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HomeMy WebLinkAboutTR-9717A Glenn Goldsmith,President �QF S (/p Town Hall Annex A. Nicholas Krupski,Vice President ,`Oy�lO 54375 Route 25 John M. Bredeme er III P.O. Box 1179 York Y � l�L Southold,New York 11971 Michael J.Domino G Q Telephone(631) 765-1892 Greg Williams �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1803C Date: March 24, 2021 THIS CERTIFIES that the addition of one 2"x12"x10' board to the existinlZ two boards, sister landscape fabric on landward side and add coir logs along approximate 100' of seaward side; supplement eroded-soil with clean soil and revegetate; At 1795 Bayview Avenue, Southold Suffolk County Tax Map #1000-52-5-6 Conforms to the application for a Trustees Permit heretofore filed in this office Dated September 18, 2020 pursuant to which Trustees Administrative Permit#9717A 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 addition of one 2"x12"x10' board to the existing two boards, sister landscape fabric on landward side and add coir logs along approximate 100' of seaward side; supplement eroded soil with clean soil and reve eg tate. The certificate is issued to Charles & Stephanie McEvily vers oft aforesaid property. Authorized Signature Glenn Goldsmith,President \QF SD(/ry Town Hall Annex A.Nicholas Krupski,Vice President ,`O l0 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold, New York 11971 Michael J. Domino y G @ Telephone(631)'765-1892 Greg Williams �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 3 ZI INSPECTED BY: ?)A V1 Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale-line/silt boom/silt curtain 1St day of construction 1/2 constructed x Project complete, compliance inspection COMMENTS: ® / CERTIFICATE OF COMPLIANCE: Glenn Goldsmith,President �QF S0!/lTown Hall Annex 1; Michael J.Domino ,`O l0 54375 Route 25 - - - John M.Bredemeyer III" P.O.Box 1179 _ Southold,New York 11971 ' A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams %�� �� Fax(631) 765-6641 ftpi BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9717A Date of Receipt of Application: September 18, 2020 Applicant: Charles & Stephanie McEvily SCTM#: 1000-52-5-6 Project Location: 1795 Bayview Avenue, Southold Date of ResolutionlIssuance: October 14, 2020 Date of Expiration: October 14, 2022 Reviewed by: Michael J Domino, Trustee Project Description: Add one 2"x12"x10'-board to the existing two boards, sister landscape,fabric on landward side and add coir logs along approximate 100' of seaward side; supplement eroded.soil with clean soil and revegetate. 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 Charles McEvily, received on September 25, 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 Glenn Goldsmith,President �QF S�U�y Town Hall Annex 0 Michael J.Domino,Vice-President �� �O 54375 Route 25 T: P.O.Box 1 John M.Bredemeyer III Southold,New York 11971 A.Nicholas Krupski v' G � Telephone(631)765-1892 Greg Williams O Fax(631) 765-6641 �y00UNT`I,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 7iHOURS PRIOR td COMMENCEMENT OF.THE ACTIVITIES CH'CKED OFF BELOW INSPECTION SCHEDULE Pre-eonstructPofv;--k 4' bare'-Ii e/s lt.1006 n/sil#curtain day of construction - constructed When-project complete, call for compliance inspection; Project description for 1795 Bayview Ave.,Southold NY 11971: Add one board 2"x12"x10'to existing two boards running approximately 100'along existing erosion control on Arshomomoque pond and sister landscape fabric behind (landward side) proposed three boards and back(landward side)two feet along ground and add coir logs along approximately 100'on water side of proposed structure. This will supplement natural vegetation erosion control on bank by limiting further erosion of soil into Arshomomoque pond. Supplement eroded soil with clean soil and plant spatina patens(or similar)grass to further restrict erosion. Nr--W p Roiflosr b •U-vk-K I10 13oxE's acz ou.2 5�CWN THP,,U _WOP05N2 TUMING ANP WPANKMEW F, 5%Ot? ON 0 s for OF 5LOPE AMM LANPWAM OF PP.OP05ED fMa WM_L5 I fO DE FILLED W TH CLEAN 5AN17 M17 ffVEGEfAfEt7 WrfOM or 51,01T -+`�-----NM----- ►� _ � ,__.�1 ALW� _01_01, PKOP05W WlficE WALL5(M) (2" x 12" x 10'130AM5 W iWt3 OMEN 1.25" x 6' -8'6ALVMJIZE19 PIPE5) p E /t t4cj(2rte .11'te 17-�i� /o�' , oA-JZD T X T/,�- -rLLV z 2D5'1 sis/e+- - °ak rf G a A& e O i r � p U4— AF 4— _ A,,PROVED BY _. BOARD OF 1 RUSTEES I, y TOWN OF SOUTHOLD i; { SEP 2 5 202 DATE, ®u�,e t Zoap Glenn Goldsmith, Pres t �OSUFFt?(�C � O Town Hall Annex Michael J. Domino, Vice-Prf--.-ent ��� a��� 54375 Route 25 John M. Bredemeyer III y P.O. Box 1179 A. Nicholas Krupski o Southold, NY 11971 Greg Williams y, �ao�� Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: y® /,170;V Completed in field by: CHARLES & STEPHANIE McEVILY request an Administrative Permit to add one 2"x12"x10' board to the existing two boards, sister landscape fabric on landward side and add coir logs along approximate 100' of seaward side; supplement eroded soil with clean soil and revegetate. Located: 1795 Bayview Avenue, Southold. SCTM#: 1000-52-5-6 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/standards: I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other Project description for 1795 Bayview Ave.,Southold NY 11971: Add one board 2"x12"x10'to existing two boards running approximately 100'along existing erosion control on Arshomomoque pond and sister landscape fabric behind (landward side) proposed three boards and back(landward side)two feet along ground and add coir logs along approximately 100'on water side of proposed structure. This will supplement natural vegetation erosion control on bank by limiting further erosion of soil into Arshomomoque pond. Supplement eroded soil with clean soil and plant spatina patens(or similar)grass to further restrict erosion. IN EW P AO PO;6 b 'ink-K /IJ BotV,-F s d c6ou.2 5�C110N THP,,U ppOP05�P 1VMIN6 ANP WDANKM f T5fRA110N U\ r' % ' fop or%OM MA5 LANOWAM OF PROP05CO fElVa WALL5 f0 M PILLED WITH CLrM 5ANO ANp RFVLGEfAfrD ' •7 �X,GK'N� --- ------C,�...r' � t30ftOM�51,01' \ P. t-0 FAIR -- -- 7.J__ ' aw" .01_001 PROP05ev twee WAl.L5(fw.) L \ EX G+ (2" x 12" x 10' 13OMP5 TEP TV r3EMEN 1.25" x 6' -8'GALVNJIZW PIPi;S) o E /t AcI�rte � � �z''jl /o ,�oA;2D T X T/fir Tush z62b5� rt C_ a- d e-o i r '� "� r ' SEP 2 5 2020 Sn���lnl()Tpl'!il Boar of Tr��t�e� SURVEY OF PROPERTY N SITUATE: SOUTHOLD TOWN: SOUTHOLD s W E SUFFOLK COUNTY, NY o SURVEYED 05-30-2013 SUFFOLK COUNTY TAX# Fj E 1000- 52 - 5 -8.1 �� Ali �! CERTIFIED T0: ' SEP t 8 2020 ANDREW WILLS sollthold Tol"rn KAREN L. WILLS 0ardofTru:,1"e �e�L i 0 OP_pNG��o�\�� OV4 Go �O a 01 10 3 l: 9 O / c9 yon / 61 `b / v GS 2 / 10 �>a 9/ S� / q V C0 L / `•�y,LO��\ Oho /4th / � \\o0 7011 7y 9 �O O'L�O S,� ° Q J �8 I \ \ 3 X� S s (\ (-J O 2Q \� •`� `'�P�gCp�C WETLAND FLAG5 SHOWN THUS 15ET BY EN-CONSULTANTS ON BACCHARIS BUSHES AT EDGE OF VEGETATED SALTWATER WETLANDS ON 5-1-13 LOTS G 1 ,G2, 4: G3 AS SHOWN ON A CERTAIN MAP ENTITLED "MAP SHOWING SUBDIVISION OF PROPERTY KNOWN AS SUMMER LAZ ZSJ�J HAVEN", AND FILED IN THE OFFICE OF THE CLERK OF THE COUNTY OF SUFFOLK ON JULY 5, 1933 AS MAP NO. 1 133 'Unauthorized alteration or addition to a survey NOTES mop bearing a licensed land surveyors seal is a wlotlon ofsclI,n9l,,o of the S7AKEFOUND VEYOR York State Education I X 1 = ELEVATION I. 'Only from the original survey C . EHLERS LAND SURmarked on of lothiseurveyos Ft. stomped seal shall be considered to be valid true Area = 24,821 Set. Ft. "Certifications indicated hereon signify that the Area = 0.5G98 Acres survey was prepared sn accordance with the ex G EAST MAIN STREET N.Y.S. LIC. NO. 50202 sling Code of Practice for Land Surveys adopted by the New York State Association of Professional GRAPHIC SCALE I II_ 3OI Land Surveyors Said certifications shall run only �J RIVERhEAD N.Y. ! 190 I 369-8288 Fax 3G9-8287 �a hire pm„n era>r company. ,s ernm n � and on his behalf to the title company, governmen— lon I5landlandSUrveyor.com total agency and lending institution listed hereon,and 9 the assignees of the lending institution Certifica— tions ore not transferable to additional Institutions a mmuo i Glenn Goldsmith,PresV '� �OSIIFFOL,�c Town Hall Annex Michael J. Domino ��� Gy 54375 Route 25 John M.Bredemeyer III w a P.O.Box 1179 A.Nicholas Krupski % Southold,NY 11971 Greg Williams I p� Telephone(631)765-1892 y� Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in field by: CHARLES McEVILY requests a Pre-Submission Inspection to discuss possible ways of re-stabilizing the bank that is slushing into Arshamomaque Pond; permitted 2015 embankment restoration is now failing. Located: 1795 Bayview Avenue, Southold. SCTM# 1000-52-5-6 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 leasing 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 Surveys 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: A6:: - 4zt±t C_, dee" .�-�. c��► _ , L& dtg�_) A,. 4 LOU 42 t I have read & acknowledged the foregoing Trustees comments: G Agent/Owner: IRAN fORPCL NO. a -- e '1e 7A N SEESEC.NO 1.4 e a / 3 isZRAW r 70.3 •i O .� b , 211 �� as1-0sam�,t, c A e 9 •b �A' (REOSERYED AOR PARK `) tzal(U \r Y OQ \ N b 0 1 e g AND PUYOROUND) \ 44 3• ,� 3 \\ e� s � '�> � -- � •~ � �� - _ �, �• �- - - _ sa '`•�'• mac) ,y �e � l � -'/� e M1 -, "$ tine.t� .m3. ts�(P) ,).�ErsrsaN ,. -' 6aT'•a 1,Ka) - d A? \ ti m • e �,++ g ear �. �l 40 �` sss ', . t e` mE Fn I sea b S\ 55A 6(L2 fesA- TOWN OF SOUDIOID - /� to + , S15 i ©\\� ,' >\_� '�� r,G•' aevenr,tertmatna m i \ SAW) 6 l - ' - \\\\\ `�;.per •� S `. s oma' _ , PECONICUNDTRUST 1.3 I w fa rl w 913 P 2011 FOR PCL NO. I as tyle s •,. ffi irn�Ntt - "�a,k ( SEE SEC NO.MR 6 'i 73 NO SEESEC.N0. ,aev'd N0. \ 65601-044.1 • 0 1'� e �'� 0wolatu SEE SEC.NO _ - Nm —__—__ 15A 058011N1.f1 ------------ -1____------ — \iZ-----UNEMATCH ------.�-----UNE A -MATCH - SEESMHO.ase SEE SEC NO 059 vaxAn a�tR� NOTICE COUNTY OF SUFFOLK© x ;ao °" O15*°""°° SOUTHOLD SECTION NO E �„�� —�— ,....... (21) ®„� O �— -- -- --^-- NNxDw A vA an PcaA Real Property Tax Service AgenCy r G emr ___ 0.10..+. o m --��-- ower--taa-- Detweun COatryfiatarlan d.NY11W1 M 1ss 004 asa Nu tLEa 052 _ _ . axocurcrdapxall0: ••••••- r 0q� mum --e-- orr.--w+-- 6LLYnut WimnroUt WP19Pe0aBiRD ® 1 ...., ,.�utryel—A py yTNf aE0.n P Pse DAwc,xo i00D PROPERTY MAP txtµc) -- -- _ '_ caxsaamemalme - \�a \�m r"T \ \ s k � 'Y � f w � 'Q-4 E g �F r, go K K< J 14 IN tv Ok-+ n 7,4 E -n J l Board of Trustees,Southold Town � SEP 2 5 2020 f 77 ATTN: Ms. Diane DISalvo Bo rd of Trust_,,; Re:Application for administrative permit for 1795 Bayview Ave.Southold NY Dear Ms. DiSalvo: Attached is an original and two copies of the combined plan and description of the work for which I seek administrative approval. Thank you for your assistance on this application. Sincerely, - Charles McEvily OFFICE LOCATION: " 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 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 CHARLES & STEPHANIE McEVILY SCTM# 1000-52-5-6 CHARLES & STEPHANIE McEVILY request an Administrative Permit to add one 2"x12"x10' board to the existing two boards, sister landscape fabric on landward side and add coir logs along approximate 100' of seaward side; supplement eroded soil with clean soil and revegetate. Located: 1795 Bayview Avenue, SoutholD. SCTM#: 1000-52-5-6 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the LWRP policies and therefore CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Damon Hagan, Assistant Town Attorney i` Glenn Goldsmith,President I'� S0 Town Hall Annex Michael J.Domino,Vice-President C� 54375 Route 25 John M.Bredemeyer III P.O.Box 1179 Southold,New York 11971 A.Nicholas Krupski rn Telephone(631)765-1892 Greg Williams z � rya Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extension --;V-'­Received �, Received Application: •fig•?d V Received Fee:$ =Completed Application: .2Z- Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): ,h { r,R ! F) 4 LWRP Consistency Assessment Form Sent: U r--- --�------� ` CAC Referral Sent: �DateofInspection: SEP 1 8 202 Receipt of CAC Report: Technical Review: Public Hearing Held: I& • •ZQ 5 =n Resolution: Boird of Owner(s)Legal Name of Property (as shown on Deed); 4c. (� !q Mailing Address: i / Phone Number: �S�(o -50 3 . Suffolk County Tax Map Number: 1000 - 5a - t_Z- G Property Location: 2 �6 i4 y(// (,� / Z aLZjLX 1) d,/V / & (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: - - ----Project description for 1795-Bayview Ave., South-old-NY 11971:--- - -- - - - - - - -- - - Add one board 2"x6"x10'to existing two boards running approximately 100' along existing erosion control on Arshomomoque pond and sister landscape fabric behind (landward side) proposed three boards and back(landward side) two feet along ground and add coir logs along approximately 100'on water side of proposed structure. This will supplement natural vegetation erosion control on bank by limiting further erosion of soil into Arshomomoque_pond. Supplement eroded soil with clean soil and plant spatina patens grass to further restrict erosion. Board of Trustees Appl' ,,tion GENERAL DATA Land Area(in square feet): /Z 2 9 7 Area Zoning: sc n r=�/ w Previous use of property: 51, Intended use of property: 5 l aqk 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 _,�L'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 — C 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 _4J10 Does the structure (s)on property have a valid Certificate of Occupancy?___-_Yes No Prior permits/approvals for site improvements: Agency Date sly Z013— No 0/No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?_ No Yes If yes,provide explanation: Project Description(use attachments if necessary): Sed f� Board of Trustees App;, ,ation WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: "eJ60A 1ti+1,1 '�„o '42 CLJ Lair IrXl9 Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands:_D feet Closest distance between nearest proposed structure and upland edge of wetlands: 5-q feet Does the project involve excavation or filling? ✓ No Yes If yes,how much material will be excavated? O cubic yards How much material will be filled? Q cubic yards Depth of which material will be removed or deposited: 0/0 feet Proposed slope throughout the area of operations: so--WE Manner in which material will be removed or deposited: J+A-P b D U.G- TRawue- I 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): JV/ff APPLICANT/ TRANSACTIONAL DISCLOSURE FORM The Town of SouEhold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees Ru The roose of this form Is to provide inforination which can alert the town of Rgssi�l&conflicts,of interest and allow i►tai take whatever action is necessary 4o avoid same. `,, YOUR NAME:_ G.110Gt l e'.Sy�e E w (Last name,first name,ipiddle initial,unles§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.)� Rerwl 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 br 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 applicont (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(wh6a 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 Jit!' teAoo ZOZo Signature Print Name of 64, eo v Form TS 1 Board of Trustees Appl tion AFFIDAVIT C.14ew eg ie ^}ltG�v BEING DULY SWORN DEPOSES AND AFFIAM9 THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS MENTS 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. G Signature of Property Owner *Sig2tureProperty Owner SWORN TO BEFORE ME THIS_ DAY OF c r '20 Z o Notary Public /U� 1� J u Nv. OA Ajc 42�63a3 4 G ,s-o737 y 3 G xv /ris //�� Zo 2-0 l 6I Z20 Appendix B Sliort 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 a lee" )n,-_ S- Name of Action or Project: (1)I if6G C� Project Location(describe,and attach a location(nap): S a P.v zv Brief Description f Proposedcti� 1146 Name of Applicant or Sponsor. Telephone: --� 5193 7 7 E-Mail: G twl.fd`/y � -OW, ZO M4 Address: City/PO: State: Zip Code: 11Q 71 ,may' /'4 �/ 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 0 El may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: 3.a.Total acreage of the site of the proposed action? 100 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 esidential(suburban) ❑Forest ❑Agriculture QKq-uatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO I 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 Apes it adjoin,a state listed Critical Env'�pnmental Area? NO At If Yes,identify W£f L4 r-1 ACAg S (A 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES 12 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 requirI AI ements? O YES If the proposed action will exceed requirements,describe design features and technologies: ❑ 10. Will the proposed action connect to an existing publiclprivate 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: P ❑ 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 O YES wetlands or other waterbodies regulated by a federal,state or local agency? b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline OForest ❑Agricultural/grasslands ❑Early mid-successional ❑ Wetland [J Urban El 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? ❑ tg 16.Is the project site located in the 100 year flood plain? NO YES IRr 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 R-7 ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: LJ 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: Rr ❑ 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: {� ISI ❑ 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: ❑ 1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/spons am l�l�� Q r 1 C.S vj te: Q `/A- z U7 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 I. 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 ❑ ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: F] ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? ❑ ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, El 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)? 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 d problems? =M EJ 11. Will the proposed action create a hazard to environmental resources or human health? El Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. 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 in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Town of Southold f LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS I. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town) 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website(southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM#(!LD PROJECT NAME The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity, agency regulation,land transaction) (b) Financial assistance(e.g.grant,loan, subsidy) (c) Permit, approval, license,certification: Nature and extent of action: mer T!'uslees ►r►SpCG n oN L?/9)zazo 5a4fil/wiP*tt i,nIy n& exis�ioc 4-mjo 14499� - s sis 1 zcf� i Location of action: 1 '7 9 Site acreage:__ Present land use: Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing address:_ 17 9 13,+V /&tj G At 11,P71 (c) Telephone number: Area Code no (d) Application number,if any: -A4L- Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes ❑ No 0 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 ❑ NoLin 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 11 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 ❑ No � Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria Yes ❑ No ❑ Not Applicable00. . � 1 Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No 14 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 t 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" Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No P 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. ❑ YeJ:1 No% Not Applicable Attach additional sheets if necessary f WORIONG COAST POid%-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. ❑ Yes ❑ No M 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 LVVRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No V Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III—Policies; Pages 62 through 65 for evaluation criteria. ❑Yes ❑ No 14 Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑Yes ❑ No Not Applicable PREPARED BY TITLE VL V&1J DATE /d° 20