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HomeMy WebLinkAboutTR-10503A Glenn Goldsmith,President ®F S0 Town Hall Annex A.Nicholas Krupski,Vice President ®� ®� 54375 Route 25 °l ® P.O.Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 CIO Nil, BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE 2110C Date: December 13, 2023 THIS CERTIFIES that the existing 800sq.ft.deck with 18'x5' stairs and railings; At 725 Munn Lane, Orient Suffolk County Tax Map#1000-17-2-6.3 Conforms to the application for a Trustees Permit heretofore filed in this office Dated November 28, 2023 pursuant to which Trustees Administrative Permit#10503A Dated December 13. 2023 was issued and conforms to all the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for existing 800sqft deck with 18'x5' stairs and railings. The certificate is issued to Barbara Dow Revocable Trust owner of the aforesaid property. Authorized Signature Glenn Goldsmith, President ®��®� S® Town Hall Annex U��®� 54375 Route 25 A. Nicholas Krupski,Vice President ® P.O. Box 1179 Eric SepenoskiE Southold, New York 11971 Liz Gillooly Telephone (631) 765-1892 Elizabeth Peeples a® Fax(631) 765-6641 COU -N 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 kWhen project complete, call for compliance inspection; Glenn Goldsmith, President *®F SO Town Hall Annex A.Nicholas Krupski,Vice President ®� ®� 54375 Route 25 °l ® P.O. Box 1179 Eric Sepenoski J Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples �� Fax(631) 765-6641 C4UNT`l,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE 2110C Date: December 13, 2023 THIS CERTIFIES that the existing 800sq.ft. deck with 18'x5' stairs and railings; At 725 Munn Lane, Orient Suffolk County Tax Map#1000-17-2-6.3 Conforms to the application for a Trustees Permit heretofore filed in this office Dated November 28, 2023 pursuant to which Trustees Administrative Permit#10503A Dated December 13, 2023 was issued and conforms to all the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for existing 800sq ft deck with 18'x5' stairs and railings. The certificate is issued to Barbara Dow Revocable Trust owner of the aforesaid property. Authorized Signature Glenn Goldsmith, President ®� S®U�� Town Hall Annex ®� ®� 54375 Route 25 A. Nicholas Krupski,Vice President ® P.O. Box 1179 AL Eric Sepenoski Southold, New York 11971 Liz Gillooly Telephone (631) 765-1892 Elizabeth Peeples ® a® Fax(631) 765-6641 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; t s• X. .50 MAP OF ISLAND40 NOR SUBDIVISION PREPARED FOR 110v 2 $ tj 23 q BARBARAB, DOW "T �A} r � �� V i. .i'i'i•,i7,.� AT ORIENT �.�II ACRE.'S � 1r'� •J .V ,, r ly, TONIN OF SOUTHOLD, N .Y. APPROXIMATE SCALE 1" = 100' �jy I • Sr `` ' k'rrR 4�7 CESSP04l'-•�,,,•t � i "i.r:�_Y,r I 100 0 50 100 200 400 t FAMILY � ► �'fS�-! �il7 i ;';'�.,,1'� F#tAME HOUSE KEY Y MAP � y.� �ty� '�•O!, '1�� � • .,; Y;i 1 'JM „ IN FM SCALE 1" =600' � ;. CESSPOOL ss incl, = loo {> r,.r`'''''� AREA - ,•;�,' ,..r+�.;;��, ,�, ,.;.. 1 4. 99 ACRES ` ' f,. j. TEST NOLI' 2.0 ACRES OWNED AND DEVELOPED BY.' CONSERVATON w EAsEmENr BARBARA61 DOW �, �tiRc 87 MARJO-RIE COURT MANHASSET NEW YORK 1 " ' 'r"', ' ., �' 374'Tn wAT�a 4' 1030 ' ' ' ' �; 1 SUFFOLK C ,.. , � OUNTY TAX PARCEL 'I 54y , 1000-017—Q2—Ofi 10W r ; ,,., 51.2 ' z r , +' -, --a i '� ,Isar �' N BUILDING ZQNE R-40 f+T rA a TYPICAL LOT 00 H 89'37'0(7" E -..!m AREA - I 2 ",. ' ' `', •,tir l (NOT To scAL0 50.00 "n + SUBJECT TO COVENANT I! S�RES'11RiCT1QN5 L18EE.__,�,,,, ..i N X8'36, W :•,�-_ b 3 f S 8x31'30" N PAGE— � +` k S 85`481Qtr et g disposal facilities z The water supply8c sewage � G. ROWSAb! BURYING ! SUTrt+'OI� COMMIfEPA7i'1'7AM OF WALTH SEIMUS for both lots an this map comply with the ' y' l*'; _ 4 GROUND standards and requirements of the Suffolk `' L z�l ui , � H►UPPAUGE, N.Y. County Department of Health Servides. Dots DEC U 5 1996 fjC�A.te CJ ' RODERICK WAN TUYL, P.C. '1 a, RiGHT OF WAY COURSE'S: . i 2. H 748'3(7" E 75.0' This i to csrt3fy that th�,propossd Realty 5ubdi+rielon or Oevslopment J[1 in the I 3• - '°r � r` �' PROFESSIONAL LICENSED LAND SURVEYOR � SE yet. � �+• N 38•f 0 57.79 with o totlol of, —=1at was SEPTIC TANK ' Lr ' approved on the above dpts. Water Suppllles and Sewagis Dlspasal �•Y S. LICENSE N4. 2Jr �6 �j FaniUWM moat conform to oonetrNetion standlards in effect at the time ;W,r of construction and ars sybffsat to wMarots permits punwont to those GREENPORT N.Y. CESSPOOtS C} y t SS standards. This approval shall be valid only, if the real subdivision/ ' derilopMrnt map Is duty filed wRh the ,County Clark wither ons your of this duh. Consent In hersby given for the filing df this mqp on APPROVED'l/�`D ' -� Which thio'sndgrosment oppears In the Offiro of the County cleric in 11's1�i t�.•ii accordance with the provisions of the Pulblie Health Law and theh'1 ti a`• ~'- 1 Suffolk County 5anttory Code. PLA dING BCCA 4 t" S 83.59'40" E A declaration of covenants and restrictions affecting z 30,02. lots on this subdivision has been filed in Suffolk. TOWN F SCUT OLD . ;, I 4 County Clerk's Office in Liber 11684 Page 996 and 1 36 Page 681. �� 5 r ' Liber 17 . +• Joseph W. Baler. P E �,1 Director, OMelcin of Envtronrnshtal Rualrty TEST HOLE � D' qL BROWN • LAAAiY SAND r °�c'6i'f 2. SP 5W ' I PALE BROWN CLAYEY SOMoLb EMO"SAND WttH PLANNING BO&RD SUN WME LAYERS OF HE4VEY cskva. ,4 WE HEREBY CERTIFY THAT NEITHER LO ON TH S MAP Q IS LESS THAN 80,000 sq, ft, IN AR AND TH S WAS I BY , 1995 ANDTHATAL UFROM ACTUAL AUGUST14NCRETE M NUMENTS 22HAV£ BEEN SET AT POINTS SHOW THUS: a PAIS BROWN b 1 STAMP FINE TO •� MEDIUM SAND *+ 25' uNAMORIIF.DDALTiFAAnON OR ADDITION / WATER IN To SECT IS UIg Ey JI THE OLA11ON OF YORK STATE STAMP ,/ PALE TO �Il EDUCATION LAW. I?ODERf CK WAN TUYL, P.C. rl MEDIUM SAND 31' THEiLAND SURYEY 'S INKED SEAL$RHINO TO BETA VISEAL JD TRUE COPi'K#LL NOT BE CONSIDERED -- MAIN .COAD N. Y. rG aJ �ESDIEORUN PE�N FOR WWM THE SURVEY �� IS PREPARED, ANID ON HiS BEHALF 70 THE '� �' 1M LICENSED LAND SURVZYpfi r TITLE CO ,MPANYGOVERNMENTAL AGENCY AND �yf�- ; 4 ; I TOING 1N$iMMION LISTED H N, AND r , �F a ' GREENPDRT N.Y. , ft7 THE A9TDGFIEE'S OF'THE LH INafi- nMON. GlU1RANTEEHS ARE Mn TRANSFMBLE. LAND 1 i ' .-,. ..,.... I••••.•�...r,..-•.•rw- +^+•''.'"•' ."'f,.'•"`..-•.•+•w."...... . - -�r.m•"„•.,,......,.,,..,,,r.....w•+...Y.r.� w....•ra..�...-+..-r�,wr.y-..,w...rr....r'.-....,.-�.., .w-,. I.._..I... ...---,.w,�.-r-""---r«r. .. ... • r.'y , { ✓, 7r- S''R'. F ' I R ! yi ' -cy I a 1i1'o a 2 8 202 K���r..�r�.•-y. rod'� _ .. � r, ,p, r ! I1 fir: } tJ` 'f fR � ' �\;a1t �. , "4�•.r''��,R "��r� ,'V '�'.?�.« u-' y..�~fh�,+e• tx �•i' J}w'."r Ll l'�►. �•-...�. F� t f ..w � ! 1 ..�r -�!' - �•5 ;0'•�S!r ! 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'.p'_� �Ib' i, _ '�'' ` r..],'{„` I, - x,. ,•i'_ w,,�" - IJ L.I - rye', ;."lI 5 3F(I, t: ;� S I M�' I M ' ' tl r «:t L� ,•, _'f - ,L,'.1:,:;="' F:{e, "'' I.r' I.. r '=.�.: P,r*' if'C`:I ,iReSi..Rc1'4.'tx k'•.':'r Al �"A(-„,VED BY ABOARD OF 1 RUSTEES TOWN OF SOUTHO D DATE �rrt� 13 Zo2� Cheryl Newton Architects LLC EXISTING HOUSE 39 New London Tpke, Suite 320 Glastonbury, CT 06033 (860)633-2477 Revisions: EXISTING HOUSE EXISTING HOUSE EXISTING BEAM TO REMAIN N 0 V 2 8 2023 �0 1 I I I I I I I I I I Po\\ 0111 // I I I I I I I I I I I I I ► \\ 1 1 1 1 1 1 COhTIdUO S xl 11 17/� PSI. I I I 1 1 1 I I I I I I I I I I I I I 1 1 1 �L1J — L1- -J I I I I I 1 1 C4 1 1 1 1 1 1 ICID 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 11 EXIST. 48” I 11 1 I I I I ; II 1 1 1 1 1 1 1 1 1 I I I PF�ES SURE' TR ATIkD 1 1 11 CONCRETE I 1 1 1 1 1 1 1 'f I I I I I I I 1 1 x101 FRAMING 12rO.Cl I I I I I I N FOUNDATION ( r x(I I LA,0,,,1110 „ � L V � I (� -11 I I I I 11 IIx I I I I I I I � � 1 1 1 1 1 1 IN \1 �, I I I I I�� ailQS IUj F I I I I I I I I I I I I I 1 I I I I I 1 I I I I0 l� W I � NTINUOl11S 1/12 XI 11 17/ PS 1 1 ► 1 1 1 1 1 1 1 r-I y z I � ITI w 6X6 PT POST - L- -J- J - L- -L -j --i .L _L -I- -L ON EXIST. 16"X16" 31'-1" J CONCRETE FOOTING LU z 1 FRAMING PLAN -f--j HOUSE : 1/411 /4" = 1'-011 EXISTING HOUSE Lo 0 NEW IPE DECKING ` V 0 �- NEW HOT TUB o ih AT EXISTING LOCATION 36" R LING WITH S �S " ® 3" 0.C. \O'° 18 RISERS ® 6 7/8" 17 TREADS CSD 11" 4X4 IPE POST 12'-0" 12'-0" CABLE RAILINGS ® 3" O.C. IPE POST24X4 FLOOR P LAN Drawing Name: CABLE RAILINGS 1/4" = 1'-0" ® 3' O.C. DECK PLANS 36" IPE RAILING WITH SS CABLES ® 3" O.C. 00 Scale: AS NOTED Date: June 20, 2023 Drawing Number: 5'-4," 2 Glenn Goldsmith,President �W, sou Town Hall Annex A.Nicholas Krupski,Vice President ,`®V� ®�® 54375 Route P.O. Box 11799 Eric Sepenoski 8 Southold,New York 11971 Liz Gillooly ees Telephone(631) 765-1892 Elizabeth Peeples � y� Fax(631) 765-6641 c®U ,� BOARD OF TOWN TRUSTEES - TOWN OF SOUTHOLD Permit No.: 10503A Date of Receipt of Application: November 28, 2023 Applicant: Barbara Dow Revocable Trust SCTM#: 1000-17-2-6.3 Project Location: 725 Munn Lane, Orient Date of Resolution/Issuance: December 13, 2023 Date of Expiration: December 13, 2026 Reviewed by: Eric Sepenoski, Trustee Project Description: As-built 800sq.ft. deck with 18'x5' stairs and railings. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as.indicated on the site plan prepared by Cheryl Newton Architects LLC, received on November 28, 2023, and stamped approved on December 13, 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. .4K t�f� Glenn Goldsmith, President Board of Trustees 1 Glenn Goldsmith,President ���0 COGy R Town Hall Annex A.Nicholas Krupski,Vice President a < ` 54375 Route 25 0 Eric Sepenoski * ,? P.O.Box 1179 Liz Gillooly �y • O��f Southold,NY 11971 Elizabeth Peeples �0 t¢ , Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: na Completed in field by: Ai� /07 BARBARA B. DOW REVOCABLE TRUST by Dorothy Anderson,Trustee requests an Administrative Permit for an as-built 800sq.ft. deck with 18'x5' stairs and railings. Located: 725 Munn Lane, Orient. SCTM#: 1000-17-2-6.3 Type of area to be impacted: Saltwater Wetland Freshwater Wetland aXsound Bay Part of Town Code proposed work falls under: fCHapt.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.: Present Were: G. Goldsmith N. Krupski ✓ E. Sepenoski L. Gillooly E. Peeples - - j ..- -. -.:y:,,�a --�__�_ _ .ems` ��- �'t' • . . 1 • 'I I I i Each tread is 1"x 11"x 76". =836 cubic inches= .48 Cubic Feet Each post is 3.5"x 3.5"x 14"= 171.5 cubic inches=.1 Cubic Foot Each Stringer is 5.5"wide x area of irregular shape(265 square inches)= 1,457.5 Cubic Inches=.87 Cubic Feet NOT SHOWN:Stone landing at bottom of stairs=6"x 36"x 74"= 15,984 cubic inches=9.25 Cubic Feet Total Volume= 1.44 (risers).2(posts) 1.74 (stringers)9.25(stone landing)= 12.63 Cubic Feet SUBJECT PROPERTY PHOTO AD[ UM Client: Estate of B i Dow,Go Dorothy Anderson File No: PVP13-519-7251122 Property Address:725 Munn Lane Case No City:Orient State: NY Zil):11957-1013 FRONT VIEW O SUBJECT PERTY ailed Date:October 2,2013 =� = Appraised Value:$1,3ao,000 77 REAR VIEW OF SUBJECTPROPERTY STREET E ,+All. MPL e n! � � •�r .� Iry e I 5 °{ ct � f . 11/27/23, 11:22 AM Gmail subject) in 4 ■ Et � I see 4 x spa mg- w 3!H z. F� � ��.� S� � a cM � �ti„�s�),�� i� f� d�� °? 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J _ •i54 iY 2. l p amu` Y E 5]A ! � S zu 2d1c1 ..r 22 13.1 3" 1 w Lc O u t0 I. / NA t5 J _ - -._. ,w•o�l+__.. ^ t a.ena Kai 1 I 6 a+r^� >Q, 3 R11 - ------ — '0.-- "� --•-- ra11cE COUNTY OF SUFFOLK © E D secnoN No Q __F_ r __�,__ Real Property Tax Service Agency r E M--- _ _. ---- u-- -- a-�.a.......MrH. a 017 P ® ,wc�w tfM PROPERTY YAP i MAILING ADDRESS: PLANNING BOARD MEMBERS �QF SO(/jP.O.Box 1179 DONALD J.WILCENSKI ��� Old Southold,NY 11971 Chair OFFICE LOCATION: JAMES H.RICH III y Town Hall Annex MARTIN SIDOR �� 54375 State Route 25 PIERCE RAFFERTY (cor.Main Rd. &Youngs Ave.) AMELIA JEALOUS-DANK `?COUff " Southold, NY (�{� Telephone: 631 765-1938 www.southoldtownny.gov PLANNING BOARD OFFICE TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: December 11, 2023 Re: LWRP Coastal Consistency Review for BARBARA B. DOW SCTM# 1000-17-2-6.3 BARBARA B. DOW REVOCABLE TRUST requests an Administrative Permit for ah as-built 800sq.ft. deck with 18'x5' stairs and railings. Located: 725 Munn Lane, Orient. SCTM#: 1000-17- 2-6.3 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is INCONSISTENT with LWRP Policy 6.3 and therefore, INCONSISTENT with the LWRP. 6.3 Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction 1. Comply with Trustee regulations and recommendations as set forth in,Trustee permit conditions. The as-built work was completed without a Board of Trustee review or permit. 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 Town Hall Annex A.Nicholas Krupski,Vice Presidents ��t� 54375 Route 25 P.O.Box 1179 Eric$e enoski p - Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples ';e� '� .�4 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Onlyff Coastal Erosion Permit Application Wetland Permit Application iii tt ' Y. Administrative Permit �' INV 28 Amendment(Transfer/Extension Received Application: Received Fee: Completed Application: Incomplete: SEQRA Classification: Type I_ Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): LWRP Consistency Assessment Form Sent: CAC Referral Sent: Date of Inspection: Receipt of CAC Report: __Technical Review: Public Hearing Held:,. Resolution: Owner(s)Legal Name of Property (as shown on Deed): 8 A 2 BA,24 'bo w ?a ua CA r4 j_E R OsT Mailing Address: !0 9 N E Y jj,2,_? L,, 'be4 La Sre r0 G3 a R) 6-F r)b 0 5 3 Phone Number: EMp+lL ci_vro4-6q Aow. cind"erson&gtTiAil,Cotn Suffolk County Tax Map Number: 1000- 14? 3 RR -t 17. -21,-(, •At 3 Property Location: -7 a_&s _m u NN L ANC o T2(,ENT (If necessary,provide LILCO Pole#, distance to cross streets, and"location) AGENT(If applicable): Mailing Address: Phone Number: Email: Board of Trustees Al ication GENERAL DATA Land Area(in square feet): Area Zoning: Lo A) - b Eros c ---/ Previous use of property: R E S T Do&)r tNq L- Intended use of property: �,E S 1*�, E w.z t 4 L Covenants and Restrictions on property? Yes _Q_No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes _nNo 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 _E�_No If"Yes", please provide copy of decision. is project recimyj 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_D_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?_a No_a Yes If yes, provide explanation: Project Description (use attachments if necessary): fRAII-Ilu4s lr� aoo-11. 'be C.le- 01mE/USr0rJS 900 S2 Sia fgS Ix ri r mr,7u) S rales ARC :iLi Gu- -4 LaN6Eae 7" TKAw 1 l ' L o N " T-)4 LL -a- C1 ' 4" L 0 ruC, 5 F F r4.� r c-J4E b 7�\+A :5ROw r lot) V-0 Lv m EJ Board of Trustees Al ication WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: P-E-Pio t P 11 p GA GE ( EGIL . -6-rg ti2S. A,vn P_(-1rL1N45 ON EXI5TIN4 F'0VN0R9-1CN5 ro MEED -- e U R (ZEtJ,' " ( 01I)E5 AfuQ `RaPo 12/ 12LPLfq L'E P_or-y/aU 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? 041A cubic yards How much material will be filled? r 11A cubic yards Depth of which material will be removed or deposited: ?4 A feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: aR P�n/�Ry IY�,4Tf� SLS WERE 1ELI✓LR�-I) Atil) JfJ6TALtC-7D &,l 14,41UD . I RvcLs Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1-Project and Sponsor Information Name of Action or Project: -bP_(_K 5101 (Z REPAID j Project Location(describe,and attach a location map): Nlw (' of rnrNvlz SoSDiL/fs;dn` Brief Description of Proposed Action: r=PH 112 J PLacF C-V- AN St FIRS Name of Applicant or Sponsor: Telephone: Sleo_6 lq_ g q& -7 '1)0RvTi4q A A)D F-12,5o.J E-Mail: c�odo�d�y, loco,a��eosun „ham,/, Address: cow Jog l���vr7ooD �j(?. City/PO: State: Zip Code: 615Tons 3 o RV Lr 0&033 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? ,q acres b.Total acreage to be physically disturbed? rp acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. CheI land us at occur on,adjoining an ar the propqsC4action. Urban Q4JRuraI(non-agriculture) Industrial Commercial i?Residential(suburban) Forest ❑Agriculture X Aquatic QOther(specify): OParkland Page 1 of 4 S 5. Is the proposed action, NO YES I N/A a.A permitted use under the zoning regulations? x b.Consistent with the adopted comprehensive plan? 7( 6. Is the proposed action consistent with the predominant character of the existing built or natural .NO . .YES landscape? X 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 4X b.Are public transportation service(s)available at or near the site of the proposed action? X c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? �[ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO .YES If No,describe method for providing potable water: inc 15—, 1 IJ(4 WEI-L a ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: P i7 L f e.E55 POOL 5 El ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? x b. Is the proposed action located in an archeological sensitive area? 13 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain jq_0 _rJ PYES wetlands or other waterbodies regulated by a federal,state or local agency? x b. Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? X If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: EF 14. ntify the typic bitat types that ocn,or are likely to be found on t"roject site. Check all that apply: Shoreline Forest Agricultural/grasslands u Early mid-successional Wetland HUrban ESuburban 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? x i 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 If Yes, a. Will storm water discharges flow to adjacent properties? ❑NO DYES a E b.Will storm water discharges be directed to established conveyance systemsff an drains)? If Yes,briefly describe: [7NO YES Page 2 of 4 l� 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)? 1f Yes,explain purpose and size: ❑ ❑ 1 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: FYI ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name:- -(>t7 Ra�a� 7. _/}iyo e�pN Date Signature: _�ytFfe�>.. �i, Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? El 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ �. 3. W ill the proposed action impair the character or quality of the existing community? ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the El E]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 ❑ 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)? El Page 3 of 4 17 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 ❑ problems? El I 1. Will the proposed action create a hazard to environmental resources or human health? El E Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 . S' 3 F APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM k The Town of Southold's Code of Ethics prohibits conflicts of interest on the Hart of town officers and employees.The purpose of this form is to provide information which can alert the town of ssible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: A;&2Q Eko 5 poe O-C f' a- ,I�t�S � 10 0C(3i4- 17 cW 'P�vocA 13 LL,5 (Last name first naine,.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 employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO —X If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this Zig day of N 0 V- 20 2 Signature Print Nam Form TS 1 r Name' i Board of Trustees Agr__cation AFFIDAVIT b v a o rr,y Aevo c,e-so nJ J -W v51{€r 13d-2( !,gjg4- -bow tZeuocA,3L9- Tevsj- 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. Signa ure of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS 281 DAY OF #0V6M4 ,.20 23 4W Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. O1 D1475593 Qualified In Suffolk County My Commission Expires April 30, 20-- 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 evaluate& as to its sianificant 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 i local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# PROJECT NAME_ b EC-k 12 e Pt iQ Z P_EP L/}(-Cly C—,tJ7 . -72-5 nI VAIN La- Ori EiL)7 ' The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. 0 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: Repal2 RePLWCtr 7ecrj STFII�S 2 Location of action: 7�cy ury La n1_Tp?R l ENT 9011 Site acreage: 2•Rol. Present land use: R C-5 r ne:aZn A G Present zoning classification: tow IN EN 51T1( . R:5 l D E/N7 J AZ_ 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: 'po a o i?-cam/ A oU 0 ERS o,1J (b) Mailing address: I o q PLL Y wood 72, �i La4 Sro N '9yP!/ C'T-,- 0(of)33 (c) Telephone number: _2(p0 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. [—]Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No ❑ Not Applicablem /3 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 sP Yes ❑ No ld Not Applicable SES -3Ti at PS N6 b To 14avC RDb li�oN� L TR��7�s ��v_r�_ �_i5�R _(3 c c,4us E o c-D S T-A t !25 tj E f2 L 0 '/* " T A LL -A LJ }t2 E -7 Attach additional sheets if necessary — Policy S. 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 ®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. No Not Applicable ❑ Yes ❑ l�F Attach additional sheets ifnecessary 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 a 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. ❑ Ye❑ No[)(I 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❑ 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