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Home My WebLink AboutTR-7790A John M. Bredemeyer III,President *0f soyo Town Hall Annex O l Michael J. Domino,Vice-President � � 54375 Main Road P.O.Box 1179 James F. King,Trustee Southold,New York 11971-0959 Dave Bergen,Trustee G Charles J.Sanders,Trustee Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1055C Date: October 8,2014 THIS CERTIFIES that the construction of a 4'x5' free-standing outdoor shower with appropriate drywell At 800 Sterling Road, Cutchogue,New York Suffolk County Tax Map# 104-4-9 Conforms to the application for a Trustees Permit heretofore filed in this office Dated April 27, 2012 pursuant to which Trustees Administrative Permit#7790A 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 construction of a 4'x5' free-standing outdoor shower with appropriate drywell. The certificate is issued to DIANE&HENRY HOBBS owners of the aforesaid property. Authorized Signature ! w John M. Bredemeyer 111, President �OgufFD4C Town Hall,53095 Main Rd. Michael J. Domino,Vice-President j�0 �Gy P.O.Box 1179 James F. King y Southold,NY 11971 Dave Bergen Telephone(631)765-1892 Charles J.Sanders y��l �a0 Fax(63 l)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: v 3 G Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction '/constructed _Z Project complete, compliance inspection. INSPECTED BY: e:L1 COMMENTS: / CERTIFICATE OF COMPLIANCE: (? James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction % constructed 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.: 7790A Date of Receipt of Application: April 27, 2012 Applicant: Diane & Henry Hobbs SCTM#: 104-4-9 Project Location: 800 Sterling Rd., Cutchogue Date of Resolution/Issuance: May 16, 2012 Date of Expiration: May 16, 2014 Reviewed by: Board of Trustees Project Description: To construct a 4'X 5' free-standing outdoor shower with appropriate drywell. 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 27, 2012 and as depicted on the 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. Jar~F. King, Presi~nt Board of Trustees James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Brederaeyer 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 ' ~ [ ~-'") i I ~ has been reviewed by this Board at the regular meeting of ~'-J hhl 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: BY: James F. King, President Board of Trustees Bob G6osio, Jr., Vice-President Dave Bergen John Bredemeyer P.O. Box I 179 Southold, NY 11971 Telephone (631 765-1892 Fax (631 ) 765-6641 Southold Town Board of Trustees Field Inspection/VVorksession Report Date/Time: l.._ DIANE & HENRY HOBBS request an Administrative Permit to construct a 4'X 5' free-standing outdoor shower with appropriate drywell. Located: 800 Sterling Rd., Cutchogue. SCTM#104-4-9 Type of area to be impacted: __Saltwater Wetland ~,-,Freshwater Wetland Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: __Chapt.275 Chapt. 111 other Sound Bay Type of Application: __ Wetland ~Ad ministrative__Emergency __ Coastal Erosion Pre-Submission __Amendment Violation Info needed: Modifications: Conditions: Present Were: __J. King __B. Ghosio "/D. Bergen, J. Bredemeyer___ Michael Domino D. Dzenkowski __ Form filled out in the f_ield by Mailed/Faxed to: Date: other NEW YO~TE DEPARTMENT OF ENV'RONMENTAE C~VAT'ON DEC PERMIT NUMBER ~ EFFECTIVE DATE 1-4738-03865/00001 -- --. I ~ March 25, 2009 ,AC,Lrn' PRO R NUMBE.S) PERMIT EXPIRATION DATE(S) · Under the Environmental March 25. 2014 Conservation Law TYPE OF PERMIT · New E] Renewal [] Modification [] Permit to Construct E] Permit to Operate [] Article 15, Title 5: Protection of Waters [] 6NYCRR 608: Water Quality [] Article 27. Title 7; 6NYCRR 360: E3 Article 15. Title 15: Water Supply [] Article 15, Title 15: Water Transport [3 Article 15. Title 15: Long Island Wells [] Article 15. Title 27: Wild. Scenic and Recreational Rivers Certification D Article 17, Titles 7, 8: SPDES [3 Article 19: Air Pollution Control D Article 23, T'~le 27: Mined Land Reclamation · Article 24: Freshwater Wetlands PERMIT ISSUED TO Henr7 Hobbs APR 2 7 2012 ADDRESS OF PERMiTFEE 800 Steding Road, Cutcho~lue, NY 11935 CONTACT PERSON FOR PERMITTED WORK Catherine Mesiano, Inc., 12 Mill Pond Lane, East Moriches, NY 11940-1222 NAME AND ADDRESS OF PROJECT/FACILITY Solid Waste Management Article 27, Title 9; 6NYCRR 373: HaTardous Waste Management Article 34: Coastal Erosion Management [3 Adicle 36: Floodplain Management [] Articles 1, 3, 17, 19, 27, 37; 6NYCRR 380: Radiation Control ITELEPHONE NUMBER (631)734-2907 ITELEPHONE NUMBER (631) 878-8951 Hobbs property, 800 Stedin~l Road, Cutcho~lue COUNTY I TOWN Suffolk Southold DESCRIPTION OF AUTHORIZED ACTIVITY: I WATERCOURSE I NYTM COORDINATES FW ~-SO-55 E:713.8 N:4543.6 Construct second floor addition and expand front porch. In addition, install two new dry wells, one in the northeast comer of property and the other in the northwest corner of property. All work must be in accordance to the attached plan prepared by Nathan Taft Corwin III, last revised 2/26/09 and stamped NYSDEC approved 3/25/09. By acceptance of this permit, the permittee agrees that the permit is contingent upon stdct compliance with the ECL, all applicable regulations, the General Conditions specified (see page 2 & 3) and any Special Condition· included as part of this permit. PERM~/ADMINIST~~'~ I ADDRESS "~ Region 1 Headquarterst John/)(. Wieland ,,('MAM) SUNY (~ Stony Brook, ~0 Circle Road, Stony Brook, NY 11790-3409 I ./, ' Page I of 4 ~ ,~ /~ ~ ~--. March 26, 2009 New York State O . · Department of En.vlronmental Conservation Division of Environmental Permits, Region,1 SUNY {~ Stony Brook 50 Circle Road, Stony Brook, NY 11790-3409 Phone: (631) 444-0365 · Fax: (631) 444-0360 PERMIT MODIFICATION Alexander B. Grannis Commissioner July 7, 2010 Mr. Henry Hobbs 800 Sterling Rd. Cutchogue, N.Y. 11935 Re: Permit #1-4738-03865/00001 APR 2 7 2012 Dear Mr. Hobbs: The Department of Environmental Conservation (DEC) has reviewed your request to modify the above referenced permit in accordance with the Uniform Procedures Regulations (6NYCRR Part 621 ). It has been determined that the proposed modifications will not substantially change the scope of the permitted actions or the existing permit conditions. Therefore, the permit is hereby modified to authorize: Terrace the property, extend the patio and install an outdoor shower with a drywell. All work must be done according to the plan prepared by Hobbs dated 6/15110 and stamped NYSDEC approved on 7/7/10. Conditions 3 and 4 have been modified and conditions 11 and 12 have been added as follows: 3-Prior to commencement of any construction activities, a continuou.s row of straw bales shall b® staked end to end downslope of any areas of ground dfsturbance. 4-Straw bales shall be entrenched two to four inches into the ground. 11-The bales shall b.e maintained, repaired and replaced as often as necessary to ensure proper ~nctmn, until all disturbed areas are permanentl ye etated. average useful life of a bale is a,~,,r,-,,~---*~,, ~.A .... ,_ - _. y .g. The r-r- .-..,.,,...;,~ .... ,,,u.ms. ~ealments trapped by the bales shall be removed to an approved upland location before the bales themselves are removed. 12-Shower wastewater disposal: Waste from the new outdoor shower shall be directed to a drywell located at any point above the 12 foot contour line as shown on the approved plans. 4YearsOf stewar4sHp 197o-2010 This letter is a modification to the odginal permit and must be available at the job site whenever authorized work is in progress. Ail oth/q~rms~ions remai~ written in the original permit. cc: BOH, File [Type text] ~0~o $~q'E PLAN ~-E: 1" = 20'-0' OFFICE LOCATION: Town Hail Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY 11971 M~IL[NGADDRESS: P.O. Box 1179 Southold, NYl1971 Telephone: 631 765-1938 Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Jim King, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: May9,2012 Re: Proposed Wetland Permit for DIANE & HENRY HOBBS SCTM#1000-104-4-9 DIANE & HENRY HOBBS request an Administrative Permit to construct a 4'X 5' free-standing outdoor shower with appropriate drywell. Located: 800 Sterling Rd., Cutchogue. SCTM#104-4-9 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the action is CONSISTENT with the LWRP Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application --Wetland Permit Application ~ Administrative Permit AmendmentFfransfer/Exlension ~Received Application:~ ~r Received Fee:$,~' ~ ' ~-/~ompleted Application Q. !~-][ [2L Incomplete __SEQRA Classification: Type l__Type Il Unlisted Coordination:(date sent) ~WRP Consistency Asse_~ssment Form ~.[ .9--1 lit ~ CAC Referral Sent: ~)ate of Inspection: ~ q. !{~-- __Receipt of CAC Report: __Lead Agency Determination: Technical Review: ~.~P'~blic Hearing Held: ~..! (0 ( [ ~' Resolution: APR 2 7 2012 Name of Applicant Suffolk County Tax Map Number: 1000 - ]o t4 - tt - cl LILCo bo/., ? (provide LILCO I~ole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: of Trustees Application GENERAL DATA Land Area (in square feet): oYT, ~ 7~ a'~. {7+ . Area Zoning: Previous use of property: Intended use of property: / ~.~'d',~ Covenants and Restrictions: Yes X/ No If "Yes", please provide copy. Does this project require a variance from the Zoning Board of Appeals __Yes X No If "Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept. _ Yes tX No Does the structure (s) on property have a valid Certificate of Occupancy X Yes __ No Prior permits/approvals for site improvements: Agency Date I,¥73 . 03 l ' No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? ~ No__ Yes If yes, provide explanation: Project Description (use attachments if necessary) Bo of Trustees Applicatlon WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ~. ~_ ~./~;/~ ~ ~w/~j~'~-~ Area of wetlands on lot: ~ square feet Percent coverage of lot: S° % Closest distance between nearest existing structure and upland edge of wetlands~jotpre/.'~;.~ feet Closest distance between nearest proposed structure and upland edge of wetlands feet Does the project involve excavation or filling? No X Yes If yes, how much material will be excavated? ~q, t>~ cubic yards How much material will be filled? ,~. o~ cubic yards Depth of which material will be removed or deposited: .~ feet Proposed slope throughout the area of operations:/~z Manner in which material will be removed or deposited: Xa,.~ 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): PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 1. APPLICANT / SPONSOR 3.PROJECT LOCATION: Municipality C~~, ~"s~s, 4. PRECISE LOCATION: eet Adde and Road Intersections, Prominent landmarks etc -or provide map 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 SEQR 5. IS PROPOSED ACTION: [] New [] Expansion ~]Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL ROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~Yes [] No If no. describe briefly: 9~ReT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) sidential [~lndustrial [~Commerclal [~Agriculture []Park/Forest/OpenSpace E~Other (describe) 10. DOES ACTION iNVOLVE A PERMIT APPROVAL, OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) [~es [~ yes, agency name and permit / approvak No TT~ ABVEL;I (JH tHE A~:TION HAVE A CU~ VALID PERMIT OR APPROVAL? g~Yes g~]No if yes, list agency name and permit / approval: 12, AS A R~ESU~OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I~Yes I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE ~ Sponsor Name Date: If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: $.C.T.M. #: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A ~t S/~-.~oY '~/ L; STORM-WATER~ GRADING, DRAINAGE AND EROSION CONTROL FLAN CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCI'ION ITI~M # / WORK.A~SF_~SMENT I Yes No a. What is the Total Area of the Project Parcels? Total Area of all Parcels located within ///.~ / 1 Will ~hia Project Retain All Starm-Watar Run-Off (Include Generated by a Two (2') Inch Rainfall on Site? the Scope of Work for Pmpesed Construction) (This item will include all mn-off created by site b. What is the Total Area of Land Cleadng (s.~. / Acres) cleadng and/or construction activities as well as all and/or Ground Disturbance for the proposed ,~/~v~- / Site Improvements and the permanent creation of construction acflvi[y? impen, ious surfaces.) (S.F.~) 2 Does the Site Plan andlor Survey Show All Propesed PRO~J])E BRIEF PRO. I-ECF DESCEHq]ON (P,w~ ~,~a=,.a P~ ~ ~ Drainage Structures Indicating Size & Location? This Item shall include all Proposed Grade Changes and ~,.'/'~oo( .~.ho,~¢~Dvtcx, ~(,~1)//7/~5'~) 3 Does the Site P~an andlor Surveydescdbe the er°s~nand sediment control practices that will be used ta - I ~ contrctsiteerosionandstormwatardischarges. This ~ ~ o, ('~. ¢.,. ~ ~r~ ~-'( ~ Jr J'te. ~' J3o,.~e_~r ~'~o~ I ~) e. item must be maintained throughout the Entire Construction Peded. I~<.¥0~ ~:~,~[~, tO~... ~.3[ Cct~'~'~JCe~. , ,% ('4~Y',4 c~l/ 4 Wi[I this Project Require any Land Filling, Gradingor Excavation where there is a change to the Natural 5'~c~t~ ~3~ ~lOC~r_~ + =~/~ I"0c1~¢/ I'CC/~ ,?/~0[/ ~ Existing Gradelnvolving morethan200CubicYards ~/i./~ ~'/~ ~/)0~1e ~ dfi/(~E//~ ~J~t~c~Xr~t~(z~L~A/ of Material within any Parcel? ~ / - , / / 5 Will this Application Require Land Disturbing Activities ~, ~ . Encompassing an Area in Excess of Five Thousand .P '~/" bf~£ d//~'~7/~e. ~/.~ /5' ~ ~'~4,r,~ / (5,000 S.F.) Square Feet of Ground Sun'ace? -- r?~//i.~/ ~ ~?~/n.~ ~-~/~///~/n~ 6 is there a Natural Water Coume Running through the Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Requirements: or within One Hundred (100') feet of a Wetland orL~J -- Submission of a SWPPP is required for all ConsthJction activities involving so~l Beach? disturbances ~f one (1) or more acres; including disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes ~ are paK of a la.jar common plan that ~il ullimalety disturb one or more acres of land; which Exceed Fifteen (15) feet of Vertical Rise to ~ iociuding Consbucaon acth~iUes involving soil dislurbances of less than one (1) acre where One Hundred (100') of Horizontal Distance? L~J the DEC has deterrn~ned that a SPDES permit is required for storm w~ate r discharges. SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit 8 Will Driveways, Parking Areas or other Impervious / for Storm Water Discharges from Construction activity. Permit No. GP-O-10-001.) Surfaces be Sloped to Direct Storm-Water Run-Off v 1. The SWPPP shall be prepared prio~ fo the submittal of the NOL The NOI shall be into and/or in the direction of a Town fight-of-way? submitted ~o the Department pdor to the commencement of construcUon activity. 2. The SWPPP shall describe Ihe erosion and sediment control practlees and where 9Will this Project Require the Placement of Material, required, post-construction sform water management practices that will be used and/or Removal of Vegetation and/or the Construction of any~ i constructed to reduce the pchutants in storm water discharges aed to assure Item Within the Town Right-of-Way or Road Shoulder compliance with the terms and conditions o~ this permit. In addition, the SWPPP shall STATE OF NEW YORK, COUNTY OF ................ .~ .................. SS .................... i,d ,y worn. /md that he/she is the ..~'..W.,g.D...~.~,,.., ................................................ OvmeL Contracfor. Agent, Corborafo Officer, ~fo.) ..................... Owner and/or representative of the Ova]er or Owners, and is duly authorized to perform o~Nl~i~(~l~Ol~4e said work and to make and file this application; that all statements contained in this application arc tnae t~i~P/).~l/~b{',l~l~e~dnd belief; and r~o 015T6!64008 that the work will be performed in the manner set forth in the application filed herewith. Qualified in Surf0 k Count,, Commission Expires A~ril 9, ~(~ I ~' Swom to before me this; _ ............ .d. 2.~...., ............. day of.~ ........................ 20.,/.,.~- (Signature of Applicant) FORM - 06/10 Trustees Application County of Suffolk State of New York b~a,;a,e ~o~bs BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND 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 1N CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signature SWORN TO BEFORE ME THIS ~r)~x' DAY OF ~ ,20 Public LAUREN M. STANDISH Notary ~blic, State of New York No, 015T6164008 Qualified in Suffolk County Commission Expires April 9, 20 ~ of Trustees Application (print owner of property) AUTHORIZATION (where the applicant is not the owner) residing at ' (ma!li~ig 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 orohibits conflicts of interest on the mtrt of town 6ffleers and emolovees. The Dumose of this form is to orovide information which can alert the town of~ossible conflicts of interest and allow it to take whatever action is necessary to avoid same. (Last name; first name, gaiddle 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.) Trax grievance Building Variance Trustee Change &Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, nlarriage, or business interest. "Business interest'? means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO ~ 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 applicantJagent]mpresentative) and the town officer or employee. Either check thc appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): A) the owner of greater than 5% of the shares of the corporate stock of the applicant (when the 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 Submitted this aT~ daygf ~ltarJ ] 205' '~' Signature ~,.~,_ ~ ' PdntName "/)t~-~d~ ~O?B~ 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 Waterfzont 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. Thns~ each answer must be explained in detafl~ listing both supporting and non- snooortin~ 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 The Application has been submitted to (check appropriate response): TownBoard [-] Planning Board ~] Building Dept. [-~ BoardofTrustees [~ Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g. capital construction, planning activity, agency regulation, land transaction) (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nature and extent of action: Location of action: Site acreage: . d,2d tlc Present land use: Present zoning classification: If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing address: (c) Telephone number: Area Code (~J' ,11) S't , 'TV-t q (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?. C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III - Policies; Page 2 for evaluation criteria. ~-~ Yes [~ No [~ot 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 ~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 L~ot Applicable At~ach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. Sec LwRP Section III - Policies Pages 8 through 16 for evaluation criteria ~-~ Yes [--] No ~Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III - Policies Pages 16 through 21 for evaluation criteria Yes ~-] No ~Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. 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 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. Sec 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 E No 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 ~ ~o~° APPROVED A~ APR 2 7 2012 SITE PLAN SCAt. E: 1" = 20'-0' 'NOVEL. · ",.\t~D OF TRUSTEES _ TOWN OF SOUTHOLD DATE