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HomeMy WebLinkAboutTR-10088A a� ' �. Town Hall Annex Glenn Goldsmith, President ; 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 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 1012_ INSPECTED BY: pegteS Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain K 1 s' tior GrT e P P�fie PrrCziit '/2 constructed Project complete, compliance inspection COMMENTS: rrwyal o� rs� rv- - CERTIFICATE OF COMPLIANCE: l r f Glenn Goldsmith, President *OF SO(/jyO Town Hall Annex A. Nicholas Krupski,Vice President �O �� 54375 Route 25 P.O. Box 1179 Eric Sepenoski ::v. 1 E [ Southold,New York 11971 Liz Gillill0000ly G Elizabeth Peeples Q Telephone(631) 765-1892 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 COMMENCEMENTO.F:THE ACTIVITIES,CHECKED OF,F BELOW: INSPECTION SCHEDULE ` Pr&-construe tion,,hay,bale.ane/silt boom%silt curtain 1:St day:of construction /.? constructed When project complete,;call for compliance inspection, CA MICHAE` SUFFOLK CO.HEALTH DEPT.APPROVAL' _ QES AWYAN H-S. NO. �♦ hJ-38.4O'501E. 'LAtCE Vt AV w � FiLED BOARD OF ST �' ISTATEMENT OF INTENT v TO V UTTTTLD THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEMS FOR THIS RESIDENCE W4LL �D- .v Q CONFORM TO THE STANDARDS OF THE ' f, I� DATE �j��/_ ,? SUFFOLK . OF E TH SERVICE <b� aT/C.liPr (/F�rli I iS) — a — a APPLICANT SUFFOLK COUNTY DEPT. OF HEALTH SERVICES — FOR APPROVAL OF CONSTRUCT 11N QNLY DATE: 17 5, Z H.S.REF.NO.: MAP PIG� 2-1-Y APPROVED:. �U"� FLOOD I--FVJOO ZONE A-S tEL.11 KX `` `✓bJIG�L Y�C= �ifL ZONE G SUFFOLK CO.TAX MAP DESIGNATN \ ` r DIST. SECT. BLOCK �t� HMAft " .: fZ " 232T3 < V St �( r w AT ^&X 1579OWNERS ADDRESS: .._a,9:-t W,875 ���std, ...__Zx3THctt.Q.,Ny. rEL 765-3f6[;BU5.�65.3770. � "it should be noted `hat since this I �� y e,�. a / A _ reperly is located tr. on agrfultuml DEED:L.. P� (tzF } < L Oreo, 'rhe passibij'Y eV;sts that TEST HOLE AMP SCALA s 50'•I wate- sU1,9!Y f: ; 01+c:n t-o« ? r1ciME!�tr ,o 1= CTOC�iS of OCSiI''�y r1 aa:'.:�:ns;;::,-:.•. m iwc wm.s. Gti P0 T tC9cw lsr a wt nw wn urn 1P Q� )'o" �— 'cF �;-tkCi AL PIPE SLkc:vi csctx sly ` = - Hur✓!us SICCA M1AW. U^0 � ° ,� I' agd�a L ;� Af?�A°d5O0pt5:F cultroctIm we oo�sore�aa�w,.w of I r � m '�• �1,y r �,rp r:it ��:i,. SATJGY IMMID U rar r Co,a'a h yR� R�1 E ii.o.g 8g d , ' ``' - t:O1�h1 m t A v,w aur cor.. i' DUAAAK s oaf•r®wua+i,wr w. rrS 0 I �1" I%OSOT NOS.•2OAD 4'A,, FE N&MES R Ft l2 TO-NiAP NO__Z(3F �A L COLirTm v'r'o'"NFOt�I npr`vf� a 3i , r UcE T PEC I,C riii'�TCES�F'LEC iN T E SUFI GQ LL-r21C'S vF�iCE Lso..,.6twrwnt6Tfp yp - A�tS.MAP Na.64. ileo&WAMAWM,a nor&.fon.. 3a•fit w i 2-FL1r VA'i0 N 5 f2EF'E R TO MF�\I SFA LEVEL t]CTL}t�i ,'�""'"+- • `•, �'� LI- N rU�. >� sem_co. .g.w. AET2u,C . -- - - — - - SEAL In 01 Z a ra*1.;,i' � � �.p..,,a��p7 REQUIRED {�1p�if���61 l-4APPED - AP12.FsiQ85 it�M c x�ne� GL•5r Fd3 Y L`SVe^ 1W if N 0. .7,wukaYisT�r6 9 €� ��3� 4aGrM� r IRE ROD RICKVANTUY C—'j1 " LICENSED LAND SURV ORS �•1 E3` 1 " i GREENPORT NEW YORK R\fOYNLrOSr r$pq FEB 2 3 2M i a Southold Town Board of Trusses Glenn Goldsmith,President ' �8 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 �+ ^�� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10088A Date of Receipt of Application: February 23, 2022 Applicant: Kathleen Chamberlain SCTM#: 1000-67-3-6 Project Location: 515 Lakeview Avenue, Peconic Date of Resolution/Issuance: March 16, 2022 Date of Expiration: March 16, 2024 Reviewed by: Elizabeth Peeples, Trustee Project Description: Ten (10) Year Maintenance Permit to hand-cut Common Reed (Phragmites australis) to 12" in height by-hand, as needed and to remove other invasive species, as allowed. 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 Kathleen Chamberlain, received on February 23, 2022, and stamped approved on March 16, 2022. § 275-5 Permit procedures. (i) Cutting of common reed (Phragmites australis) to within 12 inches of the soil surface landward of the wetland boundary. This does not include mowing to ground level. Special Conditions: Do not disturb native vegetation during the hand cutting of Common Reed (Phragmites australis), including but not limited to; Eastern Red Cedar (Juniperus virginiana), Northern Bayberry (Myrica pensylvanica), Marsh Elder (Iva frutescens), and Groundsel Bush (Baccharis halimfolia). The approved operations must be commenced within two (2) years from the date of the resolution. The permittee is required to provide the Trustees with before and after photos of the area within this time period before any further maintenance is conducted. 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. e Reids 1 r Roard cf Trus ees Glenn Gold �`th, President (tiro �FFi7( `_F'. � Town Hall Annex A Nicholas KrupsKK Vice-President `'�J,q 54375 Route 25 Eric Sepenoski o "` P.O. Box 1179 Liz Gillooly a ® Southold, NY 11971 Elizabeth Peeples `y�Ip� �a Telephone (631)(631) -1892 65 6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: )j jE2- 8<<45c Completed in field by: & �ee+py-S KATHLEEN CHAMBERLAIN requests a Ten (10) Year Maintenance Permit to hand-cut Common Reed (Phragmites australis ) to 12" in height by hand, as needed and to remove other invasive species, as allowed. Located: 515 Lakeview Avenue, Peconic. SCTM#: 1000-67-3-6 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 V1 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: S-}raral�vwa>� — rev-►ewed t`� I���s� I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: ✓ E. Peeples L. Gillooly ✓ G. Goldsmith ___\ZN. Krupski ✓ E. Sepenoski Other CAfLMiCFfAEL SUFFOLK CO.HEALTH DEPT.APPROVAL' O-- C Lacs) � � H.S. NO. /gt N_3g_4p'-,O•E LAKE VIEW AVENVE' 278.0z u .o 7 A-/ P.i.A - HAP to STATEMENT OF INTENT v u) ,�� THE WATER SUPPLY AND SEWAGE DISPOSAL 4�d SYSTEMS FOR THIS RESIDENCE WILL CONFORM TO THE STANDARDS OF THE + 4`f SUFFOLKOF,}IEALTH SER VICESJ APPLICANT SUFFOLK COUNTY DEPT. OF HEALTH SERVICES - FOR APPROVAL OF CONSTRUCT�N1 QNLY i \ 20 a DATE: "c Z H.S.REF.NO.: MAP JF PkO;,--7-E F,-,TY APPROVED: �\ Rt_aoo I---FLOOO ZONEA-8(EL..11 � 5'-JR�lEYEC r+IL } SUFFOLK CO.TAX MAP DESiG►i#T ZONE } ) } 11 t t' _ t (�/� DIST. SECT. BLOCK 1�T7' tAf1II�.:... < V w wit W A� - - BMX 8'6+ OWNERS ADDRESS: d Q X� ?E�vl�IC ?.9:.50W 8713 J / jw(�o1Q, l�� JL1Ik3C2L1�,l�1Y. !19,71 �/� i �;.f� ;F SGC:Tf�ri1 X1971 — r 3 1 roc `(_Y 1'EL 765-3!61;BU5.765.3770. !o "1t sf:cufd be reed that since this II� 2 a 1 pregetty is locoted in on agrtculturol DEED:L.. f �RFF) 4 y 0 g tS tk•ai ':+e TEST HOLE AMP x etso, ihs �os.iLiiity _ ( ?�, . 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Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 G • Telephone: 631 765-1938 c4Uffm��� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: March 14, 2022 Re: LWRP Coastal Consistency Review for KATHLEEN CHAMBERLAIN SCTM# 1000-67-3-6 KATHLEEN CHAMBERLAIN requests a Ten (10) Year Maintenance Permit;to hand-cut Common Reed (Phragmites australis) to 12" in height by hand, as needed and to remove other invasive species, as allowed. Located: 515 Lakeview Avenue, Peconic. SCTM#: 1000-67-3-6 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 Policy Standards and therefore is INCONSISTENT with the LWRP. 1. The Board of Trustees in 2004 issued a denial to cut phragmites and specified that the area was to be left undisturbed. There was no map in the file. 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�r 'Town Hall Annex A.Nicholas Krupski,Vice President ,`O ��� 54375 Route 25 P.O.Box 1179 , John M. Bredemeyer III l l Southold,New York 11971 Michael J.Domino G Q Telephone(631) 765 1892 Greg Williams Fax(631) 765-6641 BOARD`OY TOWN'TRUS TEES 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,@ Completed Application: 2•Z •2Y Incomplete: +-SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec 7Lead AgencyDeterminat ion Date: t.� � oordination:(date sent): rE I V E LWRP Consistency Assessment Form Sent: r -/AC Referral Sent: Date of Inspection: FEB 23 .' Receipt of CAC Report: G �echnical Review: Southold _ V Public Hearing Held: Board ofrrustm Resolution: Owner(s) Legal Name of Property (as shown on Deed) Ka H 4.EE .o•.f oX 4v� Ccw�cc ! I1 Mailing Address: l Phone Number: ti. Suffolk County Tax Map Number: 1000 - 'Property 000 - I - t�' l...v_. ey f.cw . Property Location: � � � (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Email: -� Board of Trustees Applin, ,ion GENERAL DATA Land Area(in square feet): '`1 D S�0 S �. • Z4 �o Area Zoning: r'e4 ; r Previous use of property:Pprty: CJ Intended use of property: VLA ct'a vt e Covenants and Restrictions on property? Yes X No If"Yes",please provide a copy. Will this project require-aBuil-din g 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? Yes No �l��- V(0 Prior permits/approvals for site improvements: Agency /� Date k No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? X No Yes If yes,provide explanation: Project Description (use attachments if necessary): J t 9 &,,,r u-Eta , �'Lsi w. �- br k' 7/4 GZ cls crams uz S czS Q-4 '1 Ing S �pe4 zi C V�2 r 5 Ha 4'r ct u�Q ,_s LAA-w r t%,1kc 4,e t ri'w w 6dG Board of Trustees Applic"-. .on WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: j�d -'rPM c rDAe- i 7iit reLlcup �S QZteQ O e7,1 L/4 Si ve_ 5i Q ci GS `u57�G4 KS - ri �7aLir' �-0 12 Area of wetlands on lot: ("400 square.feet Percent coverage of lot: Closest distance between nearest existing structure and upland edge of wetlands: /v IS 0 feet Closest distance between nearest proposed structure and upland edge of wetlands: u feet Does the project involve excavation or filling? X No Yes If yes, how much material will be excavated? K /a— cubic yards How much material will be filled? 12! cubic yards Depth of which material will be removed or deposited: hA- feet n1 u, a-u Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 1 C L T J S � t fO � r' to, (( S ewe- a c e.� t,/1, w,V 7—r, �( 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 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 Iead agency;attach additional pages as necessary to supplement any item. Part I-Project and Sponsor Information Name of Action or Project: -br,) t 2. iM� 4ccci O ILtV6cSiV� �cc Project Location tdescrib d attach a location map): / I ru ti's t' �¢'Q XU u 14, _"t 1_.1« s e V4 af S 4116 c Brief Description of Proposed Action: �vt 4 " eGi e5S I Gtie �cG �' Ccs o S U S VC. sr � t--uS s � s Cb + oC,r l/r�'S Grams . �•l( ADZ Name of Applicant or Sponsor; Telephone: 3 !. 74 1, 1&Q E-Ivlail:, Address: 0 x d o �. City/PO: State: Zip Code: I C j��Go,cJ _ I f 4J 5 c 1.Does the proposed action only involve the legislative adoption of a plan,local Iaw,ordinance, NO YES administrative rule,or regulation? If Yes,attacha 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?. p acres b.Total acreage to be physically disturbed?. 0,a Z� 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 ®Rural(non-agriculture) ❑Industrial ❑Commercial El Residential(suburban) ❑forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page I 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? © El 6. is the proposed action consistentwith 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: © ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES LK I❑ b.Are public transportation service(s)available at or near the site of the proposed action? ❑ LX 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_ . . 01141 ❑ 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:- f a- ❑ '. 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? FZOI b.Is the proposed action located in an archeological sensitive area? FRI ❑ 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? L❑J a If Yes,identify the wetland or waterbody andextent of alterations in square feet or acres: N 1 a DO T e---,';►Kc4r,- LVL/?x e.0,7t haLIC P 14 La 4 gt vasfsei -5 �-:3' cu t6a�fz 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ®Shoreline El Forest ❑Agri cultural/grasslands El 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? ® ❑ 16.Is the project site located in the 100 year flood plain? 7 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? [M NO ❑YES ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: LANO ❑YES 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: Fx . ❑. I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY -- --- -KNOWLEDGE Applicant/sponsor name: \ .T14 LF_'C^l &I A( r42L4� Date: A IV ZD Z2 Signature: ' Part 2-Impact Assessment: The Lead Agency is responsible for thecompletion 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? u 3. Will the,proposed action impair the character or quality of the existing community? RJ 4. Will the proposed action have an.impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? El 5. Will the proposed action result in an adverse change in the existing level.of traffic or ® ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action-cause an increase in the use of energy and it fails to incorporate reasonably available energy conservation or renewable energy opportunities? FX 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)? 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? EK ❑ 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, -- - ---- - -- --- - - VI/A-- 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 /!fl T�i'�EEN �'h��9�+'113 R�I i i✓ 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 1N THE IMANNER SET.FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN:BOARD OF TRUSTEES. - THEAPPLIC-- AGREES-TO HOLD TH-KTOWN OF: 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,THEi.IR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION: ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE=PREMISES.IN CONJUNCTIONWITH THIS APPLICATION, INCLUDING A.FINAL INSPECTION. I FURTHER AUTHORIZE-..THE BOARD OF TRUSTEES TO ENTER,ONTO MY.PROPERTY AND.AS REQUIRED:TOINSURE. 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 Signature of Property Owner SWORN TO BEFORE ME THIS 31 DAY OF yary , 20 az � ,iib .lyy LYNNM. C4 -PA W stat of New York x Rei'+F irr�tion#02PAS213o59 Not Public Qua��,� d In '�. `` :. .< Coin , New York Caunty . m'�s �n. tc ire N6V,2 APPLICANT/AGENT/REPRESENT ATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the hart of town officers and employees.The nurnose 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: fntlkMAE,2L.KVA (Last name,first name,middle initial;unless you are applying in the name of someone else or other entity,such as a company.If so,indicate;the-other person's or company's name.) NAME OF APPLICATION: (Check.all that apply.) - --.--Tax grievance.--- - - --Building. .. -- Variance Trustee K . 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 ofiSouthold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial,ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO X If you answered"YES'%complete the balance of this form and date and sign where indicated. Name,of person employed by,the'Town of Southold Title-or position.of that person 14 / 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 towmn -fficer or employee or his or her spouse,sibling,_paient,or child is(check all that apply): ' A)the owner of greater than 5%of the shares of the corporate stock of the applicant F��:B) (when the applicant is a corporation); 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 N�� Submitted this 30 day of J AW ua 2er6' Z4 zz- Signature. A414A&A,-v Print Name W r+.TW t_6r#4 6f A-Sk A r.A L.A., 4.1 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 Builong: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"tlie.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 Towne 1 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 reviewaw. Thus, each answer must be explained in detail; listing both suUporting and non-. supporting faets. If an action cannot be certified as consistent with the LWRP policv standards and conditions,it shall not be undertaken. '.A copy of the LWRP is'.available in the following places: online at the To of Southold.'s . website(soutloldtown.northfork.net), the Board of Trustees Office, the Planning Department, all` local libraries and the Town Clerk's office. B .a DESCRIPTION OF SITE=AND PROP.OSED-ACTION, $.CTM#: nn PROJECT.NAME �r�a' La6ev "asd O14eL ^y L�*S IVa :-� :¢c .&V The.Application has been submitted to(check appropriate response): CGS, ,; Ind 4 rG CAI. w .Zl �tn Town Board= 0 Planning Board 0 Building Dept. ❑ Board of Trustees. 0 1: Category of.Town of Southold agency action(check appropriate response): a Actionundertaken-directly-by Town agency(a•g• capital n LJ 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: A, � �1 Location of action: LX L4 pe e%n4 i Site acreage: (Q, ,q Present land use: Ua-<am 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: klr4—i-c} Af 1-I A I'1 '(b) Mailing address: 13 4x �F fro (c) Telephone'number:Area Code( 31 14 1 h4 (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;whichtate or federal agency C Evaluate the`_.project to the following policies by'anal` how the protect will further suppoit:'or Pt s^upport the policies Provide.all proposed BestlYlanagement Practices that;will further each Incomplete answers,will.require that the, form be returned for comp.ehon. p y . , DEVELOPED COAST POLICY Policy 1. Fbster'a pattern of development to the Town of Southold that enhances 'community character,, preserves open`spaee, 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. Q'Ves ❑ No ❑X 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 IN 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 forevaluation.criteria Yes ❑ 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 LWR . Section III-Policies Pages 8 through 16.for.evaluation criteria ❑ Yes ❑..No Not Applicable Attach a dditionalsheets if necessary Policy 5. Protect-and im rove water.quality and supply in the Town of Southold. Se uah P q "e-L,WRP Section In. —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'HI—Policies; Pages 22 through 32 for evaluation criteria. Yes No Nor' 1pplicable 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 3.4 for evaluation criteria. Yes [:] No2 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. 0,Yes 0 No 0 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. YeLl No© Not Applicable Attach additional sheets if necessary -%, WORKING COAST POI, n[ES t Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section 111--Policies; Pages.47 through 56 for evaluation criteria. Yes ❑.No © Not 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 LWR-P Section III'-Policies;:Pages 571 hrou gli 62 for evaluation criteria: Yes ❑ No 0 Not Applicable ` 'Attach additional sheets if necessary Policy 12. Protect agricultural:lands in the Town of Southold. See LWRP Section IIT—Policies.;.Pages `62,through65 for evaluation criteria. ❑ Yes ❑ N61A Not Ap.plica6le 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 F PREPARED BY ke(.i .L rt e14 TITLE 05 A -r,()) DATE L L3 L 1, r