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HomeMy WebLinkAboutTR-9746A Glenn Goldsmith,President �QF s�(/ry Town Hall Annex 0 54375 Route 25 Michael J. Domino,Vice-President h0 l0 P.O.Box 1179 John M.Bredemeyer III [ Southold,New York 11971 A.Nicholas Krupski N ,c G � Telephone(631)765-1892 Greg Williams �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFIGE,OF THE BOARDOFTRUSTEES 7Z'HOURS'PRIOR TO'COMMENCEIVIENT OF THE ACTIVITIES CHECKED',O#F BELOW . - - = INSPECTION SCHEDULE _f f Pre-conistructi6ti-,'hK y'4al'e-lm&/gilt boom/silt$ctutain' -10 day of-construction %constructed When project complete, call for compliance inspection; r Glenn Goldsmith,President ��0f S0!/r�o Town HallEAnnex' :- Michael J.Domino 54375 Route 25 P.O.Box 117 John M.Bre&m— eyes III 9= Southold,New York 111 971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams '0 �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9746A Date of Receipt of Application: October 20, 2020 Applicant: Loretta Hinderling -SCTM#: 1000-76-2-2.6 Project Location: 1326,Smith Drive N., Southold Date of'Resolution/Issuance: November 18, 2020 Date of Expiration: November 18, 2022 Reviewed by: Michael J. Domino, Trustee Project Description: Install a 20kw automatic generator on a-40"42" concrete pad, alongside existing air-conditioning condenser. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth-iri 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 Sean'O'Neill, received on*October 20, 2020 and stamped approved on November 18, 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 -SURVEY FOR 'ING LORETTA HIND8RL cool AT BAYVIEW HOLD TOWN OF SOUT "t-001,t Geer#TIOPI SUFFOLK COUNTY, N.Y 1000-76-02-2.5 7 well SJ�AL 2002 7, wl w u —I — E CC, fE r' ZONE AE �Iucl P.003 reoyWON, NOV.7au h' Pb.2001 f9dX4,1211e) )L LOT 26 2004(REVISEVI L-5j 1; 2004 (rdv;sIcvv LOT 2,5 ba OCT 2 0 2020 SEPT. �9,_-004 r-,*7 LOT 28 Scuthold To,.,,,n ZONE x oird of 4 112,sty ax 17W 18*AddWon to b�- OYCOVOW 10 614vatlgr 5 M HSC Basement re fi Excavolad material(approx. 62 _-u_ ydsi to be aeod for C 0t&nq around crap, garage, 11r," Ieridt to be removed from slle ©7' CO VERA GF ?9766 - Qfyt 77 of 6;mpiefion 0, projact� EyIsling 149t s;j'tI'A 2697 sq.11.a9766 9% 2S IY L nP EL t28° JZmr x !b ELEt%77ONS REFERENCED To N,G.V DA TUM kT FLOOD ZONES FROM fLO0.0 INSURANCE RA rE MAP NUMBER, i6jo-IC0166 EFFEVNE DATE: MAP. MA APPROVED BY MA Y 4, 1998, f LOT NUMBERS REFER TO *MAP OF Goost'WECK' 'I ®AR® '9"S�Ocv r f "I RUSTEES F7tED IN THC SUFFOLK COUNTY CLER % AS FU NO. 1663, T N S 0 UT,H 0 L .03-00'W ss DAIE No✓& a w— Ny 'jZ.,,jk 18 0020 I P17CONIC SURVEyal7s, P:Ir_.,I'I, W:Y:ALMWAWN 0R'A0,?" 502b FAX (637) A aArPi 765-4797 4�0r� ff ' (631) 765' or==q 72CM111 1 1; C,00N tAW, 7, 7;0�* 7222-svapwsm:..AU G�PM" •Rlo, Box 909 6" M*Ir AW s,ALO rM 7,Iqs aAP A 1,C I WRIV M.r 1 1230 TRAVELER SrREE vo 6w OR CWgS SFAR 7WE WPRC5gD SMAL Or WE StRWYCIR (ITHOLD, N,Y. 11971 02-338 it, 50� yyy0�Ptpt E4tWAR.WE A;'PtARS "kotl. c ' . _ _ e �- _fly SURVEY FOR 0000 AT BAYVIEW TOWN OF ,S`OUTHQL.L1 SUFFOLK C'U t`J7NT Y, MY �2 OWE.. # �� 1000-76 2. 02- 5 (-� r F'a t�`' fi ;i 9 C= (�_ i ... .✓r' �+4{L' ti , /J ?tr'»' v3 "� raS"IsA:4 E..' 1 ---30' E.II'—�•El� (� 1{ ,a f'1 f,=' I! 1 _ ,s �` F �' isf r� DEC. 3, 2002 E s t & ,SONE AE (r L. 8J � �-,..�'" � 116.7 r608 tree^;s;vu, g;a;,KNEAO � u ft l7 y,�=•="'" Pk7V,ib' 003 f LOT 26 � aE[!N«" JAdvit?' O 5,2 L}O-�1vREVt NIDI LOT Z'5 5 iJ r W # .56Pi. G9, 2004 OCT 2 0 2020 2T LO 28 in ZONE X D.r,ofTi;sf2PC te.r'-✓6 br dy /t_ f Yf.?STY raa k- o d<w t: C>i�r �Lr fh' HSE t. 4._ ' far •tom» Sasoment -17'x18'AddJPtotf to be oxcova:ed to atevailan 5 _ x r� {� 29 ✓ ra , r,:•r.<, ^,. Exaovoled material lapprox. 62 Co- ydsl to be used for around prop. rraraye. material to be remavad from sJJ. ONE- _ .._.. LOT COVERAGE '## / 4 ! --•✓^` M ExFslin 1491 sqq.11.729766 = .53. a P CN, t kat cam Petton of project, 2697 s 11,129766= 9X 4 PROR'lTtAf � 2'S 'r2 - CY ZONk X ELEV.477ONS REFERENCED TO N.G.V" DATUM a rt o' 4 3 s "`�� �� k, FLOOD ZONES FROM FLOOD INSURANCE RATE MAR MAP•NUMBER: .36103CO166 EFFECnliE DATE: -MA Y 4, 1991 r ( ;4 °tt11 � LOT NuueERs REFER TO WAP OF cXSCi9 ; t i F7LEO IN THE SUFFOLK COUNTY C ""FE F; : i57. 5 A5 FIE NO., 1663. , P.a 7+'', 0009 4 618 F'EG7dYlG.5UR 1 QE 51- r AW At TMA nay CR AtA;'tL 1.rxt r�s:uJxcr is A star (831) 765-51120 FAX (6311 765-1757 9F,.�CnOM 7h7�t1r`rill'l"Ill YLY¢� 41MIl t:MC4JVM.LA W. ARE 4=2 X66 S.F rx r as rix aL�PW 7201,ZVM Ov s,ALG,c�'xrX7CAnI-A"s P�G. BOX 9119 r1EaEea� S V,?txr FOR rMS u-rp WiV 00,4rs 7trtWCe Oft r?' 123t? TRAVELER STREET` TO TIE LUNE 0=PIPE ARR6 APP Ws�s tMOV �D s�A .cr rn�s�z� 'SOUTH N.Y I1_97 7 02-338 Glenn Goldsmith, PresVc oyOS11FFl?(keaG ` ,Town Hall Annex Michael J. Domino ,y ,�� �� 154375 Route 25 John M. Bredemeyer III o '` P.O. 13-&-1 17 9 A. Nicholas Krupski o Southold, NY 11971 Greg Williams y �apl� Telephone 16 -1892 Fax (63 ) 765 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time:�`( Completed in field by:•'� �- Sean O'Neill'on behalf of LORETTA HINDERLING requests an Administrative Permit to install a 20kw automatic generator on a 40"x52" concrete pad. Located: 1325 Smith Drive N., Southold. SCTM#: 1000-76-2-2.5 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q 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: X0 I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other t 11 X11 a i // •' �- 13 _ 1 § to N� ° WN �fi \ teat \ t_ B �., t. / �•, \ ^• ?H 213 0, - IS 4f,/,, +at.e`t� �\ - \ Al SECTION COUNTY OF SUFFOLK © arce E w toxo _ �..� �N��, Kcal Property Taa Service Agency N rwrrrav+�.ntaiawN suE oa Y 010 mo •m vui or ... m _—•,'__ ,,,0.»,.__—._ _ W E stwert,on cx>xr rantwx of n1e d _ E iwn .. ——•__ r __.—_ y°�.. -- ..`�.�. in aro...: u 300[en,e.(��.e.R,e.M1,N hY[/All uFF-oUc aunt/rNe wt/a rroarEo A , ww _ _ Pk mal P9a®a 6 i�E soun+o�p 076 p --•—— --"—— `"' --- .�,®�. u1) ...a..�. •, �,� -- csa�cmry nx seem rme P �_ ---- S Glenn Goldsmith,President �Of SO(/�y Town Hall Annex Michael J.Domino,Vice-President ��� ��� 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III J�[ [ Southold,New York 11971 A.Nicholas Krupski G Teleplio e(631.)765:1$92 r Greg Williams �0��, �� x2 3 1 5-6 41EJ 0 CT 2 8 2020 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BUILL�'PM,DPS Z TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIREMENTS roperi Qwner Name: A1VWu N� Date'Seril­tb`BIdg: Glenn Goldsmith,President jj Town Han Annex Michael J.Domino,Vice-President' `�' 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III R i Southold,New York 11971 A.Nicholas Krupski Telephone(631)765-1892 5111 Greg Wilhams e � Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application _ Wetland Permit Application g7"Administrative Permit Amendment/Transfer/Extension Received Applicaion: 10,20.20 :��,-;Received_ ____• NiM� Completed Application: l 0,22.ZO Incomplete: SEORA Classification: TypeI Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: oordination:(date sent); `d �� LWRP Consistency Assessment Form Sent: - )r -. _ � Ft,{ 1D1AC Referral Sent:ate of Inspection:._ Receipt of CAI ( OCT 20 2020 /Technical Re, p Z—Public Hearings Resolution: D Owner(s)Legal Name of Property(as shown on Deed): 1,0 Mailing Address:_ uy Phone Number: - 3 d - �' (O a i r Suffolk County Tax M�zg Number: 1000 - 2& v Property Location: _ Ja& Dom!y.( 4 ®-`rh (If necessary,provide LILCO Pole,#?distance to cross �streets, and location) V AGENT(If applicable): �cr4/ /y.e< Z.L Mailing Address: 0 - 13®)e (a 0 / TY- Phone Number: r FT`` .( Southold Trustees Board: OCT 2 0 2020 RE: Loretta Hinderling Southold Town 1000-76-02=2.5 Board of TrwdLes Attached to this is a surrey.Project description Is 20kw Briggs& Stratton automatic generator installation. The concrete pad that this equipment sets on is 40" x 52"x 3" (w x 1 x h) Just for a point of reference,this equipment will be at the same height as the AC condenser as well the same area, Board of Trustees Application GENERA.DATA Land Area(in square feet): Area Zoning: es®dk� h4a Ad--- Previous use of property: Intended use of property' Covenants and Restrictions on property? Yes No If"Yes",pleaseprovide a copy. Will this project require a Building Permit as per Town Code? es No If"Yes",be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No If"Yes",please provide copy of decision.1 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? ✓ No Yes If yes,provide explanation: Project Description(use attachments if necessary): Boar of Trustees Appli.-,;ion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 'r- e Area of wetlands on lot: 0?p't P-a square feet Percent coverage of lot:_ feR % ji/.G��lt�aolf 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? 0,f cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: IVIX Manner in which material will be removed or deposited: . Statement of the effect, if any,on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): 61 Z20 Appendix:B Short Environmental Assessment Form lnstrudi6ns.fttr Comt li-tins� Part I -Project Information. The applicant or project sponsor is responsible for the completion of Part I. Responses become part,of the application For approval or funding,are subject to public review,and may be subject to,further verification. Complete Part l based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part I-Project and Sponsor Information Name of Action or Project: Project Location(de/scribe,and attach a locatio map): �J 4Z 7J- - / /'Ov �/l��i Brief Description of Proposed Action: 7 elf c cr/<- y �Cw.e0--" Name of Applicant.or Sponsor e Telephoner 1 E-Mail: Address: a City/PO: State: -Zip Code:" /V 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 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? • 66 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? . I (P 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? ❑ ( 1:1 d I b.Consistent with the adopted comprehensive plan? ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natu11 ral NO YES,' landscape? E] ' 7. Is the,site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 4.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ 12. a.Does the site contain a structure that"is listed on either the'State or National Register of Historic NO YES Places? � ❑ b.Is the proposed action located in an archeological sensitive area? ❑ ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain -NO- . YES wetlands or other waterbodies regulated-by a federal,state or local agency? b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? rj If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: El Shoreline El Forest ❑Agricultural/grasslands ❑Early mid-successional ❑ Wetland ❑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? 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, a.Will'storm water discharges flow to adjacent properties? ❑NO ❑YES �, ❑ b.WillstghO water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly.describe: ❑NO ❑YES Page 2 of 4 l 8.Does the proposed action include'construction or other activities that resuIf in the impoundment of NO YES water orother liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO _ YES solid waste management facility? If Yes,describe: 20.Has the site of the proposed action or an adjoining property beet'the subject of remediation(ongoing or NO YES completed)for-hazardous waste? If Yes,describe: I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE ApplicanUsponsor ne: _ / Date: O 11,6 Signature4 ' Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the,following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project,sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? 3. Will the proposed action impair the character or quality of the existing community? (-j 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: ( (—] 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, I-1 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)? L_J 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? 11. Will the proposed action create a hazard to environmental resources or human health? El I 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. ElCheck this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature-of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Board of Trustees Application AFFIDAVIT ® ti�ft •( L4 i,7 s BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR'THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD,OF TRUSTEES. THE APPLICANT AGREES'TO HOLD THE TOWN,OF SOUTHOLDAND THE , BOARD OF TRUSTEES HARMLESS AND FREEFROMANY 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 MYTROPERTY 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. Y Signature of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS; DAY OF, � /)d , 20 1-0 Notary ubl FRANK I BLANGIARDO 1Yf fA P PUBLIC,STAMOF NEW YORK RP9i9tMi0ft No,02BL6337529 Qliftiified In Suffolk County Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) ' e A Ute, owners of the property identified as SCTM# 1000- -:7 6 o; S' in the town of 64 �40 .New York,hereby authorizes ( Lau 021.eizl 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. e, Property Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS� // F DAY OF � 20 Not ublic FRANK J BLANOIARDO NOTARY PUBLIC,STATE OF NEW YORK Registration No.02BL6337529 Qualified in Suffolk County My Conunission Expires: APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM T "'Town of S thoiiI's`Code Et ics' o ibits conflict o int r on the, alt til to �'-rs atiet'e` o'eos:Ille fiurDdsd o this form is tb•provid'e infowhieh'eari alert file t, iwn stpcis @6,;conflibb ofiritdriA.and allow it-to take wiiateu rac$oh is neoessaryoiil same: r�J�� ,p YOUR.NAME: & � � _ a��' •s�(/Z (Last name,ffrit name,Anidi:116 initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance _ Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map _• Planning Other (lf"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 interesk"Business interest"means a-business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than•5%of the shares. YES NO _ If you answered"YES",complete the balance of this form,and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicantiagentlrepresentative)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 appiicent (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thisy of �/2 / 5i�itaktire "" Print Name Form TS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT.FORM A. INSTRUCTIONS 1y All applicants for permits* including Town of Southold agencies, shah 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 Crustal Erosion Hazard Area. 2w 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_uronosed--action-will, be-ev uat _as to its sinifi ant beneficial and adverse efregIg u an the coastal area which includes ill o Sdu old 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 LWRPP-policy standards and conditions contained in the consistency teview law. Thus, each,answer-must,be explained in_detail, .listing both sunnorting and non u� -_--- -_-- _--_ ---_-- -- : Ifan action cannot be certified as cansist �v�;tli-tlie�'Q�dR�'-po#Acy-standards-anti------- cond�tkl sJkta ;nofl .'undertaken. A copy of the Lt�VRP is available'in the following places: online at the Town of Southold's website(southoldtown northfork.net),the Board-of Trustees 0ffice,'.the,Plwuiing Department, all local libraries and the Town Clerk's office. ; R. DESCRIPTION OF SITE AND PROPOSED ACTION : PROJECT NAME /' Qt�rl -- _ - �t�, -. /i1� ` ' /i�r A44, The Application has been submitted to(checkappropriateresponse): Town Tloard ❑ Planning Board❑ Building Dept, ❑ Board of Trustees r 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: 1�1 Nature and extent of action: r w.r� 12117 ,C f-dAU Location ofaction: /Zr..0C/C Present land use: 2—e r.,d e--1_ 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, Gr't r _ ..... (b) Mailing address: T Al (c) Telephone number:Area Code( - - - - ----(d)-Application mmnber-ifaii'!(� - --- - --- -- _-- -- _-- - - -_--- ` -- - - - Will the action be directly undertaken,require funding,or approval by a state or federal.agency? Yes Q No If yes,which state or federal-agepc ? C. Evaluate the project to the following policies by analyzing-how the project will further-support or not support the policies. Provide all proposed Fest Management Practices that will further each-policy.• - - Incomplete answers will require that the form be returned for completion. IDWYIJOPED;OAST PULICY. Policy 14 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 LVW Section Ill-Policies,Page 2 for evaluation criteria. [:]Yes No Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LNW Section III-ZApplicable ' Pages 3 through 6 for evaluation criteria QYes.� No Attach additionalsheets if necessary Policy I 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 l i l`�ot Applicable Attach additional streets iGocessary - - - - - NATURAL COAST POLICIES -- - - - ----------- ------------ Policy 4. AIinimize loss of life, structures,and natural resources from flooding and erosion. See�VVA ' Section III—Policies Pages-8 through 16 for evaluation criteria : Yes No �ot Applicable Attach additional sheets if necessary, Policy.5. Protect and in water quality and supply,in the Town of Southold.See LWRP Section III Policies Pages If through 21 for evaluation criteria 0 Yes E#No eNotApp,licable Attach additional sheets if necessary - - Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and•Wildlife Habitats and wetlands: See-LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria, Yes No Not.Applicable b Attacfiadditicnalsheets,ifnecessazy '- -- - -" -- � -- -- - _ - - Policy 7. Protect and improve air quality in the Town of Southold. See LWltP Section III —Policies Pages 32 through 34 for evaluation criteria. Yes []No, of Applicable Attach addid6ji .sheeisifnecessar Policy 8, Minimize-environmental degradation in Town of Southold from solid waste and hazardous substances and W;N s. ee LWRP Section M-Policies;-Pages 34 through 38 Tor evaluatioxa criteria. Yes : 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 LUMP Section III—Policies;Pages 38 through 45 for evaluation criteria. 3l No Not Applicable Attach additional sheets fhi cssary - WOREING COAST POLICIES Policy 10..Protect Southold's water-dependent uses and promote siting of-nw-water-dependent uses In suitable locations. See LVWRP Section III—Policies;'Pages 47 through 56 for evaluation criteria. ,E] No ONot Applicable Attach additional sheets W necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LNVRP Section III-»PoIicies; Pages 57 through 62 for evaluation criteria. 11 Yes 1:1 No O Not Applicable ;Attach addi.669 sheets ifnecessaiy Policy 12. Protect agricottural lauds � thy-Town of SeUthold. See LWRP Secti'fi III_ �--Policies; Pages- 62 ihrough.65 for,evaluation criteria. ' 0 Yes D Nv� Xot Applicable Attach additional sheets ifnecessary ` Policy 13. Promote appropriate use and development of energy and, mineral resources. See LWRI' Section III—Policies;Pages-65 through 68 for evaluation criteria. Yes No Nat Applicable PREPARED.BY TITLE - .DATE