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HomeMy WebLinkAboutTR-10561A Glenn Goldsmith,President ®�q�®� S® Town Hall Annex U��o®� 54375 Route 25 A. Nicholas Krupski,Vice President ® P.O. Box 1179 Eric Sepenoski P8 Southold,New York 11971 Liz Gillooly Telephone (631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 UII�,��' 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 '/Z constructed When project complete, call for compliance inspection; Glenn Goldsmith, President ®F so Town Hall Annex ®� ®� 54375 Route 25 A. Nicholas Krupski,Vice President ® P.O. Box 1179 Eric Sepenoskii 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.: 10561A Date of Receipt of Application: March 11, 2024 Applicant: Jonathan Tibett SCTM#: 1000-56-5-11 Project Location: 845 Budd's Pond Road, Southold Date of Resolution/Issuance: April 17, 2024 Date of Expiration: April 17, 2034 Reviewed by: Board of Trustees Project Description: Ten-Year Maintenance Permit to hand-cut Common Reed (Phragmites australis) to 12" in height by hand, as needed. 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 Jonathan Tibett, received on March 11, 2024, and stamped approved on April 17, 2024. § 275-5 Permit procedures: (i) Cutting of common reed (Phragmites australis) to within 12 inches of the soil surface landward of the wetland boundary. This does not include mowing to ground level. Special Conditions: No other vegetation is permitted to be cut on the property without further review. Do not disturb any native vegetation during the hand cutting of Common Reed (Phragmites australis), including but not limited to; Eastern Red Cedar (Juniperus virginiana), Northern Bayberry (Myrica pensylvanica), Marsh Elder (Iva frutescens), and Groundsel Bush (Baccharis halimfolia). Inspections: The approved operations must be commenced within three (3) years from the date of the resolution. The permittee is required to request a Trustee inspection upon completion of the initial cutting. 2 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. 414- 44-UY Glenn Goldsmith, President Board of Trustees OUTHI S O- LD RUSTEES — Now 10 5.4 I . q Issued, T sona%4%ury 7f; %ber - Date y/ ��'���f. Address. THIS FIOTICE MUST BE DIS e4YED DUItINf, COMSTIttJCT801V TOWN TRUSTEES OFFICE TOWN OF SOUT1iOLD SOUTFIOLD. N.Y. 11971 TEL.: 765-1892 BOARD OF TRUSTEES SYMBOL LEGEND 'TOWN OF. SOUTHOLD \\ El MONUMENT RD IM GAS UEIER O :.P/LB.RD IN WATER METER 0 I.P./I.B.SET M GAS VALVE y4 SPOT ELEVM1RONS O,T WATER VALVE D TE F TRAFFIC SIGNAL POLE Q!TEST HOLE UTILOUYITY POLE `>W�S+ TREE P r'1 I 1 �O I'm 10 j 51 02 - o o 3 UINI POLE W/UGHT ®WRE OLRLLABRD ,f A% /- N\ T� LIGHT POLE WETLAND FLAG ` \ SIGN D.C.DEPRESSED CURB fE�ti ORE HYDRANT FE.FENCE ® MANHOLE AS.MASONRY E3"A"-INLET PLAT.PLATFORM A,9 - 8'B•-INLET W W WINDOW WELL jo"E--INIET B/W BAY WINDOW n910" "//„ 'A M YARD INLET C/E CELLAR ENTRANCE 3 - r �f, �� YARD INLET O/H OVERHANG q " ffaa NqT N s9'�..•.. 1 J NTn CABLE TV B LANDSCAPED R/O ROOF OVER - � �......; n q �A/C UNIT L.S.A. NDSCAPEO AREA O Q � J ♦♦UVV((V 11 LD ELECTRIC ETER CANT.CANTILEVER DO .'NU;,ENAV'. .AARACE 5»V wnLL wnu 4 sTEvs I`•:� / � sTFPs 2 STORY co STEPS 1 i +1' 1¢� 7.' GUARANTEED TO: FM LOT 9 g I A/C 1� �'�y y LOT JONATHAN TIBETT LIAR 1 1 // zu.s' v » FIRST AMERICAN TITLE INSURANCE COMPANY 2024 a 1 .o .. .. .�.... .... ........" ....-... ,. ..,. .!!EDGES ..,.. Southold Town N87°14.20"II RAMBUNC w5E FEH.--• .. Board of Trustees ; 1 �'+ •f� dT, A 239.67' I 1 I _ GRAPHIC SCALE I FM LOT To �D a 15 3D TAX LOT 12.1 \ LOT AREA 26,047.84 S.F. ( IN FEET ) 0.60 AC. f44IE: f inch = 30 fL a SNOW COVER AT TIME OF SURVEY ALL WALKS, DECKS @ PATIOS NOT SHOWN HEREON NOT GUARANTEED O�NElaH C 10SUF FOLK A 500 011000 LOT 9 SURVEY OF PROPERTY SURVEYING P.C. JOB No.S17-1066 WILLOW POINT 1966 A I w 8 y S U f1 I' FILE 1 n t DATE SURVEYED: 12/14/2017 FILE DATE: 6/1SITUATE MAP N0. 4652 BB-:o5 Wen Hoffm Wuan A—U, LmdeP , Ne,Yn,L v 57 SOUTHOLD TOWN OF SOUTHOLD "I', N I E,_,I Mlscahce@tnjslaPasuneycoin Phone.63T?ST 2400 Fnx 63,-==6-R.,an DR.:MC CREW.:AL SCALE:1" = 30' SUFFOLK COUNTY, NEW YORK 'J�SF i�J� my n�a�.�s�'. amw w"�"°'m sws.• cam . "°°iw� ''�. M ew..v..amn:u s",n'w®JO.m.�" mow. �„., wo�.m v.�ncmn a r«s m.aw.s.�.s.w.soo.Mn v.vn.,s auw.m.ummKc.��a P.�,m,.nw as ()LAND S\�; �inmFRA��.�...a,o„wM.Twa�AAIM.a_.,4,•�.•. aow,w...�.a.o,.l.,,9�.,a Glenn Goldsmith, President ®F so Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ®� ®�® P.O. Box 1179 Eric Sepenoski !�[ 1 Southold, New York 11971 Liz Gillooly us Telephone(631) 765-1892 Elizabeth Peeples � a� Fax(631) 765-6641 C®Ui�f`l,i� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10561A Date of Receipt of Application: March 11, 2024 Applicant: Jonathan Tibett SCTM#: 1000-56-5-11 Project Location: 845 Budd's Pond Road, Southold Date of Resolution/Issuance: April 17, 2024 Date of Expiration: April 17, 2034 Reviewed by: Board of Trustees Project Description: Ten-Year Maintenance Permit to hand-cut Common Reed (Phragmites australis) to 12" in height by hand, as needed. 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 Jonathan Tibett, received on March 11, 2024, and stamped approved on April 17, 2024. § 275-5 Permit procedures: (i) Cutting of common reed (Phragmites australis) to within 12 inches of the soil surface landward of the wetland boundary. This does not include mowing to ground level. Special Conditions: No other vegetation is permitted to be cut on the property without further review. Do not disturb any native vegetation during the hand cutting of Common Reed (Phragmites australis), including but not limited to; Eastern Red Cedar (Juniperus virginiana), Northern Bayberry (Myrica pensylvanica), Marsh Elder (Iva frutescens), and Groundsel Bush (Baccharis halimfolia). Inspections: The approved operations must be commenced within three (3) years from the date of the resolution. The permittee is required to request a Trustee inspection upon completion of the initial cutting. 2 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"'.4" Glenn Goldsmith, President Board of Trustees ..RUST S SOUTH LD , .T .. EE ��. 1'05�(al A . issued- diress. 14-15 'oIa��n Y; be'tt' - Datesy� ��'��emkll's ni THIS NOTICEMUST BE DIS�LA1(ED DURING CONSTRUCTION TOWN TRUSTEES OFFICE.TOWN ,OF SOlJ7'HOLD TEL.:, 765-5 892 Glenn Goldsmith,President ®� S®�/,� 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 01 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; OFFICE LOCATION: O��QF S�(/ryQl MAILING ADDRESS: Town Hall Annex O P.O.Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) va Southold, NY 11971 �Q Telephone: 631 76b-1938 o�yCou ,� 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: April 15, 2024 Re: LWRP Coastal Consistency Review for JONATHAN TIBETT SCTM# 1000-56-5-11 Twin Fork Landscape Contracting, Inc. on behalf of JONATHAN TIBETT requests an Administrative Permit for a Ten (10)Year Maintenance Permit to trim the hand-cut Common Reed (Phragmites australis)to not less than 12" in height by hand, as needed. Located: 845 Budd's Pond Road, Southold. SCTM# 1000-56-5-11 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 action is INCONSISTENT with LWRP Policy 6 and, therefore, INCONSISTENT with the LWRP. 1. A Wetlands Permit issued in 1990 for the parcel required that the"existing berm is to be left in its natural state." The plans do not show the berm. Natural state would not include the cutting of phragmites. 2. Native plantings are not proposed. 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 Qg�FFOC,�c Glenn Goldsmith,President �. OGy� Town Hall Annex A.Nicholas Krupski,Vice President < 54375 Route 25 0 Eric Sepenoski W ,z P.O.Box 1179 Liz Gillooly �y • o�� Southold,NY 11971 Elizabeth Peeples l �a Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees ` Field Inspection Report Date/Time: y 2-Li Completed in field by: L- G' 116 �y Twin Fork Landscape Contracting, Inc. on behalf of JONATHAN TIBETT requests an Administrative Permit for a Ten (10) Year Maintenance Permit to trim the hand-cut Common Reed (Phragmites australis) to not less than 12" in height by hand, as needed. Located: 845 Budd's Pond Road, Southold. SCTM# 1000-56-5-11 Type of area to be impacted: x Saltwater Wetland Freshwater Wetland Sound ,c Bay Part of Town Code proposed work falls under: ,r Chapt. 275 Chapt. 111 other Type of Application: -t Wetland Coastal Erosion Amendment k, Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications/Conditions/Etc.: Cove y►LX, + keel 1-6 avoj CA G.GC.1cQ�-( QI iy',yuFL-1 i raw ©f OLO(dr11tX to slepe-(,-A1 ivied. Gedat 'h^ees . Ic4 . Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples \ SYMBOL LEGEND E) MONUMENT RD ©GAS METER \ 0 I.P./I.B.END II@ WATER METER ,0 I.P./I.B.SET A GAS VALVE \ ,aiz SPOT ELEVATIONS WATER VALVE g�a TRAFFIC SIGNAL POLE 0 TEST HOLE URUTY POLE �"^,�TREE �T 8 Ij N �— CUY YnRE ®SHRUB pM 1PT 10 i6j.0 WD uD TY'POLE WAIGHT • BOLLARD FIX / ]� UGHT POLE ®WETLAND FLAG \��\ SGN D C.DEPRESSED CURB PRE HYDRANT FE.FENCE ® MANHOLE MAS.MASONRY Y\ \ ZA A�. \� EM'B--INLET PLAT. WINDOW WELL W i /'+O••r / 3 YARD INLET B/W BAY Ni DOW ENT 1 °39 'V .A \ YARD INLET C/E CELLAR ENTRANCE N6J� -@ \ ®YARD INLET O/HRIO OVERHANG V _ , \ 0 CABLE N BOX R/0 ROOF OVER C UNIT A.LANDSCAPED AREA EL �`�1 •H�ci.5 // I' � IE1 ELECTRIC METER CA CANT.CANTIEVER GO HiR: yNAN.1U.� \ £ �/ /... 4 STORY ' \ /GARAGE SMP 6TE O P5 WALL Iq I„•.� � ——— ____�_ STEPS �j \ 10.5 \ O _ �� 1 ` FRAME DURDINO uIT I b IBIS I po S1EP5 \ 4.0' I - \ I � ��I�o J Do (�1 F�— n fffJJJ E� FM LOT 9 GUARANTEED TO: E 'I_ I� 11(f I,� I p Soh 4T• 12� T JONATHAN TIBETT ® LJ LJ IL— U LL I1 p A%cam�° �' _ TAX LOT 11 \ 4 I r 39.8' \ � FIRST AMERICAN TITLE INSURANCE COMPANY �I � aDs• O 81 l of \o MAR 1 1 2024 I \ HEDGES FND 0.4 t N87°�4 zo••w W,RE FEN RAMDDNG _ FEN + z39.67• —— I Southold Town ; I Boa�-.Q�.TGust I I \ — I \ FM LOT 10 \ 30 a Ts sD TAX LOT 12.1 LOT AREA 26,047.84 S.F. ( ) 0.60 AC. IN FEET 1 inch = 30 ft. 8'3 SNOW COVER AT TIME OF SURVEY ALL WALKS, DECKS&PATIOS NOT SHOWN HEREON NOT GUARANTEED ��pF+�Etd {/A; SUFFOLK TAX MAP NO. SURVEY OF PROPERTY I 7777'CALICE II g��—{^1r$1.�r 1000-05600-0500-011000 LOT 9 f CAA vt .l✓ 9 '�..,A .9_ ° e MAP OF JOB No.S77-1066 WILLOW POINT A .1 W it y S O Ti P O 1 U t DATE SURVEYED: 12/14/2017 FlLE DATE: 6/1 S/1966 ITUATE MAP N0. 4652 69->•S West Hoffman A-., Lindenhurst NewY.A 1.1.757 SOUTHOLD, TOWN OF SOUTHOLD F NO10a08��2 Eman.nMscas:e��:nlcla�dsoNey cMn, Pho-:61,.e57.:400 F,r631116,4 O DR.:MC CREW.:AL I SCALE:1" = 30• SUFFOLK COUNTY, NEW YORK 4 m..,a ���, ,�me.µ..,o,M w,.�,,, ,�,... - _� �.i,i,�a,,:.,F.,oz«�.a„m,.,..,�E nl,��.,N.«�,�•o=o,.R a o.:n,.n.m.°...w,....,�.»�.�,,,. �S{IY '• i j f r f (� Southeast 3/7/24 ea till Fvt, r ����IIII�IIII��III�� I ��� SEE et �rmxW 9 r`�� 4ATCH :. 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Positive Dec. Lead Agency Determination Date: _ Coordination:(date sent): _�_LWRP Consistency Assessment Form Sent: V 7 CAC Referral Sent: Date of Inspection: Receipt of CAC Report: _Technical Review: (Public Hearing Held: 1 oZ Resolution: ° Owner(s) Legal Name of Property (as shown on Deed): Jo n Mailing Address: Q 5 �o p p c,r 3}r e,e_+ N e- �- ter Phone Number: 51 '�t Q G �-�"• 1 5 Suffolk County Tax Map Number: 1000 - Property Location: LA 6 uuJ of Po n J Ca_ 5oL.A- N1 110i -11 - (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): h C) C � L �nc� S L J C d(IN rc`C., Mailing Address: 1" 0 coo C,1.'+J---) C) Phone Number: Lp�>> -`1��� " 6 U-4 Email t�O EA W i n 'o r 1C 1 ax_v� S cn Pe con- rct C'-1 nn GU d of Trustees Applicat GENERAL DATA Land Area(in square feet): J 5 `L Sn Area Zoning: q G Previous use of property: 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? E-Yes -%No If"Yes",be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? =Yes M_No If"Yes", please provide copy of decision. WrTis project realure any demolition as per Town Code or as determined by the Building Dept.? Yes -W—No Does the structure(s) on property have a valid Certificate of Occupancy?gYes=No Prior permits/approvals for site improvements: Agency Date ❑ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?-a No_a Yes If yes, provide explanation: Project Description(use attachments if necessary): C'_ A-� \-Da Gk P h c'cq rn I' to vN 64 1 erj a.reo 40d of Trustees Applicat" WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: b a c ,_M f n- Area of wetlands on lot: H ) 3 2-5 `( square feet Percent coverage of lot: Y R , I % Closest distance between nearest existing structure and upland edge of wetlands: 35 feet Closest distance between nearest proposed structure and upland edge of wetlands: ''--feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated?_ cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason.of such proposed operations (use attachments if appropriate): 00 40 617.20 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 1 -Project and Sponsor Information Name of Action or Project: ram, V& P h rc.. Project Location(describe,and attach a locgltibn map): y 5 3 uk-j01 S n 01 h Brief Description of Proposed Action: G u-'+ VD c' C' aV e�� r G vU r- h r 0, 1 �� Name of Applicant or Sponsor: Telephone: ? w►c- o d LC.r-J S C_cLpC_ L,o r,4r c,c._4In c >;-M 'I: P'G C t< e, Address: L. Ga n�#`G CA)C-)_g . Co cam City/PO: State: Zip Code: G.I-A c��o L'L e N -1 1 , 1 1 -�5 1.Does the proposed acti 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. L�J 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? acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor`? acres 4. Che I land us"at occur on,adjoining an ar the propqse4 action. Urban L_JRural(non-agriculture) Industrial Commercial Residential(suburban) Forest [:]Agriculture Aquatic ❑Other(specify): OParkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? b.Consistent with the adopted comprehensive plan? 6. Is the proposed action consistent with the predominant character of the existing built or natural O ( YES landscape? 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: R] ❑ 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? I c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? �L 9.Does the proposed action meet or exceed the state energy code requirements? N6 S 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: M ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ® JM_ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? b. Is the proposed action located in an archeological sensitive area? 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. ntify the typic bitat types that oc n,or are likely to be found on t"roject site. Check all that apply: Shoreline Forest Agricultural/grasslands 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? M_ F-1 16.is the project site located in the 100 year flood plain? NO YES IT T71 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO If Yes, a. Will storm water discharges flow to adjacent properties? ONO DES b. Will storm water discharges be directed to established conveyance systems ff an m drains)? If Yes,briefly describe: rJNO YES Page 2 of 4 _ 00 40 f 13. Does the proposed action include construction or other activities that result in the impoundment of - water or other liquids(e.g. retention pond, waste lagoon, dam)? If Yes,explain purpose and size: Iful � 'j 119.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)fbr hazardous waste? If Yes,describe: [ AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicantlspon r n : Oy) Di l�Jvr f `� Date:_........ _.__. 7 _-._... ._ ,._.._._.._W_..___. . .._.. Signature: Part 2-Im act Assessment. The Lead Agency is responsible forthe 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 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 1 occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑ �! regulations? Lnu 2. Will the proposed action result in-a change in the use or intensity of ttse 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 o a establishment of a Critical Environmental.Area(CEA)? _ T 5. Will the proposed action result in an adverse change in the existing level of traffic or affect existing infrastructure for mass transit, biking or walkway'? i a 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: _ _ ® ❑ 4 a.public!private water supplies? i b.public 1 private wastewater treatment utilities? ® 'e ❑ j S. Will the proposed action impair the character or quality of important historic,archaeological, k ❑ i architectural or aesthetic resources? i { 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, fill waterbodies,groundwater,air quality,flora and fauna)? Pave 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 Elproblems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting 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 d of Trustees Applicat AFFIDAVIT BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS 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 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 SOU`I'HOLD 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. Si natui f Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF TuvY , 20 JAIME H. GAYNOR NOTARY PUBLIC-STATE OF NEW YORK Notary Public No.01 GA6161068 Qualified in Nassau County MY Commission Expires 08-07-2026 rd of Trustees Applica AUTHORIZATION (Where the applicant is not the owner) I/We,—�)ma�an owners of the property identified as SCTM# 1000- 7 L• �- ( in the town of New York, hereby authorizes 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. P perty O ner's Signature Property Owner's Signature -SWORN TO BEFORE ME THIS 9 DAY OF R D YI l C��l/� , 20 a ` l W& 4&ny� \J Notary Public JAIME H. GAYNOR NOTARY PUBLIC-STATE OF NEW YORK No.01GA6151068 Qualified in Nassau County My Commission Expires 08-07_2026 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the hart of town officers and employees.The numose 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. 1 YOUR NAME: I I -, i J U n (Last name,first name.4fiddic initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other",name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO f4 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 applicanttagent/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): _aA)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,partnei,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this_ day of 20Z Signature4M4 _ Print Name Fonn TS i 6.3 B.3 Comply with the regulatory requirements of the Tidal Wetlands Act for the protection of mapped tidal wetlands including tidal fresh marsh;intertidal marsh;coastal shoals, bars and flats; high marsh or salt meadow; littoral zones;and formerly connected tidal wetlands. 6.4 B.2 F4view existing species records and field survey proposed development sites,at the appropriate times,for the presence of listed species or conditions that meet their habitat requirements. 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 significant 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# i&-" - SL•'r- 11 PROJECT NAME f hY'0 M 6 S C LJ�bOJJ- 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: 1 Location of action: $1'�� 3 v cW-� Pao arA so-e,+6du t tjy Site acreage: o 6'1 Present land use: _ d_;_vm Oe► l4ip aesl ejeYY`6d Present zoning classification: (>1ne, �7a, ,l year pund lZt 5td'cnce 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: (b) Mailing address: (c) Telephone number: Area Code( } (d) Application number,if any: 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, h av►t� S�- � r e5 it��e1� wl Q,veG.S Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LMW 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 II �,1" 5.1 151.1 rrvsGrye- ex,'J, ;o-q v me4-&47by% k,G Y,I u4 coiyJI -6 iv e- scenic �Ucs� land�r 61cufb he PVC i y%va5 N a V KMQ ' e5 -6 "am e+ strV, . o+ i r'A i�ehou5 Spec i'eS Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No'AIJI 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 ®Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. W ❑ ❑ Yes No Not Aolle 146-6zs ssoc;okied t,'A tiaiwa,( ecoto iccJ Cc'il'dMWc 4i6 G,Z .ZCL rated- i rob: Ie�,n s �. .e- a`�'10 �e2, e�i �c.GA _e�nrnurir .Z{3.L ►on�cN� r e:1 a �GC� -e,rb 04 o-K-1i rules kcrm e- Ll$ S`Avorck rwrm tmt oAye( e, ch .`�o e- octcc g fycess ucAirvei ressderrHal cvjne-s ns 4� lWVI—ilb-M beneFai75 COMFa+,be 1�,;,ltse and I0nClscc,,r,Wa -�ev1mw„e< ,ll 6e, esserr l 4A gC016q"Mt 11?Ck\JA1 o-+ Sc ranee we1.l�wr�cJ1 eUr eo,s ,�, � , T s-'ee- c-e u A e • e ors set- A lyk�rilke. perms+ yondl-6ons 5 ArnA'rCt�M N 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 1/j\ 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 0 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. ❑ YeSF1 No n Not Applicable Attach additional sheets if necessary `WORKING COAST POLIC160 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 11A k I plames ovimVWq impe'a"Ce ow r.wnie3A�:�. 4z Iong.4e in ijeaLA ar,�l 4unole occ df rraa6kll-. f i sher c es A. uJ c us ed ectb aboftlan e e Wd dyers i J +- e; urine re cute Il-1 Aa cloes tj r f ilh ulcarho'A and he,6744 f,n A4-enC1nLe an r -IKsir��`a-&I elf AS a A.L1 vse 6e +- ayvolm le eie +Mls iv► rnem ►n -4he rescYc'eS S- ;rv' '►ZeS W&Je aftj reduces 4 5cjand nmor+a1(+.,. &F me riir a Pis (:Cwurce5 Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ No 0 Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No 0 Not Applicable PREPARED BY 4°'} �V � TITLE P'�� DATE � � �