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TR-9445A
Glenn Goldsmith,President *QF SU(/lTown Hall Annex A. Nicholas Krupski,Vice President ,`O� ��� 54375 Route 25 III P.O.Box 1179 John M.Bredemeer Y � � Southold,New York 11971 Michael J.Domino G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 OUNT`I,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD May 20, 2021 Douglas & Leslie Hirsch 5028 New Suffolk Avenue Mattituck, NY- 11952 RE: 5028 NEW.SUFFOLK AVENUE, MATTITUCK SCTM# 10,00-115-10-2 Dear Mr. and Mrs. Hirsch: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday,,May 19, 2021: RESOLVED, that the Southold Town Board of Trustees APPROVE the request for a Transfer of Wetland Permit#9445A from Geert Martens & Thomas Murray to Douglas & Leslie Hirsch, as issued on May 15, 2019. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. If you have any questions, please contact our office at (631) 765-1892. Sincer ly, Glenn Goldsmith, President Board of Trustees GG/dd Glenn Gold th, President OS�FF��i Town Hall Annex A. Ni'choias Krupski, Vice-President ,�� ya 54375 Route 25 John M. Bredemeyer, III y 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 11 Date/Time: 5/1-7121 $!4S Completed in field by: G. �o rlS� DOUGLAS & LESLIE HIRSCH request a Transfer of Wetland Permit #9445A from Geert Martens & Thomas Murray, as issued on May 15, 2019. Located: 5028 New Suffolk Avenue, Mattituck. SCTM#: 1000-115-10-2 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 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 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: �kra.A�`� � s b✓c�cdl .J I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other Douglas and Leslie Hirsch 5028 New Suffolk Avenue Mattituck, N.Y. 11952 Elizabeth Cantrell D E Q E V V EflD Senior Office Assistant APR 2 1 2021 Town of Southold Board of Trustees r Sou'hoitl Town Town Hall Annex Board of l�ustees 54375 Route 25 Southold,NY 11971 Re:Permit Transfer For 5028 New Suffolk,Avenue Dear Sir or Madam; I am the new owner of 5028 New Suffolk Avenue,Mattituck,NY. I am-writing to request that the following permits be transferred from the prior owners to me and my wife: 1.Permit No. 5101 dated,January 26,2000•—wetlands permit to construct a single family dwelling with pool,cabana and garage. 2.Permit'No. 5932 dated May 26,2004=wetlands permit to construct dock 3.Permit No. 9445A dated May 15,2019—hot tub permit Enclosed please find a check in the amount of$150 to cover the application fees for the transfer- of the three permits. Should you need anything further, please email me at dhirscbasadis.com or call me at 516-456-6886. Thank you. e , Very truly yours, IN Douglas Hir h c Board of Trustees Appl ration 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 INTHE 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'O.F TRUSTEES DURING THE TERM OF THE PERMIT. ' Signature of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS ` DAY OF l 202— Notary Public �0 f-m' a4c Af wthr {r�C �° o 16 r 6 3 l a T APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM Tlie Town of Southold's Code`of Ethics prohibits conflicts of interest on the part oftown iifficers and employees Thepurpose of this form is'to provide in'focination which'ean alert ihe,town of possible conflicts of interesi and.allow it to take whateyer action is necessary to avgid same. ����// YOUR NAME: Icsta S t (Last name,firk name,middle initial,unle you are applyingin 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 _ OtherS, (If"Other,name the activity.) Do yoti;persbrialiy{ar;thevughyaur cgmpany,spouse-sibling,p"creat,or child),have a re(ationsl�ip Frithany officer or'employee of tlie'I'o•Wn,gfsouthold? iiicludesbyblqod,irtacriage,orbusiness%terest."Business-interes6 means a business, including.a•,partners rip,iir whieh'tlie town aB'icer oi,employee has even s psi Pial otvnersitip of(or-'ega}iloyttient by},a CAtpoi tIatt JdWbjdjtf.e.t6w)t.©fftcer1or employee.,oWns Moro than•'M/0 dflft sliaM- . 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(agenttrepresentative)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)tha owner:ofgieatdt thaw 5%,617the shares of the corporate stock of the applicant (when the applicant is'a.corpotation); $)the legal or beneficial_owner of any interest-in a non-corporate entity(when the 'applicant is not a oorporatibn); C)an officer;director,partner`,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted hr / day of �� ` 20 2 1 Signature $C L� Print Name t9 Form TS l i 4 Michael J.Domino,President *QF SQ(/Ty Town Hall Annex John M. Bredemeyer III,Vice-President 54375 Route 25 P.O. Box 1179 Glenn Goldsmith l [ Southold,New York 11971 A. Nicholas Krupski G 1 Telephone(631) 765-1892 Greg Williams �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1614C Date: September 5, 2019 THIS CERTIFIES that the as-built 7'5"x7'5"hot tub and 908sq.ft.deck on the north side of house; At 5028 New Suffolk Avenue, Mattituck Suffolk County Tax Map#1000-115-10-2 Conforms to the application for a Trustees Permit heretofore filed in this office dated April 8, 2019 pursuant to which Trustees Administrative Permit#9445A Dated May 15, 2019,was issued and conforms to all of the requirements and conditions of the applicable provisions of law. The project , for which this certificate is being issued is for the as-built 7'5"x7'5"hot tub and 908sq.ft.deck on the north side of house. The certificate is issued to Thomas Murray&Geert Martens owners of the aforesaid property. Authorized Signature Michael J.Domino,President q SOUr�o Town Hall Annex John M.Bredemeyer III,Vice-President ,`O l0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold, New York 11971 Colo A. Nicholas Krupski • Q Telephone (631) 765-1892 Greg WilliamsOOUNTV, O Fax(631) 765-6641 �� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction % constructed X Project complete, compliance inspection. INSPECTED BY: G. fdSn�► �� COMMENTS: &,N; %v, c?csn4 944-SA oana 4 19120 1 R. GK � C ok CERTIFICATE OF COMPLIANCE: CTr'zz' Michael J. Domino, President A� S11FFD( Town Hall Annex John M. Bredemeyer, III, Vice-Presidents y-�_ 54375 Route 25 Glenn Goldsmith (y 4 P.O. Box 1179 A Nicholas Krupski • ���Y Southold, NY 11971 Greg Williams 4,, , . Telephone (631) 765-1892 Fax (631) 765-6641 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 �i When project complete, call for compliance inspection; Michael J.Domino,President �QF S0(/P Town Hall Annex John M.Bredemeyer III,Vice-President ,`Oy��® 54375 Route 25 P.O:Box 1179 Glenn Goldsmith J�L Southold,New York 11971 A. Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williamsa0 Fax(631) 765-6641 �lyCOLINT`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9445A Date of Receipt of Application: April 8, 2019 Applicant: Thomas Murray & Geert Martens SCTM#: 1000-115-10-2 Project Location: 5028 New Suffolk Avenue, Mattituck Date of Resolution/Issuance: May 15, 2019 Date of Expiration: May 15, 2021 Reviewed by: Board of Trustees Project Description: For the as-built" 7'5"x7'5" hot tub and 908sq.ft. deck on the north side of house. 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 submitted by Geert Martens, received on April 8, 2019, and stamped approved on May 15, 2019. Special Conditions: Hot tub is not to be drained into Town waters. 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. Michael J. Domino, President Board of Trustees UTILITY POLE LIL #45 VEMENT 2+ FOUND EDGE OF PA 97 .23 STONE MON• E 9 N 7B-40'3P, 0.00 23,75' 13.47' Ul N 11 1 O-LO m y\ \ O . 1 z O �5\ 750.00' U`) \\ (_ 1 N \ l W I Un UTILITY POLE 1 O I I = LIL #1 -- O'1 1 0 1 6? f � \ D. 00 Co Im 1 m l Z� I Ln C ► 1 IrUTILITY POLE ry�ham. / 11 Q�w � / /O 3/� UTILITY POLE LIL #3 \ N 1 1 I \ Lj W 0 a W to \ CO I 1 U CID 1 � SURVEY OF PROPERTY COL / CIO SI T UA TED A T \1 ""' , 1 APPROX. /� /\A T T T T C K�I 1 Z I N �� C01 PAGE LOCATION 1 �J 1 TOWN OF SOUTHOLD 1 1 SUFFOLK COUNTY, NEW YORKGO 1 S.C. TAX No. 1 000- 1 1 5- 10-02 � I DO O CESSPOOL SCALE 1 "=30' 1 'I DECEMBER 23 1999 \ { FEBRUARY 3, 2000 ADDED 50' BUFFER FEBRUARY 11, 2000 ADDED EDGE OF CULTIVATED FARM FIELD APRIL 7, 2000 ADDED PROPOSED PROPERTY LINE AGREEMENT LINE APRIL 19, 2000 REVISION BY WILLIAM BIALOSKY, ARCHITECT 1 oil , MAY 5, 2000 REVISION BY WILLIAM BIALOSKY, ARCHITECT \ I o ; 15 84 JUNE 5, 2000 ADDED PROPERTY LINE FOR S.C. TAX LOT 1000-115-10-01 o I o N/O/F 1 JUNE 19, 2000 REVISED BOUNDARY LINE AGREEMENT LINES �rn 1 o II I O RULAND _ AUGUST 14, 2000 UNDER CONSTRUCTION SURVEY o 1 z 1 1 O , 0" E SEPTEMBER 8, 2000 ADDED PROPOSED GARAGE -� 1 I ICn 40 OCTOBER 18, 2000 UPDATE SURVEY 1 N I 6°40'20" Etn r1 78° cn N 1 0' 11, O JULY 12, 2001 FINAL SURVEY \ I 5.88 �g6. PLANTER JANUARY 29, 2002 REVISED FENCE HEIGHT 10.02 1 = I (rl AIR CONDITIONER UNIT AUGUST 28, 2002 REVISED PROPOSED GARAGE CONC. MON. ELECTRIC METER I 111 I -+ JANUARY 30, 2003 FINAL SURVEY FOR GARAGE PLANTER 0 WOOD FENCE — W FEBRUARY 25, 2003 CORRECTED GARAGE MEASUREMENT I oz GRAVEL NOVEMBER 19, 2018 UPDATE SURVEY z i D Z. 237' I GATE U —UNDERGROUND I FLAG00 1 STORY j PROPANE TANK COVER I ' O I o o.. FRAME GARAGE I 1 LOT AREA = 46,012.16 s ff. 00 I < GAR. flr. N I 1 q II T U' e1.=24.5 U I 1 .056 ❑O. O 1 IGRAVEL WALK I I' 1 WOOD CERTIFIED T0: til 2p'3— I &3 STONE L� STEPS , I FLAG m GRAVEL WALK GEERT MARTENS IL ----F-�I Ln*� I 1 RAY MURRAY I I Zo TUB I WOOD 1 D NORTH FORK BANK 01111 nR- WOOD `ECK SANITARY ` \1 0 WALL BASE EGRESS I FLAG a NOTE: LEACHING POOL I I v 18'8 I WINDOW WELL 1 III, 1. FLOOD ZONE INFORMATION TAKEN FROM: I 11� TANK I BAY 1 I z FLOOD INSURANCE RATE MAP No. 36103CO482 G I I p _ I WINDOW ZONE A#: BASE FLOOD ELEVATIONS DETERMINED X3_711 11- O— 3.8 i I 1 d�l. 0 G , $ O WOOD 1 = ZONE X*: AREAS CF 500-YEAR FLOOD; AREAS OF 100-YEAR FLOOD WITH AVERAGE fN I I F��Z"'0, STEPS g DEPTH OF LESS THAN 1 FOOT OR WITH DRAINAGE AREAS LESS THAN 1 SQUARE MILE; AND AREAS PROTECTED BY LEVEES FROM 100-YEAR FLOOD. I I *t ° o 0 m m � ZONE X: AREAS DETERMINED TO BE OUTSIDE 500-YEAR FLOODPLAIN. Il D N 1 Zmm 2. ELEVATIONS ARE REFERENCED TO N.G.V.D. 1929 DATUM. II -- 3.6' r�i 1 I o °Z0 I L---- D mz Kom -n _ 35.6' 0 AF O I 1 mu) I I (n r mo �n Z v Z"A 1O Ln �2 s I C + o0 1� - - - 4- -7-2 - - _ _ —m o C'. = ROOF OVER WOOD DECK' 0 12 o , 11 ' z o 2 / Cll 'dog m 0 0 f all, / J I o z o o a ` FLAG N �\ 0 v 0 z / I N FLOATING O o r m p - a11, I DOCK Z m oW FIXED WOOD o O - \ 111, III. DOCK FLAG RAMP 46.1 , 54.1' \ \ W OD STEPS 7�/����17 19.0' ` P�7�/ N FRAME BUILDING o � FLAG I 0 0-a STONE ZJIL 0 Z o WALK x 1 QO f m am OD all. av r m x * W ooyc �Zi 1 uj Z I W m p I Z <0 o I N1 W 0 aIL 1 I Z t G P I o o I 1 N D1+I I, Z N G o0 I �0 I O o — ahs Q W 1 lit 'kill j I FOUNI I 1 GONG. C9 1 4' OF HOLLY BUSHES 95 O/F ROW 1 2$.3 •��. N/ LINTY Y 50s"ES SUFFOLK CO N, ROW OF eIERGREENS IAT zG ROW OF �t1 0" N OF EVERGREENS 0 5 7 6 4 Row 01-1 UNAUTHORIZED ALTERATION OR ADDITION T OF WAY o CK/DROBET OBET 5°ECTHON 7209 OFIS SURVEY STHEVNEWTIYORKON °STATE Jr' RIGH JA Y S. DR EDUCATION LAW. - - VV4 GREENS DOROTN COPIES OF THIS SURVEY MAP NOT BEARING OF N/ / USTHE LAND & EMBOSSED SEAL SHALL R'SINOTDBEEAL CONS CONSIDERED EDWARD HAN TO BE A VALID TRUE COPY. CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTI- TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. THE EXISTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD, IF ANY, NOT SHOWN ARE NOT GUARANTEED. ■ PREPARED_SIN-AGCOR.DANCE WITH THE MINIMUM Nathan Taft Corwin 'I' STANDARDS F�F� ALE PPRO E AS ESTABLISHED BY,aR e �A 5 I�D-APPROVED AND ADOPTED MQ, C Y-- ,HE% W'YORK STATE LAND Land Surveyor Successor To: Stanley J. Isaksen, Jr. L.S. r Joseph A. Ingegno L.S. ` p Title Surveys — Subdivisions — Site Plans — Construction Layout PHONE (631)727-2090 Fox (631)727-1727 :, OFFICES LOCATED AT MAILING ADDRESS0 1586 Main Road P.O. Box 16 Jamesport, New York 11947 Jamesport, New York 11947 N.Y.S. Lic. No. 50467 99-779N J FLAG g EDGE OF WETLANDS FLAGGED , BY EN-CONSULTANTS INC, i ON NOVEMBER 30, 1999 u F IN !r p I O TOP OF BANK 3 . ® .o r " Y cr-J ®\ Li 5¢ 5 W3 C3 V, � � p~ 3 rl s O WW ♦ / k O 0 v� -i mo 0 3v) vn y10 } w p ` 00 j�� Z 00 pN Oy m3 m i I 00 (� w a ¢ o w v o w a WOOD WALK . W w 3� -�--3o J --- --- z n z w I I INGROUND POOL Z i ,, 61.2' CHIM Vwo 40' w v l I F-m w tl on m 1 STORY FRAME HOUSE m WOOD O S l c - -_ -----JWOOD DECK STEPS 3`J11BdO Ld 15 E -- 12.0' 24.4' Cs� W 25.5' W.i•AL K'1 24.8' ri W` zl o-, U i„ CELLAR\ o p ol ►=x O w 0< c v�I o w¢ ` �Oy EPlTFtANCE WOOD ?� 1 w h r V CN n I N�- 14 v�, WOOD 6c DECK MM STONE STEPS O W N V7 Q u. N I ;,PIP 12.7 ^Q U w (� U ��. �S�ONE STOOP / O O � I I _ 6 -HIGH WOOD FENCE 20, x.00 S 15.2' 25 5' _ I ,n N CONC. APRON L --- ------J I ._� 7 -�' AP � I l O � SLATE � ��_'.� I o � I ----- -__- Z GRAVEL DRIVEWAY �'?1 I I WALK I o. lo.00 N - _•_I -BOARD OF TRUSTEES az 22.68' << ; TONIN-OF SOUTHOLD _ ---------------� � I �_ N 08' 09'00 W ; `� I` �� \ DATE N/0/F m o � L( -.477 C Michael J. Domino, Presider 0�0 �'OG _ Town Hall Annex John M. Bredemeyer III,Vice-Pr-esident �� y� 54375 Route 25 Glenn Goldsmith o "� P.O.Box 1179 A.Nicholas Krupski 07 Southold,NY 11971 Greg Williams ydap! Telephone(631)765-1892 . Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time:�� /�9 .5-'36 Completed in field by: THOMAS MURRAY & GEERT MARTENS request an Administrative Permit for the "as-built" 7'5"x7'5" hot tub and 908sq.ft. deck on the north side of house. Located: 5028 New Suffolk Avenue, Mattituck.-SCTM#: 1000- 115-10-2 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 Hearing Card Posted: Y / N Ch. 275 v11 Ch. 111 SEQRA Type: 1 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: �QjiJIT en �CG�r�nnn�o wo'f'h D1Af�S. No IN'�rAta�/L� r°nyl�onr��°.n'to.l rripr�C�, L.o.nr�wa�.� oF hr,e�s�. I have read & acknowledged the foregoing Trustees comments: Agent/Owner: r Present were: J. Bredemeyer M. Domino ✓G. Goldsmith N. Krupski G. Williams Other @4 1 � � u • lye•_. - _ ' .� w.. �.� _ t � , 01 /� r �i�' frl�: (f`, It o Jed A i� SEE SEG NO tae Rp a4 .1 sff xc.xo:+m 1 y x - x _`7Z j 32 B 92 1BA(c).r r ±1r0 144 1 11 I -A(c) a' h m $ 20A I, 2 CK V ry i o1A O '4 5 5 w 131 �1 2B.dA I v 24 W4 >21A(cl ] n' r +6 s4(c) �RwvxaFsoimdn �(mwx�s°uman 5 ) ^181 ke > 3 P i Ows?xc�nsl �� � xrrrm .n4 1+�..r�^ ,5 v!✓iL' A �„ "�'S � ' 9 OQi 102j1 ts�e2 P,x9„"Y "" a '.f 1.JA(c) i mg B a1 r � q 1 rn N eF 5 t S R q V3. 20 1.3 23 t we) 1d^'OF suOnd� a m '9 m 24 I2K(c) t5 r� C^ 0>yl^i `\� •OOe51�x £ 1] - 311> g ,s, � 1AMld Y , P _ 21 1 J IT v I > MARRATO(KAr J 15 >t6 DIKE iw� &16K.)avc1 ^ SUFF1125.OLK Y+ >IT 30 1j25^ "Zl 9 t r Nc1 B "W.) a Y ]t 10 r' It IN �r 1 nK 1T1 Y n 1A1c) Lc) 51( - 92r (a..un) M yr 11z 2z 1 \t 24c1 10 /. °^ iT25 > or sartxoln r { 1 m �� I ♦ 30.1 31 t ^ t0'1Ac OF S1 I ^r1J -]r v+ a p W� gUFFOLK air a /Z n q ♦,�� b r �'N � �t�l iII O. 8.5 2.]�(c) 8 .� 5 !•n j('�"'�� £^ X30 q, 3.0l4cl z,. T M.3Mc) FOR MRCEL NO. ` +�\ 1 £2 � 14 n® SEE SEC.NO r y 3 41 12 ,1 . 10 , 15 It a ^ 18 ^>19 •� ^�t\I� ^\t 16 \ted i i 123-01002.2 �' S.1 O h 2T 14r 1J Y ^ > e 1 Yd r 10 1.14(cl r 1p � �pQOg .c � 14 15 ^t8 r m - 18 _I rOR PMCEL NO - 11 M Ixw os1 3 P 4n �s'o,14 .0 _12s r+\t 12 S.IMc) @@ SEE SEC NO SEE SEC NO Y z3-°1-0021 12 a FOR PCL No 1 a x e v in e tz2 os5w _ r 22A(c) SEE SEc.rro x' \ w 4me T 5 a t] __ K --_---- 123N-------- x - x xQ _ ---�_ — --__—�—— —� S I.UTCM 11NE 'L O p r wnr u IINE 4 15s st•F see.x°.t WTCH m & SEE SEC.NO 1a18s i cn ,5- 14 !f 13 5 12 1 IgLE e SrCTION NO _ _ �. _. (z,1 ��w — ,xxx, " Real Property Tax Service Agency v w�Ea 15 �r 1�`� r��•e`n�` t"`r�i"`'�"' "k+'�h�9'S�""q).`:,+t?S'',"`°" �r ^vim ;.=;'� �:•»'-Ml�affi�N�cwr�'ryw, - - — — --- — t r � 1✓rte. J � 1 OFFICE LOCATION: ®F S®Ur�® MAILING ADDRESS: Town Hall Annex P.O.Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold,NY 11971 ® Telephone: 631765-1938 C®UiV�Y 9� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: May 13, 2019 Re: LWRP Coastal Consistency Review for THOMAS MURRAY & GEERT MARTENS SCTM# 1000-115-10-2 THOMAS MURRAY & GEERT MARTENS request an Administrative Permit for the "as-built" 7'5"x7'5" hot tub and 908sq.ft.'deck on the north side of house. Located: 5028 New Suffolk Avenue, Mattituck. SCTM#: 1000-115-10-2 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 proposed action is INCONSISTENT with LWRP Policy 6, and therefore, INCONSISTENT with the LWRP. 6.3 Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction. 1. Comply with Trustee regulations and recommendations as set forth in Trustee permit conditions. A Wetlands Permit for the hot tub and deck was lot located within Town records. In the event the action is approved, verify how the hot tub is drained,, 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 Michael J. Domino, President ��o�psUFFo(�e0l Town Hall Annex John M. Bredemeyer, III, Vice-President o 54375 Route 25 Glenn Goldsmith N x P.O. Box 1179 A Nicholas Krupski y Southold, NY 11971 Greg Williams dol , dao Telephone (631) 765-1892 Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERN115 RE REMENTS ��� - 82019 L. Property Owner Name: 1( Date Sent to Bldg. Dept: The Office of the Board of'Trustees is forwarding the above referenced application for verification of the Building. Department's permitting requirements stated below: YES NO Will the proposed project require a Building Permit? Will the proposed project require a variance determination from the Zoning Board of Appeals? Willany part of this application be considered a Dernnolition as described under Town Code? COMMENTS: Signature of Reviewer Date Michael J.Domino,President N � Yr ' Town-Haft Annex, John-M.Bredemeyer Hf,,-Vice-Presidentk?� � � - 75;Route. 6 P. Box 1179 C31enn'Qoldsmith Soutiiotd'NewYork 11971 A:-Nicholas_K�rup� i_-� _s •Aq�' d„;gip Teiephoiie(631)765-1892 Fax°(dk,)765=6641 M'f'ss Y�s+� r,&�.� ri`�s:ta-43":.; �Y.+-- • 4: ' -`BOARD OF`TOVTT- -R- 7STEES t TO_ W�T-t)F`-SOUTIHOLD Coastal Erosi66.PioMfit—ppltcation.f, =Wetland Permit Appli6ition Administrativ�.:i : F^l;.=.' ;. '`..` a `~ :SF l;'Gar P%.r ;):yi % 3,, +• ,) Amendment/Transfer/Extensi n ^ ; � TJ` `�' Received Application- << APR 8 2019 -Received peer - A-S- Ul -—- — -• - -= h--. = ===-- = - -=-- - - Complete8 Application: Southr.Jd totirn Incomplete: , Board of Vugtu SEORA Class'mcation: Type I Type II Unlisted Negative Dec. Positive Dec. Lead:Agency Deteriiirii�tiori tflateh._ -}1' Coordination:(date sent): 3; =LWRP Consistency Assessment Form 5• '� CAC Referral Sent:-. 'Date of Inspection a5•��. �.rr,..r. � ..;_ t ; + ��-,,y'r�,«.,r,�. �:d.^..}� �yg�'y�_ :f-��������rw i- 2� : :y ��f�•a fN �{yam, `a A}I i Receipt f CkQ Repprt: `j'�` 7 s i;: - �t a a< . s`•• ` Pu6tic=lteacingrHetd �..:4;5 (5,� ���»� ;.,:T R .Resolution• n •F ��y'w�.w•��d,. ';`4 i.�k;,'S': a yrp= - pr'oi . .df,': •.s°�«°, sr.�x^, z .. _�.�'% •e..;-=t:ti;r. � � i:�1^ '�s' ;i . . Owner(s)Legal NamddPiope y(6ifio Mailing Address:„ "��o L ST E �AJ AUT A J D,Oe E Phone Number:` .:f�'l Suffolk Coutzt� a �Map.�Iuintier 1:p00.- �/ �o O • �' r, a 'v"�._#a'e;� ..e..f,,. t:,, ..;.:s - . 9- ,aL� ..:x..r.•<, YF_>. .<. .. �'i t�,•r 4 y .}a• Y�,«'' £°..o- `•aSs?�.„5 )) Property Location: -SOIx .(If necessary ,prbvl"cue LII,,r✓O•Pole-" distance to eross'str`eets;and loeadoti) �� __'.-�".i .e:✓���1�7 � ;�t:��» �+�sP--- `,� g.�., ,. _ 'C'�;” - ,r'4 r'* "rrY P-� -.S'.r. { AGENT(If applicable)! Mailing.Address: 77 7 Phone Niiriilier: - } Board of -Trustees ApplJ a,UQn GENERAL DATA Land Area(in square feet): lf D/ C % Area Zoning: ,^ 51-'AFAJi i 2 G- ; - a Previous use of property: 4C�.a; A; 7-1&4=' „ Intended use of property: g- A/n.-VLl G 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 If"Yes$$,be advised this application will be reviewed by the Bullding"Dept vprior,tq afBgard of-Trustee,review and Elevation Plans will be required. Does this project require.a variance from the Zoning Board of Appeals? Yes , , �S-_-No If"Yes",=please;prot�ide copy of decisiioxt- Will this project require.any demolition as per.Town Code or,'A9�deteruflned:by the Building,Dept:? Yes No Does the structure(s)on property have a valid Certificate of Occupancy?-_ Yes No.s , Prior permits/approvals for site.improvements; Agency Date .�[,////(%Alr: �.� it % €Jll._ . _. --- ;�: , :;D.'.a.�;;�;:-rr,:;>.• °.: tea , No prior..pennits/.approvals for,site improvements._-_ Has any-permitiapproval ever been.reyoked;or suspended by a governmental agency?, No Yes If yes,provideexplanation: Project Description(use attachments if necessary): 01tJ D E Aon SL :- A ;46& l� - -,Board6f�Trustees Appl3�.a::ion WETLANDfrRUSTEE'LANDS APPLICATION DATA Purpose of the.proposed operations: _.fT07T�BECK , . .._.. , , . ._ .. . . .__ ._ ;._._ ,• . _. -. ,. Area of wetlands on lot:- square feet , .,. 'Per�ent�ca►verage:of lot;%�p,��ti:='s%x �° ,n _a .,'_,! .,, v_ ., , . > �� , ,. . " �: . ,' t� - -Closest distance-between nearest existi4g-structure and-upland.edge_of-wetlands:_ a__ °.feet Closest distance between nearest proposed structure and upland-:edge:of�retlands.:.- ;- Does=thW6raject-1nlve excavati+an-or•fiUingg.,,_ "A",:Yes; If yes,how much material will be excavated? cubic yards .,, r. •: ,pry, ':. >", ., , f : How much material will be filled?- ubic yards Depth of which material will,be remav or deposited: feet „ Proposed slope thttst�ghout.t ..__. . .'afprratios Manner in which m r.41 will, q Fpmgyed_ar deposited: . _.State iezzt:of:the.effect,.if.uuX,_on the_Wetls-artd_Mdal ,waters of the town�th�t.may result:�Y: reason of such proposed operations(use attachments if appropriate): Y » 61Z20 >� Appendix B Short Environmental Assessment Form ,fin"s ruetftins•for CowetinR Part:l-Project Iriformation.,The-aliolicarit or•project•sponsorjis=responsible for the completion of Part 1: Responses ,become pa4,of the andi pplication for approval or fung,are subject to public review,and may be subject to further:verification. Complete bait,I based on information currently available. If additional research or Investigation would be needed to fully resppossible based on c ond to anyitem;please answer as thoroughiy_as urrent information: _ Complete-a(I ifems in Part 1. You may also provide any additional information which you believe will be needed by or useful to'ihe'lead'agency;attach additiohal.pages as necessary,to'supplement any item... r :Part I-iPT�oject's dd Sponsor Information Q — -� �C ;M `Name' Action or Projecf: Pi*0I*ition'(desoi,an`d attach-iiwation iitap) �Og MEW Brief Description of Proposed Action: Z.7 Nair 0,. icant or Sponsor. i '7� Mall: Q X i ' F4k _ 'PUC Gity/P0: ; . a. ,••v Sta�e� Code• . 1.Does the pioposed.action only`.lnvolve the-legislative adoption of a"plan,local Eav�i,.ordinarice,_ NO : ;YIDS; administrative rule,or regulation?_4- - to `Fai.1 ti �. s' < t ' '�` t If Yes,attach"a narrative;descri tion Df the'#nteiit`of the ropOsed'action'End'the environinentat'Pesources that; j 1, i may be affected in'tlie triµiiici}iality aria proceed to part`2. fno;'continile"'to question 2. i �. -.2.-Doe ed a-I n.r, uire a permit,.approval or funding`&om.aiiy.bther.govemmenfai'Agettcy? `NO~t``YES If Yep,I,i'st agency(s)name'and perr"riit.or`appro'val: 31.'76tat acreage of the site df the p'roposed-action? Lb,Totai acreage to be physically disturbed? !!i/ ^a, Sy fT ?,:6.'Totafdcieage(project site'and,any.cgntiguous:propert'ies)owned- -pi-controlled wned - -or-controlled by the applicant or project sponsor? ^� acres b 4.--Check-all land us that__ ur_on,adjoining and near the proposed action.. ❑Urban'°:Rural(tion-agriculture),':(].Industrial • 00ommercial,�; esidential,(suburban) r ❑Forest ®Agriculture"", Aquatic ❑Other(specify)i,_ - OParkland Pagel of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? b.Consistent with the adopted comprehensivey"lain `6. Is the proposed action consistent with the predominant character of the existing built or natural NO. YES landscape? 7.1s the7sife of the'proposM-'action located_ in;br,dogs-iV1ddj9in,-a stateligtedCritical-Envirddmental.Atea?.,: If"'y.''es Identify:- t. a.Will the proposed action result iii'iii tial1n&iiisetntra ica v orAen:t levels? ;NWAAESJ b.Are public transportation service(s)qvailabI6 at ornear.the!s1te ofthe proposed,.qctjton?- q,Are any pedestrian accommodations or bicycle routes available on or near site,of tho�propoied,.a6iioa? 9.Does the proposed action meet or exceed the state energy code requirements?- • �,_KO_ J' YES' If the proposed WII'6( dd reqqin�ftts'descri C sign'featcidsim:4technologies:po. Wi!l-the- proposed action connect �,;NO "V98 If.No,-describe method for pi'oviding.pota§le.water.,,-...-,,..-.------.--. 11.Willtheproposed action connect to existing wasteWater6t`iIi1i6i?_ '.NO`: AYES:� If No,describe method for providing wastewater treatment: listed on either the"Stite" or National Register'of Historic ;,NP f2. a.Does the site contain a structure that is lis e Places" logical sensitive area? 1�"the pr�fi s�d actio ed,ik,a �a eo o n j6ming,ifi =proposedaction;contain 1*0'�_. JVES." wetlands or other wateibodies regulated-by a federal,state or local agency? V:4 sed-action-ph .-b-.-WodIdthe-pro' physically-alter-..or-,encroac*h,idt�o,,4any'exis"iirfg.�Wettaifd dr*aterbodyT, PO If Yesldeiiiify"the wetland or wate6r6dy and extent of alterations in square feet or acres:. 75, 77 ----------------- -identify'di aipjilkely jorbe�(bufid- --th C R� e.fjpjcaI.hdb1t4j.,Vpcsthat o: 1. "fiec all, 1 1 OPRCCQUE^. a,,app y: M, � §horeiinie" 'bP6resf ,essio q, s.a n- 15-Voesihe site of the proposed action contain any species of animal,or ass ja :kqbiWtqj listed N .�:Y,.ES 6te or Federal.government as threatened or endangered? Wl I 17.Will the proposed action crealte,sform water dischhrje;eftfier' roiWpoint b 46h rce§? -if-Yes n.,Will stoim water-dischargesLj; f tqwpgOja� :pj b.Will stormm�ateV':dis6harg6s bc)&&t6&weitablish6d 'If Yes,briefly describe: Q U LiNYES Pa'-&2,of 4 Poes the proposed action include construction or other activities that result in the impoundment of -IVO - YES ,,,water or other liquids(e.g.retention pond,waste lagoon,dam)? 1f;Yes;explain purpose and size: a 19.'Ha5=fhe Site'oft_he proposed•acfion or`an'adjoining property, een the_tocation.ofanactivs orctosed ; .NQ',,`; YES - solid waste manFage'menf facility? IfYes;descnbe: 16-.'Hgthe site'•of the'•proposed`acfion IfY�ieFst,.,'t�tt-f'set'l+`sirc:rdiftiiie++::`_(+ii;7�fi%s',-'l'rrr::)}S-t:'Rr-'=.''.P t�;r�t°•e'J.S.'i.i,"f-Y.`:i.'�.o. a `:at djs..t.o:.:i,nl=>in:,>.g..•pr.o-p•e`rt{yi>5-b;ee_niiSttEth;'es.subject ubject.o.>.f !7'rFiet;.ne:.diia:t`io^n.;.J(,o.-n,gvoi.,=ng or hYdErJTSF� . cothplete )'forwte ` t;riNova M1AFFItNPIiOVIDED- ovEf8tkMANI) 4CCRiVIViHE, E KNOWLEDGE Applicant/sponsor name: Date: Signature: rl 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 'I.' 'Will the proposed aofion create a material conflict with an adopted land use plan or zoning t—I regutations? (— .2. Will the proposed action result In a change in the use or intensity of use of-land? 3. Wil)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 0 establishment of a Critical Epvironmental Area(CEA)? __ yrF��i. �..�-�, 'ay s�•-.?ai, 'I!t'a�' :'Y,. :_SY,.__I__:._..r.-• ;. ,..• W lt'tlie proposed'ac ton resu'1t`tn°an'adverse cfiange-rr`the'exisfing IeGel of-tiafri ' affect existinginfrastructiire'for�taass tialisie;bllcing'ar'waikwa-yff -;6:1,,W11E.the;proposedtiaction cause;aq increase,itt the,use.nf,energy,,antf it failsto in r orate,, -,,, reasonab)y available ever conservatior%ortenewable ener .' ortunities R_ =a -. -Viii the proposed action impact existing: ? '151 'Y wa.- iclpvateater ; . b:public-/private wastewater treatment utilities? ' 8., W1tl fhe proposed',action, mpair,Ehe character or quality of impoitarit historic,archaeological, -11-_,1 #' architectural oraesthetic resources? v I a. 9.,;,WIll the:proposed.attioll result-In an adyerse•change.to natural resources(e.g.,-wetlands, n ;Q water, . ies,•grqundwater,air quality,,Mora and fauna'? _ t t Page,3 of 4 NOW- Moderate small tollarge impact -impact may may occur occur l0. Will'the Proposed'action-resolt-In an=increase'-.4i-tpotential;for,erosion;flooding or dramage (�''� s;; Problems? t , .:� L „� " Will"the Proposed,action create-a hazard to environmental resources or•human•health? ❑; %" Q Part 3-iDeiermiriation•of•signiricance. The Lead.•A,gency_is.responsible•for the completion-of Part 3. For every question in_Pact 2.that;was:answer'.ed;`;moderte,to,targe iiripact;mayroccur",.oc,f theie,is aneed;to eXplsin why:a-particular element ofthe_proposed actton.may pr vrilt not'result in a significant adverse ' vironmental,impact,•please complete Part 3. AN 3',06iild„in sufficient detail,identify the impact,,including any`measures'or design elements that have been,included by ,. t .: ... the+p%lecbsponsor to avoid or reduce'impacts.Vfart 3 should"id explain how the'lead agency determined that•the impact t may of will not tie sigmficant.,Eaai potential-impact-s o4ld-beassessed-considering--ifs setti'n`g;prolialiility ofoccurririg, duration''i versibi� ^ e' cad y t Jre, ity;,g og hic scope and ma rtittiii'e` A o co' il`e ” ;gY , Is •nsi r;tfie;potedtia!•for'short='teiiri;long-term:arid" cumulative isiipacts: = s s t - . r ... _ .l•e .___' ... __ wt....... ...... -_ . t. _r-. .' .rr,•6. N•� t.. ..'r.....:•:..e .: , ,. `.a. ..:.• `� Gheck'this box ifyou'have iieteciriired;based an_the•information and analysis above,fand,any supporting„documentation;i . . xa. .that the Opqposed action 'may result in one or,more ..,•.., ,.y. .,.a f :,. . tand,an _ - environmental iiipact-statemefivlsrequired: I Chegk this�oz ifyoii fiaueitefermirie"d (mase'd:oii the:inf6rmation'6rid•analysts`above-and•any�supportirig:documen"tatioti; ;,._.. that the, ro"osed;action,H!itt;notresult:irraii'si at iraritrad"verse eri6ironmental=im aets.• Town d Southold-,06,rd or(rustees E °Tta'me`iif tread Agency "Date _ f. __. -- --. RrBsident•- _ . Piinf i Type-Name of{teapoiisib1e;Officer int and-'A eticy` r ".itie"of,i2esponsi61e pffieer signature 6f ttesponsibte Officef in Lead'Agency' �S�igtiatiire pf P"repai'e (if iiifferent'from Respoiisitile Offiae�j ,. PRINT Pge 4 6f'4 Board of .Trustees App1j_ O_ tion AFFIDAVIT V lol7jqS l &U e,� Z-t-- 0�� aHJkJNG DULY SWORN DEPOSES;AND AFFIRMS THAT HE1,SHE IS THE APPLICANT FOR DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRttE fi0'THE:BEST.OF HISIHER KNOV!LDGEAND¢BELIEF ;AND,1'i AT y ALL WORK WILL,BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY TIME•SOUTHOLD TOWN BOARD OF TRUSTEES. THE..APPY.ICANT,AGREES-T,O— IOL-U;THE--T,O f OF►SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE ANY AND AI.L UAYVI�iGES AND CLAIM_ S ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED: INCOMI'LETINGI'HIS APPLICATION I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT yI'Ht PREMISES1K CONJUNCFI4Nt WITH T IIS 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 WE1'L_tkND QR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT, ....�._^...\__..,..,...... z S'.£''` �fR.at^ ,•.�, '•le;'a:et`; .____ `—__^_, ----"_a A-:",�,CiJ&''d_�`7r,pt'�(. -__. ..r�t-.,� ' Signature of Owner S:i9i itttire of Property-Qvviier SWORN TO BEFORE ME THIS V r� DAYOF___ jM)_ j20 I E -otary Public Book Ling Tse Notary Public,state of New Yotk No.01T35023903 Qualified in New York Coun Commission Expires May 3,20 B6ard of Trmbt6bs Application AUT.H0jHZ-- ON (Where the applicant is not the owner) I/We 7�7 owners e pr - of th aiSCTM A -.1 r -,k yl, necessary. C wor m-vov6d-. ih1h6'app icatimprocessi, or', t( permi �s)ftto�.$ Board of T6946s,O this ----------- Property,"Ovmeeg Sign;4ture Property Owner's Sign4tt"_ SWORN TO BEFbkEME THIS -DAY OF. 20 -Notary Pub0c APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The pumgse of this form is to provide information which can alert the town of p2ssible conflicts of interest and allow it to take whatever action is necessary to avoid same. `` I YOUR NAME: Tf'I amO i �I CCC �� (Last name,first name,middle initial,unless ou are applying to the name of — - someone-el se oLother 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 planning - Exemption from plat or official map 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 Ifyou answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title br 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,of 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 heapplicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Dated: �(JSignature Print Name f Form TS I / APPLICANT'/AGENT/REPRESEN'Y A. TVE TRANSACTIONAL DISCLOSURE;FORM • :. - _. :,,,.;�5,,., e; �:,-,lii-,�;- - 'ib"•c-��i' .,o�-:,.tt. � :, Via. deo.__-o= -_, _u' , ` s_. ;; 'o"` 'ide:..f:r.,Ar fie e .ow f "bieco c_ , r(e`• • .,_ --. .- t °'-._._u`..-...,, '"ctid" • - ,-,fie`itcrnr`v�iri'aiiii[d 4�nfe.:ry - -;•: -�'' :. ` YOUR NAME (Last name,-first name,jpiddle initial,unless you are applyingin the name of someone eine or other entity,such.as a company.if so,jndicate-thb other person's or company's name.) ='° :.NAME OF.APPLiGATIQN:(Giieck all that apply.). �: • ;' °} ,d - Tax grievance - " wilding '° Variance Trustee t:hange ofZore =. ..�.`�`Y ,_. oastal_Erosion - APProvat4fplat . ° .t; �: . .::? ;.< _, Moo�ing,; Exemption from pial of officJal map, J Pian_nIn'9 ' 3yz -` -�-SKC• x�•l. 4Lr?Y' '2 Mee- .-, ., - ��lfx`Other";'i�anie�the`activity:): A�.� „4:-..� :>•::,, �, .; _. _ . _ :.- .. .... .:r„ . . Do you personally(ar-through iiiir'company;spouse,sibling,paretlit,grrdi lc Have ri relaFlgii lip wi ulyo eer�iremp[dyce of the Town of,Souttibfd? "Relationship"incttides'by blood;rtt aM3801 of'biis"iness itjterest."f3usiness-ititotest"siitcans a'bUsincss `including-ti partnership;iict ?hich-the t¢ tit o""flee%{o�cit�ploye Lias• sn,;}:PnetiR(ok�Fl ls1}p'aaF(o�CinptQY.41*fiyy �rorPorption �.. z' - Inwhich le.town officer or ernployeG oyrits;ri�oi tfi?►tl of the sh(cis >. 31..-f.;�.� :'• .F of 4 Z'\.:iS`>> °S3P YES NO _-°' If you answered"YES",complete the balance of this form aitddatesind 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,rine A).through fl),and/or describe itt the,space,provide#! ' _•f% Y The town officer of employee or his'or her spouse,Jstbling,parent;or child is(check all that iTply): >t A) the-owner of greater-than S%of the stiacies of rile txirpoiafc stock of to appiicsnt (whep•tlie applicarnd4*a:eoi�a` bQnt` �' B)the legdtorbend�cial o't jjer of any Intetest inn non_-corporate emit)+ tivnch the` applicant is not 1;corporation); C)an officer,director,partner,orempioyee`of the applicant,o"r, D)-the'actual applicant. vZ DESCRIP11710l OF REUATIONS11tl' Submitted this W of %2-2m__2 CIA ' • Form IS 1 �G/��- Town of Southold L'V RP CONSISTENCII ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for_permits* including Town of Southold agencies, shall earnplete this CCAF for =,proposed',actions that are subject to the Town of Southold Waterfront Consistency;Review Law. This _ �..-. . ..Y.-.. � , assessment•is intendednto supplement="othe% infor Location of actionyL ,/�ICIv Site acreage: Present land use• zleS% Presedt5zonizigclossification• � Si�dG % G nX` -+ i=�: M ; 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: ?� (a)_.Nacoe.af-applicant; (bj_D!iailixig.address: 14 - �' 4ZIY �TGET /1PT . _ ,t i'F•:... .;i:Ai.'kk.,zr}.,t.., .. 'i' '� s. {a) Telephone number:Area Code( )_ � ,�� 9 _115 (d) Application number,if any: JA ._. "i:.,.J��3 _.BV L'r... ..- ,i.:�,i�' �,.•.:r','„ie•79F •ti. t .. a.. _i - _ _ .,, Will the action be directly undertaken,-,require-f mdir g;-or a&f6vo,,by°aisttite or-fedeihl�agency?: Yes El No Er If yes,"which state o;federal age 4y? :i4' ".i4{_<sAC ;{ a G ' : {•`t b ~ ,'Evaluate the.project,to the.folto�'Ing.policies;by_analy,ziag bo—w,.tbe-projeot.wgtfo rtber.As-upport or° inot_suppoirt_thc,policies._Provide.all-proposed-Bot.-Mani gement Practices that-will.further_each_policy. -.-Ineomplete..answers will require.that-the form be-returned for completion. - �E�ELOP D-COASL'.POLICX � 'oliGy,X < 'ostera�p„attern�o�fdeve�opnentin�tLesTown;of,S,Quhold�thatpnhancecommiiy�charcter, preserve open space,makes efficient use of W kik tructure,�makes beae caa uste oma caasta�location,aad minimizes adverse,effects of development. See LWRPNgechon IIT–Policies;Page 2 for evaluation criteria. _,�.• ;, . f r 'i`� e_..0--hio ot'Ap lkkbli Attach-additional sheets if necessary ic,�8 '- +•t'P ;, ".'.� '.t? ';e4}K j. .,.,: .,.nr• ii:i i.1, .,,�� r.Fp •- - .,. L�.� s.."" f.t, $`5,'{ .»32.ti.� "r,:7 i Y. �: Poliiey;`2+. Protect;and Dreserve his' oric'and archaeological,resources,of the."Town of Southold: See L'WRP Section`III=Policies Pages 3-d&ugl b for evil ui6n, ditet•ia_ p .� 'Yes No WNot Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protects cenicjt, dunces throughout-the=tTlown,of-Bouthold. See LW CRP Section III-Policies Pages 6 through 7 for evaluation criteria i2.,..� i :.yy. :yf' 4,. 1.;a;'� •f 1 �AC�`4.1 y .� .. 1, .. - +":)k .41;f C :Y', .. .. ("•,•-its){�d�.l.. .�_..>__- _>.. l:r,i.t,v. .. Yes No^ Not Applicable ;z i' Attach-adctitibtl$ls}ieetsifnecessaTy, .� �� - .- }' - "_ -V• — _.-_-._.. -_ ...„_. ,._.___ - - - •- NATURAIL,-�QAST-POL-ICI�S - - - --- -- - - ' ---- - --- - ' - - --- ' - - -- - - - - - -- - - Policy 4. Minimize loss of life, structures, and natural resources-from flooding-and erosion.'See LWRp y Section'ITi—I'olicfes Pages:$lthrtiugh fi for evaluation�criteria Yes V;oNat,App�ieable lc; s r'CvY a`"R.+fi,; >a.' y•r;i't y�a�,yr c°4i :h 'r�. t -ry . .. - - - ............., .. '•zi,�: . �S^,?_� i.,ji`�' _C•:1 _'r_n, _,.eb,3 i�fr�e C"£=z ;y�.=z •�>, �.�., - . 2 ?r.,yv f,F.A: L�f..i)x'x ^.•,17';, 'L. ..�:3 s,'x .',s;f w:.>s:v.:E�_..:s-.. w.: '` .t �,;° � - .�'t. .t'��.5.':;',3._a°.•-Su: t' :: Z'ya'.-^- ..id '*'.r:'.r. iF: !:� sat.=4 "m a,Zr,. ,.t a�'-x::43 trN a� - •'.w'.r s.. :Y+• x'-• ^.!; ...SS..nS:�"�•.s ro--r: -s�t Attach addf&:a-1 sheets • � rv��l •.`K'' � �:`,r l�p•�,>l,,'�Ao• a,r;,;„ r:f.•����.lvr." _ �,.•},Pr§. � ,r..:.. ''S= :f.. 'a+� 5 ...• £..,t^ Pdlie `;5.' Prbteet�-an 'un ro a Ovate "ati ;i u �' ,_ d :, P qua�xty d.'s tpply4 in.tlie�"ovvn,o o`ttliold. e`' hon'I'I'I + x.�X,a, y a ; —Poll�le�`Page9~l� �h�� `Sk ,g s � t s. T.i'T^�"i. s � - _l. '.�i 4':E':� :�•�1:sx�C.} 4rs'Y^.SY r}'- - if` _ i `t b`57 o�ugh'��fo e�►alu t�bn;crit ria'.. ' ,€�" 0 Yes Oj No 1"Not Applica'bie ' - �.._ �_....._ _ -_.... __'"'- ......- y- - , .__ -^kms._... -.._.-.� ..... ,..,.-___--_ ._•-. . v -' ,•t'y., _ *>-a:>�.:- ��- --- _ - _`+R, .._._.. .�.._ . ...., ..r,..,_....-,._..+.«,_.-«..._ ...,..,,+.-.... ,.�. ..tee.-,«-.d+..... ......... ...-__.._.....,.-..-.. .._..-._ - 1... � , , MachAditionalsheetsJfIi6dessary �l'olicy 6. Proteet yand restore the gu t ty,and-i'unctiQn ,of the Town of Southold eeopsy�stems.including "?.'C; :a 7,' i.-m_ ,2;;• .-,,�4,y,4;. 7a�vJ''.L�:,•}.. .y to ii,-Polic 'ies�Pa``es 22 ugh 32 for evaluation criteria. , °k�:.��• :T �.< .{�a_''>t�:�a > ;. sg�Ys� ;.: .ss ,. . R+. Yes No Not Applicable 6 _;lea - •- - - Attach additional iheeis if necessary _. Policy,7,.; Protect.and improve air quality in the,.-Town of Southold.See UW13P.Section .III.-,Policies Pages 32 through 34 for evaluation criteria. Yes:,�-.K�No' � , iallot=APPlicaiile r• _�''�•" .. z a.ra_:�'r Y� :ik;r;= .. .Tf<a .. , f.': .. •�:r,.::. q .,c •: , �. < Attach-additional sheets 1€7icessary Policy-6. Minimize•envlronniental degradation in Town of Soutbiold fro n.-!solid;'waste Z and;;hazardous substances and wastes; See LWRP Section III Policies;Pages 34 through 38 for evaluation criteria. zi a' ,.,!$3� r �� �a�� rr_':�f',.: :3•ss: ,�r��3i@�r�§ ?t, � �"itt•,�.' :�t:.� vs3;:"kin � sof"",. ;;,�Sa e:3.:+v>'. c .. Yes No Not Applicable .a rLi�i :rP3;4 n`i�;•cI4 ti „ l .... ......... - - °. ,. . , , - ..an>._,Yrt .�.>r.cc+--,._ -r�rrx .-r,r_f.•z. _ -.v..,._.. _ - -PUBLIC COAST•POLICi - -- - - - -._. .. __ _ _--- ..__._._ _ , __ -T ,,l'oligy 9: Provide for,public access to and recreattional use Ayf oasal w tern, �ubiic annus, and,public �5•�` i' :&:.Y'w' "�:rt-2 •r9:' 1i 65w`,� .{' 7s!.Rr.- "'S�s� "i'r• 7,it,S':r2XY-�TS'�`:ar�..�- '��t5! ?•di'F•f` >t�}E! +",k'f fP:�.�'L.1 r9 lr�.. 'N-_vs. -sT. resources of the Town of Southiold. `S�e.LWRP` ecion III policies; Pag4es 38`thrQugh 46-for^eyaluatton ? :7: ,`'xr:!i.'. .' � se...;i:r..: z ,d= r• criteria. ` (� ,J 3 -•'�`i, i. ?'�i '`��f 4eF~ .-- ,trt - 0 1 F1YeD No Not Applicable ' Attach additional sheets'if necessary r I , WORKING COAST POLICIES _ Policy 14. Protect Southold!>s water-dependentuses and promote siting of new water-dependent use_s in _suitable"locatfons, -See LWRP Section III_-Policies;Pages 47 through 56 for,,evaluation criteria. E],Yes _Q No_ Not.Appl oable -- _ '��< _ _ �). -`-C _'.'.-- r . h `�z._a _.....z•-._...,._s.. .vw....s.,.,r..c st a _ ... - .s, .. a.._a. ws i a..vary.. _ - .. ,.... . .. - _ _ .. ,, .,........_.<,.......r,-. ._�i •r'X.:'•_-• «-F' .z,arq/+ iJ.S.v'4'e,3.'`;'��F i ds^ 4Lh 1: �a`"i-x y sz;-,iq ?i`r �'r.6 c fi s6 %Y' .x3; rt qrq tar. -- `"^:.:,, ,, Fa "`:�... k`"s:'t cis ra atxa:..Z.:% i• A :� - Ahach additional•sIieets ifnscessary Policy ,11, Promote sustainable use ,of 'living marine resources inyLong,islaiid Sound, the I',econic Estdary and Town waters. See LWRP Secttori III--Policie9;Pages 57 tliroagh 6iior evaluation criteria. Applic$bLe . ....r•f:.c.'"t�/iS•�9'ail�u+xj4CYL.{ 3:.i:r.-". ,Attaciz�aiidi�onai siieeis;if��`�cess'airy+�•." . 4 3���"���r: �a> ��•: .�a�d:;�.. • ��• -•=A, `. ._ t ;r,,- �;F ;r r,I �,'°. :"� ._ •� , .i;,r:�i3J. ;:4J{},�..�;e„ FJ-_ .i �3�0^ni`. ... s ;�; rts•°".=it -"� -' .. ,r_• _� . � .. .. � .-. � .. Policy 12. Protect agricultural lands in the Town of Southold, See LW-RP Section'III Policies; Pages 02 thronjgh 65 for evaluation criteria. g �'1,T1'�es-���:�:o ��t _plicable-----. .� . . ., . .. _. .. --_, - . . .._ ,._.... ._ • -� ._. .__�...._..1 _'ter ,-.-�_.-. ...,. .-_._.v._.._, _.._...._ � ,-..,•......�..........,.--. .._-....-_,....... .,.-,._. •, .-,. ..-�_ ... ,-.-.r.,•.,-c-.re-r.....r.,.w....a.r....=._ Attach-Qdit�onai sheets ifnecess* 07;qt �r:1 ro_mote Y~Q iYS dr^.4t'.i 5?r.�+t•.xt8 f.a - �Y.(r Ya-::..� J i,° x.5.4 -, ' r.<`a �.� i F•�'.' -L , ' T7 • -i !s;..'d: ; rd'... �^d..r Fr.�,,s � i�.t �rja'�"i i3 L 8J3� :" pP. �prtafe use and-c�evelop.`menf`,ofxedergy`and nuneal res'oiire : -See LP F r ;. TSeQ61�n4IIll t '~i'Krair ,..r.-fg.R Tr ohciee;-Pages}65't Trough�8;fo'r`ev i usition criteria: } Yes No iYot Applicable �PREPARED,B'Y.,� T TITIaEG�iT 5` .