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Home My WebLink AboutTR-7620A Jmnea F. King, Pr~ident Bob (}ho~io, Jr., Vie~Pr~id~nt Dave Bergen John Br~d~m~yer Michael J. Domino Town H~ll Am~ 543?§ ~ ~ P.O. Box 1179 Southold, l~lew York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRU~FFAgS TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0785C Date: August 13, 2012 THIS CERTIFIES that the removal of the existin~ ext~ior deck and stem and reolace with an addition to the dwelline. At 128 Reservoir Road, Fishers Island. New York Suffolk County Tax Map # 9-8-3.2 Conforms to the application for a Trustees Permit heretofore flied in this office Dated August 8, 2011 pursuant to which Trustees Administrative Permit #7620A Dated · Auaust 24, 2011, 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 removal of the existing, exterior deck and st~os and reolace with an addition to thc dwcllirm. The certificate i~ issued to HIRAM F. MOODY, JR. owner of the aforesaid property. James F. King, President Bob Oho~io, Jr., Vice-President Dave Bergen John Bredemoyer Michael J. Domino Town Hall, 53095 Main Rd. P.O. Box 1179 Sou~old, NY 11971 Telephone ( 631 ) 765-1892 Fax (631) 765-664! BOARD OF TOWN TRUSTEE~ TOWN OF $OUTHOLD DATE OF INSPECTION: ~, Ch. 275 Ch. 111 INSPECTION SCHEDULE Pm-construction, hay bale line/silt boom/silt curtain 1st day of construction ½ constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: CERTIFICATE OF COMPLIANCE: Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Bredemeyer Town Hall Annex 54375MainRoad P.O. Box 1179 Southold, NewYork11971-0959 Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OFSOUTHOLD Please be advised that your application dated ~ I ~l I ~ has been reviewed by this Board at the regular meeting of R !~q. ! I I 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) 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 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 V/'Project complete, compliance inspection 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 Permit No.: 7620A Date of Receipt of Application: August 8, 2011 Applicant: Hiram F. Moody & Sarah R. Goulard SCTM#: 9-8-3.2 Project Location: 128 Reservoir Rd., Fishers Island Date of Resolution/Issuance: August 24, 2011 Date of Expiration: August 24, 2013 Reviewed by: Trustee John Bredemeyer Project Description: To remove the existing exterior deck and steps and replace with an addition to the dwelling. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Richard H. Streuse dated June 7, 2011 and stamped approved on August 24, 2011. 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. Bo,,Cd of Trustees Jill M Doherty, President Bob Ghosio, Jr., Vice-Presidenl 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 Inspection/Worksession Report Date/Time: 7/.2-'~/),z ~.~-f Stephen L. Ham, III on behalf of HIRAM MOODY requests a jurisdictional determination for the construction of an addition to the existing dwelling and the installation of a drywell. Administrative application or full Wetland Permit application? Located: Winthrop Dr., Fishers Island. SCTM#9-8-3.2 y~-y~pe of area to be impacted: Saltwater Wetland Freshwater Wetland Distance of proposed work to edge of wetland ~of Town Code proposed work falls under: __Chapt.275 Chapt. 111 other Type of Application: /Wetland __Coastal Erosion __Administrative__Emergency Pre-Submission Info needed: Sound Bay ~Amendment Violation ~ r ~-~-'-~--'-* ......--~"~,', )6, ' '~z'"t~,'~'M¢ ~jnt Were: J. Doherty B. Ghosio J. King D. Bergen, · Bredemeyer D. Dzenkowski other Form filled Out in the field by Mailed/Faxed to: Date: File Edil: ¥ie~ Toolbar Window Help ~ D~n L~J Image:~ ~ site[ll Re~ COUNTY OF SUFFOLK Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax (63 I) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only __Coastal Erosion Permit Application ~Wetland Permit Application ~/' Administrative Permit Amendment/Transfer/Extension fReceiv'~d Application: .~Received Fee:$ ~'Completed Application __Incomplete __SEQKA Classification: Type I Type Il Unlisted Coordination:(date sent) ~WRP Consistency Assessment Form CAC Referral Sent: ~2Date of Inspection: __Receipt of CAC Report: __Lead Agency Determination: puChnical Review: blic Hearing Held: Resolution: Name of Applicant Hiram F. Moody, Jr., as Trustee Sarah R. Goulard, as Trustee Address 2127 Rabbit Road, Wickenburg, AZ 85390; P.O. Box 2119, Wickenburg, AZ Phone Number:(63 } 283-2400 Suffolk County Tax Map Number: 1000 - 009.00 - 08.00 - 003.002 PropcrtyLocation: 128 Reservoir Road, Fishers Island northwest corner of Winthrop Drive and Reservoir Road (provide LILCO Pole #, distance to cross streets, and locmion) AGENT: Stephen L. Ham, III 85358 (If applicable) Address: 38 lqugent Street, Southampton, bP/ 11968 Phone: (631) 283-2400 Bo of Trustees Application 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 15,151 R- 40 single-family dwelling with deck and steps single-family dwelling with addition Yes x No Does this project require a variance from the Zoning Board of Appeals X Yes No If "Yes", please provide copy of decision. Hearing expected to be scheduled for October 6, 2011 Prior permits/approvals for site improvements: Agency Date Town Building Department February 4, 1998 February 4, 1998 (CO for prexisting dwelling) (CO for accessory storage shed) February 4, 1998 (CO for closet to bathroom alteration) Town Building Department Town Building Department __ 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): removal of existing exterior deck and steps and replacement with addition to dwelling for living space B~rd of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: provision of addltlnnml l ~vqng ~pace Area of wetlands on lot: 190 .square feet Percent coverage of lot: 1.25 % Closest distance between nearest existing structure and upland edge of wetlands: 92 +/-feet Closest distance between nearest proposed structure and upland edge of wetlands: 94 +/- feet Does the project involve excavation or filling? No X Yes (excavation for addition footings) If yes, how much material will be excavated? 20 cubic yards How much material will be filled? 0 cubic yards Depth of which material will be removed or deposited: 4 feet Proposed slope throughout the area of operations: existing Mariner in which material will be removed or deposited: trucked off site ..~atemen_t of~e effec_t~ i fan_y~ o~_n the w~t_l_a9_ _d. ~ andfidal wa__te_r_s _of.~e. _t?vLn' __tha_t ._ma~ _r_esultby reason of such proposed operations (use attachments if appropriate): No adverse effect as area of construction is already improved with a wooden deck. Benefit will result from project in that leaders and drywell will contain runoff from storm water. PROJECT ID NUMBER 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) SEQR PART 1 - PROJECT INFORMATION 1. APPLICANT / SPONSOR 2. PROJECT NAME Hiram F. Moody, Jr. & Sarah R. Goulard Addition to Dwelling at 128 Reservoir Road 3.PROJECT LOCATION: Municipality Town of Southold County Suffolk 4. PRECISE LOCATION: Street Addess and Road InlersectJons, Prominent landmarks etc -or provide mad 128 Reservoir Road, Fishers Island, New York (SC'tH # 1000-009.00-08.00-003.002) 5 IS PROPOSED ACTION: [] New [] Expansion [] Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: removal of existing deck and ~teps on exterior of dwelling and replacement of the same with an addition to be enclosed and used as living space 7. AMOUNT OF LAND AFFECTED: Initially 0.35 acres Ultimately 0.35 acres 8. WILL PROPOSED ACTION COMPLY WiTH EXISTING ZONING OR OTHER RESTRICTIONS? r~Yes [] No If no, describe briefly: the proposed addition is located partly outside the permitted building envelope which requires a 35-foot front yard setback; proposed addition is as close as 28 fee 9 WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) E~]Residential []Industrial [~Commercia, E~]Agriculture E~] Park / Forest / Open Space E~]Other (describe) R - 40 Zone District under the Town of Southold Zoning Code 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) E~]Yes ['--~No if yes, list agency name and permit / approval: Town of Southold Board of Appeals. for variance; Town Building Dept. if variance gran 11. L)OE~5 ANY ASPE(51 OI- IHb A(.;IION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? E]Yes E~No If yes, list agency name and permit / approval: 12, AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? Des ~]No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsc~ Name Hiram F. Moody~ Jr. & Sarah_R. Goqlard, Trustees Date: 08/08/11 By Stephen L. nam, III, autnorizea agent Signature Stephen L. Ham, III, authorized agent If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment ed 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 FAF. [] Yes [] No VVlLL ACTION RECEIVE COORDINATED REVIEVV AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative dectaration may be superseded by another involved agency. [--]Yes []No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing a r qua ry, surface or groundwater quality or quantity, noise levels, existing traffic paffem, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archseological, historic, or other natural or cultural resources; or community or neighbed~oed charaster? Explele bhetiy: I C3. Vegetation or fauna, fish, shellfish or wildlife species, significant hehfiala, or threatened or endangered species? Explain'briefly: I C4. A community's ex,ting plans or goats as officially adopted, or a change in use or intensily of use of land or other natural resoumes? Explain briefly: C5 Gm h .......... ' · wt 1 subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6 L "' · ong term, short term, cumulative, or other effects not identified in C1-C57 Explain briefly: I C7. Other impacts (includin~ changes in use of ether quontiti/or ~pe of energy/? Explain beetle': I D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA ICEA}? [] Yes [~NoJ I,, ' /If~'es'explainbdefl~/: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTL~L ADVERSE ENVIRONMENTAL IMPACTS? If ~'es explain: PART III - DI=] ~-I~alNATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For eacil adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. 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 d of part ii was checked yes, the determination of significance 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 mom potentially large or significant adverse impacts which NIAY occur. Then proceed dire(fly Io the FULI FAF and/or prepare a positive declaration. Check this pox ifyeu have determined, based on the infom~ation and analysis above and any supporting documentation, that the proposed a(flo~ WILL NOT result in any signlflsanl sdveme environmental impacts AND provide, on attachments as necessary, the reasons supporting thi= determination. Board of Trustees Name of Lead Agency Date Jill M. Dohert¥ President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATIOa: S.C.T.M. ~ THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A 1000 9 * 8 3 · 2 STORM-WATER~ GRADING~ DRAINAGE AND EROSION CONTROL PLAN ot~M, ct secUo, ak~x Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YOF~. scOpE OF WORK - PROPOSED CONSTRUCTION l't'l~l# / WORKASSESSMENT ] Yes No a. What is the TotaJ Ama of the Project Parce!s? I WillthisProjectRelainAtiStorrn-WaterRun-Off (Ioct ude Total Area of all Parcels located wi~in 15~[51 S.F. Generated by a Two (2") Inch Rainfall on Site? the Scope of Work for proposed Construction) (s.F. t A~) (This item wilt include all mn-off created by see X b. What is the Total Ama of Land Clearing clearing and/or construction activities as well as all -- andlor Ground Disturbance for the proposed ~0.5 S.F. Site Improvements and the permanent creation of impervious surfaces.) construction acfivtiy? (S.F., *a~s) 2 Does the Site Plan and/or Survey Show Ail proposed PROVH3E B]I~ PROJ'~Cr DESC~HH'[ON ~ ~ P~- ~,,,~ Drainage Structures Indicating Size & Location? This X Item shall include ali Proposed Grade Changes and -- Slopes Controlling Surface Water Flow. removal of existing deck and steps on 3 Does the Site Plan and/or Survey describe the erosion exterior of dwelling and replacement and sndiment control practices that wtil be used to X conl~ol site erosion and storm water discharges. T~is -- of the same with an addition to be item must be maintained throughout the Entire Construction Period. enclosed and used as living space 4 Willthis Project Require any Land Filling, Grading or Excavation where there is a change to Ihe Natural Existing Grade Involving more than 200 Cubic Yards of Material within any Pamel? 5 Will this Application Require Land Disturbing Activffies Encompassing an Area in Excess of Five T~ousand~ _~_ (5,000 S.F.) Square Feet of Ground Surface? 6 Is there a Natural Water Course Running through the Site? IsthisProjectwithintheTrusteesjurisdictio~~ X or within One Hundred (100') feet of a Wetland or -- General DEC SWPPP Requirements: Beach? ~iisturbances ~f one (1) o~ mom acres; Includingdisturhencesof~essthanoneac~elha[ 7Will there be Site preparafion on Existing Grade Stopes SWPPP's Shell meet the Minimum Requlrement~ of the SPDES General pemlit ] 8 Will Driveways, Parking Areas or other Impervious STATE OF NEW YORK, O,,FFr, LK q~ - Stephen L. Ham, III --' '- sworn, deposes and says that he/she is the applicant for Permiig nat 1 ................ ~'~%i'~gJ'~j~'~)' ................... oemg (]tuy Owner and/or representative of the Owner or Owners, and is duly authorized to perform or have pedormed 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 performed in the manner set forth in the application filed herewith. Sworn to before me this; i~T~ -- f August 20 11 FORM - 06/10 Qualified in Sufl.olk County ,~ Commission Expires June 30, of Trustees Apu County of Suffolk State of New York AUTHORIZED AGENT OF THE / STEPHEN L. HAM, III / BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THEt~a..PPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. 1N 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. Signature Stephen L. Ham, III SWORN TO BEFORE ME THIS ~ FT~ DAY OF AUGUST 20 11 /~/Notary Public / Y JOANN E. SCHNAUFER. Notary Public, State of New York No. 01SC5081241 Qualified in Suffolk County Commission Eypirc'* .hm~. 30. ~:~0/ Hiram F. Moody, Jr.,as Trustee Sarah R. Goulard, as Trustee 2127 Rabbit Road Wickenburg, AZ 85390 August2,2011 Board of Trustees Town of Southold 53095 Main Road Southold, NY 11971 Re: Application for Administrative Permit at Premises at 128 Reservoir Road, Fishers Island (SCTM No. 1000-009.00-08.00-003.002) Dear Board Members: The undersigned, Hiram F. Moody, Jr., in his capacity as Trustee of the Hiram F. Moody, Jr. QPRT u/d May 16, 2011, and Sarah R. Goulard, in her capacity as Trustee of the Sarah R. Goulard QPRT u/d May 16, 2011, as co-owners of the referenced premises situate at Fishers Island, New York, hereby authorize Stephen L. Ham, III of Matthews & Ham, 38 Nugent Street, Southampton, New York 11968, to act as our agent in making such applications to your Board and in taking any and all incidental actions in regard thereto, including without limitation, completing and executing the required forms, giving any required notices and appearing at any public hearings, as he shall deem necessary or advisable in order to procure from your Board an administrative permit and such other relief as your Board may deem just and proper with respect to the construction of an addition at the subject premises as shown on the Site Plan prepared for Hiram F. Moody, Jr. and Sarah R. Goulard, by CME Associates Engineering, Land Surveying & Amhitecture PLLC, dated June 7,2011, as the same may be revised from time to time. Very truly yours, Hiram F. Moody, Jr., as Trustee APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE. FORM The Town of Southold's Code of Ethics vrohibits conflicts of interest on the tort of town officers and emnlovees. The oumose of t3is form is to orovide information which can alert the town of unssible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOU'RNAME: lt'iram F. I%ody, Jr. & Sarah R. Goulard (Last name, fa'st name,~aiddle initial, unless you are applying in the n~,~¢ 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 X Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (1 f"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 ofllccr or employee has even a partial ownemhip of(or employment by) a corporation in which thc town officer or employee owns more than 5% of the shares. YES NO X I f 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 the app}icant is a corporation); B) the legal or beneficial own~ of any interest in a non-corporate entity (when the applicant is not a cot~poration); ___C) an officer, director, par~er, or employee of the applicant; or D) the actual applicant. DESCRIPTIObl OF RELATIONSHIP Form TS I Submitted this ~ t~ day of Aulgust 20{)1 Signature -~ t_. t~, J~' PrintName Stephen L. ltam, III, authorized agent Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area (which includes all of Southold Town). If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus~ each answer must be explained in detail~ listing both supporting and non- suooorting facts. If an action cannot 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# 1000-009 - 00-08.00- 003.002 PROJECT NAME SITE PLAN FOR HIRAM F. MOODY, JR. & SARAH R. GOULARD The Application has been submitted to (check appropriate response): TownBoard [] Planning Board [~ Building Dept. ~] BoardofTrustees 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: administrative permit to allow construction of an addition to an existing residence that is partially within a 100-foot setback from the tidal wetland Locmionofaction: 128 Reservoir Road (northwest corner of Reservoir Road and Winthrop Drive), Fishers Island Si~ acreage: 0.35 acre Present land use: residential property improved with single-family dwellSng Present zoning classification: R-40 Zone District If an application for the proposed action has been filed ~4th the Town of Southold agency, the follourhng information shall be provided: (a) Nameofapplicant: Hiram F. Moody, Jr. & Sarah R. Goulard (b) Mallingaddress: P.o. Box 2119, Wickenburg, AZ 85358 (c) Telephone number: Area Code ( ) c/o Matthews & Ham (631) 283-2400 (d) Application nurnber, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes [] No [X~ 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 ~] Not Applicable property is already essentially developed; the addition will be placed in an area on the property that is already disturbed 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 project is a simple addition to an existinm dwelling 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 project is not intended to, nor will it have any impaat on: v~m,~l mmlitv or scenic resources 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 location of addition on property is well outside flood area leaders and drywell will contain roof storm water runoff not 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 project is not designed to affect nor will it have any impact on water quality 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 HI - Policies; Pages 22 through 32 for evaluation criteria. Yes No Not A project is neither designed nor intended to have, nor will it have, any impact on the quality or function of the Town of Southold ecosystems 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 project is neither designed nor intended to have, nor will it have, any impact on' air quality 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 project is not intended or designed to have, nor will it have, any impact on environmental degradation from solid waste or hazardous substances 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. [] YeJ--~ No ~ Not Applicable project is located on private property to which the public does not now nor will it have the right of access or use 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 project is neither intended nor designed to have. nor will it have. any impac~ on water-dependent uses Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peeonie Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. [-q Yes ~-] No ~ Not Applicable ' project is neither designed nor intended to have, nor will it have, any impact on living marine resources in the Town of Southold 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 no agricultural uses are now, nor will they be, undertaken at the property other than those ancillary to the single-family residential use 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 project is neither designed nor intended to have, nor will it have, any impact on the use and development of energy and mineral resources Stephen L. Ham, III TITLE Authorized Agent DATE 08/06/11 Ms. Lauren Standish Board of Town Trustees Town of Southold P.O. Box 1179 Southold, NY 11971 I~ATTHEWS ~ H~.~ ATTORNEYS AND ~OUNSELORS iT LXw 38 NUGENT STREET SOUTHAMPTOR, NEW YORK 11908 August 6,2011 Re: Application for an Administrative Permit by Hiram F. Moody, Jr. and Sarah R. Goulard, as Trustees (SCTM # 1000-009-08-003.002) Dear Lauren: In accordance with our recent telephone conferences, I have enclosed the the original and one copy of each of the following documents relating to the referenced application: 1. Letter of Authorization from the owners authorizing me to act on their behalf in connection with the application. 2. Board of Trustees Application, signed and sworn to by me as authorized agent. 3. Shod Environmental Assessment Form, signed by me as authorized agent, 4. Town of Southold Erosion, Sedimentation & Storm-Water Run-off Assessment Form, signed and sworn to by me as authorized agent. 5. Applicant/Agent/Representative Transactional Disclosure Form, signed by me as authorized agent. LWRP Consistency Assessment Form, signed by me as authorized agent. Ms. Lauren Standish Page 2 August 6, 2011 7. Site Plan prepared for Hiram F. Moody, jr. & Sarah R. Goulard by CME Associates Engineering, Land Surveying & Architecture, PLLC, dated June 7, 2011. As you know, I have previously submitted the $50 application fee. Dick Strouse has advised me that he spoke with John Bredemeyer yesterday and that John is now satisfied that the additional drywell he initially requested for the landward side of the house is not necessary since the proposed drywell in the rear yard will be adequate to contain all roof runoff. If you require any further information, documentation or payments before this application can be processed, please notify me immediately. Thank you for your attention to this matter. Enclosures CC: Ms. Sarah R. Goulard Mr. Hiram F. Moody, Jr. (w/o enclosures) Sincerely, Stephen L. Ham, Ill ATT0~NEYS AN~) COUNSELORS X~ ~W SOUT~MPTON, NEW YORK 11968 Board of Town Trustees Southold Town Hall Annex 54375 Main Road Southold, NY 11971 Re: Jurisdictional Issue for Proposed Construction at 128 Reservoir Road on Fishers Island July 19, 2011 Dear Board Members: I represent Hiram F. Moody, Jr. and Sarah R. Goulard, the owners of premises at 128 Reservoir Road on Fishers Island (SCTM No. 1000-009.00-08.00- 003.002). My clients are in the process of applying to the Zoning Board of Appeals for a setback variance that will allow them to add an new interior room to their single-family dwelling which will replace an existing exterior deck and steps. I have enclosed a print of a site plan, prepared by CME Associates Engineering, Landscaping & Architecture, PLLC under date of June 7, 2011, showing the proposed addition as well as existing conditions. As you can see from the enclosed site plan, a portion of the proposed addition appears to be within 100 feet of the tidal wetlands bordering the subject property on the west and the proposed construction is presumably within your jurisdiction. I would appreciate it if you would advise me of the type of permit and amount of the fee my clients would be required to obtain from and pay to your agency in order to proceed with the construction. At the same time, please send me the appropriate application form and any other documentation that must be submitted. Alternatively, if due to the fact that the area has already been disturbed or in light of its elevation or otherwise you are able to issue a letter of non-jurisdiction for this project, please do so and mail the same to me. I will provide specific evidence of my authority to act for the owners in due course if you need more than the copy of the enclosed letter of authorization addressed to the Zoning Board. In the meantime, if you need to visit the site to make your determination, I have enclosed my firm's check to the Town of Southold for the $50 inspection fee. . . - : - Thank you for your attention to this matter. , JUL 2 0 2011 Very truly y~urs, Stephen L. Ham, III Enclosures Hiram F. Moody, Jr.,as Trustee Sarah R. Goulard, as Trustee 2127 Rabbit Road Wickenburg, AZ 85390 July 5, 2011 Board of Appeals Town of Southold 53095 Main Road Southold, NY 11971 Re: Application for Variance at Premises at 128 Reservoir Road, Fishers Island (SCTM No. 1000-009.00-08.00-003.002) Dear Board Members: The undersigned, Hiram F. Moody, Jr., in his capacity as Trustee of the Hiram F. Moody, Jr. QPRT u/d May 16, 2011, and Sarah R. Goulard, in her capacity as Trustee of the Sarah R. Goulard QPRT u/d May 16,2011, as co-owners of the referenced premises situate at Fishers Island, New York, hereby authorize Stephen L. Ham, III of Matthews & Ham, 38 Nugent Street, Southampton, New York 11968, to act as our agent in making such applications to your Board and in taking any and all incidental actions in regard thereto, including without limitation, completing and executing the required forms, giving any required notices and appearing at any public hearings, as he shall deem necessary or advisable in order to obtain approval of a variance or variances and such other relief as your Board may deem just and proper with respect to such premises in accordance with the Site Plan prepared for Hiram F. Moody, Jr. and Sarah R. Goulard, by CME Associates Engineering, Land Surveying & Architecture PLLC, dated June 7, 2011, as the same may be revised from time to time. Very truly yours, Hiram F. Moody, Jr., as Trustee Sarah R. Goulard, as Trustee ~ ~ ROOF AREA-EXiSTING & PROPOSED = 1600 SF ~ REQUIRED = 1600 SF x 1.0 X 2/12 = 26'7 CF 1.) SURVEY MAP PROPER~' TO BE CONVEYED TO i ~ ~.. 267 CF / 50,27 CF/VF = 5.5 VF ISLAND, NY CHANDLER, PALMER & KING ARCHffECTURE~ ENGINEERING AND SURVEYING 110 BROADWAY NORWICH, RESIDENCE , 5,) SITE IS IN THE TOWN OF SOUTHOLD, COUNW OF SUFFOLK TAX MAP ~ ~ORMWATER D~ELL D~AIL 10' ~ ~,) ~O~*L A.~ = 1~,~5~* S~, ~, ~ , LOCATION MAP SCALE 1"=400' 7,) SITE IS LOCATED IN R-4O ZONE. ~ ~ ~z ~ERS (SEE D~N~ ~TIDAL W~NDS~ BANK~ ~[ '~{ ~ ~0 I N/F NOW OR FORMERLY OVERH~D WIRES PROJECT MAN~ ~ ~/~/J/ WOOD FENCE DATE: 06/07/2011 ' SCALE: 1" = 20' [~,.~E~AL F X 22.4 SPOT EL~ATION ' ~U~TU~L SHE~: 1 OF 1