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HomeMy WebLinkAboutOLD MILL INN TRUSTEES John M. Bredemeyer, IlL President Albert J. Krupski. Jr., Vice President Henry P. Smith John B. Tuthill William G. Albertson Telephone (516) 765-1892 Fax (516) 3'65-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SUPERVISOR SCOTT L. HARRIS Town Hall 53095 Main Road EO. Box 1179 Southold. New York 11971 Office Use Only: Coastal Erosion Permit Application Coastal Erosion Variance Application Wetland Permit Application Waiver from Chapter 97(Application/permit) Trustee Lands Permit Application Grandfather Permit Application __Completed Apps. Date: Inspection date: CAC comments-Date: Sent__Rec. Variance Required: (Y/N) Neighbors notified-Date: SEQ}~ Type Coord.: Date sent SEQRA Determin./date: Public Hearing/date: Findings: Approved (Y/N) Special Conditions: (see file) Permit(s) issued-date: SOUTH© ' Application Fee: Application NumberjSCTM~1000- !~3~ ~--~ Date: Address: ~C"~ ~)~ ~ ' ~4['d ~''~ Interest: (owner, consultant, lessee,etc.) Owner of Property: O~ ~c// Address ~-~/~ ~a ~ ~ Subject Proper~y (Provide LILCO Pole ~, Distance to cross Streets if not on location map) THIS IS NOT A PERMIT Page 1 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: <%D Distance project extends beyond similar projects in area: Area zoning: ~-- Land area in acres: ~~k~ Is project for private or business use: Intended use of property: Describe known prior operations conducted on premises: Has any prior license or permit been issued to erect structures, dredge, or deposit fill on said premises: ~6~ Has any license or permit ever been revoked or suspended by a Governmental Agency: Project Description The project description must also include plans for reclamation of land disturbed during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). THIS IS NOT A PERMIT , Page 2 ;4. :'. ' 1~'~,6'4 t2f87~'Fext 12 617.-, Appendix C State Environmental Quality Review .:' SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be completed by Applicant or Proiect Sponsor) SEQ~ 1. APPLICANT/SPONSOR I 2. PRO~LECT HAME 3. 4. PRECISE LOCATION (Street address an~ read intersections, p~ommen~ landmarks, etc., or provide s. Is P~ED XCTION~an=,oa [] ModifieetioWalteratien 6. DESCRIBE PROJECT BRIEFLY: AMOUNT OF LAND AEFEC~.ED: Initially~ acres Ultimately ' ,~'"~" acres WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTZONS? No If No. describe brietly WHAT IS PRESENT LAHD USE IN VICINITY OF PROJECT? [] ResidentJal [] !ndustrial DesCrlDe: [] Agriculture [] Park/ForestfOsen space [] Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? [] NO I! ye~, Fist agency(s) and permit/approvals DOES ANY [Ar~CT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [] Yes ~ If yes, list aaency name and permit/approval ~ AS A RESULT OF PROPOSED ACT[ON WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? [] Yes .~ I CE~TylNPORMA ION i~VIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE \~ Applicant/sponsor na ~' ~ ' _ Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 A. DOES ACTION EXCEED ANY TYPE F~'J.RESHOLD ~N 6 NYC~R. PAR~ 617.127 I¢ ye~, co~ ~[o me rewew procesa ~d use t~a [ULL ~ Ye, ~ No · B. WILL ACTION RECK]YE COORDINATED R~v'IEW AS PROVIDE :) FOR UNLISTED ACTIONS IN 6 NYCRP. PART 617.87 If No, a negative oe¢larab~n may be superseded my another involved agency. C. COULD ACT[ON RESULT iN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: [Answers may De handwritten, ii' [eq~Dle! C1. Existing air quahty, surface or grounowa~er quality or eua. nmy, noise leve~s, ex~s~mg traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Ex,lain brlelly: C2. Aesthetic, agricultural, arChaeologica, historic, or Ortner natural mr cultural resources; or communr~y or neig~lborhood character? Explain briefly: C7. Other imnac~s fincI~Jding changes in use of either ouan y or type of energy)? Explain briefly, D. tS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL h'~ PAC¥S? [] Yes [] Ho if Yes, explain briefly PART III--DETER~,4INATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For eacJ~ adverse effect identJtied above, determine whether if is substantial, targa, important or other,vise significant. Each effect should be assessed in connection with its (a,~ setting (i.e. urban or rural); {b) proDability of occurring; (c) oNratlon; Jrrevermbilii¥; [e) geographic scope; and (f) magnitude. If necessary, add attachmenfs or reference supporting materi~,ls, Ensure ihat explanations contain sufficient detail 1o show that all relevant adverse impacts have been identified and adequately aeeressed. [] Check this box if you have identified one or more potentially large or significant adverse impacts which ' occur. Then proceed directly to t~e FULL FAF 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 action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: County of Suffolk ) State of New York ) BEING DULY SWO~N DEPOSES AND AFFIRMS ~THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITIS) 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 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 PERMITIS), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(s) OR REPRESENTATIVEIs), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVI~; OF THIS APPLICATION. SIGNATURE SWORN TO BEFORE ME THIS DAY OF ,19 NOTARY PUBLIC Suggested space for location Map THIS IS NOT A PERMIT 1194 i.a.I