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Home My WebLink AboutTR-7360 Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Bredemeyer Town Hall Annex 54375MainRoad 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 # 0670c Date July 13,2011 THIS CERTIFIES that the reconstruction of existing 713 sf. deck with a 216 sf. addition At 2725 Wells Ave., Southold Suffolk County Tax Map #70-4-16 Conforms to the application for a Trustees Permit heretofore fried in this office Dated 6/30/10.pursuant to which Trustees Wetland Permit #7360 dated 7/21/10 was issued 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 reconstruction of the existing 713 sr. deck with a 216 sr. addition. The certificate is issued to MATTHEW STANTON owner of the_aforesaid property. Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F~ King Dave Bergen John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax (63t) 765-6641 DATE OF INSPECTION: Ch. 275 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1st day of construction ~ constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (63 I) 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 PERM}T NO. 7360 DATE: JULY 2I~ 20~0 ISSUED TO: MATTHEW STANTON PROPERTY ADDRESS: 2725 WELLS AVENUE~ SOUTHOLD SCTM# 70-4-16 AUTHORIZATION Pursuant to the provisions of Chapter 275 and/or Chapter 111 of the Tqwn Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted/~t the thgeting held on July 21. 20!0, and in consideration of application fee in the sum of $250.00 paid by Matthew Stanton and subj~ect tothe Terms and Conditions as stated in the Resolution, the Southold Town Board of TruStees authorizes and permits the following: Wetland Permit to rebuild and construct an addition to the existing dec~ attached t° the dwelling; and as depicted On the site Plan prepared bY Kenneth Babits, Architect, last dated June 28, 2010, and stamped approved on Au~st 9, 2010. 1N 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. -~o~n Br;den~ TERMS AND CONDITIONS The Permittee Matthew Stanton, residing at 2725 Wells Avenue, Southold, New York as part of the consideration for the issuance of the Permit does understand and prescribe to the following: That the said Board of Trustees and the 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 fight of the public to pass and repass along the beach between high and Iow water marks. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work her6in 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 her6in stated without expenses to the Town of Southold. That the said Board will be notified by the Permittee of thc completion of the work authorized. That the Permittee will obtain all other permits and consents that may be required supplemental to this pelmit, which may be subject to revoke upon failure to obtain same. Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Brederneyer Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 July 21, 2010 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Vincent LaBate 8 Begonia Road Rocky Point, NY 11778 RE: MATTHEW STANTON 2725 WELLS AVENUE, SOUTHOLD SCTM# 70-4-16 Dear Mr. LaBate: The Board of Town Trustees took the following action dudng its regular meeting held on Wednesday, July 21, 2010 regarding the above matter: WHEREAS, Vincent LaBate on behalf of MATTHEW STANTON 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 June 30, 2010, 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 Public Hearing was held by the Town Trustees with respect to said application on July 21, 2010, 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 MATTHEW STANTON to rebuild and construct an addition to the existing deck attached to the dwelling; and as depicted on the site plan prepared by Kenneth Babits, Architect, last dated June 28, 2010, and stamped approved on August 9, 2010. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of $50.00 per inspection. (See attached schedule.) Fees: $50.00 Very truly yours, President, Board of Trustees JMD/eac Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Rd. P.O. Box 1179 $outhold, NY 11971 Telephone (63 I) 765-1892 Fax (631) 765-6641 I0/ I~ Please be advised that your application dated -,,~GII~ ~X:)/ (27010 has been reviewed by this Board at the regular meeting of ~v4v, o~1; 03910 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) __ ½ Constructed ($50.00) v/' 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: Jill M. Doherty, President Board of Trustees Peter Young, 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., July 14, 2010, the following recommendation was made: Moved by Doug Hardy, seconded by Jack McGreevy, it was RESOLVED to SUPPORT the Wetland Permit application of MATTHEW STANTON to rebuild and construct an addition to the existing deck attached to the dwelling. Located: 2725 Wells Ave., Southold. SCTM#70-4-16 Inspected by: Doug Hardy The CAC Supports the application with the Condition there is no turf underneath the deck. Vote of Council: Ayes: All Motion Carried Jill M Doherty, President James F King~ Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer 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: MATTHEW STANTON requests a Wetland Permit to rebuild and construct an addition to the existing deck attached to the dwelling. Located: 2725 Wells Ave., Southold. SCTM#70-4-16 T~rea to be impacted: ter Wetland Freshwater Wetland Sound Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: ~pt.275 Chapt. 111 __other Type of Application: C..-.-~etland __Coastal Erosion __Amendment __Administrative__Emergency Pre-Submission __Violation Info needed: Modifications: Conditions: B.Ghosio, D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: Date: OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, N-Y 11971 MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971 Telephone: 631 765-1938 Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Jill Doherty, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: July 19, 2010 Re: Proposed Wetland Permit for MATTHEW STANTON SCTM#70-4-16 Vincent LaBate on behalf of MATTHEW STANTON requests a Wetland Permit to rebuild and construct an addition to the existing deck attached to the dwelling. Located: 2725 Wells Ave., Southold. SCTM#70-4-16 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT from LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 Telephone (631 ) 765-1892 Fax (63 [ ) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application ZWetland Permit Application __ Administrative Permit Amendment/Transfer/Extension ~Rece~ved Application:~_ ~'-Received Fee:$ c;~':::Z) ~"f2ompleted Application Incomplete SEQRA Classification: Type I Type II Unlisted__ Coordination:(date sent) - ~LWRP Consistency Ass~m~ J CAC Referral Sent:~]~=~ c,~Date o f Inspection:~j[l~ !1 ~ Receipt of CAC ReT" Lead Agency Determination: Technical Review: x.k~hblic Hearing Held: ~ Resolution: Name of Applicant Address Suffolk County Tax Map Number: 1000 - ~'~ ~,) -~ Property Location: ~-7~"' ~:~//~' (provide LILCO Pole #, distance to cross streets, and location) (If applicable) ~)~ I I ~)'-) t~ Phone: ! ~d of Trustees Appllcatio0 GENERAL DATA Previous use of property: Intended use of property: Covenants and Restrictions: Area (in square feet): ,s-6~ Area Zoning: ?- 4/~ Yes If "Yes", please provide copy. Does this project require a variance from the Zoning Board of Appeals tf "Yes", please provide copy of decision. Yes ~No Prior permits/approvals for site improvements: Agengy. __ No prior permits/approvals for site improvements. / Has any permit/approval ever been revoked or susp~nd~x~b..y a gOVevWental If yes, provide explanation: agency?. Project DescriPfion (use attachments ifnecessary): ~z~/.t~x~' 7~ '¢'-"-t, pc_ox,,,//: ~. ~,< ~ _/?,,~/4 ox,_/~ ~4.. ~,~ '¢' ~:- Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: /~c~///~.) /~ EX..c//,~ ~ Area of wetlands on lot: ~,oc~. ~ square feet Percent coverage of lot: /~, ~ % Closest distance between nearest existing structure and upland -~/ edge of wetlands: {,,~ feet Closest distance between nearest proposed structure and upland edge ofwetlands: ~ ' feet Does the p~gject involve excavation or filling? ,/ v No Yes If yes, how much material will be excavated? How much material will be filled? t~ cubic yards cubic yards Depth of which material will be removed or deposited: Proposed slope tl~ou~out M~er 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): Vd of Trustees Applicatio~ COASTAL EROSION APPLICATION DATA Purposes of proposed activity: ~ Are wetl~ds present ~thin 100 feet of the proposed activin? No ~Yes Does ~roject ~volve excavation or filling? ~ No Yes If Yes, how much mater Mll be excavated? How much material will be filled? ~) ~ ~ M~ 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) PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 3.PROJECT LOCATION: Municipality ,~ -) ~. .~ t,,,..~ /I/.-.¢ 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 SEQR 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map 5. iS PROPOSED ACTION: ~ New ~xpansion ~Modifi.Uon/altaraUo, 7, AMOUNT OF LAND AFFECT : Initially ~)~_~ acres ~'~,~ Ultimately ¢~v/~ acres 0 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? r-~Yes [] No If no, describe briefly: ReAT IS PRESENT LAND USE iN VICINITY OF PROJECT? (Choose as many asapply.) sidential r---]Industrial r~commercial r-'~Agriculture r--] park / Forest / Open Space r---~Other (describe) DOE ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL E~9(Federal. State or Local) ~Y'es ~-]No If yes, list agency name and permit / approval: 11. DOES ANY~JY~.~SPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [~Yes r~No if yes, list agency name and permit / approval: 12. AS A RESr.~OF [~'es I'q No I CERTIFy/THAT TF~ INFORMATION PROVID.~ED ABOVE IS TRUE.~TO THF~EST OF .-: // PROPOSED ACTION WILL EXiSTiNG PERMIT/ APPROVAL REQUIRE MODIFICATION? MY KNOWLEDGE Date: ~/.,~///~ I ~'~ ~ Z/ 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 TI-IRESHOLD IN 6 NYCRR. PART 617.47 If yes, ccordtnate the review procass and use the FULL EAF. I-I 171"o B. WILL ACTION RECEIVE COORDINATED REVlEVVAS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative I--iv,, C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwdtMfl, if legllfle) C1~ Existing ak quaity, su~ase or groundwater quality o~ quantity. ~ leVels, ex,ting traffic pa#em, solid waste production or dlslx~al, pofen~d for erosion, drainage or flooding probtems? Explain · Aesifle~c, agdculturol, archaeological, historic, or other natural or cu#ural re~oumas; or comnlunfly ~' neighborhor~l charaster? Explain brfl~lly: C3. V~a~,;=[;~, o~ fauna, fish. shellfish or wildlife species, significant habltete, or threatum~d or endangered species? Explain briefly:. C_~. G~a, 8UbMlqcant do~lolx~nt, or ml~t~l e~ffi~ll~ §l~llt to be indesed I~ tho ~opo~d aefl~? F~,~a!~ I~: CO. Long term. sh~rt term, c~mulaflve, or other effects not identified in C1.C57 Explain briefly: I"° C7. iOther ~,T, pac~,(tecludin~ ch~ in use of eib~r quanti~/or t'fpe of eseq]],'? Explain bdefl~ D. ~AILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITIC, At ENVIRONMENTAL AREA (CEA)? (If yes. explain briefly,: I--'lYes E. 18 THERE, OR IS THERE UKELY TO BE~ CONTROVERSY RELATED TO'poTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If ~es ~v?e!~: PART Iii - Dc ~ cRMINAllON OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadvemee~ectidenti~adabeve~determ~new~etheritlesubstan~a~arge~impa~tant~r~s~n~nL Each effect should be assessed in connection with its (a) setting (i.e. Urban or rural); (b) probability of occurring; (c) duration; (d) Irrevemibility; (e) geographic scope; and (0 magnitude. If necsesa~y, add attachments or reference suppa~ng matadals. Ensure that exptenations contain suftictent detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the detennlnatio~ of significonce must evaluate the potential impact ofthepropceed ac~on off the environmental characteristics of the CEA Checkiftis box if you have tdentlflad one or mom pofentislly large or Mgnifisast adverse impacts which MAy occur. Titen pfo~ed directly to the FUU EAF and/or prepare a positive dectemtlon. Ch* t ed< this box ff you have determined, based on the informaben and analysis above and any supporling documentation, that the proposed astisf WILL NOT result In any significant adverse environmental Impaols AND pro~dde, on attachments as necassa~/, the maasfls supporting doforminofis~. Board of Trustees Name of Lead Agency Jill M. Doherty I Print or Type Name of Responsible Officer in Lead Agency Date President Title of Responsible Officer Signature of Preparer (If different from responsible officer) Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 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 MATTHEW STANTON COUNTY OF SUFFOLK) STATE OF NEW YORK) I, . ~ i~ ~ AFFIDAVIT OF POSTING/// /,o//~ ~ ~-/~/J ~t~ ~ ~ffvesiding at/dba ~/;)~ ~_~/'~ being duly sworn, depose and say: That on the/fl- day of ,-~/c/ ,2010, 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 prior to the date of the public hearing. Date of hearing noted thereon to be held Wed., July 21~ 2010 on or about 6:00 PM. Dated: ~,,~/d,/~ ,~?~/~ ....~//~ / (sign~ature) Swom to before me this day of, Ja~--300 &ol o Notary~ublic ' '- MARGARET I.ABATE Notary PubliC, State of New York No. 4689422 Qualified in Suffotk County Commission Expires July 31, 20 ~ PROOF OF MAll ,lNG OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS [] Addressee Date of Delivew ~17 I-lyes · degvep] addreae below: [] No ~Retam Rece/pt ll3r Me~chmxflse [] C.O.D, 3580 9511 Vme~f L~ ,~id~gat o , ~'~' . , berg duly swo~ d~ses ~d sa~ ~at on ~e [ A~ ~Y of ~ ~[~ ,20 ~ 0, d~on~t m~l~ a ~e ~py of ~e Notice s~ fo~. ~ ~e Bo~ of T~tees Applieafio~ ~t~ to e~h of ~e above n~ed p~o~ at ~e ~s~ set opposite ~e r~five ~; ~at ~e ~esses set op~site ~e n~es of s~d p~o~ ~ ~e ad~e~ of s~d p~ ~ sho~ on ~e c~ent ~s~sm~t roll of~e To~ of Sou~old; ~t s~d Nofic~ w~ m~l~ at ~e United States Post ~ , ~at s~d Notices w~e m~l~ to~h~f s~id pe~ons by Office at ~h~C~ ~,~], Sworn to before me this Dayof T~I~ ,20 MARGARET LABATE Notery Public, State of New York No, 4,qa9422 Ouallfied ia Suffolk Cou.~,w ,, ~. Commission Expires July 31, ~..;~ I ':~ Cour~T of Su~If~k ~r ~kD ~ ~ ~ ~GD~YSWO~ D~S ~ ~ ~T ~ IS ~ ~ ~OR ~ ~O~ D~s~ED p~T(S) ~ ~T ~L STA~S C0~~D ~ ~ ~ WO~ ~ TO ~ BEST OF ~ ~O~ ~ B~, ~ ~T MAY ~L BE DO~ ~ ~ ~ SET FOR~.~ ~S ~P~CA~ON ~ ~ BE ~PRO~ BY ~ ~O~ TO~ BO~ O~ ~US~S. ~ ~PLIC~ AGeS TO HOLD T~ TO~ OF so~O~ ~ ~ TO~ ~US~S ~PLICA~ON, I ~Y AU~O~ ~ ~US~S, ~ AG~(S) OR ~P~S~ATI~$~ TO ~ O~O ~ PRO~ TO ~SPE~ T~ P~SES ~ Co~ON WI'I fl ~W OF ~S ~ICA~ON. SWOICN TO BEFORI~ ME TI-ES__~ ?-~ Not~ry Publi~ AU.~-~ZATIoN (wh~r~ the applicant i~ not the owner) to a~!~ly for p~it(s) Southol~l ~oard of Town T=uste~s on ~ b~half. (Owne=' s si~na=u~e ~ APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics orohibits conflicts of interest on the hart of Wwn officers and emolovees. The nuroose of this form is to nmvide in formation~hich can alefft the town of nossible conflicts of intereSt and allow it to take whatever action is ,' , (Last name, mst name ~niddle in'tiat, y app y'ng' someone else or other en6ty, such as a eompeny. If so, indieat~ the other person's or company's name.) NAME OF APPLICATION: (Check all ~at 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 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 applicantYagentJrepresentative) 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 (cheek all that apply): __.A) the owner of greater than 5% of the shams of the corporate steek of the applicant (when the applicant is a corporation); __.B) the legal or beneficial own~ 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 ~.day of Signature Print Name 200/~ W'd~ ~is APPlication Require Land D~turbJn9 Ac~ Enoompassing an Ar% in ~ ~ Fi,Y, Thousand (6,000) ~quare Is ~lare into ~ (Th~ i~m will H~ ~¢lude ~e InsUlin ~ DH~ ~'l ~ PmJe~ Require ~te ~pam,~ ~ ~e ~, ~,~ (1~) Year F~ ~.eny Wa~? E AnY An~er {e Qu~lo~s One ~eugh Niae ts ~s~ ~ a C~ ~ in ~e B~.. & E~ Coati P~n EXEMPTION: Yes No Does ~ pro~c~ meet the mini,mum standards for classification aG en AgricutturaJ Proje~ N0~e: If YOU A~wer~d Ye~ to b~ls Quaatlo~, e ~ltom~Water, C~dlflg, Drainage A'Eru~n ContrM plan I~ NOT IR~q~ STATE OF NEW YORK, ~ C~O1 ~ ...................................... (~er, ~,~ ~r, ~) mats~m to ~ me ~;mc ~ ~ ~ ~cd ~ ~e m~ner set fo~ in ~e app/ic~6~ fded he~, ~ ///. FO~ - ~7 o,, ~_ ,..,~. =:..-.~ c,~ Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M. #: District Section B L~t THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM-WATER~ GRADING~ DRAINAGE AND EROSION CONTROL PLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK, Item Number: (NOTE: A Check Mark (~) for each Question is Required for a Complete Application) 1 Will this Project Retain All Storm-Water Run-Off Generated by a Two (2") inch Rainfall on Site? Yes No 2 3 4 5 6 7 8 (This item will include all run-off created by site clearing and/or construction acfivfties as well as ali Site Improvements and the permanent creation of impervious surfaces.) Does the Site Plan and/or Survey Show All Proposed Drainage Structures Indicating Size & Location? This Item shall include all Proposed Grade Changes and Slopes Conbolling Surface WaterFIow! Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Natural Existing Grade Involving more than 200 Cubic Yards of Matedal within any Parcel? Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five Thousand (5,000) Square Feet of Ground Surface? Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction or within One Hundred {100') feet of a Wetland or Beach? Will there be Site preparation on Existing Grade Slopes which Exceed Fifteen (15) feet of Vertical Rise to One Hundred (100') of Horizontal Distance? Will Driveways, Parking Areas or other Impervious Surfaces be Sloped to Direct Storm-Water Run-Off into and/or in the direction of a Town right-of-way? Will this Project Require the Placement of Material, Removal of Vegetation and/or the Construction of any Item Within the Town Right-of-Way or Road Shoulder Area? (This item will NOT include the Installation of Driveway Aprons.) Will this Project Require Site Preparation within the One Hundred (100) Year Floodplain of any Walercourse? O NOTE: if Any Answer to Questions One through Nine is Answered with a Check Mark in the Box, a Storm-Water, Grading, Drainage & Erosion Control Plan Is Required and Must be Submitted for Review Prior to Issuance of Any Building Permlfl EXEMPTION: Yes Does this project meet the minimum standards for classification as an Agricultural Project? Note: ff You Answered Yes to this Question, a Storm.Water, Grading, Drainage &'Ereslon Control ptan is NOT Requlredl STATE OF NEW YORK, ~COUNTY OF ...~..'..~...~..~. J.}.}~ SS s ,s {Name of indiv~ual signing ~u~nt) ~d ~at h~she is ~e ........................... ....................................................... O~er an&or representative of ~e ~er of O~er's, ired is duly au~orized m perform or have ~ffonned fl~e smd work ~d to m~e ~d file ~s application; ~lat MI smtemenB conmh~ed in ~is application am true m ~e best of his ~owle~e and belief; ;md · at ~e work Mil be performed in ~e manner set for~ in ~e application filed herem~. Sworn m before me tiffs; ........................ ~. .......... day of ......~.~ ..................... 20./~ FORM - 06/07 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.ne0, the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION PROJECT NAME ~'~ ~"~ The Application has been submitted to (check appropriate response): j Town Board [] Planning Board ~ Building Dept. ~ Board of Trustees 1. 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 ~xansaction) (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 }tc~on has be~ filed with the Town of Southold agency, the following information shall be provided: / / . //_ a Nameofa heart () pp' t: (c) Telephone number: Area Code ((3/ ? fi/& ~ J'~/ff~ (d) Application number, if any: Will the action be ,~ectly 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. ~Not ~-~¥es ~-~ No 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 visuaJ/quality and protect scenic resources, throughout the Town of Southold. See LWRP Section III - Polfi6ies Pages 6 through 7 for evaluation criteria [-] Yes ~'] No M Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. Sec LWRP Section III - Policies Pag~gs 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~t22 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. Sec LWRP Section III - Policies; Pages 22 through 32 for cvaluati/on criteria. Yes No ~ot App~le 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 f~valuation 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 Ill - 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 iocations~LWRP Section IH- 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 Peconic Estuary and Tow~ers. See.LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. [~ Yes [-~ No I I Not Apphcable 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~,uation e.n.'teria. ~'~ Yes [--] No 1/___1 Not Appheable Attach additional sheets if necessary Policy 13. Promote appropriate use and developmeut of energy and mineral resources. See LWRP Section III - Polie~ges 65 i. hrough 68 for evaluation criteria. ~-] Yes [] No [ '~ ] Not Appheable PREPARED BY KENNETH BABITS-ARCHITECT 127 CAROLINE AVENUE PORT JEFFERSON, N.Y. 11777 631-331-1798 N fllOI~ 6g° 00' S SURVEY OF PROPERTY A T SOUTHOLD TOWN OF SOUTHOLD SUFFOLK COUNTY, N.Y.' 1000 =04307 16 Sc-aleT07,,- Dec. 20, 7990 June 28, 1991(found. loc.) ~iGKeoLO \ cHRIS TINE · oAKLA WN 80° 34' 00" V~/ o.~'s A. w~$EMANN AREA = 23,965 sq. ft. Prepared in accordance with the minimum standards for title surveys as estabfiahed bfYomthe L.I.A.L.S. and approved and adopted such uae b)~ The New York State Land Title Aa$ocist~o~ KS LIC NO PECOI~T~=~J~VEYORS, P.C. (516) 765 ~ 5020 P.O. BOX 909 MAIN ROAD 49678 APPROVED BY -- LOAP, D OF TRU3T~ES ,,J~N OF SOUTHOLD i '1