The URL can be used to link to this page

Home My WebLink AboutTR-6254 James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. 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 CERTIFICATE OF COMPLIANCE # 0272C Date November 15,2007 THIS CERTIFIES that the in-ground swimming pool and pool backwash drywell At 2797 Cedar Beach Rd., Southold Suffolk County Tax Map # 79-8-15.2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 2/25/03 pursuant to which Trustees Permit #5730 Dated 3/18/03 and Amended on 4/21/04 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 an in-ground swimming pool and pool backwash drvwell. The certificate is issued to GIACOMO CHICCO owner of the aforesaid property. f-o<~ Authorized Signature 'A-3174 Town of Southold Suffolk County, NY ~hf;E~ ~DRESS W ~y~ The People of the State of New York VS. /' ~ FIRST NAME 074001'>>0 JC" I hU ffE:; 700 STATE AlV UCENSE OR REGISTRATION NUMBER ZIP /tJrj / / MIDDLE INIT1AL P' APT. NO. PLATE NO. DATE EXPIRES STATE o N.Y. 0 N.J. 0 N.Y. 0 N.J. 0 PLATE TYPE o PASS o COMM 0 0 CADIUAC 0 PLYM 0 0 BUS 0 MCY 0 VAN 0 o S.W. VEHICLE MAKE 0 BUICK 0 CHEV 0 FORD 0 OLDS 0 TOYOTA 0 VOLKS BODY 0 2DR 0 4DR TYPE 0 TRUCK 0 TRAILER VIN NUMBER o o DODGE PONTIAC _Fo~~tr4~~n&bor.Q.I PARKING SCHEDULED FINE $ ~~'--=7iio7\.,.r CONTACT COURT'O THE PERSON DESCRIBED ABOVE IS SUMMONED TO APPEAR AT SOUTHOLD TOWN JUSTICE COURT, 53095 ROUTE 25, SOUTHOLD, NY 11171 ON ~~;;:;~- I AT 93~ ~ FALSE STATEMENTS HERBN ARE PUNISHABLE AS A ClASS A MISDEMEANOR PURSUANT TO SECTION 210.45 OF THE P.LN. V.S. I~re~h BADGE # ~ . A- 3173 I uwn UI ~UUlllUIU Suffolk County, NY The People of the State of New York VS. ~T E EFENDANT) /' _ FIRST NAME _~ O""/~at!)~i) po STR~SS IJ ,.0- S'T c5c.J<< ~.NO. ~IT) Cl .. . STATE ZIP IVCMJ l"lt/j' P-t ~;/ UCENSE OR REGISTRATION NUMBER MIDDLE INITIAL PLATE NO. DATE EXPIRES STATE o N.Y. 0 N.J. 0 N.Y. 0 N.J. 0 PLATE TYPE o PASS 0 COMM 0 o o DODGE PONTIAC VEHICLE MAKE o BUICK o FORD o TOYOTA o S.W. 4DR TRAILER o BUS o VAN o MCY o VIN NUMBER FACTUAL PART (NOT FOR TVB) I . ~--;::;n,oo~_"'=~re'~_-l'~ i ~::~~~~ II The~J;fD~~&bol.~~::VF5ftt(.)m- Ii PARKlNGSCHEDULEDRNE$. CONTACT COURT 0 THE PERSON DESCRIBED ABOVE IS SUMMONED TO APPEAR AT SOUTHOLD TOWN JUSTICE COURT, 53095 ROUTE 25, SOUTHOLD. NY 11171 I AT 730 (jIr ON DATE OF AI'I'EAIlANCS (NOT FOR_ S-/J3/o 7 FALSE STATEMENTS HERBNARE PUNISHABLE AS A ClASS A MISDEMEANOR PURSUANT TO SECT1ON2,O.45 OF THE P.LN.V.S. COMPLAINANT d#~ :/"1 7:-;~ I~Y/uld BADGE # ArT I DATE, ,/. /' o o A. B. C. ~ H. I. B. Residence Statu, 0 Temp. Res. - Foreign Nat. a Resident BTouri't OStudent DOther Commuter Military 0 Homeless 0 Unk 31. Apparent Condition o Impaired Drugs 0 Mental Dis 0 Unk. o Impaired Alco 0 Inj I III 0 App Norm J. K. L. M. N. 14. Inquiries (Check all that apply) o DMV 0 WantlWarrant o Crim. History 0 Stolen Property o Scofflaw o Other 15. NYSPIN Mes..ge No. 16. Complainant Signature 11. Reporting Officer Signature (Include Rank) 78 ID No 79. Supervisor', Signature (Include Rank) BO. 10 No. o Open 0 Closed (If Closed. check box below) 0 Unfounded o Arrest 0 Pro,. Declined 0 Warrant Advi,ed o Arrest -Juv. 0 Offender Dead 0 Extrad. Deciln 0 Unknown page of Pages Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A, Dickerson BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 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 v/' Project complete, compliance inspection. Board Of $outhold 'Town Trustees SOUTHOLD, NEW YORK PERMIT Pursuant to the provi.slons of Chapter 616 of the I.~ws of the. Slate of New ¥orlc, 1893, end Chapter ~ of the ,L~.w~ of the ' S!ate of blew Yorlc 19~2; and the Southold To~n OrdinAnce tilled 7'REGUlaTING AND -THE,PLACING. OF OBSIRUC~LQ~S IN AND ON TOWN WATERS AND PUBLIC LANDS end'-the REI~IOVAL OF SAND, GRAVEUO,R, OTHER MATERIALS~F~OM LANDS .UNDER TOWN WATERS;?... and in a~cordan~e wi~h 'tEe Resolution of The Board adopted afa meeilng held on 2005 and in conslderalion of the sum of $ ......... %~.~.,.~ ... pard by G±a¢omo Chicco Terms end Conditions llsied .on the reverse dde hereof, of SouthoJd Town' Trustees authorizes and permJfs the foJJow|ng: ~etland ?erm±t to add ~ one-story ~2~X].l~ ad~it±o~ for a s~roam ~d e~pa~d the k±tchen by ac!.din~ a one-~ca~'¥ 9~X1~ ~the condition gutters and drywells are installed to contain the ;roof run-off, and as ~e~icted on the su~ey.prepared by all Jn accordance wdh the deta~d sp~ff,caho.s es pre~nted ihe odglnailng appfi~ti~. 3CauZey a. ~aksen, Jr. ree~d on ~o~. 30 2005.. IN WITNESS WHERE', ~e sei~ Boer8 of Trustees ~re- ~u~s its ~r~refe Seal to be 8~xed, ~n8 fiese ~/esen~ suB~ed by ~'m*j~ of the seid ~8rd as of Tr:l s ,.d CONOmONS ~ p~ Giacomo Chicco ii .~Jt 2797 C~dar Beach Rd., Southold ..... N. ~.~ · ~. That this Petmk should be retained indefinitely, or ~ long ~ the ~kl l~etmlttee ~4s~ ' t~' n~l~ntin the structure o~ project involved, to p~ovlae evi&a~e to anyone amc~'ned ~*t ~h- 4. That the ~o~k Involved will .be subjea to ~e ~ ~ ~t~ ~ ~ ~ ~ o~ Albert J. Krupski, President James I~ng, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Te]ephone (631) 765-1892 Fax (631) 765-6641 December 21,2005 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Frederick Seifert 285 Meadow Beach Lane Mattituck, NY 11952 RE: GIACOMO CHICCO 2797 CEDAR BEACH RD., SOUTHOLD SCTM#79-8-15.2 Dear Mr. Seifert: The Board of Town Trustees took the following action during its regular meeting held on December 21,2005 regarding the above matter: WHEREAS, Frederick Seifert on behalf of GIACOMO CHICCO 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 November 30, 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 December 21,2005, 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, WHEREAS, the structure 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, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approve the application of GIACOMO CHICCO to add a one-story 22'X 11' addition for a sunroom and expand the kitchen by adding a one-story 9'X 14' addition, with the condition gutters and drywells are installed to contain the roof run-off, and as depicted on the survey prepared by Stanley J. Isaksen, Jr. received on November 30, 2005. 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 inspection. (See attached schedule.) Fees: $50.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/Ims Telephone (631) 765-1892 Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971~0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Wed., December 14, 2005, the following recommendation was made: Moved by Don Wilder, seconded by Jennifer Mannino, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A CONDITION of the Wetland, Permit application of GIACOMO CHICCO to add a one- story 22'X 11' addition for a sunroom and expand the kitchen by adding a one-story 9'X 14' addition. Located: 2797 Cedar Beach Rd., Southold. SCTM#79-8-15.2 The CAC recommends Approval of the application with the Condition drywells and gutters are installed to contain the roof run-off, to the west of the structure. Vote of Council: Ayes: All Motion Carried Albert J. Krupski, President James King, Vice-President Attic Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application --..~Vetland Permit Application Amendment/Trans let/Extension ~-~ce~vved Application: fReceived Fee:$ ...---Completed Applicafion~/ __Incomplete __SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) ~VRP Consistency Assessment Form .--'CAC Referral Sent: ///~0}0 ~ of Inspection: /~//t//O~ Receipt of CAC Report: __Lead Agency Determination:__ Technical Review: --4r~lic Hearing Held: /~L] ol I ] ~ ~'~ __Resolution:_ Administrative Permit Name of Applicant ~{ACo~ O-~Ce--o Address o 757 Yb ,e-u , , PhoneNumber:g,30 7t,,,~' ,2'~&[ c~ (q. lZ) Z'Z~/- ~q~ Suffolk County Tax Map Number: 1000- ~7~ - ~, - ~tS". & Property Location: ~qq'7 e_e'-O~lk_ '[:3e~q-O-t. ~=,~b , ~,~,-q-~t--O ~.~.~/. (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: '~'~ ~ ik/g'qlJ) o~,3 5~,e~c.x-t L-ar. Phone: Ooard of Trustees Applicat GENERAL DATA Land Area (in square feet): ! ~. 2.. & C It ~-'~ Area Zoning: ~- ~:% ~'~,e~a"v~/~ Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency Date __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspenj~ed by a governmental agency? ~/ No Yes If yes, provide explanation: Project Description (use attachments if necessary): O~ard of Trustees Applica~ WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: '~: ~ ~l)e ~xaT ~t~xt Area of wetlands on lot: ~'~ ,C~C> square feet Percent coverage of lot: '~ % Closest distance between nearest existing structure and upland edge of wetlands: 9 ~ feet Closest distance between nearest proposed structure and upland edge of wetlands:, c/o _feet Does the project involve excavation or filling? No v/ Yes If yes, how much material will be excavated? ~{50 cubic yards How much material will be filled? (~ cubic yards Depth of which material will be removed or deposited: ~ ~ Proposed slope throughout the area of operations: ~t_t,~- 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): of Trustees Applica~ COASTAL EROSION APPLICATION DATA Purposes of proposed activity: ~-~ Are wetlands present within 100 feet of the proposed activity? Does the project involve excavation or filling7 No ~/ Yes If Yes, how much material will be excavated? How much mater/al will be filled? Manner in which material will be removed or deposited: (cubic yards) (cubic yards) Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 1. APPLICANT / SPONSOR 3 PROJECT LOCATION: Municipality ,~ C:~ ~.~ -r'-~, o [...~) county 4. PRECISE LOCATtON: Street Addess and Road Intersec~ons, Prominent landmarks etc -or provide map 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by A~plicant or Project Sponsor) 2. PROJECT NAME 5. IS PROPOSED ACTION: [] New [] Expansion ~Modification/alteration 6. DESCRIBE PROJECT BRIEFLY; 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, descdbe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose asmanyasapply.) [~esidenflal E~] Industrial E~] Commercial (~Agriculture ~] Park / Forest / Open Space I--]Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, AGENCY (Federal, State or Local) ]Yes ~ No If yes, list agency name and permit / approval: L~ NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? E~Yes ~;;]No If yes, list agency name and permit / approval: I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name ,.Cil. I~LiCI~- ~"l~';~¢"~--4¢' Date: Signature ,.~~ ~,.,~ (~ 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 by Lead Agency) A. DOES ACTION EXCEED ANY TYPE t THRESHOLD IN 6 NYCRR, PART 617.4? if yes, coordinate the review process and use the FULL EAF. 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. 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, 3otential for emsioo, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cuRural resources; or community or neighborhood character? Explain briefly: O3. veg~tafion or fauna, fish, shell~sh or wiidlife species, significsnt habitats, or threatened ~ endangered Species? Expiain briefly: D4. A commuady's exis~ing plans or goals as officially adopted, or a change in use er intensii~ of use of land o~ other natural resoum~$? Explain brit~fly: 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-C57 Explain bdefly: C7. Othe~ impacts'(inCludin~ chan~es in use of either 9uan!ity or type of energy? Explain brieflyi 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,,,: ESYes I--1No I E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL iMPACTS? If yes explain: PARI III - DFTERMINATION OF $1ONIFICANCE {To be completed by Agency) INSTRUCTIONS: For eachadvemeeffectidentified above, determinewhetber ffiasubstantial, large, important or otherwiaesignificsnt. 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) ge~raphie scope: and {0 magnitude. If necessary, add attachments or re~erence supporting materiels. Insure that explaaatioas 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 determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed direcdy to the FULL FAF 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 resufl 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 (I;~ different from responsible officer) AIfftlORIZATION LETTER $outhold To~I Trustees P.O.Box 1179 Southold Town Hall Main Road, Southold, NY 11971 New York State Department of Environmental Conservation Building 40-SUNY Stony Brook, New York 11790-2356 Att: Regulatory Permits Any and all other State, Coun[y, or Local agencies. AGENT: name: Patricia C. Moore Esq. address: 51020 Main Road, Southold NY 11971 telephone number: 631-765-4330 Dear Sir or Madam; The undersigned owners authorize Patricia C. Moore Esq. as our agent for all submissions to the Southold TOwn Trustees, The New York State Deparsment of Environmental Consel~-ation, and any other State, County, or'Local agency which may be required. C ~IgERS: Giacomo,)F. Ch±cco Clare L. Crossley PROPERTY: Cedar Beach Road, Southold NY $0TM#:1000-079-08-25.2 PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: STATE OF NEW YORK COUNTY OF SUFFOLK Address: ~]. N,~. 11~7/ ~ct~-~c) ~o¢l~--~,u.-r , residing at 2~' M~vOoo4 T~-qcff WO~T, ~rLt~ , ,"~, '/. , being duly sworn, deposes and says that on the q day of ~ Ce_ ,20 o~,, 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 ba~-x,..~ 5,~:fc~c-t<' , that said Notices were mailed to each of said persons by (certified) (registered) mail. . ~ & Sworn to before me this Day of I~-~_ , 20 $USAN J, NAGY Notary Publlo 8tats of New Ye.'k No. 4898785 Qualified in Suffolk County Commission Expires May 20 ~..EZ 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-b~,(~1 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of ..................... COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, _ ~-'7~43 ~q f~c~r- , residing at 1;~%- ~t~2ooo '--&o~-"'wc-pt La,. being duly sworn, depose and say: That on the '7 day of De ¢- ,2005, I personally posted the property known as by placing the Board of Trustees official poster where it c~n 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 hearing. Date of hearing noted thereon to be held (Jl-zff 0 Dated: Sworn to before me this ~ dayof~/~ 200~" Notary Pub,~~~ ,~USAN J. NAGY Notary Public State of New Yo.'k No. 4896735 Qualified In Suffolk County Commission Expires May Board of Trustees Application County of Suffolk State of New York ~ c.~cr.~- ~ · ~'~,~--¢.-,r 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 BEAPPROVED 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, ! HEREBY AUTHORIZE THE TRUSTEES, THElR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. §t~lV PuhlIo 8tare of New York · ~a ~ ~pl~ May (where AUTHORIZATION the applicant is not the owner) I, CQtAC~ ¢~t--l't~-~- ~ (print owner of property) residing at ~757 e=~O~ (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (~er' s signature) 8 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the oart of town officers and employees. The vumose of this form is to provide information which can alert thc town of possible conflicts of intem~t and allow it to take whatever action is necessary to avoid same. YOUR NAME: ~ I ~,C.O b'[ b C~4.1.~ O (Last name, first name, gaiddle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If~'Other'', name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, marriage, or business interest. "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO ~ If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative) and the town officer or employee. Either check thc 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): __fi) the owner of greater than 5% of the shares of the corporate stock of the applicont (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, parteer, or employee of the applicant; or ___D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Submitted this ~..~day of /Ms6 ~ Signature ~ ~,~ ~ ~ Print Name ~"'~r~'O ,f~/c't'~r 2oo - 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 Building 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 proposed action will be evaluated as to its significant 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, listino both suooortin~, and non- suooortine 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# logo - O'~q o~ - PROJECT NAME The Application has been submitted to (check appropriate response): TownBoard [] Planning Board [~ Building Dept. ~ 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 extent of action: Location ofaction: Site acreage: Present land use: Present zoning classification: 1'~, o,e-~x-~ t~ ~ 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 ~ NoD 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 ~ 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 I~"1 Yes ~ No [] Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III - Policies Pages 6 through 7 for evaluation criteria ~ Yes ~ No [--] 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 I~ Yes [] No [~ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III - Policies Pages 16 through 21 for evaluation criteria ~ Yes [] No [-~ Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. Yes No Not Aglicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies Pages 32 th. rough 34 for evaluation criteria. ~ Yes [~ No [~ Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. [] Yes ~ No ~-] Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. [] Yes~ No ~ Not Applicable Attach additional sheets if necessary WORKING COAST POLIC~ 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 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 Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages 62 through 65 for evaluation criteria. Yes [] No Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III - Policies; Pages 65 through 68 for evaluation criteria. Yes [] No [~T]~ Not Applicable PREPARED BY TITLE DATE