Loading...
HomeMy WebLinkAboutTR-9634A Glenn Goldsmith,President \\QF SO(/T� Town Hall Annex 54375 Route 25 0 Michael J. Domino,Vice-President h0 l0 P.O. Box 1179 John M. Bredemeyer III [ Southold, New York 11971 A. Nicholas Krupski G Telephone(631) 765-1892 Greg Williams YO Fax(631) 765-6641 �yOOUNNI BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1704C Date: June 4, 2020 THIS CERTIFIES that the as-built front entry stairs measuring 72"W X 55"D landing with two steps each 72"W X 7"H X 11"D total Area: 72"W X 771); framing: CCA pressure-treated wood • landing and steps: cedar; and as-built rear entry stairs; 80"W X 36"D landing with three steps each 80"W X 7H X 11"D total area: 80"W X 69"D framing: CCA pressure-treated wood landing and steps: cedar; At 21225 Soundview Avenue, Southold Suffolk County Tax Map #1000-135-1-1 Conforms to the application for a Trustees Permit heretofore filed in this office Dated January 10, 2020 pursuant to which Trustees Administrative Permit#9634A Dated February 12, 2020,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 the as built front entry stairs measuring 72"W X 55"D landing with two steps, each 72"W X 7"H X 11"D total Area: 72"W X 77"D• framing: CCA pressure-treated wood.; landing and steps: cedar; and as built rear entry stairs; 80"W X 36"D landing with three steps, each 80"W X 711 X 11"D total area: 80"W X 69"D framing: CCA pressure-treated wood landing and steps: cedar. The certificate is issued to Bim Strasberg & Alexandra Lewis owners of the f resaid p perty. Authorized Signature Glenn Goldsmith,President *OF s�(/jy Town Hall Annex Michael J.Domino,Vice-President �Q� Ol0 54375 Route 25 P.O. Box 1179 John M.Bredemeyer III J [ Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams • �� Fax(631) 765-6641 oly�oU0,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: INSPECTED BY:` !/ Ch. 275 . Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt-boom/silt curtain 1 St day of construction Y2 constructed Project complete, compliance inspection COMMENTS: CERTIFICATE OF COMPLIANCE: r Town Hall Annex Glenn Goldsmith, President o���F SOUlyOl 54375 Route 25 Michael J.Domino,Vice-President O P.O.Box 1179 John M.Bredemeyer III 1xL Southold,New York 11971 A. Nicholas Krupski G Telephone (631) 765-1892 Greg Williams Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD 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-construcfl6n*,°#* bale line/sijt'boorri/sift curtain 1St day of construction % constructed When project complete, call for compliance inspection; i Glenn Goldsmith,President �'QF SDU�y Town Hall Annex Michael J.Domino,Vice-President ,`OVv ��� 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III [ Southold,New York 11971 A.Nicholas Krupski G Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 COUNT`I,Nc� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9634A Date of Receipt of Application: January 10, 2020 Applicant: Bim Strasberg & Alexandra Lewis SCTM#: 1000-135-1-1 Project Location: 21225Soundview Avenue, Southold Date of Resolution/Issuance: February 12, 2020 Date-of Expiration: February 12, 2022 - Reviewed by: Michael J. Domino, Vice-President Project Description: For the as-built front entry stairs measuring 72"W X 55"D landing with two steps, each 72"W X 7"H X 11"D, total Area: 72"W X 77"D; framing: CCA, pressure-treated wood.; landing and steps: cedar; and as-built rear entry stairs; 80"W X 36"D landing with three steps;,e6ch*80"W X 7°H X11`'D;'total area: 80'W X 69"D, framing: CCA, pressure-treated wood landing and steps: cedar. 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 Bim Strasberg, received on January 14, 2020 and stamped approved on February 12, 2020. Special Conditions: None. Inspections: Final Inspection. ` � r 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. Glenn Goldsmith, President Board of Trustees ••-A-+.Imo,/ ,'iq. � _ . . T - SUFFOLK' 7x R .1000- j R ALLSCALL Nowmi NO t�EWE8 22o' trite` RE}� 5.-CAi12S- SOW �, `M �H " { i JAN 14 2020 :,,� S`EPS:Cedes- �' •_ -. . -.,. ., p Pt Airs— " .+ "' �✓vo p St F°S 2 57rS:7 x WT 17'eH Y('► '..`...-.•rte ��'l i Ai%; CC/F 4� ( C2cir AP VED- ",BOARQ F I RU5TEE- IOWN. OUTHOL® ®ATE : �Rv4p� ,,X „ 12 2OW ' ' Michael J. Domino, Pre, it O�QSVEFD(�-�oG ',�nt Town Hall Annex John M. Bredemeyer III, Vice-r-resident �� -.�, A 54375 Route 25 Glenn Goldsmith N P.O. Box 1179 A.Nicholas Krupski Southold,NY 11971 Greg Williams `yTelephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN,OF SOUTHOLD y" Date/Time: Completed in field by: BIM STRASBERG & ALEXANDRA LEWIS request an Administrative permit for the as-built front stairs measuring 72"W X 55"D landing with two steps, each 72"W X 7"H X 11"D, total Area: 72"W X 77"D;-framing: CCA, pressure-treated wood.; landing and steps: cedar; and as-built rear stairs; 80"W' X 36"D landing with three steps, each 80"W X 7"H X 11"D, total area: 80"W X 69"D, framing: CCA, pressure-treated wood landing and steps: cedar. Located: 21225 Soundview Avenue, Southold. SCTM#: 1000-135-1-1. 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: 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/stand ards: Il�'�y k rte rt�1--Ge-0—sr-�s+ �,�L�t-tom I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other �--�� LONA` ISLAND -� r-- SO UND W" AT N&°f 12'12"E 51.09, ON TOP OF ATt WALKHEAD BULKNEAO TIC LINE Z WIM O£GK)W.7 CS`t soP' OFr A7 A0 coW_.oLocx J4 ,SURVEY OF PROPERTY TT Rr:T .wfLL A T SO UTHOLD rte. V;;, TOWN N OF SO UTHOLD V a-16 ' SUFFOLK COUNTY,, N. Y.. , Tri 1000-135-01-01 ET .WAU_ SCALE.' 1'-20' FLOOD 7z1�� ` NOVEA48ER 5, 2017 f �' --� rre►+eER NOVEMBER 22, 2017 (CER77FICA770N.5) get WALL - ' ZONE -y � 2 s o -� o5b 0 �'v 7. .\ ~� 10 _*moi• , POLE JAN 1 ® 2020 E 7A I ICA 00 "'WALL GERrIF1ED TO, C.OULO�� WILLIAM MGMAHON ROBERT MGMAHON 'DIM E. 5TRA5DERC-7 ALEXANDRA M. LF-W15 F(DELT I Y NATIONAL TITLE MURANGE '5ERV IGE5 LLC, PAS. t SoUN.DVIE W AVE. .9 -MONUMENT clF NEW Q !ELEVATION5 ' AND GONTOURLINE5 FROM NAVCU 88 g�p ;FLOOD ZONE' FROM FIRM 36103G0156H - ;MAP' EFFEOTIVE- DATE, SEPTEMBER 25, 2009 -� LIG. NO. 49618 tcA ORS. P.C. ANY-ALTZRATiON ort=FAOOIT104 TO THIS "SAVEY rs A VraATroN n' {6 gJ 20 FAX(631) 765 17`f7 ;vP,±3isvi'ivJiPiu,'T"v='Tr%•i�:.�+'i:r�.n;i+,1iC•%+ivvni'vi: i..�i% - _•1y1611�'�1.O��Vv •S'`�.fj ` iEXGEPf. AS;.�k:R 'sEcnora•'�ac�9�su�otvisioN -z Au CZRllFrcATroN5 a. P. .O. 9 09 ry ►+EttEorr nrt�:s.vnt i�- ort •TNrs,ww;ANC7 coPres T►EAL' oa. CH.;Y rr TO =TE' LINA' 1230 TR'AVE'LER STREET ! ""�C�¢ SAfD:tIM. vR C.OPIES^DEAR::1F iraPR�ssEo SOF THE'5kRVEYOR' ;w►�os�' srsNArucrr,APre�s'.+ ort 5OUTHOLO N.Y. 11971 DiSalvo, Diane From: Bim Strasberg <BStrasberg@brooklyn.cuny.edu> Sent: Monday,January 13, 2020 10:56 AM To: DiSalvo, Diane Subject: Strasberg/Lewis Permit Application Attachments: Strasberg-Lewis Project.docx; Strasberg-Lewis Project rev.docx Diane,As discussed, please find attached spec sheet for our Administrative Permit application.Sorry I couldn't get this to you sooner but it was only on my office computer and I am only now getting to the office since we spoke. Please note, however,that we have decided not to build the proposed outdoor shower after all and request that you strike it from our application. I have highlighted that item on the attached Word document in red and added a note that this item should be removed,just to make clear that any reference to it elsewhere in the papers be disregarded.Should you need to remove it entirely from that sheet, please feel free to use the revised version that I'm attaching, which deletes it. Please confirm that you have received this and let me know if you have any further questions or need supplementary info. My cell phone is 917-494-7020. Thanks for all your help. Sincerely, Bim Bim Strasberg Concert Office Coordinator Conservatory of Music of Brooklyn College 718 951-5792 bstrasberg@brooklyn.cuny.edu ATTENTION: This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. i 1....»...._ Tit- Im] 7 ENa G December 31,2019 Town of Southold Building Department Main Road Southold, NY 11971 RE: BP#42734Z - 21225 Soundview Avenue I have inspected the front and rear entry decks for the above referenced dwelling.I certify to the best of my ability that it is that footings and the strappings for both decks have been constructed according to the International Residential Building Code. BOARD CERTIFIED IN STRUCTURAL ENGINEERING JOSEPH@FISCHETTI.COM FISCHETTIENGINEERING.COM 63 1 -76S-29S4 1 7 2 5 H O B ART ROAD S o u -r E3 I- D , N EW YO RK 1 1 9 7 1 f� t �F pY � s t T ' P We NOW ars�—�--•° r w -' yvy . a _ .f' f R. ✓ � t✓S V 1 y 0l-0 v- hovsco— 2— { y c _i • �z �g < y t _1 4 fv `:moi �p Fill ..b. r* }:,.$yi 7►� ,�,e,�',hw `.'M` W x .`s ,�.„ "'< a`,x 1P" <..».9'w'- ,,Td r '� ' �,e "aR�, l. 3i $ iN M _', ♦'F/�. � ,' w. +a� IM..'� a' `�'y"d rr`l sii �.� �y ��"„ �•+}+�r:A � T�'j;" i , � r i � 4 r n r k a r r x F. { a 5, ffi�y��l}y A i r s � ) t . J WMI ,'^ _tit=, - t^ •>aY t'!' 7u M1 p' 'C..., ,i a �' .•f � r ;l �tr�,.� '�y :...L t ���)ice Y � � 1 s $ry d r, .M' r f s ... k •'cti . { _ ? T 4t^�, .�. ya;.. �'t ero t9V� V k0k4r/ 'VQS� S'II�C G� �Clt� �L�C�/t1�r ZO�q Z i s a� III I Mr " .� PRIM 17, „c • ti. u , • k: -txr �, �.. "'is.. 1. ��� .wo t s ,f wr? ;{. �'i""'"`= i*'! n aux- �> �' a^f ,{ �� h3• .. .,�. ... _ L. ,,; ... •.., _,. � � ec.. .F. ?• xq+l > ,, ^a�te'�'" ,4,. M1�..fy•a'�e r��3 Y g .,b�'y,r�.. s� kkk .,� k,_w� s., r z; x � tea .�*t"�'�-��+� tir `49���a,"►,�r� '� `^ ,r,�„y - _ - ��TA3'� x .g �, IMS _ 134 1 A R,� mff out rwrrrc oaf •z.Y't ..... ___ n.� .. w -*nxaa..t n.«.� -Y P ._,.... ., S arMl.. •n,.µms.,.,�..,».:; +x SOUND i a ISLAND LONG pU 41, N011TH FMK r ♦ .� , �, i tcta•v.Ha�,t ♦ 5♦ O , '�'�, .' (FOM UNRS 1 ♦ � � �, � A� NOE,75C01) lb 3 A ' SOVN 7.M A�. • a �j • / a i P 4 ! + munroaiswx IP, 2 :a, � P o � 91 HawmMmuck pow �♦ . nr a 26 25 ` SOL ed 301 `T3 �" CIgE 7, , 8 77 3. \ SOVN a a 70.1 41 M�y00 A NOTICE wu,�y COUNTY OF SUFFOLK © E 'x0 SOUTHOLD SECTION NO E a�o—�r✓ " O1) O urtr w— o.r�--�.*-- ewx*riutce.r,eNaroH.orva[one C --�— Z Real Property Tax d,Nyi1 Agency v � I ------- a --- — -- -�---•-- �.a.�a.—..M......,,.9 M 135 ..p:a n .� tx tHel a•ixu u. —__— o.ru. --.-- or.tr--tw-- � 9Im pmt mc•w 100° PROPERTY MAP OFFICE LOCATION: ®��®v s® � MAILING ADDRESS: Town Hall Annex ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 Telephone: 631 765-1938 ® = a Fax: 631765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To Glenn Goldsmith, President Town of Southold Board of Trustees From. Mark Terry, AICP LWRP Coordinator Date: February 6, 2020 Re. LWRP Coastal Consistency Review BIM STRASBERG &ALEXANDRA LEWIS SCTM# 1000- 135-1-1 BIM STRASBERG &ALEXANDRA LEWIS request an Administrative permit for the as-built front entry stairs measuring 72"W X 55"D landing with two steps, each 72"W X T'H X 11"D, total Area: 72"W X 77"D; framing: CCA, pressure-treated wood ; landing and steps: cedar; and as-built rear entry stairs; 80"W X 36"D landing with three steps, each 80"W X T'H X 11"D, total area: 80"W X 69"D, framing: CCA, pressure-treated wood landing and steps: cedar. Located. 21225 Soundview Avenue, Southold. SCTM#: 1000-135-1-1 The proposed action is recommended as INCONSISTENT with policy 6.3 below and the LWRP. Policy 6 3. Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under theirjurisdiction 1. Comply with Trustee regulations and recommendations as set forth in Trustee permit conditions. According to Town records,the as built structures were constructed without obtaining regulatory permits. In the event the action is approved, a vegetated, non-turf buffer is recommended to be installed landward of the top of bluff/bank to further Policy 6. Native and salt tolerant vegetation is recommended. Portions of structure lack storm water controls (gutters, leaders,drywells) as shown in the submitted photos. Verify that Chapter 236 Storm Water Management of the Southold Town Code is complied with. Surface and subsurface runoff is expected to be towards Long Island Sound. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Co. Damon Hagan, Assistant Town Attorney Glenn Goldsmith,President *QF SO(/ry Town Hall Annex Michael J.Domino,Vice-President ,`O� ��� 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III 1 [ i[ Southold,New York 11971 A. Nicholas Krupski CA) Q Telephone(631) 765-1892 Greg Williams %� �� Fax(631) 765-6641 Fax BOARD OF TOWN TRUSTEES JAN 1 3 2020 TOWN OF SOUTHOLD TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIREMENTS SCTM#: — , z ` ST�so9e6- - Lzwls Property Owner Name: Date Sent to Bidd. Dept: I•l 3•ZO 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: PQWc S `� )AAaA 11 a Signature of Reviewer Date ' o�aOF SO(/JyOl Town Hall Annex Michael J.Domino,President 54375 Route 25 John M.Bredemeyer III,Vice-President P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski �pQ Telephone(631) 765-1892 Greg Williams flycoum Fax(631) 765-6641 BOARD bF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application X Administrative Permit Amendment/Transfer/Extension JAN 1 0 2020 a Received Application:T Received Fee: $ Z00 00 AS-BdILT ` r t._ Completed Application: l0•ZD Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: �Coordination:(date sent): 1,31.2-0 LWRP Consistency Assessment Form Sent: -CAC Referral Sent: Date of Inspection: ZS RD Receipt of CAC Report: Technical Review: Public Hearing Held: ?'-aw Resolution: Owner(s) Legal Name of Property (as shown on Deed): �o( � Mailing Address: 1701 '5-&o t - roll Tr6° l M NY Y I I M Phone Number: _ q17 ��z® Suffolk County Tax Map Number: 1000 - Property Location: /, l 2 Z g o v J v 1y w n` e 6 Y V(?7 (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): Mailing Address: Phone Number: Strasberg/Lewis Project Materials and Measurements Front Stairs(as-built and certified) l 72"W X 55"D landing with two steps, each 72"W X 7"H X 11"D Total Area: 72"W X 77"D Framing: CCA, pressure-treated wood i Landing and steps: cedar Rear Stairs (as-built and certified) 80"W X 36"D landing* with three steps, each 80"W X 7"H X 11"D Total Area: 80"W X 69"D* Framing: CCA, pressure-treated wood Landing and steps: cedar *landing to be extended to 36" as per State code, and stairs adjusted accordingly i Board of Trustees ApIT `,cation GENERAL DATA Land Area(in square feet): t 76 5 Area Zoning: —5--St4t- ( k qO Previous use of property: "44ce-- Intended use of property: �S��v I�� Covenants and Restrictions on property? Yes ✓ No If"Yes",please provide a copy. / Will this project require a Building Permit as per Town Code? Yes ✓ No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No 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 �5 Date Z-L 7�6, 2-0 c No prior permits/approvals for site improvements. /Yes Has an ermit/a roval ever been revoked or sus ended b a overnmental agency? No Y p pp P Y g q If yes, provide explanation: &I kLW- ( 12th LicA-k 6-v *o vo�tc a I F1 ✓ l Project Description (use attachments if necessary): Lae /C _ 0 At � 5 �LC9 7(l K 14-c� et-jf-�, C 1a �l (-� 06r +oat eras (nc+ -ft &por) d ak�12A 22 -�- -�" (Ceey rjk,� �!/`bd l/r d f f �L�i' ( oar 2`�Dbv f �p fl �l�121 (l 1 ���irlRJ�2��Cvl t,-e— Board of Trustees Ap, `~,.,cation WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ��y i1� e �F 6�-� r wit 5u 5i'ho L Area of wetlands on lot: �- �J[" square feet ` 5,9 0m ( S f Percent coverage of lot: I % Closest distance between nearest existing structure and upland edge of wetlands: '°� ® feet Closest distance between nearest proposed structure and upland edge of wetlands:'' i'i� 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?-V 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: 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): /I/SIM= 617.20 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: r2l1 r `"- 0 Proje t Location(describe,and attach a location map): 50 'lLG QNfN t,'V /fie.w 6-f goV5er Oc¢Woor Sluwv Cq Wes ,q Sjd�L W 1�6 Brief Description of Proposed Action: � Avw S o'5' /PA- hey L e�-r 2� bates A / a�i`e moi`�V�! [� ��1 CE(/�I r7Z�lF ' �B4 /✓L/ �C `p/�./sS/ Q�S 6U1 o't /tie `f c✓�'S�u sr`�� {�c �� Name of Applicant or Sponsor: J pp Telephone: 917 ;! C f_ 70ZD 4-d�it$,�.YI�tGt� (.ew f S E-Mail: �y'yyt _ 5`Fhs� ' ✓cam i 2® > Address: 7hai-e— KOf .i , - City/PO: p Stat 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 orf 1 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 a enc (s)n me nd permit or approval: ( A'� -i � X.,_4 U i 7-t- ?ND-5j yr - ��s� 5y ����-, Qw+- Pte- ��--��� �y z 3.a.Atal acreage of the site of the proposed action? m��OW yy//��// acres b.Total acreage to be physically disturbed? �(//// acres c.Total acreage(project site and any contiguous properties)owned T or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. F-1 Urban El Rural(non-agriculture) ❑Industrial E]Commercial E&sidential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 i 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ ❑ b.Consistent with the adopted comprehensive plan? El 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? 2 ❑ 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. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water:�pl/Ce_- �dCy /i10 ❑ 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? � F]b.Is the proposed action located in an archeological sensitive area? a El 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: Er 0- 14. Id ntify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline El Forest ❑Agri cultural/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 _ r5 Gv f�ht 4vl of Dr UV'q f' 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES 1f Yes, a.Will storm water discharges flow to adjacent properties? [D/NO []YES ❑ b.Will storm water discharges be directed to established conveyance systems(run9ff and storm drains)? If Yes,briefly describe: NO ❑YES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: ❑ i I 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: ❑ L� 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 I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/spons me: Igtm Date: t Signature: �- Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" i 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? u, f, l ❑ 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? �r ✓ ❑ ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the di V ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑� ' affect existing infrastructure for mass transit,biking or walkway? Ln i' ❑ 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate reasonably available energy conservation or renewable energy opportunities? I G/� ❑ 7. Will the proposed action impact existing: -All ❑ a.public/private water supplies? v b.public/private wastewater treatment utilities? 1 ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, tib;f ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, Fj ❑ 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 Il,s ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? l: 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, *,at the proposed action may result in one or more potentially large or significant adverse impacts and an r nvironmental impact statement is required. a 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 i Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT , Page 4 of 4 Board of- Trustees App '�,cation _1 AFFIDAVIT �� ii X111 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. Sig ture o rope caner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF - , 20 l R Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. O1 D1475593 Qualified In Suffolk County My Commission Expires April 30, 2022 APPLICANUAGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM I 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 same. YOUR NAME: (Last name, irst name,.niddle 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 Submitted this ( a �C�f/► 20d q Signature Print Name Form TS 1 f APPLICANVAGENT/REPRESENTA.Tm TRANSAC'T'IONAL DISCLOSURE FORM The Town of Southold's Ctrde of Ethics ornhibits conflicts of interest on the part of town oflicer5 and emnipvees.The nurposC of this form is to provide rnforination which'can alert the town of possible conf)icts of tntercAund allow it to take whateveraetton is necessary to avoid.-; c. /r �J r YOURNAME: � j, `7 +Z`�� \ (Last name,fi_rit name,ipiddle 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 _ 1/ 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 ul'Southold? "Reltationsiaip"includes by blood,marriage,or business intmest."Business interest'means a business, including a partnership,in which the town otticer or employee has even a partial ownership of for cnaploynrent by)a corporation in which the town officer or employee owns more than i^,u o the shares. YES _ NO I f you ans%vea ed"YES",complete the balance of this form and date and sfgn 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 Iegal 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 W n_ day�of` F�°tVa+ 200-8 Signature Print Name AA 10.1,114 Form TS l 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 sigmficarit 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# /0-0-0 - - '— 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: 2 Nature and extent of actiop: l r7iLe eg o ���,e ®44 ex, n din� prof AY ��i Location of action:- CiJ&(r5• t 8°!i ®vL sJe- Site acreage: 1-61 3116 5 Present land use: ® �Q Present zoning classification: �� qo 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: 7rr2_ 6�v l�— 4e kv, LA�r� (b) Mailing address: �'��l d�l��— grew-klyc,c AYY 1/90� (c) Telephone number: Area Code( ) �� C� G ` 7 d (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 2/Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section IIIPolicies Pages 3 through 6 for evaluation criteria 1:1Yes ❑ No L"1 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 F1 Yes ❑ No dNot 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 throu h 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. ❑ ❑ ❑IIVI, Yes No -tot 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[�j 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 LV-/RP Section III—Policies; Pages 34 through 38 for evaluation criteria. 1:1 Yes 1:1 No 1:9/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. ❑ YesEl No dNot Applicable Attach additional sheets if necessary WORKING COAST LICIES 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 [g 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 1:1 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 eva:Not tion criteria. ElYes 1:1 No 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 2Not Applicable PREPARED BY TITLE DATE _4�� ir eBl✓he�