Loading...
HomeMy WebLinkAboutTR-7591 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 OFSOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE __ Pre-construction, hay bale line 1st day of construction % constructed _.~ Project complete, compliance inspection BOARD OF SOUTHOLD TOWN TRUSTEES SOUTHOLD, NEW YORK PERMIT NO. 7591 DATE: JULY 20~ 2011 ISSUED TO: STEPHENSON ROAD~ LLC PROPERTY ADDRESS: 19340 ROUTE 25~ ORIENT SCTM# 17-5-4 AUTHORIZATION Pursuant to the provisions of Chapter 275 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 July 20, 2011, and in consideration of application fee in the sum of $250.00 paid by Stephenson Road, LLC and subject to the Terms and Conditions as stated in the Resolution, the Southold Town Board of Trustees authorizes and permits the following: Wetland Permit to permit existing shed (crab shack) structure, replace existing pile supports and girders under existing frame shed and deck; replace decking with untreated lumber; install 4'x39' catwalk to facilitate access to existing shed and mitigate pedestrian traffic over vegetated wetlands; improve steps from road elevation to catwalk elevation; construct access steps for passing up and over the catwalk; and construct a locking privacy gate at beginning of catwalk; with the conditions of the use of a silt boom that will retain all suspended sediments within the immediate project area; no habitable space, water, sewage, or electric in the structure; and the use of open grate decking; and as depicted on the site plan prepared by lan Crowley, received on February 8, 2012, and stamped approved on February 10, 2012. 1N WITNESS WHEREOF, the said Board of Trustees hereby causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority oftbe said Board as of this date. Jill M. Doher~y TERMS AND CONDITIONS The Pennittee Stephenson Road LLC, residing at 19340 Route 25, Orient, New York 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 concemed 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-co~npliance 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 the work herein authorized. That there shall be no interference with the 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 notified 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. James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hail Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765~6641 July 20, 2011 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Stephenson Road, LLC cio Charlotte Greene P.O. Box 566 Orient, NY 11957 RE: STEPHENSON ROAD, LLC 19340 ROUTE 25, ORIENT SCTM# 17-5-4 Dear Ms. Greene: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, July 20, 2011 regarding the above matter: WHEREAS, STEPHENSON ROAD, LLC 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 9, 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, the LWRP Coordinator issued a recommendation that the application be found Consistent with the Local Waterfront Revitalization Program policy standards, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on July 20, 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 have found the application to be Consistent with the Local Waterfront Revitalization Program, and, RESOLVED, that the Board of Trustees approve the application of STEPHENSON ROAD, LLC to permit existing shed (crab shack) and decking, replace existing pile supports and girders under existing frame shed and deck; replace decking with untreated lumber; install 4'x39' catwalk to facilitate access to existing shed and mitigate pedestrian traffic over vegetated wetlands; improve steps from road elevation to catwalk elevation; construct access steps for passing up and over the catwalk; and construct a locking privacy gate at beginning of catwalk; with the conditions of the use of a silt boom that will retain all suspended sediments within the immediate project area; no habitable space, water, sewage, or electric in the structure; and the use of open grate decking; and as depicted on the site plan prepared by lan Crowley, received on February 8, 2012, and stamped approved on February 10, 2012. 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, President, Board of Trustees JMD/eac ~PPROVED BY B~ )ARD OF TRUSTEES F B9°14'10'' E 29 09' 89°31'10" E N 89°51'00'' W 200.00' / UTILIW POLE~ ~_ -- , ~OVERHE. AB WIRES ,~ ~=o~\ 1/O .9 1 /: 2,518'J: SURVEY OF PROPERTY S/TUA T£ ORIENT TOWN OF SOUIHOhO SUFFOLK COUNTY, N[W Y09N S.C. TAX No. 1000-17-05-04 SCALE 1"--,30' DECEMBER 25, 2009 AREA = 40,416 sq. ff. 0.928 ac. PREPARED IN ACCORDANCE STANDARDS FOR TITLE BY THE LLAi. S AND FOR SUCH USE BY T TITLE ASSOCIATION UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION '7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT B~'NRING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY 15 PREPARED, AND ON HIS BEHALF /'O THE TITLE COMPANY, DOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTI TUTION CERTIFICATIONS ARE NOT TRANSFERABLE NY.S, Lic. No. 50467 Nathan Taft Corwin III Land Surveyor Tdle Su~eys Subdiws~ons -- Site Plans -- Construcbon Layout PHONE (631)727-2090 Fox (631)727-1727 JOHN W. LOMAS Cedarnook P.O. Box 822 Orient, New York 11957 $outhhold Town 8oard of Tresteet} Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Bredemeyer Town Hall Annex 54375 Route 25, P.O. Box 1179 Southold, NY 11971 Telephone (63 I) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: STEPHENSON ROAD, LLC Please be advised that your application dated June 9, 2011 has been reviewed by this Board at the regular meeting of July 20, 2011 and your application has been approved pending the completion of the following items checked off below. XX Revised Plans for proposed project __ Pre-Construction Hay Bale Line Inspection Fee ($50.00) __ Ist Day of Construction ($50.00) __ ~ Constructed ($50.00) XX 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: Final Inspection Fee - $50.00 '~)~ [/ TOTAL FEES DUE: $ 50.00 ~?~ ~')~%/ BY: Jill M. Doherty, President Board of Trustees 11305 Spaulding St. Omaha, NE. 68164 July 14, 2011 SCTM #I 7-5-3 Board of Trustees, Town of Southold PO Box 1179 Southold, NY 11971 Re: Boathouse Repair, 19340 Route 25, Orient, NY Dear Sir or Madam: As owner of property located at 19915 Main Rd, Orient, I have reviewed the Notice of Adjacent Property Owner regarding the boathouse repair project located at 19340 Route 25, Orient. I am in full agreement with issuance ora permit from the Board to conduct the project as proposed. The boathouse, known locally for generations as the Orient crab shack is a local landmark and I commend Stephenson Road LLC in initiating necessary repairs. CC~ Stephensons Road LLC PO Box 566 Orient, NY 11957 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., July 13, 2011, the following recommendation was made: Moved by Derek Bossen, seconded by Audrey Horton, it was RESOLVED to SUPPORT the Wetland Permit application of STEPHENSON ROAD, LLC to replace existing pile supports and girders under existing frame shed and deck; install 4'X 39' catwalk to facilitate access to existing shed and mitigate pedestrian traffic over vegetated wetlands; and improve steps from road elevation to catwalk elevation. Located: 19340 Route 25, Odent. SCTM#17-5-4 Inspected by: Derek Bossen, Audrey Horton Vote of Council: Ayes: All Motion Carried Jill M. Dohedy, President Bob Ghosio, Jr, Vice-President James F. King Dave Bergen John Bredemeym PO Box 1179 Southold, NY 11971 Telephone (631 765-1892 Fax (63 ~ ) 765-664 Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: STEPHENSON ROAD, LLC requests a Wetland Permit to replace existing pile supports and girders under existing frame shed and deck; install 4'X 39' catwalk to facilitate access to existing shed and mitigate pedestrian traffic over vegetated wetlands; and improve steps from road elevation to catwalk elevation. Located: 19340 Route 25, Orient. SCTM#17-5-4 Tf.~altwf 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: ~/~hapt.275 Chapt. 111 other Type of Application: __ Wetland __Coastal Erosion __Amendment __Administrative__Emergency Pre-Submission __Violation Info needed: Modifications: Conditions: ¢tc,/,c'//ff/~,~&.d¢ J'~e~.¢ c,'~,'~ ~ ~d¢¢ ~c ~'~ -' Present Were: ~ohe~y ~Ghosio 4. King ~. Bergen, ~J. Bredemeyer D. Dzenkowski __other Form filled out in the field by Mailed/Faxed to: Date: To: ce: From: Re: NYS DEPARTMENT OF STATE DIVISION OF COASTAL RESOURCES MEMORANDUM Mark Terry, LWRP Coordinator, Dept. of Planning Jill Doherty, President, Board of Trustees Jennifer L. Street, Coastal Resources Specialist, Consistency Review u itr~ ~'~) F-2011-0479 U.S. Army Corps of Engineers/New York District Permit Application for Stephenson Road, LLC to install temporary supports to move framed shack to allow for installation of 9 permanent piles with necessary support beams. Reconstruct 4' x 17' and 6' x 17' decks. Construct 4' x 39' pile supported walkway on north side of facility to allow for pedestrian access. Replace steps at road grade down to new elevated walkway. Date: June 22, 2011 Enclosed is a copy of the Federal Consistency Assessment form and permit application for the above-referenced project for your information and preliminary review. Please contact me at (518) 474-1737 to discuss applicable LWRP policies and concerns, and any additional information which may be necessary to assist you in reviewing this project. Any comments you may have will assist the Department in reaching a decision as to the consistency of the proposed action with the approved Town of Southold LWRP. We would appreciate hearing from you on this proposed project within thirty days, or by July 22, 2011. If we do not hear from you by that date, we will presume that you have no objections to the proposed project. Enclosures cc: NYSDEC - Matthew Penski (1-4738-04052/0000 COE/New York District Stacey Jensen-t,~7~d' COASTAL RESOURCES NEW YORK STATE DEPARTMENT OF STATE COASTAL MANAGEMENT PROGRAM dUN 2 7 2011 Federal Consistency Assessment Form Southhold Town Board of Trustees An applicant, seeking a permit, license, waiver, certification or ,~imilar type of approval from a fcdcral agency which is subject to thc New York S rate Coastal Management Program (CMP), shall complete this assessment form for any proposed activity that will occur within and/or directly affect the State's Coastal Area. This form is intended to assist an applicant in certifying that the proposed activity is consistent with Ncw York State's CMP as required by U.S. Dcparmacnt of C~mm~rc~regu~ati~us(~5CFR93~.57).It~h~u~db~c~mp~t~tlatthctim~wh~nth~f~dexa~applicati~nisprepared. Thc Department of State will usc the completed form and accompanying information in ils ~'view of thc applicant's cortification of consistency. A. APPLICANT (please print) B. PROPOSED ACTIVITY I. Brief description of activity:. Install temporary supports to move framed shack east to allow for installation of 9 permanent piles with necessary support beams. Reconsbuct 4'x17' and 6'x17' decks. C(mlmct pile supported 4'x39' elevated walkway on north side of faciliiy to allow for pedestrian access. ~eptace steps at road grade down to new elevate(] Walk'way. ~ "Crab ,~h~ck" wa~-~on~cte~-i~ ~, 1~0,~. ~ ~u~ und~ ~e buildi~ an~- ~ave,~me ~m~mi~ and n~ to ~ m~a~. ~e ~ ~ d~ ~11 ~p~ e ~m ~ ano ~ng ~sum ~r many as ~e ~a~ is ~ble ~ Route 25 and ~as ~e a qu~e ~ble f~m of our t~. I 3. Location of activity:. Suffolk Odent State Road Route 25 County City, Town, or Village Street or Site Description 4. Type of federal pemlit/liceuse required:ACOE Nationwide concurrence 5. Federal application nmnber, if known: 6 ff a state penmOlicanse was l~.~led or IS/eqHJred for the proposed achwty,/dantify the state agancy and provide the application or permit number, ifknowu: NYSDEC permit number to be detormined C. COASTAL ASSESSMENT Check either "YES" or"NO" for each of these questiona. Tho numbers following each question refer to the policies described in the CMP document (see footnote on page 2) which may be affected by proposed activity. 1. Will the proposed activity reanlt in any of the following: YES/NO a. Large physical change to a site within the coastal area which will require the proparation of an environmental impact statement? (11,22,25,32,37,38,41,43) ................ [] [] b. Physical alteration of more than two acres of land along the shoreline, land under water or coastal waters? (2,11,12,20,28,35,44) .......................... [] [] c. Revilalizatiun/redevalopment of a deteriorated or underutilized waterfront site? ( 1 ) ...... [~_ ~[] d. Reduetionofexistingorpotenfialpublicacg, ess to or along coestal waters? (19,20) ...... ['"] .l~ e. Adverse effect upon the counnorcial ori~ecreatiunal use of coastal fish resources? (9,10)... [~_ .~ f. Siting of a facility essential to the exploration, development and production of energy resources in coastal waters or on the Outer Continental Shelf? (29) ................... ~ [~] g. Sitmgofafaeilityessentialtothegenerafionor~ransmissionofenergy?. (27) ........... [~L -~] h. Mining, excavation, or dredging activities, or the placement of dredged or fill material in coastal waters? (15, 35) .................................................... ~ .~] i. Discharge of toxics, hazardous substances or other pollutants into coastal waters? (8,15,35) [~_ j. Draining o f stormwater ronoff or sewer overfinws into coustal waters? (33) ............ k. Tumsport, storage, treatment, or disposul of solid wastes or hazardous materials? (36,39). E~_ 1. Adverse effect upon land or water usos within thc State's small harbors? (4) ............ 2. Will thc proposed activity affect or be located in, un, or adjacent to any of the following: ~S/NO a. State designated fxeshwater or tidal wetland? (44) ................................ b. Federally designated flood and/or state designated erosion hazard area? (11, 12, 17,) ..... c. State designated significant fish and/or wildlife habitat? (7) ........................ d. State designated s~Enificant scenic resource or area? (24) .......................... e. State designated important agricultural lands? (26) ............................... f. Beach, dune or barrier island? (12) ........................................... g. Major ports of Albany, Buffalo, Ogdensburg, Oswego or N~w York? (3) ............... [~. _~] h. State, county, or incal park? (19,20) .......................................... i. Historic resource listed on flae Nationul or State Register of Historic Places? (23) ........ 3. Will ti~ proposed activity requ~ any of the following: YES / NO a. Waterfront site? (2,21,22) ................................................. [] [] b. Provision of new public services or infxestructure in unduvulopcd or sparely populated sections of the coastal area? (5) .............................................. 8 ~ c. Construction or reconsm~cfion cfa flood or erosion control smumu~? (13, 14, 16) ....... tL State water quality permit or ceCdfication? (30, 38, 40) ............................ ~- '~ e. State air quality permit or eertification? (41,43) ................................. ~ '~ 4. Will the proposed activity occur within and/or aff~t an ama covomd by a Stat~ approved local waterfront revitalization program? (see policies in local program docmnent) .............. [~_ __~ D. ADDITIONAL STEPS 1. If all of the questions in Section C are answered "NOw, than the applicant or agancy shall complete Section E and submit the decumantation required by Section F. 2. ffany of thc questions in Section C are answered "YES", then the applicant or agent is advised to consult the CMP, or where appropriate, thc local waterfront revitalizadon program document*. The proposad activitymust be analyzed in more detail with respect to the applicable state or local coastal polieies. On a separate page(s), thc applicant or agent shall: (a) idantify, by their policy numbers, which coastal policias are affected by the activity, Co) briefly assess the effects of the activity upon the policy; and, (c) state how the activity is eonsistont with each policy. Following the completion of this written assessment, the applicant or agency shall complete Section E and submit the documentation required by Section F. E. CERA'WiCATION The applicant or agent must ccifify that thc proposed activity is eom/stant with the State's CMP or the approved local water'out revitalization program, as appropriate. If this certification cannot be made, the proposed activity shall not be undertakem If this certification can be made, complete this Section. The proposed act~mty complies v, qth New York State s approved Coastal Management Program, or w~th the applicable approved local waterfront revitalization program, and will be conducted in a manner consistent with such program." Telephone: Area Code ~3 [) 3~-3 --X~'~ ( f Applicant/Agant'sSignature: ~~ ~ ~__.~.-P.__.t~te: c~ ,,~c,V~. ~),C)' I F. SUBMISSION REQUIREMENTS 1. The applicant or agent shall submit the following documents to the New York State Department of State, Office of Coastal, Local Government and Community Sustataability, At~: Consistency Review Unit, 1 Commerce pla~% 99 Washington Avenue - Suite 1010, Albany, New York 12231. a. Copy of original signed form. b. Copy of the completed federal agency application. c. Other available information which would support the certification of annsistaney. 2. The applicant or agent shall also submit a copy of this completed form along with his&er application to the federal agancy. 3. ffthere are any questions regarding the submission of this form, contact the Department of State at (518) 474-6000. *These state and local decumems are available for mspectioa at the offices of masy federal agencies, ~t of envinmm~tal Consentation and D~parlm~nt of State regional offioe~, and the aplaupfiat~ mgiesal and ~oanty plannlnE agencies. Local program documents are also available for in.qpeetian at ~t~ offi~n~ of tho appropriate local gOVrnmucat May31,2011 New York State Department of State Coastal Management Program Albany, New York 12231 To whom it may concern, As required for issuance of a New York State Department of State Coastal Management permit, we are filling out our Federal Consistency Assessment Form. In the process it has came to our attention that the project we propose is relevant to a few of the State's Coastal policies as ouUined in the State Coastal Policies pa mphlet. The project as described involves the following Coastal policies. Policy I section d: The action should improve the deteriorated condition of a site etc... The project as proposed is an effort to preserve the integrity of a visual landmark known to all locals and many folks passing through. The project involves installing a new pile foundation and supports for the shack and existing decks as well as the installation of a catwalk to allow the owners to access the shed without tmmpling the weUands. The shed had had an access catwalk in years past, but is not in place at the present time. Policy I section e ... campatible with the character of the area, architectural style etc... The project matedals for the underpinning will be environmentally friendly, and all materials on the topside will be untreated and in keeping with the period ofthe amhitecture. Cedar shingle mol and Cedar siding~ Policy I section g... improve upland views of the water etc... The 'crab shack" as it sits is a cause of concam for the cammunity for the candition it is in. There are many postcards, photographs, and paintings with the crab shack as its focal point, It is a key point in an important scenic ovedook area. The loss, or serious damage to the building would be a loss to the cammunity and all folks who enjoy the scene it creates. Policy 44 Preserve and protect tidal wetlands... And benefits derived from the area. The crab shack is still used by the family and friends throughout the cammunity extensively in the recreational hanmsting of blue claw crabs, clams, oysters, and eels. The majodty of the creek is accessible to the residents of Orient and East Marion through the extensive shoreline owned by the OEM park district. The crab shack is the focal point of meaningful scenic overlook that has been extensively documented in multiple forms of art. The action as proposed is encompassed by the Southold Town Waterfront Revitalization Program. It is part of our submission to the Town, that we fill out a LWRP consistency assessment form. This is a 5 page assessment form that will be submitted to the LWRP coordinator to ensure that our project is in good keeping with the policies the Town adopted to form this program. In summation it is our finn belief that the project is necessary, and will be conducted in a manner that is expeditious, with the welfare of the public and environment kept in consideration throughout. It is our intention to make sure the project is also done in manner to ensure a sturdy and aesthetically pleasing "crab shack" for many years to come. We would like to thank you in advance for your timely consideration in this matter which is important to our fomily and the collective community. Sincerely,  ~ECEiVED ~OZNT APPLT~T~ON FORM ~ .For PermiLs/l~termirmUm~ ~ ~ ~-,~ , ~L. RE~OU~CE~~i~' we~s, c~l a~ a~ ~u~ of wa~ supply. Nm Yo~ ~va~ ~b/~i~ m~ ~ ~or US Afl.y Cm'l~ of mental '--~4~ Water ~ali~ ~erUfic~cion ~n ~ ~n W~r N~w~e ~) - ~en~ ~um~s): ~ .~ ;. ,,,6tare Code Contact/a~eet Name ' Name State 7~p Cod~ Te~phorm (daytime) Emil ~. ~proJect / ~r~,'litv ~ JPmperty Tax ~p SecUon / mock/Cot ~umber Project LocaUon - Provide directk~,~ and disbmces fa) marls, b~es and bodk~; of waters: Street Addt,~, if applicable Post Olh:e Oty State ~]p Code T~phon~, if applicab~ ~fl Town / ~1~ / ~ / ~"n~ 6. IFappllcan~ is no~ th~ ~, ,=,, bc~h mu~ sign the appflc~ton. herewith is true to th~ b~st of my knowledge and belief. ~ h~reby affirm th~ bWormaUon provided off this form and afl at~ach~ ~bm~ Section 2~0.45 of lhe Penal Law. False stateme~s trade heroin are punishable a~ a Oass A misdemeanor pursuant to Further, the applk:ant accepts full responsibility for all damage, direct or Indirect, of whatever nature, and by whomever suffered, arising out c~ the pro~ect described herein and agrees to Indemnify and save harmless the State fnxn suits, ac~m~s, damages and costs of every name and d~aui~ion resulting from said pn~ect ~n addlUon, Federal Law,/8 U.S.C., Section ~00! provides for a fine of not more t~an $10,000 or imprisonment for not more than 5 years, or both where an applicant knowingly and willingly fals~fies, conceals, or cove~ up a mat~rla! fact; or knowingly makes or uses a false, ficl~dous or frdudulent s~atement Signature of Owner Pr/~m:l Name ~"~-- TiUe Signature of Agent OlNT APPIACR'I/ON lORN 05/Oil .1(~ APPI_tCA'rtON FORH - PAGE SuhmiL this completed page u part of your Applicatlon~- 7. Pro, eot De~cHpt~ and Pm't~me: P'm¥ide a i:omplete narrative description of ~ p~ · n~. Z~e: ~ ~ ~ ~ 8~ ~ ~ ~ ~11 ~ ~ by ~ ~ i~l~; ~ a~ ~ ~ m~ ~ ~ ~ (Le., ~b& ~ ~ ~ R of fill ma~l ~w m~n h~h ~r); a~a ~ ~ ~ d ~1~, ~ ~ ~1 ~ ~ ~ and Has Work Begun on ProJect? I~ Public Yes I~ Commercial Will Prejec~ Occupy ~eral, State or Municipal Land? If yes, please specfy. I lNo IfYes, exl~ai~. / !~ Estimated CompleUon oa~: ~;~/ r'~/ ~-;'~ ?/ Yes, please list: LO. Ba~ed o~ the mits and detennm requestecl and p~oject IOCeUO~, check aB f~e boxes con~pondlng to eac~ ~l,t~e Agencies am10mces to which y~u are filing an appllcaUo~. For Agency addresses and ar~a~ covered, refer to the Agency Contact ]nformauon on the Applicath3n ~G~ON 1 Stony Brook ~IREG/ON 2 Long ~lancl City *~REGION 3 New Paltz REGION 4 SchenesU~/ REGION 4 Stamford Sub-Office Deparbneflt of Em/inmmental Conservation BRC--:GZON 5 Ray Erook REGION S Warrensburg $~ I--]REGAON 6 Watertown FR~-G~ON 7 Syrdcuse RE(~ON 7 Coddand Sub-Office F-IREGLON 8 Avon r--IRE(~ON 9 Buffalo ~--IRL::(~ON 9 Allegany Sub-Office ~"-I NYS Ofl-K:e of General D= fl:Ke~XN~r~uN OF NO PERM:TI' REQUIRED Agency Project NUmber this applk:aUon. ~lency Represe,,LaG,,,e: Name (p.;.;=d) )~NT APPLTCATZON FORM 0$/0B Applk:atiofl Farm Pag~ 2 of 2 Department of Environmental Conservation PERMISSION TO INSPECT PROPERTY By sj~oning this permission form for submission with an application for a permit(s) to the Department of Environmental Conservation ("DEC"), the signer consents to inspection by DEC staff of the project site or facility for which a permit is sought and. to the extent necessary, areas adjacent to the project site or facility. This consent allows DEC staff to enter upon and pass through such property in order to inspect the project site or facility, without prior notice, between the hours of 7:00 a~m. and 7:00 p.m.,-Monday through Friday. If DEC staffshould wish to conduct an inspection at any other time. s, DEC staff will so notify the applicant and will obtain a separate consent for such an inspection. Inspections may take place as part of the application review prior to a decision to grant or deny the permit(s) sought. By si~ning this consent form, the signer ugr~s that this consunt remains in effect as long as the application is pending, and is effective regardless of whether the signer, applicant or an agent is present at the time of the inspection. In the event that the project site or facility is posted with any form of "posted" or "keep out" notices, or fenced in with an unlocked gate, this permission authorizes DEC staff to disregard such notices or unlocked gates at the time of inspection. The signer fu~er agrees that during an inspection, DEC staffmay, among other things, take measurements, may analyze physical charac~istics of tho site including, but not limited to, soils and vegetation (taking samples for analysis), and may make drawings and take photographs. Failure to grant consent for an inspection is grounds for, and may result ia, denial of the permit(s) sought by the application. Permi~ion is granted for inspection of property located at thc following address(es): By signing this form, I a~rm under penalo~ of pe~ury that Iam authorized to give consent to entry by DEC staff as described above. I understand that false statements mnrl~ herein are puniehable as a Class ~4 misdemeanor _pur~ ~a~ to ~eation 210.45 of the Penal Za~.* Print Name and Title Signature Date *TI~ sig~r of ~ form must I~ a. i.dlvidual ~ ~ll~i,ed l~pre~aitiv~ ~£ a l~/al Inaity tam: · ow~s_ fcc litlc said is in i9osses~d~ of the ~mlx~ty ideniified above; tl~ PmPmY f~ the propose of c~mealing to ~peclion of sud~ ~.nterty' 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I - P rI~:)JECT INFORIIATION ~To be completed b~ Applicant or Project Sponsor) 1. APPLICANT/SPONSOR ]2_ PROJECT HAUE . 3. PROJECT LOCATION: 4. PRECISE LOCATION (Sleet address and mad intersm~ofls, prominm~ landmarks, el~, o; Fovide map) I ~ DESCRIBE PRO,.L~T BRIEFLY: 17. AMOUNT OF L~ND AFFECTED: 8. 1NILE ~r~;IPOS~ ACTII~N~ COMPLY WITH EXISTING ZONING; OR OTHER EXISTING; I.~ND USE RESTRICTIONS? L~ Ye~ U No IfNo, d~s~bebl~e~y 9. V~4AT~,~/~T LAND USE IN NqCINIIY OF PROJECT? i~:Reskien0al r--IIndustlial I'--lcoimen:ial E]'a<~icullum I--1Pall~Fofe~d/C)pen~ r--IOIher 10. DOES ACTION INVOLVE A PERMIT APPROVA~ OR FUNDING, NOVV OR ULTIMATELY FROM NqY OTHER GO~E~NM ENTAL AGENCy (~y~ S~ATE OR LOCAL)? [] NO If Ye% list ~,,nay(~) ~;ne and pemlif/app~o~ls: ii. UTM L~No If Ye~ ~st age~c~s) na~e and permil/ap~q~k Iif the~a_?_.?_n, ~_i_n_ _th_e_ _ _Cc~a~:_Ni A .r~a,_ and you~a_r~=a sta~9_, a.9~. ncy, complete the ~-~, ~menc form m~ore proc-_-c-3.qg wire this _~_t=_'~_ment J · PART II - IMPACT ASSESSMENT ~ ~ DOES ACTION EXC~F~ ~ TYPE I THRESHOLD IN 6 NYCRR. p.ad~T 617.47 B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNUS~-D ACTIONS IN 6 NYCRR. P~T 617_67 If No. a negate F--I Yes [~No C. COULD ACTION RESULT IN ANY ADVERS~ C~ '; ~u I u ASSOCIATED ~ THE FOLLOWING: (~lswe~ may be C1. ~ air quar"e/, strafe °r groundwater qua~y or quarry, noise leeels, e~ds~g traffic pattern, s~lkl waste pm(luctio~ or ~, c6. Lmxj~em~sh~tte~n, cumula6~.oroa~eff~tsnotk~ed~Cl_C5? F-x~a~b~e~. C7. O~her Intpacts (inc~Jding changes in use of eilhe~ q~ or lype o~ ener~0? O. WILL THE I:~OJEC'I' HAVE/~1 IMPACT ON THE ENVIRONMENTAL CHARAC ~ t=~ISTICS ~-IAT CAUSEI) THE ESTABUSHME~IT OF A c~mc~ ENVIRONMENTAL ~REA (CEA)? F_ IS THERE. OR IS ~ :~__~_ UKELy TO BE. CONTROVERSy RF_[~3ED TO PO'rENT]AL ADVERSE ENVIRONMENTAL IMPACTS? [::] Y"~ C-]No PART III - ~NATION OF Sl6NIFICANCE (To be ca~lpleied by Agency) should be assessed in conneclion wilh its (a) setling (i.e. urban m mini); (b) probab~ of occurring; (c) duratioa; (d) ~ (e) ge°graphic sc~°e; and (0 magnitude- If nee~'~"~'Y, add attae~'nes~s or reference suppo~ ~. If que~ion O of Part II ~ ~3eck~ YeS, the de'emanation of signirmance must evaluate ~e Ix~m~l ~..~ oflhe ........... ;oogle Maps I Get Google Maps on your phone .T~:lhe w~d "GI~tA~$" to 400453 ~2g11 Google tt~maps~g~g~e~c~m~?ie=UTF8&~=41~14~981~-72~3~566&spn=~24757~57~34&t~h&~15&~w~2 Page ! of I ENVIRONMENTAL QUESTIONNAIRF This is intended to supplement ENG Form 4345, Application for Department of the Army Permit, or the Joint Application for Permit used in the State of New York. Please provide complete answers to all questions below which ara ralevant to your projec£ Any answers may be continued on separate sheet(s) of paperto be attached to this form. PRIVACY ACT STATEMENT The purpose of this form is to provide the Corps of Engineers with basic information regarding your projecL This information will be used to facilitate evaluation of your permit application and for public dissemination as required by regulation. Failure to provide complete information may result in your application being declared incomplete for processing, thereby delaying processing of your application. GENERAL-APPLICABLE TO ALL PROJECTR 1. Explain the need for, and purpose of, the proposed work. 2. Provide the names and addrasses of properb/ owners adjacent to your work site (if not shown on the application form or project drawings). (Please note that depending upon the natura and extent of your projec~ you may be requested to provide the names and addresses of additional property owners proximate to your project site to ensura proper coordination.) 3. Photographs of the project site should be submitted. For projects in tidal areas, photographs of the waterway vicinily should be taken at Iow tide. Using a separate copy of your plan view, indicate the location and direction of each photograph as well as the date and time at which the photograph was taken. Provide a sufficient number of photographs so as to provide a clear understanding of conditions on and proximate to your project site. 4. Provide a copy of any environmental impact statemen~ or any other environmental raport which was prepared for your project. 5, Provide a thorough discussion of alternatives to your proposaL This discussion should include, but not necessarily be limited to, the "no action" alternative and alternative(s) resulting in less disturbance to waters ofthe United States. Forfilling projects in waters of the United States, including wetlands, your alternatives discussion should demonstrate that there are no practicable alternatives to your proposed filling and that your project meets with current mitigation policy (i.e. avoidance, minimization and compensation). I# ~v~ t~r/~Ml)~ ~10 //~7o~/ ~//11 /,~1/ IX~ 77~ ~/~4~- ~,~l~v/&r ~f DREDGING PROJECTS Answer the following if your project involves dredging. I. Indicate the estimated volume of material to be dredged and the depth (below mean low water) to which dredging would occur. Would there be overdepth dredging? 2. You can apply for a tan-year permit for maintenance dredging, ff you wish to apply for a tan-year permit, please provide the number of additional dredging events during the ton-year life of the permit and the amount of material to be removed during future events. 3. Indicate of your drawings the dewatering ama (if applicable) and disposal site for the dredged material (except landfill sites). Submit a sufficient number of photographs of the dewatering and disposal sites as applicable so as to provide a clear indication of existing conditions. Forten-year maintenance dredging permits, indicate the dewatering/disposal sites for future dredging events, if known. 4. Describe the method of dredging (i.e. clamshell, dragline, etc.) and the expected duration of dredging. 5. Indicate the physical nature of the material to be dredged fi.e. sand, silt, clay, etc.) and provide estimated percentages of the various constituents ff available. For beach nourishment projects, grain size analysis data is required. 6. Describe the method of dredged material containment (i.e. hay bales, embankmenC bulkhead, etc.) and whether return flow from the dewatering/disposal site would reenter any waterway. Also indicate if there would be any barge overflow. MOORING FACILITIES Answer the following ff your project includes the construction or rehabilitation of recreational mooring facilities. f . It is generally recommended that any fixed piers and walk ramps be limited to four feet in width, and that floats be limited to eight feet in width and rest at least two feet above the waterway bottom at mean low water. Terminal floats at private, non. commercial facilities should be limited to 20 feet in length. If you do not believe your proposal can meet with these recommendations, please provide the reason(s). 2. Using your plan view, show to scale the location(s), position(s) and size(s) (including length, beam and draft) of vessel(s) to be moored at the proposed facility, including those of transient vessel(s) if known. ~ 3. For commercial mooring sites such as marinas, indicate the capacity of the facility and indicate on the plan view the location(s) of any proposed fueling and/or sewage pumpout facilities. If pumpout facilities are not planned, please discuss the rationale below and indicate the distance to the nearest available pumpout station. 4. Indicate on your plan view the distance to adjacent marine structures, if any are proximate and show the locations and dimensions of such structures. 5. Discuss the need for wave protection at the proposed facility. Please be advised that if a permit is issued, you would be required to recognize that the mooring facility may be subject to wave action from wakes of passing vessels, whose operations would not be required to be modified. Issuance of a permit would not relieve you of ensuring the integrity of the authorized structure(s) and the United States would not be held responsible for damages to the structure(s) and vessel(s) moored thereto from wakes from passing vessels. BULKHEADING/BANK STABILIZATION/FILLING ACTIVITIES Answer the following if your project includes construction of bulkheading (also retaining walls and seawalls) with backfill, filling of waters/wetlands, or any other bank stabilization fills such as riprap, revetments, gabions, etc. 1. Indicate the total volume of fill (including backfill behind a structure such as a bulkhead) as well as the volume of fill to be placed into waters of the United States. The amount of fill in waters of the United States can be determined by calculating the amount of fill to be placed below the plane of spring high tide in tidal areas and below ordinary high water in non-tidal areas. 2. Indicate the source(s) and type(s) of fill material 3. Indicate the method of fill placement (i.e. by hand, bulldozer, crane, etc.). Would any temporary fills be required in waterways or wetlands to provide access, for construction equipment? ff so, please indicate the area of such waters and/or wetlands to be filled, and show on the plan and sectional views, The foregoing requests basic information on the most common types of projects requiring Department of the Army permits. It is intended to obviate or reduce the need for requesting additional information; however, additional information may be requested above and beyond what is requested in this form. Please feel free to add any additional information regarding your project which you believe may facilitate our review. 39°14'10" 29.09' MAIN S 89°31'10" E RAILING WIRE N 89°51'00'' W 200.00' 170.91' 2,318'± UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE TrlLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTI- TUTION CERTIFICATIONS ARE NOT TRANSFERABLE SURVEY OF PRC )~TY ,?ITUA T£ ORIENT TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-17-05-04 SCALE 1"--50' DECEMBER 25, 2009 AREA = 40,416 sq. ff. 0.928 ac. PREPARED IN ACCORDANCE STANDARDS FOR TITLE BY THE LJ,A. LS. AND FOR SUCH USE BY TITLE ASSOC~TION. N.Y.S. Lic. No. 50467 Nathan Taft Corwin III Land Surveyor Title Surveys Subdivisions -- Site Plons -- Construction Loyout PHONE (651)727-2090 Fox (651)727-1727 Google Maps 5131111 9:lSAM maps Set Google Maps on your phone T~t the ~1 ~GMAP$"Io 4664 $ 3 (~1111 Google I~ d~f~ ~01 ~ Google htt~ma~s~g~e~c~m~?ie~J]~8&~41~14~981~-72~3~66&s~m=~24757~7~34&t~h&z~15&pw~2 Page I of I OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY 11971 MAILING 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 ~ 8 20]] B?aCd of Trustees Date: July 18, 2011 Re: Proposed Wetland Permit for STEPHENSON ROAD, LLC SCTM#17-5-4 STEPHENSON ROAD, LLC requests a Wetland Permit to replace existing pile supports and girders under existing frame shed and deck; install 4'× 39' catwalk to facilitate access to existing shed and mitigate pedestrian traffic over vegetated wetlands; and improve steps from road elevation to catwalk elevation. Located: 19340 Route 25, Orient. SCTM#17-5-4 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP provided the following best management practice is required pursuant to: § 275-11. Construction and operation standards. A. General. The following standards are required for all operations within the jurisdiction of the Trustees: (2) Erosion control. Installation of an erosion control structure is necessary during any building, grading, landscaping or site work activity within Trustee jurisdiction. This structure may include, but is not limited to, installation of a silt fence, hay bales, wood chip berm and silt booms. The placement of the erosion control structure(s) shall be determined by the Trustees or their designee. All intertidal construction and excavation requires the installation of a silt boom that will retain all suspended sediments within the immediate project area_ Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney Town of Southold ~oard of Trustees Application ~ e~nit Application Adminislrative ~ ppueat/on£_~.~/It ~Ympleted Appliea~ __/neOmplele ~-~ oordination:(date sent). ~,..~Date of Inspeefion-~ --R~eipt ofCAC ~~ ~Technioal Review: ~l~ubli¢ Hearing HeI~ ~Resolu6on: Name of Applicant Address~ Address: Suffolk County Tax Map Number: 1000 -/~_~_~ Pro~YLoca,ion: ~ & ~ Z~ AGENT: , ~ce to Cross ~e~, ~d location)='0, ~ ~' ~, _Phone: Land Area (in square feet): Area Zoning: ~ (~ Previous use of property: Intended use of property: Covenants and Restrictions: GENERAL DATA Yes ~ No If "Yes", please provide copy. Does this project require a variance ~om the Zoning Board of Appeals __ If "Yes", please provide copy of decision. Prior permits/approvals for site improvements: Agency Date Yes l~No ///No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspe_nde/d by // No If yes, provide explanation: a governmental agency? Yes Project Description (use attachments if necessary): ~ ff~ff~ tTez~ag4 of Trustees Ap~licatio0 WETLANDfrRUSTEE LANDS APPLICATION DATA of the proposed operations' Area of wetlands on lot: /f/trt-o square feet Percent coverage of lot: 2,~ % Closest distance between nearest existing structure and upland edge of wetlands: 0 feet Closest distance between nearest proposed structure and upland edge of wetlands: ~5 feet Does the project involve excavation or filling? ~ No Yes If yes, how much material will be excavated? ~ cubic yards How much material will be filled? f cubic yards 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: 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): / Appendix C Stab~ Environmental Quali~y Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART ! - PROJECT INFORMATION ~To be c~m.l,~,~ by 3. ~T L~A~: g. VWlAT__[8~'~:~t:NT LAND USE IN VIGINI]Y O~ PROJECT? 10, DOES ACTION INVOLVE A Pr::RMIT AI:~ROV/~L, O~ FUNDING, NOW OR UL'I1MA'I~y FROM ANY OTHE~ GOVERNMENTAL AGENCY (~ 8TAI'~ O~ LO~)? [~Ye~ r--]No UTM L~No ~2. ~]A ~T OF ~No~bL) ACT1ON WILL Exi~i lNG ic~..RMiT/APPROVAL RE(~UiRE MODi~? I G/:~ I I~'¥ TI"IAT THE II~J~IATION PROVII~ A~OVE i~ TRUE TO 11.1E 13E~E OF My i~ PART II - IMPACT ASSESSMENT (To be completed by Lead Agency) A. DOES ACTION EXCEEO ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the revtsw process and use the FULL EAF. E~Yes ~'lNo 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. E~Yes r~No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing sir quality, surfaco or groundwater quality or quantity, noise levels, existing traffic poltem, solid waste produc~on or disposal, potential for erosion, drainage or flooding problems? Explain briefly: I C2. Aesthetic, egdcutiural, archaeological, historic, or other natural or cotiurol resources: or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered spedes? Explain bdefly: I 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: C5. Growth, subsequent development, or related activti~es fikely to bo induced by the proposed achon Explain bdetiy C6. Long tefra, shod term, cumulative, or other effects not identified in C1-Cfi? Explain briefiy: I C7. Other impacts Itnctudin~ chanties in use of either cluandt~ or t~/pe of ene~ Explain bdefi¥: I D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRON MENTAL AREA ICEAI? Ill ~'as, explain bdeti),: I-lYes r~No I E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? [---]Yes [~]No If yes explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INS'I'RUCTIONS: For each adverse effect identified above, determine whether it is substantial, la~ge, important or othenvise significant. Each effect should be assessed in connection with its (a) se~ting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f} magnitude. If necessary, add attachments or refemnca 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 oftba proposed action on the environmental characteristics of the CEA. Check this box if you have idendrmd one or moro potentially large or significant adverse Impacts which MAY occur. Then pmcesd directly to the FUU FAF and/or prepare a positive deciarefion. Check this box if you have determined, based on the information and analysis above and any supporting documentation, Ihat the proposed actim WILL NOT msuti in any significant adveree envlronmonfal impacts AND provide, on attachments as uecessary, the masons supporting thi~ determination. Board of Trustees Name of Lead Agency Jill M. Doherty Pr~,nt or Type Name of Responsible Officer in Lead Agency Date President Title of Responsible Officer Signature of Pmparar (If different from responsible officer) of Trustees A~licatio~ County of Suffolk State of New York DEPOSES AND AFFIRMS THAT HE/SHE fS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF 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 ~ ,2o / / VERONICA F. CIDONE Notaw Public, State of New No. 01Cl4661406 Qualified in Suffolk Count'/ Commission Expires Oec. 31,2013 of Trustees A~plicatioO AUTHORIZATION (where the applicam is not the owner) (print owner of property) residing at (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Brcdemeyer Town IlalL 53095 Main Rd. P.o. Box 1179 Southold, NY [1971 Telephone (63 I) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTItOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of STEPHENSON ROAD~ LLC COUNTY OF SUFFOLK) STATE OF NEW YORK) ;5.9A AFFIDAVIT OF POSTING l, ¢~c~?~ ~'~; ,~,l, esiding at/dba being duly'~v~)~, depose an'd say: That .on tl~ '.] c~y of "q ~ A, 201I, Ipersonally postqd th_¢ property known as by blacing the Board of Trustees oft~&~f ~'os-ier'wt{ere ~"5"ca-h easiiy ~e see'n, arid that 1 have checked to be sure the poster has remained in place for eight days prior to the date of the public hearing. Date of hearing noted thereon to be held Wed, July 20~ 2011 on or about 6:00 PM. Dated: Sworn to betbre me this 15'aay ~'--ry Public LAUREN M. STANDISH Notary Public, State of New York No. 01ST6164008 Qualified in Suffolk Count~ Commission Expires April 9, PROOF OF MAILING OF NOTICE MAIL RECEIPTS Address: COUNTY OF SUFFOLK (~t"", ~ ¢3 ~ \~ , being duly sworn, deposes and says that on the --.._%- ' d~ydf .~__~ ,20 ~ \, deponent mailed a tme copy of the Notice ~et forth i-~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 asse~sment_roll ofl. hc Tmvn of Southold; that said Notices were mailed at the United States Post Office at .~_e,~X~.~ , that said Notices were mailed to each of said persons by ~ertified! (registerexl) rrlail, e~/~ co~ ~. Sworn tO ~efor~ me this Vayof XI,AY. , ,20 1' t -- t Notary Public - - APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics nmhibits conflicts of interest on the cart of town officers and emolovces. The DUranSC of this form is to omvide information which can alert the town of cossible conflicts of interest and allow it to take whatever action is neecssarv to avoid same. (Last name, first name, ~niddl¢ initial, unless you am applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply,) Tax grievance Building Variance Trustee ~i, Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other", na~0e 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 ownemhip 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 mlatioaship between yourself(the applicant/ngent/represantative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space pm~ided. The town officer or employee or his or her spouse, sibling, parent, or ~hild is (check all that apply): __A) the owner of greater than 5% of the shams of the corporate stock of the applic0nt (when the applicant is a corporation); __B) the legal or bceeficial owner of any interest in a non-corporate entity (when the applicant is not a coq)oration); __.C) an officer, director, partner, or employee of the applicant; or __.D) the actual applicant.. DESCRIPTION OF RELATIONSHIP Form TS 1 Signature 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 forra 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", then the proposed action may affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, the action should be analyzed in more detail and, if necessary, modified prior to making a determination that it is consistent to the maximum extent practicable with the LWRP policy standards and conditions. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following phces: 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 The Appfieation has been submitted to (check appropriate response): TownBoard ~-~ Planning Dept. [] 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 Iransaction) (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nature and extent of action: l Location of action: Site acreage: . Presem land Present zoning classification: ~_ ~0 · If an application for the proposed action has b¢~n fil~ with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing add. ss: (c) Telephone number: Area Code ((0~ I "~ ;~ 3 -- ;~L -~ I (d) Application number, if any:. Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ~/No ~'~ If yes, which state or federal agency? ,~,Z-) a]l~'~t /f-(.,~. 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 n coastal location, and minimizes adverse effects of development. See LWRP ~'tion Ill - Policies; Page 2 for evaluation criteria. ~Yes [] No [] (Not Applicable- please explain) .. At~ach additional shee~s if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section IH - Policies Pages 3 through 6 for evaluation criteria [~ Yes ~-~ No ~] (Not Applicgble - please explain) . Attaoh additional shem ifnoe~ssary Policy 3. Enhance visual qnality and protect scenic resources throughout the Town of Southoid. See LWRP Section IH - Policies Pages 6 through 7 for evaluation criteria ~/Yes ~ No ~-~ (Not Applicable - please explain) -- Attach additional she~cts if necessary NATURAL COAST POLICIES Policy 4. ~llnlmlze loss of life, structures, and natural resources from flooding and erosion. See LWRP Section HI - Policies Pagos 8 through 16 for evaluation criteria ~ Yes ~ NO[~'~.(NOt Applicable - nlease explain) ARach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section IH - Policies Pages 16 throuJgh 21 for evaluation criteria .~ yes L_~ N9 t2_l (Not Applicable please explain) At~ach additional sh~x~ts ff necessary Policy 6. Protect and restore the q.ali~y and function of the Town of Southold ecosystems including Significant Coastal Fish and W'ddllfe Habitats and wetlands. See LVf-I~P Section IH -- Policies; Pages 22 through 32 for evaluation criteria. F~ Yes [] NO ]-~ (Not Applicable - please explain) Auach additional sh~ ffnecessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section HI - Policies Pages 32 through 34 for evaluation criteria. See Section HI - Policies Pages; 34 through 38 for evaluation criteria. ~ Yes [] Noir(Not Applicable- please explain) Attach additional sheets if necessary Policy g. ~ginimi~e envifonme~ltal degradation in Town of Southold from solid waste and ha,ardous substances and wastes. Sec LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. [] Yes [] No ~/(Not Applicable- please explain) / 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 LVv'RP Section HI - Policies; Pages 38 through 46 for evaluation criteria. ~'~ Yes~ No ~-~ (Not Applicable - please explain) Attach additional shy'ts ifn~ssary WORKING COAST POLICIES Policy 10. Protect Southold's water-dq~endant uses and promote siting of new water-dependant uses in suitable locations. See LV~RP Section IH - Policies; Pages 47 through $6 for evaluation criteria. Attach additional sheets if necessary Policy 11. Estuary and'Town waters. See LWRP Section IH - t ~,,~ N° ~-~/N°t Applicable - Plcase explain Promote sustainable use of living marine resources in Long Island Sound, the Pecouic olicies; Pages 57 through 62 for evaluation criteria. At~ach additional sheets if necessary Policy 12. Protect agricultural lands in the Town o~ Southold. 62 through ~ for evaluation criteria. ~ No ~/Not Applicable - please explain ARach additional sheets if necessary Policy 13. Promote appropriate use and deveiop~ Section IH - Policies; Pages 65 through 68 for evaluat ~-~ Yes [] N_o ~ Not Applicable - please explain See LWRP Section IH - Policies; Pages ent of aner~y and mineral resources. Sec LWRP on criteria.