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Home My WebLink AboutTR-10828A a,. Town Hai: 'r nex � Soo . 54 +5 Ro u-e 25Q � "79 p p Box Gienn Goidsm Pres!;ie^c ��+I.RJ' hrups V'Ce PrBS; ,._ .��' JOt.._, 1d. �i?W �!Orn ,.9i A as k: 7Y v ^u 631 ',05 i39.) ter... 1eoenos k, { T"��^O^� \ lacc5 66 Liz G`100.v �. BOARD OF TOWNTRo SnTEES Tows' OF SOu SOliTHOLD TOWN BOARD OF TRUSTEES RUST CON TACT THE OFFICE OF THE BOARD OFT OFFEES YOU ARE REQUIRED TO 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES C BELOW INSPECTION SCHEDULE Pre-construction. hay bale line/silt boom/silt curtain 15� day of constructor' / constructed spector . VVhen project complete. cal for compliance in Glenn Goldsmith, President ®F so Town Hall Annex ski,Vice President ®� ®� 54375 Route 25 A. Nicholas Kru p °` ® P.O. Box 1179 Eric Sepenoski J Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 C®U ,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10828A Date of Receipt of Application: August 1, 2025 Applicant: Keith, Randi & Phyllis Klein SCTM#: 1000-127-6-11 Project Location: 1460,North Oakwood Road, Laurel Date of Resolution/Issuance: August 13, 2025 Date of Expiration: August 13, 2028 Reviewed by: Board of Trustees Project Description: Repair 36' long x 4.5' high retaining wall and 4' long x 2' high retaining wall. 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 survey prepared by Nathan Taft Corwin III, received on August 1, 2025, and stamped approved on August 13, 2025. 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 SITUATED AT LAUREL TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000- 127-06- 1 1 SCALE 1 "=20' APRIL 26, 1999 MARCH 10, 2017 UPDATE SURVEY MAY 14, 2025 UPDATE SURVEY AREA = 21,666.11 sq. ft. 0.497 ac. CERTIFIED TO: KEITH KLEIN RANDI KLEIN S S PHYLLIS KLEIN ,06. SPANO ABSTRACT SERVICE Corp. #SP51720_S q�0 ::: \ ¢2�• �, �� FIRST AMERICAN TITLE INSURANCE COMPANY NOTES: foPP� ::.:::: :: :::: :::'::':;:�� 1 . LOT NUMBERS SHOWN THUS: LOT 48 REFER TO Fo,N MAP OF LAUREL PARK a \N :::. ... FILE IN THE OFFICE OF THE CLERK OF SUFFOLK COUNTY W°°Meo \ vtiF °NsF� ON OCTOBER 5, 1925 AS FILE No. 212 q9 �;'6N : .:.:. ... \ aH qpR 0 Rp N `::::::::.0• .::.� 9ts c6 W�0 ONCE G w Gk 19 F R o �,::::... �.� r �CE\N 0\SRRp� d 6 '� , :. 4 i e. e C NUER DES `' m$ o N1 (' m :' .:.'.: :::::::::.........::':^�' '• OONC• � .• 8'2 � CONC' �O oz 00) R • N• 0 11ES C i aPV � -TA n ` a-10 e oA , �Q\✓J /' \ Gp? N 70•yam y1 PS o. 69 v e. .. �* �Fp yt� e c� tTN ! 1 jar.C . • a:v Oct�XJ ino O 39-.5 O *t C�+ Vs .�• N fO�N �• OAB F 1�/0/F 1�erif iH `��/ ,p "•. L •:.iitr^'�a%1C P:.' ?P�0 0S' � & Q.rI / , .. .• a �• •d �:.•. Z 0140 f0 �3•. U� O Z n• O 0 1 UTILITY POLE •• e . t• ••.•.-.':?O �RFIFAfl�Ri •/ / / 0 APPROVED t.3' 1 r�` d' • - / D/L• �A BOARD OF ) r:USTEES OT O TOWN OF SOUTHOLD P/ DATE 13 �o L � O Wp�R M / \RE W�0 ® ; •.a. 14/0/F DIANE -----I COLL '• & q 7 ' o DRIS OT O o ' ' O FOVNO p'' NIOLyIE P/0 L O •: Qf 9e B Z O 6 PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED BY THE LIALS. AND APPROVED AND ADOPTED FOR SUCH USE BY ]NE NEW YORK STATE LAND + = TITLE ASSOCIATI,1i t 3 0!1 I I • � _ �zro'�"` �� C` 'v EtrV AUG o Southold'rown fees tea/ \ \ �:• •�G'' tea. p ,S�) '`r +�Y�'^' '-`•�' N.Y.S. Lic. No. 50467 Y _ Vo' N UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF Nathan Taft Corwin III SECTION 7209 OF THE NEW YORK STATE v EDUCATION LAW. 0 COPIES OF THIS SURVEY MAP NOT BEARING Land Surveyor THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. �O CERTIFICATIONS INDICATED HEREON SHALL RUN Successor To: Stanley J. Isaksen, Jr. L.S. ONLY TO THE PERSON FOR WHOM THE SURVEY Joseph A. Ingegno L.S. IS PREPARED, AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND Title Surveys — Subdivisions — Site Plans — Construction Layout LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSn— PHONE 631 7Z7—ZO9O FOX TLMON. CERTIFICATIONS ARE NOT TRANSFERABLE. (631)727-1727 THE EXISTENCE OF RIGHTS OF WAY OFFICES LOCATED AT MAILING ADDRESS AND/OR EASEMENTS OF RECORD, IF 1586 Main Road P.O. Box 16 ANY, NOT SHOWN ARE NOT GUARANTEED. Jamesport, New York 11947 Jamesport, New York 11947 afi—nAp TRUSTEES No.SOUTHOLD. �ag :A Issued To '�.rt,, ��a: ,. e�y��;s K�%, Date.� �i 3(a s Address.' NCOl�o�� oaKNoo� RAI L�uc��. THIS. NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN. TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765.1892 Xzcrz:r� gpFFO(,rcOGyq f' Glenn Goldsmith,President Town Hall Annex A.Nicholas Krupski,Vice President o < 54375 Route 25 Eric Sepenoski ?, P.O.Box 1179 Liz Gillooly , • �� f Southold,NY 11971 Elizabeth PeeplesOl Telephone(631)765-1892 �zur-x� Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: $Z n/2S Completed in field by: (�. �� lols M► ��, KEITH, RANDI & PHYLLIS KLEIN request an Administrative Permit to repair 36' long x 4.5' high retaining wall and 4' long x 2' high retaining wall. Located: 1460 North Oakwood Road, Laurel. SCTM# 1000-127-6-11 Typyof area to be impacted: ✓ Saltwater Wetland Freshwater Wetland Sound s/ Bay Part of Town Code proposed work falls under: ° /Chapt. 275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment ✓Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications/Conditions/Etc.: �A;sl�gtl�sc.� o� c°X��'tina 5�cuc�y'�e.S , r.,•��,:nc� ao�na 'TtJ'�� Seal -Mostly or\ 10,nL1Jacd CIAO, Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples SURVEY OF PROPERTY SITUATED AT LAUREL TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-127-06-11 SCALE 1"=20' APRIL 26, 1999 MARCH 10.2017 UPDATE SURVEY MAY 14. 2025 UPDATE SURVEY AREA= 21,666.11 sq.ft. 0.497 cc. CERTIFIED TO: (j'j� KEITH KLEIN 'f j'�• S RANDI KLEINPHYLLI 'tti KLEIN S ANOSABSTRACT SERVICE Corp.#SP51720-S OBo v (�Ao• \ �� FIRST AMERICAN TITLE INSURANCE COMPANY <�;•:?� \ f S�' a \ NOTES:1.SLOT NUMBERS SHOWN THUS:LOT 4BO REFER TO ,a^^o> "' MAP OF LAUREL PARK °� `• `:' : �' •� .....•::.. Mom @ jl FILE IN THE OFFICE OF THE CLERK OF SUFFOLK COUNTY /� ;. \T4q •[j ON OCTOBER 5, 1925 AS FILE No. 212 .•. �6 �... w4Ao, \ .'....:.�. a N\ •.::::•:::i::::iti ems. _.• .. 9f ILO D2 . LOT :: R/ 6� ffi 2025 aouss b1 F/O L0T A U G ',� W;+•:o_ o+c�jDr'�. � �i��/ N/L/FNAD(b1EL g(cN�L.— 4° Southold Town r/ Board of Trustees TSIP o /1 D017 R�p��r back Q e, •. :i`ono, �° Or Y7 LTS Did F/0 LDT gDL b9 re ( LVQ Y .� ' � 69 oe z RZ pal r r •^F�� "' �CC n c�C k S`�1�+ l DREDNE6 m ARLR6NNS xn1 Txe Npmnn 5 �Nnwms roR tm�a.ncls ns rn�mm® Z jJ�1 Yr 1 �� rtmc'[��rai;Ne Imr�iow,sutE�vam g6W O IDS) KY.$.Ur_Ne.5 67 Nathan Taft Corwin III Land Surveyor mmp�YAl 3NML N0!FE COI�A91 ro tc A loom NO2 cwr. _•(Og �a�IP6 omGim NOew 9WL Rla 6aaasar T.,baDM1 Stmdx J.babes.Jr.L5. 1N` M Mi6M rnN na n¢smh A hop.L4 a rYPt➢AREA ArD w v Roue ro THE rrx s�-sm,,;.ro�a-sT. - �Lww Nye „p�TpgE PHONE(531)727-2090 Fm(631)727-1727 THE[Il61QICE Of MGM Of WAY OTCS IDfAFD AT N=N0 A00@Sfi WaOR E/SE1m05 OF M ORO.6 1556 md.RaaJ P.O.Baa 18 ANT.NOT SN[NOI AI¢NOT OWRANI®. J=.",,t Nn Yoh 11947 Jwmpwt Nar Yoh 11947 45-08 �� , ' I �r� � it ��'��.� /' a,.i•V -- f L' ! 4 a o i r � Jt M { r � : y,:.4... •n � i•y<"1 n d.' `1 +e-A'. 4i e� Y �a aa`.•9•�?N'�t' 7/31/25,9:33 AM i t (,I r !;oi/ ' IMG_4382.jpg I , .._. •��'.��w+lFG ear.,, -t I� ?�� •��,�;��t � ., t - https://mail.google.com/mail/u/0/#inbox/FMfcgzQbecLsTMINWhzVGPNtgZQcdWJD?projector=1&messagePartld=0.1 1/1 L 4 a7 cum- y y � .ram['•r A .. I�rlli`�`r�l►�M� . s, 4. r i 1 max. T.. � •w 9 ��• �`r7`-' � �� ~tom•"'� • �r - - ; � � . �,�j+' f :..►� , try . . /1 + ',,w AK[C�� INdE� r t ;E �a �. \ � 1. •�i .,�a+•q+'ems \ IN Alt IN ',on,00 ''JJ.*p�r� r •\ }. ��k. i 4 � ' s Ste/� AAr f e Z •� ,°` _ COUNTY OF SUFFOLK J "r•ee E. `} iK roe _ sEcraN rro E •—JL— — imw*iax �iw�n 127 „ .•,. ,. u. . 'U b W- I svwlA LV�A•wa eP�B12'J ,_ Miami— p n - __.-- wu---�K ••. ..•m..a w. (Tt) .�..... �:. Kmun wwmai wansrw p � g aeN RCfPFnP/r.�;eprviCE,G i y OFFICE LOCATION: MAILING ADDRESS: Town Hall Annex P.O.Box 1179 54375 State Route 25 Southold NY 11971 (cor.Main Rd. &Youngs Ave.) "•;tit. ' Telephone: 631 765-1938 Southold,NY 11971 f - r FuL ' LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: Glenn Goldsmith, President Town of Southold Board of Trustees From: Mark Terry, AICP LWRP Coordinator Date: August 7, 2025 Re: LWRP Coastal Consistency Review for KEITH, RANDI & PHYLLIS KLEIN SCTM# 1000-127-6-11 KEITH, RANDI & PHYLLIS KLEIN request an Administrative Permit to repair 36' long x 4.5' high retaining wall and 4' long x 2' high retaining wall. Located: 1460 North Oakwood Road, Laurel. SCTM# 1000-127-6-11 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the action is CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Honorable Lori Hulse, Attorney Glenn Goldsmith,President ®F S®�/,�, Town Hall Annex A. Nicholas Krupski,Vice President ,�� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski & Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples ®�� a® Fax(631) 765-6641 COUNTi BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only 1{� _ {�qJ Coastal Erosion Permit Application ILD Wetland Permit Application �C Administrative Permit EAUG1025 Amendment/Transfer/Extension k Received Application: � / If ___j Southold Town Received Fee: $ S a• 6° 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 0 a� �LWRP Consistency Assessment Form Sent: CAC Referral Sent: X Date of Inspection: Receipt of CAC Report: Technical Review: Public Hearing Held: Resolution: Owner(s) Legal Name of Property (as shown on Deed): KBr dr' Ne1h Mailing Address: /Ad Nadin Gq_ hw2ad Laym T ivy r/ !U Phone Number:.. 20 S 20-2— Suffolk County Tax Map Number: 1000 - Property Location: �od' Okkytroe ken d La,,wl 61y I M � (If necessary, provide LILCO Pole #, distance to cross streets, and location) AGENT (If applicable): Mailing Address: Phone Number: Email: Board of Trustees Applia� .,on GENERAL DATA Land Area(in square feet): I k4 d Area Zoning: G-511 a Previous use of property: 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? Yes No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals. Yes No If"Yes", please provide copy of decision. Will this project require 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? / Yes No Prior permits/approvals for site improvements: Agency Date U ustee,& gr 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): e,,Q,, Stn a 11 rc tart wafl 3�M s'H gvd WiL xeft N o _ l Board of Trustees Applic _ ,on WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: A 1",121 W Area of wetlands on lot: 1300 square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: C_feet Closest distance between nearest proposed structure and land edge of wetlands: S 0 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: &Ev bn Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason o such proposed operations (use attachments if appropriate): an 41- 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part l -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: Project Location(describe,and attach a location map): Brief Description of Proposed Action: Name //of Applicant or Sponsor: Telephone: `ZQ_ 3 Z 6 T'�'1 K I�IY� GV1 �(�V�C�1 i�t�I E-Mail: Address: IqGo RorAh Oakv.,Od City/PO: � �� State: L _ • Zip Code:q� T I f f 9 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? ,,i. acres b.Total acreage to be physically disturbed? acres c. Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? _acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial []Commercial dResidential(suburban) ❑Forest ❑Agriculture El Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 i 5. Is the proposed action, NO YE N/A a. A permitted use under the zoning regulations? ❑ ❑ b.Consistent with the adopted comprehensive plan? ❑ ❑ 10 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: 2 ❑ 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? 100, ❑ 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: IV ❑ 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. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional a Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed N01011 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, ❑ a.Will storm water discharges flow to adjacent properties? dNO DYES b.Will storm water discharges be directed to established conveyance systems(ru off and storm drains)? If Yes,briefly describe: NO DYES 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: 14 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: I�/ I ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: M ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsorvame: Date: � . 2- 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 [—y ❑ establishment of a Critical Environmental Area(CEA)? �y 5. Will the proposed action result in an adverse change in the existing level of traffic or ® ❑ 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 21, ❑ 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, �J( ❑ architectural or aesthetic resources? ILvJ� 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage \41 ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? 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. ElCheck 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. 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 Board of Trustees Application AFFIDAVIT BEING DULY SWORN DEPMEA AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. ignat a of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS J DAY OF �;J�� , 20 15" DUST I N A.CAETANO `TARP pur,-LIC STATC OF NEW YORK _ No 0I CA6430997 Notary Public Qtic IiLe;i in Nassau CauntY Co:n!n;ssion Czpirus 03/20/202t Board of Trustees Applic_ Lon AFFIDAVIT t ((�� (� O BEING DULY SWORN il 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 BEFORE ME THIS 7� DAY OF N20 al) Notary Public,State of New York No.01 BU6185050 Qualified in Suffolk County Commission Expires April 14,2 Notary Public APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics rohibits 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. f YOUR NAME: �f " ^ �`Jet �� ri (Last name,first name,piddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate.the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other'',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship.with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest"Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5.%of/the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); Q an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this E da of 1C 200 14r Signature Print Name 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 significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# PROJECT NAME �CP�lar,,�r- " lai�A ie q 1'.0.4 61S The Application has been submitted to (check appropriate response): �/ Town Board ❑ Planning Board❑ Building Dept. El Board of Trustees L� 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity, agency regulation,land transaction) ❑ (b) Financial assistance(e.g. grant, loan, subsidy) (c) Permit, approval, license,certification: Nature and extent of action: C /� e pail,, rra t -t t&,- rdf Ike-fra kt,4 th Location of action: 6"l ib® Ni 014 11 '.awl Site acreage: Present land use: Present zoning classification: ,`�� is 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: el �j Ot (c) Telephone number: Area Code ( ) W &V7 � Q 3 2 02 (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 [YNot 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 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 [yNot 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 Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No 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. ❑ ❑ Cr A114 Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No Es.of 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. �y ElYeO No U Not Applicable Attach additional sheets if necessary y 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 VNot 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 E 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 ev uation criteria. El Yes El 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; ages 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED BY ke,I A Van TITLE HV Ftt Q�t-(jtr DATE Z311 �,