The URL can be used to link to this page

Home My WebLink AboutTR-9941A Glenn Goldsmith,PresidentofjF S0(/�yQl Town Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold,New York 11971 Michael J. Domino G • Telephone(631) 765-1892 Greg Williams 'Q Fax(631) 765-6641 �yCOUNTY,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1847C Date: August 11, 2021 THIS CERTIFIES that the cutting back of a hanging limb on Oak tree,trim top of hedge, prune lower level branches on Oak trees; At 2415 Long Creek Drive, Southold Suffolk County Tax Map#1000-52-8-3 Conforms to the application for a Trustees Permit heretofore filed in this office Dated June 28, 2021 pursuant to which Trustees Administrative Permit#9941A Dated July 14, 2021,was issued and conforms to all the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the cutting back of a hanging_limb on Oak tree trim top of hedge,prune lower level branches on Oak trees. The certificate is issued to Charles& Gina Ciravolo owners of the aforesaid o erty. Authorized Signature Glenn Goldsmith,President SOF SO!/rTown Hall Annex A. Nicholas Krupski,Vice President ,`O� �� 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold, New York 11971 Michael J. Domino N G Q Telephone(631) 765-1892 Greg Williams �' �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 1/ J INSPECTEDBY: ✓ , Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale-line/silt, boom/silt curtain 1St day of construction Y constructed Project complete, compliance inspection J p COMMENTS: CERTIFICATE OF COMPLIANCE: �' Sole Town Hall Annex Glenn Goldsmith,President � �, A. Nicholas Krupski,Vice President y 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold, New York 11971 Michael J. Domino Telephone(631) 765-1892 Greg Williams �" ' Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction; hay bale line/silt boom/silt curtain 1St day of construction- % constructed When project complete, call for compliance inspection; Glenn Goldsmith, President Town Hall Annex A. Nicholas Krupski,Vice President h , 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold, New York 11971 Michael J. Domino �'� �� Telephone(631) 765-1892 Greg Williamseo Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9941A Date of Receipt of Application: June 28, 2021 Applicant: Charles & Gina Ciravolo SCTM#: 1000-52-8-3 Project Location: 2415 Long Creek Drive, Southold Date of Resolution/Issuance: July 14, 2021 Date of Expiration: July 14, 2023 Reviewed by: Board of Trustees Project Description: Cut back hanging limb on Oak tree, trim top of hedge, prune lower level branches on Oak trees. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the project plan prepared by Shamrock Tree Co., received on June 28, 2021 and stamped approved on July 14, 2021. Special Conditions: Pruning of lower level branches to be no more than 15' high„ 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. 4e. 4-e" Glenn Goldsmith, President Board of Trustees Abaft SHAMROCK TREE CO. P.O. BOX 1472 • MATTITUCK, N.Y. 11952 Date Scheduled: 631.298.2175 Date Completed: Inspected by: Estimate for: Uk r v dl Deposit Check#: Street: `'� L + rw -- Amt: Date: City, State, Zip: au-'1 Balance Check#: Phone: (�,�\ ) � d� � Amt: Date: Work to be Performed: t Wzr 1 , b F� �Af QCJL vLer er e Lo-J BOARD OF TRUSTEES e T F w OWN O SOUT HOLD DATE Sino( I q Zai '.J u N 2 8 2021 ..,.:, Board of Trustees Shamrock Tree Co.is not responsible for any damage done to sprinkler systems, wiring or other underground utilities while grinding stumps. Cost of Services $ Sales Tax....................... $ Total ................................. ....... .......... $ 10% Deposit Due on Approval ............ $ Balance Due at Completion ................... $ Submitted by Date Accepted by Date � r si N w w r w, i 0/ E rvc P W � M J UN 2 8 2021 Southold Town �r 4111- r� w dlz u A �. Ke 4. R pJ w�M g J e 4t IE c outho own acrd of Lr�L� tees- a x � " u > .0 m A aYtl v �V �°� "� •i� ia. �, "� 6 N J m ' a wl r IIGG M I N d u�,. q "~� � rr X sa�y r " .�„.� �,w � � ^"� ^p i" � o• 'rya '"F,' "P 19!'1 e ►-CtweK bmkCAe.J 0-g 1,"e- freei �.I a VA TAUVAf,0itb aN aA,�j.4 C a q gta7 +atN��aa� 4a "ba a sM"e ser y w Ok y .: .. DANIEL SLATXIN �. " -„°•.. S S L0 b'IbWQ BOND 6874T68,8ECt ON6` I REAk0. AT SOUTNOID WWN OF OWTHOI.OLL 4 T!r �1 vtd�r hod�W fer� W 1Y• SUMN 0"Ty,NLV VM HL Va.0107 n ra rrw r d a�v�Caw at AN*of wokom*06i4if T4 OUC” oft toppANALM T � � �� ° rM r •... ,.w ,. awnwm ea wvrxaw a iaa a ronrc owe o.r YOUNG YOUNGra l mu nun"*A as i7, Asr A ""a &"Wm mK%& Nal " "a Ilmman Glenn Goldsm �resident �S�FFU(�C ti. Town Hall Annex A. Nicholas_Krupski, Vice-President ,�� 54375 Route 25 John M. Bredemeyer, III o ` P.O. Box 1179 Michael J. Domino %�bSouthold,NY 11971 Greg Williams ��1j0 �ao�� TelepFax ) Telephone -1892 765 6641, BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time:® �ZC 'K,6 Completed in field by: CHARLES & GINA CIRAVOLO request an Administrative Permit to cut back hanging limb on Oak tree, trim top of hedge, prune lower level branches on Oak trees. Located: 2415 Long Creek Drive, Southold. SCTM#: 1000-52-8-3 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q 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: I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino . Goldsmith ✓ N. Krupski V/G. Williams Other SHAMROCK TREE CO. P.O. BOX 1472 • MATTITUCK, N.Y. 11952 Date Scheduled: 631.298.2175 Date Completed: Inspected by: Estimate for: U Cc'y Ol(7 Deposit Check#: Street: �`'� �� 1—vneGreek-�� Amt: Date: City, State, Zip: 5vw� CA Balance Check#: Phone: (\A\, ) �Qq—I — CYISO Amt: Date: Work to be Performed: "Ove, k Uwzr 11 %1-46 ��(Jw G0JL veer L'�Cjer Cy'owp GF +fab �., hL..(,.L�.. i�cam-✓� v o4c-,( �gA Co 1'" w CAP, JUN 2 8 2021 Board of Trustees Shamrock Tree Co.is not responsible for any damage done to sprinkler systems, wiring or other underground utilities while grinding stumps. Cost of Services $ ALU v Sales Tax.......................Qll•+-. $ Total ...................................................... $ 10% Deposit Due on Approval ............ $ Balance Due at Completion .................. $ Velvti �'- '�ALAQAX-c; k-q �-1 kc S Submitted by Date Accepted by Date ., a ;� may, �-y\_ a� •r , ice• ,� _ '4 ,-`� - .. i �i �1•I� !4 - � 1. 1 I MziA �7 - Sv .. . E C E 1 U E c` � "� � d A_ ;r �• y s ��t �p��i�{�.�4 r � �k' s,�1� c �$ �'�i.A� "r• ''��I1�" a� 7,7 f�yC5y1- u• - ' �� y °z - • ° PF ,C - ., c Z� a`Y .K ^ 1.. �J¢ • % icy '. t - 1 Y R "11 t: ..�, �1.�{ra .Cc .�. ?!y�.�` °'� •,,Hyl� �,.R. :c..."•r. c+d 'ISS �' .",�' =t. '. 2021 • 6 1 9 •i t IN Oz "All '24- 49 'K 'r"• ,p ..i _ ; •amt '" „' v t +-�•* OP.: f �� .� rte` ��,, � � � � ,\ •; y��f K-7� E C EIV E ceem�ITae oeaeTTia�e ew eram • . uomli�l►�me�a�a�i oto• �� law u1 M at1.a+e.m.a�aw �IeeN Beet an 1. -09101V It Volvo vat A tp Df -10 ' ��j Sf eDUIiIYD�AAAMBROFN SIiRV6X FOR V bANl6l SI.A7KI14 �. $�fs wr 4"Lhe POND ESTATES,SECT ONe I*map dsvm aom�t AT SOWHOLD eara• i I--., ean6mm tr9ds=, IwK SDWN OF SONTHOLD Se". t S 2 21 4" S SUFFi�IJc CCTV.Nkat►vm Me 02-OMT I JUN �urvTwallarro w,owlaew,°a a.I*IN., emm? . Pa}4} 6t ref tragic AMaa•49"w ,MM°F Tri 04f 2 OL T �•� W Southold Town M -w TO[eMi71WeT 1°e ° Board of Trustees �so o"Wi MMS."— �, fever TT M ris tw T r� wiewe° L mTrr lsl tau ll®leueee oxrx�rinture' t16i 11r�T11/MfO�M►fit hall°W/11►0[M�TNff aro an rpt"12 AIN m AtNwr Um an m Tn mm"P rum YOUNG &YOUNG �pp",�o aAROrv"MM Fam MT THB 0"at v TM AYeIF Op fLM W.Telgta MFmMw&Ot=wn SUMLR COWRY 0 CM 17,"AS FM ft Was 417UM awir ea KTSu=z M in a uTmrse, tiIM1YSTbt1 MT1AY —QMIMI 1pHosYWaNarlY9aab7.mw.Mar wXauGLR�t IFa,7i�] acnlolnm+ re»eyaoerm M.M. ora r.ro a s°�®a vm 1 OFFICE LOCATION: so 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®UA�'y1yryo m�A�� 9 `cv 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: July 9, 2021 Re: Local Waterfront Coastal Consistency Review for CHARLES & GINA CIRAVOLO SCTM# 1000-52-8-3 CHARLES & GINA CIRAVOLO request an Administrative Permit to cut back hanging limb on Oak tree, trim top of hedge, prune lower level branches on Oak trees. Located: 2415 Long Creek Drive, Southold. SCTM#: 1000-52-8-3 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc. Damon Hagan, Assistant Town Attorney Glenn Goldsmith,President tf so Town Hall Annex Michael J.Domino,Vice-President ,`Q 54375 Route 25 P.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 A.Nicholas Krupski Telephone(631) 765-1892 Greg Williams �sfliJrr �4 Fax(631) 765-6641 pl cou a � 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: $ 100.0 Completed Application: Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): ® U 2 V LWRP Consistency Assessment Form Sent: r V lS CAC Referral Sent: Date of Inspection: JUN 2 g 2g" Receipt of CAC Report: Technical Review: :Public Hearing Held: •ZI Southold Town Resolution: Board of Trustees OwnerCACArs)Legal Name of Property(as shown on Deed): I� (2,tic, 1✓'CLLJO X) Mailing Address: cLr Zi 7 C)/` %F d J V% /4y N V�)'11fe-fVchIV ll7 Y� Phone Number: �� 7 / 6 7 )` ®7,� o Suffolk County Tax Map Number: 1000 - 52-9-3 Property Location: g-2 / �/ (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Board of Trustees Applic__ion GENERAL DATA Land Area(in square feet): / 14 Area Zoning: Lam-[I ¢r V/ Previous use of property: wq�, Intended use of property: 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 f No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No If"Yes", please provide copy of decision. Will this project require a y demolition as per Town Code or as determined by the Building Dept.? Yes fNo Does the structure-{s) on property have a valid Certificate of Occupancy. /Yes No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No Yes If yes, provide explanation: Project Description (use attachments if necessary): Lw114aeA- -zamot hizd Board of Trustees Appli< ion WETLAND/TRUSTEE LANDS APPLICATI®N DATA Purpose of the proposed operations: '_ Ylee &X&,X47 6LIAV '4Wzpa'I 0 Area of wetlands on lot: /CSU square feet Percent coverage of lot: /0 Closest distance between nearest existing structure and upland edge of wetlands: /Do feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? cubic yards Haw much material will be filled? cubic yards Depth of which material will be removed or deposited: / feet Proposed slope throughout the area of operations: A1i`4 Manner in which material will be removed or deposited: _ r�-@ —C C) C 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): IVIA Board of Trustees Applic' _ ion AFFIDAVIT G✓`/�S1 a(G v'� ) !� �`'�l v BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECTIHE 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. Signature of Property Owner ignature of Property Owner h n SWORN TO BEFORE ME THIS 1t DAY OF P�� ` ,20 a LINDA NICi.1dLA N , otary' Pub)ic,State o3.t4evu Yo Nei:04Nt4868&T-- Queer ccung� ` Expires Aug, 10, 20-1-K _ �� e�1C,-� Notary Public 61 Z20 Appendix E Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part l -Project and Spo sor Informatio Name of Action or roj t: 10"&Aak ILL/P /640 Project Location(desc ibe, 'd a ch cation_rnapy "A 02��nit�7 &C;x k_1 Brief Description of Proposed Actio Name of Applicant or Sponsor: 7 Telephone: 6 6 E-Mail: Address: hl",Le) CAI Cit O: State ip Code: A/y 7 1.Does the proposed action only involve the legisl the adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 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: ❑ EEr 3.a.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? 0 acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? �� acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban F-1 Rural(non-agriculture) ❑Industrial ❑Commercial esidential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES I N/A a.A permitted use under the zoning regulations? ❑ ❑ nI b.Consistent with the adopted comprehensive plan? EJ ❑ 1❑ 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: _ff_H_ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ❑ 9.Does the proposed action meet or exceed the state energy code requirements? V NO YES If the proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: B] ❑ 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 listed on either the State or National Register of Historic NO YES Places? � ❑ b.Is the proposed action located in an archeological sensitive area? ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? E]If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: Ef 14. tify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Idep Shoreline El Forest ❑Agricultural/grasslands E]Early mid-successional (Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? IV 1r ❑ ❑ 16.Is the project site located in the 100 year flood plain? NO YES —ff= 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, (7( a. Will storm water discharges flow to adjacent properties? ❑NO [:]YES E5 ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO DYES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond;waste lagoon,dam)? If Yes,explain purpose and size: 19. Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: � ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE REST OF MY KNOWLEDGE 9C41'1& /C41 / Applicant/spo or ame:- �! '/& Bbg�i e ��lJl� Date: d Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning F-1 ❑ 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? ( -1 ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ El 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 F-1 El available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ ❑ a.public/private water supplies? b.public/private/wastewater treatment utilities? ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, F-1 F]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? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT I Page 4 of 4 APPLICANT/AGENT/REPRESENTAUVE TRANSACTIONAL DISCLOSURE FORINT The Towwn of Sauthold's Code of Ethics VmLiibits conflicts of interest on the p4oftown dfig &rs and employees. h v of this form is to pmv information which carr alert the town of possible conflicts of interest and_allow it to take whatever action is necessary',to avoid same, o/ YOURNAME: _ C'rCAv� `AG�`/P V-� v ci L (Last name,first name,4►iddle 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.) ekm- IPrJn'wit �__ Do you personally,(br 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,ntarriage,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)acorporation in which the town officer or employee owns more than.5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title br position of that person Describe the relationship between yourself(the applieantlagent/representative)and the town officer or employee.Either check the appropriate line A)through D)andlor 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)*,owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is u corporation); B)the legal of 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 Submitte 7 day of ou_ 20 a Signatur C� Print Name r,a ed a�^ c:J/ Form TS I Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated. as to its si tg_u�c_at beneficial and adverse effeots upon the coastal area(which includes alf of Southold Town). 3: If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of gouthold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# - PROJECT NAME The Application has been submitted to(check appropriate response): Town Board ❑ PIanning Board❑ Building Dept.'❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate'response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity,agency regulation,land transaction) ❑ (b) Financial assistance(e.g.grant,loan,subsidy) (c) Permit,approval,license,certification: Nature and extent of action: I ►-m NnN�° _ Location of action: L/�� Z12,41L Site acreage: ) Present land use: Present zoning classification: �c�2 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: 6W11LZ6a.'1 b- (b) Mailing address: (c) Telephone number: Area Code J (d) Application number, if any: Ig Will the action be di ctly undertaken,require finding, or approval by a state or federal agency? Yes 1:1No If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial-use of a coastal location,and minimizes adverse effects of development. See LWRP Section III–Policies; Page 2 for evaluation trite 'a. Yes No Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWR.P Section III–Policies Pages 3 through 6 for evaluation criteria Yes �-1 No l� Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria Ef Yes ❑ No ❑ Not Applicable 1-1162= A— err i Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ITNo ❑ Not Applicable Attach additional sheets if necessary Policy 5. 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 ❑ No Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ ❑ e Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LVW Section III — Policies Pages 32 through 34 for evaluation criteria. F] Yes E] No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ YesF1 No U Not Applicable Attach additional sheets if necessary i WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III--Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No ENot Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. oe ❑ Yes ❑ No EJ Not Applicable ` Attach'additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III —Policies; Pages 62 through 65 for evaluation criteria. Q Yes F] --� No Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No ❑/Not Applicable PREPARED BY U'W16U 0'y UyD/Z>4- TITLE.e® DATE ;7IIa l C,J�� f✓Cedol�