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HomeMy WebLinkAboutRoberts Custom Homes/KochAlbert 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 December 7, 2005 Ms. Heather Koch 324 Jay Street Katonah, New York 10536 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Re: 80 RABBIT LANE, EAST MARION SCTM # 31-18-3 Dear Ms. Koch, A permit for the above referenced property was approved on July 20, 2005 by the Board of Trustees for the following: Construct a 22'6" by 14' deck and place sand to the bulkhead, demolish 17.4' x 19.8' portion of existing dwelling and construct new first and second floor additions to dwelling, and a new septic system, With the following conditions: 1. Revise the survey to include the location of the new septic system. 2. There will be only native landscaping and drought resistant plantings. 3. No turf(grass) on the seaward side of the house. 4. Gutters and drywells to contain all run off. 5. No CCA treated lumber to be used. Enclosed is the original survey that was submitted with the application. Please revise to include the conditions of the permit, and send to this office with the inspection fee and we will mail your permit. Please contact this office with any further questions. Sincerely, Heather Cusack Environmental Technician Albert J. Krupski, President James King, Vice-President Artie Foster Ken Pollwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated reviewed by this Board at the regular meeting of following action was taken: has been and the ( ~/)Application Approved (see below) (__) Application Denied (see below) ( )Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees. The fee is computed below according to the schedule of rates as set forth in the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $ ~--OrC~ SIGNED: PRESIDENT, BOARD OF TRUSTEES Jm~e 15, 2005 Field Inoction June 15, 2005 Field In{~ction Telephone (631) 765-1892 Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Wed., July 13, 2005, the following recommendation was made: Moved by Don Wilder, seconded by Jack McGreevy, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH CONDITIONS of the Wetland Permit application of ROBERT'S CUSTOM HOMES to construct a 22.6'X 14' deck and sand to bulkhead, demolish 17.4' X 19.8' portion of existing dwelling and construct new first and second floor additions to dwelling. Located: 80 Rabbit Lane, East Marion. SCTM#31-18-3 The CAC recommends Approval of the application with the following conditions: no turf on the seaward side of the house gutters and drywells are installed to contain the roof run-off no CCA treated lumber. Vote of Council: Ayes: All Motion Carried Sou~o!d Town -- ~ ~d~ed grade I~ I~0 ~L ~P~C T~NK ~ ~. ~ ~ 8'~ ~ 2' ~ Lem~ Pools !o ~ ~ 3 ~on ~ c~ I . / O~ famE/or with the STANDAPDE FOP APPPOVAL AND CONS~UC~ON OF SUBSURFACE SEWAGE DISPOSAL EYE,MS F~ SINGLE FAMILY EEE/DENCE3 NOTE and will ab/de b~ the conditions set forth there~ and on the to construct. \ NO SUBSURFACE SEEAGE DISPOSAL SYS TEW DESIGN BY, JOSEPH FISCHETTt~ P.E. HOBART ROAD ~ SOUTHOLD, N.Y. 11971 (63,, 765 - 295~ The Iocotion of wells ond cesspoo/s shown hereon ore from field observations ond or from doto obtoined from others. AN)' ALTERA770N ON AI~21DON TO THIS SURVEY IS A ~10LATION OF SEC~70N 7209 OF I~E NEW YORK STATE EDUCATION LA~ EXCEPT AS PER SECTION 7~O~-SUBDIViSION 2. ALL CERTIFTCAITONS MEREO~I ARE VALID F-OR IHIS MAP AND COPIES THEREOF ONLY IF SAID MAP OR COP1£$ BEAR THE IMPRESSED SEAL OF THE SURVEYOR WHOSE ~VA TURF APPE~$ HEREON. El~votion$ referenced to N.G. AREA=4,079 SQ. FT. TO DE LINE RETAINING 1~4LL ",.~ . /. CONCRETE- 4000psi 2. STEEL 60 ks/ 3. ~YA TER PROOF THE INSIDE FACE OF RETAINING 4. STEEL REINFORCING TO BE r~VSPEC T~O By ENGINEER BEFORE PL.;CEMENT OF CONCRETE, FLOOD ZONE AE (eL 9) FIRM 3610.~C0/77 G SURVEY OF PROPERTY AT EAST MARION TO~N OF SOUTHOLD SUFFOLK COUNTY, N.Y. 1000-31-i8-03 SCALE' 1'--20' FEBRUARY 1, 2005 June 2, ~00§ (B OI H ] / ~ECONIC S~T/~YOR~, (6J1~ 765-5020 FAX P.O. BOX 909 ~79 7 $OdTHOLO, N.Y. 1197~ I 05--11"'° ELIZABETH A. NEVILLE TOWN CLERK REGISTHA~ OF VITAL STATISTICS MARRIAGE OFFICER RECORDS ¥~%NAGEMENT OFFICER FREEDOM OF INFOI~MATION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD APPLICATION FOR PUBLIC ACCESS TO RECORDS INSTRUCTIONS: Please complete Section I of this form and give to Town Clerk's Office (agency Freedom of Information Officer). One copy will be returned to you in response to your request, or as an interim response. SECTION I. · o: (Department or Officer, if known, that has the information you are requesting.) RECORD YOU WISH TO INSPECT: (Describe the record sought. If possible, supply date, file title, tax map number, and any other pertinent information.) Signature of Applicant:~_/~ ~ Prilrlted Name: -7~/~I /~/~U/~ Address: gb~]SC ~'/~C/~JlFffTz~'U~-c~/ X~/L~ //~;~- Mailing Address (if different from above): Telephone Number: ~O~-~ Date: [ ] APPROVED [ ] APPROVED WITH DELAY* [ ] DENIED* E Ii ~be[h-~R~. Freedom of Informat Officer N~AY - 1 20©~ Date $outl~]d * If delayed or denied see reverse side for explanation. N Li 5°0 ~EPTIC SYSTE~ - 3 BeSroom Hse. I- I000 OAL .~PTIC TANK Pele Bt, f~I 97 8'~ ~ 2' deep Lee~ Pools wll~/'~ . ~P* ~ ~l*/l~'l~'.~/~ ~ NOTE, ~ ~ ~ ~ 1~ ~ '~ ~ SUBSURFACE SEWA~ DISPOSAL ~ I~/- ~ ~1-~~ S~T~DES~N , , , ~ ~ ~ ~ } ~ ~ BY JOSEPH FISCHETTI~ P.E. ~_.~ /~% ~ SOUTHOLD, N.Y. 11971 Om f~ilior with the STANDARDS FOR APPROVAL ~~~ ~ ~63H 765 - ~54 N~ C~S~UCEON OF SUBSURFACE SEWAGE ~s~o~ 'ISPOSAL S~MS FOR SINGLE FAMILY RESIDENCES ' ~ , ~ nd will ~fde by the conditions set forth therein ond on the ~ ~ ~ I ermit to construct. Iocot/on of we/Is ond cesspoo/s shown hereon ore field observotions and or from doto obtoined from others. NO TE ' '~ ',,~o I. CONCRETE- 4000psi 2. STEEL 60 ks/ ¢.d- 3. WA TER PROOF THE INSIDE FACE' OF RETAINING 4. STEEL REINFORCING TO BE INSPECTED BY ENGINEER BEFORE PLACEMENT OF CONCRETE. FLOOD ZONE AE (el 9] FIRM 36105C0/77 G SURVEY OF PROPERTY AT EAST MARION TOWN OF SOUTHOLD SUFFOLK COUNTY, N.Y. 1000-31-18--03 ECALE: 1'=~0' FEBRUARY.I, 2005 Jur,~ ~, SO05 tB ot H ) PLANNING BOARD MEMBERS JERILYN B. WOODHOUSE Chair WILLIAM J. CREMERS KENNETH L. EDWARDS MARTIN H. SIDOR GEORGE D. SOLOMON MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971 OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cot. Main Rd. & Youngs Ave.) Southold, NY Telephone: 631 765-1938 Fax: 631 765-3136 PLANNING BOARD OFFICE TOWN OF SOUTHOLD To: Town of Southold Board of Trustees From: Mark Terry, Senior Environmental Planner LWRP Coordinator Date: July 14, 2005 Re: Request for Permit for Roberts Custom Homes SCTM#1000-31-18-03 The proposed action involves the construction of an 22.6' x 14' deck, a 10 x 17.7' one-story addition, a 22.5 x 42.2 second story addition to a existing single family residence, In addition a sanitary system landward of the existing single structure. The parcel is located on Gardiner's Bay in REACH 5. The proposed action has been reviewed to Chapter 95, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is generally CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP provided that the following standard best management practices are implemented. 1. Require water quality protection measures for areas generating nmolT (gutters, downspouts, dry wells and pervious driveways) post construction. Depth to groundwater is 3.4 feet. To further Policy 5 and protect ground water quality and conserve water supply to the greatest extent possible it is requested that the Board require the following best management practices for landscaping and lawn establishment post construction: 1. Require native landscaping to minimize irrigation and avoid fertilizer applications. 2. Require disease-resistant and drought-tolerant plants (where possible). 3. Retain existing vegetation within non-disturbed buffers to minimize lawn areas. 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. Cc: Kieran Corcoran, Assistant Town Attorney Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 153095 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 ~-ctland Permit Application Amendment/Transfer/Extension ¢~' Rece~vved Applicati. o~~"' "Received Fee:$ II/l~'~ ~ompleted Application ~ __Incomplete __SEQKA Classification: Type I Type II Unlisted __Coordination:(date sent)_ · ,,,L'"WRP Consistency Assessment Form ~AC Referral Sent:~ ~ate of Inspection: __Receipt of CAC Report: __Lead Agency Determination:__ Technical Review: Administrative Permit ~-~¢~olic Hearing Held:~:l~L_ Resolution: Name o f Applicant ~ }~'~5 &~.~,b77L Address O~ ~b~ ~ ~~ ~ ehoneNumber:&~ 52/ ~/ Suffolk County T~ Map Nmber: 1000- 31 ~ i 8 ' D D mropeay Location: ~0 ~h ~ ~ ~ ~a (provide LILCO Pole ~, dist~ce to cross s~e~ts, ~d location) (If applicable) Address:k~t:~ ~-~"£i_0~0~7)'~'~ ~. . Phone: ~.7)~- c>~c~[~ )ard of Trustees Applicat GENERAL DATA Land Area (in square feet): Area Zoning: ~ O Previous use of property: ~i 130x\l? Intended use of property: Prior permits/approvals for site improvements: 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 attachments if necessary): r~oQ,/.~' X ! ~-~ ' ~ard of Trustees Applicat COASTAL EROSION APPLICATION DATA No J Yes Does the project involve excavation or filling? t~ No Yes If Yes, how much material will be excavated? ~ How much material will be filled? ~K2Zr- Manner in which material will be removed or deposited: (cubic yards) (cubic yards) Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) )ard of Trustees Applicat WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: (qj~__(4~ 3;1 ~0q- _(~'~ Mea ofwetl~ds on lot: 0 - .square feet Percent coverage of lot: 0 % Closest dist~ce between ne~yst existing structure ~d upl~d edge of wetl~ds: ~ ~ feet Closest dist~ce between newest proposed structure ~d upl~d edge ofwetl~ds: ~ ~ feet Does ~e project involve excavation or filling? ~No Yes If yes, how much matehal will be excavated? ~ cubic y~ds How much material will be filled? ~ cubic ymds Dep~ of which material will be removed or deposited: ~ feet Proposed slope t~oughout the area of operations: ~ f~ which material will be removed or deposited: ~ / M~er in 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): Albert J. Krupski, President James King, Vice~President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-~/ BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTiNG , residing at ['~tx~ being duly sworn, depose and say: That on the t Z- day of .,3/~t ,~, , 2005, Ipersonally posted the property known as by placing the Board of Trustees official poster where it can easily be seen, and that I have checked to be sure the poster has remained in place for eight days prior to the date of the public hearing. Date of hearing noted thereon to be held ~,/Jll~.5 ~t/~/ ~-~O! ~0~}~' ° _. Dated: Sworn to b.~.efore me tj.l.lgs day of~/x.~c/2005 BONNIEL DO.SKI Nota~ Public, S~ No. 01D06095328 Suffolk Term ~ ~ JglI ~. 20~ NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES~ TOWN OF SOUTHOLD In the matter of applicant: SCTM# 1000---3t" l x~~ YOU ARE HEREBY GiVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees ~ propeffy Cw~ic~ ls~uBject ~<f ~nv,ronmental Review ,s located adjacent your property and is described as follows: 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 Southold and does not reference any other agency that might have to review same proposal. OWNERS NAME: ~")b~kl, ~,._~c_~ MAILiNG ADDRESS: . 5~'.'.~"at..d xq-d~.J ..~'t- Enc: Copy of sketch or plan showing proposal for your convenience. PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: 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 ID NUMBER PART 1 - PROJECT INFORMATION 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 1 APPLICANT / SPONE~)R 1 3.PROJECT LOCATION: ~"O Rc bloi '-F Lo_ne Municipality ~.4~1" 4. PRECISE LOCATION: Street Addess and Road Intersec~ons, Prominent landmarks etc -or provide mad IS PROPOSED ACTION: ~ New ~ Expansion ~ Modification/alteration 2. PROJECT NAME DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially [~'~'~ ~ ~,~- acres ~_,~ ~" ~ , Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~Yes [] No If no, describe bdefly; 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) [~] Residential E~ Industrial E~ Commercial [~Agriculture Fi Park / Forest / Open Space E] Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) E~]Yes ~]No If yes, list agency name and permit/approval: il. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? E~]Yes r~No If yes, list agency name and permit / approval: 12, AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/ Sponsor Name ~.~[ 'To'T'~ -- ~-'~ Date: Signature ~ ~,~TM '~ ~.(~ 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 A~ency) A. DOES ACTION EXCEED ANY TYPE ~ THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. [] Yes [] No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative declaration may be superseded by another involved agency. E~Yes [~]No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pa[tern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aestheticl agr cu rural, ~r~haeolog~ical, historicl 0r other natural or cultural resources; or commun iy or n~ighborhood ~harac er? Explain briefly: C3. ' , : : : i: ' ' i : . Vegetation or fauna, fish shellfish or wddllfe spe~;~es s~gmfica~t habitats '~)r threatened or endangered spec~es'~ Explain briefly · commundy' .... s existing plans or goa s as officially adopted, or al change 'm use or : ~mtens~ty of use of_ and or o~[!o her natural resources?. Explain' : :briefly . Long term, short term, cumulative, or other effec s not dentified in C1-C57 Explain briefly: C7. Other impacts (including ch'antes'i'll' Use of e her quantit~ (~r type of ~er~;? Explain briefi D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICA ENVIRONMENTAL AREA ICEAI? f es ex lain briefl · [] Yes [] NO ] ( ¥ ' P I E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If },es explain: 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 (0 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 directly to the FULl EAF and/er 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 Title of Responsible Officer Pdnt or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) Board of Trustees Application County of Suffolk State of New York DEPOSES AND-AFFI~V~S THX~ HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF mS/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. 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. Signature SWORN TO BEFORE ME THIS 0Q ~)/ DAYOF-~[I.~ ,20.05 NotaW P~c BONNIE J. DOW Notmy Public, State rio. 01D0600S228. Suffoa of Trustees A~plicat~ AU~HORIZATTON (where the applicant is not the owner) (print o~ner of property) residing at ~c~ Mt (mailing ~ddress) do hereby authorize ( Agent ) apply for permit(s) from the Southold Board of Town Trustees on my behalf. ~(~her41~gn~/.~ APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics nmhibits conflicts of interest on the t~art of town Officers and emnlovces. The t>uroose of this form is to ~rovide information which can alert the town of ~ossible conflicts of interest and allow it to take whatever action is (Last name~ first nat~e~gaiddle init¥1, unle~s-yo~l ~e applying in the name of someone else or other entity, such as a company. If so, indicate the other pemon'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, marriage, or business intere~ "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 town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or Child is (check all that apply): __A) the owner of greater than 5% of the 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, parmer, or employee of the applicant; or __D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town 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", 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 LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the To~vn 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#/~00-~/-/~ ~t~ - The Application has been submitted to (check appropriate response): Town Board ~-] Planning Dept. [~ Building Dept. [] Board of Trustees Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g. capital construction, 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 l~d use: Present zo~g cl~sification: If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: ~ (b) Mailing address: ~-) (c) Telephone number: Area Code ~0~ I ~)~[ (d) Application number, if any: Will the action be directly tmdertaken, require funding, or approval by a state or federal agency? Yes [] No F-~ If yes, which state or federal agency?. 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. Sec 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 7] 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 Aitach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III - Policies Pages 8 through 16 for evaluation criteria [] Yes [-] No ~] Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III -Policies Pages 16 through 21 for evaluation criteria [] Yes ~ No [] Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. [] Yes ~ No~ Not Applicable 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~7-~ 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. ~-~ Yes ~ No [] Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria. ~ Yes R No ~ Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peeonie Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. [~ Yes ~-] 1No ~ 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 criteria. ~-] Yes ~ No [~ Not Applicable Created on 5/25/05 11.'20 AM