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HomeMy WebLinkAboutTR-9510A Michael J.Domino,President QF S0!/rTown Hall Annex John M. Bredemeyer III,Vice-President ,`O� Ol0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold, New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams '� �� Fax(631) 765-6641 COUNT`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE 1629C Date: September 27, 2019 THIS CERTIFIES that the replacement of existingwalkway and landing with 3'x75' bluestone walkway on a cement pad with 8'x10' landing, At 1825 Truman's Path,East Marion Suffolk County Tax Map#1000-31-13-3 Conforms to the application for a Trustees Permit heretofore filed in this office Dated June 27, 2019 pursuant to which Trustees Administrative Permit#9510A Dated August 14,2019,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 existing walkway and landing with 3'x75' bluestone walkway on a cement pad with 8'x10' landing. The certificate is issued to Jennifer B. Gould owner of the aforesaid property. Authorized Signature 1 Michael J.Domino, 1.sident SO } Town Hall Annex John M. Bredemeyer III,Vice-President h0 l0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski • Q Telephone(631) 765-1892 Greg Williams100UNT`11 O Fax(631) 765-6641 0c� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: _�a 7 J Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction 'h constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: m CERTIFICATE OF COMPLIANCE: �Yti cam-. Michael J. Domino, President o� o� Town Hall Annex John M. Bredemeyer, III, Vice-President 54375 Route 25 Glenn Goldsmith N = P.O. Box 1179 A Nicholas Krupski y • ;�`r Southold, NY 11971 Greg Williams � 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 % constructed When project complete, call for compliance inspection; Michael J.Domino,President QF SOUrTown Hall Annex John M.Bredemeyer III,Vice-President ,`O� �. 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 olyIrou BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9510A Date of Receipt of Application: June 27, 2019 Applicant: Jennifer B. Gould SCTM#: 1000-31-13-3 Project Location: 1825 Truman's Path, East Marion Date of Resolution/Issuance: August 14, 2019 Date of Expiration: August 14, 2021 Reviewed by: John M. Bredemeyer III Project Description: Replace existing walkway and landing with Tx75' bluestone walkway on a cement pad with 8'x10' landing. 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 Jennifer B. Gould, received on June 27, 2019 and stamped approved on August 14, 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. N0. DISTRICT: 1000 SECTION: 31 BLOCK: 13 LOT(S):3 O Ivo U c E V E 1 JUN 2 7 2019 A- o 4* MON fO Y Seuthol�i Town EL EL 15.2 U.P. P. OZ plact ✓�c� eX1',:�sfLo5 wutkwol i EL 12.5 O� 6'N �t�` 0.6.WLO LO C1 IG W CL � �1)5fa i 1 0 V* o �Nr_ 4 °�O L�t t cpvMPvl t P0.C) �i'�11 PY1Si[)v1 S X a 1n d I a odn t.r �O; GL 4bM•L•p'J Y,''- �0 2a EL 17.2 16' r• r�4 CS k } d U.P. OPEN TRELLIS OVER ENTRY 6• Y LL --- -- - - - - - -- �- -- `'••� ,.��e�. ` e• 120 �, ° 2 MON. 1818 EL 17 APPROVED, �)5 ®'T •�l FF` ` =Yp`s':i 0.5'E BOARD OF 1 RUSTEES 601 .TOWN OF SO,UTHOLD .z.', ::,Q�.w, � ?.: : + DATE ����»�• �•r r r - - = � • � :; - 0.8 w �qJ��� - �ry� �r f r rf rrr THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL J J LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS, s•c NAVD88 X% J rJ f J ELEVATION DATUM. _________________________ AREA: 7,410.68 S.F. OR 0. 17 ACRES UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION 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 TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE. 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 ERECTION OF FENCES, ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS. EASEMENTS AND/OR SUBSURFACE STRUffURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME OF SURVEY SURVEY OF: DESCRIBED PROPERTY CERTIFIED TO: JENNIFER B. GOULD; MAP OF: JOHN C. WILLIAMS; FIDELITY NATIONAL TITLE INSURACNE; FILED: SITUATED AT: EAST MARION TOWN OF: SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Desi n P.O. Box 153 Aquebogue, New York 11931 PHONE (631)298-1588 FAX (631) 298-1588 FILE # 16-53 SCALE: 1 =20� DATE: MAY 1, 2016 N.Y.S. LISC. NO. 050882 maintaining the records of Robert J. Hennessy k Kenneth H. Noychuk SVFFOJ, N% Town Hall Annex Michael J. Dommo, 1, lento C John M. Bredemeyer III, Vtce=rresident r,`Z �, oG�,,,�� - u.., 543,7.5 Route 25 Glenn Goldsmith y P .O.'Box 1179 Ze A.Nicholas Krupski %�b Southold,NY 11971 Greg Williams y�ol p�' Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: �l 1� 1 �J�DO Completed in field by: Eligio Lopez, on behalf of JENNIFER B. GOULD requests an Administrative Permit to replace existing walkway and landing with 3'x75' bluestone walkway on a cement pad with 8'x10' landing. Located: 1825 Truman''s Path, East Marion. SCTM#: 1000-31-13-3. 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_I 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 Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: 711OXAM612L, ExA _jk, I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: VJ. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other S.C.T,M. NO. DISTRICT: 1000 SECTION: 31 BLOCK: 13 LOT(S):3 %^ t 0 y. Co EE JUN 2 7 2019 .� po �y MON app' Southold Tum �A Board of Trustees EL 15.2 U.P. U.P. X02 F EL 12.5 p� 6'N 0.6'W y� 0 XO; C, 00 �Za EL 17.2 Z U.P. ;;.•�5� a, OPEN TRELLIS 0-� 6 e�. ,LO OVER ENTRY 0. �. � '�,.�..'• '',.500• �1� YOM v VV MON. EL 17 0.5'E ,a 2• t�� i 60' C, 5 EL' 17.4 r rr rr rr �r • J o :-�•rr f rr err rr� rrr 0.8'W THE WATER SUPPLY, WELLS, ORYWELLS AND CESSPOOL LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS. �. Q) rr� f�r fr J rr ELEVATION DATUM: __NAVD88 NAVD88----------------- ti J AREA: 7,410.68 S.F. OR 0. 17 ACRES UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW, COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S 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 TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE. 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 ERECTION OF FENCES, ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS AND/OR SUBSURFACE STRUC-TURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME OF SURVEY SURVEY OF: DESCRIBED PROPERTY CERTIFIED TO: JENNIFER B. GOULD; MAP OF: JOHN C. WILLIAMS; FILED: FIDELITY NATIONAL TITLE INSURACNE; SITUATED AT: EAST MARION TOWN OF: SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design { f P.O. Box 153 Aquebogue, New York 11831 PHONE (831)298-1588 FAX (631) 298-1588 FILE # 16-53 SCALE: 1"=20' DATE: MAY 1, 2016 N,Y,S. LISC, NO. 050882 maintaining the records of Robert J. Hennessy & Kenneth M. Iloychuk SUFFOC Michael J. Domino, sident opo _ Town Hall Annex John M_ Bredemeyer, III, Vice-Presidento� y� 54375 Route 25 Glenn Goldsmith C/' P.O. Box 1179 A Nicholas Krupski y � � Southold, NY 11971 Greg Williams I ,� � Telephone (631) 765-1892 Fax (631) 765-6641 SOU`I'ROLD TOWN BOARD OF TRUSTEES TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQ Eft T _ SCTM#: l -� JUL 1 6 2019 ' GOVLD Property Owner Name: +++��� ///jjj DEP�• Date Sent to Bldg. Dept: IA 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: Ja u o R viewer Date OFFICE LOCATION: ®� ®f s® y®l MAILING ADDRESS: Town Hall Annex _ ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) N Southold, NY 11971 ® �p� Telephone: 631 765-1938 ®lyc®UNTY,�� 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: August 12, 2019 Re: LWRP Coastal Consistency Review for JENNIFER B. GOULD SCTM# 1000-31-13-3. Eligio Lopez, on behalf of JENNIFER B. GOULD requests an Administrative Permit to replace existing walkway and landing with 3'x75' bluestone walkway on a cement pad with 8'x10' landing. Located: 1825 Truman's Path, East Marion. SCTM#: 1000-31-13-3. The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is EXEMPT from LWRP coastal consistency review. 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 �*rif SDUry� Town Hall Annex John M.Bredemeyer III,Vice-President h0 l0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold, New York 11971 A.Nicholas Krupski apQ Telephone(631) 765-1892 Greg Williams 'rDUff NFax(631) 765-6641 oly ,�� - BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application E `(� � E Wetland Permit Application Administrative Permit &M 7 2(q9 Amendment/Transfer/Extension Received Application: 6-21-7.1g eceived Fee: $ 100,00 Southold To,ran Completed Application: 7r/2► Bo r a Tnlsters Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): LWRP Consistency Assessment Form Sent: 7 CAC Referral Sent: C�r�L"I _Date of Inspection: 8'i 7Iq Receipt of CAC Report: Technical Review: Public Hearing Held: , Resolution: Owner(s) Legal Name of Property (as shown on Deed): �9_e0Yl jf-e r �TbuICQ Mailing Address: P O - 8 o X 3 A Phone Number: 6.--61 - rl(n5-S:Sq �off=c4e� Suffolk County Tax Map Number: 1000 - D`31 . 0 O 13. 0 O — Q 0 3 . 00 O _ Q 150+ Property Location: -fru V 7 a 0 S Pafin , (=a S+ IN)Q r 10 V1 , �� I I q 3q f►'LIQ f hl kr��� us I �SaD iruwoYjPala 0100-00 , �y 11839 (If necessary; provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): I t Gb L.OAQ L Mailing Address: �O O m G ley) 2d0U4(140qUQ_' � Phone Number: l�3 [ - q � �� Board of Trustees Appli tion GENERAL DATA Land Area(in square feet): 9 ,14 10, h • F Area Zoning: Previous use of property: (fl S;C(p y7+1'ot.(, Intended use of property: rP S(A f 0+)'4 U Covenants and Restrictions on property? Yes __J_No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes __K_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 -Tr U5-te-es 4-D repiCla r4ama5ec-'l l-U ?3$ - 035457 00002. bu l lrlwa c1 ', -WbSS9A cta+ed q--t9-zoo(. srngle s-tor-f D��2 ^^1- w°q.r:-� and a cl d rt 4 o A 10 el w•e(I oG '1 '1 4 1' 0 1-cl Ohl 9(22(200� u ,-n•)I 'P,affarv»-t g-tawwo buIIcheacl Wood pla-tfo rvt --r s-ta;rwa 3Ut(d°A6 Wf. gl(s116 *gv9o,7 os'bu.*(t garag•P al4predlo,o too4ecL 5-24-81 Z- lolc'! '3?-clor,n�nr erdcl �4�or� �fioru52 t lna(fbcrtti ; tl-I-gS ZIM116 pre C. 0 ; b- rm�} 1#3'��41-� -A(lPo1Gt•F�o�s� p�clelrf�o✓1 , No prior permits/approvals for site improvement. Z-32822- Ol-oz-200$ 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): Rep Cd e eysf('✓1G► t t�C((t_u)CLA A L - 0 ✓I CI dr? to i-t'L`, PS WC1 I k 1,D Avid G dl d I'✓1 r� to 4-1' r�'ew►e04 na d . -b,,vn•eos( odu� of wa t Nina" � ' X *7� I Q' Ad tctodl& 1 Board of Trustees Appli tion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: (J�t S�c'nGr W a I L t,-,3 —�0 0 lh v1'P U P tti o yi d un-so �r u Area of wetlands on lot: P 0 0C• square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? _ 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: o1 rout d level Manner in which material will be removed or deposited: 'S+ WCI W Wu�4 n7 A rZrA L Of So:kp —fib ko 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): M o �)Q— J 4 61 Z20 Appendix B Short Environmental Assessment Form Instructions for CompletinIz 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 �_(i c i c Ld -ez i' s Ac ev)4 o , Qu)4 r Name of Action or Project: Plan -er P, M(A (d - 0 W ffle r- Project Location(describe,and attach a location map): s Ir" wows Pe-( b, E asi ( ( 3 Brief Description of Proposed Action: Re vt),,�Q_ .0x1 s+l'nc� u of 0 sine Wet k Way� �- (a l7�► PC p)a CQ_ LA-),-t- tA WO CA Pe- U00 wA� -t �G»�►� 5 Name of Applicant or Sponsor: Telephone: F_ I t ` p z E-Mail: 'l Address: City/PO: State: Zip Code: C 4-tc too uQ-) -,- 1.Does the propose ction only involve the legislative adoption of a plan,local law,ordinande, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that 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? 74 10•(o$' acres S h 0 r . 1`1 6L(-re 5, b.Total acreage to be physically disturbed? OL_ acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? PSnLA,1w,acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) [:]Industrial ❑Commercial K Residential(suburban) ❑Forest ❑Agriculture ]Aquatic ❑Other(specify): ❑Parkland TFAy-fco a f Page 1 of 4 J A 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ X❑ ❑ 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? ❑ 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: ® ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? © ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: F] FXJ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: n ❑ LAJ 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? ® ❑ b.Is the proposed action located in an archeological sensitive area? ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: PC Shoreline ❑Forest ❑Agri cultural/grassIan ds EJ 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 K 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 E]YES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO AYES Page 2 of 4 G 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: n ❑ 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: ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY ]KNOWLEDGE >l Applicant/sponsor name: L �r <® ® C- Date: Signature: Coo y,, o � 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 I. Will the proposed action create a material conflict with an adopted land use plan or zoning El Elregulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? ❑ ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the F] El of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El ❑ 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 El 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? 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 a i 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? 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 tion AFFIDAVIT Y) I-f P r C—Ot4 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. &ature of roperty Owner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF JVA/6 , 20 C�X Notary Public LINDA S. CARLSON Notary Public, State of New York No. 01 CA6137178 Qualified in Suffolk County Commission Expires Nov. 14, 20�� Board of Trustees Appli tion AUTHORIZATION (Where the applicant is not the owner) I/We, I-P d1 Yl i-FPr- g C-tx,I d owners of the property identified as SCTM# 1000- 031.00 — 13-bO--003.ODbin the town of New York, hereby authorizes i o Lb 2 Z 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. Pr&y O- wneA Signature Property Owner's Signature r SWORN TO BEFORE ME THIS � DAY OF �UNe , 20 H Notary Public LINDA S. CARLSON Notary Public, State of New York No. 01 CA6137178 Qualified in Suffolk County Commission Expires Nov. 14, 20- 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 puroose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. ,J (� YOUR NAME: (rotd�l d .) CQ o o tf fO r (Last name,first name,.piiddle 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 of,Southold? "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 J Submitted this 95h day of J U AQ, 20P Signature n Print Nam�����i��r������ Form TS I J I APPLICANT/AGENTIREPRESENTATIVE 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 f necessary to avoid same. YOUR NAME: pG (Last name,first name,Middle initial,unless you are applying to 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 l (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,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 use sibling,parent,or child is check all that apply): ' Po � g P � ( 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. - - f DESCRIPTION OF RELATIONSHIP I - --- ----- -- — — — - -- -- -- - ---- ------ ----- ------- Submitted this —day of Lt t 200 Signature & L fi e d P Print Name , 11 Form TS l y 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 ficant beneficial and adverse effects upon the coastal area(which includes all of Southold Town 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is,available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# ) 00 0 - 31.00 I3 — 0 0 3 .60 a PROJECT NAME '� yJ CTtl(k. rMV0 ( of eyls-t Lrn wo ( The Application has been submitted to (check appropriate response): �p-� Town Board El Planning Board❑ Building Dept. ElBoardof Trustees K] 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: CIdm,ni-sHiAW-FAI Nature and extent of action: ff - fPvYbQ Fx.i's4 i ho Mieu-eo , m P S-W uon 1 k ua U t (cmd i o %acQ, Waltwcc(A + 1 G 0d) f)u W414 10([Le- (:0W--- Location of action: I 2 S Tr N M C/ o 'S PCHII) WOO 0 o. Site acreage: G C re s Present land use: (^-P S 'C(.Q Of i'CL L Present zoning classification: — q Q 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: E/r q t D Lopez U qae u4 (b) Mailing address: 3&�b o V17 d i o 2d , ( JV V DLV oto J- Iot7,12 r Id P- 0 go-f, 92 Fiws-1 WO6210 /l . AlH 1q3� (c) Telephone number: Area Code i - X7;4— 5 353 ( E Ly De Z (d) Application number,if any: 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 [5d 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 ❑ Yes ❑ No ® Not Applicable L 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 [N 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 Pages 8 through 16 for evaluation criteria �] 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 III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes 1:1 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. ❑ ❑ ® DoT U p p uca(dq, Yes No Is 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 [g 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 P'Q] 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. ❑ YeSF1 No,4 Not Applicable Attach additional sheets if necessary WORKING COAST PO' 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 y 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 L741 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 1� Not Applicable PREPARED BY �- TITLE d w ytQ DATE