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HomeMy WebLinkAboutTR-10843A K _. SO Town Hall Annex Glenn Goldsmith, President ®� 54375 Route 25 ® P.O. Box 1179 A Nicl'lolas Krupski, Vice President Southold, New York 11971 Eric Sepenoski *d' Telephone (631) 765-1,392 Liz Gi!iooly �® Fax (631) 765-6641 Elizabeth Peeples 00UNTV,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE ES CHECKED OFF BOARD OF EES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTT BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 15i day of construction '/2 constructed When project complete, call for compliance inspection; Glenn Goldsmith, President �`�®F S0 Town Hall Annex V� ®A. Nicholas Krupski,Vice President �® �® 54375 Route 25P.O. Box 1179 Eric Sepenoski J l Southold, New York 11971 Liz Gillooly nbhc Telephone(631) 765-1892 Elizabeth Peeples � �� Fax(631) 765-6641 c®Um,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10843A Date of Receipt of Application: September 17, 2025 Applicant: Mattituck Park District SCTM#: 1000-99-2-19.1 & 99-3-14 Project Location: 5155 Breakwater Road & 2205 Bailie Beach Road, Mattituck Date of Resolution/Issuance: September 17, 2025 Date of Expiration: September 17, 2028 Reviewed by: Board of Trustees Project Description: Remove vegetation in order to eliminate invasive plant species and decrease the amount of American beach grass, Beach Pea, and non-native species at Breakwater Beach, Mattituck; any viable native species that are removed are to be transplanted in areas such as the fore-dune (northwest) and leeward end (southeast) areas along Bailie's Beach, Mattituck; all work to be performed using hand tools and hand pulling. 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 Jennifer Murray, received on September 17, 2025, and stamped approved on September 17, 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. .lr ' 4&7'L4'X Glenn Goldsmith, President Board of Trustees V3TZE4KW A-TC-R '-R &ACkA BO,6 GPI RUSTEES TOWN OF s6t)THOLD I�A � I TE Sc�i �`� ► 7- ell 47 a � D S 7 � (" A TTI � vcll EP 1 025 eA RY,b 1S'TR tT Southold Town Board of Try�stees ` F ` . f hC = vest- I U RT L�B�G1L c cnv S cc-A)T�-=R LLB P 1 7 2025 'L- i A '.a w_ • +T u r F ,y v IN JV 14 0 • t♦ • •' ` , r R� t••,i� _# /� ��• .t - .h attituck I RE. 3 '.; u�*, ofTown h � d '� __ ._ . . _,.. ° �'•.� _.,._, ,4� No. I0%N3 Ae ' Issued To ��i�u�K �'arK bsm,,cs Date Address + aaos �; Ie BeAch RX THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN'TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL..i 765-1892 Glenn Goldsmith,President S�FFO(,tcop, Town Hall Annex A.Nicholas Krupski,Vice President �� y:"e 54375 Route 25 0 Eric Sepenoski nz, P.O.Box 1119 Liz Gillooly �y • p!� Southold,NY 11971 Elizabeth Peeples ��l �a Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: Completed in field by: Turtleback Conservation Center on behalf of MATTITUCK PARK DISTRICT requests an Administrative Permit to remove vegetation in order to eliminate invasive plant species and decrease the amount of American beach grass, Beach Pea, and non-native species at Breakwater Beach, Mattituck; any viable native species that are removed are to be transplanted in areas such as the fore-dune (northwest) and leeward end (southeast) areas along Bailie's Beach, Mattituck; all work to be performed using hand tools and hand pulling. Located: 5155 Breakwater Road & 2205 Bailie Beach Road, Mattituck. SCTM# 1000-99-2-19.1 & 1000-99-3-14 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.: Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples J NEW Department of Office of Department ,- ST� Environmental General Services of State Conservation us Afmy Corps t of Englneers.. JOINT APPLICATION FORM For Permits for activities activities affecting streams,waterways,waterbodies,wetlands, coastal areas,sources of water, and endangered and threaterred species. You must separately apply for and obtain Permits from each involved agency before starting work. Please read all instructions. 1. Applications To: >NYS Department of Environmental Conservation %J Check here to confirm you sent.this fomi to:NYSDEC. Cheek all pernwis that apply: ❑Darns and Impound- Tidal Wetlands ❑Water Withdrawal [_1 Stream Disturbance ment Structures ❑VAId, Scenic and ❑ Long Island Well ❑ Excavation and Fill in ❑401 Water Quality Recreational Rivers ❑Incidental Take of Navigable Waters Certification' K71 Coastal Erosion Endangered! ❑ Docks,Moorings or ❑Freshwater Wetlands L1 "Management Threatened Species Platforms See Instructions(page 3) >US Army Corps of Engineers ❑ Check hereto confirm you sent.thisform to USACE. Check all hermits that Wpkji ❑Section 444 Clean Water Act ❑SecUm 10 Fdvets and Harbors Act Is the project Federally funded? Yes X No If yes, name of Federal Agency: General Permit Type(s),if known: Preconstruction Notification: Yes No >NYS Office of General Services ❑ Check hereto confirm you sent this form to.NYSOGS. Check all permits that apply: ❑ State Owned Lands Under Water ❑ Utility Easement(pipelines, conduits, cables, etc.) ❑ Docks, Moorings or Platforms >NYS Department of State ❑ Check here to confirm you sent this form to NYSDOS: Check if this anodes: ❑Coastal Consistency Concurrence 2. Name of Ap licant Tax er ID if licant is NOT an individual t C 1S^ K I 1 Mailing Address Post Office/City State Zip 12�0 ��e�� Pe man+ c �y ivc� • M �T I T 0 CIS Telephone 631- 296- 9 t 0 3 Email C a i r1 cJ 1(l1 Ct rl a C O Applicant Must be(check all that apply): 9 Owner ❑ Operator ❑ Lessee 3. Name of Property Owner if different than Applicant Mailing Address Post Office/City State Zi Telephone Email For'Ailericy Use Only Agency:Applleatlz ~� � a x� on Number £> � sa. R � . JOINT APPLICATION FOL, 'Continued. Submit this completed page,. r'art of your Application. 4. Name of Contact I Agent C.UN SeR\J AT1 D cc--,/,�TE`I? V Mailing Address Post Office/City State Zip 'Pd �30X Zee c- ►J) c_ 9 1 I l Telephone 15-2 Email 0 o 1 r Q 1 OM 5. Project I Facility Name Property Tax Map Section/Block/Lot Number: �A `"� T- � � t00o- 9 2- Project Street Address, if applicable Post Office I City State Zip 5-7-99 - 5Ua3 Lt,+be -s Kos MA-7TITVC-- --] NY Provide directions and distances to roads, intersections, bridges and bodies of water 0 UW D AV 1= -To Ccox N GcK RD C-N4 fri) 1 E r7 DM UVIL-4NKWA-N�.'R/L-QMe1ZS RD rn I Town ldlla a Cit County StreamNVaterbod Name TOUTAl OP S0 o L U FF o L- A- 'T'u,!�K i\1 Project Location Coordinates: Enter Latitude and Longitude in degrees; minutes, seconds: Latitude: ' , 3 " Longitude: ®' j "w 6. Project Description: Provide the following information about your project.Continue each response and provide any additional information on other pages.Attach plans on separate pages. a. Purpose of the proposedproject: Rec'noval a.+ �/e�e}zrE;or, AD inc.re-aS-l°• ava� Ia�le ne n9 habr -4- 40.,r -Pq i rj Plovers, �ea5-�I er Sl card Common Tar-ns, b. Descri lion of current site conditions: ve� s+s main \y AM-P-f-+COM B'e-a0ln3ra55 4mm,�Pb la �rev►i►hula-�a, 3�e�ch P � La�`hyrus �Qp��� �u5 , and non-n�-� c. Proposed site changes: lZ e u c-e- v e J'e--tzk-"o.n �� lO % n r d vS�d a r-ec& , d. Type of structures and fill materials to be installed,and quantity of materials to be used (e.g.,square feet of coverage,cubic yards of fill material,structures below ordinary/mean high water,etc.): e. Area of excavation or dredging,volume of material to be removed, location of dredged materialplacement: 0'� PV-ox. 30( 000 Sl � 'rl1 'IrnvCLS%Ve- , nof1- oct-1 ve +V1a ✓4 1,1a--vici .Milt k�e ba39-e-J a"J C1;� 3oSec� 4, F� �J aC-'\ j ra.SS Qoel BcachPe� vV�Il he 1 1-0Aure blow o areas o J%'e c f. is tree cutting or clearing proposed? Yes if Yes,explain below. No Timing of the proposed cutting or clearing (month/year): I d C✓7 D V C Number of trees to be cut: Acreage of trees to be cleared: JOINT APPLICATION Fo' Continued. Submit this completed page tart of your Application. Work methods and type of equipment to be used: CLOA sinovel s (cab0.✓2� h. Describe the planned sequence of activities: refy)oVe 1YWa.SlVt Ptants or" J�tsPCos6L re- e-\ov'e rn e� c.lu0- FG D 6eac� 1r& SS OLT" u -� 1 ►v1-e av �ns i. Pollution control methods and other actions proposed too mitigate environmental impacts: Gt n+s Cc c-�4Y)CT�-V Ci \dr► v00d o9S -o a-%,j QWJ SCfdti O AS j. Erosion and site w taot n atwds thaL vAU kae used W pKeyent water k. Alternatives considered to avoid regulated areas. If no feasible alternatives exist, explain how the project will minimize i cis: /q►-ea_ will have V-e-t�'-e1wfion va rq i�n� p -� o o wrth er Q0- (nor- -ta-{ ay, .S u v,��e CLd QPI'rOX 18-2 V ap a H- df -v�-edane a.r)4 W P ss o r - and ro osed gre&- 0k+ I. Proposed use: ❑ Private ©Public ❑Commercial m.Proposed Start Date: r 202 5 Estimated Completion Date: . o n u a rLi n. Has work begun on project? Yes if Yes, explain below. No o. Will project occupy Federal, State, or Municipal Land? Yes If Yes, explain below. No M,th- i(-k Fork �'►S'1t^+L is mu �►c; Pal 1 a(\d;:. LeoS+ TerA av\cl Kave �.een nes-�- r j of �h►s s► �pr c�ec��eS }?. List any 7evmus DEC,USACE,IDGS T)T DOS PETmii f AppftaUn nunl)e7s im aut]V ies-at t'Rts loac bun'. q. Will this project require additional Federal,State,or'Local authorizations,including zoning changes? Yes If Yes, list below. — No JOINT APPUCATION Ft� Continued. Submit this completed pagi/ part of your Application. 7. Signatures. Applicant and Owner(ff different)must sign the.apptication. tfthe applicant is the landowner,the landowner attestation foram can be used as an electronic signature as an alternative to the signature below, if necessary. Append additional pages of this Sign;Auye section if there aye multiple Appbcarns,ownem or ContactlAgents. I hereby affirm that information provided on this form and all attachments submitted herewith is true to the best of my knowledge and belief. Permission to Inspect - I hereby consent to Agency inspection of the project site and adjacent property areas. Agency staff may enter the property without notice between 7:00 am and 7:00 pm, Monday - Friday. Inspection may occur without the owner, applicant or agent present. If the property is posted with "keep out'signs or fenced with an unlocked gate, Agency staff may still enter the property. Agency staff may take measurements, analyze site physical characteristics, take soil and vegetation samples, sketch and photograph the site. I understand that failure to give this consent may result in denial of the permit(s)sought by this application. False staternents made herein are punishable as a Class A rnisrlerneanor pursuant to Section 210.45 of the NYS Penal Law. Further, the applicant accepts full responsibility for all damage, direct or indirect, of whatever nature, and by whomever suffered, arising out of the project described herein and agrees to indemnify and save harmless the State from suits, actions, damages and costs of every name and description resulting from said project. In addition, Federal Law, 18 U.S.C., Section 1001 provides for a fine of not more than $10,000 or imprisonment for not more than 5 years, or both where an applicant knowingly and willingly falsifies, conceals, or covers up a material fact; or knowingly makes or uses a false,fictitious or fraudulent statement. Si nature f licant Date Applicant Must be (check all that apply): ❑ Owner Operator ❑Lessee Printed Name Title L�16610_x 0 W(II/I - I Sig nature of owner Ifi different than AppbcanQ Date F __1 I Printed Name Title Sig natu re_vkContaqtJ Agent Date Printed N e Title lVIVlF-EP, MURPAVNwe6rd MCeVIQ er For Ad t hs*arzfW f f2Mfi�tR:7Tt�lot fTF ILK?:PERhffT RE1 tht12Et? Agenc "Application.,Number (Agency Name] has determined that No Rermitis req*ed:from IN-5 Age-nc}.font a pru}ebt.described in.this as ficarltai = Agency-Representative:. Printed Title Name =. F. Signature - Date 0 U7 1-1 w swa °y aso,m or.rue o eRI wnaor . S d A A pqV. s jLN o? ; \ �\ BBN—�-F-r r-g' wmrucx vARx _ -- 1 V \\ / ) i V ,'1A{c LaA(cY: \ aL 6 STATEOFNEWYoNx �. �}' �',w. vwnnuac PAfM asrw �;rwasv \, �.. 'n \ \\ -4s 't'• .I /If _ �ry �`•'9 y4. � F,yA T.q, rawrw, 1'!3 ,� 9 2�'l1^t,.ulq d1�S$' .� _ 1xr` 0 f FOE POL NO. FOR FCL NOS\°L'�� SEES r • SEE�wE4;0. nn$¢1� ( i] a 10 Y.. .y� � ^^� I�c3•.I 1 �v� � x.aAlq HATCH LINE MATCH LINE p N - q x,;`, �yc Nn fm BEE SEC.NO.IeB ` x N,S R0.CR r w 21 _ _ w ° NOTICE mu�� COUNTY OF SUFFOLK © K t� °F SOUiNOLD SECTION NO c —� 1.1 Real Property Tax Service Agency P v —ftly m °�a Nxoo 099 100a ---- t09 PROPERTY MAP Glenn Goldsmith,President ��F s®�,r� Town Hall Annex A. Nicholas Krupski,Vice President A$i ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly G lephene-(631)_Z65 Elizabeth Peeples A ® ��6 �_�4 U UNTV, �J S E P 1 7 2025 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Southold Town This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extension Received Application: Received Fee: $ �Sb- 00 Completed Application: Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): __LWRP Consistency Assessment Form Sent: CIA 41 -S 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): 9 d 1 a �U Ck r k l S ct Mailing Address: 2g(7 Qrec P-cGoyl►C tic,/ 'BkyG � � q5Z. Phone Number: 6-0_3 1 - Z 9 8- g l Oa, 1. Suffolk County Tax Map Number: 1000 - 9 Q � ` 2 � i + Property Location: S 1 9 9' 5 003 LAj"h?,S (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): Je rl l Hurrav I�( r-��e C W e D R �C�lnr Mailing Address: Phone Number: 5 15 2-9 Email: O� v, ���d 1-0 r ma i ,yard of Trustees Applicat, GENERAL DATA Land Area (in square feet): Area Zoning: Previous use of property: 6000C+4 Intended use of property: �5 C--A-6,k-A 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 C 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 7�- No If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes X No 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 permit/approval ever been revoked or suspended by a governmental agency? No Yes If yes, provide explanation: Project Description (use attachments if necessary): Removal vQ a .4a om 6'�0)1 n c�- j by a�� v�� b-eao rugs kn b t a ch �Pra �� c�i s �se u �-a s-�`�� n-� Vie- .. �.ard of Trustees Applicat, WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: s�- ..(' c ) grass -h-arl s* rr4-� oY 13ec, kc Bea Ck 'P u� c�r�-har Area of wetlands on lot: q 1416 square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: 5 Q feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? X No Yes If yes, how much material will be excavated? /eZ— cubic yards How much material will be filled? A 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: +�a n A -r awes- a NC 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 Completing Part 1 -Project Information.• The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: B a I 1 Li Dail �i �-takw air \I `D `aT) Project Location(describe,and attach a location map Lea s -er o ' n Brief Description of Proposed Action: V-q-167cbOn removal i) shor-.e rJ ne s�nj (Acen n� C-e M igVZJ bt a 6k Name of Applicant or Sponsor: Telephon _S z()— ( 5 2 s Ta f4 e b u r Se ry r E-Mail: h D, S or2 b+Y'qs Address: m a,t 1 C o 0 2-6 J City/PO: State: Zip Code: 40es 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: . ❑ t)C—C _T dcd wtfiancts /CoaOXI rcro &loh �Aana � r% 3.a.Total acreage of the site of the proposed action? L , acres ('gry_aY—W mte_r tex c-r b.Total acreage to be physically disturbed? (p " acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? IL °S3acres 0�a k�e 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial ]Residential(suburban) ❑Forest ❑Agriculture Aquatic ❑Other(specify): Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A perrpitted 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: X ❑ 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? LLN ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ❑ 12 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: � ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: IFNI ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? [0 ❑ b.Is the proposed action located in an archeological sensitive area? ❑ LZ 13.a. Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YE 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? 0 ❑ 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 ❑ Wetland ❑Urban ❑Suburban 1 S.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-point sources? NO YES If Yes, Ela.Will storm water discharges flow to adjacent properties? ❑NO DYES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO DYES Page 2 of 4 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 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: _��Ylt Lk V1 (Ct 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 El ❑ 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 ❑ ❑ 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, ❑ ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ ❑ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage ❑ Elproblems? 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. FJCheck this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 'ard of Trustees Applicati. 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 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. Sign t r"er, wner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OFSL-� \L� 520 NotaVPtreic JEAN S. SCHWEIBISH Notary Public, State of New York No. 01 SC5074710 Qualified in Suffolk County Commission Expires March 17, 20�� `ard of Trustees Applicatj' _ AUTHORIZATION (Where the applicant is not the owner) I/We, Gt , 4k Fn�-k J1 S+y ic+ owners of the property identified as SCTM# 1000- Q ` 2 _ 1 in the town of New York, hereby authorizes 7 l--H-el a 6k l,O n S 2 V-V Cc'k �uln Cc Vlr 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. Pro - r s Signature Property Owner's Signature SWORN TO BEFORE ME THIS T�` DAY OF 1 \,(— , 20 _ Notary Public JEAN S.SCHWEIBISH Notary Public, State of New York No. 01 SC5074710 Qualified in Suffolk County Commission Expires March 17,20 'Z APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoids same. (` YOUR NAME: �1 U Vm 1 �I�\1 N tT 'TV f'J�� GIt o v, (Last na e,first name, iddle 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(oremployment 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 orbeneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this ` ay o Jt vV+`P r 2 C6 2 i Signature Print Name v u wmy, Y Form TS 1 I Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the'Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant 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# 1 o b® - `i - 2 — 19, YCt t l i t Bk a cell PROJECT NAME�� 4C r o ck V l r a I\Q M OV 6-1 S (-afi an 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: RX Nature and extent of action: Gt� v , ov o —ln RP (A r ta Vo,i I , i-1, n c Location of action: Y Q aZr�e✓ �-Q(a r ao3 Ian Gk Site acreage: , 3 Present land use: F t cA, 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: 3 n!4f M iAM I TA4 (Oh �- (b) Mailing address:-Fb may 23 9 Ve.c-z>,r z (c) Telephone number: Area Code ( ) (5,31 SL a �2 (d) Application number,if any: 1J/A Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes N, No❑ If yes, which state or federal agency? ��G 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. a j r GY'Q.Ct S-e- r2 r re.A once ®Yes No ❑ Not Applicable o proJe o{- i �! rS v►rl S ce S `Y► e O n �-e SS -Zpo ' n 'Al2 h Ce K-P 12-: Se- ht a c.tn -n deYrl s ne e VA 1iZ2 C &Ve 4 aY a_ r ka to On r �"V a S146) (1-C. AhR Odfkfna r C111 ti ( y .D 1 M r ` Wl C. c Attach additional sheets if necessary --kc e�"v j ro rwf6i —G/h 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 K Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria Yes ❑ No ❑ Not Applicable Mo�f� Tn Vu e,U-e- n DrVAC.G'f sce"i L re s th l rC C 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 S through 16 for evaluation criteria ® Yes ❑ No ❑ Not Applicable 11S C¢ �n (� zinc (etnd w-xs swt q-s e,Vj4& 1 o v'I ' 1-c� n r ' uS So��� m lz D 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. Ye No Not A,,',-,-cable I'i G'ITi"�V1 G h(e- '%5 a \ III CD a SIMI 'W 1 it .wi t\ e i y ` e s__ ' e Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No� Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No �' Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ] ElYe�] No u Not Applicable Attach additional sheets if necessary WORKING COAST POLICL, 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. k Yes ❑ No ❑ Not Applicable S S �� P_ r r -4v— 6 a V1 ,c c Mcvi A ti gwoct r Attach additional sheets if necessary Policy 11. Promote sustainable use of Paving 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 Not Applicable PREPARED BY 2 TITLE DATE