Loading...
HomeMy WebLinkAboutTR-9875A Glenn Goldsmith, President �QFso �/,� Town Hall Annex A. Nicholas Krupski,Vice President ®� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly �s Elizabeth Peeples Telephone(631) 765-1892 '� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1953C Date: August 29, 2022 THIS CERTIFIES that construction of an 8'6"x26' one-story addition connectingexisting house to existingag rage; At 900 Goose Creek Lane, Southold Suffolk County Tax Map#1000-78-8-2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated April 13, 2021 pursuant to which Trustees Administrative Permit# 9875A Dated May 19,2021,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 construction of an 8'6"x26' one-story addition connecting existing house to existing garage. The certificate is issued to Joseph& Barbara Orlando owner of the aforesaid property. 4 ew" 3 f Authorized Signature J, 7 Glenn Goldsmith, President Town Hall Annex a� 54375 Route 25 A. Nicholas Krupski,Vice Presidents ,. P.O. Box 1179 Eric Sepenoski ? ? Southold, New York 11971 Liz Gillooly s<. ,. a Y Telephone (631) 765-1892 Elizabeth Peeples ,t� �,, Fax (631) 765 6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: $ ZR Z2 INSPECTED BY: EVOAC k PLCP�CS Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1St day of construction '/2 constructed Project complete, compliance inspection COMMENTS- - orwara issue Cbpc Node sl�ak� var i�cdion in ori4iv�u1 drawi�` fns r4 o,njqNo g&AMnw►cx►�-at iw�a�cki n ��t,►h9tS. th Pm Elevx.6" SiNke wir��ow is ct 4=4 uvAeu mean, ivy 6M R of door. -Dh P.. &v ney&-A agvUe kgors hecumg -lria6 doors ayuA ��ooa niV,s ex�e '►v�-► c�r�esr w�I��u�, '4y\F=A Elwe�ffi siWr Jamr eliN1�-�.� a� wltn�w it�s�llc� iy��'a� CERTIFICATE OF COMPLIANCE: P,�� Glenn Goldsmith, President �QF soap Town Hall Annex A. Nicholas Krupski,Vice President ��� ��� 54375 Route 25 John M. Bredemeyer III P.O. Box 1179 Southold,New York 11971 Michael J. Domino G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 olycoulm,�c 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;,Ftay-bale,line/silt-boom/silt curtain 1 st day of consttuctio'n - constructed- When project complete, call for compliance inspection; Glenn Goldsmith,President �QF SO!/j Town Hall Annex A. Nicholas Krupski,Vice President ,`O� yplo 54375 Route 25 John M. Bredemeyer III P.O.Box 1179 Southold,New York 11971 Michael J.Domino cn ar G Q Telephone(631) 765-1892 Greg Williams �'� �� Fax(631) 765-6641 UN11 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9875A Date of Receipt of Application: April 13, 2021 Applicant: Joseph & Barbara Orlando SCTM#: 1000-78-8-2 Project Location: 900 Goose Creek Lane, Southold Date of Resolution/Issuance: May 19, 2021 Date of Expiration: May 19, 2023 Reviewed by: John M. Bredemeyer, III, Trustee Project Description: Construct an 8'6"x26' one-story addition connecting existing house to existing garage. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan-prepared by Elizabeth Thompson, Architect, dated February 16, 2021 and stamped approved on May 19, 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. Glenn Goldsmith, President Board of Trustees I l =` \\h, r or Exl,r c,6w-� � s APPROVED BY 90ARD OF .I RUSTEES �_- -- - TOWN OF SOUTHOLD ®ATE M 4y 14 ZozI - --�II� V q\ LL ; I 7 �01-1 ati! i�klS Pl.hW � .y-'"��ca f�'i-;ZCG{GES SIiC �iui��E`f IIIFfl. - ' � �� i'w"�- 1 �1Y �t� n!✓ i r la f I llz P,c„ k`�r,�,�y F. z�� I APR 13 2021 PSG, Elizabeth Thompson : Architect Jab =� G h�;�: G 'G I�IJ� oath Y z Southold Town �/ ( ) Board of Trustees LiY 165 East 118`h St. Suite 7A Title Scale �itl New York, NY 10035 917-848-1541 I '" I � ' I I — - 6x I,i t'I K'I 1, Li \ I \ , 1 E 1,1 i Gic,ruP6tr� cki IaE;v KUvlo - - -q - - - �i II i� it Tlf rr i;l I I 1 ' I � uP F 6 A P R 13 2021 Southold Town Job Date Board of Trustt22-----j Elizabeth Thompson Architect P O.Box 464 917-848-1541 Title Scale 11957 www a �I�T Fie PIAS Vg www llzazabeththompsonarchltect corn I I _ I L i I j i I I A P R 1 3 2021 Southold Town lob Date Board of Truste2a____j Elizabeth Thompson Architect 900 4,OOG5 4t't4�-LA, 6vvrH-ar - M`( y P.O.Box 464 917-848-1541 Title Scale Orient,NY 11957 WWW elizabeththompsonarchitect corn ('�l i 1/811,1�pli 0 ED CL]IQ]LTI CCl ED i A P R 13 2021 Southold Town Elizabeth Thompson Architect lob Date Board of Trustees P O.Box 464 917-848-1541 Title Scale Orient,NY 11957 www elizabeththompsonarchitect corn Fr�tilr�F�PP17,10w I ' ' I y - L _ I I I til • I APR 1 3 2021 `" ='✓ i = Southold TownJ°bDate Elizabeth Thompson Architect G✓uT�s{ � ,�tY Board of Trustees P O. Box 464 917-848-1541 Title Scale Orient,NY 11957 �• r rl. u www ehzabeththompsonarchitect.com `'' �'- �'"ti �=�1`''I j I rf=� %I•=- Residence Addition — �� 900 Goose Creek Lane z. Southold NY .` Lot: 1000-78-8-2 _ MOM = i ; )�,'� First Floor Finish Elevation:+10.4 ft Total Lot Area: 19,356 sq. ft. Total Existing Lot Coverage: 2 319 s 1i. ° Total Addition Lot Coverage: 221 sq.ft. (;; Site Total coverage: 2,540 a, 13% 077- a Proposed Lot List of Drawings• 1 Zoning&List of Drawings 2 Site Plan t 3 First Floor Plan 4 First Floor Reflected Clg.&Electrical Plans 5 Roof Plan 6 North Elevation 7 East Elevation � E C E p U E 8 South Elevation 9 West Elevation ._-• APR 13 2021 Southold Town Board of Trustees Elizabeth Thompson . Architect yob Date Y / 165 East 118Ih St. Suite 7A Title scale New York, NY 2:0 Al �I.,T c�F C'.�`,vll4",s 10035 917-848-1541 �' Glenn'C ':,mit" ",residentd SAF ��'$ �'� Cp±� � Town Hall Annex A. Ni...�Ias I':iaoski, Vice-President „�� ��,:� 54375 Route 25 John M. Bredemeyer, III o P.O. Box 1179 Michael J. Domino Southold, NY 11971 Greg Williams y00�� Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 9Completed in field by: 1,7—1 4 Elizabeth Thompson Architect on behalf of JOSEPH & BARBARA ORLANDO requests an Administrative Permit to construct an 8'6"x26' one-story addition connecting existing house to existing garage. Located: 900 Goose Creek Lane, Southold. SCTM#: 1000-78-8-2 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 earing 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 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 LOT AREA = 19,356 SQ. FT. GAR. ELEV. = 9.7 17-178 AREA LANDWARD TIDAL WETLANDS BOUNDARY = 17,763 SQ. FT. FFL. ELEV. = 11.4 18-193 AREA SEAWARD TIDAL WETLANDS BOUNDARY = 1,593 SQ. FT. DATUM N.A.V.D. 1988 ZONE X TOTAL LOT COVERAGE = 13% (using area landward of total wetland boundary) GOOSE CREEK N g3o4 2, O 24�� 5o dredged canal ,44 E 52• 32' N 5635 apProXirSate high water flag flog flag E7 "Y E7 flagmO1sh vegetation flag E2 " TIDAL WETLAND BOUNDARY, wall �X6• fla 3 / AS DELINEATED BY z 0.6'W 5g flag Er EN-CONSULTANTS, 10-19-2016 " E4 / wall wall2.6'W O /'10' wide NON"ment UFF FC N BUFFER 0.3'E O FC _ O U 1.3'W z natural areas �(Plantiz x W p lawn �7 lawn OO p 1 sty, w/ 2nd �7 sty roof deck Q R o covered (D D M 0open porch wd qe 10'x16' r 0 10'x24' p ck o 1 la 0' 19.3' �°1 3t Cx 19.5' 24• N qty 27.5' a 2 _0 dr ?I 2¢ M °• 6 dia. \ 0� outdoor -ti o8'deshower Qfp ,. Q A 24 0' 30 drywell o LL1 0_ 6' dia. p Q 19' encl. 8'deep O LL. Q 2 0()'j Sy porch on c toad I� rA 19 B 39.6 39.6' �0' pergola /— p O 1O W O Yo N O n wood F 7.6 z T` deck ° G R o A 38 A 37 (pergola 91 �Roi N B 46.6 8 38 Q O over) m i mco s 0' rna gravel N� A 58.6 A 58 pole dri�a � 657.6 a o B51 Y (AA elec. C) drain � meter -- � overhead wires 0 U FC LF water.' ater ravel ' FC 866.65' 1.0'N� meter I gdrive 10.6'N 0.6'W xpost and rail fence x 0.5'W , " S 67°53'50"W 74.09' S 64°08'50W � CME E GOOSE CREEK ROAD D �----- ( PRIVATE ROAD APR 13 2021 NOTE: CESSPOOL, SEPTIC TANK & WATER SERVICE LOCATIONS BY OTHERS. Southold Tovrn THE EXISTENCE OF RIGHT OF WAYS AND OR EASEMENTS 8-17-201 B FINAL IStIf Trustees OF RECORD, IF ANY, NOT SHOWN ARE NOT GUARANTEED. 8-8-2017 LOCATED FOUNDATION THE OFFSETS (OR DIMENSIONS) SHOWN HEREON FROM THE STRUCTURES TO THE PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND USE AND THEREFORE ARE NOT JOB No. 15-251 FILE No. 975 F INTENDED TO GUIDE THE ERECTION OF FENCES. RETAINING WALLS. POOLS. PATIOS, PUNTING AREAS. ADDITION TO BUILDINGS OR ANY OTHER CONSTRUCTION. UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION SURVEYED FOR JOSEPH A. ORLANDO & 7209 OF THE NEW YORK STATE EDUCATION LAW. BARBARA J. CATALAN O-ORLANDO GUARANTEES INDICATED HEREON SNAIL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE TTTLE COMPANY, GOVERNMENTAL SITUATED AT BAYVIEW AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION. GUARANTIE=S ARE NOT TRANSFERABLE TO ADDITIONAL INSMUPONS TOWN OF SOUTHOLD OR SUBSEQUENT OWNERS. COPIES OF THIS SURVEY MAP NOT BEARING THE LAUD SURVEYOR'S INKED SM OR SCALE 1" = 30' DATE 12-3-2015 EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. FILED MAP No. DATE CERTIFIED ONLY TO: TAX MAP No. 1000-78-8-2 DISK 2015 JOSEPH A. ORLANDO & BARBARA J. CATALANO-ORLANDO OLD REPUBLIC TITLE INSURANCE COMPANY HAROLD F. TRANCHON JR. P.C. ALL NEW YORK TITLE AGENCY, INC. LAND SURVEYOR P.O. BOX-616'• ' 1866 WADING RIVER-MANOR RD. WADING RIVER, NEW YORK, 11792 HAROLD F. TRANCHON JR. PENN. LICNNNo. 218159E 631-929-4695 Residence Addition 900 Goose Creek Lane Southold, Lot: 1000-78-8-2 Armrt= t� First Floor Finish Elevation:+10.4 ft (, Total Lot Area: 19,356 sq. ft. Total Existing Lot Coverage: 2,319 sq. ft. @ 12% Total Addition Lot Coverage:221 sq.ft. 1 k,Hti� T ', Site i �''`�; Total Proposed Lot coverage: 2,540 a, 13% List of Drawings: 1 Zoning&List of Drawings 2 Site Plan 3 First Floor Plan 4 First Floor Reflected Clg.&Electrical Plans 5 Roof Plan 6 North Elevation 7 East Elevation 8 South Elevation 9 West Elevation APR 13 2021 ( lc OF t, J i U L_ Southold Town Elizabeth Thompson .. Architect yob Date Board of Trustees P ��� " '� '-�'G°� t�: Z1l1 1zf 165 fast 1181h St. Suite 7A TitleScole New York, NY Zola; r +"r DF F°2,411) 10035 917-848-1541 G,° , 11 � �-' �,�p,����' �--'�, �._r � -, ��=��-, - i-✓stn- \`�� � or EXi,r c,ok►a- \v/4p. - G -q� on �. IF P.or�F DGac � -3- i I � Cfl U _ _.lNFofhlAri Lti1 ©r 1 ii415Plhf J / ; _ri O h� ave" ` �x,; �'i -' 41 1 moi- PGI�GE� f t I t3Y RAF�01 v P,�, I APRI a►a� hVf�`!t:(o a�y,L 1 3 2021 �-rJ�Yc, X11; ► �r.; r'�I�+ •�,_i;•. Southold Town Elizabeth Thompson : Architect Jab I�� Gr��;r� ��`, [A05 Date Board of Trustees Li f -Z/l(I(2) 165 East 1181'St. Suite 7A Title scale New York, NY 10035 917-848-1541 I ` I I I 1 _ I ' uEA O O ' tI —hli.1K .9 IJ6\V��SID 'A H, ro =q - _ _ -- I ur ArE Akr APR 13 2021 Southold Town Elizabeth Thompson Architect JobDate IL `I Board of Trustees 6o Ttt�a Wf For P.O.Box 464 917-848-1541 Title scale Orient, ri www elizazabeththeththompsonarchitect.com I 1 I I - T�z - - -- - - - --- - - - ! L� ! I UI I fill APR 1 3 2029 Southold Town Elizabeth Thompson Architect tob9oo �� e_ft LA, Board of Trustees p P O Box 464 917-848-1541 Title Scale Orient,NY 11957 www ellzazabeththompsonarchltect com PfvT F�4p i3j1�1 1 Dt ILA M fr- E -- i FFT E C E v E I, % SPR 1 3 2021 f I -- Elizabeth Thompson Architect Job uthold Town t Board of Trustees P.O Box 464 917-848-1541 Title scale Orient,NY 11957 www elizabeththompsonarchitect corn Elizabeth Thompson, Architect P.O.Box 464 www.elizabeththompsonarchitect.com Orient,NY 11957 tel. 917-848-1541 Apr. 14, 2021 Southold Town Trustees Re: 900 Goose Creek La., Southold See attached supplemental information for Administrative Wetland permit application, recently submitted. -Project Description, 1 page -Short Environmental Assessment Form,4 pages -LVW Consistancy Assessment Form, 5 pages -Applicant Transactional Disclosure Form, 1 page Sincerely, i Elizabeth Thompson, R.A. , APPLICAN'T'S PROJECT DESCRIPTION (For ZBA Reference) Applicant. `I e)sep'+ DPJt A/lj Drp Date Prepared- I. For Demolition of Existing Building Areas Please describe areas being removed: II. New Construction Areas (New Dwelling or New Additions/Extensions): Dimensions of first floor extension:_ Dimensions of new second floor: Dimensions of floor above second level: Height (from finished ground to top of ridge). j t Is basement or lowest floor area being constructed? If yes, please provide height(above ground measured from natural existing grade to first floor: _[ !C) ) III. Proposed Construction Description (Alterations or Structural Changes) (attach extra sheet if necessary)- Please describe building areas: Number of Floors and General Characteristics BEFORE Alterations: STo N - ^I S 1 D L Cu t(> Number of Floors and Changes WITH Alterations: S o s _ � _ _ IV. Calculations of building areas and lot coverage(from surveyor): Existing square footage of buildings on your property: Z 3(q S F Proposed increase of building coverage: _22( sp Square footage of your lot: Percentage of coverage of your lot by building area. 1 3 ®�o V Purpose of New Construction: G p N N 0 14005 To totJ o 0 VI. Please describe the land contours (flat, slope %, heavily wooded, marsh area, etc.) on your land and how it relates to the difficulty in meeting the code requirement(s): L 'r e FF E tV SIT[ P u %Xls i i u CIA 2.4 c_y-. D oES IV�1 M EST .QyfEL4E—p:� PES( D E LD C.1= S Please submit seven (7) photos,labeled to show different angles of yard areas after staking corners for new construction), and photos of building area to be altered with yard view. 7/2002; 2/2005; 1/2007 900 Goose Creek l e. Cutchogue �� 'z 1 --- J ,� 1 _ View from the South t rwi 1 \` f View from the South-Detail VIA -� ---_ . Wkr 5r. View from the Southwest 3 900 Goose Creek Lane, Cutchogue 00 zl View from the North east View from the West Him .--e..__,�,,,.� _ .•moi , ": ti R '�q� 4,�'f�,� � I .a""--',.....�•--- �` j t I ,� -�••`•���•y�_� (� IJP{,.1 �1 � ��'1 � 1)1 n • r ' r � , 1 View from the East 4 `�1' View from the North Al ,r A � 40 d4m l ':»sem-r.+• { t ,. t ! NE oNo 1, � LNE SLEEPY HOLLOW ^ om yy e„ye " Oa ocm ° ,o.xa r is re,6 10.1 IOa I ,0A nszeas v.6n a y,%^ IIA ix '`N�luk) / �•\ ; _ :-al .a ,:, :�l s ^ 106 �W' ?,W NrA B . xt '^' wim x-_ s 1' . A .•••�•'.-.. 6soo-zo 1 I �' F L 7f, \'33 rt',�:. \a \ a kr,,'l,,• s p �9p i4 l 1 s N t� V \ ssEa BD oro' ' umipis .I r {{ b/ 4• '4 ,a 0� r y d'i'la _' w s__ m 14 la. a a ,/ aD .•^T ew ( mss- - xo s 219.(� �b _II "No", -ter � � :' - t7 T �t��_- r 1 ;y pP�• �aw Zp) ro., y �! F3 + �•�_..., d+(�\ \� 93 I A lea a� 6ii z,F lA2w IS I w2 I p As ObW'?4jD,'`�Y _J___" 'A N. _ 5s ]b i "£d-: % il� �4 R• f L ( 41 L ¢J -er. �'r -- �____-._ er'' ,i` , ''y, dae naf,,,, t i.. v y' e, 'a ,,J,r •V t�„� rso-) ✓A r, / / Prr�.s�—m-i ^>.-''."�„�.._tr z + ,- C\ �� /�P` `/L .eil,,.♦ 3j ' / .^ \ r \ d -�7 (aa T y� t��let�.- ,rr J, /j e1 I I e, I G 's._ ,; a n'x• .* / rs•` ^`!' tr �/ !' Y ♦.,♦ ,,r - ,yµ.T'J Std �' zla ! t 1' r N ,+I .e A, � } \ � ��,�i� ® aza ... y f{ [z ��s J Z + I •q1. 3� 66w 1,p" '=.-r fi `� :4I . /� 4d F +i: \ ! 4 N-g'�, �' r !Y l !t 2� 1; e> ✓A �r�- °/`os t+'��,7r •••r d/ <, �Y % �\ `\�i ��,s �plll� n/ 4_.`aseT : �A ar,aidz ` ` ��-... r' h La`'��t YI `..i l+ k "� _ !: I unore -* !.•, - j t e r•, s - \ / I W 6xa N 1 I I Tr eS P j p.. ,A • PP H Bo s 95�...b+ paarJ�"' •�_..n�6 9� _:,,,. d^ � I •��\a: f B`''-"�u�l� ,zN �7 ptHPS v v' 9`..- Y s,. cv,O _� c » % .� I .•i r.Ww - J �0! 1 =y. ` �•_� a� r �:,A, 1 N /'d.IpW a °syf ate.o __ S�m4r•,! •Jr/ r+., ^ i�, '�� k ' v /• Mq y '� 'eTh !--til -_-�a♦a l ! - / �^ aY tlu t II`-_i•l ,s 1J�tr?�^ar ) - { F �y'" •5� T " F a'I"^,» yez e ♦e/ 4 d c-. -•,' .,� /c: T =s x/I t ✓ta.d !yr a ,� I 'x. v F' x I �,• y6.a. ,.M ,9 „•.e +r'a 'J 4, \ 4v / �,q d / 7�,"•'�, d u rz N r z l :e i rdl Bza` Nl m I''o w. (s ! '� ""..•.1� •fro : i+rtl ..' 60 �i;" ? '''•.,c• - .F�, Ar -1 ,�A •� F, Jr e/ bd y�z / % dJs �'ti: T°tx'' sq 6 a .Lopw -a ......'. ,,. •.i. M >• S t s a�� 4 Y .�ae HN v' ` � sfis y, 1 F 7 r.a.z-,.t ;'Jt✓rb1I.t'o[.'rli aNL,rt®3F,• _yIs�a�'w �I u`.r'!c'';1W It T, ,�,�• fzosyr moi, b u t; ^ez c x!�^ ` s o y y 16 ;��.-r«-*� �' (. d�+ J �k N !• Im rad --� 1 zM l ) a s, s r tr uI ';r 4t'.��'. 1aww, r �, p/d ,r.,. .tel E,zil(...:ipu� v ^„�. !�•,., 1 I uk) _.r, Ba ea ro �'E% '.l j a,-.� ! yp 4 r -•I � •46z!) � \ 4 � � �� l � o � x `raF n� t ��` RO !l T � ` S -T-H LINE SGE eED NO OeT w 4 , COUNTY K "••••."•""•• - "" ' OF SUFFOLK ratwE �. sEcnDN nn - - .•.,....�o°`'°__;-- - ,,. k u� 1y T ' ice Agenc,. Mwnera•.r�A an > .. Qz BNo. 0 8 •.��--.-- — -- '� _—__— :. r :._... .• CPr< *E� � �„�� sourlloLo •� OFFICE LOCATION: � � �k MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) �ry Southold, NY 11971 Telephone: 631 765-1938 R 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: March 12, 2021 Re: Local Waterfront Coastal Consistency Review for JOSEPH & BARBARA ORLANDO SCTM# 1000-78-8-2 Elizabeth Thompson Architect on behalf of JOSEPH & BARBARA ORLANDO requests an Administrative Permit to construct a 8'6"x26' one-story addition connecting existing house to existing garage. Located: 900 Goose Creek Lane, Southold. SCTM#: 1000-78-8-2 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. 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 Hrl/� Glenn Goldsmith,President , Town Hall Annex A.Nicholas Krupski,Vice President �f - ��' 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 Michael J.Domino Telephone(631) 765-1892 Greg Williamsp ,', 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 Received Application:_ Received Fee: $ 100.00 Completed Application: Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): E C E �LWRP Consistency Assessment Form Sent: Q l5 CAC Referral Sent: /—Date of Inspection: 'g2 ��� 202 Receipt of CAC Report: Technical Review: Public Hearing Held: Southold Town Resolution: Board of Trustees Owner(s)Legal Name of Property(as shown on Deed): ,j osaC N f,�Rt+WA 091,61,150 Mailing Address: SS iL.GA e ALn 1Z t N C,E F->b I 469R45-00 NY I b5-2 P Phone Number: 9 0 - 6,54 - 19 10 Suffolk County Tax Map Number: 1000 - 7S - $ - 1, Property Location: a®o 6 ooec 4,06t— LAf-D-� �u Tt+en b* (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): _ J�L42-4 ajjn-! Mailing Address: F- 0 , 95)X 4&4 Phone Number:_ l`7-g S—l 5± Email: e��e l ��`N11 C�►owpso�Q"�:d+� •ca n� Board of Trustees lopplr tion GENERAL DATA Land Area(in square feet): _ 194 2 SF Area Zoning: -40 _ Previous use of property: S to e.Lz- d41µI ce-i 1Lts i ]>z7focz Intended use of property: 12*=S o De-m c t- Covenants and Restrictions on property? Yes X' 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? X Yes No If"Yes", please provide copy of decision. (I6,j>1Nc, Will this project require 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? X Yes No Prior permits/approvals for site improvements: Agency Date pzDom►. A 2D+�C No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No Yes If yes,provide explanation: Project Description(use attachments if necessary): o LnE - Std e4r A2DTd arJ ��TIN Xls�11.9c �A-R�-CSC Board of Trustees Appl ,tion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Si N&l-tt r/Aun Lyr RtA-z,r t>�`c Area of wetlands on lot: �, q 27 square feet Percent coverage of lot: F3 % Closest distance between nearest existing structure and upland edge of wetlands: 48 S feet Closest distance between nearest proposed structure and upland edge of wetlands: l®o feet Does the project involve excavation or filling? lNo Yes If yes, how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: �L A-T Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): 'ok R.,Fz- I S N o c-fFeT o N W e7-ri.Alo p S o P- T,D&L. UJ Z4— AS � 1?-�Su� eF T(-4�S �2od f✓��' 1 Board of Trustees Application AFFIDAVIT BEING 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. /Ygnature of Property Owner Signature of Property Owner SWORN T EFORE ME THIS _ DAY OF 741 tk Public JAMES P.REDUTO Notary No.02REtate of w York 5026899 Oualitied in Westchester County Commission Expires April 25,2022 APPLICANT/AGF,NT/RF,PRESENTAT TRANSACTIONAL DISCLOSURE',FORM Ilic Town ofSouthoi s ggde.of Ethics prohibitsconflicts ofintemst the part o town officers and cMogyees.The u of this fqM kio provider a a"on which ca,zleft the iavMi ibis con icts ofW=and alt w t to take t ha vs i ` Is necessary to avoid_same. YOURNAME:, Al�O �MEA/ A (Last name,first name,.;niddie initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indican the other person's,or company's name.) NAMIIJ 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,siblings,parent,orchild)have a relationship with any officer oremplsoyee of theTown of Southdld=? "Relationship"includes by blood,tnorriagc,or business interest."Business interest'r means a business, including a,partneiship,in which the town officer or employee I=evert a partial ownership of(dr em loyment by)a 040r40M in Which the town OtTper or employee owns more than 5016 of-the'sharas, YES NO 1f you answered"YW,-,complete the baWce of this form and date and sign where indicated Name of person employed by the Town of Southold, Title'orposition ofthat person Describe the relationship between yourself(the applicantfagentlrepresentative)and the town oEfcer or employee;Either check the appropriate line A)through D)and/or describe in the space prodided. The town officer or employee or,his or her spouse,sibling,parent,or child is(check all thatapply): A)-tha owner ofgrcater than 5 ,of the shares of the corporate stock of the applic,•int (when,the applicant is a corporation);' B)the legal or bencticiai owner of any interest in:t non-corporate entity(when the a pi",ktisnotacorporation); C)anoff cer.,director,paruter,or employee of the applioam;or D)the actual"applicant, DESCRIPTION OF`RELATIONSI-IIP Submitted this_ -21 Sdav f Aran- 20 Z,-1 Signature PrintNam T��4 gRo Form TS I 617.20 Append&B Short Envrronmentall Assessment Form Instructions for Completing Part I -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information cu-rently 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: lZes I rj tUG L-� /�-D t T t o tJ I G A-9,4&C— lZE lU o V A-71-t b Project Location(describe,and attach a location map): SSI DENT( Ar L, I-.ol- d*� 6Leose cReE- f- , ©GYITt®l� M►}P 5�� c,l Brief Description of Proposed Action: tr tt , 7 (ot 1710 1,J GolUNGLTIti6.1 RC-SIDEMr,(55- TO �c!� 21a-�c t✓t (Zro ISO V A TLC)tQ 6t t; l M Tb F Name of Applicant or Sponsor- Telephone: u �I b►�l FSo� 412-111-141 '- E-Mail:2.-�' // Address: L�t a e'fb►Tltow� ho-r �i4-ctc W City/PO: State: Zip Code- adoption a �-t1✓1,,T l(� 57 1.Does the proposed anion only involve the legislative of a plan,local law,ordinance, 71'ES administrative rule, or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: C-OMGTWC-Ac lVtt.c.. Pte- `j 4�IRE� �`( E>L)(L tN� DE t • X 3 a.Total acreage of the site of the proposed action? Lam a b Total acreage to be physically disturbed? aer-eZ ts S F c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? M?r S(o aer-Ng F 4 Check a[I land uses that occur on,adjoining and near the proposed action. ❑ Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial Residential(suburban) ❑ Forest ❑Agriculture YAquatic ❑Other(specify). ❑ Parkland Page 1 of 4 ra'.A s the proposed action, permitted use under the zoning regulations? NO YES N/A b.Consistent with the adopted comprehensive plan? 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? 7. is the site of the proposed action located in, or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes, identify: S a.Will the proposed action result in a substantial increase in traffic above present levels? TNOYESb.Are public transportation services)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? If the proposed action will exceed requirements,describe design features and technologies: NO YES X 10. Will the proposed action connect to an existing public/private water supply9 NO YES If No,describe method for providing otable water: ,l4gu G P �P � TC-`(L 13 F 11. Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ` 12. a Does the site contain a structure that is li Places? sted on either the State or National Register of Historic NO YES 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? If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site Check all that apply: J Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional Wetland ❑Urban bSuburban 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? n NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources9 NO YES If Yes, a. Will storm water discharges flow to adjacent propertiesv ANO ❑YES b. Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO KYES C.00VrV OK3 Page 2 of I the proposed action include construction or other activities that result in the impoundment of NO YES er or other liquids(e g retention pond,waste lagoon,dam)'? explain purpose and size X 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- X I AFFIILNI THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF i<fY KNOWLEDGE Applicant/sponsor me: % b Date: 3b �pZ Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" f, - - ; , •_•E. +.r _ No,or Moderate small to large _.. - - _ -- -" �•r=, ♦yi Lig impact impact _ - may may =';. :•. :,- ' ;, :-�,.Ff, =�'__ occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zonincr 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 J� establishment of a Critical Environmental Area(CEA)? x 5. Will the proposed action result in an adverse change in the existing level of traffic or affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ` a"public/private water supplies? x b.public/private wastewater treatment utilities9 8 Will the proposed action impair the character or quality of important historic, archaeological, architectural or aesthetic resources? 9 Will the proposed action result in an adverse change to natural resources(e g.,wetlands, waterbodies,groundwater,air quality, flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may ` occur occur 10. Will the proposed action result in an increase in the potential for erosion, flooding or drainage problems 11. Will the proposed action create a hazard to environmental resources or human health? X 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. Name of Lead Agency Date 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) Page 4 of 4 Town of Southold I_, NNP 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 supple-.rent other information used by a Tovtin of Southold agency in making a determination of consistency. *Except nzino- exempt actions Including Building Permits and other mi;zisterfal permits not located within the Coastal Erosion HaaarciArea. ?. 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 Town). 3. If any question in Section C on this form is answered "yes", then the proposed action may affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, the action should be analyzed in more detail and, if necessary, modified prior to making a determination that it is consistent to the maximum extent practicable with the LV/RP policy standards and conditions. 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: onlme 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 SCTM9 The Application has been submitted to (check appropriate response): Town Board 0 Planning Dept. E Building Dept. Board of Trustees 1 Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g.capital construction, planning activity, agency regulation, land transaction) (b) Financial assistance (e.g.grant, loan, subsidy) (c) Permit, approval, license, certification Nature and extent of action: F� �tDg'f �-R-D < CrSAU� V qP1 PrNu— 7— Location of aciion: r�0 OpS C 'C'�K- Sdu'ffl cert Site acreage: 9 Present land use: Present zoning classification: — O 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: U (b) Mailing address: , © _ R O X 0 F4 L�')T (c) Telephone number: Area Code( ) 1117 1 -5— (d) (d) Application number, if any: M, A, , Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ❑ No 91 If yes, which state or federal agency? tD 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 L'VVRP Section III—Policies; Page 2 for evaluation criteria. VYes [:] No [:] (Not Applicable-please explain) bJ C e-,-rt) 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 ❑ Yes ❑ No;K (Not Applicable— please explain) DDrT1OU ff:l - rl1(2 vn l��v`1 ���fL« ©Z Attach additional sheets it necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LN P.P Section III- Policies Pages 6 through 7 for evaluation criteria LX' �Ves 0 No D (Not Applicable- please explain) 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 S through 16 for evaluation criteria Yes 0 No 'L�IR4 (Not Applicable-please explain) &]>Pt71d>0 /-2/S r40 ErFE�-�- oti �2ooDr1.��� ot�Ff��sto�1 Attach additional sheets if necessary Policy S. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III -Policies Pages 16 through 21 for evaluation criteria Yes 0 No Lz� (Not Applicable-please explain) 111!12 /�I J D r T r D U LL6:S tU D r=E�T7 b k) W Art t2 Sty � LIT 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. 17, Yes r, No,n (Not Applicable- please explain) —(�1 - D a_ITZ 0 oV 146-S VU 0 S f 1 Attach addit onal sheets if necessary Police 7. Protect and improve air quality in the To-mi of Southold. See LW'R.P Section III - Policies Pages 33 through 34 for evaluation criteria. See Section III-Policies Pages; 34 through 38 for evaluation criteria. 0 Yes ❑ No X(Not Applicable-please explain) EZ-jr- A-1 fZ A-L., ,attach additional sheets if necessary Policy S. Minimize environmental degradation in Town o: Southold from solid waste and hazardous substances and wastes. See MNRP Section III-Policies; Pages 34 through 38 for evaluation criteria. 0 Yes El No �(Not Applicable-please explain) _!T t Tl C+j F}�A S N O C�� T 'r�Mim /�t iV 1 m 1 ns:- U F, [pt Fv 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 L`VRP Section III-Policies; Pages 38 through 46 for evaluati n criteria. ❑ Ye-C No� (Not Applicable- please explain) T+ts D D t i t o t�J l+l�S N o t,f Ft✓c-T no y F,uG U s e. o iZ a e fav g U c— t_. " t� Go�1 S i►�-L leu f-�'[-c�` 0 2 IFL) U C Attach additional sheets ifnecessary WORKING COAST POLICIES i Policy 10. Protect Southold's grater-dependent uses and proniott sitit,II of ne,,v water-de � � pe ndent uses in suitable locations. See LWRP Section III—Policies; Pages 47 through 56 for evaluation criteria. ❑j Yes ❑ No FV (Not :applicable —please explain) A->D t Tt c+J N o c E 1"(,L o(� )`f (A)14 T(ER _ �t✓`�t=+J���i UsCS 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 LVVRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No 12"ON Not Applicable— please explain �1l S /?-D A r l o iy 1-1-i4S N o i= T a l. M 2 !y f -Sa 2rr'S Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See L`VRP Section III—Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ No X Not Applicable— please explain ti A-( P—t C-0(.Tu R44-f_ Attach additional sheets if necessary Policy 13. Promote appropriate use andevelopment of energy and mineral resources. See L`VR,D Section III—Policies; Pages 65 through 63 for evaluation criteria. ❑ Yes ❑ No V Not Applicable—please explain I S 1�-D D f Tl D N Fri Py o L,rFL��-T- a —p e-g U`Z C>L l APPLICANUAGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold'c'Code of Ethics prohibits conflicts of interest on the part of town officers and employeos.The purpose of this form is to provide information which can alert the town of possible conflicts-of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: <1� 01&4 re pu L•l 2/9 ETt f (Last name,first name,middle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building 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 X 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 this day A F�C L ?9* 2 o Z f Signature Print Name N Form TS I Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) I/We,�- osc--�F a� �A-(L��4fL14 �2[.H 1•��0 owners of the property identified as SCTM# 1000- 78 — 8 — in the town of n Two L I> ,New York,hereby authorizes Int 7,A-M e-rt-iRdiFSS, L jer=T to act as my agent and handle all necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for this property. r perty Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS 10' \ DAY OF 1 14. N y Public JAMES P.REDUTO Niel ry Public,State of New York No.02RE5026899 QA1A1,iti-0 in Westchester County 4E@?rRfP§lP>T Expires April 25,2029 0 Elizabeth Thompson, Architect P.O.Box 464 www.elizabeththompsonarchitect.com Orient,NY 11957 tel. 917-848-1541 ® E C E 0 V E APR 9 3 2029 Southold Town Board of Trustees If