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HomeMy WebLinkAboutRugg, BettyJames 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 ApplicattO~ --Wetland Permit Application~/ Administrative Permit ~ Amendment/Transfer/Extension __Rece~vved Application: ] Jf0/'(~ 0 ~Keceived Fee:$ ,~- __Completed Application __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: --d~ublic Hearing Held: ! ] {~q,{(3c] Resolution: Name of Applicant Address Phone Number:( Suffolk County Tax Map Number: 1000 - Property Location: /~cj~ O,./'~.ir-~,/d~ (provide LILCO Pole #, distance to cross streets, and location) ,~/C~'-.~. ~ P-~ ,~¢,'9Z) AGENT: ~-"z:)A~r/'L ~~~ / ~~-~ (If applicable) ~ ~ Address: Phone: of Trustees Ap~ Land Area (in square feet): Area Zoning:. GENERAL DATA Previous use of property: Intended use of property: Prior pemfits/approvals for site improvements: Agency Date ~/No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspen,,~d by a governmental agency? v' No Yes If yes, provide explanation: Project Description (use attachments if necessary):. ~rd of Trustees WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ~'&3A)~:~__-..~ ~&-~r.J'~r.~7- square feet Area of wetlands on lot: ~ Percent coverage of lot: ~,~2~ % Closest distance bet~veen nearest existing structure and upland edge of wetlands: .,,4.~°, ~-~ feet Closest distance between nearest proposed structure and upland edge of ~vetlands: ~-' ~ feet Does the.~[~oject involve excavation or filling? / ~ No Yes If yes, how much material will be excavated? A/-/~ cubic yards How much material will be filled? /,.XZ) cubic yards 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: feet Statement of the effect, if any, on the wetlands and tidal waters of the town that ma result by reason of such proposed operations (use attachments it' ~pProPriate)i PROJECT ID NUMBER PART 1 - PROJECT INFORMATION ( To be completed by Ap 6t7.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only )licant or Project Sponsor) SEQR 1. APPLICANT / SPONSOR 2. PROJECT NAME 3.PROJECT LOCATION: Munic,pality ~ ~2 ~.,,) ~_~j ¢~..) ~' ~'¢/~'~(' County ~,~2~ 4 PRECISE LOCATION: Strem Addess and Road Intersections, Prominem landmarks etc -or provide map 5. IS PROPOSED ACTION: ~ New ~ Expansion ~MoOifica~ion/alteration 6 DESCRIBE PROJEOT BRIEFLY: 7 A~OUNT OF LA~D AFFECTED: Initially acres Ultimately acres 8~ WIL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~s ~ No II no, describe briefly: 9 W AT IS PRESENT LAND USE IN VICINI~ OF PROJECT? (Choose as many as apply,) ~esiden,ial ~lndustrial ~Commercial ~Agdculture ~Park/Forest/OpenSpace ~Other (describe) 10 DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTJMATELY PROM ANY OTHER GOVERNMENTAL AG~Y (Federal, State or Local) s ~No If yes, list agency name and permit / approval: - ~; ~ ~ 11. MObS --~ OF IHE ACHON HA~'A CURRENTLY ~A~I~RMIT OR APPROVAL? ~Yes ~No If yes, list agency name and permit / approval: 12. AS A RE~LT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I ~Y THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / SI Date: ~ 0~ t~, 2~ Signature ] ~ 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~ency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes, coordinate the review process and use the FULL FAF. E~TM E~No 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 E~Yes E~]No COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: {Answers may be handwriflen, 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 Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or communily or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species sign fican hab a s, or hrea ened or endangered Spec es? E~plain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly: C5 Growih subsequent development or related acbwhes flkely o be nduced by he proposed acfion? Explain briefly:" C6 Long term, shod term, cumulaiive, or'ether'effects not identified in C1-C57 Explain briefly: C7 Other impacts (including changes in use of egher quantity or type of energy/? Explain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (~EAt? /If)fas, explain briefly: [~] Yes [~No .... t E IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ErqVIRONMENTAL 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 olherwise 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 (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacls have been identified and adequately addressed. If question d of part ii was checked yes,qhe~eterminat!on o f sig n!ficc nos must evc~uate~he potential impaet of the propec, cd c. ctlo n an th,~ e~vironm,,cntr~i cha r~,cterist~cs of [h~ C.'-A. 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 ibis b~x i:~ y~ hav~ d~errn~'ne'dl b~sed o~ ihe information and ~nalysis ~bove and any ~upporting documentation, that ~he-i~rop~ ~cfl~rl WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons suppoding this determination. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from responsible officer) Board of Trustees Appli~ion County of Suffolk State of New York /~"-~_~,,L//<: ~'[~::F_~ff_dt~)/'q J-fi(_.. BErG D~Y SWORN DEPOSES AND AFF~S THAT HE/S~ IS T~ ~PLIC~T FOR T~ ~OVE DESC~ED PERMIT(S) ~ T~t ~L STATE~NTS CONT~D ~IN A~ TRUE TO T~ BEST OF ~S/~R ~OWLEDGE A~ BELmF, ~ t~W ~L WO~ WILL BE DO~ ~ tE~ M~NER SET FORTH ~ T~S ~PLICATION A~ AS MAY BE APPRO~D BY T~ SOUTHOLD TO~ BO~D OF TRUSTEES. t~ ~PLIC~T AGREES TO HOLD T~ TO~ OF SOUTHOLD ~ t~ WO~ TRUSTEES ~ESS ~D F~E FROM ~Y A~ ALL D~AGES ~D CL~S ~S~G ~DER OR BY VIRT~ OF SAD PE~IT(S), ~ G~TED. ~ CO~LET~G T~S ~PLICATION, I ~BY AUTHORIZE t~ ~US~ES, t~m AGENT(S) OR ~PRESENTATI~S(S), TO EN~R ONTO MY PROPERTY TO ~SPECT t~ P~SES m CON~CTION W Tins ~PLICATION. Signature SWORN TO BEFORE IV[E THIS DAY 01~¥~ ~ 3&(.~ BONNI£ J.~ltOSIg Notap/Public, State Of New ~lt #o. 01D06095328, Suffolk CoAqtI TermExpiresJutyT. 20 0 /_ of Trustees Applica~ ( where · o~er of p~p~ty) AUTHORIZATION 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. APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics orohibits conflicts of interest on the hart of town officers and emolovees. The nuroose of this form is to orovide information which can alert the town of vossible conflicts of intereSt and allow it to take whatever action is Oecessarv to avoid same, YOURNAME: ,~____~/~ ~t~__..~-t~t~.~ ff~7~ t~'~fff~g'~ ~(..]-~-~ (Last name, first name, ~fiddle initial, unless you arc 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.) ,~:>~--~] 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, nlarriage, or business interest- "Business interest" means a business, including a partnership, in which the town officer or elnployee has even a partial ownership of (or employment by) a corporation in which the town officer or employee owns more than 5% oftbe shares. YES NO J 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 applicanffagenffrepresentative) 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 applic0nt (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 of the applicant; or ___D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Submitted this ~ay of Signature 7.~/~/~ ' . Print Name CREE ALTERATION WEST MILL K DRIVE ~ TO T,E [ SURV~ By JOSEPH A. ~NGEGNO, p.e.1 ~ DATED: 11/02/2005 ~ ~ SOUSA ~ RUGG ~ RESIDENCE L -- I DOARD OF TRUSTEES ~ ~ SOUTHOLD, NY -- ~ 1695 WEST M~LL CREEK ~ PROPOSED 'I ~ ~ ! TOWN OF SOUTHOLD g i DATE ~ F~NK UE~ENDA,L J ~ GREENPORT, ~ 119~ ~ TEL: 631-477 8624 ,~ F~: 631-477 2997 j j j ~~ OWNERS & B~ RUGG -- J 162-01 P~EL~ C~ BL~ ~ ~ WHI~STONE, ~ 11~57 - ~ ~L: 917-864-4751 TEL: 718-747-~717 TEL: 6~1-765-~71 ' ~ DATE: 01/17/2007 SCALE: 1/16" =1'-0" SCALE: V16'= r-o" F 1 SITEPLAN i~ SITE PLAN SCT,#: 1000-51-06-32 ARSHAMOMAQUE POND TOWN OF SOUTHOLD SUFFOLK COUN'h', NEW YORK ~ ~ A- 1 ©~ DWO. NO SURVEY OF' PROPERTY ARSHAMOMAQUE TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-51-06-52 SCALE 1"=50' NOVEMBER 2, 2005 AREA -- 18,975.95 sq. ft. (TO TIE LINE) 0.436 CERT]£V£'D 7'0: PHYLLIS SOUSA BETTY RUGG PECONIC ABSTRACT, INC. FIRST AMERICAN TITLE INSURANCE COMPANY OF NEW Y J. P. MORGAN CHASE BANK, N. A. PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED 5~' THE L.I.A.L.B. AND APPROVED AND ADOPTED FOR SUCH USE BY THE NEW Y©RK STATE LAND .los Land Surveyor Htle Surveys -- Subdivisions S~te Plans Consfruc~ion Lo.You! :HONE (631)727-2090 Fox (63!)727 !727 CERTIFICATIONS INDICATED HEREON SNAI~ RUN ONLY TO THE PERSON FOR WHOM THE IS PREPARED, AND ON HIS BEHALF TO THE TfTL~ COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO TH[ ASSIGNEES OF THE LENDING INSTI- ]U]ION CERTIFICATIONS ARE NOT TRANBFERA~3'E THE EXISTENCE OF RIGHTS OF WAY AND/OR EASEMENTS OF RECORD, IF James F. King, President Jill M. Doherty, Vice-President Pegg~ 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 Please be advised that your application dated reviewed by this Board at the regular meeting of following action was taken: ( V/) Application Approved (see below) ( )Application Denied (see below) has been and the )Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees. The fee is computed below according to the schedule of rates as set forth in Chapter 97 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: BY: Jgrnes F~ King, President Board of Trustees