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HomeMy WebLinkAboutTR-10851A ��U Town Hall Annex ��� ��0® 54375 Route 25 Glenn Goldsmith, President P.O. Box 1179 A. Nicholas Krupski, Vice President l® �® Southold, New York 11971 Eric Sepenoski Telephone (631) 765.1892 Liz Gillooly ' �® Fax (631) 765-6641 Elizabeth Peeples �eoum,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTROILD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF .THE BOARD COF TRUSTEES EF 72 HOURS PRIOR TO COMMENCEMENT OF.THE ACTIVITIES C BE` INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 15T day of construction _ '/2 constructed When project complete. call for compliance inspection; Glenn.Goldsmith, President _.`�®F.S0 Town Hall Annex A. Nicholas Krupski,Vice President ®V� ®�® 54375 Route 25 P.O. BOX 1179 Eric Sepenoski l Southold, New York 11971 Liz Gillooly G Telephone (631) 765-1892 Elizabeth Peeples • �® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10851A Date of Receipt of Application: September 15, 2025 Applicant: KONSTANTINOS D. KATSIRIS &,JULIA MELINDA ORLIE- KATSIRIS SCTM#: 1000-90-3-3 Project Location: 400 Lakeside Drive North, Southold Date of Resolution/Issuance: October'15, 2025 Date of Expiration: October 15, 2028 Reviewed by: Board of Trustees Project Description: Install a 108"x108" above ground hot tub. 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 Konstantinos Katsiris, received on September 15, 2025, and stamped approved on October 15, 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 APPROVED B w SURVEY OF: o55 4.I'OARD OF i RUSTEES nor:M AP 00 • = TOWN:OF SOUTHOLD CEDAR FUM 0ecCemHbe,M,1RPv. L. SITUATE DATE B-AYVIEW bye r � aO� 1 OWN OF SOUTHOLD: . FOLK COUNTY,NEW YORK cer° e i' SCALE 1"=40' JUNE 24,2021 J. all ce NOTES: �' <J 1.ELEVATIONS SHOWN ARE IN NAVD88"DATUM AND ARE say THUS SHOWN x 7.85 ' 2.FLOOD ZONE INFORMATION TAKEN FROM' 1 : 1 STOfZY FRAME USE FLOOD,INSURANCE RATE MAP No. 36103CO167H H � N.4O W��\ ZONE AE:BASE FLOOD,ELEVATIONS DETERMINED AREAOF- ELEV.=6 MINIMAL,FLOOD — L 3.ZONE X:0.2%ANNUAL CHANCE FLOOD HAZARD HAZ ARD , ) ' PROPOSED o HOT TUB ia� wwa �'I� !/ AERIAL LAND SURVEYING MP.d. .�., SJ PROBST DRNE / SMRLE$NY71987 PxINlE:(933)787-=3 Nil EAWL SURVEYSQAERWWNDSURVEYING.COU c' WEBS MWWWAEMnLMMWJRVEYING.COM �nw�r.�rnMa•�n.�a•`r Lor® ZONE AE 6 ZONE a —ce f �C•lI 7 r .. "���.a`.�..�e�.,°:. �w msiRlcr:laoo LOT:3 BLocK:a sEcnox'eo. I' MAP.PLEN0:9a r�r,D SEP 5 CASE NO Na ro�?4 /^ .v e. .m !,"�• .s.a .. 2025 MAP OF.Mapd Cedar Bead:Pak IA v . � r�r oiaiw.a \ew w W RIED DATE:December 2D,19V Y LEGEND: `"'° gsouthold Town TRLE NO:BAl51729. ;„ LAMP POST o V and,,.�{{ µµ •. �.�� � � a I TnJJIEQs COUNTY TAX ID:1000490aD0304403900 —•—•—•—OVERHEAD UTILITY WIRES IC 'R SRUA7ED AT eayr4v,ToendSoutAdd STILLWATER LA db , ti UTILITY POLE (SALTWATER) "O soeomswx MAP LOTes:ss Law . WATER.METER / Kons ant os D. X is tsirand Jul a Melinda Bridge Abstract LLC ® NFG Naliond Title Insurance Company TREE / Welle Forgo Bank ISAO JOBNa: L2 783E •4) - .. DATEJuna Yd,302t .. USTEES OUT 0 D T L.- No. lo$5I A kenS'r4es(;noS KoTS:r:s Issued To _ •. �,.��., a��� - K�S:f:s Date, �o 11-5 /�s Address 'loo �.-aK�cS,: de ��:ve, lJoril�,, Sou'i'�old THIS;. NOTICE MUST BE DISPLAYED, DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD; N.Y. 11.971 TEL.: 765.1892 Glenn Goldsmith,President ��S�FFOC�C � b Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 Eric Sepenoski o ` P.O.Box 1179 Liz Gillooly y �! Southold,NY 11971 Elizabeth Peeples �� Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time:Oc,Abt/ 61 2o15 Completed in field by: QZ06A PeWle{S, KONSTANTINOS D. KATSIRIS &JULIA MELINDA ORLIE-KATSIRIS request an Administrative Permit to install a 108"x108" above ground hot tub. Located: 400 Lakeside Drive, Southold. SCTM# 1000-90-3-3 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: Chapt. 275 Chapt. 111 other Typof Application: Wetland Coastal Erosion Amendment %,/ Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications/Conditions/Etc.: S�korw&r A Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples 2^. SURVEY OF :a ' Z LOT 55 Wo. 11 s I.- . MAP OF Z CEDAR BEACH PARK U FIE NO.90 FILED:December 2D,1927 SITUATE BAYVIEW \ 14 TOWN OF SOUTHOLD � ,$� oR ozB,'kFsioFo SUFFOLK COUNTY,NEW YORK a e� �� 9 aO'e Ri�F SCALE["=40e Seg a a.y ®,., \".� JUNE 24,2021 n r \\n M \ i H�.o o+ NOTES: d ...% n r 1.ELEVATIONS SHOWN ARE IN NAVD88'DATUM AND ARE THUS SHOWN X 7.85 I 1 STOR}! °u a 2.FLOOD ZONE INFORMATION TAKEN FROM: FRAME "I �, HgLISE FLOOD INSURANCE RATE MAP No. 36103COI67H N .40 \\ ZONE AE:BASE FLOOD ELEVATIONS DETERMINED AREA OF ELEV.=6 r---� MINIMAL FLOOD a \— —ULx 3.ZONE X:0.2%ANNUAL CHANCE FLOOD HAZARD HAZARD %A [{ Belpion \. ^\ aeer Fero Cm Cx xvr .ei�,re0 y �aT® w�a j kxi s°^� wT® AERIAL LAND SURVEYING D.P.C. Sr P 53 PROB9T DRIVE TRe u o c¢naww A 1 5 2025 I C F� d� / SHIRLEY,NY 11967 1:0#/I PHONE:(633)7137A393 `✓Ittl(rn4na^xr yT E-MAIL SURVEYS@AERIALLANDSURVEYING.COMe�MEvars'ieia�1pEwurouuw a WEBSITE:WJWOAERIALLANDSURVEYING.COM Southold Town I,mr® ZONE At 6 i Board of Trustees ZONE "aPu DISTRICT:1000 LOT:3 BLOCK:]SECTION:90o .a Mamx. xs.,u�...ne.,.,,,- • cm.' Wxmm ,.m o..mc,orn• MAP FILE ND:9D .a— nn a/q�Q?g• e. f° e n BUMeaa -L (q�. CASE NO:NIA 'y n xpn wear (°0° MAP OF:Map of Cedar Beach Perk -!sd �rw� owmozi SOP NEly1 LEGEND: ri� eearoaa w ro MAP FILED DATE:December 20,1927' � H .+ 3'LAMP POST TITLE NO:BAL6172S ,A /// - /w+ w^^^^^K COUNTY TAX 10:1000-09000-0300-003000 * y X f —•— —•— OVERHEAD UTILITY WIRES / ;' ' o SITUATED AT:Bsyvlew,Town o}goaMold � Rr3te G' / STILLWATER LAKE " v "IL, UTILITY POLE / [SALTWATER) n SUBDIVISION MAP LOTIRS:BS �LAtID KonstantinDS D.Kotsiris and Julia Melinda ' WATER METER Orlie Katsiris — Bridge Abstract LLC ® INFG National Title TREE Insurance Company ��+ w Wells Fargo Bank ISAOA JOB No.:21-763E V DATE:June 24,2021 .t MONARCH PORTABLE .SPA STAUKLESS STEEL AiBo l)E .GROUND 5 aP..A s SPECAFICAP;i nONS P O O L S SPEC SHEET FOR PRE—PLANNING & ESTIMATING ONLY FILTER ACCESS E 0 SEP 1 5 202 0 0 'a r ` 39" Southold Town Board of Trustees_ I u EQUIPMENT,PIPING TOUCH'SCREEN SPA CONTROLS E; &INSULATION AREA I SHOWN WITH OPTIONAL STAINLESS " --N FRAME MOUNTED - LIFTING POINTS(4X) STEEL REMOVABLE ACCESS PANEL' FEATURES: b.so + 316L STAINLESS STEEL SPA SHELL WITH 304L STAINLESS STEEL FRAME 16.00 BENCH TYP + REMOVABLE ACCESS PANELS ARE AVAILABLE IN STAINLESS STEEL OR COPPER +.5-6.BATHER CAPACITY � 86.00 - + 'LED LIGHTING 27.50 63.50 + 14 HYDROTHERAPY JETS 37.00 + FULLY INSULATED WITHi2=PART POLYURETHANE FOAM(NOT SHOWN) • RIGID FOAM COVER WITH'R-15 INSULATION AND ASTM CERTIFICATION + UV LIGHT&HYDROGEN PEROXIDE SANITIZATION + OVERALL DIMENSIONS:86"X 86"X 39" O + WATER CAPACITY:387 GALLONS 16.UD + EMPTY WEIGHT: 1,742 LBS O + FULL WEIGHT:4,970 LBS 6.50 7300 6.50 86.00 - _ien�cccw:atw=�tovw:+cr.•=srr� -CERTIFICATIONS: STAINLESS STEEL SHELLS ONLY: + CERTIFIED TO MEET CEC APPLIANCE EFFICIENCY STANDARDS FOR n II PORTABLE ELECTRIC SPAS ♦ CERTIFIED TO MEET ANSI/APSP-14 STANDARD FOR PORTABLE SPA — � — __._ -ENERGY-EFFICIENCY— __-- STAINLESS STEEL&COPPER SHELLS: I ' +'IAPMOEGS LISTING FOR UL.1795 AND CSA C22.2 STANDARDS t POWER REQUIREMENTS: ` �+ (1 X)230V SOA GFCI SERVICE AT EQUIPMENT FOR SPA CONTROL 16N ANO 5.5KW ELECTRIC HEATER —teto ♦ (OPTIONAL 1X)230V 30A GFCI SERVICE AT EQUIPMENT FOR AUX O n S.SKW ELECTRIC HEATER �I + SPA SHELL AND ALL EQUIPMENT TO BE BONDED W/MIN.#6AWG BAR E COPPER CON DUCTOR i � e EQUIPMENT SERVICE SPACE 1.800.951.SPAS(7727) 720.864.9115. FAX 866.605.2358 DIAMONDSPAS.COM INFOODIAMONOSPAS.COM ' THE INFORMATION CONTAINED IN THIS DRAWING IS THE SOLE PROPERTY OF DIAMOND SPAS INC.ANY REPRODUCTION IN PART OR WHOLE WITHOUT THE WRITTEN PERMISSION OF DIAMOND SPAS INC. IS PROHIBITED. FRAME MOUNTED LIFTING POINTS(4X) 6.50 16.D0 BENCH TYP FILTER ACCESS 0 37.00 - e ' f27.50 1 63:50 e j 86.00 16.00 6.50 73.00 6.50 SPA CONTROLS ' 86.00 4.75 76.50 4.75 4.75 SEP 1 5 2025 D O • � O ® m 29.50 m Southold Town • 39.00 Board of Trustees 4asAn SPA DATA -SPA SURFACE AREA = 31 SQ.FT. SPA FRAME MUST BE INCOMPLETE CONTACT WITH A FLAT TO PREVENT FRAME AND SHELL CORROSION, -SPA CAPACITY = 387 GALLONS AND LEVEL STRUCTURAL SURFACE.INSTALLATION SURFACE TO ADEQUATE DRAINAGE IS REQUIRED.FRAME OR -SPA WATER WEIGHT = 3228 LBS. MAINTAIN FLATNESS OF+/-0.125".ANY GAP LARGER THAN SHELL MUST NOT-RESIDE IN STANDING WATER. -SPA SHELL WEIGHT = 1258 LBS. 0.25"BETWEEN THE FRAME AND INSTALLATION SURFACE MUST BE SHIMMED.CONTACT DSI FOR SHIMMING INSTRUCTIONS -SPA TOTAL WEIGHT = 4486 LBS. MONARCH SPA STAINLESS STEEL ABOVE-GROUND DIMENSIONS ARE IN INCHES UNLESS OTHERWISE SPECIFIED DIMENSIONS DRAWN - �.!p,,NOTES: � � � � ARE IN INCHES.DO NOTSCALE DRAWING MR 6/4/2024 � � 4 -� - 4409 Coriolis Way ��4 k - due to t m TOLERANCES: he custom nature and welding processes involved in fabrication, MATERIAL CHECKED Frederick,CO 80504 there may be some distortion,warping and or pitting of the Flat surfaces on our products. FRACTIONAL±114' 316L STAINLESS STEEL 6/4/2024 '�� �` +' ph.720-8644115 all inside weld seams will be visible. sl 1-800-951-SPAS spa Will be insulated with a 2-part polyurethane foam. TWO PLACE DECIMAL±0.25 FINISH REVISION SHEET :S,.r `yA.-s fax. 7-866-605-2358 ROTARY HAND BRUSHED B 2 OF 9 L,�: lip, arm r '• 14 ol �+.It Ai -V i• 7� ReW^^^c Dr;xa, e osnm z ax1 Dz - oszxo] maeao tatau TDWN or "" sourxo,o "' \ r v e cv \ s.1u.Yn j CFpAR \ m, pR ` evt F'OIryT pAr � b 1 z W. tp,CESDE w xo ^a e 4 8 m a 5 1.8A 1 Me IYm nm � mn _____"____ � ! W OI IA TOWN DF SOUTxOID C "• Y ., ZQW) 14 P nm WEST xi or LAKE t _ 1 s 1.(f�c a 9 p�O9R tpC/A,', �5 rw pnx.uu u.0 ) __ �.v TOYYN OF 1 1 o m� t8 n � b x8 yv„ SOUIIIgD en 14.1 'i .. W 18KE ,� RB.t 'a w1 ♦ ... 18 1 ] HOG' NECK BAY E '_ O ��.. --.�' NOTICE SSil o?1- COUNTYOFSUFFOLK © E '^+� SOOIHOLD CTIONNO � Real Property Tax Service Agency r CeMU9U ry cwr P xuci r.° 1880 }i' PROPERTY MAP r- OFFICE LOCATION: 4 jsOUl' Lf ' MAILING ADDRESS: Town Hall Annex cry.; ' 's P.O.Box 1179 54375 State Route 25 'r� r Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) 1� Telephone:631765-1938 Southold, NY 11971 • y0' LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: Glenn Goldsmith, President Town of Southold Board of Trustees Cc: Honorable Lori Hulse, Attorney From: Heather Lanza, AICP, Planning Director LWRP Coordinator Date: October 14, 2025 Re: LWRP Coastal Consistency Review KATSIRIS & ORLIE-KATSIRIS, SCTM# 1000-90-3-3 This application is to install an 81 sq.ft. above ground hot tub. 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, it is my recommendation that the proposal is a MINOR ACTION pursuant to Town Code §268-3 CC, and is not subject to review for LWRP consistency. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Glenn Goldsmith,President V.SO�r Town Hall Annex 54375 Route 25 A.Nicholas Krupski,Vice President P.O.Box 1179 Eric SepenoskiL lL Southold,New York 11971 Liz Gillooly cn ac Elizabeth Peeples Telephone(631) 765-1892. y Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit _ Amendment/Transfer/Extension Received Application: Received Fee: $ _ 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: l��'l CAC Referral Sent: S E P 1 5 2025: Date of Inspection: Receipt of CAC Report: _ . I __Technical Review: Southold Town Board of Trustees Public Hearing Held: . Resolution: Owner(s) Legal Name of Property (as shown on Deed): (� �n d�, 0 412 Mailing Address: 3 n. ku�ov�' P 1, 5 Q . W`f N�j Phone Number: Lf (0) 39 2- 3 Li 81 _ Suffolk County Tax Map Number: 1000 - 09'0 00 - 0 3 b D 003 b on- Property 1-Location: 0 L n 'k99,CLe DK. bU4-b (If necessary,provide LILCO Pole #, distance to cross streets, and location) - AGENT (If applicable): Mailing Address: _ Phone.Number: Email: 1 ' Board of Trustees Applic :Lon GENERAL DATA Land Area insquare feet).: 0 is 10" Area Zoning: K, S 1 dLQ(a GC, Previous use of property; Intended use of property: Resl o�en�d,l Covenants and Restrictions on property? Yes -2_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 _a_No If"Yes", please provide copy of decision. WMIL-this project re any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure(s) on property have a valid Certificate of Occupancy? Yes=No Prior permits/approvals for site improvements: Agency Date �?�OZ2— CLNo 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): 1 11 h of ^' I0g 10`d a Dv-Z �►,-o-vn A kbjr -hob Board of Trustees Applic ;.on WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: (FAaXA.fi Lehi Area of wetlands on lot: square feet - Percent coverage of lot:'. _ _ _% Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: 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): 61.7.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part I -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 su ject 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: at) a kvm Project Location(describe,and attach a location map): ed o _q Ln a Sq0 odd N Brief Descri tion of Pro osed Actio : 10o are( Name of Applicant or Sponsor: 1 Telephone: ��ll VL1lli-� T�`+�lS E-Mail: O 4mait �Or►'1 Address: . N4 ba - City/PO: State: Zip Code: l ti�gb I.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. 11 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 sponsor? acres 4. Che 11 land us at occur on,adjoining an ar the prop9seqaction. Urban Rural(non-agriculture) Industrial Commercial residential(suburban) Forest ❑Agriculture Aquatic ❑Other(specify):' Parkland Page I of 4 5. Isthe 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: FT ❑ I 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? 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: Er F] 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: . . 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? B.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: ffEl 14. ntify the_typic bitat typesthat oc n,or are likely to be found on tl�-project site.,Check all that apply: Shoreline Forest A ricultural/grasslands Early mid-successional Wetland Urban Suburban 15.Does the site of the proposed action contain any species of animal,or associated'habitats, listed NO YES by the State or Federal government as threatened or endangered? 16.Is the project site located in the 100 year flood plain? NO {YES 17.Will the proposed action create storm water discharge,either from poinf'or non-point sources? NO If Yes, a. Will storm water discharges flow to adjacent properties? []NO OYES b.Will storm water discharges be directed to established conveyance systems ff an m drains)? If Yes, briefly describe: NO. _YES.. Page 2 of 4 I ...... .. .\ ... .....-. ... ................... ..... 18.Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: ... ... _ ....... .. --- _.. 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 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 �/.S�Date:. /Q2,�.2.5- Signature...::. ........ . Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2,-Answer all ofthe.following TT questions in Part 2 using the information contained in Frt 1 and other materials submitted by the project sponsoror otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will-the proposed action create imaterial 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? Ei �. 3. Will the proposed action impair the character or quality of the existing community. � F1 4. W ill the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or affect existing infrastructure for mass transit,biking or walkway? a 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?. . El.-..- 7. Will the proposed action impact existing: a.public/private water supplies? a...- 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 problems? 11. Will the proposed'action create a hazard to environmental resources or human health? Cl Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration, irreversibility,geographic scope and magnitude. Also consider the potential for short-term, long-term and .cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. ` Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) 'PRINT Page 4 of 4 \ Board of Trustees 'Applii- 'Lon AFFIDAVIT` K�,aTANTLJo� D.. �ts..,,,.t_�'���► M .Oa:u�-K�t�wSBEINGDULY SWORN.:. DEPOSES AND AFFIRMS THAT I-IE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S).AND:THAYALL STATEMENTS CONTAINED HEREIN ARE:TRUE:TO THE:BEST`OF HIS/HER-KNOWI;EDGE AND BELIEF,AND THAT ALL:WORK WILL:BE DONE IN THE MANNER-SET.FORTH.IN.THIS APPLICATION AND AS MAYBEAPPROVED 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 UE.8lkT OF.SAiD:PERMIT(S) IF_. ". GRANTED. IN COMPLETING THIS APPLICATIONS 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 TRUSTEE S:TOENTER ONTO:MY PROPERTY AND AS REOUIRED T( 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:Praperty.OWner: Signature o erty.Oy�me SWORN TO.BEFORE ME-:THIS :.._ .: .. : DAY ......... . IVotary.Pitbhc i JASON WAYNE CUMMINGS NOTARY•PUBLIC,State of NewYork NO.01 CU6235797 f QUALIFIEI)IN_NEW YORK COUNTY COMMISSION EXPIRES1��/� 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 avoid same. YOUR NAME: Pi(l f) AA, �// L I e ' ��91 1'J l►� !_S (Last name,first name,jpiddle initial,unless you are applying in the name of someone else or other entity,'such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other",name the activity.) . . Do you 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 employce,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 _n 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): _nA)the owner of greater than 5%of the shares of the corporate stock of the applicant EL (when the applicant is a corporation); B)the legal or-beneficial owner of any interest in a non-coipbrate 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 14 20-Z Signature _ Print Name ^Y AEI G/';n0e 614 k,ris Fortn TS 1 APPLICANT/AGENUREPRE SENTATIVE TRANSACTIONAL DISCLOSURE FORM The,Town of Southold.s.Code of Ethics broliibits conflicts.of interest on:the serf oftown`om&ts anumnlovees The purrwse'of:: thisifomi is'to urovide mformatioi%.which can`alerEthe;town'of ij ib confltcts:of interest end allow it to take whateveraction is necessary to avoid same:. YOUR NAME:,.• r al-isTGfI/1, ��cJ '.� • . (Last name;first narfie,jpidc!16 initial,unless you are applyingbi the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) y 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 pers6all (irr ihro y ugh:your company,spouse,smiling,patent;onchild)have a rt:Iatraiishtp a+rith airy officer or employee of the Town ofSouthold? "Relauonship"includes bjc:blood marriage,ur birsrnes5 inten;st "Business interest"meansa bustiaess, inc[dding a partnersh p.:Jn tiirhich the;town officeror employee has evens;partial.ownership of(or employmenCby):a corporaton in which thdl"nno ffceroremployee.owns.morethan,5°/ooft sihares. 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,of child is(check all that apply): A)the owner of gieater than'b%ofthc:shares of the corporate stock of the app(c nt: _E (when the appliearit is a corporation); B)the legal or beneficial owner of any interest in a non�coipota entil (when the Etapplicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or m the actual applicant DESCRIPTION OF RELATIONSHIP Submitted this day of 20 Signature: Print Name �S Fonn TS I Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS . 1. All applicants for,,permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in: making a determination of consistency. *Except minor- exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should 'review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A._proposed action will be evaluated as to its significant beneficial and adverse effects.upon the coastal area(which includes all-'of Southold Townl. 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 condition's contained:in the consistency review law: Thus, each answer must be explained in detai4 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 lanning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# lU 00 _- .0 9 00 -. D3DD 00300o' PROJECT NAME Bbo "Xos pf f u b ' n i . The Application has been submitted to (check appropriate response): Town Board ❑. Planning Board❑ Building Dept. ❑ Board of Trustee 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 iransaction) ❑ (b) Financial assistance(e:g.'grant,loan,subsidy) t 4ei (c), ` Ni Permrthpproval,license,certification: ' Nature and extent of action: N �� 1 n a on b� KY (o6 Gr 6)v F- av' fv�d Ina - �,,�,•h _ � __ . Location of action qb D L6t,kl c,,1 AV, (U�j��/ Site acreage: :I t,- a c K.al., 0,16 6L G rt S Present land use: Present zoning classification: G/ 2. If an application for the proposed action has been filed with'the.Town.of.Southold agency, the following information shall be provided: Dept- (a) Name of applicant:- 18 All, OV ki Ka1s i✓�� (b) Mailing address: Av Wr,/y I D2, (c) Telephone number: 644 u R ..=- Will the action be directly undertaken,require funding,or approval by a state or federal agency? . Yes ] No 1. 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. [aYes Na Not;Applicable OKIA J2^<W MO( D T Attach additional sheets if necessary Policy 2. Protect and preserve, historic and archaeological resources :of :the Town of Southold. See LWRP Section III—Poli ies Pages 3 through 6 for evaluation criteria . El Yes0 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 ❑ Not 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 /�e/yi 4.ei 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 throu 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 IH—Policies; Pages 22 through 32 for evaluation criteria. No Not Applicable Yes ❑ _ ,fio 5 f'1(��' l►'1'l G G .Q G o 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 ,h 4::: «�-� ua l 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 rX e l A Z a �/11S 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. ❑ Ye❑ No ONO Applicable 1015 h 6� AWZC bib c Attach additional sheets if necessary WORKING COAST POLIOE Policy 10.. Protect:Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP.Section III'-Policies; Pages 47 through 56 for evaluation criteria. ❑Yes ❑ No Not Applicable a Q-P' h we VA !-c� awl- sus 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 Attich 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 1f at-r d ,�ni w, l by r4 I '), d 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 oNot Applicable. ejkW I ,L �/Y P TITLE 6�t/1'�Fi;/ DATE !L125 PREPARED. BY . " 4L i U. aI - - �S .