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HomeMy WebLinkAboutTR-9750A 3 � Glenn Goldsmith, President `��� �> Town Hall Annex ' � 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly i Telephone (631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: all'I'? INSPECTED BY: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1s1 day of construction % constructed Project complete, compliance inspection COMMENTS: or Qr G eq C LAW i(1 w•4'^ '*97SOA CERTIFICATE OF COMPLIANCE: Glenn Goldsmith,President ®®� ®f SOU� Town Hall Annex A. Nicholas Krupski,Vice President ® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly V2 G Telephone(631) 765-1892 Elizabeth Peeples ® `�� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1975C Date: November 6, 2022 TRIS CERTIFIES that the existing 12'1"x9'2" sunroom; At 1392 Park Avenue, Mattituck Suffolk County Tax Map#1000-123-8-2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated November 4,2020 pursuant to which Trustees Administrative Permit#9750A Dated November 18, 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 existing_12'1"x9'2" sunroom. The certificate is issued to June Beckstead owner of the aforesaid property. Authorized Signature Glenn Goldsmith,President q sv(/jy Town Hall Annex 54375 Route 25 Michael J.Domino,Vice-President h0 l0 P.O.Box 1179 John M.Bredemeyer III J [ Southold,New York 11971 A.Nicholas Krupski N 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_OFFICE OF THE BOARD-OF TRUSTEES 72'HOf�RS PRIOR TO'COIMMENCEMENT OF THE ACl'IVITIES CHE EbrnEF INSPECTION SCHEDULE = Pre-construction;.W'E'a1'e�lirre silt'b©offi/s1t`o idgain ' • 1 stday of cohstructipn % constructed X When project complete, call for compliance inspection; Glenn Goldsmith,President OF S0�ry Town Hall Annex ��� O1 54375-Route 25 Michael J.Domino P.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 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.: 9750A_ Date of Receipt of Application: November 4, 2020 Applicant: June Beckstead SCTM#: 1000-123-8-2 - Project Location: 1392 Park Avenue; Mattituck Date of Resolution/Issuance: November 18, 2020 Date of Expiration: November 18, 2022 Reviewed by: Glenn Goldsmith, President Project Description: As-built 12'1"47 sunroom. 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 site plan prepared by Neal Beckstedt, received on November-4, 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. 41. Glenn Goldsmith, President Board of Trustees I r� I Jf� �/r� xwlmxew.N mravvereo uxfeaa x 1 arxm APPROVE NER T CTOR _ t1—?� rxovuuroeeou,newm afxeavae wwrxsuxxum vnex revao w� a J E ! 11947,LLC gV II)NK4T N! �m'O �twrt^ra�ry a/� py JAMESIPORT,NY 1,947 NOV 4 2020 nvwul xuss x an x mrxryepQ�.iml I,�K® OF q iSTEES T 5,8322,537 ,, ®x K w e%mnr,re°f wr/ Iur wr tt VVIR OF S THOL® 1� e 1, narcl nm '.DATE,,.f II/2' IIIc IVT wwrorzrmwrea weu a ro+a1 mf /VoveAw— _VLL//{{// /i J N0 NA FE91AR n® naauna °eu�wnmo n roecem,vv KW mm FEIRAR � Y 2' � am,w nuenwaenvo CD IDJt /+� unv+,wnerenexreT°o '>N M MUM13IN6 MISER PIMPAM ® u rom" N,f,5, --- � b PROPOSED POWDER ROOM REFURBISH EXISTING BATHROOM RECONFIGURE KITCHEN CABINETS AND FUTURES IN I, 1sf'iA'FBEtR-]• x6's eweREVISION DATE DESCRIPTION tYd•%t , xAlt 827/2020 PERMIT SET Jt%ca• 01 111=019 PERMITSET C-2 i• ,ra' P°WNER THE BECKSTEAD RESIDENCE ® 1392 PARK AVENUE MATTITUCK,NY 11952 O 6P NEAL BECKSTEDT STUDIO o LINE OF r<xv.v WALLS TO BE 134 WEST TWENTY-SIXTH STREET,1140 REMOVED NEW YORK,NEW YORK 10001 TELEPHONE(212) 0D FACSIMILE 90 iP rxa re^xvf, to 1•xtra• WWW NBECKSTEDTEOTSTUDI46-02TUDIO COM P REMOVE SLIDING x DOOR—_\ ARCHITECT OF RECORD •xo ANNE SHERRY ARCHITECT 27 HODDER AVENUE rR_ EAST HAMPTON,NV 11937 � ya,Roy T 6313285059 PBa aa"'w"u wnoN %�r CONSTRUCTION PLANS ss < f �""'" a xrz•R L NOTE SCALE 1/4"=1'-O" NEWAC Q BY Cs SYSTEMS INSTALLED PROCT NO 1710 SPECS PROVIDED IN SEPARATE y DOCUMENTATION i REFURBISH EXISTING BATHROOM PROPOSED FIRST FLOOR PROPOSED SECOND FLOOR NOTE SEAL AND SIGNATURE EXISTING EXTERIOR WILL NOT BE CHANGED ,mewunc.w"maoeo mmmuu+,e�w.m.m.nw.awv.wnmasru..reaoe.movumrwwswerox.rvs,erwoereo.uaasmwo.romxm�vxa,awwmx�.cx.wnroManewamwcvaurmuwn,smnraac.�ewnmue+wx.+mmwo...w..wPROPOSED eavnALL WImmrmuDOr,unc.,mBE REPLA CE INKING mT.w rcr.roE•uo,eN ew SERIES REs /A` 1 00+.00� I Glenn Goldsmith, Presid` �OgUFFU(41CO ,^ y 'i own Hall Annex Michael J. Domino ��� - --j4375 Route 25 John M. Bredemeyer III o ` P.O: Box 1179 A. Nicholas Krupski o Southold, NY 11971 Greg Williams y p! Telephone (631) 765-1892 hod Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 0?4]L•h2,?o g.yo Completed in field by: JUNE BECKSTEAD requests an Administrative Permit for as-built 12'1"x9'2" sunroom. Located: 1392 Park Avenue, Mattituck. SCTM#: 1000-123-8-2 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 Ch. 111 SEQRA Type: 1 11 Unlisted Action P 1' 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 GENERAL CONTRACTOR � �'I �_` -- T_-� ' rsowuroeeo uauxeo mx mr[sexm[o R 'eo lin«i[ o [vlo e'6"i[°^uv OA BOX317NBUIlDER6,LLC PO BOX 317 I W YOXT NM a JAMESPORT,NY 11947 I nluwuavnvole T 518 322 1537 NOV IUT IVT I t VP- 1- 'T � �—•}� R[aa 02f(I Ci �°." ,._ _ IVT VT i UT-- °.°+aei cm[c�eu°.�nwlcn.�uo XC W FP91'V [ Nmuaa eoxsr[uc[loa w[na aeeu eesrerrmrowrww NMI Ne'_ "'- CD Y exmeeerrv+cero ami[acro CO IDg nevnew ureevueno NN , FLUMM6 KI5FR PIAGPAM � � • m PROPOSED POWDER COM REFUR819H EXISTING BATHROOM RECONF GORE KITCHEN CABINETS ANO FUCTURE9 ', eGuueFR a F uo Xrtare IN DATES I Ile,-T 2y rdX6C I XI d n _ xXtL i I T T ! B1 10]0/2019 0P20E SET� 0 THE BECKSTEAD RESIDENCE 1392 PARK AVENUE MATTITUCK,NY 11952 0xi s,X2:,• w � NEAL BECKSTEDT i r3A`�;u i STUDIO s LINE OP r 134 WEST TWEN" STREET,1140 WALLS TO BE [cs NEW YORK,NEW YORK 10001 REMOVED 4 TELEPHONE 924-0700 FAC81MILE(212))646.290 ,s rxaia r�TMt r erx rs ,[ WWW NBECKSTEOTSTUDIO.COM ' REMOVE t SLICING n y° J A IBX] t OCOfl ARCHITECT OF RECORD NE 1j 77 HODD AV ERARCHITECT 27 HODDER AVENUE •1.1 4 d xpmu PTO T 631329 50BAST HAM N,NY 1193] r 5 ou�Drw.....T.K rrXPT FPROJECT RUCTION PLANS .1- -c 6 .1 xFaz a6 NOTE SCALE,1/4"=1'-0" 6 pEWJN HFAOER NEWAC YSYSTEC9 NSTALLE NO 1710 SPECS PROVIDEDIN SEPARATE DOCUMENTATION Y 2 REFURBISH EXISTING BATHROOM PROPOSED FIRST FLOOR 1 PROPOSED SECOND FLOOR NOTE SEAL AND SIGNATURE R EX TING EXTERIOR WALL NOT BE CHANGED B PROPOSED ALL WINDOWS TO BE REPLACE IN KIND WITH ANDERSEN 400SERIES A-1 00.00 �+•m w.+a[..[.mae.ome.ay.•rm.w•m,,..nw.m...w.,.°.......a..eww".wwoerno.ew.mmsno.wxaoon.e.ecm,u.w.arrow.wmw.w.ora.u..�.nw.ru+wueae.are.u..an..ow.wn..nw.mmi..u>uae.w+.am..rmnmu,e.nnn.uvwsarwmanwn.a.aw+..wuaa.e,so++w,m v..ua«,.w. ame+nQ.pmmmoou[ SEE SEC.N0.115 SEE SEC NO.115 - SEE SEC NO 115 4 wtu,u< ,wo NAICN — NIIE—�.. 3' 1U1C11 — --.� UNE eH t•e.No.ns —_—_�__— w E . f11KN0. 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I laws ,10U1110tD SECT10N N0 .Nonce COUNTY OF SUFFOLK © E Nrux,v«xcE,k unci E - Real Property Tax Service Agency v N.,,�, M Glenn Goldsmith,President So Town Hall Annex 54375 Route 25 Michael J.Domino,Vice-President P.O.Box 1179 John M.Bredeme er III Y h, atl, Southold,New York 11971 A Nicholas Krupski G t Telephone(631) 765-1892 Greg Williams �` �� Fax(631) 765-6641 100dB111 i BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application aiE Wetland Permit Application r -- - Administrative Permit Amendment/Transfer/Extension NOV - 4 2020 Received Application: «•�.Z® Received Fee: $ Z00,60 A$ 6111t ------ ____ — ' Completed Application: lie&.20 ' Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: �Coordination:(date sent): LWRP Consistency Assessment Form Sent: CAC Referral Sent: Date of Inspection: Receipt of CAC Report: —/ Technical Review: Public Hearing Held: Resolution: Owner(s)Legal Name of Property(as shown on Deed): J Un�' �e-cl<5fe4,5P Mailing Address: S' / `� Sire_--t ,4-vd'-1 Phone Number: ��� 0 W6 0-L-1 Suffolk County Tax Map Number: 1000 - /;Z300 08� 0 o Property Location: 3 9 � �� (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): Mailing Address: Phone Number: Maim Diane From: June Beckstead <junebeckstead@yahoo.com> Sent: Thursday, November 05, 2020 6:58 PM To: DiSalvo, Diane Subject: [SPAM] - 1392 Park Ave Mattituck NY 11952 Hi Diane For my application the work done: Replaced rotten areas in the sunroom, walls as required. Existing foundation,slab floor, concrete columns and roof rafters remain. The Sunroom is 12' 1" x 9' 2". The Tax Map number is 1000-123-8-2. PIs let me know if there is any other information needed. Thank you. June Beckstead Sent from my Whone Board of Trustees Appli< ion ,'1 GENERAL DATA Land Area(in square feet): �f 0 , ZC'd b 4;t�- Area Zoning: Yc 5® !54 e,4�a Previous use of property: VeS 1 GQ-ei4 J7 Intended use ofropertY� r-e- S P - - Covenants and Restrictions on property? Yes _�o If"Yes",please provide a copy. S Will this project require a Building Permit as per Town Code? ✓ Yes No /`�T7 of p��rn p j q g P 0n1 r-1L� 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 L�No If"Yes",please provide copy of decision. Will this project require y demolition as per Town Code or as determined by the Building Dept.? Yes Mo Does the structure (s) on property have a valid Certificate of Occupancy? Z�Yes No Prior permits/approvals for site improvements: Agency�p -4� �S3 � Date 12- No ZNo prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? l_,-,No Yes If yes,provide explanation: Project Description(use attachments if necessary): WOOD Board of Trustees Appli :ion WETLAND/TRUSTEE LANDS APPLICATI®N DATA Purpose of the proposed operations: aw—a-3 I h .J arl K0 o/h ego, rep fS7,1/J 477 Z!�vd� C01CY.1-6 Com- S f oo/ /Z &A46t f� tJ Area of wetlands on lot: square feet Percent coverage of lot: 0/0 Closest distance between nearest existing structure and upland edge of wetlands: g3 g 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: C?< 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): �A 61 Z20 Appendix B Short Environmental Assessment Form Instructions for Completing Part I -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 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 .-Tv/-) e- 434—, C/c 7-e a--0 S v o A ci E l Name of Action or Project: ] //9 5c� aa-r-k CG / T/ v miff Project Location(describe,and attach a location map): 0o D Brief Description of Proposed Action: /!7 S()/J �e o o l�(,JG�iLAC.S ESC l 517,ro(::> J':D 0 A'✓7 0/,7 'V7ZD 12-e Name of Applicant or Sponsor. Telephone: 2 E-Mail:- Address: City/PO: State: l Zip Code. 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that 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? oZ- 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? 0 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial idential(suburban) ❑Forest ❑Agriculture ❑Aquatic J]Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ ❑ b.Consistent with the adopted comprehensive plan? 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: ❑ 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: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: Kr ❑ 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? ED- b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ET 0 / 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 El Forest ❑Agricultural/grass lands ❑Early mid-successional ❑ Wetland ❑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? IgFff 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, F-1a.Will storm water discharges flow to adjacent properties? ❑NO [:]YES b.Will storm water discharges be directed to established conveyance systems(runo d storm drains)? If Yes,briefly describe: Df4o DYES 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: Ll E 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: a ti ,20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO I yXS completed)for hazardous waste? If Yes,describe: ❑ I AFFIRM.THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/spon me: e Date: 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 EJ ❑ 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 El 1:1establishment 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, ❑ ❑ 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 1:1 1:1problems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,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. 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 Board of Trustees Appli(;\ )ion AFFIDAVIT EING 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. Signa o rop Owner Sign a Pro rty Owner � ?.D SWORN TO BEFORE ME THIS_ DAY OF NDS- , 2U A�A( 'Ah__ - Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. OID1475593 Qualified In Suffolk County MY Commission Expires April 30, 2041/ APPLICANT/AGENT/REPRESENTATwE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and emblovees.,The puroose of this form is to provide information which can alert the town of possible conflicts of interest and allow rtto take whatever action is necessary to avoid same. YOUR NAME:_ e—e--)c �C— (Last name,first name,ipiddle 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 (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"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 I - If you ansnvered"YES",complete the balance of this form and date and sign where indicated Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/ag(�nt/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or-beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of .dee'�✓� Signature Print Name Fotm TS l Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its sini ficant 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# 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: GAS 6;Y[Sr1/U D ,09D 4— v ,_S' LA D Location of action: Al A-177 ,WL G Site acreage:- D 1 9 - v Present land use: rcJ 4 ` Present zoning classification: _ V&S 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: �c (b) Mailing address: �E 9, (c) Telephone number:Area Code :7162- (d) Application number,if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes ❑ No U' 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 0 No of Applicable Attach additional sheets if necessary Policy 2. Protect and press a historic and archaeological resources of the Town of Southold. See LWRP Section III—PoliciplTages 3 through 6 for evaluation criteria ❑ Yes ❑ No 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 ��ot 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 t ough 16 for evaluation criteria ❑ Yes ❑ No of Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑. Yes ❑, No U�6`tApplicable 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 ildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation 'teria. ❑ ❑ Yes Nor _tIpplicable 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 UXot 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 of 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. ❑ YeT1 No Not Applicable Attach additional sheets if necessary WORKING COAST POL —aES ` Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See L Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No t Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town water ee LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes 1:1No 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 forEzlicable riteria. ❑Yes ❑ No Attach additional sheets if necessary Policy 13. Promote appropriate se and development of energy and mineral resources. See LWRP Section III—Policies; Pages 6 rough 68 for evaluation criteria. ❑ Yes ❑ No QXot Applicable PREPARED BY TITLE HATE