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Home My WebLink AboutTR-7553A Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Bredemeyer Town Hail 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 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 % constructed Project complete, compliance inspection Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. I~ng Dave Bergen John Bredemeyer Town Hall Annex 54375MainRoad P.O. BOx 1179 Southold, NewYork 11971-0959 Telephone (631) 765-1892 F~x (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 7553A Date of Receipt of Application: May 11, 2011 Applicant: Anthony Graziano SCTM#: 90-4-6.1 Project Location: 915 Lakeside Dr. North, Southold Date of Resolution/Issuance: May 18, 2011 Date of Expiration: May 18, 2013 Reviewed by: Trustee Bob Ghosio, Jr. Project Description: To hand-cut Common Reed (Phragmites australis) to 12" in height by hand, as needed. 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 application received on May 11,2011 and survey stamped approved on May 18, 2011. § 275-5 Permit procedures, (i) Cutting of common reed (Phragmites australis) to within 12 inches of the soil surface landward of the wetland boundary. This does not include mowing to ground level. Special Conditions: Do not disturb native vegetation during the hand cutting of Common Reed (Phragmites australis), including but not limited to; Eastern Red Cedar (Juniperus virginiana), Northern Bayberry (Myrica pensylvanica), Marsh Elder (Iva frutescens), and Groundsel Bush (Baccharis halimfolia). 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 $outhold Town Code, a Wetland Permit will be required. This is~not a determination from any other agency. Jill Mt./Doherty, President ~/ Board of Trustees -- 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 ! 1971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated ~ J I ] I I has been reviewed by this Board at the regular meeting of and your application has been approved pending the completion of the following items checked off below. __ Revised Plans for proposed project __ Pre-Construction Hay Bale Line Inspection Fee ($50.00) __ 1st Day of Construction ($50.00) __ ~ Constructed ($50.00) v'~inal 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: $ ~-~, O~ BY: Jill M. Dohedy, President Board of Trustees Jill M. Dohe~y, President Bob Ghosio, Jr, Vice-President James F King Dave Bergen John Bredemeyer P.O. Box 1179 Southold. NY 11971 Telephone(631 765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field InspectionNVorksession Report ANTHONY GRAZlANO requests an Administrative Permit to trim the phragmites to 12" by hand, as needed. Located: 915 Lakeside Dr., Southold. SCTM#90-4-6.1 TY~ 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: J. Doherty D u.u io J. King__ J. Bredemeyer___ D. Dzenkowski __other Form filled out in the field by ,¢:~.- D. Bergen, Mailed/Faxed to: Date: N~CK -N COUNTY OF SUFFOLK SOUTHOLO APPLICATION INSTRUCTIONS ADMINISTRATIVE PERMIT Application Fee - $50.00 One original of completed application packet. One copy of completed application packet. One original and one copy of the survey and/or site plan depicting the proposed project. Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (63 I) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only __Coastal Erosion Permit Application __Wetland Permit Application __ Administrative Permit ~endmentFrrans fer/Extension __Received Application: __Received Fee:$ __Completed Application __Incomplete __SEQRA Classification: Type I Type II Unlisted__ __Coordination:(date sent) __LWRP Consistency Assessment Form __CAC Referral Sent: __Date of Inspection: __Receipt of CAC Report: Lead Agency Determination: Technical Review: __Public Hearing Held: __Resolution: Phone Number:( )~'3[ -"7(~' Suffolk County Tax Map Number: 1000- (-J [0 - () t+ Prope~yLocation: ?~ ~ ' ~ ~ ~ (provide LIL~O Pole ~, distance to ~oss streets, and location) AGENT: (If applicable) Address: Phone: Board of Trustees Application GENERAL DATA Land Area (in square feet): Area Zoning: k% ~i?~4'~ Previous use of property:. Intended use of property:. Covenants and Restrictions: If "Yes", please provide copy. Yes ~/ No Does this project require a variance from the Zoning Board of Appeals __ If "Yes", please provide copy of decision. Yes "/ Prior permits/approvals for site improvements: ~. \A~ggncy ~ No __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspend~Lby a governmental agency? '~-~ No Yes If yes, provide explanation: Project Description (use attachments if necessary):_ Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Areaofwetlands onlot: [~" ~%~/-~ square feet Percent coverage of lot: J ~'~ % Closest distance between nearest existing structure and upland edge of wetlands: ~ q~'~ 'b'¥ feet Closest distance between nearest proposed structure and upland edge of wetlands: 4~ ~,~ 5'5 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? 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: cubic yards cubic yards feet Statement of_t).~ ~ff_ec_t~ if any~ o_n the well_ap_ _d. S and tida[ wa_ters 9f[h_~ ~t0wn tha_t _may_.r__e_s_u.l.~_b3 reason of such proposed operations (use attachments if appropriate): PROJECT ID NUMBER PART I - PROJECT INFORMATION 1. APPLIC/~NT / SPONSOR · 3.PROJECT LOCAl-ION: 6t7.20 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 SEQR Munlclpalit~ ~ j '~ .), /. 4. PRECISE LOCATION: Sl~eet Addess and Road Intersections, Prominent landmarks etc -or provide map DESCRIBE PROJECT BRIEFLY: ..... Initially acres Ultimately acres 8, WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~ [] NO If no, describe briefly: 9 WHAT $ PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) ~ntial [] Industrial E~Commercial E~Agriculture E~] Park / Forest / Open Space []Other(describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) E~Yes ~ If list name and / yes, agency permit approval: L_J 11. UU~ ANY ASPIC4 OF ~~R]~E/;iT[~f VALID PERMIT OR APIS~(~L~ ~]Yes r--~ If yes. list agency name and permit/ approval: 12. AS A RESU -OF PROPOSED ACTION WiLL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I CERTIFY..TIdA'T~THE,~IN'~ORMATION- -- PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor~-fiame (// ' ~,~"/ ~fthe action-is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCrA~TI. ON: S.C.T.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A Disidct Sect on B~OC~ cot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. scOPE OF WORK - PROPOSED CONSTRUCTION ITEM# / WORKASSESSMY_,NT I Yes No a. What is the Total Area of the Project Parcels? this Project Retain Storm-Water Run-Off (include Total Area of all Parcels located within / ' ~%(' Generated by a Two (2") Inch Rainfall on Site? the Scope of Work for Proposed Construction) (This item w~ll include all run-off created by site r~ b. What is the Total Area of Land Clearing (S.F. I~'~) clearing and/or construction ac§v/ties as well as ail and/or Ground Disturbance for the proposed ~ Site Improvements and the permanent crest~on of construction activity? Impervious surfaces.) (S.F. t Acres) 2 Does the Site Plan and/or Survey Show All Proposed PROVIDE BRIE.~' PROJ'~CT DF,,SC1U[F~ON (~,~d~,~.9[~..=N~) Drainage Structures Indicating Size & Location? This Item shall include all Proposed Grade Changes and 3 Does the Site Plan and/or Survey descdbe the erosion and sediment control practices that will be used to control site erosion and storm water discharges. This item must be maintained throughout the Entire Consbuction Period, 4 Will this project Require any Land Filtiog, Grading or Excavation where there is a change to the Natural Existing Grade Involving more than 200 Cubic YardsL.~ -- of Material within any Parcel? 5 Will this Application Require Land Disturbing Activities r'--1 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 Proiect within the Trustses jurisdiction Genera( DEC SWPPP Requiremenls: or within One Hundred (10ff) feet of a Wet/and or STATE OF NEW YORK, COUNTY OF ........................................... SS That I ................................................................................. being duly sworn, deposes and says that he/she is the applicant for Permit, And that he/she is the .................................................................................................................................................................... Owner and/or representative of the Owner or Owners, and is duly authorized to perform or have performed the said work and to make 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 perfornmd in the manner set forth in the application filed herewith. Sworn to before me this; ............................................... day o[ ............................................. 20 ..... Notary Public: .......................................................................................... FORM - 06/10 Board of Trustees Application Coumy of Suffolk State of New York HAT 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 IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD TIlE 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, TH~I~ 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 IVll~ THIS DAY OF ,20.__ Notary Public Board of Trustees Application AUTHORIZATION (where the applicant is not the owner) (print owner of property) residing at (mailing address) do hereby authorize (Agent) to apply for permit(s) from the southold Board of Town Trustees on my behalf. (Owner's signature) APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE. FORM The Town of Southold's Code of Ethics nrohibits conflicts of interest on the nar~ of town Officers and emnlovecs. The t~uroose of this form is to erovide information which can alert the town ofnossible conflicts of interest and allow it to take whatever action is n~ec~ssar~ to avoid same. ?· . , , ~ . . (Last name, first name, ~niddle initial, unless yom are applying in the name of someone e se or other entity, such as a company If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check ail that apply.) Tax grievance Building ~--~ Variance Trustee J 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 thc Town of Southold? "Relanonsh~p' includes by blood, r~arriage, or business interest- 'Busmess 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 mom than 5% of the shares. YES NO '~'" 1 fyou 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 ~hild is (check all that apply): A) the o~vner 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, partner, or employee of the applicant; or D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Submitted this ~day orr b*~t a~ / 20~ '~_ Signature Print Nam* / I Location of action: Site acreage: { (-}f~ (~i Present land use: ~ Present zoning classification: If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Nameofapplicant: '~¢J(J~t ~'~r~']~'/l~" (c) Telephone number: Area Code ( )~'!"~I -'76./~ ~"-¢~'} (d) Application number, if any: Will the action be dir~9tly 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 bc 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 r~ No F~ot Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of thc Town of Southold. See LWRP Section III - Policies Pages 3 through 6 for evaluation criteria 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 Pa~ges 8 through 16 for evaluation criteria [] Yes [] No ~7~ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III - PoliCies Pages 16 through 21 for evaluation criteria [] Yes ~-] NoI--O/L21 Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southoid ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies Pages 32 through 34 for evaluation criteria. ~-~ Yes ~ No ~/Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. Yes No - NotApplicable 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. V-~ Yes~ No ~ Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III.- Policies; Pages 47 through 56 for evaluation criteria. ~ Yes ~ 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. F-~ Yes ~ No ~/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[-~l~ I Not Applicable At~ach 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 [5 ot Applicab,e TITLE 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 Mon., Wed., Fri., 8:00 AM-3:00 PM Suffolk County Dept. of Health Services 360 Yaphank Ave., Suite C Yaphank, NY 11980 852-570O U.S. Army Corp. of Engineers New York District 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 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 Office Use Only __Coastal Erosion Permit Applicafionj __Wetland Permit Application v/Administrative Permit Amendment/Transfer/Extension ~4{ece-~vved Application: ,.~eceived Fee:$ ~' ' ' _~O~mpleted Application _~ I Incomplete SEQRA Classification: Type I Type ll~Unlisted Coordination:(date sent). LWRP Consistency Assessment Fom~ CAC Referral Sent: ~ t/Date of Inspection: Receipt of CAC Report: Lead Agency Determination:__ Technical Review: ~/Public Hearing Held: Resolution: Phone Number:( ~/~3/ Suffolk County Tax Map Number: 1000- 0C~0- O ~ Property Location: ~r~'l~ [--_~-~z~IB~57 ~5~ (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: rd of Trustees Applicatlo~ Land Area (in square feet): Area Zoning: ¢~ ~'~4~'e~. Previous use of property: Intended use of property: Covenants and Restrictions: If "Yes", please provide copy. GENERAL DATA Yes ~/ 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: 50 , ,A,g c Yes __. No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspende.~l~y a governmental agency?. u-~ No Yes If yes, provide explanation: ~J No Project Description (use attachments if necessary): Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: / ('P, % ~ ~ square feet Percent coverage of lot: / ~'~2~ % Closest distance between nearest existing structure and upland edge of wetlands: '~ (~'~ 3'5 feet Closest distance between nearest proposed structure and upland edge of wetlands: ~ ~'~ ~'~, feet Does the project involve excavation or filling? V// No Yes If yes, how much material will be excavated? How much material will be filled? 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: cubic yards cubic yards feet Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of Such l~r6i~cl 0p~atk~n~'(uS~ 617.20 PROJECT ID NUMBER APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART '1. PROJECT INFORMATION ( To be completed by Applicant or Project Sponsor) 1. APPLIC,~NT / SPONS.,OR~] [/~L~, ¥,,J~3,PROJECT LOCA~ION:~{'~" ~" I/~' 2. PROJECT NAME 4. PRECISE LOCATION: S~eet Addess and Road Intersections. Prominent landmarks etc -or arovide mad SEQR 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECT/T.F~D: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? E~Yes E] No If no, describe briefly: 9 WHAT PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) ~tial r~ Industrial E~ Commercial E~]Agriculture [~ Park / Forest / Open Space 10 DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, AGENCY (Federal, State or Local) F--lYes ~ If list name and permit / yes, agency approval: E~Other (describe) NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL .... ~1~1. DUE5 ANY ASPP~.~-f.)F tHE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? E]Yes E~ If yes, list name and permit / approval: agency 12. AS A R~F PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? E~Yes I'qNo I CERTIF~"THE I~ORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant , Spons.~-.d~ame /UI - D t.' lethe actlon/~s a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment of Trustees Applica~ County of Suffolk State of New York DEPOSES AN~ 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 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 SAD 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 CONJUNCTiONc~.7..~/~WI~ ~A~. Sigr ute SWORN TO BEFORE ME THIS ,2o// LAUREN M. STANDISH Nota~ Public, State of New York No. 01ST6164008 Qualified in Suffo k County Commission Expires April 9, APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE. FORM The Town of Southold's Code of Ethics orohibits conflicts of interest on the oart of town Officers and emolovees. The om'nose of [his form is to on>vide informat on which can alert the town of~ossible conflicts of intereSt and allow it to take whatever action is necessary to avoid same. (Last name, flint name,~niddle initial, unless you are applying ra 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 f Variance Trustee J Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (lf"0ther", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of thc Town of Southold? "Relationship" includes by blood, marriage, or business interest_ "Business interesf? means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by) a corporation in which the town officer or employee owns more than 5% of the shares~ YES NO ~' If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or ~hild is (check all that apply): A) the owner of greater than 5% of the shares of the corporate stock of the applicont (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 KELATIONSHIP Form TS I Submitted this _7~._day of~ Signature Printlqam~'~ ) (~J~'l/~¥v~ . 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- suooortinv facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.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# The Application has been submitted to (check appropriate response): TownBoard ~-~ Planning Board ~ Building Dept. ~ 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: Present zoning classification: If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (b) Mailingaddress: q [',~ .~'['~'~t>~-~(' b.J ~(c(' ~.~ (c) Telephone number: AreaCode ) (-Q3t -'7~-~ . '3 '[ ./- t~'q q (d) Application number, if any:_ Will the action be direc31y 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 ~otApplicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III - Policies Pages 3 through 6 for evaluation criteria ['-] Yes ~ No ~Not Applicable Attach additional sheets if necessary Policy 3. Enhance 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 Pa~s 8 through 16 for evaluation criteria ~-] Yes ~ No[--~ ' Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III - PoliCies Pages 16 through 21 for evaluation criteria ~ Yes ~-] No[~12 Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. Yes No Not App~le Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies Pages 32 through 34 for evaluation criteria. [--] Yes ~ No ~/~ot Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. ~ee LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. ~ Yes ~-~ No~/~ Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. ~ Yes~ No ~ Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES~ Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria. [] Yes [-~ No ~/~ot 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 ~fNot 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 lVl[~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 N 29°38'50"W N/F MELL Y LOT72 FD CM LOT73 ?D CM CM f~/O lo2-?,¢ WOOD DECK W/ROOF OVER 2 STORY RESIDENCE N 83° 38,11. pV APPR6VED y BOARD OF TRUSTEES TOWN OF SOUTHOLD DATE ~ - 1(~' II WOOD DECK 288. ?0' P/O LOT 74 TM# 1000-090..04-06. 1 SURVEY OF LOT 73 AND P/O LOT 74 IN MAP OF CEDAR BEACH PARK SI TUA TE BA YVlEW, TOWN OF SOUTHOLD SUFFOLK COUNT~, N. Y. SURVEYED FOR: ANTHONY F. GRAZIANO JULIA M. GRAZIANO SURVEYED STANLEY J. ISAKSEN, JR. P.O. BOX 294 04R1BgBRI