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HomeMy WebLinkAboutTR-6061 James F.King, President ��OF S yO Town Hall Annex Jill M. Doherty,Vice-President �� l0 54375 Main Road P.O. Box Peggy A. Dickerson Southold,New Yorkk 11971-0959 Dave Bergen G Q • �O Telephone(631) 765-1892 Bob Ghosio,'Jr. COU Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE #0508C Date: January 19, 2010 THIS CERTIFIES that the expansion of the existing dwelling by converting decks and front stoop into interior livingspace pace At 7345 Soundview Avenue, Southold,New York Suffolk County Tax Map# 59-6-5.2 Conforms to the applications for a Trustees Permit heretofore filed in this office Dated 12/29/04 pursuant to which Trustees Wetland Permit# 6061 Dated 1/19/05 was issued conforms to all of the requirements and conditions of the applicable provisions of law.The project for which this certificate is being issued is for the expansion of existing dwelling by converting decks and front stoop into interior living space The certificate is issued to Zbigniew Kozlowski owner of the aforesaid property. ;XP_" C;7. -�5r Authorized Signature %IFFDJ James F.King,President � Town Hall,53095 Main Rd. Jill M.Doherty,Vice President w- rsf. �. P.O.Box 1179 Peggy A.Dickerson *► `�`. Southold,NY 11971 Dave Bergen 'f0 ���' Telephone(631)765-1892 Bob Ghosio,Jr. 1 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE F INSPECTION: - Ch. 275. Ch. 111. INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain istday of construction constructed Project complete, compliance inspection. . 'INSPECTED BY: COMMENTS: CERTIFICATE OF COMPLIANCE:vr . \ ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION E CT 7 OF SE 209 OF THE NEW YORK STATE EDUCATION LAW. EyER °ppPF.RD EXCEPT AS PER SECTION 7209 - SUBDIVISION 2. ALL CERTIFICATIONS HERSPNs 23 5� R� SAIDEON A RE MAP OR COPIE1jDS BEARH/THEAMPRESSEO COPIES HO THEOSURVEYOR WHOSE SIGNA TORE APPEARS HEREON. f' 01F R v. 8 �s �, ADDITIONALL Y TO COMPL Y WITH SAID LAW TERM 'AL TERED BY RSRE MUST BE USED BY ANY AND ALL SURVEYORS UTILIZING A COPY N E Q OF ANOTHER SURVEYOR'S MAP. TERMS SUCH 'INSPECTED 'AND °52 5Q" E �x°2 ��E °F ��• BROUGHT - TO - DATE 'ARE NOT IN COMPLG4NCE WITH THE LAW. 9utKtEAv rot cc,-y we I/ P /oo-f L yIIRE/ \o� (roof r-anv1F ' , �oro � 0VI�r , shFo�r `ONr. SURVEY OF PROPERTY 22.31 AT SOUTHOLD czda�r� Q WOOD 2 STY. i o TOWN OF SOUTHOLD f���� o �'o DOCK FR. SUFFOLK COUNTY, N. Y. I 6 8 's.-'Nu i ;� oHS f 25 ► w 1O 1000 — 59 06 — wow5.2 RAW --00 SCALE 1" = 30' JUNE 27 2003 Deo. 9, 2003 (revisions) Z- vV \ s /a4' X LOT COVERAGE �� CY 2 WETLANDS- 8397/32373 = 26% HOUSE (existing) = 4.4% o ! alter construction 7% I` o NO D JAN 3 2005 " s- �i Southold Town Board of Trustees 1-9 PZE OF NFyy C'j ` A `e�� Jam• / / � T.Me AREA = 32,373 sq.fl.+ 5O FLOOD ZONES FROM FIRM E s ORS . Map # 36103COI54 G (63/) -°-5¢ 3(J 765 - /797 May 41, 1998 P. 0. D RS RES CONTOUR LINES ARE REFERENCED TO N.G.V.D. 1230 TSOUTHOLD, 1197/ 03 - 15s S'-0 33 co O " �NY ALTERATION OR ADDITION TO TNS SURVEY IS A VIOLATION d C7 OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. EXCEPT AS PER SECTION 7209-SUBDIVISION 2.ALL CERTIFICATIONS HEREON ARE VALID FOR TNS MAP AND COPIES THEREOF ONLY IF SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR N,E°,d�peD� 2g 5) nn nn nn N o WHOSE SIGNATURE APPEARS HEREON. SP1.1 ,RV• ADDITIONALLY TO COMPLY WITH SAID LAW TERM'ALTERED BY C-D n o MUST Be USED BY ANY AND ALL SURVEYORS UTILIZING A- COPY coOF ANOTHER SURVEYORS MAP. TERMS SUCH'NSPECTED AND N�OIF f �fJyGaE Foy BROUGHT- TO-DATE'ARE NOT IN COMPLIANCE WITH THE LAW. 52.501 x pD BULOEAD CJ�• f C4 \0 11 101 \ �aS ,OF SURVEY OF PROPERTY\ 11 , coma yj 01 i�a o er \ I shower �y �� ��F AT SOUTHOLD 1. ZZ' h TOWN OF SOUTHOLD I a.dLif - R !� � I 8�« ,, i c"� �o SUFFOLK COUNTY, N. Y. r cons/ FILTr ° o I -9 1000 - 59 - 06 - �.2 f ' I �' SCALE 1" = 30' VOW OIX r D t I acy ;Qa JUNE 27, 2003 \ a Z` ' F DeC. 9, 2003 (revisions) f EM 6 \ n o u °o it A 4 �( ! July 21, 2004 (tLXonds l)agsJ Nk 1 o 1 Aug. 25, 2004 (LIMITS OF CLEARING) 0VV \ a / Z O a p, �� ./ -/neofh%\be.le5 I> LOT COVERAGE r�/m 2 WETLANDS 8397 132373 = 26% 5.Kl HOUSE (existing) = 4.4% after construction 7% 3 doyF� i6 fr,� �cY /CSni sF�s3o. I h ph _tt�G� OF aEIV ro �O lk- cr -999 �� ` Q S+ccjc� •'9�'• �I °c �Ab.aso a T Al o o� `t�Q f„lamlC!N 96l B FLOOD ZONES FROM FIRM 'ffECONIC s YORS, P.C. REA = 32,373 Sq.fl.-* 50 Map # 36103CO154 G (63I) 765 - -_ FAX (630 765 - 1797 May 4, 1998 P. 0. BOX 909 1230 TRAVELER STREET = WETLANDS FLAG SOUTHOLD, N.Y. . 11971 7NTOUR LINES AR9 REFERENCED TO N.G.V.D. Albert J. Krupski,Pre at s Town Hall James King,Vice-President �OS�FFO(/�'C 53095 Route 25 Artie Foster �O oG P.O.Box 1179 Ken Poliwoda O 1J� Southold,New York 11971-0959 Peggy A. Dickerson y Z Telephone(631) 765-1892 O Fax(631) 765-1366 y !. O BOARD OF TO"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 1 sr day of construction % constructed ✓Project complete, compliance inspection. •,{tom — �.�'_—' _—.<. '_ — r - ' � � I Board . Of Southold Town Trustees x SOUTHOLD, NEW YORK �_• PERMIT N DATE: ..Jan....19,,-,,.2005 1, x ISSUED TO ...ZBIgIEW KOZL.OWSKI............................................................................. « 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 �.s State of New York 1952; and the Southold Town Ordinance en- titled ."REGULATING AND TIDE•PLACING.OF.-.0.8STRUCTIONS •' IN AND ON TOWN WATERS AND. PUBLIC LANDS and*-the REMOVAL OF SAND, GRAVEL OTHER MATERIALS.-,f1OM s LANDS _UNDER TOWN WATERS;". and in. accordance wifh'the Resolution of The Board adopted at a meeting held on _..Jan,.J2,__. 2005.:, and in consideration of the sum of $ ..._... paid by ' Zbigniew Kozlowski ........................ .. of Southold subject..................................................... N. Y. and, subject to.-the Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: y. Wetland .Permit to expand the existing single-family dwelling i by converting decks and the front stoop into interior living space, and all as depicted on the survey prepared-'.by John T. Metzger last dated August 25, 2004. all,is accordance with the detailed specifications as presented in t the originating application. \ .y IN WITNESS WHEREOF, The said Board of Trustees lwre- by causes its Corporate Seal to be affixed, and these presents to be subscribed by a malonty of the said Board .as of this datie. C Artie r TERMS and CONDITIONS M Permittee Zbigniew Kozlowski t�Csldithg at 7345 Souridview Ave. . 5011thol d . , _ N. Y., as ,put• of the consideration for. the issuance of the, Permit does understand and prescribe to the fo1= tawit�r - i. That the said Board of Trustees and the Town of Southold are released from any and all damages, `or dabs for damages, of salts arising:dita*or b&tcctly as It CWU of any open- adoe[{ om�ed .pur:oaat tt:: p t� .! ._the acid prrm ox.: .u..l S or hoer own esp�e, defend.any and all such sulteinid by ated third patties, and the said l�dtme "Sum" full liability with respect thereto, to-theete"exclusion of the Board of Trustees of the Town of Soud4d. 2. That this lPet6* h valid for i &-tiod of 24-.-- mos.. whtdi•is ftddered to be the estimated time'required to complete the vvork invoived,but should dreuth antes warrant, request for an ezteagon .may be made to the Board at it later dote: - 3. That this Permit should be retained indefinitely, or as long as the said Permittee wishes to maintain the strucque or project involved, to provide evidence to anyone concerned that autlr odation was originally obtained. . 4. That the work involved will be subject to the inspection and approval of the Board or -. Its agents, and non-oonrplianae with the prov has of the originating application, maybe cause for revocation of this Permit by resolution of the said Board. 5. That there will be no unteasooable interference with navigation as a result of the mode herein atkbotbe& 6. That there shall be no interference with the right of the public to pass and repass along the beach between high-and low water rnadrs. 7. That if future operations of the Town of Southold require the.trmoval and/or altesatioat in the location of the vaodc fherela =d wbmd, or lf, in the opinion of-die.Board of Trustees,the. work-shall cause unreasonable obstruction to free navigation, the said Peadme will be required, upon-due notice to temove or alW this work or project herein stated without e:peases to the Town ` of Southold 8. That the said Board will be notified by the Permittee of the eoc*edon.of the work suatbr oozed. 9. That the'Pexmittee wlll nbouin all other permits and coameats dut tray be required sadr plementai to this permit which may-be subject to revoke upon failure to obtain same. . L c Albert J.Krupski,President Q�. QG Town Hall James King,Vice-President j� y� 53095 Route 25 Artie Foster y - P.O.Box 1179 Ken Poliwoda Southold,New York 11971-0959 Peggy A. Dickerson 'yifJo aQ� Telephone(631) 765-1892 1 `1► Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD January 19, 2005 Mr. Zbigniew Kozlowski 7345 Soundview Ave. Southold, NY 11971 RE: 7345 SOUNDVIEW AVE., SOUTHOLD SCTM#59-6-5.2 Dear Mr. Kozlowski: The Board of Town Trustees took the following action during its regular meeting held on Wed., January 19, 2005 regarding the above matter: WHEREAS, ZBIGNIEW KOZLOWSKI 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 December 29, 2004 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 January 19, 2005, 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 standards set forth in Chapter 97 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 approve the application of ZBIGNIEW KOZLOWSKI to expand the existing single-family dwelling by converting decks and the front stoop into interior living space, and all as depicted on the survey prepared by John T. Metzger last dated August 25, 2004. 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$50.00 per inspection. (See attached schedule.) Fees: $50.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/Ims Albert J. Krupski,President ���S COG Town Hall . James King, Vice-President = �f. 53095 Route 25 Artie Foster p P.O.Box 1179 Ken Poliwoda Southold, New York 11971-0959 Peggy A. Dickerson � Telephone(631) 765-1892 Fax(631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: r)0-z(C3wm (IJ Please be advised that your application dated )aliq�ell has been reviewed by this Board at the regular meeting of_I I� 0 and the following action was taken: (_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: TOTAL FEES DUE: SIGNED: ' PRESIDENT, BOARD OF TRUSTEES 11/15/04 Field Inspection WO .e , 4 , .<x S y: o�oS�FFO(,�cOG �� yam► Telephone p Town Hall (631)765-1892 w 53095 Route 25 Q .�C P.O.Box 1179 Southold,New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD TO: Southold Town Board of Trustees FROM: Southold Town Conservation Advisory Council DATE: January 11, 2005 RE: Recommendations A meeting of the Southold Town Conservation Advisory Council was held Tues., January 11, 2005. The following recommendations were made: DISCUSSION AND RECOMMENDATION OF WETLAND PERMIT & COASTAL EROSION PERMIT APPLICATIONS Moved by William Cook, seconded by Don Wilder, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the Wetland Permit application of ZBIGNIEW KOZLOWSKI to expand the existing single- family dwelling by converting decks and the front stoop into interior living space. Located: 7345 Soundview Ave., Southold. SCTM#59-6-5.2 Vote of Council: Ayes: All Motion Carried NEW YORI \TE DEPARTMENT OF ENVIRONMENTAL CC RVATION DEC PERMIT NUMBER EFFECTIVE DATE 1-4738-03360/00001 16 November 2004 FACILITY/PROGRAM NUMBER(S) PERMIT EXPIRATION DATE(S) Under the Environmental 30 November 2009 Conservation Law TYPE OF PERMIT ■ New ❑ Renewal ❑ Modification ❑Permit to Construct ❑ Permit to Operate ❑ Article 15,Title 5: Protection of ❑ 6NYCRR 608:Water Quality ❑ Article 27,Title 7; 6NYCRR 360: Waters Certification Solid Waste Management ❑ Article 15,Title 15:Water Supply ❑ Article 17,Titles 7,8: SPDES ❑ Article 27,Title 9; 6NYCRR 373: Hazardous Waste Management ❑ Article 15,Title 15:Water Transport ❑ Article 19:Air Pollution Control ❑ Article 34: Coastal Erosion ❑ Article 15,Title 15: Long Island Wells ❑ Article 23,Title 27: Mined Land Management Reclamation ❑ Article 15,Title 27:Wild, Scenic and ❑ Article 36: Floodplain Management Recrea tional Rivers ■ Article 24: Freshwater Wetlands ❑ Articles 1, 3, 17, 19,27, 37; ❑ Article 25:Tidal Wetlands 6NYCRR 380: Radiation Control PERMIT ISSUED TO TELEPHONE NUMBER Zbigniew Kozlowski 631-765-5040 ADDRESS OF PERMITTEE 7345 Soundview Avenue,Southold, NY 11971 CONTACT PERSON FOR PERMITTED WORK TELEPHONE NUMBER iZbi niew Kozlowski %.NAME AND ADDRESS OF PROJECT/FACILITY Kozlowski Property,7345 Soundview Avenue,Southold LOCATION OF PROJECT/FACILITY S CTM: 1000-059-06-5.2 COUNTY TOWN WATERCOURSE NYTM COORDINATES Suffolk Southold Great Pond E:713.9 N:4549.0 DESCRIPTION OF AUTHORIZED ACTIVITY: Expand the existing single family dwelling by converting decks and the front stoop into interior living space. Install an additional drywell to capture roof runoff. All work is to be done in accordance with the attached plans stamped NYSDEC approved. i" By acceptance of this permit,the permittee agrees that the permit is contingent upon strict compliance with the ECL,all applicable ijegulations,the General Conditions specified(see page 2&3)and any Special Conditions included as part of this permit. PERMIT ADMINISTRATOR: ADDRESS George W. Hammarth, Region 1 Headquarters Deputy Permit Adminstrator Bldg.#40,SUNY, Stony Brook, NY 11790 2356 AUTHORIZED SIGNATURE DATE Page 1 of 4 ..... : _ os-z-°i \O �� '• ) 'B v - '+ �;c '+� 4ap, 9. °:~s.•iP w b' a� -f �'. .. 12-06-01 �\\_ � '4: fit','•' i+`O �` 'L � Q�p ,Y O.s �-�d-u O s `, a� m n -@ - ^e't?i:?' ,';vS'O,°`�' ^J .ti•3 �J m ��`c` rn �� iJr ri•T Ja a M1 + "° ,I?.•. ♦ zas z��• Jy ®e 1 e° , � f� . 2 `Ja •• a {'b + t `�a z„` a ~ O Y v�~o a J m� `� JLJ G ��� ,•B� � a a a J) Jr 9 e�//n+ h. ♦'^ry F, a 26.1 17.6A MA ` m hip .e 2{) s y ]0211tl 22(J � y •+ t Yak h R. 1S1 r TORN OF SOUT1Cl0 3• s 5 GREAT PoNO 1. hh � �A� `' FM Pa M m Cr, O r1EElBNS lMEI ��9' 4-16 SEE SECM f '•� ��' ,+ J °m, —Awm •r 9C � s JJ 'as r ,� e s J J . 1 ry M 1°TY a M1h J 2.1 4i ulie Ile 261A m a ,s 42AIc) ti ,�� Loslm .a h+0 fJ •ed q la lht B N ]0b s ,M1B SS i c C""w SWFO 12.9µm 1.011d Ms + s A T.641m S.� 28-2 7 �mv[,cnEM xrcaiv � "+ti h' 1e511c1 26.1 �� � z •._+ a ] s 9 s 6e 6 '° SEE 9SM IYI. BSAIm 1 + w- J 069-01-009.1 + 12.011c1 m s O• x .`n Weu TCN SEE SEC.W.0� YATQ �— m—A, �• p //�\ SEE SEG No.00 LYVE a9-^to31 0 sr>� —zz— s.a,w„Aeuo-,.e (21) e — —_ m.n�m„.,� w.69 E Aw,m w ----- o-,e owmm e O o. --°-- n+u.mm.+u. •o-E .-r. Tjn--Lou msrruis NOTICE N �. �Xlw >< .n,°. —_•—_ w.n — —_ —�r _ . ® . COUNTY OF SUFFOLK © K t91N6 D °�� 2] me�m 1zl Alm or u.0 ..emu. —_ °nt Pn"r u. —_.__ —_ —_ x.ww,� IIAnr6euxrE,Auwrio,,suE m, SOUTHOLD SECTION NO XA, oa,Feu m „PORTm Real Property Tax Service Agency Y "° -- ,^^=o-n.t,w.—..__ , rAna6 suroX couxrr TAX uer¢rnoesnFo P• Cvl ty Center &eXjma4 N Y 11301 n1ArE s 059 -_ -_ 161XTFp Tnxyr TIUrTFn PFIe1165gN Oi i14 ti SrJIF m REI• M laAl rx°vEan T.z sE2xxE Ac[I,cr. ap ao' A p "., a mTlxT x9 1000 PROPERTY MAP 1-11T v DAM Au..24 uac _ T Q�OSCO _ Albert J.Krupski,President ION/( Town Hall53095 Route 25 James King,Vice-President G P.O.Box 1179 Henry Smith o� y� Southold,New York 11971-0959 Artie Foster ti Z Ken Poliwoda ip • !`� Telephone(631) 765-1892 �01 �aQ Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application -Wetland Permit Application / Major Minor _Waiver/Amendment/Changes _R6-ceived Applicatio ' 410 deceived Fee:$ 1 I !-completed Application a — _Incomplete ® ECEQ 'WE _SEQRA Classification: Type I Type I1 Unlisted D EC 2 g 2004 Coordination:(date sent) ,RAC Referral Sent: O C 0 .R~ate of Inspection: f /7 Southold Town _Receipt of CAC Report: Board of Trustees _Lead Agency Determination: Technical Review: _-;'_IP ublic Hearing Held. Resolution: Name of Applicant �3 6-N I KO z L J W 5 K I Address r7?4 rJ uN D VIuk) A -VE. �0UTHOL) j j g 7( Phone Number:( Suffolk County Tax Map Number: 1000 - 40 5g 0 0 0 6- U� T ODD �O.� ` O Property Location: OUN)WIG-W AVE, (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: I Board of Trustees Application GENERAL DATA Land Area(in square feet): 33 _r)-19 ICJ 4 I Area Zoning: ,'DES i e +1_ IO- Previous use of property: ae s i c/ell c er Intended use of property: 1 - (A rn el Prior permits/approvals for site improvements: Agency Date J S D cc, Fvy I s-.i`13-c n 7 4 G -�. 3 - 1� 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: N I ✓� Project Description(use attachments if necessary): -�Or k1le6a e )c :ens ►�� Paoe F o r- 'CXisri- nq 64eLk Frv,,f 00arck ex fen s ;ttJ, Cre rw 0 Jo_( or geclr OJeC A iA O _jard of Trustees Applicat��.. WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: L`nta r� r k i' fe ke n. A n 0 ECCAT P6 rc h n clef rV P i- TE i Yriti Rear d c,1c . Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: .2 S + feet Closest distance between nearest proposed structure and upland edge of wetlands: ,-3-+ feet Does the project 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 e Proposed slope throughout the area of operations:© 10 o 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): Albert J. Krupski, President O�0$UFFO(�CD Town Hall James King,Vice-President 53095 Route 25 Artie Foster p P.O.Box 1179 Ken Poliwoda Southold, New York 11971-0959 Peggy A. Dickerson � � Telephone(631) 765-1892 ,( Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD DEC E � V --------------------------------------------------------------- In the Matter of the Application JAN 2005 of --1`1�21- -- �� __zbr _ _ `-"� ________________ Southold Town COUNTY OF SUFFOLK) Board of Trustees STATE OF NEW YORK) AFFIDAVIT OF POSTING residing at �23 being duly sworn, depose and say: That on the G/ day of (32 , 2005-1-1 personally posted the property known as by placing the Board of Trustees official poster where 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 k LW - 10 Dated: (si ature) Sworn to before me this 3'j day of 3;N-Ay200 S tart'Public John M.Judge NOTARY PUBLIC,State of New York No.01JU6059400 Qualified In Suffolk County Commission Expires May 29,20 OD. NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES , TOWN OF SOUTHOLD In the matter of applicant: 2h� _ iti«w I�OZ ���Sk�• SCTM#1000- �_9-4 YOU ARE HEREBY GIVEN NOTICE : 1 . That it is the intention of the undersigned to request a Permit from the Board of Trustees to: 2 . That the property which is the subject of Environmental Review--is located adjacent to your property and is described as follows : �}I-f�b�v��-f���1�S O v�� 1J�.��.t Jv�g 40 ho -e- or Over IV- 0 rc L 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 • 2j[4iiae-W KOZ-to 9 kk MAILING ADDRESS 73GS S0uojV���U .. My It 9f PHONE #: C�-t - l Enc. : Copy of sketch or plan showing proposal for your convenience. S • l board of Trustees Application County of Suffolk State of New York � 1 Ct' BEING DULY SWORN DEPOSEOND 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 HISMR 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. Signature SWORN TO BEFORE ME THIS 2 q 4 DAY OF r-->e-c 6 e fL ,20 04 otary Public John M.Judge NOTARY PUBLIC State of New York No.OtJU605940b Qualified In Suffolk County Commission Expires May 29,20 0 1A-16.4(2187)—Text 12 PROJECT I.D.NUMBER 617.21 SEO 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 Z,bi n ew kozl,owsk,� i ddtlilon -o 4he 400EC, 3. PROJE OCATiON: . t]3 G S 50V ndVL 2W AVe SOc�.r-�L►�O�� I N Y It I Municipality County S 4. PRECISE LOCATION(Street address and road intersections, prominent landmarks, etc.,or provide map) . l - 5. IS PROPOSED ACTION: / ❑New �Expansion L^'Modification/alteration G. DESCRI13E PFJOJECT BRIEFLY: F, or kt-f-c titer 2-11�17 fto r ) r041 over e kTS4 k1 �eckl rcGL. 4CA Still - 7. AMOUNT OF LAND AFFECTED: See sutV Initially acres Ultimately acres 8. WILL "ROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? s Q No If No,describe briefly 9. WHAT IS PRESENT LAt D USE IN VICINITY OF PROJECT? _ $—Residential r,!ndustrial r Commercial ❑agriculture ParklForestlOoen soace '_ Other Desc:ibekl::�r`✓�� h�VS-� - 10. DOES ACTION INVOLVE A PERMIT APPROVAL OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL, STATE OR LOCAL)? --; I ' Jam, � & "Yes G No If yes,list agency nd permitlapprovals UmcLer � Lnvt roofeklia(, Wn�'✓— va�°a.�, La.� C -I--'l tits.-!- 1- �t 73-F GO y GL-{dZGI�R 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? S1J'/�Ci @Yes' ❑No If yes,list agency name and permitlapproval See, 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? ❑Yes 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicantisponsor name: Date: Signature: If the action-is in the Coastal Area, and ;you are a state acency, complete the iCoastal Assessmen•. Form before,proceeding with this assessment OVER y 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 emDployces.The purpose 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 same. I. ' YOUR NAME: Ke./ Z L'�J/�VV S K I Z-51 6 N'C w (Last name,first name,middle initial,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.) 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 ✓ If you answered"YES",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/agent/representative)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 NI/4�-- Submitted this AOM day of 200� Signature �-�- Print Name PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS A Name. Z J l ha'"W 11�o90,03I&L' Address: t> (,t,(j, f!t eW AtIc Souu4k,o d py l L qr7( STATE OF NEW YORK COUNTY OF SUFFOLK i � ou,�3 L( ,residing at let., N'l 1 G L7 7/ ,being duly sworn, deposes and says that on the f 2 day of �?3 ,20D�f, 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 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 � Day of 20 of Not Public John M.Judge NOTARY PUBLIC,State.of New York No. otJU6059400 Qualified In suffolk Count commission Expires May 9,20-