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HomeMy WebLinkAboutTR-2097 James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen Jolm Bredemeyer Michael J. Domino Town Hall Annex 54375 Route 25, P.O. Box 1179 Southold, NY 11971 Telephone (631 ) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: ~ ii_) a ~_)fi~f- Please be advised that your application dated ;;L/bl.q/I 0-' has been reviewed by this Board at the regular meeting of ~ }~1 ~ I ~ and your application has been approved pending the c~le{ion of the following items checked off below, __ Revised Plans for proposed project Pre-Construction Hay Bale Line Inspection Fee ($50.00) __ 1st Day of Construction ($50.00) ~ Constructed ($50.00) ~ Final Inspection Fee ($50.00) __ Dock Fees ($3.00 per sq. ~.) Pe~it fees am now due. Please make check or money order payable to Town of Southold. The fee is ~mputed below accoffiing to the schedule of rotes as set fodh in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessa~. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $ ~(O; DF) BY: James F. King, President Board of Trustees James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631) 765-6641 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 Ist day of construction ½ constructed Project complete, compliance inspection James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 Mamh 21, 2012 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. David Melrose Melrose Madne Service, Inc. 123 Huron St. #2 Brooklyn, NY 11222 RE: WALTER BLUM 260 ROBINSON RD., GREENPORT SCTM#34-5-12 Dear Mr. Melrose: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wed., March 21, 2012: WHEREAS, Melrose Marine Service, Inc. on behalf of WALTER BLUM applied to the Southold Town Trustees for Transfer of Wetland Permit #2097 from Robert E. Copas, as issued on November 27, 1985 and an Amendment to Wetland Permit #2097 under the provisions of Chapter 275 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated February 29, 2012, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator for their findings and recommendations, and, WHEREAS, in accordance with Chapter 268, said application was found to be Exempt from the Local Waterfront Revitalization Program policy standards, and, WHEREAS, the project complies with the standards set forth in Chapter 275 of the Southold Town Code, and, WHEREAS, the Board has determined that the project will not affect the health, safety and general welfare of the people of the town, and, NOW THEREFORE BE IT, RESOLVED, that the Southold Town Board of Trustees APPROVES the Transfer of Wetland Permit #2097 from Robert E. Copas to Walter Blum, as issued on November 27, 1985, and, BE IT FUTHER RESOLVED, that the Southold Town Board of Trustees APPROVES the Amendment to Wetland Permit #2097 for the existing 4'X 15' ramp and 8'X 70' floating dock and to replace the storm-damaged pilings to secure the float, and as depicted on the site plan prepared by Melrose Marine Service, Inc. dated November 2011 and stamped approved on Mamh 21, 2012. This is not a determination from any other agency. Sincerely, Jarn~s F. King, Presi(;~efit Board of Trustees JFK:lms Peter Young, Chairman Lauren Standish, Secretary Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631 ) 765-1892 Fax (631) 765-6641 Conservation Advisory Council Town of Southold At the meeting of the Southold Town Conservation Advisory Council held Wed., March 14, 2012 the following recommendation was made: Moved by William McDermott, seconded by Jack McGreevy, it was RESOLVED to SUPPORT the application of WALTER BLUM to Amend Wetland Permit #2097 for the existing 4'X 15' ramp and 8'X 70' floating dock and to replace the storm- damaged pilings to secure the float. Located: 260 Robinson Rd., Greenport. SCTM#34-5-12 Inspected by: Jack McGreevy, William McDermott, Doug Hardy The CAC Supports the application, however, recommends a plan to address the stormwater run-off, the installation of a non-turf buffer between the bulkhead and the deck and a non-disturbance buffer in the undeveloped area north of the end of the bulkhead. Vote of Council: Ayes: All Motion Carried James F. King, President Bob Ghosio, Jl., Vice-President Dave Bergen .Iohn Brcdemeyer Michael J Domino PO Box II79 Southold. NY 11971 Telephone(631 765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: Melrose Marine Service, Inc. on behalf of WALTER BLUM requests a Transfer of Wetland Permit #2097 from Robert E. Copas to Walter Blum, as issued on November 27, 1985, and an Amendment to Wetland Permit #2097 for the existing 4'X 15' ramp and 8'X 70' floating dock and to replace the storm-damaged pilings to secure the float. Located: 260 Robinson Rd., Greenport. SCTM#34-5-12 T~warea to be impacted: ater Wetland Freshwater Wetland Sound Bay Dista, pce of proposed work to edge of wetland Town Code proposed work falls under:' Chapt.275 Chapt. 111 other Type of Application: __ Wetland __Coastal Erosion __Amendment __Administrative__Emergency Pre-Submission __Violation Info needed: Modifications: Conditions: ..~',,¢¢~-~ ~ ~ ,"~/ ~..s(~nt ~rW~ere: /~. Ki/R8- ~-B. Ghosio · B edeme~- /,//'-M~chaet Domino __ D. Bergen, D. Dzenkowski Form filled out in the field by Mailed/Faxed to: Date: __.other SiTE PI~OTO AND I~AP FROM (A) LOOKING WEST/NORTHWEST SHOWING THE LOCATION OF THE MISSING PILE MAP MELROSE APPLICATION Walter Blum At: 320 Robinson Rd, On: Sterling Harbor PO: Greenport County: Suffolk State: NY All Photos taken at Low Water (+,3') 4;30pm 10110tll Winds: Northeast at 10-15 Knots - Moon 95% visable Sheet 1 OF 1 (including PHOTO MAP) Board Of $outhold Town SOUTHOLD, NEW YORK Mooring No. N/A PERMIT NO...2.9~.7 ................. DATE: ...~.~t...'~.7..f. .... !SSl~lF~.q TO Robert E. Cogas Pursuant to t~ pmvi~ions of ~Chapt~ 6~15' of the ~w~ of · '~-fhe ~a~ ~Ne~ York; 893, and ~ter ~ pf ~e ~ ~.fhe ""Sfa~e Of Ne~ ~or~ '.19s2;~n~ ~ 'S~hoid T~,' Ordinan~ ';~NI~ "R~U~TIN~ ~ T~E P~CIN~ OF OBSTRUC~ONS by causes'ifs C~orporate Se~l fo be subscrlbedl by a majority of the )R 'O~HER and. in 'acCord ,: the Resolution of The Board adopted at a meefin9 held on 19~....5.._.., and in ¢onslderafian of:th,e-sum of $..~..0..9. ........ paid by .................................... ......................................................................... of ......G..~.e....e..~g.~.!~ ..................................................... N, Y. ~nd subject to the Terms and C~ond~tlons listed on the rev~e si;lo hereof, of Southold Town Trustees authorizes and permffs the follow,ng: Application approved to secure a permit for a 8' x 4~' section of dock and three pilings in Sterling Creek, Greenport, all in ac¢ordaflce a~kth the, appl~ga,~io~, ~b~itt.~.d .. m accoraance wi?n The ae?a~ea spec,TtC~TIOnS as presented in the originating application. IN WITNESS WHEREOF, The said Board of Trustees kere- t~[~sents to Please tear off and return to the Trustee Office. TERMS and GONDITIONS T~e P~mlttee Rober: E. Copas · ~dl-g at 260 Robinson ~oad, Greenport N. ¥, -. p~t o: ti~e co~idaa~o~ fo, ~,~ ~ ~ ~ ~ ~ ~&l~ ~ ~ ~ ~ :~.. ]~: 1. ~t ~ T~st~ Pe~t ~st ~ p~y ~la~ on ~e p~s ~f~ ~ d~inc~ ~e ~i~ 0f ~rk ~d~ ~e ~t. 1. ~ac ~e s~d B~d of I'm~s ~d ~e Town ~ ~old. ~ ~ f~ ~ ~ ~ ~% or ~ for d~ag~, of ~ ~ ~y ~ ~y m s ~,l~ of ~ o~- a~ ~0~ ~t to thk ~ ~ ~e ~d P~ ~ ~ ~ ~ ~ ~ ~& ~pert ~erem, m ~e ~mplete ~cl~on o~ ~e ~ ~ T~ ~ ~ Toga ~ ~M 2. That this Permit is valid for, a period of 12 . mos. which is considered to be the estimated time requited, to coml~lete the work involved, but sho-~dd citmmr~ances warrant, cequest for aa extension may be ,made ~a the Board at a later dat~ 5. That this Permit sh0~dd be r~ialned indefinitely, or as long a~ the said Penni~'~ wishes "to maintain the stmcutce or project involved, to provide evidence to anyone ~oncemed that a~th- orlz~tfion was offlglnally obtained. 4. That the wOrk involved will be subject to the inspection sad approval of tim Board or ,its agen~ and non-compHaace with the provisions of the originating applkation~ m~y be ~,,~ for revocation of this Petmlt by resolution of the said Board. 5. That there will be no utweasonable interf~ence with navigation a~ a r~ult of th~ wo~ herein authorized. 6. That there shah be no interference with the right of the. public to pass and tepa.~ along the beach between high a_nd low water marks. 7. That if future Operations of the Town of SouthOld require the l~moval aad/or alter~tinm in the location of the work herein authorized, or if, in the opinion of tim Board of Tmste~ d~ work ~hal! cause unreasonable ohstrumon to free navigation, the said P~tt~ will be r~pdred, upon dae notice~ to r~move or alter this work or project herein stated without ~xpan.~ to th~ Town of Southold. S. That the said Board will be notified by the Permittee ot the completion Of the work auth- otized. 9. That the Permittee will obtain aH other permits and comen~ thst may plemental to this I~ermlt which may be subject to revoke upon failu~ to (5;a tear oft~ sh~t. ) BO&RD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, $3095 Main Road P.O. Box 728 Southold, New York 11971 T~LEPHONE (516) 765-1892 APPLICATION IS HEREBY MADE TO THE TOWN TRUSTEES OF TNE TOWN OF SOUTHOLD, SUFFOLK COUNTY, NEW YORK FOR THE ISSUANCE OF A PERMIT pURSUANT TO THE LAWS, ORDINANCES AND REGULATIONS GOVERNING TH~ COASTAL AND INTERIOR WETLANDS, FLOOD PLAINS AND DRAINAQE' AREAS OF THE TOWN OF SOUTHO; D, AND THE ISSUANCE OF PERMITS PURSUANT TO CHAPTER 32 OF THE CODES OF THE TOWN OF SOUTH0~P. APPLICATION NO. DATE OF APP~ AGENT ........ .pHONE NO._~_ ~i' lgOCAT I ON .OF pROPERTY HOME ADDRESS OF PERMI T CREEK, SAY OR HARBOR SIZE OF PROPOSED WORK WIDTH HEIGHT ABOVE HIGH WATER / / APPLICANT IF DIFFERENT FROM AFORESAID ~:ATION FRONTING PROPERTY_ ~ -, , DEPTH BELOR LOW WAT~ WIDTH OF CANAL, CREEK OR BAy FRONTING PROPERTY DEPTH AT /.OR TIDE AVERASE RISE IN Ti.~ ~C D / DISTANCE To THE NEA~ST CHANNEL____O______FT. DISTANCE PROJECT EXTENDS SEYOND SIMILAR PROJEOTS AREA EONI NG MANNER IH WHICH MATERIAL WILL SE REMOVED OR DEPOSITED DESCRIBE ANY KNOWN PRIOR OPERATIONS CONDUCTED ON THE STRUCTURES OR TO DREDGE OR DEPOSIT FILL ON SAID PREMI~E~ ~ND. IHETHER ANY PERMITS OR LICENSES WER~ EVER ~SPEflDED OR REVOKED BY A - --' '~ ~[ L~OV~R""E"--A- Fu~y AND PROPOSED CONDITION OF THE PREMISEs AFTER THE WORK IS COMPLETED INCLUDE Afl ADDITIONAL SURVEy OF THE PROJECT SITE IF NECESSARY' WRITTEN CONSENT OF THE OWNER OF THE PROPERTY, APPLICANT. IF'NOT THE SAME AS THE YOUR DEED THAT WOULD BOARD OF TOWN TRUSTEi TOWN OF SOUTHOLD SHORT ENVIRONMENTAL ASSESSMENT FORM Project Information (To be completed by Applicant or Project sponsor) 2. Project Name g. What.[~.ptesqrtt land use in vicinity el project? [~Resldential [] Indust,ial ~Commerclal [] ABricultur. D Parkland/open space ~ Othe, Does acti.~t involve ~1 pe~mjUapproval, or funding, now or ultimately. Irom any other ~overnmental a~ncy (Federal. state ~Ye~ ~ No If yes, list agent,s) and ~rmiEapprova~s D~ a~y at.ct of ~h Iron have a currently valid ~rm~l or approval~ D Yes ~ If ye;, list agency name and ~rmi~approval type [] Ye, , I CERTIFY THAT THE INFORM^TION PROVIDED ABOVE IS TRUE TO TtiE DES1' OF MY KNOWLEDCE Date COUNTY OF SUFFOLK STATE OF NEW YORK )SS: BEING DULY SWORN DEPOSES AND SAYS THAT HE IS THE APPLICANT FOR THE ABOVE DESCRIBED PEF~'~ITS, AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS KNOWLEDGE AND BELIEF, THAT THE WORK WILL BE BONE IN THE MANNER BET FORTH IN THIS APPLICATION AND AS MAY DE APPROVED BY THE TOWN BOARD OF THE TOWN OF SOUTHOLD, THE APPLICANT ASREBS TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND ;REE FROM ANY AND AL'_ DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PER~]'r, IF GRANTED. SWORN TO BEFORE HE THIS /,:2- DAY OF 'BY. MINED MARY BESS PHILLIPS ~O'~ARY RU6LIC, ~Jale oJ NIW Nm 469091.5 APPROVED "'WETLANDS" PERMIT (CHAPTER 97) APPROVED "BOAT,DOCKS, WHARVES" PERMIT (CHAPTER 3Z) DISAPPROVED "WETLANDS PERMIT" (CHAPTER 97) (CHAPTER EXAHINING BODY SIGNATURE OF CHAIRMAN COMPUTATION OF FEES ' ~ . ~BOARD~F ~TOWN TRUSTEES TOWN' OF 8OUTHOLD s~095 M~ ~o~ P~o~o 76s-,ag: N9 ~ ~0840' Southoid, N. Y. n971 .,qA / - BOARD OF TOWN TRUSTE~ES t N OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY 11971 MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971 Telephone: 631 765-1938 Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Jim King, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: March 15, 2012 Re: Proposed Wetland Permit for WALTER BLUM SCTM#1000-34-5-12 Melrose Marine Service, Inc. on behalf of WALTER BLUM requests a Transfer of Wetland Permit #2097 from Robert E. Copas to Walter Blum, as issued on November 27, 1985, and an Amendment to Wetland Permit #2097 for the existing 4'X 15' ramp and 8'X 70' floating dock and to replace the storm- damaged pilings to secure the float. Located: 260 Robinson Rd., Greenport. SCTM#34-5-12 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is EXEMPT from LWRP review pursuant to: § 268~3. Definitions. MINOR ACTIONS item "B" which states: B. Replacement, rehabilitation or reconstruction of a structure or facility, in kind, on the same site (inplace), including upgrading buildings to meet building or fire codes, except for structures in areas designated by the Coastal Erosion Hazard Area (CEHA) law where structures may not be replaced, rehabilitated or reconstructed without a permit and shoreline erosion control structures (including, but not limited to, groins, jetties, bulkheads, filled piers) located within Great Peconic Bay, Cutchogue Harbor, Little Peconic Bay, Hog Neck Bay, Noyack Bay, Southold Bay, Shelter Island Sound, Pipes Cove, Orient Harbor, Gardiners Bay, Long Island Sound, Fishers Island Sound and Block Island Sound (excluding all creeks); Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney Date: February 28, 2012 MELI SE MARINE SERVICE, INC. 500 ROBINSON ROAD GREENPORT, NY 11944 www.melrosems.com (631) 477-1546 Board of Trustees Town of Southold P.O. Box 1197 Southold, New York 11971-0959 Permit Transfer Request Permit # 2097 David Melrose, Melrose Marine Serv'ce Inc., Authorized Agent Re: Permit Transfer Request Permit # 2097 Walter Blum, 260 Robinson Rd. Greenport, NY 11944 Suffolk County Tax Map: Dist. 1000, Sect. 034, Block 5. Lot 12. Permit # 2097 - Date: Nov. 27, 1985 Issued to: Robert E. Copas Ladies and Gentlemen of the Board, Mr. Walter Blum of 260 Robinson Road in Greenport, New York and has authorized Melrose Marine Service Inc. to act as an agent in procurement of permits for his before stated property and all structures associated. Mr. B]um is asking the board lbr its permission to replace a single float pile located at the southern end of his dock damaged during hurricane Irene. The floating dock and accompanying float piles have been in their current location since the work conducted under Southold Town Permit # 2097 in 1985. All of the waterfront structures at this location have been in existence since Mr. Blums' purchase of the property from Mr. Robert Copas and were acknowledged by the town at that time. I have applied for the transfer of the existing Town of Southold permit number 2097 from the former owner Mr. Robert E. Copas to the current owner Mr. Walter Blum on February 10, 2012. In response to my request I have been informed that I will need to amend this permit to reflect the current conditions found on the survey provided. With this letter 1 am asking the board to make snch an amendment and allow fbr Mr. Blum to replace the storm damaged pile to secure his float and the vessels moored to it. Mr. Blum currently has permission for the New York State Department of Environmental Conservation to replace this and all floal pile in-kind and in-place as required dated February 22, 2012. (NYSDEC Permit # 1-4738-03384/000002) Included please find: Agent Authorizmion Form Two Copies of a Recent Survey LWRP Form Transaction Disclosure Form Short EAF Board of Trustees Form Current Photos of Structam Transfer Fee of $50 (to be hand delivered by MMSI) Please notify me of any fnrther information you may reqnire and 1 ;viii do my best to oblige. Thank You, David Melrose Environmental Consultant Melrose Marine Service Inc. 123 Huron St. #2 Brooklyn, NY 11222 34'?-742-779 ] d!L:_elro, c~L~e h'osenis.co n: 617.20 ta~e Appendix C S Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I - PROJECT INFORMATION (To be completed by ADplicant or Project Sponsor) 1. APPLICANT/SPONSOR /2. PROJECT NAME David Melrose / Melrose Marine Service Inc. /Blum Residence 3. PROJECT LOCATION: Municipality Southold County Suffolk 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) 260 Robinson Rd. Greenport, NY 11944 5. PROPOSED ACTION IS: [] New [] Expansion [] Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: Immediate emergency replacement of one existing float pile broken in Hurricane Irene and subsequent replacement of the four standing piles when and as required. This action is required to secure existing floating dock and sailboat moored to it. 7. AMOUNT OF LAND AFFECTED: Initially N/A acres Ultimately N/A acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EX ST NG LAND USE RESTRICTIONS? ~L~J Yes [] No If NO, describe briefly 9. WHAT IS PRESENT LAND USE IN V C NITY OF PROJECT? [] Residential [] Industrial [] Commercial [] Agriculture [] Park/Forest/Open Space [] Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? [] Yes [] No If Yes, list agency(s) name and permit/approvals: USACE Nationwide, US Dept of State Consistency Assessment and Southold Town Board of Trustees 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [] Yes [] No If Yes, list agency(s) name and permit/approvals: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? []Yes []No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: Date: Signature: If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II - IMPACT ASSESSMENT (To be completed by Lead A~lency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes, c~o~inate the review process a~d use the FULL EAF. B. WILL ACTION RECEIVE COORDINATED RE%flEWAS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR~ PART 617.67 if No, a negatlm declaralion may be supe~-,ded by enof~or involved agency. C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handw~tten, If legible) C1. F-$d$~ng ak quality, surtsce or gmundwate~ quality or quantity, noise levels, existing traffic paUem, solid waste preduc~oa or disposal, potentfat for erosion, drainage or flooding problems? F-d~laie bdefly: I C2. A~bL~[C, ~, k,ulld~ll, ~,.~m14o~lcaL historic, of other natural or ct~ural msotlrces; or comalul~ of asighb~od chara~ec? Explain b~y: I I ~.3. Vegefation or fauna, fish, ~efllish or wllddfe ~,. significant habitats, or threster~ or endangore~ ~,n~ ~? E.~ain bdeffy.' C4. A w,,,,.un~ s existing pts~s or goals as officla ly adopted or a change m use or intensity of use of [and ~x other natural msouroe$? Ex~a[a bdefly . · velopment, or re[ated activities hkely to be reduced by Ihe proposed action? F-x~aM briefly- C6 Longtorm shorttefm, cumula{we orothereffec~sno denhfledmCt-C5~ Explainbdefly: ! I C7. Other ~,~a~L~ (including changes in use of either quang[y or type of eries7? Explain bdefly: ...... O. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL ARF-R (CEAI? ~lf yes, explain briefly: [] Yea OR IS THERE UKELy TO I~, CONTROVERSY RELATED TO POTENTIAL ADVER~ ENVIRCNMC.%'TAL IMPACTS? PART III - ut:l~h-,iATiON OF &iG~ii~iCANCE (To be oompleted by A~ency) . IgS'g~UCTIOflS: For each adverse effe~ Identified above, de~etmi~e wflelfler ~ls substan~l, large, Impertant or o~hewdse s~gnificanL Each effe~ should be =__ _ _,~essed In coe~ with its (a) setting (i.e. urban or rural); (lb) pro,ability of oocutfl~; (c) duratlor~; (d) Irrevemlbility; (e) suffident detail to show grot ail relevant adveme impa~ts have been identified and adeflua~ ~ If question d of part il was checked Cdeck thfa bex If Yeu have adfaaranad, based on the informabea and ame/sls abeve and any suppali~ deeume~atloa, that ~ ~ ~ WILL NOT result In any · determinat~n, signlfioant adverse environmental Impacts AND p~0~e, off aUaohme~s as necassar/, Ihe rasso~ls suppo~ng Iht~ Board of Trustees Name of Lead Agency Print or Type Name of Responsible OffiT~Lead Agency SigJf&ture of Responsible Officer in Lead~ Date President Title of Responsible O~oer Signa~re of Preparer (If different eom responsible officer} Board of Trustees Application A'u TUORI ZATTON (where the applicant is not the owner) Walter Blum (print owner of prOPerty) 260 Robinson Rd residing at (mailing address) Greenpo~, NY 11944 do hereby authorize David Melrose of Melrose Marine Service inc. (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner' s signature) of Trustees Applicatio~ County of Suffolk State of New York ~~/~g'7'~'~ ~/~"7 __ BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR ~ ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HISnmR KNOWLEDGE AND BELIEF, AND THAT ALL WORK WrLL BE DONE rN THE MANNER SET FORTH.IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), 1~' GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONIUNCTION V~TH REVIEW OF THIS APPLICATION. Signature SWORN TO BEFORE ME THIS ~) ~ DAY OF t4/ac/~/7 b,~'-~' ,20_/,,~ Notary Public APPLICANT/AGENT/REPRESENTATIV~ TRANSACTIONAL DISCLOSURE FORM The Town of ~ous/hold's Code of Ethics orohibits conflicts ofinterast on the oart of town officem and emolovces. The oun~oS~ of this form i~ to om~de in for~alion which ~ ~e~ ~ to~ of ~ssibl~ coatlic~ of ~t~ ~d ~low il ~ ~ ~a~r a~n is ne~ ~ avoid ~me. someon~ ~1~ or o~r ~nti~, ~ch ~ a comp~. If so, indicat~ ~e o~r 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 (lf"Other', name the activity.) Do you pemonally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town qf~%uthgtd? "Relationship" includes by blood, n~arriage, o? business interest "Business interest" means a business, including a paanership, in which the town officer or employee has even a panini ownership of (oF employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO / 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 br position &that person Describe the relationship between yourseif (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 ~hild is (cheek all that apply): __?) the o?ner of greater than 5% of the shares of the corporate stock of the applicon! (when the applicant is a coq:~'afion); __.Bi the legal or 'eeneficial own.es of any interest in a non-corporate entity (when the applicant is not a corporation); __.C) an officer, dir~tor, pai'lnei', or employee of thc applicant; or ____.D) the: actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Submitted Signaturo Print Name 03/01/2012 11:54 171838~ ATLAS PHONE PAGE 81 Town of Southold Ao I~STRUCTIONS 1. LwRP coNSISTI~NCY ASSESSMENT F0KM ~ - ~ 2~2 All a~li~ ~r ~J~* ~cl~ing To~ of S~old ~;i~, sha~ ~pl~ ~is CC~ p~pm~ a~iom ~t sm subj~t ~ ~e T~ of S~thold Wat~t ~m~tm~ R~ Law. ~e~m~c is intended to s~l~t o~er ~f~on ~ by a To~ of ~old ~cy m~ng a d~e~inati~ of consist~cy. *~c~I minor ~empt acti~ i~ludin~ Bu~d~g P~mltx ~ other min~ter~l~mit~ not l~ated wffhin the Coaxml Erosion ff~rd ~rea. 2. Before answering the questions in Section C, the preparer of this f, nm should review the exenapt minor action list, policies and explanations o£ each policy contained in the Town of Southold Local Wate~'fi-ont Kevitalization Program. A proposed action will. be evaluated as to its significant beneficial and adverse effects upon thc coastal area (which includes all of Southold Town). 3. If any queStion in Section C on this form is answered "yes", theft the psuposed action may affect the achievement &the LWRP policy standards and conditions contained in the consistency review law. Thus, the action should be analyzed in more detail and, if n~essary, modified prior to making a determination that it is consistent to the maximum extent practicable with the LwRP pohcy standards and conditions. If an action cannot be certified as eonsistont with the LWRP policy stlmdards and conditions, it shall not be.underuiken. A copy of the LWRP is available in the following places: online at the Town of Southold's webalte (sontholdtown.northfork. net), the Board of Trustees Office, the Planning Deparancnt, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED AurlON SCTM# 03~ 5 12 The Application has been submitted to (check appropriate response): TownBoard [] Planni.gDept. [] BufldingDept [] Board of Trustees [] Category of Tow~ of Southold agency a~tion (check appropriate response): (a) Action undea'tak~u directly by Town agency (e,$. capital [] con.m~mtion, planning activity, agency regulation, land transaction) [] (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nat'ute and extent of action; Immediate emergency replacement of one float pile broken in Hurricane Irene an0 subsequent replacement of of any of the standing 4 pile as rec~uimd, 03/01/2012 11:54 1711 ATLAS PHONE PAGE 02 Location of'action: 260 Robinson Rd. Greenport, NY 11944 Site acreage: See Survey Present land use: Private Residential Pr~ent zoning classification: Residential If an application for the proposed action has been filed with the Town of Southold a~nlcy, the following information shall be provided: (a) Name of applicant: Walter Blum 870 Fairfeild Ave. Weatbury, NY 11590 (b) M.~iling addre~: (c) Tel~hone number:..,Lrea Code ( ) 516-993-0778 (d) Application number, ifany: Will the action be directly undertaken, require fimding, or approval by $ state or federal agency? Yes [] No [] ffyes, which state or federal agoney? NYSDEC-Wetlands Permit (received), USACE-Nationwide, US Dept of State-Consistency DEVELOPED COAST POLICY Policy l. Foster a pattern of development ~n the Town of Southold that enhances community character, preserves open space~ makes efficient use of infrastructure, makes beneficial use of a coastal Iocaflon~ and minimizes adverSe effects of development. See LWRp Section H~ - Policies; Page 2 for evaluation criteria. [] Yes [] No [] Not Applicable Attach additional sheets if n~essary Policy 2. Protect and preserve historic and archaeological resourc~ of the Town of Southold, LWRP Section HI - Policies Pages 3 through 6 for evaluation criteria ~=~ Yes [] No ~'~ Not Applicable 03/~1/2012 11:54 ~TLAS PHOKE Attach i~diti~.l ~h,~'t~ if n~-,~'y Policy 3. ~ ~ qu~ ~d ~ ~e ~ ~ ~e TO~ ~ ~id. ~ L~P ~on ~ - PoDdo P~e 6 ~rough I for evaluation ~ ~ Y~ ~ ~o ~ Not Appli~ble AUa°h: ~lditt~al shoots tf~ NATURAL COAST PO~CIF, S Policy 4. Minimize loes of fife, structures, and natural resources from floodb~ and erodou. See LWRP Section E[][- Policies Pages 8 through 16 for evaluation criteria [] Yes [] No [] Not ,ppii ble Attaoh ~ddltioaal shcc~ Policy $. Protect and improve water quality and supply in the TowR oF So~thold. See LWRP Section - Policies Pages 16 through 21 for evaluation criteria Yes [] No [~NotApplicable At~.~h additJo~aJ sheet~ Ifn~aty Policy 6. Pro*__~__ and restor~ the quality and function of the Town of Southoid eco~q including ~gnificant Coastal Fish and Wildlife l~ahitats and wetlands. See LWRP Section Ill - Policies; Pages 22 through 32 for evaluation criteria. [] Yes [] ~No[~ Not Applicable [] Yes [] No ~r] Not Applicable Policy 8. Minimize ~ d~._a-*Ion bi ToWn of ~ substances nd wastes. See LWRP Section Ill- Folici~; Pages ~4 throug138 ~oreydmatimrcdted~ * [] Yes [] No [] Not Applicable PUBLIC COAST POLICIES PoUcy 9. Prov/de for pub#c aeeess to, and recreaflonni use of, constal ,,~e~, public lands x~rces of the Towla of Southold. See LWRP SectiOn III- Pollei~ 11:54 [] Yes [] No ~] Not Applicable Crea~ed on :~ /2.~105 11:20 AM ME ROSE MARINE SERVICE, INC. 500 ROBINSON ROAD GREENPORT, NY 11944 www.melrosems.com (631) 477-1546 Date: February 10, 2012 To: From: Board of Trustees Town of Southold P.O. Box 1197 Southold, New York 11971-0959 David Melrose, Melrose Marine Service Inc., Authorized agent Re: Permit Transfer Request Walter Blum, 260 Robinson Rd. Greenport, NY 11944 Suffolk County Tax Map: Dist. 1000, Sect. 034, Block 5. Lot 12. Permit # 2097 - Date: Nov. 27, 1985 - Issued to: Robert E. Copas Ladies and Gentlemen of the Board, Mr. Walter Blum of 260 Robinson Road in Greenport, New York and has authorized Melrose Marine Service Inc. to act as an agent in procurement of permits for his before stated property and all structures associated. As his agent I would like to request a transfer of Town of Southold permit number 2097 from the former owner Mr. Robert E. Copas to the current owner Mr. Walter Blum. Included please find: A Copy of Permit # 2097 Original Application Forms Agent Authorization Form Recent Survey Transfer Fee of $50 Please notify me of any further information you may require and I will do my best to oblige. Thank You, ~2 .~,// ~ - David Melrose Environmental Consultant Melrose Marine Service Inc. 123 Huron St. #2 Brooklyn, NY 11222 347-742-7791 dmelrose~bmelrosems.com GARAGE DWELLING POOL DECK PLAN VIEW EXISTING SCALE:I" =20' ?."APPROVEDBY GUNITE POOL / / PROJECT NOTES: 1)THIS IS TO BE AN IN-KIND AND IN-PLACE REPLACEMENT OF THE BROKEN PILE. 2)EXISTING FLOAT AND RAMPTO REMAIN IN-PLACE. -6.25' PROPOSED NEW PILE TO REPLACE IN-KIND AND IN.PLACE PILE BROKEN DURING HURRICANE IRENE PREPARED BY: MAP3NE SER.V~CE INC. -3.75' PROPOSED: EMERGENCY REPLACEMENT OF BROKEN FLOAT PILE IN-KIND AND IN-PLACE DAMAGED IN HURRICANE IRENE ON: STERING HARBOR AR GREENPORT COUNTY: SUFFOLK STATE: NY APPLICATION BY: W. BLUM SHEET: 2 OF 2 DATE: NOVEMBER 2011 MELROSE MARINE SERVIC~ INC. SURVEY OF PROPERTY A T OREENPORT TO~rN OF SOUTHOLD SUFFOLK COUNTY, N.Y. SCALE' 1'= 30 NO~B~ 20, 20~1 JANUARY 25, 2012 (LOC, ~ND FLAGS) AREA= 1Z826 SO. ~ (TO TIE LINES) ELEVA liONS ARE REFERENCED TO NGVD DA TUM. = WETLAND FLAG. LANDWARD EDGE OF TIDAL 19ETLANDS AS DELINEATED BY SUFFOLK ENVIRONMENTAL CONSULTING, INC. ON JANUARY 2#, 2012 PIPE ANY ALTERATION OR ADD/LION TO THIS SURVEY IS A 14OLA TION OF SECTiON 7209OF THE NEW YORK STATE EDUCATI(:~*V LAW. EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTiFICAtiONS HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR WHOSE SIGNATURE APPEARS HEREON. N86'19'40'W 16,07' 2O]2 NO. 4961~ (~JI) 7~5-5020 FAX (~$~) 7~$-~7~7 P.O. BOX 909 1250 TRAVELER STREET SOUTHOLO. N.× .97~ .----,~,o~, SURVEY OF PROPERTY A T GREENPORT TO,tN OF SOUTHOLD SUFFOLK COUNTY, N.Y. 1000-$4-05-1B SCALE' 1~ BO' NOVETvlBER 20, 2011 JANUARY 25, 2012 (LOC. W~TLAND FL^CS) AREA= 17,8~6 SO. FT. (TO TIE LINES) ELEVATIONS ARE REFERENCED TO NGVD DA TUM. ~ = WETtAND FLAG. LANDWARD EDGE OF TIDAL WETLANDS AS DELINEA TED BY SUFFOLK ENVIRONMENTAL CONSULTING, INC. ON JANUARY 24, 2012 PIPE ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 72090F THE NEW YORK STATE EDUCATION LAI~. EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTIFICATIONS HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR WHOSE SIGNATURE APPEARS HEREON. TOP N86'I 9'40"W 16.07' /P~CON/C gU~YORS, (6J1) 765-5020 FAX (631) 765-1797 P.O. BOX 909 12~0 TRAVELER STREET sourHO~O, ~.~ .~ < v' .:, -. \�'% ,l.\may Y!� •'��! :! � _• �"• �l, �.Ls—_—=sr��r"�".��a" � ,L �i�.i9"r�:i.�•+!'✓�:_i.!�yr:�����r.?s„� .�.�...���"�,�."t"ti'f i� � .! Of Southold Town Trustee- lit stees � Board ou �,,� ` rdi •... -I, SOUTHOLD, NEW YORK C. ;•:.;... I Mooring No. N/A " 2097 DATE:PERMIT NO TE: Nov 2 7, 1 5' s �{ !Sci irn Tn Robert' E. Copas I► ,�;:.: . . .. .......................................................................................................................................... -cac 114 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 �i.::.. State of New York 1952; and the Southold Town Ordinance�! en- ib. titled "REGULATING AND THE PLACING OF OBSTRUCTIONS ' IN AND ON TOWN WATERS .AND PUBLIC LANDS and the = i �j REMOVAL OF SAND, GRAVEL OR'OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;" and in accordance with the I ='+ �' ;• Resolution of The Board adopted at a meeting held on .Npv.n.....27..,, ak 1985....... and in consideration of the sum of 5. 00 Robert- E. a t E. Copas � - a i ....................................................................................................................................................................... of Greenport ..., ..... N. Y. and subject to the Terms and Conditions listed on the reverse side hereof, ;a of Southold Town -Trustees authorizes and permits the following: ,' l Application approved to secure a permit for a 8 x 4Q' section of dock and three pilings in Sterling Creek, Greenport, all in accordance E ' li4 +} nth the appliC atio su itt d. ' a I m accordance with the Red s ecifications as presented in - .- ,.. P , t the originating application. ( ,IN WITNESS WHEREOF a The said Board of Trustees here- by causes its Corporate Seal to be affixed, d these presents to be subscribed by a majority of the s ' and as of this date ffflryi, r re- o - ti i+ sj►� d Cn �F•' rust es �� !- ` sa,r�r,1�a ..F�O ./.r✓.-..�f a�','.,:$.:x'"+ s�• iY'r�d, i' t f �s� a�,�.S„fi,.,.P..��,1F.�9��att�.�r,�x t/ . �W).,i „ / iTJl.-7A^oi N� 3 YA i�` .YAK �✓"v i, Y �. ._Y '�%,�Y ;.YA l r�'� YA "�/ Y�.i1 � / A ti K / ;.:�iy '8..:�i'�SRM�\ ��i r '��' 9i "o. i >.. •, :l, ,�a !--------`--=/ --- ------ ----- ---- ---- ----- ----- -- Please tear off and return to the Trustee Office. Board Of Southold Town Trustees SOUTHOLD, NEW YORK Mooring Permit No. Date: Mooring No. I� certify that the work as authorized in this permit has been completed and is now ready for your inspection. Also; the number required on 'this project - is clearly visible, �.. I further understand this permit is not valid until this tear offsheet is 'returned to the Trustee Office. Awl TERMS and CONDITIONS The Permittee Robert E. Copas residing at 260 Robinson Road, Greenport. N. Y. as Yaii va ulc cUilSiucaauvu iva iuc va Lu.: a cauu& aaana uuucibuuiu aim Yicauiuc w iuc ava- ' lowing: 1. That the Trustee Permit most be prominently displayed on the premises effected thereby during the period of work under the permit. 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 result of any oper- ation performed pursuant to this permit, and the said Permittee will, at his or her own expense, defend any and all'such suits initiated by third parties, and the said Permittee assumes full liability with respect thereto, to the complete exclusion of the Board of.Trustees of the Town of Southold 2. That this Permit is valid for .a period of 12 mos. which is considered to be the estimated time required to complete the work involved, but should circumstances warrant, request for an extension may be made to the Board at a later date. 3. That this Permit should be retained indefinitely, or as long as the said 1ermittee wishes to maintain the structure or project involved, to provide evidence to anyone concerned that auth- orization 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. 5. That there will be no unreasonable interference with navigation as a result of the work herein authorized. 6. That there shall be no interference with..the right of the public to pass and repass along the beach between high and low water marks. 7. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstruction to free navigation, the said Pernittee will be required, upon due notice, to remove or alter this work or project herein stated without expenses to the Town of Southold 8. That the said Board will be notified by the Permittee or the completion of the work auth- orized. 9. That the Permittee will obtain all other permits and consents -that may be required sup- plemental to this ermit which may be subject to revoke upon failure to obtain same. (See tear of sheet.) 02 RESOLUTION NO. 2 - NOVEMBER' '2`7.,;:�'19 8`5" RESOLVED that the Southold Town Trustees Approve/Deny the Trustee application submitted by Robert E. Copas to install an additional floating dock (8 ' x 40 ' ) and 3 pilings adjacent to an existing floating dock in Sterling Creek. Property is located at 260 Robinson Road, Greenport. 30 TELEPHONE (516) 765-1892 BOARD OF TOWN TRUSTEES -TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 APPLICATION 1S 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, ORDINANCES AND REGULATIONS GOVERNING THE COASTAL AND INTERIOR WETLANDS, FLOOD PLAINS AND DRAINAGE AREAS OF THE TOWN OF SOUTHOLD, AND THE ISSUANCE OF PERMITS PURSUANT TO CHAPTER 32 OF THE CODES OF THE TOWN OF SOUTHOLD. APPLICATION NO. - DATE OF APPLICATION ��'�� -�[� -------------------- IDENTITY OF APPL I CANT_ ?' ----------PHONE NO___ ADDRESS OF APPL I CANT_3-J ��/6 s ------------ ----------------------- TAX MAP NO. -2 LSD /f1���_ T s -------- AGENT PHONE NO . PERMIT REQUESTED T01�/ � L _ d�/ �.� _ LL1e�7=/v �C& ----_--- LOCATION OF PROPERTY FOR WHICH PERMIT WANTED—0?6 0 cSe)A,) HOME ADDRESS OF PERMIT APPLICANT IF DIFFERENT FROM AFORESAID LOCATION CREEK, BAY OR HARBOR FRONTING PROr�PERTY ,5' —1-111)6 SIZE OF PROPOSED WORK CrU i -------- LENGTH ®---------------------_---------------------------- WIDTH HEIGHT ABOVE HIGH WATER DEPTH BELOW LOW WATER_ . �� JJ YARDS TO BE EXCAVATED--1l)O/ ---------------------------------- YARDS TO BE F I LLED A)0/0-6- WIDTH OF CANAL, CREEK OR BAY FRONTING PROPERTY_ J � DEPTH AT. LOW: TIDE AVERAGE RISE IN TIDE / DISTANCE TO THE NEAREST CHANNEL FT. DISTANCE PROJECT EXTENDS BEYOND SIMILARR PROJECTS IN THE AREA ® FT. ? •� 1S THIS FOR PRIVATE OR BUSINESS USE . / ,�/d§pr6-- ----------------------------- AREA ZONING—/L CI� ✓� C� � � ---------------- --- MANNER IN WHICH MATERIAL WILL BE REMOVED OR' DEPOSITED--A�1 ---------- -------------- I NTENDED USE OF PROPERTY-6k—tl�zpE DESCRIBE ANY ANY KNOWN PRIOR OPERATIONS CONDUCTED ON THE PREMISE—AND WHETHER ANY PRIOR LICENSE. OR. PERMITS HAVE BEEN ISSUED TO ERRECT STRUCTURES OR TO DREDGE OR DEPOSIT FILL ON SAID PREMISES AND WHETHER ANY PERMITS OR LICENSES WERE EVER SUSPENDED OR REVOKED BY A GOVERNMENTAL y. AGENCY-- O Jar Cad = �C IX AC _ —7v —I 9 -------------- DESCRIBE FULLY THE REHABILITATION AND PROPOSED CONDITION OF THE PREMISES AFTER THE WORK .1S COMPLETED INCLUDE AN ADDITIONAL SURVEY OF THE ._ PROJECT SITE IF NECESSARY ------------------------------------------------------------------------ ----------------------=------------------------------------------------- WRITTEN CONSENT OF THE OWNER OF THE PROPERTY, IF NOT THE SAME AS THE APPLICANT. 1 — ------------------- ARE THERE ANY COVENANTS OR RESTRICTIONS IN YOUR DEED THAT WOULD PROHIBIT THIS PROJECT? N� i BOARD OF.. TOWN TRUSTEES':--•"- TOWN. ..OF. .SOUTHOLD - SHORT ENVIRONMENTAL ASSESSMENT FORM -' - Project Information (To be completed by Applicant or Project sponsor) I 1. Applicant/sponsor 2. Project Name- -- � /`-'����- �r � .,;�.5 • 3. Project location: Municipality ��� Countys��° 4. Is proposed action: ❑ New LVExpansion ❑ Modification/alteration 5. Describe project briefly: 1N✓CMI—e— a9oV� FC0,177,V6 -D(9ae a)17V J ®,4I'V�+.5 76W 7 70' f�i sTi'/V �Gt��T!/d/6 �D C?� �7 '5 7 / vc 6. Precise location(road intersections,prominent landmarks,etc.or provide map) I� sc��d-7� ��da� s �o 7- 1z • I 7. Amount of land affected: Initially acres Ultimately acres 8. Will pro used action comply with existing zoning or other existing land use restrictions? 1" Yes ❑ No If No,describe briefly 9. What js present land use in vicinity of project? Residential El Industrial Commercial ❑ Agriculture ❑ Parkland/open spac'e/ ❑ Other Describe: 1171"1116 s' 00,wxvneemve_ r�s/Y/fV6, f�aL~� 10. Does actin involve a permit/approval,or funding,now or ultimately,from any other governmental agency(Federal,state or local)? FYes ❑ No If yes, list agency(s)and permit/approvals 4De 11. Does any aspect of�th action have a currently valid permit or approval? ❑ Yes Ll No If yes, list agency name and permit/approval type ' I 12. As result of proposed action will existing permit/approval require modification? ❑ Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: Date: J/ 12 JPJ li. Signature: V i - I r PART II Environmental Assostnent (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 617.7? 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: j C2. Historic,archeological,visual or aesthetic,or other natural or cultural resources;agricultural districts;or community or neighborhood character?Explain briefly: 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. i 1 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 Signatureffitle Date COUNTY OF SUFFOLK ) STATE OF NEW YORK ) SS: BEING DULY SWORN DEPOSES AND SAYS THAT HE 1S 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. SIGNATURE OF APi;y CANT SWORN TO BEFORE ME THIS DAY OF Nay�� ��� 19 NOTARY PU LIC NOTARY PUBLIC, State of New Yore No. 4690915 Qualified in Suffolk County Cgmmission Expires March 30, 19�/�' 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 - i I Ln TELEPHONE (516) 765-1892 BOARD OF TOWN TRUSTEES -TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 1.1971 APPLICATION 1S 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, ORDINANCES AND REGULATIONS GOVERNING THE COASTAL AND INTERIOR WETLANDS , FLOOD PLAINS AND DRAINAGE AREAS OF .THE TOWN OF SOUTHOLD, AND THE ISSUANCE OF PERMITS PURSUANT TO CHAPTER 32 OF THE CODES OF THE TOWN OF SOUTHOLD. APPLICATION NO. DATE OF APPL I CAT ION I DENT I TY OF APPL I CANT_OM/Q7'---y-T - _-lJ� a3 ---PHONE; NO_-_ ADDRESS OF APPL 1 CANT /,, Pl '01 r-® —__-__- TAX MAP NO. AGENT PHONE1NO. PERMIT REQUESTED TO 11V 6& IVP.1) 77e A4d C-4-4-v✓977✓v 6_-bd e'�e LOCATION OF PROPERTY FOR WHICH PERMIT WANTED-.;76�_✓�-U[7��$�/d/ __-_- --------- - ---------------------- �'�E�L- 2T Xiv J/o S1�---- HOME ADDRESS OF PERMIT APPLICANT IF DIFFERENT FROM AFORESAID LOCATION CREEK, BAY OR HARBOR FRONTING PROPERTY-.=SJ_._L1 __��----------- SIZE OF PROPOSED WORK LENGTH_- y�J J WIDTH HE I GHT ABOVE H I GH WATER— A ' .. .. DEPTH BELOW LOW WATER YARDS TO BE EXCAVATED-d&�C----y- YARDS TO BE FILLED--- ING WIDTH OF CANAL, CREEK OR BAY FRONTING PROPERTY-✓V_am DEPTH AT LOW: T 1 DE (� AVERAGE RISE IN TIDE v2 3 DISTANCE TO THE NEAREST CHANNEL DISTANCE PROJECT EXTENDS BEYOND SIMILAR PROJECTS IN THE AREA ® FT. iS THIS FOR PRIVATE OR BUSINESS USE? AREA ZONING- J�LU� /�C_- Cxo�7�!✓� � t�-------------------= MANNER IN WHICH MATERIAL WILL BE REMOVED OR DEPOSITED }NTENbED USE OF PROPERTY_ �/v — �_��-�T � ----------------- DESCRIBE ANY KNOWN PRIOR OPERATIONS CONDUCTED ON THE PREMISE AND WHETHER ANY PRIOR LICENSE OR PERMITS HAVE BEEN ISSUED TO ERRECT STRUCTURES OR TO DREDGE OR DEPOSIT' F1LL ON SAID PREMISES AND WHETHER ANY PERMITS OR LICENSES WERE EVER SUSPENDED OR REVOKED BY A GOVERNMENTAL AGENCY------�� ---KD --c9�E��1G� LC� .10/C/4 - -------- DESCRIBE FULLY THE REHABILITATION AND PROPOSED CONDITION OF THE PREMISES AFTER THE WORK IS COMPLETED INCLUDE AN ADDITIONAL SURVEY OF THE PROJECT SITE IF NECESSARY ----------------------------------------------------------------------- WRITTEN CONSENT OF THE OWNER OF THE PROPERTY, IF`-NOT THE SAME AS THE APPLICANT. -------------------- - ------------------------+---------- -- 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 Information (To be completed by Applicant or Project sponsor) 1. Applicant/sponsor 2. Project Name 3. Project location: Municipality tSQ- L-10 County 4. Is proposed action: ❑ New Expansion ❑ ModificationlaIteration 5. Describe project briefly: ������ ��� ������ �,�,� �✓�� � �/,Li��� i 721 6. Precise location(road intersections,prominent landmarks,etc,or provide map) 8e0 9;0t' S 07- 12—_ l'91A ll6LE �i��`7�� ���' ��d.���'✓`� 7. Amount of land affected: Initially acres Ultimately acres 8. Will proposedaction comply with existing zoning or other existing land use restrictions? LJ Yes ❑ No If No,describe briefly 9. Whatjs present land use in vicinity of project?�� llFi Residenntial ❑ Industrial L�'Jj Commercial ❑ Agriculture ❑ Parklandlopen/space ❑ Other Describe: 10. Does involve a permitlapproval,or funding,now or ultimately,from any other governmental agency(Federal,state or local)? act' ❑ No If yes, list agency(s)and permitlapprovals 11. Does any aspect of�the'action have a currently valid permit or approval? ❑ Yes LT No If yes, list agency name and permitlapproval type 12. As result of proposed action will existing permit/approval require modification? ❑ Yes E No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE { ] G Applicant/sponsor name: Date: Signature: 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. ❑ 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 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 briefly: 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 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 suppo�tng this determination: Agency-Name Agency Preparer's Name Preparer's SignatureiTitle Date COUNTY OF SUFFOLK ) STATE OF NEW YORK ) SS: 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 1N 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. SIGNATURE OF APP ICANT SWORN TO BEFORE ME THIS Ioti DAY OF 1 9 NOTARY PU LIC S NOTARY PUBLIC, State of New York No. 4690915 Qualified in Suffolk County 'EXAMINED Commission Expires March 30 19 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 COUNTY OF SUFFOLK ) STATE OF NEW YORK ) SS: BE 1 NG 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, 1F GRANTED. SIG ATU E OF AP ICANT SWORN TO -BEFORE ME THIS 4�\ DAY OF WC),)S' -QQ- , 19. NOTARY PUB I C MARY BESS PHILLIPS NOTARY PUBLIC, State of New Yor4 No. 4690M Qualified in Suffolk County EXAMINED CMmission Expires March 30, 19 29 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 O�OCJ�FFo(���G TELEPHONE (516) 765-1892 BOARD OF TOWN TRUSTEES — TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 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, ORDINANCES AND REGULATIONS GOVERNING THE COASTAL AND INTERIOR WETLANDS, FLOOD PLAINS AND DRAINAGE AREAS OF THE TOWN OF SOUTHOLD, AND THE ISSUANCE OF PERMITS PURSUANT TO CHAPTER 32 OF THE CODES OF THE TOWN .OF SOUTHOLD. APPLICATION NO. -- � _DATE OF APPLICATION / /;Z ------- ----------- 93 IDENTITY OF APPL 1 CANT; i��2j � ` � PHONE NO___ ADDRESS OF APPL I CANT136_=_ /�,e ------------------ TAX MAP NO. I��_�0��_ �Z o• -- � `�-- d� I ---------- AGENT PHONE NO . PERMIT REQUESTED TO�NSi i r7'riS i/r1C_ czsf------------ LOCATION OF PROPERTY FOR WHICH PERMIT WANTED -76,0 --P, &&1 (f S.#x)_ -_— HOME ADDRESS OF PERMIT APPLICANT IF DIFFERENT FROM �AFORESAID LOCATION CREEK, BAY OR HARBOR FRONTING PROPERTYi�✓�L�Ae/� SIZE OF PROPOSED WORK X p f � LENGTH ! WIDTH -- HEIGHT ABOVE HIGH WATER DEPTH BELOW LOW WATER YARDS TO BE EXCAVATED AVAIC YARDS TO BE FILLED It)tW WIDTH OF CANAL , CREEK OR BAY FRONTING PROPERTY ti 0 DEPTH AT LOW: T 1 DE �+ AVERAGE RISE IN TIDE - DISTANCE TO THE NEAREST CHANNEL D FT. DISTANCE PROJECT EXTENDS BEYOND SIMILAR PROJECTS IN THE AREA ® FT. 15 THIS FOR PRIVATE OR BUSINESS USE? . AREA ZONING- &-S4P&W77AC_ efly 4- MANNER IN WHICH MATERIAL WILL BE REMOVED OR DEPOSITED INTENDED USE OF PROPSRTY DESCRIBE ANY KNOWN PRIOR OPERATIONS CONDUCTED ON THE PREMISE ' ) --- AND WHETHER ANY PRIOR LICENSE OR PERMITS HAVE BEEN ISSUED TO ERRECT STRUCTURES OR TO DREDGE OR '.DEPOSIT' FILL ON SAID PREMISES AND WHETHER ANY PERMITS OR LICENSES WERE EVERSUSPENDED OR REVOKED BY A GOVERNMENTAL AGENCY--------- /do0,4661AAO C_ Jzw-v emea'IIitle- ----- ---------------- DESCRIBE FULLY THE REHABILITATION AND PROPOSED CONDITION OF THE PREMISES AFTER THE WORK IS COMPLETED INCLUDE AN ADDITIONAL SURVEY OF THE PROJECT SITE IF NECESSARY ------------------------------------------------------------------------ WRITTEN CONSENT OF THE OWNER OF THE PROPERTY, IF• NOT THE SAME AS THE APPLICANT. ; -----------------------------------------°y----------------- ARE THERE ANY COVENANTS OR RESTRICTIONS IN YOUR DEED THAT WOULD PROHIBIT THIS PROJECT? �Q .y BOARD OF TOWN TRUSTEES:.-... TOWN....OF. .SOUTHOLD SHORT ENVIRONMENTAL ASSESSMENT FORM - Project Information (To be completed by Applicant or Project sponsor) 1. Applicant/sponsor 2. Project Name Foj6670 r 3. Project location: Municipality --`�OV 7 7/-0 County 4. Is proposed action: ❑ New /Expansion ❑ Modification/alteration S. Describe project briefly: IA�S�.�Vle 6. Precise location(road intersections,prominent landmarks,etc.or provide map) i 60ti'T1Nv b 0 G& Tp / 011,0e�i.7 7. Amount of land affected: Initially acres Ultimately acres 8. Will p�oposed action comply with existing zoning or other existing land use restrictions? v� Yes El No If No,describe briefly 9. What's present land use in vicinity of project? Residential ❑ Industrial Commercial El Agriculture ElParkland/open space El Other Describe:'Rcs,z)�C63` 1",Oell2ws' �tJ/ /�3 '�A/3G P/S%v -00Ce 10. Does rac�ti n involve a permit/approval,or funding,now or ultimately,from any other governmental agency(Federal,state or local)? L"J 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 21No If yes,list agency name and permiVapproval type 12. As result of proposed action will existing permit/approval require modification? ❑ Yes ©No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: Date: ��'—/Z" Signature: w11 -� PART 11 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 6,17.7? 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 briefly: C3. Vegetation or fauna,movement of fish or.wildlife species,significant habitats,or threatened or endangered species? Explain briefly: i 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. i 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 Cl-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 SignatureiTitle Date O�Oc�vFFO( rl®o TELEPHONE (516) 765-1892 BOARD OF TOWN TRUSTEES - -TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 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, ORDINANCES AND REGULATIONS GOVERNING THE COASTAL AND INTERIOR WETLANDS, FLOOD PLAINS AND DRAINAGE AREAS OF THE TOWN OF SOUTHOLD, AND THE ISSUANCE OF PERMITS PURSUANT TO CHAPTER 32 OF THE CODES OF THE TOWN OF SOUTHOLD. APPLICATION NO. --DATE OF APPLICATION ------------- ------------------- IDENTITY OF APPLICANT,- -!-'I�JC,-7- E------ a ���-S --------------PHONE NO---- ADDRESS OF APPL 1 CANT 3 6 -,L&-yV r SE--------------------------- 1� Li 1 TAX MAP NO. r)l sr l®®© -- cS—ti i/ 3 -- 1-v az S---L-�✓. ----- AGENT PHONE NO . PERMIT REQUESTED TO S/ L_L — ��� �0 �i��j� ��� _------- =? TO iS dill --mod CAC- LOCATION OF PROPERTY FOR WHICH PERMIT WANTED- 7�11z — ------- HOME ADDRESS OF PERMIT APPLICANT IF DIFFERENT FROM AFORESAID LOCATION---- --—---- ----- =L --------------- CREEK, BAY OR HARBOR FRONTING PROPERTY-�LC��.L —(.iJ�_ ----------- SIZE OF PROPOSED WORK LENGTH WIDTH - ------------------------------------------------------- ---- HEIGHT ABOVE HIGH WATER I ' DEPTH BELOW LOW WATER- YARDS TO BE EXCAVATED /VQA) YARDS TO BE FILLED 109NE _ WIDTH OF CANAL, CREEK OR BAY FRONTING PROPERTY DEPTH AT LPW: TIDE (o + AVERAGE RISE IN TIDE ` 3 DISTANCE TO THE NEAREST CHANNEL---_a----FT. DISTANCE PROJECT EXTENDS BEYOND SIMILAR PROJECTS IN THE AREA --_FT. IS THIS FOR PRIVATE OR BUSINESS USE? /C.IVo 1-6- AREA ZONING-- ���_7v� I _Co -cr G- t 09- MANNER IN WHICH MATERIAL WILL BE REMOVED OR' DEPOSITED nn I NTENDED USE OF PROPERTY ^a.44 6 c --E=jJ/ DESCRIBE ANY KNOWN PRIOR OPERATIONS -CONDUCTED ON THE PREMISE���� ----- AND WHETHER ANY PRIOR LICENSE OR PERMITS HAVE BEEN ISSUED TO ERRECT STRUCTURES OR TO DREDGE OR' DEPOSIT FILL ON SAID PREMISES AND WHETHER ANY PERMITS OR LICENSES WERE EVER SUSPENDED OR REVOKEDBY ApGO`VERNMENTAL AGENCY � � ----- � 6e%� �/ ® !1I _ C?a�C/JZ._ '" d� - �_7 7/ --------- DESCRIBE FULLY THE REHABILITATION AND PROPOSED CONDITION OF THE PREMISES AFTER THE WORK IS COMPLETED INCLUDE AN ADDITIONAL SURVEY OF THE PROJECT SITE IF NECESSARY-- 7----------- -------- -----------—--- -------- ----------- -------- -- WRITTEN CONSENT OF THE OWNER OF THE PROPERTY, IF"-NOT THE SAME AS THE APPLICANT. ARE THERE ANY COVENANTS OR RESTRICTIONS IN YOUR DEED THAT WOULD PROHIBIT THIS PROJECT? )U BOARD OF TOWN TRUSTEES.- TOWN.. .OF. SOUTHOLD SHORT ENVIRONMENTAL ASSESSMENT FORM Project Information (To be completed by Applicant or Project sponsor) 1. Applicants onsor 2. Project Name 3. Project location: Municipality V L County 4. Is proposed action: �_�� ❑ New E Expansion ❑ Modification/alteration b D 5. Describe project briefly: . /�V ��. a� !'_tom �(.�1•si"� � �d'Gi/UGs, > J"i�CAL-711 T %o !�FX!s 7wea )r-7Gfi 4 7'/N6; 4�0�•�� �9 T 6. Precise location(road intersections,prominent landmarks,etc.or provide map) 7. Amount of land affected: Initially acres .Ultimately acres 8. W posed action comply with existing zoning or other existing land use restrictions? Will ❑ No If No,describe briefly 9. Whh t' present land use in vicinity of project? f Residential El Industrial Commercial ❑ Agriculture ❑ Parkland/open space ❑ Other Describe: 10. Does as t'°n involve a permit/approval,or funding,now or ultimately,from any other governmental agency(Federal,state or local)? LI Yes ❑ No If yes, list agency(s)and permit/approvals 11. Does any aspect of He action have a currently valid permit or approval? ❑ Yes No If yes, list agency name and permit/approval type 12. As result of propose action will existing permit/approval require modification? ❑ Yes LJ No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE ApplicantJsponsor name: Date: Signature: 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 617.7? 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 briefly: 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 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 Suppo�tng this determination: Agency-Name Agency Preparer's Name Preparer's SignaturerTitle Date COUNTY OF SUFFOLK ) STATE OF NEW YORK ) SS: 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 AP PLICATION '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. SIGNATURE OF APPLI ANT SWORN TO BEFORE ME THIS DAY OF _I�OV�Iret2.. I9 NOTARY UBL I C MARY BESS PHILLIPS NOTARY PUBLIC, State of New York No. 4690915 Qualified in Suffolk County 'EXAM I NED Commission Expires March 30, 19 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 FEE SCHEDULE PURSUANT TO CHAPTER 97' WETLANDS PERMIT $50 . 00 FILING FEE $ 5 . 00 FEE FOR EACH ADDITIONAL INSPECTION FEE FOR BOATS,_DOCKS_AND WHARVES - CHAPTER 32 A. A MINIMUM FEE OF , $5 . 00 WILL BE CHARGED AGAINST ALL APPLICATIONS. THIS FEE IS PAYABLE AT THE TIME OF FILING, AND IS NOT RETURNABLE . REGARDLESS OF THE ACTION TAKEN. B. FEE FOR MOORING ; AT THE RATE OF, $5 . 00 PER PILING, $5 . 00 PER STAKE OR MUSHROOM ANCHOR. FEE FOR DOCKS AT ' THE RATE OF . 25 PER SQ. FT. OF DOCK SURFACE OFFSHORE OF THE ORDINARY HIGH WATER MARK, PLUS , $5 . 00 PER PILING USED TO SECURE A FLOAT OR BOAT . $� X 7� - �a04� = ' `8O,d-0 f- 3 �iciwG� C.S - 95 C-a D. FEE FOR' BULKHEADS AT THE RATE OF, $3 . 00 PER LINEAL FOOT OF CONSTRUCTION OFFSHORE OF ORDINARY HIGH WATER MARK. E . FEE FOR DREDGING/FILLING AT THE RATE OF, $2 . 00 PER CUBIC YARD BASED UPON THE ESTIMATED MAXIMUM FROM COMPUTING THE APPLICATION. F. FEES FOR SPECIAL PURPOSES AT A RATE DEPENDING ON . THE TYPE OF WORK. f TELEPHONE (516)765-1892 -'' BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 APPLICATION FOR WETLANDS PERMIT '( CHAPTER 97 CODES OF SOUTHOLD TOWNT ) AND/OR DOCKS, WHARVES (CHAPTER 32 CODES OF SOUTHOLD TOWN. ) INSTRUCTIONS A. NO OPERATION SHALL BE INITIATED BY THE. APPLICANT UNTIL ALL PERMIT( S ) REQUIRED ARE ISSUED. B. THIS APPLICATION IS TO BE COMPLETELY FILLED IN BY TYPEWRITER OR INK AND SUBMITTED TO THE TOWN TRUSTEE OFFICE IN QUADRUPLICATE, ACCOMPANIED BY WRITTEN PERMISSION FROM THE OWNER OF THE PROPERTY, IF NOT THE SAME AS THE APPLICANT . C. NO PERMIT SHALL BE ISSUED UNTIL ALL OUTSTANDING PERMIT FEES ARE COLLECTED BY THE SECRETARY TO .•THE TRUSTEES. D. THE APPL I CA..T'I'ON. _MU'ST �,CONTA l r4 A .PILOT PLAN -TO SCALE•`SHOWING THE LOCATION OF THE PROPERTY ( INCLUDING AVAILABLE LANDMARK, SUCH AS A LILCO POLE NUMBER) THE NAME AND LOCATIONS OF OWNERS OF ADJACENT PROPERTIES AND A DETAILED DESCRIPTION OF THE PROJECT. IF THE PLAN DOES NOT CLEARLY SHOW THE LOCATION OF THE PROJECT AN AREA MAP, AVAILABLE FROM THE SECRETARY TO THE TRUSTEES , SHOULD BE COMPLETED AND ATTACHED TO THE APPLICATION. E. 1F A PERMIT IS BEING SOUGHT FOR A MORE SIZEABLE EXCAVATION THAN THE CONSTRUCTION OF A PRIVATE SINGLE DOCK OR JETTY, THEN THIS APPLICATION MUST BE ACCOMPANIED BY A SURVEY .AND TOPOGRAPHICAL MAP CERTIFIED BY A REGISTERED LAND SURVEY OR PROFESS'IONAL , CNGINEER. . THE. HORIZONTAL CONTROL OF SURVEY SHALL BE BASED UPON AN APPROVAL COORDINATE SYSTEM. THE VERTICAL CONTROL FOR ELEVATION AND SOUNDINGS SHALL BE BASED UPON UNITED STATES COAST AND GEODETIC SURVEY AND/OR UNITED STATES GEOLOGICAL SURVEY DATUM. FOR SUCH PROJECTS THE TRUSTEES MAY REQUEST A MORE DETAILED. DESCRIPTION OF THE PROJECT SITE AS DESCRIBED IN ARTICLE II , SECTION 97 - 21 SUBDIVISION D. F. UPON APPROVAL OF THIS APPLICATION THE SECRETARY TO THE TRUSTEES WILL ISSUE THE APPROPRIATE PERMIT( S ) TO THE APPLICANT . SUCH PERMIT( S ) SHALL BE AVAILABLE FOR INSPECTION AT ANY TIME , UPON REQUEST. TRUSTEE PERMIT NUMBERS MUST BE DISPLAYED ON ALL STRUCTURES WITH THREE ( 3 ) INCH HIGH, CLEARLY VISIBLE NUMBERS. { � 1 I roc BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD \' 53095 Main Road Phone 765-1892 �� v 30846 " Southold, N. Y. U971 Date / "�%�� 19 RECEIVED OF 7Q�f�ollurs For //� BOARD OF TOWN TRUSTEES Cash [!Cash Check • 3 4v By, � '� 1,�,1.,'�I./fp�.,,,-.1.�,11-I'I,IA.,.;.�.L.,,m.i!,�.i I I—�II...,—,-1;1�I..�/,.iI..��--...­ .,.1 ...;`'.vI�t,q...r.r;....r +.,+M,?_ ", .ta pa"mr j ti .wr+:w^'ir.�'y k>kMI�, , M`''�," r':c`�*I+rv:"�ur nay I n t k t S t � + C r 1 °'�� ,rr a I.I,.I:,'�;,�.I_,-,—,"��7..,",­O,:L,����,�.I,..,".:,,'.I.,,..�,,,i. .�;4.1�I/I..,,�,;*..,—,t"-I.­..:.,I.—.I,.,.,�. t r9' >IIf, t �'rx t yif x v ,"✓. - 4 10 f 1 ,`ti h ryt, i nag r+ rf5. i i J ! - ! J t� . .�. Ir l yam' �yv,[, i,, ° c 8 N,;W '� t f y,'{r (��/' -C1 l/ _.� �y,o#y;.-- ,A 6 r / ( } y t�yp�ti J ,r. 44 a 1` ' l . •Jr11 �`� , +., _ Y7. i, yf .- r" I I "K,,„ t'w iy i15yt1 i Xi.. 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Y 1"� 1I{ ty, a'C_6t S 'f'( Y A 5r u , 7 f 1 it fe,(t x l i *,j aG ( d r }tip Y 2 rlar " 3 .¢ 7yk ( `} k. t \ f J t i1 { A.ik;"4�Qi rc31,`s t j A' q '� t . .. e � ,.. _ .. - d r ¢i YA r d J 1' 1 1 7. .:- - ♦ .. p , i( ? tj1 �, Jt•R .1 {y 1} N , � , r. h r i Ayy .y Cf�. l y 1 _ - �,y�Avg M riouaht�,a T>�!UI W NEW WAwL STAT{ �'` "RA f' f�?1A�i OP W¢ 1 N' !, -IAA' r, „ fr iEAI$f1ALLMDTMy4 Y° 0. rarptw�'»ki ,V,'. p TeuE t, k' s '' �{1/iR MW�AfEQ,1�gC�11 SKAtk a �tx. x, 1. ql = {"T 10"t,"RACN jQR V�I!I�fRt II , ti r 4. w ON HI;IRNK�(TCJ CIE s aY ! 1 AA y�11Wy : pM.'�+�"�l'/7`^^.'.!Mw/ �y��� a� ; St J �4i YL' t / ]M J I Y• I� PP •lIl �• �Rl!f MQ� W �.OWH1lWlMTA1 f fA F 1 4:: TN.1Y dd ,l. (�ggMlCr iPIST,ITUtIQ��IS11D HC�A9M AM{ , �� td T ASdK S+1F It'I LrMON/G lf1f14 h ._- w+ l� 'rV .f .: . ' Z�1yf t ' r'N"y+A C� 6 M X a a Rp ylIOMlI AA r�o►Mi.M 4R' r t I` yy' 5 p t I °t+l t Jr 1AY'i i N 6itb'>�v IM 1".'dP i°'" 'r ,1 ry w+ E 'h Si.` f t+k tj + 3 P i t i - . , . 00 . 1,,:5 , . 1' P e'%y 0 s=s'uF 4 - J Ik" r , , i . . � '. . .. A a. TELEPHONE (516) 765-1892 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 December 3, 1985 Mr. Robert E. Copas 36 Front Street Greenport, New York 11944 Dear Mr. Copas: The Trustees reviewed your application at their regular meeting held on November 27, 1985. The following is the Board' s findings and determination recently rendered regarding this matter. 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 documentation submitted concerning this request; and WHEREAS, the Board made the following findings of fact: 1. By this request, appellant requests permission to construct a 10 ' x 30 ' Solarium, that will replace an existing porch. 2 . The solarium proposed is located approximately 50 ' landward of the bulkhead. 3. Chapter 97, Section 97-13 (A-3) all lands immediately adjacent to a tidal wetland as defined in Section 97-13 A-3 and lying within seventy-five (75 ' ) landward of the most landward edge of such a tidal wetland. In considering this request, the Trustees find and determined: (a) That relief requested is not substantial under the " circumstances. (b) That by allowing the request as conditionally noted below, that there will not be any adverse affects to the wetlands. (c) That the safety, health, welfare, comfort, convenience and order of the Town--will not be adversely affected by the proposed request. Accordingly, on motion made by Trustee Bredemeyer seconded- by Trustee Bednoski it was RESOLVED permission Be and Hereby is Granted as requested- for Robert E. Copas subject "-to the following provisions: Board of Trustees In the Matter of Robert E. Copas Page 2. 1. During excavation the fill must be contained so that it does not wash into the creek. 2. Care should be taken so as to preclude the entry of any construction material into the adjacent waters. 3. Immediately following construction, all areas of exposed soil shall be properly protected with suitable erosion control devices and/or vegetated to prevent entry of eroded soil into the creek. If you have any questions or concerns, please do not hesitate contacting this office at the telephone number listed above. Thank you for this opportunity to be of service to you. We look forward to serving you in the future. Very truly yours, Henry P. Smith, President Board of Trustees r Ilene Pfifferling Secretary to Board HPS; ip cc: Bldg. Dept. Board,.of Appeals Mr. Blair Dibble Trustees File <AIVER/APPLICAT. PROCESS: Robert E. Copas, 260 Robinson Road, Greenport, New York - To construct within 75' a solarium in place ,of a porch on premises . INSPECTION CHECK OFF SHEET In accordance with Chapter 97, Article II, Section 97-28 the Trustees may adopt a resolution directing the issuance of a permit to perform operations applied for only if it determines that such operations will not substantially: Adversely affect the wetlands of the Town. Cause damage from erosion, turbidity or siltation. Cause saltwater intrusion into the fresh water resources of the town. Adversely affect fish, shellfish or other beneficial marine organisams, aquatic wildlife and vegetation or the natural habitat thereof. Increase the danger of flood and storm-tide damage. Adversely affect navigation on tidal waters or the Tidal flow of the tidal waters of the town. Change the course of any channel or the natural movement or flow of any waters. Weaken or undermine the lateral support of other -lands in the vicinity. Otherwise adversely affect the health, safety and general welfare of the people of the town. IP FORM NO.3 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD,N.Y. NOTICE OF DISAPPROVAL Date . . !�. 4�ti?'!'�. . . ���. . . ., 19 T3 PLEASE TAKE NOTICE that your application dated . . . . . . . . . . . . . . . . . . . . . . . ., 19 .�.':� for permit to �- �tA'�'t'`'L..` ^^.. �c'a. .�. . . cA-�.0 . . . . . at Location of Property �?�. . . . . . . . . . . . . . . . . House No. Street Hamlet County Tax Map No. 1000 Section . . . Block . . . �?.S.,". . . . . . . Lot . . .�. . . . . . . . . . . Subdivision . . . . . . . . . . . . . . . . . Filed Map No. . . . . . . . . . . . . . . . . Lont No. . . . . . . . . . . . . . . . . . Q1 za is returned herewith and disapproved on the following grounds . ` . . .lid . . . . . . . . . . . . . . . . . . CL ct , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Building Inspector RV 1/80 „.`. •+�vw,.:u.,y;.,..ter-aec _ —.._.--_i ..-, ... . ......- ...�..+,,.... .•... ... .- ..+....r..w.1:.+wrw..-ys�,,,;,;s..s..,.w•bs„'f.�-L,r^ _'l,T!"'! .,,,!j�"pK`R'• .. / l�.l i�• 'YI!-I`! f...•G?;"I yiW0 I i1� M P o ' 1. aW rp36: a ' 4 .:!'''w i'. a«llq�'y ,i'! i 1 x fkk ILIx t •, u ve aV y: v ,r*1 Aw f ' 'mot Iva . 4 ////111 (ryf(lJ/ 77{l1Ayj I�{ J (It•.• ( ^I Y+ ^'Y .� 'f ))) � ,�Lh�,2,{`1y'•�yZN. Yt :'� 1 ,•i'��1P-_�-'_`� / �'L` �fr.�,MTT N J ''Jy�' r} 1 1 } !: i:�J'*�, a R +� • J }. Ab4QdATKpa 4x At7AIT1 : f ta+ veiv t3vwe�vlqo w i M•1 lV;;J m 7z!of fMl MW V6W SCAT6 r �' aye,LAW. CAI. iS i�j ' r cow 49 TNIS S "MY'N.V,,NOS �• ;' 6P4 LAMD�w�vavol�► f 4� IA90ZM 54At!NoAat x ` J OU 11AF M3"ICAT® �p�. , •' ! WAY I*T9es PeaGN FOq WifB?dA IM UN 1Q c;oAwAW, QOYMIWINTAI e43PICY V:17 W./4'7f Y tIM04q INSTITUTION IISTM M11W.N. A” !' fO THE A.Sd1GN4$Of TMI VMIKQ 'I`OVIa y J wP 0U AAOVS Aar 40T TOaAlavdA" g0� '!1?dl�i idbtoo nr...a QR fUASsa`�' , ,i..;� '• FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N' Y. 11971 TEL.: 765-1802 Examined . . . . . . . . . . . . . . . .. 19 . . . Received . . . . . . . . . . . . 19 — Approved . . . . . . . . . . . . . . . .. 19 . . . Permit No. . . . . . . . . . . . Disapproved a/c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Building Inspector) APPLICATION FOR BUILDING PERMIT Date. . . . . . . . . . . . . . . . . . .. 19 INSTRUCTIONSa. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with sets of plans,accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or,public stree or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this app' cation. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such peril shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupan: shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to t Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein describe The applicant agrees to comply with all applicable laws, ordinances, building code, housip code, and regulations, and admit authorized inspectors on premises and in building for necessary 1 tions� ? --, .0. . . . . . . . . . . . . . . . . . . . . . (Signaiu�i applicant,/or name, if a corporati n) Jf. . . . . . . Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builds bu,1�;. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . premises C44 Pl�'Name of owner of prei . . . . . . . . . . . V* (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name and title of corporate officer) 4V � . Builder's License No. . . . . . . . . . . . . . . . . . . Plumber's License No. . . . . . . . . . . . . . . . . . . . . . . . . Electrician's License No. . . . . . . . . . . . . . . . . . . . . . . Other Trade's License No. . . . . . . . . . . . . . . . . . . . . . 1. Location of land on which proposed work will be done. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . House Number Street Hamlet County Tax Map No. 1000 Section . .0 . . . . . . . . . . Block' . . . . . . . . . . . . Lot . . . .114-rt . . . . . . . . Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. . . . . . . . . . . . . . . Lot . . . . . . . . . . . . . . (Name) 2. State existing use and Occupancy of premises and intended use and Occupancy of proposed construction: /11 — a. Existing use and occupancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . b. Intended use and occupancy . . . . . . . . . . . . `i 5 3. Nature of work (check which applicable): New Building . . . . . . . . . . . . . . . . . . . . . Alteration . . . . . . . . . . Repair . . . . . . . . . . . . . . Removal . . . . . , . . . . . . . . Demolition . . . . . . . . . . . . . . Other Work . . . . . . . . . . . . . . . (Description) 4. Estimated Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ` (to be paid on filing this application) 5. If dwelling,number of dwelling units . . . . . . . . . . . . . . . Number of dwelling units on each floor ... . . . . . . . . . . . . . . If garage,number of cars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use . . . . . . . . . . . . ... . . . . . . . 7. Dimensions of existing structures, if any: Front . . . . . . . . . . . . . . . Rear . . . . . . . .. . . . . . . Depth . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimensions of same structure with alterations or additions: Front . . . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . . . . . . . . Number of Stories. . . . . . . . . . . . . . . . . . . . . . 8. Dimensions of entire new construction: Front . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 9. Size of lot: Front . . . . . . . . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . . . . . . . . 10. Date of Purchase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of Former Owner . . . . . .. . . . . . . . . . . . . . . . . . ... . . . . 11. Zone or use district in which premises are situated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Does proposed construction violate any zoning law, ordinance or regulation: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 13. Will lot be regraded . . . . . . . . . . . . . . . . . . . . . . . . . . . . Will excess fill be removed from premises: Yes No 14. Name of Owner of premises . . . . : . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . .. . . . . . . . . Name of Architect . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . .r. . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . Name of Contractor . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and.indicate all set-back dimensions from property lines. Give street and block number or description according to deed,'and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, S.S COUNTY OF . . . . . . . . . . . . . . . . . • • • • • • • • • • • • • . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. - is the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Contractor, agent,corporate officer, etc.) ,)f said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief;and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this �-'J. . . . . .day of. . . . . 011... . . . . . . . . . .1 19 lotary Public, v,N '. . . . .�Q .�! 64e... . . . . . County HELEN ROTARY PUBLIC,S'� No Y� . . . . . . • . . . . . . • (Signature of applicant) No. E 70788,hiolk Co —^ Te � �o a e� �� vt G a �b(,,k 2 - t y CO'A 1 F-- �a. _.1 �- 1 _ l -