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HomeMy WebLinkAboutTR-10469A Glenn Goldsmith, President ®F so�r� Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric SepenoskiSY Southold, New York 11971 Liz Gillooly Telephone (631) 765-1892 Elizabeth Peeples ® a® Fax(631) 765-6641 C®UN11,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction '/2 constructed When project complete, call for compliance inspection; i Glenn Goldsmith,President ®F so Town Hall Annex 54375 Route 25 A.Nicholas Krupski,Vice President ®� ®�® P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples �® ® ,® Fax(631) 765-6641 coum BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10469A Date of Receipt of Application: September 5, 2023 Applicant: Andrew M. Pettersen & Randy A. Statham SCTM#: 1000-78-7-5.5 Project Location: 5805 Main Bayview Road, Southold Date of Resolution/Issuance: October 18, 2023 Date of Expiration: October 18, 2026 Reviewed by: Elizabeth Peeples, Trustee Project Description: For the as-built planting of sixty (60) 6-8' tall green giant arborvitae onto a 16-24" berm at southeast corner of property, minor limbing of small branches on trees for driveway access and sunlight for plantings. 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 North Fork Landscapes., received on September 5, 2023, and stamped approved on October 18, 2023. Special Conditions: Temporary irrigation for a two (2) year time period, and then the removal of same. 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. �*_ b4"- Glenn Goldsmith, President Board of Trustees Project: 5805 Main Bay View Rd Southold Date:08/28/2023 `UE C � , Project Scope: Screen Tree Planting along Main Bayview Road ! �� SEP - 5 2023 i �►a T�Wr a 14, ore i t. x Google North Fork UNDSCAMW COMPLETE MANITENUCE 6 MSM SERVICES Project: 5805 Main Bay View Rd Southold Date:08/28/2023 ;1 E E I V E Project Scope: Screen Tree Planting along Main Bayview Road ���-11 SEP— r q41' ._.. BOARD OF 'i RUSTEES TOWN OF SOUTHOLD -}' DATE pcT60 �8 2 E Existing Irrigated Turf Lawn ' . New Screen Tree Planting Existing Privet Hedge North Fork LANDSCAPES COMPLETE MAINTENANCE & DESIGN SERVICES Glenn Goldsmith,President ,�0�0". �COGy� Town Hall Annex A.Nicholas Krupski,Vice President .c 54375 Route 25 0 Eric Sepenoski P.O.Box 1179 Liz Gillooly �y • ��� 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: U to 30 Completed in field by: R-12 OCkc P-ef P .,S North Fork Landscapes LLC on behalf of ANDREW M. PETTERSEN & RANDY A. STATHAM requests an Administrative Permit for the as-built planting of sixty (60) 6-8' tall green giant arborvitae onto a 16-24" berm at southeast corner of property, minor limbing of small branches on trees for driveway access and sunlight for plantings. Located: 5805 Main Bayview Road, Southold. SCTM#: 1000-78-7-5.5 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.: D nccr" eV i gnibr\ M +he "hobk01T 'bw o& Ae lin �� alrbDYli�RC wj�v, rk dose. !,,,A,!� , tg i-kc wed Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly �E. Peeples Fg Young & Young ! 400 Osla dar A—C. Rio hand.IV—York 11901 PH 691-727-290 L N APPROVED BY 21--d a a.x Ld S\ v4Nor Th.—c. Prof^^^n;E-yi - N PLANNING BOARD Re6�rLAa c r G ArvMbct R.-Id S.PJVAL Lm t cap.A-hit.. TOWN OF SOUTHOLD m giw F.Adnms.PRRTc ianOL L'ay.,<.4T LOCA-110N.MAP iOCTscnLE.1•=bOODATE O1 192mUE W E 5 SITE DATA TOTAL AREA=6.7848 ACRES JX MOD w'++c�'v'S�.°e-•' ZDNINS TE D:1aTGIGT v N=v`MJTTIK/-D .CLSS � S V 1R ' OATUM c N5.1.DATA4 OASJ_.19]97 1 17 t�j ISE� y' OLEALOT!2 A AND AREA) a 51918 Sq.FL ' / •4+ fo I �U AREA TO B':OLARD v 2SZ 5q-R. eE� a�/o H1H 6ba`is 9 JAN 3 C 2DK yggf a ?/ I-r]&-. AR!AJ/A TO 02- OF LOT CLPYa15 6E° I A �O \ eu O N//S j 519 a sq.Ptr15S 2 5e.rt.-4ve5 c a��9k �..��55"t, % `` $E�% GAO Fw ra«, Rya y I q-'wS. i..✓ ^l REFER To S.h �` __ .._�.+.--+--a-••� SUWrVISILOT GN TARP BURS P 6TWS 00r��NEWK FILED I FIDE of TFIE p9 N. C4 ^-_ \ GLEE OF S FFOLK GO NTY ON NOV.75.M45 AS Pd.E NO.1665. �12o �i '+� _ TEST HOLE ENGINEER'S CERTIFICATION w�' / / \\ .� r(4 •?/� vATC�05/10/04 •I HEREBY CERT, THAT THE Y(ATFR 5UPFLT(S)AHD/0R r<io�/,Y �Y P / 40 �• Der W OR WDBR 0511- nro�=K AsED UPON A /9 / Lf/ nwnw�s S a• 'r,( H�J,a' ena®sSw a CAR_'L AND THcRo"sr/LY OF TE SOIL.SITE AND TIE-IN /1� � 3 @^y A vSO 3n R.m MnJt 9�� N S ° laRO KATER CONDITIONS,ALL LOT5.AS PROPOS y RS�A • or neuwm.Ncv.O°4a�a0 mm 83'06'51'E 3��° r SERVIC t oQ ST SUFFO�xLVrIcW S ANDA• S DZ IP 5 51.00'00•E 93500' ,r �O' t�7 5 58.15' VIGEB GON'TRL'OTION STANDARDS IN 6 58 fOL DATE• �.� C 44) 9je56°' lam' •, / >° c qA �.� o .'/ cl�` Hp+ a• . 1 '1 \ A01, - �} I H.M ID YL YOIMS. E 4.Wra q 81463 c'' THOMAS G. AVAF T.N.YS.PE N7.OSTr 'V \ DOIkSLAS C ADAMS.N.YS.PE N0.5059•f G)S 11i ,I 11 L`r�I Y< 9 pT /� >>s3H D SURVEYOR'S CERTIFICATION A .0/ry \ \ a ms•µm m y)3 6c .yyoe I IL NOV I S 2O[JS -I li i GECTIFY THAT ALL LOTS SROM ON 1.7-19 PWTWmFL:Y ' R.a® «Llll 4•� b O�\rory ` w Lot I N \%� s° laa• Dy OTH TL=BJILDr16 ZONEoRD7HA}:CE of TI'E TOAD ofSOUTH4 (Exlsting Dwelllno) y�0`' fi "Fa �y Area=1.4I�Acres •1 HAY OEMSPY THAT TAB MAP WAS)NIDE BY AGNAL 9 (Upland ATea s 1290'7 AOTe6) SRVETS COHPL IN J,I AO.Y0a3 AND THAT ALL EIRNL'riSTE Bab MOIE1IONIS SHOWN Tom.n ACTUALLY AL AID ENSIO 9Y Cp NOTES POSITIONS ARE GORRES.AR SHOYI`L AND ALL DIMENSIONAL 0 • I m THE A-PROVK OF TICS MAP DOCS NOT COILS-. THE AN0 6FADEnC OL=TAIL9 AR:GORRFOT.' � ACCEPTANCE OF HIEHIWAY5 SHOWN INEREON AS POLM ROADS D 0� /i �j A DECLARATION of CXM3 1Ts AND RESTRICTIONS HAS BEEN FILED IH T)E JIT+DL/.fdJYTY O.P31C5 or�Ice 01 �j mx�« Lor uNES OF SUBDIVISION MAPS AS FILED.CANNOT Be THE o .�/O `�` ALTPRED WITibX FERMISSION FROM T U PLAWINO BOARD.AND NOAARD K YCLIN4 kY •L5. .4 / LOT5 MUST BE FOLD AS 5WrN ON THE S.150IVLNON MAP. 45 f $, STORM NATER REM LTDN FROM THE DEVF1DFtENi AND1MgROVE�@!T OF LC 3 OR ANY OF n5 Lois SMALL BE I✓ RETAF33 AN0 DEPTF-£D OF ON 517E NO STORM WAT62 SHALL 4` --- occ//^ ,M D\ BE SUBIECT CDVEWITS& sTntrnONS Nam 1244 I ONMER 1l G �y� PAGE �G6_ MARK 5AXTER fgp *a o 5805 MAIN BAYVIEVI ROAD p6CAA SUFFOLK COUNTY DEPARTMENT OF SOLD YORK 14471 / HEALTH SERVICE5 lip. vATE JAN 27 218 HAUPPAU&E,N.Y. @g TMs u To CERTIFY THAT TNS PRMFvty REALTY-IOPY5ION OR SU9DI V ISION MAP q D T DFtEM FOX W/ DAxi6R M THE TOW'I OP SaIMOLo MTH A �/y T��T/��/ �}•���/y CC TOTKOP3LORNA9 APPHaMm aNT�A9DaC DATCMMFTL SFFL�i M/ ,1 �1 1// ,XT�� AND SEtAbi'DY+pAV.FACWifES Mbi CO.aN TO C016TFE1cOW BI'_fm"M LTTAZT AT Tc V: or COtEfR'GTON AIY AFiE oe r+T la SB'ARATE PBaaS M1R=NMIT TO TIDY 9TAID/WD(.TN5 AR4'1VK . s ALL LAE VALD ONLY IF TIE RFiALTY 9l9DMSION-v V[io=Im+r MAF At 80 lew,ToPu7 of Southold IS W.Y FtIPD MIN:IE Ca1RlfY O'3TaC IVTON ONE MAF OF TITS DATC .oh,3iT 6 M_3/6M:N FOR Tit ML of TNM In.=ON M TCB SuFfolk Country New York �Oo ]tr AFFT'ARS M T. oFF1x OF TIE cn.Nir 4J3>K IN A[OOIDANCS WI'N FRa✓15-m OF TIE FLWf HEALTH LAM AN',715 9 K CO MTY f-ITARY01- S� 1000000 U--Ba vlra A Imc-L Pa Govnty Tax Map mwm 1 7B15 eea OT Lm 5.4 DRTS.TO.R __Or LTO/IRDN,A]�K aUAI-RY a PLANNING BOARD CERTIFICATION THS S ro GBiTFT TINT TN6 TIIOI�.CJeN Foal IIA<+�+AR'aGV®eY 6'i� Ta:RAMIIIYa BOAPG OF 712 TOYII OF s7l[HO:D. §��°[a MAP PREPARED NOV.14.3009 '-EA DATE or AF9R x f owA O^ (HOLD PLA•MK`°50ARn7 GOALS V-i00' C 4f i, �. � f;� {I I,y Fes.-• F+ \1 I DYYa.3003-0]66_FNOIPIat - �a U' SEP ' 5 2023 Southold Town 1 Board ofTrus�ees n.sums .. .-., '.- .......... ! ,t 2340 ,',• : - •: .r u -- r<.\\: .-, - SEC. : 'qq 1 E m-t9.01 u` •.: \', \ '>:+ ..\�:•.`-_.- �\. ,..Ci £'F <fiEE SCC fN OTO i!b C) p>'Y.M"r> ., ;^.;.:..._-_•.5"'--'•..<v:J�..............'.;...:�'��...- ,. -•;{••. .. p , ... 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W YIiWtCW.ry FMM1W 6 Aun,&W M o:a q au y❑UiH❑L❑ Q�V .__.___ 1211 o.<.e .. v2a,ri❑!ttm¢vN aF,if N ❑ —_•—— x+.e __:._.— w <...:e.,. __.___ $ ,w'xvrlr ToesErt°rE w❑ti P w--•iao n r OFFICE LOCATION: �� SI�UryOl MAILING ADDRESS: Town Hall Annex O P.O.Box 1179 54375 State Route 25 l Southold, NY 11971 (cor.Main Rd. &Yourigs Ave.) N Southold, NY 11971 G • Q Telephone: 631765-1938 � � COUNT`I,� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: October 16, 2023 Re: LWRP Coastal Consistency Review for ANDREW M. PETTERSEN & RANDY A. STATHAM SCTM# 1000-78-7-5.5 North Fork Landscapes LLC on behalf of ANDREW M. PETTERSEN & RANDY A. STATHAM requests an Administrative Permit for the as-built planting of sixty (60) 6-8' tall green giant arborvitae onto a 16-24" berm at southeast corner of property, minor limbing of small branches on trees for driveway access and sunlight for plantings. Located: 5805 Main Bayview Road, Southold. SCTM#: 1000-78-7-5.5 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 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 Request for Admin Permit for 5805 Main Bayview Rd Southold, NY, 11971 North Fork Landscapes LLC Brandon Lake (631)356-4318 Brandon@northforklandscapes.com Project Description:Property owners requested a screen tree planting directly behind an existing privet hedge along main Bayview Road.The goal of the screen trees was to provide winter privacy for when the privet plants drop their leaves 60 green giant arborvitae 6—8 feet tall were planted in a line approximately 15-20 feet off main Bayview Road.Trees were planted in a small berm (16-24")for additional height. Minor limbing of small branches on a few trees was performed for driveway access and sunlight for newly planted trees. Project Situation:All plantings were completed well inside the existing irrigated turf grass,as well as directly behind the existing privet planting. Homeowners received a citation from bay constable stating some of plantings occurred within 100 feet of a wetland without a permit.The issue occurs at the southeast corner of the property. Thank you for your time and help. Please let me know if you need any additional information. E E Er �- SEP - 5 2023 i Southold Town Board of Trustaes North Fork. A 44�c rEA"L LANDw A 5 COMPLETE MAINTENANCE & DESIGN SERVICES Glenn Goldsmith,President ®F S®�,�� Town Hall Annex ' � ® 54375 Route 25 ' A. Nicholas Krupski,Vice President �® �® P.O. Box 1179 Eric Sepenoski i Southold, New York 11971 Liz Gillooly G Telephone(631) 765-1892 Elizabeth Peeples ®� a® E C®UNTI,� D BOARD OF TOWN TRUSTEES SEP 5 200 TOWN OF SOUTHOLD This Section For Office Use Only Board of Trustees Coastal Erosion Permit Application Wetland Permit Application X Administrative Permit Amendment/Transfer/Extenasio X Received Application: `l Received Fee: $ ®.W ASP—OWLr -i —Completed Application: X23 Incomplete: - SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): K LWRP Consistency Assessment Form Sent: CAC Referral Sent: JC Date of Inspection: �0•II•Z3 Receipt of CAC Report: Technical Review: Public Hearing Held: Z3 Resolution: Owner(s) Legal Name of Property (as shown on Deed): An eLo .m PWozzie e aJi A N-m4o- " Mailing Address: 56o;_7 ma-, 1 �c5-gl9Com. Pj l S® `1 �r�'� ,���o ��,l Phone Number: 7 ) �� —6,q 6�f Suffolk County Tax Map Number: 1000 - _Loc V- / Lo-1- Property Location: 7L (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): h 1 V Mailing Address: 309 3o I �- ��'���� 1��� 119 �-c'23 Phone Number: io3 L Email: ®is'� ��IG C�-�n�Sc9:09S,C0%A Board of Trustees Applic �.on GENERAL DATA Land Area(in square feet): Area Zoning: Previous use of property: �G�:(lam U��•c�.� Intended use of property: Covenants and Restrictions on property? Yes No If"Yes", please provide a copy. Will this ro'ect require a Building Permit as per Town Code? Yes v No p J 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 thisJ ro'ect require a variance from the Zoning Board of Appeals? Yes No p If"Yes", please provide copy of decision. Will this project require a�demolition as per Town Code or as determined by the Building Dept.? Yes t/ No Does the structure (s) on property have a valid Certificate of Occupancy? L' Yes No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? -, No Yes If yes, provide explanation: Project Description (use attachments if necessary): G jo�o " A N o n zj Board of Trustees Applic kion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ` (-ice sC cy r,�,N<4 -Qn, Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: I 0 feet Closest distance between nearest proposed structure and upland edge of wetlands: — feet Does the project involve excavation or filling? No t/ Yes If yes, how much material will be excavated? cubic yards How much material will be filled? ';; CD cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: (,S ;`5 `` 11 Manner in which material will be removed or deposited: MCL���,1 lf� � aed 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 e-Kec4- we+1mAIL Board of Trustees Al Lcation AUTHORIZATION (Where the applicant is not the owner) I/We, _ / N +atZF- w M . 1'6-- T6f' sE v �-A ' °b� A , S-CWT%^A*%j owners of the property identified as S CTM# 1000- 01 S. -- - in the town of New York, hereby authorizes r a-de N L4 P La Cg I S 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"w w er's Signature SWORN TO BEFORE ME THIS DAY OF S t 20 Notary Public AMY KAPPEL 'Notary Public,State of NewYork Registration No.07KA6404445 Qualified in Nassau County Commission Expires February 18.20_&Y 3 f _ Board of Trustees Al--,,-, :ication AFFIDAVIT 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 of Property Owner --!%Mature 4f Property Owner SWORN TO BEFORE ME THIS DAY OF S"t�� Q , 20 3 'lltui�r.J� 'Rotary Public AW KAPPM NotaryPublic,State of New Vb* Registration No.01KA6404445 Qualified in Nassau County Commission Expires Febniary A 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 pumose 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. 1L e w �1 _ P 6 t✓ s v+� R Pt �1 S-rA�Ttl 'L, i YOUR NAME: �J (Last name,first name,ipiddle 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 ofTcer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%ofthe 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): E_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 ORE_LATIONSHIP Submitted this day of � �w�-Rr 20 Signatured1 r _ _ _ a - zsl-`�-� Print Name A L re -'�- j�e�lV vsr C_-14Pi-. Sia-AL-1 Form TSI l 1 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 pumose 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: L-6p— � (Last name,first name,.riddle 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 employee has even a partial ownership of(or employment by)a corporation in which the town office r 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 '*K3 Title or position of that person 'Dc u+y L 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 RELATIONS141P Submftted this 05 day of s 2jjo}QcuV 2002 Signature Print Name ®vl_ La P Form TS 1 617.20 Appendix,o 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 l 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 attach a location map): Briefl5escription of Proposed Action: 6 Gig, Name of Applicant or Sponsor: Telephone: 1 35 i�-C. o ude VE-Mail: C�1n1�COL $Ci $; Address: C-0 01A \Q-T' City/PO: State: Zip Code: v I I<= 1�8 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? L4 6(p acres b.Total acreage to be physically disturbed? s2)5' acres c. Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? J- 15 acres 4. Check all land uses thw occur on,adjoining and near the proposed action. ��,�// ❑��/UUrban ural (non-agriculture) ,❑,,Industrial E]Commercial OffResidential (suburban) LEForest ❑Agriculture 52Aquatic ❑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? I❑I ❑ 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: EJ ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES ErT 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? D! ❑ 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: [�J ❑ 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 00 YES [qrPlaces? F1b.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 El Forest ❑Agricultural/grasslands El Early mid-successional ❑ Wetland ❑Urban 5Kuburban 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, ❑ ❑ a.Will storm water discharges flow to adjacent properties? R?'N'O DYES b. Will storm water discharges be directed to established conveyance systems(run and storm drains)? If Yes,briefly describe: [ZNO ❑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,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 ,s,y� Applicant/sponso ame: //%���'x�(�� XeDate: �q�V7 1Z02Q 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 ❑ 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, ❑ 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 [�K ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? Fr 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 nviron mental 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 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 si fgru icant 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# - - PROJECT NAME, �J ®�7 &Agjycl\ &*4 V StW 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: r � a P Location of action: �r� Site acreage: q .5 r. Present land use: ��; l�4 w�-i Present zoning classification: gE3.�'ruA-wal 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing address: (c) Telephone number: Area Code( ) (d) Application number, if any: A^ Will the action be directly undertaken,/require funding, or approval by a state or federal agency? Yes ❑ No� If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. dYcs ❑ 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 Er 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 ErYes ❑ 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 ETYes ❑ 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 Z1 Yes ❑ No ❑Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III —Policies; Pages 22 through 32 for evaluation criteria. Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. Vyes ❑ 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. es ❑ No ❑ Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ Yeo❑ Not Applicable Attach additional sheets if necessary WORKING COAST POL1ctES 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 0 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 1:1 No L-► 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 eval ation 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 � �� L,a TITLECW S DATE ���`�I .t�C1C*\V0C1%1 LCWUKCg0S U-C.