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Home My WebLink AboutTR-10581A �� \ Glenn Goldsmith,President Town Hall Annex 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 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 1It day of construction '/z constructed When project complete, call for compliance inspection; A J Glenn Goldsmith,President ��®¢ so�, Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ® P.O.Box 1179 AL Eric Sepenoski awSouthold, New York 11971 Liz Gillooly G Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 ®l�C®UV g� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10581A Date of Receipt of Application: May 7, 2024 Applicant: DKJK FAMILY TRUST, c/o DAVID KRUPNICK SCTM#: 1000-115-12-13 Project Location: 880 Deep Hold Drive, Mattituck Date of Resolution/Issuance: June 12, 2024 Date of Expiration: June 12, 2027 Reviewed by: Board of Trustees Project Description: For the as-built installation of a 52"x32" generator pad and generator. 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 David Krupnick, received on May 7, 2024, and stamped approved on June 12, 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. Glenn Goldsmith, President Board of Trustees i SOUTHOLD TR . ..... USTEES Naa l o S g l A Issued . -To �KSK �GM:1� Cu5z Date Address , $ go b exp "or, ' br:vcx mc,%-w �`t.AcK THIS NOTICE .MUST BE DISPLAYED DURING CONSTRUCTION .TOWN TRUSTEES OFFICE,TOVIIN O,F SOUTHOLD SOUTHOLp� Flol(. 11971 TEL.: 765-1892 .:y 5U Al C ROVED BY e-00"', -A A BOARD OF 'i RUSTEES ITUATE . t K VIAITITUC TOWN OF. SOUTHOLD RVEY 01= RO RTY DATE NEW SU LK TOWN 5C UTHOLD UE f FO OUNTY, NY & , WETLAND FLAG5 5HO N THUS r#5ET BY ENCON5ULTANT5 5URVEYED 12- 1 1 - 20145 UPDATE 02- 14-2018� 04- 10-2018 IAT EDGE OF VEGETATE ) TLAND5 ON 08-OG-2018 UPDATE 08- 1 8 , 08- 17- 10-30-2015j ELEVATIONS REFS ENCE NAVD 1988 DATUM PROP05ED GARAGPE 0 1 -02-2019 11 REVISED 0 1 -30- 0 139 02- 15- 20195, 02-2G-2019 ,07- 1 1 -2019 FEMA FLOOD ZONES 5HOWN ON 'PANEL 3G r 03C0482H HD FINAL 12-01 -2020 !AND NOW R FORMERLY OF: CON5TA CE A. CON Ly00 5UFfOLK COUNTY TAX PAUL=��. cONNOR �, � 1000 - 1 1 - I -� 13LL- DWELLING �� PU B ur C WATER ° 1 1 , CERTIFIED TO: 0 1 00' WETLANDS :SETBACK w f- David Krupnick .� � ,� � ; 1 � _ 281 Lowell T. Blumenthal 07-01 r k of � O�Ban .mer# , N.A. 10 FirstAmerican TitleInsurance Company C ! � WATER �. , W•ER 50( ETEi O � GAL. STAdvantageiitl '. 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' 40.2' GRAVEL DRIVEWAY to `- .. ♦ �- .r 4 O I - .............................. 0 1 LO � . _.._ -- --- - HD REFERENCE NUMBER: R 10- 1 �9-00y49 r ' UNegj GRO f ND -- ..T PI .� _ 1 1W 5UFE OLK CC JINTY HEALTH DEPARTMENT APPROVAL I 1 ?01 WETLAND5 +�Y �r 1/��Y� ~ \ti LAND NOW OR FOl�t�rl !ERLy oF: LC RRAINE Wj!1 DT d 1 DWELLING FU13L1C WATER F _.!n n i i PAY - 7 2024 Lj:�j Eorrd of ,-,!Ftees LL NOTES; *Unauthorized auteration or additIon to a surveyE- mop beoring c licensed land so r "s seal Is a �_ � '7 � r7 12 h110NUMEtT FOUND I ' D viololion of seniors 7209. sub-dI islon 2. of the JOHINICe EHLER5 WOOD FENCE5U New York S{ate , ducatlon Law." Yo 'Only copies from the origtn(3 of this survey `��✓, ",�� -_ r marked with on originci of thtlland surveyor's '._,` , • J PROPERTY ZONE stamped seal shati be consldeed be valid trueR-40 copies" 50202 EAST MAIN 5TREET 'Certifications indicated hereon t9nify that this survey was prepared .in cccordoflCp wilh the eK— isling Code of Practice. for Land rurve�ys adapted Area = 2 1 ,OBG ,'.,,3 . Ft. I' I V ERHE D9 N X. 1 190 1 3G9-82",6�"`}-' Fax `�} G9-8r °87 by the New York State Assoclatioli of Processional Land Surveyors, Sold certificaticnr shall rein only Area = 0.r483 Acre je�urvey@optonline. net to the person for wham the surj�ey is prepared, and' on his behalf to the title comp y, governmen- 1 ►PH�C SCALE ��= ' tot agency and lending Insittution lid -d hereon, and o the assI neeg of the lendirs Insl to an. Ctrilfita— .., ,t�_ ! 34 tions are not transte�robie to oddlt- nol Institutlone Glenn Goldsmith,President ��o�0S0fF0(�0.9, Town Hall Annex A.Nicholas Krupski,Vice President e 54375 Route 25 0 Eric Sepenoski ? P.O.Box 1179 Liz Gillooly y • �p� Southold,NY 11971 Elizabeth Peeples l Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: lob Completed infield by: G� CWS,;A DKJK FAMILY TRUST, c/o DAVID KRUPNICK requests an Administrative Permit for the as-built installation of a 52"x32" generator pad and generator. Located: 880 Deep Hole Drive, Mattituck. SCTM# 1000-115-12-13 Type of area to be impacted: ✓Saltwater Wetland Freshwater Wetland Sound ✓ Bay Part of Town Code proposed work falls under: -/Chapt. 275 Chapt. 111 other Type of Application: 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 -1-ee ne 4u % 37 32 6 02--l— 922 17.5mo 01 02-2� I'S 3a Tic—ou S. 24 1 21 32 IN, i 3 T,—.I F�- IS Iwo- 03— S CI O IO 12 S 0& 7-7. % V W-) it r 7n A V 4 ie 21 to T—23- MARRATOCM • a —b 21 :z art., ie P, 6, —40 21 2S 31.1 il 2. I 2311 01 n a: L 12 e' � imp3 iz- -iz--- it,j \0 A 9 1- a, Ilk, I..21 21A 9 'j, -V 13 17 -S, I . 1 _- 4 1 6N.) 14 -12 IS aN IS 1,", SEEGE-0 I !,A IS -01 —ce 'I \T IS VAIA C, 13 %— I %, --Iv \, �'� Al 13 I-- 2S 10 JN,) IS -n 1�1-21 �,'(l 4 121 1B, T 7M V\ IS'i' 3 1 1 1 WIL NOTICE G Real P,-,e,,,T-lereice Agency .---'. COUNTY OF SUFFOLK(D E I.—I Still 115 — N -1 —.—SS.- 110, OFFICE LOCATION: O��OF yQl MAILING ADDRESS: Town Hall Annex '` P.O.Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) N -4w. Southold, NY 11971 Q Telephone: 631 765-1938 olyOwn LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: June 12, 2024 Re: LWRP Coastal Consistency Review for DKJK FAMILY TRUST, c/o DAVID KRUPNICK SCTM: 1000-115-12-13 DKJK FAMILY TRUST, c/o DAVID KRUPNICK requests an Administrative Permit for the as-built installation of a 52"x32"generator pad and generator. Located: 880 Deep Hole Drive, Mattituck. SCTM# 1000-115-12- 13 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 CONSISTENT with the LWRP. 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 ®F S12 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 ® a® Fax 631) 765-6641 � E BOARD OF TOWN TRUSTEES NAg - 7 2024 TOWN OF SOUTHOLD I This Section For Office Use Only �Qllr�,ol;a; fQtNm II 4�'��ii�ll ofi Trru�tEc� f Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amen dm ent/Transfer/Exten s i o Received Application: Received Fee: $ '.r' e Completed Application: Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): __V__LWRP Consistency Assessment Form Sent: 6,A�Y CAC Referral Sent: Date of Inspection: 6Z a Receipt of CAC Report: Technical Review: ____�_Public Hearing Held: oZ Resolution: Owner(s) Legal Name of Property (as shown on Deed): f�� I� � / .l sf—" Mailing Address: q U `►'�l �- �� IL q Phone Number: p�- o 7\4-oZ40 1 Suffolk County Tax Map Number: 1000 - 1 (5 ia- Property Location: 0 b (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Email: •oard of Trustees Applicati GENERA/L�DATA Land Area(in square feet): 02_ f d 10 S% Area Zoning: Previous use of property: Intended use of property: Covenants and Restrictions on property? Yes No If"Yes", please provide a copy. q� Will this project require a Building Permit as per Town Code? / 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 No If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes X —No Does the structure (s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Aged Date X err/�i l� �.3�4 / �5 No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental'agency? / No Yes If yes, provide explanation: Project Description (use attachments if necessary): 1� n��e- W, mks e - s 01LIT • �oard of Trustees Applicati WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: 7 3 square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: / feet Closest distance between nearest proposed structure and upland edge of wetlands:`-✓r / feet Does the project involve excavation or filling? K 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: /yD �/ �/� `e 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): 61 Z20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: Project Location(de ribe,and atta h a to tion map): Brief Description of ProposedAction: f U U Name of Applicant or Sponsor: Telephone: zmJl< ��'��/ / "' �7\, E-Mail: d1ky- l9 Address: City/PO:� � ,.t-s/A State: Zip Co i// �0 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or ap roval: ❑ 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. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) [—]Industrial ❑Commercial residential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ ❑ b. Consistent with the adopted comprehensive plan? ❑ ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural OF 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: 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? NO YES If the proposed action will exceed requirements,describe design features and technologies: El 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ❑ b.Is the proposed action located in an archeological sensitive area? ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YE wetlands or other waterbodies regulated by a federal,state or local agency? El 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. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline El Forest ❑Agri cultural/grass Ian ds El 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? ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, a.Will storm water discharges flow to adjacent properties?. ❑NO ❑YES ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO []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: �xl ❑ 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: J I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: �404 k Date: 5 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 conflict with an adopted land use plan or zoning El ❑ regulations? 2. Will 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 ❑ El of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El ❑ affect 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 El ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a.public/private water supplies? b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ El or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ Elwaterbodies,groundwater,air quality,flora and fauna)? 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 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 KwtZMA'N "Lri vEiz, LLP A•rrO1lNEvsA'r LAW ONE,\ORTii BROADWAY, 12n'Rom CHRISTINE KONF,FAL -260 NIAI)ISON,Mr.NUIi, IGn`FLOOR M.trr�P::Ai vs,'New YoIu:1 Ol>01 Of Counsel Nr:w YoKK,NI:W YoRK 10016 ckondal a Leiaw.com Tea:_(9:14)285-9800 '1*1;1.;(212)697-5550 I'e1X:(914)285-9855 '1 (914)993.604E I:(914)993-G020 I A\:(914)285-9855 CORRr.SPO\UENcis$IIOUI.b Br SE\T:TO"TIIE 1 ilft PL NS ADDRESS May 7, 2024 Towa of Southol 14,I3,oard_of'Trustces Southold Town I`Iall Annex D`4375 MainAoad 110"Bos 1179" i Southold,:NY .11'97,1.- Re: 880 Decp Hole Drive, Mattituck,NY (the"Property") To-Whom-It May Concern: Tlease note that, by deed dated Novcmbcr 24. 2020 and recorded January 2`l; 2021 at I,.iber;DOW13087-page'854, title to the r6creficed Property was trailsferredto'David Krupnick and Jordann.Krupnick, as,Co=frLISICCS of the DKJK 1'llllily'l'rust. l David' Krupnick and Jordana Krupnick-remain the trustees of the DKJK Fanitly"'I`rust. With ,respeet Wo rcal,'property. the Trust-Agrecnlcnt creating .the 'trust grants the trustees"the autliority, ailiong alhei powers;to improve or otherwise deal with any real property; to improve, repair and: niake—alterations from time to time in any Of' the.-structures upon any such real property; to.,equip ,structures upon any such real property and to make any and all other improvements of Any kind` or character whatsoever in connection with the development and improvement-thereof; and to execute,the necessary instruments and covenants to effectuate-,tile f -foregoing powers. i l gddr singly„-David and Jordana Krupnick, as Co-Trustee's. have the authority to make any and all decisions about the Property-and,the:house'.located thereon. j Very truly yours, Christinc Koncfal i '— _�loard of Trustees Applicati.— AFFIDAVIT 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 Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF , 20 MARIA PRIKAS GANLEY Notary Public-State of New York NO.01PR5003206 Qualified in Suffolk County Notary Public My Commission Expires Oct 19, 2026 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 purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: �V C 1� �C%T"— I " (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 (If"Other",name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship.with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES _ NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted is U day of VU` ?•�`�� Signature_ ��—=_ Print Name9CK— Form TS l 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# - ( 04Z- - 13 PROJECT NAME &Qn-/W- 4 f y- The Application has been submitted to(check appropriate response): ] Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees ,l~J 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: !jj�sWk+-M 52� 3Q U C-5fu nuts -Pd - h5 -T- Location of action: NrO �VC> l� �• �. (i� V5��, I Site acreage: Present land use: 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: ( ) Name a of applicant: (b) Mailing address: R �jmj 10 EdStIT56-1p I" "! V-32 (c) Telephone number: Area Code (d) Application number,if any: A)1 Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ❑ No Jd"be 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 W 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 0 No Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages S through 16 for evaluation criteria ❑ Yes ❑ Noe 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 Lott�Applica' 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 ❑ Nor 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. FO ❑ Yes ❑ No Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ Yer-1 No 0 Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ Nor 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 9Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED BY T�W < � TITLE 1��'Ue/" DATE 12T