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TR-10652A
� � Glenn Goldsmith, President 5o Town Hall Annex54375 Route 25 A. Nicholas Krupski, Vice Presidents P.O. Box 1179 Eric Sepenoski 3 Southold, New York 11971 Liz Gillooly CATelephone (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 OFFICECHECOKED OFF 72 HOURS PRIOR TO COMMENCEMENT OF THE AC IV T ES BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 sc day of construction '/2 constructed When project complete, call for compliance inspection; Glenn Goldsmith,President `�QF S0 Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ,`®V� ®�® P.O.Box 1179 Eric Sepenoski J Southold, New York 11971 Liz Gillooly cgs Telephone(631) 765-1892 Elizabeth Peeples ® �� Fax(631) 765-6641 c®m� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10652A Date of Receipt of Application: October 2, 2024 Applicant: Kenneth & Kathleen Heidt SCTM#: 1000-126-11-22 Project Location: 8530 Peconic Bay Boulevard, Laurel Date of Resolution/Issuance: October 16, 2024 Date of Expiration: October 16, 2027 Reviewed by: Board of Trustees Project Description: To construct a 12' x 30' on grade patio. 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 Nathan Taft Corwin III, Land Surveyor, received on October 2, 2024, and stamped approved on October 16, 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 SURVEY OF PROPERTY tS� SI T UA TE A� ' : MATTITUCK TOWN OF SOUTHOL•D e. .O1G'.' •+ / alb SUFFOLK COUNTY, NEW YORK ,� Y : • .. ...; \ o ,� S.C. TAX No. 1000- 126- 1 1 —22 SCALE 1 "=20' ': a pp ° \ \ � J U LY 16, 2010 ono .o \ JANUARY 26, 2011 ADDED PROPOSED DECK \ APRIL 4, 2011 UPDATE HIGH WATER MARK '•�' • ' / '�°y �\ \ APRIL 27, 2011 REVISE PROPOSED DECK & STEPS \ \ AUGUST 27, 2012 STAKE PROPERTY LINES • � kP \ \ MAY 2, 2017 FINAL SURVEY ° � SEPTEMBER 20, 2022 UPDATE HIGH AND LOW WATER MARKS AREA = 22,481 sq. ft. (TO HIGH WATER MARK) 0.51 6 cc. " 11 �D e►� \ 4 \ \ •+. . . �►� .• \ $ \\ \\ CERTIFIED T0: \ \ TEACHERS FEDERAL CREDIT UNION 1(Y> a ' / c. .• D `"�\ \ BOUNDARY TITLE SERVICES, INC. Q S y ':• \ \ OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY KATHLEEN HEIDT \ r'- A.. \ \ \\ APPROVED BY \ BOARD OF I RUSTEES TOWN OF SOUTHOLD DATE r \ D9,�• v \ \ 0010, r' I! _ •' ' •�. a �' \ \ 4e • C� \ o� tido c^ \ J \ \ t-4y UNAUTHORIZED ALTERATION OR ADDITION ,OS \\\ \\\ E �/ TO THIS SURVEY IS A VIOLATION OF �7 SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. \ \ OCT �1 COPIES OF THIS SURVEY MAP NOT BEARING L OR SEPTIC SYSTEM TIE MEASUREMENTS 2 3 � \ \\ \ 1 2 20 4 EMBOTHE SSED SEAL HALLD SURVEYOR'S 'NKED NOT BEECONS CONSIDERED k2 �� TO BE A VALID TRUE COPY. HOUSE HOUSE \ \ \ CERTIFICATIONS INDICATED HEREON SHALL RUN CORNER CORNER© \, G \ , rdTTowns ONLY TO THE PERSON FOR WHOM THE SURVEY SEPTIC TANK °'\ \ SO IS PREPARED, AND ON HIS BEHALF TO THE 9' Of T 22' COVER TITLE COMPANY, GOVERNMENTAL AGENCY AND e LENDING INSTITUTION LISTED HEREON, AND LEACHING POOL TO THE ASSIGNEES OF THE LENDING INSTI— COVER 1 20 20 TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. 12. so �, ✓✓✓ LEACHING POOL COVER 2 22.5 35 THE EXISTENCE OF RIGHTS OF WAY ANY, NOT SH WNTAREFNOTCORD GUARANTEED. (� Ir/ OS O��P 0��t� •���� � 0 o � N. PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED BY THE LIALS. AND APPROVED AND ADOPTED FOR SUCH USE BY THE NEW YORK STATE LAND t^S� TITLE ASSOCIATION. o y ry COO Y tia 0J94 �P�1,1O\ry�ry Vv. W 0% N.Y.S. Lim. No. 50467 60 Nathan Taft Corwin III Land Surveyor Successor To: Stanley J. Isaksen, Jr. L.S. Joseph A. Ingegno L.S. Title Surveys — Subdivisions — Site Plans — Construction Layout PHONE (631)727-2090 Fax (631)727-1727 OFFICES LOCATED AT MAILING ADDRESS 1586 Main Road P.O. Box 16 Jamesport, New York 11947 Jamesport, New York 11947 SURVEY OF PROPERTY I tS� SIT ILIA TE E MATTITUC]K TOWN OF SOUTHOLD I ddn . �10''�� SUFFOLK COUNTY NEW YORK ° X 7 e •a.e \ o�`' ,� S.C. TAX No. 1000- 126- 1 1 -22 i d SCALE 1 "=20' JANUARY 26, 2011 ADDED PROPOSED DECK �-�, tl' a ,y° , APRIL 4, 2011 UPDATE HIGH WATER MARK cir� . °ti \ \ APRIL 27, 2011 REVISE PROPOSED DECK & STEPS I Q \ \ AUGUST 27, 2012 STAKE PROPERTY LINES I MAY 2, 2017 FINAL SURVEY I AREA = 24,238 sq. ff. (TO HIGH WATER MARK) 0.556 aC. \ \ a' °e •�' Q .���� �\\ \\ CERTIFIED TO: TEACHERS UNION ° °•° dp ��� \ �$ \\ \\ BOUNDARY TITD ERA ERVICDES, INC. •a n.• a ,� s��\ \ OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY � KENNETH HEIDT KATHLEEN HEIDT \\ =RECEF 1%"�non '"M4. t W."'.=v �fi des;n e•," f..6 f",�!"��.,1 b .`:� 4✓i,.,.. O. \ .. '° e ° - \ \ -?'s";tf"''tn.t�(�.1'S•" (`,`«�2'-� " of:,,',�,p �ifir'w.":'� ,� O e ► \ \ �fm CIF .t \ ..., {.t I 1 `' s.�f'':r° S«' ,w;,� O,�.,,,.-.m• i � .\A "D A• d OA�.•` �a � \ \9'� n.,s.,.a ,,.e 4„«t_e 44` µ.!-;•;.;�.�?�`.,;.,� ,.R,,.n�•,-w;�,�:a+-.a+� t• C?...., ,nna ,a JJ '\ .� d. a•� eA 1 \ \ \ � l`+,.k-';'�.f;,�•�`�",a �".:J�_,��•.�,�i^^••�(,�. A d fL .. A•\ / 6 \ \p�L, {{""�.br,.pr,'p.{�}���,:n l.�,,.,�.m.e.wr�.!'.w,imenn•m,abn. ..+A D \ \ \ e e, A-A d , C.a a 1PP Yy O \ \ p d a O is \G \\ 11 E I V O P ® J`0 \\ \ i OCT 272024 60 N OD d \ fl`�R Southold Town o \ Bird of Trustees d s \\ \ UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF \ SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW, yy COPIES OF THIS SURVEY MAP NOT BEARING SEPTIC SYSTEM TIE MEASUREMENTS 3 THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. HOUSE HOUSE paQ \ \ \ CORNER QA CORNER Q CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY SEPTIC TANK IS PREPARED, AND ON HIS BEHALF TO THE COVER 9 22 TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND LEACHING POOL TO THE ASSIGNEES OF THE LENDING INSTI— COVER 1 20' 20' TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. f, LEACHING POOL 22 5' 35' ° COVER 2 E�Y o THE EXISTENCE OF RIGHTS OF WAY ANY. NOT SHOWN TARE FNOT CGUARANTEED. l\'/ �pORD. IF o°�`'�° �COR `V I' PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED I' BY THE L.I.A.L.S. AND-APPROVED.-AND ADOPTED sG FOR SUCH USE 5Y 711 NEW `�OR1t.STATE LAND ,Fy TITLE ASSOCIATION, T�' ia. yam, G pp Iti IP— S �c°�O N.Y.S. Lic. No. 50467 Nathan Taft Corwin III Land Surveyor Successor To: Stanley J. Isaksen, Jr. L.S. �� Joseph A. Ingegno L.S. / Y Title Surveys — Subdivisions — Site Plans — Construction Layout PHONE (631)727-2090 Fax (631)727-1727 OFFICES LOCATED AT MAILING ADDRESS 1586 Main Road P.O. Box 16 Jamesport, New York 11947 Jamesport, New York 11947 / is — {: I SOUTHO.L D TRUS.TEES No. I-00se A Issued T Date Address 8530 Peco�:c; sa%k giva, l. �ure1 THIS.. NOTICE MUST BE DISPLAYED DURING CONSTRUCTION' TOWN, TRUSTEES OFFICE,TOWN OF 501JTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765-1892 -- Glenn Goldsmith,President 0�� COG Town Hall Annex A.Nicholas Krupski,Vice President �� yrc 54375 Route 25 Eric Sepenoski P.O.Box 1179 Liz Gillooly �y • ol �ti Southold,NY 11971 Elizabeth Peeples ��l �� '` P ' Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report 1 Date/Time: OA/24 Completed in field by:. , 4�y Ga Usr") E. Danowski & Son Inc., DBA Cutting Edge Landscaping on behalf of KENNETH & KATHLEEN HEIDT requests an Administrative Permit to construct a 12' x 30' on grade patio. Located: 8530 Peconic Bay Boulevard. SCTM# 1000-11-22 Typ"f 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 need ed/Mo�ldifications/Conditions/Etc.: NJ Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples 3 r f I I t v y 1 j:c J 'i I �t rN., 't !, I • •. 1►•' t I `.f_ .'t t, -"�'t \:. 41 �r ( k ff'".�'o-a 'rt ; ,.,f a 1..t•f3 1.4. !. + c ••i b x. '-" •:.. (•�" L{.f :aK�yr r.'td-t+' ^'f""k(`��nt,Fr' ^t tx�.. 1�v .y-" ,.I �4 as ..A ._�►, � f•r.���G-� � 3x<' ,>� :f'�� „� �.. r �' � - Ski 1 '�� j. •yp6 �.,�Y' J�, .,f•F '� t}...A,x 1 ,.'.,!?I T , �x' t :I/ r ��� t !M •� �:C ,r. 'f{... Q,y!sJ :;�'< e.:J. 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"A`� -�A �: ai eee sec w rze �" .4� Y o hl-�_—.. == "' _ •. _O «..,._ - �._ 11Nj R,.0OUNTY OF SUFFOLK G� rants ,cl' z...� t000 E _ __ _ — ___ f ,I. 1K��.+ W aiwriwr roa%ncv T,E v •.�,cry rs (211 , ,•." .>,�„r >•/rax.wunrrwawrsamattD n N°i°` 8011TMOtD 126 o✓ � mu,rur wm,ot waavrn a S i OFFICE LOCATION: '�` �Jr,r.',;' MAILING ADDRESS: Town Hall Annex P.O.Box 1179 54375 State Route 25 Southold,NY 11971 '1; i (cor.Main Rd. &Youngs Ave.) ' '''ice; - .H Southold NY 11971 tG �• . ' ', Telephone: 631 765-1938 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: October 15, 2024 Re: LWRP Coastal Consistency Review for KENNETH & KATHLEEN HEIDT SCTM# 1000-126-11-22 E. Danowski & Son Inc., DBA Cutting Edge Landscaping on behalf of KENNETH & KATHLEEN HEIDT requests an Administrative Permit to construct a 12' x 30' on grade patio. Located: 8530 Peconic Bay Boulevard. SCTM# 1000-126-11-22 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 SW Town Hall Annex 54375 Route 25 A.Nicholas Krupski,Vice President P.O.Box 1179 Eric Repenoski Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only D E C E I V E Coastal Erosion Permit Application I D b Wetland Permit Application n Administrative Permit OCT 2 2 Amendment(Transfer/Extension _!] Received Application: Ewwiis Town Received Fee: $ Boardufftstm Completed Application: Incomplete: SEQRA Classification: Type I_ Type 11 Unlisted Negative Dec. Positive Dec. -Lead Agency Determination Date: Coordination:(date sent): LVVRP Consistency Assessment Form Sent: CAC Referral Sent: Date of Inspection: Receipt of CAC Report: —Technical Review: Public Hearing Held: -Resolution: Owner(s)Legal Name of Property (as shown on Deed): -Avqt161--) Y_&_Witeco He_tdi- Mailing Address: '?Q) 220 Y 215 I,.t1J f sA a Phone Number: Suffolk County Tax Map Number: 1000- Property Location: S95 1c) 'BkVCk my k I'Y-k (If necessary,provide LILCO Pole#, distance-tocross streets, and location) C,-s C, LA AGENT(If applicable): f.lcso_j-jit, k �F_N� - milk tj k\X S Mailing Address: PhoneNumber: - Email:. `ard of Trustees Applicat , GENERAL DATA Land Area(in square feet):_...:_.. Z Area Zoning: Previous use of property: OA L Intended use of property: �1�b It-,L, Covenants and Restrictions on property? —ElYes �/No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? flYes _nNo 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. is project rITNO demolition as per Town Code or as determined by the Building Dept.?rT Yes Does the structure(s) on property have a valid Certificate of Occupancy? Yes=No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permittapproval ever been revoked or suspended by a governmental agency? No_n Yes If yes, provide explanation: Project Description(use attachments if necessary): Cc, e and of Trustees Applicati WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: o Area of wetlands on lot: 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? ❑ No Yes If yes, how much material will be excavated? U cubic yards How much material will be filled? b cubic yards Depth of which material will be removed or deposited: . e- S feet Proposed slope throughout the area of operations:�l8 1V Manner in which material will be removed or deposited: W�N ct.l 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.Comnlefing Part 1 -Project]information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: L &1 ; D - �vzC l 4f tom`a A Project '7 Location(describe, d attach a location map): Soj4 S i&#— _D� �0c1.t Brief Description of Proposed Action: �r1.d��l� D✓l-� e- j0ot- Name of Applicant or Sponsor: Telephone, 1 Z48 � ?04 17.eLa0UJ-4 L Z Ec' I,—.Tq L E-Mail: p� <<.e a eA+ edd Address: City/PO: 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? 0.514 acres b.Total acreage to be physically disturbed? a.. tiD$ acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Che 11 land us at occur on,adjoining an ar the propqSC4 action. Urban Rural(non-agriculture) Industrial Commercial Residential(suburban) Forest agriculture Aquatic QOther(specify): Parkland Page I 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 NO z .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 ATTJ b.Are public transportation service(s)available at or nearthe site of the proposed action? 4F 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? NQ YES Ifthe proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable-water: ❑ 11.Will the proposed action connect to existing wastewater utilities? NO ES 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? 1I a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. ntify the typic bitat types that oc n,or are likely to be found on t"roject site. Check all that apply: Shoreline Forest Agricultural/grasslands LJ Early mid-successional Wetland Urban ESuburban 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-p' m ourees? NO If Yes, a.Will storm water discharges flow to adjacent properties? O -❑YES b.Will storm water discharges be directed to established conveyance systems an drains)? If Yes,briefly describe: O 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:, 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO AES solid waste management facility? If Yes,describe: a . 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO - ES completed)for hazardous waste? If Yes,describe:. -- I AFFIRM`THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name ,. ( / Date: Signature:,-- 1/1 JUR121_ Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all ofthe,,following questions in Part 2 using the information contained in Part 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 regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? a 3. Will the proposed action impair the character or quality of the existing community? F1 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 a 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 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? FT 8. Will the proposed action impair the character or quality of important historic,archaeological, a 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 i 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? !d/ ,a1 71 . 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, Q that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. ElCheck 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 oard of Trustees Applicatia AFFIDAVIT BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK.WELL 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 JAP K DAY OF 20J y Notary Publidl KEVIN F. CAREY NOTARY PUBLIC,STATE OF NEW YORK Regisfi'ation No.02CA4992229 Qualified in Suffolk County Commission E;:;ir .Maly 22,2N2(o oard of Trustees Applicat i AUTHORIZATION (Where the applicant is not the owner) owners of the property identified as SCTM# 1000-, G I." ZZ__.._______ in the town of Lc.,u rf.A New York,hereby authorizes E Dan o w s k, �- 5cm I lkn -D�5A ��.11_ I�,S �� axcl5 to act as my agent and handle all necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for this property. Property Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS :o2'f ' DAY OF Notary Public MR FF CAREY NOTARY PUBIC,STATE OF NEW YORK Reglstrafon No.02CA4992229 QuallfiW In Suffolk County Commisslon ExpIms July 22,20 e APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's.Code of Ethias.orohibits conflicts of intereston,the part oftowe,offrceri and emlglovees:The•pum-ose of ahis form:is to:provide-inforiiiatiori'whicli can.Wirtthe.town of possible conflicts o iinfd&st and allow itto takewhateve-raction is nec.b-, to avoid:sameff.11 ,J I YOUR NAME: (Last name,first name,jpiddle initial,unless you are applyingin,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 (lf"Other",name the activity.) Do you personally(or through your,company,spouse;sibling,parent,•or child)havea:relationship with any officer of employee of the Town of Southold? "Relationship"includes by blood;.marriage,or business;interest:"-Business intetesf'menns.a business. including a partnership,in which the townoftiozror employee-has even a,p3rtiaf ownership of(or employment by).a corporation in which the town officer or employee owns more then,50/.of thes hares. 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 applicantlagent/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(chcdc all that apply): ELA)the owner of greater than 5%ofthe 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(whin 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 2 S day ofJt -kMbAr20 Z 7' Signature:. .QZ�i►. Print Name_ Form TS I APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE DORM The Town of•Southold's-Code of Ethics prohibiFs•confIicts.of inierest°on the-part oftown=officers and employees.The:numose of. k Ais form>is to:provide information which can alert=ttie:town.of onssibte=conflicts of interest end allow It to take whatever action is necessary to avoid same: YOURNAME: cw)owy >y l eXwArA —j (Last name,first name,jpiddle 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 personsklly,(or through your:,company,spouse;sibling,parent;orchild),have4 relationship with any of)iaer ot-employee of the Town ofSouthvid? "Relation`ship"includes by blood,marri.ge;_or'business interest:"Business inteiesf'means,a busincss, including a partnership,in,which the town-oflicer or employee has even a partial ownership of(or employmentby)a corporation in which the'town�ofticer or employee-owns:more.than.50/•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°4`of thc•shares of the corporate stock of the--appti. � (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when=the applicant is not a corporation); C)an officer,director,partnei,or employee of the applicant;or D)the actual applicant DESCRIPTION OF RELATIONSHIP Submitted this dq of e 20 Signature , Print Name t%dWr+��l VGnowst�� Fonn TS I Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. -A proposed .action will .be. evaluated as to its si iig� f cant .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,_listink both supporting_and non.- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,if 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# Vp PROJECT NAME The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g.capital ❑ construction,planning activity,agency regulation,land transaction) ❑ (b) Financial assistance(e.g.grant,loan,subsidy) (c) Permit,approval,license,certification: N Nature and extent of action: Location of action: 5573C3 ?5c,14 Bw Laxir—1 1JY 1 te,►Gj Site acreage: fl Present land use:. �S 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'applicarit: (b) Mailing address: r b -b®K 2 (c) Telephone number: —✓ 10 -- k Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes 0 No W If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. Yes ❑ No, Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages.3 through 6 for evaluation criteria ❑ Yes El No Not Applicable 1 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 grNot 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 8 through 16 for evaluation criteria Yes ❑ No xNot Applicable Attach additional sheets if necessary .�__ ����'� � _ T 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 19of 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 E(Not Applicable 1 Attach additional sheets ifnecessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑No KNot 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 WNot 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. ((�� ❑ YeD No Not Applicable Attach additional sheets if necessary " WORE ING 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 LMW Section III—Policies; Pages 57 through 62 for evaluation criteria ❑Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III—Policies; Pages 62 through 65 for evaluation criteria. ❑Yes ❑ No qNot 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 [Dyes ❑ No Not Applicable PREPARED BY 4��'h LZ-en 14e-[ o�— TITLE h ky d l kn-I l' DATE O.—Z S 2�