Loading...
HomeMy WebLinkAboutTR-9446A Michael J.Domino,President SOF SOUTH, Town Hall Annex 054375 Route 25 John M. Bredemeyer III,Vice-President �� l0 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams 'cam �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE 1664C Date: December 9, 2019 THIS CERTIFIES that the installation of a 12'x'10' ground level landscape tie base for a 9'x7'7"hot tub; At 1415 Harbor Lane, Cutchog_ue Suffolk County Tax Map#1000-97-6-10 Conforms to the application for a Trustees Permit heretofore filed in this office Dated March 21,2019 pursuant to which Trustees Administrative Permit#9446A Dated May 15, 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 installation of a 12'x'10' ground level landscape tie base for a 9'x7'7"hot tub. The certificate is issued to Eric&Eileen Daley owners of the aforesaid property. J bow-.—o -o Authorized Signature Michael J. Domino,President *zf SOUjyO Town Hall Annex John M. Bredemeyer III,Vice-President h0 lQ 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A. Nicholas Krupski • Telephone (631) 765-1892 Greg Williams �COUNT`I, O Fax(631) 765-6641 � �� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: ���3A Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction __.,... Y2-constructed- 4_1 2-constructed 1 Project complete, compliance inspection. INSPECTED BY: COMMENTS: \ N 401 JZ) j N ( �e, ft-kPnV_14J1 ) Vb( 1111� e CERTIFICATE OF COMPLIANCE: �gUFFOt,��o Michael J. Domino, President Town Hall Annex,�''o �, John M. Bredemeyer, III, Vice-President �� y1 54375 Route 25 Glenn Goldsmith ' y x P.O. Box 1179 A Nicholas Krupski �y • ��fr Southold, NY 11971 Greg Williams j0� , �a°fir' 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 1 st day of construction % constructed When project complete, call for compliance inspection; Michael J. Domino,President �Qf SUUjTown Hall Annex John M.Bredemeyer III,Vice-President ,`O� ��� 54375 Route 25 P.O.Box 1179 Glenn Goldsmith J 1t Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams �0 ® �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9446A Date of Receipt of Application: March 21, 2019 Applicant: Eric & Eileen Daley SCTM#: 1000-97-6-10 Project Location: 1415 Harbor Lane, Cutchogue Date of Resolution/Issuance: May 15, 2019 Date of Expiration: May 15, 2021 Reviewed by: Board of Trustees Project Description: Install a 12'x10' ground level landscape tie base for a 9'x7'7" hot tub. 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 Bud Handel, received on March 21, 2019, and stamped approved on May 15, 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 S.C.T.M.# DISTRICT: 1000 SECTION: 97 BLOCK: 6 LOT:10 MAIN ROAD I LAND N/F OF , LAND N/F TIDAL WETLAND BOUNDARY AS WILLIAM & ELEANOR FORTE OF PETER C. STERLING DELINEATED BY EN—CONSULTANTS 542.00' DEC. 22, 2016 N 67'46'00" E N 67'46'00" E •'vnRE FD-ALONG LINE w- r 207.96' — �« — - - -- - - -- _ - -- - w i — — — — — PIPE �.WELL I .i:i�FRM.iiCil�tACL�O i CT I W/LOFi....P0 I COLIC. M. 9':': 1 O DRAIN 28.3'_: W t:' 1 O j 1 tit 8'x20' I ® Py TIMBER CURB PY � FLOATING CURB ,,,tet K I TIMBER SOK DRWEWAY �pNE CATS QIPo S� y �p1TNG III GATE p sN ::o fs NCE 4' W00RAIL I ►, g - I STK' y�o CAT£ '' o•.>:. :>:.::: LAND N/F $ _,...•., OF '. ^.. :. HUGH & KATHLEEN ENOS e i tComPOOLs PROWVt EDED .`::`ii:i:::>.' g '.::::: o { Fn BY PRECISION MARK-OUTS WC 5';= :.::.:'. :':_.::.:`,:..:. O 12/30/16 !1 : : :: ; �., 1. IM C 7S.i?i ii I O . ...... .. ICq { z \� I *' 4' WOOD RAIL FENCE y STK. 4, r 0.1'N y i I STK. 77.72' STK. N 6 32.501'' STK GATE ' STK. STK' i STK. \ I — — STK. 590.00 -- - --- - - -- - - -- - - S 6746'00" w 7.0's \ I\ \ MAP OF EAST CREEK ESTATES #12120 \ { h� LOT 1 \ LANDDFN/FO /! DAVID & BARBARA HAZARD / W C, N 71'508'E `All41 S / z 153.39' a cnU ~ o6 U mo 25' RIGHT OF WAY #��A � , ?��g / STONE/DIRT DRIVEWAY , O W { 150.25' I / I / l / I / I / 1 / ZONED R-80 THE WA 7E-R SUPPLY.{ AND CES UPDATE 11-29-18 LOCATIONS SHOWN ARE FROM FIELDLLOBSERVA77ONNSSOOL I I AREA: 93,394.01 SQ.FT. or 2.14 ACRES AND OR DATA OBTAINED FROM OTHERS I UNAUTHORIZED ALTERATION OR ADD117ON TO THIS SURVEY IS A WOLA71ON OF SEC77ON 7209 OF THE NEW YORK STATE EDUCA770M LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN { ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE 777LE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE. I THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE { NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE EREC77ON OF FENCES, A00177ONAL STRUCTURES OR AND 07HER IMPROVEMENTS. EASEMENTS I AND/OR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE 77ME OF SURVEY SURVEY OF. DESCRIBED PROPERTY CERTIFIED TO: ERIC H. DALEY; EILEEN GRACE DALEY; I MAP OF: OLD REPUBLIC TITLE COMPANY, I FILED: SITUATED AT:CUTCHOGUE — ' TOWN OF: SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design P.O. Box 153 Aquebogue, New York 11931 FILE # 28-37 SCALE:1".40' DATE: MAY 25, 2008 PHONE ( N.Y.S. LISC. NO. 050882 maintaining the records of Robert J. Henn631)298-1588 FAX essy & Kenneth Y. Woyehuk D ' - �' Q 1 ei'X7 ►7 �► 10 _-- N c "APPROVED BY 1-90ARD OF 1 RUSNEES TOWN-OF 'SOUTHOLD . DATE �. " 6 East End Spa d&Sauna 631-722-5502 631-779-2715 fax eastendspaandsauna@gmaal.com ^ = Ica �'�►�' 15 a � � a;s•a+���o o•w,r tea«uk+sR'"°Y' .. --- a v�:.itil' ,�BL'�j Y1µn•$•x,Y gar a¢4�R +y,i`�t ke � U/.".l' s e®°a `s *'Arae M:n N •�:.'!b ®:«'• ®,m a«'" arva"-�a 4 e#y int►^a,•W �,-.�; 61OZ i HVN , s.,r k>1 R » q a� '1'b q w p YR a•�' N w e e,+Y �4 ►s '^ ♦°• +•»Na R'° s e` m?n a'v r.ai rTw.+'wr*u*acw ,-R 'A*N.s,,ee+r.ev+°. s4 +�+"e,r;ea"+r.+r�0`;,".a►"'N ,�.e' , . a,r � , 1;� ; -', - ��y®ti'» .r e' +M' ro. r�T'� <., a .,♦ v m a r' s ! m.'.R s _.� i iY�y,s!w q,■#wasa6s s#'®sr» ia e�y ws•�s..ae�xlrs,,,r A4°� #, n,��,�wN �'' �ii._� '�` --� i ",tl -'� ,,sesa• *�e;.ASYI�! °s+rsa*°`'.asl�'"sY.4 s� �w�., " ..:' �rcmeta�',� t� �'' �1 � �i �' �E {` 7 R;T ! � qia 4 �n e RAib K w� wq e� s wa,,a♦ t m' ! G' 1.. �9 .moi ,`.E A �A•+,sib+`s a. Oles°A Npr Mi r e ma o 9'.rr�`W N lNa A d r s^VI �°a`er°' s vlfN '' •__-._.___-._ O'a R i« ,gwArd�.s4 aen•aa.## w,awya'A'�e„3�•#,°asNN+pT.trP,A #sWya+e[T4"wru 'rw R M 7,i F M"¢�r e �;e 4 N tl4 a+.W a#.#..m+w I.N i..� *., v 7,ti1;e a!r'�it w♦ N ._a aTe #sea � aT e„yr `ow e ,• Ake** wr4 p 0.6 peh1 e ' ra M� s�,w V grab d#aim♦ a oap,a.mw9t!aR#c.lw"'� 01TRea14e, 'vql ':'yeyres�i s�„p$a a�P�M,°,'ru bs ilk RTk lm rn A o e wm" ®a w, aw e w yr •R` ` » � �a'srs 45�kr.ar�;wlsb q4►r+Aw�d.nm .`f�*"a� - 0#`�g��r tee« ^s"�,'•.;$�-,r#`aso+wp�®erasra� etd« Nr` ,sA�' •# sae #e sills NIt< • l7 Ts,w sa.s - .,"• �' dr a&a'oie tare ,o aM r4 Eswi�MnaxwQds wse rk el;'Tf rsrrwaw #e'a r,gads°'Rs,.ydNrw,a>ws'!+ff+'°sswRea�m+'4k�r nvsA�e.rtn *� P . �4� � �`A'i*w�sq+tlrV�eAleeif�goo*w'4'��r �pfw a.r• r,a a�Nr.r 4MlM"rtia�+es ,,yytt��dl sev'n�egi., wN� st'i as w',.y'N`ey.ao T*�µ rtwart 'w NSR +w Weer !~'d b • w Nlw*� rri ray' 113J 9 1GZ-6LL-1£9 ZO -Z -10 uungs. ;p eds pug IseE CANTABRIA NOTAIl.glimensions are approximate;measure your spa before making critical design or pathway decisions. t. MAR 2 1, 2019 t Cabinet 108.0"(274 cm) (Front Uew) 32.5" 38" 61.5°(156 cm) (83 cm) (97 cm) Door Opening 1 Electrical Cut-Out (both sides) N'(10 cm)up from 93.375"(237 cm) - bottom of spa Drain / Front Panel (Center of Spa) Air Vent Air Vent DOOR SIDE Air Vent Electrical Cut-Out r Do Not Block Do Not Block Do Not Block (both sides) 13" (33 cm) (Bottom View) 85.125" Base Pan Side Walls M I[MI 102.0"(259 cm) Base Pan Side Walls NOTE:WATKINS WELLNESS requires that the CANTABRIA be installed on a minimum 4"(10 cm)thick reinforced concrete pad or structurally sound deck able to support the"dead weight"found in the spa specification chart. WARDING:The CANTABRIA must not be shimmed in any manner. Page 5 Michael J.•Domino,Preside o�0$QFF01K�o 4 _,Z_=Town Hall Annex John M. Bredemeyer III,Vice-President f,� � � 54375 Route 25 Glenn Goldsmith � z P.O.Box 1179 A.Nicholas Krupski Southold,NY 11971 Greg Williams � �ap� 'Telephone(631)765-1892 Fax(631)765-6641 • -zu BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: � � Completed in field by: /Vsplw East End Spa & Sauna on behalf of ERIC & EILEEN DA_LEY requests an Administrative Permit to install a 12'x10' ground level landscape tie base for a 9'x7'7" hot tub. Located: 1415 Harbor•Lane, Cutchogue. SCTM#: 1000-97-6-10 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related-structures: 50 feet 6. Landscaping or gardening:'50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. , Residence: 100 feet 2. Driveway: 100-feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 ✓ Ch."1-11 SEIQRA Type: I. II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: t �r�( I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J., Bredemeyer M. Domino G. Goldsmith N. Krupski 'G. Williams Other OFFICE LOCATION: ®��®f ®��i�� MAILING ADDRESS: Town Hall Annex ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 Telephone: 631 765-1938 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: May 10, 2019 Re: LWRP Coastal Consistency Review for ERIC & EILEEN DALEY SCTM# 1000-97-6-10 East End Spa & Sauna on behalf of ERIC & EILEEN DALEY requests an Administrative Permit to install a 12'x10' ground level landscape tie base for a 9'x7'7" hot tub. Located: 1415 Harbor Lane, Cutchogue. SCTM#: 1000-97-6-10 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 the following is required to further Policy 6. 1. Require hot tub dewatering drainage. 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 Michael J. Domino, President �O�pSUFFOC��0el Town Hall Annex John M. Bredemeyer, III, Vice-President o 54375 Route 25 Glenn Goldsmith N ,_ P.O. Box 1179 A Nicholas Krupski y �� TeleSouthold, NY 11971 Greg Williams dol ,�,� ��� phone (631) 765-1892 Fax (631) 765-6641 SOUTROLD TOWN BOARD OF TRUSTEES TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIREMENTS Q 10 s ` SCTM#: Property Owner Name: APO Date Sent to Bldg. Dept: `�Z`�R E The Office of the Board of Trustees is forwarding the above referenced application for Y 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: 4 a ure of Reviewer Date Ll IV Michael J.Domino,President ' Town Hall Annex John M.Bredemeyer III,Vice-President F-`�- 54375 Route 25 Glenn Goldsmith " P.O.Box 1179 CA � Southold,New York 11971 A.Nicholas Krupski Telephone(631)765-1892 Greg Williams a�"�� - Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application �Wetland Permit Application . _Administrative Permit Amendment/Transfer/Extension Received Application: - Received Fee: $_ 100,6 Completed Application: - aZ�. Incomplete: SEORA Classification: Type I Type II Unlisted Negative Dec. . __ Positive Dec. Lead Agency Determination Date:- ; ;, f sal Coordination:(date sent): _ - -.•_''r-='—.,r �LWRP Consistency Assessment Form Sent: S 3• _ ( f'j J CAC Referral Sent. _ f' `-E MAR Date of Inspection: •S� _ _ 2019 Receipt of CAC Report: � Technical Review: 17� Public Hearing Held ---"—,---- --�---- a-- y Resolution: Owner(s) Legal Name of Property (as shown on Deed): L C- .� r�>_Q-C_e a e-u Mailing Address: �a C_ o co '�r-Lt� s � u-(` L SS©�s-'�'� �� ©-7 Phone Number: -. G_V 3` `7 2-Z-- 2 0 O Suffolk County Tax Map Number: 1000- C�-1 - L Property Location: I ��� `C�a �`e- ► ` ` 3 (If necessary,provide LILCO Pole#,"distance to cross streets,and location) AGENT(If applicable): U.c� v\ a e A �s�g A C� ->:A C 'K Mailing Address: 0 a uC Phone Number: t G-- i Board of Trustees Appli:.aZion GENERAL DATA Land Area(in square feet): S 6 C-7 Area Zoning: c `� t ` Previous use of property: C� e ,, ( Intended use of property: l��} �'� t o 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 z 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 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): �gyS`�61- _ C O C' S_ Uoe-k - 6C 1 - -' Board of Trustees Appli..a'tion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: P4 o, Area of wetlands on lot:, �1 C�l - square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: 5 feet i Closest distance between nearest proposed structure and upland edge of wetlands: '1'S►`5 feet Does the project involve excavation or filling? No Yes If yes,how much material will be excavated? - _ -_ _ cubic yards How much material will be filled? 6 cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations Manner in which material will be removed or deposited: 1-..(::v ------------- , - - - 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): APPLICANUAGENUREPRESENTATI VE TRANSACTIONAL DISCLOSURE,FORM The'Town of Southold's Code ofeEthid,6rOliibifs conflicts-of interest on the nart'oftown 6ffcers.and1cm610'vees.The nutvose of this form is to-irdvide infb iiiation which eawalertthe•town-ofpossible conflicts�of interest anti-allow it to take,'whatek6ttron.ts neaessary taavoid same. pp f YOURNAME: t-CX - (Last name,first name,;iiddle 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 ofZone _ - Coastal Erosion Approval of plat Mooring Exemption from plat or official map _ Planning - Other (lf"Other',name the activity.) - - Do you persdnally`(or'through youftompany,souse,sibling,pare,64 or child)have,a relationship with any dffteer or employee of the Town of S66thbld? "Relationship"includes_by blood,nIarriage,or business interest;"Business interest"-ancaps_a•business, including a partnership, in which the town,officerondmployee has even a partialowhmliippf(or-dm'loyment,by),3porporation in which the town officer or employee,owns4bre tharr3ofo,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 t 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 cor'poiation);_ B)the legal or beneficial o}viler of any-intemst in anon-corporate entity'(when the applicant is nota corporation); C)an officer,director,partner,or employee of the applicant;or - D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this Z+ day of 200 I� Signature _ --_ Print Name Form TS 1 \ APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE,FORM The'T6wn of Southold's Go21e of Ethits'or6hibitk-conffi6ts of interest,on the nartof town officers,and emnlovees.1iie'numose of this form'is to provide information which cw alert the-town•of possible conflicts=of tntcrett and allow rt to Take whatever action necessary to atloid YOUR NAME:- �'` ��� /� r/ (Last name,first name,4iiddle initial,unless you aralapplying in,the name of someone else or other entity,such as a company./so,indicate the,other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) T 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 yotft'company,-spouse,sibling,parent,or child)haven relationship with any o'fficcr ur•ctnployee of the Town of Southold? "Relationship"includes by blood,marriage,or business interist "Business interest"incans a,busincss; including a partnership, in which the town oftiter or etnpl6yee lios'even a pnrtial:ozytieiship of{ot ettiployn�ent lay)a corporation in which the town officer or employee owns.mori than 5V*of the shares. YES NO --- -- k 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-50)o of the shares of the Corporate:stock of the applicant (when the applicant is a cotporation);' ; B)the legat or beneficial oiVner of any interest in a n_on-corporate entity'(wli6ri 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 this 200 Signature-- - - 1 Print Name-- �_v, Form TS 1 7f r Board of Trustees Applir__,;ion AFFIDAVIT �lBEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE PPLICANT 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. r" Signature of Property O er Signature-oT?Wp4jOw-ne1r J, T�- SWORN TO BEFORE ME THIS DAY OF20 /'�— Notary Public `®�0%1 NOTARY pj/ o��s ' I ` Board of Trustees Appli�a::ion / AUTHORIZATION (Where the applicant is not the owner) IIWe, '/I • UQ Aev vo- 6 lem hft, bg Lev -owners of the property identified as SCTM# 1000- ,!9-'C47a0 -77. 2/or, 6 in the town of Io4: /O New York,hereby authorizes 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. roperty wner's Si tore Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF M64 G ,20 Notary Public PRY PU®l%iris ep aCS n � O 0�2 � 61 Z20 Appendix B Short Environmental Assessment Form Ingtructiong'for C.o mpletin, 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 l 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 andSponsor Information - C. V"�e k_ - - -- -- -- -- -'Name of iAction or Project: -Project Location(describe,and attach a location map): Brief DescrqAon of Proposed Action: Name of Applicant or Sponsor: Telephone: _ �b.CQ �C4Lcl'\!� G�R E-Mail `fCJi'►'ItQS` GZ,�Q , Add s: - - - - — - - G �Y\ c- City/PO: State: Zip Code: VV 1.Does the proposed action only involve'the'legislative adoption of a plan,local law,ordinance, — 1010 YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources thatEl-- 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 govemmental Agency? NO YES 'If Yes,list agency(s)name and permit or approval: - -3.a.Total,acreage of the site of the proposed action? a acres b.Total acreage to be physically disturbed? ` Z �F acres 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. F1 Urban El Rural(non-agriculture) ❑Industrial E]Commercial Aesidential(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? _ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO_' `YES landscape? 10 .1 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. I a.Will the proposed action result in a substantial increase in traffic above present levels? NO 1 YES. J10 1 b.Are public transportation service(s)available at or near the site of the proposed action? El El: 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: — - - - - ❑ M -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: - ❑ 12. a.Does the site contain a structure that is listed on-either-the State or National Register of Historic 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? i❑ 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. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline El Forest ❑Agricultural/grasslands 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? - - 16.Is the project site located in the 100 year flood plain? - ? NVO 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? ❑NO OYES ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ONO ❑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: - LJ 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:,_ _ FJ 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: I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY• KNOWLEDGE I ` Applicant/sponsor nam 1,�� ' C� U`C► Date: 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? EJ ❑, 2. Will the proposed action result in a change in the a 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 El 1:1establishment of a Critical Environmental Area(CEA)? S. 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 reasonably_available energy-conservEl ation or renewabl .energy_opportunities? 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? ❑ El 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ F1waterbodies,groundwater,air quality,flora and fauna,? Page 3 of 4 t _ No,or Moderate- small oderatesmall 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 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. Check this box ifyou 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. ElCheck 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 LWAP-CONSISTENCY-ASSESSMENT FORM A. INSTRUCTIONS la'l 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 i 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,__sigamc,ant 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, listingboth supporting and.non- supportink frets. If an action cannot be certified as consistent with the LWRP policy standards and conditions,-ifslfiall 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# CO :_�_- L O PROJECT NAME The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees i 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 -� -- - -� _ I A 1 � Location of action: - I ®�'4� �� CC,��-C���Le— Site acreage: Present land use: S�c -,�. � i1 < 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) Mailing address: (c) Telephone number: Area Code( ) (d) Application number,if any: _ AJ16 � l Will the action be directly undertaken,Ilreq__uire 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. r 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 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 c ❑ Yes:❑ Nog Not Applicable 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 ,0 NoNot 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—Policies Pages 8 through 16 for evaluation criteria F-1 u Yes ❑-. NoCO Not 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 through 21 for evaluation criteria ❑ Yes ❑ 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. ❑ ❑ El h k Yes No Not Applica Attach additional sheefs ifnecessary- Policy 7. r Protect and improve air quality in the Town of Southold. See LWRP Section III — PoIicies Pages 32 through 34 for evaluation criteria. ; F] Yes 0 No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous g substances and wastes. See LMW Section III—Policies; Pages 34 through 3,8 for evaluation criteria. 4 F1 Yes }0 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 LW13P Section III-p Policies; Pages 38 through 46 for evaluation criteria. Ye.0 No Not Applicable Attach additional sheets if necessary i 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 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 waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. Yes ❑ No O 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 evaluation criteria. Yes ❑ NA Not Applicable , Attach additional sheets if necessary Policy 13. ' Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED B cX�X TITLE DAT I