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Home My WebLink AboutTR-6177 Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson . ) . Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTH OLD 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 j Pre-construction, hay bale line 1 st day of construction Y, constructed / Project complete, compliance inspection. Board Of Southold 'Town Trustees SOUTH OLD, NEW YORK PERMIT No.c'111.. ..... DATE: ...:\.tl~u"t..?~.,---.2005 ISSUED TO .m..m~~.~!.~~:....~~r..N.J:........... ._n.................................. 1\utltnrii!atintl Pursuant to the provisions of Chapter 615 of the Laws of the State of New Yor\:, 1893; and Chapter 404 he . State of New Yor\: 1952: and the Sout own Ordinance en- titled "REGULATING AND THE P NG OF OBSTRUClJQNS IN AND ON TOWN WATERS D PUBLIC LANDS and the REMOVAL OF SAND, GRAVE OR OTHER MA.TER~~M LANDS UNDER TOWN W RS:~'. and i~C~~:~~.the Resolution of The Board ado ted am' h~IJ~.._..\1g_.,.?~i..JO ........, and in consideration f t.h(/m \jT..2~Q,.QO..m paid ...........Am.e.l:i,.<!--J'...---Mancini..... f Southold N Y o ...... ........__........................... . . . ...........'"'''' . . Terms and Conditions liste reverse side hereof, of Southold Town Trustees authorizes and permits the foUowing: Wetlan~ Permit to construct a first and second floor addition t the :x~sting dwelling and to extend the existing deck with the condltlons of haybales and drywells and all as depicted on the plan .prepared by Stalllell J Isak en J 0:k',2Q)~ '* aU in accordance with the aetalleil sp'edfi~ations as presented in the originating application. .~ rev(S~.\ A,,-,"l~ 21, ;l.col;. . IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporat~ S~al to be ll~xed, llnd these ~esents to be subscn'bed by a malority of the said Board .as of this dat.e. $;5;;1?JJ PeQ:Q:v :P1\~~r~nn Ken Poliwoda Trruim . . TERMS and CONDI11QNS 'l'Jje PermIttee Amelia P. Mancini. ~at Southold . "'.. N. Y..'IS f'a"' of the coosidetatioo lor me l<<".~ of che PUmit does III1deatJOd .Ad ptC$a'lbe to the fot- towios: 1. That the said .lloaJ:d ol Trustees and me Town 01 SouIhold ate releNed lrom illY and aU damages, or cWms for damages, of suits atiADg. clitecdy or tndifecdy as a result of IllY op<<- atIoo: perfoaned pw:suaot''(O..~. ~t, ~~e f&l4 ~~ .~. ~ bJsor.a.e., own expeasc. defend any and all such suilS'lnltl.~ by third .,atties, and the said l'um.lttee _~ fullliabl1lty with <<e$pect thereto., w'lh~ettdusiOll of the Board of TllI$tte$. of the Town of ~ 2. That chis Pe1lblt q'nJid for a period of .24: lDOS. -wbkh h ~ to be the esdmated time. required tommplete the work luoll'Cd, ....ti:hoald clrh~""'" wutIl1t, request . lor III extension .may be made to the Po<<rd at . latu il4leo . 3. Tbat this PetlDit should be ttUlned indeClOildy, or as long as the .aId Perlllittee 1I'isha . to . maintain the sttucture or project involved, to provide evidence to 1llY0De roncerned Ih2t 1l1Ih- ~tion was ori&/nilly obr.lned. . 4. That dle wode Involved wi1I be subject to the i~ and appronl of che Boud Ot la agents, and non-compllaoce wim me provisions of (he orlgl,;.t1..g application, may be CIII$e for moanon of this PetlDit by resolution of the said Boud. S. That there wi1I be no W1tta$OO.ble interferen<e with aaYigation as . result of the work beRln aUd1orized. . . 6. That there sbaIl be no lnterferen<e with the cip. of che pubIlc to poss and ft{>US aIoog the beach between high and low water mark$. . 7. That if future operations of the Town of South9ld ~ cbc. -.I md/nr alcetat/.oas In the location of the work bereln...~~ or U, in the otXaIoo ol6e>>oara 01 Tmsreer, die. wad:. shall cause ~e obstrudlOD to free aavl&ulon. the said P-nl~ wi1I be ~ ..-.due notice, totemO\'e or alter chis work or project beRln stated wkbo\lt ~ to the TOWII' . . . of bthold. . . . . 8. That the said Board wi1I be notified by the 1'ermlttte or the ~" of the work aath- odzed. 9. That the .........lttee wi1I d>tIln all otber pem>iIS and ClOI*Illi.Chat -r be required sap; 1"_'" to chis permit ~ maybe subject to revoIce upoa fUlate to obtain ame. -:- ., \\\ \\\ \\\ \\ '~ { ~ ,..k # , ~ );' 0 x ~ t ,- Q -\ I , ( ., t 4 " , j I 1; I l I;: \ " i' ) ( u1~ BOARD OF TRUSTEES TOWN OF SOUT OAD ( OUNN ROA.: 48) DATE 'fhA . ;PI 2005 ~..-1 Z L-J ~ o ~ o o ~- 100.00' '......, \ if'; \ \ i-- ., .1 .' I, I \ \. l"'--O, I"i. 1,'\7 -;r,,- \ r - 9, '/ ' EL 18 i ' ? '~'I ' 'I IT -,f- ';.//" -'-'{liAr \ i~;6~:': ~~~.. \ I: \ ~~ ) \ I ASPHALT OR/, 3C; '- ~_._......._._.. ItO\.-D I I I I I I ~l) .' ... iQ '//1.1' I 1 - .'/ ./' I' ."" t::; CO 0\'\\ ~x (J)\S' ej"--\ ~ ;0-' ~ -< 1:. :;oC" ~ 0.>1 o 0 'i; CO < ~ w Z o ,. ~ w u i< a. "- ---- 2: c '" 7' 9- --II: . \J, )\\" \1 I" \ "', <" f \ o = - 37,7'- '- 111'--:::o~'- '!-,. r ,)>, ',_ !-R/ s: '0 -:'2;'.~ P ~ .-..:o/;U"--.... z."fT\ -..... v... N"~ // W O 0 CJ_:~,_ czi' . "- Jj',(, -Ul., <r)'/Z .,.,,(Jl. .<2'~>'< ' 20>( B_qrcl': &: CONe STOOP w/RArUNGS 0\ y, !<t ,;.,<-;s' " \~\) ~ 1- \). N (J1 o \ \ \0 ~ tL ---- I' 0." -~ . ,;-- WOOD STeps W/(l) WOOD DECK W/RAIlING . "" , ) '. c-' \z P)P( V '?\ ~, ~ ~z V>t';, 100.00' J ".~ -J oJ >[.; T +",' \ Ul'kl'3-';J ~' ,-:-r _.-:\ (~; "C' ~ 't.. N ';\',,,,Z "\\ \-, .../1".'; l:)'__~ --.' \; -J\ -\"'11:) SURVEY OF [' l\ .- \~' '1' DESCRIBED PROPERTY ,j I: ~ ((, SITUATE L rJ 'if ARSHAMOMAQUE, TOWN OF SOUTHOLD SUFFOLK COUNTY, N.Y. /' S 57" 6'OO"W / C WELLS r' "iOTE: ELEVATIONS::' -', HEREON ARE IN 192 ': D. SURVEYED FOR: AMELIA P. MANCINI ANN MARIE VER PAULT G~'A.:;AN1T[S INDICA rm H[FC. .:..'... SHALL RUN 01.:" y TO T1-f[ PERSON FOR 1'11'-.31 THE SURVEY If PREPARED, AND ON HIS E__~.r TO THE :j rl CONe 1./011 /J) L-J N o -I>- o o rei C) ::tJ o < [Tj ::tJ o )> o N (Jl o -"f ~ SURVEYED: 7 0, =ER 2004 . 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) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD t3 ~ e.l (" f. fYliAr>U..... " w TO: Please be advised that your applicatjon dated :)0 \, 2J I LoCI; has been reviewed by this Board at the regular meeting of )'h...,7 2.,'i ) 200 ~ and the following action was taken: ( ~ 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: L1 So -Ae-'1 1..-.( ~ Inl rf<--+'~ Ji. l, D .ffl-<.. ( I^' f< ~J)J TOTAL FEES DUE: $ ) OD I OD o . .., ooS S)1\'1-1 ... SIGNED: ~.I? ~'7f1<LJ.'0 PRESIDENT, BOARD OF TRUSTEES . . Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Soutbold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD August 24, 2005 Amelia P. Mancini 600 Grove Road South old , NY 11971 RE: AMELIA P. MANCINI 600 GROVE ROAD, SOUTH OLD sCTM# 151-6-25 Dear Ms. Mancini: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, August 24, 2005 regarding the above matter: WHEREAS, AMELIA P. MANCINI applied to the South old Town Trustees for a permit under the provisions of Chapter 97 of the South old Town Code, the Wetland Ordinance of the Town of Southold, application dated July 28, 2005, and WHEREAS, said application was referred to the South old 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 August 24, 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 thisapplication, 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, 2 . . RESOLVED, that the Board of Trustees approve the application of AMELIA P. MANCINI to construct a first and second floor addition to the existing dwelling and to extend the existing deck with the conditions of haybales and drywells and all as depicted on the plan prepared by Stanley J. Isaksen, Jr. October 7,2004 and revised and approved on August 29, 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.) This is not a determination from any other agency. Fees: $100.00 Very truly yours, D/x..y. 9. ~.(} Albert J. Krupski, Jr. President, Board of Trustees AJKlhct . . T~lephone (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., August 17,2005, the following recommendation was made: AMELIA P. MANCINI to construct a first and second floor addition to the existing dwelling and to extend the existing deck. Located: 600 Grove Rd., Southold. SCTM#151-6-25 The CAC did not make an inspection, therefore no recommendation was made. July 19,2005 Field Insp_on . . " .. 0; '" " ~ "C n; ii: V) o o N 0\ >, :; -. " _,'f', J .... ". i-, ":r .' . '? ",' d , ',~ ',~ .r:._ :'1' ~ " 'I-' ,. 11.'1 ,'"'1'1 .{. . '"- ;.... '""',". ,; ,'" . . . ~, ... . '; :.,....~~-" j. ""r!~; ~'. , " ..'-:~.~ ,.. '.r, _' ,,' -",:t;.. .~ t ,~Cj~ ,:;; ,:', f." I ,J j .. '''I';''.:" _ I . -, ~:l.,. },I. 'J': l.' -'~}I '.;... :'~ I~"" :,"y" ~.) . . \'t~.i:. ~.. "i , ,. ,~'\;-'~. ~~AA ';" .,'...;, '."'J~": '/./'a~ ...:. ~-~. '~r;. t';__. .. \ 1;f."'; - ~.... ., t'..:.v. .. . f:' r .I' '\,' I "'" " -';. .~ L '. ..,,~ - -., ~ ,~~ '-~}J...... 1-.~':,; }. t;;;;. !-, lItl:, i' ,_ -'i:.:;:. . ~\..... .'... t- ' - :t. '........\ r.,~I.",~~ '/'.:...: ., ' t",(: -,~'" 'i." f. ~ ,'. -: l ',0:.,.: l..,.M: :', ,;.,-- - <-::"~, ~.;'i. h.).,,~. ~j".~'^: .~\\. ", '... '" \\'<.1 ~.;>~~'~;~~~~ ~f"...I.~.::1.'" . I'"" '\'1",.(,....... . . '..i:Z (\'"" r. - ~ ~ 1 _ - ~""X\/:'4 ".,... ':. . ., :/ t?~:..:. -~'-~, -. " ~ :!1, .f":;<.:, , . ~~); I"":'" ';..;:.:.:.:" . f..{t:-' "'-,-. '. ,"". . , ,'~t" , '/). . {'\ii' . .; )::1,-- '...... ", '. Il':~~?I' ~'" .." ~:' T '. ~ '-t 4~ _. --" _ "'r ',:it:~1a,.~' "1<~, '~":\t\?f-~,.1 I,. ~.':'" ~'\~, '.'., . <1' :r.~ . .,....,..j t. . ,.... '., . ~~.: -.\ ".. 1 .~L ~~. .\\ '... f~' ~"'''''''.' .....)..;#..'->;, '.. . \i~!~ !~'h './~..,-~"'jl"'i .:;,\~..., ~'. (. \.q~ ",," (~, ,. _. I.. ' , I ~ . . ". . " I ',r ,_,\"'<\._. '_ '7 ~ ~Z'.- ~j' _.'. f _ ' 1'. ." 1"1- ',..., I ., " : "';' ..... , \ . , .., f...,. .t. . " '~ t .,~. t \ & . o o r-> W x ~ . o o ~ w x ~ . . . . . . . . 009 Bx W 011 Bx W 012 Bx W 013 Bx W . . . ~ x [() ~ o ~ X [() ltl o o . ~ X [() <Xl o o ~ X [() I"- o o . . . . . . 001 Bx W 002 Bx W 003 Bx W 004 Bx W (. . .. 4 . .~ 10":14-19994,41Pt.1 FROt.1 FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-22185 Date HARCH 9 , 1993 THIS CERTIFIES that the building ADDITION Location of Property 600 GROVE ROAD House No. Street SOUTHOLD, N. Y. Hamlet County Tax Map No. 1000 Section 51 IHock 6 Lot 25 Subdivision Filed Map.Nc. Lot No. conforms sUbstantially to the Application for BUilding Permit heretofore filed in this office dated OCTOBER 28, 1992 pursuant to which BUildfng Permit No. 21063-Z dated NOVEMBER 5, 1992 , . was :issued,and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ADDITION TO AN EXISTING ONE FAMILY Dwn.LING AS APPLIED FOR. The certificate is issued to WILLIAM & ~N HAGEN (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL MIA UNDERWRITERS CERTIFICATE NO. H-033651 - HARCH 2, 1993 PLUMBERS CERTIFICATION DATED NIA ~ ;!d~ uilding InspectoJ;' Rev. 1/81 4- P.21 10-14-1999 4041PH . . FROt,1 / ,//' FORM NO. 4 Office TOWN OF SOUTHOLD BUILDING DEPARTMENT of the Building Inspector Town Hall Southold. N.Y. CERTIFICATE OF OCCuPANCY No Z-18362 Date SEPTEMBER 12, 19B9 THIS CERTIFIES that the building ACCESSORY Location of Property 600 CROVE ROAD House No. SOUTHOLO, N,y, street HaJI'Ilet County Tax Map No. 1000 Section 51 Block G Lot 25 Subdivision riled Map No. Lot No. conforms substantially, to the Application for Building Pe~it heretofore filed in ,this office dated SEPTEMBER I, 1989 ---pursuant to which BUilding Permit No. 18469-Z dated SEPTEMBER 1. 1989 was issued, and conforms to all of the re~~irements of the applicable provisions of the law. The occupancy for which this certificate is issued is ACCESSORY SHED AS APPLIED FOR The certificate is issued to DONALD ZIERAN (owner) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL NIA N/A- UNDERWRITERS CERTlFICATE NO. PLUMBERS CERTIFICATION DATED NIA ~ );,t~'dQ' Rev. l/Bl P_22 .. - 10-14':'1999 4,41 Pt.1 . FROt.j . / FOlUl NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT office of the Building Inspector Town Hall Sout.hold, N.Y. pro;:- EXISTING CERTIFICATE OF OCCUPANCY No Z-lB3&3 Date SEPTEMBER 12, 1989 THIS CERTIFIES that the building ONE FAMILY DWELLING Location of ,property &00 GROVE ROAD House NO. SOUTliOLD. N. Y . street Ilamlet county Tax Map No. 1000 Section SI Block 6 Lot 25 subdivision Filed Map'No. Lot NO. confo~s substantially to the requirements for a private one family dwelling built prior to: APRIL 9, 1951 pursuant to which CERTIfICATE OF OCC. HZ-IB3&3 dated SEPTEMBER 12, 19B9 was issued, a~d conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ONE FAMILY DWELLING . The certificate is issued to OONALD Z I ERJ\N (owner) of the aforesaid building- SUFFOI,K COUN~ DEPARTMENT OF HEALTH APPROVAL NO RECORD PRE EXISTING UNDERWRItERS CERTIFICATE NO. NO RECORD PRE EXISTING PLUl-IlJERS CERTIFICATION DATED NO RECORD PRE EXISTING 'PLEASE SEE ATTACHED INSPECTION REPORT. A7 Q. ji~- I Building Inspeetor Rev. 1/61 P.23 \ \ ~ - 10-14":1999 4, 42Pt,l . . FROt,l P,24 : .T 1/ / . " / ./ TOWN Of SOUTHOLD CUllOING DEPARTMENT ornc. of th. Ouildl"lI Inspector Town Hall SOUlhold. N.Y. . ',V ,..... ," ......r~ 'T.,....,.. .. ~T,...;I. l.b. FORM NO.4 Certificate "Of Occupancy N~ .. P.l.49.1.;J........ Date. . . . . . . . . . . 9.c.t;<?~!l.r: . . . ~.2. ... . . . .. 19 ~.4. TillS CERTIFIES thatlhe building. . . . . .l\9"'~.t,~C?~. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Location or Property. . - .. (ill.O...... ...... ... . ~.I:qy!!. .~q, .. .. . .. .... . {l?u.t;~9,l.q . . . '" HousI No. Str~lt H.m/~t CounlyTa~ Mal' No. 1000 Seclion '" .Q~L... .Block .... .Q~....... .Lot. ...o.~~.......... Subdi*iol1 . . . . . . .1{; . . . . . . . . . . . . . . . . . . . . . .Filed Map No. ....... .Lot No. ............. conforms suustantially to the Application ror BuihJing Permit heretofore filed in this orrice dated '" .l;1ilY...... .~4...... J9~~. pursuant to which Duilding Pennit No. .. .~?~.5.1.~........... dalcd .'... .t:l!lY. . .:. . , .~; . . . .. . . . . . . 19~~. , was issued, and conforms to aU or the requirements of Ihe applicable provisions of the law. The OCcl'pancy for which this certincate is issued is . . . . . . . . . . ..l?~~.~ .~~~.i.t;~9!'\. .1:9. f-,"~~~~.'1q .P!".~H~!".q. r:............................ .'.,.. 11.e cerlificate is issued to ... .Qqt:'. . .Z.~~jVI.li.. .................. ....... ...........:... (oWfler. leu"""", -M4J or Ihe aforesaid building. . Surfolk Counly Department or Health Apl'roval ........... .'. . . N./.1I. . . . . . . . . . . . . . . . . . . . . . . , i UNDERWRITERS CERT/FICA TE NO. . .. .. .. . . .. . .. .. .. . , . . rVlI. .. . . . .. .. .. . .. . . . . _ .. . ......~..~1~!. .......... ....... tJuilding Inspector "'Y. 1181 . '10-14-1999 4,42Pt.1 .: . . FROt.l P.25 ...- "lOWN 01' SOUTHOLO BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. , \ Cerlificale Of Occupancy No. ..~) !l.J.~ 1... ..... February 9 81 Date......................... ,......019... TillS CERTIFIES that the building. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FOO Grave "~Qd. 9ou~hold" ~.r. Location of Property ............................................................... .' HO<l$' No. SI"., /{aml.t , County Tax Map N~. 1000 Section .... ..51.. . .Block ......(....... .Lot .... ., . . ;.5....... Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. ....... .Lot No. ............. cOnforms substantially to the Application for Duilding Pelmit heretofore filed in this office dated July 1, 14 73~7 Z . . . . . . . . . . . . . . . . . . . . . . 19 . . . pursuant to which Building Permit No. ..................... July 1, ;4 dated. . ... . . . ...... .............. 19.... was issued. and conforms to all of the requirements of the applicable provisions of the law. The oCCUpa!lcy for which this certincate is issued is ...... " . I ,.t,dt'.1t~!on t'J 1'}','lollin;; /' . ................., ........... ........ ........... .., ............. ...........-..... (l"nnld Z1eran TIle certificate is issued to ......... ............ i(}'Wr"';.J~:,M';';'j.":':~.' ............... of the aforesaid building. Suffolk County Department of Health Approval lIl/R ............ ............................... N/R . UNDERWRITERS CERTIFICATE NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .C~.. 01::~~4n. ...... Building Inspeclor R....l/e1 , . . 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) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Board of Trustees Field Inspection -ll~i)lor 000 ~\J\ Jt) 56\-,~(~ ((V1d\ c.ol~ Date Address Owner ~ y\" ~~ Ve.-r pili '^ I t- S J (, ~ \ 8' S f...5 8 SCTM# Inspected by tt-.Qc--, IhQ ~ '\ ~'7 I~ c 0- ~ "'" <f'w c.,re-\ J.", j. Findings W.\low, ('trJllNf'--") yw&- ~.9J l s.~c;.....!-cA.tJ., hidl 'Me~ ( rwtu, rum.+- ~ ll'U.+'~ Photos taken ~~ (11 OV'~ f'1J("4.A.<> --f.,.(\ k.- 07/27/2005 10:24 5318_477 A NEW!DAV!4U~!T0 4~r C- PAGE 01 OFFICE OF THE BUI ING INSPECTOR TOWN OF S UTHOLD Fax (516) 765-1823 Telephone (516) 765-1802 Town Hall, 53095 Main Road P. O. Box 1179 Southold. New Yorl< 11971 ~~;.'! Your Building Pennit application is being ret ad as incomplete for the following reasons; DATED: .'i~ &; :~: ';.~ : . dnl\ ri\ClV\Q VequUl+ Cill ~~ ~ 3/& '~3g Town Hall, 53095 Main Road p, O. Box 1179 Soulhold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1802 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD TO: C~ ~oc; ~ ~:m'i' ~Ik~ ~, ~~p"Y2:>t..) ! tv'j 1\'l6~ Your Building Permit application is being returned as incomplete for the following reasons; (:0/1.5712 VcT- OIJ IA_J / -rH i,v Ic::ti ,. ~r FNLXJIIAJ/fn72 IUP7?__rttJ'DS I ~E"(' .f- /1l!.tx:/ce ~f/dLJv'rn- ; . ~6b 7 DATED: ....-.. FR01 lmage>ReSponSive.ign ArchtS f'I-(N: NO. 631 874 2. \ ~ ,. r I, I, ~~ Nlf <ANK N 57'56'OO"E \ ~..'-!.~o 'J, ,7' ~ I t! '" "- \ " ~ 1,)' <;' '.. " ';. 1 ~. ~ *' Z "" N ci ... 6 o :i I ~~. f-' f i ~: I. .0 !: ~ <' } \, ..I' , . t /lorr, ELEVATIONS SHOWN HE:RE:ON t AR.t IN 1929 NOVO. I, ~.. . '...... . ..., c. '" ~ ~ NIF WEllS ~ !'" 01 o f \ \ CE:SSPOOLS 0 \ (3) \ \ \0 )Pi ~ \;\-'Y., ?~\ '-- ---- '-!. '" Jul. 172005 11:13AM P1 NORTH ROA() (COUNTY 110:"0 48) \ ~ -....., 1:( 18 \ ~ -\ " 20.4' o 2: '" (j) ... " '" ~ ~ z ~ ~ g 0 '" <:> ::! ~ ..., .. < ;:: "" '" ~ :0 - ,.., ., VI 55 - '" " z () '" . -20.4' . ;; O(CI< co . -<)HI; ::::ERTY '" o ~ -- 100.00' ~ \ 100.00' \ \ \ \ ASPHl\t r ORiVE: . ~ 'o! ~ 07.7' o ..-,.,1 IA'ICK .. CONe SrQClP W/~NGS ~ v 06.3' SITI./ATE: ARSHAMOMAQUE, TOW', OF SOUTHOlD SUFFOLK COV-.Tt. N, y, , ! WAffAN1[ES INDICA JEV HERE ON SHALL RUN : eM. y TO THE PERSON FOR ttHOJJ 7H~ SURVE:'r' :: je; l'Ct:'p.Rrn J1.Nn,..", HK -.JJ./ t" Tf) Ttlt" r,M ji ~St(P.s PIPE. \:;: / S 57" 6'OO"W I r\ SURVEY ( DESCRIBED P SURVEYED FOR; AME ::>, MANCINI ANN 1..--'::: VER PAUlT 05\ -0(0- OLS CON<: .... ~PE SURVEYEO, 7 OCTOBER 2004 ~ ,,, 11 '" '" '" 0: Vl ~ o ... o o rrf G) ::0 o < IT] :::0 o )> o ~ !'" 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'::),.:'/; \. f.~~:. , ...,.,' ,.,,'.' ,~. "-':~1~"',~,, ~._..i~~:'~", '.)' ~-. I.JI"t ... ..,..'::'!/ .....~.~~~..~,. . AVER PAULT ..,,8~, ._~.. PAGE ~1 P.26' .....,_...".. _..,--~ ---....-..-,- z ~- ." .., N )> Z r-: . \ I <P" ~t: I '" ~\ I ~\), r: \ r~ ,150.~ " ,- 't2 ,~"-,f) ". ....). ~N___"""'_ '. ....... h c) On (j ~:~.~~~;~il~~~c' I ,;:-!.~..... , ...... ....__ I I , : -;.~~~ ,~~~.i I I i I I ! i ! I I , I I ...;~- I..: , .~ + ".".. C"- 1-- ']:'.. ~< .~ -.-) I~ ,z,'I> I^'~l t) ; ~'!'1) :): '~': }} 'C-\ , '!f' ..-... : "',' I -' :H, ;'r ~ j'Pij'" i I_I '.,'~ J. 1 A -( I ,. I' I '.. ' . ,) I . -.,.., . '''1/ n' I \ I~I$ IttJI~I~ ~ CJ.() .....,{) I rl1 J z m I ~- : ,~, :< :C I -< . 'f;;. I I /'6' .. _I ~.j ! ' 'i, \ . :--:---! .,"...... 0-'"'' 0;0::+ SOUND ISLAND LONG + + l -..r"". E___ ~_'n~ -r- _...,..",,--.-- _........''''--.-- ......" ,."" "...."'. "--'- ,., .~.... ".. ",,,.~o """~". ::'" --+.--- =." NOTle. ~..:.~.~T~~~':':'":" ~ COUNTYOFSUFFOLK@ ~'''",,",,'-1AReaProDerty Tax Servlce Agency SOUTHOLO SECTION NO Ar. . . MAIUNG ADDRESS: P.O. Box 1179 Southold, NY 11971 OFFICE WCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY PLANNING BOARD MEMBERS JERILYN B. WOODHOUSE Chair WILLIAM J. CREMERS KENNETH L. EDWARDS MARTIN H. SIDOR GEORGE D. SOLOMON Telephone: 631 765-1938 Fax: 631 765-3136 PLANNING BOARD OFFICE TOWN OF SOUTHOLD To: Town of South old Board of Trustees / Mark Terry, Senior Environmental Planner ~ L WRP Coordinator . ~ ~ 1~~2 ~I l::jr~ II' .i1j .L-I From: Date: August 19,2005 Re: Request for Permit for Amelia Mancini SCTM#1000-51-6-25 ._,>,/J The proposed action involves requests a Wetland Permit to con addition to the existing dwelling and to extend the existing deck. Located: Southold. SG\:t(,~I',d TO'Nn old JTlustcf'$ r 600 Grove Rd., The proposed action has been reviewed to Chapter 95, Waterfront Consistency Review of the Town of South old Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the L WRP 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 L WRP provided that the following standard best management practices are implemented. 1. Require erosion and sediment controls (haybales, silt fencing) to protect the stream/wetland system to the southeast of the property. 2. Require water quality protection measures for constructed areas generating runoff (gutters, downspouts, dry wells and pervious driveways). 3. To further the intent ofLWRP Policies 5, 6, and 8; protect water quality and the health of the users ofthe structure; require that no CCA treated wood, oil based preservatives containinl! creosote (CRT) or pentachlorophenol (PCP), applied to the surface of wood materials shall be permitted in the construction materials of the structure. The applicant shall use a decav resistant alternative. 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 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) 765-6641 _ 9lastal Erosion Permit Application ~etland Permit Application _ Administrative Permit _ Amendrnent/Transrj%O~ion . ..--itOceived Applica 'on: ') _RtlCOivedFee:$ - _ ..elltnpleted Application _Incomplete _SEQRA Classification: Type I_Type II_Unlisted_ _ Coordination:( date sent) ~WRP Consistency Assessment Form f) fd-'8 to\' ./(':AC Referral Sent: ~d ~j~ ~te of Inspection: ! I If)) _Receipt ofCAC Report: _Lead Agency Determination:_ Technical Review: lM5Iic Hearing Held: 'ib/~l(1 O'S _Resolution: Office Use Only ~ [E ~. [ ~ '.01. [E f\~.. o ill 1\ , III j JUl- i. l) L'~JJ 0 SOUti1D\d 1iJ'Nn B(la'~ oj Trl:ct'?PS AGENT: S.9I11R (If applicable) Address: S 1I?Ij[ Phone:C#') .a &-.5t,3f? ,,~~ '\ \~\/ ~Board of Trustees APPliC1llrn GENERAL DATA Land Area (in squarefeet): /1. .:?.?O ,( -5't> Area Zoning: Previous use of property: (f)/J/-€ F/JHfL...y ]JW'ELLIN6 {) AlE ~ I L Y ']) /IV J;;L-L ",J C, , Intended use of property: Prior permits/approvals for site improvements: ('Se;G A A\11\C.l-\'E D ') Agency '"B'''1I..:t>'~6 OeM. ,I' h Date . HAe&t t:L t'\l13 5'~€..- 1"Z- I \Q'i5'1 S'~~\:w- 12, \q~ V~~ ;;;2;;;>" \ 1"'\'&\,1 Pee. bv-~'1 c\. \ '\. 'is 1 It II It II II It _ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? LNo_ Yes If yes, provide explanation: Project Description (use att~~hments if necessary): '"Pro -posed (AtTtbfltf.lOJr .6) O:J(/?'4'J.Rllrfo{M.i.i-'~~\.4w~ O-fP~\ rvtCi k ll.(- ~qfo ..sc:. 'V\U5 gec.o",d -CtODv- ~-\t0f\ 58'Co Sr. Pt/..So u~ ~ e.-\-t~ d.e~ ~~D"-{\~~ \1J-\- S~. 4Ifoard of Trustees APPlicillrn WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: t::'o-r e'A ~1"'t2.,Ma..L-+ ~ ~IS+-"'j f1-Ae.. k~.\~ Owe.\\\~l -Cv- ~e'D.V- y-euN1 ('9{'C' ufW""''' ~ Q\J'fY"~-\ oW\l!le~. o square feet o % Area of wetlands on lot: Percent coverage oflot: Closest distance between nearest existing structure and upland edge of wetlands: /J / A feet , Closest distance betweennearest proposed structure and upland edge of wetlands: N A feet I Does the proj ect involve excavation Sf .!ill;,,!>? No )( Yes If yes, how much material will be excavated? ---1L cubic yards How much material will be filled? o cubic yards Depth of which material will be removed or deposited: -..3 feet ("tu.l. -e,€/..-OuJ G~) Proposed slope throughout the area of operations: 10/0 Manner in which material will be removed or deposited: 'B'I l,\(lo,tJI>. 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): - rtO..:Je - . . NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES. TOWN OF SOUTHOLD In the matter of applicant: ~ha... ~ L{ o...~\ ~ \ YOU ARE HEREBY GNEN NOTICE: SCTM# I coo - \ S I ~ Oc., -Cl.;} -;- 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: <::Proceed ,,, O~W\\"5 0... ~U\\~~':J ~""N\\+. 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: (,00 G/!.-OvE .e.oA-b M A> WAOS-r s;0'9 C),c G,tf!avE .e-~ 63;;).:)/ .sO</T).,l or- 'tJMI- Cc.ouiJT'f .eol:fl> ~J') 3. That the project which is subject to Environmental Review under Chapters 32, 37, and/or 97 of the Town Code is open to public comment on: . You may contact the Trustees Office at 765-1892 or in writing. The above-referenced proposal is under review of the Board of Trustees of the Town of South old and does not reference any other agency that might have to review same proposal. OWNERS NAME: ~e..\\c;... \>. ~~~V\.. MAILING ADDRESS: ;Z ~3 ~e.>t:.\i~ ~V\ve.- Wee,-\: \~.s~ ~. \S'S~ PHONE #: t. - "tsc..,cR'" Enc: Copy of sketch or plan showing proposal for your convenience. ('~~ ~) . . PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: . Address:. s; .J ;'/to I cI (!/112../J td.1?I-I-S t. ')0 GY"o~e. ,eel. if,e.,.1-j.es .fdm~s h-z:vn)( 500 G'r(N~ /!d, J ~".;-J..8 /~ . 1/;e1-J.j,es 00"11// C. jJnce (,1 )l,;dsOYJ ~ t::1oya/ ~rr/ N/ /100/ Vt'11<?41;l6 Jj;.shOlJ4.rol, /~-<{) /3ts;..~ c';/e;e. Ani, IVy //357... STATE OF NEW YORK COUNTY OF SUFFOLK , residing at , being duly sworn, deposes and says that on the day of , 20_, deponent mailed a true copy of the Notice set forth. in the Board of Trustees Application, directed to each of the above named persons at the addresses set opposite there respective names; that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment roll of the Town of Southold; that said Notices were mailed at the United States Post Office at , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to before me this Day of ,20_ Notary Public PROJECT 10 NUMBER 617.20 . APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only (To be completed by Applicant or Project Sponsor) ./ SEQR PART 1 - PROJECT INFORMATtON 1~~PLlCANT I SPONSOR IY.o....V\C-\. ~ , 2. PROJECT NAME MAI.JcJ.,,).- V€e.IJ4;q 4"'I~ce "l\e\ \0.... --p- I ~_ Grl.oJ6 '"E'b. 3.PROJECT LOCATION: Municipality .so UT\-\ol.- "- County s.l.iE='FoL..~ 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks ate ~ or orovide maD ,"CO GQ..ov~ ~b.J Wf05T SI~E, ~:l.S'S~ ~ /VOe:m. f!:D ( n. ~ ~ L/-8' 5. IS PROPOSED ACTION: D New o Expansion ~ Modification I alteration 6. DESCRIBE PROJECT BRIEFLY: eN LoA€.G 11\1 (;. 6<.lSnl\J(, -l::.12.L"hl\\C:, f"___A S\'(511 &.ltAeG /() 6 F~€ DetJ 5' 'lr" ANO g-' X to' NGW lJT1l.-I~ dco(yt f'L.NS NGW Sl5CO,.,;D A..voe.. A"bl::>'"'\D00, t N C'-U)) \1\}6 M~ 15eo~ AN\:> lL{ A-sre-e.- '""BA'n\ . A.L~o. ~~o )t'J6 ~t ~T'\ II,) (; LOOOb ~ -t-o P/2..op-r (l.O(4JeL b~ ~us.s . 7. AMOUNT OF LAND AFFECTED: Initiallytl.;2sz>.sfacres O.;:l ~ Ultimately 1\ ';J.Sb SF acres o",;;}s:f!r B~L PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? Yes D No If no, describe briefly: ~HAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) Residential D Industrial 0 Commercial DAQriculture D Park I Forest I Open Space o Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ~Yes 0 No If yes, list agency name and permit I approval: -eO L1."OI oJ t. ~ ^-" oj e-r..:rr M"~P,1 ~ 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? DYes ~NO If yes, list agency name and permIt I approval: 12. AS A ~ULT OF PROPOSED ACTION WILL EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION? Oves No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant I Sponsor Name 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 I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. DYes DNo B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. OVes DNo 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 briefly: I I C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: I I C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: I - C4. A community's existing plans or goals as officially adopted, or a. change in use or intensity of use of land or other natural resources? Explain brieny; I I C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: I - I C6. Long term, short term, cumulative, or other effects not identified in C1-C5? Explain briefly: I I C7. Other impacts including chanQes in use of either Quantity or type of energy? Explain briefly: I , 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: I DYes 0 No I E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: DYes 0 No I I PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, Important or otherwise significant. Each effect should be assessed in connection with Its (a) setting (I.e. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance 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 direcUy to the FUL EAF and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed 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 Date Pnnt or rype Name of ResponsIble Officer In Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency SIgnature of Preparer (If different from responsible officer) r- PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS soQLJ,;' If hs€ I Address:. ~'Jtio/cI 0,-o.e. Pel. r ~;'-t! v'~ &. ) ~ .,.,ti~ /d ffirlsi'Y> ,,{Jd,' 0"Y'al Ari::/ fL.l/ /100/ 1 '0 /J".I;... {?,//C;e. 4>>1/ IVY. //3S"L Name: co r'I o f'- Ir ~ Ul co r'I o o o U.S. Postal Service"" CERTIFIED MAIL"" RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) o r'I r'I rn rn o SentTo ~ ~~#Jt:i~::::~~;~::::::::;?Q:::::::::::::::: ~OJ~L ~9~ A 19 at <<33 A ey/..,,,,k ~""....<e. ....7'k'" , ~ duly sworn, deposesand says that on the eX 7' day oh7~ /t..' , 200 '\,deponent mailed a true copy ofthe Notice set forth in the Board o(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 :5of/Mo<< A/ y. , that said Notices were mailed to each of said persons by (certified) (registered) mail. Postage $ UNIT ID: 0971 Certified Fee 2.30 Return Reciept Fee 1.75 Po_ (Endorsement Required) He", Restricted Delivery Fee Clerk: KW2JC4 (Endorsement Required) Tolal Postage & Fees $ 4.42 07/29/05 4~ ~ ~~~ Sworn to before me this Z C\ ~ '" Day of ':)"Iy , 20~ ~t~l~ John M. Judqe NOTARY PU8L1C, State of New York No.01JU6059400 Qualified In Sutiolk County Commission Expires May 29, 20.QJ. . . 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-~~1 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of _____/1}1'JJJ.J.a___~1!t~a~(M_______________~m COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, 4e'h~ /I J../"u".;, residing at ~-33 .I.~/-:;/k ~~c__--(" WL.S./ ~5.A.~ct )I_V /I~ being duly sworn, depose and say: ~/ .- That on the ~tday of.Jv 7 ,2001., I personally posted the roperty known as ~ 8~ k!o --<'0 L /, /19 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 ~. ~ . ~~J ~sp. '011 <0-' OClt:r'): ~ rn. Dated: ~~ ~ \\%~ (signature) " Sworn to before me this l"rt~day of Jvly 2005 ~blj~~ John M. Judge NOTARY PUBLlC6 Slate of New York No. 01 JU60594o Qualified In Suffolk County Commission Expires May 29, 2O.Q4 4Itoard of Trustees APPlica~n County of Suffolk State of New York ~ ~ - eJlo.... "=. H <>..YIC-' VI . 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 HlSIHER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. ~~ ~~I\ '~ Signatur~ SWORN TO BEFORE ME THIS 2&+1,. DAY OF j...ly ,2005 ~li~~ ~oJf~i~8~tlc Slale of New York No 01JU6059406 Qualified In Suffolk County 0'" Commission Expires May 29. 20.:::!....l . . APPLICANT/AGENTntEPRESENTATrvE TRANSACTIONAL DISCLOSURE FORM The Town of South oJ d's Code of Ethics orohibitc; conflicts ofinterest on the Dart of town officers and emolovees. The Dumose of this form is to orovide information which can alert the town of oossible conflicts of interest and allow it to take whatever action is necessmv to avoid same. . YOUR NAME: ~,,,,.... --Po u.O\.'<'I.c:.,^' (Last name. first name, J11iddle initial. ~less you are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.)' NAME OF APPLICATION: (Check all that apply.) Tax grievance Variance Change of Zone Approval of plat Exemption from plat or official map Other (If "Other", name the activity.) Building Trustee Coastal Erosion Mooring Planning v V Do you personally (or tl'!rough your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of South~ld? "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 x If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of South old NJ A Title or position of that person ~ ) A . , 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 desctibe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): _A) the owner of greater than of the shares of the corporate stock of the applic~nt (when the applican. corporation); _B) the legal or. lcial own~ of any interest in a non-corporate entity (when the applic . not a corporation); . _C) an cer, director. partner. or employee of the applicant; or e actual applicant. DESCRIPTION OF RELATIONSHIP S?bmitte~.8- ~Of~200 5 Signature S ~ I~ . , Print Name ~ a ""l" ;, V"\ ~ Form TS I ~ Board of Trustees ApPliC~ion County of Suffolk State of New York 4d4- ..jJ ~~n; BEING DULY SWORN DEPOSES AND AFFIRM THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF IDS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN TillS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING TillS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATlVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF TIDS APPLICATION. +~~~ Signatur 2"i" SWORN TO BEFORE ME TIDS 1) DAY OF -r,,17 20 DJ- '- N* ~~ ~"6'fA~yJ~BH~,c, Slala of New York No 01JU6059400 Qualified In Suffolk COMunt~9 20 0' Commission Expires ay , - . . APPLICANT/AGENTIREPRESENT ATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's. Code of Ethics orohibitcz conflicts of interest on the Dart of town officers and emo]ovees. The Durnose of this fonn is to orovide information which can alert the town of DOssible conflicts of interest and allow it to take whatever action is neces..'WV to avoid same. YOUR NAME: ~"...... ~_ l{O\'.tI.':V\- (Last name, first name. J1liddle 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 APPLICA nON: (Check all that apply.) Tax grievance Variance Change of Zone Approval of plat Exemption from plat or official map Other (If "Other", name the activity.) Building Trustee Coastal Erosion Mooring Planning v- I/" 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 buslness 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 x 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 III J A Title or position of that person ~ ) A . , Descrihe the relationship hetween yourself (the applicant/agent/representlllive) 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, sihling, parent, or child is (check all that apply): A) the owner of greater than ofthe shares of the corporllle stock of the applicant - (when the applican' corporation); . _B) the legal or leial own~r of any interest in a non-corporate entity (when the applic . not a corporation); . C) an cer, director, partner, or employee of the applicant; or e actual applicant. DESCRIPTION OF RELATIONSHIP Fonn TS 1 S?bmitted~a~ 200 0;:- S 'gnature - . . Print Name j . "" '\c-r. ~ . Town Of South old . . LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for perrnits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of South old Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area (which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes", then the proposed action may affect the achievement of the LWRP policy standards and conditions contained in 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 L WRP policy standards and conditions, it shall not be undertaken. B. A copy of the LWRP is available in the following places: online at the Town of South old's website (southoldtown.northfork.net), the Board of Trustees Office' aI libraries and the Town Clerk's office. 0 n DESCRIPTION OF SITE AND PROPOSED ACTION J U c 2~' ZOOJ l1:b SCTM#IDOO.I51_ 06 - o;lS The Application has been submitted to (check appropriate response): Town Board 0 Planning Dept. 0 Building Dept. 1SJ Board of Trustees ~ Soutl101d Town Board of Trustees I. 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) o o (b) Financial assistance (e.g. grant; loan, subsidy) permit~ license, certification: ~ (c) Nature and extent of action: _1>>en (>o;;.ec ~\"t:6VT 'A L- ~'b \:) \\1 (),j Location of action: 10 G-ro-Je 12c>~\ ~\~ \ \ 02SD sF l 12:G$ I 'b ~ 'A1- IV,.." Site acreage: Present land use: Present zoning classification: 1<- Lt- 0 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: AYV\.e...\'\.C!- V. 8o..~~\V\' 0--.-. G<Yh/l!.- t20o..r.\ 0('33 N.)(. \ \SSQL (b) Mailing address: k'S~ ~, w~ ~~d. (c) Telephone number: Area Code f?lQ 4'5 I - ~ &'0.8'" (d) Application number, if any: ~~e\ -led ~ ~<..1~ \ cl.'~ ~ ~ c:. den, c.J. 7/1s-fro" (see ~) Will the action be directly undertaken, reqUITe funding, or approval by a state or federal agency? Yes 0 No t8J If yes, which state or federal agency? DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of South old 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. DYes D No [8J Not Applicable -1,,)U>lN):> Attach additional sheets ifnecessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Sonthold. See L WRP Section III- Policies Pages 3 through 6 for evaluation criteria DYes D No ~ Not Applicable " Attach additional sheets if necess. . Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See L WRP Section III - Policies Pages 6 through 7 for evaluation criteria DYes D No lK] 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 L WRP Section III - Policies Pages 8 through 16 for evaluation criteria DYes D No t3J 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 DYes D No ~NotAPPlicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of South old ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section 111- Policies; Pages 22 through 32 for evaluation criteria. DYes D No I8l Not Applicable . . Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of South old. See LWRP Section III _ Policies Pages 32 through 34 for evaluation criteria. DYes 0 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 L WRP Section III - Policies; Pages 34 through 38 for evaluation criteria. DYes 0 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. DYes 0 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 L WRP Section III - Policies; Pages 47 through 56 for evaluation criteria. DYes 0 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 L WRP Section 111- Policies; Pages 57 through 62 for evaluation criteria. DYes D No ~ Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of South old. See L WRP Section 111- Policies; Pages 62 through 65 for evaluation criteria. DYes 0 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. DYes 0 No ~ Not Applicable Created on 5/25/05 11:20 AM