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HomeMy WebLinkAboutTR-9960A Glenn Goldsmith,President �1®F SO Town Hall Annex ®� ®l 54375 Route 25 A.Nicholas Krupski,Vice President ® P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples �® ® �a® Fax(631) 765-6641 COUNTi BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE #2026C - Date: May 6, 2023 THIS CERTIFIES that the installation of a 4' high black wire fence around backyard and in left front of house install a 4' high picket fence with a double gate• install an above ground hot tub on an 80"x 93" cement slab; At 1630 Beebe Drive, Cutchogue Suffolk County Tax Map#1000-103-3-18 Conforms to the application for a Trustees Permit heretofore filed in this office Dated July 23, 2021 pursuant to which Trustees Administrative Permit#9960A Dated August 18,2021,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 installation of a 4' high black wire fence around backyard and in left front of house install a 4' high picket fence with a double gate• install an above ground hot tub on an 80" x 93" cement slab. The certificate is issued to Glenn Koopersmith& Eva Green Koopersmith owner of the aforesaid property. 0 Authorized Signature Glenn Goldsmith,President ®F S®//T� Town Hall Annex A.Nicholas Krupski,Vice President .�®� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples ® y® Fax(631) 765-6641 Court BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: S (o Z3 INSPECTED BY: Ill • Y��Pf�` h. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1 sc day of construction % constructed Project complete, compliance inspection COMMENTS: ldd-- c/ 2" lis CERTIFICATE OF COMPLIANCE: Glenn Goldsmith, President q SQ(Jly Town Hall Annex A. Nicholas Krupski,Vice President ��Vv Old 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III l [ [ Southold, New York 11971 Michael J. Domino G 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 lime/silt boom/siltcurtain 1St day of construction- Y2 constructed When project complete, call for compliance inspection; Glenn Goldsmith, President SOF SOUTy Town Hall Annex A. Nicholas Krupski,Vice President ,`O� Ol0 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold,New York 11971 Michael J.Domino G Q Telephone(631) 765-1892 Greg Williams to Fax(631) 765-6641 OUNT`I BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9960A Date of Receipt of Application: July 23, 2021 Applicant: Glenn Koopersmith & Eva Green Koopersmith SCTM#: 1000-103-3-18 Project Location: 1630 Beebe Drive, Cutchogue Date of Resolution/Issuance: August 18, 2021 Date of Expiration: August 18, 2023 Reviewed by: A Nicholas Krupski, Vice-President Project Description: Install a 4' high black wire fence around backyard and in left front of house install a 4' high picket fence with a double gate; install an above ground hot tub on an 80" x 93" cement slab. 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 Glenn Koopersmith, received on July 23, 2021, and stamped approved on August 18, 2021. Special Conditions: Fence is to stay within the lawn edge area. 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. _*,,.- 44-�g Glenn Goldsmith, President Board of Trustees ate ► r�,.�.. c (Ic4c .. _. Lo --- CE,I - - _ _� -. , -: Glen • �' - vh -_ - - r - " - _pus t Southold Towm - ; Board of 7fustees filk Qj OF Glenn Goldsr" President o�0 Town Hall Annex A. Nichola-b mrupski, Vice-President 54375 Route 25 John M. Bredemeyer, III y P.O. Box 1179 Michael J. Domino o Southold, NY 11971 Greg Williams y �� Telephone (631) 765-1892 dol Fax (631) 765-6641 BOARD OF TOWN TRUSTEES _ / TOWN OF SOUTHOLD Date/Time: .$�T9�2( Completed in field by: NY - GLENN KOOPERSMITH & EVA GREEN KOOPERSMITH request an Administrative Permit to install a 4' high black wire fence around backyard and in left front of house install a 4' high picket fence with a double gate; install an above ground hot tub on an 80" x 93" cement slab. Located: 1630 Beebe Drive, Cutchogue. SCTM#: 1000-103-3-18 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 `J 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: FN ct 4o 6e, 4 c14, .;w. -D,wa-, +ujf:� ?fr� y4Wys�t 14M I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other Standard N.Y.B.T.0 Form 8002-Bargain and Sale Deed,with Covenant against Grantor's Acts-Individual or Corporation (Single Sheet) CONSULT YOUR LAWYER BEFORE SIGNING THIS INSTRUMENT-THIS INSTRUMENT SHOULD BE USED BY LAWYERS THIS INDENTURE,made the day of 2021 BETWEEN RICHARD A. M. JONES AND DARCY GAZZA, HIS WIFE, residing at 1630 Beebe Drive, Cutchogue, NY 11935 �}• party of the first part,,/and LENN KOOPERMSMITH AND EVE GREEN KOOPERSMITH,HIS WIFE,residing at 16 Terrace Drive, Ai;t. Port Washington,NY 11050 000 Sect. party of the second part, 103.00 WITNESSETH, that the.party, of the first part, in consideration of TEN DOLLARS ($90:00) and•other valuable consideration paid by the party of thesecond part, does,hereby grant and release unto the party-of alk. the second part,the heirs or successors and assigns-of the.party of the.second part forever, )3.00 ALL that certain plot,.piece:or parcel of land, lying and being`in the got )18.000 SEE SCHEDULE "A" ATTACHED HERETO AND'MADE A PART.HEREOF BEING the same premises described`in deed dated 101111996, recorded 10/1111996.in Liber 11795, Page 949. TOGETHER with all right, title.and',-interest, if any, of the party of the first part in and to any streets and roads abutting.the above described premises to the center lines thereof, TOGETHER with the,appurtenances-and all the estate and.rights of the party-of the first part in and to said premises, TO'HAVE AND TO HOLD the,premises herein granted unto the party of the second part,'the heirs or successors and assigns of the party,of the'second part forever AND the party of`the first,part covenants that the,party of the first part has not done or suffered anything whereby the said premises have been encumbered in any way whatever, except as aforesaid. AND the party of the first part, in compliance with Section 13 of the Lien Law, covenants that.the party of the first part will receive the consideration for this conveyance and will hold the right to receive such consideration as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same,first to the payment of the cost of the improvement before using any part of the total of the same for any other purpose. The word "party" shall be construed as if it read"parties"whenever the sense of this indenture so requires. IN WITNESS WHEREOF, the party of the first part has duly executed this deed the day and year first .above written. a STATE OF NEW YORK, COUNTY OF SUFFOLK ss: On the day ofil��f in the year 2021, before me, the undersigned, personally appeared RICHARD A. M. JONES AND DARCY GAZZA personally known to me or proved to me on the basis of satisfactory evidence to be the individual (s) whose name (s) is (are) subscribed to the within instrument and acknowledged to me that he/shelthey executed the same in his/her/their capacity(ies), and that by his/her/their signature.(s) on the instrument, the individual(s), T r the person upon behalf of which the individual (s) acted, executed the instrument. STEpHANIE KUBLER �%�—r•-z� NOS Public,State of New Wk I l No.01KU6104350 oualified In as January nty 20�% CommissionExplres DISTRICT 1000 BARGAIN AND SALE DEED SECTION 103.00 WITH COVENANT AGAINST GRANTOR'S ACTS BLOCK" 03.00 r �Q' LOT 018.000, Title No. � +G J COUNTY OR TOWN Suffolk STREET ADDRESS' 1630 Beebe Dr. Cutchogue, NY RICHARD A. M.-JONES AND DARCY'GAZZA, HIS WIFE TO GLENN KOOPEF2SMITH AND EVE`OkEEN'KOOPERSMITH, HIS'INIFE RETURN BY-MAIL TO Lisa�Go(den, Esq. 1050,Franklin.Ave., Ste. 10`8- Garden City, NY11530 (516) 307-1:616' r Stewart Title Xrzsuraizee Corrzparzy Title Number: PY32658 Page 1 SCHEDULE A DESCRIPTION ALL that certain plot, piece or parcel of land, with the buildings and improvements thereon erected, situate, lying and being at East Cutchogue, Town of Southold, County of Suffolk and State of New York, being bounded and described as follows: BEGINNING at a point on the southwesterly side of Beebe Drive, at the easterly corner of premises herein described adjoining land now or formerly of Beaney on the south; RUNNING THENCE along the southwesterly side of Beebe Drive two courses and distances as follows: 1. North 57 degrees 30 minutes West, .110.0 feet;, 2. North 31 degrees 44 minutes 20-sec6nds West, 23.94,feet to land now or formerly,of Reunis; RUNNING THENCE South 76 degrees,43-min6tesA0"seconds West, 372.83 feet'fo,the oedinary high water mark of Eugene Creek; RUNNING THENCE along.said high'water mark South 29 degrees I minutes East, 104:00 feet to land ow or formerly of Beaney; THENCE along said land two courses and distances,,as,,follows: 1_ ,Nor,•th'76 degrees 43 minutes 40 seconds East, 309.30 feet; 2. North 77 degrees 27 minutes 40 seconds East, 119.27 feet'to'the point or place of BEGINNING. 1 ' . . � � \ ' . � 15. 10 O\H Go -45 WMB ' T sil ` ' DATE-MAY 2021 jos No.2021-212 O\t CERTIFIED TO. 1?,\)\ EVE GREEN KOOPERSMITH STEWART TITLE INSURANCE COMPANY Survey for: I GLENN KOOPERSMITH & EVE GREEN KOOPERSMITH At Cutcho gue Town of Southold D . Suffolk County, New York JUL2 3 20M 64 SUNSET AVENUE WESTI-JAMPTON BEACH, N.Y 11978 -Southold Town agNOTES Board of Trustees I AREA = 39.525 S-F 2. m� MONUMENT FOUND, 0 PIPE FOUND 3 REFERENCE DEED L 11796 CP 949 . . | � DWG 2021-212 ' - � •n4xt:H INf ". .x ,, littE tixT - : •li''. '` .. Oft 4C'_ O .{n x.0e.ta �.. ]v 1� .�• f.' �1.- 1� ". ,. 'l Z M x .BM i ag06-0 ro B m w - ,.. <.a •N�e> l sat „a,,,y .� � � a� a.d� ..Ir e F y B a 44.J c Sed '. 'rr�Fq. �g`S ii`a: w. pl$.s .B[' > a �'4"-•a•_"_...�..—_-�-•_ " ! F O�• a 70 � ar. : ,, -..� X10...3 �AN '.� g�R� 31 17 4 2T1• -et v yj WX13.,� 'f9 e S i-. .. y.—.-- . 313 leer 1ry'o l: y !7 �•\n , � q _. :'' d .-.�- b.- g„ �.. h YF�y``h�!` i.'4l F B •. ,�„y, 4'A'de Y .-.Y'i ..may- ry]1.YY *g Z,yrs q m 1e ........... B p a, a•! F 4 a'A;' .o. .... ^ "3 B.h e R 'M. 01 J F•..• K. ` w ;.`` r $ F . ,OY.i .--^"wusG "o tf a l� 2. 3 ' ,, a ,' �'+ •'- +, F 4"<y � 't�� `-�e� 4 t�Y - ,� `\� .. Lb) t -�t o k d 3 'ie S�. �e-> — y e r e< 'e e,. F-v `? +F �J _ � - ".- �' - t>'a. �a•w a _ ..._.g�,r� s , ��� _•�0 a a3 -.. ti 'eW �,ti t' e B r . ..� lRgCk g •tS1� ,Kd ` o0 se g a e 0 .y :eft:, 1 ♦7i tic i�... e J 04' z e M Al9 41 , ,� i '-.. d,,. s GAS A�-♦ 41,b i e` !.. K.. " < _. ••< .,..r�.«.6,..,,,< ....:., -- .a-,,. .,. COUNTY OF OC 10 cy w 0-, —�— ,t� R.A P-perty lax Secvicc Agenr a. wutnoto M o.e 1 US B OFFICE LOCATION: �� MAILING ADDRESS: Town Hall Annex 'A, P.O. Box 1179 54375 State Route 25 r�� Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) 4 Southold, NY 11971 f Telephone: 631 765-1938 � .. 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, AICP LWRP Coordinator Date: August 9, 2021 Re:: LWRP Coastal Consistency Review for GLENN KOOPERSMITH & EVA GREEN KOOPERSMITH SCTM# 1000-103-3-18 GLENN KOOPERSMITH & EVA GREEN KOOPERSMITH request an Administrative Permit to install a 4' high black wire fence around backyard and in left front of house install a 4' high picket fence with a double gate; install an above ground hot tub on an 80" x 93" cement slab. Located: 1630 Beebe Drive, Cutchogue. SCTM#: 1000-103-3-18 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 policies and therefore CONSISTENT with the LWRP provided: 1. A de-watering drywell is required. 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 *Qf So(/�y Town Hall Annex A.Nicholas Krupski,Vice President ,`O� Ol0 54375 Route 25 John M. Bredeme er III P.O. Box 1179 York Y �[ � Southold,New York 11971 Michael J.Domino G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 ol�Cum BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only fjD U E 0 V E Coastal Erosion Permit Application Wetland Permit Application JUL 2 Administrative Permit 3 2M Amendm'ent/Transfer/Extension Received Application:• 23.21 Soathold Town Received Fee: $, Pq•00 Board of Trustees Completed Application: •� Incomplete: SEQRA Classification:"Type I Type II Unlisted Negative Dec. Positive Dec. ' Lead Agency Determination Date: /C oordination:(date sent). LWRP Consistency'Assessment Form Sent: AC Referral Sent: Date of Inspection: Receipt of CAC Report: Technical Review: —70! Public Hearing Held: /g'ZO Resolution: Owner(s)Legal Name of Property (as shown on Deed): wv+ (66 j;r►`I% Mailing Address: PO t)daC Il Sj cAahagy-2, to Phone Number: (631 J ]4 " 9 � 1 Suffolk County Tax Map Number: 1000 - D-5,Do s 0-� 00— 0 L8 0,0 cq Property Location: j G 310 2e6ae� Q u iye , C oCky et ae 0 Y (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): P Mailing Address: Phone Number: Email: Board of Trustees Applies ,tion GENERAL DATA Land Area(in square feet): 6-00 0 IV Area Zoning: K g Previous use of property: Rut"&Mco Intended use of property: RRgs A y►C_Q_ 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 X 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 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 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): /✓►�"/``�� ��� bio �� '�� y( �f ®(�i1rl boiC/L m/6(. -74 v�� ^inS /� v,l�i�� 7�G��f A/7 Q__ T �fli V�/*Aloud/t �f c �� � ��,e,� �-a��� kdA f4b QA ce q Board of Trustees Appl--'"' tion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: lo`F v Area of wetlands on lot: / ' f square feet Percent coverage of lot:TW 3 % Closest distance between nearest existing structure and upland edge of wetlands: 6 �,r. feet Closest distance-between nearest proposed structure and upland edge of wetland /® feet Does the project involve excavation or filling? X No Yes If yes, how much material will be excavated? © cubic yards How much,materialwill be filled? 0 cubic yards Depth of which material will be removed or deposited: CCS feet Proposed slope throughout the area of operations: d ll' Manner in which material will be removed or deposited: 0) A 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): 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part l -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 l based on infonnation currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: Project Location(describe,and attach a location map): )22_4',17&e_1- d1� (�`�c/�)`�l/C� Prl 7�10,77t_ ®T'r WL�1"& Brief Description of Proposed Action: �dl 5 f 1// y/ /I!<'4 1�Ln e_.- �•.,� ��,�� of /n/c�/��®/s t ft r+4 l go wick b y 93 v4c-h h-a+ °fob Name of Applicant or Sponsor: `�� / Telephone: &3/ '73Y-.P-:?1-3 Irve- e/e4., /�o�a��ini7h �- C��e.,n �� RrS�n i E-Mail: Address: 1tp.36 �lx • City/PO: State: Zip Code: Graf c'k u 7 D �J eg 3 I.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that ❑ may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: ❑ 3.a.Total acreage of the site of the proposed action? a acres b.Total acreage to be physically disturbed? a c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? 13 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial Residential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ ❑ 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 ction ocated in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: Id CI &VIg 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO kVES b.Are public transportation service(s)available at or near the site of the proposed action? ILI c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: {] 10. Will the proposed action connect to an existing public/private water supply? NO YES -11 If No,describe method for providing potable water: ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater-treatment: El 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? ET ❑ IT 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? ElIf 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: ❑S reline El Forest ❑Agri cultural/grasslands El Early mid-successional etland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO S by the State or Federal government as threatened or endangered? ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, ❑ a.Will storm water discharges flow to adjacent properties? ❑NO E]YES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO AYES 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: 10 ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO I Y S completed)for hazardous waste? /11 If Yes,describe: Pr ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/spons name: 19AI e) �6-°��sm Date: 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?" ; No,or Moderate ' small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoningElregulations? 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)? op 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 j-J reasonably available energy conservation or renewable energy opportunities? E�K 11_�_I 7. Will the proposed action impact existing: ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ waterbodies,groundwater,air quality,flora and fauna)? Rr Page 3 of 4 No,or Moderate small to large impact impact may may occur e 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? El 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 Page 4 of 4 ' Board of Trustees Apple 'ltion 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. Signature of Noppdy O er Signatur pe Owner SWORN TO BEFORE ME THIS DAY OF �� , 20_1�_ MIJAAk� L Notary Public MF!ANIF SU OFF N Notary Public ate ew York !o HO 529 ed in ssau Co yr) MELANIE SUE HOPFMAN ,ion Aires Se ' Notary Public, State of New York No.01H04609529 Qualified in Nassau County Commission Expires Sept 30,20it 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 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: A0 (Last naifie,first name,ipiddle' itial,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 oDSouthold? "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%oft shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person-employed by the Town of Southold Title or position'of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of 200 Signature f Print Name Form TS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront, Revitalization Program. A proposed action will be evaluated as-to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). - 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting-and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold-,'s website (southoldtown.northfork.net), the Board of Trustees Office; the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCT-M# D ,iv - im ab - 01,2,60no PROJECT NAME The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees V 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:e , Location of action: 1630 Ree,6 �in&, C—AdVve. kNVf 1113 Site acreage: 53 Q o-ej Present land use: Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing address: (c) Telephone number: Area Code( ) (d) Application number,if any: A) Will the,action be directly undertaken,require funding, or approval by a state or federal,agency? Yes ❑ No❑ 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. Poster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure,makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2-for evaluation criteria. 9yes ❑ No [—] Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic,resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria VYes ❑ No ❑ Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Sectio III—Policies Pages S through 16 for evaluation criteria Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of.Southold. See LWRP Section III —Poli 'es 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 throu h 32 for evaluation criteria. Yes No N4',_, pplicable ` Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for valuation criteria. Yes ❑ No Not Applicable t 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., ❑ YesEl No DNot Applicable _ PP 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. ❑ Yep n l No Not Applicable Attach additional sheets if necessary WORKING COAST POL—JES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations7NLo WRP Section III–Policies; Pages 47 through 56 for evaluation criteria. ❑ r Yes [:] Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estu - and Town waters. See LWRP Section III–Policies; Pages 57 through 62 for evaluation criteria. 7Yes ❑ No ❑ Not Applicable ` Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III–Policies; Pages 62 through 65 foreva nation criteria. ❑ Yes. 1:1No 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 r SiNI l TITLE DATE