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Home My WebLink AboutTR-6242Albert J. ICrupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 TO: Please be advised that your application dated reviewed by this Board at the regular meeting of following action was taken: TOWN OF SOUTHOLD i~I ' : '-{--~,~e_r~ ~"~ ;~, DEC -2 2005 J/ //b oF and~ (7) Application 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: $ 100 ,' O0 SIGNED: PRESIDENT, BOARD OF TRUSTEES Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 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 ¼ constructed Project complete, compliance inspection. Board Of $outhold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. ~' DATE: Nov.16, 2005 ISSUED TO c~g~¥~. HANSEN Aut'l arizatian Pursuenf to t~ provlslon~ of Chapter 615 of ~e ~ws of the. Sfa~ of New Yor~, 1893; and ~apfer ~ of the ~ws of Sfa{e of New Yor~ 1952; and ihe So.hold To~n Ordman~ ~led '."RE~U~TIN~ AND-~E.P~ClN~ OF QBStRUGI~HS IN AND ON TOWN WATERS AND PUBLIC ~NDS and {M REMOVAL OF SAND, ~VEL-OR OTHER MAT~IALS~FgOM ~NDS .UNDER TOWN WA~RSi[t. and in acc~dan~ with Resol~ion of ~e Board adopted afa meeting held on _...~0.E,,. g.q~., and in consideraiion of {he sum of $_~.,.~.0 ...... paid by Chery[ ~ansen of ......~{{?~_.~.~.~.~.~.~.._~LLL~p.~.. ' ' a.d ~ubjecf So She Terms and ~ndifions Jis~ed on ihe revere ride ~reof, of ~uihold Town Tr~ees authorizes and perm~ the fot[o~ng: ~erland Perm~r ~o consLrucr a st~gZe ZamtZ~ dwe[ttn ~tth' condition ~har a s~aked hayba[= ~-~ ~= ~ulkheaa duri~ constructio~ a~d';~t;~=,P~e~_50 ,~rom the ~]]?~.~ ~on~a~n ~oof runoff and all a= depicted on the a. m .ccoraance wdh ~.e aov~a sp~mca~ons as pre~ntea m -~e odglnafin9 IN WITNESS WHERE., ~e s~id Boerd 0f T~stees ~re- ~u~s its ~r~rale Seel ~o be ~xed, en~ ~ese ~[esen~ su~%ed by A'mejm~ of the s~ld ~rd as of {h~s TER~S ,,nd CONDITIONS Cheryl Hansen. Arlington Heights, Illinois Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town H~l 53095 Route 25 P.O. Box 1179 Southold, New York l1971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 November 16, 2005 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Cheryl Hansen 305 S. Windsor Drive Arlington Heights, Illinois 60004 RE: 405 WILLIAMSBURG ROAD, SOUTHOLD SCTM# 78-05-17 Dear Ms. Hansen: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, November 16, 2005 regarding the above matter: WHEREAS, CHERYL HANSEN applied to the Southold Town Trustees for a permit under the provisions of Chapter 97 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated October 14, 2005, and WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on November 16, 2005 at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, 2 WHEREAS, the proposal complies with the standards set forth in Chapter 97 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, RESOLVED, that the Board of Trustees approve the application of CHERYL HANSEN to construct a single family dwelling with the condition that a staked hay bale line be placed 50' from the bulkhead during construction and gutters and drywells put on the house to contain roof runoff and all as depicted on the plan surveyed by John Metzger revised 9/26/05. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of $50.00 per ~nspection. (See attached schedule.) This is not a determination from any other agency. Fees:S100.00 Very Truly Yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/hkc Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 TO: Please be advised that your application dated reviewed by this Board at the regular meeting of following action was taken: BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD ~/) Application Approved (see below) __.)Application Denied (see below) ( )Application Tabled (see below) has been and the If your application is approved as noted above, a permit fee ~s 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: $ /OO ,, O0 SIGNED: PRESIDENT, BOARD OF TRUSTEES Telephone (631) 765-1892 Town Hall 53095 Route 25 P.O~ Box 1179 Southold, New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Wed., November 9, 2005, the following recommendation was made: Moved by Don Wilder, seconded by Tom Schlichter, it was RESOLVED to TABLE the Wetland Permit application of CHERYL HANSEN to construct a single-family dwelling. Located: 405 Williamsburg Rd., Southold. SCTM#78-5-17 The CAC Tables the application because the project was not staked, however the proposed dwelling appears to be too close to the bulkhead and at least a 35' non-turf buffer is recommended. Vote of Council: Ayes: All Motion Carried Oct, 13,2005 Field Inspection TYPICAL POOL AREA = 14, 54 7 SQ. F T. ~-- prop ~ {eV, TEST BORING 5.5 CERTIFIED TO: CENTURY ABSTRACT CORP. ERIK R HANSEN SURVEY FOR ERIK P. HANSEN AT BAYVIEW P. O. 80X 909 ',,.,,~u LP, NO "~"~,." 1230 TRAVEL'ER STI:~ £OUTHOLD: .V, Y. .,'1,97/ TOWN OF SOUTHOLD SUFFOLK COUNTY, N.Y. I000 - 7'8 - 05 - 17 SCALE: I"= J U NE 2.8, 19 85 ~-2~-~.~-.,,v~,¢,~(,'~, ~,o~ ELEVATIONS ARE REFERENCED TO AN ASSUMED DATUM 85 - 246 AREA=I4,547SQ. FT. '~.,~ TEST BORING 5,5 ~8 P. O. BOX 909 IP30 TRAVEL'ER £OUTHOLB~ IV. Y. q971 CERTIFIED TO: CENTURY ABSTRA CT CORP ERIK P. HANSEN SURVEY FOR ERIK P. HANSEN AT BAYVIEW TOWN OF SOUTHOLD SUFFOLK COUNTY, N.Y. I000 ' 78 - 05 - 17 SCALE: I"= JUNE 28, 1985 REVISED 7- 24-85 ~,¢ A5 P~/~ DEC ~ ELEVATIONS ARE REFERENCED TO AN ,4SSUMED DATUM 85 - 246 PLANNING BOARD MEMBERS JERILYN B. WOODHOUSE Chair WILLIAM J. CREMERS KENNETH L. EDWARDS MARTIN H. SIDOR GEORGE D. SOLOMON To: Town of Southold Board of Trustees From: Mark Terry, Senior Environmental Planner LWRP Coordinator PLANNING BOARD OFFICE TOWN OF SOUTHOLD Date: November 7, 2005 Re: Request for Wetland Permit for Cheryl Hansen SCTM#78-5-17 MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971 OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southald, NY Telephone: 631 765-1938 Fax: 631 765-3136 NOV i 0 2005 CHERYL HANSEN requests a Wetland Permit to construct a single-family dwelling, Located: 405 Williamsburg Rd., Southold. SCTM#78-5-17 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 provided that: 1. Require a 30' non-disturbance, non-fertilization buffer with native plantings to provide habitat and a buffer area to the waterway. 2. A row ofhaybales during construction. 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. A~bert J. Krupski, President J~:mes King, Vice-President Attic Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application ~'~Wetland Permit Application __ Administrative Permit AmendmentJTrans fer/Extensiog, -~"Received Appl/cation: ---~eceived Fee:$ ~ ~ ~-.~5:"6mpleted Application IO]lt[/O~ ~complete __SEQRA Classification: Type I__Type II Unlisted Coordination:(date sent) ~--~TWRP Consistency Assessment Form /~l~]O -'C-AC Referral Sent: ~ate of Inspection: ! __Receipt of CAC Report: __Lead Agency Determination:__ Technical Review: ~.~*ublic Hearing Held: t[/[ ~/0~ __Resolution: Suffolk County Tax Map Number: 1000- ~I,~. DO~'./~ Property Location: ~7/0~'~ ~/, II,qmS ~OC3 ~O~ 1'3 (provide LILCO Pole #, distance to crdss streets, and location) AGENT: (If applicable) Address: Phone: ~ard of Trustees Applicat GENERAL DATA Land Area (in square feet): /,..~ .3~-q '? Area Zoning: /K/~'.g t /~'tu 7'/h/-- Previous use of property: %/~-~ i0r .t,,J 'U Intended use of property: ~ ~ tr ~ ~. 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 >ard of Trustees Applica~ WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: (?t~n/$ z'~,o'~Z" ,0 d*lg46~/- ~ Area of wetlands on lot: 3/0~/&J square feet Percent coverageoflot: A/~ % Closest distance between nearest existing structure and upland edge of wetlands: ,nd/¢ feet Closest distance between nearest proposed structure and upland edge of wetlands: A//~ feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? ! 7'7 cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: c-2 Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: feet 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): PROJECT ID NUMBER PART t - PROJECT INFORMATION 1 APPLICANT / SPONSOR Ur/CO [.- g 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. PROJECT NAME 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc - or provide map 5, IS PROPOSED ACTION: ~/New 6. DESCRIBE PROJECT BRIEFLY: E~ E×p@nsi~n J-'--~ Modification / alteration SEQR 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~/es [] No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) I~esidential I~ Industrial i'~lcommercial ~lAgriculture I~ Park / 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) I~es I~lNo If yes, list agency name and permit / approval: ~'~/'-~'~-'~,.~r 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ]Yes [~1~o If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? E es I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant , Spon~sor Name ~ ~-~-~L.- /~(~l~z(J S~'~'~ Date: )~. Signatllre ,~~ ~l~ ,~;;2~.~j V If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment P. ART II - IMPACT ASSESSMENT (To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE ~ THRESHOLD IN 6 NYCRR, PART 617.47 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 617.67 If No, a negative declaration may be superseded by another involved agency. r~Yes [--']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 pattern, solid waste production or disposal, ,otential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natt~ral or cultural raseumes; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildiife species, significant habit~i~, or threatened o[endangerad species? Explain brieflyl C4. A community's existing plans or goals as officially adopted, or a change i~ use or intensity oi Use of land or other natural resources? Explain briefly: C5. Growth, subsequent development, or related activities likely to be in(Juced by the proposed aciion? Explain bdefly: C6. Long term, short term, cumulative, or other effects not identified in Cl-C57 Explain briefly: I C7. Other impacts (including chan~es in use of either quantity or type of energy? Explain briefl},: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? (If yes, explain briefly: E~] Yes li~No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: r-lYes I~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 wes checked yes, the detsrmination of significan ce must evaluate the potential impact of th e proposed action on the environmental characteristics of the C EA. 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 actior 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 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) PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: pt'"'r[.LWZ ', [J-j..~ Fg..I~ I I0- 0 STATE OF NEW YORK I ~_t_ ~.,'d6 COUNTY OF .Sj, j:F. FOL_K CoO , residing at ~ JO/O /-//~' _/x~ ~ Z- , being duly sworn, deposes and says that on the / day of A'*~ t,~,-ta ~,~ ,20 ~4'7, deponent mailed a tree 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}~oll of the Town ,o[ Southold; that said Notices were mailed at the United States Post Office at/-/1~t.//O~-rO~, /-t'~-7'5 , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to.before me this ( ~ Day of ~,1~ ;~tv-~ ,200~ /'// Ctary e!ablic i J NOTARY PUBLIC- STA~ ~ ILLIN~S ~ ~ MY C~SS~ ~~R~S:~7 Lot Number 78-5-10 *78-5-9 78-5-16 * '78-5-15 Name Jeffrey Green Marjorie Smith Peter & Aletm Pagios Erik Hansen Address 143 Berry Hill Road Syosset, NY 11791 370 Williamsburg Road P. O. Box 936 Southold, NY 11971 26 Amherst Road Port Washington, NY 11051 305 S. Windsor Drive Arlington Heights, I1 60004 Marjorie Smith passed away July 1, 2005. I am executrix of her will. I did not send a letter to her address. All her mail is forwarded to me. Erik Hansen is my husband. Attached is a note saying he is in full agreemem with my plans. Erik P. Hansen 305 S. Windsor Drive Arlington Heights, I1 60004 847-577-3528 November 2, 2004 To Whom It May Concern: This is to inform you that I am aware that my wife Cheryl Hansen is requesting a building envelope on the property adjacent to a home I own at 305 Williamsburg Road. I am in full agreement with her plans. Cheryl Hansen 305 S. Windsor Drive Arlington Heights, IL 60004 847-577-3528 October 25, 2005 To whom it may concern; This is to authorize Les Ga~7ola to act as my agent and post the Notice of Hearing sign on my lot at 405 Williamsburg Road, Southold. Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-~0~] BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of ........ ('_ _~_~_ _ __/~O._~ ........................ COUNTY OF SUFFOLk:) ST^'rE OF MW YOR~:) being duly sworn, depose and say: That on~oeo~?f.~dayc,~( ~(t~-f ~ ~ 3~,ers~ffllf~osted ~r:~y~w~, by placing the Bo~d of Trustees offici~po~er where it can easily be seen, and that I have checked to be sure the poster has remained in place for eight days prior to the date of the public heming. Date ofhe~ing noted thereon to be held ~ ~. ~ (~ /¢ ~)~ ~, Sworn to before me this =~,¢ day ofe0/'4~-2005~' Notary Public (sig ~/ // Cheil Hansen 305 S. Windsor Drive Arlington Heights, IL 60004 847-577-3528 October 25, 2005 To whom it may concern; This is to authorize Les Gazzola to act as my agent and post the Notice of Hearing sign on my lot at 405 Williamsburg Road, Southold. Board of Trustees Application County of Suffolk State of New York ~//~//~// /-/~ AJX ~-/~/ BEING DULY SWO~ DEPOSES ~F~S THAT ~/S~ IS Tm ~PLIC~T FOR T~ ~O~ DESC~ED PE~T(S) ~ T~T ~L STATE~NTS CONT~D ~ ~ ~m rO ~ ~S~ O~ mS~ ~O~[~a~ *~ ~Lm~, ~ ~ ~L WO~ ~LL BE DO~ ~ T~ ~R SET FORTH ~ T~S ~PLICATION ~ AS MAY BE ~PRO~D BY T~ SOUTHOLD TO~ BO~ OF TRUSTEES. ~ ~PLIC~T *~S *O "OL~ ~m ~O~ OF SOUmOL~ ~ ~m TO~ r~VSr~S ~ESS ~ ~E ~OM ~Y ~ ~L D~AGES ~ CL~S ~S~G ~e~ O~ BY m~ OF Sm e~mT(S), ~ ~mTm m COmLET*~ TInS ~PLICATION, I ~BY AUTHOmE Tm ~US~ES, T~m AGENT(S) OR ~P~SENTATI~S(S), TO EN~R O~O ~ PROPERTY TO ~SPECT T~ P~SES ~ CON~CTION ~TH ~mW OF TInS ~PLICATION SWORN TO BEFORE ME THIS Signature DAYOF 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 pumose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever antinn is necessary to avoid same. (Last name, first nange,~alddle initial, ~less 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 Mooting Exemption from plat or official map Planning Other (If"Other", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, marriage, or business interest "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO ~ If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): __.A) the owner of greater than 5% of the shares of the corporate stock of the applic0nt (when the applicant is a corporation); B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a corporation); __.C) an officer, director, partner, or employee of the applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I Submitted this day of t 200 __ Signature ..~-~,~.5A y~/t:L~z~e~ ~ . PrintName (~ (~t~-p.~. /.~j..~-/~ Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A~ INSTRUCTIONS 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 BuiMing Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 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 vroposed action will be evaluated as to its siemificant beneficial and adverse effects upon the coastal area (which includes all of Southold Town). 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 exolained in detail, listin~ both suo~ortino and non- suooorting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall n9t 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# 7 - - / PROJECT NAME ~V/~/~Li~04~; I~0 P-- ocr ~-J~C30 ~ ~' The Application has been submitted to (check appropriate response): TownBoard [-~ PlanaingBoard[-~ BuildingDcpt. ~ BoardofTrustees 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 exten, t of~a):tion:~~ '~/9 .F) Location of action: Site acreage: Present land use: £o Ib Present zoning classification: /~.E. ffl~/t/T/JO/.~ 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 [-~ 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. [~es No Not Ap ica.hie . . · 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 [-q~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 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 Ili - Policies Pages 8 through 16 for evaluation criteria Yes [] No Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III - Policies Pages 16 through 21 for evaluation criteria 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 Aq~icable 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 [] 7- ot 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. [] Yes~ No ~--~Not Applicable Attach additional sheets if necessary WORKING COAST POLIC~ P~licy 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 Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peeonie Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. 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 7] No [] Not Applicable PREPARED BY ~/'~-~/ ~ AJ ~ ~c-/~ TITLE DATE