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HomeMy WebLinkAboutTR-9604A i J S�f Ff^ a:��. Michael J. Domino, President �o�o 'o�y Town Hall Annex John M. Bredemeyer, III, Vice-President Z-3 1 54375 Route 25 Glenn Goldsmith r N ,? ' P.O. Box 1179 A Nicholas Krupski y o�,�;' Southold, NY 11971 Greg Williams �o % 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 '/2 constructed Whenjroect complete, call for compliance inspection; p Michael J.Domino,President S0(/lTown 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 COUNVI BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9604A Date of Receipt of Application: November 4, 2019 Applicant: Peter Lojac SCTM#: 1000-87-3-44.1 Project Location: 2750 Minnehaha Blvd., Southold Date of Resolution/Issuance: December 11, 2019 Date of Expiration: December 11, 2021 Reviewed by: Greg Williams, Trustee Project Description: Remove approximately 3800sq.ft. of lawn area adjacent to creek, replace with native plantings, mulch and gravel; and for Ten (10) Year Maintenance Permit to hand-cut Common Reed (Phragmites australis) located on property to 12" in height by hand, as needed. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by_ David Cichanowicz, Creative Environmental Design, dated November 4, 2019 and stamped approved on December 11, 2019. § 275-5 Permit procedures. (i) Cutting of common reed (Phragmites australis) to within 12 inches of the soil surface landward of the wetland boundary. This does not include mowing to ground level. Special Conditions: Do not disturb native vegetation during the hand cutting of Common Reed (Phragmites australis), including but not limited to; Eastern Red Cedar (Juniperus virginiana), Northern Bayberry (Myrica pensylvanica), Marsh Elder(Iva frutescens), and Groundsel Bush (Baccharis halimfolia). The approved operations must be commenced within two (2) years from the date of the resolution. The permittee is required to provide the Trustees with before and after photos of the area within this time period before any further maintenance is conducted. 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. ► 1 1 1 1 1 i 1 1 ► ► 1 1 • • — Q / 1 I , 4 I ... r % n 'mm� .. �� 1 TING �HRAGMITES "I a �IBACMARI5 — NA TIVE SALT TOLERANT �O GARBAGE BIN °PLAN INc 5 WITH N(ULiF CH �I 1 AREA �'.h s 1 EXI9T,9PRIJCE 1 D3 DD 1 1AREA 0F AFFECTED wE-rLANC6 � .k LAWN 1 TWG94IT I l' I LAWN I ,r Q ` LJ nI u JJl I 4 I �� GRAVEL IvaJLCH ' 1 1...1...1 � I , 1 .;/ D ING PHRAGMITE5 GRAVEL o a X\ • __ -_ 1 mac"_... •^ DRIVE • 1 � � � , 1 II , NATIVE SALT TOLERANT O ' _ fLANTING5 W .CRAVED' ' RE51PENCE © 1 oo CLkEY CREEK 1 D i 1 I , 0 A 1 1 y 1 1 711„ ;i= 111111�� 1 I 1 1 II l' 1 I 1 1 r 1 ' 1 1 - X\ GR VEL IVULCH I ' 1 AC � � { III � 1 � ( 1 APPROVED BY I' , ' 1 BOARD OF ) RUSTEES 1 ALT T L R � TOWN OF SouTHOL� NATI1��� 0 E ANT; < �> IPLANTINGS W G;R�►VEL DATE p��,�,� rr zoo LAWN 1 I 1 y R ( 1 1 1 I 1 1 \4,J 1 1 , - - — — _ �\LL1/r_ �\A. l ' ETER OJAG GRAVEL PULCH ' yN. SCTM , - = NATIVE 5ALT TOLERANT'l 71,_ 1 - - - _ - PLANTING W GRAVEL Nov 20194 1 1 1 1 is�on #• Scale: Landscape Plan : 6-25- 19Landscape Design by: Dave Cichanowicz 11 /4/2019Lo� 1 o Crea Ive Design a 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. 0�* � j - .# Michael J. Domino, President Board of Trustees Michael J. Domino, Presic o��S11FFU(kC � Town Hall Annex John M. Bredemeyer III,Vice-President �� �%,,� 54375 Route 25 Glenn Goldsmith y P.O.Box 1179 ZZ A.Nicholas Krupski 1 Southold,NY 11971 Greg Williams p! Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 06P c- �3 Completed in field by: Creative Environmental Design on behalf of PETER LOJAC requests an Administrative Permit to remove approximately 3800sq.ft. of lawn area adjacent to creek, replace with native plantings, mulch and gravel; and for Ten (10) Year Maintenance Permit to hand-cut Common Reed (Phragmites australis) located on property to 12" in height by hand, as needed. Located: 2750 Minnehaha Boulevard, Southold. SCTM#: 1000-87-3-44.1 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: I have read & acknowledge g Trustees comments: Agent/Owner: \ I �Gl C�`c��: 4LJ C 2 Q Present were: Bredem M. Domino G. Goldsmith N. Krupski G. Williams Other t z £ ANYTOR ADDITION TO THIS SURVEY IS A VIOLATION OF SECCTIONION 726 7169 OF THE NEW YORK STATE EDUCATION LAW EXCEPT AS PER SECTION HIS MAP OMSION 2 ALL CERTIFICATIONSONLY IF N/O/F SANDRA HAGS HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY E SAID MAP GNATURE APPEARS HEREON OR COPIES 6EAR THE ESSEO SEAL Of THE SURVEYOR WHOSE s:N 88'59'00"e a, 1B7e SURVEY OF PROPERTY 2 1 Cd / AT LAUGHING WATER TOWN OF SOUTHOLD SUFFOLK COUNTY , N.Y. 1000-87-03-44.1 SCALE: 1'-20' ApN117,1999 October 2,2017(CERTIFICATIONS ADDED) rj � __ of � I CERTIFIED TO. PETER LOJAC FERNANDA MENEGASSI-LOJAC WELLS FARGO BANK,N A o !1 z t I II -p II S 1561 ■-MONUMENT I AREA = 28,774 sq. ft. / - to tie lines Nfe ��.� p OP NENJ 0 N MET=0�f �11 >TFc�p ` /0/F RICHARD8/ z�NUE1 P m d YS LIC NO 49618 E RS, P C `o RROAt,L 1D.=R' '!I IJ9.1 i FI s 0 1 I ER STREET nn_�C� SOUTHOLD, NY 11971 JJ V SAr� 4" E°ec u• a Ica .. _Z—_ t1NE 3 4 b2 H� 3 15 p a ' bf0 a r- tl 15 � \1 \ • 4_ a fa 19 p � f�'Y1 z,to + �t 241 15/�(c � tl, .�.J t /f 1 .�•s a f tA(c � _ pp�p b.e 21 I a�m SOl1t�101D w• a.eNj n c y �• ..�� d t) � 114 2t 11 �ae'1 . spa ♦ ^ 7' C \� / f. +/... ,.Q _, ` p +, eM b.8 < t 211 +� 1p�+r•Lc,i� '4 a °" a. ./' _ " � ` •' na EDH uN1Ts � lzvcl n a z, 6.1• H i *. 4 4 3 _ SEE SEG Oe7.01 J J '= D 3 2 � + alas• � \w �. _ b.) p / IJ ape.4 ,� ♦c T ED ATSDUT,OID Q B a ?7 23A 23JS §r` 10.1 MIN '�.ry / exa.•nRARE.v e.eA ZINC) b 3 9 { 3?Idc) 3 `�6 i56•5 � •w'. TO++T OF SWTMOLD ,ea He4A(c) .45- 21 13 4♦ ^"p T // 3. r O28 L.D. V I So.T t) 1.aA(cl 4i "!:' � , ,52 PARK a �22 p41 9+ , F.D. 4� Y < ��� eH iSTacT Cava Cwk ss, 1411 4e ,• .i Hoc ALVK e4r �- I t1z� NOTICE DTTHO K or SLD CTiON s. E b` 4 �rp� L' Real Property Tax SeNce Agency 3 ,I r, t1 OFFICE LOCATION: *0f S�(/r�OlO MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) VID Southold, NY 11971 • �O� Telephone: 631 765-1938 ly�oUm,�c� 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: December 9, 2019 Re: LWRP Coastal Consistency Review PETER LOJAC SCTM# SCTM# 1000-87-3-44.1 Creative Environmental Design on behalf of PETER LOJAC requests an Administrative Permit to remove approximately 3800sq.ft. of lawn area adjacent to creek, replace with native plantings, mulch and gravel; and for Ten (10) Year Maintenance Permit to hand-cut Common Reed (Phragmites australis) located on property to 12" in height by hand, as needed. Located: 2750 Minnehaha Boulevard, Southold. SCTM#: 1000-87-3-44.1 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 provided the following is considered to further LWRP Policy 6: 1. Clarify the species to be planted. 2. Limit fertilization in the non-turf buffer. 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 0�*0 SOUry� Town Hall Annex John M.Bredemeyer III,Vice-President h ?Q 54375 Route 25 Glenn Goldsmith l P.O.Box 1179 A.Nicholas Krupski Southold,New York 11971 G • �Q Telephone(631) 765-1892 Greg Williams Ol Fax(631)765-6641 COU ]BOARD BOARDD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit 7 Amendment/Transfer/Extension Received Application:_ 11.(�,1 q Received Fee: $ 100,00 Completed Application: T F tl Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): ! �: , r 1 ;� ° ' LWRP Consistency Assessment Form Sent: 1 ]2!fCAC Referral Sent: �; Date of Inspection:_ 12���( � NOV 4 2019 - Receipt of CAC Report: j TechnicalReview: Public Hearing Held: Resolution: - Owner(s)Legal Name of Property (as shown on Deed): l �" Mailing Address: ICA Phone Number: Suffolk County Tax Map Number: 1000 - 6�_--a _j-Jq, Property Location: 'Z150 ln/1I 8n4 ,,jR1W (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Creative Environmental> �e Sjgm PO Box 160 Mailing Address: Peconic NY 11958 Phone Number: &A Board of Trustees Applic .on GENERAL DATA Land Area(in square feet):,T� L4 Area Zoning: _1j Previous use of property: Intended use of property: 0 Covenants and Restrictions on property? Yes 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 62 and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes "l- 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 X_ No Does the structure(s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? &, No Yes If yes,provide explanation: Project Description (use attachments if necessary): , Smoo E , c� P.tirs �- G��,►��t ®��- ( to SOC " INla�aR�{Ir�eil?��M;�- Cee — �1,.�r ►a"� . ��l a wa- 9�64R a� ce-o C til- l�' Board of Trustees Applic< _on WETLAND/TRUSTEE LANDS APPLICATI®N DATA Purpose of the proposed operations: 1_0 04:1L nq%)i -� 101.04941 Area of wetlands on lot: LXC.0 V\ 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? _j�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: Manner in which material will be removed or deposited: (' dUSs L'et\'\ ins b k o G\/Okhk 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): 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 purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid sa�men ��,/,, r n n / , YOUR NAME: I v 1 Y 61{ (a, l" q V SS/�— t o a G (Last name,first name,griddle in al,unless you are pplymg 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 Submitted this -P day of MD'2/4P/i20-L�) S ignatiire Print Name Form TS I ',Board of Trustees Applica )n AUTHORIZATION (Where the applicant is not the owner) I/We, kryanda— —Lo , owners of the property identified as SCTM# 1000- ✓ — 7 -1 � 1 in the town of .New York, hereby authorizes CY C I'Ve- ED UI (D n&Q"16L� � 1'1 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. . s Property Owner's Siatu14 Property Owner's Signature SWORN TO BEFORE ME THIS VA DAY OF P0118-04R_ , 20 1 g Notary Public DIANE ®ISALVO %BW� ftfl1;-8TATE OF NEW YORK %.. 0MAIU11+3 =' Board of Trustees Applic' ton AFFIDAVI`£ BEING DULY SWORN DEPOSES AND AFFIRMS THAT 1YE/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. Signature of Prope4 Owor Signature of Property Owner Iq SWORN TO BEFORE ME THIS DAY OF YO V61 , 20 Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. O1 D1475593 ®uolified in Suffolk County My Commission Expires April 30, 20?/e Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) I/We, e r L D-5c, owners of the property identified as SCTM# 1000- 3 in the town of New York,hereby authorizes David Cichanowicz, Pres. Creative Envionmental Design 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, Property Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS_ DAY OF NoU�iwb�. ,,ao l9 Notary.Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. OID1475593 Qualified In Suffolk County My Comml34ion Expires April 30, 20Z2— f Board of Trustees Application .AFFIDAVIT BEING DULY SWORN DEPOSES ANIDAFFIRMS THAT RE/SRR 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. Signature of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF 20 jq Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No, O1 D1475593 %joliflod In Suffolk County w tbmW t"Uplres April 30. 20�!?' Ilk APPLICANT/AGENT/REPRESENT A T TRANSACTIONAL(DISCLOSURE FORM 't jic Town of 8outh6ld'c Code of Ethic.�hsbitc cbrif7icts of intereston the naft of iown•aftiecrs'and`cmnlo'yccs.'1 fle•nurhrQsc of tliis.tapn i5 to prnvide iiifotiiiation which on alert the town o£��sible confr,-t,of interest anti i►low i!fn take�vltatrver action is necessary to avoiiLsame. YOUR NAME: ®Tq c �� ✓ (Last name,first name,griddle 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 _.X Variance Trustee Change of Zone -- Coastal Erosion ni Approval of plat Moor �__ g • . Exemption from plat or official map _ _ Planning Other (If"Other",name the activity.) --- t70 yau;persiirially'(or through your,compapy;'spouse,sibling;,parent;or child)�Ilavc a relationship%viih any otlicer-or employee of.tli Torvn:oC.Southo(d? "ItclatidttsI6;includes by blood;ritarriiil ar'btrsiness iittcrest'.lUisiness-hrtcrest"means,a busint ss, inclua nga partnership;in which tlic town of ceroi cuiployce.has_cverj;a partial owrtciship pf(or+enijaloyrnent b} a corporation in wliich tlic town,oftieer oor emiiloyee'omri s rnore'than,5%'oftlic shares. YES NO, X If,you answered"YES",complete the balance of this form and slate and sign where indicated. Name of persorremployed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agGnt/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 ihaif5%ofthc shares of the eorptiratc.stock of the applicput (when the appllcmm_is'a corpoeation) ' B)the legal or beneticial'owner of any,interest in a non_-carporate entity(rvticnthn applicant is nota corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this y oflfr, 200 Signature = Print Name Form TS 1 APPLICANT/AGENT/REPRESENTATM TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of Lown officers and emplovees The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOURNAME: XIC�nP� � ��s��6fRi G2 (Last name,fast name,ipiddle inti ,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 busmess 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 Ifyou answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate,line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submittem., of A Signature Print Name Form TS I 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 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1-Project and Sponsor Information Name of Action or Project: Project Location(describe,and attach a location map): AV Brief Description of Proposed Action: VCE7SC1 ��500 _S�'V+• V\&4` Name of Applicant or Sponsor: Telephone: E-Mail:G � Address: Ya r� tB PO Box 16® r City/PO: 9 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? 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: V ❑ 3.a.Total acreage of the site of the proposed action? b.Total acreage to be physically disturbed? 3 asp c.Total acreage(project site and any contiguous properties)owned �/F or controlled by the applicant or project sponsor? 4. Check all land uses that occur on,adjoining and near the proposed action. ,_,� E3 Urban El Rural(non-agriculture) El Industrial F] E Commercial residential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page I of 4 5. Is the proposed action, a.A permitted use under the zoning regulations? NO YES N/A ❑ Q Elb.Consistent with the adopted comprehensive plan? ❑ ❑ 6. Is the proposed action,co landscape? , nsistent with the predominant character of the existing built or natural NO YES 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: , _ff 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?' If the proposed action will exceed requirements,describe design features and technologies: NO YES 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ I l.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: p ❑ 12. a.Does the site contain a structure that is listed on either the State or Nat Places? ional Register of Historic' NO YES 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. Id ntify the typical habitat types that occur on,or are likely to be found on,the project site. Check all that apply: UShoreline ❑Forest ❑Agricultural/grasslands El Early mid-successional ❑ Wetland ❑Urban ❑Suburban 15.,Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? ❑ 16.Is the project site located in the 100 year flood plain? NO YES MTT 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 ❑YES ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ONO 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: 19'E1 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:' U�-I ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE r Applicants arae• - Date.: Signature: ` Part 2-Impact Assessment. ,The Lead Agency is,responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part l and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my- responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? ❑ ❑ 2. Will the,proposed action result in a change in the use or intensity of use of land? El 1:13. 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 establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El F]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 ❑ Elreasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: El ❑ 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, Elarchitectural or aesthetic resources? 01 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ ❑ waterbodies,groundwater,air-quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage problems? 1:1 ❑ 11. Will the proposed action create a hazard to environmental resources or human health? 171 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. EICheck this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should'review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be 'evaluated as to its siufficant 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. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# - - 4c f• 1 PROJECT NAME 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: Location of action: 9`150 mc, x�- Site acreage:_ Present land use:_ , Present zoning classification: R,-Lo 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:__ �' JD ►)VI J��9 ,;�; (rArb (c) Telephone number:Area Code (d) Application number,if any: /Ul Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes ❑ No�If yes,which state or federal enc . ag y? 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 LNVRP Section III—Policies; Page 2 for evaluation criteria. EfYes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LVW Section III—Pol' ies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No EJ Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria Yes ❑ No ❑ 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 —Policies Pages 8 through 16 for evaluation criteria VYesE3No ❑ 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 —P oliei Pages 16 through 21 for evaluation criteria izYes ❑ 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 throug 32 for evaluation criteria. ❑ ❑ Yes No. Notplicable _ Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 rough 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 wee LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No of 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 Dn No . Not Applicable Attach additional sheets if necessary •• WORKING COAST POLICdS Policy 10. Protect Southold°s water-dependent uses and promote siting of new water-dependent uses in s37NOE] tions. See LWRP Section III Policies;Pages 47 through 56 for evaluation criteria. Not Applicable Attach additional sheets,if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the,Peconic Estua nd Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. VYes ❑ 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 foVevalu on criteria. ❑ Yes ❑ NoApplicable Attach additional sheets if necessary Policy Promote appropriate use and development of energy and mineral resources. See LWRP Secti III—Policies; Pages 65 through 68 for evaluation criteria. XYes ❑,No ❑ Not Applicable PREPARED BY G L pL, ,�5, TITLE_ DATE