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HomeMy WebLinkAboutTR-6253 James F. King, President x0f solit,O Town Hall Jill M. Doherty, Vice-President ,`O l0 53095 Route 25 P.O. Box 1179 Peggy A. Dickerson l Southold, New York 11971-0959 Dave Bergen G Bob Ghosio, Jr. Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0254C Date: September 19, 2007 THIS CERTIFIES that the bluff restoration and replanting At 62615 County Road 48, Greenport, New York Suffolk County Tax Map # 40-1-8 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 11/22/05 pursuant to which Trustees Permit # 6253E Dated 12/21/05. Was issued, and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the bluff restoration and replanting. The certificate is issued to DOROTHY YOUNG owner of the aforesaid property. Authorized Signature Albert J. Krupski, President i t Town Hall James King, Vice-President ~$VFFO~I~'CO 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda J.~ Southold, New York 11971-0959 Peggy A. Dickerson Telephone (631) 765-1892 Fax (631) 765-1366 col ~ Sao BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1 st day of construction % constructed Project complete, compliance inspection. R118JD1 8~ Albert J. Krupski, President i Town Hall James King, Vice-President ~S11fF~L~-~, 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda J.~ Southold, New York 11971-0959 Peggy A. Dickerson 4 Telephone (631) 765-1892 Fax (831) 765-1366 col ~ Sao BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction '/z constructed Project complete, compliance inspection. Albert J. Krupsici, President S~UlyO Town Hall James King, Vice-President 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda Southold, New York 11971-0959 Peggy A. Dickerson OQ ~ Telephone (631) 765-1892 CON% Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD COASTAL EROSION MANAGEMENT PERMIT Permit #6253C Date: December 21, 2005 SCTM#40-1-8 Name of Applicant/Agent: Dorothy Young Name of Permittee: Dorothy Young Address of Permittee: 62615 County Rd. 48, Greenport Property Located: 62615 County Rd. 48, Greenport DESCRIPTION OF ACTIVITY: Coastal Erosion Permit to restore the bluff face by spreading clean fill on bluff face by hand and replanting with perenial rye grass as a temporary ground cover. Final restoration of the bluff shall be done in the Spring. The Coastal Erosion Management Permit allows for the operations as indicated on the bluff resotration plan prepared by James A. Richter dated October 31, 2005. Permit to construct and complete project will expire two years from the date the permit is signed. 4&141 9~ Albert J. Krupski, Jr. President, Board of Trustees 0 0 Albert J. Krupski, President ~*0 s0(/TyO Town Hall James King, Vice-President ,`O l0 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda Southold, New York 11971-0959 Peggy A. Dickerson .Ol • Telephone (631) 765-1892 ~c4UFax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No.: 6253E Date of Receipt of Application: November 22, 2005 Applicant: Dorothy Young SCTM#: 40-1-8 Project Location: 62615 County Rd. 48, Greenport Date of Resolution/Issuance- December 21, 2005 Date of Expiration: December 21, 2007 Reviewed by: Board of Trustees Project Description: To restore the bluff face by spreading clean fill on bluff face by hand and replanting with perenial rye grass as a temporary ground cover. Final restoration of the bluff face shall be done in the Spring. Findings: The project meets all the requirements .for issuance of an Emergency Wetlands Permit as determined by the Board of Trustees. The issuance of the Emergency Wetlands Permit allows for the operations as indicated on the bluff face restoration plan prepared by James A. Richter dated October 31, 2005. Special Conditions: Final inspection. This is not a determination from any other agency. Albert J. Krupski, Jr., President Board of Trustees Albert J. Krupski, President SOUry~ Town Hall James King, Vice-President 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda c~ Southold, New York 11971-0959 Peggy A. Dickerson Telephone (631) 765-1892 CDU,~ Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated Waa-lo'~_ has been reviewed by this Board at the regular meeting of 01 and the following action was taken: L,.,,~TAppl!cation Approved (see below) Application Denied (see below) Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees. The fee is computed below according to the schedule of rates as set forth in the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $ S~, 00 ,Gain SIGNED: PRESIDENT, BOARD OF TRUSTEES LD STATES DEPT OF AGFdCULTURE Natural Resources N Conservation Service 423 Griffing Avenue, Suite 110 Riverhead, New York 11901 Telephone: (631) 727-2315 FAX: (631) 727-3160 malt 2ftli3-ft.conn'blip-nyr.usda.go~ Ms. Dorothy Young 62615 North Road P.O. Box 658 Greenport, NY 11944 October 27, 2005 Dear Ms. Young: An onsite inspection of the bluff erosion on your property revealed the following; the erosion of the bluff face appears to have been caused by the extensive rainfall we received recently. The extreme weight of the saturated soil caused the bluff face to shear off. There is no indication that this problem was associated with erosion of the toe of the slope or from runoff flowing over the top edge of the bluff. The soil material that was lost is now sitting at the base of the bluff and has created a shelf approximately 20 to 30 feet above the toe of the slope. There are large rocks protecting the toe of the slope so this soil material should be protected from future erosion after it is replanted to suitable vegetation. A terrace can be built on this shelf using 6 X 6 landscaping ties or equivalent building materials to create a platform in order to replace the soil material lost when the erosion took place and create a flatter slope for revegetation purposes. The terrace construction can begin as soon as permits are secured, however any fill placement and revegetation efforts must be delayed until the spring of next year. Follow the revegetation instructions provided in the enclosed handout entitled: Stabilization ofEro&ng Bluffs. A diversity of plantings is the key to a successful planting because if one species of plants dies back others will be there to fill the void. I would strongly recommend that the warm season grass mixture be planted first as described in the handout then the beach grass and adapted shrubs such as bayberry, rugosa rose and beach plum. I have included a list of suppliers of these plants and seed- Local suppliers include H.R. Talmage & Son in Riverhead and Peat & Son Nursery in Westhampton. Consult the directories for addresses and phone numbers. The warm season grass seed can be obtained locally from the Long Island Cauliflower Association, 139 Marcy Ave. Riverhead, NY 11901 telephone: 631-727-2212 If you have questions regarding this process or I can be of further assistance feel free to contact me. N Si ely, an onne11 District Conservationist The U. S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal .or because all or part ofan individual's income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD)- To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 7'20-6382 (TDD). 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Box 1179 JERILYN B. WOODHOUSE ti0~~ Ty~~ Southold, NY 11971 Chair WILLIAM J. CREMERS OMCE LOCATION; Tav~m Hall Annex KENNETH L. EDWARDS MARTIN H. SIDOR ~Q 54375 State Route 25 GEORGE D. SOLOMON (cor. Main Rd. & Youngs Ave.) ~U Southold, NY Telephone: 631 765-1938 Fax: 681 765-8136 PLANNING BOARD OFFICE TOWN OF SOUTHOLD To: Town of Southold Board of Trustees From: Mark Terry, Senior Environmental Planner LWRP Coordinator Date: December 1, 2005 Re: Request for Wetland Permit for Dorothy Young SCTM# 40-01-08 DOROTHY YOUNG requests a Wetland and.a Coastal Erosion permit for the restoration of the bluff face with fill and plantings. SCTM# 40-01-08 The proposed action has been reviewed to Chapter 95, 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 proposed action is generally CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP. Pursuant to Chapter 95, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Please contact me at (631) 765-1938 if you have any questions regarding the above. Albert J. Krupski, President Town Hall James King, Vice-President ,`O l0 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda Southold, New York 11971-0959 Peggy A. Dickerson G p Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only -;'--Wetland Erosion Permit Application LI ~f~i /Wetland Pemnit Application Administrative Permit Ern ~~G~~~ AmendznentlTransfe /Ext nsio -'-IG-ceived Application:-// Received Fee:$ r a .Completed Application 1,1- 0 _Incomplete i _SEQRA Classification: 3 NOV z 2 L'u~ Type I Type II Unlisted -Coordination: (date sent) _xWRP Consistency Assessment Form f / /aa l0 ! CAC Referral Sent: 'Date of Inspection: /,2 /r// D Receipt of CAC Report: Lead Agency Determination: -Technical Review: __Y-ublic Hearing Held: 1 f Resolution: Name of Applicant J` OAO-rHy q. youN'G Address !62615 fl IT14 rZo~ LC. R. 45? Aq. 65F GK6,e5wPOP-r Phone Number:( ) 63l 4.77- 9RP- Suffolk County Tax Map Number: 1000 - Vo -pi V- o,T Property Location: 62619 MORrN ROAD C;.R. GAF, -I oK i N / E4iFA5r Hsu ItvEY nRP car (provide LILCO Pole distance to cross streets, and location) AGENT:_ VI (If applicable) Address: Phone: *ard of Trustees Applicato GENERAL DATA Land Area (in square feet): ~ 4 5 / S.y 7v l rr~/~ s Area Zoning: R - 80 Previous use of property: 1?r51Jt5NTl hL- Intended use of property: R Cs t J L NY i A Prior permits/approvals for site improvements: Pf 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): C1-CAN Fru_ D 60,7, sm? D, Aw-p SOX, I.oArf Ax w I["ZAWo1 aF TdPSyrc~ fo 13C ys'Q Hit} -SPrcoQl o" ZWFr= FACC 13Y Y nll, or? '-roe' ot= 5#C-L = CRt- 4rE-D WfitCH 15 Zo t,,-- 3o /j5cr - 146ov -T-a oF s(s'p4 fj"L _GKNa E SYi9c.L. 13C ~i'? LWC tnk'TF( Cxt57 e,4 -712COii 5WF ~ard of Trustees Applicat~ WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: -8 1-U FF ~~CCr 5 Il c?~tl ~a R/ Area of wetlands on lot: -A'' square feet Percent coverage of lot: IV % Closest distance between nearest existing structure and upland edge of wetlands: ell, 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? Roo or- - cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: /I C'& Manner in which material will be removed or deposited: 191'5W' w- Y L1G16 i `t1~/GH'f C3RC/t- rte" 9N ' ~r - r~ ai ~~r ~tc~ ~~~rc-N: CQui/'ry' ie ALS011, TcK10i4Lg As s ~C7 ~>!L i ~e, .vc ~ 1 i~'~~~N- ~H7Z:7tr N c ~Kuv+r L'°,vr~'~ ~ {~c. ~f~ I(`~ c~T"p r ~'c7 ~ 4.c c~F ~K~Y~ IV~kJ Fi c c B Y I-lRr? D. 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): ~ard of Trustees Applicat COASTAL EROSION APPLICATION DATA Purposes of proposed activity: P8 LU Fr. f'N CL~ J?L S To a N i rv r? Are wetlands present within 100 feet of the proposed activity? No Yes 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? 2oo- ! - (cubic yards) Manner in which material will be removed or deposited: 11-Ang-o'y L h11e.L BE- r'~avG r] ~ BCcTFP..fACC, Gy N11D[ A10W AIL.[ (JILL Bf- SIOK RAJ crvb a3~cxr~ fiS~G 13y fi/~wj( Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) L. kZ?U r2e vur, HC-707-1i- AS 71-/( ,5 (-rFFo.+~ -r- n/ ~ivG r.?C ' ft C ~c St 77 fl-it-,v 4jt irr 5' !~'l~ ce Fi ~ ~~Tf~ ~ E~T~o2L= Tfr~ C~~u F~ 7~c; 1 I ~ cwt ryt~- ~ /~rc~i Prec y c` ~ PROJECT ID NUMBER 617.20 SEAR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART '1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1. APPLICANT I SPONSOR 2. PROJECT NAME ,DOY4 ]74 Y R . °lo c4 1/6- D IL 't/G- _ B LU t-7'r f 4CC A'F57r0 to qT f -AZ 3.PROJECT LOCATION: Municipality S 0 "-7 W 4nL_') County Surr01_ 1< 4. PRECISE LOCATION: Street Adde s and Road Intersections, Prominent landmarks etc -or provide map A/0(+ .1 N l a,n'D' CCC6A,- )0 'Cow 4'T GR_=reV14oR7_. IVY. C~5 i c~F SuNSC r' ?Lta ; ~ t f. ~,el v~w+~ r 5 ~~l+s ~ ~ f S'_ MoTL . 5. IS PROPOSED ACTION : 0 New ? Expansion ? Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: 'Z; REPI'll 75l~' en 13LUFf: rliC(< C194seD SY ,~)[7-Gn/51vC Rff12.'7-'_HLG- /k C3cTG~4 E'r~ e i.J IGc~ C~~ SAIL+r~fF7 Scl~ criwac~ -rf'1,~5_ RLuFr /jyCL' 11~' SH,04Q GF~. %H,5~6 - 1,5 r?C 1413rcATCe.? 77-,-,d;- 7*6 1q'Coo[e tti1 !4 S /`~;SS ~ G [ N 7~= s7 ~v11 Tt7' L= /2 ~ S[ e n? c F Tly cam' l o ~ ~ Lc3 167,11~_ O!Q l~un/a fF 7z_e,,ur n/`G cP VL 2 7T IC 7_c;1?;7 45i,::7- dt' lW e 13 Lct r=F ~NrS j'r?6T&:_C_ [S 'r'te 1 66 7C_,12L :D1 h'^-111G1.c] T3LLJ F~ 71CC _U 1 clq1G[nrA t-G N/~+] t T f ©"t/ 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? 10 Yes ? No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) R1 Residential ? Industrial ? Commercial ?Agriculture ? Park 1 Forest / Open Space ? Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ?Yes R1 No If yes, list agency name and permit I approval: 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ?Yes [ONO If yes, list agency name and permit 1 approval, 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT 1 APPROVAL REQUIRE MODIFICATION? es No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Date: X Y~ Signature :_~J If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT To be completed b Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. ? Yes ? No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. ? Yes 1:1 No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattem, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: - - I C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A communitys existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly, C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1-C5? Explain briefly: C7. Other impacts includin than es in use of either uanti or t e of ener ? Ex lain briefl : D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA CEA ? If es, ex lain briefs : ? Yes ? No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If es ex lain: Yes ? No PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance mustevaluate the potential impactof the proposed action on the environmental characteristics oftheCEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed actin WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. Name of Lead Agency Date Print or Type Name o esponsr a Officer in ea gency Title of Responsible Officer Signature o Responsible Officer in Lea Agency Signature o Preparer ( different from responsible officer) NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: -b09077+Y f9. Ya 4/'C- SCTM# Or YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: 96P-d19 43LU Fr Flqc C-' 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: y ua/G- Re-S+3) e- "«L L9615 11/O KTw Ro d. , gre-ev^ Z T, Al. 5( 4 - C65 9". 3. That the project which is subject to Environmental Review under Chapters 32, 37, and/or 97 of the Town Code is open to public comment on: You may contact the Trustees Office at 765-1892 or in writing. The above-referenced proposal is under review of the Board of Trustees of the Town of Southold and does not reference any other agency that might have to review same proposal. OWNERS NAME: Nlrl,k/Cyy MI/CHNCL FOCL y MAILING ADDRESS: 4Q0597:..__ 6 ~g. 4,6!> Al y//f PHONE 3 FS'Sc S Enc: Copy of sketch or plan showing proposal for your convenience. PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK , residing at , being duly sworn, deposes and says that on the day of , 20_, deponent mailed a true copy of the Notice set forth in the Board of Trustees Application, directed to each of the above named persons at the addresses set opposite there respective names; that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment roll of the Town of Southold; that said Notices were mailed at the United States Post Office at , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to before me this Day of , 20 Notary Public Board of Trustees Application County of Suffolk State of New York A, 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 TOWN 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(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signature SWORN TO BEFORE ME THIS r DAY OF -A/SV6YJ5iA ,20 D J JOSEPH W. IRMN Notary P011C, State of f Now York Not Public No. 4921106, SUtkAk County Term Expires May 16, 9 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of lawn 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 necessgry to avoid same. YOUR NAME: Last name, first name, middle 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 i~ 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 appiigwt (when the applicant is a corporation); B) the legal or beneficial owner of any interest in a non-corporate entity (whets 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 kot day of It-_ve-~-~~ _ 200 S Signature K11 Print Name t&- Form 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 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- supgortinQ 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# /XO-k -0/ - Q S' PROJECT NAME c:t . y©u?V(r ~LI.+ I'2t=S ~oK Nita~? The Application has been submitted to (check appropriate response): Town Board ? Planning Board El Building Dept. ? Board of Trustees Rr 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: pp _ -ZDflMKC-e E) j3y l~-i15YL,, &MVFHLL 11V CCrVr3iZ Ac--ces?vw,4j- 3 st-u- Amlo R i/Ly9wnq'r- of yeGer';o-w f ,~R~NIftL ~Y~r G12/`xSs ~I~v~ / ~M,U^J CJ~ ~~R CR GRASS . P(.~?~E ~c~ 5 t Gt4 f-?Z. #4-A r 1co k U-3E-N1L ,5 . Location of action: 6C-6115 opQ -f Roo r C Gezl /Me j /VY Site acreage:______ O ?r-9 3 . Present land use: PrS I-TEA/7-/F1 L. Present zoning classification: Res 1 EN ri'9 1 910 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: (c) Telephone number: Area Code ( } (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ? No 0 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 7 Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III - Policies Pages 3 through 6 for evaluation criteria ? Yes ? No © Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWR.P Section III - Policies Pages 6 through 7 for evaluation criteria ? Yes ? No [2r 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 0 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. ? ? Yes No Not Apicable 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 0 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 0 Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. ? YesO No 0 Not Applicable Attach additional sheets if necessary WORKING COAST POLICR 0 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 1:1 No Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. ? Yes ? No Z 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. 1:1 Yes 1:1 No u 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 ',D Owrtt~, - Y~ n{, . -TITLE P&(JERr'1( OWN6-12 DATE OS~