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HomeMy WebLinkAboutKamrowski, Susan 'Oil F04 � Glenn Goldsmith,President CDTown Hall Annex Michael J.Domino O ` 54375 Route 25 John M.Bredemeyer III 'y�o ao��� R.O.Box 1179 A.Nicholas Krupski ,1 Southold,NY 11971 Greg Williams � `" Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD July 14, 2020 Susan Kamrowski P.O. Box 776 East Marion, NY 11939 RE: 285 HUCKLEBERRY HILL ROAD, EAST MARION SCTM#: 1000-31-16-6 Dear Ms. Kamrowski, Regarding your phone conversation on July 13, 2020, at your request we are returning your personal check#475 to you as you had formally requested to withdraw your Administrative Permit application verbally to this office over the phone. Sincerely, *izabeth Cantrell Senior Clerk Typ, -:--- 77- Town of Sou tholl G N Board of Trusted �^�`�SU.S 4—V SK,,,. KAMRD220 3404 4.�n5 --R-6 60k I`76 _ ST MARION NY X7939 AA PAX TO THE,. Y M ORDER OF U DOLL4� Debi'd'Fgrn. &T Bank w MyClaoic1um d _ IVIEIvIO 1f9' °•_�r'� �`V WWK/� - � t 3:� 02"2000046r: ��L49 - 8 411'047r5 ,� �` SUSbN V ICAMR0WSKl 'moo sgoa 47 5 P&B JX 776 BAST MARION NY 11939 ' DA �� PAY TO THE ORDER OF 3 : F l DOLLARS M Bank My Ch Prelxiium MEMO i:0 Z°2000046 : 8 149 8 411'0475 Susan Kamrowski Incomplete Wetland Application, Checklist of items needed for Board of Trustees Review : 1) Application materials labeled by Clerk as "blank" need to be completed. 2) A copy of a recent licensed survey of the property is required. 3) A project plan to scale must show the dimensions of all proposed fences and signs. 4) The application must disclose what type of fencing is proposed. At its discretion, the Board of Trustees may consider fencing that is "open constructed" and not limiting to wildlife. Typically, for beach environments a maximum of a 3'-4' (three-four foot) high split rail fence without wire or screen attached, is the maximum allowed by the Board, but may be further reduced as a result of field conditions evident during inspection. The type and size of fence must be disclosed in the project description. 5) If signs are intended to disclose "Private Property" or similar, their location must be shown on the project plan and be included in the project description.. 6) The total height of any open type fence proposed for the top=of the existing groin must not exceed 6' (six feet) for the combined height of fence and groin. 7) There can be no approvals that limit the right of NYS Residents to pass and repass along the foreshore year-round. Signature of Mrs. Susan V. Kamrowski: r Date: BO Representative: J✓ 171 Glenn Goldsmith,President � p - ?oo Town Hall Annex 54375 Route 25 Michael J.Domino,Vice-President Q <° { P.O.Box 1179 John MBredemeyer III Southold,New York 11971 A.Nicholas Krupski . 9. Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 ev ' BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extension Received Application: Received Fee: $ Completed Application: Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): LWRP Consistency Assessment Form Sent:. CAC Referral Sent: Date of Inspection: Receipt of CAC Report: Technical Review: Public Hearing Held: Resolution: Owner(s)Legal Name of Property(as shown-on Deed):. S v so r Kam s, Mailing Address: 2�' v e -Neb2c c j�;\\ `(�� � Z 7(E, � Phone Number: CS�Q) `t 33 3 3 Suffolk County Tax Map Number: 1000 - Property Location: 2 g5 1 vC-�Oer)CkC Cf--, M4 lc&D� (If necessary,provide LILCO Pole#, distance to cross streets, and.location) AGENT (If applicable): Mailing Address: Phone Number: Glenn Goldsmith,'President �' �� Q �* Town Hall Annex . �,'. Michael J.'Domino,Vice-President ` ` 54375 Route 25 . John,M.Bredeme er III P.O.Box 1179 Joh Y Southold,New YoZ# A-971 A.Nicholas Krupski, Telephone(631) 765=1892 Greg Williams' " �� Yea Fax(631) 765-6641 BUARD'_OFTOWN TRUSTEES TOWN.OF-SOUTHOL'D APPLICATION INSTRUCTIONS ADMINISTRATIVE WETLAND PERMIT' In accordance with Chapter 275-5 (B)Administrative Permit &275-7 (A).Permit Fees.. Application Fee- $100:00`(Fee made payable to: Town of Southold):- As-Built Fee-$200.00 - DO NOT SUBMIT PAPERWORK WITH PAGES PRINT BACK TO BACK The original application packet fully completed and one photocopy of the completed.'application packet. An original Affidavit, Applicant/Agent/Representative Transactional Disclosure Form, and-Agent Authorization Form'must be completed by each owner whose name-appears on the most current property deed. If said property is owned by an LLC or Inc., Articles of Organization must be submitted along with the required authorization forms in order to show proof(s) of ownership. One original and three (3) photocopies of a survey-bf;the.property. One original and three (3) photocopies of the site plan/project plan depicting the proposed. project, (must be "to-scale" and include dimensions and material(s)type for all existing/proposed structures). Current photographs of the subject area showing the proposed area of operations from at least two opposite directions. Each photo should be labeled with the date, time and'direction. The applicant is responsible for staking/marking out the proposed project prior to the date of the Board of Trustees Field Inspection. Upon receipt of a completed application to this office, the project will be reviewed by the Building Department. If the`project requires a Zoning Board of Appeals variance, the application will be held until a determination is made by the ZBA. Maim Diane From: Bredemeyer,John Sent: Thursday, May 28, 2020 10:18 AM To: Cantrell, Elizabeth; DiSalvo, Diane Cc: Standish,Jeff; Goldsmith, Glenn; Hagan, Damon Subject: Mrs. Kamrowski, Huckleberry Hill Rd, EM Good Morning all, I met with Mrs. Kamrowski, at Jeffs/Liz's referral at her home, with her daughter present, on 5-26-20 (Covid-19 compliant, with masks) in the afternoon to discuss her concerns of alleged trespassing on her beach at Huckleberry Hill Rd. East Marion. There is the possibility that short, 11'-15' fence additions at her property lines and at the corner of her pre-existing bulkhead leading to OHWM would help her demarcate that part of her beach above OHWM that she might reasonably justify as her own. She mistakenly thinks she owns to MLW and was generally argumentative with several of my suggestions, including when I suggested she put a chain across her stairs when she complained people were coming up on her deck??? I suggested she file for an administrative permit. If she calls for an application, reiterate that she should get in touch with me so I can flag and measure the maximum extent of fences the Board might even possibly consider. You may give her my cell number as I will put her number in my directory, presently. Due to her mentality, I request that a pre-submission form be provided me for her to sign, should she file for a permit. Due to Covid-19 pressure on the beaches and shorelines we might request that such applications be given some priority processing when again we meet. Thanks, 4 �r Jay I e OltFl . i Board of Trustees Application GENERAL DATA Land Area(in square feet): 5-0 eL,,11arAcV Area Zoning: Previous use of property: -c-C�L� c-1�r✓.� t-�� Intended use of property: +-z- Covenants and Restrictions on property? Yes X No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes x No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No 2 If"Yes",please provide copy of decision. Will this project require any demolition as per Town Code oras determined by the Building Dept.? Yes JC 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? ANo Yes If yes,provide explanation: Project Description(use attachments if necessary): fur pQ�� VY-13 1�e�vcme h 2av�1 -tc, -11v& ect roie-rrli C w; fire.sPgss t\o f- A 1a�`gh ��rU�er►�na�(e auNaanck, 'r.S off- oY, �e-i+o i,I e&\k.ihfrs 40 boC)L yard l � �ws stvleh beach �n��cel4 eVf,Af- u-agu\& WS*- -r-0 .�,,k t� ra Fe vice c,�4-er »,ar �QLh�- -Eco 1S 2 C V 66,-x' () v y W � To Se.('Ve �l S a c� �� S x;,SS i✓1� ) -�.� N��(� da fV1G� ahol fx,4eM4.d e-VxAaVyxr ,�n•,-. Board „of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: re-n c 2 woo d sP r o-Q o s a A9_-,Suyr Q n-\- n rc +aror�&Q pG cSec-s Cla Y1 Ce- re`e(tj high ce v 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? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 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): Board'of.LTrus tees::Application AFFIDAVIT BEING DULY SWORN D OSES AND AFFI S THAT /SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARKTRUE 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 TOHOLD THETOWN,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 AUTHORIZ_E THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECTTHE PREMISES IN CONJUNCTION,WITHTHIS 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' . y . . EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Si a of Pro Owner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF C6,PLf— 20 2,0 NOt ROBERT A MAZZAFERRO NOTARY PUBLIC-STATE OF NEW YORK NO.OI MA6207376 OUALIFIED IN SUFFOLK COMMISSION EXPIRES JUNE 15,20� Board of- .Trustees Application AUTHORIZATION (Where the applicant is not the owner) owners of the property identified as SCTM# 1000 ��tS��rr=�"� in the town of New York, hereby authorizes to act as my agent and handle all necessary work involved with the application process,for pen-nit(s) from the Southold Town Board of Trustees for this property. Property Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF , 20 Notary Public 61 Z20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or-project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 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: �A ' cnre ori e6 �er;MG2k 1�2 Project Location(describe,and attach a location map): 2 yv�[e(e be )T MG AM 6 Ch 09M� Brief Description of Proposed Action: Aa L a -k h(e +0 ins 3�) wader rnau� 'F �b se�r� a Sa �e.�rea�t-�� Name of Applicant or Sponsor: Telephone: S,�o L13-7 3 333 SU r1 rn D SSC E-Mail: Sue Y-a m C>(9) a©1.ccxm Address: City/PO: State: Zip Code: 1' t' Eo-f_ -77 F-6st MAR;or Ny f 93q 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? ,33 acres b.Total acreage to be physically disturbed? acres C c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? % 33 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) -❑Industrial [:]Commercial 'EResidential(suburban) ❑Forest ❑Agriculture [Aquatic []Other(specify): ❑Parkland Page 1 of 4. 5. is the proposed action, NO YE. N/A a. A permitted use under the zoning regulations? ❑ ❑ ❑ b.Consistent with the adopted comprehensive plan? ❑ F� ❑ 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: 1 F] 8. a.Will the proposed action result in a'substantial increase in traffic above present levels? NO YES L_1 ❑ 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? ❑ 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: ❑ 1-1 10. Will the proposed action connect to an existing public/private water supply? N 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: U ❑ 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? IT 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain N 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 orwaterbody? -� ❑ 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: LqJ Shoreline El 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? ❑ ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create stone water discharge,either from point or non-point sources? aNO YES If Yes, a.Will storm water discharges flow to adjacent properties? ❑NO ❑YES ❑ b.Will stone water discharges be directed-to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: E]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: V ❑ 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 1 Applicant/spon o name: ����1�+ Date: ;o 1211/a--Z Signature: Part 2-Impact ssessme . The Lead Ag ncy is responsible for the completion of Part 2. Answer all of the following questions in Pa 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise av 'able 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? D F1 3. Will the proposed action impair the character or quality of the existing community? a 4. Will the proposed action have an impact on the environmental characteristics that caused the (�( E]establishment of a Critical Environmental Area(CEA)? �1 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 a.public/private water supplies? b.public/private wastewater treatment utilities? 8. Will the proposed action impair.the character or quality of important historic,archaeological, ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse,change to natural resources(e.g.,wetlands, ❑ waterbodies,groundwater,air quality,flora and fauna)? - Page 3 of.4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage. [:1problems? 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 wiI I 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 61 Z20 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 L 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: "Cc Co (�G VC P MGI_ , 2 Project Location(describe,and attach a location map): be oAA Brief Description of Propos Action: a�1d c( a �2 h �e -�J F4� Yh i`41� Wn}2 ►hG'� IG S�J` U-0- G S ct c£�L�r f 2v)t Name of Applicant or Sponsor: Telephone: SI Ll 3-7 3 3 3 3 SUn YVl 'V 'S�t E-Mail: Address: a 0 ti,ccon 93 5 live.)=telae rr i-h 1 I City/PO: �. State: Zi D . ode: 65-t' N1c� ;�n p C_ N.\/ 1 19 3q 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, administrative rule,or regulation? NO YES 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. M ❑ 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? 33 b.Total acreage to be physically disturbed? —acres c.Total acreage(project site and any contiguous properties)owned acres C or controlled by the applicant or project sponsor? • 3 3 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban (]Rural(non-agriculture) []industrial ❑Commercial Residential(suburban) ❑Forest []Agriculture RAquatic ❑Other(specify): ❑Parkland ..�--,.._._._...._.._.__.__....._._............_.____. Page 1 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? ❑ ❑ ❑ 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: y = ❑ ❑ S. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES ❑ ❑ b.Are public transportation service(s)available at or near the site of the proposed action? ❑ ❑ 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: _..... _ _._.. - ❑ ❑ 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: ❑ EJ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ❑ ❑ b.1s 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? 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: El Shoreline 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? ❑ ❑ I6.Is the project site located in the 100 year flood plain? r YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, El 1:1a.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 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 Applicant/sponsor name: 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 targe impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning 1-1 ❑ 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 El 1:1establishment of a Critical Environmental Area(CEA)? 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? ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ ❑ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage 1:1problems? 11. Will the proposed action create a hazard to environmental resources or human health? El 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 wiiI 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 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 significant beneficial and adverse effects upon the coastal area(which includes all of Southold Townl. 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 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: /)M 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, snakes 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 n Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes 0 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 ❑ 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 h through 16 for evaluation criteria ❑ Yes n No ❑ 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 ❑ Yes ❑ No n 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. ❑ ❑ ❑ Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: R--, nc2 we' d Sj Y-4- -0- 6.s C, rv} -V V-'2 fhv.o� �roy�� � ;���Sers h t�li, C��tnC� rP`Y�(►� 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? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 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): Board of Trustees Application GENERAL DATA Land Area(in square feet): Area Zoning: Previous use of property: Intended use of property: 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 X No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes X No Does the structure (s) on property have a valid Certificate of Occupancy? Yes No 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? A No Yes If yes, provide explanation: Project Description(use attachments if necessary): Our co i a� beDC A -t Pic c zrvim2 11 O o or"I r ­T�\k arJe_ G W;tel (\of � h WCA4''1r"r'k q��i Y1C�' cila(/�it�� O rt- OYl '�21 . i�tT�kiM� v1 "1 `S 40bacl_ <lavd\6eGk � Wa5 s-t(Ae.n Y)e&c 0 &J4 eA-c e. like- -ro e- -t- 7 hM h 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 S. 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. Yes[] No❑ Not Applicable Attach additional sheets if necessary 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 P No ❑ Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes P 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 2 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. ❑ No ® Not Applicable ❑ Yes PREPARED BY TITLE DATE