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Home My WebLink AboutTR-7609A 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 I st day of construction ~ constructed 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.: 7609A Date of Receipt of Application: July 19, 2011 Applicant: Suzanne Egan SCTM#: 20-1-3.2 Project Location: 37415 Main Rd., Orient Date of Resolution/Issuance: August 24, 2011 Date of Expiration: August 24, 2013 Reviewed by: Board of Trustees Project Description: To install a 200 If. post and rail fence along the property line. 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 June 19, 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 $outhold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Boa~ 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 Southeld, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application datedg ll tl l ,, has been reviewed by this Board at the regular meeting of ~')~.) Ii 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: $ ~), 0/~ BY: Jill M. Doherty, President Board of Trustees Jill M Doherty, Presidem Bob Ghosio, Jt., Vice P~esidenl James F Krug Dave Bergen John Bredemeyer PO Box 1179 Southold. NY 11971 Telephone (631 765-1892 Fax (631 ) 765-6641 Southold Town Board of Trustees Field Inspection/VVorksession Report Date/Time: q-i-)' Il 1,~ "~ SUZANNE EGAN requests an Administrative Permit to install a 200 If. post and rail fence along the property line. Located: 37415 Main Rd., Orient. SCTM#20-1-3.2 T_T_~alLf area to be impacted: ater Wetland Freshwater Wetland Sound Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: j,~,1~apt.275 //~hapt. 111 other Type of Application: ~etland __Coastal Erosion __Amendment __Administrative__Emergency Pre-Submission __Violation Info needed: Modifications: Conditions: Present Were: ~'J. Doherty B. Ghosio L,~King __ '[,/J~. Bredemeyer D. Dzenkowski --other Form filled out in the field by D. Bergen, Mailed/Faxed to: Date: F'ROPOSFIP "JOY.C,E P. SITUATE: ORIENT TOP, IN OF SOUTHOLIP SUFFOLK C, OUNTY., NY' to~°~ O$ .... P OPFRT'P TERRY SET-OFF &URVf=YFD OI-21-qq AHEN~ED O~-2q-qq OS-2&-qq, O&-02-O0, .Oq-05-O0, I1-10-OO SUFFOLK COUNTY TAX IOOO - 20 - I - IOOO - 20 - I - D.D I000 - 20 - I - 9.4 SUt=POLI< COUNTY HEALTH E;;'EPT. ~ ~lo-qq-ooI..~ OhlNIERS - APPLICANTS: hloin P-.ood At;~A HAP fl:f--.,ALE I": ~00' S.C. TAX LOT ~ 1000-20-1-..~.2 ORVILLE TFP-,P-.Y ~ THF TOF~N OP SOUTHOLD HAIN ROAD ORIENT, NY IIq,D~' . TAX LOT ~ 1000-20-I-D.D Jo"r'CF P. TERRY HAIN ROAP ORIENT, NY IIqS-'/ S.C. TAX LOT .~ 1000-20-1-~.4 EE:::,!AIARO J. IdYSOCKI HAIN ROAD ORIENT, NY MELISSA A. SPIRO LAND PRESERVATION COORDINATOR melissa.spiro @ town.southold.ny.us Telephone (631) 765-5711 Facsimile (631 ) 765-6640 OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (comer of Main Road & Youngs Avenue) Southold. New York MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971-0959 DEPARTMENT OF LAND PRESERVATION TOWN OF SOUTHOLD July 13, 2011 Suzanne Egan P.O. Box 501 Orient, NY 11957 RE: SCTM # 1000-21).-1-3.2 ~' ~ ' EGAN ProperO/ ~/~-E~T-A'~T~I~O~ILLE TERRY) Request for Land Preservation Committee Review of fencing installation on property on which Town owns a development rights easement Dear Ms. Egan: The Land Preservation Committee Members, in accordance with Section 70-5 C. (2) [3] of the Town Code, reviewed your request dated June 30, 2011 for fencing installation to be located upon land on which the Town owns a development rights easement. The recorded easement for this property allows land within the easement to be used for the purpose of agricultural production which includes fencing. Section 70-5-C. (2) [3] requires that the Committee serve as a review board for the granting of permits for the construction, reconstruction and additions of and to structures in or on agricultural lands in which the development rights have been acquired by the Town. The Committee is approving the use you requested, as listed and cladfied below, to be allowed within the development rights easement area. The .Committee's approval does not mean that you can proceed with installation. All ~mprovements are subject to all applicable Town Code requirements. Erection of fencing for the purpose of indicating the actual eastern property boundary line from LI Sound to an existing monument located along the property line. The fencing will further establish the property's boundary line where there is an existing lawn encroachment into the development rights easement area. Please note that the Committee's approval of this use within the easement does not mean that such use will be approved or permitted by other Town Departments or agencies. The Committee's approval allows you to proceed with pursuing any applicable approvals that are required by Town Code. Please feel free to call me if you have any questions regarding the above. Sincerely, Melissa Spiro Land Preservation Coordinator MS/md eric.: Request form w/attachment cc: Planning Department w/enc. Building Department w/eric. M~LL~A A. LAND PREgER-VATION COORDrNATOR · T~lepbone (63 I) 765-571 I Facsimile (631) 765-6640 TOWN'OF SOUT~OLD hame. of Owner (ple. ase print): · ' ' Name(s)~pipreviousowher: ..:(i~ appIicab e) ' Mailing Address: -OFFICE LOCATION: TO~ ltall ~4375 Sta~ Rome 25 (<:a'n~' of Main Rd-& Youngs Ave)' Somhold, N~v York P.O. Box 1179 gou&old, Ny 11~71-~59 - · . -. REOUEST for Rg~icuitural Structure'Piacement.on PDR i~and; -I. am the.owner of .ti~e. property described ~elow and on w~lch,the 'To,Wn purchased a development rights/c~.nservatloneasemen~ on o~ abou{.. 1 ct~:;~ ~ ? ~, (date). .... Ph0n~ Number: ' P/'oPe~Y Lecat on: , :... , .):iist'type;size.'and. useof, each. a~icufti~ralstructur~pmp~sedi ~'....., .... . .:. . . . .. :/.. '.. -~'~.~, '~;m~n~'.:. ~ '-~r-~'-l, q~, '."C~ peen·:{," - - "- ' -o'~. ~ ~~.~ .~.~ ~:'~ .~-':~ ': ' , ; '. ...... · ,:. ,u,, ,- ,,u~ey. 'x' map. o, sk~cn, plan,' snowing '~ac~ment ~,, Of 'agdcultu.[ ~u~)..~ '- ' ' di~efr°m'pr~P~'~n~a~inesLa~dan~rea~l~'a~ila~lei~{o~maflonr~i~ti~gto, yobr 'eque~: ' ' YOO may'talk wRh the COordinator at (631)765-57il.m d Scu~ qu~onk ~[ ~. ~mnge to'pa~icipete n any of :. . '... the.regbla['meetings'ofthe~Pmsewation~m~Ree.. · .'. . .... :: . · - ; · Please.return the completed~form with attad{ments to: Town of SouthoId- Land PreservafiokDepartm~nt ' ~AIl..attachments must be signed andilate'd by property owner. .JUL - DEPT. OF L~NO, '. PRESERVAT~I~ 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 (631) 765-6641 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD Office Use Only Coastal Erosion Permit Application~. ~Wetland Permit Application ~ Administrative Permit V/R __AmendmenffTrans fer/E~tension eceived Application: / Q ! I~ ~../Reeeived Fee:$ ~ ' . ~'Completed Application r j ![ ~ Incomplete SEQRA Classification: , Type I Type II__Unlisted Coordination: (date sent) Consistency Assessment ~,,~aAC Referral Sent: hlO~ , te of Inspection: O Ilr'-I I {t Receipt ofCAC Rep~:" ' Lead Agency Determination: Technical Review: ~[;ublic Hearing Held: ~ .~1 Resolution: NameofApplicant ~LbTCkC3~'~- ~__.~C~ ~. ,_9 g~ t t ~ ¢'¢ Phone Numb~:¢D .~ ' ~' ~ C Suffolk County Tax Map Number: 1000 - cO.~O. ' ]._ - 3 eropertyLocation: ~-Q~'~--_(ff"l p(O~0--C}'~ ~5)OUt(~dSO~j (provide LILCO Pole #, distance to cross s'treets, and location) AGENT: (If applicable) Address: B~d of Trustees Application GENERAL DATA Land Area (in square feet): Area Zoning: Pre~ous use ofprope~y: ~Q Int~ded use ofprop~y: A ~ Coven~ts ~d Resffictions: If"Yes", please provide copy. Does this project require a variance from the Zoning Board of Appeals __ If "Yes", please provide copy of decision. Yes "/ Prior pm'mits/approvals for site improvements: Agency ....... ~ Date No No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? y 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: Area of wetlands on lot: -- 0 -- square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge o f wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? How much material ~vill 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_Ihe ~ffect, if any, 0_n the wetlands and_tidal_ w~_t??s~ of the toxvn tha~t ~ay result by_ reason of such proposed operations (use attachments if appropriate): PROJECT kD NUMBER PART 1 - PROJECT INFORMATION 1. AP(~LICANT / SPONSOR ].PROJECT LOCATION: ~ 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 NAME County ~_'~OI I~. SEQR Muni¢ipalily ~,~,~ ~ ~ [-~ OiC0 PRECISE LOCATION: Streel Addess and Road Intemections, Prominent landmarks el¢ -or Drovide mad 5. IS PROPOSED ACTION: [] New [~Expansion E]ModiflcatJon/alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~]Yes [] No if no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) ~ Residential [] Industrial E~ Commercial ,[~']Agriculture BI Park / Forest / Open Space r'~ Other (describe) 10.' DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, AGENCY (Federal, State or Local) E~Yes ~-~No If yes, list agency name and permit / approval: NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL 11. DUE5 ANY A~SPEIJI fJ;- IHE ACTION HAVE A CURRENTLY' VALID PERMIT OR APPROVAL? ~f yes, list agency name and permit / a royal: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponso¢ Name ~OZ-~r'~V~,~- ~Oj~/'~ Date:'I'~' I'~ Signature ~. I'~, ~._ ~=S ~-t//~ 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 A~lency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes, coordinate the review process and use the FULL EAF. I~1 Yes ~']No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative declaration may be superseded by another involved agency. I~Yes r-~-i No c. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answere may be handwritten, if legible) C1. Existing air quality, surfaco or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste produeflon or disposal, potential for erosion, drainage or flooding problems? Explain briefly: I C2. Aesthetic, egdcultural, archaeological, 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 intensi~ of use of land or other natural resources? Explain briefly: I I I C5. Growth, subsequent devetupment, or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or olher effects not identified in C1-C5. Explain briefly: C7. O_thor impacts lincludin~ chanl~ies in use of either c~uanti{7 or t~pe of ene~l~'? Explain briefli/: / I D. VVILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL Ei_~I ~eOsN M Ei~.~ALNoAilA I CEA/ ? (If yes, explain briefly,: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If ~'es explain: PART Itt - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each 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 occorring; (c) duration; (d) ii'reversibility; (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 more potentially large or signlficont adverse Impacts which MAY oncur. Then proceed directly to ~he FULl FAF and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that lhe proposed actio~ WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as neoessa~, the reasons supporting thli determination. Board of Trustees Name of Lead Agency Jill M. Doherty Pd~ or _Type Nar~of Re~p~n.~ Officer in Lead Agency (../~rSigneture of Responsib~ Officer in Lead Agency Date President Title of Responsible Officor Signature of Preparer (If different from responsible officor) Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM-WATEI~ GRADING; DRAINAGE AND EROSION CONTROl. PLAN o~tdct S~ctinn Block Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. OF WORK - PROPOSED CONSTRUurION fl'l~I # / WORKASSF_~ [ Yes No SCOPE a. What is the Total Area of the Pro'ject Parcels? ~:..~C~(~ ([~'~' 1 Will this ProJect Retain NI Stom~Water Run-Off (Include Total Area of all Parcels located within the Scope of Work for Proposed Construction) ,~ ~.~ ~. Generated by a Two (2') Inch Rainfall on Site? r~ b. What is the Total Ama of Land Clsarthg (s.~.~Ao~es) (This item will include all ron-off created by slte cleadng and/or construction aclJvitles as well as all -- and/or Ground Disturbance for the propesed ~(~ ! (j~, ~C~./~ Site Improvemente and the permanent creation of construction activily? (~.F~'7~-~' impervious surfaces.) 2 Does the Site Plan and/or Survey Show,NI Proposed PROVIDE BRIEF PROJECT DF~CRIPTION (F~.~e~,.;..~ Drainage Structures Indicating Size & Location? This r~ item shall include all Proposed Grade Changes and C,re h_o o-C- S,epeeCo. o,li.gS*aceWatar.ow. and sediment control practices that will be used to control see erosion and storm water discharges. This -- t ~ ~ ~ (~C),_h ~ ~ ~ item must be maintained throughouttheEnfire Construction Pedud. ~) I'~J~)L~r"~l~/t l[t'f'"~ tp[~-- ~"-,~ 4 Will this Project Require any Land Filling, Gradingor ~ Excavation where there is a change to the Nalural r"'l '~,~'~ I ~ ~[ '~ j' Iq ~(-~} ~/~ Existing Grade involving morotha. 200CubicYardsI--I £ncompessing an Area in I=xoess of Fi¥o Thco~ed __ -~ ~._~[~__~ (~_~_~_ ~flXC~/~(~ S Wiil this Application Require Land Distudfing Activities _ (5,000 S.F.) Square Feet of Ground Surface? 6,a there a Natural Water Course Running through the Site? Is this Project within the TrusSes jurisdiction General DEC SWPPP Requirements: or within One Hundred (100') feet of a Weflaed or Submission of a SWPPP is required for all Construction activities invoNing sell Beach'} dishJrbances of one (1) or more acres; inctudiog cib~turbances of less than one acre that 7Will there be Site preparation on Existing Grade Slopes ~ are par~ of a larger common plan that w~# uitimein~y disturb one or more ac~es of land; which Exceed Fifteen (15) feet of Vertical Rise to ~ including Construction activllJes involving soil dislurbances of less than one (1) acre where One Hundred (100') of Horizontal Distance? Ihe DEC has detemllned that a SPDES permit is required for storm water discharges. SWPPP's Shell meet the Minimum Requirements of the SPDES General pen'nit 8 Will Driveways, Parking Areas or other Impervious ~ for Sform Water Discharges frmll Con$~-uofion activity. Permit No. GP-0-t0-001.) Surfaces be Sloped to Direct S~rm-Water Run-Off 1. ~e SWPPP shall be prepared prior fo the subm~ital of the NOL The NOI shaJl he into and/or in the direction of a Tov~ fight-of-way? submllted to the Departr~ent prior fo ~he commencement of construction activity. 2. The SWPPP shall desedbe the erosion and sediment control pracUce~ end where 9Will this Project Require the Placement of Material, required, post-construction storm water management practices that will he used and/or Removal of Vegetation and/or the Construction of any ii constructed to reduce the pctlutants in Stsml water discharges and to assure item Within the Town Right-of-Way or Road Shoulder compliance with the terms and condiUons of this permit. In addition, the SWPPP shaJl Area? (Th~ ~tem Mil NOT Inelude th~ IIl~tailMIOll et ~ identify p~entidl s~Jrces of polction which may reasonably he expected ~o affect the componeof shall be pregarsd by a qualified Design professorial Ucensed in New York a Storm-Wster, Gradthg, Drainage & Ero~inn Conb~st Pinn I~ Requhed by the To~m of STATE OF NEW ¥OP,~, ~ //~} Il, (Owner, Contractor, Agent, C<xporate Officer, etc.) Owner and/or rcprcsculadvc of thc Owner or Owners, ;md ~s duly authorized to pcd'o~m or h~vc performed thc s~d work ;md to make and ~]c d~s ~ppl~cafion; that ail statcmcu~ cont~ncd in d~[s applicadou are ~uc to thc best of h~s knowledge and be]Jc£; that thc work will be pcd'ormcd in thc m;mucr set £o~h in thc app)icad, on filed bercv,~th. Sworn to before mc th~s; FORM - 06/10 Ce ~ualifiedin Suff~ mmi~ion Expires Sept. 29, Y.,~ 1 ~ Bard of Trustees Applicat~ County of Suffolk State of New York c'~) ~ Q I~ Y~(} ~-'~7',~%~-- ~ BEING DULY SWORN DEPOSES AND AFFIRMS THP~T~I~E/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH 1N THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, 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. ~)~ Signatur~eh~--, SWORN TO BEFORE ME THIS /~7 DAY OF ,J ~ ,20 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 ouranse of this form is to orovidc informat on which can alert the town ofoossible conflicts of interest and allow it to take whatever action is necessary to avoid same. (Last name,'~rst name, ~iddle initial, unless you are app yiag in the name of somanne else or other entity, such as a company. If so, indicate~the other person's or company's name.) NAME OF APPLICATION: (Check ali that apply,) Tax grievance Building Variance Trustee 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, nlaffiag¢, or business interesL "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicant/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 applic0nt (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, partnei', or employee of the applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I Submitted this-., I ~ day of '-J U_(t-~l 200 Signature "xo~-~ vq, ~ ~ 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- suooortiw, 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# 1000-2-0 -~__.-.~___~ PROJECT NAME The Application has been submitted to (check appropriate response): Town Board [~ Planning Board [] Building Dept. ~ Board of Trustees ~ 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: Appr vc Location of action: Site acreage: o. 1 ao¢ Present land use: A~C{C~ Present~ningcl~sificafion: ~e~ D[ [~.~ ~(g~C~ If m application for ~e proposed action h~ ~en filed M~ ~e To~ of Sou~old agency, ~e follo~g i~o~gion sh~l be prohded: (a) N~eofapplic~t: ~ QG~ ~ ~'~ (c) Telephonenmber:~eaCode( ~ ~) ~ ~ ~[ ~ (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? No[~ If yes, which state or federal agency?. Yes 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. [q~Yes t,o¼,ch 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 Pages 8 through 16 for evaluation criteria Yes [] No~'N~I Blot Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section HI - PoliCies Pages 16 through 21 for evaluation criteria Yes [] No ])~lNot 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 Ap At~ach 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,~7~ 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. ~ YeJ--~ 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 TITLE ~/~-- DATE DATE E~U~VEEYED OI-21-qq AIHENOED O~-2q-qq O~-2&-qq, O&-02-O0, .Oq-05-O0, I1-10-00 ~UFFOLI< C, OUNTY I000 - 2..0 I000 - 2.0 I000 - 20 SUPFOLK COUNTY HEALTH ~I=PT. =~ &lO-qq-ooID Ok',INF=P-.9 - APPLIC.,ANT~: S.C,. TAX LOT ~ 1000-20-I-D.2 O~VILLF' TEt~.~"¢' ~ THE TOY',IN OP SOUTHOLD MAIN OP-,IENT, N'"fl IIqS-'/ __C,. TAX LOT '~ 1000-20-1-~.D JOYC, E P. TEP-.~Y PLAIN P-.OAO OP-.IF:NT, Nh" ...... . - ._ .... .~,~ TAX LOT '~ 1000-20-1-,~.4 MAIN ROAP O~I~T, N% I Iq~ ..~1 TUATN_- TOHN OF: 6UF::F:OI.,,, K MAi° PROPOSF:]Z:) "JOYC, F: P. TERR'Y SF..T-OFF. OP..II=NT SOUTHOL]P d, OUNT"r', NY' N J iII ,$ JOHN C. EHLERS LAND