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HomeMy WebLinkAboutTR-7395 James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino 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 September 19, 2012 Mr. Alex Hillenbrand PO Box 1265 Cutchogue, NY 11935 RE: ALEX HILLENBRAND 50 LUPTON'S POINT ROAD, MATTITUCK SCTM# 115-11-23 Dear Mr. Hillenbrand: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, September 19, 2012: RESOLVED that the Southold Town Board of Trustees grants a One-Year Extension to Wetland Permit #7395, as issued on September 22, 2010. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, King President, Board of Trustees JFK:amn 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 (631 ) 765 - 1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction ½ constructed V//Project complete, compliance inspection. BOARD OF SOUTHOLD TOWN TRUSTEES SOUTHOLD, NEW YORK PERMIT NO. 7395 DATE: SEPTEMBER 22~ 2010 ISSUED TO: ALEX HILLENBRAND PROPERTY ADDRESS: 50 LUPTON'S POINT ROAD~ MATTITUCK SCTM# 115-11-23 AUTHORIZATION Pursuant to the provisions of Chapter 275 and/or Chapter 111 of the Town Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted at th~ meeting held on September 22, 2010, and in consideration of application fee in the stun of $250.00 paid by Alex Hillenbrand and subject to the Terms and Conditions as slated in the Resolution, the Southold Town Board of Trustees authorizes and permits the following: Wetland Permit to install a retaining wall adjacent to the house and renovate wetland plantings to native species; and as depicted on the site plan prepared by Creative Environmental Design, received on August 31, 2010, and stamped approved on September 22, 2010. IN WITNESS WHEREOF, the said Board of Trustees hereby causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date. TERMS AND CONDITIONS The Permittee Alex Hillenbrand, residing at 50 Lupton's Point Road, Mattituck, 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 right of the public to pass and repass along the beach between high and low water marks. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstruction to free navigation, the said Permittee will be required, upon due notice, to remove or alter this work project herein stated without expenses to the Town of Southold. That the said Board will be notified by the Permittee of the completion of the work authorized. That the Permittee will obtain all other permits and consents that may be required supplemental to this permit, which may be subject to revoke upon failure to obtain same. Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 September 22, 2010 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. David Cichanowicz Creative Environmental Design P.O. Box 160 Peconic, NY 11958 RE: ALEX HILLENBRAND 50 LUPTON'S POINT ROAD, MATTITUCK SCTM# 115-1%23 Dear Mr. Cichanowicz: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, September 22, 2010 regarding the above matter: WHEREAS, Creative Environmental Design on behalf of ALEX HILLENBRAND 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 August 31,2010, 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 Headng was held by the Town Trustees with respect to said application on September 22, 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 wi~h 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 ALEX HILLENBRAND to install a retaining wall adjacent to the house and renovate wetland plantings to native species; and as depicted on the site plan prepared by Creative Environmental Design, received on August 31, 2010, and stamped approved on September 22, 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, Jill ~.'Doherty ~ President, Board of Trustees JMD/eac 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 (631 ) 765 - 1892 Fax (631 ) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated/gJ'Ctc~Lc.q], c:~O/O has been reviewed by this Board at the regular meeting o~,~7~?, ¢,~o/O 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) __ Ist Day of Construction ($50.00) __ ¼ Constructed ($50.00) y'/" 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 Southotd 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 abc~ve. 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., September 15, 2010, the following recommendation was made: Moved by Jack McGreevy, seconded by Doug Hardy, it was RESOLVED to NOT SUPPORT the Wetland Permit application of ALEX HILLENBRAND to install a retaining wall adjacent to the house and renovate wetland plantings to native species. Located: 50 Lupton's Point Rd., Mattituck. SCTM#115-11-23 Inspected by: Audrey Horton, Jack McGreevy The CAC does Not Support the application because the project was not staked and there is a serious drainage condition coming from the dwelling. There is also a road run-off condition that should be corrected by the Town. 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 I 179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631) 765-6641 Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: ALEX HILLENBRAND requests a Wetland Permit to install a retaining wall adjacent to the house and renovate wetland plantings to native species. Located: 50 Lupton's Point Rd., Mattituck. SCTM#115-11-23 Type/of area to be impacted: · ~altwater Wetland Freshwater Wetland Sound Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: __Chapt.275 Chapt. 111 other Type of Application: t-'~Wetland __Coastal Erosion __Administrative__Emergency Pre-Submission __ .__Amendment Violation Info needed: Conditions: Present Were: ¢/J.King __J.Doherty__J. Bredemeyer B.Ghosio,_ D. Dzenkowski other Form filled out in the field by D. Bergen__ Mailed/Faxed to: Date: OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY 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: From: Date: Re: Jill Doherty, President Town of Southold Board of Trustees Mark Terry, Principal Planner LWRP Coordinator September 16, 2010 Proposed Wetland Permit for ALEX HILLENBRAND SCTM# 1000-115-11-23 SE? 2 1 LSog, fhhold Town , , Boerd_~o~TLustees ALEX HILLENBRAND requests a Wetland Permit to install a retaining wall adjacent to the house and renovate wetland plantings to native species. Located: 50 Lupton's Point Rd. Mattituck. SCTM#115-11- 23 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 with the denoted following Policy Standards and therefore is CONSISTENT with the 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 (631) 765-664I BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only ~7,Cwoastal Erosion Permit Application etland Permit Application Administrative Permit RR Amendment/Trans fer/F~tension ece~vved Application: ~]~//r'O eceived Fee:~ .! ~ Completed Application~.~L Incomplete SEQRA Classification: Type I Type I1 Unlisted__ Coordination:(date sent) ./'~WRP Consistency Ass~essment Form ~ 10--I [13 ,.~AC Referral Sent: q~,~\~ -'"~ate of Inspection: qli~10 Receipt of CAC Report: Lead Agency Determination: Technical Review: .l~fl~lic Hearing Held: 6~[ i21,~ ~,O Resolution: Name of Applicant Address Phone Number:(t~l) 7~,q,~ - /~/,~ Suffolk CountyTax Map Number: 1000- Property Location: .-~) ~ot91LOt'~oi(l-~ (provide LILCO Pole ~, dist~ce to cross streets, ~d location) (If applicable)~~W ~ ~1~~ Address: ~d of Trustees Applicatio~ Land Area (in square feet): Area Zoning: c~C--~ , Previous use of property: ~ Intended use of property: Covenants and Restrictions: Yes If "Yes", please provide copy. GENERAL DATA Does this project require a variance from the Zoning Board of Appeals __ If "Yes", please provide copy of decision. Prior permits/approvals for site improvements: Agency Date Yes L~No *'/No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspend~126y a governmental agency? x./No Yes If yes, provide explanation: Project Description (use attachments if necessary): of Trustees Applicati~ WETLAND/TRUSTEE LANDS APPLICATION DATA Pmposeoftheproposedoperations: I~q-~t~ ~7-~,~J~O L~kL~ % Area of wetlands on lot: ~l~-~)~) square feet Percent coverage of lot: '40 % Closest distance between nearest existing structure and upland edge of wetlands: ~ 0 feet Closest distance between nearest proposed structure and upland edge of wetlands: [ 2- feet Does the project involve excavation or filling? No / Yes If yes, how much material will be excavated? I C) cubic yards How much material will be filled? ~.~ O cubic yards Depth of which material will be removed or deposited: ,~ feet Proposed slope throughout the area of operations: ~ ; Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): Vd of Trustees Applicatio0 COASTAL EROSION APPLICATION DATA Purposes of proposed activity: J,J,,-,o 'C..--¢.bs., ye Are wetlands present within 100 feet of the proposed activity? No /Yes Does the project involve excavation or filling? No ~Yes If Yes, how much material will be excavated? I 0 .(cubic yards) How much material will be filled? (cubic yards) Manner in which material will be removed or deposited: 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 DART 1 - PROJECT INFORMATION lt.J~ICAN_T / SPONSOR - 3.PROJECT LOCATION: 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. PRO ME t County 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map 5. IS PROPOSED ACTION: [] New [] Expansion [~4(~diflcation / alteration SEQR 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially ~,0~ acres Ultimately . O¢ 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING [~Yes [] No If no, describe briefly: acres OR OTHER RESTRICTIONS? lS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) dential ["--~[ndustrial []Commercial r-~Agriculture r-]Park/Forest/OpenSpace [~]Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal.~ate or Local) E~Yes I i~r~lo if yes, list agency name and permit/ approval: 11. DOES ANY~YASP~ASP CT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ]Yes [~ If yes, list agency name and permit / approval: RES 12.~YesAS A ~ OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? CERTIFY THAT THE INFORMATION PROVI~DED ABOVE IS TRUE TO THE BEST-OF MY KNOWLEDGE Applic~~t~--~L'~,k-~l~' ~''/~E ~'~J~ ~)-~'-~'~' Date: rea, and you a re a state agency, complete the Coastal Assessment Form before proceeding with this assessment PARTII- IMPACTA$SESSMENT obecom letedb LeadA en · B de~~TiONSiN6NYCRR, p/~T617.67. IfNo, anega6ve C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS Ae ...... '~'-"-~. -.~ -ws, ~,~,.u .amc pat~am, ~o#d wa~e ) 04. No ~tl No D. ~1~. R'I'~o~E p._.~i./~LC~T HAVE AN iMPACT ON THE ENVIRONMENTAL CHARACTERISTICS ....... L~ Yes [] No , tv,,. ~,Ru~ED THE ESTABLISHMENt' OF A J__lll U. Doherty . / P. dnt °r Type Nam,~.,~f R~;.Pu.aible/(~cer in Lead Agency ~ S/gnature o~R'espo~s/ble in Lead Agency P~resldent Date Title of Responsible Officer Signature of reparer mN respo o r) Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATtON: S.C.T.M. #: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A f~'l'~(~) //~" /t/ ~ ~ STORM-WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN District Section Block Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YOR~. SCOPE OF WORK - PROPOSED CONSTRUCTION l'l'.l~l # / WORK ~SF_,,SSM.F_2qT Yes No a. What is the Total Area of the Project Parcels? / --/ 1 Will this Project Retain All Storm-Water Run-Off (~nclude Total Area of all Parcels located within 23~,~,,/__~'~' Generated by a Two (2") inch Rainfall on Site? the Scope of Work for Proposed Construction) (This item will include all mn-off created by site b, What is the Total Area of Land Clea6ng/ cleedng and/or construction activities as well as all Disturbance for the proposed ~O / ~ Site improvements and the permanent creation of and/or Ground construction activity?/ ·vi impervious surfaces,) tS.F, I AC~eS) 2 Does the Site Plan and/or Survey Show AJI Proposed pRO~,rJ~E BIUT~F PROJECT D[SCEIPT[ON {prov~d, ~dd~ p~.. N.e~.a) Drainage Structures indicating Size & Location? This Item shall include all Proposed Grade Changes and j~k,J,~l-3q't.,L ~--L~'~'?r-tf.,J k/~([,~t P---~'~c'~'~c~..- Slopes Controlling Surface Water FIow. 3 Dees the Site Plan and/or Survey describe the erosion and sediment control practices that will be used to cee~ol site erosion and storm water discharges. This -- ~---~,t/'~--~ '~,~c~I"~/,V~] ~ /tam must be maintained throughout the Entire Construction Period. , o¢C 4 Will this Project Require any Land Filling, Gradingor r---'l Excavation where there is a change to the Natural I ! Existing Grade Involving more than 200 Cubic Yards of Material within any Parcel? 5 W/Ii this Application Require Land Disturbing Activities ~ Encompassing an Area in Excess of Five Thousand~ __ (5,000 S.F.) Square Feet of Ground Surface? 6 Is there a Natural Water Course Running through the Site? Is this project within the Trustees jurisdic0on~ General DEC SWPPP Requirements: or within One Hundred (100') feet of a Wetland or Submission el a SWPPP is required f~' all Constmcben activities in'.~ving soil Beach? ; disturbances of one (1) or more acres; including disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes are par1 of a larger common plan that will ultimately disturb one or more acres of land; which Exceed Fifteen (15) feet of Vertical Rise to~ including Construction act~vilies invoNing soil disturbances of less than one (1) acm where One Hundred (100') of Horizontal Distance? -- Ihe DEC has determined that a SPDES permit is required for storm water discharges. SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit 8 Will Driveways, Parking Areas or other impervious [~ tar Stom~ Water DJ$cberges from Construction acBvlty - Pemfit No. GP-0-10-00t.) Surfaces be Sloped to Direct Storm-Water Run*Off 1. The SWPPP shell be prepared pdor to the submittal of the NOI. The NOI shall be into and/or in the direction of a Town fight-of-way?~ -- 2. The SWPPP shall describe the erosion and sediment control practices end where 9 Will this Project Require the Placement of Matadal. STATE OF NEW YOI1K, ~ COUNTY OF ........................................... SS That I' ,.~\d, (,~t ..~.....~...~(?:._<ff.{..C.'.~. be ng au y swbm, deposes and says that he/she is the applicant for Pernfit And that he/she is the ...................... 1~,~.1~1....I......: .................................................................................................................. Owner anffor representative of the Owner or Owners, and is duly authorized to perform c~U~i'~, ~'gI~qtaie said work and to make and nte this apphcat~on; that all statements contmned m thts apphcat~on are true tt~ll~,il~g}~gY$ hnd beheh and that the work will be performed in the manner set ford~ in fl)e applica~on filed herewifl). Sworn to before me riffs; ~ ~.~.~0mm~ AI:~I tL zOjZ~. } . .q~ / ........ day of ....(JJ.d-.~.. .......................... 20(~. ~ X / /- ~ ~ =ORM - 06/10 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 ALEX HILLENBRAND COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING , residing at/dba being duly sworn, depose and say: That on the/~/day of .~-4)4~F , 2010, I personallyLposted the property known as __ by placing the Board of Trustees official poster where it can ~asily be seen, and that I h~[ checked to be sure the poster has remained in place for ei~t days prior to the date of the public hearing. Date of heating noted thereon to be held Wed.~ September 22~ 2010 on or about 6:00 PM. Dated: ql ql Sworn to before me this [~ day of~ff¢"20~O Not~y Public/ Jeanne Sweet Bartos NOTARY PUBLIC, State of New York No. 018A6210083 Qualified in $~olk County Commission Expires August 10, 20_~ PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Address: n r-~ r~ $0,00 Postmark being duly sworn, d~oses and says that on the / c/ 20 lQ, deponent mailed a true copy of the Notice set forth, in the Board ~ 'Trustees Application, directed to each oft. he above named persons at the addresses set opposite there respective names; that the addresses set opposite thc names of said persons arc the address of said persons as shown on the current assessment roll of thc Town of Southold; that said Notices wcrc mailed at the United States Post Officeat pecD[I)'c, I~? ,thatsaidN°ficeswcremailedt°each°fsaidpers°nsby Sworn to before me this~ Day of / N~ry Public WENDY L. KUKLA Notary Public, State of New York; No. 01 KU6176871 Qualified in Suffolk County Commission Expires 11/0512011 Board of Trustees Applic~on County of Suffolk State of New York 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 I~S/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~P~ ,L}CAT4ON. SWORN TO BEFORE ME THIS DAY OF ~ W ,20 /0 "-~&ary Public LAUREN M. STANDISH Notaw .~blic, State of New York fro. 015T6164008 _ Qualified n Suffo k County Commission Exoi~ Ap.I 9, 20_j~ AUTHORI ZA'r£ON (where the applicant is not the owner) (~p~r i~n ~ ~le~-c~ residing at t owner of property) (mailing address) C~~. ~q !~.~ do hereby authorize ( Agent ) --~~O'~C~Q~~~,~ to apply for permit(s) from the Southold Board of Town Trustees on my behalf. ( Owner ' s signature ) APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM Thc Town of Southold's Code of Ethics nmhibits conflicts of interest on the oart of town officers and emnlovees. The ourvosc of this form is to orovide information which can alert lhe town of ~ossible conflicts of interest and allow it to rake whatever action is ne toa old me. (Last name, ~ name, ~aiddle initial, unle~ you are applyh~ in the nan~e of someone aisc or other entity, such as a company. If so, indicate, tbe other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relatinnship" includes by blood, marriage, or bu~icess 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 coq)oration in which the town officer or employee owns more than 5% of the shares. NO YES 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 spo?e, 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 applie0nt (when the applicant is a corporation); __B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a corporation); C) an officer, director, partner, or employee of the applicant; or D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I S u b mit t e ~a~.~.~ay ~ O'T 20~O $ ignat ure~ ~c_~...~~.~.~~ PrintName ~--~.~ ~ ~' T. own 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 Waterfi:ont 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- suooortin8 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.norttffork.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# ] l - I I o3 PaOJ CTNA l-/,lieu The Application has been submitted to (check appropriate response): TownBoard ~ Planning Board ~ BuildingOept. [-~ Board ofTrustees 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: Nature and extent of action: Location of action: Site acreage:. ~-°~-~ Present land use: ~-~ Present zoning classification: ~ Zo 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 ( ) (d) Application number, if any:. Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes [] No ~ If yes, which state or federal agency?. C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III - Policies; Page 2 for evaluation criteria. ~ Yes [] No ~NotApplicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III - Polici~ Pages 3 through 6 for evaluation criteria ~ Yes [] No~l Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III - Policies Pages 6 through 7 for evaluation criteria ~ Yes ~ No ~Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III - Policies Pag/es 8 through 16 for evaluation criteria ] I Yesl ~ No It'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 throug/h 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 evaluati~criteria. 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~ot 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.~ ~ ~No Yeo · No tApplicable 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 ~ No~Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. Yes ~'~ No I~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 - Polic~ges 65 through 68 for evaluation criteria. [] Yes ~ No~_] Not Applicable PREPARED BY TITLE DATE ,'?PROVED [7'/ [©ARD OF TRU$i'LES TOWN OF $OUTHOLD DATE H~ LL~H BP-A~/D ~ £upTEN P~' ,E,~, ,h"l;:\'F7/T'UC,K , t'~, ~d_Th~-~ (000- I1..-~- II - CO-\L~ ; I"= Zo:o" /quc'7~o~T 2_Z)10