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HomeMy WebLinkAboutTR-10514A ®A,��� Glenn Goldsmith, President Sig Town Hall Annex VV' ol 54375 Route 25 A. Nicholas Krupski,Vice President a0 ® P.O. Box 1179 Eric SepenoskiB Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples a® Fax(631) 765-6641 C®UNTI,� 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 *®F S®Uj 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 May 17, 2024 Philip & Francine Medaglia 8 Plymouth Road Port Washington, NY 11050 RE: 360 WIGGINS LANE, GREENPORT SCTM# 1000-34-4-28.33 Dear Mr. and Mrs. Medaglia: The following action was taken at the Southold Town Board of Trustees regular meeting held on Wednesday, March 20, 2024: RESOLVED, that the Southold Town Board of Trustees APPROVE the request for a Transfer of Administrative Permit#10514A, as issued on January 17, 2024. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. If you have any questions, please contact our office at (631) 765-1892. Sincerely, Glenn Goldsmith, President Board of Trustees GG/dd _ 1 Glenn Goldsmith,President SpFFO(,��O Town Hall Annex A.Nicholas Krupski,Vice President y�e 54375 Route 25 Eric Sepenoski Co ? P.O.Box 1179 Liz Gillooly �y • p�� Southold,NY 11971 Elizabeth Peeples �Ol ��" Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: Completed in field by: .- Michael Kimack on behalf of PHILIP & FRANCINE MEDAGLIA requests a Transfer of Administrative Permit#10514A, as issued on January 17, 2024. Located: 360 Wiggins Lane, Greenport. SCTM# 1000-35-4-28.33 Type of area to be impacted: _,Saltwater Wetland Freshwater Wetland Sound -%c Bay Part of Town Code proposed work falls under: -rChapt. 275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment ,ul Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No 'Not Applicable Info neede /Modifi ations/Conditions/Etc.: Present Were: G. Goldsmith N. Krupski 4-15. Sepenoski L. Gillooly E. Peeples B Town Hall Annex Glenn Goldsmith,President A. Nicholas Krupski,Vice President ® 54375 Route 25 't ® P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly eea Telephone(631) 765-1892 Elizabeth Peeples � a� Fax(631) 765-6641 C®U�IY�,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10514A Date of Receipt of Application: December 4, 2023 Applicant: Blue Moon Partners, LLC SCTM#: 1000-35-4-28.33 Project Location: 360 Wiggins Lane, Greenport Date of Resolution/Issuance: January 17, 2024 Date of Expiration: January 17, 2027 Reviewed by: Eric Sepenoski, Trustee Project Description: As-built 10.67'x11.5' (122.7sq.ft.) second floor open deck with three (3) ft. composite railing and 5/4" composite decking, carried by 2" x 8" double joisted @ 16" OC joists with (4) 2"x10" girders, supported by two (2) 6"x6" posts (wrapped) on 12"x12" piers on 2'x2' footings at three (3) foot depth from grade. 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 James J. Deerkoski, LPE, dated November 26, 2023, and stamped approved on January 17, 2024. 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. .4, 41AL,.X Glenn Goldsmith, President Board of Trustees Glenn Goldsmith,President � SpFFO( Town Hall Annex A.Nicholas Krupski,Vice Presidents :`e 54375 Route 25 Eric Sepenoski P.O.Box 1179 Liz Gillooly �y • Southold,NY 11971 % Elizabeth Peeples Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: Z Completed in field by: Michael A. Kimack on ehalf of BLUE MOON PARTNERS, LLC requests an Administrative Permit for the as-built 10.67'x11.5' (122.7sq.ft.) second floor open deck with three (3) ft. composite railing and 5/4" composite decking, carried by 2" x 8" double joisted @ 16" OC joists with (4) 2"x10" girders, supported by two (2) 6"x6" posts (wrapped) on 12"x12" piers on 2'x2' footings at three (3) foot depth from grade. Located: 360 Wiggins Lane, Greenport. SCTM#: 1000-35-4-28.33 Type 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 NoNot Applicable Info needed/Modifications/Conditions/Etc.: /ur' �M►-�, Gam✓ Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples SITE DATA PROPERTY: 28,513 SF 0.655 ac UNDERWATER AREA: 7,307 SF 0.168 ac FORDHAM ACRES UPLAND AREA: 21,206 SF 0.487 ac \ - NON CONFORMING LOT: M ! _ (280-124)SETBACKS: ZONE: R-40 `J H_ Design Services ' Z 2X8 LEDGER, FALSHED DESCRIPTION: AREA LOT COVERAGE: ESITMATED TO REMOVE: ESTIMATED TO FILL: I I � � FASTENED WITH (2)COLUMNS EXISTING: 3,400.3 SF OF LAGS w/WASHERS @16"OC 7 �¢� AS-BUILT DECK: 123.1 SF www.mchdesignservices.com TOTAL: 3,523.4 SF 16,62% phone: I I (631)298-2250 o 0? I i METES AND BOUNDS: SURVEYOR: NATHAN TAFT CORWIN DATE SURVEYED: MARCH 27,2009 email: E O I I michael@mchdesignservices.com 2 SCTM: 1000-35-04-28.33 ELEVATIONS REFRENCE: NAVD 1988 N 5 PROJECT NORTH I CN W I I 6X6 POST(WRAPPED) OVER 12"X12"CONC. PIER w/ 2'X2'Xl'FTG T BELOW GRADE �O I (4)2X10 GIRDER I I I I EXISTING FOUNDATION PLAN 11_81, 8'-2" 1'-8" SCALE: 1/4" = 1'-0" 11'-611 7141 VAGGINS LANE S 30 5' 40" E 135 .0' GRAVEL _- DRIVEWAY v_ O Q0 Ln � 5/4X COMPOSITE } �! E -, DECKING � x N S PROJECT NORTH. -- - - X W - _ W I v 0 3'h COMPOSITE —= EXISTING K x _-- RAILING =_ PORCH � �-� I (259.3 SF) EXISTING 2ND FLOOR PLAN SCALE: 1/4" = 1'-0" EXISTING w 7'-411 x Z POOL 7� EXISTING FRAMED HOUSE C (530.3 SF) ^ .. 2611.7 SF I f� C M r M l J E ` W Y 7.3I•KJ_'I EX.PATIO r �a ' ON GRADE O 2ND.FLOOR r/ ' DECK -'J G N (123.1 SF) - � � — \�`n w'-1. Vol �v✓ � o 0 I y OI x \J0x X M \10 o z M RIP CO RAP V • WOOD TIE WALL 00 a IGN W AT RIP MARK CONC.WALx RAP h POLE � TIE WALL Q FLAG 77 r- // v f• BULKHEAD /%,pgggd A i jam^A" FLOATING WOOD y , DOCK DOCK RAMP .�y 1 i s ! e „ FLOATING DOCK a H N _ N 230 58' 4011 E 157.25' o ,� EXISTING FORDH M CANAL \10 Q0 o \10 Q0 _ M Z 2X8 DJ @ib"OC N 230 58' 40" E 199.07' 2X8 LEDGER BD. SITE PLAN �, _ • � ,..; (2) LAGS @16"OC (4)2X10 I � GIRDER —, SCALE 1" — 20'-0" „n _ Ly .. EXISTING I 9 ♦. 1 iF. 6X6 POST (WRAPPED) _. ..,,:--.._ ..... ...-r... _..-_., ,-_.__....- TthUu,4ie�( 174 Zo2* DRAWN BY: MH _ _____, l 11/26/2023 ai a�`-111=III=11i=III=HIE-= l=III=III=III III=111=III ,'o -III=III = 12°X12°PIER SCALE: SEE PLAN c o EXISTING a v. 2'X2'Xl'FTG [SITE PHOTOS SE }.O SHEET NO: CROSS SECTION SCALE: 1/4" = P-0" �Q 725 .u ARQfi_Ss� P�' g �5� SURVEY OF LOT 20 O p,� Rp 9� �, AIAP OF ' K L 0 FORDHAM ACRES QyS� k14Y. SECTION TWO ba FILE No. 4605 FILED APRIL S. 1966 SITUATE GREENPORT TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-35-04-28.33 ,- . SCALE 1"=20' MARCH 27. 2009 MARCH 15 2018 WATER DEPTHS MAY 10, SURVEY rFYp, Y¢AT�O •%• •, DECEMBER 120120 A UPDATE UPDATE SURVEY �#1i pR 00` � NOVEMBER 7, 2023 UPDATE SURVEY i KC 4 20Zb GOT ARF,A DATA C I A. ' 4 t a N41• UPLAND AREA 21.206 . 0 _ .0. ' ' mot UNDERWATER AREA 7.307 sq. 11. - A rfl" 1^ Y' 0.166 ce. i d 3 ; TOTAL—� 26,513 sq. ft. ll iS 0.655 oc. CA 6 ' CERTIFIED TO: N\ � •� 1 t E �'+ •, Yom) PHILIP MEDAGLIA •+ rc ` . ` . . + dIA * /* FRANCINE MEDAGUA •�O _ti 9 sK jPMORGAN CHASE BANK, N.A. ITS SUCCESSORS AND/OR ASSIGNS, \ 86©00 AS THEIR INTEREST MAY APPEAR t1 AC- ` FIRST AMERICAN TITLE INSURANCE COMPANY V2 .• 78 A0 ! f , .• NATIONAL GRANITE TITLE INSURANCE AGENCY, INC. E 'v. / 7 L N M \ 'II•�jp �' Its, t ,y' �'� i ¢.'yam{. T.� 6 ' . • • • dq veal r 10 MS 9M H•O.+ AA YGRM W. 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OFFICE LOCATION: O�*QF S�UjyOl MAILING ADDRESS: Town Hall Annex 'l O P.O. Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) G • Q Telephone: 631765-1938 Southold, NY 11971 COUNVI LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: January 16, 2024 Re: LWRP Coastal Consistency Review for BLUE MOON PARTNERS, LLC SCTM# 1000-35-4-28.33 Michael A. Kimack on behalf of BLUE MOON PARTNERS, LLC requests an Administrative Permit for the as-built 10.67'x11.5' (122.7sq.ft.) second floor open deck with three (3) ft. composite railing and 5/4" composite decking, carried by 2" x 8" double joisted @ 16" OC joists with (4) 2"x10" girders, supported by two (2) 6"x6" posts (wrapped) on 12"x12" piers on 2'x2' footings at three (3) foot depth from grade. Located: 360 Wiggins Lane, Greenport. SCTM#: 1000-35-4-28.33 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. Policy 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. The structure was constructed without a Wetlands 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 � � i� f j =;_ Town Hall Annex - l; y = '%':, 54375 Route 25 ski,Vice President A. Nicholas Kru '- . ., p �:#.• ? �' P.O.Box 1179 Eric Sepenoski i t '" .` a 4' Southold,New York 11971 Liz Gillooly r '';,.-;,`5;} - Elizabeth Peeples a `� '+ ;',' Telephone(631) 765-1892 ' � ' r Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application F x Administrative Permit Amendment/Transfer/Extensi n� OEC 4 W04-5 Received Application: _ Received Fee:::L Completed Application: 147! r��'...,�.._•.._ ,_�.,_.: _ Incomplete: SEQRA Classification: Type I__ Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: -Coordination:(date sent):LVW WRP Consistency Assessment Form Sent: X CAC Referral Sent: 1C Date of Inspection: ,Z?j Receipt of CAC Report: 4 Technical Review: _ _ Public Hearing Held: Resolution: Owner(s) Legal Name of Property (as shown on Deed): B/U 106/Io Mailing Address: t' 4QA#-5W�,1WA1T MY 114) "O Phone Number: 5_//6 776 — 9L94— Suffolk County Tax Map Number: 1000 - 1'!r—04 – 2R. Z-3 Property Location: C�2 �M'10 ; Ny. 11984 (If necessary,provide LILCO Pole #, distance to cross streets, and location) AGENT (If applicable): ,&/ C& /rJ/2eW Ck Mailing Address: __ eo , /(�4 7. 57 V—//7 ZZ Phone Number: � � 8_ �(�_..__(,� Email: 40 Blue Moon Partners LLC: Project Description Legalize 10.67 ft. x 11.5 ft. ( 122.7 SF ) second floor open deck with three ( 3 )ft. composite railing and 5/4" composite decking, carried by 2" x 8" D1 @ 16 "O.C.joists with (4) 2 "x 10 " girder, supported by two(2) 6" x 6 " posts (wrapped ) on 12 "x 12" piers on 2 "x 2 'footings at three ( 3 ) foot depth from grade Board of Trustees ApI cation GENERAL DATA Land Area(in square feet):_ Area Zoning: Previous use of property: �Q,�,P� FN D—,��GA1,E Ai�l/ll Intended use of property: Covenants and Restrictions on property? Yes No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? MYes _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 _ No If"Yes", please provide copy of decision. his project re 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-1—No Prior permits/approvals for site improvements: Agency Date ��'(>JD;�zt 72lJZ �8 Z o v 6// re ❑ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No—n Yes If yes, provide explanation: Project Description(use attachments if necessary): Board of Trustees ApF cation WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: jICZFV � �'O�v� FG O OR oea-1, PZ5:cle Area of wetlands on lot: ��_�7 square feet Percent coverage of lot: 01 Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: 4 '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?NA 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: /I/1. 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 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 I -Project and Sponsor Information Name of Action or Project: BLUE N �z �L Project Location(describe,and attach a location map): Brief Description of Proposed Action: ASF CVP 710JV 25,9 ZZ OGU/A16 Name of Applicant or Sponsor: ,y Telepphhoon�e:�1�vN__ y u E-N Address: City/PO: State: Zip Code: 1.Does the proposed action only'involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? F-1If 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: rte( ❑ 3.a.Total acreage of the site of the proposed action? , ,7,56 acres v• 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? p_6& _�acres 4. Che I land us at occur on,adjoining an ar the prop action. Urban Rural(non-agriculture) Industrial riCommercial ZResidential(suburban) Forest Agriculture HAquatic QOther(specify): Parkland Page 1 of 4 Blue Moon Partners LLC: Project Description Legalize 10.67 ft. x 11.5 ft. ( 122.7 SF ) second floor open deck with three ( 3 ) ft. composite railing and 5/4" composite decking, carried by 2"x 8" DJ @ 16 "O.C.joists with (4) 2 "x 10 " girder, supported by two (2) 6" x 6 " posts (wrapped ) on 12 "x 12" piers on 2 "x 2 'footings at three ( 3 ) foot depth from grade 5. Is the proposed action, NO ( YES NIA a. A permitted use under the zoning regulations? 17 b.Consistent with the adopted comprehensive plan? 6. Is the proposed action consistent with the predominant character of the existing built or natural I NO . YE 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 nearthe site o?the proposed action? c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? I - -El 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; 4 � F 10. Will the proposed action connect to an existing public/private water supply?� _ NO YES If No,describe method for providing potable water: AIIA ❑ 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? 1I 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: _ 14ntify the typicv Lb#bitat types that oc n,or are likely to be found on tf.-groject site. Check all that apply: UShoreline Forest Agricultural/grasslands u 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? n 16.Is the project site located in the I00'year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? XNO 4� If Yes, a. Will storm water discharges flow to adjacent properties? ONO DYESr b.Will storm water discharges be directed to established conveyance systems ff an m drains)? If Yes,briefly describe: rTO . ES Page 2 of 4 18. Does the proposed action include'construction or other activities that result in the impoundment of NO I YES water or other liquids (e.g.retention pond,waste lagoon, dam)? If Yes,explain purpose and size: _ �� __��_�. Y�� � ❑ 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:,_ C � � ht. � G'!� 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 1. Will the proposed action create a material conflictwith an adopted land use plan or zoning Elregulations? 2. W ill 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 F1 1:1establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or F-1 El 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? F-1 F 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate `. small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage (� problems? !___J a 11. Will,the proposed action create^a hazard to environmental resources or human health? o a. Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 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 dOCOmentation,' 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) RRINT Page 4 of 4 Board of Trustees Ap_ -'.cation AFFIDAVIT Rs-ND.411 L . A a/9AA0 1` BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SIIE 1S "THE 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 THAI- ALL IIAIALL WORK WILL BE DONE. IN THE MANNER SET FORTH 1N 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, ]NCLI,DING 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. 4 Signature o£Property Owner Signature of 1'ropert), Oxviier A���PyUR�'T, NlAV.4C&WG SWORN 1-0 BEFORE ME THIS �1, DAY OF _.._._����,c,ti 20 23 Notary Public CHUL YOUNG KIM Notary Public,State of New York No.011016151172 Qualified in Nassau County Commission Myr^rr e Aug 14,20 Board of Trustees Al 1cation AUTHORIZATION (Where the applicant is not the owner) QW e, — d?r�i�l�L. �rll��y�sT- , owners of the property identified as SCTM# 1000-1� -04– 2 c?. 97� _ in the town of New York, hereby authorizes e11111 Nz 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. bQ c Property Owner's Signature Property Owner's Signature /y 4,V,4G/VG SWORN TO BEFORE ME THIS 21 DAY OF M 01 ev&b&17— 20_�3 Notary Public CHULY®UNG KIM Notary Public,State of Now York No.01 KI6151172 Qualified in!Nassau County Commission Elco res.Aug 14,20`�-b APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the Part of town officers and employees The mtwsc 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: _ C�`i� l�,Q,S`e� j ,�L�L • _ (Last name,first name,rpiddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (lf"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 1-1.._... 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,of child is(check all that apply): ]aA)the owner of greater than 5%of the shares of the corporate stock of the applicant _n (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the 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 y of Signature Print Name AWAI Zit Fonn TS I APPLICANUAGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold!s Code,of Ethics-prohibits conflicts of interest on the part of'town officers and•emplovees.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 necessaryto-avoid same. YOUR NAME: (Last name,first name,r;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 ofthe Town.of Southold? "Relationship"includesby blood.,marriage,or business interest."Business interest"means a business, including a partnershipjn 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 n 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 br 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): ,nA)the owner of greater.than 5%of the shares of the corporate stock of the applico.at _n (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,partnei,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this rr day of 201 Signature _ r Print Name Form IS 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 Programa A 12r606sed_ action_.will".be .evaluated as to its significant beneficial and.advers6 effects-Mton.the coastal Area(which'includd§411 of:Southold Town). 3 If any question in Section C on this.form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus; each answer must be explained in detail:listing both supporting and,non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards"and conditions,it shall-not be undertaken. A copy of the LWRP is available in the following places: online-at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# PROJECT NAME � 1 O�NL1,�TNPS' L C The Application has been submitted to (check appropriate response): Town Board ElPlanning, $pard❑ Building Dept. ElBoard of'Trustees.0 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: Blue Moon Partners LLC: Project Description Legalize 10.67 ft. x 11.5 ft. ( 122.7 SF ) second floor open deck with three ( 3 )ft. composite railing and 5/4" composite decking, carried by 2" x 8" DJ @ 16 "O.C.joists with (4) 2 "x 10" girder, supported by two (2) 6" x 6 "posts(wrapped ) on 12 "x 12" piers on 2 "x 2 'footings at three ( 3 ) foot depth from grade Location.of action: 0 W_l -&-wi 4 �G/eF�/-'eQ&7- Site acreage: 0. 63- r Present land use: „ ; 03 jrAH11-V 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: C/O: (b) Mailing address:®Q B0�/6� j ! . (c) Telephone number: f25_Ab'- -6 80-.7 — Will the action be directly undertaken,require funding,or approval by a state or,federal agency? Yes ❑ Noo 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 ❑.NoZ. Not Applicable RO Z/ C z.. . 7-6 Qe,�04�meati Attach additional sheets ff necessaiy .. .. 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 NJ Not Applicable nDiI y N 2�12 AR l C-4,7 acv Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See L . Section III—Policies Pages S through 16 for evaluation criteria ElYes ❑ No ® Not Applicable P6L1 CY W N 710 A !'P41 C4Vd-Al Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of.Southold. See LWIIP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No ®Not Applicable FOUCY S- NIA rb P C Al- Attach 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 XNot Applicable c A1 c ,4 rzzw 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 ❑Nom Not Applicable P611 CY 7 /V/W T-V - -PPL/C.¢ 7`-!Q/,/ 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 L e9 /V14- 7`6 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❑ NoO Not Applicable PGUCY 9 N1A nn -4& ,QC 7-1ati Attach additional sheets if necessary WORKING COAST i-va�ICIES 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 Dong Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑Yes ❑ NoNot 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 XrNot Applicable ON D / � O. 4577— Attach 57 .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 0 Not Applicable SOU C 19 X14 76 4AP ZCA Y20AZ . PREPARED BY_&,.4. kZ&4 C1G TI'T'LE /���/9/r DATE/Z/��-