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HomeMy WebLinkAboutTR-10553A Glenn Goldsmith, President ®� sou Town Hall Annex A. Nicholas Krupski,Vice President ®� ®SO P.O. Route 25 P.O. Box 1179 Eric Sepenoski S8 Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples ® �® Fax(631) 765-6641 Owl BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE #2168 C Date: August 26, 2024 THIS CERTIFIES that the demolition of existing 16 9'x32.3' garage,• backfilling of area to match adjacent(neighbor) grade; placement of a 10'xl4' shed in the area of demolished garage, At 50 Rabbit Lane, East Marion Suffolk County Tax Map#1000-31-18-2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated February 23, 2024 pursuant to which Trustees Administrative Permit#10553A Dated March 20, 2024,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 demolition of existing 16.9'x32.3' garage-, backfilling of area to match adjacent(neighbor) grade; placement of a 10'x14' shed in the area of demolished garage. The certificate is issued to PAUL&LORETTA DOMBROWSKI owners of the aforesaid property. ,41.- 4" Authorized Signature Glenn Goldsmith,President QF S0 Town Hall Annex �� �®� A.Nicholas Krupski,Vice President ® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly G � Telephone(631) 765-1892 Elizabeth Peeples ® a® Fax(631) 765-6641 COUNTi,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: INSPECTED BY: --'Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1st day of construction '/2 constructed Project complete, compliance inspection COMMENTS: CERTIFICATE OF COMPLIANCE: Town Hall Annex Glenn Goldsmith, President ®��®F ®UT�®� 54375 Route 25 A. Nicholas Krupski,Vice President s� ® P.O. Box 1179 Eric Sepenoski & Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 NV 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 1 sc day of construction % constructed When project complete, call for compliance inspection; J Glenn Goldsmith, President ®� S®U�� Town Hall Annex A. Nicholas Krupski,Vice President ®� ®�® 54375 Route 25 AL P.O. Box 1179 Eric Sepenoskif Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples ® y® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10553A Date of Receipt of Application: February 23, 2024 Applicant: Paul & Loretta Dombrowski SCTM#: 1000-31-18-2 Project Location: 50 Rabbit Lane, East Marion Date of Resolution/Issuance: March 20, 2024 Date of Expiration: March 20, 2027 Reviewed by: Eric Sepenoski, Trustee Project Description: Demolish existing 16.9'x32.3' garage; backfill area to match adjacent (neighbor) grade; place a 10'x14' shed in the area of demolished garage. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the project plan prepared by Paul Dombrowski received on February 29, 2024, and stamped approved on March 20, 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. GI nn Goldsmith, President Board of Trustees USTEE OLD TH. S0U__ lo S! -0 Assu ed �O �Alll. W�I�YK�R'l ���� p 0 jo j . so AMWMeAtNAddress rUEIP .l � JRTHIS'N011C � CON5 7t1CTIOd T01RL!!I TRUSTEES OFFICEJOWFI OF SOIJTFIOLD SOlJTFIOLDa RloYo 119,71 TEL:: 765.1892 SURN sl . .. . EAST XfARI ul TOWN OF SOUT G SUFFOLK COUNTY, NEIA 10, 1 S.C. TAX No. 1000-31 -- �� ,rye SCALE 109=209 APRIL 30, 199, 7TO J NOVEMBER 16, 2012 ADD COASTi�L FEBRUARY 22, 2024 ADD 100' 1 ETLOC AREA = 4,303.88 (TO BULKHEAD) 0.099 ac, Noel VJ O %` s Gy 6: APPROVED BY BOARD OF TRUSTEES TOWN OF SOUTHOLD 4 w- .-w DATE mqgQf ?-0 2°yf " _ P, I6 �» E WITH THE MINIMUM '��VED�ANDDA opTEEDm F E B 2 9 2024 EW YORK STATE LANE) Southold 'Town •,• 0,9�i� Board of Trustees Y 1 Y SURVEY OF PROPERTY SITUATED AT N 690 EAST MARION TOWN OF SOUTHOLD Iro SUFFOLK COUNTY, NEW YORK 10"r'� S.C. TAX No. 1000-31 - 18-02 0q,%�oo ,�� 'zo,, SCALE 1 "=20' APRIL 30, 1998 .001,�,��, NOVEMBER 16, 2012 ADD COASTAL EROSION HAZARD LINE FEBRUARY 22, 2024 ADD 100' WETLAND SETBACK LINE A o O.•° AREA = 4,303.88 sq. ft. If, y? O�F�. sc�,o�. (TO BULKHEAD) 0.099 ac. 9� V% �O CT Or 9. c`� -: O �► CIA 10 IPA km 0 `%Gd,� O ,sue 00. 0 FED 2 9 2024 GZGp��pQ Southold Town Board of Trustees---- PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED BY THE LIALS. AND APPROVED AND ADOPTED FOR SUCH USE BY THE NEW YORK STATE LAND TITLE ASSOCIATION. ®'®®16lDIB,spa�� lop 4 1 e •• O poi �'• •. 5046�.•°'J��®�� ®�i Q C ••SJ���s. Uc. No. 50467 CERTIFIED TO: COMMONWEALTH LAND TITLE INSURANCE COMPANY Nathan Taft Corwin III UNAUTHORIZED ALTERATION OR ADDITION ROBERT KOCH TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE Land Surveyor EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VAUD TRUE COPY. Successor To: Stanley J. Isaksen, Jr. L.S. CERTIFICATIONS INDICATED HEREON SHALL RUN Joseph A. Ingegno L.S. ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE Title Surveys — Subdivisions — Site Plans — Construction Layout TIRE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND PHONE (631)727-2090 Fax (631)727-1727 TO THE ASSIGNEES OF THE LENDING INSTI— TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. OFFICES LOCATED AT MAILING ADDRESS 1586 Main Road P.O. Box 16 THE EXISTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD, IF Jamesport, New York 11947 Jamesport, New York 11947 ANY, NOT SHOWN ARE NOT GUARANTEED. Glenn Goldsmith,President �� Town Hall Annex A.Nicholas Krupski,Vice President �_ :c 54375 Route 25 Eric Sepenoski ti ,z P.O.Box 1179 Liz Gillooly �y • 0� Southold,NY 11971 Elizabeth PeeplesOl ��'` Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: Completed infield by: Je PAUL & LORETTA DOMBROWSKI request an Administrative Permit to demolish existing 16.9'x32.3' garage; backfill area to match adjacent (neighbor) grade; place a 10'x14' shed in the area of demolished garage. Located: 50 Rabbit Lane, East Marion. SCTM# 1000-31-18-2 Type of area to be impacted: Saltwater Wetland ,*- Freshwater Wetland Sound ,k- Bay Part of Town Code proposed work falls under: ,�Chapt. 275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications/Conditions/Etc.: Present Were: G. Goldsmith N. Krupski "_­'E. Sepenoski L. Gillooly E. Peeples zI2z )ZLI 6-e 6 V a t' Lro A-4(�' Ott IN cv �04 s m tom, � c JU J(� cOp �l l� C.- C 4 (zZ /Jy J-v P<,w q)3, l I - - O At Or L o o kit-, c A)P: -,I N O '7 - ' /,�• ` c� CV CFO CN r.. 17 r LU is �. a. �•� ',��{�'y'-��t l'� 4 �' �y��p ``N fit, y.�S► �' q s _ � .ir?C, � �,,.9M�w � t � r- � ie�i-fijll•,`$ ��ry.�'S, --'T-� •v ram,,._ �,.- .y , r. 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' # msr, 7,: s� � J ` MARIONLAKe .•^�`1 � k �q �� W 19 •R,3 's; �.�,. v" ,i,,, „ .E ss °^ •t . �. .. �t+� zw I c.�s�n,pt.p \ / ozi os.0 •.,_. ,...r ,°� f�'�a' y ,#'r 8'. ,, we:a R 9 }\ .a aY^".� P _ l� • ,� .y�y ^ , ,w :� •f•dsgo w `N «� _ - "r•; ;'fie Y b'Fs an b #,ds •� ? sa+ ,p. � n,e ,pti� ' .r d xinct !, '16'J F + .FYIIw1fxl.Wrta � J � O � �T r:SysA'�+ a,- __-- s' :x'n» '7«wx on, ��. •,,"c"»,>".`� .. -- _ _ ... COUNTY OF SUFFOLK J, N NOTCE K „„t.rw IPN w,0v ne, x.w W' 1 E6r6v�TOR,Fui r E ,w♦—�_—— ro - —. y a. ,w MIUMpID k A p u --•—— ` - -__+ — u — _— "� �I •' __ B xEx Mt9lfv TAYf9M6 A'eLY r _-• �o J r. OFFICE LOCATION: O��QF S�UryOl MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 [ Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) N Southold,NY 11971 �pQ Telephone: 631 765-1938 COU LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: Glenn,Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: March 19, 2024 Re: LWRP Coastal Consistency Review for PAUL & LORETTA DOMBROWSKI SCTM# 1000-31-18-2 PAUL & LORETTA DOMBROWSKI request an Administrative Permit to demolish existing 16.9'x32.3' garage; backfill area to match adjacent (neighbor) grade; place a 10'x14' shed in the area of demolished garage. Located: 50 Rabbit Lane, East Marion. SCTM# 1000-31-18-2 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department and the records available to me, I recommend that the proposal is INCONSISTENT with LWRP Policy 4 and with the LWRP. The placement of structures in FEMA flood zones (AE) is not recommended due to potential for loss. 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 :.; 54375 Route 25 A.Nicholas Krupski,Vice President P.O.Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly TF 2 Elizabeth Peeples 6 T 3 20�4BOARD OF TOWN TRUSTEESTOWN OF SOUTHOLDld Town ... . o rustees This Section For Office Use On, Coastal Erosion Permit Application Wetland Permit Application .Administrative Permit Amendment/Transfer/Extension Received Application: 5-3 La� Received Fee:S. 1 Completed Application:..316 AX Incomplete: ., SEQRA Classification: Type I__ Type II Unlisted,____ Negative Dec. Positive Dec., Lead Agency Determination Date: Coordination:(date sent):. \4 LWRP Consistency Assessment Form Sent: 3 d` .CAC Referral Sent: _ _Date of Inspection: Receipt of CAC Report:_ _Technical Review: Public Hearing Held:,. �G Resolution: Owner(s) Legal Name of Property (as shown on Deed): Paul & Loretta Dombrowski Mailing Address: 1700 Fairway Dr. Cutchogue NY 11935 Phone Number: (631) 734-8569.. ............ . Suffolk County Tax Map Number: 1000-31-18-02 Property Location: 50 Rabbit Lane East Marion NY (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Email:paul64pe@aol.com and of Trustees Applicat:`' GENERAL DATA Land Area(in square feet):4,303.88 Area Zoning: Residential Previous use of property: Garage Intended use of property: Shed Covenants and Restrictions on property? —ayes -2_No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? E—Yes F�J No If"Yes",be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? =Yes -_No If"Yes", please provide copy of decision. his project re any demolition as per Town Code or as determined by the Building Dept.? YesNo Does the structure(s) on property have a valid Certificate of Occupancy? Yes�No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?11 No Wi Yes If yes,provide explanation: . Project Description(use attachments if necessary): Demolish existing garage, backfill area to match adjacent (neighbor) grade, place 10'x 14' shed per Town Guidelines: T from property line; 35'from road and 100+'from bulkhead lard of Trustees Applicat, WETLANDITRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 5 Jt2 2n C e Area of wetlands on lot: 2,866 square feet Percent coverage of lot: 65 Closest distance between nearest existing structure and upland edge of wetlands:_23 feet Closest distance between nearest proposed structure and upland edge of wetlands: 98.6 feet Does the project involve excavation or filling? ❑ No ✓ Yes If yes, how much material will be,excavated? 0 cubic yards How much material will be filled?.2.0 cubic yards Depth of which material will be removed or deposited: 2..... feet Proposed slope throughout the area of operations: match adjacent Manner in which material will be removed or deposited: Unloaded directly from trucks Approximately 2cys will be placed in the wetlands area 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): None 61 Z20 Appendix B . Short Environmental Assessment Form Instructions f6r.Completine 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 l -Project and Sponsor Information Demolish garage Name of Action or Project: 50 Rabbit Lane East Marion Project Location(describe,and attach a location map): Brief Description of Proposed Action: Demolish existing garage, place clean fill and stone top to match adjacent (neighbor's) grade Name of Applicant or Sponsor: Telephone:631-734-8569 Paul Dombrowski . '.E.-M.ail:paul64pq@aol.com .. . ... ..... . ..... Address: 1700 Fairway Dr City/PO: State: Zip Code: Cutchogue NY 111935 ........: ..... 1.Does'the proposed action only involve the legislative adoption of a plan,local law,ordinance, 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. ` s 2. Does the proposed action require a permit,approval or funding from any other governmenial�Agency? NO YtS If Yes, list agency(s)name and permit or approval: Z ❑. .: 3.a.Total acreage of the site of the proposed action? .099 acres b.Total acreage to be physically disturbed? c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? •099 acres 4. Che 11 land us at occur on,adjoining anomiar the propTC4 action. Urban Rural(non-agriculture) Industrial Commercial ©Residential(suburban) Forest ❑Agriculture HAquatic' Other(specify): Parkland Page 1 of 4 .S. Is the proposed action, NO I YES N/A a.A permitted use under the zoning regulations? ✓ b.Consistent with the adopted comprehensive plan? ✓ _. 6. Is the proposed action consistent with the predominant character of the existing built or natural NO....: .YES.• landscape? M. 7.' 1`s the site of the proposed action located in,or does it adjoin,a state listed Critical*Environmental Area? NO. ; ,YES: If Yes,identify: El 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO, YES. b.Are public transportation service(s)available at or near the site of the proposed action? ✓ 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? N.O..., :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: 11:Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment:.._none re u Q _ .ire._.d:.. .-stora e g. shed. 12. a.Does the site contain a structure ilia['is listed on either the State or National Register of Historic NO YES Places? ✓ b. Is the proposed action located in an archeological sensitive area? ✓ ........................ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain "NO.. : .YES wetlands or other waterbodies regulated by a federal,state or local agency? ✓ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres:existing.gara-ge is approx 1.5'within the.100'.guideline limit...approx.4.0sf will be..impacted . .. 14.—Identify the typic bitat types that oc n,or are likely to be found on tF}�groject site. Check all that apply: Shoreline Forest Agricultural/grasslands Early mid-successional Wetland HUrban Suburban 1 S.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 1'00 year flood plain? NO YES . 17.Will the proposed action'6reate storm water discharge,either from point or non-point sources? NO. If Yes, a. Will storm water discharges flow to adjacent properties? _]NO ES ❑✓ ; b.Will storm water discharges be directed to established conveyance systems ff an drains)? If Yes, briefly describe: N0 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:, �. El 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES1 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 MV KNOW LEDGE Applicant/sponsor e:_.Pa.UI.DO bra . Ski....::..::.: Date: _... Signature:. L Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all ofthe,following questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsoror 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 ulations re g 1. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑ ❑ 2. Will the proposed action result in a change in the use or intensity of use of land? C❑ El 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? ❑ ❑ 5. Will the proposed action result in an adverse change in the existing level of traffic or j� affect existing infrastructure for mass transit, biking or walkway? E J ❑ 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? E ❑..... b.public/private_wastewater treatment utilities? ❑ ❑ ......... 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ El 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 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? 11. Will the proposed action create a hazard to environmental resources or human health. �= Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact, including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or,will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts. Check this box if you have determined,based on t}ie 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 :....N Date ame of Lead Agency President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signahrre of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 1 'Ard of Trustees Applicat.J' ti AFFIDAVIT Paul and Loretta Dombrowski BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD_THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of Property Owner Sign"Propgy-Owner SWORN TO BEFORE ME THIS DAY OF vJl V 20 No#ylqblic SETH G BANK Notary Public-State of New York NO.01BA6427783 Qualified in Suffolk County 26 MY Commission Expires Jan 3,20 and of Trustees Applicat,; AUTHORIZATION (Where the applicant is not the owner) I/We, owners of the property identified as SCTM# 1000-. in the town of New York, hereby authorizes to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. Property Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF 20 Notary Public APPLICANT/AGENT/REPRESEN'Y'ATIVE TRANSACTIONAL DISCLOSURE FORM TheTowmofSouthold's.Code:of ttliics`orohibits conflicts of ihteresfoh the oerf of town bffrcers and emy oyees:The numose:of ;tiers form into`pmvr e:mforrnati town of aossible conflicts:of interest-and gllow;ii to take:whateveraction is necessaryto_avwi same: YOUR NAME: Dombrowski, Paul S. (Last name,first name,diddle initial,ulirless you are applyingiti 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 personialy(or through yopr company,spousei.sibling;parent',ot..child)'have a-.relatioiisfiip:with any off cer:or`employeg ofthe Town of Southold? "Relationship"includes by.bioad,thaniage,;or'tiusiiie'sslnterest,`$Usiness`temsf meansa business, including a,partnerstiipr:in which the, wti offrcer.or employce.;has.eYen;a:partial ownership of'(or employment by a'corporation in which the town otlicer,or employee:owns.-ore thari..5%o the shares. YES n NO n .. .. 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): fjA)the owner of greatcir than 51%of..;th shares of the corporatc`.s;ock ufthe app[icaut. _n (when the appiieant is a corporation); B)the legal or beneficial owner of any interest in a non-eoipotute:entily.(W. If he j4applicant is not a corporation); C)an officer,director,partner',or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted'this 2 3 day of T63. 20 2,/ Signature. Print Name 6 JAj Form TS I 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 Prog ram. A .proposed.actfon..w ill be evaluated.. as to..its. .signifiI ".Z beneficial and°adverse effects,upoa'the coastal area(whicli.includes,M of..Southold.,Townl: 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 ea review aw. T us,. ch-,:MU*er must::be::exnlamed In_Aetarl,_.Ustmli both..supporting~and non- suaportina faets: If an action cannot be certified as consistent with the LWRP policy standards and ..,...., conditions,,--Ifshall:hot lie.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# 1000. 31 „18-2 PROJECT NAME Garage Demolition The Application has been submitted to,(check appropriate response): Town Board ❑ Planning Board❑ Building Dept ❑ Board of Trustees ❑✓ 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g.capital , ❑ construction,planning activity,agency regulation, land transaction) ❑ (b) Financial assistance(e.g.grant,loan,subsidy) (c) Permit,approval,license,certification: Nature and extent of action: .Demolish.existing.garage ' R E Location of action: 50 Rabbit Lane East Marion NY Site acreage, •099 - Present land use: Residential Present zoning classification:Seasonal Residential. 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:.Paul Dombrowski (b) Mailing address: 1700 Fairway Dr Cutchogue NY (c) Telephone number: (631) 734-8569 .. 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 Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section IH—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No❑✓ Not Applicable ' ttach ad itional 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 F Yes ❑ No ❑✓ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No ONot 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 Z Not Applicable y 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 0 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 0 Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES r 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 Z 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 ❑YNo❑✓ Not Applicable PREPARED BY Paul Dombrowski TITLE Owner ... DATE Z�Z