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HomeMy WebLinkAboutTR-9538A Glenn Goldsmith, President *QF SUUTTown Hall Annex Michael J. Domino,Vice-President ��� ��� 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III l�t Southold, New York 11971 A.Nicholas Krupski G Telephone(631) 765-1892 Greg Williams �� �� Fax(631) 765-6641 �y��UNT`I,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1702C Date: June 3, 2020 THIS CERTIFIES that demolition of an existing 1O'x40' deck and construction of a 13'x34' deck with approximate 28'x20' on grade patio with fire pit; At 170 Dolphin Drive, Southold Suffolk County Tax Map #1000-56-7-6 Conforms to the application for a Trustees Permit heretofore filed in this office Dated July 8, 2019 pursuant to which Trustees Administrative Permit#9538A Dated September 18, 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 demolition of an existin¢10'x40' deck and construction of a 13'x34' deck with qpproximate 28'x20' onrg_ade patio with fire pit. The certificate is issued to Lee & Catherine Sewell owners 4 the aforesaid property. Authorize Signature ;i Glenn Goldsmith,President 'of SU!/rTown Hall Annex Michael J.Domino,Vice-President Q`� ��� 54375 Route 25 P.O79 John M.Bredemeyer III .IL k T Southoldd,, Box 11 New York 11971 A.Nicholas Krupski G� Q Telephone(631) 765-1892 Greg Williams %�`0 �� Fax(631) 765-6641 �y�4UNTY,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 1'0�00_Lv INSPECTED BY:' Ch. 275 . Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt-boom/silt curtain 1 St day of construction % constructed Project complete, compliance inspection COMMENTS: CERTIFICATE OF COMPLIANC �q" Michael J. Domino, President opo cow Town Hall Annex John M. Bredemeyer, III, Vice-President ;'�� y�A 54375 Route 25 Glenn Goldsmith r N ,z P.O. Box 1179 A Nicholas Krupski3 y • Southold, NY 11971 Greg Williams �01 , �a�% Telephone (631) 765-1892 Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction '/Z constructed When project complete, call for compliance inspection; Michael J.Domino,President *OF SQ(/l Town Hall Annex John M.Bredemeyer III,Vice-President �Q� yplo 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 oly�ou BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9538A Date of Receipt of Application: July 8, 2019 Applicant: Lee & Catherine Sewell SCTM#: 1000-56-7-6 Project Location: 170 Dolphin Drive, Southold .'Date of Resolution/Issuance: September 18, 2019 Date of Expiration: September 18, 2021 Reviewed by: John M. Bredemeyer, III, Vice-President Project Description: Demolish existing 10'x40'deck and construct a 13'x34' deck with approximate 28'x20' on grade patio with fire pit. 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 D&D Landscape Design & Construction, received on August 29, 2019 and stamped approved on September 18, 2019. Special Conditions: None. Inspections: Final Inspection. { If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Michael J. Domino, President Board of Trustees Michael J. Domino, Pre, t o�QS � � Town Hall Annex John M. Bredemeyer III,Vice-rr6sident 54375 Route 25 Glenn Goldsmith aP.O.Box 1179 A.Nicholas Krupski Southold,NY 11971 Greg Williams ?/�0( p� Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES / g TOWN OF SOUTHOLD Date/Time: 9� b '�/ �I 3� Completed in field by: j - LEE & CATHERINE SEWELL request an Administrative Permit to demolish existing 10'x40'deck and construct a 13'x34' deck with approximate 28'x20' on grade patio. Located: 170 Dolphin Drive, Southold. SCTM#: 1000-56-7-6 1 kris• Ft"fir. 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 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: v/� /CU►.lc� 416t-nj I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: _izJ. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other NOTES t1 4.1 i L/ u Ll � AUG , APPROVED BY UG 2 9 2019I BOARD OF ) RUSTEES L TOWN OF SOUTHOLD T'.., R ^54 o:_T_ --- - ♦ DATE sMmpXk g Zo1q ♦ RESIDENCE EXISTING DECK CUTBACK EXISTING DECK FT. PROPERTY LINE i COPYRKNT 201q --- - -- -- -- - ---- ------- ---- --- -- - -- ----- ----- ------ -- —'- REVISED 6-25-2019 __. SKIRT DECK REVISED 06-12-201q MODULAR BLOCK WALL ......:..- MODULAR BLOCK SEAT LL LANDSCAPE SKETCH ♦ :: ` :..:.: -:.:; PAVER PA GRADE TIO AT SEWELL RESIDENCE 170 DOLPHIN DRIVE = SOUTHOLD NY DECONSTRUCT FIREPIT REBUILD PATIO SKETCH 0 MODULAR BLOCK LIGHT PIERS DESIGNED t RENDERED BY: DSD LAND5CAPE DESGN t CONSTRUCTION 5640 OLD SUNRISE HWY MASSAPEQUA , NY 516-7q5-835q ♦ sua V4" = f0" "rxara cpm�By KLF —A �w DD `� CAM JUNE 20Iq a�M mob, NMAIN RD. SURVEY OF PROPERTY (NYS RTE. 25) A T ARSHAMOMA 0 UE TOWN OF SO UTHOLD SUFFOLK COUNTY, N. Y. 1000-56-07-06 RE� SCALE.• 1'--30 AUGUST.14, 2019 of $ . 519 / 4! N9 o� $ o 01 / BRICK RET. LOT 14 WA O AC 26. WLF .�J9OO N s 0 O EDGE OF 77DAL WETLANDS AS WOOD s.s'r ?' DETERMINED BY SOU774OLD TOWN WLF DECK a $ N 7RUS7EE ON AUGUST 14, 2019SLATE LANDING O G STAKE FND. LOT 15 1 SN• 9.7' SLATE STOOP 1 p CHASE FRro .' � 1 HOUSE LOT NUMBERS REFER TO "MAP OF SOUTHOLD SHORES" ]WLF T CATCH FILED IN 7HE SUFFOLK COUNTY CLERK'S OFFICE ON 00-M58.3 ��' BASIN AUGUST 29, 1963 AS FILE NO. 3893. -13 I" Z J b O j \ VINYL EBAR KEY p01. SHED p FND• 0 ` a.3' WOOD s3 4' a s A WL SHED Q = REBAR m ® = WELL O /MBER LINED PLANTER BOX a A = STAKE ' = TEST HOLE • = PIPE LF 0 0 10 ■ = MONUMENT = WETLAND FLAG - BOLT c-M = U77L17Y POLE FND• � � LOT 16 NOS®r-NEW .MEr��® ® E C E i V E x EI-EVA77ONS REFERENCED TO NAM 88 AUG 2 9 2019 01 j Ab ANY AL7ERA77ON OR ADDI77ON TO THIS SURVEY IS A WOLA77ON OF LIC. NO. 49618 SEC77ON 7209 OF THE NEW YORK STATE EDUCA77ON LAW. EXCEPT AREA= 19 8�9 SQ. F7: Southold Town PECONIC �W"Wekvp.C. AS PER SEC77ON 7209—SUBDIVISION 2. ALL CER70CA77ONS HEREON 631 765JFAX 631 765-1797 ARE VAUD FOR THIS MAP AND COPIES ]HEREOF ONLY IF SAID MAP P 3 BOX OR COPIES BEAR 7HE IMPRESSED SEAL OF THE SURVEYOR WHOSE909 SIGNATURE APPEARS HEREON. \ � SOU THOLDVEN.Y. 11971 T 116-0311 Town Hall Annex Michael J. Domino, Presi John M. Bredemeyer III,Vice-1-resident ��,,` -r 54375 Route 25 Glenn Goldsmith o "` P.O.Box 1179 � z A.Nicholas Krupski ® � Southold,NY 11971 Greg Williams �� gyp! Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: i�� �� Completed in field by: , . LEE & CATHERINE SEWELL request an Administrative permit to construct a 3'x30' elevated deck extension to an existing 10'x40' deck. Located: 170 Dolphin Drive, Southold. SCTM#: 1000-56-7-6 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q 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: 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: H e � 'LZ I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other �,� �� la?4116 ND T-0 �� 7/3/2019 'V k 0(3264x2448 VAM W< s4 a Sl 0 } v } z z https://mail-attachment.googleusercontent.com/attachment/u/0/'?ui=2&ik=cdO3fc956f&view=att&th=l 6bb7bdb84f0828f&attid=0.4&disp=inline&safe=1&... 1/1 7/3/2019 0(3264x2448 O E �F I'.11 f€IEl .EEEE '^h �E �E https://mail-attachment.googleusercontent.com/attachment/u/0/?ui=2&ik=cd03fc956f&view=att&th=16bb7bdb84f0828f&attid=0.3&disp=inline&safe=1&... 1/1 * U e �° y .. {� ..•;y, LNC +[ 4'.'- ...ac�. + - .. � .. a�, � +- .3,��� ,i-• " ♦ „ ,pd_b^r a R Y \ .j _a�te,,v @ Y �. •a.•';^.......-..w.,..��"`...+�^.„. t � . •��� �� � � - e- y e � J s _ u V 4 x � 9 , 4 ' * f 't s - x 7/3/2019 0(3264x2448 Q CI rig 222{{{ €4 F ^ " 6 r " a x m https://mail-attachment.googleusercontent.com/attachment/u/0/?ui=2&ik=cd03fc956f&view=att&th=16bb7bdb84fO828f&attid=0.6&disp=inline&safe=l&... 1/1 7/3/2019 Gmail-(no subj Catherine Sewell <sewellc698@gmail.com> (no subject) 1 message Catherine Sewell <sewellc698@gmail.com> Wed, Jul 3, 2019 at 8:09 AM To: sewellc698@gmail.com 6 attachments IMG-3763.JPG 3877K IMG-3764.JPG 3819K IMG-3765.JPG 3332K IMG-3766.JPG 3647K IMG-3767.JPG https://mail.google.com/mail/u/0?ik=cd03fc956f&view=pt&search=all&permthid=thread-f%3Al638039072237716111&simpl=msg-f%3A163803907223... 1/2 7/3/2019 Gmail-(no subs 3341 K f IMG-3768.JPG 3619K https://mail.googIe.com/mail/u/0?ik=cdO3fc956f&view=pt&search=all&permthid=thread-f%3Al638039072237716111&simpl=msg-f%3A163803907223... 2/2 _ . c SEE SEC MO OSB --- SEESEC NO 1152 --------- ------- n --- --m lFFeEC N0. 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Domino, Pi . lent �oN5, ca Town Hall Annex John M_ Bredemeyer, M, Vice-President o 54375 Route 25 Glenn Goldsmith N x P.O. Box 1179 A Nicholas Krupski y Southold, NY 11971 Greg Williams l ,� dao Telephone (631) 765-1892 Fax (631) 765-6641 SOYITHOr.D TOWN BOARD OF TRLJSZEESt � t D(\1J ' JUL 1 2 2019 TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIRErAijN ty sOUTHOLD S CTM#: Property Owner Name: SEUI�LL� 7, Date Sent to Bldg. Dept: ll.IR % 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 Deriolition as described under Town Code? COMMENTS: C IS \as- bu lI �l an o�veSn` ee s� (220 du-k_ e-K_kn,9�0 Ps ,rtey a nde d rp(a e e vtd � gl2gfr9 Signature of Reviewer Date ' r� 'OFFICE LOCATION: �W S® �® MAILING ADDRESS: Town Hall Annex �® �® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) C �e Southold, NY 11971 ella Telephone: 631765-1938 C®U 9� 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: September 18, 2019. Re:, LWRP Coastal Consistency Review for LEE & CATHERINE SEWELL SCTM# 1000-56-7-6 LEE & CATHERINE SEWELL request an Administrative Permit to demolish existing 10'x40'deck and construct a 13'x34' deck with approximate 28'x20' on grade patio with firepit. Located: 170 Dolphin Drive, Southold. SCTM#: 1000-56-7-6 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 CONSISTENT with the LWRP policies°and therefore CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Damon Hagan, Assistant Town Attorney Michael J_ Domino, F-. z ident ��o�o c y_ Town Hall Annex John M. Bredemeyer, III, Vice-President o 54375 Route 25 Glenn Goldsmith N P.O. Box 1179 A Nicholas Krupski y Southold, NY 11971 Greg Williams ��l , dao Telephone (631) 765-1892 Fax (631) 765-6641 SOUTEfOLD TOWN BOARD OF TRUSTEES rD� s JUL 1 2 2019 TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIREMI�(,N, SCTM#: Property Owner Name: Iq 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_ q,4.lq YES NO Q Will the proposed project require a Built i Will thero osed project require a van p P from the Zoning Board of Appeals? Will any part of this application be considered a Demolition as described under Town Code? COMMENTS: e Cl`S ��S- ��I` ' �, Gln Q�02Sn` se-I-ba�./� �ll S19nature of Reviewer Date art _ Lee and Catherine Sewell 170 Dolphin Drive Southold, NY 11971 r August 15, 2019 AUG 1 5 2019 1p�u ,tlt'dil Caardaf rt�sl�es Southold Town Hall Annex 54375 Route 25 Southold, NY 11971 To Whom It May Concern: We are revising the project dimensions and on grade patio. 1) Demolish the existing wooden deck 2) Build a new deck that will not interfere with the side yard setback 3) The dimensions for the new deck will be 34 feet x 13 feet 4) On grade patio will be in front of the deck 5) Dimensions for the patio (see landscape sketch) �i,tre ky) Thank you. Sincerely, c P ee r-i 1 f Lee and Catherine Sewell sewellc698@gmail.com cell: 516.473.3151 . ire i^1 ' Fr .fi AUG 1 5 2019 i southnld'vin Board of riuse2s \ RESOENCE PROPERTY LME DECK B'0' fo*- COPYRIGHT 20A 7 rREV15ED (-25-2019 S ED M4-27ASYJR7 DECKMODULAR BLOCK WALL MODULAR BLOCK SEATWALL 2416- LANDSCAPE SKETC4 ` 14d' 5S-4 RESIDENCE 170 DOLPM DRIVE 200, SouTHOLo,NY PAVER PATIO AT GRADE DECONSTRUCT FlREPff b REESUo-D ped' d \ PATIO SKETCH `(ul DESIGNED t RENDERED BY: \ O MODULAR BLOCK L IGNT PERS DSD LANDSCAPD E ESIGN V 0 r�5 NRI5E HWY MA55APEGUA,NY 516-7%-8359 Of a td' —A .UE 20M ) AUG 1 5 2019 �Gl1:llai lown 8 3fu of 1CU$tGG RESIDENCE PROPERTY LINE \ DECK \ GOPYRK,NT Z0i9 REVISED 6-25-249 \ SKIRT DECK REVSED MODULAR BLOCK WALL \ lj ,>t A `�x _ d lxJ4r='Si J,{•„. r-dS.T` Sr.X + MODULAR BLOCK SEATWALL �� LANDSCAPE SKEfCI-b PAVER PATO AT GRADE 5EWELL REMENCE 'rye Y - rY K ay + h0 DOLPNN DRIVE q _tlI-'! 50UTNOLD NY p,.S�'E7•' j`�I' Vr`[, Ze.�r "� � DECONSTRUCT FIREPIT It REBUILD InNci PATIO SKETCH 4 7- JL MODULAR BLOCK LIGHT PIERS DESIGNED#RENDERED BY, "ry O D*D LANDSCAPE DE51GN 4 CONSTRUCTION 5640 OLD SUNRISE MY 7-OSTRICH FERN -1 GAL MA55APEQUA,NY 5V,--795-8359 \ 5-STEEDS HOLLY-5-6 FT \ E-LW I—A e�4�) 1 Michael J.Domino,*President �*rjf SOujyO Town Hall Annex John M.Bredemeyer III,Vice-President l0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith V43 41C� Southold,New York 11971 A.Nicholas Krupski apQ Telephone(631) 765-1892 Greg Williams y Fax(631) 765-6641 COUNT`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only 2(� p Coastal Erosion Permit Application E ``�' L�, u V Wetland Permit Application Administrative Permit JUL 8 2019 /Amendment/Transfer/Extensi VReceivedApplication: // Received Fee: $ 00160 Southold Town Completed Application: -th I T Boardf Trustee Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): LWRP Consistency Assessment Form Sent: CAC Referral Sent:, Date of Inspection: r� Receipt of CAC Report: Technical Review: Public Hearing Held: Yo` .l Resolution: rr�, eye �C��'her� 1�e Owner(s)Legal Name of Property (as shown on Deed). � �) IVY sewlcl Mailing Address: 1� 0 Pernlock brt ve - 1'Q rlYl I i� dale, / " 'Y /t Z3 Phone Number: (�Ib) 473 - 316 ' Suffolk County Tax Map Number: 1000 - O S6 Property Location: 170 -U I k I h- ))rive SNY Y 16 71 (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): Mailing Address: Phone Number: Board of Trustees Appl' Ltion - -- – -CGENE?RAL DAcT? Area(in square feet): O 6- `� -� P ­ Land - - �eArea Zoning: Previous use of property: Re e w opch o r Intended use of property: bec K — ,e 1e )1a+eo1 ___ Covenants and Restrictions on property? Yes CJV- N0 If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No If"Yes", please provide copy of decision. Will this project require any demolition as per-Town Code or as determined by the Building Dept.? Yes No Does the structure (s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency Date 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: / r/ I Project Description (use attachments if necessary): G`eyaiedeck ex� S �®A � le���ian s 3 �S /iAcA ej Board of Trustees Apple- 3.tion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: O S PCL ice Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation,or filling? 'V No Yes If yes, how much material will be excavate? cubic yards How much material will be filled? /" cubic yards Depth of which material will be removed or deposited: l�`� feet Proposed slope throughout the area of operations: `V I/ Manner in which material will be removed or deposited: 1" 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): vti-e 61 Z20 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 I based on information currently available. if additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: 11119f? c Project Location(describe,and attach a location map): Rear- o f hove 1.7o 17d� ��►� fir. 119 7 Brief Description of Proposed Action: 1 �o.jo rOXI(/hrA4Pl-1/ 3 Name of Applicant or Sponsor: Telephone: S110 _ 4 73 ` 3 /,1;- lee Slee Sege!l d eo4�crf 41(f_ SetXeff E-Mai10Q�se1111e11 S)006d1 11'4e. net Address: 40 llfrnl6ck —b(i v e City/PO: _ State: Zip Code- da r� I da le AJ /!g �/ L Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that ❑ ❑ 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? 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? 0. 4 7 acres 4. Check all land uses that occur on,adjoining and near the proposed action. / E-]Urban E]Rural(non-agriculture) E]Industrial E]Commercial [Residential(suburban) El Forest ❑Agriculture El Aquatic ❑Other(specify). ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ ❑ 2 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: IJ ❑ 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: 10 1-1 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: M ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: Z ❑ 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: LTJ 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 ❑Early mid-successional ❑ Wetland ❑Urban [Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, 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: ❑NO OYES 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: V ❑ 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: w ❑ 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: V ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/ssor -e: Date: _y 3, Signature: l J 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 Elregulations? 2. Will the proposed action result in a change in the use or intensity of use of land? 9 n 3. Will the proposed action impair the character or quality of the existing community? W ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the (-�1' ❑ establishment of a Critical Environmental Area(CEA)? �J 5. Will the proposed action result in an adverse change in the existing level of traffic or F-1affect 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 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, V- ❑ architectural or aesthetic resources? 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 / L 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? u 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. F] 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 Appl,� Ltion AFFIDAVIT Ze,e SCovf�erihc, SDULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL, TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. 4L,I Sig4ture of Property&3er Signature of Property Owner SWORN TO BEFORE ME THIS — DAY OF , 20_L_!I_ y�pT o� Nancy Messer f `' Notary P"C State o[NewYork NOTARV Notary Pu is *i. �.` :* No01ME6177256 Puaucl I Qualified in Suffolk CouutY ° �.!' commission Explms 1U13IZ0 - Board of Trustees Appl ition t AUTHORIZATION (Where the applicant is not the owner) I/We � �e Sew2� � and ea-Acrihe, sentjcll—, owners of thero ert identified as SCTM# 1000- - in the town of P p Y Sou A d I � 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. Prop y Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS ^ DAY OFAU 201 ,� ytATEp� NancyMeSse[ Notary Pu lic f j 1 TAgy:, Notary Public,StafeofNewXork awe i* No 01ME 6177256 UBUC .•' £ Qualified in Suffolk County Commission Expires 111130Z,q„ APPLICANUAGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the hart 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. I YOUR NAME. Sewell I Lee °� Sevie,llf ea,-Aerlhe (Last name,first name,Viddle 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 (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 V If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted t t O Jay of Signature - PrintName l " d� Legg Form TS l �e� e('1/. 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# S 4 - I - V PROJECT NAME MIA The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity, agency regulation,land transaction) ❑ (b) Financial assistance(e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nature and extent of action: 3 ' deck e Ae m l o n tWq4e d d-e dc e,,i,�ej,� sio3 ` x 3C0 E I Ck , S /0 1 �O X 9-6,4C, C& Oedawo"h 1'S 30 inche-s �o pnbOld IF-71 Location of action: e Site acreage: 0' `f7 Present land use: )Of S/d e h a 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: Zee Sewc H 4- G '-�Ae f i!)C SeWe- 11 (b) Mailing address: e`Y1 loe it) dGQ le /v `/ X1735^ (c) Telephone number: Area Code z173 -3/ S- (d) (d) Application number,if any: / /�/ 1 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 iii 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 [XNot 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 10 Not Applicable 1 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 2 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 IH—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No 2r 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 VNot 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 ,!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[0 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 2 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 Z Not Applicable Attach additional sheets if necessary WORKING COAST P(!_)CIES t 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 ❑yNot 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 ® 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; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No ❑Z Not Applicable PREPARED BY Z&1-0 3e�� TITLE V e r DATE 01Q1%e rt'/) e Se W e1/