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Home My WebLink AboutTR-10291A ®� soy Town Hall Annex Glenn Goldsmith, President �� ®� 54375 Route 25 A. Nicholas Krupski,Vice President ® P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly Telephone (631) 765-1892 ZZ Elizabeth Peeples Fax(631) 765-6641 29 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 1 It day of construction % constructed When project complete, call for compliance inspection; Glenn Goldsmith,President so Town Hall Annex A. Nicholas Krupski, Vice President � ® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10291A Date of Receipt of Application: January 3, 2023 Applicant: Paul & Constance Connor SCTM#: 1000-115-12-12 Project Location: 830 Deep Hole Drive, Mattituck Date of Resolution/Issuance: January 18, 2023 Date of Expiration: January 18, 2025 Reviewed by: Glenn Goldsmith, President Project Description: For the as-built 10'x12' shed and for the installation of a proposed 14'x10' on grade patio with 4" sand base with stone laid on top (without mortar). 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 site plan prepared by M.A. Kimack, dated December 22, 2022, and stamped approved on January 18, 2023. Special Conditions: None Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Glenn Goldsmith, President Board of Trustees �t./�lVtl ��✓r elti �� "(�C�1 C.i IT16C� �"@�i# _�_P ApoI;Lor:" FlauI Gonnor J T" ,Y Proposed: Dock A DecK =OLK GOUN T Y, N.Y 5GA!= I"= SO' -- _ 5it�...,Ve:Niottituck 1A-JM: MSL NG�/D'2q W T • C gin: Southold 5uffOlk County —i-DE rZAN6E: 25' +/- S D E ' V r Pr Rum: w N,_--;\/0'N,_--;\/0'24 • t �J loci na Dock JAN 3 2022 • =10G= n0t it G, ; I time OF SJ-veu 23 ` • C i "'` SGT= ;000-!!�-.c-II __ _ ;_and a=: 5nttilo!d7tr��ri - James Vr. Boar r d MTfu4— 6`I r Ave. PROPOSED 10 FT.X kmerica 14 FT.ON GRADE. -cram, NY i;72? �O STONE PATIO WI O MORTOR SET -b3 5.7 _3= - ON 4"OF COURSE SAND "AS BUILT"10 FT.X 12 FT.SHED +r- 4'° tlG _3t: ,< (4' X bb - x 6 (3' X,'14') - -52 V , 5-1 ,r,� IIG -IID 152 C - - - - - - - G N1 rye ` p_ �F "bs 11.4 - -`13 ..tb -fi.•4 -6b _ t �" 7D V i 475 -G;- -'2 62 SGTI 1000-II- 25 ft. a -; \ - � ExfSti� Lano op. a 12-t1 ry Fr ame __ - 1l.5' IN lde 5., 63 73 a - .`a -- 11.3 I iJ ext�Rd 2 47 -b - los No Fill required ns q3t ,�'i ii ':-• , or qGid - yp�� ` �� ----"-- __-- 63 73 ^ 105 •- g�2e�9. AP ROVE® t Q`� e�� c `v Il+ 100 FT.TRUSTEEVj BOARD OF 1 TRUSTEES � �TI000-)17-12-13 JURISDICTION LINE TOWN OF SOUTHOLD Ja„an osp, DATE 41-1022 Street DATE i3au51de, Newyork �l+lfl(u472 T I Paul & Constance Codnor 830 Deep Hole Drive,Mattituck7 '�`j __ I 'Proposed On Grade Stone Patios .� Legalize "As Built-Shed O �• 1�Iolk �4' X .3S') By: M.A.Kimack Dated: Dec.22,2022 co Gross 5�ection � 20' 35' cbove Erode ROMP (5' x 14') Floo {b' x 20') 1 SEA - __ -----, " LCL MSL o. - - -- - - - - -- - - - - - - - - - -- - - --- - - _ _ - I ____- --- - -- - (., t rc 6 EAST MAIN 5TREET - _ +Z" '• +�D,N- [IR01 --- - " r r r THtS PLO7+tNA5 G-V=-LOPFD 5*-7271-315-7 -------------------------------------------- 8,t dia. 1 , FROM FELDOF 12-22-01 =AX 5i-3bq-6287 - - - - - - - - - - - - - - - - - - - G Ar'�iIPS G -j - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - `4�rLv;m,"I�r— eet 1 Of I O 20 40 60 80 100 - - I20 140 160 ROBE=RT H. I✓� W5 LIz# 50MI i ' i _ SUfF01 ti.: , Gler«i goldsmith,President �p�� crGy Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 Eric Sepenoski ,? P.O.Box 1179 Liz Gillooly �y ® �� Southold,NY 11971 Elizabeth Peeples ��1 ��p Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 1)/23 Completed in field by: 6o W Michael A. Kimack on behalf of PAUL & CONSTANCE CONNOR requests an Administrative Permit for the as-built 10'x12'shed and for the installation of a proposed 14'x10' on grade patio with 4" sand base with stone laid on top (without mortar). Located: 6$e Deep Hole Drive, Mattituck. SCTM#: 1000-115-12-12 iia Typ of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: ,/Chapt.275 Chapt. 111 other Typ 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.: Present Were: +r G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples I� .r.."..._._,. _ . ..+�1 sur If 1:✓r rr'ropo5ed: �oGk e Deck AL= _ Sit�e:MottituC.k W C ibvgn: Southold Sefolk Gounty S Furpo5en bate Mooring _ Datum: m5L NGVD'2 i 1� ;7 Lond Of__i2-li. Domes W. �a!n[or: PROPOSED 10 FT.X 14 FT.ON GRADE 6ci <VneriGo eve. STONE PATIO-W/O MORTOR SET --orom. NY (172-7 j l "AS BUILT10 FT. } ON 4"OF COURSE SAND p �.�.■ X 12 FT.SHED bb ' t7 9bPP Equipment - - �.'�'•� +:i. t� 1 y. '- - `�--� "' '� U. '\-._.... ..._..-IID 4 / 62 "..•. AGG@55 :- -_ f+ � i. vI �n�`^ ,,..:x:11,^nra.<ov.a�:.a.� 7L•i f �• l D _ V 475' _ b 6.2 SGT 000-I f5 12c -. Lana �ISt:.,g � of. Go 1 1: ole g , 60 No fmIto or y 11.0IID g7 _ lOG 73105 " :• f� '+ � l� IID •,5 1100 FT.TRUSTEE N UUU" SGT IOOG-115-t2_j3 RISDICTION LINE ~ Land of: John Kosloski 41-10221 5traet n Bauside. Nero York Paul 8 Constance Connor 830 Deep Hole Drive,Mattituck Proposed On.Grade Stone Patio 'Legalize "As Built "Shed �Q O lNalk (4' x 58) BY: M.A.Kimack Dated: Dec.22,2022 CO 55' above Grade i2amp (3' x 14') �r Float (6' x - - - - - - - - - - - - - - - - - - - - - i � mss, !! air_' r►,.F� i �Y; �`1 of � •�.. ,,,(^`� ,!Ar rf ,, 2022! 12! 11 15 : ? 6 J .r 2022/ 12! 17 15--fi7— w .. ' "`�"° � ,yam• s. __`. _- ' NINE 1 t' MEMO T _ a ANA ww 2022/ 12/ 17 15 * 17 (3)Connor Residence Taken Dec. 17, 2022 Looking North �A F . s (4 Connor Residence 'qi,, i Taken Dec. 17,2022 �; g '�i a.� • "'R ti► nom" @ Looking ENE ML 1 U6 mom + aw11M7awN..:p., r k y (S)Connor Residence ` Taken Dec.17,2022 Looking SE it.f �s A^ lill i n r Fr � 4 {li)Connor Residence Taken Dec. 17,2022 Looking ENE CONNOR RESIDENCE � ' _ �' �� i� Legend 830 Dee Hole Dr Write a description for your map. p ZA ' "+ � t(" a r�r'i'.y�" °� '+ x lf�R' �''#.1l Y � 't' •'y �'S'}°�r}g� '�. + ; ! + a, 4 Y yrr + ,.�. �'r`: - ♦+ d p. .'' i� '' '� 4 � t,`0`ra `� �W; �1� ;,�wJ � ✓ ,�';.'�" 6.j xr r„� b iMfa+ s 'f' w Y ✓.: �t�'}' .�,«�� 't.� #s'l�y#�,� `�`�,, A iC }a��:.».* � ��i* t � j✓ t4 9 `�,t`��y fi +.,,,�f f � _ Sod ti .M� yr A, - w{ rs f� r,�a. �.,�►w )4 A 11 , �1ry OFFICE LOCATION: �� Soyo 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: 631765-1938 oly00U ,� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: ;Mark;Terry, AlCF r ;LWRP Coordinator Date: January 17, 2023 f, Re: LWRP Coastal Consistency Review for PAUL &CONSTANCE CONNOR SCTM# 1000-115-12-12. Michael A. Kimack.on:behalf of PAUsL&CONSTANCE CONNOR.requests an Administrative Permit for the as-built 10'x12' shed and for the installation of a proposed 14'x10' on grade patio with 4" sand base with stone laid on top (without mortar). Located: 68*Deep Hole Drive, Mattituck. SCTM#: 1000-115-12-12. 830 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 as built to, is INCONSISTENT with the Policy Standards and therefore is INCONSISTENT• with the LWRP. The,proposed on grade patio is recommended as Consistent with the LWRP. 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 jt� d�so&.,,' s 54375 Route 26 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sen enoski V Southold,New York 1.1.971 Liz Gillooly S cn 1 G je3 Telephone(631) 765-1892 Elizabeth Peeples �Q �'3F Fax(631) 765-6641. BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD _. This Section For Office Use OnI ii 2 r 2 e E Coastal Erosion Permit Application D Lr- LS 0 Wetland Permit Application JAN — 3 2023 —Administrative Permit Amendment/Transfer/Extension )C Received Application: 1.3120 _ Southold Town Received Fee: $ 2.WDd6 *11P.r Board of Trustees Completed Application:. 1.523 Incomplete: ^SEQRA Classification: Type I Type If Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: --/Coordination:(date sent): LWRP Consistency Assessment Form Sent: AC Referral Sent: Date of Inspection: Receipt of CAC Report: chnical Review: _/Public Hearing Held. ?3 Resolution: Owner(s) Legal Name of Property (as shown on Deed): BQLZ CAJiVtO'/W C45 C®/10/I1oR Mailing Address: bloo &Zze&Z PRI VS-. 11-Y !19 7 Phone Number: �~ Z��— 1�_?Zc? Suffolk County Tax Map Number: 1000 - �/�" /Z f Property Location: -.2 04 &1115/ (If necessary, provide LILCO Pole #, distance to cross streets, and location) AGENT (If applicable): 91YA 4 Mailing Address:. P® 80}t jt242_.S oO •y®C4) /I/ 7/ Phone Number: � ��_ Email: je/ 4gALe �1 �f��•�•�� Board of Trustees Appl ttion GENERAL DATA Land Area (in square feet): 04,00 Area Zoning: f- 4 Previous use of property: 92&�1,� N nA-1- O-A/4 Intended use of property: 96IC122A5& "i�L- ad X.4/`'l/L. / - Covenants and Rdstrictions on property? Yes _XNo 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 )C 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: Agency Date 2�R- fl-Z4 U&V—O&/f-P") 16/:t 71QZ- 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): Project Description Install a proposed 14 ft. x 10 ft. patio on grade ( 140 SF ) consisting of a 4" sand base with stone laid on top without mortar. Legalize 10 ft. x 12 ft. shed ( 120 SF ). Both structures located within 100 ft. of MHW line Board of Trustees Appl, Rtion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: CRAr�E .4 ,A5 OeA71 014 Area of wetlands on lot: 1495' square feet Percent coverage of lot: 15" % 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? 1, cubic yards How much material will be filled? j, I cubic yards Depth of which material will be removed or deposited: 4 &WF - Proposed slope throughout the area of operations: < �Io Manner in which material will be removed or deposited: &AND S- Hrl V�L 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): WILL AN IQ Y 4Y-A= ANY Z65�:CZ mpzm aze-r% &D-s 617.20 AppenAr B Short Environmental Assessment Form lostruetions'-for Completing Part l -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 l -Project and Sponsor Information Name of Action or Project: C D AIN OR JOR ®.? OW ' Project Location(describe,and attach a location map): Brief Description of Proposed Action: 4E A Name of Applicant or Sponsor: Telephone: �1 E-Mak l! ®,dl.A 7 Address; City/PO: State: Zip Code: -'®U rpo e r1 Y l 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 EX Q 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: Elu 3.a.Total acreage of the site of the proposed action? 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? vacres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban []Rural(non-agriculture) ❑industrial ❑Commercial (Residential(suburban) ❑Forest ❑Agriculture ❑Aquatic []Other(specify): ❑Parkland Page I of 4 Project Description Install a proposed 14 ft. x 10 ft. patio on grade ( 140 SF ) consisting of a 4" sand base with stone laid on top without mortar. Legalize 10 ft. x 12 ft. shed ( 120 SF ). Both structures located within 100 ft. of MHW line 5'. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ ❑ b. Consistent with the adopted comprehensive plan? ❑ ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ 7. is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: ❑ 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? ❑ 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: IZNJ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: IVIA pc�l ❑ 11. Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: A11A X ❑ 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? —17 13.a..Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain N07-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: �1 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline El Forest ❑Agricultural/grasslands El Early mid-successional Nd Wetland ❑Urban 1�71 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? � ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Wil I the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, Ela. Will storm water discharges flow to adjacent properties? F-1NO ]YES b. Will storm water discharges be directed to established conveyance systems(runoffand storm drains)? If Yes,briefly describe: F-1 NO ❑YES Page 2 of i 1 may_ 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g. retention pond,waste lagoon,dam)? If Yes,explain purpose and size: __ 19. Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE ,2ZSiApp Iicantlsponsor name: Date; 12121L2 0,2?- Signature: gnature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning Elregulations? 2. Will the proposed action result in a change in the use or intensity of use of land? F ❑ 3. Will the proposed action impair the character or quality of the existing community? UF-1 El 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or Elaffect existing infrastructure for mass transit,biking or walkway? El 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate (�j reasonably available energy conservation or renewable energy opportunities? EJ 11�-..I! 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, 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)? L_l 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 drainage1:1problems? 11. Will the proposed action create a hazard to environmental resources or human health? F I ❑ Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should, in sufficient detail, identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant. Each potential impact should be assessed considering its setting,probability of occurring, duration, irreversibility,geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency_ Signature of Preparer(if different from Responsible Officer) PRINT7 Page 4 of 4 1 � i Boaz-d of Trustees ApYr-�cation AFFIDAVIT /L T C0'66-Z;--4iVc-A5 A. CW&OR BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT AL1, 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 TRUSTEE;. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES I-IARNILESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIR'rUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREB AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORS' COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLL;DING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF 'TRUSTEES TO ENTER ONTO MY PROPERTYAND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOABM OF TRUSTEES DURING THE TERM OF THE PERMIT. �ign._�ture tlz� �" Signature of Property Owner SWORN TO I3EFORE M>✓ TRIS .__....-� I:►AY OF 20 �? Notary Public MICHAEL A. KIMACK Notary Public,State of New York No. 02KI5056823 Qualified in Nassau County Commission Expires March 11,2026 Board of Trus-gees App-_—cation AUTHORIZATION (Where the applicant is not the owner) owners of the property identified as SCTM# 1000-_ /�'�=/� iL° in the town of _ �ta4Tr/TU Ck . New York, hereby authorizes to act as my agent and handle all necessary work involved with the application procesi for permit(s) from the Southold Town Board of Trustees for thi,; property, U P yer's`Signature Property Owner's Signature CcJ/VS74—NCS .4, COiV/1011�' SWUR`1 'I U BEFORE IV1E THIS 1 TT DAY OF 20 22 Notary Public MICHAEL A. KIMACK Notary Public,State of New York No. 02KI5056823 Qualified in Nassau County Commission Expires March 11,2026 ( A.P'PL:[CANT/AGLPIT/REPRES +NTATIIT . TRANSACTIONAL DISCLOSURE FORVI The Town of Southold's Code orDhics prohibits conflicts of interest on the part of[own officers and employees.The purpose of this firm is to provide information which ccan alert the town of ossihle Conflicts of interest ane allow it to take whatever actit in is necessw-y to avoid same. YOU It NAME: (Last name,first narr.e,iriddle initial,unless you are applying in the name of someone else or otht:r entity,such as a 2ompariy.if so,indicate the other person's or company's name.) NAME Or APPLICATION: (Check all that apply.) Tax zrievance —_ _ Building. Varialce —" Trustee Change of Lone -- Coastal Erosion _ Appr•:-val of plat _--- Exemption from plat or official map Planning Other (If"C)thcr name the activity.) Do you t-crsonally for through your company,spouse,sibling,parent.or child)have a reladonship«ith any officer or cmhlo.,cc of the"I`nun of Southold? "Relationship"includes by blood,❑tarriag:.%or bu::iness interest_"Business interesi'means a buoina>. including a parurcrship, in which the town i.flicer or employs has,ev:n a partial ownership of for er:rployment by)a corpor,r[ion in which the ww;n officer or employes own, more than 5%of the shares. YES NO X )fyor. answered"YES complete the balani of this romi and date arbJ sign where indicated. Name of person employed by the Town of Southold Title cr position of:hat person Describe the relationship between yourself(the applicartt/agendtepres_ntative)and the town otft-er or employee.Lather check the appropriate line A)through D)and/or describe in the space provid-:d. The town officer or employee or his or her spouse,sibling, pawn•,or khild is(check aft:hat appty): __A)the owner of greater than 51A of the shares of[he corp-)rate ;tock of the applicant (when the applicant is a corporation): ___8)the legal or beneficial owner of ary interest in a nor:-curpor rte entity(when the applicant is not a corporation); __.--__C)an officer,director,partner,or employee ofthe appli--ant;or --.---D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this ` of �.tcC, 201'21 Signature_- Print Name "J; CQAI.vo r Form"I'S I APPLICANT/AGED IT/REPRESENTA.TINT TF'.ANSACTIONAL DISCLOSURE FORM The Town of Soutliold's Code c:f Ethics prohibits conflicts of interes.on the part of town officers and emolovees.The purpose of this fiirni is to provide inRnznation which qui alert the town c,r"possif le conflicts of interest and allow it to take whatever action is necessary to avoid sarne. YUtllt NAME: _.CO ll�t M-`C��d ['L�_ �. (Last name,first name,Middle initial,unless you are applying in the name,of someone else or other entity,such as a company. If so,indicate the other person's or company's name.) NAME- OF APPLICATION: (Check all thst apply.) Tax erievance __— Building Varia:ce Trustee Change ofZone ---_ Coastal Erosion Approval of plat Mooring Exemption from plat or official rnap ------ — Planning _ Other (If"Usher",name the activity.) Do you rersmwll} (or through your company,spouse,sibling. parent,or child)have a re.litionship with any officer or cntplo�cv of the"1 own of Southold? "Relation<.hip"includes by blood,utarriage,or business interest.-Business inlcresi'means a including a partnership. in which the town o ticcror employee h,:sev(.n a partial twmership of(cr cinpl�>yiricnt by)a corporation in whik:h the uown officer or employee owns more than 4'„of The sharps. YES NO If von answered complete the balance of this firm arna date an 1 sign where indicated. Naini:of person employed by the'ro%vn ofSouthold ---- Title or )sition of that person Describe the relationship between yourself(tie applicant,agentire:presentative)and the town officer or employee. hither check the appropriate line A)through D)and/or dneribe in the space provided_ The town officer or employee or his or tier spouse,sibling, part-ni,or child is(check all that apply): ___A) the o«•Fier of greater than 5'%of th.,shares of the corporate stock of the app]icant ;when the applicant is a corporation),- f3)the legal or beneficial owner of any interest in a non-corporte entity(when the applicant is not a corporation); an olTicer,director,partner,or employee of the applicant;or J)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted ik /�J— y of Sig 'l/�U Print Name Form'I'S I APPLICANT/AGF,NT/RE-PRF,SENTATIVE TRANSACTI®NAL DISCLOSURE FORM The Town ofSouthold's Code`ofEthics prohibits conflicts of interest on the dart of town afacers.and employees The purpose of this form.l:to provide.injRprination w rich can aten the town of 12osalle conflicts of interest:and allow it tb take wti:`ttever action i necessarX to avoid same. y YOUR NAME: ) ! C!7 G ,14 (Last name,first name,giiddle initial, unless you are applying In.the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance __ Building Variance Trustee 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 ol1'iceror employee of the To%vn of Southold? "Relationship"includes.by blood,inarriage,or business interest-"Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a curporation in which the town,offiwer 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 br position of that person Describe the relationship between yourself(the applicant/agent/represeritative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this 21 da of7— Signature_ Print Name. C I 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 Arotaosed action will be evaluated as to its si ifs scant 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- supporthig 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 AC'T'ION SCTM# - _ PROJECT NAME ,�i�U, = CQNJZ;7 � CON&OR The Application has been submitted to (check appropriate response): FZA 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: 1-71 Nature and extent of action: Project Description Install a proposed 14 ft. x 10 ft. patio on grade ( 140 SF ) consisting of a 4" sand base with stone laid on top without mortar. Legalize 10 ft. x 12 ft. shed ( 120 SF ). Both structures located within 100 ft. of MHW line Location of action: Site acreage: Q. Present land use: FzEFI Pah-5l144 ONE 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: H!C'P 251— .04, e I H14 C—�L (b) Mailing address: ®. D9C o 4 7 (c) Telephone number: Area Code ( } �l� � a 6 0 7 (d) Application number, if any: / Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ❑ No^1 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 LWI2P Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ No ® Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LVb'RP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No 0 Not Applicable L_ l) 4j2M 1 r " /09. ,d 14EAR OR A22 5' ear 7"C�� P Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See L WR.P Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No 0 Not Applicable P®L/cX -? &4A 1 1C- oe 1C A 774 PA-LZO CIA/ CMA04 Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LW1-P Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ NoX 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 Not Applicable I OU CY .4` A-1 1A n9 2% /s A RAQ c'-4ZQ-V 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. ❑ ❑ X] ' Yes No &t Applicable e6 61 c y n �1�P.RZ/ C4 n6Aj Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See IlWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No® Not Applicable E® L/Cy -7 A/114 7-0 7-9 !S_A RAU CA 7'10AI Attach additional sheets if necessary Policy S. Minimize environmental degradation in 'Town of Southold from solid waste and hazardous substances and wastes. See I.WRP Section III —Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No ® Not Applicable PUBLIC OAST 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❑ NoNot Applicable Attach additional sheets if necessary WORKING COAST P,,..,ICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III—Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No.PQ Not Applicable P-01—IC d AVIA n2 rMIT 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 kn�j 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 ❑ N(YE7JI Not Applicable FL`CX `Z & A- a 774 1_57 A PPL. CA 7-10,V 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 El No Not e Ap licab �o�s C y 1.r �-o �L�is ��c,��-1®AI PREPARED PY TITLE DATEJZZZ ®��