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HomeMy WebLinkAboutFreed, Todd Glenn Goldsmith,President ijlf So 7. Town Hall Annex Michael J.Domino e 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 A.Nicholas Krupski Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD NOTICE OF DISAPPROVAL - ADMINISTRATIVE PERMIT Date of Receipt of Application: November 5, 2020 Applicant: Todd Freed & Edith Webster-Freed SCTM#: 1000-116-6-12.2 Project Location: 12400 New Suffolk Avenue, Cutchogue Date of Resolution/Issuance: November 18, 2020 Date of Expiration: November 18, 2022 Reviewed by: A. Nicholas Krupski, Trustee Project Description: Remove two (2) dead locust trees along with the stumps and place approximately one yard of fill and revegetate. Findings: The Board of Trustees DENIES WITHOUT PREJUDICE the application as submitted. The project does not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The Board of Trustees determined upon inspection that the two (2) trees are still living. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. 4'1�' 491. t4// Glenn Goldsmith, President Board of Trustees Glenn Goldsmith, Presir`�3 ~'�,Town Hall Annex Michael J. Domino 'I" _ OGy� `- j'`54375 Route"25 John M. Bredemeyer III o - P.O. Box 1179 A. -Nicholas Krupski o Southold, NY 11971 Greg Williams y o!• Telephone (631) 765-1892 ��l �a Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 1 t 1,h L" Completed in field by: N Creative Environmental Design on behalf of TODD FREED & EDITH WEBSTER-FREED requests an Administrative Permit to remove two (2) dead locust trees along with the stumps and place approximately one yard of fill and revegetate. Located: 12400 New Suffolk Avenue, Cutchogue. SCTM#: 1000-116-6-12.2 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 V 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: MVf+ (R Plot e Get�'� Nu-- y, 4(f11s . a d( �4 W Mq+v,t ajJ .74t . UJ c,'J �-wf 4o Mg.4,c� t�, Xy� I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer �XM. Domino `/G. Goldsmith N. Krupski ✓G. Williams Other STREET ADDRESS. 12400 NEW SUFFOLK AVENUE SCDHS # = RIO-1¢-0019 SURVEY OF PROPERTY A T CUTCH'OGUE TEST HOLE DATA TOWN OF SOUTHOLD BY McDONALD GEOSCIENCE PUS 1C G WI SUFFOLK COUNTY, X Y: 6/11/13 R} 1000-116-06-12.1 & 122 EL 6.5' DARK BROWN LOAM OL SCALE.- 1'=30' - � PU8 1 SEPTEMBER 6, 2012 __.. 1• F,�, WA WIT}1 JULY 2. 2013 (TOPO do B.O.H) BROWN CLAYEY SAND SC SEPTEMBER 6, 2013 (REVISIONS) SEPTEMBER 1C. 2013 (LOC. VEGETATION) '-' 3' ``t 4 NOVEMBER 22, 2013 (SETBACK LINES & LOC. TREES) EDGE OF BEACH FLAGS Y�cc. meo DECEMBER 3, 2013 PALE BROWN FINE SAND SP tn--ns-•��� �'V { } TE FEBRUARY 5, 2014 (PROPOSED HOUSE) EL. 1.4' -A 5.i' �Qe A `VAC FEBRUARY 11, 2014 (SEPTIC SYSTEM) ANT} APRIL 24, 2014 (REVISIONS) 20111 WA R IN MAY 29, 2014 ( WATER IN PALE BROWN FINE SAND SP z _ ft' , ' (REVISIONS) -- _ S EE �� � JULY 2, 2014 (ADDITIONS) JULY 29, 2014 (REVISIONS) JANUARY 15. 2015 (FOUNDATION LOCATION) 12' 7 MAY 13. 2016 (FINAL) S MAY 31. 2016 (REVISIONS) NOVEMBER 7, 2016 DRAINAGE CALCULATIONS ?'Y -___ _ "`,,t�,< NOVEMBER 17. 2016 (REVISIONS) o r --- t 0Q' - DECEMBER 20. 2016 (REVISIONS) -`--_ DECEMBER 29, 2016 (REVISIONS) SMALL MASONRY TERRACE ' ' " r ~� JANUARY 09, 2017 (REVISIONS) 154 sq.ft. x 2' X 1 25 Ill JANUARY 10, 2017 {REV1510N5} USE POOL DISCHARGE DRY WELL zO 8`0 x 4' DEEP = 201 C.F. ry LARGE MASONRY TERRACE ADJACENT TO HOUSE '` '! � 464 sq.ft. 464 sq.ft. x 2'x 1 — 77.5 af. USE 8'0 x 2' DEEP 84.4 C.F. i 60 r to •',,., A SMALL MASONRY TERRACE ADJACENT TO POOL r 1 a'' `'�� ' '� c7ti V +V I r.0 , --. Al rr ' 4y I 374 sq.ft, � __ t _, 374 sq.ft. x 2'x 1 - 62.5 c.f. C7 r r ' ; - �►, 8'0 x 2' DEEP = 84.4 C.F. ; ;` d` NYDEC ADJACENT AREA TABLE 0 RI �` "`y- - ° �r DESCRIPTION ARE,4 LOT COVERAGE AREA WITHIN 300' OF WETLANDS 45.122 sq.ft. EXISTING HOUSE & PORCHES 4,550 sq.ft_ 10.1% �'�' _ �t .,'.,x,.•, WAY - oR�,.,;,.,'c. �-.,.�ck� � PROPOSED MASONRY TERRACES 988 sq.ft. 2.2% ON GRADE ''•tib';Iny.: j .. ....- r t +� STp�,VE 1 !4 PROPOSED POOL_ 675 sq.ft. 1.99 y_ r EXISTING BRICK WALK 240 sq.ft. 0.5% AL DRIt AY E?CiSTING APRON 248 sq.ft. 0.6% ' s X04 ; --- _ �► op EXISTING CELLAR ENTRANCE _..63 sq.ft. O_lX >� aY n �' t .. EXIST B.B. PART Of DRIVEWAY 1404 sq.ft. 3.1% _ d PROP. LOOSE SLATE WALKS p +� -_ _i'-==_ ` q _ 392 sq.ft_ 0.9i PRCPTOTAL 8560 sq.ft. o r ST e. �€n = OR pact PcrSIN_ , EL D ll�jU £ Rttgu SIL p014ELljNG 1128' S - � � t`7rr ¢ UBIJC WA rFrlry ti ,� � ;' f � aaq t } T01MAI OF SOUTHOLD BUILDABLE LAND acre `� "-- # e DESCRiPT9flN AREA LOT COVERAGE r s' 7o. opp rf SpOiyE — w, iv w. 57,181 sq.ft. `-- - '�"`-- ^jj LP� `- f `" a' EXISTING HOUSE & PORCHES 4,550 sq.ft_ 7I-II .9 —..., L• f r r' PROPOSED POOL 675 3 .ft. 1.2% ►lee... � s , ..y. r ..,cC rp -- 'a -�� Z TOTAL __.. 5225 sq.ft. 9.1% ! w r ry A - Cr A Ohl FLOOD ZONE FROM FLOOD INSURANCE RATE MAP fovC roe t (e) MAP NUMBER 36103CO501 H SEPTEMBER 25, 2009 + re; ` fh Y►i ; , �r:f; — ' w �O'" H+r ;r? � '��,< < _ L _f fl� ELEVATIONS & CONTOURLINES REFERENCED TO N.A.V.D. 198$ ANO PDXrCE 7 l LA �- '` ' ' ' •. 4N ;' y PARCEL 1 AREA-50,510 80. FT. TO 11E UNE EDGECV Aw �v.; c�a .. cr ;' su P 2 AFF-A-14,748 �. F�: TO TSE LAVE M 3r a Sft7?`! .. F - v 1 .n T I c IS De V rAL ]q ?ala z U f X13i IC �. y��' R - rI�pT ., -• ' ,� .. .. TOTAL AREA-85,258 80. Fr. TO TE LIVE or 1498 Acres gy�p¢�•,- -; � , SE4WARD 01, 710, u• •: �� < `� 1: fipppp�''' rFwcAI - -.• ,. \41: . 1.;., •-...V r���•�"•.�• r ,. 1 �XN WAf AT FYB•OL OF KEY A ... HEDGES rro Cf s' '° ,A `~ CERTIFIED TO: ■ =MONUMENT M� kMra X68•¢2, 9 ? ED�H FREED FREED "' ADVOCATES ABSTRACT INC #ADA2455—S �S( =SPOT ELEVATION �A g IS� cy nr ; STEWART TITLE INSURANCE. COMPANY Coy4 ?b I c f ;: TREE TO BE REMOVED ` �� ?` = TREE TO BE TRANSPLANTED OR REPLACED ' t Ili r 46 NOV - 5 2020 . = TREE TO REMAIN — PROPOSED DRYWELL I , EXISTING DRYWELL I am familiar with the STANDARDS FOR APPROVAL - AND CONSTRUCTION OF SUBSURFACE SEWAGE DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES M. Y.S LIC. NO. 49618 ANY A0ERA17ON OR ADR770N TO THIS SURVEY IS A VIDtATl0M and will abide by the conditions set forth therein and on the OF SEC770M 7209OF" THE NEW YORK STATE EDUCAn4N LAK! permit to construct. PECONIC SURVEYORS, P.C. EXCEPT AS PER SECTTQN 7209—SUBDIVISION 2. ALL CERTIRCATIONS (631) 765-5021 FAX (631) 765-7797 HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF The location of wells and cesspools shown hereon are P.O. BOX 909 SAll3 MAP OR CORES BEAR THE IMPRESSED SEAL OF' THE SURVEYOR OSE SIGNATURE APPEARS HEREON_ from field observations and or from data obtained from others. 1230 TRAVELER STREET SOUTHOLD, NI 11971 12-240 1• , 7. r.. \. '1 r' �• � i � i'ir ; `•: Ij S tN • I �� ��•• 'FOR FCL NO:-_ :w'.» FOR vCLr j:yt-, a SEE ,oTAAW ]] -A(,) / TOM OF sDUTHO D 1 51(M TOM OF S -OLD I 3S PE ICIANDTRUSa tp.3A , �uLSFmw,wtF�eEUER,1 1 - ' � // a I e4 1.1 wvcr�ror++rsJ 4.3n1c1 I, �.- ° O - ]3Nc1 }\� f O TONALoi�, w� 28Nc) r4 I a0V11101D' a6 1 \\•• j';. .I'. R1 r- 'I 7 17.aHa I 1 \ \ v 12 wo IA 15 ]]A(e I pEvEIDPYEM R.,ma) ��NIC—TRUSt 17Zayc) v V-•.� �' } CASE "m f } p tro \ K - 701Mt t SUFFOL / ...—_.. t ] LtA ✓.� .. ZwW 3 s �j� • �.. ° 1]. a a, az J— a2 3 \ 1] ,SA tt.© t t.eHd P ,a .. - awa w teHG s 12 ' ' ,oa 10� 1t +] it' 4.1 ^ I /q,TClgd16 m • / ] :.\1 aaA(W 1.,NG ,�w(=, t4NW 2eHG 4 ,,1 NEwa11F7OUt t3"(q i z]Ha. 7 y 1! , He}3 i 1.1Hc 1e Vµd ! ) to \ awuoacr s • a7Ala.. t 1.1A(�'� • d 6 t® e 1' `) t, Lwe) -\ ` %/�- 1.-7 .. .w.. ! 7 r •.t e 1. u w IAW) 22.2 t tHe1 0, • 01 j /"�-\.•\. • °, PECONIC OF '�.a b F.0.29 LD. ' +4 te.]�`' O. •4 w ~ - SEE SEC.NO.IM ,AHG ♦v c ° °yo- w s .�\-��� w ,5 GOO ( + 71 a4 •Aµt 4 s 4 p-O•/�' � - w NOTICE s�n3 COUNTY OF SUFFOLK © E ew aF SOUTHOLD SECTION NO S Tax Rea (21) lPropertyTenricece Agency v , oeR�R e tF�„roR.t E cam7D•Rt•y Tax Se v .F EeF 116 Plow+ PROPERTY MAP mtwetaw,wa:sra ao Michael J.Doniino,-President John M.Bredemeyer III, Annex Ha -President Town ll Vice To54375 Route 25 Glenn Goldsmith "OIL P.O.Box 1179 A.Nichol"ICrupsld CO2- Southold,New York 11971 Greg Williams Telephone(631)765-1892 Fax(631) 765-6641 BOARID OF TOWN TPUgTZEq TOWN OF SOUTHOLD �Th�'sSect�'OnAvOr�OMce�Uae�Onjy -_Coastal Erosion Permit Application -,---�Wetland Permit Application Administrative Permit —,-- Amendmentgransfer/F ,Xtension Received Application: ;-16,0" Received Fee: OmPleted Application: .Incomplete- -SEQRA Classification: , e I —J-ead Agency Determination Date: Unlisted Negative Dec. —Positive Dec. oordination�,(date sent). WRP Consistency As;essMent,.Form, -Sent,: �CAC Referral,Sent: ii Date Of Inspection. NOV 5 2020 —Receipt of CAC Rep7ft..---- ---,/-Technical Review: --.K—Public HearingHeld: — Tt-iin -Resolution: Owner(s)Legal Name of property OR shown on Deed): cl� Mailing Address: Phone Number: --------------- Suffol,k County Tax Map Number: 1000 1 n A Property Location: 1 M rl.rn 14 AP (If necessary,provide LILCO Pole distance to cross streets, and location) AGENT(if applicable): Mailing Address: flen Phone Number: b -j9,--) S11'', Box 160 sign -- -------------- Board of Trus-tees App:', ;atiora GENERAL DATA Land Area(in square feet): Area Zoning: Previous use of property: Intended use of property: Covenants and Restrictions on property? Yes If"Yes",please provide a copy. No Will'tlus,project require a Building Permit as per Town Code? Yes No If"Yes", be advised this applicati n will be reviewed by the Building Dept.p—o to a Board and Elevation Plans will be required, of Trustee review Does this project require a variance from the Zoning Board of Appeals? Yes ��No If"Yes",please provide copy of decision: Will this project requirea�y demolition as.per Town Code or as determined'by the Bui Yeslding Dept.? �/ No Does the structure(s)on property have a valid Certificate of Occuanc P y• 1,0 Yes No Prior permits/approvals for site improvements: Agency Date Z- No prior permits/approvals for site improvements. _ p ovements. Has any permit/approval ever been revoked or suspended by a governmental agency? �No Yes If yes,provide explanation: Project Description(use atfiacbmeints;if necessary): __ _ 1d— &C Stk � Board of Trustees Applj -',tion WETLAND/TRUSTEE LANDS APELIItCATHON DATA Purpose of the proposed operations: i h Area of wetlands on lot: square feet Percent coverage of lot: Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling?* - ��No Yes If yes,how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect,if any, on the wetland's and tidal waters of the town that may result by reason of such proposed operations(use attachments if appropriate): 617.20 Appendix B Short Environmental Assessment Form Instpuction 9 for eCoYnnletina 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,'Info ation �� I . Name of Action or Project: Project Location(describe,and,attach a locatiommap): Brief)es cripttio�n'pof,P,roposedrA�ction: I toy. CL Name of Applicant or Sponsor. Telephone: 3 °a E-Mail: Address: - "'"�� �- PO BOX 160 City/ 10: Mai - State: Zip Code: 1.Does the proposed,action only in volvethelegislative adoption of a;plan,local 1'aw,.ordinance, administrative rule,or-regulation? NO YES 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. La ❑ 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? b.Total acreage to be physically disturbed? acres c.Total acreage(project ro ect site and any contiguous properties)owned acres 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 Q Commercialresidential(suburban) ❑ ❑Forest Agriculture ❑'Aquatic ❑Other(specify). ❑Parkland Page 1 of 4 5. Is the proposed action, a.A permitted use under the zoning regulations? NO YES N/A b.Consistent with the adopted comprehensive plan? ❑ ❑ 6. Is the proposed action consistent with the predominant character ofthe existing built or natural ❑ NO landscape? YES 7. Is the site ofthe proposed action located in,or does it adjoin,a state listed Critical Environmental Area? N❑O YES ET IfYes,identify 8. a.Will the proposd action result in a substantial increase in traffic above present levels? ❑ YES fy 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? If the proposed,action will exceed requirements,describe design features and technologies: NO YES El El' 10. Will the proposed action connect to anexisting;public/private water supply? NO YES If No,describe method for providing,potable water: ❑ I 1.Will the proposed action connect.to,existing wastewater utilities? NO YES If No,describe method.for providing wastewater,treatment: ❑ 12. a.Does the site contain a structure that i0isted on-either the.State or National Register of Historic NO YES Places? b.Is the proposed action located>in an archeological sensitive area? I❑ 13.a.Does any,portion of the site of the ro osedl action,or lands adjoining.the proposed action,contain NO YES 19 wetlands or other waterbodies regula'ted',by a federal,state or local agency? b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody7 If Yes,identify the wetland or waterbody and exient-of'alterations in,square feet or acres: ❑ 1.4. Id tify the,typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: 'Shoreline ❑Forest [IAgricultural/grasslands [I Early mid-successional ElWetland El Urban E]Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened'or endangered? 16.is the project site located in the 1-00 year flood plain? El- YES YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? N® Y'ES If Yes, a.Will storm water,discharges flow to adjacent properties? ❑NO ❑YES ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NQ ❑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 ofthe proposed action or an-adjoining property been the location of an active or closed- NO YES solid waste management facility? If Yes,describe: ❑ 20.Has the site•of the proposed.action or an adjoining property been the subject of remediation(ongoing or NO YES completed),for hazardous waste? 1f Yes,describe: YEl ' I AFPYRIt<i(THAT THE,INFORMATION-pROVI DEID ABOVE IS TRUE AND ACCURATE To TH, E BEST OF It Y KNOWLEIDsGE Applicant/s�Rsarn e• Date: I -L4- pp" 1.f.- Signature• Part 2-Impact Assessment. TheLead A4;gency is:-, sible°for the completion of-Part 2. Answer all of the.following questioris,in Part 2 usingAbe•information-contained in Part I and-,other materials submitted„by the,preject sponsor or otherwise available to thexgviewer. 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 tolarge 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,&change in the use.or intensity of use of land? ❑ ❑ 3. Will-the.proposed:aetion impair the character or quality ofthe existing•community? ❑ 4. Will the proposed action have-an.impact on theienvironmental characteristics that caused the ❑ El of a Critical,Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El El 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? El 7. Will the proposed action impact existing: ❑ ❑ a.public%private water supplies? b.public/private wastewater treatment utilities? ❑' ❑ 8. Willi the proposed action impair the character or quality of important historic,archaeological, El 1:1architectural or,aesthetic,resources? 9. Will the proposed•action result,in.awadverse,change to.natural resources(e.g.,wetlands, El Elwaterbodies,groundwater,•air quality,flora and fauna)? Page 3 of 4 e TNo, 7Moderate 10. Will the proposed action result in an increase in thi potential for erosion,flooding or drainage problems? ❑ ❑ I 1. Will the proposed action create a hazard to environmental resources or human health? C: Part 3-Determination of significance, The LeadELgency 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 aneed to explain why a particular element of the pioposed,action may or,wilDnot result im a significant.adverse environmental irn a Part 3 should,in sufficient,detail;identify1he impact,including,any measures or.design elements thathave beenlease plete Part 3. included by the project sponsor to avoid.orreduc6 impacts: Part,`3 should,also explain,how the lead agency determined,that the impact may or will not be significant.,Eachrpotelftl ,impacishoul'd be,assessed'considering its setting,probability of occurring, duration,irreversibility,geographic�scopdand,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. Check this box if you have,determined,based on the information and analysis above,and any supporting documentation, that the proposed.action'wi'll novresulf in any signfficant,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 Responsib'le.Officer•in Lead-Agency Signature of Preparer(if different from Responsible Officer) PRINT Fage4 of 4 Board of Trustees Application AFFIDAVIT Ove �L41f V111, BEING DULY SWORN DEPOSES A AFFIRMN THATS 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. I'a - Signature of Property Owner ffigpature of ProperV Owner SWORN TO BEFORE ME THIS Fa DAY OF U1 o dt.,PA e 41 20__LQ_ Notary Public Notary uhlio•S ate N EUGENE of New EAD York No.01 RE6333452 Qualified in New York County My Commission Expires 17/23/2023 Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) 10 I/We, ftea4�it S te(,- owners of the property identified as SCTM# 1000- I b + & 1 12-Zin the town of New York,hereby authorizes David Cichanowicz, Pres. Creative Envionmental Design to act as my agent and handle all necessary work involved with the application process for pmnit(s)from the Southold Town Board of Trustees for this property. Property Owner's Signature Property Owner's Signaihe SWORN TO BEFORE ME THIS Fa vU/-{'k DAY OF P20 w._6 d� ,20 G Notary Public ALLEN EUGENE READ JR Notary Public-State of New York No.01 RE6333452 Qualified in New York County My commission Expires 11/2312023 APPLICANT/AGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of So ithold's Code of Ethics prohibits conflicts of interecton the 11gd gjtown officers and emntoms The aumosc of fhis farm Igo provide info tion which Can alert the town of noasible canflig($of interest and allow it to take whatever action is neg ssary to avoid same. YOUR NAME: +��ia l®U�(/! - (l.sstname,fust name,middle mi' unless you are applying ii the Warne 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 X 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 titrough your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"Includes by blood,rmaniago,or business intawt."Business itrtercsft means a business,. including a partnership,in which the town officer or employee has even a partial ownctswp of(orimployment by)a corporation in which the town officer or employee owns more than 5%of ttte shares. YES NO X If you answered"YES',complete the balance of this form and date and sign whereIndicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agont/representadve)and the town officer or employee.Either check the appropriate line A)through D)and/or dcsolbe In the space provided. The town officer or employee or his or her sponse,sibling,parent;or child Is(check all that apply): A)the owner of greater than 50A of the shams of the corporate stock of the applicout (when the applicant is a corporationN B)the legal orbeneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,perdtei or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted th1 day of 20 Signature Print Name® Form TS l APPLE IC /A GENTIMp ESA TRAMACT ONA IDgSCLOS M FORM TheTown; outhold'sCode of Ethicsnrohibits conflicts of interest on the Dart oftown officers and em to ees.The this form is to nrovtde mformatton which<can al P Y purpose of ert the.town of possible confli6W;of�tencst and allow itto.take whatever action is - N„avo u same. -- YOUR NAME: (lust n fttst name, piddle uupal,unless you are applying in the name of someone else or oilier entity,such as;a company.If so,indic*.the.ofln pe'rson's or company's name.) NAME.OF APPLICA,nON: (Check all that,apply.) Tax grievance Building neChange Change of Zone _ Coastal,Erosion Approval of plat Mooring Exemption from plat or,official map plug Other — ; (If"Other'',name the activity.) Do you.personally(or through your company:,spouse,sib'lin&parent,orchild)ehave a•relationship:with any,officer or employee of the Town of'Soutligld?'"Itel_ationsliip3'°anclnd,, " blood;;Marriage„orbusiness interest:"Business interest”means a business, including a partnership,in vr---_l he.to,- ';- cei',o-employee has even a:partial,owners}up of(or employment.by)a corporation in wliictiathe town,off�tcer or employee.owns�moi+e tban-5f/oYof 21ie:- z_ s YES NO Ifyou answered"YES",complete,the,balance of this.form•an&date and sign where indicated. Name ofperson employed by.the Town.df Southold Title or position-of'that;person, Describe the relationship-between yourself(the.applicant/aggntirepresentatixe)and the town officer or employee.Tither check the appropriate line A)Azough iii itd/or de'scnjtWp jfffjthe spaci provid6d The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner ofgreater than 5%ofthe shares ofthe corporate stock ofthe applicant (when the applicant is a.corpomtion)., B)the legator%eneflcial,owner of-any interest in a pon-corporate entity(when the applicant isnot a corporation); C)anofficer,,director,p6ftec,or employee of the applicant;,or D)the actual applicant. DESCRIPTION OF RELATIONSHIP SubmYte�l-thi a� ' PrintN Signature ' Form TS 1 I�tSI[STENC� SES S1 LNTIEpI[�I A. IINSTRUCTIONq 1• A11 applicants for permits* incl ' tiding 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 agent maldng a-determination of consistency, *E used in pt minor exempt actions including Buildin Pe Y and other ministes•ial permits not located within the Coastal Erosion HazardArea. S r mats 2• Before answering the questions in Section C, the preparer of this form.should rrninor action list,policies;and explanations of each policy contained in the Town of Southold review the Local Waterfront Revitalization beneficial PrO • A - ro osed _ tion will be evaluated. as, to its si and adverse effects u on the coastal area.which includes all of Southold Town . . cant 3. If any question in Section.C on this form is answered "yes"' or: .",. o.�",affect he achievement ath_=enot➢the sProposed roposed action.n® '�`h . Policy andconditi ons contained in law. Thi. eath,� wer=�must"be',lbfl9Mdthe consistency u- coridi't�-o�a's .it; - e n`sisteut-vv�th=fihe I,.i. .�� - lit standar • ;, �`'� :notalie-und-- '` rcn. ��'po Y cls and A copy, of the LW--RP is available iffi the website sou foil°gig plus: online at the,Town of Southold 's than �To ork*net), the Board of Trustees Office, g apartment, all local libraries and- Clerk's•office, the Planning D SC�i# FRO-:CT NAME �� - The Appflicati®n has been 3nbM*0,.to�(check appropriate.response)., Town Board ❑ Plan*,Board❑ Bna#d�g Dept. ❑ Board -- of 7t'n•aesgees l. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly.by Town agency(e.g,capital ❑ construction,pflaonirng acti�rity,agency regulation,land transaction) (b). Financial-assistance e. . ❑ (. g,grant,loan,subsidy). (c) Permit,approval,license,certf cation: ELI Nature and extent of action: � . �G� IVB rJCLGtr,•L iad�� Location of Site acreage: g _ Present land use: Present zoning classification: 2. If an application.for the proposed action,lies been flied with the Town of Southold enc the follo i�orination shall be provided.: agency, Wigg . (a) Name of applicant: (b) Maifing address_: 0 v' ao (c) Tolephone number:A.=,,Code.( ) (d) App'lication.numbex„if any: r Will,the action be directly undertaken,re u re funding q. _ ° � ,or approval by a state or federal agency? Yes ❑ NoIf yeS,which state 4_r federal:agency'? Q Evainate.tinep.ygjjecg to ,he_%OP rHflYgr!�,O$Il�Hes+ ,atffi Iby �fi,f ,.gAow tine�a sect vva9fl;ffann lnea'support®a' nno$saiFp® t�ao•policn'eso a��;1 -fit, ra omnplete,amm P pos 9 go ,. ma�8I - that w, ;ft�na'ther eachoYfl IGnc e�aYl' a ;g9n �t os-aia b_e;nye . swe qe faavt �,f � ;ffo �onnpfl�ta®mmo p $DE 41JR, D tC�t1� P CY NUCY1. Nestor a:Patten°Ba of dewqlopmenn = .,tl�e"T®, n of gouthoja that eahmees commm unity eHnaraetep9 p�eseaves open agtaec makes a acgvmm$ease of! as",ctturep,mm ekes halmeffiew'use Oft eoastaR Rocaatlun9 and Mikhnizes adverse effects of deveBopMeDt. See L Section M—PoUcles9 gage B ffon•edaHaaataon criteria. Yes ❑ R1'o Ullot APP➢flcgble Attach additional sheets if,necessary PolncY 20 Protect annd ,preserv,e h sg pne and zrchaeol®gncal resources -of the Towns of SouthoRd. See ILS Section,EII= ofli� s IFages-34,hronagh 61 for�daiaa4*On cn�iten�a Yes ❑ Ne Not,Appy ; I t - Attach additional sheets if necessary- Policy 3. ]Enbl npe dee m�'isaaal uali M maid protect scenic resources throughout tToo f �0 flatold.tion _Policies Pages 6,through 7 for evaluation criteria g1e yecs ❑ No ❑ Not Applicable Attach additional sheets if necessary • NATURAL COAST F®Lames Policy 4. Mme loss of life,�e❑c4�on IgY_ s8achares,,and,Policies Pig g t natural resources from f 000uh1fr gWlo � ttren ding =d B Yes ❑ No ] I�ot Applicalbu Attach additional sheets if necessary . PPO'Ucy S. Protect a"ianprowe water —Polfdies]ages b-6,through 21 for eva uation criter-Uppia 4be,Town of Bout'hOld.See LWRP Section ffi Yes ❑ Ido of Applicable Attach additional sheets if necessary ]Policy 6. Protect anal, restore the cant q ' tg, anI fianetflona of the Town Of Southold ecosystems incfluft through f Coastal +' bend wildlife$ .ba44gs.and-�wetlands. SeeLW Section III—Policies; gh�ough�2 for evaluation,cpitearia: , Pages 22 ❑ ❑ i = Yes additional sheets if necessary JPCHIIT 7. PrOectt a Md 1MIRrove Sir quality in th Town off Sou P4ges�2 through 34 for evaluation;r.teraao Southold. See L WW Section I[Yll — Polic' flea ❑ Yes ❑N'® N,9tt APP'h04ble Attach additional sheets if necessary = Policy 8* iffime eiivirmiien$a�l de adaon ° - '- in 7o�►n of ®"ahold ffr-oiin solid Waste aind hazardom substances sled wMNot ee g:,.�. <�� ,-,�eettaonffi_Policies; Pages 34 tth;rou , ❑Yes ❑ leogh 38 for ev.-duatioln criteria. Applicable PUBLIC C®AS;['P®1GICMS Policy 9. Provide for pulbuc access to., and reca-eattioala ruse off cos IresOur-ces of the Town of Soutlaolal° See I[,�� _ 9 _ stta'waters, paiblic lands, and public criteria. Section ILII ' Policies; Pages 38 throuffii 46 for evaluatti®an ❑ Yen No of App licable Attach additional sheets ifnecessary suitable l Pa°otect South d's water dependent us suitabfle locations, See L es and promote sitting of anesw water-depemdenat uses Mm �ectibaa�{—Policies;Mages 49 through 56 for evalu2tion ca°itea°ia 9 Yes ❑ rqoqg't Applicable ° Attach,additional sheets if necessary - Polley Yfl° 'Pro➢n9te sustainable, use of IEstuarTand,Tom Water so See Y., - � �arane resources Long Island Sound, the peen ° Section M—policies; Pages 57 through 62 for evaluation eriterimnc ❑ Yes ❑ gl® a. of Applie-ble Attach additional sheets if necessary Policy �2 flea°�2. Protect Ugric I g�nxal.I�nds.. �'o� of �, , in the Southold. dee ]C, 1ED see on policies;,Mages h.65 for tedalia -mn,ca-tem : ❑ Yes ❑ o Not AppliggoRe Attach additional sheets ifnecessary , Polar "3. Promote appa®p fate use and development of energy SectionIIII—Policies;,Pa ' ge y through.68 for pdalanatioar criterand mineral resources. See g, ia. Yes ❑ No of Applicable PREPARED BY t L 7t'g'a'L DATE (�