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HomeMy WebLinkAboutTR-7871A*qf SO John M. Bredemeyer III, President Michael J. Domino, Vice -President James F. King, Trustee CA Dave Bergen, Trustee a� Charles J. Sanders, Trustee ®l�COUNNT BOARD OF TOWN TRUSTEES. - TOWN. OF SOUTHOLD Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 CERTIFICATE OF COMPLIANCE Telephone (631) 765-1892 Fax (631) 765-6641 # 1079C - Date: December 5, 2014 THIS CERTIFIES that the construction of a 250sq_ft second -floor addition over an existing screened porch; first and second -story addition on the landward side of the dwelling; installation of a drywell At 7800 Peconic Bgy Blvd., Laurel, New York Suffolk County Tax Map # 126-11-15 Conforms to the application for a Trustees Permit heretofore filed in this office Dated August 2, 2012 pursuant to which Trustees Administrative Permit #7871A Dated. August 22;.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 250sq ft second -floor addition over an existing screened porch; first and second -story addition on the landward side of the dwelling; installation of a dWyell. The certificate is issued to STEVEN & SUSAN BLOOM owners of the aforesaid property. .D'lPIT:!1r Authorized Signature John M. Bredemeyer Ill, President Michael J. Domino, Vice -President James F. King Dave Bergen Charles J. Sanders FDL,` 9 Gy O O w BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Ch. 275 Ch. III INSPECTION SCHEDULE Pre -construction, hay bale linelsilt boomisilt curtain 1 sf day of construction %Z constructed roject complete, compliance inspection. INSPECTED BY: �, [Z! /C; 6_ COMMENTS: CERTIFICATE OF COMPLIANCE:�� Town Hall, 53095 Main Rd- P-0. dP.O. Box 1 179 Southold; NY 11971 Telephone(631) 765-1892 Fax (63 l) 765-6641 James F. King, President Bob Ghosio, Jr., Vice -President Dave Bergen John Bredemeyer Michael J. Domino 0 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD 0 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 15t day of construction _ % constructed Project complete, compliance inspection 0 James F. King, President Bob Ghosio, Jr., Vice -President Dave Bergen John Bredemeyer Michael J. Domino BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 7871A Date of Receipt of Application: August 2, 2012 Applicant: Steven & Susan Bloom SCTM#: 126-11-15 Project Location: 7800 Peconic Bay Blvd., Laurel Date of Resolution/Issuance: August 22, 2012 Date of Expiration: August 22, 2014 Reviewed by: Trustee Jim King 0 Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 Project Description: To construct a 250 sf. second -floor addition over an existing screened porch; first and second -story addition on the landward side of the dwelling; install a 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 site plan prepared by Fairweather -Brown Design Associates, Inc., last dated on July 31, 2012 and stamped approved on August 22, 2012. Special Conditions: None 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, Wetland Permit will be required. This is not a determination from any other agency. James F. King, President Board of Trustees 0 0 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated Z has been reviewed by this Board at the regular meeting of 2 bi 2- and your application has been approved pending the cort letion o the following items checked off below. Revised Plans for proposed project Pre -Construction Hay Bale Line Inspection Fee ($50.00) 151 Day of Construction ($50.00) % Constructed ($50.00) ✓ Final Inspection Fee ($50.00) Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: J 'FInoTn sptJi 6n — t SD. Ob (11 u P TOTAL FEES DUE: $ 50. DD BY: James F. King, President Board of Trustees _, CD James F. King, President o y Z Town Hall Annex Bob Ghosio, Jr., Vice -President Dave Bergen w �.f. 54375 Route 25, P.O. Box 1179 bbl Southold, NY 11971 John Bredemeyer ,�a� Telephone (631) 765-1892 Michael J. Domino Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated Z has been reviewed by this Board at the regular meeting of 2 bi 2- and your application has been approved pending the cort letion o the following items checked off below. Revised Plans for proposed project Pre -Construction Hay Bale Line Inspection Fee ($50.00) 151 Day of Construction ($50.00) % Constructed ($50.00) ✓ Final Inspection Fee ($50.00) Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: J 'FInoTn sptJi 6n — t SD. Ob (11 u P TOTAL FEES DUE: $ 50. DD BY: James F. King, President Board of Trustees James F. King. President P.O. Box 1179 Bob Ghosio, Jr., Vice -President Y� GS Southold, NY 11971 Dave Bergen ti Telephone (631 765-1892 John Bredemeyer ,�, Fax (631) 765-6641 Michael J. Domino y '� Southold Town Board of Trustees Field Inspection/Worksession Report 1y; 36 Date/Time: 9d (s / 7 1 Z STEVEN & SUSAN BLOOM request an Administrative Permit to construct a 250 sf. second -floor addition over an existing screened porch; first and second -story addition on the landward side of the dwelling; and to install a drywell. Located: 7800 Peconic Bay Blvd., Laurel. SCTM#126-11-15 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: _Chapt.275 Chapt. 111 _other Type of Application:_ Wetland _Coastal Erosion _Amendment .�dministrative_Emergency Pre -Submission Violation Info needed: Not41i` Conditio Present Were: �J. King _B. Ghosio D. Bergen, J. Bredemeyer Michael Domino D. Dzenkowski other Form filled out in the field by I 6, Mailed/Faxed to: , / O x F / COUM OF SUFFOLK © R PmmMnyT SeMw/'WM Ys 126 p x .- 9� warm• �' �/ `a 'O ga acrt ' � i �i rix' • O - I � V � Qo ♦� ,�,9� j ����r� ff[vt raw '.ri � �/ ♦p �Y Fa i' Grt n SII >avo � , / O x F / COUM OF SUFFOLK © R PmmMnyT SeMw/'WM Ys 126 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: August 10, 2012 Re: Proposed Wetland Permit for STEVEN & SUSAN BLOOM SCTM# 1000-126-11-15 AUG 10 OFFICE LOCATION: ��OF SOpjho l� MAILING ADDRESS: Town Hall Annex ,�O P.O. Box 1179 54375 State Route 25 y .If, Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) Southold, NY 11971 N O Telephone: 631 765-1935 ;41^^�a 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: August 10, 2012 Re: Proposed Wetland Permit for STEVEN & SUSAN BLOOM SCTM# 1000-126-11-15 Board of Town Fairweather Design Associates on behalf of STEVEN & SUSAN BLOOM requests and Administrative Permit to construct a 250 square foot second -floor addition over an existing screened porch; first and second -story addition on the landward side of the dwelling; and install a drywell. Located: 7800 Peconic Bay Boulevard, Laurel. SCTM# 126-11-15 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 "BB" and "II" which states: is located in a coastal erosion hazard area: II. Additions to an existing building or rebuilt residential structure which results in no net increase in ground area coverage, except where the parcel is located in a coastal erosion hazard 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 AUG 10 201E Board of Town Fairweather Design Associates on behalf of STEVEN & SUSAN BLOOM requests and Administrative Permit to construct a 250 square foot second -floor addition over an existing screened porch; first and second -story addition on the landward side of the dwelling; and install a drywell. Located: 7800 Peconic Bay Boulevard, Laurel. SCTM# 126-11-15 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 "BB" and "II" which states: is located in a coastal erosion hazard area: II. Additions to an existing building or rebuilt residential structure which results in no net increase in ground area coverage, except where the parcel is located in a coastal erosion hazard 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 James F. King, President Bob Ghosio, Jr., Vice -President Dave Bergen John Bredemeyer Michael J. Domino TOWN OF SOUTHOLD Office Use minty _Coastal Erosion Permit Application _Wetland Permit ApplicationAdministrative Permit Amendment/Transfe /Extensio _✓Received Application:-�� I_1- -4teceived Fee:$ 0 _completed Application _Incomplete _SEQRA Classification: Type I_Type 11 Unlisted _Coordination:(date sent) EWRP Consistency Assessment Form _CAC Referral Sent: A) )q ,Hate of Inspection: (by _Receipt of CAC Report: _Lead Agency Determination: Technical Review: Inc Hearing Held.,— Resolution: Name of Applicant `7/f Kw --W 5UJAW DOOM L Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax(631)765-6641 +i �'JG - 2 2012 I Address Jgeo r4F60W(G P�j RJUGt- ✓Aw , !%NJlm N V. Number:(6� Suffolk County Tax Map Number: 1000 - 298.00(67 /2(a - //- /5 Property Location: /Rf9W %06/Dk " Aeolq/C SSA`/ /pw(I i (provide LILCO Pole #, distance to cross streets, and location) AGENT: AMY %144 rl/'{ - %/l? &&Af7j" b6 !;/dqA/ ASSOG . (If applicable) Address: 2D5 ,lfW Aye 41wetll76127 N V G3/- 41-77 - 9-152 Board of Trustees Application • GENERAL DATA Land Area (in square feet): 53/%0 Area Zoning: K' 4O Previous use of property: 61At&,t M MNC/ Intended use of property: ! Ame- Covenants and Restrictions: Yes ✓ No If "Yes", please provide copy. Does this project require a variance from the Zoning Board of Appeals Yes '� 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. i Yes No Does the structure (s) on property have a valid Certificate of Occupancy ✓ Yes No Prior permits/approvals for site improvements: Agency�m.,� Date N/ ,i 1 60 ,I/�/zn Iwo - Anut, /IAO/ 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): 2Nb h002 Ayolfial; OWL U/S7W4 Bod of Trustees Application • WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ZNb hoon Rty2/f1rN eW27 U/417t/4 51 a 0'V&C Area of wetlands on lot: IV0116 square feet Percent coverage of lot: NONC % Closest distance between nearest existing structure and upland edge of wetlands: NONE feet Closest distance between nearest proposed structure and upland edge of wetlands: Wb'V e feet Does the project involve excavation or filling? ✓ Yes If yes, how much material will be excavated? /Z cubic yards How much material will be filled? AID We cubic yards Depth of which material will be removed or deposited: 3 feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 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): Nn EFFECT [PROJECT ID NUMBER • 617.20 • SEQR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 - PROJECT INFORMATION ( To be completed by Applicant or Project Sponsor) 1. APPLICANT/SPONSOR 2. PROJECT NAME IXDZW 3.PROJECT LOCATION: �y rV Municipality County? 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc or provide map 1$A7 reeoAorc Ow AvwaY-~, CAVnsr-, N `/. 5. IS PROPOSED ACTION: ❑ New ❑ Expansion K❑ Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: 12 r-aon Av,W alon/ O!/&Z E wl yl/N4 7. AMOUNT OF LAND AFFECTED: �^ G Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? PlYes ❑ No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) F✓ Residential ❑ Industrial 0Commercial DAgriculture ❑ Park / Forest / Open Space ❑Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) Yes If yes, list agency name and permit / approval: MV nNo A CURRENTLY VALID PERMITOR APPROVAL? ❑Yes ❑No If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? Dyes Q No 1 CERTIFY THAT INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE //TS�H"�E /f!! Applicant / Sponsor Name /pfio'r f 0**f4yV AS:rp 4i '-ES Date: 711 f// -Z Signature If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment 0 PART II . IMPACT ASSESSMENT (To be completed by Lead ADencv) 0 A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. Yes 0 No R WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. ❑ Yes ❑✓ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly: C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1-05? Explain briefly: C7. Other impacts(including changes in use of either quantity or type of energy? Explain briefly: --- D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA CEA ? I( ves, explain briefly: Yes ❑✓ No . IS THERE, OR IS THERE Yes ❑✓ No 17 LIKELY TO BE CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If es explain: PART III • DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial,large, important or otherwise significant Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (1) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proosed directly to the f EAF and/or prepare a positive declaration. Check this box If you have determined, based on the information and analysis above and any supporting documentation, that the proposed a WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting determination. Board of Trustees a Name of lead Agency Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency President Is Title of Responsible Officer Signature of Preparer (If different from responsible officer) 0 0 Op Town of Southold Erosion, Sedimentation t& Storm -Water Run-off ASSESSMENT FORM vb PROPERTY LOCATION: S.c.T.M.a: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM -WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN 'tf{syr'E- acr -glace CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTION ITEM # / WORK ASSESSMENT Yes No a. What Is the Total Area of the Project Parcels? 1 Will this Project Retain All Storm -Water Run -Off (Include Total Area of all Parcels located within 5.j wo s f Generated by a Two (2') Inch Rainfall on Sita? the Scope of Work for Proposed Construction) (S.F./A.) (This item will include all ronor created by site ✓ ❑ b. What is the Total Area of Land Clearing clearing and/or construction activities as well as all and/or Ground Disturbance for the proposed 40 S.F Site Improvements and the permanent creation of construction w Wly? impervious surfaces.) 2 Does the SitePlan and/or Survey Show Proposed PROVIDE BRIEF PROJECt' DESCRIPTION (NaWte odainasN wlea.aNeatlat) ru Drainage Structures Indicating Size & Location? This l/ Item shall Include all Proposed Grade Changes and ❑ 4, ra Gj,s� ���.y p� N� L "" Slopes Controlling Surface Water Flow. 3 Does the Site Plan and/or Survey describe the erosion ffia E w %liN4 �6net/ and sediment control practices that will be used to V control site erosion and Storm water discharges. This ❑ item must be maintained throughout the Entire Construction Period. 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? ❑ Ij Will 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 Site? Is this Project within the Trustees jurisdiction ❑ ✓ or within One Hundred (100') feet of a Welland or General DEC SWPPP Requirements: Submission of a SWPPP is required for all Construction activities involving soil Beach? disturbances of one (1)or mom acres; including disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes are part of a larger common plan thatncowit ultimately disturb one or mom acres of land; which Exceed Fifteen (15) feet of Vertical Rise to ❑ ✓ including Construction activities involving sail disturbances of less than one (1) acre where One Hundred (100') of Horizontal Distance? the DEC has determined that a SPDES permit is squired for storm water discharges. (SWPPP's Shall most 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 -0.10-001.) Surfaces be Sloped to Direct Storm -Water Run -Off ❑ ✓ 1. The SWPPP shall be prepared prior to the submittal of the Not. The Not shall be Into and/or in the direction of a Town right-of-way? submitted to the Department prior to the commencement of construction activity. 2. The SWPPP shall describe the erosion and sediment control practices and where required, post+unstrucrion storm water management practices that wilt be used andfor 9 Will this Project Require the Placement of Material, ❑ Removal of Vegetation and/or the Construction of any constructed to reduce the pollutants in storm water discharges and to assure Item Within the Town Right -of -Way or Road Shoulder — compliance with the tame and conditions of this permit. in addition, the SWPPP shall Areal (Tau Imm xis NOT u-nw, ow ewwlae-,r a tmvaway Apema.) identify potential sources of pollution which may reasonably be expected to affect the quality of storm water discharges. NOTE: If Any Answer to questions One through Nine is Answsrad with a Check Mark 3. All SWPPPs that require the post-oonstructbn some water management practice in a Box and the construction site disturbance Is bstweeh 5,000 S.F. b 1 Asa In ares, component shall be prepared by a quallled Design Professional Licensed in New York a Storm -Water, ending, Drainage & Erosion Control Plan Is Required by d s Town of Southold and Must be Submitted for Rewew Prior ro Issuance of Any Building Parma. that is knowledgeable in the principles and practices of Stomn Water Management (NOTE: AChe Wa (4) aMlorAmwerfwaarh Ousstb is RoWWrora Camelia Applra ) STATE OF NEW YORK JOYCE STEVM COUNTY OF ...........Ifccoitle ............... SS NOTARY PUBLIC, STATE OF NEW YORK NO. 41111151122 � �%2.otmW4 That I, ....... .. ......................... beim dui sworn, de g y poses and says that he/ (Name of Individual signing Document) COMMSSION EITIM And that he/she is the M4 •.•.. .. (Owner, Contractor. Agent. Corporate ORcer, etc.) Owner and/or representative of the Owner or Owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed herewith. Sworn to before me this; ........................../...r............ day ......... ..................... 20JI % , Notary Public:.... r r .e�s f .........._......... ............I V� V ................................ (Signature of AppNrant) FORM - 06/10 07/27/2012 10:34 631 County of Suffolk State of New York 1 FAIRWEATHER BROS - PAGE 01-- Of 1_ of Trustees AMliCation fo�rdcfiCe /crit/ iN i'.d� :DRW%9-MeAFFJH2FJM09 MSHE.IS IM APPLICANTFOR THE ABO DESCMED, PERbIMS). THAT ALL STATMdENPS CONTAINER iEREIN ARE TRUE TO'THR BEST OF KNOWLEDGE AND BELIEF, AND THAT ALL WORK wHIL BB DONa. -IN THE SET FORTH IN THIS APPLICATION. AND AS MAY ' BE APPROVED, BY THE SO TOWk BOARD OP TRUSTEES, THE APPLICANT, .4GRSES TO HOLD TFIE LO OF SO,UTHOLD AND THE TOWN TRUSTEES HARMLESS AND FKRUEE FRO ANY AND ALL DAMAGES AND CLADdS ARISING "UNDER OR BY VUUM' OF 'PEKI&T(S� IF. GRANTM).. iN COMPLEI I O THIS APPLICATION. I HRREBY: A THE TRUSTBES, THEIR AGENT(S) OR REPRESFNTATIVES($X TO IONTO MY PROPERTY, TO INSPECT THE 'P omIsES IN, CONJUNCT IO q WITH REVIEW OF THIS APPLICATION. Signature - S . DA3F9% Boa: of Trustees Application • County of Suffolk State of New York 4N CA,QU)2 rkje BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/ HE 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 IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. O , Signature SWORN TO BEFORE ME THISlq(A DAY OF 20,je�_ sm" rATEOFPEWypp( OU4tMW + SUFFE*F0(OII(COI1Niy cavesm R9, 201 tL 07/23/2012 12:41 FAX 12123302222 PATTERSON BELKNAP Z 002/002 07/16/2012 10:14 631 • FAMRATHER BROW oL Trvgtses &"Itostioa AUrBORIZATION `` (W we the applicant is not the owner) ply 1 /f raiding of /7l�' (mailing ed rtS9) Southold Hoard of Town 4110 hereby eudwift (Agent) apply for parme(e) from the on my hebalL 2/t.•+y4s PAGE 01 0 • APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM YOUR NAME: l" A CA114,1154TI L (Last name, first name, Middle initial, unless you are applying to 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 B 'ding Variance ruste Change of Zone oastal 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, 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 more than 5% of the shares. YES NO V/ If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): A) the owner of greater than 5% of the shares of the corporate stock of the 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 /✓DNS Submitted this ay of 204 12 Signaturer/��.rr Print Name I" gAxRk2=n 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. 2. 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, listine both supporting and non - supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold ' s website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# /800 - /Zio - //- /G PROJECT NAME AnDA4 At 1bEti/C6 The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board ❑ Building Dept. 0 Board of Trustees Z 1. 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: 250 �iv i9 'ZAP hoot AVP/ r/olf 0 V6 14iV ft 'Or/a4 SG/ZEEN %'1672 CR . 2. Location of action: 71 Site acreage: /! 4C/Et- Present land use: 465/0,FN774e- Present zoning classification: k'' 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: 1A - &Rl,KWIA i & -rd4W ASfoc . (b) Mailing address: 205 jl�3Qy Ait t A/ t/. 11 -744V - (c) Telephone number: Area Code ( ) 6o5/- 077 - V 52 (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 ❑ Not Applicable �1/lD,i&-GI AW N0 *M451& /A�Ct 45- &,wlf/oN a A 96 CayJr12Z)6MP OYEn p2� Ex/ �i//✓� �lR(/(AU2a= Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III - Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III — Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No ❑ Not Applicable Ate? /%IDN P a 00'rw#w" fa LQ&6-az' Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III — Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No ❑ Not Applicable 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 AM106N* b/1f�P67G A !13 / ft*140 fb ca4ymm 2oor" 90A[ -OP -F Attach additional sheets if necessary Policy 6. Protect and restore the quality and Significant Coastal Fish and Wildlife Habitats through 32 for evaluation criteria. ❑ ❑ R function of the Town of Southold ecosystems including and wetlands. See LWRP Section III — Policies; Pages 22 Yes No Not Applole 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 0 Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III — Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No 2 Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III — Policies; Pages 38 through 46 for evaluation criteria. ❑ YeAD No ❑ Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES w 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 0 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 0 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 1� 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 PREPARED BY /W/ %/A1,WAVM 2. TITLE fRe4 - F419 WCOfWn. DATE Z% Jz. t7,04/q,V Assoc. APPROVED BY BOARD OF TRUSTEES TOWN OF SOUTHOLD DATE/dc% / / \ W E / EXISTING \ �'So I STORY011 \ 5 FRAME \ 0 HOUSE \ 0 / EXISTING 2012 O / FRAME \ PUMP \ Q / HOUSE V _F�_' OOp / \ / \ O_ E S N GRAM A c' \ GARAGE 42-2,' \ � SHED 15T * 2ND ����O\ 0 FLOOR ADDITION �e \� G' DIA. X 3'G" D '-0 \ Pym \DRYWELL \ DRAINAGE CALCULATION 2ND FLOOR A ITI / 2 STORY ADDITION: GO 5F OVER EXISTING NEW 2ND STORY ROOF: 190 SF ENCLOSED PORCH. TOTAL: 250 SF X 0. 17 = 42.5 CF PROVIDE G' DIA. X 3'G" D. @ 78.2 CF \ Ppm \ Al BASE ON SURVEY QJ� BY: ALDEN W. YOUNG Op l LAND SURVEYOR DATED: SEPT. 19, 19G3 AND SITE PLAN /° a'�� �0 0� BY: ROBERT 1. BROWN c, ��0 Q ARCHITECT, P.C. 9 TAX MAP # 1000-12G-1 1-1 5 I WE p N i I N NDER THE S IT E P& FTHE SCAgEHIlWB'MJ@rER ANY ITEM ON THIS DRAWING IN ANYWAY. ANYA-THORIZED ALTERATION MUST BE NOTED, SEALED, AND DESCRIBED IN ACCORDANCE WITH THE LAW. 0 BLOOM 07/31/2012 FAIRWEATHER-BROWN DESIGN A550CIATE5,INC. 205 BAY AVENUE GREENPORT, N.Y. 1 1944 �3 I -477-9752 (Fax) G3 I -477-0973