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HomeMy WebLinkAboutTR-9414A s\}fF0(�Com Town Hall Annex Michael J. Domino, President John M. Bredemeyer, III, Vice-President �� y�*, 54375 Route 25 CD Glenn Goldsmiths W ,? P.O. Box 1179 A Nicholas Krupski y � Southold, NY 11971 Greg Williams ��I , �a Telephone (631) 765-1892 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 Y7 constructed x When project complete, call for compliance inspection; e 1 a Michael J. Domino,President OF SOy� Town Hall Annex John M.Bredemeyer III,Vice-President Q 54375 Route 25 h O P.O.Box 1179 Glenn Goldsmith l Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams �� Fax(631) 765-6641 COUNT1,N BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9414A Date of Receipt of Application: February 12, 2019 Applicant: Douglas & Michele Gerowski SCTM#: 1000-70-10-29.2 Project Location: 2570 Clearview Avenue, Southold Date of Resolution/Issuance: April 17, 2019 Date of Expiration: April 17, 2021 Reviewed by: Board of Trustees Project Description: Ten (10) Year Maintenance Permit to hand-cut Common Reed (Phragmites australis)*,to not less than 12" in height by hand, as needed. 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 project plan prepared by Douglas Gerowski, received on February 12, 2019, and - - - -- - stamped approved on April.17_,-2019. -- -- -- - - - - - - --- § 275-5 Permit procedures. (i) Cutting of common reed (Phragmites australis) to within 12 inches of the soil surface landward of the wetland boundary. This does not include mowing to ground level. Special Conditions: Do not disturb native vegetation during the hand cutting of Common Reed (Phragmites australis), including but not limited to; Eastern Red Cedar (Juniperus virginiana), Northern ,Bayberry (Myrica pensylvanica), Marsh Elder (Iva frutescens), and Groundsel Bush (Baccharis halimfolia). The approved operations must be commenced within two (2) years from the date of the resolution. The permittee is required to provide the Trustees with before and after photos of the area within this time period before any further maintenance is conducted. 2 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 SURVEY OF PROPERTY AT SOUTHOLD TOWN OF SOUTHOLD = gl ,I li 1 j SUFFOLK COUNTY, N.Y. 1000-70-10-29.2 SCALE.' 1'=30' I SEPTEMBER 24, 2015 OCTOBER 15, 2015(REVISION) FEB. 19, 2016(PROP. POOL) M41 VI W A APRIL 29, 2016(WETLANDS FLAGS) f lY V AUGUST 18, 2016(ELEVATIONS&CONTOURS) i s "!'I X6 T�'-S8�' SEPTEMBER 2, 2016(NON DISTURBANCE AREA) 90,0 '30' SEPTEMBER 27, 2016 (REVISIONS) Q�OyiUei4i f; WATE�Maree R " Y` DECEMBER 12, 2016(REVISIONS) 90.E ' DECEMBER 2Z 2016(REVISIONS) RETAINING WALL JANUARY 09, 2017(REVISIONS) Q G i U) JANUARY 18, 2017(REVISIONS) ly � to JANUARY 25, 2017(REVISIONS) 2--/ �� p MARCH 28, 2017(REVISIONS) `+1 ➢ 04 o AUGUST 8, 2017(LOT COVERAGE REVISIONS) (f)Z STONE 7 o OCTOBER 12, 2017(TURF GRASS REVISIONS) {�. O Z RETAINING PAVER Z O', WALL r 9 XEL 4'r azo Z 5 -<� "v 24 J G b0 zZ '� 'n 249 00240 R c O = tt ELe o' 2 STORY PROPOSED POOL DRYNELL� c FRMD HOU5E o�w a 3 0' N / � �GARAGE � SUBDIVISION MAP OF SOUTHWOOD tF00C FIN FIR el-10' 4/` SUFFOLK COUNTY FILE NO 2141 }i, 4 BAY WIADOW• / �J CAHr a 16r_ PROPOSED POOL EQUIPMENT 271' AREA OF NON-FERRIZATON EXISTING j-k / AREA OF NON-FERTUZATION AND NATIVE PLANTINGS _ a 'fit o UPPER--Q- I I y. AND NATIVE PLANTINGS ZONE GS ry Tro ui- Ei-uT e 1 v �' 'STEPS a o ruvlOJ'+ j��Y TIPJ'6RA55 fATlq _FLOOI.D-ZONE 5 B T,0 rAno i� LOT COVERAGE BUILDABLE LAND y I 'ti PRopa m 1� 4'FENCE WITH 4'GATE I � Po 17900 9.R. PROPOSED 4'RAVINGS I ",c2 L�y� UNIT ITEO UNE NON-DISTURBANCE/NON-FERTUZATION EXISANGgHOUSE GARAGE <'RETAINING WALLS I, 20 PORCH&D£C!L+2578 sq.ft. 45 D' 2578/17900= 14 4X STEPPING STONES PROPOSED LOT COVERAGE V FENCE VATH V GATE HOUSE, GARAGE,PORCH&DECK 2578 sq.ft 45• LEA IN PROP,POOL&POOL PAHO 1J60 sq.ft. EL34X J9J6 sq ft. o' REMOVE MAN MADE FISH POND k WOODEN FOOT BRIDGE 3938/17900=22X ZONE AE � IY't0Y'eTd (EL 6 FEET)4 0\y 'y PROPOSED 30'WIDE (L• ---WLf p1 EL 34 � QJ1. '-+COMPOSITE WALKWAY N.Y. DEC ADJACENT AREA COVERAGE `4. WLFWLP� AREA WITHIN J00'OF 14HWM Wi ` n £XIS ANG HOUSE, GARAGE .lj �WEr W WLF UNOWARD EDGE OF TIDAL WETLANDSPORCH,DECK,STEPS OE + 2668 sq.ft. EWE WETL 5 41 AS OETERMNED BY EN-CONSULTANTS INC PAHO+ 400 sq.ft WL F WL F .� INC.ON JUNE.2000 WALKWAY TO EDGE OF WETLANDS+ 1JJ sq.ft. �, u 4 y J201/17900= 17,94 3201 sq.ft. .� LANDWARD EDGE OF TIDAL WETLANDS ZONE AE AS DETERMINED BY SUFFOLK ENVIRONMENTAL PROPOSED (EL 6 FEET) 3r CONSULTING INC.OV 04/09/2016 N.Y. DEC ADJACENT AREA COVERAGE PROPOSED AT COMPLETIONWETLANDS HOUSE, GARAGE, PORCH,DECK,GSTEPS&PAVERS= 2668 sq.ft. PROPOSED POOL= J92 sq.ft. /�Wx F NEW COMPOSITE WALKWAY= 123 sq ft. STEPS IOJ sq ft. L N CE DOUGLAS A . GEROWSKL /L 4254/17900= 18 JR 3286 sq y � � MICHELE GEROWSKI `o z $ FL000 � DOUGLAS J GEROWSKI Ll _,�fLM� m •P ABSTRACTS INC. PROPOSED AT L`OMPLE77ON N WELLS FARGO HOME MORTGAGE WITHOUT COMPOSITE WALKWAY ZONE AE EXISTING HOUSE, GARAGE, L9 (EL 7 FEET) E PORCH,DECK,STEPS&PAVERS+ 2668 sq.ft ,� nF W PROPOSED POOL- J92 sq ft 1 >t y STEPS= IOJ sq It < FTNAL RESTORATION AND/OR J16J Sq.& �r LANDSCAPE PLAN PREPARED BY 3163/17900- 176X Ltib� •� CASTILLOSCAP£S osr ,NOTE.- PROPOSED PERVIOUS TURF GRASS PAHO NOT INCLUDED IN N YD E C LOT COVERAGE N7 4 67 ■=MONUMENT P<A '��"w 0= UTILITY POLE N' eeo oAr 6,968,E B= WATER METER PvC 43 k10 - WETLANDS FLAGS rt X=SPOT ELEVATIONS M-AREA OF NON-DISTURBANCE G'005 FLOOD ZONES FROM FIRM J610JC0166H ELEVATIONS AND CONTOUR LINES ARE REFERENCED FROM NA VV 88 ANY ALTERATION OR ADDITION TO THIS SURVEY 1S A WOLAT70N N.Y.S. LIC. NO 49618 OF SECTION 7209OF THE NEW YORK STATE EDUCATION LAW. PECONIC SURVEYORS, P.0 EXCEPT AS PER SECTION 7209-SUBDIWSION 2. ALL CERTIFICATIONS AREA-0.06623 ACRES HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY If (631) 765-5020 FAX (631) 765-1797 SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR OT 29,021 SO.FT. P.O. BOX 909 WHOSE SIGNATURE APPEARS HEREON 1230 TRAVELER STREET5-187 SOUTHOLD, MY. 11971 G' --AleJ�i�rt �� y•9 �%�,7 E/,3•� a''Z' E/•ZZOO, �='Ti�e Tr+r 1bo6oh,� a .� ' F/ E/�•3 E1,5,1 4744 E/,3.�J =BOARD OF 1 RUSTEES cE TOWN OF SOUTHOLD F.eEv• 7e .... =, 5,0 DATE vorlas�s� APk•�L 17 q - 201 8.�rvlc�-G.�rE'rS.swo SSV LAiyo ! � 9Qi9� v LEW_q p`� .f_:. - ; ►e�w.�/�l�iu.�Ta�'o.Q.e � ,/1or�':G9.uoi✓�.�F•rrE.vraFTi /�E7' Tv GoA.c�yE �.szvv o90 ,*;eisWTi9,rE.vF.E 1��Ti��/yElt�•�i'•�'s lf90 .t/.) �9r Q 3®op �6 OE�iyyel�'E,�/T pfirr.�es.L`�:v1�G .�E.�d9l •l1ov 7.l6-S96 ti�w r, 1 Ey9Ti�ys .Silbw.y/14/.c%G•I-rl r�.�lo,s.�•s•) I �,�� Michael J. Domino,President ��q soyOTown Hall Annex John M.Bredemeyer III,Vice-President ,`O 01 0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski • Q Telephone (631) 765-1892 Greg WilliamsycoU O Fax(631) 765-6641 lNTY,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 9, ®0� a1 Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction Y2 constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: _ � a CERTIFICATE OF COMPLIANCE: 1 � v -e - j FEB 1 2 2019 4""'' 2/9/2019 IMG_1454.jpg • A ,�� IIIIIIIII611 111111 IIIIIIIIIIII I�IJI Ili; � I 1 5 \ 1 r k r A s 1P AI rA i_ a j•e 1 , ;l � r I �+'4 ,r •�� .��. i 't � � +� {''Y .({ •\�i �`.•�.�. / � p,�. �. �f �,��,�°.:� r�j�f'�"�;�y rt,, �a ���may: c F .!' r IS ;�f�. I 4 , I r RI � } ! � '�;;1'y•�`L� �.� �lY�T� ��l ± � /� ��i R� �� rf�'i "'rr� ,. 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Box 1179 54375 State Route 25 Southold,NY 11971 (cor. Main Rd. &Youngs Ave.) va Southold, NY 11971 • O� Telephone: 631765-1938 ® a Fax: 631765-3136 lyc®UNT`I 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 10, 2019 Re: LWRP Coastal Consistency Review for DOUG & MICHELE GEROWSKI SCTM# 1000-70-10-29.2 DOUG & MICHELE GEROWSKI request an Administrative Permit for a Ten Year Maintenance Permit hand-cut Common Reed (Phragmites australis) to not less than 12" in height by hand, as needed. Located: 2570 Clearview Avenue, Southold. SCTM# 1000-70-10-29.2 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. 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 ♦ .v( 1 John M.Bredemeyer III, President ®��®E S®!/ly®l Town Hall Annex 54375 Main Road Michael J.Domino,Vice-President ® BW P.O. Box 1179 James F.King,Trustee W Southold,New York 11971-0959 Dave Bergen,Trustee ® � Telephone (631) 765-1892 Charles J. Sanders, Trustee ` COUNTY, Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application _Wetland Permit Application _Administrative Permit % _Amendin t/Transfer/Exte Sion Received Application: 2�(2��� eceived Fee: $ �Q� 4 Completed Application: 4 Incomplete: f 2 2019 _ _SEQRA Classification: ; ! Type I Type II Unlisted �--- -------------- -! Coordination:(date sent): _T Consistency Assessment Form: iq --�---- CAC Referral Sent: Date of Inspection: _Receipt of CAC'Report: _Lead Agency Determination: Technical Review: Public Hearing Held: Resolution: Name of Applicant: Mailing Address: 5-7 ® CZ- ylf- 5o of ROR 7/Phone Number: 510- & 5 - Suffolk County Tax Map Number: 1000 - (7 " "1 qx 2— Property Property Location: e fV5( fn Cl- we-L) &G 1001 Ph5T G A&-x'15 I.ft1VD 10C? ROA-D Ll PA 1+ 557 (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: Board of Trustees Appli tion GENERAL DATA Land Area(in square feet): 2 �J`�� - 5-5 Area Zoning: R-4 o Previous use of property: tAK-elO Intended use of property: 1_N C,REA5E Vz-w 67oo5e 6zj—=:70� Covenants and Restrictions on property? Yes '� No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes No If"Yes",be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes ✓ No Does the structure(s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency Date 5_n t1Q L,b 3D 14 2--5, 2.06 5- `6VI V4 PD-D1���7� PN uv6-T 20, Cw Pt.D 3-D `Daewg-eK 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): -TO CU"f L-x(5-TiN6 PA RAb MI I If\ M x.50 �I hrrT 6-F Owe -To ®(7- bt®b5 C NG_--M ffiftIUXILOJ �� Board of Trustees Appld tion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: TO boos e- Cp' hula 'moi s c- Area of wetlands on lot: 12-t 1 '50 square feet Percent coverage of lot: 4D % Closest distance between nearest existing structure and upland edge of wetlands: 50 ° feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No Yes If yes,how much material will be excavated? ubic yards How much material will be filled? cubic yards Depth of which material will be re ved or deposited: feet Proposed slope throu the area of operations: Manner in w ' material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): Board of Trustees Appl:' tion AFFIDAVIT 'Doviz:r7 � 0Lv5f:� I BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. ix)o ledw %nature of Property Owner ell SWORN TO BEFORE ME THIS DAY OF 7 , 20 IT Notary Public R1 CHARD K VANDENBURGH N6tdry Public,State of New York %.2VA6027629-Suffolk County t6mmigalon Expires May 16,26,21-z Board of Trustees Appl --Ltion AFFIDAVIT BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Sig4aiure of Property Ownef Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF FEEO 20_�� 474 N.WAMotary Public NotMay PubHv,z;i lu:d New York No.2VA5027629-Suffolk County Commission Expires May 96, 'LD2?- APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The pumse of this form is to Provide information which can alert the town oLpossible conflicts of interest and allow it to take whatever action is necessary to avoid same. n YOUR NAME (Last name,first name,Viddle mitral,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (if"Other`,name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,rgarriage,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 than5°/c f the shares. YES NO ✓e Ifyou 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 th' �1 day of 'XPi, �-`' 20 Signature Cv� Print Name � Form TS 1L , APPLICANT/AGENT/REPRESENTATIVF, TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: Do,,,6 -t- i Y,fin l� (A�:G (Last name,first name,xpiddle 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 (If"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town ofSouthold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%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 Submitte is y of Pq�o o 1 S ignatur t Print Name Form TS I 617.20 Appendix B Short Environmental Assessment Form instructions for Completing Part l -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: OF Project Location(describe,and attach a location map): C-ti'D © �i. �t � Brief Description of Proposed Action: �( 6,,7, ,b D PttP_AbYY11-7E5 10 �'_X ► ST( N b Name of Applicant or Sponsor: Telephone: 51to- &56_ 405-5 �Olb _+ Y nY 1I�-�66 E-AD W 5E-Mail: 67eRb W 5e_l & D P Tb V U .fiC 1 Address: '2_6-7e A\r� City/PO: State: Zip Code: 6DJIi-bt'lu; 't Igr 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 LJ ❑ 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? .9-73 acres b.Total acreage to be physically disturbed? ,2.:7 -3 acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? s 10'V?—acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial [21/Residential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ ❑ b_Consistent with the adopted comprehensive plan? ❑ ❑ �J 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ 2 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: 0 I!o � ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES _ © ❑ b.Are public transportation service(s)available at or near the site of the proposed action? ® EI- c. c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 5� ❑ 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: F2 LYJ ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ Rr 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ 0 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? M ❑ 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? ❑ 10 If Yes,identify the wetland or waterbody and extent of alteratio s insquare feet or acres: v 0 2� lei t �-- ®� � c- � 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional Wetland ❑Urban '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? ❑ 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, t-�/ ❑ a.Will storm water discharges flow to adjacent properties? ❑NO ❑YES u b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: F]NO ❑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)9 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: iF] 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: ff I I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDj Applicant/ o so :�U ����`–` L(J � Date: 2-19 Signature: uawC.Z 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 I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my- responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning �y 1:1regulations? u 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? Z E 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑ establishment 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? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate rj f ❑ reasonably available energy conservation or renewable energy opportunities? l " 7. Will the proposed action impact existing: a.public/private water supplies? b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural 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 drainage1:1problems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. ❑ Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or 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 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended- to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt'actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# - VID - �2-1) -2— PROJECT NAME ( U- lM b OF keAbMUE5 ZC-) tfeI 6(+7 OF al 1 LlJ , The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity, agency regulation,land transaction) ❑ (b) Financial assistance(e.g. grant, loan,subsidy) (c) Permit, approval, license,certification: Nature and extent of action: _ CUT-TkAb, O -rtO o-c-I bwT Z)-P Z)W-e:" EO-T- Location of action: 2570 Cg= V/&U 6�1✓ �G�J� t—� Site acreage: $ �9— Present land use: Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: ,� (a) Name of applicant: b -t t nv\i Lrt�a� (b) Mailing address: 51 C) CLV IE-Lu hye 60L7r k()CAD (c) Telephone number: Area Code( ) t 10~ b�50 '4 0 5712) (d) Application number,if any: Will the action bedirectlyundertaken,require funding, or approval by a state or federal agency? Yes ❑ No LJ If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. Yes ❑ No ❑ Not Applicable m14i4if5 SSG OF Cbl% LDC 1 foll\ 1 N cei�-A-51 IjLy ylev--) OF W i4EEK Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No Eq 1Sot Applicable ' I Attach additional sheets if necessary Policy 3. Enhance visual-quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria Yes ❑ No ❑ Not Applicable e lu G I & y l V PfL- V lt-�W �TH �-/ I Iy r✓�t � CPQ e G Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages S through 16 for evaluation criteria ❑ Yes ❑ No ID;Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of,Southold. See LWRP Section IH —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No 1 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. ❑' ❑ ❑ ,R Yes No r'it s Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No�Kot Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. ee LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. Yeil No B Not Applicable Attach additional sheets if necessary 1 ; WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III-Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No dNot Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary.and Town wa rs. 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 eval tion 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; P ges 65 through 68 for evaluation criteria. F-1Yes [:] No Not Applicable PREPARED BY_DDj(j TITLE ADMIED( OOZ- DATE-2 1 Z0 19