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HomeMy WebLinkAboutTR-10275A Glenn Goldsmith, PresidentTown Hall Annex 54375' ,` „ 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski p i Southold, New York 11971 Liz Gillooly P Telephone(631) 765-1892 ps Elizabeth Peeples " Fax(631)Cou vb BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD November 17, 2023 Michael & Robin Colapietro 3800 Deep Hole Drive Mattituck, NY 11952 RE: 3800 DEEP HOLE DRIVE, MATTITUCK SCTM#: 1000-115-17-6.1 Dear Mr. and Mrs. Colapietro: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, November 15, 2023. RESOLVED that the Southold Town Board of Trustees APPROVE the Administrative Amendment to Administrative Permit#10275A to remove the existing 59'x28' concrete driveway and replace with new concrete in lieu of previously approved; extending concrete driveway slab to the stone retaining wall 13'9"x8' with pavers on top; replace driveway extension walkway 11'x6'9" with concrete, in front of retaining wall stairs with pavers on top„ and as depicted on the project plan prepared by Michael Colapietro, received on October 23, 2023,. and stamped approved on November 15, 2023. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, GNenn Goldsmith President, Board of Trustees GG/dd Iv L II .n to h n o_ N/O/F JOHN J. ZA LESKI 1 S. 790 00,00"E.. GOSr a R•IL FEN 148.09' D"N c! N.82°50 50" MON. •„ W, oROPERTY LINEA YON. 4.[•K U/ER 7/09 ►.[[7102 DEED 146.61" . n •r STONE MON W RET4UDNOWW,L FROC IER'[Rry LIN[ �S qq 0 70.,2 ,. 14/E[4S LI/[R 5342 4 Mr fBAY LU 6L N C w�Ow I WOOD OOCR F Q F: TY _� N 30=3— j.3,. FRTY .NSE y� N i goo W CONC.° WALK - Z h o3 o 0U CONIC, S q N J R n i+ R4r10 z ydl = OUNDER 2 ~_ I /OW DECK I WOMOOSW O U- 4.1 r 9` w W l 0 W :o Ql Y Z W O - C 4 � W a D - a4,7' o II W ; _x IGh°'Iw R[T41 N I N6 0 W..., yl V r 0 Z C0NC 0• EY'1 Y,COMC NDN. O./`E, CONIC„ /COCK CD I p •SYP NOMI yy 79 o 00,, I ro.D"7 MOLL OO, w CORC. { /LOCK. RET41NY14 149-77 ' WALL .LL/0/F M4RY D. l/PETER AREA = 18, 351 SQ.FT. CERTI FIED TO SURVEY OF PROPERTY ROBERT GEIS AT JOSEPHINE GEIS M fly TTI TUC K NORTH FORK BANK MATI TOWN OF _.......�_ . . N.Y. � SUFFOLK COUNTY r - 6. 23 °.� APPROVED BY SCALE 1 = 301 qyY, 1 I 4 , BOARD OF I RUSTEEfT 198 s TOWN OF SOUTHOLD Ott Y�r ii1 DATE N " 2o23 LAND& �.�.._�..�.,.._.�...�.� dk ~ Yv. LIC. N0.4 9f6E _. _.. .. _ . ?r/porea If accordant/ with he minimum _. arrlE for title surv/ys as established a br q,1%s the L-I.A.L.S. and approved and adopted §� + Th/ NOW YO r1 State lO J 'ECONI va for such use by 516 ) 76 Title AssociO"'. '.0. BOX goo LAIN ROAD � Glecn,Goldsmith,President 0Town Hall Annex�,' " A.Nicholas Krupski,Vice President 54375 Route 25 Eric Sepenoski ', P.O. Box 1179 Liz Gillooly rD Southold,NY 11971 Elizabeth Peeples Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 11 Lks 12' Completed in field by: U_S M�'FI-, MICHAEL & ROBIN COLAPIETRO request an Administrative Amendment to Administrative Permit #10275A to remove the existing 59'x28' concrete driveway and replace with new concrete in lieu of previously approved; extending concrete driveway slab to the stone retaining wall 13'9"x8' with pavers on top; replace driveway extension walkway 11'x6'9" with concrete, in front of retaining wall stairs with pavers on top. Located: 3800 Deep Hole Drive, Mattituck. SCTM#: 1000-115-17-6.1 Type of area to be impacted: ✓✓ Saltwater Wetland Freshwater Wetland Sound " Bay Part of Town Code proposed work falls under: /Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion /Amendment V Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications/Conditions/Etc.: M,%'N U M Present Were: ✓ G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples October 21, 2023 Permit No.: 10275A Applicant: Michael & Robin Colapietro SCTM#: 1000-115-17-6.1 Project Location: 3800 Deep Hole Drive, Mattituck Date of Resolution/Issuance: December 14, 2022 Date of Expiration: December 14, 2024 Reviewed by Glenn Goldsmith, President Amended Project Description: Remove existing concrete 59' X 28' driveway and replace with new concrete; extend driveway concrete slab 1_1__XX 8_to stone retaining wall with pavers on top; remove deteriorating 28' X 8' asphalt apron and install concrete slab with pavers on top; replace driveway extension walkway (concrete slab needed to be removed to install retaining wall) 11' X 6'9" with concrete, in front of retaining wall stairs with pavers on top. Iwo i .w y i OCT2, 2023 I u Glenn Goldsmith,President IF S0U�� Town Hall Annex ®� ®� 54375 Route 25 A. Nicholas Krupski,Vice President ae P.O. Box 1179 Eric Sepenoski AxL 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 1St day of construction '/2 constructed When project complete, call for compliance inspection; Glenn Goldsmith, President ��®F S0 �® Town Hall Annex A. Nicholas Krupski,Vice President a`® *1- 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly CA Telephone(631) 765-1892 Elizabeth Peeples rd ® Y® Fax(631) 765-6641 C®UNV BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10275A Date of Receipt of Application: November 18, 2022 Applicant: Michael & Robin Colapietro SCTM#: 1000-115-17-6.1 Project Location: 3800 Deep Hole Drive, Mattituck Date of Resolution/Issuance: December 14, 2022 Date of Expiration: December 14, 2024 Reviewed by: Glenn Goldsmith, President Project Description: Place concrete pavers on the existing 59'x28' concrete driveway; remove deteriorating 28'x8' asphalt apron and install concrete slab with pavers on top. 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 Michael Colapietro, received on November 18, 2022, and stamped approved on December 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. A, , 41,-A" Glenn Goldsmith, President Board of Trustees •n n O_ N/O/F JOHN J. Z4LESK1 S. 790 00,00"g POn a RAIL fewCE N. 148.09 r conic o�w_ 82 SO so-W. PROPfAry Llwl AS PER .Dm. _ 4645E UUM nos P{aE 402 146.61' i� 2 Lu i RET�r a .ION PROPERty LW9 AS > O —_30.2* ses' AQE 46,LiaERas4s f tei - 1 � N n r.CW AY r00000erc I stv. 3o_7_ 8.1 FR.NSE. W H — _ N tr 800 Lurowe:' VIALS" Q come. ; N u PATIO ztwasit I S SOr Dec, In rlwOOr p O 1 W �.L iy {.1• 746' >< ' � O yl W e W � J x{.s' o W 3 • f S,pwE O s .. RLTAINiNa o � � iA1 t, .Z COIIe. 0ervf7R y-: p MALL COwe. 11 D 02N. N ' ep OOrpp, RA'fA/w.Nf MALI 1.0,11 II 1 9 00,.W tome . Kam, NOV 2022 RETArmaN 149-77- -- I Al/0/F WAU M 4 R y p, Le PETE R Southold Town Board of Trustees AREA = 18, 351 SO-IT . CERTIFIED To SURVEY OF PROPERTY ROBERT GEIS AT JOSEPHINE GEIS M ATTI TUC K -NORTH FORK BANK �,� TOWN OF SOUT►-TOLD !�►��1 SUFFOLK COUNTY , N.Y. 11 1 IIS IP '� 6.1 (�� Cow eAtit� l000 N = 30'. L a $'rti APPROVED 10C 26 , 1989 ARD OF i RUSTFES x a� 01- TOWN OF-SOUTHOLD �NDSV DATE pawMOle- r�� zozy . � .UC.kp.49e'o8 __jvi" d S?,sSaZc*d accordance h eaabrahad 7 ♦ * daadords r title wrve$s and approved and adopted ' E - __-_. �_ •ECON I. C,; for such use by The Now York Stora Lo rIJ Title Ay,Ociatl0-l- 516 ) 76 . . 0. BOX 909 �etN ROAD "viciin Goldsmith,President... ......... ����OS' COG� Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 CO Eric Sepenoski P.O.Box 1179 Liz Gillooly �y p� Southold,NY 11971 O Elizabeth Peeples dol �� Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 8211A2 Completed in field by: �. Gv/JSM= � MICHAEL & ROBIN COLAPIETRO request an Administrative Permit to place concrete pavers on the existing 59'x28' concrete driveway; remove deteriorating 28'x8' asphalt apron and install concrete slab with pavers on top. Located: 3800 Deep Hole Drive, Mattituck. SCTM#: 1000-115-17-6.1 TyEp�of area to be impacted: Saltwater Wetland Freshwater Wetland Sound ✓Bay Part of Town Code prop6sed work falls under: C ah pt.275 ' Chapt. 111 other Typg,-of Application: Wetland Coastal Erosion Amendment ✓✓Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications/Conditions/Etc.: ��� �o��r� — �lr�✓�oc���v a r�tay� Present Were: ✓,G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples N � ' i z� noon � ,r , �, ,, . . - �� �,. =�- _ r ,, - -.. K S1a" 7_" � .r'Y�'- c P -±� -t � -.. 4 y _ fF .p;�4� 'V r ::t _ A '�-�L 3'__ £'' mi-�_- J Sim ,,��.. _ ��� i� v _ �. _� '�� .� �`, c � .: �, � .�. _ �. � �:� �� is r - �' � � ' __ K� i .Y E- /, f/�,•'� 1. �V -�'1 �� _-'r'i�1yy t t�Y ,���` � .��_fes *' / � 1 i . '� � � . . - 1�Y -�i���'' ::. _ __ �,. � '�� _� _ _. -,; -,�� - "3 ,�Y �` ~` �' '4� r-Y Y�. S � K.�' 'Tl' � 1 � s-^���" � '' � � � + � �. ti r'_fti wry.... �� �' V ` �` l _ 't Y `� .. � _. _ '` /1 >f �-}� '� � to OFFICE LOCATION: ��OF SO!/j�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 G • Q Telephone: 631 765-1938 cOUNT`l,N�a 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: :December 12, 2022 Re: LWRP Coastal Consistency Review for MICHAEL & ROBIN COLAPIETRO SCTM# 1000-115-17-6.1 MICHAEL & ROBIN-COLAPIETRO request an Administrative Permit to place;concrete pavers on the existing 59'x28' concrete driveway; remove deteriorating 28'x8' asphalt apron and install concrete slab with pavers on top. Located: 3800 Deep Hole Drive, Mattituck. SCTM#: 1000-115- 17-6.1 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, as well as the records available to me, it is my recommendation that- the proposal is CONSISTENT with LWRP Policies and with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Honorable Lori Hulse, Attorney { ' Town Hall Annex Glenn Goldsmith,President �t 0 Cl- A.Nicholas Krupski,Vice President 54375 Route 25 P.O.Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gilloy Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application —Administrative Permit Amendment/Transfer/Extension Received Application: Il•(g•Z� ;Received Fee::$ 100.00 —Completed Application: I. •2Y Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: oordination:(date sent): LWRP Consistency Assessment Form Sent: GE_ VE CAC Referral Sent: _ r---- - - Date of Inspection: Receipt of CAC Report: �022 Technical Review: Public Hearing Held, �2• •ZZ i Resolution: ' tet cdi"ierap, Beard a i;;lst�es Owner(s) Legal Name of Property(as shown on Deed):_ &1 C.tit�C�i( Z�O�I� Cly I eA" Mailing Address: Jeg©d ! I 1Zl "r'e— Phone Number: n �p D Suffolk County Tax Map Number: 1000 -. �� — 1_7 Property Location: -b,e.ep A01-e- 't)21 M A-tt J-Udl:4 11 � S�- (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): I`d , 3.!;-l � . Area Zoning: 1 06-N C--2 Previous use of property: S 1 2 !N Intended use of property: RR-s Covenants and Restrictions on property? Yes __y No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes \/No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes 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 Prior permits/approvals for site improvements: Ag enc Date ®1 el 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): P-m 2, -dR.- .peril S- N 0 ILA X Se C -f UVA\J .) S, Q. g,+ -S (Z.IV 0 M V -,L>-0A©al 2. _ r � o c3ri $ J xl S�Ct LL e o N -6 a �w S LQ''�j v I V �0'A A Q F �5�1�[+ sem.-�,�� �� d�.���.�� ►�S rao �� � Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: c` o- Area of wetlands on lot:. } square feet 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: (o,D feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? cubic yards 1�4 %NGkQ 5 Depth of which material will be removed or deposited: Proposed slope throughout the area of operations:�In APNia.t, +0 Manner in which material will be removed or deposited: I 1 '9wp op. ILLJOL 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): 61Z20 Appendix S Short Environmental Assessment Form Instructions for Conipletinp, 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 rr AlC.t✓ C.o g �� (Avt2 01.4. A-,� o t� A Name of Action or Project: 1 Project Location(describe,and attach 4location map): Brief Description of Proposed Action: t ��`i'�1,2. PiJ�/S� I R C o ►.1�.1 e- S�,e� o N 01�— �t4��C P4�r&1 O1, - op of �,o� �?Co_ �wtop CjLa�-P_ e,'0 W Co. s LAA> , Rs p hc,_C-t-- _Ue Vry C I 2�ek� Name of Applicant or Sponsor: Telephone: 0 �l lCQ 10( I,Pi E-Mail: I'1/�Co Aco nL Cyy\ a Address: 3 qez�' bzep '1 �� 1 City/PO: A State: Zi 1 C�. I� 1`t S 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinan e, 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: y ❑ 3.a.Total acreage of the site of the proposed action? acres C41.41 m Q b.Total acreage to be physically disturbed? A acres 'bz J c.Total acreage(project site and any contiguous properties)owned ) �� '�� or controlled by the applicant or project sponsor? ._�_J&_acres C4 tie Lt't 4�K 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial lesidential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO 4YESN/Aa. A permitted use under the zoning regulations? LLAJ b.Consistent with the adopted comprehensive plan? ❑6. Is the proposed action consistent with the predominant character of the existing built or natural landscape? ❑ 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO ES 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? ❑ a 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: pul ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: S G WPc ❑ 11.Will the proposed action connect to existing wastewater utilities? J NO YES If No,describe method for providing wastewater treatment: ` 1T o ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? �j ❑ b.Is the proposed action located in an archeological sensitive area? �{ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site, Check all that apply: ❑Shoreline E]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 YES by the State or Federal government as threatened or endangered? (vt ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, a.Will storm water discharges flow to adjacent properties? ❑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 �l 8.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 A'ND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: 1 Date: Jq0 J V\ _ 02©2 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 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑ ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? (� LJ 4. Will the proposed action have an impact on the environmental characteristics that caused the FJ ❑ establishment 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 El reasonably available energy conservation or renewable energy opportunities? LJ 7. Will the proposed action impact existing: ❑ ❑ a.public/private water supplies? b.public!private wastewater treatment utilities? ❑ ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, F] ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ ❑ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may j 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? 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-tens,long-term and cumulative impacts. i 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. i Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Board of Trustees Application AFFIDAVIT QIP C(9I� Q�Cbpir� ���i X1(1 BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN 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 ofP operty Owner / ignature of Propert weer SWORN TO BEFORE ME THIS pZ DAY OF NC3 , 202- . ................................ BISMAR TRUJILLO BARRIOS y i NOTARY PUBLIC,STATE OF NEW YORK NO.01TR6385456 otary Public Qualified in Suffolk County € Term Expires Jan. 7,2023 ........................... .................................__ APPLICANT!AGENT/REPRESEN'T'ATIVE TRANSACTIONAL DISCLOSURE FORM The Toym,of South ld's C'def i ics hibits conflicts.of i serest on theart of town oftieers and employees.The purngse of ibis Ong is t rovide'nf anon which can alert tha to of sib a en is f i rest low it to take w1 e e acti is necessary to avoid same. Co LO—P I JY�II1 C,-Kpt , . YOUR NAME: A LW2 iO b I iJ (Last name,first n e,Middle initial,unless you are applying its 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.)_ �t? 7,-, -tom p Q Y ji13'�l O✓JZ-(.i-Q`, Do you personally(or through your company,spouse,sibling,parent,or child)have a"relationship with any,officer or employees of the"f own of Sopthold? "Relationship"includes by blood,marriage,or business interesi"Business interest"nseans a business, including a partnership,in which the toren officer or employee has Coven a partial ownership of(or employment by)a corporation in which the Own 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); 8)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 Or RELATIONSHIP Submitted this 0 day o Signature Print Name Form TS I 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 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- s portift facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall notbe 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# I I _6 7 - PROJECT NAME J (Z©o D,e. 4o0-e-- ')>tZ . The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees L 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: 'P9/L, +Akp- ,"1A1 ti Q b �/le.�� SA.e,t'►ory 0 Zl V�wA� c„ ate°,.k, P 'ktz co 41 ,pkvms o os -6p v P N A eAJ-P- Sl.� 21v-t,r4- "-0 s- f sA& 0 d�i,rAA- , IZA4wa Q� o -,�� Soh �ti C��'��� w) 1 Ms ez U c- s A-" R-v\L2 (9 ©B NA;- Co 9 cAA-P-, aA5P1�, seek, aRAVrQ,R.a� ®� cr Qlc. Location of action: Site acreage: g 3s-1 '9 Present land use: RZI 141R�,ti Ce— Present zoning classification: Re-!s t 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: c� ��� Wo)--e- (c) �2►��— (c) Telephone number:Area Code( ) ��--7 6 70 (d) Application number,if any:._ Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST 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. Ift ❑Yes ❑ 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—Policies Pages 3 through G 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 ❑ Yes ❑ No 4A 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 P 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 F] Yes ❑ No of 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. 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 — Policies Pages 32 through 34 for evaluation criteria. Q. Yes ❑No Ix Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substancesVR and wastes. See LVP Section III—Policies; Pages 34 through 38 for evaluation criteria. 1:1Yes 0 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 L@4'I2P Section III—Policies; Pages 38 through 46 for evaluation criteria. YeO No 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 I 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 Iands in the Town of Southold. See LWRP Section III— Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ No of 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 TITLE f,0 V?-- DATE "d6t—61A) e, r 1 .s