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Home My WebLink AboutTR-10289A Glenn Goldsmith, President ®`A tf SOU��® Town Hall Annex A.Nicholas Krupski,Vice President ®�lv �® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly G Telephone(631) 765-1892 Elizabeth Peeples ® �® Fax(631) 765-6641 C4UNTV, � BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1998 C Date: January 18, 2023 THIS CERTIFIES that the existing 14 6'x15.6' deck 88"x88"x40' hot tub and 10'x12' sunshade, At 1625 Stillwater Avenue, Cutchogue Suffolk County Tax Map#1000-103-1-19.6 Conforms to the application for a Trustees Permit heretofore filed in this office Dated December 16, 2022 pursuant to which Trustees Administrative Permit# 10289A Dated January 18, 2023,was issued and conforms to all the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for existing 14 6'x15.6' deck 88"x88"x40' hot tub and 10'x12' sunshade. The certificate is issued to,Michael Lademann owner of the aforesaid property. Authorized Signature Glenn Goldsmith, President ��®f so�� Town Hall Annex A. Nicholas Krupski,Vice President ® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly G � Telephone(631) 165-1892 Elizabeth Peeples Fax(631) 765-6641 C®UN11,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10289A Date of Receipt of Application: December 16, 2022 Applicant: Michael Lademann SCTM#: 1000-103-1-19.6 Project Location: 1625 Stillwater Avenue, Cutchogue Date of Resolution/Issuance: January 18, 2023 Date of Expiration: January 18, 2025 Reviewed by: A. Nicholas Krupski, Vice-President Project Description: For the as-built 14.6'x15.6' deck, 88"x88"x40' hot tub and 10'x12' sunshade. 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 Vincent Benic Architect, dated August 11, 2022, and stamped approved on January 18, 2023. Special Conditions: Existing vegetation is to remain. 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 EXIST HOUSE GRADE - p EC - 1V--E-Ir'��] MiA Z=— VINCENT BENIC ARCHITECT _ PO Box 92,Southold NY 11971 DEC 1 6 2022 ; www.vbarch.com -- — -Sued/Revision S,. 'tavfl Board ofTrus*w 08/11/22 BUILDING DEPT SUBMISSION -- -- RIGHT OF WAY NEW HOT TUB ONC _ I - TOP OF NEW DECK �� EXIST.HOUSE - — `gyp EXIST.DRIVE AND DECK I APPROVED BY NEW STEPS = 9LF �� NEW DECK I BOARD OF i OR RUSTEES Dowty To - - _ - a �` \ c� i NEW DECK Drawings&specifications as instruments of professional service TOWN OF SOUTHOLD - — ---- _ M are,and shall remain,the property of VINCENT BENIC ASS - �` UME�-- ARCHITECT. No reproduction,in whole or N part,shall be made ARCHITECT.- - -_- -__--.--- -- EDGE OF �-" ---- without the written authorization of VINCENT BENIC ARCHITECT. A wETLANp This document is intended solely for the construction of the DATE —�� - project named herein and shall not be used by any other parties for any J ANu d,�� I y �0 + ��\ VINCENT ter construction BENIC ARCHITECT the written consent of EXIS. DECK NEW DECK --- NEW GUARDRAIL - SITE PLAN O scale:l"=50'-0" —- @36"ABOVE DECK \' a, '~ DN 0 50 100 150 200 FT - - - - -- -- - --- - - -- 14.749 EXIST. DECK NEW DECK OF!BECK En•ti &SXP 1/2"=r-o° �G J L I 00 1 2 3 4 5 F "✓/� �� r EXIST. DECK _ -_ - - NEW STEPS EXIST. DECK _ -- RAILING BEYOND DOWN TO RAILING BEYOND EXUST HOUSE 14883 NEW DECK - NEW GUARDRAIL @36"ABOVE DECK4" NEW HTON TOP OF NEWBDECK X 41" POSTS r r -- _ -- SWCURED TO JOIST/ ---- - - - - VBA Prof#: seal: W/SS CABLE RAIL --- NEW HOT TUB ON 378.2 _ @4"OC TOP OF NEW DECK Drawn: -- WM Ar Checked: VB a EXIST. DECK - - ------------------------------------------------------NEWECK 2 X 12 PT JOIST16"OC-SISTERED AT CANTALIVER of Al 2X12PTJOIST16"OC is i n i n, �-n-r�r—�--_. .rrr---._-nr--►rr n i ::i .. n :`. � ___.;-, -__i , c7 4 - (2)2 X 10 PT BEAMS BOLTED TO POST-TYP 09 ;� I � nt (2)2 X 10 P WOOD SCREEN = Project - - BEAMS BOLTED' WOOD SCREEN - DECK, SISTERED JOI -- o Posr-TYP ---= GRADE - 1625 Stillwater Ave --- e, N GRADE s°xs"PT POST_ Cutchogu Y 11935 12"ROUND 6"X 6"PT POST i i SECURED TO I Drawing Title �T CONC FOOTING SECURED TO CONCRETE @ 36"BELOW CONCRETE FOOTING WITH PLAN/ELEVATION GRADFE FOOTING WITH ANCHOR BOLT ANCHOR BOLT 12"ROUND '- -__ OF DECK i 1 NC BELOW Drawing Number CO FOOTING ------ ------- 2 SOUTHLEEEVATION @ L 2 EAST ELEVATION EXIST. DECK NEW DECK Scale 112"=1'-0" GRADFE 14.833 scale:v2'=1'-0" �----- _ -- - - - -- --- - - _ - 00 1 2 3 4 F 00 1 2 3 4 F A-100 1 / o ocAy moo, 0 J Loi PSPNP�� \GNB °� rn o 6R P lb o PSR �'�•C� o OP S•�0 "0" O \c� s o `rte 6R SSP � 0 -\ Tax Map Lot 19.6 Ar o NN- 0 sti �AOR o. I CP PLL �rn (51 �� 62� TIMBER No' 42 WALL '5;F ,SF 60 po — ASPNACT DR/VEW ° o P �O Co �+ ps TIMBER RETAIN. 17 • WALL vC� "Do 310- 00 � S8700o' 30,W Tax Map Lot 1 SURVEY OF PROPERTY SI TUA TE , E C E I V E CUTCHOGUE, TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK DEC 16 2022 TAX No. 1000-103.00-01.00-019.006 SCALE 1"=20' :s Y! `tO.'uT(YvTt OCTOBER 10, 2022 Board ofTrus4mes AREA = 40,018 sq. ft. 0.918 ac. AERIAL LAND SURVEYING, D.P.C. NOTE: LOCATIONS AND EXISTENCE OF ANY 53 PROBST DRIVE SUBSURFACE UTILITIES AND/OR STRUCTURES NOT READILY VISIBLE. ARE NOT CERTIFIED. THE SHIRLEY, NY 11967 CERTIFICATIONS HEREON ARE NOT TRANSFERABLE PHONE: 833-787-8393 E-MAIL- SURVEYSOAERIALLANDSURVEYING.COM WEBSITE: WWW.AERIAU ANDSURVMNG.COM THIS SURVEY IS 9UB.ECT TO ANY EASEMENT OF RECORD AND IXY OTHER PERTINENT FACTS WHICH A TILE SEARCH MIGHT DISCLOSE DISTf�ICT:1000 LOT:019.006 BLOCK:Q1.00 SECTION:103.00 •UNAuTHORRED ALTERATION OR ADDITION TO A SURVEY MAP BEARING A MAP/FILE NO.: N/A LICENSED LAND SURVEYOR'S SEAL IS A VIOLATION OF ARTICLE 134. BECTON 7209.SUBIIIVISION 2.OF THE NEW YORK STATE EDUCATION LAW 'Copies from the original of this cum"mop not marked uft an original » „ of the land aareyoes Weeds ed sed shall not be LEGEND. MAP OF: Not on a filed subdivision map considered a raid tie �� ed hereon sgniry that this nave was prop an i9 Code of Practice for Land rvwof Profesiond Land adop e t tate ly to the TITLE NO.: 306-S-26925 �,fi r„ an an t t the — — — e am OVERHEAD UTILITY WIRES N not traneferoae t ri d to 11r t a MAP FILED DATE: N/A COUNTY TAX MAP ID: 1000-10300-0100-019006 r CZD UTILITY POLE o SITUATED AT: CUTCHOGUE, TOWN OF SOUTHOLD ,�- J. rj CONC. MONUMENT SUBDIVISION MAP LOT & BLOCK 'S: NIA Z��O 050205 J�J� 0 ono an Greenberg SAND w Geraldine kireenberg EM ELEC. METER oCOPYRIGHT 2022 RALPH Citibank, s Successors an or Assl ns AERIAL LAND SURV�HG oP.C. wVintage Abstract Cor . JOB NO.: 22-1715 First American Title Insurance rompany DATE: OCTOBER 10, 2022 V� OCA roti �0.. �(aX MCP PSP�P�� R\GNB pF �. 0 d3 (0 9'b o p,\.� ate' �o a ()0? Ly p Tax Map Lot 19.6 0-V 16 0 OE.� %P, o ° �pG .rlopo5 N �S\M '" X12? �4 � \ " o. TIMBER �p� 60 No• 1 A2� �� RETAIN. F �p WALL Q ASP HALT DRIVFW A TIMBER RETAIN. J WALL 7DO 310. 00' S87°00' 30"�N Tax Map Lot 1 SURVEY OF PROPERTY SI TUA TE CU TCH OGU E, TOWN OF SOUTH OLD D E C E I V E SUFFOLK COUNTY, NEW YORK TAX No. 1000-103.00-01.00-019.006 DEC 16 SCALE 1"=20' OCTOBER 10, 2022 Board of T us'ees AREA = 40,018 sq. ft. 0.918 ac. AERIAL LAND SURVEYING, D.P.C. NOTE: LOCATIONS AND EXISTENCE OF ANY 53 PROBST DRIVE SUBSURFACE UTILITIES AND/OR STRUCTURES NOT READILY VISIBLE. ARE NOT CERTIFIED. THE SHIRLEY, NY 11967 CERTIFICATIONS HEREON ARE NOT TRANSFERABLE PHONE: 833-787-8393 E—MAIL- SURVEYSOAERIALLANDSURVEYING.COM WEBSITE: WWW.AERIALLANDSURVEYING.COM THS SURVEY IS SUBJECT TO ANY EASEMENT OF RECORD AND ANY OTHER PERTINENT FACTS WHICH A TITLE SEARCH MIGHT DISCLOSE DISTF�ICT:1000 LOT:019.006 BLOCK:01.00 SECTION:103.00 ,UNAUTHORIZED ALTERATION OR ADDITION TO A SURVEY MAP BEARING A LICENSED LAND SURVEYORS SEAL IS A VIOL ZION OF ARTICLE 134. MAP/FILE NO.: N/A SECTION 7209.SUBDIVISION Y.OF THE NEW YORK STATE EDUCATION LANr 'Copies tram the ar►9hal of Hits«wvey map not marked wiM on orkind » „ of the land sarve,arre Inked ed sed shall not he MAP OF. Not on a filed subdivision map considered id true rtlo ed hem sk ify that LEGEND: 'dn this AM was prep ce Code of Practice for Land ys s tate of Profesiond Land e d ly to the TITLE NO.: 306—S-26925 wA panA„ „ t and °^k, t t ad — — — OVERHEAD UTILITY WIRES N MAP FILED DATE: N/A not tr-anefent,le t Vdit d t o COUNTY TAX MAP ID: 1000-10300-0100-019006 c� UTILITY POLE SITUATED AT: CUTCHOGUE, TOWN OF SOUTHOLD CONC. MONUMENT S 8DIVISION MAP LOT & BLOCK 'S: N/A SFO �50205s�� 0 Jonathan Greenberg AND W Geraldine Ureenberg — RD.EM ELEC. METER Citibank,I I ank s Successors an or Assigns AALLANSLJVEMGC. W Vintage Abstract Cor . JOB NO.: 22-1715 irst American Title Insurance om an DATE: OCTOBER 10, 2022 Gle,u,uoldsmith,President �p�� G$ Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 Co Eric Sepenoski ,? P.O.Box 1179 Liz Gillooly �y • o!� Southold,NY 11971 Elizabeth Peeples �Ol �a Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 1 Z h3 Completed in field by: N KNPS K, Tyler Lademann on behalf of MICHAEL LADEMANN requests an Administrative Permit for the as-built 14.6'x15.6' deck, 88"x88"x40' hot tub and 10'x12' sunshade. Located: 1625 Stillwater Avenue, Cutchogue. SCTM#: 1000-103-.1-19.6 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 ---�4Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modification1s'/Conditions/Etc.: / Present Were: G. Goldsmith V N. Krupski E. Sepenoski L. Gillooly E. Peeples NT FA g Rol 1W-1 1 9la � °'s,�►�Q a �9 � �'� �• +s;►��,►� lm%;1�I ill tz- y�'�!� ./Ii ►�y ti �F f,� �P 'r IJ'. i'/ �� a.�`ti ?��' Rla ..7. ( �• �aa��..rj ( I1�P� rn r� (+ -�rr,,,,� eTLk �`��` M�FMbxd o`�Y " t �.y •Ily IRWIN*Z. �� t-; ' t.. ��n► .�y� + P� i:f�"«y��,t�u$ �'�,d}F'�Ff ff �-/.o �.. �`. � t " +�f f (!t�',L�, \F, � }fit A�` �`.raY � / �'�� a (��, �/ `�• 'rw CSI, ♦z �, v. ._ ! �� d �i"�ja3�i may..E 'a `c i a �� a > f . a w !r -. '�r ' �1�r�• ��, isAM—�ifi1►i1 ��. 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'dr +.HLF ."` s5 - � ur b �-� was q 4 4.0 A4 . t Ram, y b}$ ,x 4�+ ;e � 4j21 • J ,ya cA). 4 B 1�,. �Fq �� ' .. ww � y� 3 41 __ `9r� �. ,rv� (: aJ1 p R�•fg_ B W' )� ,heL• in i �d •� > �.� is I •�� B JP- � c _ . . m f �, x I • a, *, s J 3 J B L B 6�E SEODE�MO t Z COUNTY OF SUFFOLK _ _ I.a Heal Property I..S—i.,Ag-, N •wnev aF xreanow arcw M � '103•, :...... +a a ww—JO_—_ u _— _ • �wman awme,�rtw.r,Sp+�T�iFt ---- 5 e OFFICE LOCATION: MAILING ADDRESS: Town Hall Annex �^ P.O.Box 1179 54375 State Route 25 q��Q� ®Ury®P Southold,NY 11971 (cor.Main Rd.&Youngs Ave.) . Southold,NY � �, Telephone:631765-1938 www.southoldtownnv.gov a PLANNING BOARD OFFICE TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: MarkTerry;AICP LWRP Coordinator 1 Date: January'17;-2d23"' r Re: LWRP Coastal Consistency Review for`of MICHAEL.LADEMANN SCTM# 1000-103-1-19.6 Tyler Lademann on behalf of MICHAEL LADEMANN requests an Administrative Permit for the as-built 14.6'x15.6' deck, 88"x88"x40' hot tub and 1,0'x12',sunshade., Located: 1625 Stillwater Avenue, Cutchogue. SCTM#: 1000-103-1-19.6`" 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 proposed action is INCONSISTENT with LWRP Policy 6.3 and therefore, INCONSISTENT with the LWRP. 6.3 Protect and restore tidal and freshwater wetlands. . A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws - and regulations for all Andros Patent and other lands under their jurisdiction 1. Comply with Trustee regulations and recommendations as set forth in Trustee permit conditions. 1. The as-built structures were constructed without Board of Trustee review or permit. - 2. The 39' setback to the wetldnd with a slope to the system is not supported by Policy 6. It is close and'erodes the function"of adjacent upland ecosystems to wetlands. 3. A natural buffer is not proposed. 4. Drywells are not shown for draining the hot tub. Chapter 236 drainage requirements should be applied. Pursuant"to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Glenn Goldsmith,President 'QF s®o Town Hall Annex A. Nicholas Krupski,Vice President ®� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski [ i�8 Southold, New York 11971 Liz Gillooly Elizabeth Peeples � ® � Telephone(631) 765-1892 a Fax(631) 765-6641 ��COUMfY,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application _j,e!�_Administrative Permit Amendment/Transfer/Extension Received Applicata n: IZ'1621� Received Fee: $ 0,OD 7—Completed Application: 12•ZZZY Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: PP- oord ination:(date sent): WRP Consistency Assessment Form Sent: [FOEC . lig' I ... , CAC Referral Sent: ✓ Date of Inspection: '��•ZcJ - Receipt of CAC Report: 6 2022 ; Technical Review: Public Hearing Held: Resolution: Board u+TIds,le= -s Owner(s) Legal Name of Property (as shown on Deed): 14i L, LQetx . ;Ltl Mailing Address: A�VCv�S LIL ,,C L CA sem, �)A I,�� Phone Number: b3 l a �- 0q 9, J Suffolk County Tax Map Number: 1000 - VOA , O O r O t , O 0 00 , O O 6 Property Location: (If necessary, provide LILCO Pole #, distance to cross streets, and location) AGENT-(If applicable): Tylere�'`r-� Mailing Address: 0 _X �11►rG .S LA_ J Phone Number: 1V u1 1 Email: Board of Trustees Appli4 ,,ion II 11 ��yyVGENERAL DATA 4 Land Area(in square feet): , o�� Area Zoning: Rc<)11 Ja`6 Previous use of property:qC5 I'U&UA 14 Intended use of property: �ee-C) a - Covenants and Restrictions on property? Yes No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? —XYes 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 X No Does the structure (s) on property have a valid Certificate of Occupancy? _Yes No Prior permits/approvals for site improvements: Agency Date J� No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?__vs_No Yes If yes, provide explanation: Project Description (use attachments if necessary): -1k � kckl �i 1 0 Ilk Board of Trustees Applic, ion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ACA-1 YID Civ e Area of wetlands on lot: Q. J(Do square feet Percent coverage of lot: J 0/0 Closest distance between nearest existing structure and upland edge of wetlands: �� 1—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? O cubic yards How much material will be filled? 0 cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: kKy1we (— Manner in which material will be removed or deposited: J c) /1'c 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): 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part.1 -Project and Sponsor Information Name of Action or Project: Project Location(describe,and littach a location map): �1�( �Ct 3 Brief Description of Proposed Action: r � Name Jof Applicant or Sponsor: � 01 �+� W�a Telephone: �_ g C1 C� I f� I�G�/P l e -,L rW�ri c�' E-Mail: ft Add ess: City/PO: C,L,k*cko State: Zip CodL.c-- /l 3�-- 1.Does the proposed actio 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 ® —1 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: ❑ la.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? 7 acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? _acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial ,q,$esidential(suburban) ❑Forest PAgriculture El Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ R11 ❑ 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: V-1 El 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: n Vl El 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ® ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: n ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ® ❑ b.Is the proposed action located in an archeological sensitive area? ® ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b. Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional ❑ Wetland ❑Urban KSuburban 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.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, ❑ m,J Ela.Will storm water discharges flow to adjacent properties? �C.NO YES � b. Will storm water discharges be directed to established conveyance systems(r noff and storm drains)? If Yes,briefly describe: K]NO ❑YES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,darn)? 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: ISI ❑ 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 f Applicant/sponsor (i -rtQ (L Date: c�— 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 I. Will the proposed action create a material conflict with an adopted land use plan or zoning El 1:1regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the El 1:1establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El El existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? 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)? 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 1:1 1:1problems? 11. Will the proposed action create a hazard to environmental resources or human health? 1:1 1 ❑ 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. EICheck this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT I Page 4 of 4 V.` Board of Trustees Appli', _r':ion AFFIDAVIT qle BEING DULY SWORN DE SES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT, ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS,ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL, TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of'Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS r✓ 1 DAY OF Dl ;20 ZZ Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. 01 DI475593 Qualified in Suffolk County My Commission Expires April 30. 20 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE,FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. � YOUR NAME: I' 0C �-LXJ �eO A S 1 QAC J\ (Last name,first name,middle initial,unless you are applyi g'in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship.with any officer or employee of the Town of Southold? "Relationship"includes by blood, marriage,or business interest."Business interest"means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); : B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day ofWcah, cr 200D0— Signature-1 Print Name la nnn�nr Form TS I f 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 sib ificant beneficial and adverse effects upon the coastal area(which includes all of Southold Town 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# 1000 --16 ,0 - Ok,00 - 0 tc( , 00 6 PROJECT NAME SMll A� &U`e„ The Application has been submitted to (check appropriate response): Town Board 1:1Planning Board 1:1Building Dept. ElBoard of Trustees 1�q/I 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 actioncvv) - �i a Location of action: ) I` Vwau Site acreage: d �1 Present land use: Present zoning classification:( W� 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: c W'O-M (a) Name of applicant: -5 t. cel oI -1- (b) Mailing address: 3' (c) Telephone number: Area Code( (d) Application number, if any: 1A Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No K If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No 1�1 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 1FV.4 Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria 1-1Yes ❑ sP No � a�' 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 KINot 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 ApApplicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. Yes ❑ No L(-Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No 54 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. ❑ YesF1 No 5Q Not Applicable Attach additional sheets if necessary r � F 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 Vj 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 [�Q-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. 1:1 Yes 1:1 No� Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No r•Not Applicable �l PREPARED BY CC TITLE&)(�yt 5"VW+6C DATE P 16 ,;L