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Home My WebLink AboutTR-7074A Glenn Goldsmith,President vQF sots, Town Hall Annex Michael J.Domino,Vice-President O �� 54375 Route 25 John M.Bredemeyer III P.O.Box 1179 A. Nicholas,Krupski Southold,New York 11971 ua � �► Q Telephone(631) 765-1892 Greg Williams �'0 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD February 13, 2020 Tom Gabrielsen P.O. Box 301 Jamesport, NY 11947 RE: ADMINISTRATIVE PERMIT#7074A TRANSFER REQUEST 4955 MOORE'S LANE, CUTCHOGUE SCTM# 1000-116-2-3 Dear Mr. Gabrielsen: On January 27, 2020, a Field Inspection was performed on the above mentioned property and it was determined at that time that the fence was never constructed under Administrative Permit#7074A, as issued on April 22, 2009. The following action was taken at the Southold Town Board of Trustees regular meeting held on Wednesday,, February 12, 2020: RESOLVED, that the Southold Town Board of Trustees DENIES WITHOUT PREJUDICE the request for a Transfer of Administrative Permit#7074A from Erwin & Heather Gruber to Helen E. Powers, as issued on April 22, 2009. If you have any questions, please contact our office at (631) 765-1892. Sincerely, .r/� 401� Glenn Goldsmith President, Board of Trustees GG/dd I J To the Board of Town Trustees ' Town of Southold s SAN 9 2020 � I a To Whom it May Concern: I would like to request a transfer for Permit # 7O74A (dated April 2, 2009). The original applicant was Erwin Gruber. It would be transferred from Erwin Gruber to myself, Helen Emilie Powers. The property is located at 4955 Moore's Lane, Cutchogue. If there is any questions I can be reached at 631872-2623. Regards, rei,v,Emilie Powers PO .U;OX fat P Iz �� ,er. �►� L vv s P,7 c PLP-R"'"T / i To the Board of Town Trustees JAN 9 2020 Town of Southold To Whom it May Concern: -" Permit No: 7074 A Date of Application: April 2, 2009 SCTM# 116-2-3 I was the previous owner in 4/2/09 and am no longer the property owner. The property is located at 4955 Moore's Lane, Cutchogue. I never built the fence as on the application. There is no fencing there now. Regards, Erwin Gruber R _ Board of Trustees App? ioation AFFIDAVIT rS 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 BOARD OF 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, INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Jc ; - S' lure f Property Owner Signature of Property Owner nn \\ SWORN TO BEFORE ME THIS b DAY OF 20 aD a Notary Public MELANIE V BROWN Notary Public,State of New yo* No.01BR4908712 Qualified in Suffolk County a O a Commission Expires October 19,_� Board of Trustees Appl:i^-tion AUTHORIZATION (Where the applicant is not the owner) I/We, Ler IY� LL jC-- owners of the property identified as SCTM# 1000- in the town of r it ---,New York, hereby authorizes R el' NJto act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. Pro e 0 er's Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF ��u" , 20 a k4p,� rr , Notary Public MELANIE V BROWM Notary Public,State of New York No.01BR4908712 Qualified in Suffolk coup Commission Expires October 19,-�� Michael J. Domino, I` `cent O�QSCf Town Hall Annex John M. Bredemeyer III,Vie rresident ,,'� ' ' 54375 Route 25 Glenn Goldsmith y P.O. Box 1179 A.Nicholas Krupski Southold,NY 11971 Greg Williams 4,� p� Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: I�7 � Completed in field by: Tom Gabrielsen on behalf of HELEN E. POWERS requests a Transfer of Administrative Permit #7074A from Erwin & Heather Gruber to Helen E. Powers, as issued on April 22, 2009. Located: 4955 Moore's Lane, Cutchogue. SCTM#: 1000-116-2-3 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey :5- 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: - 400 C,11 we �v�rr� oNsT� a �(cM�, J ga s r��o��►� - AA *V, ( b�, sa PA, 4. c I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other 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 Ist day of construction ~ constructed tx/' Project complete, compliance inspection. 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 Permit No.: 7074A Date of Receipt of Application: April 2, 2009 Applicant: Erwin & Heather Gruber' SCTM#: 116-2-3 Project Location: 4955 Moore's Lane, Cutchogue Date of Resolution/issuance: April 22, 2009 Date of Expiration: April 22, 2011 Reviewed by: Trustee Dave Bergen Project Description: The clean-up of the overgrown bushes, shrubs, removal of the small trees and one grown tree, addition of top soil and seed for grass, add a post and rail fence along the street and a privacy fence along the side yard bordering the golf course. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the landscape plan received on April 2, 2009 and stamped approved on May 12, 2009. Inspections: Final If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Board of Trustees James F. King, President ~lill 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 Please be advised that your application dated zj'/& ~ 0"t has been reviewed by this Board at the regular meeting of '-/! a,~lOCJ 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) J 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 James F. King, President Jill M. Dohelxy, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr P.O Box 1179 Southold. NY 11971 Telephone (631 ) 765-1892 Fax (631 ) 765-6641 Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: ERWIN & HEATHER GRUBER request an Administrative Permit for the clean-up of the overgrown bushes, shrubs, removal of the small trees and one grown tree, addition of top soil and seed for grass, add a post and rail fence along the street and a privacy fence along the side yard bordering the golf course. Located: 4955 Moore's Lane, Cutchogue. SCTM#116-2-3 T4~e of area to be impacted: altwater Wetland Freshwater Wetland Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: X~_Chapt.275 Chapt. 111 other __Sound Bay Type of Application: Wetland V~-Ad ministrative__Emergency __ Coastal Erosion __Amendment Pre-Submission Violation Info needed: Modifications: Conditions: Present Were: __&King __J.Doherty__P.Dickerson .. __ D. Dzenkowski __Mark Terry__other Form filled out in the field by Mailed/Faxed to: Date: ~. D. Bergen__ B.Ghosio, Environmental Technician Review- Southold Town Police Roport 03/20/2009 15:13 Incident Report Case Number 01-09-002026 I Case Number Report Occurred On/From Occurred To Report Type N 01-09-002026 03/20/2009 15:13 03/20/2009 15:13 Original C Incident Type Case Status Case Status Date Cleared I TRUSTEE INSPECTION CLOSED-NO ARREST (ADMI 03/20/2009 D IlL Common Name E 4955 MOORES LN CUTCHOGUE, NY 11935 (SUFFOLK County) N Day of Week: FRIDAY Sector: 2 802 T Map Reference: CUTCH3 Total Damaged Property Value: $0.00 Location Type: YARD Total Stolen Property Value: $0.00 Sector: 2 802 Total Recovered Prope[ty Value: ~0.00 P Person Type Business/Person Name Business Phone E OWNER HEATHER GRUBER 631- R Home Phone Person Address Map Reference S ,4 631- Use Address from Incident Location Information O! Call Phone Employer Address N (215/ 776-2072 WHITE Female Birth Date Birth City 05/14/1977 Age: 31 Injury Type 1: NONE Adult/Juvenile: ADULT Medical Treatment: Not Treated Victim Type: INDIVIDUAL (I) Residency Type: RESIDENT Extent of Injury: NOT INJURED Residency Status: RESIDENT N A R R '1 I V E Topic Original DURING ROUTINE PATROL FOUND WORK BEING DONE AT I/L WITHIN 100 FEET OF WETLANDS. INTERVIEWED HOMEOWNER HEATHER GRUBER AND INFORMED HER THAT THE TOWN TRUSTEES NEEDED TO INSPECT THE PROPERTY TO DETERMINE WHETHER A PERMIT WAS NECESSARY. HOMEOWNER WAS TOLD TO CEASE ALL WORK IN THAT AREA UNTIL PROPERTY WAS INSPECTED. Reporting Officer Department Report Status: BC JOHN P KIRINCIC (4371) SOUTHOLD TOWN POLICE Approved Officer Name Date/Time Veri~ing Officer Department Date I Time SGT KEV)N J LYNCH (4821) SOUTHOLD TOWN POLICE 03/21/2009 15:24 I of 1 C o $.¥ [vl, lb 0 L S View from Moores LaneView from Moores Lane View from Moores LaneView from Moores Lane View to Moores Ln. from inside house View to Moores Ln. from inside house James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob ~nosio, Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only __Coastal Erosion Permit Application __Wetland Permit Application ~¥~'Administrative Permit __Amendment/Transfer/Extension ,.,'~eceived Application: t,/~eceived Vee:$ jrt) ,...Gompleted Application eLl. Jori 0 Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) ..~EWRP Consistency Assessment Form CAC Referral Sent: ateo In.ection: Receipt of CAC Report: Lead Agency Determination:__ __Technical Review: ~-~Public Hearing Held: __Resolution: APR - 2 ~u~'~ Suffolk County Tax Man Nun}ber: 1000 - ~\[0.01~ -- G2.. Lot, oi,440,. Property Location: ~55 ~/~(X)f'CS {-t;lYL~ (provide LILCO Pole #, distance to cross streets, and location) (If applicable) -- oo$. ~0 Address: Phone: of Trustees Applicat Land Area (in square feet): Area Zoning:. GENERAL DATA 4 z, qoo 4d- [ Previous use orproperty: ~ y~d Intended use of property: ~CttlaL ~ 0d~ Covenants and Restrictions: Yes /'~ No If "Yes", please provide copy. Prior permits/approvals for site improvements: Agency Date ~ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? ~ No Yes If yes, provide explanation: Project Description (use attaclunents if necessary): Board of Trustees Applica WETLAND/TRUSTEE LANDS APPLICATION DATA Pmposeoftheproposedoperations:'"~O OJ.t. OA~ ['('D~ ~ ~ ~V. Of~O.~ Area of wetlands on lot: Percent coverage of lot: 2. Iq~ _square feet (b~'B"~"XqU~,g,.q 1 % Closest dist~ce be~een newest existing s~c~e ~d.upl~d edgeofwetl~ds: ~0 feet ~0 ~[~6~ Closest distance betwe._en nearest proposed structure and upland edge of wetlands: '~ 0 feet ~0 ~-~l$i~, Does the project involve excavation or filling? ~ No Yes If yes, how much material will be excavated? .~ cubic yards How much material will be filled? 'a.. [ 5 cubic yards Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: NO Ct~[q6~ Manner in which material will be removed or deposit.~_~ed: ]~1,3~'t' E i~]h.~..[ [0R, fE I~ gnd S~atement of the ~ec_t~ if 9ny, on th~ w_etJ~a~ _cls and.tidgl_.wa__te~:s_ of th~ ~own that _rn_ ay__ .r_e§_ult by_ reas6n of such proposed operations (use attachments if appropriate): PROJECT ID NUMBER PART 1 - 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. PROJECT NAME County LOCATION: S~eet Addess and Road Intersec~ons. Prominent landmass etc -or provide map SEQR IS PROPOSED ACTION: r~New ~-] Expansion [~ Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: nitia,y aores , &O U.ir. ate y acre t, z.O 6, WILL PROPOSED ACTION COMPLY 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 ~]lndustrial [~]Commercial ~]Agriculture E~ 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) E~Yes ~ No If list name and permit / yes, agency approval: 11. uu~:~ ANY A;SP'I:~JI OF iHE ACIION HAVE a CURRENTLY VALID PERMIT OR APPROV~ [~Yes r--'~No If yes, list agency name and permit / approval: 12. AS ARESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Signature Date: 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 617.47 if yes, coordinate the review process and use the FULL EAF. r'-lYes r-]No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACT ONS N 6 NYCRR, PART 617.67 If No, a negative declaration may be superseded by another involved agency, r-.-1 Yes ~"-'1No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air qualfiy, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, potenlial for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic. agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: egetat~on or fauna fish shellfish or wddlife species s*gn~ficant habitats, or threatened or endangered species? Explain briefly 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 briefly: C5. Growth subsequent development or related act~wt~es hkety to be reduced by the proposed acbon? Explain briefly Other impacts (including changes in use of either quantity or type o[ energy? Explain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEAI? ~lf yes, explain briefly,,: [~Yes [~No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain' E]Yes r--INo 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 el' occurring; (c) duration; (d) irreversibilfiy; (e) geographic scope; and (t) magnitude. If necessanJ, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that ag relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked ~,'~, th-~ d~t~rm!nat!c.-. ~fs!~n!fmo~nce muat evclu 3 te~hepetent taHmpe, ct cf thc prc.cc.c, cd a ct[c.n on thc cnv~rc, nm~nt~ cha~act~r',a~,..o of~h~ CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL FAF and/or prepare a positive declaration. c~e~;~ this bo~ ~o~ ~-~J~'~:~e~rn~; b~'~'{h~ ~nfo~rnation and ~aly~is ~b~ve a~d ~; ~upp0rtin~ docu~n~i~'ii~nl that ~h~-~r0po~ WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessar?, the reasons supporting this determination. Name of Lead Agency Date Title of Responsible Officer Pdnt or Type Name of Responsible Ohicer in Lead Agency Signa{ure of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) Board of Trustees Appli~ation County of Suffolk State of New York grut BEn O DULY swo N DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR TH~ 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 ~ 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 OE 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. SWORN TO BEFORE ME THIS ~ DAY OF ,20_~ Notary Public LiNDA J COOPEF~ NOTARY PUBLIC, Stets of New York NO. 01C04822563, Suffoik Count)J,..x Term Expires December 31,20 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the Dart of town Officers and emvlovees. The purpose of this form is to erovide information which can alert the town ofvossible conflicts of interest and allow it to take whatever action is necessary to avoid same. (Lost name, first name, gaiddle initial, unless yOU ate 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 (lf "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 buginess interest. "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO ~/~ If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title Or position of that person Describe the relationship between yourself(the applicant/agent/representative) and the ~wn 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% of the shams of the corporate stock of the applicant (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, partnei', or employee of the applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Submiitedthis ,ZtXo da¥o£ }"~--~ 200c:} 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- suDDortine facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# I KO 62- PROJECT NAME &r"M ~ ~(,~ ~CC-4,{'7~-~ APR - 2 ~_Ou9 The Application has been submitted to (check appropriate response): Town Board [] Planning Board [] Building Dept. ['-] Board of Trustees [~ Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g. capital construction, planning activity, agency regulation, land transaction) (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Location of action: Site acreage: Present land use: ~-~S'[~eYX~ 0.] 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: IJo~tgt~ ~lJ~l~e.J~ (b) Mailing address: ~' ~]OOlC£'g L4q't CCt~'IO6UL~, ~] I[q~ X (c) Telephone number: Area Code (~ 3-1 (.f ~.0-1 2_ ~51 '-15q' ~"O~g (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ~ NoN 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 Southoid. 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 Yes ~ No L--~ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of.Southold. See LWRP Section III - PoliCies Pages 16 through 21 for evaluation criteria Yes po I Not Applieahle 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 q~licable 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 .~ 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. ~ Ye~'~ No ~] Not Applicable Attach additional sheets if necessary WORKING COAST POLIOS Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III- Policies; Pages 47 through 56 for evaluation criteria. [] Yes ~] No [] Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconie Estuary and Town ~vaters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. ~-~ Yes ~ No [] Not Applicable ' Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages 62 through 65 for evaluation criteria. ~ Yes ~ No [] Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III - Policies; Pages 65 through 68 for evaluation critcria. ~ Yes D No ~ Not Applicable Landscape plans include p~o_-r. ; .~ APPROVED BY o,,o. L.,,o, ,..,..,..BOARD OF TRUSTEES ,,,,~ , Sou~rHOLD ~ 'o' 'TOWN OF P indicates a tree that has already been removed '~' Indicates a post-and-rail fence we'd like to construct on the front & back yards ~-~ Indicates a privacy fence we'd like to construct on the side yards ~ q,,..._,:..,.J. ~..~,, ,,.. Lan , an, ~B J:lk.l PI, UL ,~I,O_T, ~, .~,~ APPROVED BY -'o' '."- '. ~' BOARD OF TRUSTEES .~.,., ,..,.~. '" 'TOWN OF SOUTHOLD ~ ~ Prop rty ;.Su.rve.y LOWS J~ HARSON,