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HomeMy WebLinkAboutTR-9716A Glenn Goldsmith,President �QF SQ(/�y Town Hall Annex Michael J.Domino ,`O �- 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 A.Nicholas Krupski cn G Q Telephone (631) 765-1892 Greg Williams '0 �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1776C Date:November 28, 2020 THIS CERTIFIES that the removal and replacement in place of a 5'x29' brick on-grade walkway; At 335 Private Road#3, Southold Suffolk County Tax Map#1000-70-6-13 Conforms to the application for a Trustees Permit heretofore filed in this office Dated August 14, 2020 pursuant to which Trustees Administrative Permit#9716A Dated October 14; 2020,was issued and conforms to all the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the removal and replacement in place of a 5'x29' brick on-grade walkway.' The certificate is issued to Marjory Stevens owners of the aforesaid property. Authorized Signature r / t Glenn Goldsmith,President QF soUjTown Hall Annex Michael J.Domino,Vice-President 01 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 %� YQ Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: INSPECTf'D=f3Y:j' Ch. 111 INSPECTION SCHEDULE Pre-corlstrirtotion, ha t3afe`J fie�silfi�lbaw.1-Silt curtain 1St day of construction % constructed Project complete, compliance inspection Q,MMENTS" '� CERTIFICATE OF COMPLIANCE: Glenn Goldsmith,President QF SU(/lTown Hall Annex 54375 Route 25 Michael J.Domino,Vice-President ,`O l0 P.O.Box 1179 John M. Bredemeyer III Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams �� • �� Fax(631) 765-6641 COU BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARDIOF TRUSTEES 72'HOURSPRIOR TO COMMENCEMENT OF THE ACTIVITIES CH' CKt6b*FF 'BELOW . . . ; -_•;; "• ; . INSPECTION SCHEDULE Pre-constructiob;-l�ay bare aide/sift boom/silt cii�tain 1 st day of construction constructed When project complete, call for compliance inspection; Glenn Goldsmith,President QF SOUrTown,Hall Annex. 54375 Route 25 Michael J.Domino P.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 A.Nicholas Krupski Q Telephone(631) 765-1892 Greg Williams �� Fax(631) 765-6641 CUUNT`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9716A Date of Receipt of Application: August 14, 2020 Applicant: Marjory Stevens SCTM#: 1000-70-6-13 Project Location: 335 Private Road #3, Southold Date of ResolutionlIssuance: October 14, 2020 Date of Expiration: October 14, 2022 Reviewed by: Michael J Domino, Trustee Project Description: Remove and replace in place a 5'x29' brick on-grade walkway. 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.Eligio O. Lopez, received'on August 14, 2020 and stamped approved on October 14, 2020. Special Conditions: None Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Glenn Goldsmith, President Board of Trustees BOARD OF I RUSTEES TOWN OF SOUTHOLD .r DATE oCTDWP- AUG 1 4 2020 t scatF , o'=i" i r . .r D�MOWI'1M�1.JT C *' F� wav AREA r UL / p { � 1.1s.00 sw tAarw .37 97rW/►� •uY ~\ ?+fie ,�_� J OF < / RSR t g98i `� I!V► I f so Foar .• x � ^ ';' ._�g�/ _ 1oQ.33.. ..----'� .-- J 5.1q IS'vl. N.@� ��.a.�,p 1, `'•�—• ` AC / BUEQ�,tE �' •J i . Wt'/ Glenn Goldsmith, Pres' it �o�OcvEFO(,�Cpo Town Hall Annex= Michael J. Domino, Vice Presfaent ,� y� _ 54375 Route 25 John M. Bredemeyer III o "� P.O. Box 1179 A. Nicholas Krupski o Southold, NY 11971 Greg Williams, ypl� Telephone 6) 765-6641192 Fax (63 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: �m /®%6 `'Completed in field by: 7/m, Eligio O. Lopez on behalf of MARJORY STEVENS requests an Administrative Permit to remove and replace in place a 5'x29' brick on-grade walkway. Located: 335 Private Road #3, Southold. SCTM#: 1000-70-6-13 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/consultaht/application completeness/comments/standards: s• I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other AUG •1 4 2020 �a y0 L � ; ( { f SCALE•�'O'=t" ,. Xe; 1 O�MOlJUmewJOAPipf AREA' J 0 a' 40 / • µa4 t5.T____-- -- - _.._,. ar t::.r 1 - - J .N.83.3�,i0 E• _.. X77.59 'w�.,_!wQrw_` -._ • "y_J ,/�' �- Cti 97-87 VJh`� A 3 X 1 / OF ,� < / 50 FOOT �1t;4Yf �`� 50 t X981 vi V t;i .� •i5 vl. N.Bs 2� p � l -- JJ JSEE SEG.NQ 063 mE Tawe cm k �\ eIATCN--- ----- ,AEsrNu rs. 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A pe,Ncf rq t000 PROPERTY MAP N �� ..� nlNata:ain �•• o...�.. --�-- vwr u.--w.--- mw.eanlaccny n.ar D OFFICE LOCATION: )� � "� MAILING ADDRESS: Town Hall Annex µda P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) G Telephone: 631765-1938 Southold, NY 11971 P 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: October 9, 2020 Re: LWRP Coastal Consistency Review of MARJORY STEVENS SCTM# 1000-70-6-13 Eligio O. Lopez on behalf of MARJORY STEVENS requests an Administrative Permit to remove and replace in place a 5'x29' brick on-grade walkway. Located: 335 Private Road #3, Southold. SCTM#: 1000-70-6-13 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is EXEMPT from LWRP Coastal Consistency Review. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Damon Hagan, Assistant Town Attorney Maim Diane From: DiSalvo, Diane Sent: Thursday, September 17, 2020 9:54 AM To: 'eligio lopez' Subject: FW: 335 Private Road #3 Attachments: Stevens (2).pdf Please confirm with me by return email— Your project description states that the brick walkway is 6'x29' and is located on front of the house, but your project plan that you created (see attached)says 5'x28'. These must match. Please confirm with me exactly what it is you are applying to do: remove an existing walkway?Construct a new walkway (how big and it must be shown on your plan) and is this walkway going to be on grade? Also, both Mr. and Mrs.Stevens need to sign an Applicant/Agent/Representative Transactional Disclosure Form. Diane From: DiSalvo, Diane Sent: Friday, September 04, 2020 10:01 AM To: 'eligio lopez' Subject: FW: 335 Private Road #3 1 have what you dropped in the box this morning. But, please see below email which I had sent you—There is an additional owner of this property: Peter B.Stevens. He must sign the three(3)forms that accompany this application—otherwise we are not permitted to go onto his property. Also,your description states that the brick walkway is 6'x29', but your project plan that you created says 5'x28'. These must match. At this point=I am unable to get this put on our September agenda. Diane From: DiSalvo, Diane Sent: Wednesday, September 02,•2020 11:23 AM To: 'lopez_eligio@yahoo.com' Subject: FW: 335 Private Road #3 From: DiSalvo, Diane Sent: Monday, August 31, 2020 4:11 PM To: 'elopeznursery@gmail.com' Subject: 335 Private Road #3 i DiSalvo, Diane From: DiSalvo, Diane Sent: Friday, September 04, 2020 10:01 AM To: eligio lopez' Subject: FW: 335 Private Road #3 Attachments: Stevens.pdf I have what you dropped in the box this morning. But, please see below email which I had sent you—There is an additional owner of this property: Peter B.Stevens. He must sign the three(3)forms that accompany this application—otherwise we are not permitted to go onto his property. Also,your description states that the brick walkway is 6'x29', but your project plan that,you created says 5'x28'. These must match. At this point—I am unable to get this put on our September agenda. Diane From: DiSalvo, Diane Sent: Wednesday, September 02, 2020 11:23 AM To: 'lopez—eligio@yahoo.com' Subject: FW: 335 Private Road #3 From: DiSalvo, Diane - Sent: Monday, August 31, 2020 4:11 PM To: 'elopeznursery@gmail.com' Subject: 335 Private Road #3 Our Town record indicate that there is an additional owner of this property: Peter B.Stevens. He must sign the three (3)forms that accompany this application. See attached—please complete your project description on the General Data form. Please indicate the dimensions of the walkway that is to be removed and replaced and if same will be on-grade. Also—you did not sign the attached disclosure form. This form also needs to be signed by the owners. T I> G2 v,,e 1),&2 LVO Sou.thow TOWV" Trustees 54S j s RD kte 25 P.D. PIOX 1171 SouthoLol, NY :LL9 1 1 Maim Diane From: eligio lopez <lopez_eligio@yahoo.com> Sent: Saturday, September 26, 2020 7:52 AM To: DiSalvo, Diane Subject: RE: 335 Private Road#3 Hi Diane,to answer to your questions There is-a-collapsing-walkway at front of the house-and-its-5 x 29 so-it would be replaced ori same footprint.: Walkway-would be at grade . I will have them signed papers asap. Thank you for all the help. Sent from Mail for Windows 10 From: DiSalvo, Diane Sent:Thursday,September 17, 2020 9:54 AM To: 'eligio lopez' Subject: FW: 335 Private Road#3 Please confirm with me by return email— Your project description states that the brick walkway is 6'x29' and is located on front of the house, but your project plan that you created (see attached)says 5'x28'. These must match. Please confirm with me exactly what it is you are applying to do: remove an existing walkway?Construct a new walkway (how big and it must be shown on your plan)and is this walkway going to be on grade? Also, both Mr. and Mrs.Stevens need to sign an Applicant/Agent/Representative Transactional Disclosure Form. Diane From: DiSalvo, Diane Sent: Friday, September 04, 2020 10:01 AM To: 'eligio lopez' Subject: FW: 335 Private Road #3 I have what you dropped in the box this morning. But, please see below email which I had sent you—There is an additional owner of this property: Peter B.Stevens. He must sign the three(3)forms that accompany this application—otherwise we are not permitted to go onto his property. Also,your description states that the brick walkway is 6'x29', but your project plan that you created says 5'x28'. These must match. 1 Glenn Goldsmith,President S 0,04 Town Hall Annex ` Q 't� Michael J.Domino,Vice-President � ;�� '�� 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 A.Nicholas Krupski cA+� _G• Telephone(631) 765-1592 Greg Williams •SS Fax(631) 765-6641 -, F--a I� c 6 , x;17 � L` '(„ i BOARD OF TOWN TRUSTE AUG 1 4 2Q�p TOWN OF SOUTHOLD This Section For'Offace Use Onl • Boar of tn� taes ,Coastal Erosion Permit Application - — - Wetland Permit Application Administrative Permit c Amendment/Transfer/Extensio Received Application:-_ - ?.1+.'2 Received Fee: $ 186.E - Completed Application:_ •?—� _ Incomplete:,. SEQRA Classification: TypeI Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): _/�LWRP Consistency Assessment Form Sent: CAC Referral Sent: Date of Inspection: Receipt of CAC Report: Technical Review: Public Hearing Held: Resolution: Owner(s)Legal Name of Property(as shown on Deed): o,V J o FT Mailing Address: Y I v n-k 3 fi19 a ial Al, Phone Number: _ �--- _C •� — ?_ Suffolk County Tax Map Number: 1000 - Property Location: ✓ U f'k a 6J (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable):�� �Q a�-V_ Mailing Address:: G a 6A 0 " _�� Phone Number: Board of Trustees Appl: tion GENERAL DATA Land Area(in square feet): , Area Zoning: e. f c l e k- t a -- - - — - Previous use of property: li ' Intended use of property: 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. Wilf,this;project-regairP 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?—9—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?_K No Yes If yes,provide explanation: - Project Description(use attachments if necessary): 5 Board of Trustees Appli :ion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: f R ��`� �' • ►� 41 Area of wetlands on lot: square feet Percent coverage of lot:` % Closest distance between nearest existingstructure and upland edge of wetlands: feet p 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:: 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): Board of Trustees Appli :ion AFFIDAVIT BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signatur P peer Signature of Property Owner SWORN TO BEFORE ME THIS ___ 2-3- . DAY OF _ _ OJ20 2-0 - - ^Notary Public SANDRA V. SAIEGH NOTARY PUBLIC-STATE OF NEW YORK No.02SA6407223 Qualified in Suffolk County My Commission Expires 05-18-2024 Board of Trustees Appli tion AUTHORIZATION (Where the applicant is not the owner) I/We, - owners of the property identified as SCTM# 1000- in the town of New York,hereby authorizes e,1110 ® K ,�.. 1% • L o P C �. ✓Y S Cto 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. PropeOvke ' > afure Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF , 20 Z Notary Public SANDRA V. SAIEGH NOTARY PUBLIC-STATE OF NEW YORK No.02SA6407223 Qualified in Suffolk County My Commission Expires 05-18-2024 APPLICANUAGENURE-PRESENTATIVE TRANSACTIONAL DISCLOSURE,FORM The T&Avnb-fSouth6Jd's Code of Ethics tii)hibi&6hflicLebfinttr&tarf the-partf2rtown officers and employees.The oumose,o lietown g� in � ,ihi�Lr rin-B takovidd Info mLini1ow-%-%,fii&6n 616i I .of Dssible coAfcts,,0f interest and aliowIt(6 iAev6atever ctii in,i^ ,jfe,ce,sMrv` avoid same. YOURNME: .,avaj4o z-o C. _ - (Last rfame-,-first-fiama,4iiddle initial,unless you are app firij in the name of someone else or other entity,such as aeompany.If SG-t-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 pers9pall - mpjoyee y,(or-through company,spouse,sibling; child),hov&a relatibhship,,Wlth-any dffictr-dr 9 of the Town ofSouthold? "Relaitio4ship"includes by blood,',Marriage,or buiiness interest."Business interest""means,a_business, including a partnership,in which the towrofficer or employee-has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns rnowre-,thmfMdW-share6. 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): the owner of;greatcr than�1/4-offt-sharp�ptop,corporate stock oftie,a plicant (when the appi icant.is a corporation); B)the legal or beneficial owner of apy4niterasVirf Alnon-cOrKrW,entity(wh#t the applicant is not a corporation); an officer,director,partner,or employee of the applicant or the actual applicant. DESCRIPTION or RELATIONSHIP Submitted this T—day of fe-,P 201 .0 Signature o -Mv Printllame Form TS I APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interogt gn the part of jqwn officers and emnlovees.The numpse of this form is to provide information which can alert the town ofsps,sible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: 0 ( t name,first name,diddle initial,unless you are applying to the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION; (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other pf"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 applicantlagent/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 ay of .• �20Ac�_ Signature d"11 jel Print Name ... Form TS l �\ Board, of Trustees Appli. tion AUTHORIZATION (Where the applicant is not the owner) QN owners of the property identified as SCTM# 1000- -S tM -10, l 3 =in the town of New York,hereby authorizes to act as my agent and handle all necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for this property. Property Owner's Signature Prope oerSignature SWORN TO BEFORE ME THIS_ _F( . DAY OF S401 20_ Notary Public SANDRA V. SAIEGH NOTARY PUBLIC-STATE OF NEW YORK No,02SA9407223 Qualified in Suffolk County MY Commission Expires 06-18-2024 Board of Trustees Appli - tion AFFIDAVIT lea.— �D�10&ljsBEING 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. Signeature of Property Owner Signa o o erty Owner SWORN TO BEFORE ME THIS__� -�_,_ DAY OF _ _ 20 20 „- - 966r—y Public - SANDRA V. SAIEGH NOTARY PUBLIC-STATE OF NEW YORK No.028A6407223 Qualified in Suffolk County My Commission Expires 05-18-2024 r- 1 ! 61 Z20 Appendix B Short Environmental Assessment Form histraetibns for ConipletinQ Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Uf Name of Action or Project: qt l k Project Location(desc e-,and'attach a location inap): ` Brief Description of Proposed Action;. Namee'ofApplicantorSponsor: - - Telephone: E-Mail:_ Address: City/PO: " - - - 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 N may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. roes the proposed action require a permit,approval or funding from any other governmeftiai Ageticy? NO- YES If Yes,list agency(s)name and permit or approval: 3.a:Total acreage of the site of the proposed action. y/1, acres - - b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? _acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial residential(suburban) ❑Forest ❑Agriculture ❑Aquatic []Other(specify): - ❑Parkland Page 1 of 4 5. Is the proposed action; — - - - NO ' YES N/A a. A permitted use under the zoning regulations? ❑ b.Consistent with the adopted comprehensive plan? ❑ ® ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ 7. Is-the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES__ b.Are public transportation service(s)available at or near the site of the proposed action? ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: --- R� ❑ 10. Will the proposed action connect to an existing public/private water supply? -NO` 'YES If No,describe method for providing potable water: ( j ❑ I l.Will the-proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment:_ F'�a 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO JVESPlaces? b.is the proposed action located in an archeological sensitive area? L� 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? O ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? (� ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply:= El Shoreline El Forest ❑Agricultural/grasslands ❑Early mid-successional Wetland ❑Urbanuburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NOYES by the State or Federal government as threatened or endangered? ® ❑ 16.Is the project site located in the 100 year flood plain? -NO - YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, ❑ a.Will storm water discharges flow to adjacent properties? ❑NO ❑YES b.Wilhstofm water discharges be directed to established conveyance systems(runoff 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: - 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: k� ❑ 20.Has the site of the proposed action or an adjoining property been-'the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: .- - - - --- - ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE /n Applicant/sponsor name: C11_4 /h (/ _ ,�a-.� Date: a /'L 4- 2 O 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?" 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? ® ❑ 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 Q`j ❑ reasonably available energy conservation or renewable energy opportunities? LLJJ 7. Will the proposed action impact existing: a.public/private water supplies? El b.public/private wastewater treatment utilities? �4 ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, ® El or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, (—j 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 ® a• problems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,Iong-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. F] 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 inlead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Town of Southold LW. RP 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 si_anificant 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 `�io", 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- sub orting faets. If an- action cannot be certified as consistent with the LWRP policy standards and conditions,h shallnot-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#. 70 PROJECT NAME,__ (�l nd �� 5D 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: 3 3 Site acreage: Z2 - Present land use: A c_T( Present zoning classification: __ S 1 �✓'Y d t 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: ` [o /A (c) Telephone number: Area Code (d) Application number,if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes 0 No!X 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 Pest 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 LNW Section III—Policies Pages 3 through 6 for evaluation criteria . Yes _ ❑ No 0 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 Q No KNot Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. N inimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—PolicieZNot es 8 through 16 for evaluation criteria 0 Yes No 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 D, Yes 0, 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. Yes No �_,_Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. a Yes Q No NNot 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. 0 Yes Q 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. YesO No ZNot Applicable Attach additional sheets if necessary ' 1 P WORHING COAST PO;UJL::IES 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. 0 Yes ,0 No Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. Yes f NoLX Not Applicable t Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III—Policies; Pages 62 through 65 for evaluation criteria. Q Yes F] No ENot 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. 0 Yes D No [F�Not Applicable PREPARED BY !� c `� �' _rte . TITLE DATE V10170 "