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Home My WebLink AboutTR-7786A James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino 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 CERTIFICATE OF COMPLIANCE # 0766C Date: June 28, 2012 THIS CERTIFIES that the installation of a split-rail fence along the side property lines from the front of the house to the street. At 1095 Aquaview Avenue, East Marion, New York Suffolk County Tax Map # 21-2-14 Conforms to the application for a Trustees Permit heretofore filed in this office Dated April 13, 2012 pursuant to which Trustees Administrative Permit #7786A Dated May 16, 2012 was issued and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the installation of a split-rail fence along the side property lines from the front of the house to the street. The certificate is issued to ALBERT PALUMBO owner of the aforesaid property. Authorized Signature James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 Tel~hon¢ (63 I) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE Of INSPECTION: ~ Ch. 275 Ch. 111 INSPECTION SOHEDULE __ Pre-construction, hay bale line/silt boom/silt curtain __ 1 st day of construction ¼ constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: CERTIFICATE OF COMPLIANCE: ~'~/'~- ~ / ~ James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hall Annex 54375 Route 25, P.O. Box 1179 Southold, NY 11971 Telephone (631 ) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated t~ I I ~11 ~ has been reviewed by this Board at the regular meeting of ~ 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) ½ Constructed ($50.00) ~'/ Final Inspection Fee ($50.00) __ Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE:$ ~,00 BY: James F. King, President Board of Trustees James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631 ) 765-6641 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 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 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 7786A Date of Receipt of Application: April 13, 2012 Applicant: Albert Palumbo SCTM#: 21-2-14 Project Location: 1095 Aquaview Ave., East Marion Date of Resolution/Issuance: May 16, 2012 Date of Expiration: May 16, 2014 Reviewed by: Trustee John Bredemeyer Project Description: To install a split-rail fence along the side property lines from the front of house to street. 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 April 13, 2012 and site plan stamped approved on May 16, 2012. 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. James c~ . K~in~, ~residen~ Board of Trustees James F King, President Bob Ghosio. Jr, Vice-President Dave Bergen John Bredemeyer Michael J Domino P.O. Box II 79 Southold, NY 11971 Telephone (631 765-1892 Fax (631 ) 765-6641 Southold Town Board of Trustees Field Inspection/VVorksession Report Date/Time: ._F-j"-/.~- ~,'/5' ALBERT PALUMBO requests an Administrative Permit to install a split-rail fence along the side property lines from the front of house to street. Located: 1095 Aquaview Ave., East Marion. SCTM#21-2-14 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound __Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: L-~hapt.275 __Chapt. 111 other Type of Application: ~'/Wetland __Coastal Erosion ~-'~Administrative__Emergency Pre-Submission __ __Amendment .Violation Info needed: Modifications: Conditions:/u,~; ¢/<:: ~.,r ~,¢PCZ/d' u( ~ Present Were: J. King B. Ghosio __ F'3-. Bredemeyer__ Michael Domino D. Bergen, D. Dzenkowski Form filled out in the field by Mailed/Faxed to: Date: other 3-Rail Western Red Cedar Split Rail Fence Jumbo Glade http://www.hooverfence.com/wood/cedar-split-rail.htm 4/12/2012 James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hal! Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 June 22,2009 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD Mr. & Mrs. Albert Palumbo 261 Nassau Ave. Manhasset, NY 11030 RE: 1095 AQUAVIEW AVE., EAST MARION SCTM#21-2-t4 Dear Mr. & Mrs. Palumbo: The Southold Town Board of Trustees reviewed the site plan prepared by Albert Palumbo received on June 19, 2009 and determined the proposed installation of a gate, additional gravel and Belgium blocks onto the existing driveway, and planting of.shrubs and grass to be out of the Wetland jurisdiction under Chapter 275 of the Town Wetland Code and Chapter 111 of the Town Code. Therefore, in accordance with the current Wetlands Code (Chapter 275) and the Coastal Erosion Hazard Area (Chapter 111 ) no permit is required. Please be advised, however, that no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal and/or freshwater wetlands jurisdictional boundary or seaward of the coastal erosion hazard area as indicated above, or within 100' landward fro~ the top of the bluff and/or wetlands jurisdictional boundary, without further authorization from the Southold Town Board of Trustees pursuant to Chapter 275 and/or Chapter 111 of the Town Code. It is your responsibility to ensure that all necessary best management practices are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdiction and Coastal Erosion Hazard Area, which may result from your project. This determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. Sincere/~/, , Jam F.~King, Presid~ Board of Trustees JFK:lms 10%- Oauad¢._~o ao~ f-, d~l /l~u au,,, / ,ST?. ~',e./v,, . 110,.30 TITLE TAX. SECTION J BLOCK KULHAI~I1EI~E & PLAN GUARANTEED TO DATE ~oFFo ~- ~ COUNTY OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cot. 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 To: From: MEMORANDUM Jim King, President Town of Southold Board of Trustees Mark Terry, Principal Planner LWRP Coordinator MAY -9 2012 Date: May9,2012 Re: Proposed Wetland Permit for ALBERT PALUMBO SCTM#1000-21-2-14 ALBERT PALUMBO requests an Administrative Permit to install a split-rail fence along the side property lines from the front of house to street. Located: 1095 Aquaview Ave., East Marion. SCTM#21- 2-14 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is EXEMPT from LWRP review pursuant to: § 268-3. Definitions. MINOR ACTIONS item "Z" which states: Z. Split rail fences or fences used to control nuisance wildlife that do not interfere with the public's rights of passage along the foreshore; 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 Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 Telephone (63 I) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application Wetland Permit Application Xt( Administrative Permit Amendment/Transfer/Extension Received Application: q]13ll~. ~ Received , Fee:$ ,~Completed Application Incomplete SEQRA Classification: Type I Type II Unlisted__ Coordination:(date sent) ,~'LWRP Consistency Assessment Form CAC Referral Sent: -~ ~.~4~ate of Inspection:~ ~ __Receipt of CAC Report: __Lead Agency Determination: Technical Review: ~Public Hearing Held:~x~L~ Resolution: APR 1 3 2012 Suffolk County Tax Map Number: 1000 - ~/~ c~ ~ -/ (provide LILCO Pole #, distance to cross streets, 2d location) AGENT: (If applicable) Address: of Trustees Applicatio~ Land Area (in square feet):t//'/'rl)g Area Zoning: Previous use of property: Intended use of property: Covenants and Restrictions: If "Yes", please provide copy. GENERAL DATA __ Yes /No Yes / No Does this project require a variance from the Zoning Board of Appeals If "Yes", please provide copy of decision. Will this project require any den~lition as per Town Code or as determined by the Building Dept. Yes 1/No Does the structure (s) on property have a valid Certificate of Occupancy t//Yes __ Prior permits/approvals for site improvements: Agency Date No __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspend/ed by a governmental agency?. //'No Yes If yes, provide explanation: Project Description (use attachments if necessary): ./~q/~ ~ ~DJ ¢ ~ / ard 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: % f nearest existing structure and upland ~//~ Closest distance between edge of 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 mu. ch material will be filled? Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: cubic yards cubic yards Statement of the effect, if any, on the wetlands and tidal waters of the town that max_ result b7 reason of sU~li p~'opos~d operatk~n~ (use' ~tta~%~S if ~pp~-opr/~te~i PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 1. APPLICANT / SPONSOR ~ ,'~ ~.-,,z-r- ~ up/~ 3.PROJECT LOCATION: Municipality %U7~/-.¢ O/_,- Z;2 PROJECT NAME County 4. PRECISE LOCATION: Street Addess and Road Intersections Prominent landmarks etc -or provide map 5. IS PROPOSED ACTION: [] New [] Expansion [] Modification / alteration SEQR DESCRIBE PROJECT BRIEFLY: 7 AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8 WILL ROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~Ye~ [] No If no, describe briefly: 9 WH IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) ~dential E]lndustrial ~Commercial r~Agriculture E] Park / Forest / Open Space MOther (describe) 10.' DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal,~Cate or Local) ]Yes [j~o If yes, list agency name and permit / approval: il. t)Ub5 ANY AUP'EGI OF TI-lb ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I CERTIFY THAT THE INF~TION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor me A Date: If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT {To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes. ceo~inate the review process aed use the FULL EAF. * E] Yes I'~'1 No B. ~ ACTION ~ COORDINAIED REVIEW AS PROVIDED FOR UNUSTED ACTIONS IN 6 NYCRP., PART 617.67 If No, a negative decimation nmy be supe~ded by another In~olved ageacy. C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH ~-IE FOLLOWING: (Answem may be handvallten, ~ ~i~) CI. F-~ eir quality, surface or groundwater quati~' o~ quantity, noise levels, existing traffic paffem, $OFKI waste productiofl or disposal. potential for erosion, drainage or tiooding problems? Explain bd~: I C2. A~ ~L;~ e,gK~uiknal, ard~,a~-u~,...a ~/(, histudc, or olher natural or cultural resources; or commun~y er nelghb<~'floed character? ~= ,,,~.!,~ bdetiy: .I C3. Vegetation or fauna, tish, g;.=;;;~, or wadlife species, ~lf~.lr,~ant habi~ls, or l/xeatened or endangered species? Explain bdetiy:. C4. A ~,,,,,,~ntty s =~ ,,,t~ plans or goals as officially adopted, or a change in use or inte~s~ of use of land of o~her natural resources? EX~ain bdefl¥: C5. (36. Long term, short term, cumula(l~, or o(he~ effects no( identified in C1~57 Explain briefly: I C7. O(her impacts (indudir~g changes In use of el(her quantily or lype"o'~'efleeg~f? Explaifl bdefiy: Growth, subsequen{ developll~c,d, or related activities likely to be induced by the proposed acflott? Explain beef[y: O. VVILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERiSTiCS THAT CAUSED THE ESTABLISHMENT OF A CR(TICAL ENVIRON MEN TAL AREA I:CEAI ? (If ~es, explatu briefly: E~Yes [~N°I I E. ffi ,, ,~.,~ OR 18 ,,~ UKELY TO BE~ CONTROVERSY RELATED TO POTF_NT1AL ADVERSE F--J~/I RC ;~'~ ~,'TA/~ IMPACTS~ ff ~ ~.a~;a;,~; PART III - Dc; ~.~MINATION OF SIGNIFICANCE (To ~ ~ ~ ~) . ~S: F~~n~a~,~~~,~oro~~nL ~ ~ ~ ~ ~ ~ ~ (a) ~ O.e. ~ ~; ~) ~d~ (~ dum~ (d) ~ (e) ~ ~ ~tM m~ ~ ~ ~ ~ ~y~. ff~nd~i~ Board o[ Trustees · President Signature of Respons/ble Officer in Lead Agency Signature of Preparer (If diffemn! ~om responaible officer) 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 Distuct Section Block Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. scOpE OFWORK - PROPOSED CONSTRUc'I'ION l'l'l~4I # / WORKASSESSMENT [ Yes No a. What is the Total Ama of the Project Parcels? 1 Will this Project Retain All Storm-Water Run*Off (Include Total Area of all Parcels Ioca[~=d within the Scope of Work for Proposed Construction) ,/~ 7/20 ~t ~/-. Generated by a Two (2') Inch Rainfall on Site? b. What is the Total Ama of Land Cleadng ' (S.F. / Ac~s) (This item will include all run-off created by site cleadng and/or construction aclJvifies as well as all -- and/or Ground Distu(oance for the proposed ~:~ -~ Site Improvements and the peri,anent creation of construction activity? imperious surfaces.) (s.F., ,~) 2Does the Site Plan and/or Survey Show All Proposed PROVU)F. BI~EF PROj'ECT DESCR]7]3ON ~ Add~r~ Pr ~''*~) Drainage StnJctores Indicating Size & Location? ThisI I Item shall include ail Proposed Grade Changes and -- ~ '~ ~ ~- ~.,~/-/- ~/2&~ ~z~_.~.2~ Slopes Controlling Surface Water Flow. ~/'~:,~ ~/~/~-,~ .~.~/-..~u ~h.~.~ 3 Does the Site plan andlor Survey descdbe the erosion and sediment control practices that will be used to control site erosion and storm water discharges. This -- Construction Peded. '~/~ 4 Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Natural Existing Grade Involving more than 200 Cubic Yards of Material within any Parcel? 5 W/il this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five Thousand (5,000 S.F.) Square Feet of Ground Surface? 6 Is there a Natural Water Course Running through the r'--'l site? Is this Project within the Trustees judsdiction General DEC SWPPP Requirements: or within One Hundred (100') feet of a Wet]and or -- Submission of a SWPPP is mqelred for all Construction activities/eve/ring soil Beach? disturbances of one (1) er mom acres; including disturbances of less than one acre that 7Will there be Site preparation on Existing Grade Slopes are part of a larger common plan that will ultimately disturb one or mom acres of isnd; which Exceed Fifteen (15) feet of Vertical Rise to including Cortstmction activities involving soi~ distuthences o! less than one (1) acre where One Hundred (100') of Hedzontal Distance? ~ -- the DEC has determined thai a SPDES permit is required for storm wafer discharges. SWPPP's Shall meet the Minimum Requirements of the SPDES General Pen'nit 8 Wi'Il Driveways, Parking Areas or other Impervious r~ for storm Water Discharges from Construction activity. Permit No. GP-0.t0-00t.) Surfaces be Sloped to Direct Storm-Water Run-Off 1. The SWPPP shall be prepared prle~ to the submittal of the NOI. ';'ne NOI shall pa into and/or in the direction of a Town right-of-way? -- ~ subrmtted o he DepaAmen pnor to the cornmencernen of cons rucbon activriy. ; 2. The SWPPP shell describe the erosion and sediment centre/practices and v~ere 9 Will this Project Require the Placement of Material, STATE OF NEW YORK, COUNTY OF ........................................... SS That I ................................................................................. being duly sworn, deposes and says that he/she is the applicant for Permit, And that he/she is the .................................................................................................................................................................... Owner and/or representative of the O~er or Owners, aGd is duly authorized to perform or have performed the said work and to make and file this application; that all statements con.ned in this application axe true to the best of his k~mwledge and belief; and that the work will be performed in the manner set fov~h in the application fried herewith. Sworn to before me this; ............................................... day of ............................................. 20 ..... Notary Public: .......................................................................................... FORM - 06/10 ard of Trustees Applica~n County of Suffolk State of New York /~Z~dF /~ 62tyTt~cD BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HI[StiflER 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 TH/I~PLICATION~ Signature SWORN TO BEFORE ME THIS 1 ~ DAY OF ~ ,20 /a Notary Public CONNIE D. BUNCH Notary Public, State of New York No. 01 BU6185050 Qualified in Suffolk Countv Commission Expires Apd114, ;2 ~/~L )ard of Trustees Applicati AUTHORIZATION (where the applicant is not the owner) (print owner of property) residing at (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics urohibits conflicts of interest on the uart of town Officers and emulovees. Tho uumose of this form is to urovide information which can alert the town of oossible conflicts of interegt and allow it to take whatever action is necessary to avoid same. (Last name, first name, Middle initial, unless yOU are 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 Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (lf"Other", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, marriage, or business interest. "Business interest'? means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by) a corporation in which the town officer or employee owns mom than 5% oftbe shares. YES NO /~ ' lfyou 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/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 oftbe corporate stock of the applicant (when the applicant is a corporation); B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a corporation); __ C) an officer, director, partner, or employee of the applicant; or ___D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 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- su~Dortin~ 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 LW~P is available in the following places: online at the Town of Southold's wehsite (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 scm# The Application has been submitted to (check appropriate response): TownBoard [] Planning Board ~ Building Dept. [] Board ofTrustees Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g. capital construction, planning activity, agency regulation, land transaction) (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nature and extent of action: Location ofaction: Site acreage: Presentlanduse: Present zoning classification: If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Nameofapplicant: fi~t~-7 (b) Mailing address: 2~/ /V///~.5~ /~ (c) Telephone number: Area Code,~;7~ ~,~ (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes [~ No ~f~' 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 thc 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 usc 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 V~ No .~}Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III - Policies Pages 3 through 6 for evaluation criteria ~ Yes [~ No/o~ot 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 I~Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III - Policies Pages 16 through 21 for evaluation criteria ~ Yes ~ No ~Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. Yes No Not Ap~able 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~NotApplieable / 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. Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. ~-~ Yes~ No ~Not Applicable Attach additional sheets if necessary WORKING COAST POLICIE~~ 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 ~NotApplicable TITLE ~d~ DATE L(flN ,__ ISLAND SOUND '"' .::d::'F,,~OVED BOARD OF TRUSTEES TOWN OF SOUTHOLD DATE ..51 Jl'~ ,. , ~ EXISTING CABIN ~ &z .,~¢~ BELOW BLUFF EXISTING WOOD STAIRS TO SHORELINE BELOW EXISTIN ' ' APR 13 2012 '~ 4NOOD DECK ~lOUS, SEPARATE APPFICATION] PART OF THIS APPLICATION] EXISTING, SINGLE-FAMILY, SINGLE-STOREY DWELLING -- A~ INTERIOR R~; AND NOR'fN ALTERATIONi 0 EXISTING · DRIVEWAY