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Home My WebLink AboutTR-7578 James F. King,President o��r3F soyo Town Hall Annex Bob Ghosio,Jr.,Vice-President 54 Main Road P.O.. Box 1179 Dave Bergen Southold, New York 11971-0959 John Bredemeyer G Q '� • �O Telephone(631) 765-1892 Michael J.Domino �y00UFax(631)765-6641 NT1,�` BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0858C Date: May 22, 2013 THIS CERTIFIES that the repair to damaged roof on existing cottage/boathouse; repair/replacement of siding; replacement of windows; replacement of rotted wood on existing deck; no habitation of cottage/boathouse, installation of French drains around structure At 1380 Bayberry Road, Cutchogue,New York Suffolk County Tax Map# 118-2-12 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 6/1/11 pursuant to which Trustees Wetland Permit#7578 Dated 6/22/11,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 repair to damaged roof on existing cottage/boathouse; repair/replacement of siding; replacement of windows; replacement of rotted wood on existing deck; no habitation of cottaae/boathouse; installation of French drains around structure. The certificate is issued to JOYCE SAMPIERI owner of the aforesaid property. ►thorized Signati •e 0 • James F. King, President g�►FfQ(,� Town Hall,53095 Main Rd. CO Bob Ghosio,Jr.,Vico- OW President �•l� � P.O. Box 1179 Dave Bergen = Southold,NY 11971 John Bredeneyer !� Telephone(631)765-1892 Michael J. Domino y�ol O Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE INSPECTION: �21 [�5 DATE 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1st day of construction '/z constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: JJ CERTIFICATE OF COMPLIANCE: U 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 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 V/Project complete, compliance inspection BOARD OF SOUTHOLD TOWN TRUSTEES SOUTHOLD, NEW YORK PERMIT NO. 7578 DATE: JUNE 22~ 2011 ISSUED TO: JOYCE SAMPIERI PROPERTY ADDRESS: 1380 BAYBERRY RD.~ CUTCHOGUE SCTM#118-2-12 AUTHORIZATION Pursuant to the provisions of Chapter 275 and/or Chapter 111 of the Town Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted at the meeting held on June 22. 2011 in consideration of application fee in the sum of ! __ Terms and Conditions as stated in the Resolution, the Southold Town Board of TruStees authorizes and permits tl following: Wetland Permit to repair the damaged roof on the existing cottage/boathouse; repair/replace the siding;' replace WindowS; and replaced rotted wood o~ the existing deck, with the Condition there is no habitation of the cottage/boathouse and a French drain is installed around the perimeter of the structure to contain the roof run-off, and as depicted on the survey prepared by John T. Metzger last dated September 28, 2003 and stamped approved on June 22, 2011. IN WITNESS WHEREOF, the said Board of Trustees hereby causes its Corporate Seal to be affixed, and these presents to be subscribed by,a maj0rity of the said Board as of this date. TERMS AND CONDITIONS The Permittee, Jo¥ce Sampieri, residing at 1380 Bayberry Rd.. Cutchoeue. NY, as part of the consideration for the issuance of the Permit does understand and prescribe to the following: That the said Board of Trustees and the Town of Southold are released from any and all damages, or claims for damages, of suits arising directly or indirectly as a result of any operation performed pursuant to this permit, and the said Permittee will, at his or her own expense, defend any and all such suits initiated by third parties, and the said Permittee assumes full liability with respect thereto, to the complete exclusion of the Board of Trustees of the Town of Southold. That this Permit is valid for a period of 24 months, which is considered to be the estimated time required to complete the work involved, but should circumstances warrant, request for an extension may be made to the Board at a later date. That this Permit should be retained indefinitely, or as long as the said Permittee wishes to maintain the structure or project involved, to provide evidence to anyone concerned that authorization was originally obtained. That the work involved will be subject to the inspection and approval of the Board or its agents, and non-compliance with the provisions of the originating application may be cause for revocation of this Permit by resolution of the said Board. That there will be no unreasonable interference with navigation as a result of thc work herein authorized.. That there shall be no interference with thc right of the public to pass and repass along the beach between high and low water marks. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstruction to free navigation, the said Permittee will be required, upon due notice, to remove or alter this work project herein stated without expenses to the Town of Southold. That the said Board will be n~otified by the Permittee of the completion of the work authorized. That the Permittee will obtain all other permits and consents that may be required supplemental to this permit, which may be subject to revoke upon failure to obtain same. Jill M. Doherty, President 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 F~x (631) 765-6641 June 22,2011 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mrs. Joyce Sampieri 1380 Bayberry Rd. Cutchogue, NY 11935 RE: 1380 BAYBERRY RD., CUTCHOGUE SCTM#118-2-12 Dear Mrs. Sampieri: The Board of Town Trustees took the following action during its regular meeting held on Wed., June 22, 2011 regarding the above matter: WHEREAS, JOYCE SAMPIERI applied to the Southold Town Trustees for a permit under the provisions of Chapter 275 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated June 1,2011, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator for their findings and recommendations, and, WHEREAS, in accordance with Chapter 268, said application was found to be Exempt from the Local Waterfront Revitalization Program policy standards, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on June 22, 2011, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standards set forth in Chapter 275 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees APPROVES the application of JOYCE SAMPIERI to repair the damaged roof on the existing cottage/boathouse; repair/replace the siding; replace windows; and replaced rotted wood on the existing deck, with the Condition there is no habitation of the cottage/boathouse and a French drain is installed around the perimeter of the structure to contain the roof run-off, and as depicted on the survey prepared by John T. Metzger last dated September 28, 2003 and stamped approved on June 22, 2011. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of $50.00 per inspection. (See attached schedule.) Fees: $50.00 Very truly yours, Jill I~ Doherty, President BoaYd of Trustees JMD/Ims UT~. ~v~ LOT NUMBERS ARE REFERENCED TO AMENDED MAP A MAP OF NASSAU POINT CLUB PROPERTY, FILED AUG. 16,1922 AS MAP. NO. 156 AREA = 44,6~5 sq. ft to tie, I~nes ~ ' TREES CONTOUR LINE & ELEVAT/ON$ ARE REFERENCED TO N.G.V.D, / / "SURVEY OF. . .PROPER TY A T NASSAU .POINT TOWN OF SOUTHOLD SUFFOLK COUNTY, N Y. 1000 - 118 - 02 ' 12 Sca/e, 1" = 40' July 6, 1996 July 30, 1996 Aug. 3, 1996 ( add/t contours) ~c/. ~, /996 (/,op b¢nk) Sepl. ~8, ~003 fou/line survey & lopogrophlcd info.) ~6~ STREET SOUTHOLD, N.Y, /197/ 96- 192 Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Brederaeyer Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD Please be adv sed that your application dated ~3! I J I,I has been reviewed by this Board at the regular meeting of' (~ I ,~,~! ~ ~ and your application has been approved pending the conap etlon of the following items checked off below. __ Revised Plans for proposed project __ Pre-Construction Hay Bate Line Inspection Fee ($50.00) 1st Day of Construction ($50~00) ~ Constructed ($50.00) ~/"'Final Inspection Fee ($50.00) Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days cftc-application fees will be necessary. You will receive your permit upon completion of the above, COMPUTATION OF PERMIT FEES: TOTALFEES DUE:$ ~-0,00 BY: Jill M. Doherty, President Board of Trustees Jonathan Perry 435 East S7t~ Street Apt. 14B NewYork, NY 10022 Board of Trustees, Town of Southold Town Hall Annex Building 54375 Route 25 P.O. Box 1179 Southold, NY 11971 Via Certified Mail: 7007 0220 0002 6940 1314 Re: Application of Joyce Sampieri SCTM# 118-02-12 June 13, 2011 Dear Sirs, I received a notice regarding work to be done on the Boat House of Ms. Joyce Sampieri residing on Bayberry Road in Cutchogue. I have no opposition to the proposed work. I only ask the Trustees to notify me if any work is to be done on the bottom of the adjacent Lagoon that the property directly abuts. Additionally, I am interested to know why a similar notice was not sent regarding the house directly to the south of the Sampieri property. There is extensive renovation occurring. The structure has been reduced to the studs and appears to be a total renovation, including the installation of a new cesspool. I look forward to your prompt response. Sincerely yours, Jonathan P~ NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: YOU ARE HEREBY GIVEN NOTICE: SCTMg That~lstheintent~noftheundersignedtorequesta Permitfmmthe Boa~ ~ 2. That the property .which.is the subject.of. Environmental Review is located adjacent to your property and is described as follows: 3. That the project which is subject to Environmental Review under Chapters 96,111 and/or 275 of the Town Code is open to public comment on: DATE: ~/e~ -~'un,, .,?~ / ~;ll ~ o,~ ,~J,~,'l- You may contact the Trustees Office at 765-1892 or in writing. The above-referenced proposal is under review of the Board of Trustees of the Town of Southold and does not reference any other agency that might have to review same proposal. PROPERTY OWNERS. NAME: ~ c~ '- ~.~ ~ MAILINGADDRESS:PHONE #: $ _ /..3',P~_ ~'/;r~/~,--/.-~,, ~',~ ~-~,4~,_eu,-_ ,~'/ //~',.;,-,-?~' AGENT: MAILING ADDRESS: PHONE #: Enc: Copy of sketch or plan showing proposal for your convenience. Peter Young, Chairman Lauren Standish, Secretary Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (63 I) 765-1892 Fax (631 ) 765-6641 Conservation Advisory Council Town of Southold At the meeting of the Southold Town Conservation Advisory Council held Wed., June 15, 2011, the following recommendation was made: Moved by Jack McGreevy, seconded by Meaghan Burke, it was RESOLVED to SUPPORT the Wetland Permit application of JOYCE SAMPIERI to repair the damaged roof on the existing cottage/boathouse; repaidreplace the siding; replace windows; and replace rotted wood on the existing deck. Located: 1380 Bayberry Rd., Cutchogue. SCTM#118-2-12 Inspected by: Jack McGreevy The CAC Supports the application with the Condition hay bales are installed prior to construction and a 10' non-turf buffer landward of the bulkhead. Vote of Council: Ayes: All Motion Carried Jill M. Dohetgy, 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(63D765-6641 Southold Town Board of Trustees Field Inspection/Worksession Report Datefrime: ~ (t;7-/ '( I JOYCE SAMPIERI requests a Wetland Permit to repair the damaged roof on the existing cottage/boathouse; repair/replace the siding; replace windows; and replace rotted wood on the existing deck. Located: 1380 Bayberry Rd., Cutchogue. SCTM#118-2-12 Type of area to be impacted: /Z~altwaterWetland __Freshwater Wetland Sound Bay Distance of proposed work to edge of wetland (~ (~ f P/art of Town Code proposed work falls under: 2~_Chapt.275 Chapt. 111 other Type of Application: ,,~ Wetland __Coastal Erosion __Amendment __Administrative__Emergency Pre-Submission __Violation Info needed: Modifications: Conditions: P,~entWere: ~ J. Doherty Ghosio King__ J. Bredemeyeq D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: Date: rD. Bergen, - -- 118 OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY 11971 MA~LING ADDRESS: P.O. Box 1179 Southold, NY 11971 Telephone: 631 765-1938 Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Jill Doherty, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: June 21, 2011 I , Re: Proposed Wetland Permit for JOYCE SAMPIERI SCTM#1000-118-2-12 JOYCE SAMPIERI requests a Wetland Permit to repair the damaged roof on the existing cottage/boathouse; repair/replace the siding; replace windows; and replace rotted wood on the existing deck. Located: 1380 Bayberry Rd., Cutchogue. SCTM#118-2-12 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 EXEMPT from LWRP review pursuant to: § 268-3. Definitions. MINOR ACTIONS item "A" which states: A. Maintenance or repair involving no substantial changes in an existing structure or facility; Cc: Lori Hulse, Assistant Town Attorney Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. l~ng 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 Office Use Only w OaStal Erosion Permit Application etland Permit Application Administrative Permit _._~endment/Transfer/Extension Incomplete I __SEQRA Classification: Type I__Type II Urdisted nation:(date sent) Consistency Assessment Form ,-/~ate of Inspection:~f~ __Receipt of CAC Report: __Lead Agency Determination: ~Technical Review: c-U~blic Hearing Held: __Resolution: -- c lq - 1 20: Name of Applicant ~o)t~. [~zp~.. ~ / _PhoneNumb~:(~0~ Suffolk County Tax Map Number: 1000 - ~/~ _ Pr°pe~yL°cati°n:~° ~m~be"~c~ /~ (provide ILCO Pole ~, d~st~ce to cross stree{s, and lo~tio~) AGENT: (If applicable) / Address: Phone: of Trustees Applicati~ Land Area (in square feet):_ Area Zoning:_ Previous use of property: Intended use of property:_ Covenants and Restrictions: If "Yes", please provide copy. GENERAL DATA .. Yes X' No Does this project require a variance fi.om the Zoning Board of Appeals Yes If "Yes", please provide copy of decision. Prior permits/approvals for site improvements: ~aAgency Date X No · · No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency.'? If yes, provide explanation: X No Yes Project Description (use attachments if necessary):_ ~'~,t's-/~,~7 FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. PRE EXISTING CERTIFICATE OF OCCUpANCy No Z-23509 Date FEBRUARy ~4,_199~ County Tax Map NO. Subdivision THIS CERTIFIES that the building Location of Property 1380 BAYBERRy ROAD House No. Street 1000 Section 118 Block~2 Filed Map No. ONE FAMILY DWELLING ~ 'UTCHOGUE, N.Y. Hamlet __Lot 12 Lot No. conforms substantially to the Requirements for a One Family Dwelling built Prior to: APRIL 9, 195~7 _ pursuant to which CERTIFICATE OF OCCUPANCY NUMBER Z-23509 dated FEBRUARY__24, 1~99~5 was issued, and conforms to all of the requirements of the applicable provisions of the law. The OCCupancy for which this certificate is issued is OWE FAMILy DWELLING WITH ACCESSORy NON-HABITABLE BOATHOUSE* The certificate is issued to (OWner) of the aforesaid building. SUFFOLK COUNTy DEPARTMENT OF HEALTH APPROVAL UNDERWRITERS CERTIFICATE NO. PLUMBERS CERTIFICATION DATED *PLEASE SEE ATTACHED INSPECTION P, EPORT. MARGUERITE p. MULLEIq N/A N/A N/A Rev. 1/81 B~ding insp~ector- - of Trustees Appllcatlon WETLAND/TRUSTEE LANDS APPLICATION DATA Purposeoftheproposedoperations: 7'3 /w~/~gtql~o S-/-,~uc~P~nr*e_ Area of wetlands on lot: Percent coverage of lot: ~9- % Closest distance between nearest existing structure and upland edge of wetlands: <~ feet Closest distance between nearest proposed structure and upland edge of wetlands: 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: square feet -/3~i K]~ z~qd. ,4. 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 proposed operations (use attachments if appropriate): Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 Telephone (631 ) 765-1892 Fax {631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of JOYCE SAMPIERI COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, .--~o¥=~_ -~'tqrr~,'~i , residing at/dba being duly sworn, d~ose ~d sa~: That on the '7~day of :T-. t~ e_ ,2011, I personally posted the property known as by placing the ~o~d o~Tmstees official p~st~ wherdit c~ easily be seen, ~d ~at I have checked to be s~e the post~ has r~ned in place for ei~t days prior to the date of the public hemng. Date ofhemng noted ther~n to be held Wed~ June 22~ 2011 on or about 6:00 PM. Dated: Sworn to before me this '~ dayof~-~- 20x~ Notary Public ALICIA WALKER Notmy Public, State of New York No 0iWA6153064 _ Qualifie~J in Suffolk County ~o~lmission r..xpires Sept. 25, ~..~ ~'.-~ PROJECT iD NUMBER PART 1 - PROJECT INFORMATION 1.APPLICANT/SPONSOR 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2' PROJECT ~M;~,z~c.~ County SEQR 3.PROJECT LOCATION: Municipality 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide mai) 5. IS PROPOSED ACTION: [] New [] Expansion [] Modification / atteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: B. ~lkk PROPOb~D ACIION COMPLY WiTH EXISTING ZONING OR OTHER RESTRICTIONS? []Yes [] No If no, descdbe bdefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply,) [~ResidenUal E~lndustrial []Commercial E~Agricutiure E~]Park/Forest/OpenSpace E~]Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal. State or Local) [~Yes IX]No If yes, list agency name and permit / approval: 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? (~Yes [~No If yes. list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? ~Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE / Sponsor Name ~-O)/~ ¢_ .~,~r,~Pl'c'~Zl' Date: Applicant Signature If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. [~Yes r~No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. [] Yes [] No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED V~TH THE FOLLOWING: (Answem may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: I C2. Aesthetic, agricultural, archaeolngicel, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: I C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly: ! I C5 Growth sn "' .......... .... , ubseque t development, or related activities likely to be induced by the proposed action? Explain bdefly: C6~ Long term, short tem~, cumulative, or other effects not identified in Cl-C57 Explain briefly: i I C7. Other impacts/inciudin~ changes in use Of either cluanti~ or ~:~ ;f cheryl;/? Explain bfiefii: I D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA ICEAI? /If yes, explain briefly,: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If)'es explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadversee~ectidenti~edab~ve,determinewhetheritissubstantia~~~arge~imp~rtant~r~therwisesigni~cant~ Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question ~ of part ii was checked yes, the determination of sig niflca ncc must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or mora potenfially large or significant adverse impacts which MAy occur. Tben proceed direcfiy to the FUL EAF and/or prapam a positive dectaration. Check this box ttyou have determined, based on the information and analysis above and any supporting documentation, that the proposed actio~ WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. Board of Trustees Name of Lead Agency Date Jill M. Doherty President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Pmperer (If different f~om responsible officer) Town of Sou- old Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPER3'Y LOCATION: S.C.T.M. ~ THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM-WATER, GRADING; DRAINAGE AND EROSION CONTROL PLAN ~ Distdct asctlon BlOCk Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTI'ION ITEM# / WORKASSESSMENT [ Yes No a. What is the Total Area of the Project Parcels? (Include Total Area of all Pameis Iocatod within I Will this Project Retain All Storm-Water Run-Off the Scope of Work for Proposed Construction) a~9'~,O~-{S.F. I $~ms} · (This item will include all run-off created by sitoGenerated by a Two (2") Inch Rainfall on Site?V' b. What is the Total Ama of Land Cisadng -.~ cleadng and/or construction activities as well as all and/or Gmond Disturbance for the proposed Site Improvemerds and the permanent creation of constroctlon activity? ~ imperious surfaces.) (S.F. / Acr~) 2 Does the Site Plan aed/or Survey Show All Propes~d PROVIDE BRIEIr PROJECT DESCRIPTION IP,,,~. ~ ~'~ .,~m~,~) Drainage Structures Indicating Size & Location? ThisV' Item shall include all Proposed Grade Changes and -~ ~-a.~,zo~ ,Ca~,-.,,~z.. ~ /,z:Z,~.-,~/~ Siopes Controlling Surface Water Fiow. ' ' / £ / . ~' I 3 Does the Site Plan and/or Survey describe the ems/on *~,,'t.~.*~' //,. ~'~/~,~*~.~ Z~'*~..Z-~ ~ and sediment control practices that will be used to ,,~ ., .. co. cl stie eroaion and starm water dischar, es. This item must be maintained throughout the Eh§re · - Construction Period. ~ ~ /'~"~*"'"'~'~f"*/~'-"~' 4 Will this Project Require any Land Filling, Grading or · / ~ Excavation where there is a change to the Natural 4a~- Existing Grade Involving more than 200 Cubic Yards of Matedal within any Parcel? 5 EncompassingWill this Application Require Land Disturbing Activities an Area in Excess of Five Thoesar<l (5,000 S.F.} Square Feet of Ground Surface? 6is there a Natural Water Course Running through the ~ __ Site? Is this Project within the Trustees jurisdiction ~eneral DEC SWPPP Requirements: or within One Hundred (100') feet of a Wetland or disturber~ces of one (1) or mom acres; including disiurbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes ampartofa largercommonplanthatw~l~ultimatelydisturboneormoreac~esofland; which Exceed Fifteen (15) feet ofVertical Riseto [ [ ~j~ 2. q[31e SWPPP shall describe the eroslo¢l and sediment ccofr~ practices and where 9Will this Project Require the Placement of Matadal, required, po~t.constructisn storm water management prac~c~s that will be used and/or Removal of Vegetation and/or the Construction of any ~ consbx~cted to reduce the p~lutsnts in stoma water discharges and to assure item Within the Town Right-of-Way or Road Shoulder STATE OF NEW YORK .... COUNa~ OE ......... &~.~.Yi~.L.K ......... ss ................... depo e and be/ e appli n for l'hat l, And that he/she is the ......... ..(~....t:~...~ ~.#~. .............................. Owner and/or representative of the Ow~mr or Owners, and is duly authorized to perform or bare 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 k~mwledge and belief; and that the work will be performed in the manner set forth io the application filed herewiillRIREN M. STANDISH Sworn to before me this; N0taly PU~Jc, State of New York ~'~',-i"~' '"~/~'~_ No. 01ST6164008 , / ~ Qualified in Suffolk Count~ ,_. ................. day of .......................... 20.../ Uonl ',~sion Bkoiros 'l .q Publi'(L~"~'"fl'"~"~"7"~"'r~ ............................. &/ ~' (si~ ~ ) ............... Nota~ FORM - 06/10 PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name.' ~ Return Receipt Fee (Endorsement Required) Res c ed Deliver/Fee (Endorsemenl Requ red Address: / sworn, depos%s and sfiys'that on the ~ ~ dayof ~ ,2011 ,d~ponenLmail~datmecopyoftheNotice set foflh in ~e Board of T~stees Application, directed to each of the above named persons at ~e addresses set opposite ~e respective n~es; that the addresses set opposite the n~es of said persons are the address of said persons as shown on the cu~ent assessment roll of~e Town of Southold; that said Notices were mailed at the United States Post O~ce at 5~ u ~ ,, / ~ ~,J. , ~at said Notices were mailed to each of said persons by CERTIFIED M~IL~Tu~ ~CEl~. Sworn to ~ef~re me this Q "Jl Notary Public LAUREN M, STANDISH Notapj Public, State of New York No. 01ST6164008 .. O.ualified in Suffolk CoiJnt~ .. ~ommlssion Expires April 9, 2~ / ~ NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES~ TOWN OF SOUTHOLD In the matter of applicant: YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: 3. That the project which is subject to Environmental Review under Chapters 96,111 and/or 275 of the Town Code is open to public comment on: DATE: You may contact the Trustees Office at 765-1892 or in writing. The above-referenced proposal is under review of the Board of Trustees of the Town of Southold and does not reference any other agency that might have to review same proposal. PROPERTY OWNERS NAME: ~¥c~ ~'~/~,'~/~'c~ ~-~' MAILING ADDRESS: /.~,~o /~'~'~/' V ,~',:Y' ~/-~ o¢~ ~z //~,~" PHONE#: ~,5/- ?'~--/- ~/,2~f'.=J / -"' / AGENT: MAILING ADDRESS: PHONE #: Enc: Copy of sketch or plan showing proposal for your convenience. PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK , residing at , being duly sworn, deposes and says that on the day of ,20 , deponent mailed a true copy of the Notice set forth in the Board of Trustees Application, directed to each of the above named persons at the addresses set opposite there respective names; that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment roll of the Town of Southold; that said Notices were mailed at the United States Post Office at , that said Notices were mailed to each of said persons by CERTIFIED MAIL/RETURN RECEIPT. Swom to before me this Day of ~ 20__ Notary Public Bo~d of Trustees Application County of Suffolk State of New York ~'-0¥ c~ e~ ~-~r~/a i'e ~ ' BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BEI~IEF, 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 DAY OF~-~Ov'l..~ ,20/[ ublic LAUREI~ I~ Notary PUblic, ~te of New York O Ual~:l°~A6164008 APPLICANT/AGENTfREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics nmhibits conflicts of interest on the t~t of town 0fficcm and emolovees. The nurooso of this form is to nmvide information which can ale~ the town of ~ossible conflicts of i~tera~t and allow it to rake whatever action is necossarv to avoid saree. (Last name, first nan~,~ddl¢ initial, unless you are applying in the nan~ of someone elsc or other entity, such as a company. If so, indicat~ the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zoan Coastal Erosion Approval of plat Mooring Exemption lmm 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 .e~ 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 owner of greater than 5% of the shares of the corporate stock of the applicont (when thc applicant is a corporation); __B) the legal or beneficial owner of any interest in a non-corporare 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 ~d,~of ~J-u r~ e- 200/1_ Signature ~'~ Print Name ,/"Un ,, ~e_~ ,St~r~ ~' e~' / t 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 silenificant 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~ listinl~ both supporting and non- suooorting 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# j / ~ - O ~ / ~ The Application has been submi~ed to (check appropriate response): TownBoard ~ Plann~gBoa~ Build~gDept. ~ BoardofT~stees Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g. capital construction, planning activity, agency regulation, land transaction) (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nature and extent of action: Location of action: Site acreage: Present land use.' Present zoning classification: ~- If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: ~ ! (b) Mailing address: /35o (c) Telephone number: Area Code (~.~1 (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes [~ No [] lfyes, 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 ~ Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section 111 - 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 Yes [--] No [] Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. Yes No Not Applic~ 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 [] 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 [] Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island/Sound, the Peconic Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. ~-] Yes ~ No [~ Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages 62 through 65 for evaluation criteria. [] Yes [~ No ~ Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III - Policies; Pages 65 through 68 for evaluation criteria. Yes [~ No ~ Not Applicable / PREPARED BY (~,_~/~.~..o~_- TITLE ~._,-~,.~.~ DATE ~.~////