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Home My WebLink AboutC & L REALTY INC �p� y' V' 'f ii 3 TELEPHONE (516) 765-1892 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 July 2, 1986 Mr. George A. Cottral President C & L Realty Main Road Southold, New York 11971 Dear Mr. Cottral: The following action was taken by the Board of Trustees during their regular meeting held on June 26, 1986 regarding your request for a Waiver of the Wetland Ordinance. Moved by Trustee Smith seconded by Trustee Krupski WHEREAS, George A. Cottral has requested a Waiver of the Wetland Ordinance, Chapter 97, Article II, Section 97-22, and WHEREAS,- the Trustees have inspected the property in question and the . surrounding area, and WHEREAS, the project is an improvement to the premises in question, and the surrounding area NOW, THEREFORE BE IT RESOLVED that George A. Cottral be and hereby granted a WAIVER of the Wetland Ordinance for the installation of a cesspool on the premises with the provision that he work with the Health Department and that the area is stabilized after construction to prevent erosion or run off. Please take further notice that this declaration should not be considered a determination made for any other department or agency which may also have an application pending for the same or similar project. Thank you for your continued cooperation in this matter, and we look forward to working with you in the future. Very truly yours, Henry P. Smith, President Board of Town Trustees Ilene Pfifferli e' k HPS:ip cc: C.A.C. Bldg. Dept. Trustees Page 2 a , The applicant must recognize the sensitivity of the area. There should be minimal clearing during construction; no lawns on the wetland side of the house (area between house and marsh) ; plant appropriate vegetation on wetlands side of house; and insure nutrient flow (f.rom' fertilizers , etc. ) into the creek be minimal. No . 394 - Frank R. Reilly - Recommend approval with stipulations . The cabin and retaining walls are approved. The ramp and dock are de- pendent upon neighbors approval for .. access. If the path is to cross wetland the Council does not approve . No. 403 - John Becht - Recommend approval provided the applicant follows the plans as sketched with elevation ever the spartina No. 40.4 - Goldsmith' s Boat Shop - Recommend approval. No. 405 - Mark Baxter - Recommend _a'pproval with stipulations . 1 . All drainage must be on property. 2 . Minimal clearing of vegetation. 3. Plant 10 ' of vegetation on wetland side of house, no lawn! No. 406 - Richard Anderson - Recommend' 'approval. No . 407 - Arnold Blair - .Recommend approval but keep the retaining wall in a straight line. No. 408 - The Nature Conservancy = Tabled. No. 409 - Douglas Miller - Tabled. The Council is to request additional info from applicant, but , at this time does feel it will need an EIS , Type I No. 410 - Sal R. Varano - Recommend approval' with stipulation. Replace bulkhead in place , do not move out as shown in plans . No. 41l - John Morse - Recommend approval . No. 412 - Nicholas J . Cutron - Recommend dis•ap'proval. No need for bulkhead - the slope is vegetated, there is no erosion, it is not subject to extreme storm conditions and there are no other bulkheads to either side. No. 413 Douglas Moore - Recommend approval . No. 414 - C & L Realty - Recommend approval. 1 , O Ln by Town Hall, 53095 Main Road P.O. Box 1179 TELEPHONE n �9�� Southold, New York 11971 - (516)765-1801 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL July 28, 1986 To: Southold Town Trustees From: Southold Town CAC Re: Applications reviewed by CAC at the regular meeting held July 22, 1986 No . 398 - Harold Wilsberg - Recommend disapproval - The Council would like the applicant to either resubmit or °.amend the application for only a floating dock and no bulk- head. The Council recommends the floating dock instead of the bulkhead to allow for the extensive colonization of spartina which would stabilize the land and reduce the need f6r any bulkhead. No. 400 - Sal Caiola Recommend disapproval .- Th.e Council feels it is a naural shoreline with no other bulkheads adjacent to the property and the structure could cause erosion of the adjacent beaches . The Council suggests the applicant plant natural vegetation instead. No . 402 - Gerald Rupp '-' Recommend disapproval The Council disapproves because the slope is- in good condition and is holding as is . I'f th.e applicant does anything further it could disturb the natural vegetation which would lead to serious erosion problems. The Council does recommend the repair of the stairs and existing bulkhead. They suggest the applicant either amend or resubmit the applicatic to do the repairs suggested and placing a small deck at the base of the stairs but proposing no retaining walls . No. 319_ - Ted Dowd - The Council feels a full EIS is neccessary . Significant Type I action. It should be discussed publicll. and allow imput from interested parties at the hearing. No . 388 - Leonard Schlegal - Recommend _approval' with stipulations . lee. �db olvi app/ic��ion {'ar /* �o1oce�er�t o� two 4 . ris e is /D Aes tip &iwopey P..,,om Q.ac1 one i� d,,�,"eAer. tO>hat Ive are doioj %S jo,,a"Yu �s;od;7 /orc - r�,�%a,�?� a�s �ys�r.� 6vt cvii/ be GvasKir� d;iftL,&Al �f, J��►�o/k Cowivv Me*/fi, �► c#..ec� � u� r�dc any ar#d all 49 wot yak Your aoe 7 ,�L'T..,c� r- RESOLUTION - June 26, 1986 C. &. L. Realty, Inc. RESOLVED that the Southold Town Trustees-declare itself lead - agency in regard to the State Environmental Quality Review Act in the matter of the application of George A. Cottral on Behalf of C. L.- Realty, Inc. for a Wetland Permit on certain property located at Main Road, Southold, N.Y. 11971 TELEPHONE (516)765-1892 BOARD OF. TOWN. TRUSTEES TOWN OF SOUTHOLD Town.Hall, 53095 Main Road P.O. Box 728 -Southold, New York.-119.71 f "APPLICATION - IS HEREBY MADE 'TO :THE -:TOWN TRUSTEES, OF THE TOWN 'OF,, . SOUTHOLD, SUFFOLK COUNTY, NEW YORK :FOR' THE, ISSUANCE '.OF `A PERMIT . PURSUANT TO ` THE LAWS, .vORDINANCES AND REGULATIONS GOVERNING- THE COASTAL AND INTERIOR WETLANDS,, • F.LOOD PLAINS AND 'DRAINAGE AREAS ' OF -THE TOWN OF SOUTHOLD, -AN.D',THE ISSUANCE OF. PERMITS PURSUANT TO CHAPTER 3'2 ' OF THE CODES. .OF THE TOWN OF SOUTHOLD. { APPLICATION NO..__^— _I 1 _-- —DATE OF, APPL I CAT I ON_—� 3Z� i DENT 1 TY:, OF. APPL I;CANT ` QL _ C --- —(•�/�D PHONE NO ADDRESS OF APPLICANT �I TAX MAP NO._ _�_—. ' ----- - --------------------- ----- AGENT _L JFHO VE NO PERMIT REQUESTED .TO _ ,�.— Q , hh C spIt-) t 7-I0Z. " ---=------------- - - ------ ------------------------------ LOCATION OF PROPERTY FOR WHICH. PERMIT WANTED AALIIS _IC( --- — — ---------- _ -=--=--=--=----------=---- ---=----=- HOME ADDRESS OF PERMIT. APPLICAN.T IF. DIFFERENT .FROM AFORESAID. LOCATION (SIGI ��__.. ' .�L1L..t��.L_��—�'L=--- • CREEK, B' AY` OR HARBOR FRONT Nei PROPERTY SIZE' .OF PROPOSED WORK _ _ __C� SL _/ (A�C9�-5 --------' LENGTH---- ———————— — — -- ---- — ———————————————— ----------- WIDTH HE I GHT ABOVE HIGH WATER -- —Q�,-r-- ----- DEPTH BELOW LOW WATER ------- ------------- YARDS TO BE EXCAVATED I ' YARDS. TO BE FILLED WIDTH. OF CANAL, CREEK OR .BAY, FRONTING -PROPERTY-- —_----- DEPTH AT LOW TIDE 77 AVERAGE. RISE IN TIDE - -- q-------------- —r— ^— --_-- -- — DISTANCE TO THE NEAREST CHANNEL;_ ! Q U FT t ;. DISTANCE PROJECT EXTENDS BEYOND SIMILAR PROJECTS,, -IN THE_ AREA I S• TH I.S . FOR PRIVATE OR BUS'I NESS USE AREA ZONING MANNER .,1 N WHICH MATER 1 AL W:1 L.L BE REMOVED OR DEPOS.1 TED_ � � cl INTENDED .USE; ,OF PROPERTY'� L..-_ "t'(�?.I. LY� �sL DESCRIBE ANY`.KNOWN PRIOR OPERATIONS CONDUCTED .ON ..THE.-PREMISE ------ — . : AND -'WHETHER ANY PRIOR LICENSE OR. PERM ITS 'HAVE BEEN, ISSUED TO ERECT STRUCTURES OR TO DREDGE OR DEPOSIT FILL -ON' SAID PREMISES AND WHETHER ANY PERMITS OR-,LICENSES- WERE- EVER SUSPENDED OR REVOKED BY A GOVERNMENTAL AGENCY —_ L ._ I�lt..I a - ----------------- - --------- -- -- DESCRIBE' .FULLY 'THE REHABILITATION AND PROPOSED CONDITLON' OF THE PREMISES AFTER THE WORK_ 18 CO MPLBTED INCLUDE AN ADDITIONAL SURVEY' OF THE PROJECT SITE I F NECESSARX _ � --' �� `(�DJ� � 1N L---------------------- .�-_ _ - WR 1 TTEN CON66NT OP''?THE OWNER ORf'THE':. PROPERTY IV NOT THE SAMti AS .THE APPL-1;CANT.` _ ----------------------- ------.. ti f� - ----•�. ----� -_ •�- ..... .�_ - _-_ _- .-------.. ----------- .-^- ARE. THERE ANY COVENANTS, OR:RESTRICTIONS IN YOUR DEED THAT WOULD PROHIBIT THIS..-PROJECT? �� BOARD OF TOWN TRUSTEES -- - TOWN-OF. SOUTHOLD - - SHORT ENVIRONMENTAL ASSESSMENT FORM Project Informatlon (To be completed by Applicant or Project sponsor) j �p�� Eft�T. f�I0 i 1. Applicant/sponsor 2. Pro ect Name o� I— ' 41'-r� c Or 3. Project location: Municipality �?� �� County f L 4. Is proposed action: i ❑ New ❑ Expansion Modification/alteration S. Describe project briefly: �� f �� C)iV f p C�3SP�L /�f K9 c.- Zu 1174 � 6. Precise location(road intersections,prominent landmarks,setc.or providemap) /O p ► .; �'��/ � �J� `S ��t �z•'ZtS�tnJ .f�6�T 0..� �-�,Oj a�J "�` rIV� �—,(1A � • �l-��bfJ �fil�lll� f13��}j� WI L,LE� f��►�� ( J' 7. Amount of land affected: Initially acres Ultimately acres 8. Will roposed action comply with existing zoning or other existing land use restrictions? Will ❑--No If No,describe briefly 9. What is present land use in vicinity of project? El Residential El industrial 19 Commercial ❑ Agriculture ❑" Parkland/open space ❑ Other Describe: 10. Does action involve a permit/approval,or funding,now or ultimately,from any other governmental agency(Federal,state or local)? ❑ Yes No If yes, list agency(s)and permit/approvals 11. Does any aspect of the action have a currently valid permit or approval? ❑ Yes No If yes, list agency name and permit/approval type 12. As result of proposed action will existing permit/approval require modification? ❑ Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE 15 TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: � ��J!:n GS Date: Signature: �� f � PART II Environmental Assessment (To be completed by Agency) A. Does action exceed any Type I threshold in 6 NYCRR, Part 617.12? If yes,coordinate the review process and use the FULL/LONG FORM EAF. ❑ Yes ❑ No . ..... B. Will action receive coordinated review as provided for Unlisted Actions in 6 NYCRR, Part 617.71 If No,a negative declaration may be superceded by another involved action. ❑ Yes ❑ No C. Could action result in ANY adverse effects on,to,or arising from the following:(Answers may be handwritten, if legible) C1. Existing air quality,surface or groundwater quality or quantity,noise levels,existing traffic patterns,solid waste production or disposal,potential for erosion• drainage or flooding problems?Explain briefly: C2. Historic,archeological,visual or aesthetic,or other natural or cultural resources;agricultural districts;or community or neighborhood character?Explain brief C3. Vegetation or fauna,movement of fish or wildlife species,significant habitats,orthreatened or endangered species?Explain briefly: r 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. Secondary,cumulative,or other effects not identified in C1-C6?Explain briefly. C7. A change in use of either quantity or type of energy? Explain briefly. 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. ❑ 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/LONG FORM 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 action WILL NOT result in any significant adverse environmental impacts AND provide here, and on attachments as necessary, the reasons supportng this determination: Agency Name .Agency Preparer's Name Preparer's SignaturerTrtle Date PART II Environmental Assessment(To be completed by Agency) . A. Does action exceed any Type I threshold in 6 NYCRR,Part 617.12? If yes,coordinate the review process and use the FULLILONG FORM EAF. El Yes ❑ No "` B. Will action receive coordinated review as provided for Unlisted Actions in 6 NYCRR,Part 617.7? If No,a negative declaration may be superseded by anotl involved action. ❑ Yes ❑ No C. Could action result in ANY adverse effects on,,to,or arising from the following:(Answers may be handwritten,if legible) C1. Existing air quality,surface or groundwater quality or quantity,noise levels,existing traffic patterns,solid waste production or disposal,potential for erosic drainage or flooding problems?Explain briefly: C2. Historic,archeological,visual or aesthetic,or other natural or cultural.resources;agricultural districts;or community or neighborhood character?Explain br C3. Vegetation or fauna,movement of fish 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. Secondary,cumulative,or other effects not identified in C1-C6?Explain briefly. C7. A change in use of either quantity or type of energy?Explain briefly. 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 otherwis, 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 supportin( materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identifies and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Thet proceed directly to the FULL/LONG FORM 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 action WILL NOT result in any significant adverse environmental impacts AND provide here, and or attachments as necessary, the reasons supportng this determination: Agency Name Agency Preparer's Name Preparer's Signature:Trtle Date BOARD OF TOWN TRUSTEES: TOWN. ..OF. SOUTHOLD SHORT ENVIRONMENTAL ASSESSMENT FORM Project Informatlon (To be completed by Applicant or Project sponsor) 1. Applicant/sponsor 2. Project Name 3. Project location: Municipality County 4. Is proposed action: ❑ New ❑ Expansion ❑ Modification/alteration 5. Describe project briefly: 6. Precise location(road intersections,prominent landmarks,etc.or provide map) 7. Amount of land affected: Initially acres Ultimately acres 8. Will proposed action comply with existing zoning or other existing land use restrictions? ❑ Yes ❑ No If No,describe briefly 9. What is present land use in vicinity of project? ❑ Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Parkland/open space ❑ Other Describe: 10. Does action involvg-a,permit/approval,or funding, now or ultimately, from any other governmental agency(Federal,state or local)? El,,,Ye-1p, r,�r0•t{b' of"yes,list agency(s)and permit/approvals 11. Does any aspect of the action have a currently valid permit or approval? ❑ Yes ❑ No If yes, list agency name and permit/approval type 12. As result of proposed action will existing permit/approval require modification? ❑ Yes ❑ No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE 15 TRUE TO THE BEST OF MY KNOWLEDGE ApplicanUsponsor name: Date: Signature: COUNTY OF SUFFOLK ) STATE OF NEW YORK ) SS: Co I I( AL f�jC� BEING DULY SWORN DEPOSES AND SAYS THAT HE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS., AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS KNOWLEDGE AND BELIEF , THAT THE WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE TOWN BOARD OF THE TOWN OF SOUTHOLD. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT, IF GRANTED. In completing this application I hereby authorize the Trustees agent or representative to enter onto my property to inspect the premises in conjunction with review of this plication SIGNA RE OF APP ICANT SWORN TO FORE ME THIS i DAY OF , 19 NOTARY PUBLIC „Fy,�* 1 11�reb ,1 EXAMINED APPROVED "WETLANDS" PERMIT (CHAPTER 97) APPROVED "BOAT, DOCKS, .WHARVES" PERMIT (CHAPTER 32) DISAPPROVED "WETLANDS PERMIT" (CHAPTER 97) DISAPPROVED "BOATS, DOCKS, WHARVES" PERMIT (CHAPTER 32) CONDITIONS , IF ANY EXAMINING BODY SIGNATURE OF CHAIRMAN COMPUTATION OF FEES Approved 2/27/85 .` ....... IT _"" �' _'141�`tP ^�� r _ a ' K 1 1 ;,V .' i'•ly; rt At 1 ! . PI YTF ( • , �'.� .•j 1....1 1 till :, ( ! Oy19i <1kRPlaf,'4v I � •,. ..wit{ � � �`�,' �°- yy , f•`r ,_, 19y,c1'. %.� JM. �)'111y1 vly�I IN , .• n r' ~xncia tVfVj ( Vv U � .4 SIN, ►► �� • p. ..moo ...�- 5k1►dvl ,t'i .. �� `;�m fr •.�� + :L -AN�CI pow ��..// m r •ij „i �+�y� 1�� ,. � �j r r Q nj �. 04 SAW., IDIO . Z 96 7E77, .. _ .. ^k. .77 (261 �E {. TELEPHONE (516) 765-1892 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 June 18, 1986 Mr. Martin Garrell, Chairman Southold Town Conservation Advisory Council Southold Town Hall Southold, New York 11971 Dear Mr. Garrell: Transmitted herewith is application no. 414 for ' a wetland permit submitted by George A. Cottral on behalf of C.. & . L. Realty Inc. Please prepare a written report of findings and recommendations with respect to this application. Ver trul yo rs, (a.• a Henr P. Smith, President Board of Town Trustees Ilene Pfi ff erlin g Secretary to Board Attachment �Aw TELEPHONE (516) 765-1892 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 June 18, 1986 Mr. Charles T. Hamilton Alternate Regional Permit Administrator N'.Y. S. D.E.C. Building 40, SUNY - Room 219 Stony Brook, New York 11794 Dear Mr. Hamilton: Transmitted herewith is wetland application no. 414 submitted by George A. Cottral on behalf of C. & . L. Realty, Inc. We would like to coordinate with you in our role as lead agency regarding this application. May we have your comments on same by July 16, 1986 . Thank you for your input. Very truly yours, Henry P. Smith, President Board of Town Trustees Ilene Pfifferling Secretary to Board Attachments cc: Commissioner Williams Southold Town Building Dept. file HENRY P. SMITH, President - OHN M. BREDEMEYER, Vice-Pres. TELEPHONE J *� Y' ►yy (516) 765-1892 PHILLIP J. GOUBEAUD ALBERT KRUPSKI, JR. �' ELLEN M. LARSEN �� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 June 18, 1986 To whom It May Concern: Attached hereto is a Short Environmental Assesment Form submitted by George A. Cottral on behalf of C. & L . Realty; Inc. in connection with their application for a wetland permit ' to put in one 8 ' and one 10 ' cesspool on property located at Main Rd. , Southold, N.Y. Very truly yours • 1 Henry P. Smith, President Board of Town Trustees..' HPS: ao Posted: 6/27/86 RESOLUTION - June 26, 1986 C. &. L. Realty, Inc. RESOLVED that the Southold Town Trustees declare itself lead - agency in regard to the State Environmental Quality Review Act in the matter of the application of George A. Cottral on Behalf of C. L. Realty, Inc. for a Wetland Permit on certain property located at Main Road, Southold, N.Y. 11971 l BOARD OF TOWN TRUSTEES i TOWN OF SOUTHOLD • — - i 53095 Main Road Phone 765-1892 �® 312 2 2 a i Southold, N. Y. 11971 Date RECEIVED OF ozl K r�"�1 / Dollars n /7 For BOARD OF TOWN TRUSTEES Cash 0 check �U /g,� �� ' By�c�- ell- HENRY P. SMITH, President ~ :'� TELEPHONE JOHN M. BREDEMEYER, Vice-Pres. C= Ln (516) 765-1892 PHILLIP J. GOUBEAUD ELL JR EN M. LARSEN BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 June 18, 1986 To Whom It May Concern: Attached hereto is a Short Environmental Assesment Form submitted by George A. Cottral on behalf of C. & L. Realty, Inc. in connection with their application for a wetland permit to put in one 8 ' and one 10 ' cesspool on property located at Main Rd. , Southold, N.Y. Very truly yours Henry P. Smith, President Board of Town Trustees HPS: ao Posted: 6/27/86 BOARD OF TOWN TRUSTEES. -- TOWN ..OF. SOUTHOLD SHORT ENVIRCINMENTAL ASSESSMENT FORM Project Information (To be completed by Applicant or Project sponsor) 1. Applicant/sponsor 2. Project Name -Jr=x o OPT EJ-56IT14w 3; Project location: Municipality County �- 4. Is proposed action: ❑ New ❑ Expansion Modification/alteration 5. Describe project briefly: 00`I;� pQ k,A�6F , } PtPr+ t- I tare . /fir� S �� F�.r�� }�tefgI� �16 6. Precise location(road intersections, prominent landmarks,etc.or provide map) A) —�)F,k-fir. R��D� v�`�-�l��oJ� IqL(30�TSW ()1A(0z /Ut?4,C W1 L.LVT,0 /POI AT 7. Amount of land affected: Initially acres Ultimately acres 8. Will roposed action comply with existing zoning or other existing land use restrictions? Yes 0—No If No,describe briefly � i 9. What is present land use in vicinity of project? ❑ Residential ❑ Industrial Commercial ❑ Agriculture ❑ parkland/open space ❑ Other Describe: 10. Does action involve a permit/approval,or funding,now or ultimately,from any other governmental agency(Federal,state or local)? ❑ Yes X No If yes,list agency(s)and permitlapprovals 11. Does any aspect ofthe action have a currently valid permit or approval? ❑ Yes lCy No If yes,list agency name and permit/approval type 12. As result of proposed action will existing permit/approval require modification? ❑ Yes No I CERTIFY THAT THE INFORMATION PROVIDED `lABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE I F Applicant/sponsor name: C �� ( �Y/ I—V4 vt Date: ( +� Signature: � C� ,