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Chasen, Philip & Lia
Glenn Goldsmith,Presidentrg S®U, Town Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly us G � Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 C®U ,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD NOTICE OF DISAPPROVAL - ADMINISTRATIVE PERMIT Date of Receipt of Application: December 27, 2022 Applicant: Philip & Lia Chasen SCTM#: 1000-55-7-3 Project Location: 1585 Long Creek Drive, Southold Date of Resolution/issuance: February 15, 2023 Reviewed by: Board of Trustees Project Description: For a proposed 10.2'x8.2' (83sq.ft.) pool house and a 5'x8.2' (40 sq.ft.) outdoor shower. Findings: The Board of Trustees DENIES the application as submitted. The project does not meet the requirements for issuance of an Administrative Permit as set forth in Southold Town Code Chapter 275-12A. —Adversely affects the wetlands of the Town. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. Glenn Goldsmith, President Board of Trustees Address:10200 Main Road,Unit 3A,PO Box 152,Mattituck NY 11952 A M P Architecture Phone:(631)603-9092 Design + Build LD January 17, 2023 JAN 17 "2023 BUILDING DEPT. TOWN OFSOUIHOLD Re: Chasen Residence 1585 Long Creek Rd Southold NY Diane, Enclosed please find 4 copies of the updated site plan.The owner needs to move the location of the pool house,further from the house, due to existing pipes. Please contact our office if you have any questions. Thank you, E �1I x'# Jess Magee JAN 1 6 2023 Page 1 of 1 �a v ¢_ _ SITE LAYOUT NOTES: w z m a f'ROJEGT/ZONING_DATA.------------ -- I. THIS 15 AN ARCHITECT'S SITE PLAN S 15 - ---------- w SUBJECT TO VERIFICATION BY A LICENSED TAX MAP# 1000-55-07-03 m ao a g a y SURVEYOR. THE INFORMATION OZa�<+m REPRESENTED ON THIS SITE PLAN 15 TO THE u o w ZONING DISTRICT R-60 G a== o LL ARCHITECT'S BEST OF KNOWLEDGE. x w t a LL o 2.SURVEY INFORMATION WAS OBTAINED LOT AREA 0A ACRE5 a w a w z z FROM A SURVEY DATED MARCH I5T,2021 z¢°d ° AND PREPARED BY: CofO -ADDITIONS ALTERATION Z-25624;04/0I/q8 0=a w in w 0 0 PEGONIG 5URVEYORS P.G. o z m a GofO -DECKS 6AZEB0 Z-23187;Ob/30/g4 a w =M, 1230 TRAVELER STREET m o¢Z 2=m SQUTHOLD N.Y. I Ig 11 CofO - HOME ALTERATION Z-18453; 10/10/bq Z a > r TELEPHONE: (631)-165 I'lq-1 c 2m.z y=z o CofO - HOME Z-1"126b;Oq/07/58 oQW z a'z:n x0a�W o=UoyoF wr � ;j z FEMA FLOOD ZONE X < zz a azar c�a uox�aa¢a SUFFOLK COUNTY HD APPROVAL REF: 87-50-35 a Wg U N w W w a Y FC O W tin z. ~�« N a W Z U=O U N LAUREL AVENUE � aa= LOT COVERAGE �-----, ------- 1 DESCRIPTION(FOOTPRINT) AREA % LOT COVERAGE N14"Ig'20"W 115.12' / TOTAL LOT AREA 3"1,460.0 S.F. 76 EXISTING HOME S PORCH 2,366.0 S.F. 6.3% <.I I o °o, PHOTO PLANTINGS EXISTING GAZEBO 12'1.0 S.F. 0.3% 1 EXISTING POOL "131.0 S.F. 2.0% I EXIST. 1 j � N � RECONSTRUCTED DECK 285.0 S.F. O-b% e ;i/ PLANTINC, 1 N PROPOSED POOLHOUSE S I r OUTDOOR SHOWER 123.?S.F. 0.3% m 1 1 \O \ EXIST.SMALL TOTAL AREA OF ALL STRUCTURES 3632.-1 S.F. 4.7% � I ,4A' '/// I" PATH j/'/' , \ y **MAXIMUM LOT COVERAGE ALLOWED - 20% 1 � \. I .° 23.0' 6AZE00 � 1 GRAsS / �' \ ACCESSORY STRUCTURE_REQUIREMENTS - --------------------- EXIST. AREA � -- ------- � 5AUNAO BOTTOM OF BANK a EXIST.GRAVEL DRIVEWAY \ % O, / 1 m RET•�-L RET,�-L•::K/ '� PROPOSED COMPLIES I .0' EL=O-0" EL=2'-5" /'/ JJ ` LANDWARD EDGE OF PROP- EXIST. \ TIDAL PETLAN 25 (1 SELF- O // �'' ,, AS DETERMINED BY MAXIMUM HEIGHT Ib' c1 b' YES e PATIO : TOP \ SUFFOLK ENVIRONMENTAL /' TO CONSULTING 1 JJLY 21,2020 MINIMUM SIDE YARD 10.0' 22.7' YES rn X \ ;J: C ut EXl!STINSoD EXIST. \ MINIMUM REAR YARD 10.0' 12.1' YES rn rti RESIDENCE SHINS \ I � (� 25 EXIST. :..r : GRIP PA ,/ o p WD.FIRM. :•'•' 1 19 q"x37'_10" �8 35.Fj p POOL S SPA ��f ° -------- , ° Q I O (12"COPING .. ::::°: °' - - - n �° 1 o -0 \ ROUND POO :} /•/0 y;�j'/ J%// — ` NTINCfPLAi /� I /'-►y ' // EXIST. VEGETATED WOOD NON-TURF BUFFER RAMP LJ1 Y O) O RECON. DECK ` , ZJAN 8 2023 .2 •O'' ,RET.WAWOOD CHIP PATH w W W Z e 34.0' .`f0 // J//J J/J / ;'�i _ 75 /i PROP,POOL ° %l{�r.�. V OIOD ` ORA55 AREA "`�' ;; �f P _ O O EXIST. FENCE(I?9 L.FJ b"xb"WOO :: ::::::.::' ,i WALK \ Board of ii,;3tt'es U 1 exisr. SEPTIC °PROP. 52 RET.. ���,� /' i JJ%! \ - O J 2 I (PRECAST) SELF-CLOSING \ STEP DOWN 6 •'j �' 'J° X ST..'O,EXIST. PATIO a L ~ O GATE \ INTERVALS :: RET.WALL' j ° / ti W O PROP. GRAVEL O 1 Nh �PRaP °'�' -_�;{?.'�''/�.'' I/IJ �PATHWA :--•'"' _ LL ci fn I - - - - OUTDOOR N PROP. �yz. 1O' ATH , J SHOWER POOLHOUSE %%J j J/%/, JJ J //./' ��D A"s C U)i 'G:ICE AGGEv CRY ''''''' '' ` 2 •�� !! L_-_-_-_-___-_-_ -�--r3-� CL 4o S.FU 83 S.F) °� % '/.''/ /J//ii - - - ® I% .1✓/ �� �\� ��i �� 514°21'31"E -_-_ IT4.o2_-_ 510' ' J/ ` q °54'50 JA 1 7 � rtr � 1 VEGETATED URF PLANTING5' g7.g5' '2023 '� # 0 7� PHOTO•7 AX_ 611d�y�N(s V' J '' 5cn 250 S.F. ®�mOFSOIITd-1'-r, Vp1 % �s� c �� M P#�OPOSED S 1 TE PLAN �'�'�� ��_�fl5 �� �`� ~t� V♦ SCALE: I" �a ED Alye = Gam ww_J33 ^ moaagg r�J3<� za= ¢it T m 1� o O N�3c� Al za�wwa Q?~zj z z 740$ p� ND =� www DO oz- Na mo 00FNC . z Z a J Z ¢ f c7Za�Za O W N~=U v ¢a z a Q Y O w a p r 0 F W FJ:y2�j RIDGE HEIGHT 12 zw aIr Z0<w N N 2 2 W 2 N HEADER HEIGHT FIRST FLOOR \\� ELEV. �J BASEL I NE qv ELEV. +O.O' ROOF PLAN POOL HOUSE FRONT ELEVATION POOL HOUSE RIGHT ELEVATION SCALE: 1/4"= V-O" SCALE: 1/4"= 1'-0" 5CAL E: 1/4" = V-O" E4+�i r' __ s D ./y :-3 U f ��9 a [JAN 1 8 2023 RIDGE HEIGHT 12 3 5 Bo cg 4'-7° II ITLINEN • = HEADER HEIGHT -_ N Y 0) _ry p` ELEV. +1.2' W O U z w _ PROP. 0 J Z o PROP. iv O POOLHOUSE OUTDOOR U 0O o HALF BATH SHOWER a. Lo 00 83 S.F. \ 40.E S.F.dNaLo 0 LU a o FIRST FLOOR a +6� ELEV. +0.5I WR BASEL 1NE LLL I I I 0. I- 6' CEDAR HIGF1 IRV FENCE ENCLOSURE ELEV. +O.O' N ' FIRST FLOOR PLAN POOL HOUSE REAR ELEVATION POOL HOUSE LEFT ELEVATION � Q SCALE: 1/4" = 1'-O" 51—ALE: 1/4"= V-O" 51CALE: 1/4" W W a a gyp. SufFOE _ Glen ooldsmith,President �� �oGy 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 l �a0 Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 1 23 Completed in field by: �• �ti �� �� AMP Architecture on behalf of PHILIP.& LIA CHASEN requests an Administrative Permit for a proposed 10.2'x8.2' (83sq.ft.) pool house and a 5'x8.2' (40 sq.ft.) outdoor shower. Located: 1585 Long Creek Drive, Southold. SCTM#: 1000-55-7-3 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 Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications)/.Conditions/Etc.: uo 6 {LSoi D V, 0 V �l X22 bc ,I1 - w'Q V1+ G-6 k Present Were: _,)o G. Goldsmith X N. Krupski X E. Sepenoski X L. Gillooly x- E. Peeples I.S.y� Fyl N&Aa w gp WA ae, — i iJ PHOTO #1 PHOTO #2 MO" ,. lililllll i Will PHOTO #3 PHOTO #4 10, 4 PHOTO #5 PHOTO #6 H6 De `v " r v t -1't `` y�CG NOteIM "` Y'",l r- \�'F i y a6 � -0 k`� `3. sYdy✓ "r: '6:- .A. ��. .-;3rt"-` � Wet�� .d zsM) 20A i \ s 1 e caF � -0, Mt Ms zW°) oe ee , y 0 alE ` 3 M "'� F B 2.OA 3l3Ajc) 'E MAoa 1i t .r -�,� a .k •..� ran is � i .� .,. ! � 1 y, ._.p 3 -M` ,. `, a �R� a1cwu-�'- ._w - A r J51&3t ,t. .,�F � .- •. aA •, o6vlwwem wug' _. 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'� i9 BA Y,,3, 47 >g, 3tM S 18 F Yet- r' on - `� K•I W4 gRn- 1 . z< g t �•b as tm 5aa� 1D r.„ n� .rAt uan' — S �g x SEE DEC.NO 063 }13 �• �'m, --(, L,)COUNTY OF SUFFOLK N Nonce B q N> iogo sFcnau rn E wry——— "1R10J"J°1Y•a_— V .... h.-1 I Eupwy Tex S-A-Agency W xraw�w su.a naE Y H J�, a Doun6a.o -�--- -- - - --- 065 ry w«�_——.—_ —_ __ u. . �rrti cwurr IrM,Pow�Aw'•i,nY IlBtll a r+L rEu M vu OFFICE LOCATION: ®�`!®� s®U��®� MAILING ADDRESS: Town Hall Annex ® P.O.Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 Telephone: 631 765-1938 a c®U ,� 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: ' January-17, 2023 Re: LWRP Coastal Consistency Review for PHILIP & LIA CHASEN SCTM# 1000-55-7-3 AMP Architecture.on behalf of PHILIP:,&-LIA CHASEN requests an Administrative Permit for a proposed 10.2'x8.2' (83sq.ft.) pool house and a 5'x8.2' (40 sq.ft.) outdoor shower. Located: 1585 Long Creek Drive, Southold. SCTM#: 1000-55-7-3 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 action is CONSISTENT with the Policy Standards and therefore is 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 SO& Michael J.Domino,President P, Town Hall Annex John M.Bredemeyer III,Vice-President AQ O 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Kru ski i G p �p��V Telephone(631) 765-1892 Greg Williams �ou� Fax(631) 765-6641 . BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application X Administrative Permit -�LAmendment/Transfer/Extension Received Application: IZ•27•ZZ Received Fee: $ 100.60 Completed Application: . Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: oordination:(date sent): LWRP Consistency Assessment Form Sent: E r C � f nD � E ,ZCAC Referral Sent: —� V Date of Inspection: i� F Receipt of CAC Report: DD I DEC 2 7 ZQ22 j ,Technical Review: - r/ Public Hearing Held: Resolution: Owner(s) Legal Name of Property (as shown on Deed): Philip and Lia Chasen Mailing Address: 1585 Long Creek Dr Southold NY 11971 Phone Number: 516-922-2090 Suffolk County Tax Map Number: 1000 - 55-7-3 Property Location: 1585 Long Creek Dr Southold NY 11971 ' (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): AMP Architecture Mailing Address: PO Box 152 Mattituck NY 11952 Phone Number: 631-603-9092 - Board of Trustees Application GENERAL DATA Land Area(in square feet): 37,460 Area Zoning: R-80 C Previous use of property: Single Family Residence Intended use of property: Single Family Residence Covenants and Restrictions on property? Yes x No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? x 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 x No , If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes x No Does the structure (s) on property have a valid Certificate of Occupancy? x Yes No Prior permits/approvals for site improvements: Agency Date Town of Southold Trustees (#9872) 4/12/21 -swimming pool,with patio and fence. Town of Southold Building Dept 7/27/21 - Permit for in ground swimming pool with attached spa No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?x No Yes If yes, provide explanation: Project Description (use attachments if necessary): Proposed pool house 10.2'x 8.2' (83 so and outdoor shower 5'x 8.2' (40 so Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Proposed pool house and reconstructed deck in rear yard. Area of wetlands on lot: 824 square feet Percent coverage of lot: 9'7 % Closest distance between nearest existing structure and upland edge of wetlands: 91'0 feet Closest distance between nearest proposed structure and upland edge of wetlands: 82.7 feet Does the project involve excavation or filling? x No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Land is flat Manner in which material will be removed or deposited: MINOR EXCAVATION FOR SLAB AT GRADE. 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): WETLANDS WILL NO BE AFFECTED BECAUSE THEY WILL PROTECTD BY HAY BALES DURING CONSTRUCTION,AND CONNECTED TO DRYWELLS. 617.20 Appendix B Short Environmental Assessment Form Instructions for Comnletinp Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1-Project and Sponsor Information Name of Action or Project: CHASEN POOL HOUSE AND DECK Project Location(describe,and attach a location map): 1585 LONG CREEK RD SOUTHOLD NY 11971 Brief Description of Proposed Action: -Proposed pool house 10.2'x 8.2' (83 so and outdoor shower 5'x 8.2' (40 so Name of Applicant or Sponsor: Telephone: 631-603-9092 AMP ARCHITECTURE E-Mail: JMAGEE@AMPARCHITECT.COM Address: PO Box 152 City/PO: State: Zip Code: Mattituck NY 11952 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO I YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that M ❑ may be affected in the municipality and proceed to Pail 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: TOWN OF SOUHTOLD BUILDING DEPARTMENT ❑ X❑ 3.a.Total acreage of the site of the proposed action? .9 acres b.Total acreage to be physically disturbed? ..002 acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? .9 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial ®Residential(suburban) El Forest ❑Agriculture El Aquatic ❑Other(specify): ❑Parkland Page 1 of.4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ ® ❑ b.Consistent with the adopted comprehensive plan? El � ❑ 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? I X1 ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ 1 l..Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment_ ❑ 12. a.Does the site contain a structure that-is listed on either the State or National Register of Historic NO YES Places? ® ❑ b. is the proposed action located in an archeological sensitive area? ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain . NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ 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: ElShoreline ElForest - ❑Agricultural/grasslands [:1Early 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? NXI ❑ 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 El b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO ®YES GUTTERS WILL BE ADDED TO THE POOL HOUSE. Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: FE27] F-1 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: m ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: rchi -cture,Anthony Portillo Date: �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 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 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 F]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 ❑ E]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? El 8. Will the proposed action impair the character or quality of important historic,archaeological, El 1:1architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ ❑ waterbodies,groundwater,air quality, flora and fauna)? Pate 3 of 4 No,or iYloderate 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 EI EIproblems? 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-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) PRINT Page 4 of 4 Board of Trustees App] ,ation AFFIDAVIT ��` `• �' �� � 5 �( 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 f Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF � 1 , 20 C Notary Public GINA RAGtEL No.01 RA6098973 Notary Publlc,State of New York Qualified In Nassau County ?y Commission Expires o9122120M Board of Trustees Apply' tion AUTHORIZATION (Where the applicant is not the owner) I/We, owners of the property identified as SCTM# 1000- 55-07-03 in the town of New York, hereby authorizes AMP Architecture to act as my agent and handle all necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for this property. Property Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF20 _ Notary Public GINA RAGIEL No.01 RA6098973 Notary Public.State of New York Qualified in Nassau County ily Commission Expires 09/2212o,93 APPLICANT/OWNER TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and emplovees.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 • �—'^-:.5 e, i. 0 (Last name,first name,middle in tial,unless yoare applying in the name of someone else or other entity,such as'a company.If so,indicate the other person's or company'slame.) TYPE OF APPLICATION: (Check all that apply) Tax grievance Building Permit i Variance Trustee Permit Change of Zone Coastal Erosion Approval of Plat Mooring Other(activity) Planning 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 of icer 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 that 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 of 20_11- Signature 1 rz Print Name APPLICANT/OWNER 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 : Portillo,Anthony (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.) TYPE OF APPLICATION:(Check all that apply) Tax grievance Building Permit Variance Trustee Permit X Change of Zone Coastal Erosion Approval of Plat Mooring Other(activity) Planning 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 X If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply) A)the owner of greater that 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 y am,209 Signature Print NameANTH NY PORTILLO 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 HcdardArea. 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- 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# 55 _ 7 _ 3 PROJECT NAME CHASEN POOL HOUSE The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g.capital ❑ construction,planning activity, agency regulation, land transaction) ❑ (b) Financial assistance(e.g. grant,loan,subsidy) (c) Permit, approval, license,certification: Nature and extent of action: PROPOSED POOL HOUSE 10.2' X 8.2' (83 sf) PROPOSED OUTDOOR SHOWER 5' X 8.2' (40 sf) Location of action: 1585 LONG CREEK RD SOUTHOLD NY 11971 Site,acreage:_ .9 Present land use: . SINGLE FAMILY RESIDENCE R-80 C 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: AMP ARCHITECTURE (b) Mailing address: PO BOX 152 MATTITUCK NY 11952 (c) Telephone number: Area Code( ) _ _ 631-603-9092 (d) Application number,if any.: �b Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes 0 No L�J 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 LNV" Section III.—Policies; Page 2 for evaluation criteria. ®Yes ❑ No ❑ Not Applicable TTHE POOL HOUSE ADD CHARACTER AND VALUE TO THE COMMUNITY AND WILL NOT CHANGE THE CURRENT LANDSCAPE. Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LVV"Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes 1:1No F] Not Applicable NO HISTORICAL OR ARCHAEOLOGICAL RESOURCES ARE ON THIS PROPERTY. Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWR.P Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No © Not Applicable THE POOL HOUSE IS ONLY ONE STORY AND 83 SF THERFORE THE VISUAL QUALITY WILL REMAIN THE SAME AS BEFORE. Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No ❑ Not Applicable THE EXISTING NON TURF BUFFER WILL MINIMIZE LOSS FRnM Fl or)IIGAND EROSIII.N Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWR.P Section In —PoIicies Pages 16 through 21 for evaluation criteria Yes 1:1 No ®Not Applicable WATER QUALITY WILL NOT BE AFFECTED. 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. a a o Yes No Not Applicable ALL PROPOSED WORK WILL TAKE PLACE BEFORE THE WETLANDS. THE COASTAL FISH AND WILDLTFE L NOT BE AFFECTED. 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 E] No L"t Not Applicable PROPOSED WORK WILL NOT AFFECT AIR QUALITY. Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LV*r" Section III-Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No ® Not Applicable ALL WASTE IS CONTROLLED AND ALL CONSTRUCTION DEBRI WILL BE DISPOSED OF PROPERLY. 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 LVVRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ Yes[:] No L-2J Not Applicable THIS IS A PRIVATE PROPERTY AND HAS NO PUBLIC ACCESS OR PUBLIC SPACES. 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. 0 Yes ❑ No ❑ Not Applicable THE PROPOSED CONSTRUCTION WILL NOT AFFECT WATER AREAS OR SHORELINE BECAUSE THE CONSTRUCTION WILL-TAKE PLACE BEOFRE THE WETLANDS. 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 E Not Applicable ALL CONSTRUCTION WILL TAKE PLACE AWAY FROM THE WETLANDS TO PROTECT THE LIVING MARINE RESOURCES. Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III —Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ No© Not Applicable Attach additional sheets if necessary. Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No ❑X Not Applicable AMP ARCHITECTURE PREPARED BY TITLE DATE A M P Arch i to ct u re Address:10200 Main Road,Unit 3A,PO Box 152,Mattituck NY 11952 Phone:(631)603-9092 Design + Build December 23, 2022 Re: Chasen Residence 1585 Long Creek Southold NY Elizabeth Enclosed please find a new application for Chasen.The owner is sending the check directly to you. If you do not receive it next week please let us know and I can reach out-to him. Please contact our office if you have any questions. Thank you, Jess Magee F pC 2 7 2022 Page 1 of]