HomeMy WebLinkAboutBriarcliff Landscape 12/04/2006 14:12 7656641 BOARD OF TRUSTEES PAGE 01
James.F.King,Preside-at ��%31 3aUr Town Hall
JillM_Doherty,Vice-President. k4 fj 53095 Route P.O. Box 1179
Peggy A.Dickerson Southold,New York 11971-0959
Dave Bergen
Telephone(637.)765-1892
John Holzapfel 0(�, Fax(631)765-6641
BOARD OF TOWN TRUSTEES .
TOWN OF SOUTHOLID
Office LTse Only
coastal)Erosion Permit Application
^ permit Application per Application Adminiwative Permit
Wetland
Received Application:-
--Received_,Received Fee:$_
_Completed Application •_
—Incomplete
_SEQRA Classification:
Type J _Type II ilnlisted
_Coordination:(date sent)_
_T..WRP Consistency Assessment p'orm
CAC Referral Sent;
Date of Iospcction:
_Receipt of.CAC Report: _
Load Agency Aetominatiom
_Technical Review:
_Public Hoaring Held:
Resolution:
N atne of,Applicant
Address �q 3 13 S o sJ
-To a Phone Number:(631) �
Suffolk County Tax Map Number: 1000 -
Property Location.;
� �r-n 1s `►�� she{- �m ' C�nerr!- l rin--�i�- 2�a.d _ S� � �1a.c le.rJ
(provide LILCO Pole#, distance to dross streets, and location)
AGENT:
(If applicable)
Address: 97
Phone: -
12/04/2006 14:12 7656641 BOARD OF TRUSTEES PAGE 02
Board
4
GENERAL DATA
J -7 �
� �
Land Axe'(in square feet)'
_
Area Zoning: »l
Previous use of property:
T.ntended use of property:
Prior pennits/approvals for site improvements:
Date
Agency
No prior permits/approvals for site improvements.
Has any perm.it/approval ever been revoked or suspended by a governmental agency?
_ No Yes
f yesy provide uplanation:
--y Project Description(use attachments if necessary); 4enci I Ga vj-n
. . ......---.. ..,.�r�� • �,(2�''�''malt�t 3�•�+ -h� Coasta-1 •ems►� L�n� � ,,..._.,_.. . _. ..�..�,,,.,,._..__
r if n—cle
PART It- IMPACT ASSESSMENT ffo be com leied by Lead A enc
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617,4? If yes,Coordinate the review process and use the FULL FAF,
I__I Yes J�fNo
5. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617,6? It No,a negative
deClaratlon may a superseded by another involved agency.
Yes No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be hanbwritten,if legible)
01. Existing air quality,surfece or groundwater quality or quantity,noise levels,existing traffic pattern,solid waste production or disposal,
potential for erosion,drainage or flooding problems? Explain briefly:
N& Ali \40CK :;4�0'4e CIA'-e
C2, Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly;
ne' •h1AY,s ors ec-,)ch @Ire�sId cle� r�cl lar✓��r� C_E.i� ,
C3. Vegetation or fauna,fish,shellfish or wildlife spatiesr significant habitats,or threatened or endangered species?Explain brlcfly:
go's ��
�a
C4. A community'G existing plans or goals as officially or a change in ulo or Intensity of use of land or oflior rialura►resources?Explain briofly:
d�10, J1s s abo��� is� T Wes ne�,bbbors cle� ,
C5, Growth,subsequent development,or related activities likely to be induced by the proposed action?Explain briefly:
ter 1f
C6. Long term,short term,cumulative,or other effects not idcntlfied In CI-CZ? Explain briefly;
C7, Other im acts(including than es in use of either uantE or a of ens ? Explain briefly:
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE F5TABLiSHMENT OF A CRITICAL
ENVIRONMENTAL AR (CEA? ►f yes,ex lain brlcfl :
0 Yes 21 No
E. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If xes ex lain:
Yes No
i
PART III-DETERMINATION OF SIGNIFICANCE(To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above,determine Whether It is sut)stantial,large,important or otherwise signifcant, izaCn
effect should be assessed in connection with Its(a)setting(i.e.urban or rural);(b)probability of occurring;(c)duration; (d)irrevernibility;(e)
s geographic scope; and (f1 magnitude. If necessary,add attachments or reference supporting materials. Ensure that explanations contain
oufflclent detail to Show that all relevant adverse-impacts have been identified and adequately addressed. If question d of part ii was checked
yes,tpedetarr lnat{on•ofsign cease tugteYaluateEht�pQtenEieltrr�paetofthe propGsed-aetier-rerrthe`envirenm-entaI-c a cteristi=lkh&GEA;--
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 andlor prepare a positive declaration.
Cfi W 7s b'ox if you have determined,based on the.infoimailori and analysis above and ony'supportinq documentation,that the proposed actin
WILL NOT result in any significant adverse environmental Impacts AND provide, on attachments as necessary, the reasons supporting tht
determination.
Name of Lead Agency Date
Print or Type Name of ReaponriBle Officer In Land Agency Title of Responsible Officer
519nature of Responsible Officer in 4e40 Agency signature of-PmpamM different from ressons e o tcer) �'
12/04/2006 14:12 7656641 BOARD OF TRUSTEES PAGE 03
Board of Trustees Application
County of Suffolk
State of New York
vZ C v r L i BEING DULY SWORN
.DEPOSES AND AFFIRMS T, AT FILYSHE IS TILE APPLICANT FOR THE ABOVE
DESCRIBED-PERMIT(S)AND THAT ALL STATEMENT'S CONTAINED HEREIN ARE
TRUE TO TI-IE;BEST OF:Hi.S/I-IER kNOWLEDG.E AND BELIEF, AND THAT ALL WORK
WILL BE DONE M THE MANNER SET FORTH IN TMS APPLICATION AND AS MAY
BE APPROVED BY THE SOUTI-TOED TOWN BOARD OF TRUSTEES. THE APPLICANT
AGREES TO HOLD TIE TOWN OF SOTJTHOLD AND THE TOWN TRUSTEES
HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING
UNDER OR BY VIRTUE OF SAID PEW. T(S), IF GRANTED, IN COMPLETING THIS
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,T't-(EIR AGENT(S) OR
REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PRE]VI.XS.ES IN CONJU[VCTION WITH REVI-V OF THIS APPLICATION.
Signat�ire
SWORN TO BEFORE ME THTS_ � �) DAY OF - eCCfYt
Notary Public
SHARON L.BAJEK
Notary Public,State of New York
No.4863757
Qualified in Suffolk County
Commission Expires October 20, 2.Q 0 __.—_.
12/04/2006 14:12 7656641 BOARD OF TRUSTEES PAGE 05
APpLTCANT/AGENT/REPRESENTATYVE
TRANSACTIONAL AISCLOSURE,RORM
The Town ofSouth Code of Ethicsmr ibit conflicts of intetpst o e art officers an emplov es he tZy�posc of
*t�is_form.is f,�provide in latioruwlrich can ale the toyvn of Tmqsiblii conflscts_of tntc st surd a11ow it to take wha c acti
neccary�o avoi me, jj
YOUR NAME; `i�� ca-rc 1.t C a-
(Last name,first namc,iriddlo initial,unless you arc applying to the name of
someone case or other entity,such as a company.If so,indicate thc.other
person's or company's name.)
NAME OF APPLICATION; (Check all that apply.)
Tax grievanoc _ Building
Variance Trostee
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,manage,or bwsincss 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 omployec owns more than 5%ofthc shares.
YES NO
Irydu an wercd"YES",,complete the balance of tliis form and date and sign where indicated.
Name of person employed by the Town of Southold
Title br position of that person
Describe the relationship bctwoon yourself(the applicalit/agFnt/represcntat►ve)and the town officer or employee.Either check
the appropriate iine A)through D)andlor 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);
]3)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,oe employee of the applicant;or
D)tho actual applicant
MCRIPTION OF RELATIONSHIP
Submitted this_---jay of_� 200_
Signature.
Print NaMe
Form TS 1
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