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Home My WebLink AboutTR-7920A James F. King, President a soUryO Town Hall Annex Bob Ghosio, Jr., Vice-President 54375 Main Road 'l P.O. Box 1179 Dave Bergen # Southold, New York 11971-0959 John Bredemeyer G Q iO Telephone (631) 765-1892 Michael J. Domino Q Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0944C Date: December 23, 2013 THIS CERTIFIES that the construction of addition to the existing one-story residence: deck addition with steps, and 8'x8' spa on deck At 2305 Park Avenue- Mattituck, New York Suffolk County Tax Map # 123-3-21 Conforms to the application for a Trustees Permit heretofore filed in this office Dated September 25, 2012 pursuant to which Trustees Administrative Permit #7920A Dated October 17, 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 addition to the existing one-story residence; deck addition with steps; and 8'x8' spa on deck. The certificate is issued to Maria Santig_ate owner of the aforesaid property. Authorized Signature James F. King, President =`lo~gOfFlktr 6 Town Hall, 53095 Main Rd. Bob Ghosio, Jr., Vice-President P.O. Box 1179 Dave Bergen Southold, NY 11971 John Bredemeyer a Telephone (631) 765-1892 Michael J. Domino( Fax (631) 765-6641 B TOWN OARD OF OF TOWN SOUTHOLD TRUSTEES On _ t~ PAVES I (7~ e ea DATE OF INSPECTION:n Ch. 275 Ch- 111 G w! INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curta,t t 1 at day of construction % constructed Project complete, compliance inspection. INSPECTED BY: J I 1 COMMENTS: tJ b~~ D PH 770 .V i r p,r/ SFAtJr4RA 5~~~ d~ /~.F~C`/G CERTIFICATE OF COMPLIANCE: James F. King, Pr~ident 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 __ Pru-construction, hay bale line 1 st 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.: 7920A Date of Receipt of Application: September 25, 2012 Applicant: Maria Santigate SCTM#: 123-3-21 Project Location: 2305 Park Avenue, Mattituck Date of Resolution/Issuance: October 17, 2012 Date of Expiration: October 17, 2014 Reviewed by: Jim King, Trustee Project Description: To construct an addition to the existing one-story residence; a deck addition with steps; an 8'x8' spa on deck; and install pavers at grade. 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 survey prepared by John T. Metzger, last dated on September 27, 2012, and stamped approved on October 17, 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., Vi~-President Dave Bergen John Bredemeyer Michael J. Domino Town Hall Annex 54375 Route 25, P.O. Box 1179 Southold, NY 11971 Telephone (631 ) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated q/2~'h~ · has been reviewed by this Board at the regular meeting of t / lO//7//~ and your application has been approved pending the completion o¥ th~ ~ollowing items checked off below. __ Revised Plans for proposed project __ Pre-Construction Hay Bale Line Inspection Fee ($50.00) __ Is~ Day of Const~ction ($50.00) __ ~ Constructed ($50.00) ~ Final Inspection Fee ($50.00) __ Dock Fees ($3.00 per sq. ~.) Pe~it fees are now due. Please make check or money order payable to Town of Southold. The fee is ~mput~ below ac~ing to the schedule of rotes as set fodh in Chapter 275 of the Southold Town Code. The follo~ng fee must be paid within 90 days or ~appli~tion fees ~11 be necessa~. You will receive your permit upon completion of the above, COMPUTATION OF PERMIT FEER: TOTAL FEES DUE: $...~0. ~P BY: James F. King, President Board of Trustees .lames F. Krug, President Bob Ghosio. Jr. Vicc-Prcsidcnt Dave Bergen ,Iohn Brcdcme) cr Michael I Domim) PO. Box 1179 Southoid, NY 11971 Telephone(63] 765-1892 Fax (631)765-6641 Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: Diane Herold, Architect on behalf of MARIA SANTIGATE requests an Administrative Permit to construct an addition to the existing one-story residence; deck addition with steps; an 8'x8' spa on deck; and install pavers at grade. Located: 2305 Park Avenue, Mattituck. SCTM# 123-3-21 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 ,/'.Administrative__Emergency Coastal Erosion Amendment 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 J, /~//C?~'y Mailed/Faxed to: Date: 8EP 2 6 2012 _N..e~v. York .Sta. te Department of Environmental Conservation ?~?ton_of Environmental Permits, Region One um~JnO 40- ~d. JNY, b'lony B~ook, NeW York 11790-2~ vveos~, www. ooc. state.n~.os Le~r otrNon.Jufi_.ai.q__~.... Tidal W~ ..... ~pr~ 7, 2ooo SC'~ t~-123-03-21 App~atim~ # 1-4'/38-02599/00001 SEP 2 5 2Q12 .--'-~ ,,,,.=-~-., o~ymm .Pmsasctsmo~Arlieb2S (TidalWethnds). T~ in accoMance with tim coxtcnt T'~al Wctlands Land Usel~ (6NY'CRR Part 661) no °r vql~ttion wM~n Tidal Wetlands jm~lictimi which may result ~.~n your project. Projgct (i.e. a 15' to 20' ' -"- ~'~-~a, u,~ uum wcuam~ jurtsd~oua] botmd~ and y~ur ........... ---- : you th~respomib~tyot*ob Sincerely, COUN3~fOFSUFFOLK ~) I~ * ~ Realpioper[yTaxSemlceAgenc~ Y~ li~~ 123 OCT 2 4 2012 OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY 11971 MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971 Telephone: 631 765-1938 Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD Toz From: MEMORANDUM Jim King, President Town of Southold Board of Trustees Mark Terry, Principal Planner LWRP Coordinator OCT 16 2012. Date: October 16, 2012 Rez Proposed Wetland Permit for MARIA SANTIGATE SCTM#1000-123-3-21 Diane Herold, Architect on behalf of MARIA SANTIGATE requests an Administrative Permit to construct an addition to the existing one-story residence; a deck addition with steps; an 8'x8' spa on deck; and install pavers at grade. Located: 2305 Park Avenue, Mattituck. SCTM# 123-3-21 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP provided that the following is addressed: 1. The setback is measured from the mean high water line and is incorrect. The setback must be measured from the wetland line. Further, it is recommended that the proposed 20' wide landscaped buffer (incorporating existing vegetation) be required landward of the wetland line. The property slopes towards Deep Hole Creek. 3. Require that the action comply with Chapter 236 Stormwater Management of the Southold town Code. 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 Date: October 1, 2012 To: Board of Town Trustees, Town of Southold Re: Mafia Santigate trustees permit application 2305 Park Avenue, Mattituck Diane Herold, Architect P.O. Box 884 Westhampton Beach, New York 11978 631-288-5049 phone and fax -1 r7 . ~ ~ : OCT 2 ,.,,,, Attached are the following items as requested by your Board A check in the amount of $50.00 for the administrative permit application Surveys revised to eliminate the confusion about the size of the addition and the brick patio spelled out. Please contact me if you require additional information. Thank you, Diane Herold Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Bredemeyer Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application Wetland Permit Application ~ Administrative Permit Amendment/Tr aris fe/_/E~nsion X Received Applieation:~ Y,- Received Fee:$ ~ }( Completed Application ~k Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) jr~LWRP Consistency ~§sessrpent Fo-tm ~(~CAC Referral Sent: ~K Date of Inspection: __Receipt of CAC Report: __Lead Agency Determination: Technical Review: ~Public Hearing Hetd:~.9~_ __Resolution: NameofApplicant A,'l~..l~ ,~la, tl~t Address "/Or3 l:>~--rO~ .~m~.~ Phone Suffolk County Tax Map Number: 1000- tZ'3- 0'3- ? | Property Location: ~'~05 I:>I:M~Y. la, O&tu¢l,t:, Q.ORlo~IL O~ ~ooGgt_e~ta Ltl, kl~ ~l~lk-'n'tTUO_l¢ (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: ~'~H AW F~'O D ~eA c-lt. =d of Trustees Applicatio0 GENERAL DATA Land Area (in square feet): Area Zoning: Previous use of property: ~ Intended use of property: Covenants and Restrictions: Yes If "Yes", please provide copy. )~ No 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 ~C. No Does the structure (s) on property have a valid Certificate of Occupancy g Yes __ No Prior permits/approvals for site improvements: Agency Date 5cb 14s ~. I0-' o l- ~b t? [.. ~301 __ 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):. It.$' x iq' Au~ 0 ~ 5.,~ ~x:>Dr-t'toKk.~- i- sToOl. WETLAND]TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: d~oO square feet Percent coverage of lot: t"~;;~ % Closest distance between nearest existing structure and upland edge of wetlands: !~.5 feet Closest distance between nearest proposed structure and upland edge of wetlands: 113'4 feet Does the project involve excavation or filling? No .,X" Yes If yes, how much material will be excavated7 { ~' cubic yards How much material will be filled? A,,OlOC= cubic yards Depth of which material will be removed or deposited: '~ Ow' feet Proposed slope throughout the area of operations: O- tO ~o ta,-f f~X~tT~O~O,~ 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): lot Ilot of Trustees Applicatione COASTAL EROSION APPLICATION DATA Purposes of proposed activity: p,J~ ~D t-'l l o ~..) ~ 'TO -T~ ~ CJ~ Are wetlands present within 100 feet of the proposed activity? ~' No Yes Does the project involve excavation or filling? No l~- Yes If Yes, how much material will be excavated? How much material will be filled? (cubic yards) (cubic yards) Manner in which material will be removed or deposited: m,~o..ll,~/O,-t Ia ~0 Describe the na~e ~d ext~t of the enviromental impacts to the subject prop~y or nei~bofing prope~ies reasonably anticipated resulting ~om implementation of the project as proposed, including erosion increase or adverse effects on na~ral protective features. (Use mtachments if necess~) ' PROJECT iD NUMBER PART1-PROJECTINFORMATION 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 1. APPLICANT / SPONSOR /2. PROJECT NAME 3.PROJECT LOCATION: / Municipality ~ ~kT"[i-'/'lJl?J~. SEQR At>'D I 4. PRECISE LOCATION: Slreet Addess and Road Intersections, Prominent landmarks etc -or Divide mac 5. iS PROPOSED ACTION: [] New [] Expansion [] Modification / a~teration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially O. 8 acres Ultimately O. ~ acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? [~Yes [] No If no, describe briefly; 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) ~-]Residential []Industrial []Commercial [~Agriculture r~]Park/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) ~-'rYes []No If yes. list agency name and permit / approval: TOCU~ Og 5OU"/I-(OL_X~ ~,OlL'~t~(; 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [~Yes [~]No If yes, list agency name and permit / approval: ~/"l~'~,~c /---~""¢~Of /JOlO-.SOii.-t~tC..TtOl~ A~{tt/.--7~ 7.000 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I aa I No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE iS TRUE TO THE BEST OF MY KNOWLEDGE Applicant I Sponsorf~me ry~J~--tl.~ .~./j..rt G~.7'~...~ ~[A~ ~ Date: Signature ~' ~ ~~ If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, pART 617.47 If yes, coordinate the review process and use the FULL FAF. Five., [Z]No L WILL ,~CTION RECEI'~E COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative dectaraflon may be supemeded by another involved agency. C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED W~TH THE FOLLOWING: (Answers may be handwfltton, if legible) C1.Existing air quality, surtace or groundwater q ualil-/or quantity, noise levels, existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C3. Vegetation or Pauns, fish, shellfish or wildlife species, significant habitats, or Ihreatened or endangered spedes? Explain briefly: C5~ Growth. subsequent development, or related activities likely to be induced by the proposed action? Explain bhefly: I C6. Long term, sherl term, cumulative, or other effects not identified in C1~:;57 Explain briefly: C7. Other impacts (including changes in use of either ({uanfity or type of ener(~ly? Ex,elfin bddfl~/: -- - D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL ARFA ICEAI? IIf yes, explain briefly: E. IS THERE, OR IS THERE LIKELY TO BEr CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If ~es explain: r-lyes [Z]No PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadvemee~ectidenti~edab~ve~determinewhether~tissubstantia~~~arge~impertant~r~thenvisesignirm~nL Each effect should be assessed in connection with its (a) seffing (Le. ul'oan or rural); (b) probability of occurring; (c) duration; (d) irmversibility; (e) geographic scope; and (0 magnitude. If necessaP/, add attachments or referenoe supporting materials. Ensure that explanations contain suffictect detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked y~s, the determination of s~gnificance must evaluate the p otentlal impact of the p reposed action o~ the environmental characteristics of the CEA. Check thle box if you h~ve Idendfied one er mom potentlelly la~e or significant adveme iml3acts whleh IIIIAY e~cur. Then proceed direcfiy fo the FUU. EAF and/er prepare a positive declaraiion. Check thle box If you have detemitned, based on the Infom~atlon and analysis above and any supporting decuments§on, that the~mposed actler W1LL NOT result in any signi~cent adverse environmental Impacts AND pmvlee, on attachments as necessary, the masons supporting thi,' detennina~on. Board of Trustees Name of Lead Agency I IZ / Print or T~ Name of Res~n~ble Offi~r in Lead Agenw ~ignalum o es~nsi le Offi~r ~ Agenw Date President [] Ttiie of Responsible Officer Signature of Preparer (If different from responsible officer) " Town of So'hold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M. #: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM-WATER, GRADING~ DRAINAGE AND EROSION CONTROL PLAN Distflot secben mock Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUcwION ITEM # / WORKASSEBSMENT I Yes No a. What is the Total Area of the Project Parcels? (Include Total Ama of all Pamels located within =~,, I1~(o ~//O. 8 I GeneratedWill this ProjeCtby a TwoRetain(2")AlllnchSt°rm'WaterRainfall o~RUn-Offsite? the Scope of Work for Proposed Construction) (Tl~is item will include all run-off created by site b. What is the Total Ama of Land Cleadng (S.F. / Acme) clearing and/or construction aclJvities as well as all and/or Ground Disturbance for the proposed Site Improvements and the permanent creation of construction activity? ~dO t,)~ impervious surfaces.) IS.F.,A~I 2 Does the Site Plan andlor Survey Show All pmpesed PROVIDE BRIEF PROJECT DF~CRI]FI'ION (Provue Xdd~alPagas =~ ~l Drainage Structures Indicating Size & Location? This r~ item shall include all Proposed Grade Chan~e.~ and Il- ~ ~. I't~ * [G,1J~3 8' ~z ~ ~' I1~ ~:31::3 l't'l OD[ 'to Slopes Controlling Surface Water Flow. 3 Does the Site Plan and/or Survey descdbe the erosion ~ - .~"J'Ot-~ t"~.~.~ %~:3 ~, tJ ~' and sediment control practices that will be used to control site erosion and storm water discharges. This '~:)~oU~. [l~:)~:)l-t'jtal0 I~X:3 .~'?'~ item must be maintained throughout the Entire ~/~l~ Construction Period. ?'~ucq~,.~ ~-t G ~z.~ 4 Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Natural 1~ 'K ~ ~[3t3~ (3~J '~::1~' ~,~.. Existing Grade lnvolving more than 200 Cubic Yards of Matedal 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 ,s there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdictionI~l General DEC SWPPPRequimments: or withth One Hundred (100')feetofaWetiandor -- Submission o[ a SWPPP is required for all Construction activities involving soil Beach? disturbances of one (1) or more acres; isdudisg disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes em par[ of a larger common plan that will ultimately disturb one or more acres of la~d; which Exceed Fifteen (15) feet of Vertical Rise to including Consbuction activities involving sog disturbe~ces of less than one (1) acre where One Hundred (100') of Horizontal Distance?L,~ -- the DEC has delermined that a SPDES permit is required for storm water discharges. SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit ; 8 Will Driveways1 Parking Areas or other Impervious for Storm Water Discharges from Construction activity - Pen~lt No. GP-0-t0-00t .) Surfaces be Sloped to Direct Storm-Water Run-Off 1. The SWPPP shall be prepared pdo~ to the submiltal o~ the NOL The NOI shall be into and/or in the direction of a Town right-of-way? ST~T~ O~ r~w ¥omq That I ....... ....-~....[[1~.~'..........[4~..~...~.'~.. ..................... being duly swbrn, deposes and says that be/she is the applicant lbr Permit, Owner and/or representative of the Owner or Owners, and is duty authorized to perform or have performed the said work and to make and file this applica6on; that all statements contained in this application are true to rite best of his kuowledge and belief; and that the work will be performed in the manner set foc, h in the applicatiou fded herewith. FORM - 06/10 Natary Public, State of New York No. 01SC4878999 Qualifiec~ in Suffolk County · Comm*ssion Expires Dec. 8, :fO ~.~ of Trustees Application County of Suffolk State of New York ~ I KD~ i4~iLO~::,. 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 ~) DAY OF~,20 / ar/~ublic JACOUELINE $CO'VI' N;tary Fubhc. State of h;ew York No. 013C4878999 Oualif~ecl in Suffolk County Commission Expiros Dec. 8, 20 AUTHORIZATION (where the applicant is not the owner) I, ~tkgtf~ Kc~wlk ~r~g~r& (print owner of property) residing at (mailing address) do hereby authorize (^gent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. '(Owner's sig~ture) / (J APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM Thc Town of Southold's Code of Ethics orohibits conflicts ofinterast on thc ~rt of town officcss and emnlovees. The ouroose of this form is to nrovide information which can alert thc town of vossible conflicts of interest and allow it to take whatever action is n to av id same. YOURNAME: pAg~,(L~ ~:tt-WO~ ~o-it6~'ffx '~ 'X~lg.~ [~e~LOl-~ (Last name, fi~t name,~niddle initial, unless you am applying in the name of someone else or other entity, such as a company. If so, indicate the other pomon'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 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 applicant/agcnffrepresentative) 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 osvner of greater than 5% of the shares of the corporate stock of the applic0nt (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); ___(2) an officer, director, parmer, or employee of the applicant; or ___D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 . Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Water~ont 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 Waterfi'ont 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~ listin~ both supporting and non- suooorfin~ 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# /OOO tT_.~ PROJECTNAME ~gM0"tt~T& ~.'~'o~-I'tolO ~ The Application has been submitted to (check appropriate response): TownBoard [--] Planning Board [--] BuildingOept. [~ BoardofTrustecs 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: 1~-5' ~ l~4'~x~Jx~ ~' '70 I- ~'TOflA4 ('~StX:~6 t0C ~ Location of action: Site acreage: Present l~d use: ~t~ Present ~g cl~sificafion: If ~ application for ~e propo~d action h~ been filed M~ ~e Tom of So.old agency, ~e follo~g iffo~afion sh~l be provided: (a) N~e of applic~t: ~t~ (c) Telephone nmber: ~ea Code (d) Application nmber, if ~y: Will ~e action be directly ~dea&en, require ~nding, or approvM by a state or federA agency? Yes ~ No ~ If yes, whch state or federal agencyT 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 [-] Yes ~ No [] Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III - Policies Pages 8 through 16 for evaluation criteria ~-~ Yes ~-] No [~ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southoid. See LWRP Section III - Policies Pages 16 through 21 for evaluation criteria Yes [] No [~'lNot 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 LVOIP Section III - Policies; Pages 22 through 32 for evaluation criteria. · , . ., Yes No Not Apl~ble 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 Ill - 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. Promote sustainable use of living marine resources in Long Island ,Sound, the Peeonie 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 Aitach 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 PREPAREDBY -x,.~ t~oE ~¢~[EOL-X> TITLE 9'EST HOLE D~rk I)rown sand~ loam OL' 0.5° Brown loomy 5~ Pale brown fine lo medium sand ~P I0' Hale brown f/ne s~nd SP /I.2' brown fine I am familiar wllh file STANDARDS FOR APPROVAL AND CONSTRUCTION OF SUBSURFACE SEWAGE DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES and will abide by fha conditions set forth lhereln and on lhe permit 1o conslrucf. il7' CERTIFIED TO' GRACE R. CANTONE MARIA ELENA SANTIGATE The Iocotlon$ of wells ond cesspools shown hereon ore from field observotlon$ and or from ddo ob/o/ned from others, FLOOD ZONEs FROM FIRM (NAVDJ M~P NUI,dJ~.J[ ;~6103C0482 H SEPT. ~5~ ~'009 ® ~ K1U- U1- STy. DEEp HOLE CREEK SURVEY OF PROPERTY AT MATTITUCK TOWN OF SOU.THOLD SUFFOLK COUNTY , N.Y. 1000-12~--0~21 Scale 1" = 40' Oct. 22, 1997 DEC. 23,1998'( prop. -dJ/lion, flood zones;'/) OCT. 22~ 1999 ( topo ) 'MAY 21, ::>001 ( new addition )' JUNE P?,;~2001 ('~EST HOLE ,JULY 24, 200l ;~JG. 6, ~001 ( REVISIOIV ) MA Y 15~ ~002 ( final MAY ~ 2010 b~PT. 4. 2012 fPROP ADDJ'"~ON~) SEPT. 27, 2012 APPROVED BY BOARD OF TRUSTEES AREA,=35862 eq. ff. to lie line CONTOUR LINES ARE REFERENCED TO N.G.V.D., ~ C '/?-__' __--- -- ~Y~D/NG PLAN ANY ~IIATION OR ADDITION TO THIS ~UMVEY IS A VIOLATION OF ~ 72~ ~ THE NEW Y~K STA~ E~CA~ON LAW, EX~ A~ PER SEC~ON 720g-SUB~ 2. ALL CER~FICA~S HE~ ~ VALID F~ ~IS MAP AND C~IES ~ERE~ ~LY ~ ~ ~ C~IES BEAR ~E IMPRE~D SEAL ~ ~E SUR~Y~ 1230 TRA~LE~ STREET