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HomeMy WebLinkAboutTR-9417A Michael J.Domino, President OF SOUryoy Town Hall Annex John M.Bredemeyer III,Vice-President h0 l0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold,New York 11971 CA A. Nicholas Krupski • ye Telephone(631) 765-1892 Greg WilliamsO Fax(631) 765-6641 �y�OUNTY,N� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 9/1009 Ch. 275 Ch. 111 INSPECTION SCHEDULE J Pre-construction, hay bale line/silt boom/silt curtain 1 st day of construction % constructed V/Project complete, compliance inspection. INSPECTED BY: C� G �IS►v, �� COMMENTS: ok g= C C I'/' in CkeCoirziane—ei M- 1 t_ CERTIFICATE OF COMPLIANCE: Michael J. Domino, President QF S (/j Town Hall Annex John M. Bredemeyer III,Vice-President hQ�v y�lO 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold, New York 11971 A. Nicholas Krupski G Telephone(631) 765-1892 Greg Williams YQ Fax(631) 765-6641 cOUNT`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1622C Date: September 10,2019 THIS CERTIFIES that the construction of a 370 sq.ft. on-grade patid adjacent to existing patio; addition of approximately 30 cubic yards of fill/topsoil; At 8871 Oregon Road, Cutchogue - Suffolk County Tax Map#1000-83-1-34.1 Conforms to the application for a Trustees Permit heretofore filed-in this office dated January 28, 2019 pursuant to which Trustees Administrative Permit#9417A Dated April 17, 2019,was issued and conforms to all of the requirements and conditions of.the applicable provisions of law. The project for which this certificate is being issued is for the construction of a 370 sq.ft. on-grade patio adjacent to existing_patio; addition of approximately 30 cubic yards of fill/topsoil. The certificate is issued to North Fork'Haven LLC owners of the aforesaid property. Authorized Signature -" �}FF01) Michael J. Domini resident c�o��s ` Town Hall Annex John M. Bredemeyer, III, Vice-President ��o N 54375 Route 25 Glenn Goldsmith s N 2 4 P.O_ Box 1179 A Nicholas Krupski y • V Southold, NY 11971 Greg Williams ���ol ,� �A�� Telephone (631) 765-1892 raz Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction %2 constructed When project complete, call for compliance inspection; Michael J.Domino sident �QF SO(/Jy Town Hall Annex John M. Bredemeyer III,Vice-President Q� �1 54375 Route 25 O P.O.Box 1179 Glenn Goldsmith [ Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams �� Fax(631) 765-6641 c4UNT`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit'No.: 9417A Date of Receipt of Application: January 28, 2019 Applicant: North Fork Haven LLC SCTM#: 1000-83-1-34.1 Project Location: 8871 Oregon Road, Cutchogue Date of Resolution/Issuance: April 17, 2019 Date of Expiration: April 17, 2021 Reviewed by: Board of Trustees Project Description: Construct a 370 sq.ft. on-grade_ patio adjacent to existing patio; addition of approximately 30 cubic yards of fill/topsoil. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Creative Environmental Design, received on February 7, 2019, and stamped approved on April 17, 2019. Special Conditions: None Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth,in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Michael J. Domino, President Board of Trustees Michael J. Domino, President *0� SU(/jyo Town Hall Annex John M. Bredemeyer III,Vice-President 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold, New York 11971 A.Nicholas KrupskiG Q � O Telephone (631) 765-1892 Greg WilliamsO Fax(631) 765-6641 �y�DUN% BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: y� V1 Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction '/Z constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: I 1 1 t :ht IS A",N b+ ry(wdrd. -QSf01111(y pfllacPrrd�S of C2yA r)ps o kew m .r}�tns e 4a rtr el is 01+ Or L?'M .Ce' A PAQACW4 q- 1,31 6e cQo, C�ok W ^Mfi - w t 0A,q C cA- JWK C JCP o I to 1, C; wOrA ® hese wl 1A+(: s�6r�f Jam@ Mad o�erCf4W 's ac eepLGUfe , CERTIFICATE OF COMPLIANCE: ■ P Iiii Frr■�`�, TIE EF F■ .a.r "No Tom r !!! , L �r r� --m ` --X 1117 For pill Man, ■ a!r 4 *'Fw■r3 FFww■f a,nc,■ FE aR r'wwm '"■R,'"` F■.F a. _ ■£ C.p, 11 .,F4Fd•"..r -o e'■ r_"., FFr, ^�� R.„.r" R ia. or . ■ -mw-,= �, w w s ■-„w n moi''a w, 1! i■abl ° l ■ F MOM so—' t F' E °4' .., �a.._. .R■w_'*•7 Yi. ,�. P 017 4; fig,in 55 a• RRp •I -' C ■r�, +nave �° , �"'� ° ��• 6 ). r '�1 ���, >°F■arRar Fw�s„'L"�!■ �!a3° r^ •®' �� Fes:`°'"'�R Hr�""� 79"W" !■ elm I� � �r ■� vj la IAN 1t**,1TCH1E 0 e ! ■■ RFI, i■ e ■ e E.•1a. will Y'y err, ,i , @ # 1000-83-01-34.1 No. k ® fl0 s ' r7L 5CALEs 1 =20'.O" TOP OF BLUFF Arl 1)E51C4\ED BY. GREA-fIVEENviROMVENTAL 51GN �� ■■ ,r , or 7rorwr • • - 5CALE# 1 20 .0 IN 0 ■ l� 'n ■G■r,' '�@fl "' °*Fr+ IN, a t■ La■1 , •o C 1 .y 4 r.�rim1 0' r ■ J ■ kru TOP OF BLUFF , ®�@ _ a y � r .. :@� � 4 � —_ E3. * E f aetrl ■`nR rb, aw p haw` f t ■ aw r�I,.. r `3F „gin �r ° . ` ', 19 a°:� e� ,� It FEB — ':� � .`; ;, Lr,*, FROP05ED ADDED 7 2019 i. 1 ' ' ■'■����; L , 30 C.Y. FILL & TOP 501E .1,�o�d ■ ■ . ■ F,.,a,, ° rr Of t , N ral" TTA c e. ADDED PATIO "�' r k . r A■`` * r ` APPROVED BY ■ 4.°rt a r1f E_�■P �!■.. ,■q _.,y in �� ■ a t a w r■a VFW "a :Y.. r '� R u.Y,■. • i :■ �p3+® w .IF■■� j"� �a^?" ` ■.tt' F�.arr�-w_ e' p ■p ■p ■a r E,,w ■ [• I w w;^ R'em,m^' _iY t r �.S .: ,rJ� / �■ tr■■■ a ■ ..�:��° v. 3wlw>a! r. A f t @. F,� w . „�^.. . _ ,. ,.e ° �P' r■ ■ � N;f■.,— No - BOARD OF 1 r�USTEES � ■� ! .. , ■� . ' ■� � ,�', ups'Rafl �,, w}�. °� TOWN OF SOUTHOLD . ^* WIM ■�_w _-se FROfF'i TOa�" a a■,�--- ,�� .� , •°'■ ■■fir �� F—T ra°■rs ' ";w Fri. 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"j 1 �'' 6 iH .■ 'a VON N. ° Ina- ° [3R pls�4 `a►w ■aiw c °^°m Fete SS as . � ■rsr. ■' ■a c. l,�, '■, res a r� k °w w- ■w ■w Fr. ■m a awi ■ tFrrr�F@ 'a !a ..■ ".w wwr� rP lfl.# F■ 1 1% w .? ter■ r. r� °t ,.._ � •. � ,. �. x '.�,--•�.°,—ten._.- _ J JIM J _ v L .+� Z t4l - 4wL R O Yb �- _/ SEESEC No on ./ dATGN UNE xm SOUND / PO 90 lO 2945 /113 ® I o i �-- toxo- / SCH D 9 FO n u aoA 13.5 1.3A(.) ~ It� 1ze 1Bee 11Nq 72 f 1 g� ta.eA92 / 2SVc) , ^ ♦ 123 aw[xrxrra*19 ej 1 9A(c) l.eA 2]A(c) 7.4 AW 1 m f / s 7." m 4a za to / IBA / ♦ n 17 TA J �A na w, ♦ 21 tTIA(0) 1 > V .y I / e 12.4 > 1 2— > A u3 'b ♦ 2J 4q,$�Ao I= ,]T I i e> .� ♦M . P ♦ B J`21 ;z ♦ N M1 t b ti baKO �' ♦ b Sj"/ �a b F I � I 4x A d no MTA It 11411 J , I ip ;y FOR PLC NO I VV SEE SECNOo I i ♦ v, I ♦o ]2.] 1 0n I VTA(c) FOR PCL.NO FOR PGL NO FOR PGL NO FOR PCI.NO SEE SEC NO. FOR PCL NO. SEE SEC NO SEE SEC.NO. SEESEC NO SEE SEC NO 085-02'00+"+ OBS-Ol-01+1 K OB5O1-0lM.] 095A1-009 ®841-010 �\ xH OQ � — --__--_—_-- __---2�----_ UNE —�__— __�_— \ _--�-- ♦yMATCH SEESEC MO OIS MATCH SEE SEC.ND,OtK COUNTY OF SUFFOLK © N +„ tomo. SOLWHOL0 SECTION NO NOTICE ".gam E _—_--_ we,..w --•w— ...-...��.��TM�* U" Real Property Tax Service Agency Y 083 J � OFFICE LOCATION: s® �®l® MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) Q Telephone: 631 765-1938 Southold, NY 11971 ® �® P Fax: 631 765-3136 ®l�C®U LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: April 16, 2019 Re: LWRP Coastal Consistency Review for NORTH FORK HAVEN LLC SCTM# 1000-83-1-34.1 Creative Environmental Design on behalf of NORTH FORK HAVEN LLC requests an Administrative Permit to construct a 370 sq. ft. on-grade patio adjacent to existing patio; addition of approximately 30 cubic yards of fill/topsoil. Located: 8871 Oregon Road, Cutchogue. SCTM#: 1000-83-1-34.1 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, the proposed action is recommended as CONSISTENT with the LWRP provided: 1. All storm water is retained on-site pursuant to Chapter 236 Stromwater Management of the Southold Town Code. 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: Damon Hagan, Assistant Town Attorney Creative Environmental Design P.O. Box 160 39160 Wpute 25 Peconic, N Y11958 631734-7923 Creatiyeenydesign@ayahoo.com Hand Delivered Ft FL7 n E�f •? r.� '° lam ~''>I April 11, 2019 + Southold Town Board of Trustees '. a APR i 2019 Town Hall Annex Southold, NY 11971 Town Board ofTr_i,,,Ps Re: North Fork Haven, LLC SCTM#1000-81-1-34.1 Dear Trustees: As the proposed 12'X 18' pergola is in the process of getting a ZBA review, we would once again like to remove it from the description of the proposed patio extension that is before you now. Please proceed with the administrative permit with out the pergola on it. Thank you. Sincerely, Dave Cichanowicz, Pres. Creative Environmental Design P.O. (Box 160 39160 &ute 25 Peconic, NT 11958 631734-7923 Cmativeenvdesi:an@-iahoo.com Hand Delivered February 20, 2019 Southold Town Board of Trustees Town Hall Annex. Southold, NY Re: North Haven LLC (Ritchie) 83-1-34.1 Dear Trustees: As the applicant decided to proceed with the construction of the 12' X 18' Pergola, please,add it back into the description of the project that is before you for an administrative permit. Enclosed are 2 copies of the plan showing the Pergola. Thank y . D Cichanowicz, Pre 2019 E i Michael J. Domino, President SUFFO(,t- �o�� eoGy Town Hall Annex John M. Bredemeyer, III, Vice-President o 54375 Route 25 Glenn Goldsmith N P.O. Box 1179 A Nicholas Krupski y • Southold, NY 11971 Greg Williams dol , ��� Telephone (631) 765-1892 Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT 14LUREM:ENTS� 3-T SCTM#: , J`AN 2 9 2019 Property Owner Name: NOP_T�{' f�i4V L,I L. - - ':' "T• p, i Date Sent to Bldg. Dept: zg. The Office of the Board of Trustees is forwarding the above referenced application for verification of the Building Department's permitting requirements stated below: YES NO Will the proposed project require a Building Permit? Will the proposed project require a variance determination from the Zoning Board of Appeals? Will any part of this application be considered a Demolition as described under Town Code? COMMENTS: re-V e on Al ed 11 AAM'4"IJ�A_' 113, 1111 ignature of Reviewer Date C Creative Environmental Design P.O. Boal160 39160 Wpute 25 Peconic, itNT 11958 E C E p V E 631734-7923 FEB - 7 201 Creatiyeenydesi'n@,yahioo.com ' SGlliilo(�TOV�fI Hand Delivered Board of Trustees February 7, 2019 Southold Town Board of Trustees Town Hall Annex. Southold, NY Re: Ritchie SCTM# 83-1-34.1 Dear Trustees, Attached you will find revised plans without the proposed Pergola. It was decided not to construct at this time. Please take off the description previously submitted with the application. Thank you. David Cic nowi es. ,' � UT,y Michael J.Domino President "' soTown Hall Annex(� r. John M.Bredemeyer III,Vice-President �` 54375 Route 25 p P.O.Box 1179 Glenn Goldsmith ir Southold,New York 11971 A. Nicholas Krupski i5 , �, �p� r Telephone(631) 765-1892 Greg Williams ®lyCOWN Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application —;74Administrative Permit Amendment/Transfer xtelsiQr„Iq Received Application: I G?S Received Fee: $ 100i,00 Completed Application: I►2 Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: --- — -Coordination:(date sent): LWRP Consistency Assessor n F Sent: f ; CAC Referral Sent: ' `� { Date of Inspection: ?1.12• " " JAN 2 2019 Receipt of CAC Report:-74 + Technical Review: -, Public Hearing Held: Resolution: cJ Owner(s)Legal Name of Property (as shown on Deed): f�OC4�\ 'Vds\-� �A d,\1 Mailing Address: c�S 1tAL1? (�> � ►n �-Z Phone Number: 59 -5 y(,S Suffolk County Tax Map Number: 1000- X —z LI . 1 Property Location: %`x'71 Kej2'11) n IQ � Lr��-r !1 (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): 61 d noo;( P1 Q� Mailing Address: Creative Environmental Desi Rn O Box 160 Peconic,NY 11955 ( 731,,r7-3Lr 2_7'T,,)- Phone Number: � Board of Trustees Appli ' tion GENERAL DATA Land Area(in square feet): of Area Zoning: \,�—Lip Previous use of property: Intended use of property: ICS�hutL�:� Covenants and Restrictions on property? Yes No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes 1✓ No If"Yes",be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. / Does this project require a variance from the Zoning Board of Appeals? Yes L No If"Yes",please provide copy of decision. Will this project require a demolition as per Town Code or as determined by the Building Dept.? Yes t�No Does the structure(s) on property have a valid Certificate of Occupancy?ZZs No Prior permits/approvals for site improvements: Agency Datey f-- 113 No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? /No Yes If yes, provide explanation: Project Description(use attachments if necessary): Q/��CL- Board of Trustees Appli tion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 4-o LO-W— '),AA„A P�o1 Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? _L No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? 3D cubic yards Vo Depth of which material will be removed or deposited: (,y feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Ir,(g\ , Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): Yom_ V�y C� � 0ln V,84 �.t�1 ats � AIA,6 1 ':'u/L Dl/i �f�cYL G� � Fc9rfl �-O GCi '� 4� f9fk-� i©�L�-c�a [L�1�71G�P COWL 4,,,p t9-F Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) �OFV-,- 40-41 I/We, NC V �fl owners of the property identified as SCTM#1000- �J 8 �r� d N—inthetownof fC, New York, ly authorizes David Cichanowicz, Pres.Creative Envionmental Design to act as my agent and handle all necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for this property. Property,Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS �DAY OF NATME CAPOBiANCO Notary Public-State of New York NO Pu .0 No.09 CA6305729 Qualified in Nassau County iifiy Commission Expires June 09,2022 APPLICANT/AGENT/RE-PRESENTATIVE TRANSACTIONAL DISCLOSURE,FORM Tlic Town of Southold's Code of Ethics I rnhibits conflicts of interest on the part of town officers and ctnpletYecsrTfte numou of mis form is to nrovide information which can alert the town of W.!L-ible conflictsafinterestand nnilota Ito take whatever action is nece.,MrY to avoid same. f AME: 7 ve 1 a j aON[ ( �c�1�- �e`� YOUR N (Last name,first name,quildle,initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indican.the other person's or company's mane.) NAME OF APPLICATION: (Check all that apply.) Building .X , Tax grievance Tnistee _ Variance , Change of Zone.- _ Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) Do you personally(or through your comimaY,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Toevn of Southold? "Relationship"includes by blood,man inge,or business interest."Business interest means a business, including a partnership•in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more titan 5%of the shares. YES NO X If ydu answered"YES",complete the balance of this form and data and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the appilcantlageattrepresentutive)and the town o�cer or emiployee.Either check the appropriate line A)through D)andfor describe in the space provided. The town officer or employee or his or her spouse;sibling, or child is(check all that apply): A)the owner of greater than 5°/®of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal orbenefrcial owner of any interest in a non-corporate entity(when the' applicant is not a corporation); C)an officer,direetor,paNtEr,or empioYCC of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this d Signature Print Name Form TS 1 �� Board o£ Txuateea Application ` AFFIDAVIT '�Y.0 Cf_ GULT�Q•�"I'- :BEING DULY SWORN- -_,-.DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE = DESCRIBED PERMIT(S)AND THAT-ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND-BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION ' AND AS MAY,BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. i .• THE APPLICANT AGREES TO-HOLD THE TOWN OF SOUTHOLD AND THE BOARD,OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS_ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED.,IN COMPLETING THIS-APPLICATION,I HEREBY AUTHORIZE THE- TRUSTEES,THEIR AGENT(S)OR REPRESENTATIVES,INCLUDING THE - CONSERVATION ADVISORY COUNCIL,TO ENTER-ONTO MY PROPERTY,TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF '' TRUSTEESTO ENTER ONTO,MY PROPERTY ANDAS REQUIRED TO INSURE - COMPLIANCE WITH ANY CONDITION OYANY WETLAND OR-COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM' OF THE,PERMIT. Signature.of Property Owner;i, Signature of Property Owner; - • 'SWORN TO BEFORE ME TRIS, ,DAY OF �QriULU�1�JAn ,-20 NAME CAPOBIANCO Notary Public-State of New York . Pu iC No.01 CA6305729 Qualified in Nassau County My Commission Expires June 09,2022 , Board of Trustees Application ' AUTHORIZATION (Where the applicant is not the owner) I va� I/We, �d`v r,e. , -R4 in the town of owners of the property identtfied,as SCTM# 1000- C 000 C f C11 aU' R New York,herebyauthorizes David Cichanowicz, Pres.Creative Envionmental Design to act as my agent and Handle all necessary work involved with the application process for pennit(s)from the Southold Town Board of Trustees for this property. Property Owner's Signature Property Owner's Signature SWORN TO BEFORE ME TRIS DAY OF �anjjOud 20 NATIZE CAPOBiANCO Notary Public-State of New York No .� No.01CA6305729 Qualified in Nassau County tidy commission Expires June 09,2022 Board'oi,jTrustees Ali'pplicatioa' AFFIDAVIT BEINGDULYSWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT.FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND'BELIEF,AND THAT ALL WORK'WILL BE DONE IN'THE MANNER SET FORTH IN THIS APPLICATION`-`' 'AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN,BOARD OF TRUSTEES. THEAPPLICANT AGREES.TO HOLD THE TOWN OF SOUTHOLD AND THE „ BOARD OF-TRUSTEES HARMLESS AND,FREE FROM ANYAND ALL DAMAGES AND CLAIMS ARISING UNDEROR BY VIRTUE•OF•SAIDTERMIT(S);IF GRANTED. N'COMPLETING THIS-APPLICATION,LHEREBY AUTHORIZEJTHE ; TRUSTEES,THEIR-AGENTS)OR REPRESENTATIVES,INCLUDING THE ' CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH,THIS APPLICATION, INCLUDING A FINAL INSPECTION.'I FURTHER AUTHORIZE THE°BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE ' COMdPLIANCEWITH ANY CONDITION"OF ANY WETLAND OR COASTAL 'EROSION-PERMIT ISSUED BY THE BOARD OF:TRUSTEES DURING THE TERM OF THE PERMIT. Sigaiature of Property Ownei Signature of•Progetty.Owner ' SWORN TO BEFORE ME THIS DAY OF NATIZE CAPOSIANCO Notary Public-State of,New Yorke', Pu iC No.01 CA6305729 ' Oualifled'in Nassau County My Commission Expires June 09;2022,1 i. ' .. . , `. _ _' - ' , - ' .' , ,' _; .' • , l ; _ ' ,. it `_�1 ,- APPLICANT/AGED URE-PRESENTATIVE TRANSACTIONAJL DISCLOSURE FORM Tim Town of Sontltald's Cadc of f thics nmhibits conflict-of into t Qu the part of town officers and emnloyices.The tnrmo.Se o hii ronn is to mvide inf�rinatia which Ga alert the town of ovsihle conflict-of interest and allow it to take whatever action is neves-�N_ta avail same/ �� ��� ffa,, �i YOUR NAME: r J I V !e- (Last name,fimt mine, initial,unless you ase applying in the risme of someone else or other entity,such as a company.If so,iodic*t1k otter person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building •X Variants Trustee Change ofZone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other'',name the activity.) Do you personally(or through your comixiny,spouse,sibling,parent,or child)have a relationship with any officer or employee of the T own of Southold? `Rclatiotisliie'includes by-blood,tgarri-,iM or business interest."Busin=intcrose'merits a business, including a parincrship,in which the town officer or employce has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO, X If you answered"YES",complete the balance of this form and Oft and sign where indicated. Name of person employed by the Town of Southold Tide or position of that person Describe the relationship between yourself(the applitxutt/ageutlrepresesttaiive)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the spate proMed. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 50A of the slum of the corporate stock of pre applicant (when the applicant is a corporation); 8)the legal or beneficial owner of any interest in a non-corporate entity(when the' applicant is not a corporationk C)an officer,director;partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this V d GeV �- Siprtature Print Name Form TS 1 r V( 1 G 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 1 based on information currently available. if additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: Project Location(describe,and attach a location map): Brief Description of Proposed Action: Name of Applicant or Sponsor: Telephone: E-Mail: Address: Creative Environmental Design PO Box 160 City/PO: Peeonle,NY 11958 State: Zip Code: 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that [:] d may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: ❑ 3.a.Total acreage of the site of the proposed action? 'Asbg a acres b.Total acreage to be physically disturbed? acres ZC? c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) []Industrial ❑Commercial residential(suburban) ❑Forest ❑Agriculture El Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 '5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ IF ❑ b.Consistent with the adopted comprehensive plan? El FI ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: ,—/, ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES F-1 F1 b.Are public transportation service(s)available at or near the site of the proposed action? ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment:_ 4 ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ❑ b.Is the proposed action located in an archeological sensitive area? ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Ideptify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline ❑Forest ❑Agriculturallgrasslands El Early mid-successional ❑ Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? LX ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, ❑ a.Will storm water discharges flow to adjacent properties? ffNO ❑YES b.Will storm water discharges be directed to established conveyance systems(rungff and storm drains)? If Yes,briefly describe: J7N0 [—]YES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: ❑ 1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/spOr+sor mc: Date: 0-" [� Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? F-1 El 2. Will the proposed action result in a change in the use or intensity of use of land? 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the a El of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ affect existing infrastructure for mass transit,biking or walkway? El 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ ❑ reasonably available ener y conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a.public/private water supplies? El El b.public/private wastewater treatment utilities? F-1 El 8. Will the proposed action impair the character or quality of important historic,archaeological, a EJ or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or (Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage El E]problems? 11. Will the proposed action create a hazard to-environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. IJCheck this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. F] Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORINT The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The puroose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action rs necessary to avoid same. YOUR NAME: (Last name,first name,.piddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other Of"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interese'means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thisZ day o 204!T IAN DI LV Signature NOTA PU IC TATE OF NE YORK Print Name U� elrl �D fG Form T No 01147 9 F Auall d S folk of My Cornmissiod Expires April 30, 207.2- Town of Southold LWRP CONSISTIENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* 'including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A -proposed action will be evaluated as to itssi nig ficant, beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DES�C+RIPTION OF SITE AND PROPOSED ACTION PROM CT NAME �V tV, The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1•/J 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity,agency regulation,land transaction) ❑ (b) Financial assistance(e.g. grant,loan, subsidy) (c) Permit,approval, license,certification: Nature and extent.of action: Location of action: fj� � ��_ C��, (, cce__ J v Site acreage: �.kN o Present land use: A-LE,OSl•,`cc Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: 1'l nTA-V\ V As �4"-n W-1— (b) , G —(b) Mailing address: Sy ;R LCA, -Vz)�- (—Vv (c) Telephone number: Area Code( ) l b–M2_54 k� (d) Application number,if any: n)10' Will the action be directly undertak �en, /require funding,or approval by a state or federal agency? Yes ❑ No If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space,makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LVVRP Section III–Policies; Page 2 for evaluation criter' . Yes F] No FJ Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III–jZ' ' Pages 3 through 6 for evaluation criteria ElYes ❑ NoApplicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policie Pages 6 through 7 for evaluation criteria F] Yes '❑ No of Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policiei;/Not s 8 through 16 for evaluation criteria Yes No Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of,Southold. See LWRP Section III —Policies Pages 16 throw h 21 for evaluation criteria El Yes El No Not Applicable Attach,additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ,❑ ❑ Yes No r !applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LVMP Section III — Policies Pages 32 through 34 fo evaluation criteria. ❑ Yes [:] No - Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and waste' See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes F] No Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See L-WRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ Ye�] No Not Applicable Attach additional sheets if necessary WORKING COAST PO, ;IES Policy,10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III_i Policies; Pages 47 through 56-for evaluation criteria. Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town w -sustainable See LWRP Section III–Policies; Pages 57 through 62 for evaluation criteria. Yes ❑ 'No Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III – Policies; Pages 62 through 65 for eva nation criteria. ❑ Yes No Not Applicable Attach additional sheets if necessary Policy 13. 'Promote appropriate use and development of energy and mineral resources. See LWRP Section III–Policies;rages 65 through 68 for evaluation criteria. ❑ Yes ❑ No hrjj Not Applicable i PREPARED BY - — TITLE DATE dpi