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HomeMy WebLinkAboutTR-9749A I Glenn Goldsmith,President *QF SO(/�y Town Hall Annex Michael J.Domino,Vice-President ,`O� �1 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 A.Nicholas Krupski cn G � Telephone(631)765-1892 Greg Williams �� �� Fax(631)765-6641 OOUNI`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED, TO CONTACT THE OFFICE OF TME BOARD OF !RUSTEES -72'HOURS.'PRIOR TO'COMMENCEmr=NT OF'THE ACTIVITIES-CH06'00'.60 BELOV'V ; = INSPECTION SCHEDULE Pre-constructir'c h"f*.l dl'e'airl_&t ilt#oo /�ilt��u�tain 1 st day--of construction %2 constrOcted When project complete, call for comptlance 'inspection; i Glenn Goldsmith,President �QF"so Town Town Hall Annex Michael J.Domino ,`O� ��� 5 Route 25 P..O.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 A.Nicholas Krupski G Telephone(631) 765-1892 Greg Williams O �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit-No.: 9749A Date of Receipt'of Application: November 5, 2020 Applicant: Stephen V. Fealy " SCTM#: 1000-122-4-5 _ Project Location: 1780 Ole Jule Lane, Mattituck Date of Resolution/Issuance: November 18, 2020 Date-of Expiration: November 18, 2022 Reviewed by: Glenn Goldsmith, President Project Description: Erect approximatey 290 If, of T4 high fencing along property lines. 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 Creative Environmental Design, dated November 2, 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 f FROP05AL TO INSTALL A DOG RUN FENCE WITHIN 5OUTHOLD TOWN TRUSTEES JURISDICTION z DREDGED CANAL -HG-1 WATER LINE =_ ------------r------ / EXTENT OF LAWN = / 109 / l FROM H / PROP05EP POG RUN FENCE t WATER 4, 3 -ro 4' MGN DECK / DECK DRIVE RE5IDENCE ----�-----�-/t------ i / ' f / DRIVE / - - - - - - - - - - - - - - - - - + OLEJULE LANE APPROVED BY 5TEP1 EN V. FEALY NOV - 5 2020 BOARD OF I RUSTEES OLE tJULt LANE __ . � TOWN OF SOUTHOLD i MATTITux NY 11952 DATE No, �xc�.e l8� 20w 5CTW 1000-122-04-05 Revision #: Landscape Plan: 11 -2-20 Date. 11 /3/2020 Fealy Scale: Landscape Design by: Dave Cichanowicz . ill = 20' gOFFQt� .; - Glenn Goldsmith, PresA(' _ �O el 'own Hall Annex Michael J. Domino ,�� Gym 64375 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 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 116 J Za2n 8 .,�16 Completed in field by: G cc, Idsm;A Creative Environmental Design on behalf of STEPHEN V. FEALY requests an Administrative Permit to erect approximatey 290 If, of 3'-4' high fencing along property lines. Located: 1780 Ole Jule Lane, Mattituck. SCTM#: 1000-122-4-5 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=� Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching; Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch.'111 SEQRA Type: 1 II Unlisted Action r Type of Application: Pre-Submission V"Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction i 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: skc ca�� 0C-ti✓ I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other f N SURVEY OF PROPERTY A T "MA TTIT UCK PIPE TOWN OF SO UTHOLD 3 SUFFOLK COUNTY,- N. Y. 1000-122-04-05 p" SCALE.• 1'=30' AVG.,221'20I,2, . • s Z Z N/0/F CLAUDE DA VIS k WIFE 0 a - S. 84°56'20" ` 3s5i•� E. °' CERTIFIED TO: RR 25, 0ca STEPHEN V. FEAL Y z FIRST AMERICAN TITLE INSURANCE COMPANY.. LIG"r PK OF NY POLE- SET .A. ASpyp1-TLn } O\ p O�c WALL !a O m G7 CULVERT 33.3 O ts Z W -,A, rio wit � tA X 10. HOT Ln O m 3/.06.2 uT 37.5' ^O' O RESAR SET 192, N8343'5p� O O O 89- o ROW OF EVERGREENS 1 r n g �,�, r-- o jj s>Y I NOV - 5 2020 N�°�F cINDA & ER/C ' HAAS .�=fl<• ifI _ P .A x � � A 4b.400z ELEVATIONS REFERENCED TO NA VD 88. <� LIC. N0. 49618 ANY ALTERATION OR ADD177ON TO THIS SURVEY IS A WOLA77ON IIIECONIC U flR' , P.C. pC p OF SEC77ON 7209OF THE NEW YORK STATE EDUCA77ON LAW. AREA=: FROP05AL TO IN5TALL A DOG RUN FENCE WITHIN 5ou-rHou) TOWN TRU5TEE5 Jum5w.-riON ' z DREDGED CANAL / MEAN-HG-I WATER LINE ------ ------ EXTEW ffLAwN r� / r 100' r l r PROPOSED DOG RUN FENCE r wa�rz iJ TO 4' HIGH ,r r / - -- DECK= / DRIVE __- / / RE510ENCE / �• I i I r r DRIVE ' - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\.J OLEJULE LANE NOV — 5 2020 5TEP�EN V. FEALY s OLE JuLE LANE MA-r-n-nm NY 11952 5CTW 1000-122-04-05 Revision #: Landscape Plan: 11 -2-20 Date: 11 /3/2020 Fealy Scale: Landscape Design by: Dave Cichanowicz ill = 201CreativeEnvironmental Design - _ .mLra.,�.ro�xLm _ --•-- Tom-- ----- T ri`i�wwNL �_ /NI evw ua3eoaa CE ox.awuw, rrL " °` xaL° .: ,o xoN..�.. ro --•— — -- ------ IIl KL N LeeLLAN•Mww.Na wLxp ALur� • 1,011Mw HlrnxOLLKwL°O uxinw —�—�Q -- --�n�"a —x—_ �nwwo �o—c ZZL n m A f...6yaowagxel,(YadoldWOE —zZ— uTOItLLLos [ Ln zn H Q vino- =4 AlNnoo aouoN ON NOLL03S , -�. 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Amen dment/TransferlExtension j NOV - 5 2020 ==` X Received Application: Is,Zo _Received Fee: $ I03. -- _---_- - - — �Completed Application: h, ,Lp J InCOP; a SEQRA Classification: Type I TypeII �/ Unlisted T Ne ative Dec.Lead Agency Determination Date• gPositive Dec. Coordinatiow(date sent): I.WRP Consistency,Assessment"lFormSent: �CAC.Referral,Sent• Date of lnspection: Receipt of CAC Report: Technical Review. 2Itblic Hearing Held: Resolution: Owner(s)Legal Name of Property(as shown on Deed): Mailing Address: Phone Number: Suffolk County Tax Map Number: l000__ 1 a1 t4, Property Location: (If necessary,provide LILCO Pole#, distance to,cross streets, and location) AGENT(If applicable): T Q)&W �; L Mailing Address: Creative P-nAronmental Design I'® nX 160 Phone Number: Peconic, 11958 L��1 -� ����4_�-� Board of Tr-ustees Appli ,tion GENERAL DATA Land Area(in square feet): Area Zoning: 4, 4n Previous use of property: Intended use of property: 5`r Covenants and Restrictions on property? Yes %o If"Yes",please provide a copy. Will flus project require a Building Permit as per Town Code? Yes 1::�'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 I/ No If"Yes",please provide copy of.d'ecision. Will this project require any demolition-as per Town Code or as determined,by the Building Dept.? Yeso Does the structure(s)on property, have a valsid Certificate of Occupancy? es 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? i,/ No Yes If yes,provide explanation: Project Description(use attachments if necessary):-? 1 �� �,.,�►a�1 Din �W-n 1�� I 0,7) Board of Truatees Apply_ ; ion WETLAND/TRUSTEE LANDS APPLICATH01;1 DATA Purpose of the proposed operations: 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 Toes 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 renioved.orAeposited: 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): • M • I I 617.20 _App9#t44c B Short Environmental Assessment Form Instructions for Comnletine Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part l based on informationcurrently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as.possible based on cu rrent.information. Complete all items in Part 1. You may,,al"so,;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 Ilnformation Name of Action or Project: r—n Project,Location(d'escri,, `,��e,and attach a location.map): I U 4 Brief Description,of Proposed Action: r Name of Applicant or Sponsor: Telephone: Creative Environmental Design Address: PO Box 160 Pcconic,NY 11958 City/PO: State: Zip Code: L Does the proposed,action only�involve.thetlegisl'ative adoption, 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 01" El may be affected•in�the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: 3.a.Total acreage of the site of the proposed!action? a � b.Total acreage to be physically disturbed? p acres c.Total acreage(project site and,any contiguous properties)owned or controlled by'the applicant,or project sponsor? ' acres 4. Check all land uses that occur on,adjoining_and near the proposed action. 0 Urban EI Rural(non-agriculture). EI'Industrial' 0 Commercial Residential'(suburban) ❑Forest ❑Agriculture ❑Aquatic []Other(specify): ❑Parkland Page 1 of 4 S. 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 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 _-M YES YES If Yes,identify: 8. a.Will the proposed action result in a substantial increase in traffic above present levels? _ff. Elp p NO TES b.Are public transportation service(s)ravailable 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 exceedthe state energy code requirements? ❑ If the,proposed.action will exceed requirements,describe design features and technologies: NO YES 10. Will.fhe,proposed:actiomconnect,to�anrcxistingpuilie/private-Watersu l Pp Y? NO YES If No,describe method for providing•potable water: ❑ 1 l.Will the proposed action connect to existing wastewater utilities? NO YES If No,descrlbe.method for-providing wastewater treatment: ❑ 12. a.Does the site contain,a structure that,is�listed•on-either the State.orNational 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 ro posed,action,or lands adjoining=the proposed action contain N wetlands or other waterbodies regul'at d,by a federal,state,or local agency? O YES b.Would the proposed action physicallyAter,or encroach into;any,existing wetland,or waterbody? ❑ If Yes,identify the wetland or waterbody_acid extentfof alterations in square feet or acres: ❑ 14. Icjgntify the typical habitat types that occur on,or are likely to be found on the project site., Check all that apply: Ell Shoreline ❑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 threatene&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.Will storm water discharges be directed to established conveyance systemsrunoff and storm drains)? If Yes,briefly describe: (❑NO ❑YES Page 2 of 4 18.Does the proposed'_action include-construction or other activities that result in the,impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: 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,ofthe-proposed:actiori or,an adjoining property been the subject of remediation(ongoing or NO YES completed),for hazardous waste? If Yes,describe: Er 0 I AFFFIRM,THAT THE INFO TION+PROVIDED A13'OVE IS TRUE AND ACCURATE TOTRIE BEST OF MY KNOWLEDGE Applicant/sponso ame: L ,�1 �_ - Date• l 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 I 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 consideringftlie.saale;andcontext of the proposed;aetion?" No,or Moderate small to large impact impact may may occur occur I. Willthe proposed action create a•materiat conflict with an•adopted;land'use plan or.zoriing regulations? ❑ ❑ 2. Will the proposed action result iri,a change�in the use or intensity,of•use:of land? ❑ ❑ 3. Will the proposed action impair the character onquality of the existing community? ❑ ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? El 1:1 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,orienewable energy opportunities? 7. Will'the proposed action impact existing: ❑ ❑ a.public/,private water supplies? b.public/private wastewater treattnent utilities? S. Will the proposed action impair the character or quality of important historic,archaeological, ❑ architectural'or,aesthetic-resources? EJ 9. Will the proposed action result in an,adverse change to natural,resources(e.g.,wetlands, El El groundwater,air quality,flora,and,fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage problems? E I l- Will the proposed action create a hazard to environmental resources or human health. EJ El Part 3-Determination of significance. The Lead,Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate,to lapge,impact may occur",or if there is a need to explain why a particular element of the proposed action may of villi 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 expWn'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. Check this box if you have,determine4;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 Off cer iaLead.Agency, Signature of Preparer(if different from Responsible Officer) 1?RIN Page 4 of 4 APPLICANT/AGENT/RE-PRESENTATIVE' TRANSACTIONAL DISCLOSURE FORM The Totivn of Southoid's'C:ode of Ethics nrohiliits donfliets of interesron-lhe nart of town officers and cmployie .The aumosc of this form is to ntovide infoi illation whicft c;en alert the town of onssible conflicts of inteiest,aud allow-it 166ke whatever action is necessary to avoid same. YOUR NAME: — L e- � V (Last name,--first name,middle 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 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.) po you personally(or through yrrarcompany,s�duse,sib iag,parent;or_child)have a relationship with any officer or eniploycc of the lown'of Southold? "Relationship"includes by blood,nlacriag' or business interest.`.`Business interest"means a business, iricltiding a partnership,in.wliich the town officero�employee lags even a partial orVncrsltip of(or employment by)a eorporntion in which the town 0 icer or employee owns more than 5"/0 of the shares. YES NO X If ydu answered"YES",complete the balance of this form and tfate 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/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,o"r child is(check all that apply): A)the owner of greater than 5%of!(ie shards of the coi porate stock bf the applicant (when the applicant is a corporation); B)the legal orbeneficial.owner of any interest in a non-corporate entity(when the applicant is nota corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thisday of 2t SiO iature - Print Name �y- Form TS 1 Board of Trustees Applic Lon AUTHORIZATION (Where the applicant is not the owner) I/We,. Y --- > owners of the property identified as SCTM# 10007 in the town of ,New!York,hereby authorizes i David Cichanowicz, Pres. Creative Envionniental Design to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. r ropert wner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS ( DAY OF ge ����c� ;20 Z� ROY J. SCHOENHAAR Notary Public;State Of New York No.01SC6022312 Notary Public Qualified in Suffolk County Commission Expires March 29,20 13 i I li lA Board of Trustees App1i6\, ff.on AFFIDAVIT BEING DULY SWORN DEPOSES`AND A IRMS ThAT HE/SIS 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. 14 s Signatu of Property OwnerV Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF 20 2 ROY J. SCHOENHAAR Notary Public State Of New York No.01SCG022312 Notal Public Qualifiea in Suffolk County Y Cnmmi,mon Expires March 29, 20 LS APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: ,6tw--- �\���tt 0— (Last name,first name,piddle 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 interesf'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 a 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 applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applic4nt (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 Submitteis 20 Signature Print Name ` Form TS l f Tom of,Sout.hold , L_ CONSHSTE1 CC'K SSSS N'Y'�O A. IINSTRUCnONS 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 mfomIation used by a Town of Southold agency in malAng a determination,of consistency. *.Except minor exempt actions including Building Permits ander 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-aud explanations of each policy contained in the Town of Southold Local bater&on aevitalzati'on piogratn. A ro.©sed eneficial adverse effects°,u on the coastal action be evacuated as to its si _ = area wluch.mcludes all of Southold Town 3: If any question in Section-C on this fora is answered "yes"or "no% then the proposed action will affect the achievement of{the LVRP ;policy standards and conditions contained in the consistency review law. Thtasg each, a9 M. er must,lbe a la_inedIn� de at, Yistfln�both sunnortinQ and non-, suaumoptintz facts. If an,action,catanot,be c e_ ed as eonsrstent with filie LWRP and conditions',it shall�not policy standards . � �und'ertaken. A copy of.the LWRP is available,in the.f©llow ng.place eat r s: o the Town of Southold's website(southoldtown:norhlifork.net),-the Board of Trustees Office, the planning Department, all local',libraries and the Tomon Cler-k's-office. Dllgmlr ORT ,Sm- PR lmgPO,ACTgON SCTIM# I L.__ _ FROjECT NAME Th.a Affkcatgon has been sutbmit .to.(check,appropriate response): Town Board ❑ Plaa"ing Bm"❑ II$,1ifl(&g Dept. ❑ IB®ant of Trut". 1. Category of Town of,Southold agency,action(check appropriate response): (a) Action undertaken directly'by Town agency(e.g.capital construction,planning activity,,agency regulation,land transaction) (b). Financial.assistance(e.g.grant,loan,subsidy) (C) Permit,approval;license,certlification• Nature and extent of action: 4 C Location of action: Site acreage: Present land use: Present zoning classification:_ 2. if an application.for the proposed action,lies been ld filoagency, the following information shall'be provided: ed with the Town of Southg (a) Name of applicant: I (b) Mailing,address:_ 0 a� (c) Telephone number:ArwCode( ) (d) Applicationnumber,.il'any: Will the action,be directly ands rto4m,.recluire funding,or approval bye state or federal agency? Yes ❑ No:V If yes,,which state�or federal agency? C. Evaluate the p oj_ecg tothe fofllowing,poliq es+b'y'�an.! g,how tlac; pm'ect�►a➢fl;further support®a' Mot support.the-po'li lies. F.t " �: J de;au;proposed Best 11�anagepn_en�t-rac_tices.;;hat,vvM' , further. each,policy. Incoyup'lete answers e8iil a�equre tHaa . hc4'fmaa a'ear8ei$ifor coBnpYeta`on. RENIM0 D,tCOMT FOLIrCX I?olicy to Foster a.pattOrn-Of OVV4opnaent.in ihe,Town of Routhold that enhances ecommunity character, Vreserves open sp2ee9 Makes efricie a't uge ofl'&''astrarcta r-ep,an�hes benc£acW,.ease,of a coastal,,flocation,and ardami es,aciwcrse,effecgs of 4ewe101OW ato Sed L .3 Section YTH—Po`licaes9 Phge 2 for evaluation �rflte �{o 1 ye3 El No, Not App'licab'le I�V1 Attach additional sheets if necessary FoliCy 2. Protect and preserve knsOAC 2ud arehaoffYogacai resources, of the Town of Soutlnolala See ILS Section ffi=Poli 'es Pages=3; lna'ougb, for ey lta tioaa,eritegia ❑ Yes 11 NO I�ot�1►g�,p➢i�sibfle Attach additional sheets if necessary Policy 3° IEaa'hg'nce visual quzft and protect scenic resources throughout the Town of Southold. See L Section M—Policies Pages 6 throtagfli 7 for evaluation criteria es I❑ NO ❑ Riot Applicable IA Attach additional sheets if necessary NATURAL CASTFO LYES Paflicy 4. Min a loss of life, st-puctures,,and mat ral resources from flooding and erosion. See L WI Sestioua,ffi—policies Pagea$througla'fl6-fog�v laualion criteria ❑ files ❑ No RiotApplicable Attach additional sheets if necessary Policy 5. Protect aaacl;iffipa�ove Water quality.,an�g,sn�taply an the Town of-Southold. See ILWP Secdoan M — Polities Pages 16 tI FOU Bl for e7aYivati®n criteria ❑ Yes ❑ NO Lallot AppRealble Attach additional sheets if necessary Policy 6. Protect and restore the' and function of the Town of Southold ecosystems including Siguffi ant Coastal *sh and Wildlife Wgb_ita6 aid,wetland's. See L, P-Section.ffi—Polncies9 Wages 22 through 32 for evalua n critekia-. ❑ ❑ yes l0 1L_ rgn�p �� le Attach additional sheets if necessary P®flgCY 7° Protect ancIl h-Pro"' ana° q:aua ° aaa $Ilse TOWIM of SountIlnoIlaIl° dee 1L%W rection M — IPoIlflcnes P29es;32-.thr,o0gIln 34 for, ew�u.atj-®jm.c nggerAa. Q Yes ,0,1 OP, rot abRe Attach additionalt_sheets iflnecessary PoIlacSv 8. nnmmnnze .egaia°Osrn$ ls d'egra�Iltno� 'oe�u off s �ouatrIln®Ilsfl ®un s� d �►ate and IlIlairdoaas substances a�a ��s es° 'See . ,� ao�ffi—Polisne�, Pages,34 taro.uglk"3S for evalu a ,o]n ergtena. Yes 0 No I qt Apoc $� PUKIC COAL POLICEE, Policy 9° Prov' naIle ffor Pub'ac access tto, =4 TQW-eatuoual use of, coastaIl waters2 Public Ra]mds9 and pubac yes®aunces of the Town of Southold. See Lam, ��for eaaluati Becfn®mm M o PoIlacn ,* Pales 384lna�ougHn ®r� criten�fla° nn `�eD No Lott AppOcable Attach additional,sheets--ifnecessary G- COAST PPO" PONCY 10. Protect g"'thold's water:dependent eases, and promote sitimg Of s lble loeatxioaaso See sectioan 2<FI ,Polncaes;Pages 47 through 56 for a aluatioaac At sang uses inYesElN0 G[4ot Applicably Attach additional sheets if necessary Policy IL Promote sustainable use of lig aaaarine resources in l_,oaa Es�ga�ng►and'�oma'�va�er dee�, � , �. �, „_ , , g Yslaaid aoumcd, the B�ecomic P Section policies;Pages 57 through 62 for ewaluatjon criteria. ❑yes ❑ Ido of Applicable Attach.additional sheets if necessary policy flB. Protect agric�al Al-o nds;in-$he,Tovrai._,of S.oan4hold. dee ILWIL 62'tt%ro�agh,65 46rallo!tAppacgibig n ckl'* 4. Sectraon IDi�—Policies; Pages ❑ files ❑ No .Attach,additional sheets ifnecessary INGey 13o PrOmac$e appaopaiate use and development of energy and mineral resources. 'see LWT section M—Policies;Pages 65,through 68 fotr edaflaaad®n criteria. ❑Yes ❑ hlo ' 'Ot Applicable. PREPARED 1$YI�G TV ME I DATE