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HomeMy WebLinkAboutTR-10504A Glenn Goldsmith, President �®F s®!/�y Town Hall Annex A. Nicholas Krupski,Vice President �O� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski A�R Southold, New York 11971 Liz Gillooly Telephone (631) 765-1892 Elizabeth Peeples ® �® Fax(631) 765-6641 C4UNT`1,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 2142 C Date: May 31, 2024 THIS CERTIFIES that the as-built 23'x23' on-grade steppingstone tone paver area set on bed of RCA approximately 19'x28' with seven(7)additional stones in southeast corner; At 375 Reydon Drive, Southold Suffolk County Tax Map#1000-79-5-23.1 Conforms to the application for a Trustees Permit heretofore filed in this office Dated December 1, 2023 pursuant to which Trustees Administrative Permit#10504A Dated December 13, 2023,was issued and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the as-built 23'x23' on-grade steppingstone tone paver area set on bed of RCA approximately 19'x28' with seven(7)additional stones in southeast corner. The certificate is issued to PABLOPEG LLC owners of the aforesaid properly. e Authorized Signature Glenn Goldsmith, President ®f S0 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 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 2 INSPECTED BY: Q174 tK Neple.3 Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1st day of construction % constructed Project complete, compliance inspection COMMENTS: Pro mf iS iin covnliahcc w41n g i4--+ I'Dfip 4^ . 01Lafo isS VC, Cdh of CIMbbAhce CERTIFICATE OF COMPLIANCE: I Glenn Goldsmith, President ®F 3®Uj� Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ®� ®�® P.O. Box 1179 Eric Sepenoski l Southold, New York 11971 Liz Gillooly Telephone (631) 765-1892 Elizabeth Peeples � a� Fax(631) 765-6641 c®Uf19T�,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction % constructed When project complete, call for compliance inspection; Glenn Goldsmith,President �QF SO Town Hall Annex A. Nicholas Krupski,Vice President ,`®amu ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly N Elizabeth Peeples � � � Telephone(631) 765-1892 p oe` a Fax(631) 765-6641 Cou V, BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10504A Date of Receipt of Application: December 1, 2023 Applicant: Pablopeg LLC SCTM#: 1000-79-5-23.1 Project Location: 375 Reydon Drive, Southold Date of ResolutionlIssuance: December 13, 2023 Date of Expiration: December 13, 2026 Reviewed by: Elizabeth Peeples, Trustee Project Description: As-built 23'x23' on-grade stepping stone paver area set on bed of RCA approximately 19'x28', with seven (7) additional stones in southeast corner. 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 survey prepared by Nathan Taft Corwin, III Land Surveyor, last dated November 8, 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. Glenn Goldsmith, President Board of Trustees SURVEY OF PROPERTY D BY SITUATE � USTEES BAYVIEW sOUTHOLD TOWN OF SOUTHOLD p6win�2 l3 2023 DEC - 1 X02:3 SUFFOLK COUNTY NEW YORK w � 6ge S.C. TAX No. 1000-79-05-23.1 V S0 X20i SCALE 1 =30 h E _w..._..r _-- MARCH 15, 2013 10 — —— — _ JUNE 5, 2013 ADD PROPOSED SEPTIC SYSTEM / — — — — JULY 3, 2013 ADD WELL ABANDONMENT NOTE _ — -�o NOVEMBER 1, 2013 ADD NEW SEPTIC SYSTEM / 9 — — — SEPTEMBER 19, 2022 UPDATE SURVEY FOR PROPOSED POOL _ _ __ _ J DECEMBER 8, 2022 REVISED PROPOSED POOL 8 — — — — — — — — \ C@- ��'S 0/F JANUARY 4, 2023 REVISED PROPOSED POOL 7 — FUc 10 — — ���/ ��'S SIC JANUARY 12, 2023 ADD PROPOSED PATIO p / — — ——_— — — ���� STVReq \ L III NOVEMBER 8, 2023 ADD PROPOSED STEPPING STONE PATIO _ — 5�N�F RICA,. TOTAL AREA = 58,484 sq. * ft. FRESHwq — —43 = \ \F£ip� \ \ W 1.342 ac. DELINEATEp !LAND BO ��v / ////� EN CONSudmTTS 1s"EM ' 1SO 40) \\\ \\ \\ \I \ 1 WETLANDS UPLAND AAREA =REA 49,906 sq. ft. AL 2.u \ , �/e 2022 \\ \ \ \, l i /— \\ NOTES, ,IIIc F R E 1 I 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM 'w•\/ l / W E T H W A T I / / / / l / \ \ EXISTING ELEVATIONS ARE SHOWN THUS: XX.X L A N D E / / // / / / / I / / \ \ \ \ \ \ EXISTING CONTOURS ARE SHOWN THUS: XX— — — —XX $ PROPOSED CONTOURS ARE SHOWN THUS: /p \ {i ? / // /j// / // \\ I �• \\ \y \\ 2. PROPOSED POOL IS NON—JURISDICTIONAL FOR THE S UTHOLD TOWN TRUSTEES. CV AL JIL / \ \ AL _, — , / // / /x/ �/8 "� \ � \• \ \\ o CERTIFIED T0: �— - - -� �� \�\ �Illc /// // l 3 �e�� • >` \S,Mro NRUcbNa — \���� \ \ l �tiPAUL 8— \ / / r�� �` / �� \ \ �^411. GREGORY DAND RCONNIEMJ JUDGE 10 1Q, �`� STEWARD TITLE INSURANCE COMPANY E -4- _Tic 5 ///i / / / / /\X /us \ \ / / l \ (JAZ I .q� BANK OF AMERICA §d' 13.2 �•" / / V m ti 2 \ \ / / 6. 0/S� \ ;4 � G 11 `$, / 00•/eqP� / y34 � 1? 8g ; ° w \ w\ __ice // /j - - -� / / / l s 10" of 4 _ s�oQ�00J����/ rn /// / / N o�4.0. CV / �2- — — ° D�•�J/ / i owOpP�pe ss r � $ti ,� /sq��\��\ l \NF°R�•tr '` \ \ � � / 'c)o.° !� 41 142� soN�O"�pTEST HOLE DATA X. ' 4 (TEST HOLE DUG BY McDONALD GEOSCIENCE ON MAY 20, 2013 4. x y, � r. :<' l •+!Y'4 ` —r"4R�0 j EL 16.1 0, �... 'a � ` R f/, 4n 2 DARK BROWN LOAM OL JC � �:•••• .`.. �•ti..:.�., ARS URS � 0.5' Q� lLj /�, pp� \ „ ` ii.: ;%p;•• 3XglA/y�Op(� / /is��1$ 3Q BROWN CLAYEY SAND SO c`Oj `'..;• per_ / 04 0 J�J Q� rV HQQ� \ 'l � / w O BROWN FINE SAND SP Q Ar6�p�_ �. � / M �° •• PA "Arlo ' // l w , 1 , EL. 1.0 r� rar/ON/'OI // 1 /�� GROUND WATER 15.1' V�. WATER IN BROWN FINE SAND SP j42Io 40IL ip .289 u"o1 .sl% Y • Q °#9pZo 'r 4 PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED EXISTING TOWN DEFINED LOT COVERAGE PROPOSED TOWN DEFINED LOT COVERAGE Jjj 8�q m a BY THE LI.A.LS. AND APPROVED AND ADOPTED OVER BUILDABLE LOT AREA OVER BUILDABLE LOT AREA ��' o I� FOR SUCH USE BY THE NEW YORK STATE LAND (TOTAL LOT AREA LESS WETLAND AREA = 48,578 sq. ft.) (TOTAL LOT AREA LESS WETLAND AREA = 48,578 sq. ft.) 199 �p0 TITLE ASSOCIATION. DESCRIPTION AREA X LOT COVERAGE DESCRIPTION AREA X LOT COVERAGE HOUSE 1,895 sq. ft. 3.9X EXISTING HOUSE 1,895 sq. ft. 3.9% SCREENED PORCH 460 aq. ft. 0.9X EXISTING SCREENED 460 aq. ft. 0.9X do FRONT PORCH PORCH do FRONT PORCH {�V WOOD DECKS & STEPS 480 sq. ft. 1.0X EXISTING WOOD DECKS STEPS480 aq. ft. 1.OX O CON SHED 75 aq. ft. 0.2X EXISTING SHED 75 aq. ft. 0.2X MON C TOTAL 2,910 sq. ft. 6.OX PROPOSED POOL 684 sq. ft. 1.4X PROPOSED PATIO 876 sq. ft. 1.8X TOTAL 4,470 sq. ft. 9.2% �`�f •'•�Ni N r`�T n ?� . m . z� .'`p0 .. � ` . 467 y Q 11 N.Y.S. Uc. No. 50467 UNAUTHORIZED ALTERATION OR ADDRION �P' C" -.TO THIS •�1� OF SECTION 72009 OFSTHE NEWA VIOLAnYO RK STATE $1 � EDUCATION LAW Nathan Taft Corwin III COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR Land Surveyor EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE Successor To: StanleyJ. Isaksen, Jr. L.S. TITLE COMPANY, GOVERNMENTAL AGENCY AND Joseph A. In a no L S. LENDING INSTITUTION LISTED HEREON, AND P 9 9 TO THE ASSIGNEES OF THE LENDING INSTI— TUTION. Title Surveys Subdivisions — Site Plans — Construction Layout CERTIFICATIONS ARE NOT TRANSFERABLE. Ys — Y PHONE (631)727-2090 Fax (631)727-1727 THE EXISTENCE OF RIGHTS OF WAY OFFICES LOCATED AT MAILING ADDRESS AND/OR EASEMENTS OF RECORD, IF 1586 Main Road P.O. Box 16 ANY, NOT SHOWN ARE NOT GUARANTEED. Jamesport, New York 11947 Jamesport, New York 11947 33-056A Glenn voldsmith,President �o�pg�FFl -OGy Town Hall Annex A.Nicholas Krupski,Vice President j 54375 Route 25 Eric Sepenoski C ,? P.O.Box 1179 Liz Gillooly �y • o�� Southold,NY 11971 Elizabeth Peeples lr �a Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 1L b 23 Completed in field by: i 1 i-Wt6f -k Pe,e'bLr s Eastern End Pools d/b/a East End Pool King on behalf of PABLOPEG LLC requests an Administrative Permit for an as-built 23'x23' on-grade stepping stone paver area set on bed of RCA approximately 19'x28', with seven (7) additional stones in southeast corner. Located: 375 Reydon Drive, Southold. SCTM#: 1000-79-5-23.1 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: v/ 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},ra;ial�k�,►wavd - hole. �Vnk4 nrroAD� Don1 IN nnyt-il,rislc.hon.a� Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly ✓E. Peeples •ta r. 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Box 1179 54375 State Route 25 Oy0l Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Q Southold NY Telephone: 631 765-1938 www.southoldtowimy.gov �y�0Uf1lT`1,0c`� 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 PABLO PEG SCTM# 1000-79-5-23.1 Eastern End Pools d/b/a East End;Pool.King on behalf,.of PABLOPEG LLC requests an Administrative Permit for an as-built 23'x23' on-grade stepping stone paver area set on bed of RCA approximately 19'x28', with seven (7) additional stones in'southeast corner. Located: 375 Reydon Drive, Southold. SCTM#: 1000-79-5-23.1 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.- Baaed 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 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 z1 Q s0i Town Hall Annex A.Nicholas Krupski,Vice President f `y 54375 Route 25 � � `� P.O.Box 1179 Eric Sepenoski a}, Southold,New York 11971 Liz Gillooly CA-1 nom,, Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 C'® , BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit —/—Received DEC 1/ r Received Application• tz•I 4J r Received Fee: $ SQlA_0 Completed Application: 12-i-Z3 Incomplete: T SEQRA Classification: Type I__ Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: —_Coordination:(date sent): k LWRP Consistency Assessment.Form Sent: j :` E " CAC Referral Sent: _ _Date of Inspection: 12•. •Zcf-- j Receipt of CAC Report.,. . DEC Technical Review: ti Public Hearing Held: Resolution: Owner(s) Legal Name of Property-(as shown on Deed): Paplopec LLC Mailing Address: 151 Linden Road, Mineola NY 11501 Phone Number: (516) 521-4664 Suffolk County Tax Map Number: 1000 -,79.05-23.1 Property Location: 375 Reydon Drive, Southold NY 11971 (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Eastern End Pools.DBA. East End Pool King- Jennifer DelVaglio Mailing Address:-PO Box 369 Peconic NY 11.958 Phone Number: 631-734-7600 Email:CJ @.East ENd Pool King.com Board of Trustees Appli=_,pion GENERAL DATA Land Area(in square feet):.. _ 5`3 1 B — — Area Zoning: R40 Previous use of property: Residential Intended use of property: Residential 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 A 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 _VJ_No If"Yes", please provide copy of decision. is project reculi 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 F] No Prior permits/approvals for site improvements: 'frost Agency Date a. C- -19 81- C h o ❑ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No_j:]_Yes If yes, provide explanation: k�P,S-iag,-nk L:7 Project Description (use attachments if necessary):_ U 19 X Z6 �� T�- � �.�.f� oAh own) e-,q 5LLry Board of Trustees Applin-.pion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: C� rte- Area of wetlands on.lot: AWO-A _square feet Percent coverage of lot: `f % Closest distance between nearest existing structure and upland edge of wetlands: �J'feet Closest distance between nearest proposed structure and upland edge of wetlands: o feet Does the project involve excavation or filling? 0 No Yes If yes, how much material will be excavated? cubic yards �® How much material will be filled? /`1ON� cubic yards // f Nc�C�3 Depth of which material will be removed or deposited: . Proposed slope throughout the area of operations: C� Manner in which material will be removed or deposited: 4- :55�j,,aVt°i� b� V49410 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): P)0- �Jo -eL r-9 on Board of Trus -:s Appli. :ion AFFIDAVIT BEING DULY SWORN DEPOSES AND AFFI S 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. Xn, / Signature G� ture•f Property Owner// Signature of Property Owner ' SWORN TO BEFORE ME THISDAY OF - �� CONNIE D.BUNCH Notary Public,State of New York No.OIBU618605o Notary Public Qualified in Suffolk County Commission Expires April 94,2 1_ AUTHORIZATION (Where the applicant is not the owner) I/We, owners of the property identified as SCTM# 1000- — " a-7 . --j in the town of New York, hereby authorizes O� 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 Owners Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF 20.L2. Notary Public CONNIE D.BUNCH Notary Public,State of New York No.01 BU6185050 Qualified in Suffolk County Commission Expires April 14,2-La APPLICANTIAG,NP REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM TThe ToWt of Soulhnhl's odc of I'lllicsd)fnitll)IIS Con1l1cN of intercct on lI)c earl j lo15'tl offiCGr1 and Cn1p]Q}CCS.111p ltlr sc 7 [his t') 1.iS to provide informathon which wn oleo t c lows of possible conflicts of in�cres_t nttd'lltaw it to take►vtrrtever aclinn is neces,:1EY to avoid cane. j p YOUR NAIvtE: )s- --1- - � ' hr '' f 1 �Gt l G (Last n of is first namc,rpidd! itial,unless you are applying in tile-name of sotncon` Ise 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 T Building — Variance _ Trustee _ Change of Zone N Cdastal Erosion - Approval hof plat � � Mooring T - Exemption from plat or official map � Planning - ---_ Other (lf"Other",name the Do 9'ou Ix rsanally fur ihrxlgh your company,stx�usibling,parcel.or child)have a wljttionship with;toy M'li�rr ur emph�}'ee. of dm Town of Soulhold? "Rclntionship"includes by blood,marriage,or husinoss interest."Business interest"means a business. including a partnership.in which the town officer or cmployce h:u even it partial ownership of for empltoymcnt by)it corporation in which the town officer or cmplo}ice owns more th:nl S%oi,th/e Shares. YES NO V 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 Tithe 6r position of that person_..._. Describe the relationship test►seen yourself(tile alrplicant/agent/mprescntative)and the town officer or employee.Either check flu appropriate tine A)through D)andfior describe in the space provided. The town officer or employee or his or herspouse,sihling,.parcnt,or child is(check all that apply): ._. A)cite owner of greater th:ut S°Q of the shares of the corporate stock of the applicant (wilco the applicant is a corporation); ____11)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a cotwration); ' an officer.director.partner,or employee of the applicant;or .--D)tile acival applicant. DESCRIPTION OF RELA'T'IONSHIP Subnhittcd this day of Signature"/t� Print Name _.� r..�, A Form TS l 010144,c:If inn Trustees A tnt Transactions'.-' :Iosure.Form.jpg .PPI LICANT/AG ENT/R I P SENTA,TWE TRANSACTIONAL DISCLOSURE FORM The Town of Soutl}ows axis of Ethics nroigits connicts ttf inleresi on th4 nit shown o iicers and employees 77ne twmose of this form is to VERVIdC i fo motion which can algr(d&town of s ihle cont icts of'nterest prid allow it to take whiacycractionjs JWCCwSatY 10 nVoid C1tn)C. YOUR NAME: r C L` p6lo ?el L.(' {Last nami, mist name,piddle initial,urilesc you arc applying in the name of sotmonc 61.o 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 zoite �� Coastal Erosion Approvi)tofplat _._ 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 cnip)gce of the Town of southold? "Relationship"includes by blood,marriage,or busines.s interest."Business interest'mans a business, including a partnership,in which the town officer or employee nuts even it partial ownership of(or employment by)a corporation in which the town officer(ir employee owns more than °a or/the shares. YES NO 1/ If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by dee Town of Southold Title or position of that person _..,_. Describe the relationship between yourwIf.(tlnc.ippiicant/agent/representative)and.the town officer or employee.Either check the appropriate line A)through D)and/or describe in the spaLe providers. The town officer or employee or his or her spouse,sibling,parent,or child,is(check all that apply): A)f)lc owner of greater than Sha of the sharers of the corporate stock of die applicant (when the applicant is a corporation), _,_____13)the legal or beneficial owner of any interest in a non-corporate entity(when the apptic int is not a.corporation). C)an officer,director,partner,or employee of the applicant;or _D)the actual applicant. DESCRIPTION OF RELATIONSHIP Suburi tied this t'-day of 004.E20. a^ Signature--- ' PrintNatne I:om�'TS 1 haps://rnail.google.com/mail/u/21#Search/POOLKfNG/FMfcgzG,oGw DtcgKWi fnFFhHSfJvidfl?DroiectOt--l&MessaaePArtld=O.l iii APPLICANT/AGENT/REPRESENTA.TIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: (� _ (Last name,first ame,;aid'dle' itial,unless y&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 day of �� 20 2--,— S ignature Print Name tw S�W Form TS 1 61Z20 Appendix S 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 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part V-Project and Sponsor Information Name of Action or Project: Project Location(describe,and attach a location map): 375 Reydon Drive, Southold NY 11971 Brief Description of Proposed Action: ,-�n 1 y x o��3`� � J� �'� ` 1 k O_ OXO C(�(� Name of Applicant or Sponsor: Telephone:N631-734-7600, East End Pool King- Jennifer DelVaglio E-Mail:CJ @ East ENd Pool King.co Address: PO Box 369 City/PO: State: zip-code: Peconic NY 11971 L 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? I,3 2 acres b.Total acreage to be physically disturbed? Q D1210 .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 propQsad action. Urban Rural(non-agriculture) Industrial Commercial Residential(suburban) Forest ❑Agriculture Aquatic QOther(specify): 0 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? . fl M 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? i 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 nearthe site of the proposed action? 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: a ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: _ . ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? b. Is the proposed action located in an archeological sensitive area? 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contai 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. ldf ntify the typic*Uira'tyba, pes that oc n,or are likely to be found on tE�roject site. Check all that apply: ShorelinerestAgricultural/grasslands Early mid-successional Wetland 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 If Yes, RA ❑ a. Will storm water discharges flow to adjacent properties? MNO DYES b. Will storm water discharges be directed to established conveyance systems�$O f an m drains)? If Yes, briefly describe: 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: ❑ 1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor na e: Jennifer DelVagflo Date: \'2Z Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the,fol lowing 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? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ i. 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 ('l'�. ❑ affect existing infrastructure for mass transit, biking or walkway? D� 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: F a. public/private water supplies? b.public/private wastewater treatment utilities? 1. 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, ( Elwaterbodies,groundwater,air quality,flora and fauna)? lj�-' 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 ] ❑ problems? (J�- 1]. 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. F] 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 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 ificant 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# �� o5 - 1 PROJECT NAMES 6 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 iransaction) ❑ (b) Financial assistance(e.g.grant,loan,subsidy) (c) Permit,approval, license,certification: Nature and extent of action: ado )9 X 2 e` I '�; axe- 5 ►�o t�� -eek- d- b�Rt ��-�s NJ (Oilo,res� Uo c- Location of action: - � Site acreage: Present land use:. Present zoning classification: 40 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: o (a) Name of applicant;_ V-10J - '� U (b) Mailing address: V�2 .G (c) Telephone number: _�P_- :>4 — Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes ❑ Non, 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 ONot Applicable r. 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 Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages S through 16 for evaluation criteria ❑ Yes ❑ No Not Applicable t 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 MAI 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 Vot Applicable L Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. Yes ❑No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and,hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No 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 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 zAW AM W � TITLE _ DATE23