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Home My WebLink AboutTR-10136A Glenn Goldsmith, President �� SO � Town Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25 xax P.O. Box 1179 Eric Sepenoski 3 3 Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples �age .meg# �® Fax(631) 765-6641 CCO U A I 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 K When project complete, call for compliance inspection; Glenn Goldsmith,President ®F s®�f�� Town Hall Annex ® 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski 3 Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples a� Fax(631) 765-6641 C®UNTI,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10136A Date of Receipt of Application: April 26, 2022 Applicant: Rachel Levin SCTM#: 1000-44-2-18 Project Location: 58625 CR 48, Greenport Date of Resolution/Issuance: May 18, 2022 Date of Expiration: May 18, 2024 Reviewed by: Liz Gillooly, Trustee Project Description: Replace existing fencing which runs from north to south with approximately 65' of 4' high fencing (vinyl or metal); and to replace existing fencing which runs'east to west on the south with 25' of 4' high fencing (vinyl or metal), and plant sea grass along fence (east) perimeter. 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 Rachel Levin, received on April 26, 2022, and stamped approved on May 18, 2022. 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. 4x— Glenn Goldsmith, President Board of Trustees S�FFfI' Glenn Go nitt _esident ��0 p Town Hall Annex A Nicholas KrupsKi, Vice President ,� ��; 54375-Route 25 Eric Sepenoski o -` P.O. Box 1179 Liz Gillooly o Southold, NY 11971 Elizabeth Peeples y�Ip� �00�� Tele 656641 hone 76 -1892 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: /' j ZZ Completed in field by: L • r, I Cro- � �1 RACHEL LEVIN requests an Administrative Permit to replace existing fencing which runs from north to south with approximately 65' of 4' high fencing (vinyl or metal); and to replace existing fencing which runs east to west on the south with 25' of 4' high fencing (vinyl or metal), and plant sea grass along fence (east) perimeter. Located: 58625 C.R. 48, Greenport. SCTM#: 1000-44-2-18 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 Hearing 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 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: UV C>vt to V1 L U �T r �1G1 I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: E. Peeples L. Gillooly G. Goldsmith N. Krupski E. Sepenoski Other nQ E ,C E I WE AH 2 6 2022 DD SauftidTawe �y j+ Board of Trustees A P ,}� L � e � M GRAVF ly \Z-V V*w 12 14.x/ - r & zROOF-0 VE T � -c' y,�• e &9*10 Uf - ; - 'BOARD OF 1 R"USTEES TOWN OF SOUTHOLD . 4 n ®ATE E OF CE a �C ECE8VE a _ APR 2 6 2022 ® ® 83.�s LONG ISLAND SOUND C`I3" r W = Q O® Is2 Board ofTdTown rusteesN 47o5, TIE LINE o c F A cz ce, od \ .> j-O \ " o nt :. WOOD CATWALK PROPERTY OF (l.B-oUT) \ } SUFFOLK COUNTY 9.4 ->- z U a ;> .50.3// '-`�a JYOOD CATWALX ® 2 / WOOD BULKHEAD '�x'f f (3.5-OUT) ® os82 a e� -----�� 0.z / � C4NOPYATOP n�D eq r ",tCONCJt£TE L1CHT'POLE� - �� SOOD STEPSm h /^~ / / /// bOOD DECK PAT/0 LANDING �. /.172nAPPROXIMATE - G11AVE�AREA WOOD _~�� ALL+ _-� / / S:�-" (ArAY 29,x2 LINE. 14.4 FENCE CONCRETE S6'4 W // / OOBJ 2� .: FOUNDATION-�- STORY � � q .q q �CQNCR E:, (UA'DEl RESTAURINT) � - �� `IO o ti FHlAlE. %, As,HALT -/?s. 9.5 l STORY p - BUII,DINC \ VEd / FRAd�E RUST / -FJcz �. i4.4 FF J2.7 GO.,9 /ii5.5�/ (SOUNDVIE! �� T' �� v OSD 57 FROPERTYOF �� o RC 26.0 • ROOFOVER FF 12.9 URANTJ a ry c SUFFOLK COUNTY q / R'oOFOVER'' 1 a DIRT . DAYW RG 2 �Y' , ?s, N o, RAISED CON"CRETE CONCRETE { o INDOFT B.8 / Q� y a WOOD DECK • �' (B.T.i4.5 E .� /23.5 o,/ (1.5-OUT) .AIYNIA,c - Q ) ASPHALT L�CTR/C:PAD c / 1 D.3xlD.8J RAYWIND v + `' s PAVEiIE (B.OxB.0) // // OW Is m c M NT; \/ CONCRETE•WALXl / / 157.Y (1.5-OUT) ABNINC ' 1 STORY (s.oxlo,B) a- BLOCIf vALL \ FRAME MOTEL o 1[A ' PAR )NCS LLS. I / / / v 1% 8. O T� A (loci e)-(Tyl GUARDRAIL 019. lf0 ) O.Q F \� f { / '9° CONCRETE:WgGKJY�fX ' . 40.00 CONCRETE !Ai ?, s Pa kr Y P 8.2S S.62'OD'OO"'. .' - PLANTER WITH S?GN - \ O ARKIN STALL 1.3 8.7.54. S 62°•00'00" ll u �� : (.OX12.0) (TYPl. 9.0S 0-FLAC 40. �• POLE HANDICAPPED 191.93 HYD _ . G.IS 4.OS PARKING STALLS' �' P /p C1D.OX17.,0)-(TYPICAL) ASPHALT o D.LI. PAVEMENT EDGE OF L'ONCRETE •� / / NORTH H d b OAD EDGE OF CONCRETE EDGE OF CONCRETE \� \�' MR.. 48) - (50, ]TIDE) EDGE OF CONCRETE OR UI✓�THORIZED 7VIS SURVEY IS S A VIOLATION OF ADDITIONRATION 'SLl7 .- /."=3O, - ��"s a6 �� os ��C NEW y_ _ SECTION 7209 OF THE NEr4ORK STATE j.� EDUCATION LAW. COPIES OF TRIS SURVEY DRAWN BY: R.K.H.� .t G," ' KAP NOT BEARING TRE LAND SURVEYORS - _ �� CPA LISA McQUILKIN SURVEY OF �v (NEED OR"BOSSED A SEAL ARE NOT FILE No.: Q131-08 �' G - LAND SURVEYING DESCRIBED PROPERTY � CONSIDERED S BE A TRUE VALID COPY. Ari - - DISTANCES SHOWN PROAf_PROPERTY DATE:E: 1!!AY 29, 2008. -_ � "IVES TO EXISTING STRUCTURES ARE _ �/ FOR A SPECIFIC PURPOSE AND USE.AND f - - AT ARSHAMOMOQUE - ARE NOT INTENDED TO GUIDE IN THE A ,. - ERECTION OF FENCES OR OTHER '� 274 EAST MAIN STREET TOWN OF SOUTHOLD STRUCTURES. LL RUN O THE -� EAST ISLIP, N.Y.. 11730 - SUFFOLK COUNTY, NEW YORK PERSON HEREON SHALL RUN ONLY TO THE AREA TO TIE LINES: - ® SCTM. 1000-044.00-02.00-018.0D9 PERSON POR WHOM THE.SURVEY IS q e�yy i PERPURED AND ON HIS BEHALF. TO TRE ti TEL: 6J 1-�G f!-3805 COMPANY OR AGENCIES LISTED HEREON -018.00: .10,472.10 Sq.FL=0.2404 ACRES 5 2'��' �'v� SCTM. 1000-044.00-02.00-020.00 ' AND TO TUS ASSIGNEES OF TIlE LENDING INSTITUTION. CERTIFICATIONS 020.00: 19,733.00 Sq.FL=0.4544 ACRES i '!s 5�� FAX: 631-277-3906 ARE NOT TRANSFERABLE TO ADDITIONAL p �a Pr[+ +� �` Z,�N IV rUTIOWS OR SUBSEQUENT OWNERS. riLE�ATIONO IN USC'I'G DATUM ' NORTH ROAD, ARSHAMOMOQUE ��f c,,,� �� t� �,�� z -i � � �� -. �.�w ,. g . .,. _ °e« .� ., ,� � � �. .k''r, -- ��a I � f e I v _ w r -2-, d mw fi m i ��„1 _ ��P �� -Z -(S� "� �� 1 V `� � -� z- ,+ .� . , _ . ,� �� li �� ..!II ,, W IJ rll(�;I', ��, �;� =.r.,, _.•;;,, {.�a_ a; 24 4 � � C � Z ODUNTY OF SUFF 0, 4 4 FOR NO w.w NO o �FFOLK ODUNTY OF SUF— IZ .48 41 K L SECTPON NO COUNTY OF SUFFOLK (21) Serwas Agency y JE Real Property Tax E OFFICE LOCATION: OF SO(/�y® SLING ADDRESS: Town Hall Annex h0 l0 P.O.Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd..&Youngs Ave.) Southold, NY 11971 G • Q Telephone: 631765-1938 �op ! ' CQWN 9� 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: May 4, 2022 Re: LWRP Coastal Consistency Review for RACHEL LEVIN SCTM# 1000-44-2-18 RACHEL LEVIN requests an Administrative Permit to replace existing fencing•which runs from north to south with approximately 65' of 4' high fencing (vinyl or metal); and to replace existing fencing which runs east to west on the south with 25' of 4' high fencing (vinyl or metal), and plant sea grass along fence (east) perimeter. Located: 58625 C.R. 48, Greenport. SCTM#: 1000-44-2- 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 Policy Standards and therefore is CONSISTENT with the LWRP.. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: The Honorable Lori M. Hulse, Attorney Maim Diane From: Rachel Murphy <viewrach@att.net> Sent: Friday,April 29, 2022 12:56 PM To: DiSalvo, Diane Subject: Southold town Administrative Permit. MURPHY COTTAGE Southold town Administrative Permit Rachel Levin Murphy 58625 CR 48 north road greenport NY 11944 SCTM :44-2-18 ADDITIONAL INFORMATION We propose to replace the existing fence with new fencing made of ether vinyl or metal that will stand up to the windy conditions. Below is a picture of what we propose .Although not exact, it is similar . We will replace the north to south fence on the east perimeter of the lot 65 'and also replace the fence that runs east to west along south permitter of lot around 25' Fence will be 4' high. I also plan on planting more sea grass along the perimeter of the fence on the east side for aesthetic purposes . Thank you Rachel iPad ATTENTION:This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. Glenn Goldsmith,President *®F S®�/�� Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ,�®�, ' ®�® P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly cpTelephone(631) 765-1892 Elizabeth Peeples COU D BOARD OF TOWN TRUSTEES APR 2 6 TOWN OF SOUTHOLD This Section For Office Use Only ' .- Board of Trustees Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extension Received Application: `�•2�•2� Received Fee: $ 100- Completed Application: •?1�-yam' Incomplete: SEQRA Classification: Type I Type 11 Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: ,Coordination:(date sent): ✓✓ LWRP Consistency Assessment Form Sent: ECAC Referral Sent: ,/Date of Inspection: Receipt of CAC Report: echnical Review: Public Hearing Held: •/g�Z� Resolution: . R Owner(s) Legal Name of Property (as shown on Deed): w Mailing Address: Phone Number: �Lle— Il Suffolk County Tax Map Number: 1000 - 3 -`� Ll Property Location: a •(If necessary, provide LILCO Pole #, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Email: �j Board of Trustees Applica� n } � GENERAL DATA ��cc�� $0 Land Area(in square feet): �U Area Zoning: 2r V "R�I(' Previous use of property: sec�sc Intended use of property: C, Covenants and Restrictions on property? Yes No If"Yes", please provide a copy. \ Will this project require a Building Permit as per Town Code? Yes No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes �No If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure (s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency N Date ,� No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No' Yes If yes, provide explanation: Project Description(use attachments if necessary): ICk (CC 0 4-f CA57A Ar- 3oard of Trustees Applicat. n WETLAND/TRUSTEE LANDS APPLICATION DATA g Purpose of the proposed operations: ., . .+ y Area of wetlands on lot: square feet Percent coverage of lot: % C Closest distance between nearest existing structure and upland edge of wetlands: - feet Closest distance between nearest proposed structure and upland edge of wetlands: \ feet Does the project involve excavation onfilling? No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? D cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: 6($ Manner in which material will be removed or deposited: 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): 61Z20 Appendix B Short Environmental Assessment Form Instructions for Completing Part I -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 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part.1 -Project and Sponsor Information Name of Action or Project: Cfa C2 (if rM Fri Project Location(des rite,and attach a location map): R. U1,r' 6S d r_ Nf r+tV Ro D off. 61 T i(4'1� Brief Description of Proposed Ac ion: ig Name of Applicant or Sponsor: Telephone: R RMkIr � LPN IT\( E-Mail: Address: 101Q0 1 J� City/PO: State: Zip Code: _:S .9 .-) I 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: c El o,6& 0�� '�@�8 3.a.Total acreage of the site of the proposed action? ��acres b.Total acreage to be physically disturbed? F acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? o ��' acres 4. Check all land uses th occur on,adjoining and near the proposed action. ❑Urban [�Rural(non-agriculture) ❑Industrial [CCommercial ❑Residential(suburban) ❑Forest ❑Agriculture El Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 r � f 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ 9 ❑ 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? W ❑ 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 V1 I El b.Are public transportation service(s)available at or near the site of the proposed action? ® F-1- c. 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: El 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: ® ❑ 12_ a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? F'-1 ❑ b.Is the proposed action located in an archeological sensitive area? ❑ ❑ I3.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? ® ❑ 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: Shoreline ❑Forest ❑Agricultural/grasslands ❑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? Y ❑ 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 ❑YES ® ❑ b. Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO ❑YES Page 2 of 4 a 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: FKA ❑ 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: L� ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE t iitt I 110 Applicant/sponsornarne: �j � ! �'U� U� Date: .16 Signature: Q Cine( t J tv' V 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 11regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? D E 3. Will the proposed action impair the character or quality of the existing community? F11 El 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑ establishment of a Critical Environmental Area(CEA)? ,D 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? 7. Will the proposed action impact existing: ❑ ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? D 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, ❑ Elwaterbodies,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 El ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? 1:11 E 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. ElCheck 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 Applicaf_ �n AFFIDAVIT BEING DULY SWORN DEPOS S AND AFFIRMS THAT E/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. 6VPM lhj�4,�. gnature of VroeAy Owner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF RSL , 20 _ 2Z Not Public DIANE DISALVO N�'��ov OUSLIC•STATE OF NEW YORK f@-, 010106693 l6yuMf*q� 4q%%mft c c®uunfty APPLICANUAGENUREPRESENTATIVE 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: l�Af n `� U I V-\ :::(:Last name,first name,sliiddle initial,unless you Af applyi'rng to the name of someone else or other entity,such as a company.If so,indicate.theother 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 t (If"Other',name the activity.) Tg Ga ��r vx\l`� 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 this day of 200 Signature f Print Name Form TS 1 y Towd 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 SCTM#— - - PROJECT NAME P 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: V p ffLocation of action: 0 Site acreage: Present land use: Present zoning classification: R�' t, . t ^(, 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: VF(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 ❑ NoN 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. ❑Yes ❑ No ® Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LVDP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No P 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 LTJ 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 Section III—Policies Pages 8 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 through 21 for evaluation criteria ❑ Yes ❑ No h!Pl 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 IH—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 [:] No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III--Policies; Pages 38 through 46 for evaluation criteria. ❑ Ye�] No Not Applicable Attach additional sheets if necessary WGRE ING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III.—Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No 4 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 LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ 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 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 PREPARED BY �J\?,[�CdkA +� TITLE O l�C °�r DATE ao 7_