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HomeMy WebLinkAboutTR-7428A Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen 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 CERTIFICATE OF COMPLIANCE # 0658C Date June 21,2011 THIS CERTIFIES that the addition to the existing dwelling and porch addition At 580 Old Salt Rd., Mattituck Suffolk County Tax Map #144-5-12 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 10/28/10.pursuant to which Trustees Wetland Permit #7428A dated 11/17/10 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 addition to the existing dwelling and porch addition. The certificate is issued to BOB & KARLENE CALI owners of the_aforesaid property. Jill M. Doherty, President Bob Ghosio, Jr., Vice-President Jaraes F. King Dave Bergen 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 DATE OF INSPECTION: 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: CERTIFICATE OF COMPLIANCE: Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Brederneyer Town Hall, 53095 Main Rd. P.O. Box I t 79 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 /Project complete, compliance inspection. Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town H~lAnnex 54375MainRoad P.O. Box 1179 Southold, NewYork 11971-0959 Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD Permit No.: 7428A Date of Receipt of Application: October 28, 2010 Applicant: Robert & Karlene Cali SCTM#: 144-5-12 Project Location: 580 Old Salt Road, Mattituck Date of Resolution/Issuance: November 17, 2010 Date of Expiration: November 17, 2012 Reviewed by: Trustee Jill M. Doherty, President Project Description: To construct a new addition with covered porches and interior renovations. 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 Samuels & Steelman Architects, last dated October 20, 2010, and stamped approved on November 17, 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. 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 (63 I) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated Oc.~'o~_.,"<~ c:~O/O has been reviewed by this Board at the regular meeting of,,4~ I ?,,.-2o/0 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) __ ½ 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: $_ ~"/--,}'"'-~ BY: Jill M. Doherty, President Board of Trustees 3ill M. Doher~y, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemcyer PO. Box 1179 Southold, NY 11971 Telephone(631) 765-1892 Fax (631)765-6641 Southold Town Board of Trustees Field Inspection/VVorksession Report Date/Time: Samuels & Steelman Architects on behalf of ROBERT & KARLENE CALl requests an Administrative Permit to construct a new addition with covered porches and interior renovations. Located: 580 Old Salt Rd., Mattituck. SCTM#144-5-12 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: L.-Chapt.275 Chapt. 11 t other Type of Application: ;,/Wetland __Coastal Erosion --Amendment ._Administrative__Emergency Pre-Submission __Violation Info needed: ~,[ Modifications: Conditions: Present Were: __&King ~d.~&Doherty J. Bredemeyer__ B.Ghosio, __ D. Dzenkowski __other Form filled out in the field by D. Bergen__ Mailed/Faxed to: Date: ......... ~--a~ .................................... [ ~ couNTY OF SUFFOLK (~ ~ ..... $OUTNOLD ...... ...............  144 ~= ~ ..................... ~ =~ ~- .... - ........ ~'~ Im 8T~l~mmmmmm ~nmm U ~1~ ~1111~ I~1~ [11 Ill I L~m~ mm m mm~mmm m mm , m m mmmmm OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, KY 11971 MAILING ADDRESS: P.O. Box 1179 Southold, N-Y 11971 Telephone: 631 765-1938 Fax: 631 765-3156 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Jill Doherty, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: November 16, 2010 Re~ Proposed Wetland Permit and Coastal Erosion Permit for ROBERT & KARLENE CALl SCTM# 1000-144-5-12 Samuels & Steelman Architects on behalf of ROBERT & KARLENE CALl requests an Administrative Permit to construct a new addition with covered porches and interior renovations. Located: 580 Old Salt Rd., Mattituck. SCTM#144-5-12 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the denoted following Policy Standards and therefore is CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney Town of Southold Board of Trustees Application Office Use Only __Coastal Erosion Permit Application Wetland Permit Application o"~Administrative Permit A mendment/Transf~r/Extgn~ion ~t~ece~ved Application: [~') ~A~eceived Fee:$ ~'~ '- ' ' ~-~ompleted Application~j Ih __Incomplete __SEQRA Classification: Type 1 Type 1I Unlisted Coordination:(date sent) --LWRP Consistency Assessment Form --CAC Referral Sent: ' ~-~'-ate of Inspection: I. I ~ I ~{ ~ ~ Receipt of CAC Report: Lead Agency Determination: __Technical Review: ~---,Wablic Hearing Held: [ ( ( t~ ( {0 __Resolution: NameofApplicant ~ ~L Address .'~ ~°Ft::lq~,~F~.~c3 ~; ~ ~t~m ~'~ I~ J , Phone Number:( ) ~ - ~ - ~.~ Suffolk County lax Map Number: 1000 - 1~ -O~ -- 1~ Propeay Location: ~ O~ ~[ (provide L1LCO Pole ~, distance to cross streets, and location) (lf applicable) [ - Address: Board of Trustees Application GENERAL DATA Land Area (in square feet): Area Zoning: ~- '4,0 Previous use of property: Intended use of property: Covenants and Restrictions: If"Yes", please provide copy. Yes .X No 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 No .45 No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? X No Yes If yes, provide explanation: Project Description (use attachments if necessary): ~/~t~r~_lrj4-i~w 042 Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ,~!r3~]~ ~ .,l~q,_ I~-Jo-~t-~_. Area of wetlands on lot: ~> .square feet Percent coverageoflot: O % Closest distance between nearest existing structure and upland edge of wetlands: 7~:~'-~:~" feet Closest distance between nearest proposed structure and upland edge of wetlands: /O~ ' feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? ~ cubic yards How much material will be filled? --- 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): PROJECT ID NUMBER PART 1 ' PROJECT INFORMATION ~PONSOR 3,PROJECT LOCATION: 617,20 APPENDIX C STATE ENVIRONMENTAL QUALITY REV[EW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by A[ ,licant or Project Sponsor) 2. PROJECT NAME SEQR 4 PRECISE LOCATION: Street Addess and Road Intersecl~ons. Prominent landmarks etc -o; provide mai) 5 IS PROPOSED ACTION: [] New [] Expansion [~ Modification ! alteration DESCRIBE PttOJECT ~)R)EFLY: r, '~ ~ ~_, , t ¥,(~.~j~ ,.=._ {~,,~_.~ 7. AMOUNT OF LAND AFFECTED: Initially o~) ~)I acres Ultimately , O~, ¢~ acres 8.~LL PROPOSED ACTION COMPLY ~TH EXISTING ZONING OR OTHER RESTRImlONS? ~Yes ~ No If no, des~ebfle~: 9 WHAT IS PRESENT LAND USE IN VICINITY DE PROJECT? (Choose as many as apply.) ~'~Resi~endal [~industda, r'"]Commerclal ~-~Agriculture r--~Park/Forest/ObenSpace [~Other (describe) 10. DOES ACTION iNVOLVE A PERMIT APPROVAL, OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or LOcal) r-}Yes [~No if yes, list agency name and permil / approval: 11 DOES ANY ASPECT Of: THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ---]Yes F~No If yes, fist agency name and permit / approval: i t ASA RESULT OF PROPOSED Ac'rIoN WILL EXmSTING PERMIT/ APPROVAL REQUIRE MODIFiCATiON? compete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To be completed by Lead AgenCy~ * r-I¥- 17l.o WILL ACTION ~,~t:iVE COORDINATED REVIEWAS PROVIDED FOR UNUS~r=D ACTIONS IN 6 NYCRR, PART 617.67 If No, a negsbYe C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS AS~tlA"~D WWH THE FOU-OW~NG: ~ m~y be hm~%~d~ell, if legible) P~eftO~l for ero~o~ dmlm~e or floodi~ pFo~ems? F-xplaln I~. ~o CB. Long term, short ten*n, cumulative, ~- o(her e fi'~L~ not Identified in C1-C57 Explain bdefly: D. ~/11 .I THE PROJECT HAVE AN IMPACT ON THE ENvIRONMENTAl. CHARACTERISTICS'I~IAT CAUSED THE ESTABLISHMENT OF A CRITICAL 1 ! F- I~ ~ 1."~.~, OR IS ~ UKELY TO BE~ coNTROVERsy RELATED TO'POTENTIAL ADVERSE F. NV1R~, .','~,.~', AL IMPACTS? If ~m~ + -~4-_-.':,. PART NI - ~, ~..~kir~ATl(3N OF 81GNIRCANCE (To be completed by Agency) IN,STRUCllON$: F~reach~dver~ee~ectidenti~edab~ve~deM~11inewhether~t~ssubst~ntia~'~a~~n~ Each effect should be assessed in connm::do,'l with its (a) setting (i.e. urban or rural); (b) probability of o(x:url~g; (~:) d(imfJon; (d) kTevers~stFfb~, (e) geograph~ ~Gope; and (f) magnitude. If nec~___;~ry, add attachments or feferei~e suppol~tg mat~ Ensore that exp~ (:xmtaln ~di~::lent detail to show that M relevant adverse impacts have been Identified and adequately eddremmd. If question d o~ part i~ was checked ye~. the.determlimtlon ofMgniflcan~e mustevalua(e the potential impact ofthe propo~md eciion on Ihe e~l characteristics of the CE~ EAF alldJOr prepare a pe~flve.de~. WILL NOT rer~dt In any slg~h~cant advase envlronmenlal Impa~ AND provide, on alta~hmeflls as necessmy, the reasons supp~xtlng thl Beard of Trustees Name of Lead A~mcy Jill M. Doherb/ · " ,~ltnt~or Type Name of~,p~sible Offi(~in Lead Agency President Date 'l'~Oe of Responsible Officer Signalum of Preparer (If dlffererd from respons/ble of Scer) 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 quest, ions 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 Progra~nl 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 ~2 on this form is answered "yes", then the proposed action may affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, the action should be.analyzed in mom detail and, if necessary, modified prior to making a determination that it is consistent to the maximum extent practicable with the LWRP policy standards and conditions. If an action cannot be certified as consistent with the LVvl~P policy standards and conditions, it shall not be undertaken. Bo A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.no/thfork.ne0, the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. DESCRIPTION OF SITE AND'PROPOSED ACTION SCTM# 114 05 12 The Application has been submitted to (check.appropriate response): TownBoard [] Planning Dept. [] Building Dept. [] BoardofTrustees [] Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (c.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: Renovat±on and add±t±on of a one story wood frame reidence Location ofaction: Site acreage: Presentland use: 580 Old Sait Road, Mattituck, NY 21,786 S.F. Single Family Residence Present zoning classification: .- R- 40 If an application for the propose~ action has been filed with the Town of Southold agency, the following information shall be provided: (a) Nameofapplicant: BOb and Karlene Call (b) Mailing address: 3 StOne Arc'h Rd. Old Westbury, NY 11568 (c) Telephone number: Area Code ( )_ 516-626-0833 (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.'?. DEVELOPED COAST POLICY Policy 1. Foster a pattern of devel0pnient in the Town of Southold that enhances community character, preserves open space, makes efficient'rise 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 Renovating an existing residence preserves open space around the existing residence and makes efficient use of the existing structure and property. Also the addition to the p'roperty'is far less than the 20% lot coveraqe allowed by zoninq. 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 There are no historic or archeological structures on property. 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 The addition to the existing residence is in keeping in style and scale of neiqhborinq structures. 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 Pages 8 througl/16 for evaluation criteria [] Yes [] No ~-~ Not Applicable All rainwater runoff at new addition is and will be retained on site with the use of underqround drywells. Attach additional sheets if necessary Policy 5. Protect and improve waterfiuallty and supply in the Town of Southold. See LWRP Section III -Policies Pages 16 through 21 for evaluation.criteria ~ Yes [] No [] Not Aoolicabie ' All rainwater runoff ~ the new &~dition will be retained wit the use of underground drywells. The sanitary system for the residence meets current Suffolk County Dept. of Health Services standards for sanitary waste water. The property is Attach additional sheets if necessary Policy 6. Protect and restore the qUality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. [-~ Yes [] No [~ Not Applicable No development will take p.la~e in ~he "protected" or "natural indiginous environment". 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 cr!~eria. [] Yes [] No [] Not Applicable The development will not .add pollutants into the air. All construction vehicles meet the Federal standards for ai~ pollution discharge. The mechanical systems of the residence meet the federat~standards for air pollution discharae. Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP. Se. ction II! - Policies; Pages 34 through 38 for evaluation criteria. [] Yes ~ No [] Not Applicable The construction and use of ~he residence will make use of the town's disposal and recyclin~ center. PUBLIC COAST POLICIES Policy 9. Provide for public access to', and '~ecreational 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 ' No public land involved. ,Littoral access unimpeded. Attach additional sheets if necesstuy WORKING COAST POLICIES .' Policy 10. Protect Southold's water-d~pendent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section'IH - Policies; Pages 47 through 56 for evaluation criteria. [] Yes [~ No [] Not Applicable There are no public or commercial activities or uses on site. Historically this Droperty and neiqhborinq properties are residential in use and will 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 LWRt~ Section III - Policies; Pages 57 through 62 for evaluation criteria. [] Yes ~-~ No [] Not Applicable '~.~ This project will protect and preserve the living marine resources by maintaining rainwater ~ischar~e and sanitary flow from the residence on site by approved SCDHS sanitary system and drywells for rainwater runoff. 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 There are no agricultural lands on site. 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 The construction will be using equipment approved by the Federal government for energy usage. The residence will meet Federal standards for conserving enerqy "enerqy Star Proqram" and will use "NY State Enerqy Conservation and Created on 5/25/05 DATE 25235 Main Road, Cutchogue NY 11935 (631) 734 6405 Fax (631) 734 6407 To: Board of Trustees From: Nancy Steelman Address:54375 Main Road Date: November 1, 2010 Southold, NY 11971 CC: Re: Call Residence [] Urgent x For Review [] Please Comment [] Please Reply Description: 1. Signed and notarized Application signature page 2. Transactional Forms signed by owners 3. LWRP Please include the above with the previously submitted application. Thank you Nancy Steelman Board of Trustees Application County of Suftblk State of New York /? BErG DULY SWORN D AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH 1N 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, 1 HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. ~ Signature SWORN TO BEFORE ME THIS / DAYOF PJ 0 'flC'2~ C/~20_/0 Notary Public APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees. The ~uroose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: ~J~'~ ~h (Last name, first name, middle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (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 tova~ officer or employee has even a partial ownership of (or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO .~ If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): A) the oumer of greater than 5% of the shares of the corporate stock of the applicant (when the applicant is a corporation); B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a corporation); ___C) an officer, director, parmer, or employee of the applicant; or D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I S ubmitt ed t h i s//~[~ay~"~ Signature Print ~ 200 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohihils conflicts of interest on lhc part of town officers and employees. The purpose ol this Ibnn is to pm,,idc inlbrmation which can alcrt the town of possible conflicts of interest and allow it to take whatex er action is (last nmne. first name. iniddlc initiak unless you are applying in the name of someone else or other cntits, such as a company If so. indicate the other N'~MI- Ol/~,l'Pl ICATION: (Check all that apply3 lax gricxancc . _ Building Changc ot Zonc Coastal Erosion Approval of plat Mooring l)n you pel'sr)llall? (or Ilu'ough your company, spin,se, sibling, parent, or child) have a relatk)nship with any officer or emp]o3 cc the l'own oi Southold? "Relationship" includes by blood, ma~iage, or business interest. "Business interest" means a business. incJuding a parmcrship, in which the town oflSccr or employcc has even a pa~ial ox~mrship of (or employment by) a co~oralion YIiS _ NO .~ Name ofpc~sn e p .xec by he Town t I'Southold Describe Ibc rclatkmship hetx~eett yourself(the applicant/agenffrepresentative) and the town officer or employee. Either check Ibc ;ippmprialc linc A) through D) and/or dcscrihc in thc space provided. ]he toxin officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): A) the m',ner of greater than 5% of'thc shares of the corporate stock of the applicant applicant is not a corporation): C) an officer, director, partner, or cmph}yee of the applicant: or Form TS I Submitted this day of 200 Signature~~ ~ ~.~¥- APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics t~rohibits conflicts of interest on the ~art of town officers and emt>lovees. The vuroose of this form is to r>rovide information which can alert the town of¢ossible conflicts of interest and allow it to take whatever action is necessary to avoid same. (Last n~me, first name, middl~ initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grlevm~ce 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 applicant~agenffrepresentative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): A) the owner of greater than 5% of the shares of the corporate stock of the applicant (when tbe applica~t 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 Submitte~i~f~d~ c~, ff Sign at ur c~_~..~?,d'L~. _~'?~.~n j Print Nan~ ~Fi~'~JEt~ 200 S A M U E L S & S T E E L M A N October 20, 2010 Board of Trustees Town of Southold Town Hall Annex Building P.O. Box 1179 Southold New York 11971 RE: Cali Residence 580 Old Salt Raod Mattituck, NY 11952 Tax Map # 1000-144-05-12 Dear Trustees: Enclosed please find two Site Plan drawings, and a check for $50. for the property referenced above. The proposed project is a new one story addition with new covered porches and is located greater than 100 feet from the edge of the mean high tide. We are therefore requesting a Letter of Non Jurisdiction from the Board of Trustees. If you have any questions, please do not hesitate to call us. Sincerely, SAMUELyg'~ STEELIv~ ARCHITECTS ARCHITECTS 25235 MAIN ROAD CUTCH©GUE, NEWYORK 11935 ~631 ) 734-6405 FAX (631) 734 6407 Land now Joan or Formerly of: R. Techet 0 ~- OLD SALT ROAD · A SPHA L T LOT O!4/N.~RS ASSoc. ' R=25. 0 , ,%- -%> ~/ A.' ',~.~- o~ .F_.Z._E- , t ~ ~ s. oo' [] ~ ~ .~c ^c d ^SPH^LT/~ z /,.~' r / ,' .... 2 STORY ;~' . ~ FRAME Go ~ E ,.GARAGE . ~J / ~)' ~ ~ GONG I % ~ --~' I / ./PAD 'I ~, ~ F FRAME HOUSE~ ~¢ ~ . ¢ 'EPS - ' I CONCRETE B~ <HEADI / ~ BHEAD. I UHU~ IL I 1'EAST %_ ..... WOOD dF I .......... ~-- ~ STEPS II P I SALT LAKE ~ ~ ll-~l ' o s UNE *LONe II ~ I 1[ S79'13'36"W 110.00' [ CMF GREAT PECONIC BAY SITE P LAN SCALE: 1" = 20'-0" LOT 2 SITE DATA SCTM # PROPERTY: ADDRESS OWNER: ZONING: SITE: ALLOWABLE COVERAGE: EXISTING COVERAGE: PROPOSED COVERAGE: FLOOD ZONE: SURVEYOR: 1000-144-05-12 580 Old Salt Road Mattituck NY 11952 Bob and Karlene Cali R-40 21,786 SQ. FT. = 0.5 ACRES 20% = 4357.2 SF 2597.8 SF 3038 SF X John Ehlers Main Street Rlverhead, NY LICENSE # 49273 DATED: June 26, 2007 LOCATION MAP OCT 2 8 2010 BOARD OF TRUSTEES ROJE~,~IO: 1008 DRAWN BY: NS CHECKED BY: NS DATE: 10120110 GALE: 1" = 20'-0" SHEET TITLE: SITE PLAN SHEET NO.: 1 000 000 GL. NEPI 5KY/IOt-IT~ Fr:~- r--mq II II II II II II II II II II II II iL _ j I._ _ JI II-- -- '~ I---- '~1 II II II II II II II II II II II II LL_- ~ L -_~J LIVIN~ II II GL. ~I'ITINO f~.I,'I. FIRST FLOOR PLAN SCALE: t/4" = 1' -0" in! EAST ELEVATION SCALE: t/4" [] t' -0" NORTH ELEVATION SCALE: 114" = 1' -0" BOARD OF TRUSTEES NS 3ATE: 10120/10 SCALE: 1/4" = 1' - 0" SHEET TITLE: FLOOR PLAN & ELEVATION: SHEET NO: