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Home My WebLink AboutTR-10135A Glenn Goldsmith, President Z� s®�/�� Town Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25P.O. Box 1179 Eric Sepenoski Y Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples �® Fax(631) 765-6641 C®U �� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction,'hay bale line/silt boom/silt curtain 1St day of construction % constructed When project complete, call for compliance inspection; Glenn Goldsmith,President �®� so Town Hall Annex A. Nicholas Krupski,Vice President ®V� ®r® P.O. Route 25 r2, P.O. Box 1179 � Eric Sepenoski ` 7 Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples �® Fax(631) 765-6641 r®U ,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10135A Date of Receipt of Application: April 7, 2022 Applicant: Schoensang Properties LLC SCTM#: 1000-34-5-17 Project Location: 700 Robinson Road, Greenport Date of Resolution/Issuance: May 18, 2022 Date of Expiration: May 18, 2024 Reviewed by: Eric Sepenoski, Trustee Project Description: Trench a line to install new electric line from pole to pole; install electric panel. 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 Joseph Schoenstein, received on April 7, 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. ,6&1 4" Glenn Goldsmith, President Board of Trustees SURVEY OF PROPERTY SITUATE GREENPORT TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-34-05-17 SCALE 1"=20' CJ SEPTEMBER 9, 2021 > AREA= 12.568 aq.N. (10 ilE lL1E) 0.289 ae. 35tio. ® rSRTIF7SD T0: (�� S S�•1.50� 1` �'n ® EVANGELOS GERASIMOU ` ADVOCATES ABSTRACT, Inc. MATTTNCK ASSETS LLC m 1 j ® m r W ArOTES: m _gyp 1.ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM "� EXISTING ELEVATIONS ARE SHOWN THUS:Xx N/1°re�xTTC `ora EXISTING CONTOUR LINES ARE SHOWN THUS:--——-X-——- or s DOS NTO DN$N 1 ® 125.51 5�T •16 T. ® 2. FLOOD ZONE TAKEN FROM:FLOOD IINSURANCERMATION RATE MAP No.36103CO176 H ZONE AE:ZONE X: AAPFAS DETERMINEDD TOO BEOETERMINED OUTSIDE THE 0.2%ANNUAL CHANCE FLOODPLAIN. FLOOD ELEVAMONS 00 \ '� . rA 7g 15 p0 T I \ i 4" vl J \ .o o, CL I '� 'L.9\II ,y �; \ I • I \ hi CMV m O EL ®j ml I �_ � �\ \ I � • �: vmciAm a A¢V¢WAZ WrN ra wrwar gg alAbbi✓ol ran mlc mmol w mKvwm R w n¢IJA61 N°irrPmSD AIO AaaPl® 79•p0.00^•W��• ,Ty. �\ ` I to mro`ii"a us Or M ma scae wa G ^r1£ Ely}•. • ..JII, it 4 ' 95.92' ��) PIRCINl1 6ROSd' � (� ',' `,�+ A• c�� /! 7 IAAJ,,O N.Y.%Lk.No.56107 3 Nathan Taft Corwin W —p - �� Land Surveyor A NP16 K iN4 WMl WP MT IFI.RAG �va MEW°&W�SWMB PYID 4K Q J lIDb44D:NAL Hw1 Aar R s—i—Ta SL J.=1 Jr.m •'ll ` (��' `/ p 10 BL Avll°1RUE ftVf. Jpeepl�A SR.Pk l.S sb rano- cmnrnd'a,Igwrt '-1 �-^ �• nwr ro ra van wx�nw m swnv run smrys- NV 1 �?• cZ�\\� ,rtl�mlo' �, r Tm(CJI)m16 fir Inaou oc+numi us!m Nvuw.xo PxoxE(67W 7-2076 ' 9 1 � ro 11R AsriNks a TI1[!fMva Ptm- Of15MS t..R Al W41NC FMFLSS 0 y ` lal°IL Ga°uAiCta w2 rwr litlN�3YA�IDL PA.ew,, 1586 IAYn Pond J--p,l,Na.Ym4 11!147 dl 716'. OI p{811T 0(WAl3 JanwPorf.Ne+YaM 71817 �r�^a \1I�` lam` AMD 08 xAssao115 of R[fDAO.W E-� payer may+ " , �;J .M6f 9!OWM Yd NOT WA8/f6QD• Glenn Golds[ President ��SUfFat. " Town Hall Annex A Nicholas Krupski' vice-President �� y� 54375 Route 25 Eric Sepenoski o - P.O. Box 1179 Liz Gillooly Southold, NY 11971 Elizabeth Peeples ®y'jfp® �a� Telephone 631 765 6641-1892 Fax BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 2 L&2 zaz- Completed in field by: �&o „fir SCHOENSANG PROPERTIES LLC requests an Administrative Permit to trench a line to install new electric line from pole to pole; install electric panel. Located: 700 Robinson Road, Greenport. SCTM#: 1000-34-5-17 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 X 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: have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: E. Peeples L. Gillooly G. Goldsmith N. Krupski E. Sepenoski Other SURVEY OF PROPERTY SITUATE GREENPORT _{ TOWN OF SOUTHOLD �c7 �rp (�ryrye� SUFFOLK COUNTY, NEW YORK Q �� r�j APR as ° 2022 S.C. TAX No. 11"=20' -05-17 SCALE 1"=20.' t� SEPTEMBER 9, 2021 AREA= 12,568 aq.H. (4�� Southold Town (TO 1X Ing 0.2899 c. 1� .4 Board of Trustees •(pa• 35R.�, `� MTIFMV T0: ("`'�• 5 ,iyo� •� EVANGELOS GERASIMOU �l ADVOCATES ABSTRACT, Inc. a MATTTTUCK ASSETS LLC s . s. NOTES: !� 1. ELEVATIONS ARE REFERENCED TO NA.V.D. 1988 DATUM �P EXISTING ELEVATIONS ARE SHOWN THUS:ar NI/FRT1CCHofA mJ" EXISTING CONTOUR LINES ARE SHOWN THUS:————x———— AI�CNA ONTO Ds 0 FA 6• E Ee - ror IN euRMA Y SPO 50" 2. FLOOD ZONE INFORMATION TAKEN FROM: ��71TS� � �'L5.51• .r'dP 5 13 ti FLOOD INSURANCE RATE MAP No.3610300176 H Zg 63' ZONE AE: BASE FLOOD ELEVATIONS DETERMINED �� 1 • ZONE X: AREAS DETERMINED TO 8E OUTSIDE THE O.ZR ANNUAL CHANCE FLOODPWN. \ 1 \ Uo. -7g15p0� / I LP 1 �' ' Q� 'Y q �\• `\` 9 1 I WI� 1 Y � •�.P3\il � 1 f �" h�"II. N � \\ I T^T I Q o ,o.o\ m.a to .Y �� \ I 100 . �• NdP,1PD7 a •,IN 79 -20- \ 1 / O, g u.•u uu.wwwsn„n.nw,m p � N 20u r {TYb W ,Ty. 1rT�Or rtEiy} T< ss.sz• V/RGINJN,q/r4ftos' (,I, • X11 <Arti)fU / N.S.Dc No.6SM67 Nathan Taft Corwin 111 �. G� �• °"�' Land Surveyor -. osier rc tw c.msY Naa Nor asNam as wo nmvortsre oa®�a _ in�w wan rmK mn = Suter Ta A y9•To L5.'� ,/ ' Is& wmWm NWdI vWL kul c�py"_ p,yh lk-(ywR V_ vv®ox Im wwu TMc mmn rte•Sar•Y•- "- I O 'HONE(B31)727-2090 'Fm(8Jt)727-=MkV=ADDR=YNrt nwCJWmL M GI5 1DGiID A70. 15M Mmo Raatl PA H. 18 THE OF n9Hr Oi WAYS J,,,.V ,Hn Yak 119Q ^�•N°•Ye,k 119{7 - 5- FEmRO'V E-Y t W.A a0mlmm 3 .NOf s10WN Am NOT OUAYAM®. Roselle From: Joseph Schoenstein <joesjunk53@aol.com> Sent: Thursday, April 07, 2022 3:15 PM To: Roselle i s, r r. •f�f ! wr 2� k f r �4 y� Sent from my Whone i t.a o, s m a f a \ COUNTY OF SUFFOLK v� N+' �r q!•M \ ung �� \♦ 1� ,� °+1, d� �.%�, ,a, VA _ \\ " \ s�w� \\. \\ �+ '�V' \f\�`�,F ` ^' �i�� +.o,;�\�\��CC o`•� y)' '�y'Yfgp• '¢ ?9, 5` t \ '+ / \/�� \��G" `Y� F• \.`\\�\la'\ � \,QF. SO q,, iONN OFSgI? p ' ,� r✓�+i � � "su+ g��, �H<R�\a+"y`�`�Y'�' �'. �k��+a � ��3 �.�� C��</r ,y " t �� .' S�. r \.° S`V`\ o- \3 �r r RAF yo" SUFFOLK " "arCEAgh :.. " 034 ° .�---'-- - --"'-- "' ---- w.... tzt) � .,r m�n.�a w-rtw� ate- � y ""°, •ountoyn -___- WTpR NnRld P8Wi6b1 1K. A 8 �Tr iAa BNrF rc3fH. P �� a OFFICE LOCATION: ��®E SOUr�® MAILING ADDRESS: Town Hall Annex ,`® l® P.O. Box 1179 54375 State Route 25 JIL Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) Mir IF Southold, NY 11971 ® Telephone: 631 765-1938 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator .Date: May 4, 2022 " Re: LWRP Coastal Consistency Review for SCHOENSANG PROPERTIES LLC SCTM# 1000-34-5-17 SCHOENSANG PROPERTIES LLC requests an Administrative Permit to trench a line to install new electric line from pole to pole; install electric panel. Located: 700 Robinson Road, Greenport. SCTM#: 1000-34-5-17 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 EXEMPT from LWRP Coastal Consistency Review. 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 Glenn Goldsmith,Presidentl�� Town Hall Annex ex{r k 54375 Route 25 A.Nicholas Krupski,Vice President , P.O.Box 1179 Eric Sepenoski3 ,, ,,' Southold,New York 11971 Liz Gillooly _ . Telephone(631)765-1892 Elizabeth Peeples Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Onl ECEIVE Coastal Erosion Permit Application D Wetland Permit Application _Administrative Permit "APR *w 7 2022 �/ Amendment/Transfer/Extensiion _Received Application: - 7•TZZ 7zReceived Fee;$ �o�. ggrdof mt `/ BoardofTnrstees - �^ Completed Application:�•� •�i Incomplete: SEQRA Classification: Type I Type 11- Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: oordination:(date sent):7_1 - �WRP Consistency Assessment Form Sent: AC Referral Sent: , ate of Inspection: Receipt of CAC Report: _technical Review: _ - 4/Public Hearing Held: Resolution: Owner(s)Legal Name of Property(as shown ori Deed): d%O'P Mailing Address: Phone Number: j— `7� � /�� Suffolk County Tax Map Number: 1000- Property 000 Property Location: LT ✓V-. (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Email:. _" _ aoard of Trustees Application GENERAL DATA Land Area(in square feet): g Area Zoning: C®*m'e* CV`s Previous use of property: oe 5/� 0CAe- r4 or Intended use of property:c 65;e— p; = 0 ' Covenants and Restrictions on property? Yes o If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes t----`0No 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 Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? Yes If yes,provide explanation: Project Description(use attachments if necessary): �- � Cp ow i — '� —re�ntc�f Gc LF io board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: d Jai ' A k __ 0 Area of wetlands on lot: /. square feetre� Percent coverage of lot: ? % Closest distance between nearest existing structure and upland edge of wetlands: 1V6 feet Closest distance between nearest proposed structure and upland edge of wetlands: /VD feet Does the project involve excavation or filling? �� No Yes If yes,how much material will be excavated? N40Gt/C- cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: /00/,04!!- feet Proposed slope throughout the area of operations: �, - 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): ewe 617.20 Appendix B Short Environmental Assessment Form Instructions for Con»ictinsY Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 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 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 attach a location map): Brief Description of Proposed Action e may` X4. ' > -� /L'e'i• - � - - Name of Applicant or Sponsor-.' Telephone: 121 3 3_&V-;,��'/ '� ® d�� dot"1� f - E-Mail: Address: _ City/PO: State. Zip Code: �� A 00� 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 U F]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: a 3.a.Total acreage of the site of the proposed action? _® - acres b.Total acreage to be physically disturbed? 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 ®l(fommercial 9idential(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? 1:16. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? I _ ❑ 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 I F1 b.Are public transportation service(s)available at or near the site of the proposed action? ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? Pei ❑ 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:� )'G.,/, �to'� ��/ *4 ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment:_T��- FL ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ❑ b.Is the proposed action located in an archeological sensitive area? ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? i1� If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: P1 El 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 P ES by the State or Federal government as threatened or endangered? 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO Y S If Yes, a.Will storm water discharges flow to adjacent properties? NO []YES ❑ b.Will storm water discharges be directed to established conveyance systems(runpfFand storm drains)? If Yes,briefly describe: NO YES Page 2 of 4 t 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: Er LI 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/spon . name: Date: Signat Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning � ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? Er ❑ 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the El of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or j ,��/ ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate j—�� ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a a.public/private water supplies? b.public/private wastewater treatment utilities? S. Will the proposed action impair the character or quality of important historic,archaeological, architectural or aesthetic resources? Eg/ E] 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, (-,�r 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 � Elproblems? 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 Application AFFIDAVIT BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS-CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. ; r Signa of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS L44 DAY OF C..JI Notar blic BRITTANY A CONRAD Notary Public,State of New York Reg.No.01C06245154 Qualified in Suffolk County Commission Expires July 16,20_ i APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORINT The Town ofSouthold'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 aleft the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAMEr.G��s (Last name,first name,.qtiddle initial,unless you are applying m�the name of someone else or other entity,such as a company.If so,indicate thb other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other,name the activity.) Do you personally(or through your,company,spouse,sibling,paren4 or-child)have a relationship with any officer or.employm of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."T3usiness interest"means a businc ss; including a partnership,in which the town office=r or employee has even a partial oNvaiship 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 t, Print Name Form TS I Town of Southold �— LWRP CONSISTENCE'ASSESSMENT FORM A. INSTRUCTIONS I. 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 siwiificant beneficial and adverse effects upon the coastal area which includes all of Southold Tow',n . 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- sannportin-,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 s 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: n Nature and extent of action: 1 i Location of action: Site acreage: Present land use: Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing address: (c) Telephone number:Area Code (d) Application number,if any; Will theaction be directly undertaken,require Rmding,or approval by a state or federal agency? Yes n No 10"�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 Rest Management Practices that will further each policy. Incoammplete answers will,require that the foram 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, remakes beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ leo Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Towyn of Southold. See LWRP Section III—Polici Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria 117 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 LSP Section III—Policies Pages S through 16 for evaluation criteria ❑ Yes ❑ No R Not Applicable Attach additional sheets if necessary Policy S. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria F1Yes 1:1No 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 ffi—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 LSP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ Noof Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LSP Section LII—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes 1:1No I_f Not Applicable PUBLIC COAST POLICIES Policy g. Provide for public access to, and recreational use of, coastal waters, public Iands, and public resources of the Town of Southold. See LWRP Section III—Policies;Pages 38 through 46 for evaluation criteria. ❑ 'fie❑ No 2 N®t Applicable Attach additional sheets if necessary � h WOREI:NG COAST POLICli�s Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LVVRP Section III--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 bong Island Sound, the Peconic Estuary and Town waters. See L�IVIIP Section M—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes 11No �=-I Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LVVRP 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 LVV ZP Section III—Poli65 through 68 for evaluation criteria. ❑ Yes ❑ No,-;z Applicable PREPARED BY e� �' 1 TITLE Com- DATE