HomeMy WebLinkAboutTR-5246 �o�oSUFFo�,�coG
ELIZABETH A.NEVILLE
TOWN CLERK Town Hall, 53095 Main Roa
cz
REGISTRAR OF VITAL STATISTICS COD P.O. Box 1179� Southold, New York 11971
RECORDS
MARRIAGE OFFICER • Fax (516) 765-1823
FREEDOM OFFIINFORMAT ON OFFICER
AGEMENT OFFICER y��l O�
`a Telephone (516) 765-1800
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
APPLICATION FOR PUBLIC ACCESS TO RECORDS
INSTRUCTIONS: Please complete Section I of this form and ive
Office (agency Freedom of Information Officer g to Town Clerk's
in response to your request, or as an interim response.copy will be returned to you
---------------------------
_____________________________
SECT1q.N ly -----_____
TO:
. (Department or Officer, if known, that has the informationou are
RECORD YOU WISH TO INSPECT: y requesting.)
date, file title, (Describe the record sought. If possible, supply
tax map number, and any other pertinent information.)
ol
Signature of Applicant:
PrIhted Name: f,Z
Address
Mailing Address (if different from above)
Telephone Number: ����� Date: .
� a
[ l APPROVED
[ ] APPROVED WITH DELAY* [ ] DENIED* RECEIVED
Gam[
MAR 17 2003
Eliza h A. Neville
Freedom of Information Officer Date
Southold Town Clerk
* If delayed or denied see reverse side for explanation.
OF F011rc
ELIZABETH A.NEVILLE ��� �l/y = Town Hall, 53095 Main Road
TOWN CLERK c < P.O. Box 1179
y = Southold, New York 11971
REGISTRAR OF VITAL STATISTICS v'
MARRIAGE OFFICER • �� Fax (516) 765-1823
RECORDS MANAGEMENT OFFICER ��l ��O Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
APPLICATION FOR PUBLIC ACCESS TO RECORDS
INSTRUCTIONS: Please complete Section I of this form and give to Town Clerk's
Office (agency :Freedom of Information Officer) . One copy will be returned to you
in response to your request, or as an interim response.
SECTION 1. '
TO: I y vjYI• ����e e S UY Ro L �.
(Department or Officer, if known, that has the information you are requesting. )
RECORD YOU WISH TO INSPECT: (Describe the record sought. If possible, supply
date, file title, tax map number, and any other pertinent information. )
Signature of Applicant:
Printed Name: A`C D�Qt✓A kD1—A_::0 '
Address: 38o .
Mailing Address (if differ nt above)
S
Telephone Number: t4Z��
-------------------------------------------------
[ ] APPROVED
[ ] APPROVED WITH DELAY* [ ] DENIED*
S E P , 8 2002
Elizabeth A. Neville Southold er
Freedom of Information Officer
* If delayed or denied see reverse side for explanation.
Albert J.Krupski,President �� �� Town Hall
James King,Vice-President h��� QG� 53095 Route 25
Henry Smith P.O.Box 1179
c ? Southold,New York 11971-0959
Artie Foster
Ken Poliwoda. �y� �`� Telephone(631) 765-1892
Fax(631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
May 3, 2001
�y
Mr. Gaston Criblez,President
Paradise Point Assoc.
326 Arleigh Road
Douglaston,N"Y" 11363
Re: Paradise Paint Assoc.
SCTM#81-1-1.6.1
Permit 45246
Dear Mr. Criblez:
In accordance with the above-reference Permit, Trustee Artie Foster has made a final inspection.
Two S'X S' drywells with I raff c bearing covers, casting to grade, and inter-connecting pipes
between the leaching.pools, ::lave been installed all in accordance with the terms and conditio=;s
of the Perrot.
If you have any further questions,please don't hesitate to call.
V ry i.11.zl3r yours.
LL Uri
Lauren M. Standish, Clerk
Board of Trustees
• i
04/03/2001 13:30 6313699080 CHARLES R CUDDY PAGE 01101
CHARLES R. CUDDY
Attorney at Law
445 Criffing Avenue
Riverhead, New York 11901
Tel No.: (631) 369-8200 Fax No.: (631) 369-9080
TO: Southold Town Trustees _--
Fax#; 765-1366 !' APR — 3 �l)lll
TELECOPIER COVER SHEET -
Total Number of pages l including cover sheet. -If transmission is faulty or incomplete, please inform us as soon as possible.
Operator: Mary Date: April 3, 2001
Comments;
Re: Paradise Point Association
1 represent Paradise Point Association in connection with a dredging application and decision of the
Board of Trustees dated November 21, 2000, I respectfully request that this matter be placed on this
Board's April•-&;2001 work session agenda to discuss that approval,
c9s,
Kindly contact this office should there be any problems with this request,
Charles R. Cuddy
.
Th fox transmission toy,+etl:er wit!:mz teriaCs following ore,intended fur the person.
isor perao►ts named hereon.and are
considered conf dentin!grformation. !f you have received this tranrndivn 1 error, you are directed Ito return these
materials immediately by regular Haar!to the sender al the aliave address, ,Postage incHrred for the return.will,be paid
by thif firm.
�v� �::�\ �y< \�"'"a 'tee•��`'r4'`; 'C 2`� " ,ay^ \�`yay' � •� "A �i� .� •�•':�.
-f Board Of Southold Town Trustees
SOUTHOLD, NEW YORK
11/21/00 -,
PERMIT NO. ... ...+.r..d1.. ..� DATE: ............................... w
ISSUED TO ....PARADISE..POINT'...AS.5.6CIA:TION.,..ING.................
Y
.�uurta#tun t
Pursuant to the provisions of Chapter'615 of the Laws of
the State of New York, 1893; and Chapter 404 of the Laws of the
. _ State of New York 1952; and the Southold Town Ordinance en-
titled."REGULATING AND THE PLACING OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS and the
:a�x REMOVAL OF SAND, GRAVEL-OR OTHER MATERIALS FROM
` LANDS UNDER TOWN WATERS;'.•.': and in accordance with the
Resolution of The Board adopted at a meeting held on Noy.....21........
yS
150 00 d 4
ra. 2000 ., and in consideration of the sum of $. paid by
PARADISE .POINT..:ASSOCIAT.ION,..: N.C......................................................
�?
of .Sauthald................................................................ N. Y. and sub'1ect to e
th .
,
Terms and Conditions listed on the reverse side, hereof,
of Southold Town Trustees authorizes and permits the following:
to resheath from inside existing east jetty with C-Loc series 4500 vinyl
sheathing. Also replace 1" toe rods and place washers 311x6" top clamp w
R and 2" all two drains at low point of Basin Road to eliminate potential .
run-off. Each drain to consist of Vx8" concrete leaching structure.
- Traffic bearing with one,casting to grade to receive road water.
Connecting pipe between structures to be 6" PVC. Maintenance Dredge s
Permit #5161 only at mainteance area to repair outside jetty and not
inside,(basin;: run concurrent with the Army Corp. and DEC. Ten
year permit. Any work done is subject to getting authorization from the
owner to, access property.
nC x �'
..,,1IF-„ .., saga ooara of rUstees here .
by'causes its Corporate- Seal to+e affixed,-and these''}�resents to y
be subscribed by a majority of the said;Board as of -ibis dafe.;)* _.
'IN
5
:tier - � ���
�.� •� - Trustees
• fir• /..�\• .4\�� /,�� fi "\.. � � , :�' �t
`, t •- 't `. - •: .ram oe�~ `A�•'^".$-.. `S•.. ..b• `!Y '`• -
i' �✓ a �a�►' 1�'.'•,� •
TERMS and CONDITIONS
The Permittee PARADISE POINT 'ASSOICATION, INC;
residing at N. Y., as
part of the consideration for the issuance of the Permit does understand and prescribe to the fol-
lowing:
i. 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 air oper-
ation 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 of the Town of Southold
2. That this Permit is valid for a period of '� ' mos. which is considered to be the
estimated time required to complete the work involved, but should circumstances warrant, request
for an extension may be made to the Board at a later date.
3. That this Permit should be retained' indefinitely, or as long as the said Permittee wishes
to maintain the structure or project involved, to provide evidence to anyone concerned that auth-
orization was originally obtained.
4. 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.
5. That there will be no unreasonable interference with navigation as a result of the work
herein authorized.
G. 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.
7. 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, die.
work shall cause unreasonable obstruction to free navigation, the said Permittee will be required,
upon due notice, to remove or alter this work or project herein stated without expenses to the Town
of Southold.
8. That the said B_oatd.will .be.notified by the Permittee of the completion of the work auth-
orized.
9. That the Permittee will obtain all other permits and consents that may be required sup.
plemental to this permit which may be subject to revoke upon failure to obtain same.
Albert J. Krupski,President Q$VFFOL/r Town Hall
James King,Vice-President �Gy� 53095 Route 25
Henry Smith P.O.Box 1179
Southold,New York 11971-0959
Artie Foster W
Ken Poliwoda Telephone(631) 765-1892
Oy�J01 �a0� Fax(631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
November 27 ,2000
Mr. Gaston Criblez, President
Paradise Point Assoc.
326 Arleigh Road
Douglaston, NY 11363
RE: SCTM#81-1-16 . 1
Dear Mr. Criblez :
The following action was taken by the Board of Town Trustees
during a Regular Meeting, held on November 21, 2000 . regarding
the above matter.
WHEREAS, GASTON CRIBLEZ on behalf of PARADISE POINT ASSOCIATION,
INC. applied to the Southold Town Trustees for a permit under
the provisions of the Wetland Ordinance of the Town of Southold,
application dated NOVEMBER 3, 2000 and
WHEREAS, said application was referred to the Southold Town
Conservation Advisory Council for their findings and
recommendations, and
WHEREAS, a Public Hearing was held by the Town Trustees with
respect to said application on November 21, 2000 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 standard set forth in
Chapter 97-18 of the Southold Town Code,
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 the Board of Trustees approved the application of
PARADISE POINT ASSOCIATION, INC. to resheath from inside
existing east jetty with C-Loc series 4500 vinyl sheathing.
Also replace 1"toe rods and place washers 311x6" top clamp and 2"
all two drains at low point of Basin Road to eliminate potential
run-off. Each drain to consist of 8"x8" concrete leaching
structure. Traffic bearing with one casting to grade to receive
road water. Connecting pipe between structures to be 6" PVC.
Maintenance Dredge Permit #5161 only at maintenance area to
repair outside jetty and not inside basin, run concurrent with
the Army Corp. and DEC. Ten year permit. Any work done is
subject to getting authorization from the owner to access
property.
BE IT FURTHER RESOLVED that this determination should not be
considered a determination made for any other Department or
Agency which may also have an application pending for the same
or similar project.
Permit to construct project will expire two years from the date
it is signed. Fees must be paid, if applicable, and permit
issued witin six months of the date of this notification.
Fees must be paid, ' if applicable, and permit issued within six
months of the date of this notification.
Two inspections are required and the Trustees are to be notified
when project is started and on completion of said project.
FEES: NONE
Very truly yours,
e'"�
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/cjc
cc: DEC
ACE
Dept. of State.
Paradise Point Association
C/O Gaston I Criblez
326 Arleigh Road
Douglaston,NY 11363
January 23, 2001
Ms Charlotte Cunningham
Southold Trustee Department
PO Box 1179
Southold,NY 11971
i
�I
Dear Charlotte:
Enclosed is two dollars for the copy of minutes you are sending me regarding Paradise
Point Association three permit application.
Thank you for your help.
Gaston Criblez
President
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Paradise Point Association
C/O Gaston J. Criblez
326 Arleigh Road
Douglaston,NY 11363
January 23, 2001
Ms Charlotte Cunningham
Southold Trustee Department
PO Box 1179
Southold,NY 11971
Dear Charlotte:
Enclosed is two dollars for the copy of minutes you are sending me regarding Paradise
Point Association three permit application.
Thank you for your help.
Gaston Criblez
President
Print or Type: ACCESS CONSENT FORM Office use Only
FOR ACCESS File #:
THROUGH PRIVATE PROPERTY Permit #:
�Fck6/�Z1 ) Toe-to/SE1�061rASD fir/,
(Name of Applicant ) (Address)
2) ' .S%�1-vllefV /'060X/-1// 111W7_r1 1CK,
(Name & Address of Contractor Involved)
3) FWeAb1SF &,c-11 1000-8/ - / _ 29
(Project Location) (S.C.T.M. #)
(Name of Road or Privffate ' Propelrty Involved) (Hamlet )
5 ) 8v'e#D/Sc f�r.V! �7sSD /,cJCa
(Name & Address of Homeow ers Association / Property Owner)
(Brief Job Description)
7 ) Starting Date: A l- 141 36 261U/ Completion Date: fR.J3/A14/3/. 200/
8) Estimated Cost of Proposed Wark: 3YD6U -
9) Insurance Coverage:
A. The coverage requi red to be extended to the Property Owner :
Bodily injury & Property Damage ;
$300,000/$500,000 Bodily Injury & $50,000 Property Damage .
B. Insurance Company: C'D�✓l/��TL ��URLTy ��f �D 1����
C. Insurance Agent n/
Name 4 Telephone # l!l��FlJS-S PE E,�lCy ("151) 72Z -3'5 Oo
D. Policy #
E. State whether policy or certification
is on file with the Trustees Office:
( If no, Provide a copy with Application ) (yes/no)
2 Z-
f�a-nat a o Ap ant ) (Date)
-------------------------------�® - - ------'-------
To be completed by -the Property Owner:
I/We the undersigned, fully understand the nature of the Proposed
Work referenced above and have no objection to. allowing the
Applicant to cross My/Our Property to d the work.
(Si na ure he PropVfy ner
r dul y aut hori zed represent'at i ve)
N Ff O(K�o
Town Hall. 53095 Main Road
P.O. Box 1179
Telephone O . OT Southold, New.York 11971
("631) 765-1892.
SOUTHOLD TOWN
CONSERVATION ADVISORY COUNCIL_
At the meeting of the Southold Town Conservation Advisory Council held Wednesday,
November 15, 2000,the following recommendation was made:
PARADISE POINT ASSOCIATION.INC. 81-1-16.1 to re-sheath existing bulkhead (inside of
e isting-sheathingyWitli C-Loc Series 4500 vinyl sheathing, replace the tie rods and plat washers
3"X 6" top clamp and 2" CCA cap. Install two drains in low point of road to eliminate potential
run-off into boat basin, and to renew maintenance dredging permit#5161. '
Basin Road, Southold
.The-CAC-did-not_make an�inspection but would recommend hay bales during the installation of
SPOIL AREA
t 300 .YD5.
AREA.`NO:'I TO BE 1�•`. l� ^^ `.
3oo Y {� TOWN! HARBOR T
DS. `�'s
REPAIR 5TAVIIli
IN 400 L.F,
OWN HARBpR
DF BULKHEAp
ASiAl
U W ! l
Q�G0
ROLLJ
B`
Q ti AY
LOCATION M- A
rc0AD
PARADISE PO/NT ^SSOC,,/NC.
- -_— — AREA NO. 3
AREA ZA AwD 28 '' ��--�� 1'30 YDS. PRONECT PLAN
TO BE DREDC1ED Z-g
2-A SO YD5
z e = 150 YD5 �' � = Die& M P�1 N-T E I ANC E DRED C,I N C,
BOAT ENTRANCE ao 80AT BASIN `
BAsrN ;l Pt\RADIS T
P01 N
ASSOCIA-TtoN
sir,o0o sca. FT. -
;-- SOIUTHOLC) NY
f
PARADi5c PT. Assoc iNc.
rvUFFDLK -COUN-TY Tky, MAP# : 1000-081-l-PARToI• I(
i 9•P / LECIEND:
=r t J i AREA TO 5E DRCDgED:
SPO/L AREA- �':..
MEAN H/47H WATER --
j_V�� MEAN L'OVJ WA-TEFc .
/� 7� PROPERTY OWNERSEl
o PARADISE POINT ASSOC, /Nc
!- t t t s' r. f c SOCJTHOL� IVY--
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=� f - -�� of
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iS6aJ i I H.S. NO.
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ca, w `jTG L6G _11i� I STATEMENT OF INTENT
`j THE WATER SUPPLY AND SEWAGE DISPOSAL
SYSTEMS FOR THIS RESIDENCE WILL
,� �,` Q/'�l��y! 1� _�•,� S !" _/ / 'y II CONFORM TO THE STANDARDS OF THE
.Z E• W p llf� I I SUFFOLK CO. DEPT. OF HEALTH SERVICES.
i St( a'f C.?kiY:?/ I S APPLICANT
t .. t
SUFFOLK COUNTY DEPT- OF HEALTH '
�. '-�'� t n cot° O• f SERVICES — FOR APPROVAL FOR'
CONSTRUCTION ONLY
q, r� "� 6 +' r prop-I ; _ ,t 4�E_ DATE:
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APPROVED:
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al I STATEMENT OF INTENT
'rC'�`-` - A A _n - I THE WATER SUPPLY AND SEWAGE DISPOSAL
�i- .LFI ► ,��' ; f ! SYSTEMS FOR THIS RESIDENCE WILL
5.0 :- .f ' C� / •N , I CONFORM TO THE STANDARDS OF THE
SUFFOLK CO. DEPT. OF HEALTH SERVICES.
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for.
5 APPLICANT
I. Y4. , , _ r r ./ rr _ a. "1 _ ` i►yd� N'r.
SUFFOLK COUNTY DEPT. OF HEALTH
e �-
- 3 ,be� p.` SERVICES - FOR APPROVAL FOR,
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' °' P °r , k. `L .. Z4`z q"S' -T DATE:
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q t aa'-� •� -�a" �+I' APPROVED:
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-- - - — LICENSED LAND SURVEYORS ' I r I•� I �`\�CANOSJ ��'
_ GREENPORT NEW YORK I I vl
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Print or Type : ACCESS CONSENT FORM Office use Only
FOR ACCESS File #•.
THROUGH PRIVATE PROPERTY Permit #:
c
(Name of Applicant ) (Address)
2 ) ST��i/�.11 l'0 BOX/,/// !/�91T/i�ycK, All
(Name & Address of Contractor Involved)
3 ) f ,eAD/SF ,'�'i,�l�aAT g�5/�J • 1000-8/ - - 29
(Project Location) (S.C.T.M. #)
(Name of Road or Private Property Involved) (Hamlet )
(Name & Address of Homeowr(ers Association /property Owner)
6)
(Brief Job Description)
7 ) Starting Date: 44II-4Pp_ 30 2UU/ -- compl:etion Date::.:-fR�1�/�MR.y31. 200/
8) Est'imated Cost 'of Proposed Work:, U�0 -
9 ) Insurance Coverage:
A. The coverage required to be extended to the Property 'Owner :�
Bodily injury & Property Damage ;
$300,000/$500,000 Bodily Injury & $50,000 Property Damage .
B. Insurance Company: �i�T/i✓�TL �SU/ILTy �✓�` ����
C. Insurance Agent ,3/ 722 00
Name & Telephone # � '�FUS-�riTP, /—A -xke1y 6
D. Policy #
E. State whether policy or certification ���s
is on file with the Trustees Office: r
( If no, Provide a copy with Application) (yes/no)
nat e (Date)
-------------------------------
To be completed by the Property- Owner:
I/We the undersigned, fully understand the nature of the Proposed
Work referenced' 'above and have no objection to, allowing the
Applicant to' cross My/Our Property to do the .work..
i•�na ure he' Prop y ner `�/(_S
dul y aut hori zed represen.t'at i ve)
o��g�FFOL�-co Town Hall
Albert J. Krupski, President �� �/y 53095 Main Road
James King,Vice-President c P.O. Box 1179
Henry Smith ti 2 Southold,New York 11971
Artie Foster p •
Ken Poliwoda y Telephone(516) 765-18.92
�o,( Fax(516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
oastal Erosion Permit Application
Wetland Permit Application
Grandfather Permit Application
Waiver/Amendment/Changes
�Fteceived Applicat
.--Received Fee: $
✓C'ompleted Application
Incomplete
SEQRA Classification: J ''� :, •. ,'
Type I Type II '�
Unlisted
Coordination: (date se t) j { '.
✓CAC Referral Sent:
wol5ate of Inspection:
Receipt of CAC Report:
Lead Agency Determination:
Technical Review:
ublic Hearing Held:
Resolution:
Name of Applicant
Address
Phone Number: (�j /l
Suffolk County Tax Map Number: 1000 - �—
Property Location: �'IS/Oi /2� , �ry?'i�'�
(provide LILCO Pole #, distance to cross streets, and location)
AGENT:
(If applicable)
\� Address•
\� Phone:
FAX##
1
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Board of Trustees Application
GENERAL DATA
Land area ( in square feet) : 2� � C
Area Zoning:
Previous use of property: deirk
Intended use of property:
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:
w
Project Description (use attachments if necessary) : c
t1edURA J-0a
2koz-y'�-/-ec , e -, I
40
/7
;,4AVVF �
2 �! /� �
Albert J. Krupski,President gStf F01.tc - Town Hall
James King,Vice-President �� ��j� .53095 Route 25
Henry Smith P.O.Box 1179
cz = Southold,New York 11971-0959
Artie Foster
Ken Poliwoda Telephone(631) 765-1892
4_1 of ��®� Fax(631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In the Matter of the Application
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
I, fC�C .Q residing at
4�e) , n/y i/S 7/
being duly sworn, depose and say:
That on the/3/"'�'da f/►/O k/4 , 0 , I ersonally posted he q'
property known as_ /
by placing the Board of Trustees official poster her it can
easily be seen, and that I have checked to be sure the poster
has remained in place for eight days prior to the date of the /�
public hearing. Date of hearing noted thereon to be held .^/07/
Dated:
(signatur J
Swor)7 to before me this
I day o f'�;j' )0a A,Gt_2 0 0
C f
Notary Public
EDWINA t.CALLEN
Notary PuNo 99te of New Yolk
Qualified in Suffolk Cou
Commission Expires February 3,
1.4-1.6.4(2/87)—Tex1 12
PROJECT I.D. NUMBER I 617.21 SEC
Appendix 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)
1. (CANT/SPONSOR 2. PROJECT NAME
71,o.,01, 'X_
J. PROJECT LOCATION: �// /'
Municipality (/� County JrV1� �lv
4. PRECISE LOCATION (Street address and road inter ions, prominent landma etc., or provide map)
5. IS PROPOSED ACTION:
❑New ❑Expansion odificatlon/alteration
6. DESCRIBE PROJECT BRIEFLY:
6Z-- /6/J(9ZX /W //2-
5T Fy 1� /� Sig 2 X/STiAJ<�;
7. AMOUNT OF LAND AFFECTED:
Initially— L acres Ultimately acres
8. WIL FROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
, ,Yes ❑No If No,describe briefly
9. Wd iy IS PRESENT LAND USE IN VICINITY OF PROJECT?
L f Residential U.!naustriaN l_ Commercial ❑Agriculture ParidForest/Open space L Other
Describe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL,OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL,
STAT�E G LOCAL)? r
LJ Yes ❑No If yes,list agency(s)and permittapprovals
i
. s
11. 0 S ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
Yes' ❑No If yes,list agency name and permittapproval
tr
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
❑Yes ONO
I CERTIFY THAT THE INFORMATION PROM A80VE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant sponsor name: 2/J �.S �gs� ! Date: !� .3/;7 e)
IV
SignatureP�lf
.c
the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this a.�sessment
OVER
• 1
i
PART II—=NVIiiCiJh;"J i' SSESSNIEN i r7o Ce omcle:ec _-y Age.n.C•
IA. C0 ES,AC';CN ENCc Ny E ,nESHCL7 :I'll 8 NYCRF• m z,F.T 317..Z. yes. zccrclnats .ne revie-H =recess and -!se !r.e
I ids I. NO
E. WILL AC7;CN RECciVE CCF.01NAi cD RESJIEIN AS?RCV10ED =::R UPILISTED ACT1CNS iN 5 NYC=R. ?AA7 ..7.5? if No, a neYat:•re _ec:ar
may be sucerseaec ay anct`er;nvolvea agency.
E.yes No
_ _^_
C. COULD ACTION RESUL-uV ANY AGVE^Sc =r_rct.rS ASSCC;AIcD'.JIT'! -^c =•DLLC'+`DING::,:nswers may ce -oncwnt:en. :f :eylclel
C1. Existing air :uality, surface or'•;rounawater cuality or auannty, noise ievels. existing •-aific patterns, solid waste prccuc::cn br blsz:
potential for erosion• arainage or;loading proolems? :plain briefly:
C2. Aesthetic, agricultural• archaeological,historic. or other natural or cultural resources: or community or n efgnocrnoco cnaracter? =.:Drain :
C3. Vegetatlon or fauna, ilsn, sneitfisn or wildllfe species, significant habitats, or threatened or endangered scec:es? Explain brlatly:
C4. A community's existing plans or goals as offlc:ally adopted,or a cnange in use or intensity of use of land or other natural resources? Explain
CS. Growth, subseduent aaveiooment,or related activities likely to be induced by the cr000sed action? Exotain briefly.
iCS. Long :arm, snort term.cumulative,or other effects not identified in Ct-05? =xDtain onerly.
I -
I
I '
IC7. Other imoac:s iinc:ucing o`anges In use of either quantity or type ofenergy)? Explain briefly.
i - -
j
I 0. ;S THERE, OR IS THERE _:KELP TO SF_CONTROVERSY RELATED 70 POTENTIAL ADVERSE =NVIRONMENTAL:,MPACTS?
i ^
_ Yes _ No :f Yes. explain oriefly
?ART III—OETERMINA T ION OF SIZNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above.determine whether it is substantial,large,important or otherwise signi
:Each effect should be assessed in connection with its (a) setting.(i.e. urban or.-rural); (b).probability of occayng;Ac) duratit
irreversibility; (e) geogracnic scope:and (f) magnitude. If necessary; add attachments or reference supporting materials. Ensur
explanations contain sufficient detall to snow that all relevant adverse impacts have been identified and adequately addresse
Check this box if you have identified one or more potentially large or significant adverse impacts which M.
occur. Then 6roceed directly to the FULL E.>ar= and/or prepare a positive-declaration.
1 Check this pox if you have determined, based on the information and analysis above and any support:
j documencation, :hat the proposed action ;'VILL NOT result in�ny significant adverse environmental imcac
AND provide on attachments as necessary, the reasons supporting this determination:
I
.v.,oiv of LcJu Agunc'r
I
i
'rent of :vpC Naine JI ,("con%ioic t_;mcer :n LVJo.♦glnCY rIt1C of (vzoons'o IC Ult.Cef
I
;IgnJturC')f te5comioie•-I:,Cer.n Lido Agency )ignature )f er+carer or -if:e!en[ :roT re50on5101e 011it.Lll
• JJIC
2
Bc d of Trustees Application
County of Suffolk
State of New York
' -t Z PUS , I CLvaL v0l_vt�&(Vr-,BEING DULY SWORN
�POSES'JAND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMITS) 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 IN CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
7 Sig ture
SWORN TO BEFORE ME THIS DAY OF
Notary Public
EDWINA L.CALLEN
Notary PuNoe.499te of New Yotk
62
Qualified in Suffolk Co G�
Commission Expires February 3,
7
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Name: Address :
--uo
ric�avc,P
--
jv� ►_ l tx
- r�C_1SRyh
Ifz-78rt�_�v
i"Yl }� $ YVl er_S_�lC��Y�U�f-'--�t-------_'1:�_�G��L..G�S�✓,�[_t�-_.�,,2--t-t�'-.CR...�t�tccr�_.-C / d�o��a -
STATE OF NEW YORK
COUNTY OF SUFFOLK Q A �
1 rxY'cc of c s—� P� t v�
residing at
�o U!Ez' Id C"C- -j/�/ /%34, '3 being duly sworn, deposes and says
that on the ..3 . day of . Nov , 2oao, deponent
mailed a true copy of t1fe 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 persoris' as shown on the current .assessment ;.
roll of the Town of Southold; that said Notices were-.mailed,. at
the United States Post, Office at ; that
said Notices were mailed to each of said persons. by. (certified)
(registered) mail.
Sworn to before me this
3 r�
day of ,,r9 co cq,6
d EDWINA L.CALLEN
Notary Public NotaryPuNlo.4991462 New York
Qualified in Suffolk Cou
Commission Expires February 3,
74%
APPLICANT
TRANSACTIONAL DISCLOSURE FORH
The Town of Soubhold's Code of Ethics ofohibibs conflicts or
nterest on the part of town officers and em to ees. The
Purpose of this form is to-provide information which can
alert the town of possible conflicts of interest and allow
it to bake whatever action is necessary to avoid same
YOUR NAHE! '. s � ': sh;{y :�✓/� Z
La t name, Eirst name, middle initial, unless
you are applying in the name of someone else or
gther 'entiby, such as a company. If so, indicate
the other person's or company's name. )
NATURE Olt APPLICATION i (Check( k all that apply. ).
Tax grievance
Variance
Change of zone
Appipval of plat
Exemption from plat or official map
other n `/
(if "other,yy name the
Do you personally (or through Your cbmPany, sp6une, sibling,
parent, or child) have a relationship with any officer or CC//
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 thlb 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)
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.apouse,, sibling,
parent, or child is (check all that apply) i
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
noncorporate'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 ftELATIONSIIIP
• ...•, :..!•it�•^i•c� y;i;ti�f'+Y Ey..7::,." ';4f,}k'�::,,yyi�,,., .
Submitted this-
signature.
• 'Print name �'; �°• *.�:�,,0,;;:
-
._ ---
�
�
GREENPORT NEW YORK
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