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HomeMy WebLinkAboutTR-10207A Glenn Goldsmith,President ®_,`�®� S®(/� Town Hall Annex A.Nicholas Krupski,Vice President ® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly G � Telephone(631) 765-1892 Elizabeth Peeples ® a® Fax(631) 765-6641 eouw J BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1982C Date: December 12022 THIS CERTIFIES that the as-built trimming of bushes removal of poison ivy only and cutting down of two(2)trees digging of trench to top of bluff for installation of electric for landscape lighting, At 62345 C.R. 48, Greenport Suffolk County Tax Map#1000-40-1-5 Conforms to the application for a Trustees Permit heretofore filed in this office Dated August 23, 2022 pursuant to which Trustees Administrative Permit# 10207A Dated September 14,2022,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 as-built trimming of bushes removal of poison iv} only and cutting down of two (2)trees digging of trench to top of bluff for installation of electric for landscape lighting. The certificate is issued to Sunset Sound Views LLC owner of the aforesaid property. Authorized Signature d i' Glenn Goldsmith, President ®A��q S®U, ® Town Hall Annex A.Nicholas Krupski,Vice President V� 54375 Route 25 P.O. Box 1179 Eric Sepenoski JW Southold,New York 11971 Liz Gillooly G � Telephone(631) 765-1892 Elizabeth Peeples ® J® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: + Z, 1 s Z INSPECTED BY: _X Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1St day of construction % constructed Project complete, compliance inspection COMMENTS: C C�vim► � e-�-<� �, �-� � � c�. CERTIFICATE OF COMPLIANCE: y.'5 Glenn Goldsmith,President SOUP, Town Hall Annex �0 °�� 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 Peeplesgyy�p�][�°q 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 PRIORTO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 16t day of construction '/z constructed When project complete, call for compliance inspection; LONG ISLAND SOUTH - SALTWATER ° '50"E 109.80'(DEED) N47 47 107,99'(ACTUAL) o � w w o E-- o w L1J 0 X 412 4 X4 I- 6 APPARENT HIGHWAIL11 I j� 4000 \6 O Ln 10 8 Ln c- LC) 12 �0 Ln d' 14 16 1? 18 14 20 16 -�� 22 24F 8 TOFBLUFF _ 26 ?0 2 3 X ?? .30.28 XOSION HAZARD UNE 1p' COASTAL 24 28.12 ?6 29.75 ? X .y0 SHED 3.3'W X X30.51 �� 30.01 X � 0 i= V) N W C 31.97 X C C X31_56 ko 4� C J X a) D X !' _ Bu p w Hazard B yq @ 0 U- X Coastal Erosion z W x0 Tax Map Lot 5 X0 z Ifo z I- N 20.5' 34.54 .y X 34.86x 4'BLACK CHAINLINK FENCE HOUSE OUSE 36.51 X 20.5' X zo m 40 42 10AL N 42.53 .6' SHED X X 43-17 X 42 44.14 �0��7, 4 X ,,.,� 71 7� GRA C 44.26 0.1'E Ln AMP TOOP 6 'rr X4.29 n 45.6' 7.4 CONC. 132-STORY STOOP 3 CONC. HOUSE k STEPS PATIO n 'n No. 62345 N 24.3' < 7 FFL,46.72 M 45.00 C7 � RIDGENEIGHr•6a.28 X 13.5 44 64 Tn OWE HOUSE X 44.90 OOP n 21 44.19 9 °,E SURVEY OF Atev GRAVEL PROPERTY WALKWAY 19'9' DRIVEWAY Q E SI TUA TE W TOWN OF SOUTH OLD �2 w t.UG 2 3 2022 SUFFOLK COUNTY, NEW YORK CD QI' TAX No. 1000-040.00-01 .00-005.000 O to x 42.41 41.51 N X Southold Team SCALE 1"=30' t� 0 Ln '�"' ®oprdofTructees NOVEMBER 8, 2021 AREA = 49,043 sq. ft. 1.126 ac.(DEED) GRAVEL DRIVEWAY ►-`-I O 44,270 sq. ft. 1.016 ac.(ACTUAL) o X 40.85 ro F-f 42 O 40 a8.7s a AERIAL LAND SURVEYING, D.P.C. NOTE: LOCATIONS AND EXISTENCE UC ANY \ 4'SPUT A53 PROBST DRIVE CER RIL FENCE FE 1.3'W SUBSURFACE UTILITIES AND STRUCTURES NOT READILY VISIBLE, ARE NOT CERTIFIED. THE 2.3'S 4,632.88 SHIRLEY, NY 11967 CERTIFICATIONS HEREON ARE NOT TRANSFERABLE. PHONE: 833-787-8393 _OVERHEAD WRES_ _ ,_ . . _ _ E-MAIL: SURVEYS®AERIALLANDSURVEYING.COM WEBSITE: WWW.AERIALLANDSURVEYING.COM THIS SURVEY IS SUBJECT TO ANY EASEMENT OF RECORD AND ANY OTHER EDGE OF PAVEMENT ATE PERTINENT FACTS WHICH A TITLE SEARCH MIGHT DISCLOSE S56* f DISTRICT:1000 LOT:005.000 BLOCK:01.00 SECTION:040.00 *UNAUTHORIZED ALTERATION OR ADDITION TO A SURVEY MAP BEARING A 3�7 Off LICENSED LAND SURVEYOR'S SEAL IS A VIOLATION OF ARTICLE 134, W9 0. 00' 38.13 MAP/FILE NO.: N/A SECTION 7209, SUBDIVISION 2. OF THE NEW YORK STATE EDUCATION LAW C.L.40.66 NORTH T �� X lu� X 'Copies from the original of ey a t marked with an original ROAD of the land surveyors J�ea'Car Qppp eat shall not be MAP OF: "Not on a filed subdivision map considered a valid true ori `Cer Ion dic hereon signify that • this survey was prep \1n a w e I Code of Practice (MIDDLEof for Land Surveys a b w A i ton to UTILITY POLE ROAD) TITLE NO.: HBA-6396-S-2021 Profesionol Land ry a eer tatla r ly to the person for whom hQQ sur y 1 prepay and h b al to the title of MAP FILED DATE: N/A company. govern sTad gen d I q IrAptitutlo ons are not transferable o odd tonal eQu n id COUNTY TAX MAP ID: 1000-040.00-01.00-005.000 '- n � SITUATED AT: TOWN OF SOUTHOLD 0 NOTE: SUBDIVISION MAP LOT & BLOCK 'S: N A s 50205 J 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUMI Janos Varkaris � SAND EXISTING ELEVATIONS ARE SHOWN THUS: xm o -Habitat s rac , LLC First American litle Insurance Company COPYRIGHT 2021 RALPH HEIL, Valle National Bank its successors and/or assigns AERIAL LAND SURVEYING, D.P.C. LIJ as their interests may OP JOB NO.: 21-1761C U DATE: NOVEMBER 8 2021 - LONG ISLAND SOUTH SALTWATER N47047'50"E 10J. 80'(DEED) 107.99'(ACTUAL) I- W � W O 4.42 O CI I_ x 4 _ 4 O 1--- APPARENT HIGH-WATER LINE--(11/10/2021) .O � 0 ` IIYQ�Ma�Is�a�N_�N��ases�rw� r�1�6 In 10 8 O O Lf712 Ln (D 06 d - - In d d 14- ,o d- 16 - 12 , 18_ _ ,4 20 22 16 24 / TOP OF BLUFF �\ ,� 1 26 - •�- y 28 3 X X XE 10' COASTAL EROSION HAZARD LINE � nx�f;Xw "�lX .1 26 , / � I I SHED i I ; X* i I A, `..- X 29.88 O X 3o,D 1 'I -. - IQ -LjY� , _.2 4 , Y \ a 7 L , . uJ '✓1 U g N �� t I ' I31 97 X n n5 -- lL J 0 0 X x 31.56 - �.�. J - - J UJ Bu Coastal Erosion Hazard B ro O � U- X - Tax Map Lot 5 x I Y' c t; z / z C, t C � 4 X �' 34.5 � 34.8 'Z,n cmm'LiRK FENCE FE n• 2.0'w HOUSE -' 36.51 X 3$B6 20_5' X - _ x o � z ,i cn 42 AJ,.. rQ Br X 1.7-4. 42.53 j SHE X 43.17 X ., 1 �_m 0 P �RDV � L� 44.1 4 BOARD OF ) USTEEs n l PATO I X rCQNC.._GRAyEL TOWN OF SOUTHOLD > AMP..... .. TOOP 44.26 44.3 1 0.1'E N 45.6' r� per- N 7.4' 1Y2-STORY STOOP DAT `� 1/�� �zoZ2- CONC. HOUSE h STEPS PA '61 No. 62,545 v I 7 24.45-01 M �` < �f ni F 0 FL-:46J2 M c7 B11t?GEHEIEIGfiZGp.28 , X 1 .5lo.c� in 0.6'E r21.5' FEHOUSE 9 -r 0.3'E X 44.9STEPS x < SURVEY J F GRAVEL PROPERTY .GRAVEL I WALKWAY DRIVEWAY I S1 (r UA 1E Az w W pffG2 TOWN OF SOUTHOLD o 42.41 OSUFFOLK COUNTY, NEW YORK x LO X 41.51 N TAX No. 1000-040.00-01 .00-005.000 o� z SCALE 1 "=30' � o NOVEMBER 8, 2021 - 00 Boutholdw oardofTe AREA 49,043 sq. ft. 1.126 ac.(DEED)p Y 41.25 0 44,270 sq. ft. 1.016 ac.(ACTUAL) 1 - .42 X , 40 38.76 O \ 4'SPUT RAIL FENCE FE C.� AERIAL LAND SURVEYING, D.P.C. NOTE: LOCATIONS AND EXISTENCE OF ANY 1.3w 53 PROBST DRIVE SUBSURFACE UTILITIES AND/OR STRUCTURES NOT READILY VISIBLE, ARE NOT CERTIFIED. THE OVERHEAD WIRES - 2.3's 4,632 88' SHIRLEY, NY 11967 CERTIFICATIONS HEREON ARE NOT TRANSFERABLE. ^ _ PHONE: 833-787-8393 E-MAIL: SURVEYS®AERIALLANDSURVEYING.COM EDGE OF PAVEMENT ATE ��- ----------- -__ __-..... WEBSITE: WWW.AERIALLANDSURVEYING.COM THIS SURVEY IS SUBJECT TO ANY EASEMENT OF RECORD AND ANY OTHER PERTINENT FACTS WHICH A TITLE SEARCH MIGHT DISCLOSE 56 e,j 7'20"W DISTRICT:1000 LOT:005.000 BLOCK:01.00 SECTION:040.00 � "UNAUh10RIZED ALTERATION OR ADDITION TO A SURVEY MAP BEARING A C.L.40.66� NORTH 0. 0o C.L.38.13 MAP/FILE NO.: N/A LICENSED LAND SURVEYOR'S SEAL IS A VIOLATION OF ARTICLE 134, SECTION 7209, SUBDIVISION 2, OF THE NEW YORK STATE EDUCATION LAW ROAD X j�,.,�J, O L! "Copies from the original o e.qy 7 ,A;M n arked with an original --« 111.J » of the land surveya•'s i eal(7Wel�lrh6�6d I shall not be (NIDD MAP OF: "Not on a filed subdivision ma considered a valid tri lvl P c�Q�y Indict ereon signify that LE this survey was pre rstj`QrT d wi e I Code of Practice UTILITY POLE ROAD) TITLE NO.: HBA-6396-S-2021 for Land Surveys a Kdw Ya sia an of Profesional Land rvea"id cli�lNicytiona tfi { to the person for whom 1¢, r fond on h beh o the title MAP FILED DATE: N/A company, govern e d ,tu fications are not transferable quo o s." COUNTY TAX MAP ID: 1000-040.00-01.00-005.000 F' SITUATED AT: TOWN OF SOUTHOLD NOTE: s^ X5020 SUBDIVISION MAP LOT & BLOCK 'S: N A r 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM � AtvC) r�}� Q I Janos ar aris < EXISTING ELEVATIONS ARE SHOWN THUS: Habitat As rac , 0 W FirsT American litle Insurance Com an ILL. COPYRIGHT 2021 RALPH HEIL, Valle National Bank Its successors and/or asst ns AERIAL LAND SURVEYING, D.P.C. � as their interests may a JOB No.: 21-1761C DATE: NOVEMBER 8 2021 ®w`�®F U ®� Glenn Goldsmith, President S® Town Hall Annex V� r A. Nicholas Krupski, Vice President 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 com BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10207A Date of Receipt of Application: August 23, 2022 Applicant: Sunset Sound Views LLC SCTM#: 1000-40-1-5 Project Location: 62345 C.R. 48, Greenport Date of Resolution/Issuance: September 14, 2022 Date of Expiration: September 14, 2024 Reviewed by: Liz Gillooly, Trustee Project Description: As-built trimming of bushes, removal of poison ivy only and cutting down of two (2) trees, digging of trench to top of bluff for installation of electric for landscape lighting. 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 Stilianos Varkaris, received on August 23, 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. Glenn Goldsmith, President Board of Trustees vienn Goldsmith,President �® �OG� Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 Eric Sepenoski , P.O.Box 1179 Liz Gillooly �y ® 0`� Southold,NY 11971 Elizabeth Peeples �O! �a Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: I 2Z Completed in field by: L• G,'�� GzS L(„ SUNSET SOUND VIEWS LLC requests an Administrative Permit for as-built trimming of bushes, removal of vegetation, poison ivy and cutting down of two (2) trees, digging of trench to top of bluff for installation of electric for landscape lighting. Located: 62345 C.R. 48, Greenport. SCTM#: 1000-40-1-5 Type of area to be impacted: Saltwater Wetland Freshwater Wetland X Sound Bay Part of Town Code proposed work falls under: y 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 x Not Applicable Ianfoneeded/Modifications/Conditions/Etc.: d v,clit is as SKSv V1'%C. ?c \Ikec¢7. O dl r-e a-t-rr G a a+-� i c I a P te4+4-r W, `f " Present Were: G. Goldsmith N. Krupski E. Sepenoski �_ L. Gillooly E. Peeples r 1 1 i • y � r r t♦ i h r i F xy r � : f ve Y nj r j��• �, i +� • .0 , It, J7 WWI, . I, Ail Vk LC l• 3 I 3 r �'� • � V�� jjj r • `��•+" ' ^1 1 mac' •� � t u� � ,j�' ��- � �t ,I� ,�� ��. � 1. 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Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 apQ Telephone: 631765-1938 �y10'-UNV I 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 SUNSET SOUND VIEWS LLC SCTM#: 1000-40-1-5 requests an Administrative Permit for as-built trimming of bushes, removal of vegetation, poison ivy and cutting down of two (2) trees, digging of trench to top of bluff for installation of electric for landscape lighting. Located: 62345 C.R. 48, Greenport. The proposed as built 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 proposed action is INCONSISTENT with LWRP Policy 6.3 and therefore, INCONSISTENT with the LWRP. 6.3 Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction 9. Comply with Trustee regulations and recommendations as set forth in Trustee permit conditions. The as-built clearing was constructed without Board of Trustee review or permit. The language in the request to remove poison ivy-filled vegetation is unclear. The request should say "remove poison ivy" only. 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: The Honorable Lori M. Hulse, Attorney Glenn Goldsmith, President � � Scot Town Hall Annex V 54375 Route 25 A. Nicholas Krupski,Vice President u V� P.O. Box 1179 Liz Gillool Eric S shoos ki Southold, New York 11971 y all Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 �UNT`9 BOARD OF TOWN TRUSTEES TQWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application AUG 2 3 202 Wetland Permit Application 1( Administrative Permit Amendment/Transfer/Extension Southold Town -Received Application: g,2-3,0-.2— Board S1 Trustees LlZeceived Fee: $ 200.00 Qd� Completed Application: Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: oordination:(date sent):_ LWRP Consistencv " ;.V nt: CAC Refe- - ' , j Date of j A ZU 7i� Receipt\; TechnicG� 6N 7� Public I;'s FR.0WJ Resoluti i Owner(s) Legal Name of Property (as shown on Deed): 55 s e_+ S c t.v1 C� V, p�ys l-� Mailing Address: I (' L- S G- \e� AJ Phone Number: C1 I I - t-} 1 �i -7 Suffolk County Tax Map Number: 1000 - 0 4 b • q o — 0 l. cp o - O d�. oto �n Property Location: 6 23 t_I S /140 r io,- A) (0 cf (If necessary, provide LILCO Pole #, distance to c oss streets, and location) AGENT (If applicable): Al Mailing Address: Phone Number: Email: Board of Trustees App"4 -ation GENERAL DATA Land Area (in square feet): L49 . 0 4 3 ( "D ,2-�C� q y, z:� o Area Zoning: Previous use of property: IJP e S t ct �.a�-�r C, Intended use of property: 2 S �,,�4 & Covenants and Restrictions on property? Yes No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes X No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes 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? X Yes No r \ Prior permits/approvals for site improvements: �1'e�oY�,.�e e,� k s..�, Agency � � � Date Pe No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No Yes If yes, provide explanation: Project Description (use attachments if necessary): T r 1 w1 6 u5 CP-w -e- v 2. @,�—c:.�-►r,,.. �� ,o� � e inn o v � � A- e incA, - -o t� S �.tA-Y� L �Ck 04 ,-o x wta y ��L3lzZ Board of Trustees Appy `ition WETLAND/TRUSTEE LANDS APPLICATI®N DATA Purpose of the proposed operations: I" ` C, k m S b i re'erVIv"Q P015`cx\ 1vV Ve nake- r i a 43 F, � atop ��L3�2 L F� heA o. 0..vto ® 1 Ung [Jm �,25 hes S [ Area of wetlands on lot: square feet Percent coverage of lot: 1 2- % Closest distance between nearest existing structure and upland edge of wetlands: 16 p feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No ✓ Yes If yes, how much material will be excavated? q (o cubic yards How much material will be filled? ' b cubic yards Depth of which material will be removed or deposited: 2 feet Proposed slope throughout the area of operations: Smm e. Manner in which material will be removed or deposited: LO I S �uoy 2 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): i'� d►�1 617.20 AppendLx B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part l based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part I. 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: Di— 1 e-V—Yv1 l r0 r T� �.v�C t �l U� 5�C(.0 Project Location(describe,and attach a location map): 6 2 3 g S J1��r-rk Brief Description of Proposed Action: I v y l�<rte( lsQ� Y�o�-►, Name of Applicant or Sponsor: S J Telephone: �J J 7�� 7 e / ri / S. `' �uun S P� aOf,U�ri( IZ �Gd S ��C �/ E-Mail: ,-e. to e—a 'V'CU—h Address: 16 LLOC—us � cum ,e— City/PO: State: Zip Code: S- I_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 ® F1may 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? 1, 126 acres b.Total acreage to be physically disturbed? , ro 0,6 acres c_Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? L 17-6 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban [::]Rural(non-agriculture) [:]Industrial ❑Commercial Residential (suburban) ❑Forest ❑Agriculture El Aquatic E:]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? ❑ 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: S. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? © ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: f 10. Will the proposed action connect to an existing public/private water supply? h�J 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? A� El ❑ b.Is the proposed action located in an archeological sensitive area? r� ❑ ❑ 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 ❑Early mid-successional ❑ Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats, listed NO I YES by the State or Federal government as threatened or endangered? LI� F-116.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, 9 Ela.Will storm water discharges flow to adjacent properties? ❑NO ❑YES b.Will storm water discharges be directed to established conveyance systems (runoff and storm drains)? If Yes,briefly describe: NO ❑YES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: � ❑ 19. Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: � ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: ® ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE 5�—�c v�rs Applicant/sponsoS%Oupl^i V w it L Date: Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the.following questions in Part 2 using the information contained in Part 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 I. Will the proposed action create a material conflict with an adopted land use plan or zoning 1:1 ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? ❑ ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the F] ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or Elaffect 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? F-1 0 8. Will theproposed action impair the character or quality of important historic,archaeological; F] ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands;- ❑ Elwaterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage ❑ ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? El D 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 App.''- --,ation AFFIDAVIT .1y, 4-rz�S BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL, TO ENTER ONTO MY PROPERTY TO INSPECT TIME 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. p L ,4!;6- C AZ L_ rn6 m--7- 91`a- L/! 7- 5�� 7 vV e-Vre 144 0 ,1 IA Signature of Property Owner ign{ature of Property Owner AA tews e-C 1 ms`s t�, SWORN TO BEFORE ME THIS � s � DAY OF a 7 , 202-2- 44 JA+SES T�,TOS Notary Public S1,te O N-M York r �lO. Oti<Do9925;s7 Notary Public Oa�ali�ie�ic�untsy ` Nly Commission Expires.,- Z 2� APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: (Last name,first name,Middle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee `mac Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other'',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this 5� da of— XkL& 20�.Z Signature w„Q�;rti� lf r Print Name .57-/L 1~0 S A¢aeA, d Form TS I Town of Southold LWRP CONSISTENCE'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# fDVL9 0.u0- v(. ao — coo 5'. too o PROJECT NAE Z 3 q,i— IVO ,'�'� �,� a?" A IdI The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees Q 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: FIV Nature and extent of action: PEWYnAc ' aA,e_S e. S 4t ►^1 , 2 r.� r P ,�.fe�l�n I� n o t c P,►l. C VV 411-ed U ea k�tll r-e441,CVA o � 2 dead G4 r It Location of action: z3 LI /V v� Site acreage: I , 1 z Present land use: Present zoning classification: Ce,S 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: II (a) Name of applicant: V1 �e-w S L ef - 5 (b) Mailing address: 4— L,,,, (c) Telephone number: Area Code(°)l 7 j 7 - 45�� 7 (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ❑ No g If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, snakes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LVVRP Section III-Policies; Page 2 for evaluation criteria. ❑Yes ❑ NoNot Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III-Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No Not 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—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ NoLIN 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 F'� 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 9Not 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. ❑ 7 pi/ft Yes No :,)t Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LVVRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No IV Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LSP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No ® Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ XeO No 15a Not Applicable Attach additional sheets if necessary WORKING COASTf\, _"ICIES ' 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 Fj Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic ]Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages 62 through 65 forevaluation criteria. ❑ Yes 1:1 {No � &Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No� Not Applicable PREPARED BY 'V A R_ TITLEAJA__DATE 2 Z