HomeMy WebLinkAboutTR-10389A Glenn Goldsmith,President ®F Sflll3,y® Town Hall Annex
A. Nicholas Krupski,Vice President s®� �� 54375 Route 25
P.O. Box 1179
Eric Sepenoski Southold,New York 11971
Liz Gillooly QeD
G Telephone(631) 765-1892
Elizabeth Peeples Fax(631) 765-6641
CoUN'N,��
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
DATE OF INSPECTION: 2 2
INSPECTED BY: UZaW-� PC C PW
Ch. 275 Ch. 111
INSPECTION SCHEDULE
Pre-construction, haybale line/silt boom/silt curtain
1St day of construction
Y2 constructed
Project complete, compliance inspection
COMMENTS:
�kc�U 1SSvc ca�c �'( pe.mki 4103PSA
CERTIFICATE OF COMPLIANCE: ���
Glenn Goldsmith,President �OF S0Town Hall Annex
�� ®1 54375 Route 25
A. Nicholas Krupski,Vice President ® P.O. Box 1179
Eric Sepenoski Southold,New York 11971
Liz Gillooly Q Telephone(631) 765-1892
Elizabeth Peeples • a0 Fax(631) 765-6641
®!yc®u ,�
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
2054C Date: July 27, 2023
THIS CERTIFIES that the removal of debris downed trees and stumps from wetland area;
At 910 Glenn Road, Southold
Suffolk County Tax Map#1000-78-2-27
Conforms to the application for a Trustees Permit heretofore filed in this
office Dated May 23,2023 pursuant to which Trustees Administrative Permit#10389A
Dated June 14,2023,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 removal of debris downed trees and stumps from wetland area .
The certificate is issued to Roberts Premier Development LLC owner of the
aforesaid property.
,4 ftp v
Authorized Signature
Glenn Goldsmith,President ®� SO � Town Hall Annex
54375 Route 25
A. Nicholas Krupski,Vice President ®� ®�®
P.O. Box 1179
Eric Sepenoskit Southold, New York 11971
Liz Gillooly Telephone(631) 765-1892
Elizabeth Peeples ® a® Fax(631) 765-6641
COUNTd,�
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
SOUTHOLD TOWN BOARD OF TRUSTEES
YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES
72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF
BELOW
INSPECTION SCHEDULE
Pre-construction, hay bale line/silt boom/silt curtain
1st day of construction
% constructed
When project complete, call for compliance inspection;
Glenn Goldsmith,President ``�a S®�/�� Town Hall Annex
54375 Route 25
A.Nicholas Krupski,Vice President a�Vv ®l®
P.O. Box 1179
Eric Sepenoski J 1 Southold,New York 11971
Liz Gillooly Telephone(631) 765-1892
Elizabeth Peeples � �Q Fax(631) 765-6641
COURl�1,�
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Permit No.: 10389A
Date of Receipt of Application: May 23, 2023
Applicant: Roberts Premier Development LLC
SCTM#: 1000-78-2-27
Project Location: 910 Glenn, Road, Southold
Date of Resolution/Issuance: June 14, 2023
Date of Expiration: June 14, 2026
Reviewed by: Elizabeth Peeples, Trustee
Project Description: Remove debris, downed trees and stumps from wetland area.
Findings: The project meets all the requirements for issuance of an Administrative
Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an
Administrative Permit allows for the operations as indicated on the project plan prepared
by David Roberts, received on May 23, 2023, and stamped approved on June 14, 2023.
Special Conditions: One time only clean up of this non-disturbance area.
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.
Thi is not a determination from any other agency.
s '
Glenn Goldsmith, President
Board of Trustees
PROPOSED DoT COVERAGE SURVEY OF PROPERTY
PROPOSED HOUSE =2,9.33 Sq. Ft. A T SO UTHOLD
PROPOSED STEPS = 96 Sq. Ft
N PROPOSED POOL & COPING = 612 Sq. Ft TOWN OF SO UTHOLD
PROPOSED POOL EQUIP. = 25 Sq. Ft
TOTAL�PROPOSED COVERAGE=3666 Sq.Ft SUFFOLK COUNTY,
BUILDABLE AREA OF LOT
LANDWARD OF WETLANDS= 23,133 Sq.Ft. 1000-78-02-27
SCALE. 1'— 30'
v D BY 2313 3666= 0.158 or 15.8x JUNE 2, 2022 ,
BOAR 1 r�USTEES 'Lot .s ore From 'Mop Of West Creek JULY 18, 2022 PROP. HOUSE & SEP 77C)
Estot s' Rled with the Suffolk Co. Clerk AUGUST 3 20 2 ((FLAG WETLANDS)
01iVN. F. S®UTi�®L® on ug. 19, 1963, File No. 3848 AUGUST 22, 2422 REVISIONS de CORRECTIONS)
SEPTEMBER 7, 2022 (REVISIONS PER TRUSTEES)
®AT TMG- 141 Zo.23 DECEMBER 9, 2022 (FOUNDATION LOCATION)
MARCH 7, 2023 (PROP. POOL)
MARCH 20, 2023 (REVISE LOT COVERAGE)
NO KLL WI THIN 150' OF SUBJECT PARCELAPRIL 13, 2023 (15' NON—TURF BUFFER)
88 P LE'� GLENN ROAD X CL.EL 10*
0"
TO �0HW xCL. EL . IN STREET OP
Mq�N �oHw e.9 PUBLIC WATER E
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Et 10.3 END. TEST WELL R-129.83 L=100.00' EL. 8.1'
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e.2gjy P �,�ooa o W 2,956x0.17 x 1 = 503 Cu.Ft
}
MAY 2 3 2023 LJ ,�E LOT 11 „ o ,ten N 503/42.2 = 11.9 VF
W 2 Z 0 d N Provide 3 DW 8'0 x 4' Deep= 12 VF
L ----- .- - 4' 'ACCESS TO DOCK �cf Connected by Gutters & Leaders
0 3
So.r'-�jid Tov4,1 4 SEPT/C DESydV
Board o1 Trustees (V O
•— BY GY?7V/S BERRY
O I� NYS LICENSED ARCH17ECT
15' NON TURF BUFFER :t'
z N
in M8E
25' NON DISTURBANCE 5. RET WALL
NON TURF BUFFER TEST HOLE DATA
T OF p, FE END McOONALD GEOSCIENCE
05/12/22 ��:z0 AM
TOP MHW7N EL4. / MHINM '� 4.9'E Q. B9"
` EL .3 �� �� DARK BROWN LOAM OL
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TIDAL H'ETLANDS ASS
LOCA 7ED BY ROBD'?T WLF#1�' 3
ANDERSON, SUFFOLK PALE BROWN RNE SAND SP
ENWIRONMENIAL
,VL Y 21, 2022 EL A0, 7.9-
CREEK
WESTWATER 1N
jja♦ PALE BROWN RNE SAND SP
_ KEY � 288T, 110.00
= we FLAG 6 .
QQ .= RD3AR . _.. 2¢S¢0,, . 40„WBUEAD NEW.
®. .= WELL S7805' SH LOT 2 70 RFRF
A STAKE ° 1 West Creek Development �p ' ,A9
`TEST HOLE LOT ,dap of 1236 V
PIPE Subdivision File No.
Suffolk Co.
■ = MONUMENT -- �' iiccc►
c'(L = U77UTY POLE 0511 '
ELEVA77ONS & CONTOUR LINES ARE REFERENCED TO NAVD 88' CERTIFICATIONS: N• 051132-01
Roberts Premier Development, LLC .Y.S LIC. NO. 49618
ANY ALTERATION OR ADD177ON TO THIS SURVEY IS A WOLA77ON Prime Meridian Abstract, Inc. ECONIC S MORS, P.C.
OF SEC77ON 7209OF THE NEW YORK STATE EDUCA77ON LAW. Stewart Title Insurance Company 631 765 20 FAX 631 765-1797
EXCEPT AS PER SEC77ON 7209–SUBDIVISION 2. ALL CER77FICA7IONS ( ) ( )
HEREON ARE VALID FOR THIS MAP AND COPIES ]HEREOF ONLY IF P.O. BOX 909
SAID MAP OR COPIES BEAR 7HE IMPRESSED SEAL OF THE SURVEYOR AREA= 29348 SQ. FT. 1230 TRAVELER STREET 122-0121
WHOSE SIGNATURE APPEARS HEREON. ' SOU7HOLD, N.Y. 11971
SUFF04 -
Glenn Goldsmith,President '`h'�`��. -..
�p�0 awed Town Hall Annex
A.Nicholas Krupski,Vice President 54375 Route 25
0
Eric Sepenoski P.O.Box 1179
Liz Gillooly �y • 0!� Southold,NY 11971
Elizabeth Peeples � �� Telephone(631)765-1892
Fax(631)765-6641
Southold Town Board of Trustees .
Field Inspection Report
Date/Time:Jum I, 2� Completed infield by: Pto�r'A
ROBERTS PREMIER DEVELOPMENT LLC requests an Administrative Permit to
remove debris, downed trees and stumps from wetland area. Located: 910 Glenn
Road, Southold. SCTM#: 1000-78-2-27
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
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.:
Ian 6US- , ycom
mak-161in m +M4 +Yc c tAnts is a r Ar'-iwe-" ckaA- .15 Oa My\-As�,nrkt si arU
Present Were: '✓G. G Idsmith N. Krupski E. Sepenoski
L. Gillooly E. Peeples
i
Glenn Goldsmith,President
,�S11�F11(p Town Hall Annex
A.Nicholas Krupski,Vice Presidents 54375 Route 25
x
Eric Sepenoski P.O.Box 1179 n,�
Liz Gillooly �y • ��r Southold,NY 11971
Elizabeth Peeples �a Telephone(631)765-1892
Fax(631)765-6641
Southold Town Board of Trustees
Field Inspection Report
Date/Time: M2 Q 2.c)13— Completed in field by: ;NiU�tr k ky1 a
James Roberts and David Roberts on behalf of ROBERTS PREMIER DEVELOPMENT,
LLC request a Pre-Submission Inspection to discuss the current clearing summons
within the buffer area and how to mitigate it. Located: 910 Glenn Road, Southold.
SCTM# 1000-78-2-27
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.:
,r s l:c.atn �a +n Ad
�1 r � nn e. �;Imt relMc�V�i 1 � -�J Yh bJ � �Il�r�► -�c.Ps3'
Present Were: V G. Goldsmith vl' N. Krypski V E. Sepenoski
_ L. Gillooly E. Peeples
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OFFICE LOCATION: �0���� SU(/jyOl MAILING ADDRESS:
Town Hall Annex P.O. Box 1179
54375 State Route 25 Southold, NY 11971
(cor.Main Rd. &Youngs Ave.)
Southold,NY 11971 • COQ Telephone: 631765-1938
�yCOUNT`1,0ct�
LOCAL WATERFRONT REVITALIZATION PROGRAM
TOWN OF SOUTHOLD
To: Glenn Goldsmith, President
Town of Southold Board of Trustees
From: Mark Terry, AICP
LWRP Coordinator
Date: June 13, 2023
Re: LWRP Coastal Consistency Review for ROBERTS PREMIER DEVELOPMENT LLC
SCTM#: 1000-78-2-27
ROBERTS PREMIER DEVELOPMENT LLC requests an Administrative Permit to remove debris, downed
trees and stumps from wetland area. Located: 910 Glenn Road, Southold. SCTM#: 1000-78-2-27
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 INCONSISTENT with policy 6.3
the LWRP.
Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written
determination regarding the consistency of the proposed action.
Cc: Honorable Lori Hulse, Attorney
Glenn Goldsmith,President (�f ((� Town Hall Annex
A.Nicholas Krupski,Vice President `o� �lO 54375 Route 25
P.O.Box 1179
Eric Sepenoski 11 Southold,New York 11971
Liz Gillooly Telephone(631) 765-1892
Elizabeth Peeples • a� Fax(631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
This Section For Office Use Only
Coastal Erosion Permit Application
Wetland Permit Application
Administrative Permit
�Amendment/Transfer/Extension
Received Application: S•7- Z-30
Received Fee: $ olsd. _
Completed Application:. •2.3
Incomplete:
SEQRA Classification: Type I__ Type II Unlisted Ne ative Dec. Positive Dec.
Lead Agency Determination Date: _ 1 r`N
E ��, F
Coordination:(date sent): �----- - -1r(
�( LWRP Consistency Assessment Form Sent:
CAC Referral Sent:
X Date of Inspection: MAY 23 2023
Receipt of CAC Report:
Technical Review: Ec, cu i
!( Public Hearing Held: 2 Boaru o.irasz2es
Resolution:
Owner(s) Legal Name of Property (as shown on Deed): Roberts Premier Development LLC
Mailing Address: 3 Sandie lane Manorville, NY 11949
Phone Number: 631-905-4789
Suffolk County Tax Map Number: 1000 - 78-02-27
Property Location: 910 Glenn Rd Southold, NY 11971, 884.10' to main Bayview road
(If necessary,provide LILCO Pole#, distance to cross streets, and location)
AGENT(If applicable): NA
Mailing Address:
Phone Number: 631-905-4789 Email:david@djcustomhomes.com
Board of Trustees Application
GENERAL DATA
Land Area(in square feet): 29348 sq ft.
Area Zoning: R-40
Previous use of property: Single family dwelling
Intended use of property: Single family dwelling
Covenants and Restrictions on property? Yes _ ✓�No
If"Yes", please provide a copy.
Will this project require a Building Permit as per Town Code? Yes �No
If"Yes",be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review
and Elevation Plans will be required.
Does this project require a variance from the Zoning Board of Appeals? =Yes _ _No
If"Yes", please provide copy of decision.
his project req"w 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? YesF✓ _No
Prior permits/approvals for site improvements:
Agency Date
Southold Town trustees 9/14-2022
Southold Town Building 11/30/22
NYSDEC 9/23/22
❑ No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?_Z_No_a Yes
If yes, provide explanation:
Project Description(use attachments if necessary): To remove debris, down trees and stumps
from wetlands area, see photo
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: To Remove debris from wetland area
Down trees and stumps.
Area of wetlands on lot: 3029 square feet
Percent coverage of lot: •131
Closest distance between nearest existing structure and upland edge of wetlands: 100 feet
Closest distance between nearest proposed structure and upland edge of wetlands: _ feet
Does the project involve excavation or filling? 0 No F-1 —Yes
If yes,how much material will be excavated? NA cubic yards
How much material will be filled? NA cubic yards
Depth of which material will be removed or deposited: 0 feet
Proposed slope throughout the area of operations: 0
Manner in which material will be removed or deposited: NA
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):
No reasonable effect
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 ofthe 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:
Debris removal
Project Location(describe,and attach a location map):
910 Glenn rd Southold NY, 11971
Brief Description of Proposed Action:
Remove debris and down trees and stumps from wetland area
Name of Applicant or Sponsor: Telephone:631-905-4789
Roberts Premeir Development LLC E-Mail:david@djcustomhomes.com
Address:
3 Sandie Lane
City/P0: State: Zip Code:
Manorville NY 11949
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 ❑
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: ❑
3.a.Total acreage of the site of the proposed action? .74 acres
b.Total acreage to be physically disturbed? ,a acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? •74 acres
4. CheI land us at occur on,adjoining an ar the prop action.
Urban Rural(non-agriculture) Industrial Commercial ❑✓Residential(suburban)
Forest [:]Agriculture Aquatic ❑Other(specify):
NParkland
Page 1 of 4
5. Is the proposed action, NO YES N/A
a. A permitted use under the zoning regulations? ✓
fl,
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: Z ❑
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? ✓
17
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? V
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: ❑ ❑
NA
10. Will the proposed action connect to an existing public/private water supply? NO YES
If No,describe method for providing potable water: NA ❑ ❑
11.Will the proposed action connect to existing wastewater utilities? NO YES
If No,describe method for providing wastewater treatment: ❑ ❑
12. a.Does the site contain a structure that is listed on either the State or National Register of Historic 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 typic bitat types that oc n,or are likely to be found on tF[e.gro.ect site. Check all that apply:
Shoreline Forest Agricultural/grasslands Early mid-successional
✓ Wetland Urban Suburban
15.Does the site of the proposed action contain any species of animal,or associated habitats, listed NO YES
by the State or Federal government as threatened or endangered?
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? PNO Ila
If Yes, ❑ ❑
a.Will storm water discharges flow to adjacent properties? ONO EYES ✓
b.Will storm water discharges be directed to established conveyance systemsff an m drains)?
If Yes,briefly describe: r5O ES
Page 2 of 4
i
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
Applicant/sponsor name: David Robe Date5/18/2023
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
I. Will the proposed action create a material conflictwith an adopted land use plan or zoning ❑ ❑
regulations?
2. Will the proposed action result in a change in the use or intensity of use of land? ❑
3. Will the proposed action impair the character or quality of the existing community?
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 ❑ ❑
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 ❑
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, Elarchitectural 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)? El
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 a,
problems? El
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.
ElCheck this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
Town of Southold-Board of Trustees
Name of Lead Agency Date
President
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer)
PRINT Page 4 of 4
Board of Trustees Application
AFFIDAVIT
David Roberts 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.
ignANN
Property Signature of Property Owner
SWORN TO BEFORE ME THIS DAY OF ,.20a
Notary Public-
VICTORIA A
ublicVICTORIAA FERREMI
Notary Public-State of New York
NO.01FE6430360
Qualified in Suffolk County
My Commission Expires Mar 14,2026
APPLICANVAGENDREPRESENTATIVE
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 some,
YOURNAME: Roberts Premier Development LLC, David Roberts
(Last name,first name,.rpiddle 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 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 employce_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 F. 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):
12A)the owner of greater than 5%of the shares of the corporate stock of the applicant
_n (when the applicant is a corporation);
B)the legal or beneficial owner of any interest in a non-corporate entity(when the
—Rapplicant is not a corporation);
C)an officer,director,partner or employee of the applicant;or
D)the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this 18 day of MsV 2o23
Signature
Print Name David Roberts
Fonn TSI
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 sipiificant
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# 78 -02 _27
PROJECT NAME 910 Glenn rd Southold NY11971
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:
Removal of Debris, down trees and stumps
Location of action: 910 Glenn Rd Southold NY 11971
Site acreage: •73
Present land use: Residential
Present zoning classification: r-40
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: Roberts Premier Development LLC
(b) Mailing address: 3 Sandie Lane Manorville, NY11949
(c) Telephone number: 631-905-4789
Will the action be directly undertaken,require funding,or approval by a state or federal agency?
Yes ❑ No F 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
0 Yes ❑ No ❑ Not Applicable
Attach additional sheets if necessary
Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See
LWRP Section III—Policies Pages 6 through 7 for evaluation criteria
❑✓ Yes ❑ No ❑ Not Applicable
Attach additional sheets if necessary
NATURAL COAST POLICIES
Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP
Section III—Policies Pages 8 through 16 for evaluation criteria
❑ Yes ❑ No 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 ONot Applicable
AttacFad-ditional sheets if necessary
Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including
Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22
through 32 for evaluation criteria.
❑ Yes ❑No ❑� Not Applicable
I
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❑✓ 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 0 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.
❑ YeLl No❑✓ Not Applicable
Attach additional sheets if necessary
i
t
WORKING COAST POLICIES
Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in
suitable locations. See LWRP Section III—Policies; Pages 47 through 56 for evaluation criteria.
❑Yes ❑ No ❑✓ Not Applicable
Attach additional sheets if necessary
Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic
Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria.
❑Yes ❑ No❑✓ Not Applicable
Attach additional sheets if necessary
Policy 12. Protect agricultural 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❑✓ Not Applicable
PREPARED BY �� TITLE DATE