Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Levi, David & Jessica
r: rrZ: � r. SURVEY OF PROPERTY " SITUATE: MATTITUCK °-P W E TOWN: 50UTHOLD � � s SUFFOLK COUNTY, NY SURVEYED 07-23-2015 SUFFOLK COUNTY TAX# OV, - 7� 1000- 123 - 5 o�e� � N�o`A o35�pn� �a 22 may°Nyt eN° �P� N7 61 60` 5 7:FO(30 1 0 • 30` �\GN� rO,�ay •Op`_.;, 573k5yga'W o\p�0 sroNE O w Wg1,1 �Py. .....0 ... Qom NOOK �Q':.' W` p 10.1 O G) o m >- wnJ w 3 Y w 000',11_ ¢¢_IO n �p v IQZ N K= 22 OF= J. t� w� u v N 22.3 O Owl v } Q ui aK m O r }�tD c) OOO OHO � 3 ❑ �� m 5.8 Oo�«f 3�� N O�> 0 • 3 lL mo z,�w o p T�or-rL)b 3_9 PE 0 0 3 36.I a J5 0_ N l• l�/ �! 2° LA C9 N0 � 5 �O F E B 2 2 2017 �✓ p�G�N�G r 1 Southold Town i G?V L=Z!01 Truste s -_1 FLOOD ZONES ANNOTED FROM F.I.R.M.NO.3610300482H NOTES: • b-11 a ME mxWb STOC FENCE JOHN C. EIfLERS LAND SURVEYOR - STOLFA�r 'my amp..xae av sgtm o,uie 6 EAST MAIN 5TREfT N.Y.S.LIC.NO.50202 Area =8.917 Sq.Pt. RIVERHEAD,N.Y. 11001 369-8288 Fax 369-8287 btt+q cone.,vra.m ra ima suwr+�<a Area =0.2047 Acres xy a.x..ran s,e<.•.,aaaxe,a, gand y Ion isllandsurve or.com is awv a.e iaaay ex uon s,va way e.a 27'-10" n I t i Lam< 12'-0" T-8Y2" 8'-IY2" �F F— — — — — — — — — — — — FEB 2 2 2017 1 O SoutE."r-c-al dol L-4m A z 90 0.1 O 16W 22nd St New York,;NY WC." CO Cl) Key: — — — — — — — New Construction Existing Upper Deck PROJECT I NO: 25 DRAWNfaY: AD Existing DATE: Feb 14,2017 SCALE: Af SREET711LE. DEMO PLAN SHEET N 001 '��^+ram.� r�a.�-...��� • �'i l yi • R �rr 90 New York.NY Syr m< In \ l� PHOTO 1 0:7] _ rn m< z 90 76W 22nd St New York,NY a a '•' fl Y PROJECT NO DRAWN BY: ZAD OHEONED BY: SLS V j � DATE. Fed 16,1077 ,,. /" I � ;. 3.� � ' ,f �♦ • a'# SHEET TITLE: PHOTO SHEET NO'. 006 rn z J 90 r n � ` o 16W 22nd St New York,NY .�J I a� I •y _ - .ram.. _ \ PROJECT NO. 25 ` y1�, rf. l w_ • •, DRAWN BY: AD i '��• �- �� CHECKED BY. �yy SLS �i �� �I• `, DATE: Feb 16,3017 SCALE'. j L SHEET TITLE. PHOTO SHEET NO'. 005 rn [ DO o 16W 22nd St A. New York,NY I,. PROJECTNO'. 25 AD •sue \\ SS � \ DATE: FaE tl,2O17 SHEET TITLEPHOTO SHEET NO 004 rr v�• 1 11 FORM No. s TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy Z9383 January 9 79 No. . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19. . . . THIS CERTIFIES that the building located at . .4415.Camp Mineola ,Rd. }IX Map No. . . . . . . . . . . . . Block No. Lot No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REWUUIREMENTS FOR ONE FAMILY DWELLING BUILT PRIOR TO conforms substantially to the p CERTIFICATE OF OCCUPANCY dated . . .A. . .. . . . . �3. . . . . . ., 19. . . . pursuant to which No. .Zs3383. dated . . .Janus. . 9. . . . . . . ., 19 79., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is . . . . . . . Primate One Family. Dwelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The certificate is issued to . . . . .Wm. J. Tu faro & Julio Grilli , , ,, , (owner, }ea�emt�c#�eJ of the aforesaid building. Suffolk County Department of Health Approval . . . . . . . . . . .Pre.-Exis.itng. . . . . . . . . . . UNDERWRITERS CERTIFICATE No. . . . . . . . . . . . . . . . . . . . . . . .Pre 7. . . . . . . .Existing. . . . . . . . . . . HOUSE NUMBER .4 15. . . . . . . . . Street . . . . . . . . Camp Mineola Road Mattituck, New York . . . . . . . . . . . . . . (. . . . . :. ..ryl. . . . . . . . . Building Inspector County Tax Number 1000-123-9-23 i tsuiLDING DEPARTMENT TOWN OF SOUTHOLD, N. Y. HOUSING CODE INSPECTION REPORT Location 4415 Camp Mineola Rd. Mattituck number & street Municipality Subdivision Map No. Lot(s)' Name of Owner(s) Wm. J. Tufano & Julio Grilli Occupancy R-1 owner type (owner-tenant) Admitted by: self Accompanied by: self. Keyavailable Suffolk at Site Co. Tax No. 1000-123=5-23 Source of request '• fO Date January 5, 1979 DWELLING• wood one Type of construction #stories Foundation wood posts Cellar Crawl space X Total rooms, lst. F1 6 2nd. F1 3rd. Fl Bathroom(s) 1 Toilet room(s) Porch, type Deck, type wood Patio, type Breezeway Garage Utility room Type Heat electric Warm Air Hotwater Fireplace(s) No. Exits 2 Airconditioning Domestic hotwater yes Type heater electric Other ACCESSORY STRUCTURES: NONE Garage, type const. Storage, type const. Swimming pool Guest, type const. Other VIOLATIONS: Housing Code, Chapter 52 Location Description Art. Sec. 1st Bedroom windows too high and small 52 28 C 3rd Bedroom uncovered electric switbh 52 56 1 Remarks: Inspected by:_C� __Date of Insp. January 9, 1979 CURTIS HORTON Time start 11:15 end 12:10 PM AM i FORM NO.6 TOWN OF SOUTHOLD Building Department Town Hall Southold,N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink,and submitted in duplicate to the Building Inspec- tor with the following;for new buildings or new use: 1.Final survey of property with accurate location of all buildings,property lines,streets,and unusual natural or topographic features. 2.Final approval of Health Dept.of water supply and sewerage disposal—(S-9 form or equal). 3.Approval of electrical installation from Board of Fire Underwriters. 4.Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa- tions, a certificate of Code compliance from the Architect or Engineer responsible for the building. 5.Submit Planning Board approval of completed site plan requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1.Accurate survey of peoperty showing all property lines, streets, buildings and unusual natural or topographic features. 2.Sworn statement of owner or previous owner as to use,occupancy and condition of buildings. 3.Date of any housing code or safety inspection of buildings or premises, or other pertinent informa- tion required to prepare a certificate. C. Fees: 1.Certificate of occupancy $5.00 2.Certificate of occupancy on pre-existing dwelling or land use $5.00 3.Copy of certificate of occupancy $1.00 p Date .......... . � New Building ............. Old or Pre-existing Building ...x. Vacant L fd ............. Location of Property .Zi�y� .. ?�'P / yam?c�¢ (�....... House No. Street ��r Hamlet Owner or Owners of Property r�!! : � ..`.U.F' !v�,,. .-1 U e ..'',r�.......,,.. County Tax Map No.1000 Section ..1. 3...... Block .... . ....... Lot.....AJ.. ..... Subdivision.................................Map No. .. �.. ...... Lot No. .............. Permit No. .......... Date of Permit ..........Applicant ..".". f:.. .. ............. Health Dept.Approval ........................Labor Dept.Approval ....... ................. UnderwritersApproval ....... ............... ..Planning Board Approval ... ..I........... Request for Temp ry Certificate............ .........Final Certificate ..X................. v_v Fee Submitted$.. ...................... Construction on above described building7andmi ets all app' able a nd regulatio s. Applicant ....... . ......... Rev.10.10-78 0 IE DING DEPARTMENT TOWN OF SOUTHOLD, N. Y. HOUSING CODE INSPECTION REPORT Location / . number & street) Municipality Subdivision Map No. Lot(s) Name of Owner(s) Occupancy type owner -tenant Admitted by: o?/ Accompanied by: ,� Key available Suffolk Co. Tax No. /d2 —d2 3 Source of requestf� ��/rr,,i- Date DWELLING• Type of construction ,wr #stories / Foundation Cellar Crawl space Total rooms, lst. Fl _2nd. Fl 3rd. Fl Bathroom(s) / Toilet room(s) Porch, type Deck, type�r� Patio, type Breezeway Garage Utility room Type Heat_d Warm Air Hotwater Fireplace(s) No. Exits Airconditioning Domestic hotwater Type heater _9 ` Other ACCESSORY STRUCTURES: Garage, type const-. Storage,- type const. Swimming pool Guest, type const. Other VIOLATIONS: Housing Code, Chapter 52 Location Description Art. Sec. Remarks: Inspected by: Date of Insp. Time start �'� /.f end ' /� oy0s�Dl��oa Town of Southold 7/1/2016 P.O.Box 1179 3 o - °� z 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 38374 Date: 7/l/2016 THIS CERTIFIES that the building ADDITION/ALTERATION Location of Property: 4415 Camp Mineola Rd,Mattituck SCTM#: 473889 Sec/Block/Lot: 123.-5-22 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filled in this office dated 11/12/2015 pursuant to which Building Permit No. 40292 dated 11/23/2015 was issued,and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: ADDITION AND ALTERATIONS TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR The certificate is issued to Levi,David of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 40292 05-31-2016 PLUMBERS CERTIFICATION DATED 06-22-2016 Gorge J.Berry Jr a ' 6 Author' d Signatur �o�s�FFoc,�coG Town of Southold 10/5/2015 y� P.O.Box 1179 a A 53095 Main Rd Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 37812 Date: 10/5/2015 THIS CERTIFIES that the building ELECTRICAL Location of Property: 4415 Camp Mineola Rd,Mattituck SCTM#: 473889 SeeBlock/Lot: 123.-5-22 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 3/15/2013 -pursuant to which Building Permit No. 37871 dated 3/18/2013 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is: 200 AMP UNDERGROUND ELECTRIC SERVICE The certificate is issued to Willets,Adam of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. 37871 09-16-2015 PLUMBERS CERTIFICATION DATED Authorized Signature FORM NO.4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold,N.Y. Certificate Of Occupancy No. . . Z.14 4$A. . . . . . . . Date . . . . . . . .J u n e. .5 . . . . . . . . . . . . . . . . 19 8 6 THIS CERTIFIES that the building .Oew„foupd,.,, , 2n4 .story. add, , 7 ,1st„floor alt. Location of Property . .44 J 5. . . . . . . . . . . PAIDP.Mir;19 a •Rd;• . • . • • . • . . . . . .Matti tuck House No. Street Hamlei County Tax Map No. 1000 Section . . . .M. . . . .Block . . . . . . .5. . . . . . .Lot . . . 2?. . . . . . . . . . . Subdivision . . . . . . . . . . . .X. . . . . . . . . . . . . . . . . .Filed Map No. . . X . . . .Lot No. . . . X. . . . . . . . . conforms substantially to the Application for Building Permit heretofore filed in this office dated •S e A t m b ez .5. . . . . . 19 . $5pursuant to which Building Permit No. . . .14 2 9 7 Z. , , , , . . . . . . dated . . . .S e At Q m b e r; .Z 3. . . . . . . . . . 19$5. ,was issued,and conforms to all of the requirements of the applicable provisions of the law.The occupancy for which this certificate is issued is . . . . . . . . . . . . .Nem -fPJLLndat�,04; 2.114. St.Q''y. A41ition,. and, remodel 1st .floor: . , . . . The certificate is issued to . . . . . . . . . . . . . . . .N R,. A N O D S T E R N (owner,ikWWPKIM4 1 . . . . . . . . . . . . .. . . . . . . . of the aforesaid building. Suffolk County Department of Health Approval . . . . . . . . . . . . . . . .N/,4. . . . . , . . . . . . . _ . . . . , . . . UNDERWRITERS CERTIFICATE NO. . . . . . . . . . . . . . . . . . . .197.4.9.7$2. . . . . . . . . . . . . . . . . . . . . . �C C c"L . Building Inspector . Rev.1/81 eo o suF o E �. EL FOR POL NO. 3^ i •P. �� r - n•. _"":._ '�.,:+'�::5�^c.�e!'?1,T,.-`T.rp�r,-- �( - SEE SEC.NO. 37. , .d n� mB' m4 F,o .� ccF.O s' - �d'•..+^`..'^m S<.*] nsmwoe 2 '�a, T �r m 0 s ,• •A s� "- I�r�:-s.,' T B 6 a. FOR POL NO. $ ; 'm m '�♦ 6•• '� ,s'� \� ,^,II� 'N SEE SEC.NO. 1T1-BSBOA ^ nI °o�3,•A .m 9 ++� 13 a +a +g,a.o` y�R \..�... ® b 1 Y TOWN OF SO � 21 5 Ty15C1 ,T '•`'ra UIROm C mm A O 2 210?�� $S • Hn nx m! CREE �._6 K 15.BA PQ CEN B 10 B° 2• •• S• S. nn Z* J ..��._ a Y ,��,,'0 ' 23a, 3O2 m.1 33 �1.]AIc)�. . 2�: .� 29 A �'tA 1 O• o G �_•N� 6 A+ QO�/. �` 3 A s 4.5 26 32 - A.T .r r, g 9 z9 � P-m ° +�, ,a je •,9 yA. � ��P e` ,a j` S] a •, lA 2 3 9 2°'+,zr Y`� m c �� aoS 58 B3 �' P� ��, �', � ;r •e � � Hr ,` A.,a T , ,. 6 m, o+ oe` • . 0 "fFt , A nt1��y • // 0,1 4 0O) 9 1�` Bg 3 � ,22 to 15 9 _ Hr j6 t3 ,ti+aeT. '•' f�9�r r fg O owe • y Y y%' 'i 'sz+'.2+2 zs g,i*• ®jam./ - PEGON)C gA • zt za s ®j /' GW 1 s L "w+• �+` `"` Za _ O1"'� ��'A0n i6� NOTICE amar COUNTY OF SUFFOLK © K rnyxtuTMOty SECTION NO E sou ��.r —�— I•I Q � --r-- �� Real Property Tax Service Agency y E .., �a .. r —_— �„ --a-- mww--.-- prouwuxrvnx,ur�svxauN, eavxtre�n,nw.emea4,Nrns6t , VittA°6,u 123 iv. ty.o.0 M, o a ,:,Hrv,nu ---- �� — -- w,ranwn�rrax.aaaasv°x°t,xa tar. n[umov[nnrraacrmc[.ctxc.EOi p AT NB foo0 ' PROPERTY MAP w2gswx 4,R F.e�4ta,t _.. —- - — e..:.. - -..(8 - --- O _ /Cf`61KC:Otlllt�/N.,Y gOV/��CC�C. :..-r �- ,ti•- ,. OOj3A2-3920 "• .,;,. ,-- Domestio.Violl:nce,lioiline - - W1NW" UffO �c - - - - - u ov. 1 c r e_ k b.S C ton r. _ :_.^ �.� " .p,.. 'Plans. �• '��.� Michael J. Domino, vice-Proms -+enGP.O. Box 1179 m King. � James F. ng, Trust(. ,' r S6'ut, ,l, New York 11971-0959 ' � Dave Bergen, Trustee Gr � i Telephone (631)765-1892 Charles J. Sanders,Trustce Fax(631) 765-6641 BOARD OF TOWN TRUSTEES D TOWN OF SOUTHOLD FEB 2 2 2017 To: Southold-Tow6 Building Department Re: Verification of Building Department Permit Requirements BUILDINGDEPT. TOWN OF SOUTHOLD SCTM#: Property Owner Name: ' LEVI _ Date Sent to Bldg_ Dept.: 2.ZZ,17 The Office of the Board of Trustees is forwarding the above referenced application for verification of the Building Department's permitting requirements stated below. YES NO 1 - -P �.� . Will the proposed project require a Buildi �- � (S.5-1tJ S � ill the proposed project require a var � S i a l the Zoning Board of Appeals?7 I = Will an art of this application be considd any PP C ' 'described under Town Code? COMMENTS: -w- z_- Signature of Reviewer Date .5 John M.Bredemeyer III,President O�*QF SOUTyQI \ Town Hall Annex Michael J.Domino,Vice-President ~ O 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G ® p ,c� � Telephone(631)765-1892 Charles J. Sanders Ol�'CDU V Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application/ _Wetland Permit Application �/ Administrative Permit / Amendment/Transfer/Extension t/ Received Application: 21�,17 Received Fee:$ � _Completed Application 2•2Z-I _Incomplete i' _SEQRA Classification: L f i! Type I__jype II Unlisted r �' Coordination:(date sent) 1' "" LWRP Consistency Assess ��Form ' F E B 2 2 2017 CAC Referral Sent: I ; _Date of Inspection: .(� I } _R Southold Towneceipt of CAC Report: � �—�----BoarciQr�s;ees _.f _Lead Agency Determination: .-.. Technic.alRevie_w.._..--..,.... . Public Hearing Held: Z, Resolution: Name of Property Owner(s) _D i)V l")1 -r- I L,4 I—��V Y Address LH I M P M 1(J 6 L_A F, . M A Ml 114C4.4 Phone Number:(Ib*3 Suffolk County Tax Map Number: 1000 - 5- 2-2— Property Location: I°� C-A{�P � OLA �/� , � —ULK (provide LILCO Pole#, distance to cross streets, and location) AGENT: 0� C_ � l.� O (If applicable) Address: U,DlaA' `f/ �i 1 Phone: `,rd of Trustees Applicati. p q GENERAL DATA Land Area(in square feet): Area Zoning: - LID Previous use of property: °y E,,,y T-1 A-t_ 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? —X—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 __,)C_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 No Does the structure-(s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency Date 0 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): 44 O 1� ��X 7 X ��CI S t rah b� C 11:5AVm L del W h e�rAic, ird of Trustees Appli.catir WETLAND/TRUSTEE LANDS APPLICATION DATA t Purpose of the proposed operations: (5 1D S174t — i Z' )c-7 No% 1 0 Area of wetlands on lot: ® square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: 41 ,-7 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? 6_/0 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: C-1-? 6%/ 511"& TO (Le- /Urld, Manner in which material will be removed or deposited:� � Z06 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): i e . 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 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*oAdiec ct and Sponsor Information Namn or Project: Project Location(describe,and attach a location map): 4qLS`L"� Mideo- LA- )YL M A-m i TUril Brief Description of Proposed Action: �-� ��� / 61-` it 7' �-- 10 17OrJ� . E 915rr�, `I��Z� F(LA-Kt.,J Tb ROPIA-4 W � ta g� alb 46, �b l�L�b. s-t-j S rn ,(L& i 6 Name of A pliictant or Sponsor: Telephone: E-Mail: J Address: city/PO: State: Zip Code: 1.Does the proposed action o ly 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: o O�0 L"0I fa-L �� 3.a.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? .0i acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? U 47 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban [-]Rural(non-agriculture) ❑Industrial ❑Commercial Residential(suburban) ❑1 orest ❑Agriculture ❑Aquatic El Other(speci y): ❑Parkland Page 1 of 4 , I 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ 91 ❑ 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? IN 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: LiK, ❑ 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? M ❑ 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: ❑ ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: El 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment:��i /6"' ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? _Ner ❑ b.is the proposed action located in an archeological sensitive area? ❑ I3.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain O YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ Pq b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? (1�' ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Iify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline El Forest ❑eAA 'cultural/grasslands ❑Early mid-successional ElWetland ElUrban urban 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 YE 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, [:]YES ❑ a.Will storm water discharges flow to adjacent properties? ❑NO b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO DYES Page 2 of 4 i 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: X 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: ❑ I AFFIRM TH#THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLED. ( a Applicant/sp sor name: d Date: b / Signature: Part -I act Assessment. Th /ead Agency is responsible for the completion of Part 2. Answer all of the,following question Part 2 using the information contained in Part 1,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? El EL 3. Will the proposed action impair the character or quality of the existing community? F-1 El 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑ Elestablishment 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? El El b.public/private wastewater treatment utilities? ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, El ❑ 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 1 No,or Moderate small to large impact impact may may occur occur 10. W ill 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 --,.,Boakd of TtUSte0Z Application AHADAVIT 'biqvtj�) + —BEING D,UI,Y SWORN '5—EPOSOUi�ND AFFIR.MS TIE T 11cislur ISTHt APPLICANT FOR THE ABOVF DESCRIBED-PERMIT(S)AND THAT ALLSTAITNIENTS CONTAINED HEREIN ARE TRUE TO THE BUST OF HIS111101"'ONVLEDGIP,AND BELIEF,AND TITAT ALL WORK WILL BE DONE INT112'XIANNUR Sff,FORTII INTIIIS APPLI(-..-VrION AND AS IN-JAYREAPPROVED BY THE SOY.THOLD TowN BOARD OIL TRUSTEES. TJIE APPLICANT AGREICS TO'HOLD TIM'TOWN OF SOU` HOLD AND THE BOARD OF TRUSTEESITARNTLESS AND FRF*-E FROM ANY AND ALL DAMAGES NITT(S), AND CLAIMS ARISING UNDER OR By VIRTUE OF SAID PERI - IF GRANTED. IN CONIPLFTING TIIISAPPI,ICXI`IO'V-I HEREBY AUTHORIZETUE fRUSTEES,TIIF,1R AGENT(S)OR REIIRESENTATIVI:S,INCLUDING THE CONSFRV.NTION ADVISORY COUNCIL,,ro ENTER ONTO MY PRO-mRTY,ro INSPEX.7 THE VRENIISrS IN CONJUNCTION WITIITRIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AZ T110P.17%THE BOARD OF TRUSTEES TO E Ni7-ER ONTO-14Y PROPEIrFY AND AS RE(QU 1P.1g))TO INSURE, COMPLIANCENVIT11 ANY CONI)ITION OFANY WETLAND Olt COASTAL EROSION PERMIT ISSUED By 1,11p BOARD oF TRUSTEES JXTRINGTHE TERINI OF THE PERN111T. lk)rek)vl,v0PCrt, vvj4q. er 1 4� y IV JL 4-A SWORN TO BE-F'OkE ME THIS DAY OF 20 /9 Natazry Pul)lie SOBIA ARSHAD Notary Public State of New.Y6rk No.OIAR6252307 Qualified in Kings County. My commission Expires Qec"5,2011, '€:f.• "'Sri`=fr - aj; ! f , J{ • :fvyr r '116AV T BEING DULY SWORN DEPOSES AND AFFIRMS�.YEA'T;HX-1 IIE'IS'I'fIE.AP�' ;ICAI 'FOR�CIIE ®VE DESCRIBED PERMIT .WI (S)A THAT ALL STATEM19-NT SiiC,ON AINEID HE, ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORD WILL BE DONE IN,THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APFR0�1EH'W `�' °5OiJ'I'HOLI)TOWN.BOARD OF TRUSTEES. TILE APPLICANT A ItEES TO HOLD TR�'�'OWN ®F`SOU'I'HOLID AND THE BOARD OF TRUSTEES HART�MESS ANDI FREE.FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY,VIRTUE OF SAID PERMIT(S),IF GRANTED. �N OI1%I FIJET 1.CBrT'I YS"APPT;Ii 'AT IO _p.I;.HEREE�Z.AUTkIORIZE THE TRUSTEES,THEIR AGEN '. S,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER Ol�]T�Ii�IY PROPERTY TO INSPECT TgIE PREMISES 3I1�1'ttTION,y6,,U.li;THIS�APPI iCATION, INCLUDING A FINAL.INSPECTION.UFMTHER HOR IZ_"TCHE 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. ature of Property Owner SWORN TO BEFORE ME THIS . /. b>� DAY OF 20 U . ..- lV�t �� -- SOBIA ARSHAD blic Notary Public-state„p,�neW'fork, NO.01 AR62li2307 Qualified in:Kings County" My Commission Expires Dec 5,;'2019 ♦ Y 1 Board of Trustees Application AFFIDAVIT �ky L-W; BEING DULY SWORN DEPOSES AND AFFIRMS THAT HERRE 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 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. l Si a roperty Owner SWORN TO BEFORE ME THIS , 1 / DAY OF �" - 20"'e 0�. ,W.... SOBIA ARSHAD. • 'of.%1 r4 i rr r� --- - -- - _ FNotaryblic-State-o..New YorkNotary Public O.01AR625 M •fied in Kinds County.:, sion Expires..Dec 5,,2019 Hoard of Trustees Application AUTHORIZATION (where the applicant is not the owner) I, residing at (print name of owner of property) (mailing address) .do hereby authorize.- (Agent) to apply for permit(s)from the Southold Board of Town Trustees on my behalf (Owner's signature) rd of Trustees Applicatic, AUTHORIZATION (where the applicant is not the owner) I, D&A L) t Te s►ce,, 1_,e_,i residing at (print name of owner of property) (mailing address) do hereby authorize -S4s Gvj (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. w e s signature) APPLICANT/AGENT/REPRESENTA.TIVE 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. p YOUR NAME: :,wow v ow �. (Last name,ffrst name,zpiddle 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 partiat 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 br position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): 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 da of rY Qa' 2001 Signature ae/✓ Print C. uro Form TS l 3 Api,iL,ICANTIA6r,,NT/RFPRI,:SV�N'JrttTIVI', TRANSACTAIINAL DISCL0,SURRYORNM 0. --fliet";�011 i aand nlitnv it Wl"kirm.r.r action Lv tim =013r,.,=,7711svo-, an -fiPany.l(w.imlicale LVC other wims or APPLICATION;ptc&.all Oot oppily.) T*6ievancr. Variance Ttustca C11ingporzone; Ap;mvnl Of Plot Emmuption from plat ar Official rnap 0111cr (If"Other,nwou Me=-Iivity.) I)o)-tu yetsonalLy(ot uitoqmhyovrcompany.s;wsr,;s1b1inr,;pateat,orchilll hiv!2 reta6onshio ivith any offiW1,of CRIPyDycc dd,4 Town qMuthold? by W4 mwbm 0*rw b =SS ilttcrr-�V a husin,:A. incidding a Weershir,in%wIjich die tawn ofriccroremPloYce has c*vt a fortial eivncrt-10 of W cmP'0YV1=d by}ac'64tot'atIO' in which the town,officer or empfv)-oqjjs,mre than 5%of sl=M YES NO Tide;mor M-41foll 41hat pmw , m.4)cii&-dk;m1mi6wItip betty )*='•L,F(dt, uIxt tit:town olr=or mnrb))=Either check the oppco O:a c 11m,A)Ah;qkj?,h D)antO�Ior rIescsibc in d tc--P=prov Mcd, The town oftieer'or employee at hi,or Ness c,siblirT.parent,Of Lbild is(check nit A) (whci 16:qpticant is a wtItaftli6al); P)the 140 orbCatficb,I o-Ter Of aAY iftlem-�tsir�'009m,"lF�16ty(wb4ale. nmlt=a is'cot a CoqKw.2t1&1)., —D)tit-actual opplicni, I)I-SUIPTION 01;RELATIONSHIP Submitted this—!7 jola,�y Print xMile.— Poem TS I i��rrvzc,�T��c��l<�mar,rrtaF�a:�r'a'<�Tava , TRA SAC:TJONAL DIKLOSURE FORM 1 of tnsvri i7ltert al i � arcs_llu,, t �m of '1"iEc��tcnt arFSoatl�taJ.A's C.axlr.n11i1Pa4ti n.shill"ais crcyn�tiC• irieiti�[txm tttC„p•!t t?a,.IS 'r"'_.P3c� '[fi.'S!'�-••-�- thi•e Fastn i to nmvri«le"ettfg tj)tne which Can 10 tl:r.td wn ts'f mr ife__.lecla.�r1'3iticfqt7 anrt aP{mv i!f tit,:u h itrver aC.iors ns aCdL45.�,?n}to:nt'mid i::nit:,, Y010L NAhIE: .� .a._./ 1 ��...__ 55 C.�=•-•-.,.i' = ([ 1 name first n er�,>aaid'We.initial,unt_.ec you 4et applyingin the Waco of Sanxot'.'olds dxolber6111(y,awb as n Company.If<o,inclicam:Itc outer PCt9an'5 ar cg.-npaftyIs tk^74') NAM OF a1PPLICr3TI0N.(0teek ail that alilily.) T'ax pievantx lSiiidin� vaiianca Trustee Chnnl;c of Cowtil Erosion _ Ap,rmml of plot Mooring Exculptiorr Rant pl:a or official romp Ptaani¢ Wicr {If"Othcc.chair the activity) trzr'}aulxmnalty{nranoa-12)wr company.3;wasc iblinr,pateaCor child)havcarclaii4AS`lip with wlyo!!t6reOfemployce of tot Town of Sdtatlwtd7"RclarituLdtip"41010"by bloid,roniagp,or behirss ititcmit.•'Itatcin s in:ct� 'rtrG`nns a txrsir>va 5nclriding tm p4rtim rslaip in%oieh dx taut aflica!T�: ;a psrwil otvirrship of(ofeoiploymme by)a carpotallon in,,vInch the town offta r or omplo}cc otetis mate YES --•-- »- NO .• if yoi atui%med"YES",couVeja a iltabalarce of Ids fowl Atka dale and sim-%v'h-rm lo;r=.luL N nc of pcmn cntpatyvd by the Town of 5OWWRI Titleor,fo::itvary arthat pe=ii l — q�eiilie ttme rt:latian ilia betwwn}'au^slt'{tits apltliamNal aattltepte'�cntativd)tint tit tatrn ofi"rxr or ClarbIw.Either chtxk Itcip{xvpm—c line A)throagh D)amtPor dexlibc in Ice sTaco prvJ&lcrL The town oiN r or employcc or his or her mi oi:te,sibling,paren4 or child is(cbcck:ill'Ord pply): A)4bS otrntx ofVCavler than YA afthe slt=s Of the c*"Calt stock of Ute,udzliowt (wbcii the zppti=t is a Corp6tkiio nx D)the lcg d orbenatid it owner of;ty in".ere�t in a non-rmrvor tc entity(whin the apltl'ic ant u mt.a Canto Matto), C�anof loer.director,l>WL=n .®remplo?cc of tu). licz:rt;or n)the actual Opp Kean 1,)lifiCR.IPTION 6F PPLATIONSIIIP Subartittdd t I df: of f__,rc ,I 2UQ (-1 Si{ furc V-� t'ritmtNsttrc,„„ Forin TS I . m i Town of Southold - LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form.should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant ficant 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# �-3 - --� - 2 2— PROJECT NAME L EV I 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) Pen-nit, approval, license,certification: Nature and extent of action: / �� 't / D 4��� �s��R� X � � 1 ,1S �r- /-Sr4 A;1 ISi/A � 7-0 0la, �AM L�- � s-5� ��0& �� Location of action: �`f�5 C P M O&OL-& f�d� �1 1 064�o Site acreage: r 2-®qj Present land use: Present zoning classification: P,40 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 Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III 7 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 ❑ NoXNot 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 PtNotApplicable s 8 through 16 for evaluation criteria ❑ Yes ❑ No. 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. ❑ ❑ T� Yes No Not App . ..,ble 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 See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ 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. ❑ YeF-1 N 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. Se WRP 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 w ers. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ N 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 eva ation criteria. ❑ Yes ❑ N Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate 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 B DATE TITLE l ��