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Home My WebLink AboutTR-7226E �O%OFFOlk��ri Jill M. Doherty,President ti Town Hall,53095 Main Rd. James F.King,Vice-President P.O.Box 1179 ® Dave Bergen Southold,NY 11971 ,t, � �'� Bob Ghosio,Jr. Telephone(631)765-1892 John Bredemeyer y' Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No.: 7226E Date of Receipt of Application: January 7, 2010 Applicant: Joint Industry Board of Electrical Industries Educational & Cultural Holdings SCTM#: 83-2-1,2&17.2 Project Location: 3800 Duck Pond Rd., Cutchogue Date of Issuance: January 13, 2010 Date of Expiration: N/A Reviewed by: Board of Trustees Project Description: Due to recent storm damage, which caused extreme beach erosion and sea wall damage, temporarily stack 2' X 2' X 64" in length concrete cement blocks approx. 1 Y2' ton in weight per block, along 150' of existing seawall. The first row '. of 150' to be buried in sand and second row of blocks to be stacked on,top. Temporary seawall to be approx. 40" in height and 150' in length. Distribute 140 cy. of sand along beach, which was lost/eroded, with a payloader/skidloader. 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 7, 2010. Special Conditions: (1) Sand to be placed above the high water mark. (2) A full Wetland Permit and Coastal Erosion Permit must be obtained in order to conduct any further activity. This is not a determination from any other agency. F II M. Doherty, Presid n oard of Trustees (7_ 0 -. i 5URYEY OF PROPERTl' 51TUATE: GUTCHOGUE E CaW E TOWN: SOUTHOLD D SUFFOLK COUNTY, NY APR - 9 2008 SURVEYED 09-30-2007, 10-09-200"1, 10-2G-2007,11-05-2007,02-25-2008 SUFFOLK COUNTY TAX # Southhold Tewn "7 1000 - 83 - 2 - I Board of Trustees 1000 - 83 - 2 - 2 G c 2 1000 - 83 - 2 - 17.2 l ;CER71FIED T10: It W E JOINT INDUSTRY BOARD OF THEt,�p ELECTRICAL INDUSTRY STEWART TIDE INSURANCE COMPANY ;' pQ� � /�'ti°� s � vo li ('1TETE NO.TA07(08)768) 7CIS APPROVED BY �, /; 4 BOARD OF TiSTEES e ;OWN OFrSOUTH0' D f �°° di Y0 tt. h rp syr + p5 h \ A ITO /� h0 0? (101* A. We g i; S i r" o r•nr`��'y�'n�'w� .r ® Olt I s Ir S89°53 43" 1 - >70 a Land now.or formerly of: Jornes McBride Land now or formerly of: Nichoios Alliono o� i FEB 2 6 2008 Southhold Town Board of Trustees It 4� o f I r 'lheuthorfzed alteration or addition to a survey nap beer Snp a licensed land surveyor's seal is a v�ola,lon of■act ioNew York State 1109, vE&CetianoLeeha `Only Copies fro.the orl91ne1 of thle survey \WY, aerkeE with en art91ne1 of the land wrveyor's etenped see]ahe1,be Considered to ba vend,rut TITLE NOTE: Copia. r 'Certlf l<etlone lndlceted hereon signify that thio eurreY wee prepared In accordance alto the sn- tetlnp Cdoe of Pract l[e for Lantl Survtys adopted "PREMISES SHOV�IN ON THIS SURVEY ARE THE SAME AS THOSE ' by the her persYorkon Stare eeedtlet inn of P.O prepared.- Land Surveyors. Said cer,ific.ttons shall run only tr the peraon for anon the survey is prepared.an. D*half DE5GR I BED I N TITLE A550G 1 ATE5 TITLE # TAO (08) 768" and on his Ifar.f,o the tfrlr coypany.institutions a9-CY and lendinginstitution listed hereon, and to the essionees of the ending Institution. Ctrtifica- tions are not lrMpf arable,o adolt lone.- instltut gone JOHN C. EHLERS LAND SURVEYOR 6 EAST MAIN STREET N.Y.S.LIC.NO.50202 NOTES: GRAPHIC SCALE I"= 60' RIVERHEAD,N.Y. 11901 369-8288 Fax 369-8287 ■ MONUMENT REF.\\CompagserveApros\2000 pros\20-153 UPDATE 10-11-07.pro AREA = 71'1,120 S.F. OR 16.4628 ACRES �/ZS/2008 l�0'i:n'IPM \ server roe\2000 \20-153 I1PD.�1E IO-II-07 0 t _. �03+ Flask dG Jill M.Doherty,President ti Town Hall,53095 Main Rd. James F.King,Vice-President ,y. P.O.Box 1179 Dave Bergen �`� Southold,NY 11971 Bob Ghosio,Jr. Telephone(631)765-1892 John Bredemeyer y' Fax(631)765-6641 BOARD OF TOWN TRUSTEES L vJN Or OU T iiOiL D Office Use Only (Coastal Erosion Permit Application L=V Vl IWMC L/ 2 _Wetland Permit Application Administrative Permit Amendment/Transfer/Extension _Received Application: _Received Fee:$ _Completed Application _Incomplete _SEQRA Classification: Type I Type Il Unlisted _Coordination:(date sent) R,'o JAN - 7 2010 LWRP Consistency Assessment Form F' n _CAC Referral Sent: Date of Inspection: ii Board of Tra:ie s i _Receipt of CAC Report: 1.�-�--r, __ __�e,�,R.b.��.•w-.--g--•-•.-_---.-.�.. _Lead Agency Determination: _Technical Review: _Public Hearing Held: Resolution: ,jolty e►v bt),Gr�P y 3o4-01) of U-r-En77?,(eA-L-//U&iSr91E7s Name of Applicant 6�j)yC& -j OYvf t- U LMejj-L Hp L-b 1 AJ 15-9 i/ W*F-R .V V A-ry 41E�S i&Lr Jm 4--t/ 6 Address HUGH ink Nl (0-3 73 —SZZ 5 113-Ca5 Phone Number:( ) Suffolk County Tax Map Number: 1000 - Property Location: J 36D bua PO✓) CvTr—H-6 6--C/e: N q s (provide L�I"L'CO Pole#, distapnce to cross streets, and location) � AGENT: VV 1 ��I'Gl✓►�� 1� � I Al 7-.::707<L—r,A"/vl�5 G�P� C'� �/g�Tl� /U�' (If applicable) /V,, 1 Address: 0�dS �� Laric � �k0c oq Ue- V /N -75 h'1 jI-t t,l N j�-: Phone: 173 `l ! �&L13 C'0-r6-M06VF /QV s g3t5— Board of Trustees Application GENERAL DATA Lp r.5IaE Land Area(in square feet): ']/-7 1-2-t:) 5.f-. ag 16 • q&Zg &e2 Area Zoning: -/j E �_ 4 Zffyu e x Previous use of property: tkl+ej Intended use of property: �lU '� d� ':�I"l C-Lk 14-Urq- 1 V ATr- Covenants and Restrictions: Yes No If"Yes",please provide copy. Prior permits/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? No Yes If yes,provide explanation: Project Description (use attachments if necessary): �mer�en� � r�Pa�r1 Clve -o Candor► ar7d sea waI1 clam a -1-emPor7avyj Rf�Vlar' we�Hccn 5 05htreltO-e app1if,,;L 'O✓I -/0 -rol!ow p�-�nane� r P a �o �-a-7 - IM e -fi or-) Ccs yo pew- --nf r7�� amajulld ij b�hfr )d as wd ll . Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the pro osed operations: Sv5- aJ'r-k 7,610 Y4'-21'Lt S�Orm s and renal- SJ �i�i�v�f dlar"�e 9 aknOge /OC i I�t�GL Area of wetlands on lot: Zp, I � square feet Percent coverage of lot: N i' % Closest distance between nearest existing structure and upland edge of wetlands: � Y-� feet S�vcrv2E7 FX/�� w��'-v 16-D Yn IC Closest distance between nearest proposed structure and upland edge of wetlands: { feet Does the project involve excavation or filling? No Yes If yes,how much material will be excavated? cubic yards 6;5Tim A7-f�_ How much material will be filled? NO cubic yards e�P647'-Jl) Depth of which material will be removed or deposited: -Ft feet Proposed slope throughout the area of operations: 0 Manner in which material will be removed or deposited: P /aao1-0V 5(6/ �X Gl ia %P►(�nVA a r U1 ISS a l�-rJa �kl S�`/�1� ea gla l l 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): 1vd1rt_5 da m a ge � -�ki�i� WCek Pva l/ • T,�=Z_C. miall bt, P�ac^5 �� l5 v b�vl��P'S G>?lo✓1 j�' -Q�l 5-61- kia l l Yt_) Prev�� PROJECT ID NUMBER 617.20 SEAR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL.ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1 APPLICANT/SPONSOR 2 PROJECT NAME a W;i►� tm U90,b 3 PROJECT LOCATION 38-UD � G�.�v 7 Municipality EF' N'L' /I CI�S_ County SU 4.PRECISE LOCATION Street Addess and Road Intersections. Prominent landmarks etc -or provide map Old pz(,t" M rinl 1_(64e_11 5.IS PROPOSED ACTION• ❑ New Expansion ❑Modification/alteration c- Igll q� 6.DESCRIBE PROJECT BRIEFLY: �� cJ-c7 6�.5V f 1��A ,11/ � '�Vv I - 5 ,�-!I Cvi4 bvi7dt� S orgy prop . T>�L_C rl- �o� s c✓1 ,erd viYYJ'%- a a vn law 7.AMOUNT OF LAND AFFECTED- /,gyp L,IAJ _r /v a- A Initially acres Ultimately acres &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.) MResidential ❑Industrial ❑Commercial ❑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 If yes, list agency name and permit / approval ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ®Yes El No If yes, list agency name and permit / approval, 122." . AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE/ MgDIFICATION? ' 10 es ❑No 177aVAZ— /7GW' 4-01� I CERTIFY THAT THE I MATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / lS_ponnsor ame Date- / 7//0 Signature V`' 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 Agency) A. DOES ACTION EXeEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617 49 If yes,coordinate the review process and use the FULL EAF. Yes zNo B WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration may be superseded by another involved agency Yes Ej 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 far erosion,drainage or'..coding problems? Explain briefly: Wd C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly: C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain 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. I N1 A. C5. Growth,subsequent development,or related activities likely to be induced by the proposed action?Explain briefly. C6 Long /te ,short term,cumulative,or other effects not identified in C1-059 Explain briefly C7 Other impacts(including changes in use of either 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 ENVIRONMENTA4 AREA CEA)? If yes,ex Iain briefly Yes No E IS THERE,QR 15 THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes ex lain, Yes No PART 111-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it Is substantial,large,important or otherwise 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 Impacts have been Identified and adequately addressed. If question d of part ii was checked rhe-determifl ort-ofslgnific-anceroustevaluate4he-potentiaHrepastoftheprepesedaetienenthe-envifonmentaleharaderistlesoFthe-eE . — 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 actio WILL NOT result in any significant adverse environmental Impacts AND provide, on attachments as necessary, the reasons supporting thi determination. LrWbS CAFI l-7- f 261 Name of Lead Agency Date Prin o yp am of onsible Officer in Lead Agency Title of Responsible Officer Sign re 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 " 'v //U f V� 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 THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS LICATION. Signature SWORN TO BEFORE ME THIS �'�`` DAY OF A, ,20\� eALICIA WALKER Nam mm' Site of New torts No.OIJA21530d4 pim red irl Suffolk County Notary Public CO.-in isslo4l Eypires Sept.25,7x,\,-� Is Mt the oeW91 LAt, 4 dt Lu 31r0o cmk A UA fid` ca N=atct@4 ftm the sti,fid ewe cc ftuu S °73y— 33Y c-�-'�-----•_-•g�vC!'�-��-r��=�;�3�.�v-lis-�+�-.:�-- -��'�`'-'^-"--+rr'_—__- ti ___�.-.__�__ •a__ .� APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics rohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. -4W )N YOUR NAME: VIV )I( ay-y\ i • (Last name,first name,Middle 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 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%of the shares of the corporate stock of the applicant (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 Submitted this`^ d��o�_ 20¢ Signature Print Name t i Form TS l -x9 x t-w 0 -01-00 - �-v v /J rur sF6 sFc.w.on is ovvv w ix-os-w SOUNDss 124 / 90 01. wo — 46m SCH.D.9 F.D. 49 ♦ � taaloi 8 6-0 0 �S u f1�1m t9 v-xt oe tQju W. xs2 4 z Ts m m i?. �aeoi s E 6 ]zs 2L14 T 1 171 la mFlOwm any y 93 d x.B1�d TS Lu Is1m 1.0 m ]OST ' Itt '0 201 ns MT num m m a.11 ut r r m '��m � •�`�� A� n � � Cox a I� � r m s"'iry M1 m A d ae 3>r <4 zpr`i+ O S A O 3 n1 w.T. eO O va g ,p 'pr ipl m.RL ° fP to SEL In. S ��. 096-01-0115 y y de O d v'J I .Y O a v v3u4 i61 PLL IA FOR P[L IIL iCR PCL 1A FW P - N,Y 9tE YL eb SEE SFL 16 SFE SEG N0. y 8 o95-mron9s ms-of-am ws-of-olo 9o�s-o mu �� s[[s c to b 09L0]-0011 lura 60E € sF¢66L is m9 sEE YLIs).o9s COUNTY OF_SUFFOLK C c cn a 5 T SECTION NO 3 F= :Oz"' _ - - - _ --^-x-T�� ,3�•' .3 a � 3'` - - - - E _ OU HOLD �� Real�Prop !TomuUe 11-, Agaric �r- _,i;' -w z r _ �ti i'-' .. ^�- •Y t.�-��i'. .'=�. > ta� - - - -{.'w"= =-'. !a t�mre•-'"�. .-r - -'—'- � - �_ (.•,,,"..:�,.." >�^ _i. - _ spa_ - �_ �.. �'r --_�^'. s.. - - s+3x _ -- - - - _ FILE NOTES (For Office Use Only) DATE & INITIALS Jan 13 10 03:52p Twin Fork 631-734-6643 p.1 Twin Fork Landscape Contracting i ..., P.O. Box 460 Cutchogue NY, 11935 PH: {631} 734-6643 FX: (631) 734-8354 A ' AN 'r f Email: twinforklc@optonline.net L' 12 2010 ;.q TO: SOUTHOLD TRUSTEES TEMPORARY REPAIR DESCRIPTION FOR EDUCATION & CULTURAL HOLDINGS-3800 Duck Pond Rd, Cutchogue, NY 11935 TAX MAP 83-2-17.3 We are requesting an emergency repair permit due to recent storm damage which caused extreme beach erosion and sea wall damage(photos attached). This request is to provide a temporary repair to sustain present damage and to prevent possible future damage to what is left of the present sea wall, beach and the building/structures located within 3 ft of the existing/damaged sea wall/beach. Photos have been provided to illustrate beach/sea wall damage sustained from late Dec09/beginning of January 2010 northeaster. We intend on stacking 2ft x 2ft by 6-4ft in length concrete cement blocks approximately I& %ton in weight per block, along 150ft of existing seawall. The entire length of wall is required to prevent further erosion/damage at high tide. First row of 150ft will be buried in the sand and 2"d row of blocks will be stacked on top. Temporary sea wall will be approx 40" in height and 150ft in length. We also will distribute approx 140 cubic yard of sand along beach, which was lostleroded during the above mentioned storm's. Equipment to distribute material will be payloaders/skidloaders. This repair is necessary to prevent further beach erosion and sea wall damage as welt as possible structural damage to building located directly behind damaged seawall/beach approx 3ft in distance. Jill M.Doherty,President ti Town Hall,53095 Main Rd. James F.King,Vice-President P.O.Box 1179 Dave Bergen , �" Southold,NY 11971 Bob Ghosio,Jr. Telephone(631)765-1892 John Bredemeyer �# �'� Fax(631)765-6641 BOARD OF TOWN TRUSTEES T0`d N '0' S0U1 II.`�+_ LD Office Use Only _Zastal Erosion Permit ApplicationWt�(� NC (2 etland Permit Application Administrative Permit � ' �C'`1 _Amendment/Transfer/Extension e/Received Application: I'll ,/Received Fee:$ 5)01 Q0 _Completed Application _Incomplete ;i ILL, L _SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) ; JAN - 7 2010 ;y LWRP Consistency Assessment Form _CAC Referral Sent: _Date ofInspection: FO,i�Ci _ Receipt of CAC Report: _._..m_...r _Lead Agency Determination: _Technical Review: _Public Hearing Held: Resolution: ,J6/,-J7- l N 60Z.TP-Ll 3o4-e-1) OF t r Com-in��Ua Name of Applicant QVC&- /Oy\jfit. U L7Ve1 -s- HQ L-Z)/Al Address F-J-uSH-iNzr5- /13 to 5 Phone Number:( ) Suffolk County Tax Map Number: 1000 ,- du�L Property Location: o per-) J Rd Ct)77t H-6 rc N R':S (provide LILCO Pole#, distance to cross streets, and location) AGENT: k V I J. j 0 (If applicable) Address: 9jn'5- Co,1 Laylf- AN 035- M i2e)v ZIPhone: 13 Board of Trustees Application GENERAL DATA LO r /ZC Land Area(in square feet): •]/- /Z d 5.i-. B12 �� • �lo Z� �� Area Zoning: JE A-F- 4 zff 7UEx Previous use of property: Intended use of property. �`U �y1 ct- C�'t � �� C`eY4,0 ' (P IVB Covenants and Restrictions: Yes k No If"Yes",please provide copy. Prior permits/approvals for site improvements: `rf2V`, Agency �G 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): &neYSa;c� &4,7 re)n�ur- Clve CrMi aeq and sea w a l l Gla►n a�e . - -1-ernPor-za", re-pal'k; e�vlar• We4lan 5 gtshtrelt h•2 app) -10 40llow w pe�VIYIa✓l eV! rz1� a�'] �D D'1 • rY/ OfrQ� G�`► �f'�f1 D U Y�t4Len G, Cts pi-.even-t- ��' u�'VI •� U/ O r 2k��'�/�l/ fhihG/ as Board of Trustees Application WETLAND/TRUSTEE LANDS A`PPPLICATION DATA �D �7t',�1/�YGf jv` —fi t 'tel Purpose of the pro osed operations: P�064nh ✓ ��D� Su 4�u n•ed 76,-o reve&-k and rzi Y 9 -o eyi�; rt5 oe-x ,eawa mew & amoge �o swvafvtes/bl� /ac Area of wetlands on lot: square feet ' Percent coverage of lot: N r+ % Closest distance between nearest existing structure and upland , edge ofwetlands:E4-�- 3-f� feet SIVU6rv26 65e/ar'S W�Jry /Od rnv-4C Closest distance between nearest proposed structure and upland edge of wetlands: &)A feet Does the project involve excavation or filling? No ( Yes If yes,how much material will be excavated? cubic yards C,67-lm AT;6- How much material will be filled? NQ cubic yards 4Pb47ri ) Depth of which material will be removed or deposited:_feet Proposed slope throughout the area of operations: 0 Manner in which material will be removed or deposited: PCU4 f val l Y 5(6I d loader a tlj r5 Qlam) °ekl'5-ffk ,� wall - ��/C�7/ra� 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): �ic�/Ul�ICy9-n.j�— g��—�f- LDsS ¢�D�'►'1 �C��'rD,P�'js _ �'��N�h�.� IrCl1�iYL5 darxagz �o -eV15*1 U17Cfek Nall . TSLC in n ds 4b Twparar Ktfpw�- 5& Wall be, plaCi� 5 � C',. PROJECT ID NUMBER ? 617.20 SEQR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1.APPLICANT/SPONSOR IM F?46 2.PROJECT NAME &PRR,OJJE�CTTTUGC �� LOCATION• 3 oVV (� C ) ^,� �� -!� .J Municipality J E County I v 4.PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map 00 6 KM rini t it 5.IS PROPOSED ACTION: ❑ New ❑Expansion ❑Modification/alteration 6.DESCRIBE PROJECT BRIEFLY: NF;6FS5*e-V GL!7 5UMN}�l P2�-i/�11JT 2 �5 ,/CC 4-DD177,0A1 L_ TO 02 sem,j-j I Ctk14 b1117dt� S Ort Ti�L.c b�p/de_P-s a/orrx �G�ncvr l k fi �a � l 7.AMOUNT OF LAND AFFECTED. 150 L//V AJ 1� Initially acres Ultimately acres 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? I RU Yes ❑ No If no,describe briefly: 9.WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) Residential ❑Industrial ❑Commercial ❑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 If yes, list agency name and permit / approval. SYS CURRENTLY VALID PERMIT OR APPROVAL? Yes El No If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL RE'Q,U,IR_E/ MIFICATION? ' 10Yes ❑No AhP1VNVA-k_ I CERTIFY THAT THE I MATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / SS_ponnsor ame Date: _ ID 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 Agency) A. DOES ACTION EED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL EAF. Yes Z No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration may be superseded by another involved agency. Yes Z No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be han6ritten,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: Wd C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly: Y _ C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain 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: I'N1147 C5 Growth,subsequent development,or related activities likely to be induced by the proposed action?Explain briefly- C6. rieflyC6. Long tier/,short term,cumulative,or other effects not identified in C1-05? Explain briefly- C7. Other impacts(including changes in use of either 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 ENVIRONMENT AREA CEA? If es,ex Iain briefl Yes No E. IS THERE,QR I THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes ex lam: Yes No 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 otherwise 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 impacts have been identified and adequately addressed. If question d of part ii was checked yes +ham rminaticin Of Skjnif^,�a„ce,,�must-evaluate-the-petenttat-impaet effhe-prepesedaetieri-en4he-envirenrnentaUeharacteristies-ofthe-EEA 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 actio WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. Name of Lead Agency Date �t1 r L L A-nn J rk- Prin o yp am of onsible icer in Lead Agency Title of Responsible Officer Sign re of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer) •� Board of Trustees Applicz >n County of Suffolk State of New York W 1`{f r.,,, 0/- 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 THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS LICATION. �j Signature SWORN TO BEFORE ME THIS � ` DAY OF—A"_,_, AEICIA WALKER Notary PublicState of New York No.01063153064 miaoi6ed in Suffolk County Notary Public Commission Expires Sept.25,,Lg&.� t mt the em"MA . _ ; - r _ At 10 V. '. .. a - - J _ I 3q- �3sY APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. `^n J YOUR NAME: Vl/ J I 1 a Y r ` i • V v V JAI / (Last name,first name,griddle 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 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%of the shares of the corporate stock of the applicant (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 Submitted this.-_ d oY 20� Signature ip_ Print Name I Form TS l