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HomeMy WebLinkAboutTR-5914 Michael J.Domino,President OQF S0(��yOl Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 O P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams a0 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD June 19, 2019 Eileen Wingate 2805 West Mill Road Mattituck, NY 11952 RE: JOHN DiBARI 2000 GLENN ROAD, SOUTHOLD SCTM# 1000-78-2-37 Dear Ms. Wingate: The following action was taken at the Southold Town Board of Trustees regular meeting held on Wednesday, June 19, 2019: RESOLVED, that the Southold Town Board of Trustees APPROVE the request-for a Transfer of Wetland Permit#5914 from Edward L. Kavanagh, as issued on May 26, 2004 and Amended on January 19, 2005; and BE IT FURTHER RESOLVED, that the Southold Town Board of Trustees APPROVE the Administrative Amendment to Wetland #5914 to reconfigure existing deck by removing the 9'x5' first step; raising 105sq.ft. deck; installation of four (4) new treads at each end of deck, for a total of 30 sq. ft.; and as indicated on the site plan prepared by Condon Engineering, P.C., received on June 13, 2019 and stamped approved on June 19, 2019. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. If you have any questions, please contact our office at (631) 765-1892. Sincerely, Michael J. Domino, President Board of Trustees MJD/dd $ � OF©(,���,� I` �, Michael J. Domino, Presider OosSC0�$� Town Hall Annex John M. Bredemeyer III,Vice-Presluent ��, - 54375 Route 25 Glenn Goldsmith y z:. P.O.Box 1179 ze A.Nicholas Krupski 0 ;>. . Southold,NY 11971 Greg Williams '�� ® p! ( Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in field by: 14 Eileen Wingate on behalf of JOHN DiBARI requests an Administrative Permit to reconfigure existing deck by removing the 9'x5' first step; raising 105sq.ft. deck; installation of four (4) new treads at each end of deck, for a total of 30 sq. ft. Located: 2000 Glenn Road, Southold. SCTM#: 1000-78-2-37 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool); 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: �- If I have read & acknowl d� ged the foregoing Tr stees comments: �/ �. Agent/Owner: Present were: J. Bredemeyer t'___/M. Domino G. Goldsmith N. Krupski G. Williams Other ! L� 1 3 2019 BUILDER'S JOB NO. TITLE NO. REV. DAt TOTAL PLOT AREA: 24,353 t 1.S.F. 1. 2/13 Boy«Sof it a°'�°$ �.-•. z. s/zD � �ti9y I • ,,yQ' t�40'�N� Cog e1 ppt\ 6° QQ, R010 .f 1QQ' 1 yy 1 �?b �QQ wki !A,{ ;1 1 0 1 0.6� 197051 � '00° • 1 Ian � I N �{J 1 2G j 17d < � � I 0 N CP* 1 1 O � I N 1\\\ DFbVE 20' GARA(£ 1 Ld01 7 x 47' 41' 1 TT`` 8 t J Q 31' \ b � I X19 m CP _i 26' ��\ wv a z; Z \4 1-24'_w 18.5\\1 0 21.5 Q \\ii ��s \ 2 STORY FRAYS 13.4' REDDOILE _ F FLELV 16 01 o, GFLELY.14.17 57.9' lDT 21 t' " \17.0' 22.9' .. •OE4: DE CDYDEOI FtDCES SSTEPS T'EP'S I ' -- - - - - -- - _ ----_"`-` - ---IDT ZO - -- - - --- - - IDT 19 W O 4 O M N O to 0 0 O OF iOIL'E rtGt N. SUFFOLK � 99 MONUMENT — r.�ll\_.I. ,,,Y,��YR • PIPE 5,v,5' CREEK Date JUL 2 6 2006 The semage d!?p0 -I nd V."I'CT Inspe"�t�:d and/or carVuO!*,%,i':. i:8;.'`T, ' THE EXISTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD, 7F ANY, N07 SHOWN ARE NOT GUARANTEED. be satisfactory 1700.1"k THIS SURVEY WAS PREPARED IN ACCORDANCE WITH THE EXISTING CGDE OF PRACTICE FOR LAND SURVEYORS ADOPTED BY THE NEW YOR STATE ASSOCIATION OF PROFESSIONAL LAND SURVEYORS. ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES THtS SURVEY �' ''1• � h •'%T MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. ND iiCIAL OF (�I'Ii-i(�; ,. ':t'• THIS STATE, OR OF ANY CITY,COUNTY, TOWN OR VILLAGE THEREIN, CHARGED WITH THE ENFORCEMENT OF LAWS, ORDINANCES OR REGULIITIONS SHALL ACCEPT OR APPROVE ANY PLANS OR SPECIFICATIONS THAT ARE NOT STAMPED, CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO FRE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE TITL£ COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION AND TO THE ASSIGNEES OF THE LENDING INSTITUTION. CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS DR SUBSERUENT OWNERS. SUFFOLK COUNTY TAX MAP DIST: 1000 SECT: 078 SLK: 02 LOT: 37 BURTON MAP NO: 3848 AUGUST 19, 1963 LOT 20 BEHRENDT MAP OF WEST CREEK ESTATES SMITH PC LOCATION: SOUTHOLD ENGINEERS TOWN OF SOUTHOLD. SUFFOLK COUNTY, NEW YORK ARCHITECTS SURVEYORS 1 SURVEYED: JANUARY 18, 2006 f 244 EAST MAIN ST. CERTIFIED TO: MANZI HOMES PATCHOGUE, N.Y. 11772 (631) 475-0349 SCALE: 1 "=30' FILE NO: 05- 150 FAX 475-0361 EXISTING HOUSE - ---- ---- ---- ---- ❑ ❑ I I I I EXISTING DECK i EXISTING COVERED PORCH I I I I I ❑ ================= ❑ ========______=== ❑ 1 1 I I I I i I f 1 1 1 3 1 I 1 1 1 I 1 I I i i 1 i I I 1 1 i 1 1 I I 1 I I I 1 1 I 1 1 i I I 1 1 I I I I 1 1 i I 1 1 1 I 1 1 1 1 t I i i I I 1 1 1 1 1 I 1 1 1 1 1 1 I 1 3.. Lit i i I RUP REMOVE EXISTING STAIRS " i 1 I i I i I i I i i I I i I 1 1------------------------_ - - "'�S -m-=--==a-----;:-: -1=�------------------- 12'-8" 26'-1" EXISTING DECK PLAN EXISTING HOUSE JUN 1 3 2019 ,_.r APf BOARr TOWN STEES �'�� � DATE �-IrHOI.D ---- ----- ---- - piI I _ I EXISTING DECK EXISTING COVERED PORCH I I MATCH EXT'G HEIGHT I ❑ ❑ ❑ EXTENDED DECK EXISTING STAIRS: 8 RISERS AT 72'HIGH R U W/ NEW STAIRS R 7 TREADS AT 112'DEEP • . PROPOSED STAIRS: RAIL PER CODE 9 RISERS AT 72HIGH 8 TREADS AT 112 DEEP -T-B" - - 20'-9" X16 4� SCALE: PROPOSED DECK PLAN Condon Engineering, P.C. ill = 1 1.011 1755 Sigsbee Road DWG. No. DEBARI RESIDENCE Mattituck, NY 11952 2000 GLENN ROAD SOUTHOLD, NY 11971 300.01 EXISTING FOUNDATION AREA a � d da d EXT'G DECK PROP. DECK (2)2"x 8"DECK GIRDER BOLTED WITH 2'LAG BOLTS EXISTING DECK STAGGERED 16"O.C. 4" d JOIST HANGER ���—DECK SKIRT - __ _____________________=====n "x6"C.C.A.POST EXT'G(2)2"x 8"GIRDER i. = 00 I I h 011 E - I I I OST ANCHOR XIII 00 (p III x —� x «v�l r I _ i� c14 F" I NEW(2)2"x 8"GIRDER I L———J L——— 12"SONOTUBE N 24"x 24"x 12" ------ --- --9'-4' P.C.FOOTING 12"SONOTUBE N 24"x 24"x 12" P.C. FOOTING(TYP.) FOUNDATION PLAN SECTION PLAN I i E E r__� ,----i REMOVE EXISTING DECK t-.--1 E E E i E 1 XISTING DECK .iv, x �. :.' PROPOSED.40 DECK JUN 1 3 2019 Soll.li",iL ic'vgi ELEVATION ` SCALE: Condon Engineering, P.C. ill = 11-091 4 DEBARI RESIDENCE 1755 Sigsbee Road DWG. No. Mattituck, NY 11952 2000 GLENN ROAD SOUTHOLD, NY 11971 300.02 Michael J. Domino, President o�oSUFFO(�coGy Town Hall Annex John M. Bredemeyer, III, Vice-President o 54375 Route 25 Glenn Goldsmith N ,x P.O. Box 1179 A Nicholas Krupski y o� Southold, NY 11971 Greg Williams dol , �a Telephone (631) 765-1892 Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIREMENTS SCTM#: Property Owner Name: D c PEAR.I py 15 2Q1� s T. Date Sent to Bldg. Dept: �5Y a � The Office of the Board of Trustees is forwarding the above referenced application for verification of the Building Department's permitting requirements stated below: YES NO Will the proposed project require a Building Permit? Will the proposed project require a variance determination from the Zoning Board of Appeals? Will any part of this application be considered a Demolition as described under Town Code? COMMENTS: Iq AignaWture o Reviewer Date ®F �00- Town Hall Annex Michael J.Domino,President John M.Bredeme er III Vice-President °`� r4 54375 Route 25 Y �� FhY�"�`� �'� P.O.Box 1179 Glenn Goldsmith `. 'r, - Southold,New York 11971 A.Nicholas Krupski ? _ t�'i Telephone(631) 765-1892 Greg WilliamseC ,y•�( Fax(631) 765-6641 ou BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit ;',; 1 Amendment/Transfer/ExtensionMY 019 - Received Application: Received Fee: $ 1OD.DD _ Completed Application: Incomplete: (If"k SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: �Coordination:(date sent): 6.71R LWRP Consistency Assessment Form Sent: CAC Referral Sent: Date of Inspection: !0.12.1 Receipt of CAC Report: :t: Technical Review: Public Hearing Held Resolution: Owner(s) Legal Name of Property (as shown on Deed): Mailing Address: 'Q V� �`��� A Phone Number: "Jl 904Q�- Suffolk County Tax Map Number: 1000 - 1'�_ — 2 Property Location: 9mo (If necessary, provide LILCO Pole#, distance to cross streets,and location) AGENT(If applicable): akl_ Ir Mailing Address: w12A W R Phone Number: �� Q1 P I ` Michael J. Domino,President �*0f S0UTjyO Town Hall Annex John M.Bredemeyer III,Vice-President �O l0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold, New York 11971 A.Nicholas Krupski G • Q Telephone (631) 765-1892 Greg WilliamsycOU 'O Fax(631) 765-6641 � NTY,�� E ^ LEI VE BOARD OF TOWN TRUSTEES MAY 13 TOWN OF SOUTHOLD 2Q�9 Sotltticrd Town Board of Trustees APPLICATION FOR A TRANSFER OF A WETLAND PERMIT DATE I II "l OWNER - PHONE 9 I 1 _6,9 3 MAILING ADDRESS SDI "Sa&UD AGENT WMArk PHONE "5I(0 , st sj ADDRESS PROPERTY LOCATIONle►� Cl��i V"`G : AA- V y. TAX MAP NO. ODD UWe '( 6 request a Transfer of Permit# from fl U Signed B Board of Trustees- Application —� GENERAL DATA Land Area(in square feet): _ (�► i Area Zoning: Previous use of property: Sin &Ale Y) Intended use of property: Covenants and Restrictions on property? Yes No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes eK No If"Yes", please provide copy of decision. Will this project requi e y demolition as per Town Code or as determined by the Building Dept.? Yes o Does the structure (s) on property have a valid Certificate of Occupancy? 1S Yes No Prior permits/approvals for site improvements: Agency Date F)Q&D 0V (M &� I I \ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?\K' No Yes If yes, provide explanation: Project Description (use attachments if necessary): , ��V_S-n �A Ln t)PICK � ISTT�Ap_s TO B05R C�P-(D\DLaj � ' ° u k 0 _ t ` 1�t SSU� ��� � � J��'i 1�I i� � �I[�L.a�1 �V 1-�� 's �����•�. Board of Trustees Appli�a,.ion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: the E)WM 61 L.�DECK RN5- I —SIEP DCUM W MA N-W-1q,0A-BD LD j t0 to - BF-C 4 I(Aa ILAI 101t� SIS FEATURE , BUT REQUIRE -WE fWAIDU OF SE6Mb- 1 ) t- r-T I epy-116 DI -Ec-nnu -- -f- W S W Area of wetlands on lot: x(04 square feet Percent coverage of lot: ( % j nC, odd or Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No .>< Yes (1(l,5 If yes, how much material will be excavated? cubic yards J How much material will be filled? cubic yards I u �Depth of which material will be removed or deposited: �j feet y-[() o�'If1 J 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): A ����s 61 Z20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information R Name of Action or Project: \ QOM G l ►n Project Location(describe,and attach a location map): Brief Description of Proposed Action: RewC)�1 ll�e ��lS�i 61� G��2C -� (�IY1 cJL� �S v) Mine.. yy4ecs4fp� Oec+' tor� of CGLI� kx'l neq u�'C-,e 4kr�� A 3 +ceedt:> i n eoL, Name of Applicant t oQr SSponsor. �p Telephone: b t q-75(( �kll �i� \ wt at _ E-Mail:_ -�t`��(� Address: a� i � Q. C City/PO: s State: Zip Code: 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that 0 may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or finding from any other governmental Agency? NO YES If Yes, list agency(s)name and permit or approval: ❑ lc n peen`� 3.a.Total acreage of the site oWe proposed action? _j _acres b Total acreage to be physically disturbed? acres SQ, JFI , c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? y acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural (non-agriculture) [:]Industrial ❑Commercial t55Residential(suburban) ❑Forest ❑Agriculture El Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ 7?!�r ❑ b.Consistent with the adopted comprehensive plan? ❑ ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ 7. Is the site of the proposed action loclted in,or does it adjoin,a state li ted Critical Environ rental Area? NO YES If Yes,identify: Q �' Wt�_!—'0{��. W estc(-eeK ❑ ❑ 8. -a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ® ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: ❑ 2 10. Will the proposed action connect to an existing public/private water supply? C� NO YES If No,describe method for providing potable water: � � j R ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ❑ b. Is the proposed action located in an archeological sensitive area? ❑ ❑ 13.a.,Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional ❑ Wetland ❑Urban 19suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats, listed NO YES by the State or Federal government as threatened or endangered? ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, ❑ Ela.Will storm water discharges flow to adjacent properties? \17, NO ❑YES b.Will storm,water discharges be directed to established conveyance system (run f and storm drains)? If Yes,briefly describe: JSLNO '❑YES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: _ _ _� ❑ 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: _� ❑ AFFIRM THAT THE INFOR ION PRO IDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor e: _ / U _ Date: Signature: Part 2-1pact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning El Elregulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑' 3. Will the proposed action impair the character or quality of the existing community? ❑ LJ- 4. 4. Will the proposed action have an impact on the environmental characteristics that caused the El establishment of Ciitical Environmental Area(CEA)? S. Will the proposed action result in an adverse change in the existing level of traffic or El F1affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ ❑ a. public/private water supplies? b.public/private wastewater treatment utilities? ❑ ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural iesouices(e.g.,wetlands, 1:1 Elwaterbodies,groundwater,air quality, flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage a ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? E Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the 'proposed action may result in one or more,potentially large or significant adverse'impacts and an environmental impact statement is required. ElCheck this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date ^� President Print or"Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature or Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Pa-e 4 of Board of Trustees Applic- ion AUTHORIZATION (Where the applicant is not the owner) I/We, M-� owners of the property identified as SCTM# 1000- �— — �� , (� in the town of New York, hereby authorizes A /le_ to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. *PropertOwner'sSignature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF MOA 20_LL_, CONNIE D.BUNCH Notary Public,State of New York Notary Public No.016196185050 Qualified in Suffolk County Commission Expires April 14,2 U Board of Trustees Appls.o-_.—on AUTHORIZATION (Where the applicant is not the owner) UWe, owners of the,property identified as SCTM# 1000- �— _ 3� . ()- in the town of , New York,hereby authorizes V� r to act as any agent and handle all ' necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for,this property,, Prope Owner's Signature Property Owner's Signature -SWORN TO BEFORE ME THIS ! DAY OF �,20 of New Notary D.eoy Public,State®f New 1'art Notary Public No.01S196185050 Qualified in Suffolk County pp���,,�� Commission Expires April 14,2�J Board of Trustees Applin:- V;:ion AUTHORIZATION (Where the applicant isnot the owner) owners of the property identified as SCTM# 1000- L - - `.v ;in the town of ,-New York, hereby authorizes _ to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property: roperty Owner s Signa a Pr perry Owner's Signature SWORN TO BEFORE ME THIS s+ DAY OF h) Notary Public DIANE LEACH NOTARY PUBLIC OF NEW JERSEY Comm. # 2357040 My-commission Expires 31912022 Board •of, Trustees Appli-,- ;ion AFFIDAVIT BEING DULY SWORN DEPOSES AND 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 BOARD OF 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,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED.TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. r Signature of Property Owner S gna a of Property Owner SWORN TO-BEFORE ME THIS _ __DAY DAY OF, ,, 14 Notary Public DIANE LEACH NOTA YPUBLIC OF 235 040 JERSEYComm. # J My,Commission Expires 31912022 ; - APPLICANT/AGENURE PRE'SENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town ofSouthold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The numose 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 neces_sary to avoid same. YOUR NAME: Ek I 1 (Last name,ft st name,.gtiddl tial,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 Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning 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°r'o o he 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 RELATIONSI41P Submitted thi 1-day f 200 Signature Print Name Form TS 1 APPLICANT/AGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and emolovecti The purpose of 7 this form is to rovide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. (� YOUR NAME: c n ` �✓� 1 ) .�� ( o_l I (Last name,first name,.grtddle mutual,unless you are applying to 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 Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning 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'1'own of Southold? "Relationship"includes by blood,ntarriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee h.as 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 XS / 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 iclationship 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 npplicant is a corporation); B)the legal orbeneficinl 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 th s / d f /� 20 Signature Print Name Form TS ] Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of-Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt .minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its siu'ficant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shill not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# _ _--� — PROJECT NAME The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board ElBuilding Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g.capital ❑ construction,planning activity,agency regulation,land transaction) ❑ (b) Financial assistance(e.g.grant,loan,subsidy) (c) Permit,approval,license,certification: Nature and extent of action: R Location of action: 0000 ll ,(m c aGal6dEfA Site acreage: d � L Present land use: � ` Q�,1� Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: An te, (b) Mailing address: c e�tc (c) Telephone number: Area Code( ) �U21 J e)i Q -745q (d) Application number,if any: /V11 Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ NoT4 If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure,makes beneficial use of a coastal location, and minimizes adverse effects of development. See LW12P Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ Nok Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No K Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ NA Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No Ei Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No X Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes 1:1 No Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ YeO No)ZNot Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III—Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No 54 Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No Not Applicable ` Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III —Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ Nou Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No--IMk,,j Not Applicable PREPARED BYW l C TITLEI�� (DATE 4( � James F. King,President ``�OF SoV�yO Town Hall Jill M. Doherty,Vice-President ,`O lO 53095 Route 25 Peggy A.Dickerson P.O.Box 1179 Southold,New York 11971-0959 Dave Bergen John Holzapfel �Q Telephone(631) 765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0155C Date September 21, 2006 THIS CERTIFIES that the single-family dwelling, covered porch&deck At 2000 Glenn Rd., Southold , Suffolk County Tax Map # 78-2-37 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 4/28/04 pursuant to which Trustees Permit#5914 Dated 5/26/04 Was issued, and 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 a single-family dwelling, covered porch& deck The certificate is issued to EDWARD KAVANAGH owner of the aforesaid property. C� Authorized Signature Albert J.Krupski,President ®� ®� Town Hall James King,Vice-President �� °�� 53095 Route 25 Artie Foster 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 January 19, 2005 Mr. Jeffrey T. Butler P.O. Box 634 Shoreham, NY 11786 RE: EDWARD KAVANAGH 2000 GLENN RD., SOUTHOLD SCTM#78-2-37 Dear Mr. Butler: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wed., January 19, 2005: RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to Permit#5914 for an expansion of the deck and covered porch, and as depicted on the plan prepared by Jeffrey T. Butler, P.E. dated December 11, 2003. This is not a determination from any other agency. If you have.any questions, please call our office at (631) 765-1892. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees AJK:Ims '�� � •.�� � .. i.- .� ice. � s. Board Of Southold Town Trustees SOUTHOLD. NEW YORK 5-511 May 26, 2004DATE: .................................PERMIT NO. ... ;. EDWARD L. KAVANAGH ISSUEDTO ........................................................................................................................................ ��•a � ,�.�#I���t��t#tort -� 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_ D ON TOWN WATERS AND PUBLIC LANDS and the 1 IN AN � 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 .:.May...26.,..... 2004 :, and in consideration of the sum of 5...25Q.•QP....... paid by 1 > Edward L. Kavanagh Glenn Head .. N. Y. and. subject to 'the of ....... N 1 Terms and Conditions listed on the reverse side hereof, of Southold Town' Trustees authorizes and per the following: Wetland Permit to construct a two-story, single-family dwelling i with related improvements,. and all as depicted on the site plan t prepared by Jeffrey T. Butler, P.E. dated Dec. 11, 2003. �. all in accordance with the detailed specifications as presented in .the originating application. r IN WITNESS WHEREOF, The said Board of Trustees Mere- ., i by causes its Corporate Seal to be affixed, and these presents to be subscribed bye majority of the said Board .as of this date. u` �FFo ��o I M . � 01 , y► - Trurtecs 0 41 TERMS and CONDITIONS ; 00 Permittee Edward L. Kavanagh t4siding at 740 Glen Cove Ave. , Glenn Head N. Y., as part. of the consideration for the issuance of the Permit does understand ind prescribe to the fol- lowing: 1. 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 tesult of any oper- anon�onnled._pursuaat_tosbts__permrt,.gad the catd _!�.�._or._her ow.. _ defend any and all such suits-initiated by thirdparties, and the said Vermittee assumes full liability ..with respect thereto, Vo the complete'exclusion of the B,aard of Trustees of the Town of Southold 2. That this Pett}tit is.valid .for a period of ; 24 Im which is t1oWdemd to be the estimated time-required to complete the work involved, but-should warrant, request . for an artension may be made to the Poard at .a later *ft 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 aath- tion 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. S. 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 wodc herein audwdzed, or If, in the opinion of.6e.Boards of Trustees, the. work.shall cause unreasonable obstruction to free navigation, the said Penmittee will be tequited, -due notice,to remove or alter this work or project herein stated without=penes to the Town' of $outhold. g. That the said Board will be notified by the Permittee of the congdedon.of the work autb- orized. a 9. That the Permittee will }obtain all other permits and consents fiat may be required sap- elemental to this permit which way'*be subject to revoke upon failure to obtain tame. NU�ing ork State Department of Environmental Conservation Diof Environmental Permits, Region One Bu0-SUNY, Stony Brook, New York 11790-2356 Ph31)444-0365 • FAX: (631)444-0360 Wewww.dec.state.ny.us Erin M.Crotty Commissioner f p EC oWE ERMIT MODIFICATION , (40ward Kavanagh November 30, 2 JAN 1 9 2005 Gle venue Glen Head, NY 11545 Southold Town Board of Trustees Re: Permit# 1-4738-03317/00001 Dear Mr. Kavanagh: Your recent request to modify, the above permit has been reviewed pursuant to 6NYCRR Part 621 (Uniform Procedures Regulations). It has been determined that the proposed modifications will not substantially, change the scope of the permitted actions or the existing permit conditions. Therefore, the permit is modified to authorize: Addition of a covered porch and an uncovered porch to south side of proposed dwelling as shown on plans prepared by Jeffrey T. Butler, P.E., stamped NYSDEC approved on 11/30/04. This letter is a modification to the original permit, and as such, shall be available at the job site whenever authorized-work is in progress. All other terms and conditions remain as written in the original permit. Sincerely, 'Mark Carrara Permit Administrator cc: MHP J. T. Butler File SUBDIVISION MAP OF ST CREEK ESTATES" FILED IN THE OFFICE OF THE CLERK OF SUFFOLK COUNTY ON �j1/00c)01 AUGUST 19, 1963 AS FILE NO. 3848 �,�1�`�.�'. Tau•,� O �,, ►� � —��` ELEVATIONS IN N.G.V. DATUM (MSL 1929) ' N/F ROBERT' & CAMILLE WILSON EXISTING RESIDENCE PUBLIC WATER � 4 16 " TIE LINE ALONG APPROXIMATE HIGH WATER MARK I PR VER D 11" PORC 95, 115 _11 Ol'Z 8, �Z -A3�. � v 0 N o �' C)to 0 no 6 A 7D - 0 ; PORCH 7s t� PROPOSED - : q COVERED 0 PROPOSED NO 04 o� PORCH 0-� DI TURBANCE BUFFER Z z m o - - 4•�.: - ZLn �00 .0 � '�� 0�� O tJ1 O Nth .;t!1' - • • �•=�� �r �11 C \-7 t 2 1 O N N ` . 8 6 c.. W U*l .G.. •tip , l� :.s•va: O SITE PLAN OOLS = 300 1 MEN ,NG AREA 20 10 0 20 40 60 80 100 GRAPHIC SCALE 1" = 20'-0" 7F. N0. 17/00001 S-C.D.H.S. REF. NO. R10-04-0006 SITE PLAN JEFFREY T. BUTLER, P.E. :ED SINGLE FAMILY RESIDENCE 1 . � • •GLENN ROAD, SOUTHOLD, NY P.O. BOX 634 SHOREHAM, NEW YORK S.C.T.M. 1000-078-02-37 TER BODY: WEST CREEK TEL.: 631 .208.8850 FAX: 631 .727.8033 SUFFOLK TOWN OF SOUTHOLD DATE PREPARED: 12 11 03 TOT AREA = 24,353.13 SQ.FT. LOT AREA (ADJACENT TO WETLANDS) = 22,355.36 SQ.FT. FLOOD ZONE = AE PROPOSED RESIDENCE = 2415.72 SQ.FT. BASE FLOOD ELEVATION = 8.0 PROPOSED COVERED FRONT PORCH = 105.8 SQ.FT. PROPOSED COVERED REAR PORCH = 270 SQ.FT. PROPOSED UNCOVERED REAR PORCH = 180 SQ.FT. TOTAL = 2971.52 SQ.FT. = 13.30% LOT COVERAGE UTILITY POLE S 02'30'00" E 15 1 4 #15 14 12 -' 12 • ' s7, ., o a, 14 0' G ".F.=12'6 PROPOSED 2 04 STORY RESIDENCE 1?snag 502-0 � Z A 13 N TEST o ol N � HOLE O PROPOSED PROPOSED DRYWELL FOR COVERED ROOF RUNOFF MEN, PORCH GRADE OSEp GRP 12 ST ' PALE BROWN pROPDR�vEWP 00 Z SANDY LOAM L Z LP ( ) LP OL 8' 8' o ' 1.5' 0 14 Ep MIN. MIN. MIN. PALE BROWN 14 12 •SILTY SAND 2 N 02'30 00 W (SM) 250.21' ,� PROPOSED _3� SANITARY SYSTEM PALE BROWN UTILITY 3 3 L.P. 8'0. 4' DEEP FINE TO POLE N F FERUCIO FRANKOLA MEDIUM SAND p #14 EXISTING RESIDENCE 4'x25 SQ.FT.x3 (SP) -8.3' PUBLIC WATER SQ.FT. LEACf �'• NYSDEC F WATER IN PALE 1 -4738-03" BROWN FINE TO MEDIUM PROPERTY OWNER: SAND EDWARD L. KAVANAGH (SP) 740 GLEN COVE AVENUE M PROPO GLENN HEAD, NY 11545 TEST HOLE BY -15' TEL.: 516-674-0707 200 MC DONALD .Q GEOSCIENCE � �940 8/7/01 COUNTY OF S11FF0(,r�o Telephone Town Hall (631)765-1892 ti Z 53095 Route 25 Q • .�` 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 APPLICATIONS TO AMEND PERMITS Moved by William Cook, seconded by Jack McGreevy, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A CONDITION of the application of EDWARD KAVANAGH to Amend Permit#5914 for an expansion of the deck and covered porch. Located: 2000 Glenn Rd., Southold. SCTM#78-2-37 The CAC recommends Approval of the application with the Condition there'is a limit to the number of trees being removed on the property. Vote of Council: Ayes: All Motion Carried • New York State Department of Environmental Conservation Division of Environmental Permits, Region One Building 40 -SUNY, Stony Brook, New York 11790-2356 Phone: (631)444-0365 • FAX: (631)444-0360 Website: www.dec.state.ny.us Erin M.Crotty Commissioner PERMIT MODIFICATION Edward Kavanagh November 30, 2004 740 Glen Cove Avenue Glen Head, NY 11545 Re: Permit# 1-4738-03317/00001 Dear Mr. Kavanagh: Four recent request to modify the above permit has been reviewed pursuant to 6NYCRR Part 621 (Uniform Procedures Regulations). It has been determined that the proposed modifications will not substantially change the scope of the permitted actions or the existing permit conditions. Therefore, the permit is modified to authorize: Addition of a covered porch and an uncovered porch to south side of proposed dwelling as shown on plans prepared by Jeffrey T. Butler, P.E., stamped NYSDEC approved on 11/30/04. This letter is a modification to the original permit, and as such, shall be available at the job'site whenever authorized-work is in progress. All other terms and conditions remain as written in the original permit. ' Sincerely, Mark Carrara Permit Administrator cc: MHP J. T. Butler File ® E C .� DEC 13 2004 Southold Town T' gfpe'S l 1 Albert J.Krupski,Pree'l it. _ -' . Town Hall James King,Vice-President SAFF0(� 53095 Route 25 Artie Foster � ��j P.O.Box 1179 Ken Poliwoda � Southold,New York 11971-0959 Peggy A.Dickerson ti = Telephone(631) 765-1892 Fax(631) 765-1366 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 Project complete, compliance inspection.q s• OSVF f0(/-C Albert J.Krupski,President ��► QG Town Hall James King,Vice-President =� 'y� 53095 Route 25 Artie Foster y - P.O.Box 1179 Ken Poliwoda Southold,New York 11971-0959 Peggy A. Dickerson y� �0�� Telephone(631) 765-1892 Fax(631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD May 26, 2004 Jeffrey T. Butler, P.E. P.O. Box 634 Shoreham, NY 11786 RE: EDWARD L. KAVANAGH 2000 GLENN RD., SOUTHOLD SCTM#78-2-37 Dear Mr. Butler: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, May 26, 2004 regarding the above matter: WHEREAS, Jeffrey T. Butler, P.E. on behalf of EDWARD L. KAVANAGH 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 April 28, 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 May 26, 2004, 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 EDWARD L. KAVANAGH to construct a two-story, single-family dwelling with related improvements, and all as depicted on the site plan prepared by Jeffrey T. Butler, P.E. dated December 11, 2003. 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: $100.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/Ims AFFoc Albert J.Krupski,President y`O�,�S �COGy Town Hall James King,Vice President 53095 Route 25 P.O.Box 1179 Artie Foster y Z Southold,New York 11971-0959 Ken Poliwoda Peggy A.Dickerson y �'� Telephone(631)*765-1892 Fax(631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: G y Yxxoa na q h, Please be advised that your application dated ��a g�a� has been reviewed by this Board at the regular meeting of f b 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: ( Ita c a.�rC�c hQ� TOTAL FEES DUE: $ /001 OD -SIGNED: PRESIDENT, BOARD OF TRUSTEES LOT AREA = 24,353.13 SQ.FT. LOT AREA (ADJACENT TO WETLANDS) = 22,355.36 SQ.FT. SUBDIVISION MAP OF "WEST CREEK ESTATES" FILED. IN FLOOD ZONE = X & AE THE OFFICE OF THE CLERK OF SUFFOLK COUNTY ON BASE FLOOD ELEVATION = 8.0 PROPOSED RESIDENCE = 2415.72 SQ.FT. AUGUST 19, 1963 AS FILE NO. 3848 PROPOSED COVERED FRONT PORCH = 105.8 SQ.FT. PROPOSED COVERED REAR PORCH = 270 SQ.FT: ELEVATIONS IN N.G.V. DATUM (MSL 1929) —4-400, PROPOSED UNCOVERED REAR PORCH = 180 SQ.FT. N/F ROBERT & CAMILLE WILSON TOTAL = 2971.52 SQ.FT. 13.30% LOT COVERAGE EXISTING RESIDENCE UTILITY PUBLIC WATER 40 4 S 02'30'00" E POLE 1 1 X,16 TIE LINE ALONG O #15 14 _ v APPROXIMATE HIGH I PR x WATER MARK PROPOSED WATER L 12 VER D Z 12 „ PORC _+ r Ln � � 11" c� �a 2 � 67 115 a„ O 0- 0 2 o 3 0 14 G.F.=12'6"0. 123' r o Q. o PROPOSED 2 -�7v � N STORY N N Z v v r" RESIDENCE o 0 0 - Cn F.F.=15'9" m m 2�0► Z A o x �Y o � s A C Z 13 iv PORCH z m r O TEST 0 N PROPOSED<Z y 7- HOLE COVERED �� O I� 0 PROPOSED NO -c 0 PROPOSED J PROPOSED �� o PORCH DI URBANCE BUFFER _. y DRYWELL FOR ROOF RUNOFF COVERED o o o GRADE = 14.0 GRpNfE PORCH ST „ �� o AP� �� PALE BROWN pROpOR�EwPll 12 o B® RD OF T US US SANDY LOAM L LP 11 �" 2 (OL) 0 14 8' 8' LP '� N N� 03 WN OF S®UT� ®�,® E 1.5' o EP MIN. MIN. MIN. 10 8 r PALE BROWN 14 12 �' 6 SILTY SAND 2 N 02'30'00" W t° (SM) 250.21' PROPOSED 0_ SANITARY SYSTEM SITE PLAN PALE BROWN -3 UTILITY 3 3 L.P. 8'0, 4' DEEP FINE TO POLE N F FERUCIO FRANKOLA MEDIUM SAND 0 #14 EXISTING RESIDENCE 4'x25 SQ.FT.x3 POOLS = 300 1 so (SP) PUBLIC WATER SQ.FT. LEACHING AREA 20 10 0 20 40 60 80 1 —8.3' (5.7) -n GRAPHIC SCALE 1 NEGV 0 NYSDEC REF., NO. WATER IN FINE E 1 -4738-03317/00001 BE[ C E 8 V D.H.S. REF. NO. R10 TO MEDIUM PROPERTY OWNER: SAND EDWARD L. KAVANAGH SITE PLAN PLIJ DEC 13 20« IF TREY T. BUT (SP) 740 GLEN -COVE, AVENUE AD,NY 11545 PROPOSED SINGLE FAMILY RE IDE CE GLENN HEAD, P.O. BOX 634 -15' /l/ TEL.: 516-674-0707 2000 GLENN ROAD, SOUTH N Y$So of Tru°swee TEST HOLE BY �$SIO MC DONALD ' �0 Y S.C.T.M. 1000-078-0 — SHOREHAM, NEW YORK GEOSCIENCE '9Q �F� WATER BODY: WEST CREEK TEL.: 631 .208.:8850 FAX: 631 .727.8033` ' 8/7/01 COUNTY OF SUFFOLK TOWN OF SOUTHOLD .DATE PREPARED: 12 11 03 Ld Z Ld J W J X Q w PROPOSED z w ao RESIDENCE too a FINISHED FLOOR E Q_ d i I � N "14.0 12.0 10.0 8.0 4.0 PROPOSED 2.0 SEASONAL GROUND WATER SANITARY MEAN HIGH WATER SYSTEM 20 10 0 20 40 60 80 100 GRAPHIC SCALE 1" = 20*-0" HOUSE, FF = 15.75' FINISH GRADE FINISH GRADE=14.2 z 24' - o 1' MIN. TC=13.2 1' MIN. 1000 GAL. MIN. 4" DIA. APPROVED PIPE 13.0 APPROVED PIPE MIN. PITCH 1 8 1 PRECAST CONC. MIN. PITCH 1 4" 1 SEPTIC 12.50 3'-0' MIN. COLLAR DRAINAGE RING. TANK LEACHING y C. 1 NV. EL. 12.50 POOL ;� IN V. EL. � p „ = 13.0 NV. EL. 12.00 (1 OF 3) BOTTOM p p p p p p p W INV. EL. 11.50 -A 0 3 CLEAN 8.50 CAA, p p p p p p p p SAND COLLAR 8' DIA. _z GRAVEL ° D p p p p p p p p p 5.70 D °,D ppppppppp ' D p p p p p p p p p GROUND WATER ppppppppp NYSDEC REF: NO. D p 1 -4738-03317/00001 S.C.D.H.S. REF. NO. RIO-04-0006 D ° DIAMETER , M SITE PLAN JEFFREY T. BUTLER P.E. NOTE: ° ACKFlLL TO BE CLEAN GRAVEL QPROPOSED SINGLE FAMILY RESIDENCE 6' MIN. PENETRATION GROUND WATER P.O. BOX 634 IN sAr�o SAND/GRAVEL 2000 GLENN ROAD, SOUTHOLD, NY SHOREHAM, NEW YORK TYPICAL LEACHING POOL S.C.T.M. 1000-078-02-37 WATER BODY: WEST .CREEK TEL.: 631 .208.8850 FAX: 631 .727.8033 NOT TO SCALE COUNTY OF SUFFOLK TOWN OF SOUTHOLD DATE PREPARED: 12 11 03 i 4 s i- W WAr ow s., k` tp tea. _ o 4 a � 00 00 `'. Z « i _Y S♦ � f 1, ' „ Y 9 ?h 010 13 boom '•'• �il�lllt a► a"m mw mm r... r �e !� 1101 ,pq- �IIIIIIIIillll I' ' 1lo . 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M ,.µ(c) �' 5't o3 ] a w 261 l ♦ A �] as I� ' Sr' m I wu ] a s } 11 PP :P2 N t B n 9 ry, ]OI a'ID M N � �w n ZS y Q b � >r n. �' "'i f • _ < N � ..r .O s ,3 4 bJ J y'P i / 1 'z ♦ 3, � ,3 '� Z �,�. s / J ff e �' • fO�r !o- w • t.O.Yc) n - >'3N° fi a3 �' � ,. . � zo ,+♦ �9.3 F f � F1Y '°.z=xt.e � - y t 1b a @ ®.B - o $� .s.t 2sA • 9Il +., © @ - JJa ,�r< ,.<Alq ZJY`) a �. 35 ♦,2 23 blp0 IB ♦ /z Is id11c) ar s O I] I8.3 f9 vIIt � � ♦ a 1 y+� +.Orya' BI � WTdt �--1WE .s raM�iiO rest' 7 � O e...m. r__ �� --^-- NOTICE ews COUNTY OF SUFFOLK © K w am ,orwv p SECTION NO ..w.r.�m. µme— �`�`�` 1;1) __�__ ...�__,�, .+*Erw+�m.M.E<B Real Property Tax Service Agency Y = --- --•-- ...� .-- CO-" on 078 n.INwm+iu '� w.r� --r-- _ u.--r-- n"r wmrcBry ruuB:ncf w[x<r. F' A 9n 9M Om,wc,rq 1000 ]t 1 "'+"" PROPERTY MAP Michael J. Domino, President �o�10a coGy Town Ha((Annex John M. Bredemeyer, III, Vice-President o 54375 Route 25 Glenn Goldsmith N = P.O. Box 1179 A Nicholas Krupski y Southold, NY .11971 Greg Williams col ,� Sao Telephone (631) 765-1892 Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIREMENTS SCTM#: Property Owner Name: D L bN..I• M A`; 1 5 2019 s Date Sent to Bldg. Dept: �S 1 q �'• The Office of the Board of Trustees is forwarding the above referenced application for verification of the Building Department's permitting requirements stated below: YES NO Will the proposed project require a Building Permit? Will the proposed project require a variance determination from the Zoning Board of Appeals? Will any part of this application be considered a Demolition as described under Town Code? COMMENTS: Aigna4tureReviewer Date f so l U� 5 Town Hall Annex Michael J.Domino,President John M. Bredemeyer III,Vice-President �o r0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski � 4'9 Telephone(631) 765-1892 Greg Williams jcou Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application .__._..._,__. --- _... Administrative Permit y V mendment/Transfer/Extension ;: AY 20� eceived Application: 5113./�eceived Fee: $ 100.00ompleted Application: 9 "'��` 5,, .. . . i Incomplete: _ Bo<,d ri_• SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): 6,7.�q :ZLWRP Consistency Assessment Form Sent: CAC Referral Sent: Date of Inspection: Receipt of CAC Report: 2tTechnical Review: Public Hearing Held: Resolution: Owner(s)Legal Name of Property (as shown on Deed): jAW Mailing Address: 'Q VUU ���8y� ' . . sa 1 rC d P-I - Phone Number: P5,q J— 9)D4Q_ Suffolk County Tax Map Number: 1000 - 3') - C� Property Location: (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): `� d Mailing Address: wilt l d Phone Number: ` �� P - Michael J.Domino,President �*0f SOUljyD Town Hall Annex John M.Bredemeyer III,Vice-President �� lQ 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold,New York 11971 A. Nicholas Krupski G • Telephone (631) 765-1892 Greg Williams 'O Fax(631) 765-6641 �y00UNT'I,�c� p q L� (� , p lip BOARD OF TOWN TRUSTEES MAY 13 TOWN OF SOUTHOLD 2Q�Q Soutiloid Town Board of Tru to s APPLICATION FOR A TRANSFER OF A WETLAND PERMIT DATE 511 I "t OWNER � � PHONE 9 I 1 —6P 3 g MAILING ADDRESS9D , s5 alMiL P'� t AGENT W PHONE 51(U ' cCSL ) t Q 1 SDI ADDRESS PROPERTY LOCATION C�1e►1y) TAX MAP NO. �00D — WI b — a ' ✓� I/We�c 5�1� i . request a Transfer of Permit# from a U Signed B Board of Trustees Applicauion GENERAL DATA Land Area(in square feet): Area Zoning: ' Previous use of property: S Intended use of property: Vw Covenants and Restrictions on property? Yes No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? X/Yes No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes �No If"Yes", please provide copy of decision. Will this project requi e y demolition as per Town Code or as determined by the Building Dept.? Yes �No Does the structure (s) on property have a valid Certificate of Occupancy? X Yes No Prior permits/approvals for site improvements: Agency Date Fa y Or INMA Ls 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): -rarer-, Board of Trustees Appli�. ...ion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: I-Re -EMI n 6i L DECK tiPLL-2' 1 —S DUO l Area of wetlands on lot: '(04 square feet Percent coverage of lot: �, _% j ndueQ of Closest distance between nearest existing structure and upland edge of wetlands: Q_feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No Yes N 5- If yes, how much material will be excavated? cubic yards How much material will be filled? V cubic yards Depth of which material will be removed or deposited: �jl feet X.(() toonRo 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): 61 Z20 Append&B Shoff Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part I. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information AMU D' Rlpyp'� Name of Action or Project: J DOW G � V Project Location(describe,and attach a location map): Brief Description of Proposed Action: Ran K4ec r2 e�isi net cC�ec.� -lei �'e(Ylcl �5 s��p 1n I✓� �`e haw- r( < 'N► q space-- Maxo ks s4fp A �+Icn of �ec � n each Cki( can Name of Applicant or Sponsor: �p Telephone: 5 i (,�-7,s`I' Pk 1,e.e \ w �1 E-Mail: Address: City/PO: State: Zip Code: I.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or fiinding from any other governmental Agency? NO YES If Yes, list agency(s)name and permit or approval: ❑ 3.a.Total acreage of the site a proposed action? acres b.Total acreage to be physically disturbed? acres '50SQ IF'r, c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? .� 4—_acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial [—]Commercial Residential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ 'F—Rr ❑ b.Consistent with the adopted comprehensive plan? ❑ L3 ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ 7. Is the site of the proposed action located in,or does it adjoin,a'st1ate• listed Critical Environ rental Area? NO YES If Yes,identify:-ADR-0 � �(. ��a- ❑ ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? :9 ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 9. Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water:_ —� 5 `� ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? b. Is the proposed action located in an archeological sensitive area? ❑ ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: _ _ 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional ❑ Wetland ❑Urban 39Suburban 15. Does the site of the proposed action contain any species of animal,or associated habitats, listed NO YES by the State or Federal government as threatened or endangered? y<l ❑ 16.Is the project site located in the 100 year flood plain? ddN�O YES 17. Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, a.Will storm water discharges flow to adjacent properties? NO [:]YES ❑ ❑ b.Will storm water discharges be directed to established conveyance system (run,pff and storm drains)? If Yes,briefly describe: :_ NO AYES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other Iiquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size; 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe:_ ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe:_ I AFFIRM THAT THEJINFORON PRO IDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGEApplicant/sponsor e �" Date:Signature: Part 2-1 pact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning Elregulations? 2. Will the proposed action result in a change in the use or intensity of use of land? El EL 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the Elestablishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate El available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? El 0- 8. Will the proposed action impair the character or quality of important historic,archaeological, El ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion, flooding or drainage El Elproblems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact, including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant. Each potential impact should be assessed considering its setting,probability of occurring, duration, irreversibility,geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency _ Date �_.._._. President Print or Typc 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) PRINT Page 4 of 4 Board of Trustees Applic ion AUTHORIZATION (Where the applicant is not the owner) I/We, owners of the property identified as SCTM# 1000- �— _ �� in the town of New York,hereby authorizes e:i Lam e „ to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. *PropertOwner'signatuure Property Owner's Signature SWORN TO BEFORE ME THIS ! DAY OF , 20_-_ CONNIE D.BrJNCF! Notary Public,State of New York Notary Public No.01BU6185050 Qualified in Suffolk County Commission Expires April 14,2La4 Hoard of. Trustees Applic__ on AUTHOP4ZATION (Where the applicant is not the owner) UWe, D1 .� . owners of the.property identified as SCT.Mff 10..00 �—' i!) ui,.the town of �h' 1 1Vevu York,.hereby.authorizes. to act as:my agent and handle all necessary work involved with the:application process for permits)$om the Southold Town: i Boa d-of Trustees for,tills property: Prope Owner's Signature: . Property'Owner.s Signature. j SWORN TO.'BF E THIS DAY OF FM fp j ()t CONNIE D.BUNCH ,I Notary Public,State of New Y®tEt Notary Public No.01 BU6185050 Qualified in Suffolk County Commission Expires April 14,21 J Board of Trustees Appl + :ion AUTHORIZATION (Where the applicant is not the owner) I/We, Syr f, owners of the property identified as SCTM# 1000- :in the town of New York, hereby authorizes to act as my agent and handle all necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for this property: c roperty Owners Signaiure Pr perty Owner's Signature SWORN TO BEFORE.ME THIS 2 51 DAY OF Up p 14 Notary.Public DIANE LEACH NOTARY PUBLIC OF NEW JERSEY Comm. # 2357040 my Commission Exores.302022 Board of Trustees Appl .- :ion AFFIDAVIT BEING DULY SWORN DEPOSES AND 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 T MANNER SET FORTH IN THIS APPLICATI HEON AND AS MAY BE APPROVED BY.THE.SOUTHOLD TOWN BOARD-OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE.TOWN OF SOUTHOLD AND THE BOARD OF 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,INCLUDINGG THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL. EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES:DURING THE TERM OF THE PERMIT. Signature of Property Owner S gria e of Property Owner SWORN TO BEFORE ME THIS I DAY OF. . W .v� Notary Public DIANE LEACH - NOTARY.PUBLIC OF NEW JERSEY Comm. #235� My,t0mmi3si0n Ex039120Y1 APPLICANT/AGENUREPRE,SENTA.TIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The puroose 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 ncce,..saEy to avoid same. YOUR NAME: (Last name,fi st name,jriddl ' tial,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 Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning 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°u o he 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 otliccr,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thi lsday of 2001�J Signature // Print Name Form TS 1 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 purpose of this form is to provide information which can alert the town of Rossible conflicts of interest and allow it to take whatever action is necessary to avoid same. (�� YOUR NAME: t ]U___ � �,1� �� (Last name,first name,griddle mural,"'less aze applying rn 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 Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning 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'fown of Southold? "Relntionship"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 that 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal orbeneficial owner of Amy 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 th s / d f 20� Signature Print Name Form TS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated. as to its si iuficant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website(southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# _ - PROJECT NAME The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g.capital ❑ construction,planning activity,agency regulation,land transaction) ❑ (b) Financial assistance(e.g.grant,loan,subsidy) (c) Permit,approval,license,certification: ' Nature and extent of action: �C IC�II�'tZ. ��, Q�'I C S IRS _,61EP 'fig L--2)E gt::7"( IA-E V4 OPE KI I Q 61v -M BE L Location of action: 0000 G�ec�c a Y\A E a� Site acreage: A (, Present land use: Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing address: Ws i--t V-d A-1 (c) Telephone number: Area Code (d) Application number,if-,uiy: / " 1/Ig Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY . Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ No �5NO Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LVM Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No)4 Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No K Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No k Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No D�Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No x Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No [%Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ YeO No)ZNot Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III•—Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No 5,Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No ,Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III—Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ Nou Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No*--TML') Not Applicable PREPARED BY ' W l �— TITLE NffiA �YC�UIDATE24�L(4� o�oS�Ft~ot,��oG �� yam► Telephone p Town Hall (631)765-1892 h Z 53095 Route 25 O .tC 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 Tuesday, May 11, 2004, the following recommendation was made: 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 EDWARD L. KAVANAGH to construct a two-story, single-family dwelling with related improvements. Located: 2000 Glenn Rd., Southold. SCTM#78-2-37 Vote of Council: Ayes: All , .Motion Carried NEI )RI ATE DEPARTMENT OF ENVIRONMENCC + ;RVATION DEC PERMIT NUMBER EFFECTIVE DATE 1-4738-03317/00001 Aril 19,2004 FACILITY/PROGRAM NUMBER(S) Aa" PERMIT EXPIRATION DATE(S) Under the Environmental April 19,2009 Conservation Law TYPE OF PERMIT■ New ❑ Renewal ❑Modification❑Permit to Construct ❑Permit to Operate ❑ Article 15,Title 5: Protection of Waters ❑ Article 17,Titles 7,8: SPDES ❑ Article 27,Title 9; 6NYCRR 373: Hazardous Waste Management ❑ Article 15,Title 15:Water Supply ❑ Article 19:Air Pollution Control ❑ Article 34:Coastal Erosion ❑ Article 15,Title 15:Water Transport ❑ Article 23,Title 27:Mined Land Management Reclamation ❑ Article 15,Title 15: Long Island Wells ❑ Article 36: Floodplain Management ❑ Article 24: Freshwater Wetlands ❑ Article 15,Title 27: Wild,Scenic and ❑ Articles 1,3, 17, 19, 27,37;6NYCRR Recreational Rivers ■ Article 25:Tidal Wetlands 380: Radiation Control ❑6NYCRR 608:Water Quality Certifica- ❑ Article 27,Title 7; 6NYCRR 360: tion Solid Waste Management PERMIT ISSUED TO TELEPHONE NUMBER Edward Kavanagh (516) 674-0707 ADDRESS OF PERMITTEE 740 Glen Cove Avenue, Glen Head, NY 11545 CONTACT PERSON FOR PERMITTED WORK TELEPHONE NUMBER Jeffrey T. Butler, P.O. Box 634, Shoreham, NY 11786 631 208-8850 NAME AND ADDRESS OF PROJECT/FACILITY Kavanagh property, 2000 Glenn Road, Southold SCTM #1000-78-2-37 COUNTY TOWN WATERCOURSE NYTM COORDINATES Suffolk Southold West Creek DESCRIPTION OF AUTHORIZED ACTIVITY: Construct a single family dwelling with porches, septic system and drive. All work must be done in accordance with the attached plans stamped NYSDEC approved on E D ►I APR 2 Southold Town By acceptance of this permit, the.permittee agrees that the permit is c ntin ent o es cc with the ECL, all applicable regulations, the General Conditions specified (see page 2 & 3) and any Special Conditions included as part of this permit. PERMIT ADMINISTRATOR: ADDRESS John A. land CKW) Region 1 Hea uarters, Bldg.#40, SUNY, StonyBrook, NY 11790-2356 JH DATE Page 1 of 4 [ April 19, 2004 S11f FO(�- Albert J. Krupski, President Town Hall James King,Vice-President �'Z` �y 53095 Route 25 Artie Foster P.O.Box 1179 Ken Poliwoda ,y02 Southold,New York 11971-0959 Peggy A. Dickerson Telephone (631) 765-1892 Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD APPLICATION FOR AN AMENDMENT TO AT LI DATE c - , c30C)4s.__.-----" OWNER d �/Q p PHONE 1; ADDRESS0pQ)o AGENT PHONE 1o31 �O3`aS0 ADDRESS'�j_-60x lo3y k V1 Fly PROPERTY LOCATION C�Opc) G.\e n ,__ p Cat TAX MAP NO. 1 DQ0 - U-T - C)a I/We &2-eZu, request an Amendment to Permit 1 Signed By: 6 � SUFFo�� Albert J.Krupski,President ��� C� Town Hall James King,Vice-President h'Z Gy 53095 Route 25 Artie Foster o P.O.Box 1179 C& = Southold,New York 11971-0959 Ken Poliwoda Peggy A.Dickerson y ��� Telephone(631)765-1892 Fax(631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application /Wetland Permit Application, Major Minor Waiver/Amendm nt/ es ., �ceived Application: ,' iReceived Fee:$ 2 (�a f� •Completed Application D E tUi E _Incomplete _SEQRA Classification: Type I Type II Unlisted APR 2 $ ;20�� _Coordination-(date sent) .-CAC Referral Sent: y ate of Inspection: / Southold Town — Board of Trustees _Receipt of CAC Report: _Lead Agency Determination: _Technical Review: _ _/public Hearing Held: 01 V Resolution: Name of Applicant �I A 2 9 L• -1 Address -7,40 Cal' rs CovE AVEPSI L F_ , C Le-N �j dAEAt�s PX l 11545 f. Phone Number:00 I6-74- 01 p-7 per. Suffolk County Tax Map Number: 1000- r71`v -O'2- 3_7 a� 00 Property Location: 51 F,)C c7 C— Ct_6-Kj kA 19-70,5_1 ' EAST l: d^H�� cr'v�yvt�� 12o,�o cri �.rr ems, lr«j-ry 'POL" =4- 4-ANt" # I� (provide LILCO Pole#, distance to cross streets, and location) AGENT: EFF"`I E (If applicable) Address: V-Jy W79 to Phone: 0Q- 06�� Board of Trustees Application GENERAL DATA Land Area(in square feet): 24 '35 3, 13 Area Zoning: R-4 D Previous use of property: V A c A t4 r LOT Intended use of property: I N Prior permits/approvals for site improvements: Agency Date N y5OEC 1-473'3-0331'7-O0C)o 1 4 �91 D4 SCU PS J2 rho, QQ--Q4-dob(o KuI4'16, No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? /C No Yes If yes, provide explanation: Project Description(use attachments if necessary): 13>U)Q A. TW O 5-F-09-y isGLi f)"ILV 2 C SiDIhI C IF WITH Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 1�,�,�� A (-v i 1,�) S rb12 LC EAtt►L Y C) c L-PA `Newt Mu KN Area of wetlands on lot: �al �1�1 g square feet Percent coverage of lot: 1,� ® 1 % Closest distance between nearest existing structure and upland edge of wetlands:- feet Closest distance between nearest proposed structure and upland edge of wetlands: q5 ' l ) ' feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? 244 cubic yards How much material will be filled? 2_44- 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: 21 F}L X C A\14R-FED f v u ti+DA-`T(o" t.J L-c_ 15 C �JToC Ir- i LC (1 U N I-V IN N V-�, t2 F("Rc- G �1�C 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): Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: -F_61�11L V Are wetlands present within 100 feet of the proposed activity? No_ Yes Does the project involve excavation or filling? No Yes If Yes, how much material will be excavated? 2-44- (cubic yards) How much material will be filled? 24-4 (cubic yards) Manner in which material will be removed or deposited: w�T ��AL -Xc et JATE.D ba c)t'l })i L,►:D a N S 1'T(2 F( N A o- c� Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) y 617.20 SEQR PROJECT ID NUMBER 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 �►�v�I AeD L. KlavAtsla c,ti 1.tA�tiH �I�r C E 3.PROJECT LOCATION: Municipality ,SUIJTH01-b County �UFFOLIc 4.PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map 2000 -S.olrr+t SItC of 6,&nrty R,, lPoJ J9-70,67' Ejq:5'r- Ora M ill's BA-locN �j oAD. �erw[rrti U�tLrTy ol� # 14 4 L)Tt►. ►ty 6I-E1 IS 5.IS PROPOSED ACTION: n New ❑Expansion ❑Modification/alteration 6.DESCRIBE PROJECT BRIEFLY: �(ac�.�PoSED -TIn)D SToyey 2�>1rN-4LC F14M%Ly WITH (2CL-ATt .p 7.AMOUNT OF LAND AFFECTED: Initially 24,353.134acres ,5h AL. Ultimately 2q 353.13 acres .5(o AC. S.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) AYes ❑No If yes, list agency name and permit / approval: Pq:51D C. 1-4"13`2)-03_1>1-7 1 DODO 4119)D+ 5CD k -T-UWo Of SOLYTIAOLL'--' E>01 L32)\lv 11.DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? 'jq Yes ❑No If yes, list agency name and permit / approval: Y�°NYSQECoo31_1 I'D0001 41 ►q�o4- 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? Dyes ❑No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Date: 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 EAR Yes No 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. Yes No 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: F,7 gricultural,archaeological,historic,or other neighborhood _ C2. Aesthetic,a g 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. Longterm,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,ex lain briefly: ❑ Yes No E. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If es explain: ... .. ....... .. .... Yes 0 No PART III-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it 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 of significance must evaluate the potential impactof the 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 FULL 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) NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES,TOWN OF SOUTHOLD In the matter of applicant: 1>�,Jpg_b L-, KkvA�A-rH SCTM# 10D0 - D_7S-G7_-3J YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: A TWO �Ta2y� �Ir.�c�c-Fr�r-Il�y �2�s��tc�sc� ,�,T�1 f�LcAnl� ) M PI_ovc ME-Kys. 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: 5,ouT H SI 0C- D 1�7 G L4CN" Fo a-L-, 1°I-70, 5-7 ' 'dos-- OF 3AYVlE�,J i�o�t� rw�r�s U'tIL-171 POL-C �4 1, \J I (�o�_F 5 . 3. That the project which is subject to Environmental Review under Chapters 32, 37, and/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: o �- i—fl�AtiAG+-9 MAILING ADDRESS: -140 G LCrJ COVE A V E rN UL Cz�rJa�1 �ICA� Nll 11Sh� PHONE M S 1 1p- I o -1 4 - Enc: Copy of sketch or plan showing proposal for your convenience. APR;L7i 2004,"TUE 04;09 P11il ?e pC FAX No, 51 E -"53 P, 001 04/27/2804 15:22 i93 BUTLER TN PAGE 91 Board of %twte®s A"lioutica lltf'1' IZATI�T (where the appucant is not the owner) Z, IM 41,,6V residing ,at _2$0 cam.✓ ..ld 4 If pr nt owner of property} (mailing address-) G esvo✓ GCA do hereby authorize (Agent) to apply for ge rmi+.t(s) from the Southold ft d of own Trustees on any behalf (owner's Qna use g11FF0(,� Albert J.Krupski,President 0�� C� Town Hall James King,Vice-President �`Z` G.f. 53095 Route 25 Artie Foster o P.O.Box 1179 Ken Poliwoda ti 2 Southold,New York 11971-0959 Peggy A.Dickerson Telephone(631) 765-1892 ,fi 4�l jo Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD ------------------------------- ------------------------------- In the Matter of the Application of `-r --Y�A-^ h------------------ COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING L I, T, 6icA-7 11&, residing at being duly sworn, depose and say: That on the/ day of�/J� , 20 ; I personally posted the property known as /CfzZ�a- o-cc z2x�-3: 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 c"o a (\OrCO3 OL& (;vv M. Dated: �;1�� 07. �y 0-0191 (sign qe ::�_ Sworn to before me this ul'. '`day o y/200�/ Notary blic � L� RPBL SaeNoNei40TAY PUBLIC. w York INo.30-4912015 ttyy Commisssio'n Expires November 18 (�v� PROOF OF MAILING OF NOTICE ATTACK CERTIFIED MAIL RECEIPTS Name: Address: Q � r - �/bD Off/�s G 4 .,/12, STATE OF NEW YORK �'�r"- COUNTY OF SUFFOLK p ✓Efyn T, � �Ei J"le ,residing at — Sh'o��y�l ,being duly sworn, deposes and says that on the / day of 2(�� 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_ ,- irL� ,that said Notices were mailed to each of said persons by (certified) (registered)mail. Sworn to before me thisl Day of Z 200 Notary Pub c MARY M.KAVANAGH NOTARY PUBLIC.State of New York No.30-4912015 Qualified in Nassau County / Commission Expires November 16,.2 QOS APR;27i Z004/TUE 04:0'9 FM ELK_`FC FAX No. 51 E 67A P�53 P. 002 04/27/2004 15:43 <33 BUTLFR I PAGE 01 APPLICEMIAGENTAUPRESENT.A►TM TRAN&&C!"oNAL DISCL®SMW FU Tawas of 3autlaold's C e of l?thies ahilbits caggi s of interest 4a3h Ed RIM-WzM p]!i LKf �:.R.....:e.......,.:A..r.P......yeann wt.tel the town OfpoSSlble e ��d allow it to tyke neram=to acid same. YouiR NA1Vlfs: _ � L. K- tt A (L„O aattae,first name,middle initial,twit*you Oro applying in the neat o of shmwuo aloe or other entity,such as a cmmny.Irso,indicate the other petson's or wrnpaany's .) NAME OF.AM.ICATION: (Cheat all that 'fee grievance Varian= �. Choose of Zone ApPMO of plat Eatemption frame}s1At of OJMC(al rnt<p (>thet (lf'Other",anmc tie Aetivity.) Do you personally(or lbrough your company.q*use,sibling,parent,or child)have a Mlation*p with any officer or employee of the Town of 5oathold? "Relatioaahip"includes by blood,naartiage,or business totarast."Rusinew interest'means a business, including a pamerabip,in which tbo town officer or employeo has even a partial oavnwWp of(or employment by)a corporation •bo which the town offioet'or employee owns»bore than 5%ofthe shares. YES NO x if you answered"YES",eotat late the balance of this forth ad date and sign*bete indicated. How of Pelson eamployed by the Town of Southold Titk or position ofthat person Describe the relationship betwccn yourself(the appplicant/aagontheptemniativs)tied the town DMmr or errgloyoa.Either Oback the appropriate live A)through D)aodlor describe in the apace provided. 'Ile towns oolcw or c"loyee or his or her spouse;sibling,parent,or Obild is(check all that apply)_ ,A)the owner of Beater than 5%of the shares of the corpotats stock of the applicant (whop She applicant is a eoryoration); B)the legal or boWACial owner of any interest in a nottcoyporate entity(whet[tho applicant is not a corpondioza); _ C)an officer,director,patina,or employee of the applicant;Ot D)the arwal appliaant DIBSCWP71ON OF RELATE NSNIP Ya s'atbaaaitcod. 'day of l 2q�S� Signature print Nano w i9t/