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Home My WebLink AboutTR-7415A 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 CERTIFICATE OF COMPLIANCE # 0813C Date: October 15, 2012 THIS CERTIFIES that the changing of all windows and location of windows; replacement of exterior doors and existing slider; installation of new slider in new location; replacement of siding and roof; construction of gable roof layovers At 500 Deep Hole Drive, Mattituck, New York Suffolk County Tax Map # 115-12-6 Conforms to the application for a Trustees Permit heretofore filed in this office Dated October 4, 2010 pursuant to which Trustees Administrative Permit #7415A Dated October 20, 20104 was issued and Amended on November 17, 2010 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 changing of all windows and location of windows; replacement of exterior doors and existing slider; installation of new slider in new location; replacement of siding and roof; construction of gable roof layovem. The certificate is issued to SHERRI KELLY owner of the aforesaid property. 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 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: ~ Ch. 275 / Z_ ~.~,,, 2._ Ch. 111 INSPECTION SCHEDULE INSPECTED BY: COMMENTS: __ Pre-construction, hay bale line/silt boom/silt curtain __ 1st day of construction '~ constructed Project complete, compliance inspection. ,/, CERTIFICATE OF COMPLIANCE: ~'~ ' James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen John Holzapfel Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD APPLICATION FOR AN AMENDMENT TO A WETLAND PERMIT DATE OWNER 5 NeE ~ \~'CL~/ ADDreSS 3~ ~e~x~a~ ADDRESS ~ ~'~c~< 1~,98 PROPERTY LOCATION ~-'-0-o -q~e V~x3/.:,~ l~q ,, .~4'~/~DFoC~ TAX MAP NO. [Crc~- //,.C'- z';~ - ~ request an Amendment to Permit Signed By: 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 November 17, 2010 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Don Salvitti P.O. Box 1288 Cutchogue, NY 11935 RE: SHERRI KELLY 500 DEEP HOLE DR., MA'FTITUCK SCTM#115-12-6 Dear Mr. Salvitti: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wed., November 17, 2010: RESOLVED, that the Southold Town Board of Trustees APPROVES the Amendment to Administrative Permit #7415A to reflect the additional windows, slider, and gable layover, as depicted on the plans received on October 25, 2010 and stamped approved on November 17, 2010. This is not a determination from any other agency. Sincerely, Jill ~. Doherty, Presid~ht Bo~'rd of Trustees JMD:lms Jill M. Doheny, 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/VVorksession Report Date/Time: Donald Salvitti on behalf of SHERRI KELLY requests an Amendment to Administrative Permit #7415A to reflect the additional windows, slider, and gable layover, and all as depicted on the plans received on 10/25/10. Located: 500 Deep Hole Dr., Mattituck. SCTM#115-12-6 Type of area to be impacted: __Saltwater 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: __ Wetland __Coastal Erosion ~Amendment __Administrative__Emergency Pre-Submission __Violation Info needed: Modifications: Conditions: Present Were: __&King __J.Doherty __J. Bredemeyer B.Ghosio, __ D. Dzenkowski other Form filled out in the field by D. Bergen__ Mailed/Faxed to: Date: Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeye~ Town Hall, 53095 Main Rd. P.O. Box 1179 $outhold, 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 1 st day of construction ½ constructed V,/'~Project complete, compliance inspection. Jill M. Doherty, President James F. K~ng, 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 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 7415A Date of Receipt of Application: October 4, 2010 Applicant: Sherri Kelly SCTM#: 115-12-6 Project Location: 500 Deep Hole Drive, Mattituck Date of Resolution/issuance: October 20, 2010 Date of Expiration: October 20, 2012 Reviewed by: Trustee Jill Doherty, President Project Description: To change all windows and location of windows; replace extedor doors and install new slider in new location; replace siding and roof; construct roof layovers on front and right side of dwelling. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Donald Salvitti, received on October 4, 2010, and stamped approved on October 25, 2010. Special Conditions: None. Inspections: Final inspection. if the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Jill M. Doherty, Presiddht Board of Trustees JMD:eac Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghnsio, Jr. John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 Telephone (63 I) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated ~--_.~-~'- l./,,~E)l O has been reviewed by this Board at the regular meeting ofO- ~-~::pr-oqO,~lo and your application has been approved pending the completion of th~ following items checked off below. Revised Plans for proposed project __ Pre-Construction Hay Bale Line Inspection Fee ($50.00) __ 1st Day of Construction ($50.00) __ ¼ Constructed ($50.00) Final Inspection Fee ($50.00) __ Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be Paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $. 5~--~ BY: Jill M. Doherty, President Board of Trustees Jill M Dohe~y, President James g King. Vice-President Dave Bergen Bob Ghosio. Ji. John Bredemeyer P.O. Box ll79 $outhold, NY 11971 Telephone (631 ) 765-1892 Fax (631 ) 765-6641 Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: ~r: _ i~-/b Donald Sa[ff~ti on behalf of SHERRI KELLY requests an Administrative Permit to change all windows and location of windows; replace exterior doors and install new slider in new location; replace siding and roof; construct roof layovers on front and right side of dwelling. Located: 500 Deep Hole Dr., Mattituck. SCTM#115- 12-6 Type of area to be impacted: [,,-Saltwater 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: 6-"-Wetland __Coastal Erosion ~Amendment __Ad ministrative__Emergency Pre-Submission Violation Info needed: Modifications: Conditions: Present Were: __J.King P"J.Doherty__J. Bredemeyer B.Ghosio, D. Dzenkowski other Form filled out in the field by D. Bergen__ Mailed/Faxed to: Date: James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen John Holzapfcl 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 APPLICATION FOR AN AMENDMENT TO A WETLAND PERMIT DATE cc_ .. PROPERTY LOCATION TAX MAP NO. [0'rs~- _//g-'- / 2 - ~ I/We ~-~,.~ S,.~o ~WI to ~c ~c ~* r74-e request an Amendment to Permit Signed By: 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 To: Jill Doherty, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: October 15, 2010 Re: Proposed Wetland Permit for SHERRI KELLY SCTM# 1000-115-12-6 Donald Salvitti on behalf of SHERRI KELLY requests an Administrative Permit to change all windows and location of windows; replace exterior doors and install new slider in new location; replace siding and roof; construct roof layovers on front and right side of dwelling. Located: 500 Deep Hole Dr., Mattituck. SCTM#115-12-6 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 provided the following: If the action is approved, to further Policy 5: Protect and Improve Water Quality in the Town of Southold and Policy 6; Protect and Restore the Quality and Function of the Town of Southold Ecosystem it is recommended that a natural ve,qetated buffer (width to be determined) be required landward from the ed,qe of tidal wetlands. An example definition is provided below for your use. NATURAL VEGETATED BUFFER -- a land area of a certain length and width where existing vegetation occurs prior to the commencement of any grading or clearing activity. Vegetation shall be maintained to achieve a minimum percent ground cover of ninety-five (95) percent. To achieve the percent ground cover indigenous, drought tolerant vegetation shall be planted. Survival of planted vegetation shall be (ninety) 90 percent for a period of three (3) years. Maintenance activities within the buffer are limited to removing vegetation which are hazardous to life and property, trimming tree limbs up to a height of fifteen feet (15') to maintain viewsheds, replanting of vegetation and establishing a four foot (4') wide access path constructed of pervious material for access to the water-body 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 Brederneyer 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 Office Use Only Coastal Erosion Permit Applicati~on~"- Wetland Permit Application 'V Administrative Permit AmendmenttTrans fer/F.,xtansion Rece-~ved Application: ~Z-Received Fee:$ ~ ,~-tgompleted Application lO! q.i Incomplete SEQRA Classification: Type I Type II Unlisted__ Coordination:(date sent) ,~"3NRP Consistency Assessment Form [(~ ..~g'AC Referral Sent: ,~, ~ ~D-ate of Inspection: ~"X{ I ,x~[ I'~ Receipt ofCAC Repor~:~ ~ ' ' ' Lead Agency Determination: Technical Review: ~atSlic Hearing Held: Resolution: Name of Applicant Address / 0 Suffolk County Tax Map Number: 1000 - Phone Number:6 $ ~ Property Location: (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: of Trustees Applicati~ q Land Area (in square feet): Area Zoning: ~5~ GENERAL DATA Previous use of property: Intended use of property: Covenants and Restrictions: Yes ',~ No If "Yes", please provide copy. 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: Dat~ Agency Z'//'~q~ Yes No ~ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? "A No Yes If yes, provide explanation: Project Description (use attachments if necessary): ADO crl~;¢ ~ard of Trustees Applicat~ WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ~n~o~-/' I~btg-oo~ Area of wetlands on lot: (~ square feet Percent coverage of lot: ~ % Closest distance between nearest existing structure and upland edge of wetlands: ~) O feet Closest distance between nearest proposed edge of wetlands: _~ ~/~l feet Does the project involve excavation or filling? X No Yes If yes, how much material will be excavated? How much material will be filled? structure and upland cubic yards · roi//} cubic yards Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: feet Statement oft_he, e~ect, if 9ny, on the wetlands and_ .tid~ waters- 9f the town that ~az 1-_~_sult reason of such proposed operations (use attachments if appropriate): PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 1. APPLICANT / SPONSOR 6'17.20 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 ~; ~ '~--c.V~¥.. SEQR 3.PROJECT LOCATION: 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map 5. iS PROPOSED ACTION: r~ New ~ Expansion ~ Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: 7 AMOUNT OF LAND AFFECTED: Initially acres 8. WILL PROPOSED Ultimately acres ACTION COMPLY WiTH EXISTING ZONING OR OTHER RESTRICTIONS? ~lYes [] No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) ~ ~i~ Re~identia~ E~] ~ndustria~ ~ ~mmercia~ ~AgrIc~lure E] Park ~ F~r~st ~ ~pen ~pace [--']Other (describe) 10/DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, AGENCY (Federal, State or Local) [-"-'~Yes [~No If yes, list agency name and permit / approval: NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL 11. UOE:5 ANY A.~PECI 0;- INP-ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ~]Yes r~"~No If yes, list agency name and permit / approval: I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sp~ ~ Date: Signature /~--Z --/0 If tho action i~ o*tal Ama, ~nd you am a ~tat, a~n¢¥, ¢ompl~t~ th~ Coastal Assessment Form b~fom ~ro¢*odlng with thi~ a~ssm~nt PART II - IMPACT ASSESSMENT ~To be completed by ~_=_d Agency)· E3 - [Z].°' B. WlM-ACTIOi~IRECEIVECOORDINATEDREVlEWASPROVIDEDFORUNUSTEDACTIONSlN6 NYCRR, PART617.67 IfNo, anegMIve I--"1 yes r~.l No c. (X~.LD AC I-~uN RE-~ULT IN ANY AD'v~.m:il= ~-rL-:~ i ~ .av,,RSOClATED wrrH i~E FOr_LOWING: (Answors ~ be ~, ff ~) · ~., -...--..hJ~l, o, ~. _.~_ _-...-,; ~,e~, ,.o~ ~,, or other rlabJral or ctllexa I'eSoorc~; or commurdty or choracle~/ I.o C~. Grow~, _m_ _,l-,~_ ~,_,ent d,~.?.-.~,~ ii' of ~e~b~ ac~,e$ Ekely ~o be induced by ~ propesed act/on? "%T~'-.: b~k=;y. 1"° I NO , ' C'/. T I~uaeofe#her ua or of.. O. ~ '[q-lE PROJECT HAVE AN IMPACT ON 'I~-IE ENVIRONMENTA~ Ct'~LRACTERISTICS THAT CAUSED ']~IE ESTABLISHMENT OF A CRf'I'IC~ Lt~V~RONME~rr/U. ^REA (CEA)? [~] Yes r~"] N° i (If ye~, ex~a~l b~ell~: II~I'EUClX~$: F~reachadve~ee~e~tidemi~dabeve~detemMnev/~e~er~t~ssu~tan~iaL~arge~mp~ant~r~n~ Each elfec~ ~o..uld be a~essed in conm~io~ wilh its (a) set~g (1.e. ad)an or rural); (b) probal~llty of o<x=ur~,g; (O) du~ (~ ~ ~e! geographic s<x~e; a,d (0 magMtude. If necessa./, add attac~menta or reference supporllng ~ En~ure that Board of Trustees Name of Lead Agency _Jill M..Doherty I~,' or Type Name~f Re~l~ sib~_.~ irl Lead Age.cy Signature o f'Resp<x~b'~-'Of~e~ in Lead Agency President Signature of Preparer (If different from responsible officer) Title of Responsible Offiear Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A I ~ i I ~ { ~. _.~ STORM-WATER~ GRADINGs, DRAINAGE AND EROSION CONTROl. PLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTION fi'EM # / WORK ASSESSMENT I Yes No a. What ts the Yotal Ama of lhe Pmject Parcels? '~ WillthlsPmjectRetslnAllStom>WaterRun-Off (Include Total Area of all Parcels located within the Scope of Work for Proposed Construction) '~, C)~ O Generated by a Two (2") Inch Rainfall on Site? b. What is the Total Ama of Land Clearing (S.F. I Acres) (ThiS ifem wtil include all run-off created by site clearing and/or construction activities as well as all and/or Ground Disturbance for the proposed ,,~ Site Improvements and the permanent creation of impervious surfaces.) (s.I=. / ~.s) 2 Does the Site Plan and/or Survey Show All Proposed PROV]DK B~JEF PROJECT DESCTut'i1ON p'..v~e~.~P.~.~d) DminageStructuraslndicatingSize& Location?This Item shall include all Proposed Grade Changes and Slopes Controlling Sulface Water Flow. '~_~ o~,-,oc,.~s; c~,r,~.,~/ ~ 3 Doas the Site Plan and/or Survey dascdbe the eroslon ~ iOll,.3f~ . I/,~%T'I~ ~.~__v~ l/~'/~)~ and sediment control p~actices that will be used to ),I I control site erosion and storm water discharges. This ~ C~1.''10 ~ · ~-;-' C~.~,~..~,~. item must be maintained throughout the Entire Construction Period. e~ %~3,-~ ~ 'i~ ~,,A-' 4 Will this Project Require any Land Filling. Grading or Excavation wherethere is a change to the NaturalI I Existing Grade Involving mom than 200 Cubic YardsL~J of Material within any Pamel? 5 Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five Thousand (5,000 S.F.) Square Feet of Groum:l Sur[aco? 6 ts there a Natural Water Course Running through the ~ ~,, Site? Is this Project within the Trustees jurisdiction U General DEC SWPPP Requirements: or within One Hundred (100') feet of a We~and or am bert of a larger c~mmon plan that ~1 ultimately disturb one or mom acres of land; which Exceed Fifteen (15) taet of Vertical Rise to r~ required, post-constmc~n sram wate~ management practices that w~l be used and/orRemoval of Vegetation and/or the Co~slmc~on of anyI I Y STATE OF NEW YO1LK, ~ . I ~ COUNTY OF .~ ~ ..~! ..............~"-'~ ss 'liaat I ....... ~.~1...:~ ~ ~.~ ................ bein~ duly sworn, deposes and says that he/she is the applicant for Pennk, And that he/sbe is the ............ .~..L~.~;:~:X~.;aj.~ii;Di~;:~.t~:j ................................................................ Owner and/or representative of the Owner or Owners, and is duly authorized to perform or have performed the said ~rk and to hake and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application Fried herewith. Sworn to before me Ih. is; Ook f , ...............,,, .............. e o FORM - 06110 ~u llc, S~a e u~ Hew ~urk N,!. 01CU6100507 Qualhiea in Sui,olk C,,untT, Commission ~pires Oct 20/ ~ Board of Trustees Applica~n County of Suffolk State of New York OSES AND AFFIRMS THAT HE/SHE I$ THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. SWORN TO BEFORE ME THIS Signatu're~ ,2o lO N~ry Public / - ~ CY~ITHIA M. CUSATI Notary 7uhtic. ~tat~' of New York Commission Expires Oct 20~_ Board of Trustees Application AUTHORIZATION (where the applicant is not the owner) I, (print own~ro~propert¥) 0 G+C ~ / ~ K/ ]]q~'"' do hereby authorize (mailing address) (Agent) to apply for per~it(s) from the Southold Board of Town Trustees on my behalf. (Owner' s siqnatu~e) - / 8 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics orohibits conflicts of interest on the oart of town officem and employees. The ourooso of thi[; form is to orovide information which can alert the town of oossible conflicts of il~terest and allow it to take whatever action is to avoi same. (l~ast name, first name,¢iddle inttial, unle~ you are 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 Of"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 ponnership, in which the town officer or employee has/even a partial ownership of (or employment by) a cotporatlon in which the town officer or employee owns more than 5% or. 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/ngenffrepresentative) 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) thc o?vner of greater than 5% of the shares of the corporate stock of the applic~.nt (when the applicant is a corporation); ___B) the legal or'beneficial owner of any interest in a hon.-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 PfintName -~5 ~4¥F1' ~"~J Ix'/ 2oo/0 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- suooorting facts. If an action cannot bc certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold ' s website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# !t~'~ - 17~ - ~ The Appli~fion has ~en sub~ 1o (check a~wpfiate ~): TownBoard ~ PlannagBoaa~ Bufld~gDept. ~ Boa~ofTmste~ ~ Category of Town of Southold agency action (check appropriate response): (a) Action undertakenldirecfly 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: ~-cX~ Site acreage: ~t ~e~nt ~ning cl~sificafion: If ~ applimfion for ~e pm~d ~fion h~ ~en fil~ ~ ~e Tom of Sou~old agency, ~e folloMng ~o~afion sh~l ~ provided: (a) N~e of applic~t: ~/~ ~) Mhl~g ad.ss: (c) Telephone number: Area Code ( ) (d) Application number, if any:. ~/I~ 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 I. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III - Policies; Page 2 for evaluation criteria. [] Yes [] No [~ Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWliP Section III - Policies Pages 3 through 6 for evaluation criteria [] Yes [--] No [] Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III - Policies Pages 6 through 7 for evaluation criteria ~ Yes ~ No ~ Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life~ structures, and natural resources from flooding and erosion. See LWRP Section III - Policies Pages 8 through 16 for evaluation criteria ~ 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 Attach additional sheets if necessary Policy 6. Protect and restore ithe 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 Ap~ble Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section HI - Policies Pages 32 through 34 for evaluation criteria. ~-~ Yes ~-] No ~ Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. 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 POLICIO Policy 10. Protect Southoid'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 II1 - Policies; Pages 57 through 62 for evaluation criteria. [] Yes [] No ~ Not Applicable Attach additional sheets if necessapy 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 PREPARED BY~ DATE~ O~\~ OTHER POssIBLE AGENCIES YOU MIGHT HAVE TO APPLY TO N.Y.S. Dept. of Environmental Conservation (DEC) SUNY, Bldg. 40 Stony Brook, NY 11790-2356 (631) 444-0355 Mort., Wed., Fri., 8:00 AM-3:00 PM Suffolk Coun~ Dept. ofHealth Services 360 Yaphank Ave., Sure C Yaphank, NY 11980 852-5700 U.S. Army Corp. of Engineers New York Distdct 26 Federal Plaza New York, NY 10278 917-790-8007 N.Y.S. Dept. of State Coastal Management 99 Washington Ave. Albany, NY 12231 518-474-6000 NEW ?..'; F C, LK A VENUE SURVEY OF PR OPER T Y AT MATTITUCK TOWN OF SOUTHOLD SUFFOLK COUNTY, N Y 1200 115 Scale July 5, L~IOCT - 4 Southhold ~rowa NEW SUFFOLK A VENUE N/O/ EVEI YN P. TURCH~A A,~EA = 23,030 sq. ft (to rio fine) SURVEY OF PR OPER T Y A 7- MA TTITUCK TOWN OF SOUTHOLD SUFFOLK COUNTY, N. Y. 1000 115- 12- 06 Scale 1" = 30' July 5, 1990 'PECONIC P O. BC~X- MAiN SOUTIq~L~ F__A6Y ELEV, AT~ON NORTH - --/~,,~., ~,, _ I/' . .'l . ELEVAT I ON '- ~//~" ~- I ~ 0//- ......... i II _ NOl:::i~-i-t [Lt~'V'/kTt 01t . I