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HomeMy WebLinkAboutTR-10477A Glenn Goldsmith,President Zf S® � Town Hall Annex A.Nicholas Krupski,Vice President ,�®� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski 8 Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 C®UN11,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10477A Date of Receipt of Application: October 6, 2023 Applicant: Joseph Buczek & Christina Spornberger SCTM#: 1000-71-1-15 Project Location: 1605 N. Parish Drive, Southold Date of Resolution/Issuance: October 18, 2023 Date of Expiration: October 18, 2026 Reviewed by: Elizabeth Peeples, Trustee Project Description: As-built installation of an underground electric cable running from the pole on street to house. 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 Joseph Buczek, received on October 6, 2023, and stamped approved on October 18, 2023. Special Conditions: None. Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Glenn Goldsmith, President Board of Trustees JOSHUA R. WICKS P.L.S. SUPVEY OF PPOPEP77 SURVEYED BY:J.R.W. DRAWN BY:D.T.O. JOB NO,JRV/23-0222 5/mg P.O. BOX 593 myvew fObl/NOFSOU8106f7 Center Moriches, N.Y. 11934 5UPFaKCOUNW,,NeN%YOK,t JashuaRWicks@gmail.com A �T631-405-9108 Suffolk Ccurrty fax Map No.; CRnPH�SCALE 2 3(9R 1000-071,00-01,00-015,000 D D cTm Ise1 ) n ") 17ME 5UMYR):07/10/2023 5CA"E:1" >0' j iA OCT - 6 2023 xoLD BAY 16q 81 UT o ' Y SouirioldToea❑ 20 I Board cs ard Df"Cruste ' _-- ----- *t SSe q3 I NHWL - W000 BULKHE/D ____ - Cv O -------------knom OF SLOPE W000 PUT. I (� 09E &SIEPS I TOP LF_SLOPE ---------- I N WOOD DECK CO W ICD Dm I F, O � �'�JT.B•is ia:� I s 2 STY. 10.0' I E, FR. RES. F #1605 10.0' PROP 'i6.4•,o i OTO 8 ii.19.5•...v PIAT N%11.2•-i � N ,SHOWER I 4I d I - PI i O d 08E j ASPHALT DRMEWAY LO W/BLOCK CURB 24.0-12N9.0 Co o o � � o I '70.0 ... ' 0'""" N 71°29'50" W 155.00' cI NORTH PARISH DRIVE tn d� GUARANTEED TO. of NEW JOSEPH BUCZEK& CHRISTINA SPORNBEROER �(� J' FIDELITY NATIONAL TITLE INSURANCE COdIPANY `Q aVP R. JPMORCAN CHASE BANK, N.A. ISAOA/ATIAIA )Oy cFJ LOT AREA 28,209.90 S.F. 0.65 ACRE(S) ICF, 4'0 0510�'y ysFL LAND (1)UNAUTHORIZED ALTERATION OR ADDITION TO THIS SUINEY MAP BEARING A LICENSED LAND SURVEYOR'S SEAL T A MOIATION OF SECTION 7209.SUB-DMSION 2,OF NEW YORK STATE EDUCATION IAW.(2)ONLY BOUNDARY SURVEY MAPSWRN THE 5UR�t OR•5 EMBOSSED SEAL ARE GENUINE TRUE AND CORRECT COPIES OF THE SURVEYOR'S ORIGINAL WORK AND OPINION(B)CERIIFIGTONS ON THIS BOUNDARY SURVEY MAP SIGNIFY THAT THE MAP WAS PREPARED W ACCORDANCE WTM THE CURRENT EYISHNG CODE OF PRACTICE FOR LAND SURVEYS ADOPTED BY THE NN YORK STATE ASSOCIATION OF PRO—N&LAND SURVEYORS,INC.THE CERTIRCATION IS UMREO TO PERSONS FOR WHOM THE BOVNDANY SURVEY NAP IS PREPMED.TO THE TITLE COMPANY.TO THE GOVERNMENTAL AGENCY•AND TO THE LENDING INSTITUTION USTED ON TING BOUNDARY SURVEY MAP(4)THE CERTIFICATIONS HEREIN ARE NOT THANSFERABLE.(5)THE LOCATON OF UNDERGROUND IMPROVEMENTS OR ENCROACHMENTS ARE NOT ALWAYS KNOWN AND OFTEN MUST BE ESTIMATED. IF MY O UNDERGROUND IMPROVEMENTS OR ENCROACHMENTS EXIST OR ME SHOWN.TIE IMPROVEMENTS OR ENCROACHMENTS ARE NOT COVERED BY THIS SUR/ET.(G)THE OFFSET(OR DIMENSIONS)SHOWN HEREON TRDM THE STRUCTURES TO THE PROPERTY ONES ARE FOR A SPE I'D PURPOSE AND USE AND THEREFORE PRE NOT INTENDED TO GONE THE ERECTION OF FENCES.RETAINING WALLS.POOLS.PATOS PLANTING AREAS.ADDITIONS TO BUILDINGS.AND A-OTHER TYPE OF CONSTRUCTION.(T)PROPERTY CORNER MONUMENTS WERE NOT SET AS PART OF THIS SURVEY.(B)THIS SURVEY WAS PERFORMED'A iTH A TRIMBLE S8 ROBOTIC TOTAL STATION.(9)THE EXISTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD IF ANY,NOT SHOWN ME NOT GUARANTEED. JOSHUA- R. WICKS P.L.S. 5ukl/Ey or PPOPEPTY SURVEYED BY:I.R.W. DRAWN BY:D.T.O. JOB NO.:JRW23•0222 lquig P.O. BOX 599 SAY I-V III/•ram OF-1culk✓L0 Center Mori hes, N.Y. 11934 Siff .K Cc;UNiY,,&r0'Y6kK IoshuaMcke®gmail.com =t",3 #831-405-8108 ffclk f x Map Na: y4=ice GRAPHICSCALE 0 IDR) - ET9A) 319aI f"6 �� U . B(OAR[5 ' �C PEES E E ' E TOWN'OF. SOUTHOLD OCT - 6 2023 OLD BAY I6q• SATE UT8 o � Southold Town s E � -----— Board of Trustees 8 e 3+ N $ A � 1 ............................................ 41:W:�............ YIOOD BIA10(FAD O ___ -------------� ---BOTEOY OF ROPE---- SEPs 1 I NQ, TOP�90PE_-------_ _--_—_---- Cp I � � WOOD DECK I F O 2 STY. k Q FR. RES. )•o, F $ #1605 PROP 0TANX 1 SHOWER[� I AT %9v d ! 1 OBE ka d/ ASPWLT DRNMY '�p `�. 1 co LfJ / N/a=DTR 24.0'1 M - o� �.o,. 0 0 1 N 71°24'50" W 155.00+ \k NORTH PARISH DRIVE GUARANTEED TO. Q� n+e�7 u� I"a"VJ�v�' JOSEPH BUCZEX& CHRISTINA SPORNBERGER �� p,R. rn FIDELITY NATIONAL TITLE INSURANCE COMPANY �Q TJP R Wj JPMORGAN CHASE BANK, N.A. ISAOA/ATTAR X05 cfs� LOT AREA 28,209.90 S.F. 0.65 ACRE(S) (,Cf 't'o-0 A Nsf�LAND 51)UNMiHOHIZED ALTEMTON OR MI—TO Toy SURVEY NAP BEMING A UCENSCD lANO SURVEIOR'S SEA 6 A MOUTON OE SECTION]209.SUB—OMSION 9,OF NEW TOR.SLATE EWCATON UW.M ON,BWrvpARY SURVEY NAYS WOH THE SUMLYOR'S EMBOSSED FAL ARE GENUINE TRUE AND CORRELt CONEY OF NF SURVEYOR'S ORIGINAL WOR.AND OPINION(S)CERTHCAiIONS ON MIS BOUNOAAT SURVEY NAP SICNICY iNAi THE NAP WAS DREF_, W ACCORDANCE WIW THE CURRENT""TIN,CODE OF PRACBC.FOR_, SURVEYS AOOPIED BY THE NEVMOR.SLATE ASSOCIATION OF PROFESSIONAL TIND SURW(CRS,INC.THE CERTH'[WDN IS UMREO TO PERSONS FOR WHOM THE BOUNDARY SVRYM INAP IS PREPAREO,TO THE TITLE COMPANY,TO THE GOVERNMENTAL AGEMLY,FMD TO WE H LENTNNG INSTITUTION USTEO ON THIS BOUNDARY SURD YAP (4)THE CEFFTI TIONS HEREIN ARE NOT TRANSFERABEE.(5)THE L TION OF UNDERGROUND IMPROVEMENTS OR ENCRCACHMENTS ARE NOT ALWAYS KNOWN ANO OFTEN MUST BE ESTNATEO !tT' UNDER—D IMPROVEMENTS OR ENCROACHMENTS E%6T OR ARE SHOWN,THE IMPROVEMENR M ENCROACHMENTS ARE NOT COVERED DY THIS SURVEY.(S)THE OFFSET(OR DIMENSIONS)SHOWN HEREON FROM THE STRUCTURES TO THE PROPERTY UNES ARE FOR A =SPECIFIC PURPOSE MD USE AND THEREFORE ME NOT INTENDED TO GUIDE THE ERECTION OF FENCES.RETAINING WALLS.POOLS.PATIOS PUNTING MEAS.ADORIDHS TO BUIWINGS•AND ANY OWER TYPE OF CONSTRUCTION.(])PROPERTY CORNER MONUMENTS WERE NOT SET AS PMT OF NIS SURVEY.(8)THIS SUINEY WAS PERFORMED WNN A TRIMBLE S8 ROBOTIC TOTAL STATION.(9)ME EXISTENCE OF RIGHT OF WAYS MD/OR EASEMENTS OF RECORD IF ANY,NOT SHOWN ME NOT GUARANTEED. t„- 4__ ��7pTrii Glenn Goldsmith,President ��S t�COGy Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 0 Eric Sepenoski a ? P.O. Box 1179 Liz Gillooly _y • o�� Southold,NY 11971 Elizabeth Peeples l �a Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: o 0 I 23 completed in field b E-L p Y� ztA�rAn C�S JOSEPH BUCZEK & CHRISTINA SPORNBERGER request an Administrative Permit for the as-built installation of an underground electric cable running from the pole on street to house. Located: 1605 N. Parish Drive, Southold. SCTM#: 1000-71-1-15 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.: S�rwlah�o�rwaro� Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly ✓ E. Peeples T� It .� ♦ 1 r ♦ � A y xi .�� ^ a.. aJ �. . 'i � �t •int ,;�� „�-"•1.. •lit- ''`r`- o�,',n t '.. - !� �.: 141. 67 AMW At IPI "moi , l�� ♦ /'�n"' �}ri •�y. -.•a� - r' .�.� 1 `i 4Seri. �' O t ---fir- -,•... f- �..-_._�.--�-••' � .. ,� � . -.. �;`� .,�. ���lR 1p lok«. ^sr jf 7-7 WK 1. ` Y 4 r , • I ( l r y T .y + . LN l r. � •,�, ,• . Ilk y y =.Ab r Z3 �y IN, f � 1 r i a a !' it � s � i t R Mme,. ♦ ;'"ntYr .• i +�. r �.f,r`�I �.`�. �.` - .. M Adr ,,tea N a ;—Z1 .1 NNaE�RT. SOUTHOLD MY zzwq ,5 ' zWcl V N.IwmsX oIt \�, sax,u Par P w wo .. ruVor r�aq a z 3a13 ,aN / SEE IIbERI i ----- °-�� — -- --^-- NOTICE COUNTY OF SUFFOLK © x lOImIOEo SECTION NO —Z-- R'I —Q o..•_ __—X--_ �`__—�-- Qx,.- Real Property Tax Sernce Ageruy v r..X �, „a,E 071 exr P aro ime•w 100 ,�,w.i PROPERTY IMP SOU�y� CDUNT`1,�� MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: October 18, 2022 Re: LWRP Coastal Consistency Review for JOSEPH BUCZEK & CHRISTINA SPORNBERGER SCTM# 1000-71-1-15 JOSEPH BUCZEK & CHRISTINA SPORNBERGER request an Administrative Permit for the as- built installation of an underground electric cable running from the pole on street to house. Located: 1605 N. Parish Drive, Southold. SCTM#: 1000-71-1-15 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 and the records available to me, I recommend that the proposal be INCONSISTENT with LWRP policy 6. 1. The work was not approved by the Board. 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 i —� Glenn Goldsmith,President ®V S6��� Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ®� ®�� P.O. Box 1179 Eric Sepenoski Ir Southold, New York 11971 Liz Gillooly Telephone (631) 765-1892 Elizabeth Peeples ® y® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application ; ti Wetland Permit Application _Administrative Permit Amendment/Transfer/Extension OCT - 6 2023 }( Received Application: �B•G'Z-� _Received Fee: $ -00, dJ- SoLdhofdTov,n _Completed Application: /0. 23 Board of Trustees Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): X( LWRP Consistency Assessment Form Sent: CAC Referral Sent: _Date of Inspection: Receipt of CAC Report: Technical Review: YC. Public Hearing Held: Resolution: Owner(s) Legal Name of Property (as shown on Deed)J05 jj S, ZP,L° Ch Fis{Z n� rnbe-' Mailing Address: l� 1� 1'a qd,-�f• �u`���� 7 111-7 r Phone Number: Suffolk County Tax Map Number: 1000 - I •"" r I� Property Location: �cv�J� N• r0,7Sf� /✓r 016( /kjy ltq7/ (If necessary, provide LILCO Pole #, distance to cross streets, and location) AGENT (If applicable): Mailing Address: Phone Number: Email: Board of Trustees Applica . :in GENERAL DATA Land Area (in square feet): �R Area Zoning: 1? -40 Previous use of property: EI✓1 &, C� Intended use of property: S�` V7 12 ��V4 iZeSrd.Lr7� 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. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure (s) on property have a valid Certificate of Occupancy? �/ Yes No Prior permits/approvals for site improvements: Agency Date 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): Z14 ZC Board of Trustees Applica, )n WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 2U, Vi g&ble-- w l rex fd �� rb(. 4q� Wt. 1e 8 . Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? _No Yes If yes, how much material will be excavated? 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: Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part I -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: Project Location T(dcribe,and attach a location map): ansh bn vae oaJPoO MY 1071 Brief Description of Proposed Action: ZA ele&' rtc, y ea-b l c. u.�( vvi mal FV-,V(. 1.0 red- 71V htn'tc-r- . Name of Applicant or Sponsor. Telephone: �3�—�-76,44930 o !'YIS I�GL��(lel E-Mail: s 7�u G'72�t,(��• yy� Address: 1606 IV, City/PO: State: Zip Code: 6,6 NY //-7 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 F] F 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? r acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? e acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial [Residential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 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? ❑ ❑ ❑ 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? rpj c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 11. 1 1-1 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: El El 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: Xf ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: 0 ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ❑ b.Is the proposed action located in an archeological sensitive area? ❑ 13. a. Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b. Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline El Forest ❑Agricultural/grasslands El 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? NO YES If Yes, ❑ a. Will storm water discharges flow to adjacent properties? ❑NO DYES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO DYES 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 Applicant/sponsor name: Date: 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 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 ❑ ❑ 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 1:1affect 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 El 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, F-1 ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ Elwaterbodies,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 El 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 docu mentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. EICheck 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 Applica, on AFFIDAVIT J06!p� S. �avu'k EING DULY SWORN DEPOSES AND AFFIRM8 THAT HE/S11E IS TIM APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE ,CONSERVATION ADVISORY COUNCIL, TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Sig re of Propertwner Signature of roperty wner SWORN TO BEFORE ME THIS o2 DAY OF �,` f , 20 _ SARBARA H.TANOY Notary Public State Of NOW" No. OITA6086001 Qualified In Suffolk County�,S Comdoalon Evires 0 `1 Notary Public APPLICANUAGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE,FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The_puryose 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. j, pA' YOUR NAME: B UC Z_W;, a1FW S - "'~"A � i C Is-W (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 officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thi of Qch hff Signature Print NamForm TS TS 1 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 sung_ ficant 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# 10 0 9 - Zr PROJECT NAME JOSZPs 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�e tent of action:k��-- r of rd wv.,� M1 1 L•cat•i n of action: a • Site acreage: Present land use: VL t `�U,�t l Ge✓ 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: Kf (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 L)4 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 W Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No J�] 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 [,Z 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 177 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 0 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. ❑ Yes [:] No �4 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 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. ❑ YeF-1 No❑,� Not Applicable 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. ❑ 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 1� 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 0 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 10124 Z3