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HomeMy WebLinkAboutTR-9469A Michael J. Domino,President OF soyoTown Hall Annex 1 John M. Bredemeyer III,Vice-President Q 54375 Route 25 h O P.O. Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G Telephone(631) 765-1892 Greg Williams �� Fax(631) 765-6641 OUNTY,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1610C Date:August 22,2019 THIS CERTIFIES that the replacement of second story deck on west side of house with an proximate 440scft deck includinjz concrete footings support posts ftamingdecking and railings; At 900 Trumans Path, East Marion Suffolk County Tax Map#1000-31-12-4 Conforms to the application for a Trustees Permit heretofore filed in this office dated May 25, 2018 pursuant to which Trustees Administrative Permit#9469A Dated June 19, 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 replacement of second story deck on west side of house with an approximate 440sa.ft. deck including concrete footings,_suipport posts framing decking and railings. The certificate is issued to Evelyn McConlogue owner of the aforesaid property. Authorized Signature Michael J. Domino,}President OF SU(/r�o Town Hall Annex John M.Bredemeyer III,Vice-President � lQ 54375 Route 25 P.O. Box 11 Glenn Goldsmith l�[ Southold,New York 11971 A. Nicholas Krupski G Q � O Telephone (631) 765-1892 Greg WilliamsO Fax(631) 765-6641 �yIrou BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction % constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: CERTIFICATE OF COMPLIANCE. �� �� Michael J.Domino,'President 0� sQ l�ryo Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 h0 0 P.O.Box 1179 Glenn Goldsmith [ Southold,New York 11971 A.Nicholas Krupski G Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9469A Date of Receipt of Application: May 25, 2018 Applicant: Evelyn McConlogue SCTM#: 1000-31-12-4- Project Location: 900 Trumans Path, East Marion Date of Resolution/Issuance: June 19, 2019 Date of Expiration: June 19, 2021 Reviewed by: Board of Trustees Project Description: Replace second story deck on west side of house with an approximate 440sq.ft. deck, including concrete footings, support posts, framing, decking and railings 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 E. Wingate, dated April 20, 2019, and stamped approved on June 19, 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 a, f i 'I ��UFFoc� ;i Michael J. Domino, President Co Town Hall Annex�o ed John M. Bredemeyer, III, Vice-Presidents 1 54375 Route 25 Glenn Goldsmith y P.O. Box 1179 A Nicholas Krupski k y • �� Southold, NY 11971 Greg Williams Od ,� �a�*r' 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 Whenjroect complete, call for compliance inspection; p p p p SURVEY OF PROPERTY FOR: AGNIES FP.RRO,DANIEL MCCbNLOGUE � E E it V E &WIL.LIAM MCCONLOGUE SITUATE MAY ' 9 2019 EASY' MARION TOWN OF SOUTHOLD MSo��tlio�J ic:vn Y of Truste^s SUFE OLK COUNTY, N.Y. -- �IF �Tl TAX MAP NO.: 1000.031-12-004 �.ND al 1 LOT AREA: 11,845.05 S.F.(0.141 O ACRES) I► DATE SURVt '1 D:AUG.25,2018 ELEVATIONS REFER TO NAVD88 +21-48 Vol 01,SOH Lr � 1, � ��° /O� 82 �tAGv� H , l Zi.oy \� 0E 10% l l550 0A 0 \01, 04 CL LAND 04 �`e O ST N o +,Z0 A04 N�aaC raF_PH,GEIr.P. `� S/ ��' _ * --- ---- ----- -- - -- - - - - y PROFIZI§510NAL LANb SUR)fitYOR 4p 1 w ti . +2o.ey GpO� r N R0 N oe p,�► 4 ` � �0Off 0 v • � O z GO P' W \ z SCALE: I INCH 30 Fe-ET a b� 30 q is 30 60 LEGAL NOTES I.COPYRIGHT2018 ANGELO J-CECERE PROFESSIONAL LAND SURVEYING.ALL RIGHTS RESERVED. Q ��' `�{' 2.UNAUTHORIZED ALTERATION OR ADDITIONTO THIS SURVEY MAP BEARING A LICENSED LAND SURVEYOR'S SEAL IS A VIOLATION OF SECTION7209,SUB-DIVISION2.OFNEWYORKSTATE EDUCATION ,Ta U �� ,K �..Ir i I/M�(�.�1R�' &ON LY BOUNDARYSURVEY MAPS WITH THE SURVEYOR'S EMBOSSED SEAL ARE GENUINE TRUE AND CORRECTCOPIES OF THE SURVEYOR'S ORIGINAL WORKAND OPINION. T- CERTIFICA71ONS ONTHIS BOUNDARY SURVEY MAP SIGNIFYTHATTHE MAP WAS PREPARED IN ACCORDANCE WITH THE CURRENT EpSTING CODE OF PRACTICE FOR LAND SURVEYS ADOPTED BYTHE CO _ STATE CE -0-4 ^' NEWYORK ASSOCU\TIONOF PROFESSIONAL LAND SURVEYORS. CR77FlLI CATIONIS MTTED70 PERSONS FOR WHOMTIiE BOUNDARY SURVEYMAPISPREPARED.TOTHE7T[LE - R'-' COMPANY.TO-THE GOVERNMENTAL AGENCY,AND TOTHE LENDING INSTITUTION LISTED ON-THIS BOUNDARY SURVEY MAP. O ^ S.THE CERTIFICATIONS HEREIN ARE NOTTRANSFERABLE B.THE LOCATION OF UNDERGROUND IMPROVEMENTS OR ENCROACHMENTS ARE NOTALWAYS KNOWN AND OFTEN MUSTBE ESTIMATED.IF ANY UNDERGROUND IMPROVEMENTS OR ENCROACHMENTS m - E)OSTOR ARE SHOWN THE IMPROVEMENTS OR ENCROACHMENTS ARE NOT COVERED BY SURVEY. C ANT {j Y C 3 n�} 7.7HE OFFSETS(OR DIMENSIONS)SHOWN HEREON FROM THE STRUCTURES 7O THE PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND USE ANDTHEREFORE ARE NOTINTENDED TO GUIDE THE 2p1 , _ ERECTIONOFFENCES.RETAINING WALLS,POOLS,PATIOS PLANTING ARE ADDTRONSTO BUILDING AND ANY OTHER TYPE OF CONSTRUCTION. 9 g COPIES OF THIS SURVEY MAP NOTBEARING THE LAND SURVEYOR'S INKED OR EMBOSSED SEAL SHALL NOT BE CONSID RED TO BEA VALID COPY. j s 9.PROPERTY CORNER MONUMENTS WERE NOTSETAS PART OF7H19 SURVEY UNLESS OTHERWISE NOTED. @OPTOkUNE-NIET 0 I ! I U �°- --- FOR '. - 4 _ - �o-f-o _Zcr--- - tea loo iviit_1A 0 + JJI ` M AY - 9 2019 RV v ` JLl7lI14iL! ;}4iE? M /pRlar� O i \ ' APPP � ® �Y Olin C-ane, _ BOATO RD, ®F,7R•USyTEES TOWN.®F S®UT OLD =A- DATE- - 01, 70 ✓ - \ -----�= _ p LOM - � - a r _ s - woe m,.: rl r, c> Cain .tm fib �5upv 1684 s -toy - - � LAWe ----------- F SAY 9 2019 Southold town oard of Tri-t-- 73,- 4Z t"PA- I L e jjp! 40- T- RNe 9 #2 of 4- - F It L-- _j A -411- MAY 9 2019 L -41 CV illud, PLAd" 4? --------------- EE E 0 E MAY - 9 2019 SoUliold Own -4c �jl -Y: A i -goLm lio -PD5 144-im - '- 4 or-4 , x ' RIDGE RAFTER USP RS250 AT 21 / A"\RAFTER/RIDGE/RAFTERwrrRcr ' MAY _ 9 2019 ' I RIDGE RAFTER RAFTER KING STUDS s ,...... a.._._�4 STUD :+UUti1C';�To`n�_. RAR usPRT160R(2)Rn oars oT"i�.Ufe TOP PLATE TOP PLATE HEADER USP RS250 AT 21 r: USP RT20 USP RS250 AT 18' USP R'T3 USP LS ORTMU ES WALL STUD WALL STUD USP R5250 AT 17 CONNECTION USP PRODUCT NL1MBER JACK STUDS A RAFfERIPoDGEIRAFTERWrrH CT' RS250 21' RAFTER/RIDGFJRAFTER WUHOUT CT RS250 21'+LSSHI79 B RAFTEW ATE/STUD RT2D - RAFTER/PLATE RT16ar RTI PLATERSTUD RS250 16' Al RAFTER/RIDGE/RAFTERwrocr �RAFTERIPLATE/STUD �RAFTER/PLATE PLATEISTUD C HEADER/STUD Im C HEADER/STUD HEADER/JACK HEADER/JACKSTUD RS2W 12' D FLOOR TO FLOOR KLFTA ar RS250 36' E STUDPLATFJSILL RS250 36' _ SIUDPLATE RS250 16' ' PLATElSOL MP6F • - F ANCHOR BOLTS ST816 G POSTAPCHOR FOR DECKS PAU SERIES POSTANCHOR FOR COVERED PORCHES CBE SERIES _ I 1'1)Qi OR2XA-16'CYC COLLAR TIES MIN. _ __� POST USP CBE P.C.FOOTING - 2ND FLOOR WALL STUD 2ND.FLOOR WALL STUD lop ,1ST.FLOOR WALL STUD 1ST.FLOOR WALL STUD 2ND.FLOOR PLATE 2ND.FLOOR PLATE _ G POST ANCHOR FOR covEREo PORCHES SUBFLOOR 1ST,FLOOR PLATE ISL FLOOR PLATE RIM BOARD RIM BOARD SUBFLOOR SUBFLOOR USP KLFTA USP RS250 AT 36' USP RS250 AT 36' USP RS250 AT 16' 1ST.FLOOR TOP PLATES 1ST-FLOOR TOP PLATES RIM BOARD RIM BOARD DOUBLE SILL PLATE DOUBLE SILLPLATE POST USP MP6F IST FLOOR WALL STUD 1ST FLOOR WALL STUD FOUNDATION WALL FOUNDATION WALL USP PAU •- P.C.FOOTING c ,ae.,'0 FLOOR TO FLOOR FLOOR TO FLOOR STUD/PLATE/SILL STUD/PLATE PLATE/SILL G PO �e RWX a Michael J. Domino,Presi O�OSUFFU(KCO� Town Hall Annex John M. Bredemeyer III,Vice-President �� 54375 Route 25 -Glenn Goldsmith y = P.O. Box 1179 A.Nicholas Krupski Southold,NY 11971 Greg Williams p� ' Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: � j� \ 39" Completed infield by: Jason C. Leonard, on behalf of EVELYN McCONLOGUE requests an Administrative Permit to replace second story deck on west side of house with an approximate 440sq.ft. deck, including concrete footings, support posts, framing, decking and railings. Located 900 Trumans Path, East Marion. SCTM#: 1000-31-12-4 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. 111 SEQRA Type: 1 II Unlisted Action Type of Application: 'Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey :5 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: 14-9WW AgAff'l 60AM 6.12.1q I have read & acknowledged the foregoing Trustees comments: Agent/Owner: ' Present were: TJ. Bredemeyer ; M. Domino G. Goldsmith N. Krupski G. Williams Other 7 / lent o��SUFFD(�-�oG `ice( Town Hall Annex Michael J. Domino, P;� John M. Bredemeyer III,Vice-President y� 54375 Route 25 Glenn Goldsmith CIO P.O.Box 1179 Ze A.Nicholas Krupski Southold,NY 11971 Greg Williams p! Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time:. Completed in field by: Jason Leonard on behalf of EVELYN MCCONLOGUE requests an Administrative Permit to remove existing deck, support posts and footings on west side of dwelling; construct new 440sq.ft. deck including new concrete footings, support posts, framing, decking, and railings; and to replace five (5) entry doors in existing openings. Located: 900 Trumans Path, East Marion. SCTM# 1000-31-12-4 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=� 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. 111 SEQRA Type: 1 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 i Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other Ctrl 4:) ci• `°•�' Vit» r, :z '.^„,_���,?,�tkr! . yf i, r•.r 7yA� .•'..�>a,.+,�'�.. 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T� mom-tm 9ten>a 1 '� e` � M1 � ,r � a2wr "� M1•" '>4P,,�`0 ' a •a`, gid*Q v j. M1 Y COUNTYOF SUFFOLK © K°i °` souo{n SECTION Iq ..n,_ �.� '- ,.. ------ o....�.. et— u...,� • NOnCE rn E tlttw (z+) z '�„' --•-- •••". --•-- ,, Real Properly Tax Service AgeNcy •mo 01 B.I.�BE _,. ------ o-- _-_•_-- .--�_ Cr.e+Ir 1111W—CNY„M1 _ w 031 N �•,•••• -••-•• u, ___ � --"-- amu.—_�-- Y 4r P 4 ep mtwer rq TIM, PROPERTY 4WD Michael J. Domino, President �o�� co9 Town Hall Annex John M. Bredemeyer, III, Vice-President 54375 Route 25 Glenn Goldsmith N = P.O. Box 1179 A Nicholas Krupski y Southold, NY 11971 Greg Williams mol , dao Telephone (631) 765-1892 Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PER RE001REMENT SCTM#: MAY 2019- Property Owner Name: G coI/U(, 6 ,S. `7.19 ` = �; •�} ,-'.' ', : _� Date Sent to Bldg. Dept: 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: Ito Aigna"tureof Revte er Date ' 1 OFFICE LOCATION: ®f SOUTyO MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 G • �@ Telephone: 631765-1938 �olyC®U� 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: June 14, 2019 Re: LWRP Coastal Consistency Review for EVELYN McCONLOGUE SCTM# 1000-31-12-4 Jason C. Leonard, on behalf of EVELYN McCONLOGUE requests an Administrative Permit to replace second story deck on west side of house with an approximate 440sq.ft. deck, including concrete footings, support posts, framing, decking and railings. Located: 900 Trumans Path, East Marion. SCTM#: 1000-31-12-4 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 on the new submittal and my assessment, the proposed action is recommended as EXEMPT from LWRP CC review pursuant to § 268-3. Definitions: ll. Additions to an existing building or rebuilt residential structure which results in no net increase in ground area coverage, except where the parcel is located in a coastal erosion hazard area; 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 vv' Ys'f sem` Jw , J SpFFO(,� Michael J. Domino, President 40 Town Hall Annex John M. Bredemeyer, III, Vice-President �� y� 54375 Route 25 Glenn Goldsmith P.O. Box 1179 A Nicholas Krupskio • Southold, NY 11971 Greg Williams y�'41 , , -�ao� Telephone (631) 765-1892 Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIREMENTS SCTM#: Property Owner Name: IXCC-0A1L06-0E- PD, D Date Sent to Bldg. Dept: 30+17 MAY 3 0 2018 BUILDWG Dom. The Office of the Board of Trustees is forwarding the above referenced OF ,®UOLD verification of the Building Department's permitting requirements stated �� ���� — YES NO AAe�ls Z,6,4- Y7 NOWill the proposed project require a Building Will the proposed project require a variance det re min-auu from the Zoning Board of Appeals? Will any part of this application be considered a Demolition as described under Town Code? COMMENTS: s('de- d se G ikil Vig&nalLureOofReviewer Date Michael J.Domino,President 0f soyo Town Hall Annex John M.Bredemeyer III,Vice-President h0 l® 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski • Q Telephone(631) 765-1892 Greg Williams �c4UNT`I, O Fax(631) 765-6641 � �� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application FR- FE7C E V�I E Wetland Permit Application Administrative Permit �Amendment/Transfer/Extension DAAY 2 5 201 Received Applic tion: $'�'`t Received Fee: $ 106"Oo -y� Southold Town Completed Application: � 30d ar f T e Incomplete: SEQRA Classification: Type I_ Type 11 Unlisted Lead Agency Determination: ]LCoordination:(date sent): _LWRP Consistency Assessment Form Sent: �S`10 CAC Referral Sent: Date of Inspection: 743-6 Receipt of CAC Report: —/ Technical Review: —Public Hearing Held: ZDd Resolution: Legal Name of Property Owner(s): 9.��C. ,�� Me- coo Ina, Mailing Address: ?. to . Phone Number: 6 31 - 8 33— ® F3C Suffolk County Tax Map Number: 1000 - 1 12— Property Location: I CO 04A)� f 1 q 1� � AJY (If necessary,provide LILCO Pole#, distance to cross streets, and location) -AGENT(If applicable): �f� Mailing Address: -� - �® 50(,) 0 L- 1 I Phone Number: Board of Trustees Applic- " ion GENERAL DATA Land Area(in square feet): l Area Zoning: Previous use of property: '�� Intended use of property: 6*(" ' Covenants and Restrictions on property? Yes No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? 4Yes 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 n n rT74 s® N,4 S Z)C6_ , � w MM 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): ���I�o�R✓ Cpd�1��L'��5 6 \ u�C' ��r�� C �l��-d � 6 i�1C� 91LAbM4tl p0: 'Sl Board of Trustees Applic ion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Tqc , j w)l e4 � exp! �� yLA17' 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: 35 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? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: EX/S"'/�61 Manner in which 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): 61Z20 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 I -Project and Sponsor Information Name of Action or Project: M CC(> (.5 Project Location(d cribe,and attach a location map): Brief Description of Proposed Action: Name of Applicant or Sponsor: Telephone: i ���® �1 /V E-Mail:,9AS'V ejft, Address: Qs,3 .'3 6 City/PO: 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? 14 If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that ly IF]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: t4l S 'DC—Z— rVI LN S'OJT14o`-) -M JJ &IL, �^ ! �'1 , ❑ 3.a.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? ® acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? , 7 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 ❑Aquatic ❑Other(speci ❑Parkland Page 1 of 4 5. Is the proposed action, NOYES N/A a.A permitted use under the zoning regulations? ❑ ❑ b.Consistent with the adopted comprehensive plan? ❑ D 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YE 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: D D 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? ZI ❑ 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: El El 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ D 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 NO YES Places? D b.Is the proposed action located in an archeological sensitive area? D It 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? (Z11 ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: tLLNJ 14. Id tify 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 E3 Early mid-successional ,Wetland El 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, a.Will storm water discharges flow to adjacent properties? ❑NO DYES ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO DYES 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: ❑ P1 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 KNOWLED Applicant/spo or name. — r��C Date: Signature: Part -I pact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questi ns n 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 1-1 1:1regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ n 3. Will the proposed action impair the character or quality of the existing community? 1:1 EL 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 F1 El 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 conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a.public/private water supplies? b.public/private wastewater treatment utilities? El 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ n architectural or aesthetic resources? !—J 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ Elwaterbodies,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 ❑ ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? El 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 Board of Trustees Appli- '- --;ion AFFIDAVIT G^ 1/ct j eC(� �-0G U /*,A jel I,--fx4EING DULY SWORN DEPOSES AND AFFIRMS THAT14E/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALUSTATEMENTS 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. �.�toxx Signature o"t Property Owner Signa of Property Owner SWORN TO BEFORE ME THIS �Lo DAY OF4,()1-j- , 20� i KATHARINE M HINTE Notary Public -State of New York N0. 01 Suffolk Co 68 Qualified in Suffolk County My Commission Expires Apr 19, 2020 rotary Public Board of Trustees Appli43--ion AUTHORIZATION (Where the applicant is not the owner) I/We, t)-E (:iA WC .M Lowe 0-j A_o.0 � f-rC) owners of the property identified as SCTM# 1000- 031 ,. 14;) . bz) in the town of Z 0,34- wnb ,New York,hereby authorizes C Lie-w to act as my agent and handle all necessary work involved with the application process for permits) from the Southold Town Board of Trustees for this property. �?-Cf vJ� O&K4U� 4 Property O is i nature Prope Owner's 'gnature SWORN TO BEFORE ME THIS DAY OF d , 20j_?- _ KATHARINE M HINTE Notary Public-State of New York No.01 HI6108868 n Qualified in Suffolk County My commission Expires Apr 19,2020 Notary Public t 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 TheyuMose 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 necessaa to avoid same. YOUR NAME: _:j: s (Last name,fir name,middle initial,unless you are applying i t n 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&uthold? "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 Submittedthday 200_ Signature Print As aa-J Form TS I i t t TRANSACTIONAL DISCLOSURE FORM l Ir' I::y\:'[it+I_urtlthl hi";:I'n•Ii t;i 1 rf�ir.ttll hi:?il',r�nl4rt=.,1(IFfI:rt =F,rll sll;ttsrk slt l \vF++�ll�.rc:a+.l:!s�Ir;sl,+der_; _I h. l ntl it)tp_fol(1 is to(11.1,2,He ttlioitll lUin 1."Ilich C.al 1,',-1_Ij Ili- r\V11+ tti:1•_r�;l il�•l',1f1�11,T;trt Ilkh'l t";f�Iltt;klllliV II ,Id�t \+-li,:L 1 i.1[��1k_I'; IWt C+;...I V l ,lv,lit i`•:lllli. (�- YOUR NAME: -_ � �C�� �,� (Last name,first name iddle inihal,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other r 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.) L)ti y011 porst.imlt•,•(or throavii your rosnp,at}•..,pn;fse,niillini',.(t,ut•111.+•1 Child)L-M,a krt,}!i"u;ISl1r With.Ifl l,lticel \rrciuh10> 4:; t:l'thc"I v.\n tri`aouchr3(4I': "IRelatioll';hip"islelkid"s by blood,Illa.-i iw-e,a1 basin: :;m[ctt- t"lill:;ln inwiL,:t'•In'Asn';a lai•;I;kes:,, inclwlin;;a pnsillo shill, ill•dlic:h the loval'dtiecs of cniplo ek-lix.evrll a pilrtial oll•nrlshil,(:,(ol i•nl;doymelli hp)a colporalir,n ill Wtilah(lie towl)U1l ccl't•1,etllltltiy'CC u.vll:,11+'1r(h:lli 50,'n(rl t1U-SIR,L". YES NO _ • -- 1 If you answered"YES",complete the balance of this form and date and sign'where indicated. Name of perspn employed by the Town of Southold.. Title or position of that person l)e:.uit;r t;le relationship between yom-'elf(the:y g}Gra:k[l.l:;rnt/representative)and the town officer or employee.Either check the appropriat,:line A)through D)autlfnr describc u1 0L­­,—pace provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): _ A)Ih=;In%livr 1-I t?tt:;1l,r dl:in 5`7L of the shares of tht corporate stock of the applicant (\4hcn the:applic:mt is n cogxirn(ion): _13)thr 1q.-al of i-.-11Gfici'd tnsrlel orahy iilt.u'::I in;+nuu-corporate entity(when the applicaili is[)ill a corpmatioli); C:)an officer,dirt-Not,parlucr.orclnploy<-c of Ilio igylicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this aa day of 2009, - Print Name Form TS t 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# - PROJECT NAME^ c)tN )nom e The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees LN 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 ofaction: arc, X51�fQ "Ol ' ��1-c��� , ��� 6 �� I��aS Location of action: Site acreage: 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) Mailing address:_ ��� . sacJD / f� (c) Telephone number: Area Code -6-5 ® I q1O (d) Application number,if any: 1A Will the action be directly undertaken, 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 LWRP Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ No XfNot 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 ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section HI—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No D</Not 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 P ges 8 through 16 for evaluation criteria 11 Yes ❑ No 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 16thro gh 21 for evaluation criteria 1:1Yes 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 N��,_-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�<Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See 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. - ❑ Ye�] No Not Applicable Attach additional sheets if necessary WORKING COAST POI -,,[ES r 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 MNot 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 LVVRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No MI, 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 ❑ 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; ages 65 through 68 for evaluation criteria. ❑ Yes ❑ No 'K Not Applicable PREPARED BY " r' TITLE Cr DATE Jf