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HomeMy WebLinkAboutTR-9714A Glenn Goldsmith,President *QF 80 Town Town Hall Annex 'i`. 54375•Route 25 Michael J.Domino,Vice-President P.O.Box 1179 John M.Bredemeyer III l Southold,New York 11971 A.Nicholas Krupski G Telephone(631)765-1892 Greg Williams '� �� Fax(631) 765-6641 UNT` 1 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS'15 RIOR TO'COMMENCEMENT OF.THE ACTIVITIES CHk i CUFF `BELOW _ INSPECTION SCHEDULE Pre-constructioh-,',,d� baie'lih0gilfi boom/silt curtain fs day of construction = Y2 constructed x When project complete, call for compliance inspection; Glenn Goldsmith,President S0(/�y Town Hall Annex Michael J.Domino ®� Ol0 54375 Route 25 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 �y00UM`I,�� • BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9714A Date of Receipt of Application: August 14, 2020 Applicant: Giuseppe,lanello & Eliiabeth Ramos SCTM#: 1000-76-3-34:3 Project Location: 270 Smith Drive South, Southold Date of Resolution/Issuance: October 14, 2020 Date of Expiration: October 14, 2022 Reviewed by: Michael J Domino, Trustee Project Description: Construct a 6'x220'-stockade fence and-a two-hole 140' split rail fence., 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,operatio,ns as indicated on the project plan prepared by Eligio O. Lopez, received on October 5, 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 1� APPROVED BY �A1nw.w c9ee ar mu MlTLAM9S b 0[LIrIGI[D 9� Wli�pw pMpIKWTK �� wKauLma..0 aK+nac+e.3017 BOARD OF 'i RUSTEES , 1000-76-3-26.1 TOWN OF SOUTHOLD 31+00' - E10,.00' DAT ,20 T%LOT 100 -76-3-27 DY�' NOL 0 7 LOT in S �31700'0' �_. 73.00' L 1 Orlin __ ^ Aeovm s p �— f^ o LLl > IVI OCT 2020 ii W �6 m� 10 n a.q Z N 51'00'00' W 750.00' $$ I z 3 n L APPEARS PART ON THE MAP OF _ — -'"" °.T - ,[V p ro• T r y �1 GOOSE NECK.FILED 11/22/1946 FIE No. 1663. '51 30.00'00 00- w" e N alroo'oo• w � W 24.03' $ r S d 'F- IE �, \ / Barrett 11 I o z BB \. � Bonacci& Van Weele,Pc a W„ • 2^ Civil Engi— 175A C-4 D� p � f Heigpovga.W 1 1768 y \ 631 435.1111 a P6. :.bll dis ir�7 Tax Map:D151111LT 1000 SECTION 76 BLOCK 3 LOT 34.3 PROPERTY _00.00• « ,..p......a..N.. ,ym ars SIiUAR .rl SOUTHOLD N 3100'60' W 25.00' "d^"4"'�"'^"m"'"r""" 10Whawlmal6 xnwtKCOMM N.T. MAIN BAYVIEW ROAD SURVEY vAv� Y I'[a—w rpw.�r 1np w a�Wrw qN w rtecr r�'AM11�.90N� 1"•1.1 A166IiVA I Or I .v..leNImINAw..im�woq rlm�W w[nMv ruCd,IIr]d}�11 Saab M 6Ywl Mwl1 Nn.Mul.r.[,w Glenn Goldsmith, Presic t4NOa$1]fFQ�X ll , Town Hall Annex Michael J. Domino, Vice-Presiaent � s 54375 Route 25 John M. Bredemeyer III w P.O. Box 1179 A. Nicholas Krupski o A Southold, NY 11971 Greg Williams .y � �'�Y' Telephone Fax (636 92 ) 765 66431) 8 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Datef'fime: Completed in field by: -� Eligio O. Lopez on behalf of GIUSEPPE IANELLO & ELIZABETH RAMOS requests an Administrative Permit to construct a 6'x220' stockade fence and a two-hole 140' split rail fence. Located: 270 Smith Drive S., Southold. SCTM#: 1000-76-3-34.3 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet _ 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 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: ���r./.�i � Q .gra-�.�'�.�-�r� r�^h .�.at�-� •�-� �� a.� -v vt nom- ��C LVA I have read & ackno dged the foregoing Trustees comments- Agent/Owner: . Present were: i J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other — � _.... msµ.. • 01 ------------- V 1 � A P -i .' Wr P' \ \n ` •�°' � �!! 1'•�`� __ / %dam 11 \ fyl,.` ' r - jf _ �.I�_-�.'-�,� • ,1/�• 1 4t� � 'e - _ . *e ••A � I is • a1 1 I Yll a rr 1 _ F m° „tiu�A=„ .c°w^• �" o — �e� '° COUNTY OF SUFFOLK © NOTICE E 4 1°00 Rcal Property Tax S—ice Agency w.efrcxvrfexhvanoa su OF v N SECTION NO. O r __ __ __ ,.•s,aw ---_—_ m...e.� 1+.ItiJ w my PoanoN OF iNE M wr cr SOUTHOLD /c 300 c-,Dri.e,AM.he�(AY 119°1 wunv TM nw's lrY en£o A te. QIV P (21) OFFICE LOCATION: w„ 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: 631765-1938 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 GIUSEPPE IANELLO & ELIZABETH RAMOS SCTM# 1000-76-3-34.3 Eligio O. Lopez on behalf of GIUSEPPE IANELLO & ELIZABETH RAMOS requests an Administrative Permit to construct a 6'x220' stockade fence and a two-hole 140' split rail fence. Located: 270 Smith Drive S., Southold. SCTM#: 1000-76-3-34.3 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 stockade fence installation is CONSISTENT with the LWRP policies and therefore CONSISTENT with the LWRP. The installation of the split rail fence is EXEMPT. 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 dpi SOUP Town Hall Annex Michael J.Domino,Vice-President ;�4 � 54375 Route 25 P.O.Bog 1179 John M.Bredemeyer III Southold,New York 11971 A.Nicholas Krupski Telephone(631) 765-1892 Greg Williams ��� Fax 63 - LVU F BOMW OF TOWN T1E USTEES Ri AUG 14 ]2020 -' 1 TOWN OF SOUTHOLD Seriilc���,r;r This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extension Received Application:_ g•14•20 Received Fee: $ _140. Completed Application: 16 (P'W Incomplete: . SEQRA Classification: TypeI Type II Unlisted Negative Dec. Positive Dec. Lead Agency,Determination Date: Coordination:(date sent): -74-�LWRP Consistency Assessment Form Sent: _- - CAC Referral Sent: 7tDate of Inspection: Receipt of CAC Report: .._ Technical Review: _ Public Hearing Held: Resolution: Or 19 It Owner(s)Legal Name of Property(as shown on Deed): Mailing Address: . .2' _ 3' At t 14 - �Y - ,� .s 4 t1"b 9 / �/ W• Phone Number: Suffolk County Tax Map Number: 1000 - Property Location: o At(Jit (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): IF/( !a �-- Mailing AJddress:_ 6 G G o M; 41 h r e g per, aJ C- Phone Number: _ ` 7 �� T_ 1Y ® -_9� r DiSalvo, Diane;, From: eligio lopez <lopez_eligio@yahoo.com> Sent: Tuesday, October 06, 2020 9:24 AM To: �� DiSalvo, Diane Subject: RE: lanello Good morning The stockade-fence is 22:0 feet long And-the split. ail fence-is 140 feet long. Thank you Sent from Yahoo Mail on Android On Tue, Oct 6, 2020 at 9:18 AM, DiSalvo, Diane <diane.disaivo@town.southold.ny.us> wrote: THE PLAN AND THE DESCRIPTION MUST MATCH. I SO YOU EITHER SEND ME A NEW PLAN OR SEND ME A NEW DESCRIPTION. From: eligio lopez[mailto:lopez_eligio@yahoo.com] Sent: Tuesday,October 06,2020 9:18 AM To: DiSalvo,Diane • Subject:RE:Ianello That is the measurement but I did not have the survey handy Sent from Yahoo Mail on Android On Tue, Oct 6, 2020 at 9:14 AM, DiSalvo, Diane <diane.disalvontown.southold.ny.us>wrote: Your plan you dropped off yesterday says: split rail 140 feet ' 1 I GENERAL DATA Land Area(in square feet):. D Area Zoning: Previous use of property:_ c. v---,t ta. Intended use of property: ( e ± t d' R 1— --- 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 _ C�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 _X_No If"Yes",please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure(s) on property have a valid Certificate of Occupancy?_, Yes No Prior permits/approvals for site improvements: Agency 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):. 1- c 5-e-_ _ C9�, _ u--•-t �` S/ . IX ms ` s S��e p J- pro (}rrdz --- Board of Trustees Appli^iLtion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: r v l.c _ r D e Area of wetlands on lot: `��_ �_0 '9 square feet Percent coverage of lot: _ % Closest distance between nearest existing structure and upland edge of wetlands: : ( S_ o 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?—___ _ .. __(/ cubicds Yaz Depth of which material will be removed or deposited: - 'Z- feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: f ✓� r �� re ,moo V_��- � 'ti G ►"1�L _ `1 fi �c �Y_�1�Cy 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 Appl-' -- .tion AFFIDAVIT BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERNaT(S)-AND THAT ALL STATEMENTS CONTAINEDI'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 ADVISORSCOUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECTTHE 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 PERMTr ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT." Signa of Property Owner Signa a of PpertyO rowner SWORN TO BEFORE ME THIS _DAY OF:Qnb -r otary Public TRACEY L. DWYER NOTARY PUBLIC,STATE OF NEW YORK NO.01 DW6306900 QUALIFIED IN SUFFOLK COUNTY COMMISSION EXPIRES JUNE 30,20,2& t� Board of Trustees App1:; - 'tion AFFIDAVIT C�I Or 5 110 BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION:PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. gna f r perry O Signature of Property Owner 7 SWORN TO BEFORE ME THIS _;J0 1 -- DAY OF _ .A'20 'Notary Public REBECCA A LUCAK Notary Public-State of New York No.01 LU6386882 Qualified in Suffolk County My commission F-xpires Feb.04,2023 Board of Trustees Appl. itioa AUTHORIZATION (Where the applicant is not the owner) I/We, w owners of the property identified as SCTM# 1000- �, 3N in the town of New York,hereby authorizes P 2 r V-J'5 C to act as my agent and handle all necessary work involved with the application process for permits) from the Southold Town Board of Trustees for this property. rope Owner's Signature Trope Owner's Signature SWORN TO BEFORE ME THIS_ _ DAY OF ®fir _ ; 20_ a� Notary Public TRACEY L. DWYER NOTARY PUBLIC,STATE OF NEW YORK NO.01 DW6306900 QUALIFIED IN SUFFOLK COUN'T'Y / COMMISSION EXPIRES JUNE 30,2 Board of Trustees App1:;'---1,tion AUTHORIZATION (Where the applicant is not the owner) � I/We, t U� --- -6i-0 e- 3�' - owners of the property identified as SCTM# 1000-dam 20 S72,A a 50aA ,in the town of So G AOM ,New York,hereby authorizes �° L•1°� z- ►U✓Psc 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. Pr a Owner's Signat Property Owner's Signature SWORN TO BEFORE ME THIS - - - DAY OF Notary Public REBECCA A LUCAK Notary Public-State of New York No.01 LU6386882 Qualified in Suffolk County My Commission Expires Feb.04,2023 .A.PPLICANUAGENT/REPRESENTA.TIVE TRANSACTIONAL DISCLOSURE,FORM The Town of Sauthald's Code of Etliic§—r6 jbits coritlicts"of interest on the Hart of town officeis and-employees:_The;tsuraoSao f. this form is to irovide information-whi& in alert the-town.of ssible,conflicts of interest and allow rt to take whateveractton ts_ necessa-ry to avoid same: - YOUR NAME: - - -- - (Last name,first nafne,.otiddle initial,unless you are applying 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°yo"uperson_ally.(or•tItrough;your comp=31,spouse;,sibling;parent,br ch(ld)have.a nlafionsltip�viilt any officer oe;e"mployee gfthe'Ca�vn o_f.-Southold?;"Relationship:'ui6ludes by.6lood,:ugarriage,_or-business interest= usiriess_ipterest".means`a business; =inchidinga'pailnersfiip,.in which:the:town officer."or employee tins cve`n a pardit'oivnership of,(or employment by),a cocpvration; 4which•tl e town;,officer-or emisloyee own; more than-`5°l0 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 _ - Descrilkthe relationship between ygurself(the,applicantlagetitlrepresentative)and the town officer or employee.Either check the appropriate line A)t6ugls 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)lite owner 6fgreaterthan S°fa'of the shaios,of die.co►porate stock of the applicant (/filewhen the applicant is a corporation); B) -legal or beneficial owner of any mterest in anon-corporate entity(when the applicant is nota corporation); C)an ofl'icer,,diiector;"Partner,'er'employee.ofthe applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of Ctt Dom` 2020 Signature. C lC� _ rsx r L� KCJtV`Os Print Name Form TS I APPLICANT/AGENTARE-PRESEW-.,ATM- TRANSACTIONAL DISCLOSURE,FORM Town�f&ers and qmfil6vees.'Tito Pu1Roiq0r this Lorin 94 the town of possible conflicts o-fin-idiist and alloy it 6tAd jAL—i6floti is YOURNAME, (Last iia first iiame,middle initial,unless you are applying in the name of name, 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'smeans 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%W,,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 posido,h, ofthat person Describe the relationship lationship 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): 6 own rthan,.5�4otthq: h softhe, ;the owner-of S-am corporate-stock dtlhe Opricont 'tvvhtn--th6applicant�is-�-corporafloni. - hoff-c rpoll the li�gq. or-'bOtiefidial"dwtitt'dfahyintetestinA' - 0 to entity(wh&h1he applicant is not a cor 0,601tion); an officer,director,p4r*,,or employee of the applicant or the actual applicant. DESCRIPTION OF RELATIO SHIP Submitted this day of xce 200-0 PrintNarne Form TS I � t 6I Z20 Appendix B Short Environmental Assessment Form Anstraetions for ComjiletinR 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 I 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 I. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: - Project Location(describe,and attach a location map): - I,✓N t S (I/o-- _ - {J F Brief Description of Proposed Action;, Name of Applicant or Sponsor: - - Telephone:6- -A! 1,�1 c _ (r 1ti E-Mail:. Address: C Go JA_JvIi- _ _ fir✓ - - - --- - ----- - - --- - Citdpu. -- `-- - - - State: Zip Code: L t-' 1.Does the proposed action only involve the 4egislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? :NO YES If Yes,list agency(s)name and permit or approval: c is 3.6­.-Tota1 acreage-of the site of the proposed action? _ - acres - b.Total acreage to be physically disturbed? �2 .- acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? 0 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? ❑- D ❑ - 6. Is the proposed action consistent with the predominant character of the existing built or natural NO -- .YES landscape? ❑ l SCI 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: S. 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: 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment:- ❑; 12: al 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: tl'J 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 ❑Forest IKAgricultural/grasslands El Early mid-successional ❑ Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species'of animal,or associated habitats,listed NO 'YES, by the State or Federal government as threatened or endangered? LM 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, ES1fYes, ❑ a.Will storm water discharges flow to adjacent properties? tjJNO DYES b.Will,stortn water discharges be directed to established conveyance systems(ru ffand storm drains)? If Yes,briefly describe: j7NO ❑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,describer 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 TOTHE BEST OF MY KNOWLEDGE Applicant/sponsor name: l _J-6 tet_ Date:- r j li �2,� 2 D 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 11 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? t❑ 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)? LG�J. ❑ 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? L1SI El 7. Will the proposed action impact existing: a,public/private water supplies? b.public/.private wastewater treatment utilities? S. 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)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action ,result in an increase in the potential for erosion,flooding or drainage problems? Lq 11. Will the proposed action create a hazard to environmental resources or human health? a Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. F] Check this box if you have determined,based on the information and analysis above,and any supporting documentation, 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