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HomeMy WebLinkAboutTR-9846A Glenn Goldsmith,President ®F S®(/,� Town Hall Annex A.Nicholas Krupski,Vice President ®� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski if Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples • a® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 2029C Date: May 4, 2023 THIS CERTIFIES that the replacement of wooden steps with 3'x6' masonry steps; install 12'00' on- grade masonry patio; At 280 Oak Avenue, Southold; Suffolk County Tax Map#1000-77-2-3 Conforms to the application for a Trustees Permit heretofore filed in this office Dated March 8,2021 pursuant to which Trustees Administrative Permit#9846A Dated April 14, 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 replacement of wooden steps with 3'x6' masonry steps; install 12'x30' on-grade masonrypatio. The certificate is issued to Carol Clancy owner of the aforesaid property. a 1 Authorized Signature r Glenn Goldsmith,President ®��®F S® �® Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly Elizabeth Peeples � � � Telephone(631) 765-1892 Fax(631) 765-6641 ®�yCOUNTV,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 202, INSPECTED BY: BA(ZAb" Pe-.RIeA Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1 st day of construction % constructed Project complete, compliance inspection COMMENTS: __.. '' oAtd C, Sl -I�.a�' 0-vi0.�IOYpX 1 aI GI V log Y.6g l0mai o W OL Co nSlll Y�ow w l.L.�IIXP. J rent/ door( avid 6CAA A"S From MUaj Mit Dario- WW8 adX-E Mdl SiMiM WaS a d a eel: -F-Itie Im0JACa-Ei M A 0-e c n o-I C'X4tAJ ka6gj s rAwlyd o�- ±JC QQ�w CERTIFICATE OF COMPLIANCE: �iI�I Glenn Goldsmith, President �QF so(/r Town Hall Annex A. Nicholas Krupski,Vice President ,`O� yplo 54375 Route 25 P.O. Box 1179 John M.Bredeme er III Y �[ � Southold, New York 11971 Michael J. Domino G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 olyCOU ,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF - - BELOW INSPECTION SCHEDULE Pre-construction,`hay-bale line/silt-boom/silt curtain 1St day of construction- '/ constructed When project complete, call for compliance inspection; Glenn Goldsmith,President QF sorry Town Hall Annex A. Nicholas Krupski,Vice President 0. 54375 Route 25 P.O.Box 1179 John M. Bredemeyer III Southold,New York 11971 Michael J.Domino COO �r G Q Telephone(631) 765-1892 Greg Williams �'� �� Fax(631) 765-6641 Nil, BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9846A Date of Receipt of Application: March 8, 2021 Applicant: Carol Clancy SCTM#: 1000-77-2-3 Project Location: 280 Oak Avenue, Southold Date of Resolution/Issuance: April 14, 2021 Date of Expiration: April 14, 2023 Reviewed by: John M. Bredemeyer, III, Trustee Project Description: Replace wooden steps with 3'x6' masonry steps; install 12'x30' on-grade masonry patio. Findings: The project meets all,the requirements for issuance-of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the project plan prepared by Eligio Lopez, received on March 8, 2021 and stamped approved-on April 14, 2021. -Special Conditions: None. Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. 4�L 44-4 - Glenn Goldsmith, President Board of Trustees GRAPHIC 5GALE I"= 30' r �� s Situate: Goose Greek 6 Town: Southold ��t3� -12 Suffolk Gountyy +__- Datum: M5L l_l\/D'29 Tide Range: 2.5'+/,- - `p•p0 f -13 17 lop,0 o. 4e -1.2•' 1b• .. 1 �_�-d' "- �• � •ems••• �.-%_ �- 3v_-:6c� L-" 9 --� •�� OSI - l � a . APPRCo 69 G� ? ,TOA b RJQ TEES 0' TOVSOUT OLD----B- 15 DATE "� 85j, N74pt 11.0 gyp•' %C% Q\Z .V�- Fwe\1in9 0 �o r ------lo- 9 los O 9 0' Geon�y p a 2 O�q gG o�fp1 to Ah ee�po � C� 12.5 __\LE ICb �0��`� k i MAR 2021 FREFARED 5Y. SEA LEVELSoutrlold Town - H+5 PLOT DEV`ELOFE7 FROM=1=LD 5'JRV--Y5 L d MAPPING Board of Trustees Go.�ut�,T^=p 12-28-01 I 6 EA5T MAIN 5TREET . IVER—..NY 11901 �hONE 516-721-3151 ROBERT r:.FOX,NY5 UG#501Q7 FAX 516-365-8251 i2/29/Z001 1611,01AM Sheet I Of I \V+p clammer�o�sim�lanc pro Glenn Goldsmfl? resident �0 c� Town Hall Annex ___: A. Nicholas,_ , ski, Vice-President „�� ter; 54375 Route 25 John M. Bredemeyer, III o P.O. Box 1179 Michael J. Domino o Southold, NY 11971 Greg Williams y ® 0!� Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 3// Y) /U ' d Completed in field by: �r Eligio Lopez on behalf of CAROL CLANCY requests an Administrative Permit to replace wooden steps with 3'x6' masonry steps; install 12'x30' on-grade masonry patio. Located: 280 Oak Avenue, Southold. SCTM#: 1000-77-2-3 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related,structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: 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: VJ. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other - -- W 1 E -- s GRAPH I G 5GALE I"= 30' 5ituote: Goose Greek Town: Southold - 5uffolk Gounty Datum: M5L 116\/D'2Gp- i Tide Range: 2.5'+/- t D E?' --- --- --'o �a p P -6' agWF 64 i CO oQ 15 o--------- 8- t 3N 1, a Ag as�` ... . O 5.E �9CO ,�lJ I .b E6 �.3 .\� %, fl Q �Qj O .-,3 0 2 0 T u\OQoG\ox`cyo o gG o o�ht R gik6 OS N 25 lz �I '7 i 12021 F2EFA2_;7 3": SEA LEVEL I TW5 PLOT i3EVELOPED ff' �GU:hp;q Town r I F:fwm r--LD SURVEYS -01 i MAPPING f Board of Trustees coucreo 12-2b 6 EA57 MAIN 5TRFET IVER,---AD,,%Y !igCl RO$ERT H.FOX,NY5 LfGx 501-17 PHON5 516-121-5151 FAX 516-364-828, 12/24/2-10, n:n:O,AM Sheet I Of I Herisnn iaB15 i •�''/: •.,•; •:;,;.�1� -=�_�: .aro, / i J •; .•� ,. ,y. .P _=__ Vis_ !----__ �u ,,� •y.,,,ti �,• -- __nom. - -- - '----- _s [ ^ ---- ------- AVE _ a, onr aN 1 E Nonce COUNTY OF SUFFOLK © E 0e a soen+oLo SECTION NO Real Property Tax Service Agency va N u...n.. .,.^_ a...r . •n —_� asu ��•�_ y,W—�.�� Gwnry'GnurRlrnlwl.NY11,01 M 077 O..... „ ,:iNq.i:•, �- ---- '-- --•-- ...u.--"'-- £� • 1000 P PROPERTY MAP OFFICE LOCATION: ���� m n MAILING ADDRESS: Town Hall Annex r4�� P.O. Box 1179 54375 State Route 25 t"" k Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold NY 11971 �u Telephone: 631765-1938 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Heather Lanza, AICP, Town Planning Director on behalf of Mark Terry, LWRP Coordinator&Assistant Town Planning Director Date: April 12, 2021 Re: Local Waterfront Coastal Consistency Review Carol Clancy SCTM# 1000-77-2-3 The application referenced above is for a Wetland Permit for a patio located adjacent to the existing dwelling in the rear yard. 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 proposed action is CONSISTENT with the LWRP. 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 Glenn Goldsmith,President �VV Town Hall Annex Michael J.Domino,Vice-President �O ' ¢�� 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III ! 11 Southold,New York 11971 A.Nicholas Krupski c/s Sc G aC, Telephone(631)765-1892 Greg Williams �` Y® Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application I E1 MVE Wetland Permit Application f�Administrative Permit MAR - S 2021 Amendment/Transfer/Extension Received Application:_ 3414 Received Fee: $100 DO :cu�.�,�i rn„n Completed Application: 3,q.Zl Incomplete: SEQRA Classification: Type I Type 11 Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): -74LWRP Consistency Assessment Form Sent: QAC Referral Sent: ✓ Date of Inspection: •741 Receipt of CAC Report:. Technical Review: Public Hearing Held: Resolution: Owner(s)Legal Name of Property(as shown on Deed): Mailing Address: Phone Number: 6 /D - .3 D - 76 Z-] Suffolk County Tax Map Number: 1000- -7 7 - 2- -3 Property Location: 2.86 o.9 y e-n u e , so v 7 A o/C/ , A //9' 7 / (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): �-/�/p �, o P e Z Mailing Address: 200 SKy n W 4 u n e , C u4c-h o qye , Aly 1/435Phone Number: 3 l — 73 4-,JS3S3 Board of Trustees Applic Lou GENERAL DATA Land Area(in square feet): �,��/-o x i tw a--e I /SSS va 1-e Ae--. Area Zoning: R �D �"'CS/cle-nia L L o uo Previous use of property: re S1 cle n-z n L Intended use of property: 11-e 5 1 Clea-7�a L 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 No If"Yes",please provide copy of decision. Will this project re ui a any demolition as per Town Code or as determined by the Building Dept.? Yes X No Does the structure (s) on property have a valid Certificate of Occupancy? Y 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?—A-No Yes If yes,provide explanation: Project Description(use attachments if necessary): /'ego late tOoo o/en �fe ps W A as o n rSic . s . a41 Patio a4 -67,rO v If ve l �in�cnS/o/�S /Z X 20 Fee 614�ep n1Iy)ensIcLt2eje x 6 In high . Hoard of 2ruat6ea Application 4 WETLAND/TRUS1'1�E,LANDS APPLICATION DATA Purpose ofthe proposed apexatitons;:, -r �' r a ��� �'� a��1' V[ _ h Area of,*etlands on lot: --- __�__�square feet Percent coverage of lot:,- Closest ciistatic between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: _ _feet Does the project involve excavation or,filiing? r-�- -Ido -- yes ; if yes,hour much material will be,excavated? ,;;cubic yards Hopi rriiich inategial will be fitted?_ cubic ymds Depth of which material will be removed or deposited: , feet ' l � Proposed slope-throughout the,area of-operations ' Danner in which material will be removed or deposited:- L✓ i' - Statement of the,effect,if any,on the wetlands and tidal waters of the town that may,result by reason of'sdch proposed operations(use at0chments if appropriate): Board of Trustees Application AFFIDAVIT Com'a ro ! C� l C�C %' BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF 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..�IBEBY AUTHORIZE THE TRUSTEES,THEIR AGENTS) RIOR PRESENTATIVES,INCLUDI u7i --®--CONSERVATION ADVISORY ADVISORY COUNCIL,TO ENTER ON'T'O 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 COMIPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of Property Owner Signature of Property Owner SWORN TO]BEFORE ME THIS �� DAY OF .' A ,20 I otuy Public commonwealth of Pennsylvania-Noary Seal Cathy McFarlane,Notary Public Montgomery County My commission expires october'7,2022 Commission number 13417 6 Member,PennsylvaniaAssoaahon o Notaries �4 Board of Trustees Application AUTHOMZATION (Where the applicant is not the owner) I/We, �a /o l 04n C owners of the property identified as SCTM# 1000- -7 7— Z in the town of ,�O V�ho�� .New York,hereby authorizes 11G//O G.0R2 Z to act as my agent and handle all necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for this property. Property Owner's SignatureV PropertyOwner's Signature SWORN TO BEFORE ME THIS DAY OF /% '20 tart'Public Commonwealth of Pennsylvania-Notary Seal Cathy McFarlane,Notary Public Montgomery County My commission expires October 17,2022 Commission number 1341786 Member,Pennsylvania Association of Notaries APPLICANT/AGENT/REPRESENTATWE TRANSACTIONAL DISCLOSURE,FORM Tbtis�t of Soitthold's Code of 1;thies prohibits con Flirts of interest cin the pati-of town officers and employees The ow—se of- this"f "s to rovid�inforination wliich.can al'eit fire town of- s5ib1e conflicts o_f interesrand allow itto take w ate er action is necessary to avoid soote. YOURNAME• (Last name,first name,giiddie initi ,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 petsonelly"(or through your'company;spouse,sibling,parent;br_chilcl)'.have a relationship with aay.offiger oremployce­, of Elie Towit of Southold?-"Relationship"includes l y„bland;ritarriage;orbkeW ss iorrest,"Ausiaess intetesC'means a business, ineliiding a partnership,tri which the„towaufficzroi employee has•even_apartial ownership of(or eniploym6t-byj a,- 'pQraiion is which the;tawn office-or employee owns more than 5°!°of theshares. 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(aperiViepresentative)and the town officer or employee.Either check the_appropriate line A)through D)anW%r describe is the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): p)the owner.ofgreatcrthan S%of the shares ofthe corporate stock of the applicant (wiieo the'applicant:is aacorpoiation),� B).thedtgad orlieneficial owner offanyinterest in a non-corporate entity(when the ;appiicartt--is not a,corporationj . C)art officer,director; r,or ertiployee of the applicant;or Dj the actual applicant. i DESCRIPTION OF RELATIONSHIP Submitted this�ay of Signature G l r Ce A ^0 c Print Name Form TS l TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The pumose of this form is to nrovide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. /s YOUR NAME: G I anCc.! ('',ro I (Last name,first name,fiddle 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 Submitted thiA day of ALW 2001 Signature ' Print Name L Form TSI 617.20 Appendix B Short Environmental Assessment Form Instructidns4bo 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 I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1-Project and Sponsor Information (,Gt.,-o Name of Action or Project: Project Location(describe,and attach a location map): 280 o A-k ¢}v erl ve-, 5-o v 7-ho /tel , n/Y --119-7/ Brief Description of Proposed Action; cam- Pinto Name of Applicant or Sponsor: ` Telephone: ��_3io -7827 Gf C/a E-Mail:- Address: 33r L-a 0I-e- Y-/ve_ City/PO ,-State: Zip Code. 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? 'If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. ®V 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: 3.a:Total acreage of the site of the proposed action? _ acres b.Total acreage to be physically disturbed? D 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. []Urban ❑Rural(non-agriculture) ❑Industrial []Commercial (Residential(suburban) ❑Forest ❑Agriculture []Aquatic []Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ E ❑ b.Consistent with the adopted comprehensive plan? .❑ Q ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ Z 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: F7'1 ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ® ❑ 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: (\-21 ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment:, n n 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? MV If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: l4J 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline ❑Forest ®Agricultural/grasslands ❑Early mid-successional M) Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? ® ❑ 16.is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? [NO YES If Yes, ® ❑ a.Will storm water discharges flow to adjacent properties? ❑NO ❑YES b.Will,storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: NO ❑YES Page 2 of 4 18.Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: ®, ❑ 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: © ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: 1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: if'-/( 10 e-� Date: z 0 2/ Signature: T�a (2 Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the,following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑ ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? ❑ ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑ ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate 1:1reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a.public/private water supplies? b.public/private wastewater treatment utilities? ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ ❑ architectural or aesthetic resources? 9. Will the proposed action- result in an adverse change to natural resources(e.g.,wetlands, ❑ waterbodies,groundwater,air quality,flora and fauna)? El Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage problems? 0 El 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. F] Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT7, Page 4 of 4 _wz Town of Southold \ LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1., All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2., Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and'explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A_proposed,action_ will_.be evaluated as to its significant beneficial and adverse effects upon the coastal"area(which includes all of Southold-To 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- sunuorting facts: If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall-pot-be-undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website(southoldtown.northfork.net), the Board of Trustees Office,the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# /DOD _ 7 7 2 - ,3 PROJECT NAME if a -D / _ , .C /ag c y 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: FA Nature and extent of action: Location of action: 286 oaf Avenue , 5-a-1hd f�, AJ' Site acreage: Present land use: re 5Ic.✓e1;V70 L. Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided:/ (a) Name of applicant: 4�r.Ca-O /0-/) C y (b) Mailing address: 33 S �..q V✓�l D�!U� Tra�ope , A4 4 (c) Telephone number: Area Code( ) JD 3/0 — 78Z 7 (d) Application number,if any: f Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes ❑_ No V\J If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure,makes beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. LWI 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—Policies Pages 3 through 6 for evaluation criteria -0- Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LBVRP Section III —Policies Pages 16 through 21 for evaluation criteria ElYes ❑ No Zj Not Applicable 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. 7: Fl Yes No Nay_-_applicable - Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. Q Yes ❑ No' Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No LW 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 LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ YeiF] No 0 Not Applicable Attach additional sheets if necessary WORKING COAST POLAR' +S - Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. El Yes ❑ 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 evaluation criteria. -❑Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. El Yes ❑ No � Not Applicable PREPARED BY DATE Zfl 2o.y