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HomeMy WebLinkAboutTR-6272 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 Date November 21. 2006 # 0169C THIS CERTIFIES that the retaining wall At 4075 Stillwater Ave" Cutchogue, NY Suffolk County Tax Map # 137-1-8.1 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 11/4/05 pursuant to which Trustees Permit # 6272 Dated 12/21/05 "'as 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 a retaining wall. The certificate is issued to ROY R. WARD III owner of the aforesaid property, ~6l!'~ Authorized Sig!lature Albert J. Krupski, 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 ½ constructed ¢,/' Project complete, compliance inspection. Board Of $outhold 'Tom Trustees SOUTHOLD, NEW YORK PERMIT NO. 6272 DATE: Dec, 21, 2005 ISSUED TO ROY R. WARD II I%rsuant to the provisions of Chapter 615 of the L~w-s of the State of blew York, 1893~ and Chapter 404 of the ,L~. ws of the State of New Yor~ 19~2~ and the Southold To&n Ordinance t~led :'~EGU~NG AND .~E.P~NG. OF: IN AND ON TOWN WATERS AND PUBLIC ~DS EUOVAL OF SAND, eEAVEL. OrH? ~NDS .UNDER TOWN WA~RSi:.L and m ~cc~dan~ wdh 'the Resol~io. of ~e Board adopted at a meeting hel~ on ...~.5~:.~..~_~.... 2q9~..'.., end in consideration of the sum of $....~.~.,..Q0 ..... paid by of ......... ~AA~A~g~. ......................................... N. Y. and subject ~o the Terms end ~.dillons listed .on the revere ~lde ~reof, of ~uthold Town Tr~ees authorizes and permtN th~ follo~ng: ~e~icted ~n the ~1an p~e~e~ ~y Thomas ~cHen~y ~Ate~ 7/~2/0~ a~ survey ' a~ in accordance with the defend sp~i~tlons · ~e od91nafln9 appfi~ti~, p=epa=e~ 'by ~oh~ C. ghle~s last rev.: 5anua[7 16, 2006. IN WITNESS WHERE', ~e sdd Board Of Trustees ~re- ~u~s its ~r~rate Seal to be a~xed, an~ ~ese presenH 1o sub.ed by ~'mai~ of the said ~ard .as of this date, ~e~y D%cker son TER~S and CONDITIONS · ~.~ ~.,, Roy R. Ward II .~ 4075 Stillw~ter Ave.. Cutcho~ue . , , 8. That dm said Board will be notified I~ the Petmittee ot the ~al~a~.i~ ~ ~ ~ 9. Ti~t. eke .p~,~l.,., Albert J. Krupski, President James King, Vice-President Al-tie 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 December 21,2005 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Thomas McHenry Liberty Permit & Research P.O. Box 5 Center Moriches, NY 11934 RE: ROY R. WARD II 4075 STILLWATER AVE., CUTCHOGUE SCTM#137-1-8.1 Dear Mr. McHenry: The Board of Town Trustees took the following action during its regular meeting held on December 21,2005 regarding the above matter: WHEREAS, Liberty Permit & Research on behalf of ROY R. WARD II 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 4, 2005, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator 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 ROY R. WARD II to replace the existing +/-105' retaining wall in-place with C-Loc vinyl sheathing, and install +/-8' of retaining wall return along the north property line, with the condition of a 10' non- turf buffer landward of the retaining wall, all debris, including boats, in the marsh is removed, and all as depicted on the plan prepared by Tom McHenry dated July 12, 2005 and survey prepared by John C. Ehlers last revised Jan. 16, 2006. 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, President, Board of Trustees JFK/Ims Albert J. I<rupski, President James King, Vice-President Artie Fester 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 Please be advised that your application dated /I reviewed by this Board at the regular meeting of /-~ following action was taken: has been and the (~) 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: $ ~"-cO, 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., December 14, 2005, the following recommendation was made: Moved by Jack McGreevy, seconded by Don Wilder, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A CONDITION of the Wetlan(~ Permit application of ROY R. WARD II to replace the existing +/-105' retaining wall in-place with C-Loc vinyl sheathing, and install +/-8' of retaining wall return along the north property line. Located: 4075 Stillwater Ave., Cutchogue. SCTM#137-1-8.1 The CAC recommends Approval of the application with the Condition of a 10' non-turf buffer. Vote of Council: Ayes: All Motion Carried Board'Of $outhold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. 1415 DATE:~Y ?., ..~9~? ISSUED TO ......... R~LgI~a.~..1~/... S~ ....................... ull ori alimt Pursuant to the provisions of Chapter 615 of the Laws of fha State of New YorE, 189:]: and Chapter 404 of the Law~ of fha State of New\YorE 1952: and the Soufhold Town Ordinance en- titled "REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and /he REMOVAL OF SAND. GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;" and in accordance with fha Resolution of The Board adopted at a meeting held on .N.gY... 5~... 19.~9 , and 'n cons~deratlon of the sum of $ l~...O0 . paid by ...................... B~gb~d. ~..$ee~g ............................. of Cutchogue N.Y. and ,~bject to the Terms end Conditions listed 6n the reverse side hereof, of Southold Town Trustees authorizes ~nd permits the following: permission to place catwalk and floating dock at private property of the applicant as per application subject to it being placed in the open aea between th~ ra s ' ~ ineccordance with f~e ~tailed specifications as presented in the originating application. IN WITNESS WHEREOF, The said Board of Trustees kere- by causes its Corporate Seal to be affixed, and these ~resents fo be subscribed by a majority of the said Board as of this dat~. TOWN OF SOUTIIOLD OFFICE OF BUILDING INSPECTOR TOWN KALL SOUTtlOLD, NEW YORK CEHTIFICAT~. OF OCCUPANCY NONCONFORMING PREMISES THIS IS TO CErtTIFY that the No. Z11929 September 19, 1983 /~/ Land [I~l Building(s) IX/ Uss(s) , Street Hamlet shown on County taxkmap as District 1000, Section 137 . Brock 01 Lot 0~8.1 , does[not)conform to the present Building Zone Code oft he Town of Southold for the following reasons: property had insufficient area, the dwelling nas insufficient On the basis of information presented tb the Building Inspector's Office, It~as been determined that the abo~e nonconforming /~/Land /~'/Building(e) /'~/Use(s) existed on the effestive date the present Building Zone Code of the Town of Southold, and may be continued pursuant to and subject to the appli- cable provisions of said Code. IT IS FURTHER CERTIFIED that, based upon information presented to the Building Inspector's'Office, the o.-cupancy and use for which this Certifi- cate is issued is as follows: a p~,ivate one-family dwelling and non-conformin$ guest cottage. The Certificate is issued to of the aforesaid building. RICHARD SEELIG Suffolk County Department of Health Approval no record UNDERWRITERS CERTIFICATE NO~ no re~ord NOTICE IS HEREBY CIVEN that ihs owner of the above premises l-LiS NOT CONSENTED TO AN INSPECTION Gl the premises by the Building Inspec- tor to determine U the premises comply with all applicable codes and ordin- ances, other than the Building Zone Code, and therefore, no such inspection has been conducted. This Certificate, therefore, does not, and is not intended to certify that the premises comply with a11 other applicable codes and re~ula- tions. Bui: cin.~ ~,~Ss pector FOR PERMIT : ~ ~: :' United States Army C~.~Ps °~ Engineers New York State Department of Environmental Conservation Division'of Environmental Permite, Region One Building 40 - SUNY, Stony Brook, New York 11790-2356 Phone: (631) 444-0365 · FAX: (631) 444-0360 Website: www.dec.state.ny.us LETTER OF NON ,JURISDICTION-TIDAL WETLANDS Erin M. Crotty Commissioner Roy Ward 4075 Stillwater~Avenue Cutchogue, NY 11935 March 25, 2002 Re: Application #1-4738-02952/00001 Ward Property, 4075 Stillwater Avenue, Cutchogue, NY Dear Mr, Ward: Based on the information you have submitted, this Department has determined that: The property landward of the 10' elevation contour as shown on the survey prepared by John C. Ehlers last revised on 12-11-01, is beyond the jurisdiction of Article 25 (Tidal Wetlands Act). Therefore, in accordance with the current Tidal Wetlands Regulations (6NYCRR Part 661) no permit is required. Please be advised, however, that no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundary, as indicated above, without a permit. It is your responsibility to ensure that all precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdiction which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and your project (i.e. a 15' to 20' wide construction area) or erecting a temporary fence, barrier, or haie bay berm. Please be further advised that this letter does not relieve you of the responsibility of obtaining any necessary permits or approvals from other agencies. Very truly yours, Mark C. Carrara Permit Administrator CC: Land Use Ecological Services, Inc. BMHP file / / / PLANNING BOARD MEMBERS JERILYN B. WOODHOUSE Chair WILLIAM J. CREMERS tCENNETH L. EDWARDS I~LA-RTIN H. SIDOR GEORGE D. SOLOMON PLANNING BOARD OFFICE TO%tN OF SOUTHOLD MAHANG ADDRESS: P.O. Box 1179 Southold, NY 11971 OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cot, Main BA, Southold, NY Telephone: 631 765-1938 Fax: 631 765-3136 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 Ray Ward SCTM# 137-1-8.1 ROY R. WARD II requests a Wetland Permit to replace the existing +/-105' retaining wall in-place with C-Loc vinyl sheathing, and install +~-8' of retaining wall return along the north property line. Located: 4075 Stillwater Ave., Cutchogue. SCTM#137-1-8.1 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 with the following conditions: 1. No treated CCA lumber will be used. 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 James King, Vice-President Artie Foster Ken Potiwoda 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 ~etland Permit Application __ Administrative Permit Amendment/Trans fer/~xte~sio n ~lk~c~]~ed Applica~, ,.,~ Received Fee:$ (.~\~].~ ~2:ompleted Application Incomplete SEQRA Classification: Type I Type II___Unlisted__ ~C~ordination:(date sent) {q'lqC /LWRP Consistency Assessment Form ~ Referral Sent:_ g~ _ ate of,nspection: o Lead Agency DeternUnation: Technical Review: ___~./ffib lic Hearing Held: Resolution: Phone Number:( ) (~211 .~J~- ,~'l!~_ Suffolk County Tax Map Number: 1000- Property, Locatio~n: (provide LILCO Pole #, distance to cross streets, and location) (If applicable) Phone: Bo of Trustees Application Land Area (in square feet): Area Zoning:. GENERAL 'DAT~k Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency Date prior permits/approvals for site improvements. Has any permit/approval ever been revoked or sus_~ If yes, provide explanation: a governmental agency? Yes Project Description (use attachments if necessary)::~K~~r~ O~e_O_ 8' ~ ~ B~ of Trustees Applicatio~ WETLAND/TRUSTEE LANDS APPLICATION DATA P~oseoftheproposedoperations: ~ ~0~k- ~ ~4~,~ C~%~,~1~ ,~ea of wetl~ds on lot: --",% ',',' J s,~u~e feet Percent coverage of lot: Closest distance between nearest existing structure and upland edge of wetlands: _4 .~ ,' feet Closest distance between nearest proposed structure and upland edge of wetlands: -~ ~t& t feet Does the project involve excavation or filling? ~/r I~ Yes If yes, how much material will be excavated? How much material will be filled? Depth of which material will be removed or deposited: Proposed slope throughout the area Of operations: Manner in which material will be removed or deposited: cubic yards cubic yards feet Statement of the effect, if any, on the wetlands and tidal waters of~e town that may result by reason of such proposed operations (use attachments if appropriate): COASTAL EROSION APPLICATION DATA Purposes of proposed activity: Are wetlands present within 100 feet of the proposed activity? No / Does the project involve excavat~n or filling? If Yes, how much material will be excavated? (cubic yards) How much material will be filled? (cubic y~ards) Manner in which material will be removed or rep;sited: tq~'~, ~ Describe ~e na~e ~d extent of ~e envkomental ~pacts reasonably ~ticipated result~g ~om implementation of~e project ~ proposed. ~se attac~ents ifnecess~) NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES~ TOWN OF SOUTHOLD In the matter of applicant: YOU ARE HEREBY GIVEN NOTICE: SCTM#~ / That it is the intention of the tmdersigned to request a Permit fi.om the Board of Trustees 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: '~0 7.-~ .~'~-i~[ ~ /h-0~O---· 3. That the project which is subject to Environmental Review m~der 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 Enc: Copy of sketch or plan showing proposal for your convenience. PROJECT ID NUMBER PART '1 - PROJECT INFORMATION 1. APPLICANT / SPONSOR 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNUSTE, D ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. PROJECT NAME ,~EQR 7. AMOUNT CE LAND AFFECTED: Initially .~//../' acres Ultimately --~/-)/' acres 8 WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~Yes [] No If no, describe briefly: 9. W T IS PRESENT LAND USE IN VICINITY OF ~ResidentJal [] Industrial [] Commercial PROJECT? (Choose as many as apply.) ["-']Agri6ulture [] Park / Forest / Open Space E~Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, Slate or Local) .~,~ E~es ~]No If yes, list agency name and permit / appreval: ~.~(~ 11. D S ANY ASPECT OF THE ACTION HAVE A CURRENTLY 'VALID PERMIT OR APPROVAL? [~s ~No if yes, list agency name end permit I approval: RESULT OF PROP D ACTION WILL EXISTING PER iT/ APP VAL REQUIRE MODIFICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name '7'"~'/~1~Y~ /'~ ~f/'el~/~.- ~l/,~//3~-f'~' .,~12~L~ Date: If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this asses~sment PART )1 - IMPACT ASSESSMENT (To be completed by Lead Agenc. y) A. DOES ACTION ~CEED ANY TYPE I THRESHOLD IN 6 NYCRR. PART 617.4? If yes, coordinate the review process and use Jhe FULL EAF. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative decla tion may be superseded by another involved agency. I--I No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1.Existing air quality, sun'ace or groundwater quality or quantity, noise laveJs, existing traffic pattern, solid waste producflon or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, amhaeologicel, historic, or other natural or cultural resources; or con~munity'~r ~eigh~orhood char~cte~ Explain briefly: t I C3. Vegetation or fauna, fish, shellflsh'orwiidlife s~pe~ie~i signi~..a~hal~ita~sl ~ threatened ~re~l~angered species? Explain briefly: C4. A community's existing plans er goals as officiafly 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 ihduc.ed by the proposed action? Explain bdefly C6. Long term, short term, cumulative, or ether effects not identified in Cl-C57 Explain briefly: C7 Other impacts {lacludin~ ~h~n~es tn-use o~'~ith;;'~U;r~ii~ or I~e of energy? Explain briefly: " . D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHA~DTERISTIOS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENT E. IS THERE, OR I~I/THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ff ~es ex~lain: 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 otherwis.~.signiflcant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (bi 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 must evaluate the potential impact bf 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 directly to the FULl EAF and/or prepare e positive declaration. Check this box Jf you have determined, based on the Information and ~nalysis above and any suppoAing documentation, that the proposed actio~ WILL NOT result in any significant adverse environmental Impacts AND provide, on attachments as necessary, the reasons supporting thi Name of Lead Agency Date Title of Responsible Officer Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agent7 Signature of Preparer (if different from r.espons~ble of~cer) 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-~] BOARD OF TOWN TRUSTEES TOWN OF $OUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD h~ the Matter of the Application of ..... ............................. COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING , residing at .~o.~. -~. _~a.O~/M~lCJa-o,~ being duly sworn, depose and say: That on thc q day of D~om~ 200~, I personally posted the property known as by placing the Board of Trustees official poster 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 hearing. Date of hearing noted thereon to be held 'TJ)o~. A,.~O, cg-I, dO, D~~ - Dated: t (~ig~ature) 0'-' Sworn to before me this i 7~ dayof!)ee 2005- Notary P(~ic ~3 0 TRACEY LYNNE GUAGE NOTARY PUBLIC GREAT STATE OF NEW YORK 01GU6116398 COMM. EXP 9~27~08 Board of Trustees Application County of Suffolk State of New York ~0~/ f~, tt/J~-(~Z[3 ~ BEING DULY SWORN DEPOSgS 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~IER 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 HARIVILESS 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 TI-JE PREMISES IN CONJUNCTION WITH REVIEW OF TI-US APPLICATION. Signature SWORN TO BEFORE ME THIS / DAYOF ,~//-~'- 20 03"'-- Notary Public AUTHORI ~A~ION (where the applican't is not the owner) (~int owner of property) residing at.~0~ (mailing address) do hereby authorize ~,U~rr~ (Agent) to apply for Der~it(s) from the Southold Board of Town Trustees on my behalf. ~n~r~'s signature) APPLICANT/AGENT ./REPR~ESENTATIVE TRANSACTIONAL DISCLOSURE FORM Tb~ Town of Southold's Code of Ethics orohibits conflict~ of interest on the cart of town officers and emnlovees. The ouroose of this form is to vmvide information which can alert the town of nossible conflicts of interest and allow it to take whatever action is necessary to avoid s~ne. (Last name, first nam[:, x~iddi¢ initial, unless you are applying in the name of someone else or other cntlty, such as a company. If so, indicate, the other person's or coml~any's~me.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Varianc~ Trustee Change of Zone Coastal Erosion Approval of plat Mooting Exemption fwm plat or official map Planning Other (1 f"Other", name the activity.) _ Do you personally (or through your company, spoas~, sibling, pa~ent, or child) have a relationship with any officer or employee of the Town of Soathold? "Relationship" includes by blood, man'iago, or bu~inuss 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 If you answered "YES", complete the balance of this form and date and sign where indicated. Nameo pe.onemp,oyedhy the Townof oathoid d l 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 owpgr of greater tha/% oftbe shams of thc corporate stock of the applicon~ (when Se applicant is~corporation); .B) the legal or bencfici~own~r of any interest in a non-corporate entity (when the applicant is not a ~rporafion); .C) an of'riser, direc~r, partner, or employee of the applicant; or .D) t~ actual applicant. DESCRIPTION OF KELATIONSHIP Form TS 1 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 ofSouthold Waterfi'ont Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in mak/ng 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, policiea, and explanations of each policy contained in the Town of Southold Dotal Waterfi'ont 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", then the proposed action may affect the achievement of the LWRP policy standards and conditions contained itl the consistency review law. Thus, the action should be analyzed in more detail and, if necessary, modified prior to making a determination that it is consistent to the maximum extent practicable with the LWRP policy standards ,and conditions. 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 ofSouthold's website (southoldtown.northfork.net), the Board of Trustees Office, the Plamfing Department, all local libraries and the Town Clerk's office. B. DESCRiPTION OF SITE AND PROPOSED ACTION The Application has been submitted to (check appropriate response): Town Board [-~ Planning Dept. ~ Building Dept. ~ Board of Trustees [~ Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g. capital construction, plain'ting activity, agency regulation, land transaction) (b) Financial assistance (e.g. grant~ loan, subsidy) (c) Pemfit, approval, license, certification: Location of action: Site acreage: '~ Present land use: Present zoning classification: 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) Ma/hng address: (c) Telephone number: Area Code ( (d) Application nmnber, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ~ No [~ If yes, wtfich state or federal agency?~ DEVELOPED COAST POLICY Policy I. 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 Ill - 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 To~vn of Southold. See LWRP Section III - Policies Pages 3 through 6 for evaluation criteria [-~ Yes ~ No ~5~ 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 criteKia ~-~ 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 ' 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 Applicable 5 v, ll beo e' Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town.of Soutbold. See LWRP Section II/- Policies Pages 32 through 34 for evaluation criteria. ~ 'res [] No [~ Not Applicable Attach additional sheets if necessary Policy 8. Minimize euvironmental 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 POLICIES 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 II. 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. ~ 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 Ill - Policies; Pages 65 through 68 for evaluation criteria. [] Yes [] No ~Not Applicable Created on 5/25/05 11:20 AM c~ I LU ,!