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HomeMy WebLinkAboutTR-10826A Town Hai: A^.nzx Z nl1. 4 ,5437.5 Ro -e 25 G!e n Goldsm!L". p,=s:de^c ti � �� I p o So-LL: 179 9' ^' Yoram �'Lce p;es;den- JC.� ^.., u. mew 765-139.2 c !03' i 7b.5 604: L:z G:!:oo.y P. COUNTi -� BOARD OF TOWN TRUSTEES TOWS` OF SOUTH SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CON TACT THE OFFICE OF THE BOARD OF TRUSTEES MENCEMENT OF THE ACTIVITIES CHECKED 72 HOURS PRIOR TO COM BELOW INSPECTION SCHEDULE Pre-construction. hay bale line/silt boom/silt curtain 1-t day of construct,0," 1;Z constructed When project complete, call for compliance inspectiol Glenn Goldsmith,President ®� S0 Town Hall Annex ®� ®� 54375 Route 25 A.Nicholas Krupski,Vice President ® P.O. Box 1179 Eric Sepenoski J Southold,New York 11971 Liz Gillooly ,s Telephone(631) 765-1892 Elizabeth Peeples ®�� �� Fax(631) 765-6641 Cou BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10826A Date of Receipt of Application: June 30, 2025 Applicant: Deborah L. McKeand & Shannon J. Goldman SCTM#: 1000-68-3-11.1 Project Location: 100 Salt Marsh Lane, Peconic Date of Resolution/Issuance: August 13, 2025 Date of Expiration: August 13, 2028 Reviewed by: Board of Trustees Project Description: Trim tree tops and remove dead branches; conduct general maintenance of trees on 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 Deborah McKeand, received on June 30, 2025, and stamped approved on August 13, 2025. Special Conditions: Only 5-6 trees to have tops trimmed. 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 S.C.T.M.# DISTRICT 1000 SECTION 68 BLOCK 3 LOT 11.1 #R-22-0130 LONG ISLAND SOUND N 51029'09" E ,.,.,,,E•0 206.74' z y 8 ro .LION O WV ` 69' �r uK APPROVED BY BOARD OF i RUSTEES TOWN OF SOUTHOLDNil DATE �u use \3 10�- / `i r SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES 1 r _ APPROVAL OF CONSTRUCTED WORKS FOR --� I / LaAa�W rr _ r{-—•� ASINGLE FAMILY RESIDENCE r � LAND N/F Olp AM aer H S.Ref No pkmmn ,RON L,pypree+ew.0e CnOOMl.rd w.ler N,pol 1. 4.6*I M.e bpbon ne.e oeve r_ IOrt A1L4 a) !r 1 rj ..� nepected.neror1 wnAo or ye D nr%M o.aew .pn—ato-d � lbesomfecuxFORAMAIMMOF • BLDROOMS / Ci1All; LF R PL f:e 11LI LAND N1L1 F Of 0%m OfVv" br w. M. N�n. m YVONNE R GALLAGHER JIM I IRREVOCABLE TRUST �` ~ 6 � .. MBA low a"av 1=11�6t 1fm lat InAL _.._.._.._.._..— ++COMM law.or.oAfkr fi x x fAA ML / ee , / WeDW-AC"014 AMM S• 1 0// (2)s'Ar l2 CEE'Y L.P. *'TV if' 1 4. l �/ f f'�.r./ Clan ` ftfa f 7 :? so'm woo or aw �80 3 9� �� Inel www ArO,'a 56.7'Ln ECEIVE �► r IWO InvJUN 3 0 202 LAND N/F OFF RONALD ROTHMAN Southold Tow[, Board of Trustees SUBJECT TO COVENANTS, EASEMENTS, AGREEMENTS � MOOL 8 AND RESTRICTIONS OF RECORD, OF ANY. FEMA MAP/36103CO161H 0 {w{.. COASTAL EROSION HAZARD AREA MAP SHEET 7 OF 49 '` O� ELEV. 17.5 PHOTO No.57-559-93 H OL OR GROWN ,� 7•F � —0.5, BRIM sM SILTY SAW FRESHWATER WETLAND AREA: 4,972 S.F. 01" 41100L —_ PAS AREA SEAWARD OF COASTAL EROSION HAZ. BOUNDARY: 56.240 S.F. I,V S 54033'00" W sP BUILDABLE AREAL 49.076 S.F. v� � 80. SAND — 1s' AREA:110,288 SQ.Ff. or 2.51 ACRES (TOTAL) a NAV08S SC CLAYEY NKRIEST EXPECT WWROMP tAIO AL WIA N all Al mn a�WY 6 A W AA OW Or JFCE m 7iOr ►IWwoMW KMawA CI 0 SAINCY wN — MY WATER EL 2.2 ONLY TO DL I!MlW AOII WCW Dlr SLWWV w PAVRAW AND OM M MMW TO st RRt CCL/AW:OOMawl 9ft AdWY Alto LAAOAIIO MOVIUTAON WATER M LOU MEM AAo RI W At910tl11131 OF DL LLadID WSORMW 04MAMMES AAIE MOI IIIANSRRAEtL SC BMW CFFWM alOM47M Mt,sMw AQIQV MW All P4WMrY LAZE?10 RE sRIVCR AQ FM A—UPIC AtW=AND LW RLlw117m Wy AaE MOr WwrAXV IO AFOIM.AKNr AL P*gMrr LOM W 10 OILOE RL L7 VWV Or R N=AUP MW SMCRAIEY 09 AAD 00611 WRO1tI101i EAX7NINR CLAYEY AAD/LII AgmwAQ JIRMCRms MC>mw OR LNIaI11fAXE0 AK ADr AGMaANIEED mm memCaL r rmw OM W rlWASJ Ar Ipl 1Rl Gr XWWY SAND 1�' %AtWT OF;DESCRIBED PROPERTY o ^'-n CERTIRED TO:SKW40N GOLDMAN;DES MCKEAND; WATER M rAA►a: �� �+ �' �� `i FIDELITY NAT10 4AL TITLE INSURANCE SERVICES, LLC: SIP BROMM FLnk 4, MORGAN STANLEY PRNATE BANK. N.A.; FINE SAND SIUAIM All PECONIC " Tow or,SOUTHOLD ° )LBtfNlElS PlwC GARAGE FND. LOC 02-22-23 Of SUFFOUC COUNTY, NEW YORK tisF oeoes rwensma fty"yas om RL wRR s ppLr mma MD AND CESSAOLT P.O. Sm IN A"obegw. Now Yank 11fi1 LaQARl1W SWW AN MM AIM 080111MAMW —/220-1S69mm-1_-40' IfAwj V. 15]2020 ILY.S LUG NO 01111 It >fa>ds LML�w-Lar =(au)we-&= AAV Of DATA OIrAWV MM ONOM SOUTHOL u TR:qsTE' Es No. 1oga6 p� Uebora%-j McK2c4na. } issued T a - pate S/13Ia5 too Sc.NT A&,Ch bane , cnn Address.- THIS. NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TE L. 765.1892 Glenn Goldsmith,President ��� COGS. Town Hall Annex A.Nicholas ICrupski,Vice President < 54375 Route'25 Eric Sepenoski y ? P.O. Box 1179 Liz Gillooly �y • 0�`h Southold,NY 11971 Elizabeth Peeples �Ol �p'�J Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report. Date/Time: 70 S Completed in field by: 0,%JAbtk� Peate3 DEBORAH L. McKEAND & SHANNON J. GOLDMAN request an Administrative Permit to trim tree tops and remove dead branches; conduct general maintenance of trees on property. Located: 100 Salt Marsh Lane, Peconic. SCTM# 1000-68-3-11.1 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: Chapt. 275 Chapt. 111 other Typq 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.: Tor W~ fire V la 6r ine r i - bic tic r vG -{-. Present Were: G. Goldsmith N. Kru ski E. Sepenoski L. Gillooly E. Peeples Glenn Goldsmith,President �O��SUFFO(�-COGy a Town Hall Annex A.Nicholas Krupski,Vice President < 54375 Route 25 Eric Sepenoski CW1 ?? P.O.Box 1179 Liz Gillooly �y • 0�� � Southold,NY 11971 Elizabeth Peeples Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Daterrime:�v 1 r4 ,2� Completed infield by: E3 Z464k PeUl 8S DEBORAH L. McKEAND & SHANNON J. GOLDMAN request an Administrative Permit to trim tree tops and remove dead branches; conduct general maintenance of trees on property. Located: 100 Salt Marsh Lane, Peconic. SCTM# 1000-68-3-11.1 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: Chapt. 275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications/Conditions/Etc.: Trees r iYimmj ed avk e Tns ke, w review I Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly ✓ E. Peeples 11 . SUL •r�i0 r� �4�l � sr s� 100SALTMARSHLANE SOUTHEAST ��a�. `sue ►, ry� .� �- r - y:• WORKTABLE 100 SALT MARSHLANE NORTH WATER VIEW y r 4� RED DASHED LINE DEPICTS TREE TOP TRIMMING EXAMPLE JUNE 28,2025 AT 6!30 AM McKeand:'CK>Idma Rl nd— Property Maintenance WORKTABLE WN— ;DOI \ b �\ wTGt unE p IySE o" Fqi PMCE— .� SEE SEC w �aiz ,`C ''t4ci y —.1 mrt 8 491 N I`\ P��Q �. r'' 'y� ,s " suegrlsiort for nuuEERs vRE ;� 4� '_ `MM pF HpRTH NECS FllE nO w, 4 / � d F � 3 a, A // COUNtt OF SUFFOLS R.&Vc) ��% 0 ✓// ,x 9EE SEC.MO.i GOLOSMI—SIN T 1!A a,�<w.v xwruv uvu i �' PtVnr Hwy t M tAA I° d TRUSTEESOf THE \. iOMM OF SOUTngD ° m �6' tl I, .0. ,.Aut \ ava Haar {e SJ SI Se �� - ( ? 4Q'P9 s E.a • tlM01 T ( . ° PECON�C°l/°D TRUST /y I ,bv cwseuex,l _ 7 .1 -- t wTgt \ • t SEE SEC.110 SIB �\i SEE SEC.N0.°I. \s E —�— O _ �y _ _ v. NOTICE '4+ COUNTY OF SUFFOLK © K �� 90UTHO D SECTION NO Real Property Tax Service Agency Y m �8 N pt 0.�... a .� n�xr.. �.. —__— u...� --r—_ er.x.—_i__ ^ ... .i v 1v i,n'�:✓'j A 1000 PROPERTY MAP tt r i OFFICE LOCATION: MAILINGADDRESS: Town Hall Annex ` ''O`, ,; P.O.Box 1179 54375 State Route 25 `� ' Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) G ! Telephone: 631765-1938 Southold,NY 11971 •' yO �k LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: July 11, 2025 Re: LWRP Coastal Consistency Review for DEBORAH L. McKEAND & SHANNON J. GOLDMAN SCTM# 1000-68-3-11.1 DEBORAH L. McKEAND & SHANNON J. GOLDMAN request an Administrative Permit to trim tree tops and remove dead branches; conduct general maintenance of trees on property. Located: 100 Salt Marsh Lane, Peconic. SCTM# 1000-68-3-11.1 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 *OF SO(/jy Town Hall Annex 5437b Route 25 A.Nicholas Krupski,Vice President ,�0� �!� P.O.Box 1179 Eric Sepenoski J�i1 Southold,New York 11971 Liz Gillooly G Q Telephone(631)765-1892 Elizabeth Peeples ,'ni YO Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only f E C E 9 V E Coastal Erosion Permit Application Wetland Permit Application 0 -Administrative Permit JUN 3 0 2025 Amendment(Transfer/Extension Received Application: C,P.?o/as �Received Fee: $ Southold Town as Board of Trustees Completed Application: Incomplete: SEQRA Classification: Type I. Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): — C�LWRP Consistency Assessment Form Sent: _+(3155 CAC Referral Sent: k Date of Inspection: S Receipt of CAC Report: Technical Review: Public Hearing Held: A 6 f Resolution: Owner(s)Legal Name of Property (as shown on Deed): DG b 0✓a.l� �,, g 5 q,n n an T. &Id.~ Mailing Address: ?O ftX 34U kctniC, NY 1lq 5 8' Phone Number: 01 k V:'. (a q 1- 4115 I Suffolk County Tax Map Number: 1000- 6 g' 3 Property Location: 100 SalA- Wrs k L&n.C. (fie co%l i C, WY l (a 5 e (GOMC41, 4 l}�n r-►lr�ln�+n C3 W d " Vy1. *T k (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Email: and of Trustees Applicati4 GENERAL DATA Land Area(in square feet): 11 0 i "Vt T Area Zoning: Q - qD Previous use of property: R.e s dwll OA Intended use of property: O'cl d&,4"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? LlYes -14-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 5;T—No If"Yes", please provide copy of decision. is project req ' ny 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? Ye=No *- m pwccss P�' eeceiwki y Go baszd o" rce-¢A4 -�Y�/ b�rf'/cling ihs�cc�i� ��3�/a�J Prior permits/approvals for site improvements: Agency Date 81.0(r Ocr p-remkr*k50�51 155Ua 5 ail dL4 1&W6-0Vr' F eUfln1'r i*4V02-1 ISStr�•� 12 20 22, Claud S' 3o�z3, Qecu�red G� 1-e--5 1 ss"'�'� ��1.t�12Z i cxkev►sirx+ q lq I�-�I' Dew PEYLmIT*t l-�'�-38- o�{f�go/000a� 1ss�col -(2s�22 TrlusfiG� PEf-mrr * 1049?A-- 155vrcr( llh 1a3, Receiveol Ce,4-sk Come 5J3o/�q No prior permits/approvals for site improvements. Has any permittapproval ever been revoked or suspended by a governmental agency? No_a Yes If yes,provide explanation: Project Description(use attachments if necessary): G?.Y�t.✓tc�l YYII.M n��-+��1cc- o� -�c� S Ord of Trustees Applicati.c WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Pw iM OL i n�&& &A GS/ Area of wetlands on lot: Lt square feet Percent coverage of lot: .Z . 2 y % (ifq, o: '� 5F h wt l ob ib(C. GN'm Closest distance between nearest existing structure and upland edge of wetlands: 100 I' feet Closest distance between nearest proposed structure and upland edge of wetlands: 100 4- feet Does the project involve excavation or filling? �_No Yes If yes,how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect,if any,on the wetlands and tidal waters of the town that may result by reason,of such proposed operations(use attachments if appropriate): v � 617.20 Appendix B Short Environmental Assessment Form Instructions for Comnletinp- Part 1-Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part I-Project and Sponsor Information Name of Action or Project: ►A6Lean6L / CmId,man Pw IMA�n+Z4A&ACt, Project Location(describe,and attach a location map): 100 54L(f M M-5 k L4VX Pe wi c N3-( ► t 15 F Brief Description of Proposed Action: jqWly 1-49 fay a. )qerm 1, -fa -?d uct- o ne rm t maif7 f e,-la,n[e oyC frees OYI. Pwf" . 7�+�S inelwlc S �Zc �»�o f v�i�rn�'nS mow(.. nCrrlowhs de&,ow- �hcs �o , cep �Zcs laal�'ny Hitt. a noC p►•amafc dvc•- 1144J* Name of Applicant or Sponsor: Telephone: Gt l�•. bet�. ��S/ t)e,WY,r� /Y1CiC461.1�G( E-Mail: Alb u�oyiicf�64J'� G. Address: 160 Sa1�- M4rg G, LA4A . , Po l3ox 3410 City/PO: State: Zip Code: Pccenic, I )V`/ 1195r 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO I 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 c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor9 a. $! acres 4. Checl,.11 land us at occur on,adjoining and-near the pro"action. Urban Rural(non-agriculture) Industrial Commercial OResidential(suburban) Forest FlAAgriculture HAquatic ❑Other(specify): Parkland Page 1 of 4 J ' 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 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: 21 ❑ B. 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? 1011-1 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: ❑ ❑ N/�L 10. Will the proposed action connect to an existing publictprivate water supply? NO YES If No,describe method for providing potable water: ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? b.Is the proposed action located in an archeological sensitive area? 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO 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. tify the typic8al-habitat bitat types that o n,or are likely to be found on t"roject site. Check all that apply: Shoreline Forest Agricultural/grasslands Early mid-successional Wetland Urban Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed LNO YES by the State or Federal government as threatened or endangered? raY 16.Is the project site located in the 100 year flood plain? G YES ia 17.Will the proposed action create storm water discharge,either from point or non-point sources? O ' lul If Yes, ❑ a.Will stone water discharges flow to adjacent properties? ZNO DYES b.Will storm water discharges be directed to established conveyance systems Ppwff an#-tarm drains)? If Yes,briefly describe: O ES Page 2 of 4 r I S.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: M ❑ 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 THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsorname: D&Oyx'k Date: 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 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 I. 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? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? ❑ ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the El ❑ 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 ❑ 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? ❑ ❑ 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 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 Elproblems? El 11. Will the proposed action create a hazard to environmental resources or human health? I El 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. F] 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 Ord of Trustees Applicatia` AFFIDAVIT �i�41�U.Ll L • PAL BEING DULY SWORN, DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF 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 BE ME THIS d DAY OF �� '.20 ?�pg'1Z eunp sendx3 uoissiwwoo AW unoo)jjouns ui paiplenp 90 31OA m9N 10 WISNO 4 d tieION Votary Public eti"MON•0 Pa19401d 1rd of Trustees Appli.catia AUTHORIZATION (Where the applicant is not the owner) I/We, , owners of the property identified as SCTM# 1000-_ in the town of New York,hereby authorizes 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 DAY OF , 20 Notary Public APPLICANT/AGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the Hart oftown officers and employees The pumose 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 some YOUR NAME: YVI C'KZ�K lobo Ir (Last name,fast name,apiddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other",name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than.5%of the shares. YES NO if you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): 12A)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-corpornbe 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 20 Signature PrintName Form TS 1 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 ' icant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). I 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# 100 PROJECT NAME Wk j d lOof irna.n f ►vee!jy 1Mounte4ia.nce., 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: LAJ Nature and extent of action: �h�►2vl wc—"n;nMc-L-Acc_ ArPes cti Jpvw?� incl�nd,i n� +r/-e -Eo�p lrnrnint Gtr1o� r2mov�nF, dl.eael b►-wv��hcs . Location of action: l 06 Sca 4' t' ays k La ru21 V tt4MA L l JA 15e Site acreage: i Present land use: 46A,+i kk Present zoning classification: '�o 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: &IOO A h (b) Mailing address: PO HX 3 q(v PGUMi G N`( 119 5Y (c) Telephone number: I 1 I-• bq 1 q l 5 q-— — Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes ❑ Nor ff 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. F Incomplete answers will require that the Sorm,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 0 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❑ No Not Applicable 1 ,1 Attach additional sheets if necessary - Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section HI—Policies Pages 6 through 7 for evaluation criteria MYes ❑ No❑ Not Applicable C.l ✓ ` (1 w i S U-r�%\\ c e— V�S 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 IH—Policies Pages 8 through 16 for evaluation criteria Yes ❑ No❑ Not Applicable QA b1 Gt 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 Prot Applicable Attach itiona 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 ❑ Not Applicable V'L to I Q n h AM.k V t LAA t Y-toA&I:rl 1'f,64-i a. va l _S 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� Not Applicable Attach additional sheets if necessary Policy S. 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 evaluatiop criteria. ❑Yes ❑ No LPJ 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. ❑ YesO No 0 Not Applicable Attach additional sheets if necessary 4 WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III—Policies; Pages 47 through 56 for evaluation criteria. ❑Yes ❑ No 0 Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria ❑Yes ❑ No Not Applicable ` 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 Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria ❑Yes ❑ No Ltj Not Applicable PREPARED BY TITLE 6 WY?t4/ DATE � � Glenn Goldsmith,President c>�F'SI�(/T . Town Hall Annex A.Nicholas Krupski,Vice President l"��� �lO 54375 Route 25 P.O.Box 1179 Eric Sepenosld Southold,New York 11971 Liz Gillooly G Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 COUNT`l,0 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD OTHER STATE AGENCIES YOU MIGHT HAVE TO APPLY TO N.Y.S. Dept. of Environmental Conservation (DEC) SUNY at Stony Brook- ? 50 Circle Road Stony Brook, NY 11790-3409 (631) 444-0355 i Wednesday & Friday only during the hours of 8:30a.m. — Noon & 1 p.m. —3p.m. Email: r1d`600_gw-Aec.state.ny.us { Suffolk County Dept. of Health Services Office of Wastewater Management 360 Yaphank Avenue, Suite 20 Yaphank, NY 11980 (631) 852-5700 Email: WWMO-suffolkcountyny.gov U.S. Army Corps. of Engineers, N.Y. District Attn: Regulatory Branch 26 Federal Plaza, Room 1937 New York, NY 10278-0090 (917)790-8511 Website for applications & helpful information; http://www.nan.us-ge.e.arrhV.fnil/Mittiohs/Regulato!Y:aspx i N.Y.S. Department of State ` Division of Coastal Resources Consistency Review Unit One Commerce Plaza 99 Washington Ave, Suite 1010 Albany, NY 12231-00001 (518) 474-6000 Website: www.riysWaterfrontt.com. Glenn Goldsmith,President "'��F.-SQUjy'°-,'-: Town Hall Annex ski,Mice President O� 54375 Route 25 A.Nicholas Kra p P.O.Box 1179 Eric Sepenosld Southold,New York 11971 Liz Gillooly ' Telephone(631)765-1892 Elizabeth Peeples !�' • ay0 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD l COASTAL. CONTRACTOR LICENSE Effective as of January 1, 2018, Southold Town Board resolved to adopt a local law entitled: "A Local Law in relation to Amendments to Chapter 275, Wetlands and Shoreline, in connection with Coastal Contractor Licensing"., A Coastal.Contractor License is required for any.work which is done in and around wetland areas which requires a Wetland or Coastal Erosion permit. A copy of the Adopted Resolution as well as a copy of an Application for a Coastal Contractors License is available-on our Town website: https://www.southoldtownny.00v/391/Trustees