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HomeMy WebLinkAboutTR-10206A Glenn Goldsmith, President ®� s®Ur�® Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ® P.O. Box 1179 Eric Sepenoskig Southold,New York 11971 Liz Gillooly �e Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 C®UN11,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE #2132 C Date: May 30, 2024 THIS CERTIFIES that the Ten-year maintenance permit for clearing of a 4' wide beach path (within 15' deeded easement)to the sand located at the property line. At 905 Stephenson Road,Orient Suffolk County Tax Map#1000-17-1-2.2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated August 5, 2022 pursuant to which Trustees Administrative Permit#10206A Dated September 14,2022,was issued and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the Ten-year maintenance permit for clearing_of a 4' wide beach path(within 15' deeded easement)to the sand located at the property line. The certificate is issued to JOHN& CARRIE MULLINS owners of the aforesaid property. Authorized Signature Glenn Goldsmith,President ®F 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 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: LAY INSPECTED BY: e:rmo •av� Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1st day of construction % constructed Project complete, compliance inspection COMMENTS: ale, Y�GE� c CERTIFICATE OF COMPLIANCE: 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 Fax(631) 765-6641 C®UNTl,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: &` 'Pea INSPECTED BY: Ch. 275 Ch. 111 INSPECTION SCHEDULE &ZAR446- 1400-C Pre-construction, haybale line/silt boom/silt curtain 1st day of construction % constructed Project complete, compliance inspection COMMENTS: l,Jo� off- D''rcurlolrrrn. ./.�c� S, 2�'�? r Z C CERTIFICATE OF COMPLIANCE: Glenn Goldsmith, President , 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 ® lkFax(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 isc C1,6/-RJt4r IN`f Tibg '/2 constructed When project complete, call for compliance inspection; ` 4 r� r �f. rr ti a a J ` • . ti ` ,,, - .. ' Glenn Goldsmith,President ®F S0 Town Hall Annex ®� ®� 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly G � Telephone(631) 765-1892 Elizabeth Peeples y® Fax(631) 765-6641 C®UN�,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10206A Date of Receipt of Application: August 5, 2022 Applicant: John & Carrie Mullins SCTM#: 1000-17-1-2.2 Project Location: 905 Stephenson Road, Orient Date of Resolution/Issuance: September 14, 2022 Date of Expiration: September 14, 2024 Reviewed by: Eric Sepenoski, Trustee Project Description: Ten (10) year Maintenance Permit to clear a 4' wide beach path (within 15' deeded easement) to the sand, located at the property line Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the project plan prepared by Carrie Mullins, received on August 5, 2022, and stamped approved on September 14, 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. 4n V. t � Glenn Goldsmith, President Board of Trustees �DECEIVE nn AUG - 5 2022 S Uthold .+ _.�. y• ,N... _ , �` �.. ( :,. Board of Trust M — ''+` _ .». --_ ? � ._. . ._.`_ ._'_ -_.�_ --v ;'%� .. , '::�� fir•, l,.,V,��. �__._.,.......I �� --�a,;..�.�= at ... �` d t•':;,4'{ir`�.-,7 lir r`I'.-�i •. iw-, ----- 'a`• ����i.,r' Fri` ' -- a..r`°-",c�'""r"v'�— t ..•. ,.�.— ...... -•--.—�T"�t"• �SC►N MJL69ii d CAS 1Mgj1p� wafwet.--nn�r. __ s MID- `uann�t wm'ur a�yey___] Mnr.,xnarci �� •.....�........awr�u,.u•, ,......w...._._.�.�. �+ ,...oso.0 ` Wk �� ►-C cc,11i- e wK w - �L v to 109- ClQao�d 1 79 000, �"� '� / � ��' � •ill � • 4 / E C E VE I ,-- - , , , , IN AUG - 5 2022 , Southold Town tt ,� 1 • ' Board of Tws6ees ~ •• t.� 4� it IN • �� 1•�►0 p� �► '� •' BOA D OF i4STFES TOWN OF S UHOLD O 1 DATE , Town Hall Annex Glenn Goldsmith,President A.Nicholas Krupski,Vice President < 54375 Route 25 Eric Sepenoski y P.O. Box 1179 Liz Gillooly �y • �p Southold,NY 11971 Elizabeth PeeplesCXL Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: IL ;z Completed in field by: Charlotte Greene on behalf of JOHN & CARRIE MULLINS requests a Ten (10) year maintenance Permit to clear a 4' wide beach path (within 15' deeded easement) to the sand, located at the property line. Located: 905 Stephenson Road, Orient. SCTM#: 1000-17-1-2.2 Type of area to be impacted: tc Saltwater Wetland Freshwater Wetland V Sound Bay Part of Town Code proposed work falls under: X Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No A Not Applicable Info needed/Modifications/Conditions/Etc.: r Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples ,a.21,T oemv2 o<„m 12„ tzas°o wi- a6,6 012615 @-a61a lSLANO / 4, y / .o t1,s tb 0 °� ,S �7• i tM /F i �aM° Rd• w \\it A tM '1 sryM ✓ , to atr• / g4c °' R2tWd ,2114 a, 6 yNcl �'�,/ � . qtr• ° �I O. w,µt2>n� tM w.✓la S H a F t0 8 'X21 a l .+�- �+�. •- - --- a•-•- >- -- .••--- --^-- • NOTICE !41 COUNTY OF SUFFOLK © K MCTioRRo 65 � operly Tax Service Agency v�«. 22017 ip P i•c•uu 1000 PROPERTY IMP OFFICE LOCATION: �O�*of SU(/�yOl MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 a� Telephone: 631765-1938 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: September 9, 2022 Re: LWRP Coastal Consistency Review for JOHN & CARRIE MULLINS SCTM# 1000-17-1-2.2 Charlotte Greene on behalf of JOHN & CARRIE MULLINS requests a Ten (10) year maintenance Permit to clear a 4' wide beach path (within 15' deeded easement) to the sand, located at the property line. Located: 905 Stephenson Road, Orient. SCTM#: 1000-17-1-2.2 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 TownHAAvn Glenn GoIdanutb,President 0 sail Wex Route 25 Michael J.Donduo,Vice-President-President75 P.O.Box 1179 ]Southold,New York 11971 John BL Bredemeyer M A.Mdwlw KrqxAd Telephone(631)7654892 Fax(631)765-664I BOA=OF TOWN TRUMES . TOWN OF SOUTHOLD This Seeftn For Office Use 0RIY E C E I V E Coastal Fxosibn Permit Application __LVedand Pennk Applicaton I( Administrative Pamit AUG - 5 2022 /Amendmentf rransfert.Exlension Southold Town Application: Board of Trustees $ Fteived MpWedApplived �on-.-�!— ---P=P]eW: Type I T Unlisted Negative Dec. Positive Dec. SEQRA Classification: Type it Lead Agency Determination Daft: ----,,G`oordinafion:(dsta sew)-.- 0'LWRP Consistency Assessment Form Sent CAC Referral Sent Date ofInspection; Receipt of CAC Report /Technical Review: =Pubfic,Hearing Hold: Resolution: Owner(s)Legal Nam of Property(as shown on Decd)-- 0�\, Mailing Address: I k,\3 P-S '� L A) Phone Number. 00-13 Suffolk County Tax Map Number: 1000 Property Location: q S--L2 D V, (If necessary,provide LELCO Pole#,distance to cross streets,and location) 0 AGENT(If applicable): Mailing Address: 11 Phone Number: Boaxd of Tsuateas Application GENERAL DATA Land Area(in square feet): Q Area Zoning: Previous use ofproperty: V OS' a-Y\ Intended use,of property:rx P O\ (N A-6sA—� e a A-1 0 a Covenants and Restrictions on property? • Yes No If"Yee,please provide a copy. Will this project require a Building.Permit as per Town Code? —yes xG. if win be reviewed by the Buildifig Dep "Yes",tie advised this application _.t prior to.a Board of Trustee review and Elevation Plans will be required. Does this project require EL variance from the Zoning Board of Appeals? Yes .No If"Yes",plc@se provide copy of decision. Will this project require..-any demolition as per Town Code or-as d6termine4 by!WBU.A' . 'DOPO Yes ^YNo Does the structure(s)on property have a valid Certificate of Occupancy? Yes NaPrior permits/approvals for site improvements: Agency Date No prior permitslapprovals for Site improvements. Has any permittapproval ever been revoked or suspended by a governmental agency?—No Yes If yes,provide explanation: Project Description(use attachments if necessary). r ka\r 0- LA- V\J t'� e 0,C�\ Rol 4n I ri C-OA e-Z. CO- -rz )PS ins CL WETLA"frRUSTEE LANDS APPI i TION LA 1'A Purpose.of ft proposed operations! OVI -Area of wetlands on lot square feet Percent coverage of lot:..() 0/0 Closest distance between nearest existing structure,and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: ,—16z� feet Does the project involve excavation or filling? No Yes If Yes,how much material will be excavated?—.0CUbir-yards How much material will be filled? r cubic yards Depth of which material will be removed or deposited:Q feet SIS Proposed slope throughout the am Of OP=fibus: <& 5/0 1 Manner in which material will be removed or depositid'. 0 5—)— (3 LI�Vls�' V�-o 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): 617.20 Appendix B Short Environmental Assessment.Form, tnstrnefien§btC9911� part l_FrojGct lnformafion,The applicant or proj�soonsorIs respon9i_ti1..e for the completiop of Part L• Respor s become pa;t oflt►e application far approval orfunding,are subjeci:t6 WOOeeriew,and may be subject to fiiriherveri{rcation. ComQlete Fart y'based oo infotsnation currently aveilalile.:.lfa�ditioiiel;eseareh;or utveOgatien would be 4c*dedto�futfy respond.to any iteM:pldsse answer as thoroughly.as possible based on current information- add ail items is Parc.1. You may also provide any additional infoarration which you believe will be needed by or useful to_t6e lead.agetioy;attach additional pages as necessary to supglemeat any item par{1_project acid Sponsor Information Naive of: 0 or Project: CL Prajcc .'�:� ion(•escribe;aad attach a location map): Brie .Description of Pc pbW Action: 0Ow a' b +M\p r I N e of Applican Or Sponsor - +q� I Telephone: j• 3 a.7 )• �,.�nO,r '�O �Cly d cyv. 6-� Y2 E E-Mail: } r t� . , '• �.0 14L • . t dl 4�- ii �.ti--c�' �iG�1 ACLS YY�A icot—, I Address:n0 Sac 56 State: Zip Code: City/PQ: Ona' s ]_Does. re proposed action only involve the legislative adoption Of a plan,local taw,ordinance, 140 YES administrative ruk,of regulation? ❑ I If yes,attach a narrative description of the intent ofthe proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. approval or fu 'dingi'mm any other governmental Agency? NO YES 2. Does the proposed action require:a permit,appro ❑ If yes,list agency(s)name and pemtit or approval. PC;T adios? n g q7 arm la.Total acreage oftlta eft of the proposed . �'� ��.1 acres y b.Total acreage to be physically disturbed? • A2E}C S -}d C 1 e-� c.Total acreage(project etc and any contiguous properties)owned a f a q C.U-� ri `- or controlled by the applicant or project sponsor? 4. Check all land uses that occur on,adjoining and near the proposed act!.n. []Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial OResidential( barbas) ❑Forest QAgriculture ❑Aquatic �AjQtlrer{specify)- 'OC7 ' i []Parkland Page 1 of 4 5. Is the proposed action,_ _ NO. .YES 111 NIA .0 a.A permitted use under the zoning regulations? Q a b.Consistent with the adopted comprehensive plan? 6. 1s the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? U 7. is the site of the proposed action touted in,or does it adjoin a state listed Critical Environmental Area? NO .YES IfYes,identif}r_ _.. ® Q B. e.Will the proposed action result,th a substantial-increase in traffic above present levels? NO b.Are publictransportatton servtce(s)available at or nearthe site of the proposed action? ,'Q c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action?. © El 9.Does the proposed action meet.or exceed the state energy code requirements? NO YES Ifthe proposed action will exceed requirements,describe design features and technolog7ms: i 10. Will the proposed action connect to-an existing publiclprivate water supply? NO [YES If No,describe method for providing potable water 1{.Will the proposed action eorrned to existing wastewater utilities?' NO_- ES Y If No,describe method for providing wastewater treatment: I� Cl 12. a.Does the site contain a structure that is listed on either the State or National Register of Hisioric NO YES places? b.Is the proposed action located in an archeological sensitive area? I EZ j 13_a.Does any portion of the site ofthe proposed action,or lands adjoining the Proposed action,contain NO t Y� wetlands or other waterbudies regulated by a federal,stele or local agency? �. b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ® Q If Yes,identify the wetland or wawrbody and Ment of alterations m square feet or arxes: . _ 14. Identify the typical habitat types that occur on,or are{ilcely to be found on the project site Check all drat apply Mhoreiine (Forest [IAgdculturaVg assiands Day mid-successional I [[Wetland ❑urban t]Suburban I 15.Does the site ofthe proposed action contain any species of animal,or associated habitats,listed I NO I YES I by the State offederal government as threatened or endangered? 10 it%13 ttie gcfiJect s%te loctitgd in the X00year-fiood plain? NO YES 17.Wilt the proposed action rxeate storm water discharge.either from point or nbn-point soari esl NO .l YES IfYes, I NO AYES a Will storm water discharges flow to adjacent properties? b.Will stone water discharges be directed to established conveyance systems runo$-and storm drains)?' IfYes,brieft describe. NO QYES 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(es.retention pond,waste lagoon,dam)? If yes,explain purpose and size: 19.Has the site ofthe proposed action or an adjoining property been the location of an active or closed NO YES " site 'D " * solid waste managementficilitY? t lfy'�. e 's.describe" fyes,describe: EJ 20.Has the site of the proposedaction or an adywing property been the subject of remediation(ongoing or No YES completed)for hazardous waste? IfYes.describe: El ANDACCURATE TnE BEST OF MY 11 AFIMM THAT THE INFORMATION.:TW' 6 IS TRUE �bv%" KNOWLEDGE SDAWIV90 .01 W-VE ApplicarrtlsponsQrfgame: Date: Signature: Part 2-Impnet Assessment. The Lead geirey 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 ofthe proposed action?" No,or s1112ode le 1 impact to large mall i--pael impact may may 'y occur occur or zoning ❑ Wtllthe!proposed ion tea material conflict with an adopted land use plan or zoning MV LL 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 wdgrmg community? 4. will thaproposedacgon have an impact on the environmentalcharacteristics that caused the FV U establishment of Critical Environmental Area(CEA)? 5. will the proposed action result in an adverse change in n the e)CMGD9 level of traffic.or 0 affect existing infimtructm for man transit biking or walkway? 6. Will the proposed action cam an increase in the use of energy and it falls to incorporate ❑ ❑ V"Wnikbly conservation or renewable energy 6PPOTInDiflis? 7. will the proposed actionimpact existing: FYI a.public/private water supilies? b.public I private wastewater treatment utilities? S. 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, ❑ walerbodies,groundwater,air quality;flora and fauna)? Page 3 of 4 _ _�_ --- •-' Ido,or Mode+ratQ small It large impact iMpSC t may may occur occur El10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage (� problems? LLJ _`_I ' 13. Will the proposed action createa oto envitonmerital resources or human heahh? M ❑ :Part 3-Determtriatiorr oi`signifie>titee..t1ie Lend Agency is ri:spiousible for ttic:so>mpletign of pert 3: For•every rcular e adt y-off,or:rFthete is.a.n ed m CX 81111 why a gait' Part soli.iii t�art2sliaYtivas answer—wcderateto ferg"iu p leasa compfe[e.Part3. cletitent of the:proposed action tray os will not rosultid a siofaeartt adverse. vi>�tune.a tFintliave Wen•included by ?arta:slloWd,a sufiictint dbWl,-laentify the imps mcladiiogan :i?! ! f0`rd ign..- Pate 3`5hoitlda9sfl explado inhov✓tiieead eg�tcy deti,rttii° .tbaitiie:gnpa¢t the project spansorto avpid.or reilucx:impacts• coiistderin its seping,,protraiiility pf oCcurrin� may or will not besi cant.Each pateatisl isnpact:should ba assessed S _ • r def the tettpal fai skoTt-term;tong=term and duration,.;rrevibility,' eograpttx 5cope'and triagnitude- Also const . cumulative impacts. v have determined.based or the ial,011, ion and analysis.above,and any suppotO7an �Ccheckthis tion ifyo or significant adverse impacts an ttU u,at the proposed ow on may result in one or more potcntiatly large 8n environmental impact statement is requited. RiCheck this box ifyou have deteainined,based on theinformation and analysis above,and any suppo that the proposed action will not msult in arty significant adverse environmental impacts. -- Town of Southold-Board of Trustees Name of Lead Agency president �- Title or Responsible Officer Print or-fypei�iame ofResponsrble Officer in Lead Agency 1 signature of Responsible Officer in Lead Agency Signature bt pFeparer{if different from Responsible Officer) pRiNT Page 4 of Board of Trustees Application AFFIDAVIT P-1/Icli BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS HE 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 AU'T'HORIZE 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. Signature of Property Owner Signature of Property Owner - SWORN TO BEFORE ME THIS (f DAY OI - —Fi ,.20;0— Notary 204-Notary Public Mtiml-a Rios NOTARYPUBLIC,STATE OF NEWYORK Rag'lshatioa No.01R16301528 Queli&ed in Enna Courtly CommissionExpimApril 14th,2026 1 Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) I/We, '?1� ���t��j � ;� P-�U� owners of the property identified as SCTM# 1000- l _�. ._ . in the town of `',r�'e4 New York,hereby authorizes hGti'o 62 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 Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF 12 Notary Public Munska Rios NOTARY PUBLIC,STATS OF NEW YORK RegistmflonNo.0111630!518 Qualified in Bronx County. Commission Expires AprH 1416,2026 r t V Board of Trustees Application AFFMAM c h- -J-Gy-' C n Gv-P-e pn Q— BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS)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 TSE 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 AGENTS)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 TIIE PERMIT". Sigma=of Property Owner Sigaawre of Pmperly Owner SWORN TO BEFORE NIE THIS DAY OF -07 — EXECUTED before me at Sydney NSW Australia this 3 day 20)� Notary Public PHILIP SILVER Public Notary ID No.1555 0 14 Lee Street SYDI3EY _1 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM( The Town of outltold's Code of Ethics nrofiibits conflicW-4 inieieg-n the nart�offoWn 6011003 i9d,atitptoyees.T Iio this Ago into provide itifornietibn which can ala t-tTie town nUmible core is t o€imerest and allow it to tako whatever action is neocwmND avoidsam—% YOURNAME: d t.J Jf` ��l i1 _ J. 6►�" �Rl'T�+` (Last nonce, uRst name,diddle Initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other persods or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Valiance Tnistee Change ofZone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other",name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,maniage,orbusiness imcest"Business interest-means a business; including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 570 of the shares. YES NO V 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(a$entfrepr esentative)and the town officer or employee.Either check the appropriate line A)through D)andlor 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 corporations C)an officer,director.partner,or employee of the applicant;or D)the actual applicant DESCRIPTION OF RELATIONSHIP Submitted thi 20 State of New York Signature _ County f N, York PdntName. {�jz,44 VAJLiv� Subscr °e`n and swo to(or a rmed)before me this��'�day of in the year Miluska Rios NOTARY PUBLIC,STATE OF NEW YORK Xc&tmaoa No.01116301528 ignature of Notary Qualificd in Bronx County Commission Expires April 14th,2026 ApPL1 CANVA +fes .t ' 4 •0 �u i'it�iNSAQ 'WDISIL`�OSUBR ke inert of 5outhaiJ•s. odc of l:,vhichm blcri the ta�m.of tnzsibo ca c icts ofiAt n t dallorvt intakewit;;vcction ! ' form i8e'.info: ati�rt ce"ssaiv:to avoi .° Lv �— /� in ttmtte of '"oro , as 9L .$orpp 5mmr-) LM OF APPI.ICA,IIONe ( allthatM*') But7diog -- Tax grit:MW Trustee VeQiattce Coastal Bmsiun ChengooMom ` Mooring --- Approval of pial planning Emmpfion from Plat oroffiael map (if OwmvffftItefift-I h ��compaaY;spo sibling,paicnt,orchildYhaxC a rclotiop$iip with nny:operror cmploYc+. po'you persottally ltit th[oug: 'y a ar bnsinq int�aesst Busirie;s inter "% mans s ixisiness, lo.ec tins burn: patliol aivneRhip of(dr empioymnin bye a i�rporation oft 7o�vtt of Sauttlofil?'Iiztth the hip incl ccr ilr bt....,nth . it9cludiitga�crship.iii�vttich tlic town oi'fidx�x cmn Y iA'*h"ich the totvq,ol]ict-Or cmpioyce on'ns.more Than MIS OrI lin s mz--' YES _ ]t'you ans+Yeihd'. °YF-r.complete the balance of this form and date and Op whcra indicated. Ntmteof lin employed by the Town ofSouthold — Titiayr pgsitioiroftfl&t.PC= FAer check licanUagcnvmpxmft ive)�#hetdvm OM=oretnphtyee• Dc3cribe the rehd'mttsltip:tiet�v�cn lours-- ro3 (the al►� tiie apptoArintbvwA)throughD)and/grdaswbc in•thespaczFi- so7 child is(check.ti{l�iatappiy7 '[ta'ctaamofficxr•ota[tpto6uurhis'or.lmspntsr i61' - �P k stock-ElbeOPPUtO A)&C owner of gtrater than i°'o oftlie shares of the corporate. f (.�icnlhi;apyiican[isnaorpoiation), g)Uri l�g�orbenefii:ial rnvnerof any tnterast to a non-cotp=te_enMj!(wift� applicant is ndt a cortio>isiion); Gran otlictit::dirtctor.Par�orrniployec of tltc aiticartt;or �D)iheactual ePPliCOPL DESCRIPTION oFItELATIONSHIP Subtmttedtbis dayof ?0 � Signatureme PrintNa Form TS 1 Town of Southold LWRP CONSISTEIUCVASSESSNENTFORM A. WSTRVCTIONS I. All applicaals for pemIW including:Town of Southold agencies, shall OdIM tete this CCAF proposed actions that are subject to the Tows of Soulholdvat&ant ComsisWWReview Law I assessment is;2n ded to mupplement other iubmation used by a Tawe of Southold agent; makin a&4mmination of consistency. *Except minor exempt actions t ek di g B'uild'ng Pen rind other minimktt permits not loaned m to the Coastal EromonHaurddrem ' I Before answering the questions in Section C,tate pxeparer of#his form should review the exec mmosr action list,policies and esplapatttcros of4 mch policy contained m the Town of Southold Lc �Vatertagnt R+Gu'h ion Program. A::oroRosed: Add& will .be.;evaluated-as to• i#s siiaiillc bmeficid.and adverse effecis.iipon.the coastal area(Syli 6 inelndes all ofSoutfialcitom,t a I If nay question in Section C on ibis form is answered"yes"or`oto",then the proposed action i atI'ect the achievemat of the LWRP.policy standards and v0ditiaa cvi>t",in tlse cansistea review law. TLas..t tli.anstiver mt�t.be.e�cnla ned.in-deta�..listina..both•saonaAW suet n, MoartinR facts:. If an artium.canmot be certifiedas ecamst m t with the LWRP pd icy staadards, cQnditioms;it shall not be.tutdetfiakeri. A copy of the LWRP is available in the following places:oa m at the Town of Southold's website(southoldtommortb&A-uet),the Board of Musteea Office,the Plmwdng Deparhnent,a local libraries and tho Town Clerk's office. IL DESCRIPTION OF SM AND PROPOSED ACTION SCTM#: -= = PROJECTNAME The AppHeadon has been subndWd to(check oprop:Ciate,response): Town Board ❑ P1 g Board❑ BullcTmg Dept ❑ Board of Trustees 1. Category of Town of Southold agency action(check appr opsit response): (a) Actionuadettaken dbuctty by Town agency(e.g.capital ❑ CM*Hvtion,planumg may,agmwy regulation,land mon) (b) Financial mistonw(eg.giant;loan,subsidy) ((;) Permit;approval,license,eettificadon: ❑/ Natnte and:stmt of actiem: �R- Location of action: 0 C) I? S 0— Site-acre,age: Premthmduse: VD, Present mkg classification:. 2. If aa MPlicatiOn for 111D PrOPOsed action hag been filed with.the Town of Southold agency,the following jd4x3,IwI--- steal I qgbe pro (EL) i4mne of applicant: a deo LVr,0L rA C�,V\., 0, VX, L (b) Mdft 19 Teiepimm member.Area Code (d) Application mmaber,if any,. Will the action be directly undaWwn,xqdm ftm&Ww or approval bya,state arfe-derd agency? Yes Q No If y",which state or federal agenr-y"------ further.C. Evaluate the.#reject to the:I0ljcm&g policies by 9A**9 h0V.V the project wail I - -r supporter -thjt'*M further each polio - 1111MWOU net the-jaliiWs. Pievido-A-Proposed Support in mpie#e.answers w-Mrequirethatthe form beretuned for ICOMPI'lliel- DEVELOPED COAST P—OLICY Polio 1. Foster a jpa#em of&*e1opinbut In*9 TGWR Of 601"hold Out ea'b *w community, Cham0er, preserves open opine,makes etacieit qs6 of hdr*sftttm*eo malls beneficial use of 8 C00sWjOcaflou,and ,irij,j,adverse effects of-devel9pm Sw LW-pP Section 1011,611;page 2 for evaluation criteria. .L [;Zqye, n Not Applicable I,*- Attach aMond sheets if necessary policy 7. Protect gad preserve historic and archaeological r"Ources of the Town of southold. Se LWRp Section iij—Policies Pages 3 through 6 for evaluation erfte'U Yes 0 NO 11 Not Applicable Agach addtt�onal sheets if necessary PoUcy 3. Rnib�ance visusi ttualltty. ' and:p rote scenic resources through"t the Town of Southold. See I for evaluation Otearia LV6+RP Section III—Paiieies Pages 6 through yes.Q No❑ Not Applicable Attach additional sheets if neeessmy NATURAL COAST POLLS I Policy 4. Mbd mite loss of life,structures,and natural resource'from flooding and erosion.See LR Section III—Policies Pages 8 through 16 for evaluation criterra Nyes C No Q Not Applicable Attach additional sheets if necessary Policy S. _Protect.and improve water quality and guppl y in the Town of,Southall.See LWRY Section D — .9lides Pages 16 through-2 fort owbation sriUM% Lp yes ElNa I]NotApplieable Attachadditionalsheets ifnecessary :Policy 6. Protect and restore.the.tu rfy and function of the Town of Southold ecosysbms incladii gnificaut Coastal Fish and W.tldlife Habitats and wetlands. See LWRP Section III-Policies;pages through 32 for e®alun&.n criteria. No Not Applicable Attach additional sheets if necessary Polley 7. Protect and improve air quality in the Town of Southold. See LWRP Section III--Policies Pages 32 through 34 for evaluation criteria. M Yes Q.No n Not Applicable Attach additional sheets if uecessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section in—Policies;Pages 34 through 38 for evaluation criteria. Yes Q No 11 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 45 for evaluation criteria. n D YeZ] No rWNot Applicable Attach additional sheets if necessan WOREING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses In suitable locations. See LWRP Section DI—Policies;Pages 47 through 56 for evaluation criteria. D Yes ❑ No M Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable ase 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. LJ Yes 11 No ENot Applicable Auach addMnd 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 ❑ No Not Applicable Attach additional sheets ifnomssary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section M—Policies;Pages 65 through 68 for evaluation criteria. U Yes ❑ No 9Not Applicable PREPARE=D 1d��v � v�`I�TL�. DATE �5 0-'jI K �'a'