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Home My WebLink AboutTR-6813 James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall Annex 54375 Main 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 # 0488C Date: November 10, 2009 THIS CERTIFIES that the demolition of old and construction of new two story dwelllm, new septic system, and new drywells connected to gutters on dwelling At 1910 Leeton Drive, Southold, New York Suffolk County Tax Map # 58-2-12 Conforms to the applications for a Trustees Permit heretofore f'fled in this office Dated 1/8/08 pursuant to which Trustees Wetland Permit # 6813 Dated 2/27/08 was issued and Amended on 7/23/08 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 the demolition of old and construction of new two story dwelling, new septic system, and new dr/wells connected to gutters on dwelling The certificate is issued to CHRISTOPHER & ELIZABETH GRASECK 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 I 179 $outhold, NY 11971 Telephone (631 ) 765-1892 Fa~ (63 I) 765.-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: t,/ Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain day of constructic ~ constructed Y"/Project complete, compliance inspection. INSPECTED BY: COMMENTS: 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. 6813 DATE: FEBRUARY 27~ 2008 ISSUED TO: CHRISTOPHER & ELIZABETH GRASECK PROPERTY ADDRESS: 1910 LEETON DR, SOUTHOLD SCTM#58-2-12 AUTHORIZATION Pursuant to the provisions of Chapter 275 and/or Chapter 111 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 Febmar¥ 27,2008, and in consideration of application fee in the sum of $250.00 paid by Christopher & Elizabeth Graseck and subject to the Terms and Conditions as stated in the Resolution, the Southold authorizes and permits the following: Wetland Permit for the demolition of the existing roof; demolition of existing waterfront exterior wall and partial demolition of existing side/waterfront walls; addition of first floor with crawl space with second floor above; proposed new septic system, and installation of drywells to contain roof run-off, with the condition a line of staked hay bales is installed prior to the start of construction activities, and as the plans prepared by Architecnologies last dated January 7, 2008 and survey by John T. Metzger last dated January 9, 2008. 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 of the said Board as of this date. TERMS AND CONDITIONS The Permittee, Christopher & Elizabeth Graseck, residing at 421 Park Ave., Rye, NY 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 Town 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. 10. 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 February 27, 2008 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Frank Notaro Architecnologies P.O. Box 93 Mattituck, NY 11952 RE: CHRISTOPHER & ELIZABETH GRASECK 1910 LEETON DR., SOUTHOLD SCTM#58-2-12 Dear Mr. Notaro: The Board of Town Trustees took the fo ow ng act on during its regular meeting held on Wed., February 27, 2008 regarding the above matter: WHEREAS, Architecnologies on behalf of CHRISTOPHER & ELIZABETH GRASECK 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 January 8, 2008, 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 issued a recommendation that the application be found Consistent with the Local Waterfront RevitalizatiOn Program policy standards, and, WHEREAS, a Pu~'blic Hearing was held by the Town Trustees with respect to said application on February 27, 2008, 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 the Board of Trustees have found the application to be Consistent with the Local Waterfront Revitalization Program, and, RESOLVED, that the Board of Trustees approve the application of (;HRISTOPFIER & ELIZABETH GRASECK for the demolition of the existing roof; demolition of existing waterfront exterior wall and partial demolition of existing side/waterfront walls; proposed addition of first floor with crawl space with second floor above; proposed new septic system, and installation of drywells to contain roof run-off, with the condition a line of staked hay bales is installed prior to the start of construction activities, and as depicted on the plans prepared by Architecnologies last dated January 7, 2008 and survey prepared by John T. Metzger last dated January 9, 2008. 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 r~quired at a fee of $50.00 per inspection. (See attached schedule.) Fees: $100.00 Very truly yours, ¢ Jame .~King ~ '~ President, Board of Trustees JFK/Ims 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 Southotd, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: Please be advised that your application dated I] ~'/Oo~ has been reviewed by this Board at the regular meeting of and your application has been approved pending the completion of the following items checked off below. __ Revised Plans for proposed project ~/'~-Pre-Construction Hay Bale Line Inspection Fee ($50.00) __ 1st Day of Construction ($50.00) __ ¼ Constructed ($50.00) ,/'- Final Inspection Fee ($50.00) __ Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: BY: James F. King, President Board of Trustees Donald Wilder, Chairman Lauren Standish, Secretary Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631 ) 765-1892 Fax (631) 765-6641 Conservation Advisory Council Town of Southold At the meeting of the Southold Town Conservation Advisory Council held Wed., February 13, 2008, the following recommendation was made: Moved by James Eckert, seconded by Don Wilder, it was RESOLVED to SUPPORT the Wetland Permit application of CHRISTOPHER & ELIZABETH GRASECK for the demolition of the existing roof; demolition of existing waterfront exterior wall and partial demolition of existing side/waterfront walls; proposed addition of first floor with crawl space with second floor above; proposed new septic system, and installation of drywells to contain roof run-off. Located: 1910 Leeton Dr., Southold. SCTM#58-2-12 Inspected by: James Eckert Vote of Council: Ayes: All Motion Carried Jarnes 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 OFTOWNTRUSTEES TOWN OFSOUTHOLD Southold Town Board of Trustees Field Inspection/Work session Report Date/Time: CHRISTOPHER & ELIZABETH GRASECK request a Wetland Permit for the demolition of the existing roof; demolition of existing waterfront exterior wall and partial demolition of existing side/waterfront walls; proposed addition of first floor with crawl space with second floor above; proposed new septic system, and installation of drywells to contain roof run-off. Located: 1910 Leeton Dr., Southold. SCTM#58-2-12 Type of area to be impacted: Saltwater Wetland Freshwater Wetland ~'~ound Bay Distance of proposed work to edge of above: Part of Town Code proposed work falls under: __Chapt.275 Chapt. 111 other Type of Application: __ Wetland __Coastal Erosion __Amendment __Administrative __Emergency Pre-Submission Violation Planning Info needed: Modifications: Conditions: Present Were: ~.~ng __. herty__P.Dickerson [¢~. Bergen__~B. Ghosio, Jr H. Cusack D. Dzenkowski Mark Terry__other Form filled out in the field by Mailed/Faxed to: Date: Environmental Technician Review OvvICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY MAILING ADD~: P.O. Box 1179 Southold, NY 11971 Telephone: 631 765-1938 Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM COORDINATOR TOWN OF SOUTHOLD To: From: Date: Re: MEMORANDUM James King, President Town of Southold Board of Trustees Gerard Goehringer, Chair Zoning Board of Appeals ~ Mark Ten'y, Principal Planner ~ LWRP Coordinator February21,2008 Request for Wetland Permit for CHRISTOPHER & ELIZABETH GRASECK SCTM#58-2-12 :. CHRISTOPHER & ELIZABETH GRASECK request ~. W~tland Permit for the demolition of the existing roof; demolition of existing waterfront exterior wall and partial demolition of existing side/waterfront walls; proposed addition of first floor.with drawl space witl~ second floor above; proposed new septic system, and installation of drywells to ~ontain roof runLoff. Located: 1910 Leeton Dr., Southold. SCTM#58-2-12 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfi'ont 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 CONSISTENT with the denoted following Policy Standards and therefore is CONSISTENT with the LWRP. Policy Standards 4.1 Minimize losses of human life and structures from flooding and erosion hazards. The following management measures to minimize losses of human life and structures from flooding and erosion hazards are suggested: Minimize potential loss and damage by locating development and structures away from flooding and erosion hazards. Avoid development other than water-dependent uses in coastal hazard areas. Locate new development which is not water-dependent as far away from coastal hazard areas as practical. b. Avoid hazards by siting structures to maximize the distance from Coastal Erosion Hazard Areas. The proposal includes relocating the new residential structure 10 feet landward from the existing location. Due to the parcel configuration~ size~ setbacks and separation distances for sanitary systems~ there is little to no ability to site the structure (as proposed) further away from the Coastal Erosion Hazard Area. Move existing development and structures as far away from flooding and erosion hazards as practical. Maintaining existing development and structures in hazard areas may be warranted for: structures which functionally require a location on the coast or in coastal waters. water-dependent uses which cannot avoid exposure to hazards. sites in areas with extensive public investment, public infrastructure, or major public facilities. sites where relocation of an existing structure is not practical. For reasons discussed above~ the relocation of the structure is not practical and therefore the proposed action furthers the above sub- policies to the greatest extent practical. In the event that the action is approved, the following best management practice (BMP) is recommended: 1. Require a minimum 20 foot non-turf buffer between the bulkhead and the proposed new residential structure. The BMP will further Policies 5, Protect and improve water quality in the Town of Southold and 6.3 Protect and restore tidal and freshwater wetlands, item D (below). D. Provide adequate buffers between wetlands and adjacent or nearby uses and activities in order to ensure protection of the wetland's character, quality, values, and functions. Pursuant to Chapter 268, the Boards shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen John Holzapfel 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 w OaStal Erosion Permit Application etland Permit Application Administrative Permit Amendment~rrans fer/,Extension ~ece~ved Application: ~Received Fee:$ r~.~ ~_~-Completed Application __Incomplete __SEQRA Classification: Type I Type II Unlisted __Coordination:(date sent) -"L'WRP Consistency Assessment Form I]/la[i~l ~'%'5AC Referral Sent: ~.-l~ate of Inspection: __Receipt of CAC Report: __Lead Agency Determination:__ ~Teclmical Review: ~Public Hearing Held: Resolution: JAN - 8 2008 Southhold Towll Board of Trustees Suffolk County Tax Map Number: Property Location: Name of Applicant Address rhone (provide LILCO Pole #, distance to cross streets, and location) AGENT: QlqPrk3~) N.~OT~,J~ , E~...\~ t, DhCL,~Ek-% (If applicable) Address: ~, O, '~])OX C~ ~) J ~-{~TTITO~,,~, ~3,.¥ IJ"~$c.2 Phone: (~i-eflc~8- Iloq of Trustees Applicati~ Land Area (in square feet): Area Zoning: ~ - q0 Previous use of property: Intended use of property: GENERAL DATA /' Covenants and Restrictions: Yes ~ No If "Yes", please provide copy. 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? >o No Yes If yes, provide explanation: Project Description (use attachments if necessary): of Trustees Applicatio~ WETLAND/TRUSTEE LANDS APPLICATION DATA Area of wetlands on lot: square feet Percent coverage of lot: Closest distance between nearest existing structure and upland edge of wetlands: c~' feet Closest distance between nearest proposed structure and upland edge of wetlands: ~.~ ' feet Does the project involve excavation or filling? No ~ Yes If yes, how much material will be excavated? ],ff:~ cubic yards How much material will be filled? ~ ~ cubic yards Depth of which material will be removed or deposited: ~ ~ Proposed slope throughout the area of operations: ¢ ~_. feet Manner in which material will be removed or deposited: 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): ~d of Trustees Applicatio0 COASTAL EROSION APPLICATION DATA Purposes of proposed activity: tol~OgC~=q~ Are wetlands present within 100 feet of the proposed activity? No ? Yes Does the project involve excavation or filling? No ?' Yes If Yes, how much material will be excavated? [ff~ (cubic yards) How much material will be filled? /6.~ (cubic yards) Manner in which material will be removed or deposited: ~ ~0,¢~ ! }-%t7, ,_'~f3(:-~. ~/~-~E~ ~ Describe ~e na~e ~d extent of the enviromental impacts reasonably ~ticipated resulting ~om implementation of ~e prQect as proposed. (Use a~ac~ents if necess~y) 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 otc ....... ......... CO~TY OF S~FOLK) STATE OF ~W YO~) AFFDAVIT OF POSTING residing at 1~O5'- ~,~oo '~aS_ being duly sworn, depose and say: That on the ~ay of~'~,t~,O~ 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 vrior to the date~ of the public hearing. Date of hearing noted thereon to be held Dated: c>gd ~Od~'/ (signature) Sworn to before me this ,,,,~ ~ day of 7~ 200 fi" f//No~ary Public BABETTE CORNINE Notary Publio, State Of New York No. 01CO5792800 Qualified In Suffolk County/~ PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK - ~ 'r~c~. , being duly sworn, deposes and says that on the ~ tl~ day of'~-m~e.u4~ ,20~_~__, deponent mailed a true copy of the Notice Ret forth in the Board o~Truste~s 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 /1/I^1'-r3114CK_ , that said Notices were mailed to each of said persons by (~ (registered) mail. Sworn tq. before me this Day of ~-~ , 20 ~~~Nota~ Publi~ BABETTE CORNINE Notary Public, State Of New York No. 01CO5792800 Qualified In Suffolk County~ ~ Commission Expires /.C~f./...'t-z~ of Trustees Applicatio~ (where AUTHORIZATION the applicant is not the owner) (print owner of property) residing at ~ ~% ~ ~uc (mailing address) do hereby authorize~_~%~W_ ~i~.O (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. -- ~wner ' s signature) 8 of Trustees Applicati~ AUTHORIZATION (where the applicant is not the owner) (print owner of property) residing at ~ ~.% ~-%~ ~3 (mailing address do hereby authorize~%~ ~O~WF~O (Agent) to apply for per~it(s) from the Southold Board of Town Trustees on my behalf. ~3~wner ' s sign~fture ) 8 Board of Trustees Application County of Suffolk State of New York ~,~t~.- /~ t~-z~3 BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY 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. 1N 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. Signature SWORN TO BEFORE ME THIS /¢~c~ DAY OF ~ ,20 0 7 Notary Public BABETTE CORNINE Notary Public, State Of New York No. 01005792800 Qualified In Suffolk County/~, Commission Expires ~ PROJECT ID NUMBER PART I - PROJECT INFORMATION 1.APPLICANT/SPONSOR 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. P~OJECT NAME County SEQR 3.PROJECT LOCATION: 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map ! 9/0 Z-EEF~ T~g)')~ d:x. 5 . I S PROPOSED ACTION: [] New /~xpansion ~Modification / alteration · DESCRIBE PROJECT BRIEFLY: gROPCz-. 'D I F DOI /J-BZ:)/TIDTO. 71 AMOUNT O F LANDAFFECTED: ~, Initiatly ~,~,)~.~, acres Ultimately e~)4]/ acres 8. WILL PROPOSED ACTION CQMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? []Yes ~No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply,} ~Residential []Industrial ~Commercial ~Agriculture r~Park/Forest/OpenSpace r~]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 name and permit / approval: 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ]Yes .,~No If yes, list agency name and permit / approval: 12 AS ,~RE,~i.ULT OF PROPOSED ACTIQN WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Date: ~'D, I~ Signature '~'T-~~ b ~''-- _ If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Tom of Southold's Code of Ethics nrohibits conflicts of interest on the naa of town officers and emnlovees. The nuroose of this form is to orovlde information which can alert the town of ~ossible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: ~l~ar4f--k~ ~'l~q's~ ~'~-~ (Last name, first name, middle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee /~ Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If "Other", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, nlarriage, 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 shams. YES NO ?~> If you answered '~YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or ~hild is (check all that apply): A) the owner of greater than 5% oftbe shares of the corporate stock of the applic0nt (when the applicant is a corporation); __.B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a corporation); __.C) an officer, director, partner, or employee of the applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Submitted this Signature ~ Print Name \ ~ Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area (which includes all of Southold Town). If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus~ each answer must be explained in detail~ listing both supporting and non- suooortin~ facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold ' s website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION The Application has been submitted to (check appropriate response): TownBoard ~ Planning Board [-7 BuildingDept:4~SJi> BoardofTrustees Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g. capital [] construction, planning activity, agency regulation, land lransaction) [] (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nature and extent of action: 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) Nameofapplicant: ~t4~/$TL)~,Ug:-~, ,~ ~-Z/~7---/~ ~.g~ . (b) Mailing address: (c) Telephone number: Area Code ( (d) Application number, if any:. Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ~ 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 Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III - Policies; Page 2 for evaluation criteria. /~Yes ~] No ~ Not Applicable - ? Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III - Policies Pages 3 through 6 for evaluation criteria ~ Yes ~-~ No ~ Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III - Policies Pages 6 through 7 for evaluation criteria ]~Yes [] No [] Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III - Policies Pages 8 through 16 for evaluation criteria 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. No Not App~able Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies Pages 32 through 34 for evaluation criteria. [] Yes [] No~ Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. [] Yes ~ No~ot Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. [] ye~-~ N~tApplieable Attach additional sheets if necessary 'WORKING COAST POLICIESO 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 F~ N0~)Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. pYes ~ 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~;P~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. F-q Yes ~ No~ff_~ Not Applicable PREPARED BY-~--,4~ ~'~""TITLE /"K.~---~I"~- DATE [7~. I~.~'7 SCDHS ReL # R10-07-128 EXISTING HOCISE ruTH IMPROVEMENTS TO BE REMOVED ~c-l~ 7209 ~ T~ ~W Y~K EXCEP~ AS PER ~C~ 7~09 - ~DI~ ~RE~ ARE VAL~ F~ T~S MAP A~ I om fomilier wilh the STANDARDS FOR APPROVAL AND CONSTRUCTION OF SUBSURFACE SEF/AGE DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES end will eh)de by the conditions $e1 forlh therein end on the fo conslrucl. The Iocofions of wells end cesspools shown hereon ere from field observofions end or from dele ohio)ned /rom others. COASTAL EROSION HAZARD LINE FROM COASTAL EROSION HAZARD MAP PHOTO # 56-566-85 FLOOD ZONES FROM FIRM $6105C0154 G 5/04/98 ELEVATIONS ARE REFERENCED TO N. 6. V.D. r,-,. ,,_ ,, . . SURVEY OF PROPERTY . "~ ~ A T SOUTHOLD ?--;:-'-' ~' - ~ ~ TO WN OF SOUTHOLD .... SUFFOLK COUNTY, ~ ~ ~ re ~ SCALE: I%20' ~UG. 2~, 2007 ' JAN. 9~ ~008 (revisions) ~A~ SEWAGE ~O~L s~. ~ APPROVED BY ~RT ao~o BOARD OF TRUSTEES (631) 765 - ~OWN OF ~UTHOLD DATE .% VF 6¥x4' deep AREAS AREA FROM BULKHEAD TO MHWM. - 593 sq. fl. AREA FROM STREET TO BULKHEAD 7411 se. fl. TOTAL AREA - 8004 s~.fl. AREA COVERED BY NEW HOUSE 1780 sg. lL LOT COVERAG~ - AREA LEETON DRIVE TO BULKHEAD = 7, ~ 1780/7411 = 24% ~, 1~30 TRAVELER STREET SOUTHOLD~ N. Y. 119XI ' 1'17 "17'1 EX. SHED 33' SOUTH ELEVATION EAST ELEVATION 33'-6" FIRST FLOOR PLAN NORTH ELEVATION WEST ELEVATION 0 Z~ o¢ A-EX KITCHEN STO RAG E BATHROOM #1 BEDROOM #1 - 33' FIRST FLOOR PLAN LIVING ROOM DINING AREA 53' FOYER BEDIROOM #2 I BATHROOM #2 MECH. RM, BEDR1OOM #3 SECOND FLOOR PLAN M. BEDROOM M, CLOS. OPEN AREA LAUNDRY ZI LU O m A-1 18 SOUTH ELEVATION NORTH ELEVATION 32'-6" TO RIDGE 13'-6" FIN. GRADE TO TO TOP FIN. FL. WEST ELEVATION EAST ELEVATION Z III III A-2