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Home My WebLink AboutTR-7907A James F. King,President Town Hall Annex Bob Ghosio,Jr.,Vice-President �O� �6 54 Main Road P..O.O. Box 1179 Dave Bergen Southold, New York 11971-0959 John Bredemeyer OG @ Telephone(631) 765-1892 Michael J. Domino Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0831C Date: December 14, 2012 THIS CERTIFIES that the installation of a 225sq.ft. area of chain-link fencing off of the dwelling to contain nets. At 5855 New Suffolk Avenue, Mattituck, New York Suffolk County Tax Map# 115-5-18 Conforms to the application for a Trustees Permit heretofore filed in this office Dated August 15, 2012 pursuant to which Trustees Administrative Permit#7907A Dated September 19, 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 225sq.ft. area of chain-link fencing off of the dwelling to contain pets. The certificate is issued to JULIA &JOSEPH VERGARI owner of the aforesaid property. P40" 0 Authorized Signature Jill M.Doherty,President lav soolyo Town Hall Annex James F. King,Vice-President O 54375 Main Road Dave Bergen P.O. Box 1179 Southold, New York 11971-0959 Bob Ghosio,Jr. CA a� John Bredemeyerl �� Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: IJ,r 7 Zc, Z, _X Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 15t day of construction % constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: CERTIFICATE OF COMPLIANCE: v James F. King, President Bob Ghnsio, Jr., Vice-President Dave Bergen John Bredemeyer Michael $. Domino Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax (63 I) 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 __ Ist 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 Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 7907A Date of Receipt of Application: August 15, 2012 Applicant: Julia & Joseph Vergari SCTM#: 115-5-18 Project Location: 5855 New Suffolk Avenue, New Suffolk Date of Resolution/Issuance: September 19, 2012 Date of Expiration: September 19, 2014 Reviewed by: James F. King, Trustee Project Description: To install a 225 sq. ft. area of chain-link fencing off of the dwelling to contain pets. 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 project plan prepared by Julia & Joseph Vergari, received on August 15, 2012, and stamped approved on September 19, 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, a Wetland Permit will be required. This is not a determination from any other agency. James F. King, President Board of Trustees James F. King, President Bob Ghosio, Jr., Vice-President Dave Bergen $olm 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 <~//-~/~Z, t has been reviewed by this Board at the regular meeting of ~ Jl ~1/.],2_ and your application has been approved pending the completioh/o~ th6 following items checked off below. __ Revised Plans for proposed project __ Pre-Construction Hay Bale Line Inspection Fee ($50.00) __ Ist Day of Construction ($50.00) __ ½ Constructed ($50.00) V/ 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 .James F King, President Bob Ghosio, Jr, Vice-President Dave Bergen John Bredcmeser Michael J. Domino PO Box 1179 Southold, NY 11971 Yelephone {631 765-1892 Fax (631 ) 765-6641 Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: .5'/¢'? /~ 2 gt'& // ' J' o JULIA & JOSEPH VERGARI requests an Administrative Permit to install a 225sq.ft. area of chain-link fencing off of the dwelling to contain the pets. Located: 5855 New Suffolk Avenue, Mattituck. SCTM# 115-5-18 Type of area to be impacted: ,~altwater 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 Tyj;~e of Application: Wetland __Coastal Erosion __Amendment ,-/'Administrative__Emergency Pre-Submission Violation Info needed: Conditions: / Present Were: ~' J. King B. Ghosio__ J. Bredemeyer Michael Domino D. Bergen, D. Dzenkowski other Form filled out in the field by ~,. /(-"//.,/] & Mailed/Faxed to: Date: 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 $OUTHOLD Office Use Only Coastal Erosion Permit Application/ . --Wetland Permit Application ~./_ Administrative Permtt --Amendment/Trans fer/F~xtension w/Received A p p lic a tio n :_~?--= Z ec¢ived .50 t. lX , _ ~Completed Application ~! __Incomplete __SEQRA Classification: Type I___Type 11 Unlisted .LOordination:(date sent) _ WRP Consistency Assessment Form CAC Referral Sent: __Date of Inspection: .__Receipt of CAC Report: __Lead Agency Determination: Tecbnical Review:~ ~ _Public Hcarmg 1 [cld:~t~ '~['_~_. __ Resolution: · ,rA Name of Applicant ~'(/((- {/~_ ~ ./6 Suffolk County Tax Map Number: Property Location: ~-ff~-~ /~'ti~ (provide LILCO Pole #, distance to Cross streets, and location) AGENT: (If applicable) Address: Phone: Board of Trustees Apglication GENERAL DATA Land Area (in square feet):_ Area Zoning:_ Previous use of property: Intended use ofproperty:_ ~( ~cl.~,~(t~L( Covenants and Restrictions:. Yes ~ No If "Yes", please provide copy. J 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 d/emoliti°n as per Town Code or as determined by the Building Dept. Yes t,/ No Does the structure (s) on property have a valid Certificate of Occupancy Yes __No Prior permits/approvals for site improvements: Agency Date o l '2..O l i {,[,c.v-) lo[ 2..olt __ No prior permits/approvals ibr site improvements, Has any pen'nit/approval ever been revoked or suspend/ed by a governmental agency? v/ No Yes If yes, provide explanation: Project Description (use attachments if necessary): ~ ~ ~)-- -~-v ~,~ I Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland 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 much material will be filled? Depth of which material will be removed or deposited: Proposed slope throughout the area 6f operations: Manner in which material will be removed or deposited: cubic yards cubic yards feet Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): PROJECT ID NUMBER 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) ~/t2' PROJECT NAME r SEQR 3ART 1 - PROJECT INFORMATION 1, APPLICANT / SPONSOR Municipality 4. PRECISE LOCATION: Street Addess and Read Intersections, Prominent landmarks etc -or provide ma~ IS PROPOSED ACTION: ~ New ~ Expansion ~Modification/alteration DESCRIBE PROJECT BRIEFLY: 7 AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8 WILL PROPOSED ACTION COMPLY WiTH EXISTING ZONING OR OTHER RESTRICTIONS? J~JYes [] No If no, describe briefly: 9 WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) J~esidential J~lndustrial ~]Gomme~cial [~Agriculture J'--JParklForestlOpenSpace j~JOther (describe) 10 DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY PROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) J~Yes [~o If yes, list agency name and permit / approval: ~7OOt:5 AN~Y A~'FrECT OF TH~ ACT~O[q- ~:~'A~7~--~T,J~'~)'~Ero PERMIT--OR APPROVAL? J~Yes J~o if yes, Iisi agency name and permit / approval: 12 AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? [Zh'e, i--J o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / 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 ~'~ ~ PROPEaTY LOCATtON: S.C.TM.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM.WATERt GRADING; DRAINAGE AND EROSION CONTROL pLAN District Section alock Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORr~ sCOpE OF WORK - PROPOSED CONSTRUCTION ITJ~VI# / WORK ASSESSMENT [ Yes No a. What is the Total Area of Ihe project Parcels? 1 Will this Project Retain AJI Storm-Water Run-Off (Include Total Area of all Parcels Iocaled within Generated by a Two (2") Inch Rain[all on Site? the Scope of Work for Proposed Construction) is F t Acres) (This item will include all run-off 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 Site improvements and the permanent creatio~ of Impewk~ts surfaces.) construction activity? (s.F./Acres) 2 Does the Sita Plan and/or Survey Show AIl Proposed PROVIDE BRIEF PROJECT DF~CRIPTION (v~d, ~a~io,,~ P,a*, ,, N,,,a,~ Drainage Structures Indicating Size & Location? This ~ item shall include all Proposed Grade Changes and Slopes Controlling Surface Water Flow. ;: ~Ce ?_~z,~: (5 q ~o_~-') r: ~, ~¢-k'-. 3 Does the Site Plan andlor Survey describe the erosion ' and sediment control practices that will be used to ~ CL~ -~ ~"l control site erosion and storm water discharges. This -- item must be maintained throughout the Entire Construction period. 4 Wi, this Project Require any Land Fil[ing. Grading or Excavation where them is a change to the Natural Existing Grade Involving more than 200 Cubic Yards of Material within any parcel? 5 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 Coursa Running through the Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Requirements: or within One Hundred (100') feet of a Wet[and or Submission of a SWPPP is required tot all Construction activities involving soil Beach? disturbances of one (1) or more acres; including disturbances of less than one acre that 7Will there be Site preparation on Existing Grade SlopesL~ are part of a larger common plan that will ultimately distur~ one or more acres of land; which Exceed Fifteen (15) feet of Vertical Rise to including Construction activities involving soil disturbances of less the n one (t) acre where One Hundred (100') of Horizontal Distance? the DEC has determined that a SPDES permit is required lot storm water discharges, SWPPP*s Shall meet the Minimum Requirements of the SPDES General Pernllt 8 Will Driveways, Parking Areas or other Imbemious~r'""~/"~ for Storm Water Discharges from Construction activity - Permit No, Gp-O-104101.} Surfaces be Sloped to Direct Storm-Water Run-Off 1. q~e SWPPP shall be prepared prior to the submittal of the NOI. ~e NOI shall be Irlto and/or in the direction of a Town right-of-way? STATE OF NEW YORK, COUNq'Y OF .......................................... SS 'l hat I,. ............................................................................... berog duly sworn, dcposcs and says that he/she is the applicant for Permit, And that he/she is the D' c~. Owner and/or representative of the OwGer or Owners, and is duly authorized to pefforn~ 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; ............................................... day ol'. ............................................ 20 ..... Notary Public: .......................................................................................... FORM - 06/10 Board of Trustees Application County of Suffolk State of New York : 5, ~< 12 'd;~/.,-¢~ BEING DULY SWOR DEP(~SES AND AF~klRMS THAT HE/SHE iS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF H1S/H ER 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 REV1EW OF THIS APPLICATION. SWORN TO BEFORE ME THIS DAY OF _,20 Notary Public APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of ~outhold'$ Code of Ethics prohibits conflicts of interest on the vart of town officers and emolovees. The tmroose of i]4is form is to nrovide information which can alert the town of possible conflicts of h~i.~ie~t and allow it to take whatever action is necessary to avoid same. YOURNAME: ~,/'~ /~-0' . , ,.. t ,- ¢ (Last name, first na~me, ~iddle 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: (Cbeck all that apply.) Tax grievance Building Variance Trustee X. Change of Zone Coastal Erosion Approval of plat Mooring Exemption t¥om plat or official map -- Planning Other (If"Otber', 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, incluthng a pertncrship, in which lhe town officer or employee has even a partial ownership of{or employment by) a corporation in which the lown officer or employee owns more than 5% of the shares. YES NO /~ If you answered "YES", cun~plcte the bahmce of this form and date and sign where indicated. Name of person employed by the Town of Soulhold 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 linc 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 applicont (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, p,~tner, or empinyee of the applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Submittedtthis Signature Print Name t q I NOT~ I~ COUNTY OF SUFFOLK ~) OFFICE LOCATION: Town Halt 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 MEMORANDUM 8EP 1 ? 201Z To: Jim King, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: September 13, 2012 Re: Wetland Permit for JULIA & JOSEPH VERGARI JULIA & JOSEPH VERGARI requests an Administrative Permit to install a 225 sq.ft, area of chain-link fencing off of the dwelling to contain the pets. Located: 5855 New Suffolk Avenue, Mattituck. SCTM# 115-5-18 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP. 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 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 Office Use Only Coastal Erosion Permit Application. ~Wetland Permit Application ~Administrativc Permit Z __Amendment/Trans fqr/Ex~cnsion eceived Application:~ ~t/5~Received Fee:$ ~ ~/Completed Applicati0n~//~ Incomplete SEQRA Classification: Type I Type Il Unlisted Coordination:(date sent) ~/LWRP Consistency Assessment Fo~rrn ~ ] ~l /]~.~ CAC Referral Sent: Date of Inspection: .__Receipt of CAC Report: Lead Agency Determination:__ Technical Review:-- 7Public Hearing He~ I ' Resolution: -- ] NameofApplicant J6{C{//1T ~ ~,]():~gr~ l/~--~L"ar"~I ,OD ~t)< '?'~ tO~zo,~c /~ It%'~e~PhoneNumbcr:(~'/~ ~- - Suffolk County Tax Map Number: Property Location: (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: Boa~of Trustees Application GENERAL DATA Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property: Covenants and Restrictions: Yes J No If "Yes", please provide copy. Does this project require a variance from the Zoning Board of Appeals __ If "Yes", please provide copy of decision. Yes No Will this project require any d/~molition as per Town Code or as determined by the Building Dept. Yes t/ No Does the structure (s) on property have a valid Certificate of Occupancy Yes No Prior permits/approvals for site improvements: Agency Date __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspend~ext by a governmental agency? ~ No Yes If yes, provide explanation: Project Description (use attachments if necessary): Boa%o£ Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ]:::E,t ~ ,~ t t~ 6 a ~/,- rd/'¢ t,- Area of wetlands on lot: square feet Percent coverage of lot:. % Closest distance between nearest existing structure and upland 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 much material will be filled? Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: cubic yards cubic yards feet Statement of 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): IPROJECT ID NUMBER SEQR 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) PART 1 - PROJECT INFORMATION 1. APPLICANT / SPONSOR 3.PROJECT~ LOCATION: O_________________&~,~ /,~c~)J Q/"//~'~/Z Municipality 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map 5. IS PROPOSED ACTION: [] New [] Expansion [~odification / alteration 6. DESCRIBE PROJECT BRIEFLY: 7 AMOUNT OF LAND AFFECTED: initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ]Yes [] No If no, describe briefly: 9 WHAT tS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) [~esidential [~lndustrial [~Commercial E~Agriculture r-lPark/Forest/OpenSpace []Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ~Yes F~No yes, agency name permit / approval: list ]~OE-S ANY AsI~E~T'OP the ACIION HAVE A CURRENTLY VALIO~ERMIT OR APPROVAL? E~Yes [----~qo If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? E es E].o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / 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 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),es, c~ordinatu the review process and use the FULL EAF. 171No B. WILL ,~CTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declamfion may be superseded by another involved agency. C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answem may be haedwflttea, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic paifem, so~id waste production or disposal, potential for emsiou, drainage or flooding problems? Explain bdefly: I C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or ~eighborhood character? Explain briefly: I C3. Vegetation or fauna, fish, shetitish or wildlife species, significant habitats, or threatened or eedangemd species? Explain briefly: C4. A commungy s existing plans or goals as officla y adopted, or a c~ange m use or talens ly of use of land or other nature resources? Explain briefly: Cfi. Growth, subsequent development, or related activities likely Io be induced by the proposed action? Explain brieny: C6. Long term, short term, cumulative, or other effect; ~0t ici~;titi;d i; C~ ~$~ Explain O. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA {CEA~? tif ),es, explein briefly: I-I E. IS THERE, OR IS THERE UKELy TO BEI CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: PART Itt - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse eff~ identified above, determine whether it is substantial, large, important or othe~vise significant. Each effect should be assessed in connection with its (a) setting (i.e. ulban or rural); (b) probability of occurring; (c) duration; (d) irmversibility; (e) geographic scope; and (f) magnitude, If necessary, add attachments or reference supporting matel~als. 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 ~s, the determination of signiflca nce must evaluate the potential impact of the p reposed action on the envimnm entel charactel~stics of 01e CEA. Check this box if you have Id~ one or more potentially large or signifcant adverse impacts which MAY occur. Then proceed directly to the FUL FAF and/or prepare a positive declaration. Check this pox If~ou have determined, based on the information and anelysle above and any supporting documentation, that the proposed actin WILL NOT result in any significant adverse environmental Impacts AND provide, on attachments as necessary, the masons suppo~ng thi determination. Board of Trustees I~ ~",~,~ 7 ~o/ ~--- Name of Lead Agency Date J~/~~'1 /'~' ~C ~"~-/~//,/,,~ ~*~ President . me~.espon~ead Agency Title of Responsible Officer Signature of Responsible Officer in ~,,e'ad Agency Signature of Preparer (If different from responsible officer) Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPEI~P( LOCATIOH: S.C.T.M. ~. THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A S¥O~&~-WATEKF GRADINGt DRAINAGE AND EROSION CONTROL PLAN DiSbict section .lock Lot C/=K ! irll=U BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTION ri'EM# / WORK. ASSESSMENT I Yes No a. What is the Total Area of the Project Parcels? (Inctude Total Area of all Parcals located within I Will this Project Retain All Storm-Wafar Ran.Off the Scope of Work for Proposed Construction) (S.F. I Ac/e~) (This itsm will thclude all mn-off created by siteGenerated by a Two (2") Inch Rainfall on Site? b. What is the Total Area of Lar~d Cisadng clearing and/or construction activities as well as alt and/or Ground Disturbance for the proposed Site Improvements and the permanenl creation of construction activiht? impervious surfaces.) ts.F.,~) 2 Does the Site Plan and/or Survey Show Att proposed PROVIDE BRIEF PROJECT DE~CllIPTION (P.~d~ ~.a~l,o.a P*g.. ~ Drainage Structures Indicating Size & Location? This '~/ Item shall include all Proposed Grade Changes and Slopes Controlling Surface Water Flow. F~<::e 2_-~,,~ (.-~9. *:o:-F'") Fo~ ~)¢-f~ 3 Does the Site Plan and/or Suwey descdbe the erosion ~ C~-(c-~L~ and sediment control practices that will be used to ~,- t control site erosion and storm water discharges. This -- item must be maintained throughout the Entire Construction PeHed. 4 Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Natural r""~ / Existing Grade Involving more than 200 Cubic Yards of Matedal within any Parcel? 5 Will this Application Require Land Disfarbing Activities Encompassing an Area in Excess of Five Thousand (5,000 S.F.) Square Feet of Ground Surface? 6 ,s there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Requirements: or within One Hundred (100') feet of a Wetland or " Submission of a SWPPP is required for all Construction activities involving scll Beach? disturbances of one (1) or more 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 p~an that will ultimately disturb one or more acres of land; which Exceed Fifteen (15) feet of Vertical Rise to including Construction activities involving soil disturbances of less than one (1) acre where One Hundred (100') of Hodzonfal Distance? the DEC has determined that a SPDES permit is required for storm water discharges. SWPPP's Shall me~t the Minimum Requirements of the SPDES General Permtt 8 Will Driveways. Parking Areas or other Impervious1~Sr'"'l"~- for Storm Water Discharges from Construction acflvily - Pe~it NO. GP-0.t 0-00t.) Surfaces be Sloped to Direct Storm-Water Run-Off 1. The SWPPP shall be prepared prior to tbe submittal of tbe NOI. lhe NOI shall be into and/or in the direction of a Town right-of-way? required, gest-constmction storm water management pt~ctices that will be used and/or Removal of Vegetation and/or the ConstnJcfion of any S"I'ATE OF NEW YORK, COUNTY OF ........................................... SS q'hata, J?'"'~":'?'i'~'~'~'di;~d6.i;~T;~i; ................... being duly sworn, deposes and says that he/she is the applicant for Permit, And that he/she is the g2 c,J ~...~_,~ .......................................................... Owner re)d/or representative of the Owner or Owners, a~d is duly authorized to perform or have performed the smd 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; FORM - 06/10 '0696 Qualified in Suffo k County ,,, Commission Expires July Board of Trustees Application County of Suffolk State of New York ~C bZ~7~kc~ BEING DULY SWORN DEP~/SES AND AF~FIRMS 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), 1F 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. /~ signatdr~ SWORN TO BEFORE ME THIS [ ~'- DAY OF Notary Public VICKI TOTH Notary Public.State of New York No. 01T06190696 Oualified in Suffo k County . Commission Expires July 28, 20 ~ (.~ APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town 0f Southold's Code of Ethics nrohibits conflicts of interest on the naa of town officers and emnlovees. The numoso of this form is to provide 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, ~niddle 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 (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 pertoership, in which the town officer or employee has even a pantial ownership of(or employment by) a corporation in which the town officer or employee owns more than 5% of the 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 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 own~'r 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 Signature Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. Before answering the questions in Section C, the preparer of this 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). B. OESCRIVTION OF SITE AND PROPOSED ACTION SCTM# I 5- ¢ 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- suooorfine 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 th¢~io~n of Southold ' s website (southoldtown.northfork.net), the Board of Trustees Office, i~[anning Department, all local libraries and the Town Clerk's office ~{ [ AU$ ~ ~ 20 2 , ' The Application has been submitted to (check appropriate response): TownBoard ~-] Planning Board r~ 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: C 144t~ LIq~_ Location of action: Site acreage: 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 ( ) ~.G/6 - 6-/0 - 5-o~ ~ '--/ (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 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 At~ach 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 Applieahle 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 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 [] Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. Yes [] No ~'~ Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. [] Yes[--~ No~ Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria. ~ Yes ~ No ~ Not Applicable Attach additional sheets if necessary Policy 11. ~romote sustainable use of living marine resources in Long Island Sound, the Peconie 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 ~r] Not Applicable PREPARED BY ~Jb~ a [.a ~3~C-~-/~ TITLE t~-t;,~q~ ~9c~'~c DATE DU~VE¥ OF PROPERTY 51TUA ~ E; HA4 FITUC, K TO~IN.. ~OUTHOLD 5UF-I=OLK-.. C, OUNTY, NY GEI~T. REVISED JUNE 21, 2011 5UPFOLK COUNTY TAX # ~000-1~5-5-1D LOT 45 Open ¥ ¥ ¥ ¥ ®RAPHIC, SE, ALE I"= 50~ 0 DO I00 lDO N'82 °~3,$~,,~ 737.52~ ~8~°~9 JOHN C. EHLERS LAND SURVEYOR 6 EAST MAIN STREET N.Y.8. LIC. NO. 50202 RIVERHEAD, N.Y. 11901 369-8288 F~xx 369-8287