUvities as weJl as and/er Ground Disturbance for Ihe proposed ~J~ ~'O ~ Site Improvements and the permanent cma§on of construction activi[y? impervious surfaces.) [S.F. IAcres) 2 Does the Site Planand/orSurveyShowAtiProposed PROV1DE BRIEF PROJECT DF~CRIPTION (Pro~i~e --ama0.. N~) Drainage Structures Indicatthg Size & Location? This ~j/~ Item shall incJude all Proposed Grade Changes and ~J~0 ~J~ ~J~) ~---~ Slopes Controlling Surface Water Flow. ~(~"[~(~ OeCd- ~J) 3 DoestheSitePlanand/orSuryeydesc~betheomsion ,~ r~ and sediment control practices that will be used to ~) / control site erosion and storm water discharges. This -- Construction Perfod. ?~0 L. _ 4 Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Natural n Existing Grade Involving mom than 200 Cubic Yards~L~ -- of Matedal within any Parcel? ~ Will this Application Require Land Disturbing Activities n Encompassing an Ama in Excess of Five Thousand (5,000 S.F.) Square Feet of Ground Suffaca?~ -- 6 is them a Natural Water Course Running through the ~ Site? Is this Project within the Trustees jurisdiction V General DEC SWPPP Requirements: Or within One Hundred (100') feet of a Wetland or -- are part of a larger common plan that will u~timateiy disturb one or more acres of lar~l; which Exceed Fifteen (15) feet of V~racal Rise to ~ STATE O~ NgW ¥O~[, ~ · tat ~, ...~,z..v...,~.....,~..j~. ................................ ~.. ................... bcin~ duly sworn, deposes ;md says th~ he/she is the ~pplica~ for Owner a~d/'or representative of the O~er or O'~)ers, and is duly authorized to perform or have pcff'ormed the said work make and file this application; that all statemenla contahled iu this application are n'ue to the be-~t of his ksmwledge :md belief; and that the work ~fill be performed in the manner set forth in the application filed here'aSth. Sworn to before me this; ,, /'~ -- ~' .~ YORK QUAMFIED IN NASSAU COUt~Y COMMISSION EXPIRES ~/~_~/~0 COUNTY 02/10/2011 1B:35 7100474020 02/.tel 20U. 1.5:,10 765G$~ DRI BOARD OF PAGE 02 PAGE 02 PART 1 - pROJECT INFi~RMATION ~M?.~. AppENDIX C ~TATE i~NVIRONMENTAL QIJAUT'Y REV~=W SHORT ENVIRONMENTAL ASSESSMENT FORM ~r UNIJ~t'ED AG~10 NG o~ly ( To bm ,~.mple,~l by ,A~pllcant or Pmi~ sponsoO ~EQR 19.'~AT I$ PRE.RENT t~ND USE IN v~CINITY OF PROJECT9 10, ~E8 ~ION ~,~VE A PERMIT ~PROV~, OR FUNDING, N~ ~ ULTI~T~Y F~M A~ ~ ~MENTAL 11 ~ES A~ ASP~ir os ~ A~ HA~ A CURRE~LY VALID PE~IT 't.A,_,ASA I=~r~T OF !PROPOSEO AC'UON WILL EXISTING PERMIT/A~R~AL REOUI~ M~IPI~9 f ~ ~AT ~E INFO~AT~N PROviDED ~ IS ~uE ~ ~l e~ oF MY ~GE ,. / ' ~ ~e ~tlon I~a ~;bl Ama, and ~U are a S~ ag~, ~leW the Goamtal PART II. IMPACT ASSESSMENT (To be completed by ! ~=d Agenc)t) * A. F-~O~ ACT'rOhl EXt;t:~-J~ ANY TYPE I THRESHOI_D IN 6 NYCRR, pART 617.47 If Yas, cooedln~e the redew process end u~e the FULL EAF. I C7. Other ;i~ l,-.~lgcludiflg ,~,~ a .,~--e lease ere#her q~aflG~/ol' ~ Of =na~y? F ~v~l _M..n ~)de~F D. ~ THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAl:. CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRIT{CAL ENV~RONME~/TAL AREA r"~ Yes J~lNo PARr m. G,::, r"ai'WA'nofl of: SK~teRC, ANCG Cro be oon~e~d by ~een~) 'i ~ ehould be assessed In ~ vath Its (a) se~ng (i.e. urban or rural); (b) pro~ of o~; (~) dura~on: (d) In~vers~. (e) geog~Lohlc scope; and (f) magnitude. If ne~easary, add attachmenta or refemm~ m~pgol~g ma~ls. Ensure that explanal~s contain EAF and/~ prepare a Ix~fve.dedaratlen. detemlkla~'<)fl. , ~,, ..... =,,vuu~.,,=mss ~ *~.~u pemnae, en aasclloleflts as itasassaty, the ~easen$ b-~t)po~lrlg lid .,Board of Trustees Name of Lead Agency Date ,Jill M; Doherty President Print or Type Name o( Responsible Ofcer iff Lead Agency Title of Responsible Officer S~iia[uie of Responsible Officer le Lead Agency S;~i~u~u of Preparer (If diffemn~ from responsible officer) ~2/10/2~11 16:35 7188474828 ORI ~ARD ~ PAGE 03 PAGe ~ AI~PLICAXT/AGE~IT~]~ATl~ T r SACx'XO AL mSC 0Strgg C) m ,~-r. die~, petal, ~: ,mploy~ ~ th~ epptlcmt¢ c~ -- D) k'te actu~ q)plica~. DESC~.UvI'IO'N O~F R~L~TtONSHT? OZ~ P.O3 .MAY-O?-2QOa .18404 1 P.03 TOTAL PIO:!