HomeMy WebLinkAboutTR-10244A Glenn Goldsmith, President � �V'il so ,. Town Hall Annex
54375 Route 25
A. Nicholas Krupski,Vice President P.O. Box 1179
Eric Sepenoski Southold, New York 11971
Liz Gillooly Y Telephone (631) 765-1892
Elizabeth Peeples ® Fax(631) 765-6641
INV
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
DATE OF INSPECTION: 1 IS127
INSPECTED BY: tiz ► Il 60
�( Ch. 275 Ch. 111
INSPECTION SCHEDULE
Pre-construction, haybale line/silt boom/silt curtain
--rnsPIon Apkr F�r5f Tr,i"+.
% constructed
Project complete, compliance inspection
COMMENTS:
y- c z c(M<+yy L4-�6yg
W 4n `W VCra
+Y'2�P_ MICE i►n V C-S 1"\�S_
CERTIFICATE OF COMPLIANCE: o end
r
Glenn Goldsmith,President riv S��� 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
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
t ChL boL tusPffr O+FrFi- FlX51- 7 P-M
'/z constructed
When project complete, call for compliance inspection;
Glenn Goldsmith, President A`�®� so��� Town Hall Annex
A. Nicholas Krupski,Vice President ®V� ®�® 54375 Route 25
P.O. Box 1179
Eric Sepenoski Southold,New York 11971
Liz Gillooly
G � Telephone(631) 765-1892
Elizabeth Peeples ® y® Fax(631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Permit No.: 10244A
Date of Receipt of Application: October 14, 2022
Applicant: Samuel Singer
SCTM#: 1000-75-6-6.1
Project Location: 44030 Route 25, Southold
Date of ResolutionlIssuance: November 16, 2022
Date of Expiration: November 16, 2024
Reviewed by: A. Nicholas Krupski, Vice-President
Project Description: Ten (10) Year Maintenance Permit to remove invasive species
i.e., Russian Olives and Black Locusts which are growing along the permitted deer fence
area.
Findings: The project meets all the requirements for issuance of an Administrative
Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an
Administrative Permit allows for the operations as indicated on the survey prepared by
Nathan Taft Corwin, III Land Surveyor, last dated October 16, 2022, and stamped
approved on November 16, 2022.
Special Conditions: No cedar trees are removed or trimmed; no native hardwood shall
be removed; no trimming shall take place on seaward side of the existing berm; no NYS
DEC protected species, including but not limited to baccharis to be disturbed; no
trimming shall take place within Ten (10) feet of the wetland line or the top of the
precipitous slope.
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
COFFO(
Glehn`dsmith,President �o0� ry., Town Hall Annex
A.Nicholas Krupski,Vice President 54375 Route 25
Eric Sepenoski n P.O.Box 1179
Liz Gillooly �y ® ��� Southold,NY 11971
Elizabeth Peeples dol �� Telephone(631)765=1892
Fax(631)765-6641
Southold Town Board of Trustees
Field Inspection Report
Date/Time: Completed in field by:
SAMUEL SINGER requests a Ten (10) year Maintenance Permit to remove invasive
species i.e., Russian Olives and Black Locusts which are growing along the permitted
deer fence area. Located: 44030 Route 25, Southold. SCTM#: 1000-75-6-6.1
Type 9farea to be impacted:
t-*Saltwater Wetland Freshwater Wetland Sound _ Bay
Part of Town Code proposed w rk falls under: Chapt.275 Chapt. 111 other
nAd
Application: etland Coastal Erosion Amendment
ministrative Emergency Pre-Submission Violation
Notice of Hearing card posted on property: Yes No ✓ Not Applicable
Info needed/Modifications/Conditions/Etc.: 6oviif-o,- )/o L[ew., ow4 6�rM
—nl0 C� 60 CA of "'�04 /Ja #'tA✓z Aa
b Pb C(par W G/ WW+aj AlY . /V()
Present Were: Goldsmith N. Krupski E. Sepenoski
L. Gillooly E. Peeples
E C E I V E
0 C 2 1 2L22
souttlold Town
SURVEY OF PROPERTY R� tees
SITUATE
PECONIC
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
S.C. TAX No. 1000-75-06-6. 1
yJ�ad�'
e• ,� GG J ,� SCALE 1 "= 100'
FEBRUARY 1 , 2015
DECEMBER 2, 2015 ADD PROPOSED HOUSE
FEBRUARY 10, 2016 REVISED PROPOSED HOUSE
APRIL 9, 2016 REVISE SITE PLAN
�� • APRIL14, 2016 REVISE WETLAND BUFFER & PROP. DOCK
MAY 4, 2016 ADD FLOOD ZONES
JULY 12, 2016 REVISE DRIVEWAY
JULY 23, 2016 REVISE DOCK
���4J O SEPTEMBER 15 2016 REVISE UTILITIES
OCTOBER 25, 2016 ADD STORMWATER NOTES
y"O 4j DECEMBER 15, 2016 REVISE DRIVEWAY
DECEMBER 5, 2017 STAKE HOUSE & BARN FOUNDATIONS
JANUARY 018FOUNDATION LOCATION
AR 2020 FINAL SURVEY
�0. s Fs A� NROt DBY M
JULY 16, 2022 ADD PROPOSED DEER FENCE
60 c 0. BOARD OF 1 RUSTEES OCTOBER 16, 2022 STAKE EAST PROPERTY LINE & ADDED NOTE FOR REMOVAL OF INVASIVE PLANT SPECIES
''� 1rO�• `3rTOWN! OF SOUTHOLD TOTAL AREA = 1,032,796 sq. ft.
• 00+ Q 23.709 ac.
SEE DETAIL DATE Kot zoyy
CERTIFIED TO:
SAMUEL SINGER
ire °'� ° a� __.�___ ._. .__..�.._�_. --.� GOLDMAN SACHS BANK USA
'cso0 ; O `� \ STEWART TITLE INSURANCE COMPANY
.00.,0, 00- �' \ ADVOCATES ABSTRACT, Inc.
% t'
AA
AL
�� o 0. dto 01N
�— :'-: GATE DETAIL
rn
d a a do SCALE 1 "=40'
o 10
O p
0. AL CIO
*3 \
P O lam /
0.
tn
Ln
s
jp- CTI
1P O, \
tz
ts. \
t� \\ /
\ O
\ y
\
Y
1 Com]
►C
G1
11
1
J 11 `':<:''s• p
SNE
.1.� \\ .11111 D o
4. to
�lJ y \ O.
�0, T
tr
`Z ptn
m
I
•111(1- 0 f
N 00.25'22" E
102.85'
i
p r ]{L
N, r
N r
(0 M rr s
.0
z l did
y
xm
y 11 F0
e.'`;::` `Z�7D'b
t0 to q l a
l
Z i N
1 N•
1 LA
1111c O
O
O
,+ w
N 49'12'3a tj
CIV
49• C i 1111c
O c0 i
:
h (0 r
m N
O
Z O c11
0.
O Il F W
LA
C5
1 PATH•'' :<�':'•.�: •.: � ge
) a cn
l
ii' ;:
!11
O
It
tD 1 r+ ma y
O O x 1LA o
N O
039' J11.
.c� D•84 26" 1
0 `` ' TT►
G p 9 s 1 p 7tl mN
cam$ Z O w+ $
11
IL
O
•. 1
ON O
I
i O Z
N F 40
O
ypp l,ss�'�,, ]III[..
v►6'• `�� Q°�tf
O or Lj% LL PREPARED N SURVEYSR TITLE
CP Q�� 11 I ACCORDANCE WITH THE MINIMUM
•, , O OIF AgSO SHED
BY THSTANDERLIALDS OS. AND APPROVED AND ADOAS PTED
°�jOQ LIG. Y� TITLE SASSOCIATIONN.UCH USE Y THE NEW YORK STATE LAND
S �r G� <Soolv�lls
XCb
67
N. S. Lic. No. 50467
UNAUTHORIZED ALTERAION OR ADDITION NathanIlk a
TO THIS SURVEY IS A VIOLATION OF
SECTION 7209 OF THE NEW YORK STATE
EDUCACOPIES ON LAW. L Surveyor
°'�u r C
COPIES OF THIS SURVEY MAP NOT BEARING yV
THE LAND SURVEYOR'S INKED SEAL OR
EMBOSSED SEAL SHALL NOT BE CONSIDERED
TO BE A VALID TRUE COPY.
CERTIFICATIONS INDICATED HEREON SHALL RUN Successor To: Stanley J. Isaksen, Jr. L.S.
ONLY TO THE PERSON FOR WHOM THE SURVEY Joseph A. Ingegno L.S.
IS PREPARED, AND ON HIS BEHALF TO THE
TITLE COMPANY, GOVERNMENTAL AGENCY AND Title Surveys — Subdivisions — Site Plans — Construction Layout
LENDING INSTITUTION LISTED HEREON, AND
TO THE ASSIGNEES OF THE LENDING INSI- PHONE (631)727-2090 Fax (631)727-1727
TUION. CERTIFICATIONS ARE NOT TRANSFERABLE.
OFFICES LOCATED AT MAILING ADDRESS
THE EXISTENCE OF RIGHT OF WAYS 1586 Main Road P.O. Box 16
AND/OR EASEMENTS OF RECORD, IF Jamesport, New York 11947 Jamesport, New York 11947
ANY, NOT SHOWN ARE NOT GUARANTEED.
SURVEY OF PROPERTY
S1TUAT6
PECONIC
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
Zgl S.C. TAX No. 1000-75-06-6.1
SCALE 1'-100'
¢mac FEBRUARY 1,2015
Opp
g
/ Y
a''
A.TI TIo
� EE DETAIL
s
s c GATE DETAIL
SCALE 1'=40'
-
�a
c ` i
rd
Ilk
4�
-
- Q
c ; 4
z - y
a yF
Q
M
- - y
JrE r; E--1 V E + -
.r
��.——=
OCT 1 4 2022
i
Satr'NId To1vr, — Nathan Taft Corwin■
Board of Trustees _e Land Surveyor
rf i yy I.
Y/
i.
t
Figure 1. Subject parcel.
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
SURVEY OF PROPERTY
SITUATE
PECONIC
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
Zql S.C. TAX No. 1000-75-06-6.1
¢4e. t SCALE 1•=too'
FEBRUARY 1.200'15
C,T� roru ARIA.\,os3.nf.f.a.
23—
I e.
G'g` �p fid;� I`� ,6 crnrrrrrr ro�
IA R
r ✓ 4r O aol —1
ouAx>>�s u—E—1.1
y .u.ou.n.esrl,c r
EE TAI i
r
r
ro GATE DETAIL
jOr. O . V 1C\af!A� I N SCALE
•po s-• � I dr' � � \\
A \\ \\
t �-
r
N �
4 .
p rt r
r �
X �'A• d meq,
r i
r
102H
_ 1•"a
a
•M
Af33 w
r ;
f
a ra'r e"A /Z
_ ' n N
g l
!3
tr^.
LO(�T 1 .. 1 �'A� • Y'
l I I �jf
:i V10. Y:..er Nathan Taft Corwin III
BmmofTrwtees �„�®� Land Surveyor
SURVEY OF PROPERTY
SITUATE
PECONIC
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
Zhl S.C. TAX No. 1000-75-06-6.1
¢`0, SCALE 1'=100'
FEBRUARY I.2013
40P�,sa/
"Ct':' Ptd tF,f I°r ,6 Herrn m
R� �M"'.O`A 4. ru c�ow�iuinv�ix s.
J a• —TT3�T\—T,3sv cour.xr
• �� EE TAI .
4.'".
GATE DETAIL
4. Y. T !WALE
�n� g 440 • y �^\
\
♦ `�G
lti \
s V
♦ r +
.a
i
r
z rd `•` +
p 4� ♦ \ 8.
np
n �
♦ i
a
x '3'
103.x+ I
�a
1• axiom
~•eil � K
•
♦ o
= t w
9 0 g•
F
� l i
� a•s
i 0
t � 'ice �, F� � �. �'a,N•. • sp+¢
14' i 1 0
0 CT 1 4 2022
smitltq'iTown Nathan Taft Corwin IA
Board ci Trustees � Land Surveyor
® _ MUM •_.mak:su
,N
JFW �M
_r.
_ I t
s
•k
.fir ��� � � �• -
.c
*air... - .x" ..
ti
r'
.�.
AIF :. l'
,.. fir.:.,...
F. �'
�... ...
-. ``
_ „r�: � t r
T ,
f_ J
h
y t
+r
i
x Mw
C . 1
a�
•JJ v
Or
4e V
1
JW-
� A
f
\ aM
1 V'r ,yam R _ _..•,_yam; f1h �\r �
h,' t .may � f, e� � f� ��'I�yY�A;�('*,aT'�• '`m
A
• to �. .. .� _
`y
14Ad
, a
., '"* • ,
r.
,�„< l * -. '' Y 'wt .•'•\:fit
�.M�:Ix "..,.. ,. 1'�Jr ,II•4�z � yam... A i..
.•yr •,� p� .Yti y _.
''�1►`
. �
e� �
L
..�
+ � , �,
,.,
..
�_
;��
�"
,�
>,, .
.:.
'�„
,,�.: w .,
�� } �.
ett SEC NO OSS
oo
=
ti va > r ,m' ' f,v °1ta
^' unE
4.
x
oaaae
� aera�`ar ov. n" :'b t s ,_y :�`' S� 'A 'e `1T�'n":a 9'y.'•y ��a«'�wr • o
'4^
'a
9
5
GV
1 1M V d
— a • 2Mr.1 r �• x]]pcl � ��?, 90UIMOLD
-Ccevnon5+eurmcnn, '`f,
o
rsa
�' a` /•.roe ' �. 14 ♦b l _ s,.
-0 o - 7+y
J. � 1. 1 eA a y. x9 t,yet {: �
12
2.
' t / y
^tip °
14
Ix tafU k P�. � S i'• o ,-�, •�
— ♦s r
d y 4r se sr`d No Ea,o�o rx � x cera n - sesec No
_ � .^. a• :� oecmaau, 4 � _t se����a�^; a:ce.a„z - �„� ,. .�?
a
w
+d�.. ..,.:: ,:•, ,acro, me � ,.u.� ,_:. .... ::,- �.
� :a:esec rr oea •,,:c.:mac.,..
_ _ COUNTY OF SUFFOLK Co " rarer
wel 21
— - ,, 1 1 1 e ty7 D 1Kency ws]wem-rart rte.w�, TF Y
k. w,u ♦ iw
-- r
E �.... — .,. _—_•_— �„� —_— "' w,.a+a�.u.u.osmue.icu w « nounta�o 075
r»u
"�• ..c xn,nrt nwmBr]9Y6n.ar ne P nw �'�`
———" � -' eea wum,.rue ea°„rF..ovc• ••••�
1
0* _.
OFFICE LOCATION: l ��oE SU(/Ty� MAILING ADDRESS:
Town Hall Annex P.O. Box 1179
54375 State Route 25 Southold, NY 11971
(cor.Main Rd. &Youngs Ave.)
Southold, NY 11971 G • Telephone: 631 765-1938
COW
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: October 16, 2022
Re: LWRP Coastal Consistency Review for SAMUEL SINGER
SCTM# 1000-75-6-6.1
SAMUEL SINGER requests an Administrative Permit for a Ten (10) Year Maintenance Permit to
remove invasive species i.e., Russian Olives and Black Locusts which are growing along the
permitted deer fence area. Located: 44030 Route 25, Southold. SCTM#: 1000-75-6-6.1
The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the
Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy
Standards. Based upon the information provided on the LWRP Consistency Assessment Form
submitted to this department and the records available, I recommend that the proposal is
INCONSISTENT with LWRP Policies and with the LWRP provided, the following is considered.
1. Limit the clearing to specified invasive species. The proposal needs to be more
specific and give certain species as examples. The vegetation serves as a buffer to
the wetlands filtering out sediments and pollutants from runoff. Clearing should be
minimal. There are large trees located in the south of the parcel that provides
important buffering properties.
Glenn Goldsmith,President Town Hall Annex
A.Nicholas Krupski,Vice President �` ' 54375 Route
P.O. Box 11799
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
This Section For Office Use Only iD
Coastal Erosion Permit Application
Wetland Permit Application OCT 1 420M
IJ
Administrative Permit
Ainendment/Transfer/Extension
-Received Application: to'/ ,ZZ. Southold TOWA
Received Feer$ Board Of hostas!
Completed Application: ..
Incomplete:
SEQRA Classification: Type 1 Type II Unlisted Negative Dec. Positive Dec.
Lead Agency Determination Date:
oordination:(date sent):
LWRP Consistency Assessment Form Sent:
CAC Referral Sent:
Date of Inspection:
Receipt of CAC Report:
/Technical Review: .
Public Hearing Held: ZZ
Resolution:
Owner(s) Legal Name of Property(as shown on Deed):
Mailing Address: Max f
77
Phone Number: S J2� _"�� J
Suffolk County Tax Map Number: 1000 --
Property Location: Aa
(If necessary, provide LILCO Pole#, distance to cross streets, and location)
AGENT(If applicable):
Mailing Address: —. ---
Phone Number:.. Email:
Board of Trustees Application
GENERAL DATA
Land Area(in square feet): Samu 1 Singer
Area Zoning:
Previous use of property:
Intended use of property:
Covenants and Restrictions on property? _ Yes X No
If"Yes",please provide a copy.
Will this project require a Building Permit as per Town Code? Yes X No
If"Yes",be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review
and Elevation Plans will be required.
Does this project require a variance from the Zoning Board of Appeals? Yes X No
If"Yes",please provide copy of decision.
Will this project require any demolition as per Town Code or as determined by the Building Dept.?
Yes X No
Does the structure(s)on property have a valid Certificate of Occupancy? X Yes No
Prior permits/approvals for site improvements:
Agency Date
Trustee permit 10194A 8/17/2022 Deer Fence
No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency? X No Yes
If yes,provide explanation: _
Project Description(use attachments if necessary): Requesting 10 year maintenance permit to remove invasive species such as
russian olives and black locust along proposed deer fence location shown in
yellow on attached survey
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:.
remove invasive species such as russian olives and black locust so can properly install deer fence which has already been
approved by the trustees in permit 10194A ..
Area of wetlands on lot:,
Percent coverage of lot:
Closest distance between nearest existing structure and upland edge of wetlands: feet
Closest distance between nearest proposed structure and upland edge of wetlands:. feet
Does the project involve excavation or filling? X No -Yes
If yes,how much material will be excavated? cubic yards
How much material will be filled? cubic yards
Depth of which material will be removed or deposited: feet
Proposed slope throughout the area of operations:
Manner in which material will be removed or deposited:
Statement of the effect,if any, on the wetlands and tidal waters of the town that may result by
reason of such proposed operations (use attachments if appropriate):
� I
ti
61Z20
Appendix B
Short Environmental Assessment Form
Instructions for..Campleting
Part I -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 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 arty item.
Part 1-Project and Sponsor Informatio
Name Action Project:
At"
Project Location(describe, d ach a locati n map): e
�.
Brief Description of Proposed Action:
/O
or
Name of Applicarf or Sponsor: Telephone'
t
E-Mail-
Address- �J � n La 0 C
City/PO; State: oe:
Zip C
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 p
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:
ci
3.a.Total acreage of the site of the proposed action? 2 74 77.acres
b.Total acreage to be physically disturbed? acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? 2L_7_acres
4. Check all land uses that occur on,adjoining and-near the proposed action.
❑Urban ❑ ral(non-agriculture) ❑industrial ❑Commercial sidential(suburban)
❑Forest riculture ❑Aquatic El Other(specify):.. .
❑Parkland
Page 1 of 4 _.a. ..
5. Is the proposed action, NO YES N/A
a.A permitted use under the zoning regulations?
FIE141
b.Consistent with the adopted comprehensive plan?
6. is the proposed action consistent with the predominant character of the existing built or natural NO ES
landscape?
7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO 7YES
If Yes,identify:
a•
8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES
b.Are public transportation service(s)available at or near the site of the proposed action?
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? D
9.Does the proposed action meet or exceed the state energy code requirements? O YES
If the proposed action will exceed requirements,describe design features and technologies:
NK i
10.. Will the proposed action connect to an existing public/private water supply? NO YES
If No,describe method for providing potable water: F1
U
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 NOYES
oo
Places?
b.Is the proposed action located in an archeological sensitive area?
13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES
wetlands or other waterbodies regulated by a federal,state or local agency?
b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody?
If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: tt._1I
14_ Id ify the typic I h rtat types that occur ,or are likely to be found on the project site. Check all that apply:
A—Moreline Forest griculturallgrasslands El Early mid-successional
etland ❑Urban E]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? Q
16.Is the project site located in the 100 year flood plain? NO YES,
LL
17.Will the proposed action create storm water discharge,either from point or non-point sources? -NO YES
If Yes,
a.Will storm water discharges flow to adjacent properties? MO [YES LJ
b.Will storm water discharges be directed to established conveyance systemWrand storm drains)?
If Yes,briefly describe: AYES
Page 2 of
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 YE
completed)for hazardous waste?
If Yes,describe:
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE '
Applicanttsponsor e: �/ e; 0
Signature
x
Part 2-Impact Assessment. The Lead gency is responsible for the completion of Part 2. Answer all of the.following
questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or
otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my
responses been reasonable considering the scale and context of the proposed action?"
No,or Moderate
small to large
impact impact
may may
occur occur
1. Will the proposed action create a material conflict with an adopted land use plan or zoning D
regulations?
2. Will the proposed action result in a change in the use or intensity of use of land? Q
3. Will the proposed action impair the character or quality of the existing community?
4. Will the proposed*-aetion have an impact on the environmental characteristics that caused the ('(
establishment of a Critical Environmental Area(CEA)? j—.j
5. Will the proposed action result in an adverse change in the existing level of traffic or
affect existing infrastructure for mass transit,biking or walkway? (— J
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: (J 1
a.public/private water supplies? uu
b.public/private wastewater treatment utilities?
8. Will the proposed action impair the character or quality of important historic,archaeological, o
architectural or aesthetic resources? _
9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, Q o
waterbodies,groundwater,air quality,flora and fauna)? !_ 1
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
o
problems?
11. Will the proposed action create a hazard to environmental resources or human health? o
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,
L_l that the proposed action may result in one or more potentially large or significant adverse impacts and an
environmental impact statement is required.
FJCheck this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
Town of Southold-Board of Trustees
Name of Lead Agency Date
President
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer)
PRINT Page 4 of 4'
Board of Trustees Application
AFFIDAVIT
SBEING DULY SWORN
DEPOSES AND AFFIRMS THAT H HE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S)AND THArr 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.
Signature of PropertjOUwner Signature of Property Owner
S WORN TO BEFORE ME THIS .. DAY OF. OCJ'-
otary Public
KRYSTAL HASAN
Notary Public-State of New York
No.01HA5073030 --
Qualified in Queens County
CommlSS16n Expires Feb.10,
. 1 1
APPLICANUAGENUREPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Sauthold's Cotie'of Ethics prohibits conflicts of interest on the part oftown'dfficers and emnloyees The c uws;6:of`
-this 1's tQ V Myide m6rhaj" whiehcan_aiert the town of sstble ca lets' fin crest and'aflowat to w fever act o .s
.tnecessary'to avoid same.
/ 4
i
YOURNAME:..
(Last name,first name,jgpuddle initial,unless you a applying in ame 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 l
Other
(]f"Other',name the activity.)
Do you pets6nally(or through your company,spouse,sibling,parent,.or child)have a relationship With aity:officei of etnplayvc
of the'l,own of Southold? "Relationship"includes by blood;marriage;or business interest.Busih6e intetestn mcatrs'A, 4s'tticss,
including a partnership,in which the 3own officer or employee has even a partial,ownership of(ort'=ployment by)A eorporstion
in which the.town ofl'tcer or employee owns<more than °fo oft ares.
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(whe1Y 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 /�d of
Signature lv4po 1110o"
Print Name: `
Form TS 1
Town of Southold
LWRP CONSISTENCY ASSESSMENT FORM
A. INSTRUCTIONS
1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for.
proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This
assessment is intended to supplement other information used by a Town.of Southold agency in
making a determination of consistency. *Except minor exempt actions including Building.Permits
and other ministerial permits not located within the Coastal Erosion Hazard Area.
2. Before answering the questions in Section C, the preparer of this form should review the exempt
minor action list, policies and explanations of each policy contained in the Town of Southold Local
Waterfront Revitalization Program. A proposed action will be,, evaluated as to.its :gg&ficant'
beneficial:and adverse effects:upon the coastal area 6whieh'.includes all of Southold:Towr1
1 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'bc j4plained in.;de" ail, listing both supporting,and non-,.
suuPorting facts. If an action cannot be certified as consistent with the LWRP policy standards and.
conditions,it.shall.not.bemndertaken.
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# 0® ZZ--`G�^l�Qi --
PROJECT NAME
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: O
i
0�Location of action: �! 00
Site acreage:
Present land use:
Present zoning classification:
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:.
(b) Mailing address:_ ofO
(c) Telephone number: Area Code K-Le
(d) Application number,if any.,
Will the action be dire ly undertaken,require funding,or approval by a state or federal agency?
Yes No If yes,which state or federal agency?`
C. Evaluate the project to the following policies by analyzing how the project will further support or
not support the policies. Provide all proposed Best Management Practices that will further each policy:
Incomplete answers will require that the form be returned for completion.
DEVELOPED COAST POLICY
Policy 1. Foster a pattern of development in the Town of Southold that enhances community character,
preserves open space,makes efficient use of infrastructure,makes beneficial use of a coastal location,and
minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation
criteria.
Q Yes Cl No Not Applicable
Attach additional sheets if necessary
Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See
LWRP Section III—Polic' s Pages 3 through 6 for evaluation criteria
Yes No Not Applicable
Attach additional sheets if necessary
Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See
LWRP Section III—Policies Pages 6 through 7 for evaluation criteria
Q Yes ❑ No Not Applicable
Attach additional sheets if necessary
NATURAL COAST POLICIES
Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP
Section III—Policies Page 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
FlYes Q No wot
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 riteria,
a o
Yes No Not Applicable
Attach additional sheets if necessary
Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — PoIicies
Pages 32 through 34 for evaluation criteria.
Q. Yes a.No . Not Applicable
3
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.
0.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.
Q fell N of Applicable
Attach additional sheets if necessary v ���
11 ,
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 Pecome
Estuary and Town wat s. 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 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;P es 65 through 68 for evaluation criteria.
Yes ❑, No Not Applicable
Al
PREPARED BY TITL DATE