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Board Of Southold Town Trustees
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_\ SOUTHOLD, NEW YORK ib
Dec.
.
17, 2003
...............DAT
PERMIT NO. ... ......•• E:
�•
RAYMOND B. STRONG III •
,�.
" ISSUED TO .....................a........................................................................................... .
Pursuant to the provisions of Chapter 615 of, the Laws of. x
`2. 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 LANDSand the
FROM
REMOVAL OF SAND, GRAVEL-OR OTHER MATERIALS
LANDS UNDER TOWN•WATERS;'•--': and in accordance with the
Resolution of The Board adopted at a meeting held on --Dec. 17,
200 00 aid b
2003" . and m consideration of the sum of ._.._.......�................ p y lF
Raymond B. Strong III ......
............... ..................................--•--
Southold . . . ............."-.•• N. Y. and. subject to the
Terms and Conditions listed on the reverse side hereof,
' �- of Southold Town Trustees authorizes and permits the following:
ermit to construct a TX 20'fixed timber dock beginning at ALW with a
Wetland P '
TX la inshore ramp and 32"X 14'aluminum ramp to a new 6'X 20'float,and to
'float,and all in accordance with*the plans prepared
remove the existing 12'X 16
�." by Costello Marine Contracting Corp.last revised 1/15/04.
i, all in accordance with the detailed specifications as presented in
y' -the originating application.
IN WITN to be affixed, and these resents
by causes its Corporate Seal ESS WHEREOF, The said Board of Trustees hiere-
to
p - � -
be subscribed by a majority of the said Board as of this date.
o !`
Artie Foster. aJ
Trusiees u
�'/, ,'p,� Y� ""-►�.%ri�'�.��_'�-'� '� '' �`} 4--•^c�"�7 mar:ram ;t �' �
TERMS and CONDITIONS
P
The Peraiittce 'Ra rriond B. Strop III
2205 B.ayview Ave. , Southo'ld -N. Y., as
residing at presc ilie
to:the fol-
:parr of the cgoderation for-.the issuance of Abe:�etmit does.Understand and,
lowing:
i. That the-said Board of Trusttes and the Town-of Southold ate released 'from any and
all dairi'ges, or
claims•for:damages,
�f suir¢s:arising:directly or iadireoy as'a.remk of an► oper-
atioa performed pursuant ;to this permit, and -the said Pemuttee �, at his or her own-,
defend any and 1T arch suits'iaitiated by-thhd-P and the said Fermia_assumes=fall hal�lity
�p�:e cclusion;of the:Bayard of Tivstees of the Tawas of:Southold
with respect thereto, to-.the
2. That this`Permit is valid for z ted(id of - : 24 mas. which is consideredto be the
estimated time required 4o:complete the work-involved,:but'should; iraumsrances 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 Permittce wishes
to maintain the_structure or .project -involved,-to,provide evidence to anyone concerned that-curb
orizaton was originally-obtained. _
and approval of.the'Boat+d or
4. That the.work-involved will-be subject to *the inspection aPP _
its agents, and non-complianoe"with:the provisions of the:originating application, may be cause for -
revocation of this,Permit by resolution of the said,Board. _
interference with navigation as a result of the wo
5. That there will be no unreasonable
rk-herein authorized.
6. That there shall be no interference with the right of the public to pass and "repass al�g
the beach between,high and low water marks.
7. That if future operations of the Town of Southold require the removal and/.or aluradons -
30. the location of the"work:herdn authorized, or,if;-in du--opinion-Of the Board:of Trusters,,the-
wont shall cease unreasonable igation, the aid Permktee"will be 1O 'ed+
obstruction to free nav
;upon 4[ue notice, to remove or.alter this work or project herein stated without ezPcuses to the Town .
Of Southold
8. That the said Board will be notified by the Permittee of the completion.of the wort =W@-
.orized.
:9. That the=Permittee will obtain all other permits and consents Ant may be required mp-
.Plemetital to this-:permit which may be subject to revoke upon:failtue to obtain name.
SUFFoc�
Albert J.Krupski,President ��0 C� Town Hall
James King,Vice-President h`Z` Gy 53095 Route 25
Artie Foster o P.O.Box 1179
Ken Poliwoda va Z Southold,New York 11971-0959
Peggy A.Dickerson *14-4
Telephone(631) 765-1892
Fax(631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
December 17,2003
Mr. John Costello
Costello Marine Contracting Corp.
P.O.Box 2124
Greenport,NY 11944
RE: RAYMOND B. STRONG III
2205 BAYVIEW AVE., SOUTHOLD
SCTM#52-5-2
Dear Mr. Costello:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday,December 17, 2003 regarding the above matter:
WHEREAS, Costello Marine Contracting Corp. on behalf of RAYMOND B. STRONG III
applied to the Southold Town Trustees for a permit under the provisions of Chapter 97 of the
Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated
November 25, 2003, 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
December 17, 2003, 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,
2
WHEREAS,the structure complies with the standards set forth in Chapter 97 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 approve the application of RAYMOND B. STRONG
III to construct a YX 20' fixed timber dock beginning at ALW with a YX 18' inshore ramp and
32"X 14' aluminum ramp to a new 6'X 20' float, and to remove the existing 12'X 16' float, and
all in accordance with the plans prepared by Costello Marine Contracting Corp. last revised
1/15/04.
Permit to construct and complete project will expire two years from the date the permit is signed.
Fees must be paid, if applicable, and permit issued within six months of the date of this
notification.
Inspections are required at a fee of$5.00 per inspection. (See attached schedule.)
Fees: None
Very truly yours,
A' C4 �'-
Albert J. Krupski, Jr.
President,Board of Trustees
AJK/lms
r.
Town Hall
Telephone 53095 Route 25
(631)765-1892 ® P.O.Box 1179
Southold,New York 11971-0959
CONSERVATION ADVISORY COUNCIL
TOWN OF SOUTHOLD
At the meeting of the Southold Town Conservation Advisory Council held Monday,
December 8, 2003, the following recommendation was made:
RAYMOND B. STRONG I11 to construct a-3'X-30'-fixed timber dock beginning-at ALW with an 18' inshore ramp and 32"X 20' aluminum ramp to reach the existing float.
t_ocated: 2205 Bayview Ave., Southold. SCTM#52-5-2
The CAC did not make an inspection, therefore no recommendation was made.
12/10/03 Field Inspection
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12/10/03 Field Inspection
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12/10/03 Field Inspection
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Raymond Strong Agent:
2205 Bayview Avenue Costello Marine Contracting Corp.
Southold, Box 2124
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Southern dock
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Raymond Strong Agent:
2205 Bayview Avenue Costello Marine Contracting Corp.
Southold, NY 11937 P.O. Box 2124
Photo taken 7/10/03 @ ALW (3:10pm - 3:20pm) Greenport, NY 11944
311w�NOWWAing flo
w
Raymond Strong Agent:
2205 Bayview Avenue Costello Marine Contracting Corp.
Southold, NY 11937 P.O. Box 2124
Photo taken 7/10/03 @ ALW (3:10pm - 3:20pm) Greenport, NY 11944
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Client: Raymond Strong Agent: C Mo Marine Contracting Corp. Inc.
.'2205 Bayview Avenue F Box 2124
Southold, NY 11937 Greenport, NY 11944
October 19. 2003
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Client: Raymond Strong Agent: C Mo Marine Contracting Corp. Inc.
.'2205 Bayview Avenue F Box 2124
Southold, NY 11937 Greenport, NY 11944
October 19. 2003
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Client: Raymond Strong Agent: C fllo Marine Contracting Corp. Inc.
2205 Bayview Avenue F Box 2124
Southold, NY 11937 Greenport, NY 11944
October 19. 2003
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Client: Raymond Strong Agent: ( EIlo Marine Contracting Corp. Inc.
2205 Bayview Avenue F . _. Box 2124
Southold, NY 11937 Greenport, NY 11944
October 19. 2003
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COSTELLO MARINE CONTRACTING CORPORATION
DOCK BUILDING •JETTIES • BULKHEADING •STEEL&WOOD PILING • FLOATS
423 FIFTH STREET • P.O. BOX 2124 • GREENPORT, NEW YORK 11944 • (631)477-1199/477-1393/477-0682 • FAX(631)477-0005
January 29, 2004
L
Southold Town Trustees D � � � � �
P. O. Box 1179
Southold, NY 11971
Attn: Lauren FEB - 2 2004
RE: Raymond Strong, III
Southold Town
2205 Bayview Avenue Board of Trustees
Southold, NY 11971
Dear Lauren:
Enclosed please find revised drawings for the above referenced property.
Pursuant to the December 17, 2003 Public Hearing the following changes were
made:
1.) The 3'x30'timber dock was shortened to 3'x20'.
2.) The 32"x20'aluminum ramp was shortened to 32"x14'.
3.) The existing 12'x16'float will be replaced with a 6'x20'float.
If you have any questions regarding these changes, please do not hesitate to
contact me.
Yours truly,
/Jaostello Walsh
ermt Manager
Enclosure
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VICINTY MAP LOCATION MAP
1" = 2500' 1" = 100'
ADJACENT PROPERTY OWNERS
0 0
APPL I CANT
1000-52-5-1 1000-52-5-3
Thomas Byrne 8 c% Kevin Lyons
Veronica Kaliski 1000-52-5-2 a Carol LI�ons
74 Roxen Road Ra mond B. 5trong, III 86 Birch Road
Rockville Gentre, NY 11570 2205 Boy ow Avenue Molverne, NY 11565
(2345 Bayview Avenue) 5outh%v NY IIg71 ,(2085::Bayview Avenue)-
E
i 2 �n 2
E PROPOSED: D C E � U
Gonstruct a 5' x 20' f ixed timber dock
beginin at ALA with on 15' inshore ramp FEB - 2 2004
32 x R' aluminum ramp to new 6x 20 f loc t
AGGE55: Southold Town
Board of Trustees
By water using crane a barge and by land
using a 5 wide access path center of lot
PREVIOUS PERMITS:
Town of Southold Trustees Permit # 2178
issued July 51, Ig86 for a dock and f loot
Prepared Amended
p ` 0I-15-04
Costello Marine Contracting Corp. Prepared
P.O. Box 2124 6reenport, NY IIG44 II-03-03
Ph. 631-47-7-119G sheet I of 3
PLAN VIElN APPLICANT
1000-52-5-2
Rayymond B. 5trong, III
2205 Bayyview Avenue
I" = 40' 5ou%Id, NY IIG-7I
Datum B a y v j
M5L-N6VD'2G e W
Avet7 � e
6
6
P
N c� D2e m 9
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��� BQyvt e 05
W Axle
1` ca
'0U -/elk
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9 U Q
•' •,WM e seocvo// stePs
�[� `pat.,'��opQ�Y e,,,,'' '.�• ti q�lfi/t of
iM`age �OncreWeE/qn
1.6 'Dq. -�` "�.• _ by R. to w ds v 1.6 L6 D..O.. '�- -�' FCx qll qs egefq .
_ o
2.6 -Fyg_..aga5_:a_5 _on- aeo3gted
2.6 2.6 1.6 1.6
5.2.6 3.6 2.6 2.6 1.6 1 d' ,.`` "
3.6 2.6 1.6 bA - 3k- - -
4.2 3 3.6 25 2.5 w I. '•GLe._` --_-- y-
t9A.,,
4.2 3.6 3.6 �' .4 1.31.3 '-6lb_-`-_______--� R.A
4.2 3.6 3.6 ti 2.4 1.3 •FiA _O-b
4.2 3.cy4�Q;yew .2 5.2
2.4 1.3 I ! '•-Q b"",0.Q
4.5 15
4.5 4.5 4.5 1` 5/0„ LL.9Qia3.9 3.9 3.2 3.2 3.3 s� x � f iber Dock
5.2
oM.WrJ �/�S 3.-1 3�mgg.4 above grade 2.22.2 2.6 E_o
5.2 5.5.5 5.5 5.5 4.5 �.�� 3.9 3.9 3 189 ramp2�n6 � r�.E�� a
6.2 6.2 6.2 5.5 55 5.2 5:5.2 " ry� 4.5 0 x�93;� rmp to 6' x 20' float m L
6.2 6.2 6.2 5.2 5.2
6.2 5.2 4.5
b.2 5.2 5 5.2 move existing.,19' x 16' float
1.1 6.2 6.2 4.9 4.9 4.9 4.9 5.65.6
,.I ,.1 6.4 6.4 6.2 �6.2 4.9 4.5 4.5 4.5 4.2 3.6 3.61.6
,.2 6.4 w�,'�'2 6.2 4.2 4.2
,.2 6.4 'Y_Y7 b.2 b.2 6.2 APPROVED BY
,.2 6.4�Y ;fir
-1.2 ,.2 7.2 N ,.5 ,.5 6.4 6.2 6.2 5.9 5.9
6.4 6.2
,.4 ,A 7.2 ,.4 a 5 �5 ,.6 _.5 '15 ,.B 6.6 6.6 66 6.2 6. 6.2 6.2 BOARD OF TRUSTEES
7.6 a ,.B 6.2 5.9 5.9
7.5 T.5 -76 ,.6 ° f77 U c ,.B ,.B 7.5 ,.e 6.6 6.6 TOWN OF SOUTHOLD
� I
,., ,B Tb ,.B ,.B ,.B T ° t7 ,.e ,.e DATE /�
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Prepared by: ,.e -1 e B /Ja Ame ded
9
Go5tello Marine Gontractin Corp. 6 ,.B ,.6 8.1 red
d
P.O. Box 2124 Greenport, 9Y IIcI44 II-O -03
Ph. (631-4711-IIGcl Sheet 2 of 3
SEGT I ON APPLICANT
1000-52-5-2
Raymond B. Strong, III
2205 Boyyview Avenue
1" = 20' 5outhold, NY Ilq'71
Proposed 3' x 20'
Timber Dock 32" x 14' (4) new piles
Proposed min- 4' abv. gr. Aluminum 8" dia. at new
3' x 18' ramps 1 ramp float comers
6' x 20'
concrete -- -at - - -- ---- -----
-- ---- - --- ------ - ----
seawall --- ---- ----- --------- -- -------------------
I.M. '
Limit of Tidal Wetlands
i
Vegetation at concrete i remove bttm.
seawall as delineated ' Existing
by R. Fox on 10-I 1-03 FIOat
6„Dia.Piles 12' x 16'
10' on center All lumber - SYP
sHW HW LW 34"above deck
10'Penetration GGA pressure treated
All Hardware
hot dipped galvanized
DETAIL
1" = 4'
5/4" x 6"
decking
311 x / II
9 ( 511 x b"
stringers
fl caps
6" Dio. Piles I All lumber - SYP
10' on center GGA pre55ure treated
54" above deck All Hardware
10' Penetration hot dipped galvanized
bttm.
Prepared by: Amended
Costello Marine Contracting Gorp. Preppared
5-04
P.O. Box 2124 6reenport, RY IN44 II-03-03
Ph. 631-4 7 7-1 lgq Sheet 3 of 3
O�OSuFF�(�C Town Hall
Albert J.Krupski, President �G 53095 Main Road
James King,Vice-President c y� P.O.Box 1179
Henry Smith y 2 Southold, New York 11971
Artie Foster Oy �� Telephone(516) 765-18-92
Ken Poliwoda �f�l �a0 Fax(516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD ��`� ��-� �
office Use Only 5 kx aDrt
Coastal Erosion Permit Application j ' 01' C0--1W lK-
/Fletland Permit Application
Grandfather Permit Application
Waiver/Amendment/Changes ��m
/Deceived Applica ion: 1/1 0j
,%/Received Fee: $ 4RM E C E
pleted Application. / d.3
Incomplete
SEQRA Classification: Nov 2 5 9003
Type I Type II Unlisted �1 L!
Coordination: (date sent)
/<AC Referral Sent: / Southold Town
mate of Inspection: ^ 03 Board d Trustees
Receipt of CAC Report:
Lead Agency Determination:
Technical Review:
,P,ctblic Hearing Held:
Resolution:
Name of Applicant '_IIj lfl(hA -7) JtY�yIQ
Address v� � Au yie_N ,Ayntup IIA i�i 0 iGt Y I I"I I J
Phone Number: ( l (7) 0707 '26'ff
Suffolk County Tax Map Number: 1000 - ate ' SP
Property Location: O5 weoJ 4mul- , � � r`ty I jq7
(provide LILCO Pole #, distance to cross streets, and location) ('
• AGENT: Ao,tv'le'(If appliCab e Ap ✓
Address s�� X ��a ��PP onf C
Phone: 651
FAX# : (031-4} j
1 -
Board of Trustees Applica _ )n
GENERAL DATA Land Area (in square feet) : ��, 50 ft4
Area Zoning: 10 Glinplt - 1ilu
Previous use of property: 6!IM& ffa_A&JC-
Intended use of property: eAOA
Prior permits/approvals for- site improvements:
Agency Date
Ulu
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) :
�-� Q 3`x s o - beotywo 0 a4- AL-V/
2
B__ d of Trustees Applicatioi.
WETLAND/TRUSTEE LANDS APPLICATION DATA /
Purpose of the proposed operations: o ✓ r C/
Area of wetlands on lot: square feet
Percent coverage of lot: /d %
Closest distance between nearest existing structure and upland
edge of wetlands: 80 feet .
Closest distance between nearest proposed structure and upland
edge of wetlands: �rj feet
Does the project involve excavation or filling?
x No Yes
If yes , how much material' will be excavated? cubic yards
How much material will be filled? .` / h cubic yards
Depth of which material will be removed or deposited: Q
feet
Proposed slope throughout the area of operations : 1A,
Manner in which material will be removed or deposited: pt
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) :
�ir►e. �r000sed ey c�a. �2 PAUAIM&I %AA f-71u nrr� o��tortslv�
Kfo mor i on 4iy- weBa , will res -M My-
3
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
Raymond B. Strong, III SCTM # 1000-52-5-2
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request
a Permit from the Board of Trustees to:
➢ Construct a 31x30' fixed dock - beginning at apparent
low water (ALW) with an 18' inshore ramp and 32"x20'
aluminum ramp to reach existing float.
2. That the property which is the subject of
Environmental Review is located adjacent to your property
and is described as follows:
2205 Bayview Avenue, Southold, NY 11971
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. 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 an does not reference
any other agency that might have to review same proposal.
G
ri
OWNERS NAME: Raymond B. Strong, III
MAILING ADDRESS: 2205 Bayview Avenue
Southold, NY 11971
Enc. : Copy of sketch or plan showing proposal for your
convenience.
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Name 7001 2510 0006 4064 939e7 '' ] dress.
7001 2510 0006 4064 9380 ,
Q� ° �' m m� m
n� o cn: CO m m =�� �`m� �. o H a ■
O� d o� o�
y� rnm O . xb�. 0 3& 3z
N� 5 m m C n ro; o io m m aa.
z, ° oZ� m '�" '�'m mom., c a, A mID
N �, c� a y {T7,
r c a f1� f`�1 CD D m m m C7_
69
b7d l� ■ I� r �/
rD
p C�
3 IN
a;
STATE OF NEW YORK
COUNTY OF SUFFOLK
10 &k , residing at 10 Cheese_
$ , being duly sworn, deposes. and says
tha on the _ 0 day of AbVIMke►e- _, deponent mailed
a true copy of the Notice set fort - n 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 personss are the address
of said persons as shown on the current assessment roll of the
Town of Southold; that aid Notices re mailed at the United
States Post Office at Pbqrf , that said Notices
were mailed to each of said persons by (certified) ( registered)
mail.
Sworn to before me this c
day of NlD0em be_k jX 5 C N 3
Notary Public REBECCA A.VILARDI
NOTARY PUBLIC,STATE OF NEW YORK
QUALIFIED IN SUFFOLK COUNTY
NO:01 WO6039106
COMMISSION EXPIRES MARCH 27, 'aON
6
Board of Trustees Applica--on
County of Suffolk
State of New York
Jaw, Q� BEING DULY SWORN
DEPOSES AND AFFIRM8 THAT HE/SITE 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
TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
S ' na ure
SWORN TO BEFORE ME 'T'HIS DAY OF
Notary Public
REBECCA A.VILARDI
NOTARY PUBLIC,STATE OF NEW YORK
QUALIFIED IN SUFFOLK COUNTY
NO:01WO6039106
COMMISSION EXPIRES MARCH 27x—�2-00&
7
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 2.PROJECT NAME
Costello Marine Contracting Corp. Raymond B. Strong, III
3.PROJECT LOCATION:
Southold Suffolk
Municipality County
4.PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map
2205 Bayview Avenue, Southold, NY 11971
SCTM# 1000-52-5-2
5. IS PROPOSED ACTION: 21 New ❑Expansion ❑Modification/alteration
6.DESCRIBE PROJECT BRIEFLY:
Construct a 3'x30'fixed timber dock beginning at ALW with an 18'inshore ramp and 32"x20'aluminum ramp to reach
existing float.
7.AMOUNT OF LAND AFFECTED:
Initially - acres Ultimately - acres
8.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.)
❑� 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:
ACOE, NYSDOS, NYSDEC, Southold Town
11.DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
❑Yes a No If yes, list agency name and permit / approval:
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION?
Yes ❑✓ No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant / Sponsor a Jan o W Ash, Permit Manager @ CMCC Date: //�p/d 7j
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 EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL EAF
Yes ENo
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.
0 Yes 0No
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 for erosion,drainage or flooding problems? Explain briefly:
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:
C5. Growth, subsequent development,or related activities likely to be induced by the proposed action?Explain briefly:
C6. Long term, 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
ENVIRONMENTAL AREA CEA? If yes. explain briefly:
El Yes No
E. IS THERE,OR IS THERE LIKELY TO BE CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain
El Yes No
PART III -DETERMINATION OF SIGNIFICANCE(To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above,determine whetherit 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,the determination ofsignificance must evaluatethe potential impact ofthe proposed action on the environmental characteristics of the CEA.
Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FUL
I.
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 actin
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
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer)
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FROM COSTEU-0 MARINE CON 7. S
,4,ppLXC 'r/A(;EN'XY1 PRESENTATIVE
TRANSACTIONAL AMCLOSUn]FO
Co fEt ' a its Picts t ontown d tinwitiot tav'sat
. f Cn thold LIL
+ke of��'+',.,c►teTM�
LY-0 dam,f;sht.
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YptJitNAs1�A.13 ..,,-.-(T.estnatfiC,5rat r=cr dle initial,tsls V Y
SDSA4`Or1E else or Othtr bdty,auch 0$a company,,,w,ttsdlGale ncc,,
persasl'a or company's mar 1)
NAME OF A11eL>iC TT')X. (Chock all&1 Apply-)
Tax�avoaca -
Chang
o Of -
,4ppaov�:o`'!<I2t e9o1
Grp#oa fRemplat or offs �
Chbar
(i`•-0thee, my Officer or rarer 4 vlty)
tlr,.�bl'your sp�,pany:,bfau3e, irl �U rn arinys�e9sieseessst." uhave a siucssintmest,,Monsabosi ao
Do you persorraGy Cor u, irrehsdcs by blood,tr�ncie. by) caepot siiar+
of the,r"wn ofgaudtold vrhi h affioar or ensployee hAs oven a pares am=ship off(- nr
intilrrdigg a 1%W'O p• , oo rrr:�n MA of the Amm
is whim the u++va o#"sa.,or rm,.r,).,
YES pro
�;you a wrred —X-
-f4ccsrpietc tho balauco of thus rdtm and date and sign where Indi�eed.
'Name o f perm.,mpb*by the Town of Southold
y1tIc cs position of that parson Eitiw check
a Iieartda 94Vrepresentnve)and the town officer or WwWas.
ylcsyrltYs.:i•�•,,r,�u)�•Casrtrlp„�-Yfi@:1y�,►_9Salf{tLtOjyp r'.cc O,proMpte lint A)thtvuS4 D)andVar dciadbe in the spame+Prmnded.
'Ihe 1c,_7 ems.rer cr ear 1..byj%r:his or her BYieu9e,siblits8, t,or child is(chalk all that WPIY):
_A)the owper of Qroater thers S'Y.of the shares of tr a orp g e sto&of the Oaplicant
w(, yn the ears is a Corporotico)i
it3 or ber--se>ta'.a+un Pw;)rnfoe etc ut a a4aa��,TJerL.IC 5?�+f lvi 4� ;�3
" appliCSttt is not 4 carooL'40031?i
(�onoffices,director,pMcor,or=PloYee csf the applicant;er
�)the®dual appiieszst
DUSCpI2TION QV RELA'r►.ONSHIp
Subrttitted this O h�— 200 3
Syg�tures
• Ptintl�� � �•,.1 � r,�
L �4
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 pMose 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 sam .
YOUR NAME:
( ast name,first name,midle initial,unless you a applyin 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
Variance
Change of Zone
Approval of plat
Exemption from plat or official map
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 X
If you answered"Y4 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/agentlrepresentative)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 o2(7 a of 200� JOA4
Signature Tom'
Print N /