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HomeMy WebLinkAboutTR-10583A Glenn Goldsmith, President ®F so Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ,�®� ®�� P.O. Box 1179 Eric Sepenoski iR Southold, New York 11971 Liz Gillooly CA 4%r Telephone (631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 �� COU01 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE #2172 C Date: August 30, 2024 THIS CERTIFIES that the installation of a 10'xl2' shed in the backyard area of the property, At 500 Hippodrome Drive Southold Suffolk County Tax Map#1000-66-2-13 Conforms to the application for a Trustees Permit heretofore filed in this office Dated MaY30,2024 pursuant to which Trustees Administrative Permit#10583A Dated June 12, 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 installation of a 10'x12' shed in the backyard area of the property. The certificate is issued to ORA HEATH& ELLIOTT B. HEATH III owners of the aforesaid property. AL 44n�x� Authorized Signature Glenn Goldsmith, President �g SOL/ Town Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25 P.O. Box 1179 Eric Sepenoski �, , ` Southold, New York 11971 Liz Gillooly Telephone (631) 765-1892 Elizabeth Peeples �� Fax(631) 765-6641 4o' � , BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Zy INSPECT D BY: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1 st day of construction / % constructed v Project complete, compliance inspection COMMENTS: 11 �h e� )Q(J1 0,C C 0'r0J\Vxpt 17p� v►n I l7 � %?5 A. CERTIFICATE OF COMPLIANCE: d &C 71-0 r Town Hall Annex Glenn Goldsmith, President �� ® �s 54375 Route 25 A. Nicholas Krupski, Vice President P.O. Box 1179 Eric Sepenoski 3 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 1st day of construction \/ '/z constructed n When project complete, call for compliance inspection; Glenn Goldsmith, President ®��®� S�Ur�®� Town Hall Annex 54375 Route 25 A.Nicholas Krupski,Vice President ® P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10583A Date of Receipt of Application: May 30, 2024 Applicant: ORA HEATH & ELLIOTT B. HEATH III SCTM#: 1000-66-2-13 Project Location: 500 Hippodrome Drive, Southold Date of Resolution/Issuance: June 12, 2024 Date of Expiration: June 12, 2027 Reviewed by: Board of Trustees Project Description: To install a 10'X12' shed in the backyard area of the property. 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 Ora & Elliott Heath, received on May 30, 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. 4-1- Glenn Goldsmith, President Board of Trustees 0 H S L _T ST E 0 D RU E S U. T ��. los% 3k . Issued To � �a + E �1:oi'� �2G� Date* Address : 5°° �'" ' PL0aroMe Sotztto. .�d TWIS NOTICE- MUST BE DI001AYED DURING, CONSTRUCTION TOWN TttIIS.TEES OFFICE,TOVIIN OF SOUTHALD SOUTHOLD, N.Y. 11971 'TEL.: 765.1892 t RVEY OF LOT #8, E3LOGK 4 "MAP OF 13EIXIDON E5TATES" N FILED MARCH 16, Ia46 A5 # 14-12 - ro °���ad w E 51TUATE: LD , . r TOm• t �'.. r, i [<USTEES ,��wog°�d+ S 5LJFFOLK COUNTY, NY OF 5 OUTHOLD 2�p�oJtir 5URVEYED 0-7-51-01 PROPOSED ADDITIONS 05-2a-2001 WETLAND LOCATION 06-15-2001 a� 10' VAN TUYL CONTOUR ADDED 08-23-2007 �tioJc PROPVSEO 06-06-2008, 01-24-2oo8ro8-21-2008 - , °° �a�' 2 �,.�o�d 5UFFOLK COUNTY TAX y od 2`?yr�a 0( 2 C� #1000 - 66 - 2 - 13 � e;Q `Pd�A �a°' l! 10 CERTIFIED TO: ob ,Q 5 1 c ° ORA JEAN HEATH �,OCr tJ o� t� x =�' ' . STORY - •` S ELLIOT BRUGE HEATH III P_ o a, rZDDtrioN '�\ S- 0wr� \�J ° sroRr ,c, ' y Fc d`� gay ti O T DATA: ��^� �° h�a 9y ~ �'� o� eo � �G¢°°� DESCfttP ON: AREA: LOT COVERAM ♦ . +'�. - �♦ � . F fl O\d PROPERTY: LANDWARD OF WETLANDS 11. 601 S.F. Vol �� / , '♦ ariD P� '� `.,�� „� +y♦ �� ��\ 2p ��X• 1.6 EXISTING & PROPOSED HOUSE: i, d i a 5.F. 12. 19% Q' ` , , ` ` �� ;OH;� `B ���STOW w PROPOSED PORCH, STOOP. PATIO 239 S.F. 02.06% �♦ N ♦♦ �� SHEDS 272 S.F. 02.34% ♦` ` ♦ PROP ca , o r� i2 TOR ♦ ♦ Ic �, EXISTING & PROPOSED LOT COVERAGE: 1. 980 S.F. 17.06% %♦♦♦ 7� `♦ �� � �b' 2FcP5,�� �� • -`°� �o'- D' ` \ STORY BAL DEC ADJACENT AREA BETWEEN WETLANDS AND _i' ' ' *' ��i �' ��'�""�� e, 4oa S.F. -�' : y \ --' AW2 5TE05 VAN T UYL SO' CONTOUR LINE OF 1982 ♦ .t:... ZkMASONRY P IALK TO t3t EXISTING IN'DEC ADJACENT AREA 5 S.F. 0.06% \ \; _� �� Q \ e V_ �Q - o air ADDITIONS- IN DEC ADJACENT AREA 219 S.F. i.95% �� cv 6p INN CIO O� NIP 0 NOTES: xf I"IONUI�iENT FOUND •0� \ s�\\�♦ ' .f - _. `.•,• •,,,:~ _ i I i P. -. ? ' PIPE.: FOUND O �, �:� ♦�,,^ :ti,: E ; 11AY 3 0 2024 A 5TAKE FOUND o • map line `♦ - -- � ac`oaa ... 7 ctso. . , ¢ LOT AREA TQ MAP LINE 15,115 5.F. OR 0.35 ACRE �y� o� 12LEVATION5 REFER TO M5L. NGVD '2q i �;,�1 - o PARCEL RESIDES IN ZONE R--40 f NE y a F"RE=EXISTf�iGIN6 t �o 1:L�O ra 35' WOW YARD � � � � �� •� ,Go�P� G.,F1� O� ��*rs �.�..�rti,�d the a RY SIDE YARD - TOTAL 25 F �. lZEAR YARD 55 NO !r[ OFBEDRoot s P�'OPo. D DRAI NAGS GALCULATION5: - , _ � *, m.�e,ter���re�a o�c�,tee w SO�C �,�., �, �� VW,� AS PM lam DWELLING ROOF AREA 1414 S.F. � �� OF / 0� � �t ��,; TIDA[. MTLAND HOUi�iDARY A5 DEUIMATED BY TANT Inc. 1 I 1.0 = 1 G.F. ' � � �00 S' � ,�, a%„�. 14 4 X O. 7 X 24 ERT.I�Q / � �' 4�4��7' 10 � S� pon,a„y r, 0,•o,e,R„ipe to pdapv+o,.sftleMve Ori_5-2r-200`7-AND LOCATED AND Blom pox 13Y SYHE30L 1 241 % 42.24 = 5.6q V.L.F. R.EQUIR05 ��T�,��- � � �-� osm Io' hI1DE To eE PLANTEDWITH NATIVE vEGETATYoI� PROVIDE X 5'-0" DEPTH DRAIW7E POOL5 m JOIN C. E."LER SURVEYOR 11 w b Vl.F. PROVIDED 6 EAST MAIN STREET' 369-8288 Fax 369--8287 N.Y.S. LIC. NO.50202 C RAPHIG SGAL 1 - 30 - _ PROPOSED DRYYELL ,N.Y. 11901 REF.--C:Mocumeats and SM-.gslOvvnd DesktopU ath\01 247 proposed house pro Glenn Goldsmith,President r�p�OS�FF04 a Town Hall Annex A.Nicholas Krupski,Vice President �� �'< 54375 Route 25 Eric Sepenoski P.O.Box 1179 Liz Gillooly �y • ��;' Southold,NY 11971 Elizabeth Peeples ��1 Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: CD 101'7A Completed in field by: L I ORA HEATH & ELLIOTT B. HEATH III requests an Administrative Permit to install a 10'X12' shed in the backyard area of the property. Located: 500 Hippodrome Drive, Southold. SCTM# 1000-66-2-13 Typ of area to be impacted: Saltwater Wetland Freshwater Wetland Sound jBay Part of Town Code proposed work falls under: Chapt. 275 Chapt. 111 other Typ�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.: < c Present Were: G smith N. Krupski E. Sepenoski . G L. Gillooly E. Peeples r Standard Features sera Gardens Compare our quality, service &prices ,w=d- before you buy a shed 456 Route 25A Mount Sinai,N.Y. 11766 (631) 474-3800 2251b.20 Year guarantee asphalt self-sealing shingles 1/2"C.D.X. 16'O.C.Double gusseted roof Overhang on in your choice of 6 colors. Plywood roof trusses for unmatched all four sides sheathing strength eliminates streaking from water runoff Finished soffits for beauty and weather tightness Maintenance Free aluminum corners. I 00 2 Aluminum Jalousie windows with screens &shutters,or choose Full 2X4 optional windows. Kiln dried stud Custom placement at walls 16"O.C. no additional charge. ` Latex/acrylic exterior paint Renforced Double Doors Full 2X4 sill in your choice of 13 colors NIC for custom placement plates on all or clear-seated ce of Pressur Choice of Pi ensure Treated Choi e Treated four sides Maintenance Free Duratemp® or Exterior Grade 5 ply or Kiln dried 2X4 floor PRESSURE TREATED 4X4 5/8"T-1-11 Fir Siding plywood floor joists 16"O.C. foundation beams 3 on 81,5 Jacks&Headers in all door on 10'&12'and 7 on 14'wide framing to meet all State and Local Building Codes SIDING:Duratemp FOUNDATION:Pressure Treated 4 x 4 ROOF:3 Ply Plywood Exterior Sheathing On Tech Shield RAFTERS:2"x 4"—16"On Center FLOORING: 5/8"Exterior Plywood or Treated Plywood TRIM:Perma Trim (Non Wood)or 1x3 Wood Trim SIDEWALLS:2"x 4"—16"On Center WINDOWS:Vertical Siding What's so special about Gera Gardens Low Maintenance Duratemp° 5/8" T1-11 Fir Siding? Endures all temperatures and weather without cracking, splitting or checking. — No boat patches. Keeps its paint at least twice as long. — Won't show dents or.hammer marks. Gera Garden's Also Offers Maintenance Free 4 %" Dutch - Lap Vinyl Siding available in 11 colors — Two Aluminum Double Hung Windows are included plus standard features listed above n Our You - re darn right It's guaranteed! If something goes wrong in the first three years with anything on your shed that's receiving normal care and use, we'll replace or fix the guilty party. 15 Years With The Manufacturer As long as you are the original owner, Have the original receipt, and as long as your shed has not been struck by lightning, tried by fire, subject to any other abnormal treatment or man-made condition (i.e. sprinkler / water damage) or has been moved from its original location and or altered in any way we will quickly solve your problem. Utility Sheds and Playhouses have a one year warranty. All you need to do is hold on to your invoice. Xx This is a limited warranty. Following the 3 year in house warranty,the manufacturer Pro-Rates each year by 5% for the remainder of the 15 years. Gera Gardens is a third party retailer and labor is not included in the extended warranty. Please see sales associates for details. TG 3/2022 SEE SEC.NO 058• iS19� - � 5[c,po me �'0.WTCN L E' • _ _ ,ya FOR KLNO. SEE SEC.NO =aaei \•',•t••: 51•\1r'. -{ 'wo 0-5d013 @" 9 Vyc) `\'h,aT.i. bTt�,q\'E v� 1S + lip 3 ' `,b ''\�,\._(moo••`., .a'``; b`v �k � F - � , \ rZpSplc1 (212. - - - � \ �"is'�',9b•r' '�y�s ,"-�.,_`. �— „ \ .a\ - .�•'�` ''a�, �•9sac,"` sc1. 6 +-'ii-��• . ' ___ �' �•� �.. '�, or,9�s ;tiFe �, Air.. �s,p;\ .,e� }4 i°.,;r �� /. , IS q • ,f .;,""\ �, +e':`duo.^,goy' �•, "�%.+' '•'•9, - !'�' I• ( .. :a^•:1\'�q..^...a _., ': �� .'/- •der •'� - e:2IM1.,;tF6.a r,�,.axa ""'°"„"^°°"`"'""•--ram'"' •. — •^.•m�� •v. COUNTY OF SUFFOLK© N NOTICE E 9b' .•�061"'r"� l000 sEcriw No �....., _ __ •�_Yu�_ —— .•a O2 ""^"' —�— t' Reai Rnpeny lzx Service Agency rwxlwvrc xruunw suc oR v N ��__a__ _— __ --- C'rnrn Om.flela.(,5Y 1l9rif w - E diBmvlav pw roairoN OF inE A my o0 SOCTNOLO OCC V VV narea n .._ry i+. aa.a. O.]MTTPXIMP IS a H4�1EU .a«x v.,,c:�„u '' " a'amaerwb (21) .a x> as a xe .m mr�wrvmrtrel rsmasrnaire R ' S rra S9ivKE r�Nxv �� OF SOU��o CAJAU To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: June 11, 2024 Re: LWRP Coastal Consistency Review for ORA HEATH & ELLIOTT B. HEATH III SCTM# 1000-66-2-13 ORA HEATH & ELLIOTT B. HEATH III requests an Administrative Permit to install a 10'X12' shed in the backyard area of the property. Located: 500 Hippodrome Drive, Southold. SCTM# 1000-66-2-13 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 so��� Town Hall Annex ® 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski Q Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 co -- D EC E IE BOARD OF TOWN TRUSTEES I TOWN OF SOUTHOLD MAY 30 This Section For Office Use Only Southold Town Coastal Erosion Permit Application __ Board of Trustees Wetland Permit Application Administrative Permit Amendment/Transfer/Extension �/ Received Application: 01.1 Received Fee: $ aZdo Completed Application: 7 Incomplete: SEQRA Classification: Type I Type I1 Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): �LWRP Consistency Assessment Form Sent: 7 0� CAC Referral Sent: Date of Inspection: b o2 Receipt of CAC Report: Technical Review: Public Hearing Held: /d- Resolution: Owner(s) Legal Name of Property (as shown on Deed): a4 lecal � � /ate & j�f-_t Mailing Address: J�C�© ty'moo Phone Number: �31 - V3y-'3- ZL 3 0- t Suffolk County Tax Map Number: 1000 - Property Location: Z—aYLe I\- 70 (If necessary, provide LILCO Pole #, distance to cross streets, and location) AGENT (If applicable): Mailing Address: Phone Number: Email: t _ )ard of Trustees Applicati' GENERAL DATA Land Area(in square feet): S J`, , l �J ? Area Zoning: Previous use of property: i3a-COY` ro-S a i Intended use of property: 1 Covenants and Restrictions on property? Yes ✓No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes ✓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 y demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure (s) on property have a valid Certificate of Occupancy?_V/__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? No Yes If yes, provide explanation: Project Description (use attachments if necessary): S —rd (3 e, j�)�o -ems uy 1B mks:! �Al n �r �- LIDO�© ,yard of Trustees Applicat: WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: d r— C 6�s Area of wetlands on lot: _ 1 5(0 Sl'square feet Percent coverage of lot: bk % Closest distance between nearest existing structure and upland edge of wetlands: 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? Po p"� 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: ey 0'-r4-�- 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): /(�is k) X-1 61 Z20 Appendix B Short Environmental Assessment Form Instructions for Completing Part I -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 Informatiioon S:HC_a_ o n Name of Action or Project: Project Location(describ and attach a location map): Brief Description of Proposed Action: oA 63 Name of Applicant or Sponsor: �3 ) i Telephone: I —(!3 q �2�a �� ���` �. 2 � E-Mail:D `fl m-0 & P q Address: city/P State; Zip Code: 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: ❑ 3.a.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? acres SI- 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 MI residential(suburban) ❑l;orest ❑Agriculture El 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? ❑ ❑11 ❑ 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? ❑ n� 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical,Environmental Area? NO 11YrrE IIS If Yes,identify: I I ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES 11 b.Are public transportation service(s)available at or near the site of the proposed action? E� ' ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? F v1 ❑ 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: ❑ ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: �P ❑ 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 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? El ❑ 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 ❑Agricultural/grasslands ❑Early mid-successional Wetland ❑Urban 2 Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed RNO ,YES by the State or Federal government as threatened or endangered? ❑ 16.Is the project site located in the 100 year flood plain? 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? I�,VO [—]YES b. Will storm water discharges be directed to established conveyance systems(run and storm drains)? If Yes,briefly describe: EffNO ❑YES Page 2 of 4 r 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: ❑ 19. Has the site of the proposed action or an adjoining property been the location of an active or closed NO I YES solid waste management facility? If Yes,describe: i ❑ 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 r/I ❑ 1 AFFIRM THAT THE INFORMATION PRQVVED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsorna Date: 1a- 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 ❑ regulations? 9 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 �� ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a.public/private water supplies? b.public/private wastewater treatment utilities? ET 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage ❑ problems? [:�( 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 (_ =lard 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. Si n e of Pro Owner SignaturFf operty Owner SWORN TO BEFORE ME THIS DAY OF , 20 Notary Public JOANotary Puub c,S ante of New York No.4953027 Qualified in Nassau County Commission Expires . G��o� 7 APPLICANT/AGENT/REPRESENTA.TIVE TRANSACTIONAL DISCLOSURF,.FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The puMose_of this form is to provide inforination which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. _r I-I /, YOUR NAME: 02 14 �J f► / F— I I (Last name,first name,.riddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate,the.other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee ✓ Change of Zone Coastal Erosion d 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 this day of 200_ Signature r Print Name 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 si nib 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 Ido SCTM# - o). -� PROJECT NAME S j:j� QLk& 2 The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees l. 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: r Location of action: Site acreage: r �� 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: (a) Name of applicant: (b) Mailing address: i (c) Telephone number: Area Code (d) Application number, if any: N Will the actio;�= n,/require funding, or approval by a state or federal agency? Yes ❑ No 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 TYes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP ection III-Policies Pages 3 through 6 for evaluation criteria Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section —Policies Pages 8 through 16 for evaluation criteria VYes ❑ 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 1 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 Signific nt Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 throu 32 for evaluation criteria. Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes El 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 o No Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Soup old's water-dependent uses and promote siting of new water-dependent uses in suitable locationsz S e LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 11. Promote sust 3nable use of living marine resources in Long Island Sound, the Peconic Estuary and Town wat s. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 12. Protect agri ltural lands in the Town of Southold. See LWRP Section III — Policies; Pages 62 through 65 for eval ation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 13. Promote a propriate use and development of energy and mineral resources. See LWRP Section III—Policies; ages 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED BY TITLE DATE