HomeMy WebLinkAboutTR-9689A Glenn Goldsmith,President �QF S�UTy Town Hall Annex
Michael J.Domino,Vice-President ,`QOl0 54375 Route 25
P.O.Box 1179
S
John M.Bredeme III
er k
Y �i[ � Southold,New York 11971
A.Nicholas Krupski G Q Telephone(631) 765-1892
Greg Williams �� Fax(631) 765-6641
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BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
DATE OF INSPECTION: iJ'A' � JW C) /1, Q,20
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4Ot u o &7-A?V PSK I
INSPECTED BY:` fJ� �^'� P64.67 d"PIT7614P
V .Ch. 275 Ch. 111 f(kcir /95ftT" IA( 4W_
semr 0,Z) iO c
INSPECTION SCHEDULE -� F�� A- AF lkS
_�- sr- Mr of Pwim�s , Ta C7 T ox, 64 10 �
Pre-construction; haybale line/sil 'g Zl /f p�/�D 6;40040
1 Sc day of construction 6-MO &L 10 #6.
Y2 constructed
h
Project complete, compliance inspection
COMMENTS:
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CERTIFICATE OF COMPLIANCE:
Glenn Goldsmith,President sou�ti Town Hall Annex
Michael J.Domino,Vice-President ,`O� ��� 54375 Route 25
P.O.Box 1179
- JohnlVi BFP�IdmAvj-r-II1------- - - — utholc,ATew=Vork 119-7
A.Nicholas Krupski G Q Telephone(631) 765-1892
Greg Williams �� �� Fax(631) 765-6641
CUUM`I,N
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
SOUTHOLD TOWN BOARD OF TRUSTEES
r
YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD_OF TRUSTEES
72 HOURS PRIOR TO-COMMENCEMENT OF THE ACTIVITIES CHECKED-OFF
INSPECTION SCHEDULE - �•� .°'r �----•- ��--`-------------
Pre-constructl`or�;�K�ik'lgal'e_1ii6brsilt:#id M/silt bdrtain
1St day of con0ructign
constructed
x , call,for compliance inspection; ONE
Glenn Goldsmith,President SU(/r Town Hall Annex
Michael J.Domino,Vice-President ,`O� yOIO 54375 Route 25
--- - - - --- - _
P.O.Box 1179
----- -- - - -- --- - - -- -
John re emeyer 11I— - — Southold,New York 11971
A.Nicholas Krupski G Telephone(631) 765-1892
Greg Williams �� �� Fax(631) 765-6641
�y00UNTY,��
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Permit No.: 9689A
Date of Receipt of Application: August 26, 2020
Applicant: Stanley & Alexis Grodski
SCTM#: 1000-117;1-2
Project Location: 2600 Grathwohl Road, New,Suffolk
Date of ResolutionlIssuance: September 16, 2020
Date_of Expiration: September 16, 2022
Reviewed by: A. Nicholas Krupski, Trustee
Project Description: Ten (10) Year Maintenance Permit to hand-cut Common
Reed (Phragmites australis) to no less than 12" in height by hand, as needed;
and to remove Poison Ivy.
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
survey prepared by Nathan Taft Corwin, III, Land Surveyor, dated July 31, 2019,
and stamped approved on September 16, 2020.
§ 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: Compliance Inspection to be performed one (1) year
from the date of the issuance of this Permit.
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
2
- and=aftevphoto,& #-the a--withhAhis time--period=befor-�an er- - - -- - -- ---
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.
Glenn Goldsmith, President
Board of Trustees
f
APPROVED BY
BOARD OF 1RUSTEES SURVEY OF PROPERTY
TOWN OF SOUTHOLD SI T UA TE
DATEZOZ
NEW SUFFOLK
SEPT�iKP 1(, a
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
S.C. TAX No. 1000- 117-01 -02
S.C. TAX No. 1000- 117-02-09
r4
SCALE 1 "=30'
` E�FJ� JULY 31 , 2019
L• *POOR
N a1.5$, 0„ E W
UTILITY NYT#26 CO C. S 73-21' o AREA DATA
N „ S.C. TAX No. 4,820 sq. ft.
:� \ E
FRAME
w'.LIDSHED 1000-117-01—02 0.1 1 1 ac.
y \ �� 0 2 R�cINA % S.C. TAX No. 46,788 sq. ft.
00 -/ o _ fff 1000-117-02-09 1.074 cc.
\ o = 2 �. C,gLC,AT�R 51 608 s ft.
�� TOTAL q
1.185 ac.
/ / F
c�COMON. W!R cPc�R41`9R�,-Q
/ 3Q� wFENCE CER TIFIED TO:
W
O —— _ — — IF fNCE 22 ANo STANLEY GRODSKI
/ y . 0 I 3?N �un
w ALEXIS GRODSKI
y N / '- '�•r Ww0 � ':. s; Z CHA3o/Nk z� TD BANK, N.A.
C,q / O ,,� .. ° o o k, FENCE 4a PECONIC ABSTRACT, INC.
O I o ',� : , C,A 9 FIRST AMERICAN TITLE INSURANCE COMPANY
\ 1 l In Zjo a z �0 S�A�E pPS10 o SrOCk4OE FEN
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Z / Q °j' u i ? $�o ° �� BRICK NOl 40 CE
�V ti S.C. TAX No. ° ^ Z o 0 S.C. TAX No. 2
M �,9. I 1000-117-01-02 0 0 r_ es N 100)-1 17-02-09 g NOTE:
�-' s8, " E"' N to DEED REFERENCES ARE TO DEED LIBER 12860 PAGE 734.
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W SIL 7� ,' ' • •'vEOGE OF I j2 STANDARDS FOR TITLE SURVEYS AS ESTABLISHED
yhl� • • ,•' pq�EME I 40� BY THE L.I.A.L.S. AND APPROVED AND ADOPTED
0� T �.. '° , ' . : ° Nr 24I FENC FOR SUCH USE BY THE NEW YORK STATE LAND
(J • ., ?441 3Jr, pa ff TITLE ASSOCIATION. T
' v SBD, D �..-.....
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o t • ' ` ' � k
in 160-68, �'. 1 .. '.�:., :°• r. .� S
01
a N.Y.S. Lic. No. 50467
UNAUTHORIZED ALTERATION OR ADDITION
TO THIS SURVEY IS A VIOLATION OF
•� EDUCATION ZLAWOF THE NEW YORK STATE Nathan Taft Corwin Iii
N COPIES OF THIS SURVEY MAP NOT BEARING
THE LAND SURVEYOR'S INKED SEAL OR Land Surveyor
EMBOSSED SEAL SHALL NOT BE CONSIDERED
2 TO BE A VALID TRUE COPY.
CERTIFICATIONS INDICATED HEREON SHALL RUN
ONLY TO THE PERSON FOR WHOM THE SURVEY
IS PREPARED, AND ON HIS BEHALF TO THE Successor To: Stanley J. Isoksen, Jr. L.S.
TITLE COMPANY, GOVERNMENTAL AGENCY AND Joseph A. In e no L.S.
LENDING INSTITUTION LISTED HEREON, AND p 9 9
TO THE ASSIGNEES OF THE LENDING Title Surveys — Subdivisions — Site Plans — Construction Layout
INSTI-
TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. Y Y
PHONE (631)727-2090 Fax (631)727-1727
THE EXISTENCE OF RIGHTS OF WAY OFFICES LOCATED AT MAILWG ADDRESS
AND/OR EASEMENTS OF RECORD, IF 1586 Main Road P.O. Box 16
ANY, NOT SHOWN ARE NOT GUARANTEED. Jamesport, New York 11947 Jamesport, New York 11947
39-1ni
Glenn Goldsmith,,�1_'sident �OSOFFU( Cp Town Hall Annex
Michael J. Domino, Vic.- 'resident ,��� Gam,,,, ; 54375 Route 25
John M. Bredemeyer III y P.O. Box 1179
A. Nicholas Krupski o Southold, NY 11971
Greg Williams y °® �!� Telephone (631) 765-1892
Fax (631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
i
Date/Time: 1 � de", Completed in field by: N• l� J
STANLEY & ALEXIS GRODSKI request an Administrative Permit for a Ten (10) Year Maintenance
Permit to hand-cut Common Reed (Phragmites australis) to no less than 12" in height by hand, as
needed; and to remove Poison Ivy. Located: 2600 Grathwohl Road, New Suffolk. SCTM#: 1000-
117-1-2.
CH. 275-3 - SETBACKS
WETLAND BOUNDARY: Actual Footage or OK=� Setback Waiver Required
1. Residence: 100 feet
2. Driveway: 50 feet
3. Sanitary Leaching Pool (cesspool): 100 feet
4. Septic Tank: 75 feet
5. Swimming Pool and related structures: 50 feet
6. Landscaping or gardening: 50 feet
7. Placement of C&D material: 100 feet
TOP OF BLUFF:
1. Residence: 100 feet
2. Driveway: 100 feet
3. Sanitary leaching pool (cesspool) 100 feet:
4. Swimming pool and related structures: 100 feet
Public Notice of Hearing Card Posted: Y / N
Ch. 275 Ch. 111 SEQRA Type: 1 II Unlisted Action
Type of Application: Pre-Submission Administrative Amendment Wetland
Coastal Erosion Emergency Violation Non-Jurisdiction
Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line
Additional information/suggested modifications/conditions/need for outside
review/consultant/application completeness/comments/standards:
q 'yg."-s C0'Aj 0'j D rSsve�
i
I have read & acknowledged the foregoing Trustees comments:
Agent/Owner:
Present were: J. Bredemeyer M. Domino G. Goldsmith �N. Krupski
G. Williams Other
SURVEY OF PROPERTY
SIT UA TE
NEW SUFFOLK
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
S.C. TAX No. 1000- 117-01 -02
S.C. TAX No. 1000 - 117-02-09
C3 SCALE 199-309
�a dI E��I� JULY 31 , 2019
*OOR
UTILITYPOLE FO
Yrj2 6 Co S 7,3-2 AREA DA TA
Q Afoo. 00s,
58910
6. S.C. TAX No. 4,820 sq. ft.
N,
Uj-1:- C A FRAME 1000-117-01-02 0.111 k3c.
C�
CO T_ V'. 1. 3:101 �Op S.C. TAX No. 46,788 sq. ff.
CO - - 9 Z:/ 1000-117-02-09 1.074 cc.
C4Z
C4'
4 TOTAL 51,608 sq. ft.
1.185 cc.
0
C
C. WIV, 10
N, wh"0� !-'P
FENCE J44ij �6iR
;"6h CER TIFIED TO:
C&j�;T 0
0
6_71— d4 STANLEY GRODSKI
Ca
0 C; ALEXIS GRODSKI
�0 in
C,q Q 00.810 TD BANK, N.A.
C�k 0 0 19
PECONIC ABSTRACT, INC.
04 i,_� V, LLULI to
V- C;
C� 0 FIRST AMERICAN TITLE INSURANCE COMPANY
Z Q S7`0CjC4DC
15
40
(7) LL1
07-
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INCE
S.C. TAX No. S C. TAX No.
1000-117-01—02 0
r_ 1000-117-02-09 NOTE:
2 s8, 00 00
E7'"I DEED REFERENCES ARE TO DEED LIBER 12860 PAGE 734.
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PREPARED IN ACCORDANCE WITH THE MINIMUM
00.
W Coot OF. STANDARDS FOR TITLE SURVEYS AS ESTABLISHED
P11 BY THE L.I.A.L.S. AND APPROVED AND ADOPTED
7 /4414,,;x, FOR SUCH USE BY THE NEW YORK STATE LAND
( ,41) N>•
4 , TITLE ASSOCIATION.
De
ED
La N
C,
in
iD 160.68.
V
�..,'N.Y.S. Lic. No. 50467
UNAUTHORIZED ALTERATION OR ADDITION
TO THIS SURVEY IS A VIOLATION OF
SECTION 7209 OF
THE NEW YORK STATE
EDUCATION LAW. Nathan Taf t Corwin III
COPIES OF THIS SURVEY MAP NOT BEARING
THE LAND SURVEYOR'S INKED SEAL OR
EMBOSSED SEAL SHALL NOT BE CONSIDERED
TO BE A VALID TRUE COPY. I Land Surveyor
CERTIFICATIONS INDICATED HEREON SHALL RUN
ONLY TO THE PERSON FOR WHOM THE SURVEY
IS PREPARED, AND ON HIS BEHALF TO THE Successor To: Stanley J. Isaksen, Jr. L.S.
TITLE COMPANY, GOVERNMENTAL AGENCY AND
LENDING INSTITUTION LISTED HEREON, AND Joseph A. In no L.S.
TO THE ASSIGNEES OF THE LENDING INSTI—
TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. Title Surveys — Subdivisions — Site Plans — Construction Layout
PHONE (631)727-2090 Fax (631)727-1727
THE EXISTENCE OF RIGHTS OF WAY OFFICES LOCATED AT MAILING ADDRESS
AND/OR EASEMENTS OF RECORD, IF 1586 Main Road P.O. Box 16
ANY, NOT SHOWN ARE NOT GUARANTEED. Jornesport, New York 11947 Jamesport, New York 11947
39-189
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SECTION NO
o_ - — Real Property Tax Service Agency 117
OFFICE LOCATION: � ` aw MAILING ADDRESS:
Town Hall AnnexP.O. Box 1179
54375 State Route 25N Southold, NY 11971
(cor. Main Rd. &Youngs Ave.)
Southold, IVB'11971 �� �� ��"��`
Telephone: 631 765-1938
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: September 9, 2020
Re: LWRP Coastal Consistency Review of GRODSKI & GRODSKI
SCTM# 1000-117-1-2
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
Glenn Goldsmith,President �Q� so(/Ty Town Hall Annex
Michael J.Domino,Vice-President ;�®� dfQ 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-(63-14-65-6641
n
BOARD OF TOWN TRUSTEE AUG 2 6 2020
TOWN OF SOUTHOLD E
This Section For Office Use Only S,ard of 1;nt�as
3
Coastal Erosion Permit Application
Wetland Permit Application
�! _Administrative Permit
Amendment/Transfer/Extension
X Received Application:. g •�
X Received Fee:S,.-1 VQ,, .0_
X -Completed Application: �ZO
Incomplete:..
SEQRA Classification: TypeI Type II Unlisted Negative Dec. Positive Dec.
Lead Agency Determination Date:
Coordination:(date sent);. {
X LWRP Consistency Assessment Form Sent:
CAC Referral Sent:
1L Date of Inspection:
Receipt of CAC Report:
Technical Review:
_Public Hearing Held:
Resolution: .
Owner(s)Legal Name of Property(as shown on Deed):,_ U LE V Wb54,, -KLG 15 QAASM
Mailing Address:-?. ®. 'PAX _l _ _ _N l►.�_ Ol-�L IJ (� `5 �v
Phone Number: _(a 31_7a1- -18 LN
Suffolk County Tax Map Number: 1000- O
Property Location: cQ(0[)0 9 WQ 11 L—
1Lri�A LL.(Z_4 Ub�u
IN necessary,provide L CO Pole#, distance to cross streets, and location)
AGENT(If applicable): NJ ik
Mailing Address::
Phone Number: .
Board of Trustees Appioation
GENERAL DATA
p
Land Area(in square feet): L� O a®
Area Zoning: C)
Previous use of property:
Intended use of property: LQ ot)6
Covenants and Restrictions on property? Yes X No
If"Yes",please provide a copy.
Will this project require a Building Permit as per Town Code? Yes XNo
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?
Ys 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?--,X-No Yes
If yes,provide explanation:
Project Description(use attachments if necessary): s11)
N&> �bisoa I?\[ o13 AP3 AO
J, 1
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: 10 �oi2oL�ta�- Cela�F� 1AEn1 t
1�1A AJ d W,Mi-Q65 AA PO4M I V
Area of wetlands on lot: 3 a O;�o square feet
T -
Percent coverage of lot:
Closest distance between nearest existing structure and upland edge of wetlands:. feet
Closest distance between nearest proposed structure and upland edge of wetlands: feet
Does the project involve excavation or filling? No Yes
If yes, how much material will be excavated? cubic yards
How much material will be filled? cubic yards
Depth of which material will be removed or deposited: feet
Proposed slope throughout the area of operations:
Manner in which material will be removed or deposited: -At lq �l ?L.Ats-k- ZYE6"
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):
' 1
617 20
Appendix B
Sliort Environmental Assessment Form
Instructions for Comnletin
Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses
become part of the application for approval or funding,are subject to public review,and may be subject to further verification.
Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully
respond to any item,please answer as thoroughly as possible based on current information.
Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful
to the lead agency;attach additional pages as necessary to supplement any item.
Part I-Project and Sponsor Information
N of Action o Project:
SII���S o soa "( Can (1- vg�ouwi QCs
Project Location(describe,aid attach a location m ):
2Gpo 6qK-%4Wo�Lq'_k?A . 0-&Lk) 0A .
Brief Description of Proposed Action -,
Cts1 Qk-m'31Ai'fo A.L1 VoTsois 143 dLJ &IJ ASS 1r sr'bsn 2)AS'-S ,
Name of Applicant or Sponsor: c Telephone: i
J1 1Q0 �d�-� � E-Mail �P€�Q��(7itlt��l�-. 'C.O^
Ad ress: 2 L
ID- i DX V7
City/PO: State* Zip Code:
L1,` o, . 4 l l
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 KA
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:e-0-
3.a.Total acreage of the site of the proposed action? -0. acres
b.Total acreage to be physically disturbed? aGRS 'o-LI AC2tr5
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? 11416r acres
/, / s0
4. Check all land uses that occur on,adjoining and near the proposed action.
❑Urban ❑Rural(non-agriculture) ❑industrial ❑Commercial PgResidential(suburban)
❑Forest ❑Agriculture ❑Aquatic J]Other(specify):
❑Parkland
Page 1 of 4
5. Is the proposed action, NO YES N/A
a. A permitted use under the zoning regulations? `❑ 1�
b"Consistent with the adopted comprehensive plan? ❑ 9
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:
_ - - F�yl ❑
8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES--
b.
ES_b.Are public transportation service(s)available at or near the site of the proposed action? ® F-1-
c.
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? Fz F]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: ® ❑
11.Will the proposed action-connect to existing wastewater utilities? NO YES
If No,describe method for providing wastewater treatment:_ _ N ❑
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: LSI
14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply.
Shoreline ❑Forest ❑Agricultural/grasslands El Early mid-successional
Wetland El Urban F1 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? K ❑
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 YES
b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)?
If Yes,briefly describe: NO AYES
Page 2 of 4
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:
l^L
I9.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:
P� El
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE �+
Applicant/spon r name: 1 ��� Date: p1
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 I 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 Elregulations?
2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑
3. Will the proposed action impair the character or quality of the existing community? ❑ ❑
4. Will the proposed action have an impact on the environmental characteristics that caused the ❑
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?
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: �J El
a.public/private water supplies? L�J
b.public/private wastewater treatment utilities?
8. Will the proposed action impair the character or quality of important historic,archaeological,
architectural or aesthetic resources?
9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑
waterbodies,groundwater,air quality,flora and fauna)? El
Page 3 of 4
s '
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
1:1 Elproblems?
11. Will the proposed action create a hazard to environmental resources or human health? El FI
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.
i
ElCheck 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 Txustees Appycation
AFFIDAVIT
BEING DULY SWORN
DEPOSES AN 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.
Signature/
ignature o PropqOwder Signature of Property Owner
SWORN TO BEFORE ME THIS _ o��Y _ DAY OF GC (, d/ ,20 3o
LISA M.KANE
Notary Public,State of New York
Notary Public RegistraSuffolk Coution No. ntAy6379537
Commission Expires 0'7 � a
Board of Trustees Appl _ -ption
At
a
AFFIDAVIT
A L
�� 1�y • f �SI 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 I SURE
COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COAST
EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING T ERM
OF THE PERMIT.
Signature of Property Owner Signatur o Pr y O er
SWORN TO BEFORE ME THIS a`� OF J v S t , 20 a U
ary Public
JENNIFER A. LINK
NOTARY PUBLIC,STATE OF NEW YORK
No. 01 L16392948
Qualified in Suffolk County
Commission Expires June 10,20 0?3
1
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 same.
c
YOUR NAME:--- l i�LC Y.— hJ
(Last name,first rJame,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
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,i n 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`th a 02 day f 2090
Signature X//
Print Name SiA� $l,e•�
Form TS I
LISA M.KANE
Notary Public,State of New York
Registration No.OIKA6379637
Suffolk Counttyy
Commission Expires 081201 0-
t • ez-71-e
�i�a� rh. 7gne
APPLICANT/AGENT/REPRESENTATIVF
TRANSACTIONAL,DISCLOSURE FORM
The Town of Southold's Code of Ethics prohibits conflicts of intereston the part of-town officers and employees.The buroose of
this form is-to provide'inforination which can alert the town of possible conflict's of-iuterest and allow itfa,take_wha0d f action is
necess=-to avoid same.
YOUR NAME:.
(Last name,fust name, iddle 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 day of 200_
Signature
Print Name
Form TS l
' � t
Town of Southold
LWRP CONSISTENCY ASSESSMENT FORM
A. INSTRUCTIONS
1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for
proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This
assessment is intended to supplement other information used by a Town of Southold agency in
making a determination of consistency. *Except minor exempt actions including Building Permits
and other ministerial permits not located within the Coastal Erosion Hazard Area.
2. Before answering the questions in Section C, the preparer of this form should review the exempt
minor action list, policies and explanations of each policy contained in the Town of Southold Local
Waterfront Revitalization Program. A,proposed .action will be evaluated as to its significant
beneficial and adverse effects upon the coastal area(which includes all of Southold Town).
3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will
affect the achievement of the LWRP policy standards and conditions contained in the consistency
review law. Thus, each answer must be explained in detail, listing both supporting,and non-
supporting facts. If an action cannot be certified as consistent -with the LWRP policy standards and
conditions,it shallnot be undertaken.
- f
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#_/000 117
n1
PROJECT NAME V-111
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:_ 2 6 dO (-:3ftA—qWOk � N V' OLV
Site acreage: (9, ! /
Present land use:
Present zoning classification:-aS;S1hC-'6MAP1 qc))
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: . ao DS( kL
(b) Mailing address R.O, �>OX 15 Z
5fd
(c) Telephone number:Area Code(
(d) Application number,if any: _ A
Will the action be directly undertaken,require funding,or approval by a state or federal agency?
Yes 0 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 Not Applicable
Attach additional sheets if necessary
Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See
LWRP Section III—Policies Pages 3 through 6 for evaluation criteria
Yes 0 No Not Applicable
1 4
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
MZP AmrIyc Ae-69gyr�yN Fi?dht 6i'/C' Mower) *k4j41-IMS Tom.
Attach additional sheets if necessary
NATURAL COAST POLICIES
Policy 4. A Unimize loss of life, structures, and natural resources from flooding and erosion. See LWRP
Section III—Policies Pages 8 through 16 for evaluation criteria
❑ Yes ❑ No Not Applicable
Attach additional sheets if necessary
Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III
-Policies Pages 16 through 21 for evaluation criteria
❑ Yes ❑ N® J Not Applicable
Attach additional sheets if necessary
Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including
Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III-Policies; Pages 22
through 32 for evaluation criteria.
Yes No Not Applicable
12 16
&,G Ill �/
Attach additional sheets if necessary
Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies
Pages 32 through 34 for evaluation criteria.
Yes [:]No Not Applicable
Attach additional sheets if necessary
Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous
substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria.
Yes 0 No Not Applicable
PUBLIC COAST POLICIES
Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public
resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation
criteria.
0 YeZ] No Not Applicable
Attach additional sheets if necessary
�r7
WORIINNG COAST POLICIES
Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in
suitable locations. See LNVRP Section III•—Policies; Pages 47 through 56 for evaluation criteria.
❑ Yes ,❑ No Not Applicable
Attach additional sheets if necessary
Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic
Estuary and Town waters. See LNVRP Section III—Policies; Pages 57 through 62 for evaluation criteria.
❑Yes ❑ N0;z Not Applicable
Attach additional sheets if necessary
Policy 12. Protect agricultural lands in the Town of Southold. See LNVRP 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 LMW
Section III—Policies; Pages 65 through 68 for evaluation criteria.
❑ Yes ❑ No Not Applicable
PREPARED B t _ TITLE DATE 1�S Z n
TA j s(,