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Home My WebLink AboutNORRIS, SUSAN TRUSTEES }; !ohn M. B,redemeyer, III, President Henry P. Smith, Vice President Albert 2[. Kmpski, Jr. John L. Bednoski, Jr. Jolm B. Tuthill Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SUPERVISOR SCOTT L. HARRIS Town Hall 53095 Main Road P.O. Box 1179 S0uthold,'New York 11971 COASTAL EROSION MANAGEMENT PERMIT APPLICATION TOWN WETLANDS PERMIT APPLICATION TRUSTEE LANDS PERMIT APPLICATION ~ Office Use Only: ~Coastal Erosion Permit Application ~4etland Permit Application 7V~rustee Lands Permit Application p~randfather · ~C0mpleted Apps. Date: D~Variance Required, ~_~ Neighbors no%~fied Date~ , SEQRA Type~~3/~~ ~Coord. Review-op~.,,mand. Insp. comp./date: ~SEQRA Determin./date~ Public Hearing/date: Findings: Permit Vote: (Y/N): 'Special Conditions: (also see file) Apt .on Fee: Application Number; SC224 Project Name (If any) Date Prepared: Interest;: (owner, consultant,lessee,etc.)~ Owner of Property: Address Phone ( ). Subject Property Location: _~¢~.,% /~p~/~ ~/~,~_ ~. (Provide LILCO Pole ~, Distance to cross Streets if not on location map) THIS IS NOT A PERMIT Yds. to be excavated: ~ ,!~-~ YdS. to be filled: ~ Manner-in which material will be removed or deposited: Width of canal, creek or bay fronting property: Depth at low tide: Aver'. rise in tide: Distance to nearest channel: ~ Distance project extends beyond similar projects in area: Area zoning: /~, Land area in acres: ~ Is project for private or busine~ss ~se: Intendi~d use of prOperty: ,,, /:,~--<~'~/~..~x~:t.~,- ~,~C.,-.~.~,~ DescriDe known prior operations conducted on premises:O Has any prior license or permit been issued to %%ct,structu~, dredu,,~:~,osit fill on said premises:~-~£" ,~.~, ", Has any license or permit..ever been revoked or suspended by a Governmental Agency: '~c~ Project Description The project description must also include plans for reclamation of land[ disturbed during construction of the principle and accessory structures and underground structures (i.e., pipeline and septic system; make additional attachments if necessary). Authorization (Where the applicant is not the owner) I residing at (Print-owner of subject property) (Mailing address-phone) hereby/~u~ize to apply for do ~~~permit(s) from the So~hold Town Trustees /~//~~'/~g~Signature ..... ~' ~~ ~i:~ ~/' TtA PERM T THIS I~ NO County of Suffolk ) State of New York )' 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 WORK WILL BE DONE IN' THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TO~VN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OFSOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES ANqJ .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 REPRESENTATIVE(s), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. ~/ . SIGNATURE SWORN TO BEFORE ME THIS NOTAR~ PUBLIC L~NDA j COOPER - m-L -- Suggested space for location Map THIS IS NOT A PERMIT /'v/< ' · "J. Y. State Li;. Land ¢urveyor. Oate '' ~ l P~bJECT I.D. NUMBER 6176' Appendi~C State Environmental Quality Review .,. SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be completed by ApPlicant Or Project Sponsor) SEQ~ I 2. PROJECT NAME 3. PROJECT LOCATION: ~;~ , . 4. PRECIBE LOCATION (Street address and road intersectiens, prominent landmarks, etc., or'prov~d/e 5. IS PROPOSED ACTION: [~New [] Expansion [] Modification/alteration - - · 6. DESCRIBE PROJECT BRIEFLY: acres U~timately acres 8, WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE REST~ICT[ONS? .~Yes [] NO Ii, No, describe brielly WHAT IS PRESENT LAND USE IN VICIN fy OF PROJECT? _,~Res,dentiai [] !ndustria, [] Commercial [] Agriculture [] ParklForesllOpen space [] Olhe, Oescr~Pe: 10. DOES ACTI :)N NVOLVE A PERMIT APPROVAL, OR FUND[~G1 NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL. STATE OR LOCAL)? [~Yes [] No If ye~, Iisi, agency(s) and permit/approvals 11. DOES ANy ASPECT OF TH E ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? E~Yes ,~No Ii' yes, list agency name and permit/approval 0 ~., 0 No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE the acHon is in the Coastal Area, and '/ou are a state agency, complete the Coastal Assessment Form bec'ore proceeding with this assessment OVER 1 A, DOES AGTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PARr E]Yes E] No " · B. WILL ACTION RECEIVE COO,~,NATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 may be superseded by another involved agency. C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may ce handwrdten, it lecl~C~ef C1~ Existing air quality, surface or groundwaler quality er quantity, noise levels, ex,sting Iratlic patterns, solid waste procluction or disposal, potential for erosion, drainage or flooding problems? Explain brielly: t C2. Aesthetic, agricultural, archaeological, historic, o~' other natural or cultural resources; or community or neighborhood character? Exc~Jaln briefly: C4, A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land. er other natural resources? Exraln briefly Growth, subsequent develobment, or related aelivities likely to be reduced by the proposed action? Explain Dr~elly. Ca. Long term, short term, cumulative, or ether elfects not idenlitied ir~ C1-C57 Explain briefly. C7. Other impacts (incl[Jding changes in use of either quantity or type et energy}? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? [] Yes [] No If Yes, explain briefly PART III--DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse elfect identitied above, determine whether it is substantial, large, important or othec.vise significant. Each effect should be assessed in connection with its (a) selling (i.e. urban or rural); (b) probability of occurring; (cf duration; (d) irrcvers~bility; (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 adequ;ztely addressed. [-] Check this box if you have identified one or more potentially large or significant adverse impacts which [,IAY ,' occur. Then proceed directly to the FULL EAF and/or prepcre a positive declaration. [] Check this box il' you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND 2rovide on attachments as necessary, the reasons supporting this determination: TRUSTEES John M. Bredemeyen III. President Albert J. Krupski, Jr.. Vice President Henry P. Smith John B. Tuthill William G. Albertson Telephone (51.6) 765-1892 Fax (516) 765-1823 I (we) BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD 30 year Maintenance Agreement Erosion Protection Structures Chapter 37 Southold Town Code Southold Trustees as Administrator type or print name(s) the owners of record of property at: SUPERVISOR SCOTT L. HARRIS Town Hall 53095 Main Road EO. Box 1179 Southold. New York 11971 (type ,or print street address) SCTM ~1000- in applying for a Coastal Erosion permit for an Erosion Protection Structure do hereby agree to a 30 year maintenance program for a structure commonly known as a of as shown on the attached feet of length licensed survey of the as-built structure. It is ~6/our understanding that we are to maintain this structure with materials designed to endure 30 years and or equivalent to the original approved structure and that for any maintenance which involves more than 5% in length of this structure we are to give prior written notice to the administrator, waiting for their approval in all but true emergency situation's which would seriously endanger life, property and important coastal natural resource features such as bluffs or wetlands. We further understand that failure to maintain the structure could result in a requirement to post a bond and[ or have the repairs ordered as a lien against the property upon a finding by the Trustees that said lack of maintenance would risk life, property or important natural resources features including protected, rare or threatened animals and plants. Notarized Signature of owner of record SWORN TO BEFORE ME THIS DAY OF ,19 NOTARY PUBLIC Please submit three copies of a licensed land survey made within one year of the original construction. This maintenance agreement shall only be valid upon the final approval of the administrator. Subsequent owners may apply to the Southold Town Trustees to re-authorize this maintenance agreement. Civil Marine JOHN H. GEIDEMAN Consulting Engineer (516) 477-242! P.O. Box 416 E. Marion L.I. New York 11939 Ow ne r Including.'~N.Y.S Dept. of Environmental Conso. rvs5ion U. S. Army Corps of Engineers Town of ~~, Date The Southo!d Town Trustee office h~d~that your application for a ~2_ a~_-~r~'~~ n~~is ~ _D~~at/~omple__~t_~ p!ea~the following information in this r~for a.ny required return submission: cc: This notice makes no claim with respect to other jurisdictions within or outside the Town of Southold with respect to permits, permission required. 4/92 O~ 3, p orr, er ~o~ me~\'~ 0~' chor~eS formerly Dorotb¥ Or8 or~ 0 Z