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Home My WebLink AboutTR-9821 Glenn Goldsmith, President ®� ®F SDU� � Town Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly G � Telephone(631) 765-1892 Elizabeth Peeples ® q® Fax(631) 765-6641 C®UP�T(,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1978C Date: November 14, 2022 THIS CERTIFIES that the installation of a 16'x32' in-ground swimming pool made of steel and poured concrete with edge stonework trim approximately 18"-24" around the pool; excavated soil to remain on the property; and install pool enclosure fencing;with the condition that the pool backwash be connected to an existing dry At 122 HickoU Avenue, Southold Suffolk County Tax Map#1000-78-7-51 Conforms to the application for a Trustees Permit heretofore filed in this office Dated November 18, 2020 pursuant to which Trustees Wetland Permit#9821 Dated February 17, 2021,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 the installation of a 16'x32' in-ground swimming pool made of steel and poured concrete with edge stonework trim approximately 18"-24" around the pool; excavated soil to remain on the property; and install pool enclosure fencing; with the condition that the pool backwash be connected to an existing drywell. The certificate is issued to William &Jeannette Ayers owner of the aforesaid property. 4_ Authorize Ili93gnature Maim Diane From: Bill Ayers <fireline91 @aol.com> Sent: Tuesday, November 15, 2022 1:53 PM To: DiSalvo, Diane r Subject: Ayers 122 Hickory Ave Southold Permit#9821 I would like to inform the Southold Trustees that I decided not to build a 9'x12'shed and the stone walkway leading to the shed. I understand that if I want to pursue this matter in the future that it will be a brand new application process. The Permit is#9821. Sincerly, William Ayers 516 376 1910 ATTENTION:This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. 1 Glenn Goldsmith, President *Qf SoU�� Town Hall Annex A. Nicholas Krupski,Vice President �� ®�� 54375 Route 25 P.O.Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly C G Telephone(631) 765-1892 Elizabeth Peeples ® �® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 1114112, INSPECTED BY: QZCLW-h Peeaol es VXCh. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1St day of construction % constructed Project complete, compliance inspection COMMENTS: RoAt f6t fecoj l -%Qa 4e 91D'x 12i D" &W WM AA 6W a.v%A 4UC re M �1�rte ► way, �n��-alled wenn �xi,��h� �va�lk.uray �o,c �. U&\( A.% cSve cl) 'C CERTIFICATE OF COMPLIANCE: Glenn Goldsmith,President �q SO(/& Town Hall Annex A.Nicholas Krupski,Vice President ,`O� Ol0 54375 Route 25 P.O. Box 1 John M.-Bredemeyer III Southold,New York 11971 Michael J.Domino G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 eOUMy',� BOARD OF TOWN TRUSTEES .SOUTHOLD TOWN BOARD OF TRUSTEES 'YOU,ME REQUIRED-TO CONTACT THE'OFFICE OF THE--BOA-RD-OF TRUSTEES 2'HOURS PRIER 1"O COMMEN'CEMENT OF THE ACTIVITIES•CHECKED OFr" BELOW - INSPECTION SCHEDULE Pre-construction,=liay-bale-line/silt boom/silt curtain 1 st-day of constriiction- % constructed V1lkten ro}ec#complete,-call for compliance inspection; p P" - "iTli iiiso., _ __ ,�iioi ii•i•' = iii SrSi�•.- _-;i\;°°// {Illlj.� -��;,_� ��..�\°°111 9/°1j: `- -4:C``1 If 11 Ir•:-__ ��.,�1/e�%a�.��..."__ :•��1/ ilii•:��_,_ - .'Coi'iii'r•;.�=�; - '"li'iioi°: - "' //'rr _ 1 11 i• " ` l�:• g� Il��. l� �iNIV r/. ,•lnwrr • v p•r 1 s�i�6 n'rl.'1.1}'"J.,�'".b':�4t1?,•,�flrxiw"�Y!'}�!�T!�.AI.SS.invry�,xa�r«.'Y«Yn„�,EY��^'�'r•�rrtr,°.'„�'+,'rgSy'�r�'nTd2&',tiSr_W•.'v,"4r'No 1.'!t'sl.?r�9y?'�'pir.'."LS5"�'""?:':R7l.rc•r,rrfrJ.'�:4"".'<no-'�'.:v'44!{}Te;�� _ 'Eiidd `i `= !!°lei•" y, BOARD OF SOUTHOLD TOWN TRUSTEES rE i SOUTHOLD,NEW YORK , _;z � ?mss�^ l � �a�• PERMIT NO. 9821 DATE: FEBRUARY 17,2021 ISSUED TO: WILLIAM& JEANNETTE AYERS M M' � ? PROPERTY ADDRESS: 122 HICKORY AVENUE, SOUTHOLD SCTM# 1000-78-7-51 /le AUTHORIZATION r Pursuant to the provisions of Chapter 275 of the Town Code of the Town of Southold and in gaccordance with the Resolution of the Board of Trustees adopted at the meeting held on February 17,2021, and in consideration of application fee in the sum of$250.00 paid by William&Jeannette Ayers and subject to the A„ Terms and Conditions as stated in the Resolution,the Southold Town Board of Trustees authorizes and permits �' the following: t Wetland Permit to install a 161x32' in-ground swimming pool made of steel and poured concrete with edge stonework trim approximately 18"-24"around the pool; excavated soil to remain on the property; install a 9'x12' shed; install stonework from the existing walkway to the shed; and install pool enclosure fencing; with the condition that the pool backwash be ' connected to an existing drywell; and as depicted on the survey prepared by Young&Young, :,1111 Licensed Land Surveyor, received on February 9,2021and stamped approved on February 17, !,►,,: `_ 2021. ;r x IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed,and these y 1 presents to be subscribed by a majority of the said Board as of the 17th day of February,2021. '`- ufFQ(�Q$ �CO � rliy' s en - •'�I61f rl�� _ = <;�-_ __ __ _ _ �},` `s$`5 i rusf,u•d1.a�A.;3S:i;ev"�•5i', ;vYA•7):;:)tiRIF3i7"i`�i.Z•.ivr.1 r �1�• r Siu�ni•iiRi•i�i:TvY'i5iu Siil✓'fiFfiiuB'eiiiSSi•��13iF5.irC5invivd)Si..•iiilrvC•di,+.i,iiiiwrlinv'a'S•,Arin"�'`ivii••)t,iti,::ni5•iii•?i.•iFv15a'iS•,•01nY•uvie`d�e,;e•,a'1•ro�Y7v,.wtn ,S_ ..:ell 11,°.. �:;// 111 - .idd 1N �i 1 0 1°-' •i d/ 1 1,... _ :.i dl °1•=' 'Os/1 1 1°� • ejI°�d°°!°1�e;.., - '-•::ri�„ee�el,�'l� ,�::li�„�e��:%'�� ' �tle1,.,0e:°:•” ••:ed::0�1'''�r '•�°::a01'�'';. '•�'d4_°!'�'"� TERMS AND CONDITIONS The Permittee William&Jeanette Ayers, residing at 122 Hickory Avenue, Southold,New York as part of the consideration for the issuance of the Permit does understand and prescribe to the following: 1. That the said Board of Trustees and the Town of Southold are released from any and all damages, or claims for damages, of suits arising directly or indirectly as a result of any operation performed pursuant to this permit, and the said Permittee will, at his or her own expense, defend any and all such suits initiated by third parties, and the said Permittee assumes full liability with respect thereto,to the complete exclusion of the Board of Trustees of the Town of Southold. 2. That this Permit is valid for a period of 24 months,which is considered to be the estimated time required to complete the work involved, but should circumstances warrant, request for an extension may be made to the Board at a later date. 3. That this Permit should be retained indefinitely, or as long as the said Permittee wishes to maintain the structure or project involved, to provide evidence to anyone concerned that authorization was originally obtained. 4. That the work involved will be subject to the inspection and approval of the Board or its agents, and non-compliance with the provisions of the originating application may be cause for revocation of this Permit by resolution of the said Board. 5. That there will be no unreasonable interference with navigation as a result of the work herein authorized. 6. That there shall be no interference with the right of the public to pass and repass along the beach between high and low water marks. 7. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstruction to free navigation,the said Permittee will be required, upon due notice,to remove or alter this work project herein stated without expenses to the Town of Southold. 8. That the said Board will be notified by the Permittee of the completion of the work authorized. 9. That the Permittee will obtain all other permits and consents that may be required supplemental to this permit,which may be subject to revoke upon failure to obtain same. 10. No right to trespass or interfere with riparian rights. This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. Glenn Goldsmith,President 080 Town Hall Annex A. Nicholas Krupski,Vice President 01 54375 Route 25 John M.Bredeme er III P.O. Box 1179 York Y J�L � Southold,New York 11971 Michael J.Domino G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641• ��y00UNT1,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD February 23, 2021 William & Jeannette Ayers 147'Park Blvd. Malverne, NY. 11565 RE: 122,HICKORY AVENUE, SOUTHOLD SCTM# 1000-78-7-51 Dear Mr. and Mrs. Ayers: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, February 17, 2021 regarding the above matter: WHEREAS, WILLIAM &JEANNETTE AYERS applied to the Southold Town Trustees for a permit under the provisions of Chapter 275 of the•Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated November 18, 2020, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator for their findings and recommendations, and, WHEREAS, the LWRP Coordinator issued a recommendation that the application be found Consistent with the Local Waterfront Revitalization Program policy standards, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on February 17, 2021, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members-have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standards set forth in Chapter 275 of the Southold Town Code, f 2 WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees have found the application to be Consistent with the Local Waterfront Revitalization Program, and, -RESOLVED, that-the-Board of Trustees approve the application-of WILLIAM-&J€ANNIETTE AYERS to install a 16'x32' in-ground swimming pool made of steel and poured concrete with edge stonework trim approximately 18"-24" around the pool; excavated soil to remain on the property; install a 9'x12' shed; install stonework from the existing walkway to the shed; and install pool enclosure fencing; with the condition that the pool backwash be connected to an existing drywell; and as depicted on the survey prepared by Young &Young, Licensed Land Surveyor, received on February 9, 2021 and stamped approved on February 17, 2021. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of$50.00 per inspection. (See attached schedule.) Fees: $50.00 "Very truly yours, Gn Golds President, Board of Trustees GG/dd (T)UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW (2)DISTANCES SHOWN HEREON FROM PROPERTY LINES TO EXISTING STRUCTURES ARE FOR A SPECIFIC PURPOSE AND ARE NOT TO BE USED TO ESTABLISH PROPERTY LINES OR FOR ERECTION OF FENCES.(3)COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALD TRUE COPY (4)CERTIFICATION INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND CN HIS BEHALF TO THE TITLE COMPANY.GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON.AND TO THE ASSIGNEES OF THE LENDING INSTITUTION CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT OWNERS (5)THE LOCATION OF WELLS(W).SEPTIC TANKS(ST)&CESSPOOLS(CP)SHOWN HEREON ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS SITE DATA 400 Ostrander Avenue,Riverhead,New York 11901 tel.6511272505 fax.651.'72"1.0144 AREA = 55, 5'18 50. FT. �({ �T admen®youngenglnaering.com "SEE FLOOD INSURANCE RATE MAP PANEL No.5610560166 H lrl � ,�1 � � LAST DATED SEPT.25,2009. / Howard W.Young,Land Surveyor Thomas 0.� ®®® Douglas E AdAola s,Professional Engineer n o� , ®� q® w ® E Robert G.Last,Architect dt Hr HEALTH DEPARTMENT USE�\ o �°ccA• �� \�q� moo\ ` % E C E 1J�\v�f7 E 'Y R o / t/ \ �a '7y F F B — 9 2021 Southold Town Board of Trustees 800, °� \ ry 0/� ,. `GJ _ � \ ^@'�' ,� \ >' a �'po SURVEYOR'S GERTIFIGA_,yION ,�,/pQom. : d Q ��0' e 1 pl \ �0`S' 0� j��qI- / •INE HEREBY CERTIFY TO W 1 L L I A M S T rs 9 �+ 7.84 dFfi \ � V � 'ylO^ AYER5 THAT THI5 SURVEY WAS PREP,A ,IN"�GO�ANC -e 4 THE CODE OF PRACTICE FOR LAND 5uR f5�O Y" '>q-Y °Zj <r ~'rr B co s �� .z 'Y� �� / / !�O/. / YORK STATE ASSOCIATION OF IppIA LAIVEY5 •i" / �GCl/'y / U < <'=4-',:fid � '9C � •�9� ,e ,� s" ��,,y��i '� 66 !O BFL, Q 917.18 tj ,A � /49 �Q�� 9q�9c G• / / m� Lt®^ ISO 6e `� \ �V HOWARD W YOUNG,N.Y.S. /!3e` 5.NO.45 3 O L A D J p\ \q � a�o� ?*o SURVEY FOR rw� � P�/R VY JEANNETTE AYERS -9-OAD Of TRUSTEES at Southold, Town of Southold p r� 0 ��o, 40 Suffolk County, New York TOW SOUTHOLD 5UILVINC7 PERMIT SURVEY i DME / ' County Tax Map Dtstnct 1000 Section 15 Block 0-7 Lot 51 l��H� MAP PREPARED JUNE 15,2016 / v 0� // ��( REVISIONS RHgGOrd Of ReVislons DATE GENERAL AMENDMENTS SEPT.017.2016 ' ¢v, / ADDRESSED 5GDH5 NOIGA OGT. 12,2016 / / ADDRESSED 5GDH5 NOIGA per, O'I 2016 \\ —- AMENDED BUILDPE ING RMIT DATA FEB. 14 201"1 ADDED SWMG DATA MAR. 16.201AMEND '1 E MAY 011, 011 a 5A�N I TARP MEAr5UREMENT5 FOUNDA IONRLOCATIION AUG.25.201"1 0 ` FINAL SURVEY AUG.01,201e) G 8 AMENDED WATER SERVICE JAN 0T.2ol 1 ADDED BUILDING PERMIT DATA JAN.05,2021 ADDED BUILDING PERMIT DATA JAN.26.202J 03 ST 55' 251 ADDED BUILDING PERMIT DATA FEB.09.2021 I LPI 621 5T SO o 25 So 100 IL LP2 61' 511 5H:a1®: 1" = 50' JOB NO.2016-0085 O = MONUMENT SET ■= MONUMENT FOUND D= STAKE SET e= STAKE FOUND ®= PIPE SET = REBAR 4 GAP FOUND = NUMBERED F i AG DWG.2015_0159-2016_0085_bpr5 I OF I ��S11FF0(tco Glenn Goldsmith, President ��® Gy Town Hall Annex A Nicholas Krupski, Vice-President y z 54375 Route 25 John M. Bredemeyer, III o ® P.O. Box 1179 Michael J. Dominoy o� Southold, NY 11971 Greg Williams Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: WILLIAM & JEANETTE AYERS Please be advised that your application dated November 18. 2020 has been reviewed by this Board at the regular meeting of February 17, 2021 and your application has been approved pending the completion of the following items checked off below. Revised Plans for proposed project Pre-Construction Hay Bale Line Inspection Fee ($50.00) 1St Day of Construction ($50.00) %Constructed ($50.00) x Final Inspection Fee ($50.00) -SW Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town'of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $_50.00 2 BY: Glenn Goldsmith, President 401 Board of Trustees ati �t Glenn Goldsmith, Pre, ;t O��%OFFl4L,� t Town Hall Annex A.Nicholas Krupski,Vice'Presidents y `` 54375 Route 25 John M. Bredemeyer III CMtwo P.O.Box 1179 Michael J. Domino Southold,NY 11971 Greg Williams Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD r Date/Time: �' Completed in field by: � G�Q_ WILLIAM & JEANNETTE AYERS requests a Wetland Permit to install a 16'x32' in-ground swi ming pool made of steel and poured concrete with edge stonework trim approximately 18"-24" around the pool; excavated soil to remain on the property; install a 9'x12' shed; install stonework from the existing walkway to the shed; and install pool enclosure fencing. Located: 122-Hickory Avenue, Southold. SCTM# 1000-78-7-51 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: I II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey :5 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 4C• • ALTERATION OR N TO THIS SURVEY IS A VIOLATION T14E NEW YORK STATE RTY LINES TO E AND NOT TO BE USED TO SH PROPERTY LINES OR FOR ERECTION OF IES OF IS SURVEY NOT ATION (1MDCATEDOHEREON SHALL RUN ONLYDTOOTHE PERSON FOR WHOM THE SURVEYYFI5 SECTION PREPARED AND ON HIS BEHALF TO THETITLEEDUCATION GOVERNMENNTTALgAGENCY HEREON AND LENDING INSI TUTION LISTED HEREON.ANDSTRUCTURES O THE ASSIGNEES OFF THE LENDINGINSTITUTIONARE CERTIFICATIONS ARE NOT TRUANSFERABLE TO ADDITIONAL INSTITUTIONS OFENCES. SUBSEQUENT OWNERS n(5)THE LOCA ON OFB�S( THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE FIELD OBSER A TO BE A VALID TRUE COPY (4)OM OT ERS. (W),SEPTIC TANKS(ST) I CESSPOOLS(cP)SHOWN HEREON ARE FROM BC OBSERVATIONS AND OR DATA OBTAINED )CE OTHERS. SITE DATA 400 Ostrander Avenue,Riverhead,New York 11901 tel.631.72'12505 fax.631.72"1.0144 AREA = 33, 5"18 50. PT. adm►n®youngengineer►ng.com ♦1• 'SEE FLOOD INSURANCE RATE MAP PANEL NO.8610360166 H lel �y� LAST DATED SEPT.25,200'1.- �{. 4'y;1• Howard K Young,Land Surveyor s ® Thomas G.Wolpert,Professional Engineer '9 �Dtry i ® Douglas E.Adams,Professional Engineer 12 �/ ,a�( Q�^ //r"T Robert G.Tast,Architect 1/ Ie ®® ® HEALTH DEPARTMENT USE af'p°i 3� 6t 60� ®� ® sorllr�e 91 0 00 'o 6\:N 'f aO \ O,• o E C E 0 U E ry F F B ® 9 2021 j i �v ryc� < \ �,4 Southold Town 'Al <'8, \ 0 Board of Trustees �\� �� ®p® �.. \ � �' \ @•. A4<1t�� \ � ' a opt / SURVEYOR'S GERTIFIGA N-�-� vl \ '�0`� \ 0� j� q/��y / ONE HEREBY CERTIFY TO WILLIAM A EgAN E \ SQ 70 T �S 4 °j Q 7.94n� \ 0 i V / 'V/� O THAT THIS SURVEY WA5 PREP 'I AO �J/ �(` ~�� THE.ODE OF PRACTICE FOR LAND 5U AQD ` Imp, �A / YORK STATE AS�.�OGIATION OF O A S^A` ' Dei\c�C°'�9� � ',gyp • ✓ `�e7 ' 'y� / / G, 6,� Jfir /iQ �Y s E ` Q�@ o� ®k s � �S 4 5 8 9'6 4 1 \ YOUNG , / @ W. ,N.Y.S. . .NO. 93 O S rya�e, ql '' J. b �`'�/ �'" �/ s S /� / / HOWARD NL458LAND h. . \ ®\ ,g" O�^�' g o.�'^ �o o,\C\ / `� / '►° / SURVEY FOR C11 Aq� Of ® ,�' °;' ,t'?� •� �, / /0 / WILLIAM ,4YER5 JEANNETTE AYER5 at Southold, Town of Southold 0 Oa �� Suffolk County, New York BUILDING PERMIT SURVEY County Tax Map District 1000 Section 78 Block 01 Lot 51 ® `1 MAP PREPARED JUNE I5,2016 ' 0 �Q�� REVISIONS Record Of Revisions DATE ADDRESS AMENDMENTS SEPT.0-1 2016 ADDRESSED SGDHS NOIGA OCT- 12.2016 \ i i ADDRESSED SGDHS NOIGA DEG.O T,2016 AMENDED BUILDING PERMIT DATAADDED 9mc,DATA FEB. 14 201'1 AMENDEDINN D" ASE MAY 09.201? s <, 5,4N I TORY MEASUREMENTS FOUNDATION LOCATION AUG.25.2011 FINAL SURVEY AUS.07.2018 A B AMENDED WATER SERVICE JAN.0`7,201 `o ADDED BUILDINS PERMIT DATA JAN,05,2021 ADDED BUILDINS PERMIT DATA JAN,26.2021 m ST 33' 25' ADDED BUISDINS PERMIT DATA FEB.09.2021 50 0 25 50 100 LPI 62' 57' a LP2 61' 51' Scale: I" = 50' JOB NO.2016-0085 MONUMENT SET ■= MONUMENT FOUND = STAKE SET = STAKE FOUND 0= PIPE SET 0= REBAR 4 GAP FOUND = NUMBERED FLAG DWS.2015_0159-2016_0085JDpr3 I OF I 'William Jeannette Ayers .122 Hickory Avenue,Southold s2/9/21 r . .4 t 2/ 9/2021 1121 IZED ALTERATION OR THIS RVEY IS A ION OF CTION 72D9 OF THE NEW YORK STATE EDUCATION LAW 2)DISTANCES OWN ON FROM ERTY LINES TO TING ARE FOR A SPECtFIC AND ARE NOT TO BE USED LISH PROPERTY NES OR FOR CTION AND SURVEYOR'S ED SEAL ALL NOT BE TO BE A VALID E COPY (1NDICATED�HEREON SHALL RUN ONLYwTOOTHE°PERSON'FOR WHOM THE SURVEY 15P PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY.(COVERNMENTALSAGENCY AND LENDING INSTITUTION LISTED HHEREON.ANDTOSTRUCTURES ASSI ES OFF THE LENDING�INSTINIION CERTIFICATIONS ARTE NOT�TRANSFERABLE T'�ADDI ONAL INSTITUTIONS SOR SUBSEQUENT OWNERS. (5)THE LOCATION OF BEARING WELLS(N').SEPTIC TANKS(5»ffiINKED CESSPOOLS(CP)SHOWN HEREON�ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED(4)CERTIFICATION OTHERS' 511E DATA 400 Ostrander Avenue,Riverhead,New York 11401 tel.631.921.2303 fax.631.121.0144 AREA = 33,578 50. FT. adminayoungenglneering.com t SEE FLOOD INSURANCE RATE MAP PANEL N0.9610300166 H lel 4 � 4 � LAST DATED SEPT.25,2004. ! Howard W.Young,Land Surveyor ® Thomas G.Wolpert,Professional Engineer Douglas E.Adams,Professional Engineer N O\1) ' Robert G.Tast,Architect Addog ®<®® ® HEALTH DEPARTMENT USE ® rmel�e�e 'woo�``ry�' �, *G S 0 �."� °q o Ch O,% % \ 00 0] ,� ^. 440 e� ry ® F) 104 110, /,S > 11 Cb hs SURVEYOR'S CERTIFICATI is KI vl �9 \ ^�7@.S�_ \ OY -r---�Q/�h / e)NE HEREBY CERTIFY TO W I L L I A M AY ��&':kL t 794 ,E / V / 'Y/ p AYERS THAT THIS SURVEY WAS PREP ANC THE CODE OF PRACTICE FOR LAND BY YORK STATE A550CIATION OF \ ! yl ANLr� O . A / art tq� d E \ 4' @CO. ® /:v �('b 9p ,�"' .g(i'� i ' q� �O /'�E@�, �o ''>IS / / j,� 45' g 9310 HOWARD W YOUNG,N.Y.5.L.S.NO.45893 N \ ® \ "�Y� ,q ((/��"off;' ,q` ��o oo, \ / 5URVEY FOR �� \� Y41LLIAM AYERS 4 3336 : I' .,� �a ', / ' JEANNETTE AYERS at Southold, Town of Southold Suffolk Count New York ® ' E P W E y, �Ot �U� BUILDING PERMIT 5URVE1' '* JAN 9 20�f County Tax Map D,.trict 1000 sCotcoD 78 Block 07 Lot 51 a �\ MAP PREPARED JUNE 15,2016 0� // N& Record of Revisions REVISIONS DATE Southold Town GENERAL AMENDMENTS SEPT.09.2016 ' Board of Trustees ADDRESSED SCDHs NOIGA OGT, 12 2016 \ , ADQRESSED SCDHS NOIGA DEC-09 2016 AMENDED BUILDING PERMIT DATA FEB. 14-201 \< , 5AN I TARP MEA5UREMENTS ADDED DSJAIMCPR DATA MAR. I6.201'1 J ` , AMENDED DRAINAGE MAY 09.201'1 FOUNDATION LOCATION AUS-25,2011 o \� A B FINAL SURVEY AUG.09.2018 o AMENDED WATER SERVICE JAN 01,201 ADDED BUILDING PERMIT DATA JAN,05.2021 GO ST 33' 25' ADDED BUILDING PERMIT DATA JAN,26.2021 LPI 62' 57' SO o 25 so 100 LP2 61' 51' SGOle: 1" = 50' JOB No. O = MONUMENT SET ■= MONUMENT FOUND = STAKE SET A= STAKE FREBAR 8 GAP FOUND NUMBERED FLAG FOUND ®= PIPE SET DWG.20 5-0159-2016_oo85_bpr2 I of 1 = NEW YORK STA EPARTMENT OF ENVIRONMENTALNSERVATION Oboe Facility DEC ID 1-4738-04477 PERMIT Under the Environmental Conservation Law ECL Permittee and Facility Information Permit Issued To: Facility: WILLIAM AYERS AYERS PROPERTY 147 PARK BLVD 122 HICKORY AVEISCTM 1000-78-7-51 MALVERNE,NY 11565 SOUTHOLD,NY 11971 (516) 376-1910 Facility Application Contact: THOMAS WOLPERT 400 OSTRANDER AVE RIVERHEAD,NY 11901-4614 (631) 727-2303 Facility Location: in SOUTHOLD in SUFFOLK COUNTY Village: Southold Facility Principal Reference Point: NYTM-E: NYTM-N: Latitude: Longitude: Project Location: 122 Hickory Ave - Watercourse - Goose Creek Authorized Activity: Construct single family dwelling, garage, driveway and sanitary,system. All authorized activities must be in strict conformance with the attached plans stamped NYSDEC approved on 1/10/17. Permit Authorizations Tidal Wetlands -Under Article 25 Permit ID 1-4738-04477/00001 New Permit Effective Date: 1/10/2017 Expiration Date: 1/9/2022 NYSDEC Approval By acceptance of this permit,the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, and all conditions included as part of this permit. Permit Administrator:LAURA J SCOVAZZO, Deputy Regional Permit Administrator Address: NYSDEC Region 1 Headquarters SUNY @ Stony BrookJ50 Circle Rd Stony Brook, 11790 -3 9 zed Si Authors Signature: Date Page 1 of 6 A& NEW YORK STA'9�L�DEPARTMENT OF ENVIRONMENTAL NSERVATION � Facility DEC ID 1-4738-04477 . Distribution List THOMAS WOLPERT Marine Habitat Protection LAURA J SCOVAZZO Permit Components NATURAL RESOURCE PERMIT CONDITIONS GENERAL CONDITIONS, APPLY TO ALL AUTHORIZED PERMITS NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS NATURAL RESOURCE PERMIT CONDITIONS - Apply to the Following Permits: TIDAL WETLANDS 1. Post Permit Sign The permit sign enclosed with this permit shall be posted in a conspicuous location on the worksite and adequately protected from the weather. 2. Notice of Commencement At least 48 hours prior to commencement of the project,the permittee and contractor shall sign and return the top portion of the enclosed notification form certifying that they are fully aware of and understand all terms and conditions of this permit., Within 30 days of completion of project,the bottom portion of the form must also be signed and returned, along with photographs of the completed work. 3. Concrete Leachate During construction,no wet or fresh concrete or leachate shall be allowed to escape into any wetlands or waters of New York State, nor shall washings from ready-mixed concrete trucks, mixers, or other devices be allowed to enter any wetland or waters. Only watertight or waterproof forms shall be used. Wet concrete shall not be poured to displace water within the forms. 4. No.Construction Debris in Wetland or Adjacent Area Any debris or excess material from construction of this project shall be completely removed from the adjacent area(upland)and removed to an approved upland area for disposal. No debris is permitted in wetlands and/or protected buffer areas. 5., No Disturbance to Vegetated Tidal Wetlands There shall be no disturbance to,vegetated tidal wetlands or protected buffer areas as a result of the permitted activities. 6. Storage of Equipment, Materials The storage of construction equipment and materials shall be confined within the project work area and/or upland areas greater than 75 linear feet from the-tidal wetland boundary. Page 2 of 6 i NEW YORK STA EPARTMENT OF ENVIRONMENTAL&SERVATION Facility DEC ID 1-4738-04477 7. Seeding Disturbed Areas All areas of soil disturbance resulting from the approved project shall be stabilized with appropriate"vegetation(grasses, etc.)immediately following project completion or prior to permit expiration,whichever comes first. If the project site remains inactive for more than 48 hours or planting is impractical due to the season,then the area shall be stabilized with straw or hay mulch or jute matting until weather conditions favor germination. 8. Establish Vegetated Buffer To protect the values of the tidal wetlands, a permanent vegetated buffer zone shall be established. There shall be no disturbance to the natural vegetation or topography within an area extending as per NYSDEC approved plans. 9. Straw Bales or Other at Tidal Wetland A row of staked straw bales or approvable erosion control devices shall be placed at the landward edge of the buffer area as per the NYSDEC-approved plan,prior to commencement of any regulated activities and remain in place and in good, functional condition until the project is completed and all disturbed areas are stabilized with vegetation. 10. Runoff Directed to Upland Drywells Roof runoff shall be directed to drywells a minimum of 100 linear feet landward of the tidal wetland boundary for immediate on-site recharge. 11. Sanitary Systems above Groundwater Sanitary system(bottom of tank and leaching pools) shall be located a minimum of 2 feet above seasonal high-groundwater. 12. Contain Exposed, Stockpiled Soils All disturbed areas where soil will be temporarily exposed or stockpiled for longer than 48 hours shall be contained by a continuous line of staked haybales/silt curtains (or other NYSDEC approved devices)placed on the seaward side between the fill and the wetland or protected buffer area. Tarps are authorized to supplement these approved methods. 13, State May Order Removal or Alteration of Work If future operations by the State of New York require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural,resources of the State,the owner may be ordered by the Department to remove or alter the structural work, obstructions, or hazards caused thereby without expense to the State, and if,upon the expiration or revocation of this permit,the structure, fill, excavation, or other modification of the watercourse hereby authorized shall not be completed,the owners, shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require,remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watercourse.,No claim shall be made against the State of New York on account of any such removal or alteration. 14. State May Require Site Restoration If upon the expiration or revocation of this permit,the project hereby authorized has not been completed,the applicant shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may lawfully require,remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. Page•3 of 6 O NEW YORK STA DEPARTMENT OF ENVIRONMENTAL PNSERVATION Facility DEC ID 1-4738-04477 15. Precautions Against Contamination of Waters All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings,paints, concrete, leachate or any other environmentally:deleterious materials associated with the project. 16. Conformance With Plans All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or applicant's agent as part of the permit application. Such approved plans were prepared by Elizabeth McQuilkin(survey),last revised 12/8/16, stamped -NYSDEC approved 1/10/17. 17. State Not Liable for Damage The State of New York shall in no case be liable for any damage or injury to the structure or work herein authorized which may be caused by or result from future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no claim or right to compensation shall accrue from any such damage. GENERAL CONDITIONS - Apply to ALL Authorized Permits: 1. Facility Inspection by The Department The permitted site or facility;including relevant records, is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation(the Department)to determine whether the permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71- 0301 and SAPA 401(3). The permittee shall provide a person to accompany the Department's representative during an inspection to the permit area when requested by the Department. A copy of this permit, including all referenced maps, drawings and special conditions,must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy of the permit upon request by a Department representative Js a violation of this permit. 2. Relationship of this Permit to Other Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Department or any of the terms, conditions or requirements contained in such order or determination. 3. Applications For Permit Renewals,Modifications or Transfers The permittee must submit a separate written application to the Department for permit renewal, modification or transfer of this permit. Such application must include any forms or supplemental information the Department requires. Any renewal, modification or transfer granted-by the Department-must be in writing. Submission of applications for permit renewal, modification or transfer are to be submitted to: Regional Permit Administrator NYSDEC Region 1 Headquarters SUNY @-Stony BrookJ50 Circle Rd Stony Brook,NY11790 -3409 Page 4 of 6 NEW YORK STAI PEDEPARTMENT OF ENVIRONMENTAL.C SERVATION Facility DEC ID 1-4738-04477 4. Submission of Renewal Application The permittee must submit a renewal application at least 30 days before permit expiration for the following permit authorizations: Tidal Wetlands. 5. Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to exercise all available authority to modify, suspend or revoke this permit. The grounds for modification, suspension or revocation include: a. materially false or inaccurate statements in the permit application or supporting papers; b. failure by the permittee to comply with any terms or conditions of the permit; c. exceeding the scope of the project as described in the permit application; d. newly discovered material information or a material change in environmental conditions,relevant technology or applicable law or regulations since the issuance of the existing permit; e. noncompliance with previously issued permit conditions, orders of the commissioner, any provisions of the Environmental Conservation Law or regulations of the Department related to the permitted activity. 6. Permit Transfer Permits are transferrable unless specifically prohibited by statute, regulation or another permit condition. Applications for permit transfer should be submitted prior to actual transfer of ownership. NOTIFICATI®N OF ®TILER PERMITTEE OBLIGATI®NS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee, excepting state or federal agencies, expressly agrees to indemnify and hold harmless the Department of Environmental Conservation of the State of New York, its representatives, employees, and agents ("DEC") for all claims, suits, actions, and damages,to the extent attributable to the permittee's acts or omissions in connection with the permittee's undertaking of activities in connection with, or operation and maintenance of, the facility or facilities authorized by the permit whether in compliance or not in compliance with the terms and conditions of the permit. This indemnification does not extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or intentional acts or omissions, or to any claims, suits, or actions naming the DEC and arising under Article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision under federal or state laws. Item 13: Permittee's Contractors to Comply with Permit The permittee is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit, including all special conditions while acting as the permittee's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee. Page 5 of 6 Am NEW YORK STANEPARTMENT OF ENVIRONMENTAL APSERVATION oboe. Facility DEC ID 1-4738-04477 Item C: Permittee Responsible for Obtaining Other Required Permits The permittee is responsible for obtaining any other permits, approvals, lands, easements and rights-of- way that may be required to carry out the activities that are authorized by this permit. Item D: No Right to Trespass or Interfere with Riparian Rights This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights,title, or interest in real or personal property held_ or vested in a person not a party to the permit. Page 6 of 6 Construction Phasing Plan 1 . Stormwater remediation barriers with hay bales staked to the ground at 127 ft from the mean high tide line. 2. Excavation of pool with all soil remaining on site. 3. Construct a 16'X32' steel wall pool 31/2'-6' deep and auto cover box in the deep end 3'X21 ' and 3' deep. 4. Poured concrete steps, benches and collar surrounding the pool stru ctu re. 5. 2 inch plumbing to al fixtures incorporated in pool. Sand filter will be used. 6. Pressure test plumbing to insure no leaks in the system. 7. All backwash water to the drywell on site. 8. Back fill pool and install liner. s Dimensions, Material specifications and installation details for erosion and sediment. control i Silt Fencing staked into ground 100 linear feet of fencing placed at 127ft from the mean high"tide line. Hay bales f staked into ground with 4ft rebar-to prevent from moving 100 linear feet of bales placed at 127ft from the mean high tide line Wattles placed around excavated earth 120 linear feet around dirt pile to leave enough room to prevent any ! pollution from soil. Tarp covering excavated earth to help prevent erosion. ' keep dust down to a minimum 20x30 tarp size v" - a - r i 1 4 i Town of Southold - Chapter 236 - Stormwater Management ` J CONTRACTOR CCATION STATEMENT Prior to the commencement of construction activity,the owner or operator must identify ALL contractor(s)and sub-contractors)that will be responsible for installing,constructing,repairing,replacing,inspecting and maintaining the erosion and sediment control practices included in the SWPPP;and the contractor(s)and ' sub-contractors)that will be responsible for constructing the post-construction stormwater management practices included in the SWPPP. The owner and/or operator shall have each of the contractors and/or sub-contractors identify at least one person from their company that will be responsible for implementation of the SWPPP.This person shall be known as the trained contractor.The owner and/or operator shall ensure that at least one trained contractor is on site on a daily basis when soil disturbance activities are being performed. The owner and/or operator shall have each of the contractors and subcontractors identified above sign a copy of the following certification statement below before they commence any construction activity: CERTMCArnON "I hereby certify that 1 understand and agree to comply with the terms and conditions oithe SWPPP and agree to implement any corrective actions identified by the qualified inspector during a site inspection.I also understand that the owner or operator must comply with the terms and conditions of the most current version of the New York State Pollutant Discharge Elimination System("SPDES")general permit for stormwater discharges from construction activities and that it is unlawful for any person to cause or contribute to a violation of water quality t: standards_Furthermore,I understand that certifying false,incorrect or inaccurate information is a violation of the referenced permit and the laws of the State of New York and could subject me to criminal,civil and/or administrative proceedings. , �c�L� Ur�� t � y�`nlklzo In addition to providing the certification statement above,this page must also identify the specific elements of the SWPPP that each contractor and/or sub-contractor will be responsible for. Specific SWPPP Element: '31 W- I I�US(1 (Please Describe Hem) it i ---------------- ---m.._.-----------------------------------.--.------_---_ { NAME and TITLE of the Trained Contractor(s) responsible for SWPPP implementation; T\ko Y� is NAME* 'ner. NAME,address and telephone number of the Contracting Firm; i rtWD C5 Property Address and 12Z i� Suffolk County Tax Map Number of the site; S.C.TA.#: ,loan 451 -------------------- District Section Block Lot j The owner and/or operator shall attach All certification statement(s)to the copy of the SWPPP that is maintained at the construction site.If new or additional contractors are hired to implement measures identified in the SWPPP after construction has commenced,they must also sign the certification statement and provide the information listed above. For projects where the Department of Environmental Conservation requests a copy of the SWPPP or inspection reports,the owner and/or operator shall submit the documents in both electronic(PDF'only)and,paper format ! within five(5)business days,unless otherwise notified by the Department. SWPPP Certification Statement FORM: 03-12 TOWN OF SOUTHOLD xo`�srocxfip-k CHAPTER 236 C-011 _t Storm Water Management P P �� List of Approved BMPs (Best Management Practice) INTRODUCTION: Town Code,Chapter 236 requires that an Owner,Contractor or Authorized Agent submit a Storm Water Pollution Prevention Plan(SWPPP)for all new construction and/or re-development activity that involves soil disturbances of five thousand(5,000 S.F.)square feet of area. All land-disturbing activities,including the addition and/or replacement of impervious surfaces,shall provide temporary and permit construction controls to meet the requirements of Chapter 236. SEE the following list of Approved BMPs which meet the minimum requirements of Town Code Chapter 236. The purpose of this list is to develop an understanding of the type of BMP that may be required,and/or available for F. compliance with the provisions of Chapter 236. Additional design details and BMP Specifications can be found in the most recent version of the New York State Stormwater Management Design Manual. Temporary Construction Controls Infiltration Practices ' Stabilized Construction Entrance Infiltration trench(Vegetated Drainage Swale) Temporary Swale Infiltration Basin (Precast Concrete Leaching Pool) Vegetation Protection/Seeding Dry Well Straw Bale Dike Grassed Swales ' kSilt Fence Permeable Interlocking Concrete Pavers Storm Drain Inlet Protection Pervious Concrete Pavement Temporary Sediment Trap Porous Asphalt Pavement Check Dam Storm Water-Retention/Detention—Ponds Filtration Practices Dry detention ponds Bio-retention(Rain gardens) E In-line storage Catch Basin Inserts On-lot treatment Organic Filters Stormwater wetland Vegetated Filter Strip Wet'ponds Underground Sand Filter Micro-pool Extended Detention Pond Perimeter Sand Filter Wet Extended Detention Pond Multiple Pond System Open Channel Practices Pond I Wetland System Dry Swale Wetland Wet Swale Extended Detention Wetland Shallow Wetland When DEC Limits have been triggered,an Owner,Contractor or Authorized Agent must also acquire coverage j under NYS DEC SPDES General Permit for Storm Water Discharges for activities that reach the limits established for construction activity as defined under the DEC SPDES General Permit,(No.GP-0-10-001),prior to any work. ! A copy of this general permit can be found on the DEC Web Site at:(http://www_dec.ny.2ov/chemical/41392.htm1)_ i An owner or operator of a construction activity that is subject to the requirements of a regulated,traditional land use control MS4 must first develop a SWPPP in accordance with all applicable requirements of the general permit and then have its SWPPP reviewed and accepted by the MS4 prior to submitting the NOI to the DEC.The owner or operator shall have the"MS4 SWPPP Acceptance Form"signed by the Stormwater Management Officer"SMO" and then submit that form along with the NOI to the address referenced under"Notice of Intent(NOI)Submittal". For all approved SWPPPs,the owner or operator shall ensure that the provisions of the SWPPP are implemented from the commencement of construction activity until all areas of disturbance have achieved final stabilization. A Notice of Termination(NOT)must be submitted to the DEC for all DEC regulated construction activities. Town of Southold - Chapter 236 - Stormwater Management x SWPPP e Storm Water Pollution Prevention Plan Assessment (Form i,01 T� GENERAL INFORMATION: (All Requested Information is Required for a Complete Application) APPLICANT NAMEt -Agent- d� nbactorarother(Circle One) Property OWNER.(ifDifterentthan Applicant) 6bN� r le A ' Address Address: I Tclepho FmiM Telephone#: Fax#: i ��y/ i E-Mail: L,^ E-Mail: I Property Address � c?% �r Brief Description of Constmction Activity,Proposed Structural BWS,Soil Stabilization BAIPs,Project Scope and/or Sequence of Construction Activity 10410 (Pm �t AE3 imral Pa(+as as tteeaea) ' Olstrlct Setlioo Bled[ Lor _ r �' Nam of Contractor 2ndfor Contact Person Responsible for Implementation of SWPPP: -__ __ Address: _�__ / _ __.•_ -___ �� i Tela ones ph Fax# __�ti! // _ _C%V��` t—(moo✓✓(�( '`Y� �: E-mail, Name f Perso Responsible for In tion&,—once of Erosion Control Practice: e/ ------------------ Address:! -� od _ d -'------------------------------ ------ • --- i. TeleP / G Faxtk ---------------------------------------------- E-Wal ------------------------------------------ __E-Mal ! l -------------------------------------------- i i ----- _'-------_.--------- i. Tolal Area of All "� Total Area of land Gearing - - -- Project Parcels- o andiorGrolmdMsturbance. -------------------------------------------- (SF.t Azesj (SF./Affas) Start End Project Duration: 11, 9 _ ..---.--------------------------------,.___--_--- jl {Antidpat (l Date t Data: -------------------------------------------------- fi r, ..._---------•----------------- e Will this Project Disturbe five(5)or More Acres at Arty One Time During the Proposed Development? Yes No -----_----------------__----------__------__--- i OYES:Phase Answer the Fonowirryl_ -----------------------_---__--__-- .-------------- a. Does the Applicant have a Qualified Inspector On [_] Q I Staff To Conduct the Required Inspections? Yes No b._DoestheSWPPPIndipteHowFrequen!►ytheSite Q = List the ES ordesertptionof211 teAntiallytm WaterbodiesandiorWetiands: ' Inspections will Occur and for What Periodof Time? Yes No -_ � 77`_�_ f c. Does the SWPPP Adequately Identify All Temporary �] and/or Permanent Soil Stabalization Measures? Yes No I d. Does the SWPPP Adequately Identify a Complete Q Q -------- Project ------Project Phasing Plan? Yes No Status of Impacted waterbody:(eg.TMDL•303(d)Listed,Impaired.-I e. Does the SWPPP Indicate Additional Sile Specific = Q /v b� C j Practices that Will be Utilized to Protect Water Quality? Yes No _ _ _ f. Has the Applicant Submitted a Completed DEC Notice Type of Impacted Waterbody:(eq.Lake.Creek, P nd,Sound,FreshwderWetland_,) Of Intent and SWPPP Acceptance Form for Review Q F__1 �n by the Town of Southold? Yes No ---------_- _ -- S'l7A1T or NFW YORK, r. (�LL (� COUNTY OF__ ITl•Q-�_.1�._........SS That I,.Y1,9.�• 1�. •••-j •• � ••••••....being duly swum,deposes and says that lie/she is the applicant for Pennit, (Name o(mdrvi�la(sig� � tj And that he/she is the ........ �s�l•ICr.... ....."............. ......._.............._...... "• (Ow Contractor,Agent,Corporate Officer,etc.) Owner and/or representative of the Owner or 0%mers,and is duly authorized to perform or have performed the said work and to make and Glc this application;that all statements contained in this application are true to the best of his knowledge and belief;and that the work will be performed in the manner set forth in the application filed herewith. Sworn to before me this; ......�.0 --_..day of ,200 ( 6 R�±CEY L. DWYER �/v ` Notary Public .--.. ............................. !rTAIT, Y PUBLIC,STATE OF NEW YORK (SignalureofApp card) t SWPPP Assessment FO : 03-12 % QUALIFIED IN SUFFOLK COUNTY COMMISSION EXPIRES JUNE 30,2 -- -- -- -- - - - - - - ---- - -- - -- TOWN of SOUTHOLD yf CHAPTER 236 a Storm Water Management °yk Stormwater Assessment Form & Review Application Instructions NOTE:These application instructions are provided as guidance and for the convenience of applicants.In the instance that these instructions are inconsistent with Chapter 236 or the New York State Department of Environmental Conservation ONYSDEC)SPDES General Permits for Construction Activities (GP-0-10-001),Chapter 236 and the General Permit are controlling. ! I. If the land development activity involves any one of the below,the Applicant is required to Prepare a Town SWPPP with all elements of Checklist#1 and complete the General information on the SWPPP Assessment 4 Form of the application only: f a. Clearing,grubbing,grading or stripping which affects more than 5,000 square feet of ground surface. b. Excavation/filling involving more than 200 Cu.Yd.of material within any parcel or any contiguous area. I c. Site preparation on slopes which exceed 10 feet of vertical rise to 100 feet of horizontal distance. d. Site preparation within 100 feet of wetlands,beach,bluff or coastal erosion hazard area. e. Site preparation within the one-hundred year floodplain as depicted on FIRM Map of any watercourse. f Installation of new or resurfaced impervious surfaces of 1000 sq.ft.or more,unless prior approval of a Stormwater Management Control Plan was received by the Town and the proposal includes in-kind i replacement of impervious surfaces. g. If the Stormwater Management Officer or NYSDEC determines that compliance with Article II or Article III of Chapter 236 or the SPDES General Permits for Construction Activities(GP-0-10-001)is NOT required. i II. Unless otherwise required by the NYSDEC SPDES General Permit for Construction Activities (GP-0-10-001),if the land development activity involves any one of the below,the Applicant is required to Prepare a DEC-SWPPP(showing all elements of Checklist#1 and meeting requirements of GP-0-10-001); { Prepare a DEC-NOI;and complete the General Information requested on the SWPPP Assessment Form of the application: a. Construction activities that involve soil disturbance of I or more acres of land,but less than 5 acres of { land(single family residential subdivisions with 25%or less impervious cover at total site build-out; s construction of a barn or other agricultural building;single family homes that do not meet the thresholds of III c. (below). b. Construction activities that involve soil disturbances of 1 or more acres of land(Installation of underground linear utilities; environmental enhancement projects,bike paths/trails,sidewalk construction projections,slope stabilization projects,slope flattening that changes the grade of the site but does not significantly change the runoff characteristics,spoil areas that will be covered with vegetation;land clearing and grading for the purposes of creating vegetated open space;athletic fields ' that do not include construction or reconstruction of impervious area and do not alter hydrology, Demolition project where vegetation will be established and no redevelopment is planned;Overhead electric transmission line project;Structural practices identified in Table II in Agricultural Management Practiccs Catalog for Nonpoint Source Pollution in New York State). c. If the Stormwater Management Officer or the NYSDEC determines that compliance with§236-19(B)or the SPDES General Permits for Construction Activities(GP-0-10-001)is NOT required. E t ID[. If the land development activity involves construction activities that discharge or,potentiatly discharge to surface waters by a municipal separate,storm sewer system(e.&a municipal street,culver'or drain) and meet any of the below thresholds,the Applicant is required to Prepare a DEC-SWPPP(showing all` elements of Checklist#.1 and meeting the requirements of GP-0-10-001);Prepare and submit a completed DEC-Notice of Intent"NOP';and complete the General Information requested on the SWPPP Assessment Form of the application: a. Stormwater runoff from land development activities that discharge a pollutant of concern to an impaired water as designated by the NYSDEC or a TMDL designated watershed b. Stormwater runoff from land development activities disturbing 5 or more acres c. Stormwater runoff from land development activity disturbing between 1 and-5 acres of land during the course of the project,exclusive of the°construction of single family residences and construction activities at agricultural properties; d. Stormwater runoff from land'development activity associated with single family homes directly ; discharging to 303(d)segments impaired by pollutants related to land development activities; e. °Stormwater runoff from land development activity associated with single family residential subdivisions " directly discharging to'303(d)segments impaired by pollutants related to land development°activities;or f. If the Stormwater Management Officer or the NYSDEC determines that compliance with Article II and Article III,Part§236-19,of Chapter 236 or the SPDES'General Permits for Construction Activities (GP-0-10-001)is required. The role of the Town Stormwater Management Officers°is to assist the public in the application of Chapter 236. If you have any questions or would like to request a pre-application conference/review,please call or e-mail: (Jamie richter `own.southold.nyus) ' Additional Items Required for All SWPPP Review&Approvals: z ® Please Complete All Sections of General Information`required on the Storm !Nater Pollution Prevention Plan Assessment FORM provided in these Application Instructions. ® Please Provide a Self Assessment of the Proposed Land Development by utilizing the Plan Review Checklist provided in these Application Instructions'.' Please Complete the Contractor Certification Statement for All, Contractors and/or Sub- Contractors. A Separate Certification Statement shall be required for each Contractor. ® When required, please provide a copy of the completed DEC- NOI and a completed DEC-SWPPP Acceptance Form review and approval by the SMO. o An Applicants failure to adequately provide and/or submit the°following, 1. Completed SWPPP'Assessment Form; (Required for all Applications) 2. Town SWPPR including all items listed in Checklist# 1; (Required for all Applications) • " 3. -DEC SWPPP ,when required, which would include all items in, Checklist# 1 &#2 and/or as required by DEC Permit GP-0-10-001; 4. Completed DEC- Notice of Intent"NOI", when required; 5. Completed,SWPPP Acceptance Form for SMO review and approval, when required; and/or 6. Completed Contractor Certification Statement. (Required for all Applications) is cause for rejection and/or denial of the application. osu�ak DEC "SWPPP" Preparation - Chapter 236-19 For Department Use Only: Storm Water Pollution Prevention Plan 5.C,T.M.iJ: l Property Address: g1 Review Checklist Checklist # 2 11000 / (Additional Items to be included with Checklist#1 when Article III is trigered,) MUM eocllon Wook Lot REQUIRED PLAN INFORMATION AND IMPLEMENTATION DETAILS:, i i 1 i Plan Sheet YES! NO ,N.A.,Explanation for NO or N.A.Must be Approved by SMO Location g.# (Does the SWPPP Ade uatel Provide for and/or Indicate the Following: ; , (p ) 1, Does the Plan Indicate an for how all Items Require y_C ec list_ V in this Packet? » ; ( � � 2, Does rho Plan Indicate and/or Show a Description of Each Post-Constructlon Stormwater ManagementPraclice?._, ._.. ._,•.,....,:•. .....___._ 1 ' ! aCOYr_.�f1R .,- tu�iS.._W1�1�•,._,.•.,_..._ . ,...._•. 3. Does the Site Plan/Construction Drawings)Indicate andlor Show the Location&Size of _ i 0!i�i 0 Each Post,Construction Stormwater Mana ement Practice? ! ` YYl 1 t� 4. Does the Site Plan/Consltuctlon Drawings)Indicato and/or Show Hydrologic&Hydraulic Analysis For All Structural Components^of the Stormwater Management System for Applicable,Storms? _� i �,,,_,.•,„,_ _ _._ ._.»_,. . _,_ .... _._.....- ,»,_. _.. .. 5, Does the Site PIanlConstructlon Drawing(s)Indicate and/or Provide a Comparison of Post- Deveto men/Stormwater Runoff Conditions with Pro-Development Conditions? ti. Does the Site Plan/Construction Drawings)Indicate and/or Show All Dimensions,Material Specifications&Installation Details for Each Post-Construction Stormwater Practice 7 �'® (!U t,� 4 G;1 I y► 6-I�u ( ,,�0`rl�Ya��uV.1 N1y SCYt„ 7. Does the Slte Plan/Construction Drawing(s)Indicate a Maintenance Schedule Provided by ! u 1 1 the Conslractor(s)to Ensure Continuous&Effective Operation of Each Post-Construction Stormwater Management Practice? 8. Does the Sile to Drawing(s)indicate and/or Show Maintenance Easements to Ensure Access to All Stcrmwator Management Practices at the Site for the Purpose of Inspection [�� and Repair 7 9, Does the Slte Plan/Constructlon Drawing(s)Indicato and/or Show Inspection and Maintenance ; ; Agreement(s) that aro Binding on All Subsequent Landowners? 10. For Atl AcBvlties meeting the Threshold in 236-19(B)(1),the SWPPP shall be Prepared&Signed By a Professional in the Principles and Practices of Stormwater Management ti Treatmont Who Who Shall CertIN thatthe Design Meets the Requirements of Chapter 238_ 11. Does the Plan Indicate and/or Identify All Potenllal Sources of Pollution which may affect the , , , , Qualily of Stormwater Discharges? © 0 0 1 ! 1 12. Does the Plan Provide Documentation Supporting the Determination of Approval with Regard to Historic Places or Archeological Resources, n wthat Includes the Foliowlna;,____ � �©��:®! a. Informatlohether the Stormwater discharge or land development activities would have 1 1 i , SA-G0 CIA „»,_ •._.» _._._.__.,_.__ .. an effect on a propertythat Is listed or eligible for listing or eligible for listing on the 9 9 9 � _State or National Re aster of Historic Places b- The Results of Historic Resources Screenin Determin tIons--- that have been Conducted W c.'Description of Measures Necessary to Avoid or Minimize Adverse Impacts on Places Listed, ! c , or Eligible for Listing,on the State or National Register of Historic Places;and, 11=11=i= d. Where Adverse Effects May Occur,Any llVritteri Agreements In Pfa-ce with the NY3 Office � ' of Parks,Recreation and Historic Places(OPRHP)or other Governmental Agency to iQ',Q �• Mitigate Those Effects. 13. A Descrlplion of the Solis)Present at the Site,Including an Idenllficatlon of the - HYdraulicSoll Grcup-_---_,-_-,-_---_--_--_--r_, r --_.--- ---__.., 14. Identification of Any Elements of the Design that are not in Conformance with the Design manual,Including Reasons for the Deviation or Alternative Design and a Description of theEquivAlencywithtechnica/Standards.' -._---•---_-W------------------------------------ i i i TVA Hydrologic and Hydraulic Analysis forAllStructuralComponents ofthe �__-__•--�-_--_, _„ _ Stormwater ManagementControlG�!stem, . ....»...»._.»........-'•`—'--___,_.--_,__.»_.—_-- ,.—— —„_— _4 1 1 R_—,.—_-----......—»,_.»..._...........,.._.».,...,»»...... ............ _..., ,., .»..,,.. 16. A Detailed Summary,wlth-Calculations,of the Sizing Criteria that was Used to Design All PositConstructionStormwaterManagement Practices, iDol�+®i „y____„-„_-____�� _,,,,,_, -,,,,�_„•,»,__„ 17. An Operations and Malntenance Plan that Includes Inspection and Maintenance Schedules and Action to Ensure Continuous and Effective Operation of Each Post-Construction Storm Water management Practice: Storer Water Management Control Plan Checklist tG 2: 03.12 ' T.O.S. "SWPPP" For Department Use Only: S.C.T,M.#: Property Address: r Storm Water Pollution Prevention Plan Review Checklist Checklist # 1 iaoo sstrict � eio 5Lot 4 REQUIRED PLAN INFORMATION AND IMPLEMENTATION DETAILS; ir i Plan Sheet I YES i NO ,N.A.,Explanation for NO or N.A. (Does the SWPPP Adequately Provide for and/or Indicate the Following; ; , Location(pg.#) 1. Dralna a Ca cu ations&Stormwater MPs Desl ne to contain a Two Inch Raln a l On-Site. 2. Construction Phasing Pian Indicating Sequence of Proposed Construction_AcUvlti_es. 3. General l ocation Map, _•_ •. r®�Q 1 Q i _ 4. Dralame Site Plan Drawn to Scale at Sixty_(ti0')feet to the Inch or larger,Indicating the Following.. ,®117— I Q I a, Loretioji and_Descrlptlgn of Property Boun#jgs; b;,.$iLeACreage;._ .__.,___,... ._ .___._____.. ___ . .. __ c,,•All_Exisling,Natural and/or Man Made Foatures on and_within 50'of the Property,Boundary; d.__Test Hola Data•Indicating Sall Characteristics&Depth to Seasonal High Water Table; ,®,17-71 I Q, e. Contours Indicating Properly Elevations(Min.2'); - f. Spot Grade '&-Finish Floor Elevations for Exlsling and Proposed Structures; - Y g, Location o Woode reas&Isolated rees with a nlmum Dlmenslon of 8"Diameter; �®�[�101 h.• -boll ConseNatfon Distriof Solf Survey. 5. Background Information about the Scope of the ProJeet,Location&Descrlptlon of the Site, Pro osed Chan es to the Site and All Existing Development on the site Including the Following, .a, .AII.Improvernerite hipl4iding l otal Arsa,of t and DJsturkance&Total she aea;._ _ .. �'sl�' i- _ . ___. _-._ .. ._ _-----•__. _ b. All Excavation,Filling,Stripping&Grading Proposed and Identified as to depth,Volume ®;©;l_7 &,Nature-of Materials(nyolved; •__ _ a- All Areas Requlringplearingand/orGrubbing;, -! _ �C��f `JiCJ:. a L'1eGiYl0 d. All Areas Where Topsoil Is to be Removed,Stockpiled and where Topsoil will ultimately , ,=; ; IJ _ _ be placed; '®11 AllTamporary&Permanent VoAetation.to,be,Plaoed on Slle;__ __ '_._• _- _-.-'^' -- -"-�Di®r f'In•' `(>1�{•1 Ok-,V-�y-Q;�+n4u �0 bL_V1�:�2:_ _ - _ ..,. _. _f., All Temporary&Permanent Storm Water Runoff BMP Control Measures Proposed;_ ,__ ._ . .__. I I r - -- - ----- - - g. The Anticipated Pattern of Surface Drainage During Periods of Peak Runoff; h, The Location of all Roads Driveways,5ldewalks,Patlae,Structures,Utilities&Other ` •(mprovemenls,including temporary Access&doristruction Staging Areas; •� -f:-'hhio Szls`tfn`&'Final iron{oure'ana or S-ot Elevations of lite site, •-` " , I , 8. A Scliodule of the Sequence for the Installation of All Planned Soll Erosion,5edimentatlon ®�Q &Stormwater Runoff Control Measures. r i 7� Description of Pollution Prevention Measures that will be Implemented;,_________._ ;®,[� Q 1 • . _ ____,__ ..........._.._... _.__.__.,.... ,... __. ___ 8. A Descrlptlon of the Minimum Erosion&Sediment Control Practices to be Installed and/or I t i®:0,01 Implemented for Each Construction Activity that will result In Soll Disturbance._-,____- _,-• , _ , i , _,_•__ •, _,-_ ,. .... .._ ___ .__ ..___ .,.. _ __ __._ . .... 9. Description of Construction&Waste materials Expected to be Stored On-Site. Gltyr fie; , .,-,_, �(� b'n.-• t .__ ___a,,,,_ ._,. •_ „__ , „, ,_,__ _ t3 10. Temporary&Permanent SOLI Stabfllzallon Plan that meets the Current Version of the New York State Storm Water Design Manual Technical Standard Q i tePa a I s rt i r i I 11. General SI I n nd Construction Draw ng_fo he Protect• ,•,•,• O O __,_____,-_,�„ 12, Dlmensionteri s,Maal SpeeiUcatlons-&Installation Details for At Erosion&Sedlmenl Control-Practices. 13.—Temporer�jiPractfces thatwi'fiheConvertedtoPermanentcontrolMeasures �C]i�iC7 � Q i � Abe _boY,Y_er , 1p�L�ltnr�ytey��„�y�c}�SUf S 14..Implementation Schedule for Staging Temporary Erosion Control Practice or BMP. "� (�r(�' _,____, ,,•,e ,- __.. _._ ____. .......... .... _.. 15, Maintenance Schedule to Ensure Continuous&Effective Operation of Erosion& I , Sediment Control Practices. Fir—'1101 18. Names'oPotential Surface Waters of the Sjt jiET of New York end/or MS4 that may be '- , , , __ ImQected by Development. 17. Delineation of Storm Water Control Plan Implementation Res�onsibili.... for Foch part of the _ Project Constructlon Site. I i 18, All other Exist lria Data that Describes Storm Water Runoff and/or Natural Drainage SwalesT y'�i Q�I=;,______..............__..._ _ . _•_ ....,. ._..,.,. 19. Identification of All Contractors)!Sub Contractors) Responsible for Installing,Constructing, !®i©10; Repairing,Replacing,Inspecting and Maintaining the Erosion&Sediment Control Practices. Storm Water Management Control Plan Checklist#1 : 03-12 N i THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 October 16, 2020 Town of Southold 53095 ROUTE 25 PO Box 1179 SOUTHOLD NY 11971-4642 Account Information: Contact Us' PolicyHolder Details ; TSUNAMI POOLS INC DBA PLATINUM POOLS Business Service Center Business Hours: Monday- Friday (7AM -7PM Central Standard Time) Phone: (877)287-1312 Fax: (888)443-6112 Email: agency.services(cD-thehartford.com Website: hfps:Hbusiness.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTRO05 NEW Wo ' YST°n CoSation CERTIFICATE OF Board NYS WORKERS' COMPENSATION INSURANCE COVERAGE 1 a. Legal Name and address of Insured (use street address only) 1 b.Business Telephone Number of Insured TSUNAMI POOLS INC 1c. NYS Unemployment Insurance Employer 74 ELWOOD DR Registration Number of Insured NORTHPORT DR NY 11768 1d. Federal Employer Identification Number of Insured or Work Location of Insured (Only required if coverage is specifically Social Security Number limited to certain locations in New York State,i.e. a Wrap-Up Policy) 20-2730919 2. Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Hartford Underwriters Insurance Company Town of Southold 30104 53095 ROUTE 25 PO Box 1179 3b. Policy Number of Entity Listed in Box"1a": SOUTHOLD NY 11971-4642 76 WEG ZS5176 3c. Policy effective period: 10/04/2020 to 10/04/2021 3d.The Proprietor, Partners or Executive Officers are ❑ Included. (Only check box if all partners/officers included) N all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "1 a" for workers'compensation under the New York State Workers' Compensation Law. (To use this form, New York (NY) must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers' Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise, this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Worker's Compensation contract of insurance only while the underlying policy is in effect. Please Note: Upon cancellation of the workers' compensation policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers' Compensation Law. Under penalty of perjury, I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Danielle Clausen (print name of authorized representative or licensed agent of insurance carrier) Approved by: S-.if V,,,J L. 10/16/2020 (Signature) (Date) Title: Operations Manager Telephone Number of authorized representative or licensed agent of insurance carrier: (877)287-1312 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) Form WC 88 3121 F Printed in U.S.A. www.wcb.ny.gov Page 1 of 2 a 0 Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE www.wcb.ny.gov Form WC 88 3121 F Printed in U.S.A. Page 2 of 2 Ac®® CERTIFICATE OF LIABILI INSURANCE DATE(MM/DD/YYYY) 10/09/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Customer Service Department NAME. Gaslamp Insurance Services PpHic No Ext: (800)920-4125 FAXAJCN,).. (800)920-4107 E-MAIL ADDRESS: 3238 Grey Hawk Ct. INSURER(S)AFFORDING COVERAGE NAIC S Carlsbad CA 92010 INSURERA• Preferred Contractors Ins Co. 12497 INSURED INSURER B: Platinum Pools INSURER C. 74 Elwood Road INSURER D: INSURER E: Northport NY 11768 INSURER F: COVERAGES CERTIFICATE NUMBER: GL 20-21 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS TR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM DD IPOLICYEFF MM/DO/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ❑X OCCUR PREMISES Ea occu DAMAGE TO RENTED $ 50,000 MED EXP(Any one person) $ 5,000 A PCA5024-PC340032 01/29/2020 01/29/2021 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2.000,000 X POLICY ❑PRO JECT F]LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED I NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ .EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEO RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑ NIA EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Verification of Coverage `Subject to all policy terms,exclusions and conditions' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25 PO Box 1179 AUTHORIZED REPRESENTATIVE Southod NY 11971 GL 44a ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SLEEPY LOW zz 17— 4+ i �` w - eros °' w m � ice) tt�) 'w ,••� ) Gl,` ,s-+ S �R tate p. fes) TOWN OF e m, .1012 " - O w e W./y �r�� P. te]O A M SOUTHOID ,os t7 fl ] 1t}1 ryCl_ 4l ww='�: SEE BEC.NO.C" -© V ° IT IJAW ~a ww zs 2a COURNOF w w 41 41 MIA _ 1J t4 .tu 1e1 N IS a SEC-NO.eTe _ aA[ .. "Y ' � �3 21 r .t9 3 tat ,e3. 16.5 - p to t '✓ d _ 22 N B+mEte u lID. Feel z w k) ,es'yy / s , ,s e ,e e] 7 /cIi � sw•, a sf,n s6 ?a.e JB a o, O 1 `• «. >S „ Ppm y� 9e y Mea,,o ' n0 .. y +�1 ,,,,s • M•� O • U, ;mss w e'O + C+,p v' 1' a. '''A),y Q " ..w e w "n o y m 32,2 o \Ml'e ,0.2 12' '� N aee •• ,] xz r" .i�� `ti��I. - i 9 1 T a �g3 • r.qV) :° elf - �W f • �) N., G �Ji �./ ] So yM � Z ,.. A w i T? r 5 u Je °'t +/✓� fly 3.r +_ / +,e zo ; zt . 1 ,r ¢ F i )F}y >b 3. a3 F tJ1.f v/mk) zaaAk) a ED•S �'. - ,z/K -T "x? M .. .. ? '` z.M el of © ,s 11 s �f 1 • r.e, ' C i es � /2] e,4 � M - , z _ to � /T• � p M(e) � t 121 3e "• et o 17 t5e 19 to >.. a 10. 1f ,. 'w "• >7 O�t n. i M - - _ an SEC:NCLOR x SOUTHOLD SECTION NO rOTICE COUNTY OF SUFFOLK © E 1ONM E e✓. —� � � +) w _O-- � — — -- -- .N» E.KEMbN...� Real Property Tax Service Agency r aDE6E 078 Ca,n,Y C/Mr Bh/,M•e,NY,1e0, M E arru,r M:— — e w,uwr,r --•-- u_--.-- _ �s mwarrn P 0>D aerwcr.o ,Boo PROPERTY MAP U nra. a,--.. ws...•n,Hme uu �- —__ e.ru. --.-- o...,,.--••-- - - m..e®.oac.raw -- V OFFICE LOCATION: �� ° �' w MAILING ADDRESS: Town Hall Annexes P P.O. Box 1179 54375 State Route 25m Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) Southold, NY 11971 m � � Telephone:hone: 6 - P 31 765 1938 � P LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, Assistant Town Planning Director LWRP Coordinator Date: February 10, 2021 Re: Local Waterfront Coastal Consistency Review for WILLIAM & JEANNETTE AYERS SCTM# 1000-78-7-51 WILLIAM & JEANNETTE AYERS requests a Wetland Permit to install a 16'x32' in-ground swimming pool made of steel and poured concrete with edge stonework trim approximately 18"-24" around the pool; excavated soil to remain on the property; install a 9'x12' shed; install stonework from the existing walkway to the shed; and install pool enclosure fencing. Located: 122 Hickory Avenue, Southold. SCTM# 1000-78-7-51 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the action is CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP. 1. To further Policy 6 require a pool dewatering well. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Damon Hagan, Assistant Town Attorney e eE Peter Young,Chairman Q Town Hall,53095 Main Rd. Lauren Standish,Secretary P.O.Box 1179 Southold,NY 11971 Telephone(631)765-1889 Fax(631)765-1823 Conservation Advisory Council Town of Southold At the meeting of the Southold Town Conservation Advisory Council held Wed., January 13, 2021 the following recommendation was made: Moved by Carol Brown, seconded by Caroline Burghardt, it was RESOLVED to NOT SUPPORT the application of WILLIAM & JEANNETTE AYERS to install a 16'X 32' in-ground swimming pool, shed and surrounding fence. Located: 122 Hickory Ave., Southold. SCTM#78-7-51 Inspected by: John Stein, Carol Brown, Caroline Burghardt The CAC does Not Support the application and found it be incomplete. The applicant should be required to submit an updated survey/site plan with all proposed structures. Vote of Council: Ayes: All Motion Carried i Glenn Goldsmith,President �QF So(/ry Town Hall Annex Michael J.Domino,Vice-President ,`O� Ol0 54375 Route 25 John M.Bredeme er III P.O.Box 1179 York Y � � Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams �� Fax(631) 765-6641 cou BOARD OF TOWN TRUSTEES '�� l TOWN OF SOUTHOLD DEC 1 4 2020 TO: SOUTHOLD TOWN BUILDING DEPARTMENTn h- 1,,.rr RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUITE S_Ayeks _Properly Qwner'Name: =? - _ .+Li 'N o', Dat(�'S'it`te'Bl :`'Dept: 12. ZQ The Office of the Board of Trustees is forwarding the above referenced ,application for verification of the Building Department's..permitting.requirements stated below: • �:>a.. YES NO Will the proposed project require a Building Permit? Will tho proposed o osed pject require uire a variance determination q from the Zoning Board of Appeals? 'i } Will any part of this application be considered;`a,,Qe[riolition as described under Town Code? COMMENTS: S nature o eviewer Date Glenn Goldsmith,President toF soU�� Town Hall Annex Michael J.Domino,Vice-President ,�Q �� 54375 Route 25 @� � P.O.Box 1179 , John M.Bredemeyer III z�a� Southold,New York 11971 A.Nicholas Krapski de!A15 Telephone(631)765-1892 Greg Williams '_ �� Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only ; Coastal Erosion Permit Application Wetland Permit Application Administrative Permit ;- �Amendment/Transfer/Extension NOV 1 $ 2020 3 ReceivedApplication: 11.�$°� Received Fee: Completed Applicatiow-17-1-40 Incomplete: ,; !M _ _ _w_ SEORA Classification: TypeI Type II Unlisted`=-Negative Dec. Positive Dec. Lead Agency Determination Date: �Coordination:(date sent): 02 al LWRP Consistency Ass ss ent Form Sent: ; DAC Referral Sent: a ate of Inspection: a►°l I�-I Receipt of CAC Report: Technical Review: Public Hearing Held: a-I Resolution: Owner( ) g P s Legal Name of Pro a (as shown on Deed): ' ��` + 3e P- J Mailing Address: 3 )6 /91C) / Phone Number: Suffolk County Tax Map Number:j 1000 -/ Property Location: (If necessary,provide LILCO Pole#, distance to cross streets,and location) AGENT(If applicable): Mailing Address: Phone Number: � 31a1 • 1 Maim Diane From: N <fireline91 @aol.com> Sent: Monday, December 14, 2020 10:55 AM To: DiSalvo, Diane Subject: Re: 122 Hickory Ave Amended Project Description I am building an inground pool at 122 Hickory Ave in Southold. It will be in the rear of the house and be 16'x32'and range from 3 1/2 deep to 6'deep. The excavated soil will remain on the property. It will be made of steel and poured concrete. There will be edge stonework trim approximately 18"-24"around the pool, the remaining areas will be grass. There will be a 9'x12'shed towards the rear of the property and outside of the restricted 1 00'water line. There will be stone work from the existing walkway to the shed. The fencing will be aluminum post and will protect the pool from outside entrance. I can be reached at 516 376 1910 Sincerely William Ayers -----Original Message----- From: DiSalvo, Diane <diane.disaivo@town.southold.ny.us> To: 'N' <fireline91 @aol.com> Sent: Tue, Dec 8, 2020 8:35 am Subject: 122 Hickory Ave Please fill out the attached page to be included with your wetland application. Please submit to me a revised project description showing exactly with dimensions what you are applying for. Diane DiSalvo Southold Town Trustees 54375 Route 25 P.O. Box 1179 Southold, NY 11971 (631) 765-1892 (631) 765-6641 i Board of Trustees Application GENERAL DATA 33 .'7F Land Area(in square feet): Area Zoning: ° YT Previous use of property: �/��!e � � ' LY Intended use of property: i c Covenants and Restrictions on property? Yes No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? /Yes 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 Zo If"Yes", please provide copy of decision. Will this project requir any demolition as per Town Code or as determined by the Building Dept.? Yes No �F Does the structure( ) on property shave 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 Descriptio Te attachments if necessary): S�' / co Board of Trustees APplication WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of tiles proposed operations: ,Area of wetlands on lot: � � - �square feet Percent coverage of IoL- e7 of Closest distance between nearest existing structure xnd upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands*. -to feet Does the project involve excavation or idling? _No rfYes If yes, how much material grill be excavated?_ �� cubic yards I How much material will be filled? cubic yards .Depth o,fwhich material will be T=oved or deposited: f� feet f Proposed slope throughout the area of operations: �i Mannerist which material 'll be removed or deposited 75 Statement of the eMct,if ars' Ui]the wetlands aid`Yida2 waters of the town that may result by reason.ofsuch proposed operafion$ (use attachments if appropriate): 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing 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 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 Information Name of Action or Project- , 7c �C, vl"L AT-Vr 4- Project Location(describe,and attach a location map)-, 'Z t C s®, -A) L fl _ Brief Description Proposed Action: J \ /, , 0 J e l S , ' Name of Ap 11'cant or Sponsor: Telephone: E-Mail: e Address- City/PO- ddressCity/PO; _ a�� State:_ Zip 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO Y administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that r 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 y other Bove ntal Agent NO YES If Yes,list agency(s)name and permit or approval: �uW 6r 4Z Uj" G ❑ �—�/ SArC— i. O ISJS P60') ATfA-c4eJ 4 U .Total acreage of the site of the proposed action? 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? acres 4. Check all land uses that occur on,adjoining and near the proposed action. f�11 rh�r MR1irn1(nnn-aarirnitnrP) I-1 Indn-trisi FlCnmmercial ,_,Residential(Suburban) Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page X 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? ❑ _V/ ❑ 6. is the proposed action consistent with the predominant character of the existing built or natural NO YE gr 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: 9 El 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO A 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: ❑ 11.Will the proposed action connect to existing wastewater utilities? y `. NO ES If No,describe method for providing wastewater treatment:e!�t � WL'l I 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? Er ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Id iy the typical habitat types that occur on,or are likely to be found on the pr sect site. Check all that apply: horeline El Forest El Agri cultural/grasslands Early mid-successional LLJ Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO XYES 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? O ❑YES b.Will storm water discharges be directed to established conveyance systems(runoff and sto drains)? If Yes,briefly describe:- `co ,�j to-I As �� ONO EYES �J SYS VF 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: Ln 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 been the subject of remediation(ongoing or NO YAE S completed)for hazardous waste? ,rte r r� �r reess,aescnoe: I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO T E BEST OF MY KNOWLEDGE /� c Applicant/spo or ame: (� �f� — / I e Date. J —" 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 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. WiII 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? F] 4. Will the proposed action have an impact on the environmental characteristics that caused the �Jj ❑ establishment of a Critical Environmental Area(CEA)? ��f 5. Will the proposed action result in an adverse change in the existing level of traffic or �fj ❑ affect existing infrastructure for mass transit,biking or walkway? ��JJ 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, 1-1architectural 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. W ill the proposed action result in an increase in the potential for erosion,flooding or drainage I FA El problems? 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. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date �ry1 G-Al<r'J, President - My Type am Res nsible 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 SING 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. L Signature of Property Owy6r nature of Property O r SWORN TO BEFORE ME THIS D DAY OF , 20 /0 y r Public DOROTHY A.CAULFIELD Notary Public,State of New York 9931 Qualified In NNaassau Con Conwnisslon Expires September,$0,2021 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 emplojees.The pnmosc of this form is to vrovide inforination which can alert the town of nossible conflicts of interest and allow it to take whatever action is r necessary to avoid same. YOUR NAME: (Last nam6,first name,4tiddle 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 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 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 f r -- Submitted N4,"j__jdqf ` ti�,,�w Signature Print Name & r Form TS 1 PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK residing at _ 141 , eing duly sworn, deposes and says that on the day of Ili', ,20 deponent mailed a true copy of the Notice set forth in the Board of Trustees Application, directed to each of the above named persons at the addresses set opposite there respective names; that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment roll of the Town of Southold;that said Notices were mailed at the United States Post Office at -that said Notices were mailed to each of said persons by CERTIFIED MAIL/RETURN RECEIPT. Sworn to before me this Day of 20 ZO 4A U10 9 �Dl Lm, d IN Public TRACEY L. DWYER NOTARY PUBLIC,STATE OF NEW YORK NO.01 DW6306900 QUALIFIED IN SUFFOLK COUNTY COMMISSION EXPIRES JUNE 30,2j9-A—Q NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES. TOWN OF SOUTHOLD �j, Intof applicant: /l/6 SCTM# YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersignedt request a Permit from the Board of �, Jlj �l Trustees to: p 8 Q 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: � � .16 2- 3. That the project which is subject to Environmental Review under Chapters 96,111 and/or 275 of the Town Code is open to public comment on: DATE: You may contact the Trustees Office at 765-1892 or in writing. The above-referenced proposal is under review of the Board of Trustees of the Town of Southold and does not reference any other agency that might have to review same proposal. A )� %� PROPERTY OWNERS NAME: Cs1�°/"' +-J( `' AY� MAILING ADDRESS: PHONE #: AGENT: MAILING ADDRESS: PHONE #: Enc: Copy of sketch or plan showing proposal for your convenience. cF Suf�oc� Glenn Goldsmith,President �0�0 COG Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 John M.Bredemeyer III P.O.Box 1179 co Michael J.Domino o Southold,NY 11971 Greg Williams Telephone(631)765-1892 © Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD February 2, 2021 William Ayers Jeannette Ayers 147 Park Boulevard Malverne, NY 11565 Re: Board of Trustees Application of William &Jeannette Ayers 122 Hickory Avenue, Southold SCTM# 1000-78-7-51 To Whom It May Concern: You are receiving this letter as notice that, in accordance with the Governor's Executive Order 202.1, this application is now scheduled to be heard by the Southold Town Board of Trustees, via videoconferencing on Wednesday, February 17, 2021 beginning at 5:30 P.M. Please continue to check the Town's website as the meeting date approaches for the latest meeting agenda and videoconferencing information. Also enclosed is an informational notice regarding the videoconferencing meeting and how to access the online meeting. Please mail a copy of the informational notice along with all other required paperwork to each of the adjacent property owners. Please keep a copy of said informational notice for your records so that you can access the meeting in order to have a conversation with the Board during your application review. Kly Yo rs, - 4" Glenn Goldsmith, President Board of Trustees Glenn Goldsmith, PresidentO�q uFFO�'�C�G Town Hall Annex A.Nicholas Krupski, Vice President 54375 Route 25 John M. Bredemeyer IIIy _ P.O. Box 1179 Michael J.Domino 0 Southold,NY 11971 Greg Williams y ® p!�} Telephone(631)765-1892 ��! Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD WORK SESSION & PUBLIC HEARINGS WEDNESDAY, FEBRUARY 17, 2021 5:OOPM & 5:30PM A Regular Work Session and Public Board Hearings of the SOUTHOLD TOWN BOARD OF TRUSTEES will be held on Wednesday, February 17, 2021 with the Work Session beginning at 5:OOPM and Public Hearings beginning at 5:30PM. Pursuant to-Executive-Order 202.1 of-New York-Governor Andrew-Cuomo-in-person access by the public will not be permitted. Town residents are invited to attend the public meetings-virtually via the Zoom online platform. Written comments may also be submitted via email to the Trustees Clerks at elizabethc@southoldtownny.gov and diane.disalvo@town.southold.ny.us. Said comments will be considered at the public hearing provided that they am4submitted no later than 12:00 P.M. (Prevailing Time) on the day of the public hearing. The public will have access to view and listen to the meeting as it is happening via Zoom. If you do not have access to a computer or smartphone, there is an option to listen in via telephone. Further details about how to tune in to the meeting are on the Town's website at https://www.southoldtownny.gov/calendar or call the Board of Trustees office at (631) 765-1892 Monday through Friday between the hours of 8:OOAM —4:OOPM. Options for public attendance: • Online at the website zoom.us, click on "join a meeting" and enter the information below. Zoom Meeting ID: 936 5601 0209 Password: 238680 • Telephone: Call 1'(646) 558-8656 Enter Meeting ID and Password when prompted (same as above). In order to "request to speak" when the application you are interested in has begun, please press *9 on your phone and wait for someone to acknowledge your request. When prompted to unmute your phone press *6. To view the application files please visit: https://www.southoldtownny.gov At the bottom of the picture on the main screen click on the second button from the right "Town Records, Weblink/Laserfiche"; go to bottom of page and click on "pg. 2"; click on "Trustees" folder; click - on "Applications"; click on "Pending"; all files are listed by name imalphabetical order. Click on the name of the application to view the file. SUFFo�� Glenn Goldsmith,President �o�Q �'OG Tuwii Hall Annex - Michael J.Domino 4'�� :X- 54375 Route 25 John M.Bredemeyer III ra $ P.O.Box 1179 A.Nicholas Krupski Southold,NY 11971 Greg Williams '�;� p� Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BE ADVISED — AS PER CHAPTER 55 NOTICE OF PUBLIC HEARINGS Failure to submit the following originals to this office by or no later than 12:OOPM the day prior to the scheduled Public Hearing for your application will result in a postponement of said application. This office WILL NOT contact you to request said information: • All original white & green certified return receipt mail receipts stamped by U.S.P.S. • Completed original Proof of Mailing Form Failure to submit the following originals to this office by or no later than 12:OOPM the day of the scheduled Public Hearing for your application will result in a postponement of said application: • Original Affidavit of Posting form — DO NOT COMPLETE SAID FORM UNTIL THE GREEN SIGN HAS BEEN IN PLACE ON THE PROPERTY FOR AT LEAST SEVEN (7) FULL DAYS. Sign the form on the eighth day that the green notice of hearing sign has been up on said premises. All green signature cards related to said application that were returned to your office should be either dropped off in our "Trustee drop box" or mailed into our office whenever they are received. These cards are not required prior to the Public Hearing, unless specifically requested for by this office. This specific requirement is subject to change. 117 \ PROOF OF MAILING OF NOTICE ATTACK CERTIFIED MAIL RECEIPTS Name: ('I � Crn - Town I -esdl Na-m Vis anc� , �r YY eJ abc7vr— �a►-76 =19�3� r, STATE OYNEW YORK - „ C6VNT'YLK__ ---- - -- -- -- residing`at , being duly sworn,,deposes and,says that on the day of :, 20�- ,deponent-maiied,a.true copy of the Notice .. set forth in the Board of Trustees Application, directed:-to each of the above named- persons at the addresses set site.there respective naneg;-that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment.roll of the Town of Southold;that said Notices were mailed at the United States Post Office at ,that said Notices were mailed to each of said persons by CERTIFIED MAI URETURN RECEIPT. Sworn to before me this Day of ,20 Notary Public Glenn Goldsmith,President `f $11FF0(, 0 Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 John M. Bredemeyer III CD P.O.Box 1179 Michael J. Domino Southold,NY 11971 Greg Williams � �apl� Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD --------------------------------------------------------------- In the Matter of the Application of WILLIAM & JEANNETTE AYERS COUNTY OF SUFFOLK STATE OF NEW YORK AFFIDAVIT OF POSTING DO NOT COMPLETE THIS FORM UNTIL AFTER POSTING REMAINS IN PLACE FOR AT LEAST SEVENDAYS PRIOR TO THE PUBLIC HEARING DATE I �/ �' "�` j4��residin at/dba IhA) ✓041de 1�k/l) ,s being duly sworn,,, depose and say: �lt� That on the/69 day of/LeQ�U* , 20 Z-/, I personally posted the property known as by placing the Board of Trustees official noticing poster where it can easily be seen from the street, and that I have checked to be sure the noticing poster has remained in place for a full seven days immediately preceding the date of the public hearing. Date of hearing noted thereon to be held Wednesday,February 17, 2021. Dated: (signature) Sworn to before me this ]A day of W, 20 Z(_ PL46 DIANE DISALVO Notary Public NOTARY fOLIC-STATE OF NEW YORK y No. O1 D1475593 Qualified In Suffolk County My Commission Expires April 30, 202-7-*** l PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: OOL,)b /Ty y//syr 6a0/ S'lil �a�h S`f, �Trpvr��v STATE OF NEW YORK COUNTY OF-SUFFOLK' residing at t0fik K 7.36 VD. being duly sworn, deposes and says that on the S�h day of rrppjj1Wy , 20 RI, deponent mailed a-true copy of the Notice set forth in the Board of Trustees Application, directed to each of the above named persons at the addresses sPt,opposite there respective names; that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment roll of the Town of Southold; that said Notices were mailed at the United States Post Office at 1n111-V67eYE-��_, that said Notices were mailed to each of said persons by CERTIFIED MAIL/RETURN RECEIPT. Sworn to before me this .S" Day off eD/�c.�u ,20s_ Notary Publi DOROTHYA.CAULFIELD Notary public,State of New York No.01 CA6289931 Qualified in Nassau County, Commission Expires September 30,2021 NOTICE TO ADJACENT PROPERTY OWNER BOARD Of TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: GU i LLl qrn P SCTM# 16)626) - 7,5 - 7-5'1 YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: Aadd ur, 01-- - ro&�� c� 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: 3. 'That the project which is subject to Environmental"Review under Chapters 96,111 and/or 275 of the Town Code is open to,public comment on: DATE: L � r or ° You may contact the T;;astees Office at 765-1892 or in writing. The above-referenced proposal is under review of the Board of Trustees of the Town of Southold and does not reference any other agency that might have to review same proposal. PROPERTY OWNERS NAME: GAJ L -119- YI D4-JC-CE-Al x_776 14� MAILING ADDRESS: )y7 Par B/ vd PHONE #: AGENT: MAILING ADDRESS: PHONE#: Enc: Copy of sketch or plan showing propo$aj far your c9pvenjence. ar Pw me:+vi¢rawwrer�n PnEo°N.mo°:No w wBM io�Trz.[T]11uL[d,Pui.YRI]CO�DISMNµd°I,L91.c°�'cc+'Q°g1�E,INamn°n'�'amm�v,°R'usrta°Ma'1°w,,um°o r;i,ssm�O'Eara ra EE«""xy o wm�iu+wE anTl'0ic°.iuN�i�a.w 'mwv°tpRe°°'r'NOt wuTma m.°mu°nanaa Nwtt fmian�ywe�M)m[E"oc T,m+NOa wN wis f+�PeN°C na'"wo a tt�arm'icPj a°ow�,xmEw.xuEi rMOTOTw°n[�°�Aro]rx'OROv,.a°i E,N�°m uTa�,.ua°f magi Or�mi 511M DATA 400 Ostrandar Avmnuo,91—hood,New York 11901 W.691,421-2908 tax 631,92'7.0146 AREA a 59,590 So PT Admin®youngmnglnmaring cam L ST PLDOD IWT 25LC PATE MAP PANEL NO.9810'JG0166 H LAST PLOO SEPT,29,3009 s. Howard K Yang.Lard Surveyor Thomm,G r 1port,Pre aglnaor �oJ r ® / �l s� f Douglas E Fdarne,R-oPonsiancl EngNoor W-a=' E �- ---Robort a Tast,Areh1toet �� ' ,� ��\ `�✓ / HEALTH DEPARTMENTJo USE Ni cb h'R-� \ pR.Qp�� '\\ --v` ,, \ � SURVEYOR'S CERTIFICATION lD S \' a - �C� 'r1 ` °m H�9Y e.—PY TO WILLIAM AYI�B&J'ANETTE" �� \ �; �9,,R \ TAHYCEC�of PR 19GTlc;a PORLAND��s IN ADOP D®Y•HE riN a 9e ( , / i %r �y�, ''!a YORK STATE A690GIATION 0P�*r-E ION4L LAND 9URyEYORS, /'aQ Ao ��8>i• ! � Zc�Sp \� sae )'r o HOWARD W �� o�orr ��r�a!"i\� �b, �� ,r� �p� SUpR�VpEYp FOR ® b \ \ NT, Qr '/ / /tl�L�lY11�1 P'S1`�:.+` JEANNETTE AYERS iat Southold,Town of Southold ��Q Suffolk County,New York •,0 `•�` ,....v r`•�r Q(f� BUILDING PERMIT SURVEY County Tax MaP mmkf 1000 s.rnw 9B salN OZ 1. 51 MAP FWARED JIMe 19,2016 mvisl0N5 ROCord&RBv1610fls DATE aMMF. \`\ Q•-' n�ANJ:Du.".L".'YTa___ wen�o r>r.T I�+ale i r /rr2=-Q]20162016 IT 2XTA < SANITARY MEA5UREMENTS D A°06 -- - --- --- - -- HAY 420; D =B T;a�r-xyla:__-._- AAD® UILD1Nt T'�r.HlLDP3fl--._-_.-..� 5T 39' 25' 60= UILDrv�. RMIT D(�j�!- -IAN Z6 ZOZI (.PI 62' 5T' 0 25 -5O=io0 LP2 61' $1, 5a010'I°= 50' Jos No 2016-oohs .MONUMENT vovw ^BTAKC 392 A a STAKE FOUND 0•PIPE SCT `-1ZWAR 6 GAP FOUND a NVNA3ER..FLAG OW9.2o15_ol5fi 2016_0o69J]Pr2 I or I Glenn Goldsmith, President OQg0 0 Town Hall Annex A.Nicholas Krupski, Vice President y'�� Gyri 54375 Route 25 John M. Bredemeyer IIIy $ P.O. Box 1179 Michael J. Domino 0 ® Southold,NY 11971 Gres Williams �,yo ap�Y1' Telephone(631)765-1892 1 @ Fax(631)765-6641 �cc�`rr BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD WORK SESSION & PUBLIC HEARINGS WEDNESDAY, FEBRUARY 17, 2021 5:OOPM & 5:30PM A Regular Work Session and Public Board Hearings of the SOUTHOLD TOWN BOARD OF TRUSTEES will be held on Wednesday, February 17, 2021 with the Work Session beginning at 5:OOPM and Public Hearings beginning at 5:30PM. Pursuant to Executive Order 202.1 of New York Governor Andrew Cuomo in-person access by the public will not be permitted. Town residents are invited to attend the public meetings virtually via the Zoom online platform. Written comments may also be submitted via email to the Trustees Clerks at elizabethc@southoldtownny.gov and diane.disaivo@town.southold.ny.us. Said comments will be considered at the public hearing provided that they are submitted no later than 12.00 P.M. (Prevailing Time) on the day of the public hearing. The public will have access to view and listen to the meeting as it is happening via Zoom. If you do not have access to a computer or smartphone, there is an option to listen in via telephone. Further details about how to tune in to the meeting are on the Town's website at https:/Jwww.southoldtcw;tnny..qov/calendar or call the Board of Trustees office at (631) 765-1892 Monday through Friday between the hours of 8:OOAM —4:OOPM. Options for public attendance: • Online at the website zoom.us, click on "join a meeting" and enter the information below. Zoom Meeting ID: 936 5601 0209 Password: 238680 • Telephone: Call 1'(646) 558-8656 Enter Meeting ID and Password when prompted (same as above). In order to "request to speak" when the application you are interested in has begun, please press *9 on your phone and wait for someone to acknowledge your request. When prompted to unmute your phone press *6. To view the application files please visit: https://www.southoldtownnV.gov At the bottom of the picture on the main screen click on the second button from the right "Town Records, Weblink/L.aserfiche"; go to bottom of page and click on "pg. 2"; click on "Trustees" folder; click on "Applications'; click on "Pending"; all files are listed by name in-alphabetical order. Click on the name of the application to view the file. COMPLETE, i '■ Complete items 1,2,and 3. A. Signature ■ Print your name and address on the reverseX ClAgent so that we can return the card to you. ❑Addressee I ■ Attach this card to the back of the mailpiece,- B. Received by(Printed Name) C. Date o Del e I or on the front if space permits. 1. Article Addressed to: "_i D. Is delivery address different from item 1? ❑Yes j �j If YES,enter delivery address below: ❑No �o bzroh i h�Qv► I a �u07 a27� GVO6G{ �t . fIo fbroa l�, /V i 3. Service Type ❑Priority Mail Express® II�IIIIII.IIII111111III 111111 IIIII II1111111I III ❑Adult Signature ❑Registered Mal I ❑ ut Signature Restricted Delivery ❑ Restricted Mail Restricted Ve ) rtified Mail® Delivery 9590 9402 6274 0274 9752 81 ❑Certified Mail Restricted Delivery ❑Signature ConfirmationTh1. i ❑Collect on Delivery ❑Signature Confirmation J 2. Article Number(Transfer from service label) ❑Collect on Delivery Restricted Delivery Restricted Delivery ;- -;_ = --- — --- - --Insured Mail, 7020 2 4'5 0 0001 2564 -7812 `Insured Mail Restricted Delivery ' Iover$500) 1 PS Form 3811,July 2020 PSN 7530-02-000-9053 Domestic Return Receipt COMPLETESEC • . • • Fa Complete items 1,2,and 3. ASignature Print your name and address on the reverse cv so that we can return the card to you. X ■ Attach this card to the back of the mailpiece Y:, B. R ceived by(Printed Name u 1 or on the front if space permits. ) C•�Date of Relive,, 1. Article Addressed to: `+ D. Is delivery address different from item 1? Yes L IND ��Rw�� f— If YES,enter delivery below: ❑No Gad W Skopy �dGtT�/6�b, N Y //9-7--l' { I 7 3. Service Type ❑Priority Mail Express( ��1111111 IIII III I II��I II I II I IIII II �IIII III ❑Adult Signature ❑Registered Mail- :1 A�ddult Signature Restricted Delivery ❑Registered elgi is ered Mail Restricted Vuertified MaM 9590 9402 6274 0274 9775!2!9 8 U Certified Mal Restricted Delivery Delivery ❑Collect on Delivery ry ❑Signature Confirmation*b ortirtA Numher_flrartsfer fromservice IabeO ry ❑Signature Confirmation 1 Mal 7020 17 Collect on Delivery Restricted Delivery Restricted Delivery 2450 0 0 D 1 2 5 6 4 '7 7 9 9 ' ^ —erred Mail Restricted Delivery` i f PS Form 3811,July 2020 7W6!-�L=tl()B�Dg924 er$500) V U.S. Postal Service"' U.S. Postal Service'm 71 CERTIFIED MAIL0 RECEIPT CERTIFIED o . ECEIPT M Domestic Mail Only Er Domestic Mail Only r delivery information,visit our website at www.usps.cornO. .So t��o s i � EMM 5nl��tr'o�t�', 71. Certified Mail Fee Certified Mall Fee �► $3.61! P L $ $3.60 11,65 fll $ ti Ext ervices&Fees(checkbox,addfeee 40 0cte) l7� Extr Services&Fees(checkbox,edd lee p te) _ \�-t't -lr r"� ( etum Receipt(hardwpy) $ �• �� - ;1 rn Receipt(hardcopy) $ ��Ill i O ❑Return Receipt(electronic) $ -1 Postmark. �,, O ❑Return Receipt(electronic) $ $U-00_ 'y C3 ❑Certlied Mail Restricted Delivery $ - -- `(•�• ba O ❑Certified Mall ResMcted Delivery $ SHB F 0 ❑Adult Signature Required $ - �' []Adult Signature Required $ r� bl ❑Adult Signature Restricted Delivery$ 4' El Adult Signature Restricted Delivery$ tF J (� M = t X Ln Postage $0.cc &66 Ll Postage $1.1.55 rU Total Postage and F [12 J21 ru Total Postage and Fees 1.1+22%h572Ux o $ 7T.00I $ $7.00 C3 C3 sgat To sent To / S AIDRq,9d 0 /©�lTOA/E C3 2nni�e�23)& INJ q- Q/Y�eS m5 0 f.i�a� C,QAry oRo ------ ----------- Street andA t No.,or Pa BoxT-- $t�ee_and�apt No,or Pt3 Boz IU ,-- N P ------_ltJ�------ _241_v-�=------- ----------- { I_ay-�ll�KaRY �"'�E---------------------------------------------------- City,state,t"+ae City,state,Z/P+4® s®cam l N // --H sou 61A YY //9-7i PS Form 3800,April 2015 PSN7530-02-000-9047 See Rever se for Instructions, T11 TI Postal Service ■ , stal Service lir CERTIFIED MAIL& RECEIPT ru CERTIFIED MAIL@ RECEIPT nj Domestic Mail Only Domestic CD r`- at 9� 1 website E � Holtir) c[i 14 M"1 A L S .E 1-0 Certified Mail Fee 6� �1e�6e I Certified Mail Fee ru $ 2 Ln $3.60 0565 Extr ervices&Fees(checkbav,add tea p �4 03 ru $ c PLv R�/¢ 03 � r 4 eturn Receipt(hardcopy) $ �G EM. f�6ervlces&Fees(checkbox,add C ❑Return Receipt(electronic) $ stmark r-q alum Receipt(hardcopy) $ ❑Certltled Mail Restricted Delivery $ 1 i � E]Return Receipt(electronic) $ rt}^. Postm+a�rK, 1 Q ere � ❑Certified Meal Restricted Delivery $ \ Hera 1 ❑Adult Signature Required $ _ []Adult Signature Restricted Delivery$ M 0 []Adult Signature Required $ C3 0 ❑Adult Signature Restricted Delivery$ �Ctt 1 Postage $11.ce "� r/ Postage lsIll „ l ' n $ $f.55 rU Total Postage and 2021 nj Total Postage and Fe1 21 $7.00O $ �s U skTo _Cl.�f P- VIP C._�i-M,,5 ru S�tT( 96 � }r- Street and Apt.No.,or PO Boz)P---- ----- --------------------------------- U �tG�`f -- ----------- QQ S t 9� &theft afia'A/piE WK,or P(3 Box No. S GtyStafe.ZlP --------------- C`- -5� ClC1J�2I `oIs� Y05,-21P+4go boa C5 x NOTICE F HEARING NOTICE IS HEREBY GIVEN that a Public Hearing concerning this property will be held by the Southold Town Board of Trustees f via the online Zoom platform. OWNER(S) OF RECORD: WILLIAM & JEANNETTE AYERS SUBJECT OF PUBLIC HEARING: For a Wetland Permit to install a 16'x32' in-ground swimming pool made of steel and poured concrete with edge stonework trim approximately 18"-24" around the pool; excavated soil to remain on the property; install a 9'x12' shed; install stonework from the existing walkway to the shed; and install pool enclosure fencing. Located: 122 Hickory Avenue, Southold. SCTM# 1000-78-7-51 TIME & DATE OF PUBLIC HEARING: Wednesday, February 17, 2021 — at or about 5:30P.M. — To access the Zoom meeting please see the meeting agenda located in the Trustees section of the Town website. If you have an interest in this project, you are invited to view the.Town file(s) through the Southold Town website. To view the application files please visit: https://www.southoldtownny.gov At the bottom of the picture on the main screen click on the second button from the right "Town Records, Weblink/Laserfiche"; go to bottom of page and click on "pg. 2"; click on "Trustees" folder; click on "Applications"; click on "Pending"; all files are listed by name in alphabetical order. Click on the name of the application to vi'ew.the file. BOARD OF TRUSTEES * TOWN OF SOUTHOLD * (631) 765-1892 Town of Southold LWRP CONSISTENCY ASSESSMENT FORINT 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 sigaWcant 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 ANIS PROPOSED ACTION SCTM#/00® ? _ — �0 PROJECT NAME, &)"A XVL-` - A, 6115 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:/ 16 ,X �� afore and extent of action: �Q_, 1514A b ,�S/q/ �r Location of action: r 2 c � e ��`,f/TSG/•� f //l �/ Site acreage: Present land use: &pAA e Present zoning classification: ��5� o e o) T-4 ""a 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: / ( c (a) Name of applicant: �)-f/'` "'�'` A L A (b) Mailing address: l / /� (c) Telephone number:Area Code( ) 5-16 (d) Application number,if any: 1 " Og Will t he ' n be directly undertaken,require funding,or approval by a state or federal agency? Yes If yes,which state or federal agency? spy �� J � c 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 criteri . Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Po=plicable ges 3 through 6 for evaluation criteria ElYes 1:1 No 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 ❑ ❑ Not Applicabl pp 5 Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Sectio III—Policies Pages 8 through 16 for evaluation criteria Yes ❑ No ❑ Not Alicable p 7-3 1, cy Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Poli ' Pages 16 through 21 for evaluation criteria Yes ❑ No ❑Not Applicable Ak)'CY 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. Y ❑ ❑ No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section In — Policies Pages 32 through 34 for aluation criteria. Yes 1-1No Not Applicable Attach additional sheets if necessary Policy S. Mini niae emv' omental 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 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 LVVIZP Section III—Policies; Pages 38 through 46 for evaluation criteri . Ye❑ No❑ Not Applicable pp f` Attach additional sheets if necessary Y 1 WORMING COAST POLICIES Policy 0. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suit le locations. See LWRP Section III—Policies; Pages 47 through 56 for evaluation criteria. Yes ❑ No ❑ Not Applicable fJ 7 Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Es and Town waters. See LVVRP Section III—Policies; Pages 57 through 62 for evaluation criteria. 7Yes ❑ No ❑ 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 for eval tion criteria. ❑ Yes ❑ NoNot Applicable Attach additional sheets if necessary Policy 13. Promote a ropriate use and development of energy and mineral resources. See LWRP Section III—Policies; ages 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED RY n/`a ` `'�'t TITLE�� DATE3' ��