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Home My WebLink AboutTR-6582 James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall Annex 54375Main Road 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 # 0410C Date: March 16, 2009 THIS CERTIFIES that the construction of an addition to the existing dwelling, new stone terrace, the installation of gutters, leaders and drywells to dwelling, and the removal of debris from the bluff At 930 Jackson Street, New Suffolk, New York Suffolk County Tax Map # 117-10-6 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 03/27/07 pursuant to which Trustees Permit # 6582 Dated 4/18/07 and was issued, and conforms to ali of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the construction of an addition to the existing dwelling~ new stone terrace, the installation of gutters, leaders and drvwells to dwelling, and the removal of debris from the bluff The certificate is issued to ROBERT & JUDY GOLDMAN owner of the aforesaid property. Authorized Signature James F. King, President Jill M. Doherty~ Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631 ) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF/.I~SPECTION: ~/Ch. 275 Ch. 111 INSPECTION SCHEDULE __ Pre-construction, hay bale line/silt boom/silt curtain __ 1st day of construction 1~ constructed Project complete, compliance inspection. CERTIFICATE OF COMPLIANCE: 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 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 SOUTHOLD TOWN TRUSTEES SOUTHOLD, NEW YORK PERMIT NO. 6582 DATE: ~ ISSUED TO: ROBERT & JUDY GOLDMAN PROPERTY ADDRESS: 930 JACKSON STREET~ NEW SUFFOLK SCTM# 1~I 7-10-6 AUTHORIZATION Pursuant to the provisions of Chapter 275 and/or Chapter I 11 of the Town Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted at the meeting held on A~pril 18~_2007, and in consideration of application fee in the sum of $250. ' and subject to ~he Terms and Conditions as stated in th" ~>~-'---' .,_~ 00. pa~d by ~9oldman authorizes and perm/ts the following: .... *mutlon, me ~ou~old Town Board of Trustees To construct an addition to an existing residence with a new exterior stone terrace, with the condition gutters and drywells are installed to contain the roof run-off and dumping stopped on bluff with removal of debris from the bluff, and as depicted on the site plan prepared by Samuels & Steelman, dated May 9, 2007. IN WITNESS WHEREOF, the said Board of Trustees hereby causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority oft. he said Board as of this date. TERMS AND CONDITIONS The Permittee Robert & Judy Goldman, residing at 930 Jackson Street, New Suffolk, New York, as part of the consideration for the issuance of the Permit does understand and prescribe to the following: That the said Board of Trustees and the To~vn of Southold are released from any and all damages, or claims for damages, of suits arising directly or indirectly as a result of any operation performed pursuant to this permit, and the said Permittee will, at his or her own expense, defend any and all such suits initiated by third parties, and the said Permittee assumes full liability with respect thereto, to the complete exclusion of the Board of Trustees of the Town of Southold. That this Permit is valid for a period of 24 months, which is considered to be the estimated time required to complete the work involved, but should circumstances warrant, request for an extension may be made to the Board at a later date. That this Permit should be retained indefinitely, or as long as the said Permittee wishes to maintain the structure or project involved, to provide evidence to anyone concerned that authorization was originally obtained. That the work involved will be subject to the inspection and approval of the Board or its agents, and non-compliance with the provisions of the originating application may be cause for revocation of this Permit by resolution of the said Board. That there will be no unreasonable interference with navigation as a result of the work herein authorized. That there shall be no interference with the right of the public to pass and repass along the beach between high and low water marks. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstruction to free navigation, the said Permittee will be required, upon due notice, to remove or alter this work project herein stated without expenses to the Town of Southold. The Permittee is required to provide evidence that a copy of this Trustee permit has been recorded with the Suffolk County Department of Real Properties Office as a notice covenant and deed restriction to the deed of the subject parcel. Such evidence shall be provided within ninety (90) calendar days of issuance of this permit. That the said Board will be notified by the Permittee of the completion of the work authorized. That the Permittee will obtain all other permits and consents that may be required supplemental to this permit, which may be subject to revoke upon failure to obtain same. 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 April 18, 2007 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Tom Samuels Samuels & Steelman Architects 25235 Main Road Cutchogue, NY 11935 RE: ROBERT & JUDY GOLDMAN 930 JACKSON STREET, NEW SUFFOLK SCTM# 117-10-6 Dear Mr. Samuels: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, April 18, 2007 regarding the above matter: WHEREAS, Samuels & Steelman Architects on behalf of ROBERT & JUDY GOLDMAN applied to the Southold Town Trustees for a permit under the provisions of Chapter 275 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated March 27, 2007, 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, the LWRP Coordinator recommended that the proposed application be found Inconsistent with the LWRP, and, WHEREAS, the Board of Trustees has furthered Policy 6 of the Local Waterfront Revitalization Program to the greatest extent possible through the imposition of the following Best Management Practice requirements: installation of gutters and drywells to contain water runoff, the bank be cleaned up and the dumping stopped, and, 2 WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on April 18, 2007, 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 275 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 for the mitigating factors and based upon the Best Management Practice requirement imposed above, the Board of Trustees deems the action to be Consistent with the Local Waterfront Revitalization Program pursuant to Chapter 268-5 of the Southold Town Code, and, RESOLVED, that the Board of Trustees approve the application of ROBERT & JUDY GOLDMAN to construct an addition to an existing residence with a new exterior stone terrace, with the condition gutters and drywells are installed to contain the roof run-off and dumping stopped on bluff with removal of debris from the bluff, and as depicted on the site plan prepared by Samuels & Steelman, dated May 9, 2007. 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/eac 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) 765-664] BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your applicat on dated /'~ ~2% ¢~C~ reviewed by this Board at the regu ar meeting of ~-~fq I !g, ~'p has been following action was taken: , . 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 Southoid Town Trustees. The fee is computed below according to the schedule of rates as set forth in Chapter 97 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $ ~-~ ~'~ BY: James F. King, 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., April 11, 2007, the following recommendation was made: ROBERT & JUDY GOLDMAN to construct an addition to an existing residence with a new exterior stone terrace. Located: 930 Jackson St., New Suffolk. SCTM#117-10-6 The CAC did not make an inspection, therefore no recommendation was made. James F. King~ President Jill M. Doher~y, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghesio, 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 Southold Town Board of Trustees Field Inspection/Work session Report Date/Time: L'i-I['D'~ Samuels & Steelman Architects on behalf of ROBERT & JUDY GOLDMAN requests a Wetland Permit to construct an addition to an existing residence with a new exterior stone terrace. Located: 930 Jackson St., New Suffolk. SCTM#117-10-6 Type of area to be impacted: __Saltwater Wetland Freshwater Wetland Distance of proposed work to edge of above: Sound ~Bay Part of Town Code proposed work falls under: __Chapt.275 Chapt. 111 other Type of Application: V/Wetland __Coastal Erosion __Amendment __Administrative __Emergency Pre-Submission Violation Info needed: Modifications: Conditions: Present~r~}r~A! ~.King ~//J.Doherty __P.Dickerson D. Bergen__ B. Ghosio, Jr H. Cusack D. Dzenkowski Mark Terry~other Mailed/Faxed to: Environmental Technician Review ~.."~/V] f" Date: CUTCHOGUE A~lbert J. Krupski, President James King, Vice-President Henry Smith Attic Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone(631) 765-1892 Fax(631) 765-1366 BOARD OFTOWNTRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application Wetland Permit Application --. Major Waiver/Amendment/Changes Received Application: Received Fee:$ Completed Application Incomplete SEQRA Classification: Type I _Type II Unlisted Coordination:(date sent) CAC Referral Sent:' Date of Inspection:. Receipt of C AC Report: Lead Agency Determination: Technical Review: Public Hearing Held: Resolution: Minor Name of Applicant Robert and Judy Goldman Address P.O. Box 95 New Suffolk NY ] l~56 Phone Number:( ) Suffolk County Tax Map Number: 1000 - 1 ! 7-10-06 Property Location: 930 Jackson Street New Suffolk, NY 11956 (provide L1LCO Pole #, distance to cross streets, and location) AGENT: Tom Samuels, Samuels & Steelman Architects (If applicable) Address: 25235 Main Rd. Board of Trustees Application Land Area (in square feet):_ Area Zoning: R - 4 0 Previous use of property: Intended use of property: GENERAL DATA 92399.76 SF Residential Residential 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? x No Yes If yes, provide explanation: Project Description (use attachments if necessary): Addition to an existing residence with a new exterior stone terrace. Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose oftheproposedoperations: Addition to an existinit residence with a new exterior stone terrace Area of wetlands on lot: 0 .square feet Percent coverage of lot: 0 % Closest distance between nearest existing structure and upland edge of wetlands: 7 8 ' - 1" feet Closest distance between nearest proposed structure and upland edge of wetlands: ~ ~ q , _ fi. feet Does the project involve, excavation or filling? No x Yes If yes, how much material will be excavated? 17 5 cubic yards How much material will be filled? 0 cubic yards Depth of which material will be removed or deposited: 3 feet Proposed slope throughout the area of operations: 0 Manner in which material will be removed or deposited: ~×c ~,.,~ t er (mechanical) and dump truck 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): NO effect. TRANSACTIONAL DISCLOSURE FORM The Town o5 $~u~hold'a Code of 8thics Prohibits c0n~ll~ta o~ ~teresb on the parb of town officers and employe~s. The -- ~£pose of-~ie form is bo pro¥1de lnfo~mation w-~i'ch can name~ midd.le ~nit~al, unless you are applying in the nama of someone else or other entity, such ae a company, I~ co, indicate ~xe~pbios from pl~b o~ o~tolal map ~'~ Obher ~ - interest, means a business, including a partner~hip~ in which ~he town o~ficer or employee ho~ even a partial ownership or (or employment by) a corp.oration tn which th~ to~n of Eicer or e~pl~/ee ovn~ mo~e than 5~ of the If you answered "YES," complete the balance of thl~ ~orm and date and sign vhere indicated. Name o~ person employed by the TOW~ of $oUthold Title or position og bh~b person .... . Describe ~he relationship be~vee~ Y~ureelf (~ho and the town o~ftuer or employee, Either chook appropriate line A) through D) and/or d.soribe in the provided. parent, or ohlld ia (~eek all that apply)~ A) ~ho owne~ of greater tha~ 5% of the aharea of the corporate a~ouk of the aPPlio~nb (when the applicant' ia a corporation}l __ B) the legal Or bbneflolal owner Og any interaa~ tn a nonoorpora~e'en~iby (when the appllcaH~ is not a corpora ~ion ) t applicant t or ~ _D) ~he ~bual applicant. DESCRIPTION OF R~LATIONBIIIP 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I - PROJECT INFORMATION (To be corn leted b A licant or Pro'ecL S onsor 1, APPLICANT/SPONSOR Thomas C. Samuels JZ PROJECT NAME ---------- I Goldman Residence 3. PROJECT LOCATION: Municipality Southold Coun~ Suffolk 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) 930 Jackson Street New Suffolk, NY 11956 5~ PROPOSED ACTION IS: __~ New [] Expansion 6. DESCRIBE PROJECT BRIEFLY: ~] Modification/alteration 7. AMOUNT OF LAND AFFECTED: Addition to an existing residence with a new exterior stone terrace Initially ~ acres Ultimately~;~.~_ 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTR CTIONS'; [] Yes [] No If No, describe briefly ' g, V AT,S PRESENT LAN USE ,N VIC,NIb OF PROJECT? [] Residential [] Industrial [] Commercial Descdbe: [] Agriculture [] Park/Fores?Open Space [] Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? [] Yes [] No If Yes, list agency(s) name and Permit/approvals: Town Trustees Building Dept. Southold 11. DOES ANy ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [] Yes If Yes, list agency(s) name and permit/approvals: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIF CATION? ]Yes [] No I CERTIFY THAT THE IN.~FORMAT ON PROVIDED ABOVE Applicant/sponsor name: ~ ~. ~ ~,f4,1,&4. ~- ( ,~ IS TRUE TO THE BEST OF MY KNOWLEDGE _ oste . o ? Signature: OVER PLANNING BOARD MEMBERS JERILYN B. WOODHOUSE Chair KENNETH L~ EDWARDS MARTIN H. SIDOR GEORGE D. SOLOMON JOSEPH L. TOWNSEND To: PLANNING BOARD OFFICE TOWN OF SOUTHOLD Jim King, President Town of Southold Board of Trustees MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971 OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY Telephone: 631 765-1938 Fax: 631 765-3136 From: Mark Terry, Date: April 11, 2007 Senior Environmental Planner LWRP Coordinator APR ] ] 2007 Re: Proposed Wetland Permit for Robert and Judy Goldman SCTM#1000-117-10-6 ROBERT & JUDY GOLDMAN requests a Wetland Permit to construct an addition to an existing residence with a new exterior stone terrace. Located: 930 Jackson St., New Suffolk. SCTM#117-10-6 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is INCONSISTENT with the denoted following Policy Standards and therefore is INCONSISTENT with the LWRP. Policy 6. Protect and restore the quality and function of the Town of Southold ecosystem 6.3 Protect and restore tidal and freshwater wetlands. Comply with statutory and regulatory requirements of the SouthoM Town Board of Trustees laws' and regulations for all Andros Patent and other lands under their jurisdiction 1. Comply with Trustee regulations and recommendations as set forth in Trustee permit conditions. The proposed setback from the "new terrace" to the top of bluff line is 64.8 feet and the proposed setback from the "new addition" to the top of bluff line is 75.2 feet; a minimum separation distance of 100' is required Chapter § 275-3. Findings; purpose; iurisdiction; setbacks. Please require that the applicant amend the application to meet the above policy to the greatest extent possible. Additionall¥~ if the action is approved and to further Policy 5: Protect and Improve Water Quality in the Town of Southold 1. Recluire gutters~ downspouts and sub-surface drywells to control stormwater runoff. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fmx (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only IVlinor MAR 2 7 2007 Coastal Erosion Permit Application 7Wetland Permit Application / Major Waiver/Amendment/Changes ~l~eceived Application: ,~ ~eceived Fee:$ ,~gompleted Application 3 Incomplete SEQRA Classification: Type I Type II Unlisted__ Coordination:(date sent,) --CAC Referral Sent:' ~| .~Date of Inspection: q IIi Receipt of CAC Report: Lead Agency Determination:__ Technical Review: ~blic Hearing Held: Resolution: Name of Applicant Robert and Judy Goldman Address P.O. Box 95 New Suffolk u¥ ] ] 056 Phone Number:( ) Suffolk County Tax Map Number: 1000 - 117-10-06 Property Location: 930 Jackson Street New Suffolk, NY 11956 (provide LILCO Pole #, distance to cross streets, and location) AGENT: Tom Samuels, Samuels & Steelman Architects (If applicable) Address: 25235 Main Rd. Board of Trustees Application Land Area (in square feet): Area Zoning: R- 4 0 Previous use of property: Intended use of property: GENERAL DATA 92399.76 SF Residential Residential 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? x No__ Yes If yes, provide explanation: Project Description (use attachments if necessary): Addition to an existing residence with a new exterior stone terrace. Board of Trustees Application wETLAND/TRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: Addition to an existina residence with a new exterior stone terrace Area of wetlands on lot: 0 square feet Percent coverage of lot: fl % Closest distance between nearest existing structure and upland edge of wetlands: 7 8 ' - !" feet Closest distance between nearest proposed structure and upland edge of wetlands: l q 1 ' -6" feet Does the project involve excavation or filling? No ~ Yes If yes, how much material will be excavated? 17 5 cubic yards How much material will be filled? 0 cubic yards Depth of which material will be removed or deposited: 3 feet Proposed slope throughout the area of operations: 0 Manner in which material wilt be removed or deposited: (mechanical) and dump truck Excavator 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): No effect. Po~ SO.F1 Certified Fee $2 ,/40 STATE OF NEW YORK COLrNTY OF SUFFOLK .~h~u-~Q , ~ ,beingdulyswom, deposes and sa~s that on the day of /-J-~ I ,20..~. deponent mailed a true copy of the Notice - set forth, in the Board ~f 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 ~ 5L , that said Notices were mailed to each of said persons by (certified) (registered)Nail. [kD")D'~-'" .~,,.~ Sworn to before me this \'~ Dayof q'~',-k ,20c'-x Notary Public 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 BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POST1NG being duly sworn, d~Dose and say: That on tha~d~aay of ~ ,200'~ personally posted the,properly known as by placing the Board of Trustees official poster where it c~ easily be seen, ~d that I have checked to be s~e the poster has remained in place for eight day, prior to the date of the public he~ng. Dine ofhe~ng noted thereon to be held ~ Dat~ Sworn to before me this day of/¥¢ i 200 ? Notary Public [ 3::.'.. F., i,: f¢~ate of New York ~,~ 0 ~ !~16042467 Qu~i~.~i~ j i~ Suffolk County C~:, ;:i:~;~i,~i~ Expires May 30, ~ 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I - PROJECT INFORMATION (To be completed by Al~plicant or Project Sponsor) 1. APPLICANT/SPONSOR J2. PROJECT NAME Thomas C. Samuels / Goldman Residence 3. PROJECT LOCATION: Municipality Southold County Suffolk 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) 930 Jackson Street New Suffolk, NY 11956 5. PROPOSED ACTION IS: [] New [] Expansion [] Modification/aiteration 6. DESCRIBE PROJECT BRIEFLY: Addition to an existing residence with a new exterior stone terrace 7. AMOUNT OF LAND AFFECTED: Initially (3. OR acres Uitimately ,q nR acres 8. WILL PROPOSED ACTION COMPLY WiTH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? [] Yes [] No If No, desc~-ibe bdefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? [] Residential [] Industrial [] Commercial [] Agriculture [] 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)? [] Yes [] No If Yes, list agency(s) name and parmit/approvals: Town Trustees Building Dept. Southold 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAL D PERMIT OR APPROVAL? [] Yes [] No If Yes, list agency(s) name and permit/approvals: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMiT/APPROVAL REQUrRE MODiFiCATiON? []Yes []No Applicant/sponsor name: "~ ~4, 5 ~,l~&4,~ ~,. (' ,,.~ Date: ~ Signature: I If the action is in the Coastal Area, and you are a state agency, complete the I Coastal Assessment Form before proceeding with ;s assessment I OVER I PART II - IMPACT ASSESSMENT o'Be corn leted b Lead A enc ~ A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes, coordinate the review process and use the FULL EAF. [] Yes [] No B. W~LLA~T~NRE~E~vEC~RD~NATEDREV1EWA~PR~V~DEDF~RUNLISTEDA~T~NS~N6NY~RR~PART617.6? IfNo, anegative declaration may be superseded by another involved agency. i-lYes [--I 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, potential for erosion, drainage or flooding problems? Explain bhefly: C2. Aesthetic, agHc~Jitural, arohaeologioal, 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 bhefly: C4. ^ commLJnity's existing plans or goals as officially adopted, or a (:flange in use or intensity of use of land or other natural resources? Explain bdefly: 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 Cl-C57 Explain bhefly: C7. Other irr~pacts (including changes in use of either quantity or type of energy? Explain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? [] Yes I~ No If Yes, explain briefly: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? [] Yes I~ No If Yes, expiain briefly: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: Foreach adverse elfect identified above, determine whether it is substantial, large, important or otherwisa significant. Each effect should be assessed in connection with its (a) se[ting (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 signiflcance must evaluate the potential impact of the proposed action on the enviro n mental characteristics ofthe CEA. [] Checkthisb~xify~uhaveidenti~ed~ne~rm~rep~ten~s~iy~arge~rsigni~centadveraeimpactswhichMAY~ccur~ ThenproceeddirectiytotheFUL EAF and/or prepare a positive declaration. [] Check this box if you have determined, based on the information and analysis above and any supporting doc~Jmentation, that the proposed actio WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. ~ ,~ -,. Name of Lead Agency Print or Type Name of R~sponsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from responsible officer} LETTER OF AUTHORIZATION Bob Goldman PO Box 95 New Suffolk, NY 11956 March 26, 2007 I hereby authorize Thomas C. Samuels of Samuels and Steelman Architects at 25235 Main Road, Cutchogue, NY, to apply for all required permits from the Town of Southold, Suffolk County and State of New York, for my project at 930 Jackson Street, New Suffolk, NY 11956 Bob Goldman Date Thn Town o~ $~u~hold's Code of Ethics prohibits conflicts or interest on the part of town officers and employees. TIW : ~grpeee of this form is to provide information which can alert the town of possible conflicts of interest and allol~ it to take whatever action is necessary to avoid same. name, midd.le {nit[al~ unless you ar~ applying in th~ name o~ someone else or ~thec e~iby, euoh as a colnpa~y, I~ ~o, indicate 5he o%her person's 6r company's name.) NATURE OF AP'PLI~ATIoN, (Check all tha~'appl~':) ...... :~":?~' ~ '~' Tax grievance Variance ARp{~aX of plat , Exemption from plat or orfl~ial map ' Other ~' ~~ interest, means a business, including a partnership, in which (he town officer or employee has even a partial ovne~ehip of (or employment b~) a corD.oration in ~hlch the town officer or employee owns more than 5% of the If you answered oYES,, complete the balance Of ~hie form and date and sign where indicated. Name of pereon employed by the ToWn of Southold Title or position of that person "' Describe the relationship between yourself (the applicant) and the town officer or employee, Either cheek the appropriate line ~) through D) and/or desoribe In ~h~ space provided. The ~o~n officer or employee ~ hi~ or her Opous~ sibling, parent, or child is (check all that apply)~ A) the owner of greater than 5% of the shares u[ the corporate stock of the appliu~nt (when tho applicant· , ia a eorporation)l B) the legal or bbneficial o~ne~ o~ a~y interact in a nonoorporate'e.ttby (when the applicant is not a corporation) ~ . o) an offiGer~ ditector~ pa~tu~r~ or employee of tho applicant t or ' D) ~he a~uai applicanb. ~Town of Southold .LWRP CONSISTENCY ASSESSMENT FORM 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 Waterfi'ont 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 Water~ont Revitalization Program. A re osed action will be evaluated as to its si ificant beneficial and adverse effects u on the coastal area which includes all of Southold Town. If any question in Section C on this form is answered y , then the proposed action will "es" or "no" affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus each answer must be ex lained in detail listin both su ortin and non- ~. 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# lor~0 -. 1 17 -, ~a-r)6 PROJECT NA/V[E Go dm · The Application has been submitted to (check appropriate response): Town Board [] Planning Board [] Building Dept. ~ Board of Trustees 1. Category of Town of Southold agency action (cheek 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: stone terrace Loc,ation0faction: ~ . ~30 Jackson St. New Suffolk, NY Site acreage:. 2. 1 2 1 Ac. Present land use: Res i dent i a 1 Present zoning classification: R- 4 0 If an~ application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: Robert and J~dv Goldman P.O. Box 95 (a) Name of applicant: (b) Mailing address: New Suffolk, NY 11956 (c) Telephone number: Area Code ( ) (d) Application number, if any:_. Will lite action be directly undertaken, require funding, or approval by a state or federal agency? Yes [~ No [] 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 Southoid 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. far less than the 20% lot cover~ err is - al'lowed ~ Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section II/- Policies Pages 3 through 6 for evaluation criteria ~-~ Yes ~J 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 The addition to th~ ~w~tlnq r~s~deno~ is in k~n{n~ in s~vl~ and scal~. of neiahboring structures. 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 I-~ No ~-~ Not Applicable Ail rainwater runoff is and will be retained on site with the use of underqround dr wy_~_9_lls. During_construction hay__bales placed temporarily between the construction and shore will keep runoff spoils on si e. At~ach 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 ~-~ Ye~ [~ No ~ Not Applicable Ail ' t~inwater runoff is and will be retained or, site with the use of underground drywells. A sanitar~y system for the residence will meet current Suffolk Count D~t. of Health Services standards for s~ water. The roJ~_q~_~j~_is served with public water from Suf ol oun y. 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 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 The dev.'elo ment w' ' 'r. All construction vehi~les meet the Federal standards for air pollution ~e. The mechanical systems of the residence me----~t- t--~e Federal -Standar~ Attach additienal sheets if necessary Policy 8. NIinimize 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 Tho COil' ~ ~.h~ r~4~ ...... ~ ~own'S ~ILSDo~I n~ ...... ,~___ ~ U e of the was ewater "sanitar "will be dischar ed into an a roved SCDHS sanitary__~tem. 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 ~J No ~ Not Applicable At rpesent there is no on-site publlce access to the coastline from a publi~_~ roa~. Attach additional[ sheets if necessary WORKING COAST POLICIES , Policy 10. Protect So~old's water-dependent uses and prate siting of new water-dependent uses in suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria. [] Yes R No [-~ Not Appl!cable ~erties have and are r 'den ial in use and will remain residential------~-- 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 l'~ No ~ Not Applicable This .project will rotect and ~reserve the living marine resources by maintaining all rainwater discharge and sanitary flow from th~------ residen--~-~--~on site by approved ~stems an rywe s or rainw~f f. 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. There are no a__q_~icultural lands on site. Attach additionhl 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 The construction wi Governmen standard--~or conservIng energy 'energy s a pr and will use "New York State Energy Conservation and Construction o e for construction ~-~ ~h~ residence. PREPARED BY Thomas Samuels AmendedonS/l~5 TITLE Architect DATE 3/27/07 SITE DATA SCTM # PROPERTY: ADDRESS OWNER: SITE: ZONING SURVEYOR: 1000-117-10-06 930 JACKSON STREET NEW SUFFOLK, NY ROBERT GOLDMAN PO BOX 95, NEW SUFFOLK, NY 92,399.76 SF = 2.'121 ACRES R-40 JOSEPH A. INGEGNO PO BOX 1931 RIVERHEAD, NY 11901 LICENSE #49668 DATED 12/21/06 LOCATION M~AP Z ~,IT;: ~,~ ~ . ~ ~ ~ ~._ :,_ , ' , ~ ~ ~ ~ ~ '~ ' , ~- ~ / DF IN / , . / ~ L ,..' ~/ ~ / / . Y ~2TM ~ ~ ~ ~ / ~ ~ ~ / ~ 8' IxB'~ ~ EXQAVAT 0 ~ ................................................ :. ~ _ _/~,~ ~. OW.H~O w,.~ ~ '-~'.x4' ~ ~ ........... ~ .................................... ~ ~ D~ BY: UT SHEET TITLE: APPROVED BY BOARD OF TRUSTF~ SITE PLAN SITE PLAN SCALE: 1" = 20'-0" '~ ~-/~,'~- S.EE~.O.: SP APPROVALS II Z WfRE 25 28 27 ,¢ 774.56' SURVEY OF PROPERTY SITUA TED A T NEW SUF?OL~ TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-117-10-06 SCALE 1"--20' DECEMBER 21, 2006 AREA = 92,399.76 sq. ff. (TO TIE LINE) 2.121 OC, CERTIFIED TO. ROBERT GOLDMAN 27 5 S 88"12'27" W 27.07' N 77' G~A 7' W 63.39' 26 NOTES: 1. ELEVATIONS ARE REFERENCED EXISTING ELEVATIONS ARE EXISTING CONTOUR LINES S 83'59'5,',',6" ',N N =O~l[~ OF THIS SU~VEY MAP NOT BEARING 27.59 38.82, W ~ THE EXIST[NG~ OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD, IF ANY, NOT SHOWN ARE NOT GUARANTEED, TO N.G.V.D. 1929 DATUM SHOWN THUS: ARE SHOWN THUS: Ingegno Land ~rveyor PHONE (631)727-2090 Fox (631)727-~727 26-41o