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HomeMy WebLinkAboutTR-9976A Glenn Goldsmith, President 0s '', 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 00Telephone(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; AJ2rf e o ( z( 1 slallzmaij in) 7 ul U s X3.4 i jtj�4tr Of Trustees AlUt 4N, e S — - NN 41.9F ,r 4t u S,�f ZQ \ X 4 rre�ICa BOARD OF I X.A.3- 1 TOWN OF DATE �— 2024 t _ 1 Glenn Goldsmith, President �� Soo, � Town Hall Annex A. Nicholas Krupski,Vice President 'G 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 Permit No.: 9976A Date of Receipt of Application: September 1, 2021 Applicant: Nikos Theodosopoulos & Anna Loukissa SCTM#: 1000-71-1-6 Project Location: 595 N. Parish Drive, Southold Date of Resolution/Issuance: September 15, 2021 Date of Expiration: September 15, 2023 Reviewed by: John M. Bredemeyer III, Trustee Project Description: Replace the existing 5'4" on a side wood hexagon gazebo with a 3'11" (74sq.ft.) vinyl octagon gazebo to be placed on a gravel/stone base. 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 Nikos Theodosopoulos, received on September 1, 2021, and stamped approved on September 15, 2021. Special Conditions: None. Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Glenn Goldsmith, President Board of Trustees SUfFO[i'�.- Glenn Gold;' `wh, President �0 �,� Town Hall Annex A. Nichoh-;(rupski, Vice-President „�� = _ 54375 Route 25 John M. Bredemeyer, III o P.O. Box 1179 Michael J. Domino o Southold, NY 11971 Greg Williams O� Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD ,J Date/Time: J 1300 Completed in field by: NIKOS THODOSOPOULOS & ANNA LOUKISSA request an Administrative Permit to replace the existing 54" ( .) wood hexagon gazebo with a 3'11" (74sq.ft.) vinyl octagon gazebo to be placed on a gravel/stone base. Located: 595 N Parish Drive, Southold. SCTM#: 1000-70-1-6 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures- 100 feet Public Notice of earing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey :5 5 years: Y/N Wetland Line by: C.E.H.A. Line ,Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other ® � SEE - SOLIr1`1016 1ov.,rn SURVEY OF PROPERTY Boardof 7r uslees �- SI T UA TE BAYVIEW TOWN OF SOUTHOLD S O� SUFFOLK COUNTY, NEW YORK 3 S�•S �'. S.C. TAX No. 1000-71 —01 —06 SCALE 1 "=30' JULY 23, 2009 \ / J-- OCTOBER 2, 2009 SHOW RETAINING WALL & DECK TO BE REPLACED LO 6� 60 MARCH 28, 2019 UPDATE SURVEY 4 3..2 \`4' 1 \X \ \\ �voe�C\ R 9�--2?o AREA = 25,490 sq. ft. 19 (TO HIGH WATER MARK) 0,585 CIC. 2-12 X \ IzX \ : \ X-- OP \ \\ \\3 NOTES: \ \ ^ 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM / X _• EXISTING ELEVATIONS ARE SHOWN THUS:-U 3({ �'--U'11/ \ s N EXISTING CONTOUR LINES ARE SHOWN THUS: —————5————— O of F.FL - FIRST FLOOR G.FL - GARAGE FLOOR B.B. - BOTTOM OF BULKHEAD \r 1117(/ T.W. - TOP OF WALL Ppm ( I B.W. - BOTTOM OF WALL OA, FI �( =X x \ w O p4G o o / xzz fOG f OF 1\ AWN 641 STEPS A CooDFnCK�S O S1T�0 G&p F Z2 7— � 1. P zo 18.8' \ / CqIj � O m 18.9• 'Y.; CK �' l �8 14.3 O 3� 1g � ❑s 11A6C NNIT ' W���3 � W� 9 s f"rF STORY o Ho�SeRAME S 75 8 2 / a SLA 11.1, FOUND $4 5p" o i '�' e' ^8. •" CONC MON f �� cgv °e Q j 39.7' / 12 ^ 0 BRICK& / roof & X13 -LL2 S22.0p, /\o tm K tAMp • CON FOUND ON. ° m / / UNAUTHORIZED ALTERATION OR ADDITION L PO '� a / / TO THIS SURVEY IS A VIOLATION OF c 4 #4 1 \ i / // SECTION 7209 OF THE NEW YORK STATE ION ,, . / -C / / COPIES OF THIS SURVEY MAP NOT BEARING 10 • 75° / y!Rf` i 14.8 / P THE LAND SURVEYOR'S INKED SEL OR �X �~.F°�0. /'A� 2 M�1rF�R✓'--Cola N �� TO BEEMBOSSA VALID TRUE ED SEAL LCOPY. L NOT BE CONSIDERED 1 e / • ./ �: _ CERTIFICATIONS INDICATED HEREON SHALL RUN �Oj�T `r1 x ' J��O• / ONLY TO THE PERSON FOR WHOM THE SURVEY �•� IS PREPARED, AND ON HIS BEHALF TO THE A ,y ,• /� •e2p TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND X fDGe a', TO THE ASSIGNEES OF THE LENDING INSTI- `f/`C/1 ,. � PAVfM fN1 TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. DRjVE THE EXISTENCE OF RIGHTS OF WAY AND/OR EASEMENTS OF RECORD, IF ANY, NOT SHOWN ARE NOT GUARANTEED. PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED i.. Corwin BY THE L.I.A.L.S. AND APPROVED AND ADOPTED FOR SUCH USE BY THE NEW YORK STATE LAND f.ri TITLE ASSOCIATION. Land -;� 0- Via: Surveyor .;- Title Surveys — Subdivisions — Site Plans — Construction Layout , 1 PHONE (631)727-2090 Fax (631)727-1727 h �• f P OFFICES LOCATED AT MAILING ADDRESS 1586 Main Road P.O. Box 1931 -' -4' ;' N.Y.S. Lic. No. 50467 Jamesport, New York 11947 Riverhead, New York 11901-0965 29-164A "IN p Oto X Oe Xl\ O�j N4 N tio1v I :P.og was h. Aj N, ",-901 sagisruL 10 (J7 UM PfoglnoS CN leoeA d39 0 C49A 0 j ??VO02)saj (-Ypj-j-Z p25 Pq A --Olt -3�O-DaFIll -Z OZ rOjpq QV" �� �t110 71�eo�oso�a�J�o_� C-)WIjer 00d e 11/21 27 MaAJ PBS{cQO&C , ��P - 1 res ., . „ 2021 -f 3. S old Town f Trustees 4. LO 6 & J� 00 Of 9 40 3.3 �i 6.3 -1 rraJOCa�� I-*-- c` 41 7.C Adi<ess 5 135 Pac`4 lel JOB NUMBER:E223-11 PROJECT:STANDARD PLANS FOR 10' This drawing is the property of Country Lane Woodworking,LLC,provided by Timber Tech Engineering,Inc and reproduction,alteration or use of this drawing without the OCTAGON VINYL GAZEBO written consent of Country Lane Woodworking,LLC is prohibited Drawings shall not be scaled to obtain dimensions.The contractors and builders involved on this project PAGE:2 OF 3 shall verify all dimensions and conditions before starting work and any discrepancy shall be reported to the engineer in writing before starting work 3'-10�/tg 1111 44 post,wrapped (2)2x6 floor joist 2x6 skirt board w/ -'84x5#'vinyl cover strip 3'tOs 2x6 floor joist Floor Framing Plan NM � � � � � � Kit Unit D i SEP - 1 2021 Southold Town Board of Trustees OCTAGON GAZEBO SITE PREPARATION RECOMMENDATIONS _ It is important to have a solid and level foundation for your gazebo. Check the gazebo drawings to get the measurements for the foundation. Check with your local building officials and follow all local building codes. For gazebos that need an engineered seal,please ask for engineered foundation instructions. The instructions shown here are only the minimum recommendations. Stone Pad Concrete Pad Concrete Sonotube 1. Dig out 4"-6" of ground. 1. 'g out 8" of ground. 1. ig a minimum 16" diameter 2. Lay treated 6x6 boards around 2. Te orarily put boards ound hole t each octagonal poi and the perimeter of where the gazebo the p'er eter of where one in a center. (See b ow) is going. gazebo i oing. 2. Dig do a minim of 3. Fill the area with 4"-6" of stone. 3. Fill the ea with 4' of stone. 24" Check ' you local We recommend using%"clean 4. Dig a 12" 2" co tinuous building codes r ost depth stone. footer around perimeter of requirements.Y may need to the pad. dig deeper de p ndi on your Top View - 5. Use rebar ne ed. location. 450 6. Pour con rete thr ghout 3. Place a s otube in the ole at Corner base. Be s re the top o concrete each loca on shown below. is level the way aroun .We 4. Use r ar as needed. L5 OQ p OQ p OQ p O recom end the concrete d to 5. F' a sonotubes with o0�� le, be 6" ore on each side of con rete. Be sure top of concrete o�°o ° az o floor. is level with all other sonotubes. ��0000�0000�000D0000O g ao oao oafs L5 0 ° Oo°QOo°QO<° o° ,Top View �O�o041Y 015 12"xl2"Continu s Top View Oo Oo Footing 6x6 Perimeter Board Stone Cut each board at 22.5°angle to create the 45°corner A Side View 4"-6"Stone Dirt 450 '_ 45° Corners 4"Concrete Corner 16"Diam er Concrete so otubes ao oao oao oao oao ide Vie ao 0 o - aov�°�o�ao�a ao�t 0 0 12"x12" ontinuous ooting Side View �o00��00��o0p0o00 00��00� ogo oao oao oao oa°o oao ogo 000 LL- oz)�Oo�Oo�Do�Do�Oo�Oo X40�Oo -------- - -------- --------- ---- ----- _____ ___ __________________________ oo��oa�o����o�Qo�o��o�o��o�o��oo _____________ 4"S one 4"Concrete Dirt Dirt CLW is not responsible for site preparation.The property owner is responsible for permits if any are required. i .FiR µ� A or �. (ti pe- Cd b\j, L ler 1 00630 Op t 1"" i � Son MPrZ i Re,h— mi"i -12 IS ma NA wSERTA SOUTHOLD BAY 43 4 H a tat Z4A(q- V SAO)/ u+wIS 1. IS 5IS IS SEE INSERT L ------ - - T— SOUTHOLD SECTION NO E (21 N."." COUNTY OF SUFFOLK @ 1. fid � G ------ Real Property Tax Service AgencyE y E 071 A an rWcrro PROPERTY MAP OFFICE LOCATION: MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 �� Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) u . Southold, NY Telephone: 631 765-1938 �# www.southoldtownny.gov b,. X' PLANNING BOARD OFFICE TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: September 14, 2021 Re: LWRP Coastal Consistency Review of NIKOS THEODOSOPOULOS &ANNA LOUKISSA SCTM# 1000-70-1-6 NIKOS THEODOSOPOULOS &ANNA LOUKISSA request an Administrative Permit to replace the existing 5'4" (74sq.ft.) wood hexagon gazebo with a 3'11" (74sq.ft.) vinyl octagon gazebo to be placed on a gravel/stone base. Located: 595 N Parish Drive, Southold. SCTM#: 1000-70-1-6 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 the LWRP policies (4) and therefore INCONSISTENT with the LWRP. 1. The gazebo is proposed within a FEMA Flood Zone VE (Velocity Hazard) however there is no practical area to relocate it on the parcel outside of this zone. 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 � I Glenn Goldsmith,President Town Hall Annex A.Nicholas Krupski,Vice President t�'�- "> � . 54375 Route 25P.O.Box 1179 John M.Bredemeyer III Southold,New York 11971 Michael J.Domino Telephone(631) 765-1892 NA Greg Williams © �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Coastal Erosion Permit Application p � 0001� � Wetland Permit Application Administrative Permit SSP Amendment/Transfer/Extensi n 2021 Received Application: Z� eceived Fee: $ ! O _ - Southold TOWn o' Completed Application: • ' Board of Trustees __j Incomplete: SEQRA Classification: Type I Type R Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: —/Coordination:(date sent): LWRP Consistency Assessment Form Sent: XDXAC Referral Sent: ate of Inspection: Receipt of CAC Report: echnical Review: Public Hearing Held:. S' -Resolution:, Owner(s)Legal Name of Property(as shown on Deed): ` I iGSTh<3dQ50P0J 105 /�,N�U LOU kiLsq Mailing Address: rs�0-� L n a 031D Phone Number: Suffolk County Map Number:Ma Number: 1000 -_ Property Location: 5 0 4\A -P l _ LL' ) (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: I_ Phone Number: Email:'n 1 i ko-S+ � mq t l • co — Board of Trustees Applic__ion GENERAL DATA Land Area(in square feet): 6J I ��o Area Zoning: Previous use of property: _ G 1 P�1�(Cr. Intended use of property: Q_e, l e ' a. Covenants and Restrictions on property? Yes _y _No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes No If"Yes", be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes _K_No If"Yes",please provide copy of decision. Will this project req uir any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure (s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agenc Date CepLA ueco No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?--XNo Yes If yes,provide explanation: _ rro Project Description(use attachments if necessary): 2 c 2 I -_ S �+ t nc S Z d e_Xa PJ wj) Qq zed o_ _ n -__ �, e r-1-0 -n 10M Ee 01MA, C�LreA �qz_Aq naz e em � �� ti �� � � -�� T-�- w V aA✓ r,�l ( I ne bax Board of Trustees Appli.c .ion WETLAND/TRUSTEE LANDS APPLICATI®N DATA Purpose of the proposed operations: r inA wof -L2Lo lja -a e_6 o Area of wetlands on lot: o® square feet Percent coverage of lot: Closest distance between nearest existing structure and upland edge of wetlands: N 20 feet Closest distance between nearest proposed structure and upland edge of wetlands:4))_0 feet Does the project involve excavation or filling? -No Yes If yes,how much material will be excavated? �cubic yards How much material will be filled? N cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited:- << A I I I cemoue& c boo+ ' 6 n e coo it , AnW _,qC11 W QQS 0 Aa W 0 - Q__r :5 P,ba r e- se I Le '9 Ad M (3 k) ro,OeV' �0 Q'b F_nn'." CL fLSQ- C' ze 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): 61 Z20 Appendix B 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 I. 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 aach a location map): SSS d Fac(sk �c( JQ.. �O�TkOIdC. Brief Description of Proposed Action: n C—O-� IA Remove e_x(S+t ri1 '6v 1 S h e n1*• !N R VIn aZe�ae � S rn, WOO CCp�gze 6G4� etA `Te (sir r • c I gv l� C%c(k ?&b S ei na- I I A- blrSe ©-� l� Le- Name of Ap-licant 30ro ponsor- Telephone: s f 3� ©9z 6 N I KO-S. ��� S© P 0 L)�S E-Mail:- n I 1'0"r Address: 1—+ 5 PfOgrs�O+ L-A City/PO: � P/1 _ 'state:+ ^ , :Zip Code:(/3 Kk4A 5 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 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? 5 85 acres b.Total acreage to be physically disturbed? G O acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? t 5�� acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) []Industrial ❑Commercial Xtesidential(suburban) ❑Forest ❑AgricultureAquatic []Other(specify): ❑Parkland -------------- Page 1 of 4 5. Is the proposed action-, NO YES N/A a. A permitted use under the zoning regulations? Cl ❑ b.Consistent with the adopted comprehensive plan? is ❑ 6. is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? 7. Is the site of be proposed action Gated in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify S. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES ® ❑ b.Are public transportation service(s)available at or near the site of the proposed action? 154 ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 10 ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment:, ❑ ]2. 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? ❑ ; Z_ 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? IT b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: horeline El Forest ❑Agri cultural/grasslands ❑Early mid-successional 19LWetland ❑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? rM ❑ I6.Is the project site located in the 100 year flood plain? NO YE 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, a.Will storm water discharges flow to adjacent properties? ❑NO ❑YES ❑ b.Will stofm'water discharges be directed to established conveyance systemsrunoff and storm drains)? If Yes,briefly'describe: INNO DYES Page 2 of 4 l 8.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: fSa F-1 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: a 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: 1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE ( I Applicant/spo am b d?o b U Io Date: I l 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 1. Will the proposed action create a material conflict with an adopted land use plan or zoning � ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? M F] 3. Will the proposed action impair the character or quality of the existing community? (u TCS 4. Will the proposed action have an impact on the environmental characteristics that caused the (� establishment of a Critical Environmental Area(CEA)? l�J 5. Will the proposed action result in an adverse change in the existing level of traffic or a affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a.public/private water supplies? tom, b.public/private wastewater treatment utilities? 0- 8. Will the proposed action impair the character or quality of important historic,archaeological, (� ❑ architectural or aesthetic resources? J 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, (�( waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? 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 Applic-, -ion AFFIDAVIT A ti cJ cx L-o v S S I ® TO(Spen ® � BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS)AND THAT ALL STATEMENTS CONTAINED HEREIN i 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, x 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. 4 - Signature of Pope y Owner Signature of Property Owner SWORN'TO BEFORE ME THIS DAY OF n MUL YOUNG KIM - - - 1 Notary Public,State. of New York Notary Public No. 01KI6151172 Qualified In Nassau County Commission Eyplr es Aug 14,20-�- APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code-of Ethics prohibits conflicts of interest on theyart of town officers and employees.The-ouroose of this form is to provide inforinafion which can alert,the`town of possible"conflicts of-interest and allow•it to take whatever action is necessary!to avoid satme. I (� YOUR NAME:1 YlCJ 0 S 0 A►0 l 6 S i (Last name, name,gdddd(a 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 X' Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map _ Planning Other (If"Other",name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO — _ If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thi day of e,4r q 200 � Signature Print Name o Gs d S Form TS l 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 simificant 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- supportin9'1acts. 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 F SITE AND PROPOSED ACTION SCTM#_ PROJECT NAME G a e e II The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity, agency regulation,land transaction) ❑ (b) Financial assistance(e.g.grant,loan, subsidy) (c) Permit, approval,license,certification: Nature and extent of action: F� C o® is cd .e wul cLnQ CJS t A C 40, Location of action: CaTi-'s t v r Site acreage: (P-5- Present Present land use: P<-C'S(a P �- Present zoning classification:.- 2. lassification:_2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided:Ip "�' J ff (a) Name of applicant: �_� 05 l ��ocQO Mailing address: G��C �C � 1. PA , 6, �l U a( -02 Z �� (c) Telephone number:Area Code( ) 5 (d) Application number,if any: _ A, Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes 19No❑ If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure,makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III-Policies; Page 2 for evaluation criteria. SYes [-]' No ❑ Not Applicable ze �o a4k, 4ea J�C_ 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 ❑ YesF-1 No 'N7' Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No WNotApplicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages S through 16 for evaluation criteria Yes ❑ 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 —Policies Pages 16 throu h 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. Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes Q NoJ2�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 lel 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. ❑ YeED No MNot Applicable Attach additional sheets if necessary WORDING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section M.—Policies; Pages 47 through 56 for evaluation criteria. Yes ,❑ No QNot Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of Paving marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No XNot Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III—Policies; Pages 62 through 65 for evaluation criteria. ❑Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 13. Promote;appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable n�l 12-(REPARED BY TITLEDATE