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HomeMy WebLinkAboutTR-5566 \fir 1. Town Trustees Board Of Southold SOUTHOLD, NEW YORK DATE: ...M-a 002 f y....2..2 2....-.. r PERMIT NO. ... .. ........ ROGER & LESLIE WALZ ................................................. ISSUEDTO .................................................-..-........._..............I........ 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- R titled ."REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and the 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 ..-.......Y.............. t� 2002._, and in consideration of the sum of ..-...2.04�4(} ' paid by l c. Fairweather Brown..Deslgn.,Q ...Jahalf:..nf...Roger--•&:--Leslie �r Walz • ................. N. Y. and. subject to the •, �" of .................Greeiipo,t';....................-.. Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: . �1 Wetland Permit to add seconc! story to existing home 9 maintaining same footprint -no encroachment on waterside e subject to Suffolk County Health Department approval prior to construction a lin f- ha �,al s-dr we ters all in accordance with the detailed spe�iticaons a prtSen�Fediii the originating application. to retain r oof r ' IN� WITNESREQF, The said Board of Trustees h�ere- by causes its Corporate Seal to be affixed, and these resents to be subscribed by a majority of the said Board as of this date. o / Trustees VIP a•-T-- `iy i�it`'Y -� '�'•�It'Yts^�Y/�f/.r �, . all VANa TERMS and t.rONDMONS a The Permittee Rugez tes-Tre--Walz residing at 1505 Old Orchard Road, East Marion N. Y, as • part-of the consideration for the issuance of the Permit does.understand and prescribe to the fol- lowing: , 1. That the said Board of Trustees and the Town of Southold are released from any and an damages, or dainu for damages, of suits arising dirxdy or indirediy as a result of any oper- ation performed pursuant to this permit, and the said Permittee will, at his or her awn expense, defend any and an such wits initiated by third pies, and the said Pew"ttee ass"'mes fall liability with respect thereto, to the eomplete'exclusion of the Board of Trusties of the Town of Southold 2. That this Permit is*valid for a-period of .. 24 mm which is considered to be the estimated time'required to complete the work involved, but'should.cirtumseances warrant, request, for an extension may be made to the Board at a later daft 3. That this Permit should be retained indefiiedy, or as long as the said Permittee wishes to"maintain the structure or project involved, to provide evidence to anyone Concerned that sutlr Iorization was originally obtained i 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 appliratton, may be cruise 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. 6. That there shall be no interference with the right of the public to pass and WPM $long 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, the. work shall cause unreasonable obstruction to free navigation, the said Pen ttee will be requ'red, upon due notice, to remove or alter this work or project herein stated without expenses to the Tows of Southold 8. That the said Board will be noted by the Permittee of the completion,of the work Guth- orized. 9. That the Permittee will obtain all other permits and consents drat may be required sup- plemental to this permit which may be subject to revoke upon failure to obtain same. Albert J.Krupski,President . Town Hall James King,Vice-President I OSUFFO(�C 53095 Route 25 Artie Foster ��� Olj P.O.Box 1179 �. 'y Southold,New York 11971=0959 Ken Poliwoda cm Peggy A.Dickerson ca 2 Telephone(631) 765-1892 Oy �� Fax(631) 7654366 �01 � Sao BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD May 30, 2002 Ms. Amy Martin c/o Fairweather Brown Design 413 Main Street Greenport,NY 11944 RE: SCTM#37-6-5 Roger&Leslie Walz 2505 Old Orchard Road East Marion,NY Dear Ms. Martin: The following action as taken by the Board of Town Trustees during a Regular Meeting,held on May 22, 2002,regarding the above matter. WHEREAS, Fairweather Brown Design on behalf of Roger&Leslie Walz applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated May 2, 2002 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 May 22, 2002 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. _ 2 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 Roger& Leslie Walz for a Wetland Permit to add second story to existing home maintaining same footprint—no encroachment on waterside—subject to Suffolk County Health Department approval- prior to construction a line of haybales - drywells and gutters to retain roof run-off. 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. Fee must be paid, if applicable and permit issued within six months of the date of this notification. If inspections are required, at a fee of$5.00 per inspection(See attached schedule). FEES: $10.00 Very truly yours, Gi Albert J. Krupski, Jr. President,Board of Trustees AJK/cjc cc DEC Building Department �FF�(Albert J.Krupski,President Town Hall O�OS COG 53095 Main Road James King,Vice-President Q• ?.� P.O.Box 1179 Henry Smith c Southold,New York 11971 Artie Foster ti Ken Poliwoda hone(516)765-1892 � � � Telephone y�Ol �aO� Fax(516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: Fairweather Brown Design on behalf of Roaer v Leslie Walz May 2, 2002 Please be advised that your application, dated has been reviewed by this Board, at the regular meeting of and the following action was taken: ( X ) Application Approved (see below) ( ) Application Denied (see below) ( ) 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 the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMpUTATION. OF PERMIT FEES: Two Inspections @$5.00 $10.00 TOTAL FEES DUE: $ 10.00 SIGNED: �• Q PR SIDENT, BOARD OF TRUSTEES ,SUN 13 2001 BY: ,-LERK, BOARD RUSTEES 4/98 Albert J.Krupski,President Town Hall James King,Vice-President OSQFFD[/�'C 53095 Route 25 QG P.O.Box 1179 Artie Foster = y� Southold,New York 11971-0959 Ken Poliwoda Peggy A.Dickerson Telephone(631) 765-1892 Fax(631) 765-1366 1 � �► . BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction % constructed x Project complete, compliance inspection. fl?ER & LESLIE WALZ Old Orchard Road East Marion, New York INSPECTION SCHEDULE �re-construction, hay bale line. . 1st day of construction J % constructed Project complete, compliance inspection. Presented at the'Southold Town Board of Trustees Hearing on 5/22/02 Ref: Roger&Leslie Walz SCTM#1000-37-6-5 My name is Norma T. Martin. My husband, Ralph, and I live next door,to the west, of the Walz' house. Our interest regarding the proposed second story addition to the Walz'house is due largely to the additional bathrooms and/or showering facilities that will result. Since their house is at the highest elevation of the slope of land between our two houses, we are deeply concerned about the additional drain on, and possible overflow of,the sewage system. Should the existing system fail, which is a distinct possibility since it dates ftom when the house was originally built in 1950,the effluent could not only spill over onto our property, but possibly leach into the existing water table,which is only 14.9 ft. from the surface, according to their surveyor. Inasmuch as we are currently in a major drought situation, according to the National Weather Service and the DEC, and the water table is at a low point, it could very well rise as this situation improves, making leaching into the higher water table a serious consider- ation. It could also leach into the nearby shallow tidal waterway,which is only about 82 ft. from their property line. It is our understanding that the Suffolk County Department of Health has very specific regulations regarding sewage disposal systems and minimum septic tank area and capacities as set forth in their "Sewerage Disposal System for Single Family Residences, Sec. 5-120, Tables 1, 2, 3 and 4. These regulations indicate that a residence having one to four bedrooms requires a minimum septic tank capacity of 1,000 gallons,with a minimum liquid surface area of 27 square feet. Also,with a depth to groundwater of 11 to 17 feet, a minimum requirement of two pools-- each 6 feet deep and 8 feet in diameter or,three pools--each 4 feet deep and 8 feet in diameter-- ,.are-required. Will the Southold Town Building Department ascertain compliance with these regulations by seeking approval of the septic system from the Suffolk County Department of Health? Also,will the contractor that is,,selected to build a new system have a liquid waste license from Suffolk County Consumer Affairs? We understand that, according to William Baessler, Director of the Bureau of Licensing, a liquid waste license requirement is required for any business that hauls, installs or maintains sewage disposal systems in this county. Also, it was stated in the Traveler Watchman on March 14, 2002 that Trustee Krupski was concerned about sewage leaching into the waterways of Southold because the county is allowing septic system setbacks as close as 47 feet from the wetland delineation mark He asked the Town Board to place a rule in the town code that all septic tanks should be at least 100 feet away from the wetland delineation mark With the limited amount of space available on this small lot, it appears to be impossible to comply with that stipulation. All in all, it appears that this project could have a serious detrimental effect on the tidal waters nearby, as well as our adjacent property. Thank you for giving me the opportunity to voice our concerns regarding this proposed addition. Norma and Ralph Martin, Jr. F Our Town Hall. 53095 Main Road 'T P.O. Box 1179 Telephone O Southold. New York 1197 (631) 765-1892. SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Monday, May 20, 2002,.the following recommendation was made: Moved by Drew Dillingham, seconded by Scott Hilary, it was RESOLVED to recommend to the Southold Town Board of Trustees_APPROVAL of the Wetland Permit Application of ROGER-&_LESLIE WALZ to add a second-story-to-the-- existing dwelling, maintaining_the same footprint..- Located: 2505 Old Orchard Rd., East Marion. SCTM#37-6-5 Vote of Council: Ayes: All Motion Carried S FAIRWEATHER-BROWN DESIGN ASSOCIATES,INC. P.O.Box 521 413 Main Street Greenport,N.Y. 11944 631-477-9752 (fax)631-477-0973 May 1, 2002 Southold Town Trustees Re: Walz SCTM# 1000-037-6-5 The accompanying application is for the addition of a second story to an existing single family residence. The proposed addition/renovation is to maintain the existing footprint and will therefore not cause any new impact to the wetlands, in fact there will less as roof run-off will be directed to dry wells. Hay bales will be placed as directed, during construction and as no ground breaking will be done on the wetland-side of the home. The only disturbance we foresee will be in the side yard (driveway area) where the septic system will have to be upgraded, according to SCHDS standards, and again proper care will be taken during this process to assure nothing affects the local wetlands. The home is above the 10' contour. This project has been tied up with the ZBA since May 14, 2001, with the revised interpretation of the setbacks. We have been told to expect a decision on or by May 18th. Thank you for your consideration of this application. If you have any questions or need other information, please do not hesitate to contact me or Robert Brown the Architect for this project. Respectfully submitted, Amy K artin � Permit xpediter,FBDA Z �� s li , a i�f p b BOA R7 4 5ATTF.N 11 tIN'J750N RIVER VI 3 Tr 7 M05 rO:0 5AC.0 CROW' PA,'CA i'i6'PJAT TR:V (TY'1• 50AR0 4 5ATT`N - �W-PAOCIA50. �PIN.PA i'..q'r'AT TR:V �aIM FM n SOUTH r: r'^riJ P 5. Payment of i ired fee. (See attached fee schedule) " WETLAND/TRUSTEE LANDS PERMIT A Wetland Permit is required for any activities within 100 feet of any wetland or surface waters in the Town. The Trustee Lands permit applies to all moorings,piles, docks,bulkheads, and other in-water structures and activities. If you have questions regarding whether the Trustees have any jurisdiction over your activity,please contact the Trustees. The Trustees or their representatives will assist you in making this determination. The ap lication requirements for a Wetland/Trustee Lands Permit are as follows: 1) Complete application form. Fill out all items contained'in the sections identified as General Data and Wetland/Trustee Lands Permit Data, Notice to Adjacent Property Owner.Also,be sure to complete the attached statement requiring notarized signature. 2) Complete short Environmental Assessment Form. Provide a recent (within 1 year survey of the property showing all existing and proposed structural improvements, including soundings done at low tide if you are proposing a structure out into the water. Your surveyor should be aware of the survey requirements set forth in local statute. /4) Provide a photograph of the site. 5) Applicable local statute empowers the Trustees to waive certain application requirements including(1) a description of the area from which removal or in which deposited material is proposed, or in which structures are to be erected, 2) two foot contour information on a survey, and, 3)the necessity of obtaining all other required permits and approvals (prior to submitting a complete application). All requests for a waiver of these requirements must be submitted to the Trustees in written form. 6) Submit one original plus 2 copies of the application form, appropriate Environmental Assessment Form, sketch, and 3 stamped surveys. 6) Payment of required fee (See attached fee schedule). FAIA � 1 -11116 CAL.6 ..•1 �.Y'.�.. � '•4,r���L �1 .•�'..R• \:J. •J� .I 1�•;�y-): �7��.,' I+..i�• •"1 .\�I Y ••� y� �'1 a4, �•. .• .��;y Z 7 f ,1 ,r '.7• 7 , Y r v RI C/0 TEST HOLE BY McDONALD GEOSCIENCE Ar APRIL 18, 2002 (EL. 12.6) Or DARK BROWN SANDY LOAM -1 BROWN r01 SANDY LOAM 'P PALE BROWN FINE \ + LIL-21AA Q TO MEDIUM SAND ti -9' CO NC. MON. U N CONC. COVER SILTY SAND ® o -11' �O ��E �� PALE BROWN FINE �00+ ; G- • �� \ L DR /�, 1 "� �� .9' , TO MEDIUM SAND ' p 1 E• �ERNE �CIGHT 'N O 1' WATER IN PALE N �Ze NP�T FED coDRI ErE >VE BROWN FINE TO r W MEDIUM SAND N O PFO `'� � \i 210P1 5.2 -21' a sr F ® O � p0 •GJ V � �cc� � 0 '� o 6. li O �s Ca >• \ -a�=O 6 01 cs \ \ O �\ o 7 I-A_ Z fESG� A,E 0 1�Ep�o, a� pP � oa 1� z i \ I o FE�Ct� BEE H GR4 S 00 � i � �.\• �eg�A �s9, � Qv-/ 1/jh N Cl) TIE LINE ALONG / MEAN HIGH WATER 00 AREA: 12,834 S.F. = 0.295 AC. 2 ON APR1L 23, Do2. CERTIFIED TO: SURVEY OF ROGER J. WALZ PART OF LOT 5 LESLIE WALZ MAP OF GARDINERS BAY ESTATES, SECTION 2 EASEMENTS AND/OR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED SITUA TE A T ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME OF THE SURVEY. EAST MARION GUARANTEES INDIE PERSON FOR WHOM THE SURVEY TISDPREPARED, AND ON HIS BEHALHEREON SHALL RUN ONLY TOF TO THE TITLE COM— TOWN OF SOUTHOLD PANY, GOVERNMENTAL AGENCY AND LENDING INS77TUTIONS LISTED HEREON, SUFFOLK COUNTY, NEW YORK AND TO THE ASSIGNEES OF THE LENDING INSTITUTION. GUARANTEES ARE NOT TRANSFEBLE TO ADDITIONAL IOR SUBSEQUENT OWNERS. THE OFFSETS�(OR DIMENSIONS) S14OWNITUTIONS HEREON FROM THE STRUCTURES TO SCALE: 1 "=40' DATE: APRIL 23, 2002 THE PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND USE AND THERE- FORE ARE NOT INTENDED TO GUIDE THE EREC77ON OF FENCES, RETAINING S.C.T M. DIST. 1000 SEC.037 BLK.06 LOT 005.001 WALLS, POOLS, PATIOS, PLANTING AREAS, ADDITIONS TO BUILDINGS AND ANY OTHER CONSTRUCTION. JOB NO. F3769 OF NEIy r Q MAP NO. 275 ��P���.c�R� �p,F .:.:.:::::::.:.........: ..... .....................:........ ;::: ..?::;.. :,` .,..:......;:;;;;':::: ..... ............. FILED:SEPT. 23, 1927 `�" • � :.. * 107-4 ..::s:::.. s:;,:• ... h way REVISIONS: Ha on Ba ' N.Y. 46 9 o� (631) 7 B-5330 50 Mar LANDS Successors ttoL.S. Paul T. Conalizo, L.S. Robert A. Kart, L.S. license no. 050149 Good Ground Surveyors, P.C. Albert J.Krupski,President O, VS (�`► Town Hall James King,Vice-President � �Gy 53095 Route 25 P.O.Box 1179 Henry Smith p - Southold,New York 11971-0959 Artie Foster y = Ken Poliwoda 0 • `� Telephone(631) 765-1892 1'ijJol �aO� Fax(631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only %;6-astal Erosion Permit Application Wetland Permit Application Major Minor _Waiver/Amendme h79— Received _Received Applica}Iajn:Fee:$ o� _Completed Application v CD _Incomplete _SEQRA Classification: Type I Type II Unlisted _Coordination:(date sepq _CAC Referral Sent: °-1 " _Date of Inspection: 5 19 0 , MAY - 2 2G'J2 Receipt of CAC Report: Lead Agency Determination: ';tti3L _Technical Review: _Public Hearing Held:_4 0 Resolution: Name of Applicant O m + Address 015- OS 9.46 r py y Phone Number:( 17--0(o b Suffolk County Tax Map Number: 1000- 0.5 �o S Property Location: ameo."mcm s -0R gahtt6S Aa V (provide LILCO Pole#, distance to cross streets, and location) AGENT: I �m /�R/eT�� uJ W» �5/6/✓ (If applicable) Address: 413 m A,N 6 f • 5o>C ,521. E D� Aq Phone: 7-7 Board of Trustees Application GENERAL DATA Land Area(in square feet): / 2. fa y/ Area Zoning: 1 Previous use of property: jtn le 76,rn. A°eoldiel 7G�- Intended use of property: .9yn� fir». � . ,fie 5/ien ee, Prior permits/approvals for site improvements: Agency Date Ved a�i��y�n9 �yi�G�rrrA �G�Of" 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): 9W S ono(.s!oieu o ek.5 Ping Acme-- In"n Tit yn ya e- -D Awe i N T �I'I Q eY in en i4l. Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: TI& JA)A i-jES #J d 6r 72�T/.e6n rnliStfi To mAKE `�Umm�,�Z l'iOTIA-6� ���- 1�odN° 4-b me ii,-rN beam D 5Tb iE q Area of wetlands on lot: 4 y�00 D t: square feet Percent coverage of lot: Y 30 % Closest distance between nearest existing structure and upland edge of wetlands: A10 " t feet `/oI eon-to&Pie) Closest distance between nearest proposed structure and upland edge of wetlands: too# feet Does the roject involve excavation or filling? No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 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): f�Rsr �'/ooze �Jo DkI4 AlZ-44S �i�' :A le Q �P�- Board of Trustees Application County of Suffolk State of New York /7mu Al # TI ry BEING DULY SWORN DEPOSES 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 PERNIIT(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. Signature SWORN TO BEFORE ME THIS DAY OF 920 Notary Public Alberti.Krupski,President �O C� Town Hall James King,Vice-President �� Gy .53095 Route 25 P.O.Box 1179 Henry Smith y Southold,New York 11971-0959 Artie Foster Ken Poliwoda • '1C Telephone(631) 765-1892 yifJol �aO� Fax(631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD ----------------------------------- In the Matter of the Application COUN Y OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING aD I, , residing at 13/8, ` being duly sworn, depose say: That on the /O%Cday of //),*�+ 2001, I p}rsonall o ed the property known as by placing the Board of rust es official poster T.Klprp 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 h aring noted thereon to be held Dated: sign re) Sworn to befo g me this day of 200a, V"w 2 12002 I N a y ublic r' JOYCE M.V41LKINS y Notary Public,State of Now York No.4�952246,Suffolk County Terns Expires June 12, (; E6 03 3 PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name:k, Address : o�soS (IAJA� f: STATE OF NEW YORK COUNTY OF SUFFOLK avxAl x4tt�_ , residing at being duly sworn, deposes and says tha"15 on the day of ,moo , deponent mailed a true copy of the 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 persons as shown on the current assessment roll of the Town of Southold; that s id Notices were mailed at the United States Post Office at that said Notices were mailed to each of said ersons by (certified) (registered) mail . V • ��[� MAY2 I2G�2 "`�� Sworn to b fore me this day of . �2w��-- d4otar ub 61c JOYCE M.WILKINS Notary Public,State of New York No.4952246,Suffolk County Term Expires June 12, ird of Trustees Appli.cati AUTHORIZATION (where the applicant is not the owner) I (, A/T� residing .at gW'—nt owner of property) (Mailing dress) do hereby authorize Ali✓ (Agent) to apply for permits) from the Southold Board of Town Trustees on my behalf. (ow is signat ) k MAY 2 1 2 - LIQ 8 NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: U)PIIX_J SCTM#1000- YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: put - A 5eCV00 STvyey AADDiTIOIJ On f-6mP� 4- IoJFI•r+oM NoT G ft0C*1NG 1'00T Pk►1Jf �� GyC,f ST 1 N Fi" �Dt1'1 IE 2 . That the property which is the subject of Environmental Review--is located adjacent to your property and i&. described as follows : cos ®� dQ Drama.{-d b 3 . That the project which is subject to Environmental Review under Chapters 32, 37, or 97 of the Town Code is open to public comment on: You may contact the Trustees Office at 765-1892 or in writing. The above referenced proposal is under review of the Board of Trustees of the Town of Southold and does not reference any other agency that might have to review same proposal . OWNERS NAME: f- it MAILING ADDRESS• 3 tMPe�ots7 ' PHONE #: Zo t -1f+Af - 19SP Enc. : Copy of sketch or plan showing proposal for your convenience. LU 1.4-16-4(2/87)—Text t2 PROJECT I.D.NUMBER 617.21 SEQ 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. APPLICANT/SPONSOR 2. PROJECT NAME Rmy Mkpvrid W Z 3. PROJECT LOCATION: Municipality ftvr M ip County �A, d. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc.,or provide map) 25os' OLD oR.�l}iR�e pD 5. IS PROPOSED ACTION: ❑New ❑Expansion Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: �cc secca� ®Sro1e'"l f0 a 4Sr"QC- Swx�1e, -� � rescc�ence. n0 ,�,,,s�L• vn -C'oo->F Print of 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately © acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING [LAND USE :RESTRICTIONS? Yes Cw'No If No,describe briefly I Real[RED �p IQu o1 a G— Non Co n.f r rn vn sb C `>14 rd S 9. WH�A, ,//�SS PRESENT LAND USE IN VICINITY OF PROJECT? _ CrrResidential [1ndustrial ❑Commercial ❑Agriculture LJ Park/ForestlOoen space LJ Other Describe: Swrn rn it �--� e-ew - ro o d S L r,o� re Ira��Q nc�s 10. DOES ACTION INVOLVE A PERMIT APPROVAL,OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL, STATE R LOCAL)? WYes ❑No. If yes,list agency(s)and permitlapprovais 1 �Pr ` DeC non J U eL s�1&T*1 oN ti�� t o, Co fn�Tou K. BV&1AWL D fi 5CD14 5 V p IEI'e, . ST 11. DOES ANY ASPECT OF THE ACTIO14 HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑Yes' ❑No It yes,list agency name and permit/approval 12. AS A RESULT Co ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? ❑Yes N I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicantlsponsor na le •� �TfTF Date: Signature: If the action•is in the Coastal Area, and you are a state acency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART Il--VVIRC.gME. 'SSESSMENT i-,a be completea Jy 's A. DOES ACT;CN EaCEE0 ANY : -E i THRESHGLD IN 8 NYCRF. ?.�nT 317.'Z? if yes. cocrarnate the review -rocess ana use the =UL _AF. I,Yes I._:NO 3. 'NILL ACTICN RECEIVE CCCR0lNATcD RE-11EIN AS?RCVIDED F::t UNLISTED-ACTICNS iN o NYC=R. ?ART 717.3? if No, a negative dec:ara may be sucersedec cy another:nvolvea agency. l l Yes No j C. COULD ACTICN RESULT IN ANY ADVERSE EFFECTS ASSCC:ATED ',VITH 71HE FOLLOWING.!Answers nay ce nancwritten, it :egible) I C1. Existing air quality, surface or'grounawater cuality or duantity, noise ievels. ex:sting :raffic patterns. solid waste pracuc:;on or dlscc potential for erosion, drainage or;loading problems?E:olain briefly C2. Aesthetic, agricultural, archaeological,historic, or other natural or cultural resources:or community or neignbernood character? °xalain C3. Vegetation or 'auna. 'Isn. snellfish or wildlife soecies, significant naoitats,or ;hreataned or endangered soec:es? E:clain orlelly: C-1. A community's existing plans or goats as offic:aily adopted,or a cnange in use or intensity of use of land or other natural resources?Explain or C5. Growth, subsequent :evelaoment,or related ac:!vities likely to be induce❑ by the or000sea action? Exola:n briefly. CS. Long :arm, snort term. cumulative,or other erfects not identified in C.-CS? Exotain briefly. I , other!moac:s ;inc:'Licing c::anges in use of either quantity or type or anercyl? _xolain Briefly. - i i i .. I '• 1 0. :S 7HERE.08!S THERE L1Kc Y M BE.CONTROVERSY RELATED TO POTENTIAL A0VEASE ENVIRONMENTAL!!:PACTS? _ Yes NO :f Yes. exciain orietty i PART III—OETERMINA T ION OF SIGNIFICANCE (To be completed by ;agency) INSTRUCTIONS. For eac:t adverse effect identified above,determine whether it is substantial,large, imcortant or otherwise signific. Each affect snould be assessed in connection with its (a) setting (i.e. urban or rural); (b).prcbability of occazing; Cc) duration: irreversibility; (el geograonic scoce:and (f) magnitude_ If necessary, add attachments or reference supporting materials. Ensure exoianadons c--ntain sufficient detail to snow that all re!evant adverse impacts have been identified and adequately addressee. i Check this box if you have identified one or snore potentially large or significant aaverse impacts 'which -.MA'' occur. Then proceed directly to the FULL E;AF andlor prepare a positive-declaration. Check this pox if you have determined, based an the information and analvsis above and anv supporting documentation. :hat the or000sea action WILL NOT result inlay significant adverse environmental imcac:g I AND orovice on attacrments as necessary, the reasons supporting this determination: I I i ,v„ule fir :erti ,agency i inn(O( :vpC Vale JI 'f d>GOn1,Ole IJIIIC Bf.n .CJ4.agencv t[tie of :L�•:OOnS,OIC l„)InCef Orr,C2f1 ,nature-3s 1escan5,ole r:.Car�n Liao Agency i,gnawre or r're-jarer Or;;ir:erent :rOtn re50ons,Olr I JJtc APPLICANT TRANSACTIONAL DISCLOSURE PORH � The Town of SoAhold ' s Code of gthic•s • rohibits conflicts of merest on the part• of town officers and employees . The purpose of this form is to provide information which can alert the town of Ross ble conflicts of interesb and allow it to take whatever action is necessary to avoid same ._ ft. YOUR NAME: Last name , First name , m dd•le n t al , 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. ) NATURE OV APPLICATION: (Check all that apply. ) Tax grievance Variance Change of zone App Royal of plat Exe ption from plat or official map Other (If ,other, " name the activity . ) 1 :........ _ Do you personally (or through your CbMpany, 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 busineaso including a partnership, in which the town officer or employee has even a parE'1'64-; _:`-:`_;I.. r, ownership of (or employment by) a corporation I� vvhicl'i__` an of th;e owns more than 5 the town of ricer or em loyee o 96 shares. MAY 2 1 2u02 YES No If you answered "YES, ", complete the ba,iance ' of thlb form and date and sign uhere indicated. Name of person employed by the Town of sout'rioid Title or position of that person _ Describe the relationship between yourself ( bbo 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 spouse ,' siblingo . 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) t 13) the legal or beneficial owner of any interest in a noncorporate 'entity (when tt-le applicant is not a corporations C) an officer, director, partner, or empibyee. of the applicants or D) the aptual applicant . DESCRIPTION OF RELATIONSHIP • ..' ,i "t•rit I7i17t 1Y.':,ar.';�F(i"•'�N.ey• . Ak` {t f,' . _ l�':S !'i•.1'•:,i,'�1;.�1„i; .1'y... ,:),S,�f :;rt�.•1l,I !11('�... su-binittad t Sig*habUra-..!Z_rZt -Prinb name . yam, 1 I,;yit •';.•3r.��tit: }FS' r' T�c��{j �.. 'ram MR. �!�. '•I . .t..�l l,'i 4:)".a. '�n::t Pyl i ;.��'.4°,•.....?.:�M'.!Y.N.i i4.i'... i..'�kVi '' i v� w 14 12\ PF'OPOSFD 2ND FLOOR ADDITION TO EXISTING 10 1 STOI?Y f-RArlE NOUJ`=. n�r,-X \ o� O \�" o c P � O AGO \ �c r I \ •� `,(j 0 \I 6 4\ 10 12 7G, T �q l cAJ D MAP 5URVEYED N KOGLR J. t- LE5L IE V,1' ,L7 / EAST TOWN OF 50UT!10',_D, N.Y. SUf--0 COUNTY TAX r,�AP INFO: \ 1000 037 G 5 LOT NO.'5 RFf FF: TO r✓AP OF G�P D!rJEFwS DAY E51 ATE5 SECT. 2, FiLFD I"J T11E SUFF.CO.CLE^K:5 U'Ff-iCF A5 MAP 275. \ � r NOTE: P/E'RTt1!NG 5N0'V,",J IS EY'ST!''!G EXCErT AS NOTED. 40 WALZ 05!01102 C� 5 f T E P L AN' FAIRWEATNER-BROWN SCALE: 1 2o',C' DEDIGN A550CIATE5.11NC. 4 13 MAIN 5TRILI T P.0.50X 521 GREENPORT, N.Y. 1 1944 G3 1 -477-9752 (Fax) G3 1 -477-0973