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Home My WebLink AboutTR-10194A Glenn Goldsmith, President ®E S0 Town Hall Annex ®� ®1 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski qr Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 C®UNTd,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1994C Date: January 3, 2023 THIS CERTIFIES that the installation of an 8' high approximately 4,700 feet long deer fence around an 11 acre open field area; At 44030 Route 25, Southold Suffolk County Tax Map#1000-75-6-6.1 Conforms to the application for a Trustees Permit heretofore filed in this office Dated July 22, 2022 pursuant to which Trustees Administrative Permit# 10194A Dated August 17,2022,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 an 8' high approximately 4,700 feet long deer fence around an 11 acre open field area. The certificate is issu to Samuel Singer owner of the aforesaid property. Authorized Signature Glenn Goldsmith, President �a� OTown Hall Annex A. Nicholas Krupski, Vice President ;� 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly Y Telephone (631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 RI , BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: �2 INSPECTED BY: L- oo� 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: +) v- lot - CERTIFICATE OF COMPLIANCE: Glenn Goldsmith, President a\i)f sob, Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski : Southold, New York 11971 iQ'Liz Gillooly t' Telephone 631 765-1892 Elizabeth Peeples / Sz � 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 1st day of construction % constructed K When project complete, call for compliance inspection; Glenn Goldsmith, President ®� so 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 y® Fax(631) 765-6641 cou BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10194A Date of Receipt of Application: July 22, 2022 Applicant: Samuel Singer SCTM#: 1000-75-6-6.1 Project Location: 44030 Route 25, Southold Date of ResolutionlIssuance: August 17, 2022 Date of Expiration: August 17, 2024 Reviewed by: Elizabeth Peeples, Trustee Project Description: Install an 8' high approximately 4,700 feet long deer fence around an 11 acre open field area. 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 Nathan Taft Corwin, III Land Surveyor, received on July 22, 2022, and stamped approved on August 17, 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 p CEIVE JUL 2 2 2022 Southold Town Board of Trustees SURVEY OF PROPERTY SITUATE PECONIC TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK ��1 G S.C. TAX No. 1000-75-06-6. 1 SCALE 1 "- 100' FEBRUARY 1 , 2015 TOTAL AREA = 1,032,796 sq. ft. 23.709 ac. 5 APPROVED BY 0 ' CERTIFIED TO: 0. BOARD Of i RUSTEES ,. , SAMUEL SINGER �, 1 °�• e ° ts. O ,OWN OF SOUTHOL D GOLDMAN SACHS BANK USA 00, - STEWART TITLE INSURANCE COMPANY SEE DETAIL DATE hjt&tT- 1-7 Z;t- ADVOCATES ABSTRACT, Inc. •000 a O �' q $° 0. �. %o? GATE DETAIL ire N 116 o SCALE 1 "=40' 61 6++ 0 !tri• \ lip 0 A? 001 -10 IL 0.0t OIL 44� ..I (� o � O y� \ hyo W X1.8 9. 5• .jr- O \ / o� \` oos 2 as• \AL 0 ,4 �\ a \ o v?� o •moo+ J of o zo C) °. w 0% t--y N �' �• posy �P O O Au 100 '6 N tnof l �� o1 o 0 �Z g ro I N I I I O Sc ! Ng N 00.2522 E ' 102.85' I 4 � t0 M,% Nry'� 2 i ' L z 4' tnxt•"� !O oy 1� Of, i��S t0 to � i o zo W�� ' - � N• AL O O O N fig• 49.22 �•, i, .il1L O C'41 :n to i `� N A ^� 011 ! 2 f o il1L O $ N Z O0. O C14 0 'tt O .O PATH C jdL L Lp 39, 98. rm 26,, 8 W i 4' 7 '$ Z I p w o I m Q o m o �n $� C J ADL `. �Py 6 ` AtL . E 1• �o 1 r 48' RSG Dc O 's sem+ A. CP Va Q�� '1 011 PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED V BY THE I-I.A.L.S. AND APPROVED AND ADOPTED 0 yE FOR SUCH USE BY THE»NEW'YORK,STATE LAND TITLE ASSOCIATION-0: `�c d;r��i� '� r 1. .. �SrCS-- f e. No. 50467 UNAUTHORIZED ALTERATION OR ADDITION 1k a '�^ r } TO THIS SURVEY IS A VIOLATION OF ` ` Corwin III SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. r COPIES OF THIS SURVEY MAP NOT BEARINGLand ■ THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. CERTIFICATIONS INDICATED HEREON SHALL RUN Successor To: Stanley J. isaksen, Jr. L.S. ONLY TO THE PERSON FOR WHOM THE SURVEY Joseph A. Ingegno L.S. IS PREPARED, AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND Title Surveys — Subdivisions — Site Plans — Construction Layout LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTI- PHONE (631)727-2090 FOX (631)727-1727 TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. OFFICES LOCATED AT MAILING ADDRESS THE EXISTENCE OF RIGHT OF WAYS 1586 Main Road P.O. Box 16 AND/OR EASEMENTS OF RECORD, IF Jamesport, New York 11947 Jamesport, New York 11947 ANY, NOT SHOWN ARE NOT GUARANTEED. DiSalvo, Diane From: Cantrell, Elizabeth Sent: Tuesday,August 2, 2022 11:04 AM To: DiSalvo, Diane Subject: FW: Senior Office Assistant Town of Southold Board of Trustees Office: 631-765-1892 Email: elizabethc@southoldtownny.gov From:singers@MSKCC.ORG <singers@MSKCC.ORG> Sent:Tuesday,August 2, 2022 10:11 AM To: Cantrell, Elizabeth<elizabethc@town.southold.ny.us> Subject: Dear Elizabeth, On my deer fence applications m—Ickh tr lYan:< eTr� e led 11� k h cl"tie 3fe,n'c ri 8 ft high dee tinge on my application to match what was indicated on the new survey I submitted I submitted with the application, thank you, Sam Singer Please note that this e-mail and any files transmitted from Memorial Sloan Kettering Cancer Center may be privileged, confidential, and protected from disclosure under applicable law. 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Do not open attachments or click on links from unknown senders or unexpected emails. i Glenn Goldsmith,President ~�®�OSUFFO(,�cOGy r Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 Eric Sepenoski co ,� P.O.Box 1179 Liz Gillooly _1 ® �!� Southold,NY 11971 Elizabeth Peeples �Od �� Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: $II L7- Completed in field by: 91-M% e,Aln PetwleA SAMUEL SINGER requests an Administrative Permit to install an 8' high approximately 4,700 feet long deer fence around an 11 acre open field area. Located: 44030 Route 25, Southold. SCTM#: 1000-75-6-6.1 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: Chapt.275 Chapt. 111 other Typ of Application: Wetland Coastal Erosion Amendment 7Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications/Conditions/Etc.: ShralQh4�orwa.rr�( a CC GON�i�rhna�ieY► -�4Sa� dccr %nCe jS B'D Y avid rece"t 12 ur��aAtA oval .G+ acscYilp}iuvn tef4tAiN woo N- Present Were: G. Goldsmith N. Kru ski E. Sepenoski L. Gillooly N. Peeples r Ml h: 31!CR „a. msa p - IINF x asa-w �. a. � �•\ A'o�B ` ♦ Dr.n wyz � �,. t.� ..� s P ,�'> ,�� i �. asa-ns � n5 � crrn.ccgrAf' mwmA. r.. `ri to s.c_I p...,.• u gyp, ,�^ '9 'y, h `.a .2. `� ..S z M �s n .yam� ¢` � g n t ��.� '+� R '�'r�, � rM, '..� n�`,.�'•e q } s osao-,a 4 f •\q0 M1yd 9 } °r 3 ,° 3, a ,-i1 "a .os"1# ^ ,i s A`•. } a-zsm •`�. ,g t' 9 iq f.,.Y!e♦ Yn4 1�' �, •a a, za ,°� 1t ,'N` - . x RYUEM KKrrta; , ILI • .`°. r per' •;v-. ..� r-' M ,�'t 7;\! - ..r 112 is en ` aruarxrww.., 4.. ., � d• � r e °a �� .� 'r`'t � �,1 �°M r - H, + `�.�+ �� ° � °}iii A ;�'� ?°'�• '� ��„ Y1 a 8� *' e� L(cl t, � 1.5 P �.�\•v9"R FMLL W4 D • ♦ ° . . F' Q.� M .r:�. °u $, xea i� uvrat.usoumao��.x � �'^ i. a - ' 4 ie". 7. t6x 11•4 y s 38' " 'Z y.. ♦ v i.. O .'� 3 os E s rovmwsoumo�o' S q - t.. E a d16-0i-00➢, 'p BES 16,nU�+ OY1J.+J� . � � ue ser vo ses see_mac ao aae Ly ncrlcE rc ,wc, toxo sFc-icav no o �� en+u__ .... "",,,^• —� PefiCOUDITY Prup ry OF SUFFOLK �075 ID .w.___.__ w°. __.. .» -- r..e. 4211 OFFICE LOCATION: �O��oF SOU�yOI MAILING ADDRESS: Town Hall Annex O P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold,NY 11971 �pQ Telephone: 631765-1938 �yCuT`1,� 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: August 15, 2022 Re: LWRP Coastal Consistency Review for SAMUEL SINGER SCTM# 1000-75-6-6.1 SAMUEL SINGER requests an Administrative Permit to install an 8' high approximately 4,700 feet long deer fence around an 11 acre open field area. Located: 44030 Route 25, Southold, SCTM#: 1000-75-6-6.1 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 proposal is CONSISTENT with LWRP Policies and with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Honorable Lori Hulse, Attorney , e°•r; �` '- Town Hall Annex Glenn Goldsmith, President °tl` f; '>;c 54375 Route 25 A. Nicholas Krup ski,Vice President til „b�,y� � 10 P.O. Box 1179 Eric Sepenoski ±` " #+ Southold, New York 11971 Liz Gillooly4t ��t Telephone(631) 765-1892 Elizabeth Peeples i ` i Fax 631 765-6641 -- V. BOARD OF TOWN TRUSTtl JUL 2 2 TOWN OF SOUTHOLD This Section For Office Use Only Southold Town Board of Trustees Coastal Erosion Permit Application Wetland Permit Application Administrative Permit -------- ��Amendment/Transfer/Extension Received Application: ?•22•Zy _ Received Fee: $ 100, /-Completed Application: _ 7.2652.- Incomplete: __SEQRA Classification: Type I __ Type 11 Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: `�Coordination:(date sent);. LWRP Consistency Assessment Form Sent: AC 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): Samuel Singer Mailing Address: 44030 route 25,Southold, NY 11971 Phone Number: 646_330`8658 Suffolk County Tax Map Number: 1000 - 75.6._6. 1. Property Location: 644030 route 25, out old,NY 11971 _ (If necessary, provide LILCO Pole #, distance to cross streets, and location) AGENT (If applicable): _ Mailing Address: - — Phone Number: Email:_. _ Board of Trustees Applic:l _.on GENERAL DATA Land Area(in square feet): 24.2 Acres ( 1,054,152 square ft) Area Zoning: AC Previous use of property:. Vacant waterfront Intended use of property: Plan to farm organic vegetables - 1.0 year signed land lease with Will I.ee, Sang lee arms 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 X 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 X 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? X No Yes If yes, provide explanation: Project Description (use attachments if necessary): Construct a 10 foot high deer fence — 4,700 ft long around an open field area of— 11 Acres of farmable land Board of Trustees A,pplic,; on WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Farm organic vegetables as part of a .1.0 year land lease with Will Lee Sang Lee Farm Area of wetlands on lot: 345480 square feet Percent coverage of lot: 33 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? X 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: O.. 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 (u��seeJ attachments if appropriate): r ; Board of Trustees A-mlic��-__ .on AFFIDAVIT BEING DULY SWORN DEPOSES AND AFFIRMS THAT /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. ignature of Property O r Signature of Property Owner SWORN TO--,BEFORE ME THIS 67 \ DAY OF� �20� KAYSTAL HASAN Notary PublIC•State of NOW York t Public No.01 HA5073030 y Qualffied in Queens Courcy Commisslon Expires Feb.10, APPLICANT/AGENT/REPRESENT,A.TIV-R TRANSACTIONAL DISCLOSURE,FORINT The Town of Southold's Code'ofFthics prohibits conflicts of interest on the part oftown officers and employees.The purnosc of this form Is to provide information which can alert the town of possible conflicts ottnteresf and allow it to take whatever action is necessary to avoid same. YOUR NAME: . (Last name,first name,qtiddle initial,unless rA 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 _ Plann'tg �+ Other ---� �s —�/� 4 (]f"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,fttarriage;orbusiness.interest "Btisiitess:intcresP'mca»s:a business, including a partnership, in which the,town'officer or employee has even-a partial"owncrship'of(or employment t�y,),a corporation in which the town officer or employec'atvn&more than 5`/0 of e 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 br position of that person Describe the relationship between yourself(the applicant/agentirepresentative)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 of200 Signature Print Name Form TS 1 617.20 Appendix B Short Environmental Assessment Form Listructions for Coinotetin�� 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: Deer Fence construction Project Location(describe,and attach a location map): 44030 Route 25, Southold,NY 11971 Brief Description of Proposed Action: Construct a 10 foot high deer fence — 4,700 ft long around an open field area of— .11 Acres of farmable land Name of Applicant or Sponsor: Telephone: 646-330-8658 Samuel Singer E-Mail: singers@mskcc.org Address: 44030 Route 25 City/PO: Southold SNZ1p1971e 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? 214.2, acres b.Total acreage to be physically disturbed?. -W�2�—acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? 24.2 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ffRural(non-agriculture) ❑Industrial ❑Commercial [IResidential(suburban) ❑Forest CNAgriculture ❑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? ❑ ❑ 6. is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? D 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: a ❑ 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? ® ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? V1Ei ❑ 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: a ❑ 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? El Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline El Forest [Agricultural/grasslands El Early mid-successional EN 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? M D 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, F;71 ❑ a.Will storm water discharges flow to adjacent properties? ❑NO []YES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO DYES 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: �— Trv�_ _� ��. ❑ 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: X a 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: 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"}-lave 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 a 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 F-1establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or X 1:1,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 � 1:1reasonably 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? ® E] 8. Will the proposed action impair the character or quality of important historic,archaeological, F R " o architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, a waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage ❑ problems? 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 I 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 Town. 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# 1�� - G ✓ - �r PROJECT NAME J4F 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: 700 A� A 3�C Location of action: Site acreage: 2. � �C Present land use: > Present zoning classification: ZZ 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: �4a & (b) Mailing address: (c) Telephone number: Area Code ( (d) Application number,if any: Will the action be d' ectly 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 velopment. 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—PCNot .Pages 3 through 6 for evaluation criteria ❑ Yes 0 No Applicable 1 Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Polic'ts 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 8 through 16 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 throng for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ ❑ Yes No Noll,_ 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 eval tion criteria. Yes [:] No of Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and astes. e LRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes 1:1No Not ApWplicable 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. ❑ YesD No rNotApplicable Attach additional sheets if necessary WORKING COAST POLIS'-__j�S Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See Section III Policies; Pages 47 through 56 for evaluation criteria. F-1i Yes ❑ o Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and To n wat s. See LWRP Section III-Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ N of Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages 62 th ugh 65 for evaluation criteria. Yes 1:1No❑ Not Applicable Attach additional sheets if necessary Policy 13. Promote appro iate use and development of energy and mineral resources. See LWRP n Section III-Policies; Pa 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable TIJ�� DAT PREPARED BY EZ7�