Loading...
HomeMy WebLinkAboutTR-10246A Glenn Goldsmith,PresidenteH®F S0 Town Hall Annex A. Nicholas Krupski,Vice President ®� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski J Southold,New York 11971 Liz Gillooly Ca Elizabeth Peeples a Telephone(631) 765-1892 p Fax(631) 765-6641 COUNVI BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE 2042C Date: June 17, 2023 THIS CERTIFIES that the remediation of clearing by the planting of native shrubs, including rosa rugosa baerry and milkweed,• and for a Ten(10)Year Maintenance Permit for the removal of invasives; At 155 Glen Court, Cutchogue Suffolk County Tax Map#1000-83-1-2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated October 21, 2022 pursuant to which Trustees Administrative Permit#10246A Dated November 16,2022,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 remediation of clearingby the planting of native shrubs, including rosa rugosa bayberry and milkweed; and for a Ten(10)Year Maintenance Permit for the removal of invasives. The certificate is issued to Marcus R. Bryan Revocable Trust owner of the aforesaid property. d Authorized Signature Glenn Goldsmith, President ®F s®(®j� 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 tet` ® a4 Fax(631) 765-6641 UN BOARD BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: r INSPECTED BY: N- `r"P Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1st day of construction . % constructed X Project complete, compliance inspection COMMENTS: gt'�WJl ,t'�) ©AJ O K, CERTIFICATE OF COMPLIANCE: Glenn Goldsmith, President F SI Town Hall Annex A. Nicholas Krupski,Vice President ®� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski A6 l�L Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples ® a® Fax(631) 765-6641 C®UNTY,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction '/Z constructed When project complete, call for compliance inspection; ;'LYAA) Ro inN N N �O n .r e v v 0 v �o v v A—( o� �LA.NTtti�S SPI Roin xt i� m v m e ST(dN S' o U APPROVEDZY BOARD OF 6 RUSTEES TOWN OF SOUTHOLD DATE uDW, , jk Zvz?, I ep e I I I � x�s—rw �- � /�y L► ��� �S p ECEIVE OA u of OCT 2 9 2022 SDUftld Town ftafd of Th tees MARCUS R BRYAN I STATEMENT PERIOD Sep 1-Sep 30,2022 If anything in your statement looks incorrect, please let us know immediately. In case of error or questions about your electronic transfers,we can be reached bytelephone at 1-888-464-0727,or mail at P.O.Box 60,St.Cloud,MN 56302.Or, log in to your account at capitalone.com and click on the transaction.If you think your statement or receipt is wrong or if you need more information about a transfer listed on your statement or receipt,you must let us know within 60 days after we sent you the FIRST statement on which the error appeared. (1)Tell us your name and account number. (2)Describe the error or the transfer you are unsure about,and provide an explanation of why you believe it is an error or why you need more Information. (3)Tell us the dollar amount of the suspected error. We will investigate your complaint and will correct any error promptly.If we take more than 10 business days to do this,we will credit your account for the amount you think is in error,so that you will have the use of the money during the time it takes us to complete our investigation. Page 5 of S i , \( MEp1PC �+J capitalone.com \�`,)1-888-464-0727 113'11 P.O,Box 60,St.Cloud,MN 56302 ppf Ce"J'd l Glenn Goldsmith,President ®F S0 f�� 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 COUNTi,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10246A Date of Receipt of Application: October 21, 2022 Applicant: Marcus R. Bryan Revocable Trust c/o Marcus R. Bryan SCTM#: 1000-83-1-2 Project Location: 155 Glen Court, Cutchogue Date of Resolution/Issuance: November 16, 2022 Date of Expiration: November 16, 2024 Reviewed by: A. Nicholas Krupski, Vice-President Project Description: Remediate clearing by the planting of native shrubs, including rosy rugosa, bayberry and milkweed; and for a Ten (10) Year Maintenance Permit for the removal of invasives. 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 Marcus R. Bryan, received on October 21, 2022, and stamped approved on November 16, 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. en�nGo smith, President Board of Trustees Cs:�....Goldsmith,President o��g11E " cOG Town Hall Annex A.Nicholas Krupski,Vice President C, y� 54375 Route 25 0 Eric Sepenoski ,x P.O.Box 1179 Liz Gillooly �y • �`� Southold,NY 11971 Elizabeth Peeples ��! �a Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: Cl he Zz Completed in field by: �•��`N�y MARCUS R. BRYAN REVOCABLE TRUST c/o MARCUS R. BRYAN requests an Administrative Permit to remediate clearing by the planting of native shrubs, including rosa rugosa, bayberry and milkweed; and for a Ten (10) Year Maintenance Permit for the removal of invasives. Located: 155 Glen Court, Cutchogue. SCTM#: 1000-83-1-2 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: _�ZChapt.275 Chapt. 111 other VYPApplication: Wetland Coastal Erosion Amendment of Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needled/Modifications/Condig9tions/Etc.:C I Yc Ve .4 4vj -af of bOl:��wJ. a c w d rt'&d4/ A �. or S & rw' Present Were: G. Goldsmith XZN. Krupski E. Sepenoski L. Gillooly E. Peeples Duck Pond Pt qf Oz. . •� LA � 4 :. .: . �. Lir 3l II011 -- SL/�rof_KGo...HA�sTrZo'`"1 1'1A4 P 26 c I. FF 2. V.A N OTE•S: los j. 'b.4 ram LOT- Z LOT 3Z?gjE' E.r2oSION 4forrTWL T`2r E.a�-ED if.-p-R 0 r L.ot�►-roN o zs- Ex. 2515 GL EN Cou1T - �w6��nrv, G�ITGtlOGU�,N 1 11935 SGTfl.*b /DDD -a3 3•. Z54�.�.GLE,4N F,«To r3E; TrZucYEf�.�iv FZor -AN UPL AN,.b SocyrZCE �LE1y (0:.4�.��aGE'NT oWN�S C�LfZT ' 1 f(,A LL-A Z_-qt ZGE4 1_(r LL-S?1ZoPER:j� ig pC E I V &-4 FOR M-. R4r- cS f X OA Nib 3z y a N . oN OCT'.2i 2022 Lr'ont U i.SL-Af4 b 1 SvuN� ln� �uTcN o�u�• . Southold Town SU FF01.4 (•o •,Ny 11935 Board of Trustees 5f4EET 101= 2 M A,t *110 1 11 r. n.A 1U, COCOA",1AIM w Cy7 tf 4f., vr. . 40 .V4. to the pasignobscilhe jandinginsti- Jendfho institution 11itedlIGIMMd tutlon.Cuamnteesare not transkf" r AP0 to additional institutions or subWwqu7. ja L n Vat- to An $JTU r4l A 4;L T DIV U OF W. E I V'r rt" - V��U - -91. -A A T6 T -JITIT CWU 7 ^. °���� 1.S 25620 €`�j!la '511..vi'v. at.v Ti., SJ Southold Town pf 4 v Board of Trustees' .r*orlo,)0�1 is _:41 Pit - : .:: ': . .;, . fir � . ,. . . i L­ Ya 1 *, ry Lt e, DAIAR ,y - _ >; �.P''•.y •••�`,' .` SEE SEC N 0)2 - R " • , 12.pR p9 ° gDUND ..,.�� T' 1Vta'•.(N .rl''a-r. , "1 45 I,aNJ .a•'f �� `, SCN.D.9f.D 29` •T"c 1Ren •.,w to aln6 •to , N 'I � ..S '1 fA(clt DI 1f IV ' �"• < '`� =Nl17 ,+ 3 �^.•'ev,I �a JA(cl 12&Ifcl4! t.HA %/'u^� tam'` "rd< )• ce .�iiarr�i sl t,uAf:i / /l^ 122 1.9A t}3 YI ' Q�G ,,,yr':,' n,Afr> ,� ,o l A cmmrnmanx r'•.-1..ti \ Qfc „ a „ �yg ' , ' n z? , I 6l r 3ew;%j' \L �_ ;>,y v,2;!r w„i �rr.avn..ww)sJ ,.24. •f, ``r �r4r, � v el •.'�` y^�;'` ♦�,, n .,,'��., ”' Frs'.e;,� aer,cvuvvrwurs, 'g r• ti� ee' `<'9. ��i ryY'`,\ -/M1^..4^��'��9:q•8 y'♦.K•a '� f ../\ „k '';/Aq<Sq �i•-,:'� r'Q9 J�." i - ,H .a,ry •T�p',W `ai,\ , Sbnp. ' .N , F{�]2 ' "ti ,1 iY �1 •�°%�••. I'r. ,at q,_y•�,.� ,�s \g', -a ,� ''z;,� , `.t.% ✓, dr . �'.\ aIA ' "\, � �,• ,' a e'' �n �,.^" W' , \ < � , .•\''- a .Y� s �^b`pt -�- � � y �� �e1 `,� (' - - \U. .•, As.�j'i: ^ .'r -EEE SEr„ o , �^' " ,.�' ` '. � •�•'' 2)]0.fc) `.ti .a ern o `,aY,." - < , ., ' i .. `.. .` \ ♦ ^.� / IBNR.^ �r Q t ' iGR PCI NG, FIXJ PCI.NG.\+� ` FGRP0.IJG 'PGRFCl.NO�`' \^'\,\� \ ! \-' + -'`' •`'\' EEC EEC.NG. :SEE SEL NO'` Em=NO. 'CCE kCC.Nd ,•�`w-0�^�It Q,fGR pµ.NO , \s-� Tx'aCi.pHBd'• 0a'rM-W3 < p9R+JW. - `MipiLit/ `'\, ;L SCC NO 99R4sM s -� JW- "t �' ^, � LINE`•+e„^, S.�i `,MATCM � - -' LINE' S - SEE Sec.NO p9R L ,. 6Ef:5EG NO Do ('+ ti M`Hr M 0,:7.. ..-v�.,.,.<at,�tH..ulw „_ — - ,.. -- COUNTY OF SUFFOLK C� >` Iry�„� E ,.,.w�w�. f r..- v , N NQTICE K o 1DDD SECTILN rA G1p1y— _ au .awa'--n—_u—,r r` `✓ —�— rR riCJ)(a[VN<TtY']�%eJ'<rl'ie<[�);Cltey NfBMeY NTH+nTdi 6nlE 00. V E v-r_1'3_—— —— —— —— t __— --;n__ ”„ �, f?; W#E wa N of nl[ M w> ) 30UTKo n,„%t, E ED A 083 OFFICE LOCATION: *OF SO!/r�o MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 • Q Telephone: 631765-1938 �yCOW T`I,Na 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: November 11'.5''1"202'12' Re: LWRP Coastal Consistency Review for MARCUS R. BRYAN REVOCABLE TRUST c/o MARCUS R. BRYAN SCTM#: 1000-83-1-2 MARCUS R. BRYAN REVOCABLE TRUST c/o MARCUS R. BRYAN requests an Administrative Permit to remediate clearing by the planting of native shrubs, including rosa rugosa, bayberry and milkweed; and for a Ten (10) Year Maintenance Permit for the removal of invasives. Located: 155 Glen Court, Cutchogue. SCTM#: 1000-83-1-2 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 and the records available to me, it is my recommendation that.the proposal is INCONSISTENT with LWRP Policy 6 and with the LWRP. 1. The clearing of vegetation was conducted without a Wetlands Permit and Board review. 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 Glenn Goldsmith,President _A`�®F sou Town Hall Annex A. Nicholas Krupski,Vice President ®V� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski ! 3 Southold, New York 11971 Liz Gillooly Elizabeth Peeples � ® � Telephone(631) 765-1892 Fax(631) 765-6641 l�c4UNT`1,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application X Administrative Permit Amendment/Tran sfer/Extension Received Application: 10.21•ZZ Received Fee: $ 90.00 U-11kir Completed Application: 10-ZS2?— Incomplete: SEQRA Classification: TypeI Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: 'Coordination: sent): D E C E I V E LWRP Consistency Assessment Form Sent: CAC Referral Sent: 0 Date of Inspection: OCT 2 1 2022 Receipt of CAC Report: Technical Review: Southold Town Vot–Public Hearing Held: /�•�(o•L?�- Board of Trustees Resolution: Owner(s) Legal Name of Property (as shown on Deed): � 1 Mailing Address: a'3 (r-1410 c o L)(z.T, C L'-r c l4o 6=u r✓' 'Aj l Phone Number: A0 23 �' 3 `� R4j ?q3� .G*0 Suffolk County Tax Map Number: 1000 - �1 Property Location: 155 5 f-L b./s c d P-;T c,uT0/-Jo (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): Mailing Address: 144.efm Phone Number: Email: YV�A-mr&op o) Board of Trustees Applica ` on GENERAL DATA Land Area(in square feet): 7 0 o d Area Zoning: Previous use of property: V Intended use of property: y a,' A T �S 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 C No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure (s) on property have a valid Certificate of Occupancy? Yes No AU 4 Prior permits/approvals for site improvements: .* W&11 A,'d 5`r U r U1 Agency Date 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): 11- £ (UX i l� 1,4-716 1 fy Lo N Im& LA,-J—(kyJ6- A14 1%yL -9d�.vl;S ltic"Al k1l c... 1?.UaoS,c1 O.S.V, 1A ry �_P_Qy _ A "N'> A,\xLKwao_a , . A tJAUAL MAUV_( 9,AJAA)C1L l01�f--Ai 11VE 1A,?v.a-S-1VC IF LA-AJT5 �yC_t4 A4 'Z�AAA-)�Po0 Board of Trustees Applica on WETLAND/TRUSTEE LANDS APPLICATI®N DATA Purpose of the proposed operations: 12 A-&,tt 7 1 4? y&) C L 6/,(Z.1A1 G Area of wetlands on lot: q o o® square feet Percent coverage of lot: 'To ',►p 6[pt ue?RES Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? Q cubic yards How much material will be filled? 0 cubic yards Depth of which material will be removed or deposited: 0' feet Proposed slope throughout the area of operations: /V 0 3`0-P Manner in which material will be removed or deposited: H gu l'b 1 L,A,,J 71 A)6- d E.5 ti 0 ,E" gam,y Y -�Z1� /Ln 0yA-t- 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): } L �i� 61 Z 20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: Project Location(describe,and attach a location map): I ' � 47 Li).) CoU12T Brief Description of Proposed Action: (Z S IA s: l 4—il JJ ''3 Y 7'Z r►N7 1hJ6 /0 1 71 V C_ VA-0a Name of Applicant or Sponsor: Telephone: �3f ,� /VX A P, G V S �f1A) E-Mail:( Address: City/PO: State: Zip Code: 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and.the environmental resources that ® ❑ may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: ❑ 3.a.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? y acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? t acres 4. Check all land uses that occur on,adjoining and near the proposed action. F-1Urban ❑Rural(non-agriculture) E]Industrial E]Commercial Residential (suburban) ❑Forest ❑Agriculture El 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? ❑ ® Elb.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? F]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: ® ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? © ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? I El 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: 29 ❑ 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? ❑ O 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 [R'Wetland El 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? FX_1 ❑ 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, 0 Ela.Will storm water discharges flow to adjacent properties? NO DYES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO ❑V YES A-r 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 AFFIRMWna FORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLE Applicant/s '� Date: try�JC� ]SZ Signature: 0(Z 11 Part 2-Impa(lable ssessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the.following questions in Pusing the information contained in Part 1 and other materials submitted by the project sponsor or otherwise ava to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses beeonable 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 El regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? El 1:1 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the El 1:1establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or 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 1-1 1:1reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: E a.public/private water supplies? b.public/private wastewater treatment utilities? El 8. Will the proposed action impair the character or quality of important historic,archaeological, El 1:1architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ ❑ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 } No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage ❑ Elproblems? 11. Will the proposed action create a hazard to environmental resources or human health? F� ❑ 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. F1 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. F1Check 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 Applica_, ;on AFFIDAVIT _8CzqAlj 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 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. Sig ature of Property Own r Signature of Property Owner SW O TO BEFORE ME THIS 21' DAY OF Q� , 20 Notary Public D ;E E J V EE-0 DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK T No. OID1476593 CI 1 022 Qualified in Suffolk County My Commission Expires April 30, 20 Z� Southold Town Board of Tnistoes APPLICANUAGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE.FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The pumose 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: A&,N CZ e. O �� ('��� ()IIJ (Last name,first name,griddle initial,unless f6u are applying in the name of someone else or other entity,such as a company.If so,indicate,the.other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map 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 partnershipjn 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 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 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 th' day of G 2p9�2 Signature Print Nam r Form TS I Town of Southold `J J LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its si mg ficant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section.0 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# ?G co - - t 2 c)r PROJECT NAME E/A Ea(4-n sr%) 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: P Location of action: ;V7 A) C 0 U QX C vzcA06- i1 Site acreage: ! Z Present land use: V Ac-kAjT Present zoning classification: `?-"l-DE',yTAt, 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: ISA-A-C-k L 0,S '-6g A/J (b) Mailing address: G-L 6�,J t G u(C-fiV u� ,y ll�37 (c) Telephone number: Area Code( ) t 2- (d) Application number, if any: 1A Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No O If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III-Policies; Page 2 for evaluation criteria. ❑Yes ❑ No M Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III-Policies Pages 3 through 6 for evaluation criteria F-1Yes 1:1 No ® Not Applicable t 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 [4 Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No FLSs]Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ ❑ ❑ Y No Not-Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 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 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. ❑ Ye�] No P Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No / Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ NoNot Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ 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 �fl Not Applicable PREPARED BYM 1 `iJ S r�2�/A) TITLE 0 Co rJ 9 CL- DATE "q z