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HomeMy WebLinkAboutJaklevic, Roberta F & John Cantrell, Elizabeth From: mkimack2@verizon.net Sent: Monday,July 25, 2022 10:25 AM To: Cantrell, Elizabeth Subject: Jacklevic Hi Liz: I respectfully withdraw the Jacklevic application from further consideration Best Michael A. Kimack,Agent ATTENTION: This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. i Cantrell, Elizabeth From: mkimack2@verizon.net Sent: Friday,July 22, 2022 3:47 PM To: Cantrell, Elizabeth Cc: iandjake45@aol.com Subject: RE:Jaklevic; 900 South Harbor Road, New Suffolk application Hi Liz: I will have my client submit the additional check for$150.00 1 am also getting you a copy of the deed showing John Jacklevic as owner. I will submit a revised site plan Monday showing a total of 43 trees( 21) leaning/exposed roots Best From:Cantrell, Elizabeth<elizabethc@town.southold,ny:us>— — --------- Sent: Friday,July 22, 2022 10:15 AM To: mkimack2@verizon.net Subject:Jaklevic;900 South Harbor Road, New Suffolk application Mike, Regarding the above referenced application there are a couple of issues. I believe Diane on July 6th informed you that the application is to be a Wetland Permit application not an Administrative Permit application. At that time she requested an additional$150.00 for the application fee. As this has not yet been submitted, please submit the fee as soon as possible. Also,your project description does not match your project plans. your project description has less amount of trees for tree work than your plans. Please either revise the project plans and submit four(4) revised copies or email me a revised project description to match the proposed plan no later than next Monday. Senior Office Assistant Town of Southold Board of Trustees Office: 631-765-1892 Email: elizabethc@southoldtownny_.gov A&V, l 53. Umm, A'XCUVc&,' OWAL5 PREP WI �y 1 GUARANTEES INDICATED HERE ON SHALL RUN SURVEY OF ONLY TO THE PERSON FOR WHOM THE SURVEY I DESCRIBED PROPERTY 1S PREPARED, AND ON HIS BEHALF TO THE - 777LE COMPANY, GOVERNMENTAL AGENCY, LENDING 1NS77TV770N, 1F LISTED HEREON, AND SITUATE TO THE ASSIGNEES OF THE LENDING 1NS711U770N. NEW SUFFOLK, TOWN OF SOUTHOLD GUARANTEES ARE NOT TRANSFERABLE TO SUFFOLK COUNTY, N.Y. -- ADD1710NAL INSTITUTIONS OR SUBSEQUENT OWNERS. . UNAUTHORIZED ALTERA77ON OR ADD177ON TO THIS SURVEY IS A WOLA77ON OF SEC77ON 7209 OF • THE NEW YORK STATE EDUCATION LAW. O •, SURVEYED FOR: WILLIAM J. JAKLEVIC COPIES OF THIS SURVEY MAP NOT BEARING ROBERTA JAKLEVIC THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. UTfL _._ . . POOLL ES A ' O0�0�1 O FD , GUARANTEED TO: i CM 'l' WILLIAM J. JAKLEVIC JAKLEVICROBERTA COMMONWEALTH LAND TITLE INS. CO. urn POLE TM# 1000-117-05-021.1 N/F ENDEMANN �� ,yhcb - � •V Y �O N N/F KWIT APPROX. HIGH WATER LINE THIS DATE N 8755'00"W 1. S 2459'06"W 3.30' D UTIL !I 12.23' 2. S 6056'20"W 27.79' 17 -- . . POLE J. S 14 20 23"E 24.10' 4. S 72'38'46'E- 28.50' JV 13 222 5. S 33'09'31'E 10.07' 6. S 30 27'05'E 66.14' ~- kp 7. S 30 27'09'E 47.45' r'sa 8. S 23'38'38"W 9.42' Southold Tom ' `sa• 9. S 25 22'07"W 11.91' Board of Trustees 10. S 81'41'18'W 21.37' �o� 2 11. N 81 59'31"W 57.19' 12. N 84'1640"W 85.58' 13. N 82' 51'07"W 25.21' 14. N 28'2529"W 66.32' o, N/F RAYNOR N N/F WICKHAM BULKHEAD v S 87'55'00 'E 110.00' . FD y FD urIL Da. cm - FD v� FRAME cM POLE s. i �'o✓�� o� GARAGE 24.3' 2�0 N/F LOCKWOOD ` G WHO, s O onc�m Q1 FD O O ►P S 87'55'00"E 108.82' c'F o 1 CONC.Mop 1.5 00 �6�L WOOD BOVTHOJSE RAMP N k3 0 22 DEAD 1 DYING TREES eU�ky6go ® ` 0 19 LEANING/EXPOSED ROOTS TREES �5' co�A 0 0 41 PROPOSED TREES TO REMOVE `� <o 0 �� .Z REMOVE DEBRIS/DEAD LIMBS, TRUNKS IP o� e ® p KHEAD SFO 00 6' 0 N87*57'00"W 0 �� 13.21 ' ® ® , J 14 00 O ® Nq WATER13 _ Q LINE 12 EXISTING WOOD DOCK AND WALKWAyS SURVEYED: 17 SEPTEMBER 2002 SCALE 1"=40' > SCHO O•,LHo USE AREA = 42,729.37 S.F. UJEEK OR j1 0.981 ACRES SURVEYED BY STANLEY J. ISAKSEN, JR. P.O. BOX NEW SUFFOLK. N.Y," -1.1956 631-7 4-=5835 CENSED _ SURV --NYS-Lic. 0. -49273 02C 1172 I i '1 I s � -- - -17 - SURVEY OF GUARANTEES INDICATED HERE ON SHALL RUN DESCRIBED PROPERTY ONLY TO THE PERSON FOR WHOM THE SURVEY I IS PREPARED, AND ON HIS BEHALF TO THE 7ITLE COMPANY, GOVERNMENTAL AGENCY, ( SITUATE , LENDING/NSl IF EO HEREON, AND ( NEW SUFFOLKTOWN OF SOUTHOLD TO THE ASSIGNEESGNEES OF INEE ,LENDING INS7ITU710N. , GUARANTEES ARE NOT TRANSFERABLE TO ADD177ONAL INS777U7/ONS OR SUBSEQUENT OWNERS. SUFFOLK COUNTY, N.Y. •UNAU7HOR/ZED AL7ERA77ON OR ADD177ON TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF 7HE NEW YORK STATE EDUCAI70N LAW. O SURVEYED FOR: WILLIAM J. JAKLEVIC COPIES OF 7H/S SURVEY MAP NOT BEARING ROBERTA JAKLEVIC 7HE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED 7O BE A VALID 7RUE I COPY. tML it" + POLES A OO SOF �O i ' GUARANTEED TO: FD .� WILLIAM J. JAKLEVIC CM to ROBERTA JAKLEVIC COMMONWEALTH LAND TITLE INS. CO. UPL ! TM# 1000-117-05-021.1 POLE N/F ENDEMANN �P tK i t �O C> N/F KWIT APPROX. HIGH WATER LINE THIS DATE ; 1. S 2459'06"W 3.30' N 87'55'oD"W j 2. S 6056'20"W 27,79' unL 12.23 J. S 14 20'23"E 24.10' POLE 4. S 723846"E 28.50' ; 5. S 33 09'31"E 10.07' 6. S 30'27'05'E 66.14' 7, S 30'27'09"E 47.45' 8. S 2338 38"W 9.42' r'0, j 9. S 2522'07"W 11.91' 01. I 10. S 81141'18"W 21.37' 11. N 815931"W 57.19' o, 12. N 84'16'40"W 85.58' 13, N 82' 51'07"W 25.21' 4. O, N/F RAYNOR N/F WICKHAM BULKHEAD V S 8 7'55'00 'E 110.00' FD y FD..: FD POLE �j M # o CM FRAME co CM RAGE N V �C � 4.3Jll "N N/F LOCKWOOD 7- 2022 -01 p <"�w xp �, i 4 t1j� co to `ra 10 • ^ 9Southold Town FD 6,0 Board of Trustees tp S 87 55.00„E 108.82' mayo° CEUAR mow, o' cow- �; 8ATHOUSE 00 RASP kc.7 a 0 21 dead/ dying trees e-A0 10 leaning/exposed roots trees 2y s 00 31 proposed Mees to be removed + Remove debris /dead branches o � Z gyp. O KHEAD® • �� N ��' , oo� OA B00"W I I 7 57 00 W ♦7 �Z J til ` ® � _ WATER ! �8 -7"`i!� 8 —-CL--- -4_ LWE ; 10. ® ff f0�,�/ I ' EXISTING WOOD DOC K AND SURVEYED: 17 SEPTEMBER 2002 I WALKWgys SCALE 1"=40' . SCS'p OLII . /-�USF � AREA = 42,729.37 S.F. tJ [� R���. OR _ I 0.981 ACRES f SURVEYED BY STANLEY J. tSAKSE N, JR. P.O. BOX -2J4'::': NEW SU t4K. 'N-.Y,,. X1.1956 631-7 j-5835 �CENSED_ _SURV LIC. o. 49273 02C 1172 Glenn Goldsmith,President Hall Annex A. Nicholas Krupski,Vice President �c54375 Route 25 P.O.Box 1179 Eric Sepenoski 9 Southold,New York 11971 Liz Gillooly t c� ��' Telephone(631) 765-1892 Elizabeth Peeples X y 2 ulll BOARD OFTOWN TRUSTEES JUN "7 2D22 TOWN OF SOUTHOLD This Section For Office Use Only boumola Board of Trustees _Coastal Erosion Permit Application 4 Wetland Permit Application Administrative Permit r 7/ Amendment/Transfer/Extension �•7�2� drC"&jn Received Application: (/V Received Fee:S ZS0.00 Completed Application: ?� •Zy ___—Incomplete: SEQRA Classification: Type I Type II LJnlisted Negative Dec. Positive Dec. Lead Agency Determination Date: ----- --- - - --- - �-Coordination:(date sent): LWRP Consistency Assessment Form Sent: ECAC Referral Sent: Date of Inspection: Receipt of CAC Report: Technical Review: (} V74-Public Hearing Held: •I7..14 Resolution: Owner(s) Legal Name of Property (as shown on Deed): IU VAI -7' !UkLEV! C, _ Mailing Address: 45',4js? =- T-_:S�l�' � _ J9� Phone Number: 691 872 — 120q,9- Suffolk County Tax Map Number: 1000 - 117 -- Property Location: ?Q d 0422 a%Z96Z &OAD (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: �6 ���— h���� Email:_� �G�/•�G����� . � ,� Board of Trustees Application GENERAL DATA Land Area(in square feet): -72 9 6 Area Zoning: &— Oro Previous use of property: , AW&y Intended use of property: giLUD UAL 01VE P 1L, Y Covenants and Restrictions on property? Yes _ No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes _ No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes _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 _�N0 Does the structure(s) on property have a valid Certificate of Occupancy? X 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? X No Yes If yes, provide explanation: Proj ect Description(use attachments if necessary): 06Q n/1,2y1,V r CJS WOOD L AA1P U)j4RV 0AnV& ZL� C/,� Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: EE Aff d JZZ P_AE � F Area of wetlands on lot:._ 11 square feet Percent coverage of lot: Q % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: &�A 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?. AIM---cubic yards Depth of which material will be removed or deposited:A.-feet Proposed slope throughout the area of operations: Y 4 Manner in which material will be removed or deposited: L0P�6 &� � &AMO Z-A EAP W 0 0/9 Gg &04E� �E V 0Vj 9— �� � a � ��� �� ER Q VE L VOW 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): N L 1 �� a V P d 61 Z20 Appendix B Short Environmental Assessment Form Instrtictions for Coitiple inn Part I -Project Information. The applicant or project sponsor is responsible for the completion of Part I. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I 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.I -Project and Sponsor Information Name of Action or Project:i' e A �^ VEVJ 1. Project Location(describe,and attach a location map): Brief Description of Proposed Action: d CUEAN 11F LD J1�f� G Name of Applicant or Sponsor: Telephone: C&&5-L C" E- i W2 0 A . YV er Address: Q 7 City/PO: State: Zip Code: I.Does the proposed action only involve the legislative adoption of a plan,local law,ordi ante, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that X FJ 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? acres b.Total acreage to be physically disturbed? Qom,L7Q�acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑industrial ❑Commercial ZLResidential(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? ❑ ❑ 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: _ _..__ [X ❑ 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? a c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? uni ❑ 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 tech o gies: -- ----- "J ❑. 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ��� �''{ ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: {� ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? � ❑ 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? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline ❑Forest ❑Agricultural/grasslands El Early mid-successional Wetland E3 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? T%NO ❑YES ❑ b.Will storm water discharges be directed to established conveyance systems(r__utloffand storm drains)? If Yes,briefly describe: �� NOyES Page 2 of 4 i 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: M,_........._ ❑ 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: N7 ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: �C (/14te; 02� 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 I 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? El 4. Will the proposed action have an impact on the environmental characteristics that caused the D L-1establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El ❑ 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 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 1:1problems? IL Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration, irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date _ President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Board of Trustees Application AFFIDAVIT .7'O,yrV J:" UlC _ 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 I MTHE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOI;THOLD T®WN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOL.D AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), ):F 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'PERM OF THE PERMIT. Signature of Pr erty Owner Signature of Property Owner ,TOM11 ,T, i7-W4EV/C SWORN TO BEFORE ME THIS _ DAY OF 20-a Notary Public SABRINA M BORN NotaryPublic,State of New York No.01B06317038 Qualified in Suffolk county commission Expires Dec.22,2Q� Board of Trustees Application AUTHOIUZATION (Where the applicant is not the owner) owe, -fid i7: ��J�,L�V/C owners of the property identified as SCTM# 1000- al ®�- Z4 in the town of — 0 U _ New York,hereby authorizes �`C�L •� �� �; to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property, Property er S' nature ^� Property Owner's Signature tTO�yi4/ �: IkG 6U/ C SWORN TO BEFORE ME THIS DAY or2(1 -,Ir�� --- Notary Public SABRINA M BORN Notary Public,State of New York No.01B06317038 Qualified in Suffolk County Commission Expires Dec.22,200 APPLICANT/AGrENT/REPRESENTATIVI: TRANSACTIONAL DISCLOSURE FORIM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and empkyees.Thepurpose of this form 6 to"provide information which can ales-the town of pi si le conflicts of interest and a1.1(j% it to talce whatever action is necessary to avoid same. YOUR NAME: nrzW —V/C (Last name,first name,piiddle 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 Or APPLICATION: (Check all that apply.) Tax grievance __. Building Variance _ Trastee Change of Zone Coastal Erosion _ Approval of plat Mooring Exemption from plat or official map _ _ Planning Other (If"Other•,mine the activity.) Do you personally(or through your company,gh)use,sibling,p=nt,or child)have a relationsllip with any c Ricer ur'enii lu)ee of the Town,ol•Soulhuld? "Relationship"includes:by blood,man•iage,or business interest_"Busincss interest'means a bu..incs•c, including a partnership,in which the town officer or employee Ibis cvcu a partial ownership orf or cmnployment by)a Corporation in which the town officer or employee n ns nior,�than 51!0 of the shares. YES NO X If you answered"YF S",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 applican;/aacriu'representative)mind the town oTcer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The tuwn otticer or employte or his or her spouse,sibling,parent,or child is,(check all that apply): the owner of greater than 5%of the shares of:he corporate stock of the applicant (when the applicmmt is a corporation); `__Q)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corpc•ration); ______C)an officer,director,partner,or employee of the applicant;or _-_—D)-die actual appliccnt. DESCRIPTION OF RELATIONSHIP Submitted this j- d of 2012'_ Signature__ Print Name Fonn TS I APPLICANT/AGENT/REPRESEN'TATIVE TRANSACTIONAL DISCLOSURE FORM °Elie Town ofSouthold's Code nfEthics nrnhihits conflicts of Interest on the part of town officers.and employees,T he nurp sa e of flits ftirni Is to�proyide information which can.olertthe town ot`pdssible conflicts of hl bw t.and oJlgw it to take whatever.action is necessar tto avoid same. YOUR NAME: (Last name,first name,.ipiddle initial,unless you are applying iii 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 relafionship with any officeroremployce Of the TONVti cfSottthold? "Relationship"includes by blood,afarriage,or business iliter"L"•Business interest"mcans a.husincss, including a partnership,in which the town Officer or employee has even.a partial ownership of..(or employrrient by)a corporation in which the town offiecr or employee owns;morc;than 5%of the shares. YES NO _-X _ 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/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 appliegnt (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 21day of 20VZZ Signature Print Name �- Form T5 l Town of Southold LWRP CONSISTENCY ASSESSMENT FORINT 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 Towa). 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. .Thus4 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 PROTECT NAME_ 744�1� V1 C-, 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: Y Q?1E 2 Location of action: CJ Site acreage: 6-1 V Q Present land use: Present zoning classification: � �� ,��f�� �66 EA /-Z V 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: H I C`l,4,6G iQ A�/YA CE (b) Mailing address: ©. OX /04 7. _T1W " �� �, 9 7.1 (c) Telephone number: Area Code( ) ���_ �� — 6 (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 POI.,ICY 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 ❑ NoXT Not Applic ble UtICY I IVIA 71 7WLE AMIC D I 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 0 Yes ❑. No ONO 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 0 Not ADDH bl . t22 7915' A-P&ZCA7-7,QV 01ZQY Al Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No Not Ap Hble 4«Cy P 7z v&j- .4,ppL/C'f1 PgAl 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. El ❑ Ind Yes No Not Applicable Y 4 lC 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 X Not Applicable 2W Z57 ZZO Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No Not Aplicable OLS CY C IT AjW/C&MAI PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. (� ❑ Ye&O NoR711 Not Applicable 722) Attach additional sheets if necessary i 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 � Not Applicable 6 AP-RIC-MV Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑.Yes ❑ No� Not A lica le F06/ CV pa M-S ,A��CA Z2elAl 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 ❑ NA Not Ap Iicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑. No 9 Not Applicable PA iCy rT ) -VI-CAAPX I C:4 770rV PREPARED SY /4 k1 ��� TITLE__�C� DATE���,?Z , GA2RAGE N . 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