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HomeMy WebLinkAboutTR-10159A Glenn Goldsmith,President ® so Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ®� ®�� P.O. Box 1179 Eric Sepenoski l Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples �y® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1954C Date: August 31, 2022 THIS CERTIFIES that the installation of a 6' high approximately 83' long PVC fence along the easterly property line running north-,tapering to a 4' high approximately 24' long PVC fence toward street; At 2425 Mill Creek Drive, Southold Suffolk County Tax Map#1000-51-6-40 Conforms to the application for a Trustees Permit heretofore filed in this office Dated May 23, 2022 pursuant to which Trustees Administrative Permit# 10159A Dated June 15, 2022,was issued and conforms to all the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for installation of a 6' high approximately 83' long PVC fence along the easterly property line running north; tapering to a 4' high approximately 24' long PVC fence toward street; The certificate is issued to Andrew E. &Linda M. Toga owner of the aforesaid property. a Authorized Signature Glenn Goldsmith, President � �3 S � Town Hall Annex 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: h, I I 2Z INSPECTED BY: Y Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1st day of construction '/2 constructed Project complete, compliance inspection COMMENTS: CA 0av" Q1_C C o 1-01f o V1 C4\ CERTIFICATE OF COMPLIANCE: Qk AD 'S5V-e . Glenn Goldsmith, President Q� soU�® Town Hall Annex A. Nicholas Krupski, Vice President �® {� 54375 Route 25 P.O. Box 1179 Eric Sepenoski i,F Southold, New York 11971 Liz Gillooly Elizabeth Peeples 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 COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 It day of construction % constructed When project complete, call for compliance inspection; Glenn Goldsmith,President �rg s®�/�� Town Hall Annex A. Nicholas Krupski,Vice President ,,�®� ®�® 54375 Route 25 P.O. Box 1179 Eric Se i 3 3 Southold, New York 11971 Liz Gillll0000ly ly Elizabeth Peeples Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10169A Date of Receipt of Application: May 23, 2022 Applicant: Andrew E. & Linda M. Toga SCTM#: 1000-51-6-40 Project Location: 2425 Mill Creek Drive, Southold Date of Resolution/Issuance: June 15, 2022 Date of Expiration: June 15, 2024 Reviewed by: Liz Gillooly, Trustee Project Description: Install a 6' high approximately 83' long PVC fence along the easterly property line running north; tapering to a 4' high approximately 24' long PVC fence toward street. 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 survey prepared by Lisa McQuilkin, Land Surveying, last dated March 22, 2022, and stamped approved on June 15, 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. Glenn Goldsmith, President Board of Trustees TEST HOLE BY: 1G rDA cDONALD GEOSCIENCE APPROXIMATE LOCATION �tA °pyop0 TE: APRIL 10, 2017 OF WELL HEAD �,p8•pOYY „ o�c�"y°c EL 0.0 SM BROWN SILTY SAND. RY SYSTEM EL.-7.0 NOT LOCATABLE. / 9 (� Sir BROWN FINE TO COARSE SAND. C pp Op` g1 I u -9.4 1! ��iFPALE K41p� ,�° oEp � � FINE TOWATER NCOARSEBSAND. 11L�¢ Y�� YpVE�YK EL-17.0 �1 o (� WATER ENCOUNTERED III .� 0 M 56 ✓ 9.4ft_ BELOW SURFACE ALL � N l� o � I I Imo/ ��g0.0 ho• a pN. -- _ - --- II W[RE - �e� e� \f APPROVED BY �- No:l 1\1130 "� 5o L °r INLET\ o BOARD OF 'i �USTEES ELECTRIC ��A o f I 91 g5'z ETER WALL Ww TOWN OF SO! "'HOLD UNDERGROUND C\2 A PROPANE TANK �+i�IDATE Tvu6 /r Zoz�Z, DWELLING TELL WATER - W I I CONCRETE `f 1000-051.00-080-039.000 I RETAINIHALING DAYN LAND NOW FORMERLY I TH cl I � I G� I is r 1 9��• LEACHING INo.-2 I / /pti GALLEYS cli t90fG 12 �a tib' �� \ DISTRIBUTION ,tip APPROXIMATE LOCATION o ' SITYDRO-ACTION BOX OF WELL.HEAD/N, 1t39 5 AN-400 t l�O \ I _.. ► LI SIS '1N1t l_ �'R //`ry� titin IBI SEP71C SAI 27.4 \ FRAME ( /1ti (q l / 4 I R I / ELECTRIC CONCRETE 4 9 SHED - -I—f t w' COVER o : APRON I III I 1 a SUNROOM GARAGE — f •('t39. GF 13.0 - i 5.7 APPROXIMATE LOCATION SANITARY 1 -—— 123 5 OF SANITARY SYSTEM 5w�� yo , 7.Oi 3 I o tazfc MEASUREMENTS ;CELLAR ROOFOVER " j � V � �pl1 ENTRY MASONRY 4:1 ;�� / �0�5I 5.8x8.3 PORCH WELL fAl 21,5 16] HEAD HYDRO-ACTION AN 400 2.5 Cnu,lii� i ancrrF TWO STORY � FRAME DWELLING N ti 0DECK 11 ' FF G 42.4 cl- No: 2425 LEACHING GAUZY No.2 27.0 29.5 TEACHING GAUZY No-3137.0 39.5 10/J 17.3 o (�. �3' SANITARY INFORMATION: C\2 (DESIGNED BY JOSEPH FISCHETTI, P.E) 12 •(1) HYDRO-ACTION AN-400. I I I I I I `tib -�- -`"— — 'C 10 •(1) 4'0"DIAMETER DISTRIBUTION BOX. _ 8 •(3) LEACHING GALLEYS N 8x4 x4 DEEP. WOODZ I ILII I�I PIdCc \ \ \ TE STEPSSTEPS AND— No•4 ��-8--- = LANDINGS—ELK 13.1 NN S 0°20'16'''�W CALCULATED— 117.44 �°' (120±—DEED) ARSHAMOMAQUE POND (LONG CREEK) — (UNDERWATER LAND) 5* FLOATING WOOD DOCK METAL RAMP 20.0x0.0 2.7x12.3DOCK DOCK Vii,, , i; I f48 9S ±50.1S NOTES: r •SANITARY INFORMATION & LOCATIONS AS PER CLEAR RIVER ENVIRONMENTAL, DATED DECEMBER 01, 2021. f�' ECE •EXISTENCE OF ANY EASEMENTS SHOULD BE VERIFIED BY A COMPLETE TITLE SEARCH. •EXISTING WELL LOCATION PROVIDED BY HOMEOWNER. •SANITARY LOCATIONS & WELL LOCATIONS FOR ALL THE SURROUNDING BAY 2 3 ?022 • DWELLINGS ARE AS PER OLD SURVEYS, FIELD LOCATIONS AND AS PER OTHERS. •SURVEYOR IS NOT RESPONSIBLE FOR UNDERGROUND UTILITIES OR STRUCTURES. SoL"I�td wwn APPLICANT-OWNERS: DRAWING INFORMATION: �' rwstees ANDREW E. TOGA & LINDA M. TOGA SCALE: 1"=30' DRAWN BY: R.K.H. PROPERTY INFORMATION: FILE No.: Q199-11 DATE: JUNE 16, 2011 a AREA TO DEED LINES: 20,899.08± Sq.Ft.=0.48± AC. UPDATED: APRIL 12, 2017o� LISA McQUILKIN ELEVATIONS IN NAVD88 FOUNDATION LOCATION: MAY 3, 2021 60 P� H G'M`QG FINAL: MARCH 22, 2022 vti + LAND SURVEYING SURVEY OF "' — DESCRIBED PROPERTY r� 274 EAST MAIN STREET AT SOUTHOLD, TOWN OF SOUTHOLD, l' �' EAST ISLIP, N.Y. 11730 SUFFOLK COUNTY, NEW YORK 05pz11 A TEL:- 631-277-3605 SCTM: 1000-051.00-06.00-040.000 SU��� FAX: 631-277-3906 o UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7208 OF THE NEW YORK STATE EDUCATION LAW,COPIES OF THIS SURVEY YAP NOT BEARING THE LAND SURVEYORS INKED OR EMBOSSED SEAL ARE NOT CONSIDERED TO BE A TRUE VAUD COPY.DISTANCES SHOWN FROM PROPERTY LINES TO EXISTING STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE,AND ARE NOT INTENDED TO GUIDE IN THE ERECTION OF FENCES OR OTHER STRUCTURES.CERTIFICATION INDICTED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF,TO THE COMPANY OR AGENCIES LISTED HEREON AND TO THE ASSIGNEES Of THE IENDING INSTITUTION.CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT OWNERS. 2425 MILL CREEK DRIVE, SOUTHOLD Glenn Goldsmith,President O��S�FFOI;,CG Town Hall Annex A.Nicholas Krupski,Vice Presidenty''e 54375 Route 25 Eric Sepenoski ,? P.O.Box 1179 Liz Gillooly �� • O�� Southold,NY 11971 Elizabeth Peeples ��� r Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 2'L Completed in field by: L. 61 ANDREW E. & LINDA M. TOGA requests an Administrative Permit to install a 6' high approximately 83' long PVC fence along the easterly property line running north; tapering to a 4' high approximately 24' long PVC fence toward street. Located: 2425 Mill Creek Drive, Southold. SCTM#: 1000-51-6-40 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: X_Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No � Not Applicable Info needed/Modifications/Conditions/Etc.: 42, 6 /a r' A ?N Q Y ik Ct "$ �- j vj eW Lj ojdy Present Were: G. Goldsmith N. Krupski E. Sepenoski X L. Gillooly E. Peeples TEST HOLE BY: McDONALD GEOSCIENCE APPROXIMATE LOCATION 5.00o DATE: APRIL 10, 2017 OF WELL HEAD pg 40 �EgLY �� BL 0.0 I SM BROWN SILTY SAND. 114f11'4 SANITARY SYSTEM m - EL-7.0 V��cw O� NOT LOCATABLE. BI(� SW BROWN FINE TO ,� COARSE SAND.-I p0�oog ON 1 us, EL-9.4 ROWN FINE TOWATER NCOARSEPALE LE BSAND. Nara �1js EL-17.0 siBeiU"'$ACE4f W SURFACE� ICgE� loE) ti �1L III �5ott• �, °• EIDl I I °° .0 loo 0 oto WIRE��40��� -- 0 No:l 11113 5` �O cb 43 ELECTRIC DRAIN C METER WALL \C\2 W / 91• UNDERGROUND �2 A C\2 -b/ PROPANE TANK q j-H I ! 10 %. l ! n I1 1 1 41 I °ti r° DWELLING 1 CONCRETE s � WELL WATER W 1000-051.00-06,00-039.000 Aco I `yti I RETAINANING LAND NOW OR FORMERLY eP ti Am DAVID k MARILYN FUHRMANN 1 I Cal;� II m i 9 la Fly. 1 I LEACHING No-2 I ' /0ti `�� L GALLEYS I ° r- cb % 0lb -12 DISTRIBUTION titin APPROXIMATE LOCATION 7r -ACTION �� OF WELL HUD 1f390 5 y AN-400 1 f \ I -` 7 �1 � �S�. t'�C-'•�'r'l�!'-L- . 1 ti� [ ] 22.H ( l 27.4\ 5.6 ,I B SEPTIC A \ N FRAME 1 ¢ ° / ELECTRIC CONCRETE ��� SHED COVER a APRON 4.9 x I I 11 I� GARAGE " f JNROOM �4 No:3 ti I I f' I GF 13.0 --� 5.7 I APPROXIMATE LOCATION f39'1 --- 123.5 OF SANITARY SYSTEM SANITARY w � 7ceLIaR RooForea 3^ t9uc MEASUREMENTS 30 f ENTRY MASONRY 1 ISI 5.8:8.3 PORCH ` j r WELL [A] [B] d �Illlil71111��Illi ` d � HYDRO-ACTION AN-400 21.5 16.0 G ^TPIst nN I.Af ;COuw)srrE� TWO STORY ^;•, PFf .�:• ..,.;7 2,..,. DecK q,l ' FRAME DWELLING" �'' ' LEACHING GLUEY No.t o:! ,r 4-. N // 1 25.5 35.0 FF 17.4-RG 42.4 (,p No: 2425 LEACHING ceuEY No.2 11 27.0 29.5 I I I g i�IiOOj�iI II Ali IIIi'�i ! LEACHING GALLEY No 3 .... 114.8 17.3 I 37.0 39.5 � �. �'� ° SANITARY INFORMATION: �, 1 9ti m (DESIGNED BY JOSEPH FISCHETTI, P.E) �i 1 1 I I If 1 ,� I `fes ati� 0 12 •(1) HYDRO-ACTION AN-400. 10 •(1) 4 0 DIAMETER DISTRIBUTION BOX . • (3) LEACHING GALLEYS N 8x4 x4 DEEP. II I II WOOD\ COMPOSITE - - - - - - - �_8-�- p{� \ STEPS STEPS AND- Ea _ - _ , NoA° �\ = LANDINGS- 0• 2.--- 13.It _� ' CALCULATED- 117.44 No:7 2016�`YLr (120±-DEED) -ARSHAMOMAQUE POND- (LONG CREEK) - (UNDERWATER LAND) �j r FLOATING WOOD DOCK METAL RAMP 11 20.Ox8.0 2.7x12.a -DOCK DOCK-. t46.9S t50AS NOTES: •SANITARY INFORMATION & LOCATIONS AS PER CLEAR RIVER ENVIRONMENTAL, DATED DECEMBER 01, 2021. C' E 4� • EXISTENCE OF ANY EASEMENTS SHOULD BE VERIFIED BY A COMPLETE TITLE SEARCH. I • EXISTING WELL LOCATION PROVIDED BY HOMEOWNER. •SANITARY LOCATIONS & 'WELL LOCATIONS FOR ALL THE SURROUNDING NAY Z 3 ?�� • DWELLINGS ARE AS PER OLD SURVEYS, FIELD LOCATIONS AND AS PER OTHERS. •SURVEYOR IS NOT RESPONSIBLE FOR UNDERGROUND UTILITIES OR STRUCTURES. '" Id'Tcwn APPLICANT-OWNERS: DRAWING INFORMATION: ANDREW E. TOGA & LINDA M. TOGA SCALE: 1"=30' DRAWN BY: R.K.H. PROPERTY INFORMATION: FILE No.: Q199-11 DATE: JUNE 16, 2011 AREA TO DEED LINES: 20,899.08± Sq.FL=0.48± AC. UPDATED: APRIL 12, 2017 - 1 ELEVATIONS IN NAVD88 FOUNDATION LOCATION: MAY 3, 2021 `G M`Q� �� LISA McQUILMN FINAL- MARCH 22, 2022 �� + LAND SURVEYING SURVEY OF DESCRIBED PROPERTY 274 EAST MAIN STREET AT SOUTHOLD, TOWN OF SOUTHOLD, ;.;�; vo EAST ISLIP, N.Y. 11730 SUFFOLK COUNTY, NEW YORK osozl' A° TEL: 631-277-3605 SCTM: 1000-051.00-06.00-040.000 LAND FAX: 631-277-3906 UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAT.COPIES OF THIS SURVEY YAP NOT BEARING THE LAND SURVEYORS INKED OR EMBOSSED SEAL ARE NOT CONSIDERED TO BE A TRUE VALID COPY.DISTANCES SHOWN FROM PROPERTY TINES TO E%ISTING STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE,AND ARE NOT INTENDED TO GUIDE IN THE ERECCLON OF FENCU OB OTHER STRUCTURES.CERTIFICATION INDICTED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF,TO THE COMPANY OR AGENCIES LISTED HEREON AND TO THE ASSIGNEES OF THE LENDING INSTITUTION.CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT OWNERS. 2425 MILL CREEK DRIVE, SOUTHOLD (No subject) linda Imtogalaw.com <linda@lmtogalaw.com> To: linda Imtogalaw.com <linda@lmtogalaw.com> S 4 � n r Ll ' 1j U Al •�-� � �♦'� fit. _1 t , 1 1 �w PA ,� ►� ' Som -�o wjX jQ JA X12 U 1 r OJ ���� �,�-• — . �� I �.,) `i'lam(.. f �•� L V V 4,-A P,�,t Il 1 1. 1 �;o ►� 1 ; j RV.� r • Z I ZZ d1 QUO( A oi- 10 Rig ,,.w �� I r ;,04 - � t r "lt / { �u .i,t�'AY�1r c t ��t xxr ,sae nee oTa]m ,eax l;g 5a6 x a, SOUND +ea ae a+ae mm sEE 10 ISLAND ae-Dale Q.� aen-n G• 4 x.sA LOP \ w. jr 14 m.t s L.D 43 P.D 10 b w v `° +aA1d, :t•- ® �. 1H' c a 1J ] ax.� as 1 w ee s s b *.,D \ SCH.D.5 �d+c aff s¢c.w.,s yy S b ;�,� ,a lt5 at9 _ J, r�,e! ,�<' ,1yyc1 ,Vl< e•p Yt0 r• � A`4 1A ^ lt) P A w J.,J Jix itt 3] w y.Ma , a \\nY if all P-CuID rR.t itH.e,c. 1U '� " . .i •- O 11a 141 J.le •�M a Ie to lo ! �1 4 se Wo \ la �„ .a" ill +e ♦PO ,e I� s /00m _ e Pa.NO FOR wocoeNO a) � zsE ,.sl4q e.4 - es 4.14 MArcN v z•y" ,a- „a Na afi a Y 3 t•d A� 'b (x,) O __•'•__ v� NOTICE COUNTY OF SUFFOLK © e ,n P• so1TTHo D SECTION NO O•.__ Real Properly Tax Service Agency r� 051 PROPERTY MAP i Glenn Goldsmith, President �®� sour Town Hall Annex V' �® A. Nicholas Krupski,Vice President �® �® 54375 Route 25 P.O. Box 1179 Eric Sepenoski 3 Southold, New York 11971 Liz Gillooly �s Elizabeth Peeples Telephone(631) 765-1892 ® a Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Onl Coastal Erosion Permit Application D 1 Wetland Permit Application Administrative Permit "AT 23 Im — Amendment/Transfer/Extens*on - ,Received Application: bb southoldTowm E] eceived Fee: $ 1 0. Board of Trustees Completed Application: 1ZS127- Incomplete: SEQRA Classification: Typel_ Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: oordination:(date sent): to LWRP Consistency Assessment Form Sent: AC Referral Sent: Date of Inspection: Receipt of CAC Report: chnical Review: Public Hearing Held: Resolution: Owner(s) Legal Name of Property (as shown on Deed): E. 6-4 t- li/rV W+ Mailing Address: "I �'� l Lt- Cj�ee-6r-- ba- 150 Lt-J)`-Z)Z-°- Phone Number: 51 Suffolk County Tax Map Number: 1000 - OU — 06,00 l 01/0. O® U Property Location: �`�6 I (-� F fL 2 SU Lt n-tv u c) I q (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): Mailing Address: Phone Number: Email: Board of Trustees Application GENERAL DATA Land Area(in square feet): L-e-). q Area Zoning: Previous use of property: 6r�- o� o<toT r prc- Intended use of property: i be ru 4 i ✓Tu Covenants and Restrictions on property? V-__'Yes No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes 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 a y demolition as per Town Code or as determined by the Building Dept.? Yes VNo Does the structure (s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: G� Ae Y . � y Dat No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? V No Yes If yes, provide explanation: Project Description (use attachments if necessary): 44"- ' VL I)OIAd , /�vd, �4L Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: UfDelw Area of wetlands on lot: square feet Percent coverage of lot: % 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 or filling? ✓ No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? 9cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 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): tri# hAV--( on Le>�, 61Z20 Appendix B Short Environmental Assessment Form Instructions for Completing Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part l based on 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: Project Location(desc ibe,and attach 9 location map): a Brief Description of Proposed Action. All /AQ", � ��J- I/ Name of Applicant or Sponsor: �� " Telephone �� _68-"�OIZ�I,tJ �. �ld- l/1 tVD4 //`-c, TO� E-Mail: Dli�Cl� Ot,Y�� Address: / - ' �14� Utz City/PO: State: Zip Code: -59u Fav Lb A-)Y I LLq-Jr 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes, list agency(s)name and permit or approval: 3.a.Total acreage of the site of the proposed action? e s acres b.Total acreage to be physically disturbed? _ ID acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? + 5 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial esidential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? 1:1 Rr ❑ b. Consistent with the adopted comprehensive plan? Pr ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: �J ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? ❑ Er 1-1 c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? Er ❑ 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: Nr� ❑ ❑ 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: EM" ❑ 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? TT ❑ 13.a. Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain JO �YjESwetlands 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. Iden fy the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: reline El Forest ❑Agricultural/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? 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 AYES Vo 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 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: ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE `//UDA- H- 7-Z)64 Applicant/sponsor e: jL F� Date: Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the,following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 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? ❑ ❑ 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 ❑ ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ 1:1affect 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? 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? 1:1 1 0 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 1-i` 10ar✓- 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. SijnKturqbf Pr arty wne Signature of Property Owner SWORN TO BEFORE ME THIS 3 DAY OF Y'4q , 20 AZ- Notary yNotary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. OID1475593 ®ualifled In Suffolk County My Commission Expires April 30, 202& APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same..,, , YOUR NAME: /,�(�l /I�V�� //G(� G. aAW lel& ")7 " H . (Last name,first name,.riddle 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 Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this y � 7 20gZ Signature Print ame l� i nkj ' Form TS 1 V Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its si ficant 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 supportinLy 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. DESCCRIPTION OF SITE AND PROPOSED ACTION SCTM# 0"'/ D - :(?® -_VL PROJECT NAME 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: 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 the action be directly undertaken,,require funding, or approval by a state or federal agency? Yes ❑ No❑ If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. 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 LWRP Section III—zNotApplicable ages 3 through 6 for evaluation criteria ❑ Yes ❑ No 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 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 through 16 for evaluation criteria 1-1Yes ❑ 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 1:1Yes ❑ ro No Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ ❑ Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ 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 1:1 No ELKot 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. 1:1 �� Yef] No U Not Applicable Attach additional sheets if necessary i J f' v WORKING 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 <otApplicable A Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. aWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes 1:1 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 riteria. ElYes 1:1 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; Pa es 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED BY TITLE DATE