HomeMy WebLinkAbout1000-67.-1-7 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
MEMORANDUM
To:
Leslie Weisman, Chair
Members of the Zoning Board of Appeals
From: Mark Terry,
Principal Planner
LWRP Coordinator
Date: January 3, 2013
Re
Coastal Consistency Review for ZBA File Ref MICHAEL J. HIRSCHHORN #6619
SCTM#1000-67-1-7
MICHAEL J. HIRSCHHORN #6619 - Request for Variances from Article XXlII Section 280-122A and
the Building Inspector's December 4, 2012 Notice of Disapproval based on an application for building
permit for additions and alterations to an existing dwelling at: (1) a nonconforming building containing a
conforming use shall not be enlarged, reconstructed or structurally altered or moved, provided such
action does not create any new nonconformance or increase the degree of nonconformance, Pursuant
to the interpretation of Walz (5039) such alterations will thus constitute an increase in the degree of
nonconformance: (a) less than the minimum side yard setback of 10 feet, (b) less than the minimum
combined side yard setbacks of 25 feet, located at: 280 Sound Avenue (adj. to Long Island Sound)
Peconic, NY. SCTM#1000-67-1-7
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 determination that the proposed actions are
EXEMPT from LWRP review pursuant to:
§ 268-3. Definitions. MINOR ACTIONS items "F" and "Ir' which state:
F. Granting of individual setback, lot line and lot area variances, except in relation to a regulated
natural feature or a bulkhead or other shoreline defense structure or any activity within the CEHA;
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 an coastal erosion hazard area;
The parcel is not located within the Coastal Erosion Hazard Area.
Cc: Jennifer Andaloro, Assistant Town Attorney
BOARD MEMBERS
Leslie Kanes Weisman, Chairperson
James Dinizio, Jr.
Gerard P. Goehringer
George Homing
Ken Schneider
Southold Town Hall ~
53095 Main Road · P.O. Box 1179
Southold, NY 119714)959
Office Location:
Town Annex/First Floor, Capital One Bank
54375 Main Road (at Youngs Avenue)
Southold, NY 11971
http://southoldtown.northfork.net
ZONING BOARD OF APPEALS
TOWN OF SOUTHOLD
Tel. (631) 765-1809 · Fax (631) 765-9064
December 11, 2012
Mark Terry, Principal Planner
LWRP Coordinator
Planning Board Office
Town of Southold
Town Hall Annex
Southold, NY 11971
Re: ZBA File Ref. No. #6619 (Hirschhorn)
Dear Mr. Terry: (-~
We have received an application for additions and alterations in Peconic. A copy of the
Building Inspector's Notice of Disapproval under Chapter 280 (Zoning Code), and
survey map, project description form, are attached for your reference.
Your written evaluation with recommendations for this proposal, as required under the
Code procedures of LWRP Section 268-5D is requested within 30 days of receipt of this
letter.
Thank you.
Very truly yours,
Leslie K. Weisman
Chairperson
Encls.
TO:
FORM NO. 3
NOTICE OF DISAPPROVAL
Michael J. Hirschhom
c/o Suffolk Environmental Consulting, Inc.
P.O. Box 2003
Bridgehampton, NY 11932
Date: December 4, 2012
Please take notice that your application dated November 5, 2012
For permit for addition and alterations at
Location of property: 280 Sound Avenue Peconic, NY
County Tax Map No. 1000 Section 67 Block 1 Lot 7
Is returned herewith and disapproved on the following grounds:
The proposed construction, on this non-conforming 19,377 sq. ft. lot, (approx. 5,000 sq. ft. buildable)
in a R40 zone district is not permitted pursuant to Article XXIII Section 280-122A, which states:
"Nothing in this article shall be deemed to prevent the remodeling, reconstruction or enlargement of a
non-conforming building containing a conforming use, provided that such action does not create any
new non-conformance or increase the degree of non-conformance with regard to the regulations
pertaining to such buildings."
The building with alteration, notes a single side yard setback of 9.2' (10' required) and combined side
yard setback of 21.4 (25' required).
Pursuant to the interpretation of Walz (5039) such alterations will thus constitute an increase in the
degree of nonconformance.
' Authorized Signature
Note to Applicant: Any change or deviation to the above referenced application may
require further review by the Southold Town Building Department.
CC: file, Z.B.A.
IFee: $ Filed By: Assignment No. [
APPLICATION TO THE SOUTHOLD TOWN BOARD OF APPEALS
House No. 280 Street Sound View Avenue Hamlet Peconic
SCTM 1000 Section 067 meek 01 Lot(s)_007 Lot Size 19,377 s.f. Zone R-40
I (WE) APPEAL THE WRITTEN DETERMINATION OF THE BUILDING INSPECTOR
DATED BASED ON SURVEY/SITE PLAN DATED
Applicant(s)/Owner(s): Michael d. Hirschhorn, dimena, P. Martinez
Mailing Address: 307 Sterling Place, Brooklyn, NY, 11238
Telephone: (631)-537-5160 Fax: Email:
NOTE: In addition to the above, please complete below if application is signed by applicant's attorney, agent,
architect, builder, contract vendee, etc. and name of person who agent represents:
Bruce A. Anderson forr~Owne~"--~Other:
Name
of Representative:
Address: P.O. Box 2003 Bridgehampton, NY, 11932
Telephone:
(631) - 537 - 5160
Fax: (631) - 537 - 5291
Email: Bruce@suffolkenvironmental.com
Please check to specify who youth correspondence to be mailed to, fro. liLle above nantes:
[~npplicant/Owner(s), [~]Authorized Representative, U Other Name/Address below:
WHEREBY THE BUILDING INSPECTOR REVIEWED SURVEY/SITE PLAN
DATED and DENIED AN APPLICATION DATED
Building Permit
Certificate of Occupancy ( ) Pre-Certificate of Occupancy
Change of Use
Permit for As-Built Construction
Other:
Provision of the Zoning Ordinance Appealed. (Indicate Article, Section, Subsection of Zoning
Ordinance by numbers. Do not quote the code.)
Article: xx, Section: 2oo~ t22..- Subsection: A
FOR:
Type of Appeal. An Appeal is made for:
[~A Variance to the Zoning Code or Zoning Map.
A Variance due to lack of access required by New York Town Law- Section 280-A.
Interpretation of the Town Code, Article Section
r-~Reversal or Other
A prior appeal [] has, [] has not been made at any time with respect to this property,
UNDER Appeal No(s). Year(s). . (Please be sure to
research before completing this question or call our office for assistance)
ZBA File #
Pd~ ASON.""; l:OI,t ..\P'Iq,~AI, (additional xhect~ mat' he u~cd with pCClmrer
· IRt: ! I ~ IR/Ix,'('/:` REISO.YS:
(1) An undcsirahlc change will not be produced ill tile CII.\RACTER of thc neighborhood or a
detriment Io nearlD properties if granted, because:
The zonin~ variance is bein~ requested to allow for construction on the permissible second sto~
addition Ia take place within the side yard. That bein~ the case, any incursion within the side
yard will be tempom~ in nature.
(2) The benefit ~ought b~ fl~e applicant CANNel be achieved ~r ~]~h method l~asible for thc
applicanl to pursue, other lhall aH area ~ ariatlCe, because:
Due to the layout of the propeay, any lawful addition to the dwellin~ would require an
area variance because of the small side yards.
(3) The amount of relief requested is not substantial because:
The zoning variance is being requested to allow for construction on the permissible second story
addition to take place within the side yard. That being the case, any incursion within the side
yard will be temporary in nature.
(4) The variance ~ill NOT ha,,e till lit[x, el-~it! ¢[1'~_,cI of impact (ill the physical or environmental conditions
in rite neighborhood or dislricl because:
The zoning variance is being requested to allow for construction on the permissible second story
addition to take place within the side yard. That being the case, any incursion within the side
yard will be temporary in nature.
(5) tlas tile alleged difficull.~ Iicen sell'crc;He, d? [--]Yes, or [~])No.
Arc there Co'~ennn{s nmI Restrictions concerning this land: []No.
This is rile MINIMUM that is ncccssar) and adequate, an(I tit tile same dine preserve nnd protect thc
charnctcr of tile neighlmrhood ;tll(I rile health sal;erx and ~ elfarc of Ibc communib.
CTicc!~ thi.s box ~ 11-.I USI: IkIR/ I.~'['E IS Bill:X(; RIi'QIj~:SIED~.IAD PLI51SI5 ('031PL1511~ TIIU
, l'7:l('Hl!I)USI:'I, IR/IV('I:' S/ll;/:l)(1 Ica,~ to ,'otr~',~
/ ~mtui'~o~A~pellt;nt or A' - uthorized ~
Sx;orn to hefore me ~is /~
M,~tthew D. lyons
Notar,, ?u~'i~c ot Ne, w York
No 01t:6053859
Qualified in Sutio!k County
Commissior, Expires &nu~ry 22,
QUESTIONNAIRE
FOR FILING WITH YOUR ZBA APPLICATION
Is the subject premises listed on the real estate market for sale?
~_Yes ~-7-LNo
Are there any prOr.O~als to change or alter land contours?
JT-[_No ~ ~Yes please explain on attached sheet.
1.) Are there areas that contain sand or wetland grasses?
2.) Are those areas shown on the survey submitted with this application? no
3.) Is the property bulk headed between the wetlands area and the upland building
area?
4.) lfyour property contains wetlands or pond areas, have you contacted the Office of
the Town trustees for its determination of jurisdiction? ¥,s Please confirm status
of your inquiry or application with the Trustees: no Pormit Required
and if issued, please attach copies of permit with conditions and approved survey.
ls there a depression or sloping elevation near the area of proposed construction at or
below five feet above mean sea level? Yes
Are there any patios, concrete barriers, bulkheads or fences that exist that are not
shown on the survey that you are submitting? no Please show area of the
structures on a diagram if any exist. Or state none on the above line.
Do you have any construction taking place at this time concerning your
premises? no lfyes, please submit a copy of your building permit and survey as
approved by the Building Department and please describe:
Please attach all pre-certificates of occupancy and certificates of occupancy for the
subject premises, lfany are lacking, please apply to the Building Department to either
obtain them or to obtain an Amended Notice of Disapproval.
Do you or any co-owner also own other land adjoining or close to this parcel?
lfyes, please label the proximity of your lands on your survey.
garage, pool or other)
~d-signature ~nd Date
Please list present use or operations conducted at this parcel Sinflle Family Residence
and the proposed use Sin0[o Family Residenzo
· (ex emsting single Ihmily, proposed same with
AGRICULTURAL DATA STATEMENT
ZONING BOARD OF APPEALS
TOWN OF SOUTHOLD
WHEN TO USE THIS FORM: The form must be completed by the applicant for any special use permit, site
plan approval, use variance, or subdivision approval on property within an agricultural district OR within
500feet of a farm operation located in agricultural district. All applications requiring an agricultural data
statement must be referred to the Suffolk County Department of Planning in accordance with Sections 239-
m and 239-n of the General Municipal Law.
1) Name o£Applicant: Bruce A Anderson
2) Address of Applicant: PO Box 2003. Bridgehampton. NY. 11932
3) Name of Land Owner (if other than applicant): Michael Hir$chhorn & Jimena Maltinez
4) Address of Land Owner: 307 Sterling Place, Brooklyn, NY, 11238
5) Description of Proposed Project: Applicant proposes to construct a second story addition on the existing single family dwelling
6) Location of Property (road and tax map number): 280 Sound ViewAvenue. Peconic. NY
7) IS the parcel within an agricultural district?[~]No i~lYes If yes, Agricultural District Number
8) Is this parcel actively farmed? [~]No [--]Yes
9) Name and address of any owner(s) of land within the agricultural district containing active farm
operation(s) located 500 feet of the boundary of the proposed project. (Information may be available through
the Town Assessors Office, Town Hall location (765-1937) or from any public computer at the Town Hall
locations by viewing the parcel numbers on the Town of Southold Real Property Tax System.
Name and Address
(Please use back side of page if more than six property owners are identified.)
The lot numbers may be obtained, in advance, when requested from either the
~4b'z'~38 or the~ot~in~,rd of Appeals at 765-1809. Office of the Planning Board at
~/~'--" Signatt~re of P~pplicant -- Dhte
Note:
I. The local board will solicit comments from the owners of land identified above in order to consider the effect of the proposed action
on their farm operation. Solicitation will be made by supplying a copy of this statement.
2. Comments returned to the local board will be taken into consideration as part of the overall review of this application.
3. Copies of the completed Agricultural Data Statement shall be sent by applicant and/or the clerk of the board to the proper~ owners
identified above. The cost for mailing shall be paid by the applicant at the time the application is submitled for review. Failure to pa~ at
such time means the application is not complete and cannot be acted upon by the board.
1-14-09
APPLICANT'S PROJECT DESCRIPTION
(For ZBA Reference)
Applicant:Bruce A. Anderson Date Prepared: 8/8/12
I. For Demolition of Existing Building Areas
Please describe areas being removed: N/^
Il. New Construction Areas (New Dwelling or New Additions/Extensions):
Dimensions of first floor extension: See aRached floor plans for buildin0 specifics
Dimensions of new second floor: See attached floor plans for building specifics
Dimensions of floor above second level: 21.9' x 25'
Height (from finished ground to top of ridge):29.5'
Is basement or lowest floor area being constructed? If yes, please provide height (above ground)
measured from natural existing grade to first floor:
III. Proposed Construction Description (Alterations or Structural Changes)
(attach extra sheet if necessary) - Please describe building areas:
Number of Floors and General Characteristics BEFORE Alterations: One story single family dwelling with
relevant appurtenances
Number of Floors and Changes W1TH Alterations: Two story single family dwelling with relevant appurtenances
IV. Calculations of building areas and lot coverage (from surveyor):
Existing square footage of buildings on your property: 2t7§
Proposed increase of building coverage: 0
Square footage of your lot: t9.377 s.fl
Percentage of coverage of your lot by building area: tt.2%
V. Purpose of New Construction: To expand on the existing single family dwelling on the property.
VI. Please describe the land contours (flat, slope %, heavily wooded, marsh area, etc.) on your land
and how it relates to the difficulty in meeting the code requirement(s):
The land is flat and gently slopes down to Long Island Sound Much of the land is covered by beach grasses.
Please submit seven (7) photos, labeled to show different angles of yard areas after staking corners
for new construction), and photos of building area to be altered with yard view.
7/2002; 2/2005; 1/2007
APPLICANT
TRANSACTIONAL DISCLOSURE FORM
(FOR SUBMISSION BY OWNER and OWNER'S AGENT)
The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of Town officers
and employees. The purpose of this form is to provide information, which can alert the Town of
possible conflicts of interest and allow it to take whatever action is necessary to avoid same.
YOURNAME: Hirschhorn, Michael J.
(Last name, first name, middle initial, unless you are applying in the name
of someone else or other entity, such as a company. If so, indicate the
other person or company name.)
NATURE OF APPLICATION: (Checlk all that apply.)
Tax Grievance
Variance
Special Exception
If "Other",
name the activity:_
Change of Zone
Approval of Plat 1
Exemption from Plat
or Official Map
Other
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.
YESI I NO [ Z ]
Complete the balance of this form and date and sign below where indicated.
Name of person employed by the Town of Southold:
Title or position of that person:
Describe that relationship between yourself (the applicant) and the Town officer or employee.
Either check the appropriate line A through D (below) and/or describe the relationship 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);
[ J 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
[ I D) the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted~is 7th ~lz~y (~ N(~vember 2012
Print N ai~e~.·
APPLICANT
TRANSACTIONAL DISCLOSURE FORM
(FOR SUBMISSION BY OWNER and OWNER'S AGENT)
The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of Town officers
and employees. The purpose of this form is to provide information, which can alert the Town of
possible conflicts of interest and allow it to take whatever action is necessary to avoid same.
YOUR NAME: Martinez, Jimena P.
(Last name, first name, middle initial, unless you are applying in the name
of someone else or other entity, such as a company. If so, indicate the
other person or company name.)
NATURE OF APPLICATION:
Tax Grievance
Variance
Special Exception
If"Other",
name the activity:
(Check all that apply.)
Change of Zone
Approval of Plat 1
Exemption from Plat
or Official Map
Other
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.
No[ ,/ J
Complete the balance of this form and date and sign below where indicated.
Name of person employed by the Town of Southold:
Title or position of that person:
Describe that relationship between yourself (the applicant) and the Town officer or employee.
Either check the appropriate line A through D (below) and/or describe the relationship in the space
provided.
The Town officer or employee or his or her spouse, sibling, parent, or child is (check all that
apply):
I 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
Submitted this~'7'~ day of ~.o_v.emb~ 2012
Signature:/~ .~,,,'7~,~' ~
Print N~:~mena P. Marantz ~
APPLICANT
TRANSACTIONAL DISCLOSURE FORM
(FOR SUBMISSION BY OWNER andOWNER'S AGENT)
The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of Town officers
and employees. The purpose of this form is to provide information, which can alert the Town of
possible conflicts of interest and allow it to take whatever action is necessary to avoid same.
YOUR NAME: Anderson, Bruce A.
(Last name, first name, middle initial, unless you are applying in the name
of someone else or other entity, such as a company. If so, indicate the
other person or company name.)
NATURE OF APPLICATION:
Tax Grievance
Variance
Special Exception
lf"Other",
name the activity:
Change of Zone
Approval of Plat I
Exemption from Plat
or Official Map
Other
(Check all that apply.)
[ I
,,' I
L J
L J
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.
YEsL v' I NO [ ]
Complete the balance of this form and date and sign below where indicated.
Name of person employed by the Town of Southold: William Price
Title or position of that person: Justic~
Describe that relationship between yourself (the applicant) and the Town officer or employee.
Either check the appropriate line A through D (below) and/or describe the relationship 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);
[ I 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
Brother-in-Law
Submitted this ~_day of
Signature_j~~
PrintName: ffS-~.~ /k.. /.M.,ta,.~.~.,_ ,
OWNER'S ENDORSEMENT
(TO BE SIGNED IF APPLICANT IS NOT OWNER)
STATE OF NEW YORK)
COUNTY OF SUFFOLK) SS:
MICHAEL J. HIRSCHHORN & JIMENA P. MARTINEZ
being duly sworn, deposes and says; we reside at:
307 Sterling Place; Brooklyn
In the County of Kings and the state of New York , and we are the
(owners in .fee) (officer/agent of the Corporation which is owner in fee) of the
premises described in the foregoing application and that we have authorized.
SUFFOLK ENVIRONMENTAL CONSULTING, INC.
to make the foregoing application as described herein.
Signature
/b Sig~,ture
If Corporation, name of corporation and Officer
{/~o~ary Public
Officer's Title
RICARDO C. SALMON
Notary Public - State of New York
No. 01SAf~113075
Qualified in ~ings County
My Commission Expires 7~[ q' [c~
No: 35335
Town of Southold Annex
54375 Main Road
Southold, New York I 1
rG
CERTIF[ , A C dPANCY
12/13/2011
Telephone (631 ) 765-1802
Fax (631) 765-9502
TOWN OF SOUTHOLD Date: 12/13/2011
TillS CERTIFIES that the structure(s) located at:
SCTM #: 473889 Sec/Block/Lot:
Subdivision:
conforms substantially to the requirements for a
APRIL 9, 1957
280 Sound Ave, Pcconic
67.-1-7
Filed Map No.
Lot No.
built prior to
pursuant to which CERTIFICATE OF OCCUPANCY NUMBER Z, 35335
dated 12/l 3/201 l was issued and conforms to all the requriements of thc applicable provisions of the law.
The occupancy for which this certificate is issued is:
one family dwelling with finished basement and cerncnt patio.*
NOTE: BP 9910 addition with deck and central a.c. updated C/O Z-35334.
The certificate is issued to
Terranova, Paulina
-~(OWN EP.')
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
*PLEASE SEE ATTACHED INSPECTION REPORT,
14-16-4 (9/95)-Text 12 617.20
IPROJECT I.D. NUMBER Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART 1- PROJECT INFORMATION (To be completed by, ~pplicant or Proiect sponsor)
1. APPLICANT/SPONSOR 2. PROJECT NAME
Suffolk Environmental Consulting, Inc. HIRSCHHORN & MARTINEZ Property
SEQR
3. PROJECT LOCATION:
Municipality TownofSouthold County Suffolk
4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc. or provide map)
280 Sound View Avenue; Peconic; Town of Somhold, New York (SCTM #: 1000 - 067 - 01 - 007)
5. IS PROPOSED ACTION:
[] New [] Expansion [] Modification/alteration
6. DESCRIBE PROJECT BRIEFLY:
Applicant proposes to construct a 2"d-Story Addition (525.25 square feet _+) atop the existing dwelling, re-construct the railing (56.0' L _+) to
the attached rear deck, remove the concrete padding (2, 260 square feet _+) surrounding the dwelling and replace with native plantings
(Le., Cape American 8each Grass and Beach Rose) and install a wood walkway (320 square feet _+) from the parking area, along the
southwestern side of the dwelling, to the existing wood walk around the perimeter of the rear attached deck.
7. AMOUNT OF LAND EFFECTED:
Initially 0.2 acres Ultimately 0.2 acres
g. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
[] Yes [] No If No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
[]Residential i--]Industrial [--ICommercia[ []Agriculture []Park/Forest/Open space []Other
Describe:
Private single family residences with relaled appurtenances.
I0. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENT
AGENCY (FEDERAL, STATE OR LOCAL)?
[] Yes []No If yes, list agency(s) and permit/approvals
New York State Department of Envirunmental Conservation Wetlands Permit & Town of Southold Building Permit.
Il. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [] Yes [] No If yes, list agency(s) and permit/approvals
12~ AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMiT/APPROVAL REQUIRE MODIFICATION? [] Yes [] No
I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant/sponsor name: .Matt D. lyes- Suffolk Environm,~ntal Consulting, Inc. Date: December I0, 2012
Signature:
If the action is in the Coastal Area, and you are a state~gency, complete the Coastal
Assessment Form before proceeding with this assessment
OVER
PART II- ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.127 If yes, coordinate the review process and
use the FULL EAF.
[] Yes [] No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 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, sudace or groundwater quality, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion, drainage or flooding problems? Explain briefly:
C2. Aesthetic, agricultural, archeological, historical or other natural or cultural resoumes; or community or neighborhood
character? Explain briefly:
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitat, or threatened or endangered species? Explain
briefly:
C4. A community's existing plans or goals as officially adopted, or change in use or intensity of use of land or natural resoumes?
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 Cl-C57 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 CEA?
[]Yes •No
D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
[] Yes [] No If yes, explain briefly
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 (f) 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 and 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 proceed directly to
the FULL EAF and/or prepare a positive declaration.
[] Check this box if you have de~ermined, based on the information and analysis above and any supporting documentation, that the proposed action
WILL NOT resu[[ in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this
delermination:
Name of Lead Agency
Print or Type Name of Responsible Officer
Signalure of Responsible Officer in Lead Agency
Title of Responsible Officer
Signature of Preparer (if different From responsible officer)
Date
2
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 inchtding Building Permits
and other ministerial permits not located within the Coastal Erosion Hazard Area.
Before answering the questions in Section C, the preparer of this form should review the exempt
minor action list, policies and explanations of each policy contained in the Town of Southold Local
Waterfront Revitalization Program. A proposed action will be evaluated as to its significant
beneficial and adverse effects upon the coastal area (which includes all of Southold Town).
If any question in Section C on this form is answered "yes", then the proposed action may affect the
achievement of the LWRP policy standards and conditions contained in the consistency review law.
Thus, the action should be analyzed in more detail and, if necessary, modified prior to making a
determination that it is consistent to the maximum extent practicable with the LWRP policy
standards and conditions. 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# 067 01 007
The Application has been submitted to (check appropriate response):
Town Board [] Planning Dept. [] Building Dept. [] Board of Trustees []
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:
Attach additional sheets if necessary
Location of action: 280 Sound View Avenue; Peconic; Town of Southold~ New York
Site acreage: 0.4448 acre -+
Present land use: Residential
Present zoning classification: R - 40
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: MICHAEL 1. HIRSCHHORN & IIMENA P. MARTINEZ
(b) Mailing address: 307 Sterling Place~ Brooklyn, NY 11238
(c) Telephone number: Ama Code ( 631 ) 537 - 5160
(d) Application number, if any: N/A
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?. NYSDEC
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 llI- Policies; Page 2 for evaluation
criteria.
[] Yes [] No [] Not Applicable
As indicated within Policy 1, "Development that does not reinforce the traditional land use pattern of the Town of
Southold would result in a loss of the community and landscape character of Southold.", this project is a proposal to
improve upon the existing single-family dwelling within an almost entirely developed neiqhborhood (i.e., Peconic
Shores) The proposal, as desiqned, will not result in any adverse effects to the surrounding environment in that
the project will include improvements to a dwellinq that has existed harmoniously herein for over fifty years
without any form of adverse impact to the surroundinq community. Accordingly, we believe that this oroiect is
consistent with this policy.
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
Policy 2 is not applicable in that subject lot and the surrounding neighborhood cannot be deemed a substantial
historic and/or archaeological resources.
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 5 through 7 for evaluation criteria
[] Yes [] No [] Not Applicable
Subject proposal will not adversely impact the visual quality of the surrounding area in that the subject oarcel is
already improved with an existing single-family dwellinq which has not impeded visual quality or the value of local
scenic resources. This policy could not preclude both the legal creation of this property as a building lot, the legal
construction of the existinq dwelling thereon, or the proposed improvements to the existing dwellino thereon.
Therefore, we feel that the instant proposal fully complies with this Policy.
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
The proposal is for improvements to the existing dwelling within subject property, which has existed thereon for
many years without loss of life, structures and natural resources from flooding and erosion. Therefore, we feel that
the instant proposal fully complies with this Policy.
Attach additional sheets if nccessary
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
This proposal is for various improvements to the existinq dwelling, which has existed on this site for years, and
which has in itself, not resulted in any form of adverse impact to water quality and/or supply. Additionally, the
existing residential improvements within the surroundinq neighborhood have existed harmoniously within the
immediate environment also without adversely impacting the water quality and/or supply within the Town of
Southold. Therefore, we feel that the instant proposal fully complies with this Policy.
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 Applicable
Again. this DroDosal is for various improvements to the existing dwelling, which has existed on this site for years.
and which has in itself, not resulted in any form of adverse impact to the surrounding ecosystems. Additionally, all
proposed activities are to occur no closer than 275.0' _+ from the Average High Water Mark (i.e., tidal wetlands
boundary}. Further, the existing residential improvements within the surrounding neighborhood have existed
harmoniously within the immediate environment also without adversely impactinq these ecosystems within the
Town of Southold. Therefore, we feel that the instant proposal fully complies with this Policy.
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
Policy 7 is not applicable in that the proposal will be for various residential improvements to the existing single
family dwelling with related appurtenances thereon which will not result in any form of adverse effects to air
quality.
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
Policy 8 is not applicable in that the proposal does not involve disposal and/or transportation of solid waste,
hazardous waste, toxic pollutants, and petroleum products.
Attach additional sheets if necessary
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
Policy 9 is not applicable in that the proposal will not impede any access to the surface waters in and around
subject property and/or become detrimental to the recreational use of the surroundinq resources.
Attach additional sheets if necessary
WORKING COAST POLICIES
Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependence uses in
suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria
[] Yes [] No [] Not Applicable
Policy 10 is not applicable in that the proposal does not involve a water-dependent use (i.e. marina, aquaculture,
etc...).
Attach additional sheets if necessary
Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic
Estuary and Town Waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria
[] Yes [] No [] Not Applicable
Policy 11 is not applicable in that the proposal does not involve any form of marine resource management (i.e.
commercial fisheries, recreational fisheries, aquaculture, etc...).
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
Policy 12 is not applicable in that the proposal does not involve agricultural lands (i.e. the conversion of farmland,
the establishment and/or maintenance of new coastal agricultural production, etc...)
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
Policy 13 is not applicable in that the proposal does not involve the conservation of energy resources on a
commercial level and/or the promotion of alternative energy sources, proper maintenance of fuel storage facilitieq
and/or the extraction of mineral extraction.
Attach additional sheets if necessary
Town of Southold
) Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM
PROPERTY LOCATION: S.C.T.M. #: THE FOLLOWING ACTION8 MAY REQUIRE THE SUBMISSION OF A
1000 - 067 - 01 - 007 STORMoWATER~ GRADING~ DRAII~AGE AND EROSION CONTROL PLAN
Dt~tr~ S~O~ e~ck LOt CERTIFIED BY & DESIGN PROFESSIONAL IN THE STATE OF NEY/YORK.
- PROPOSED CONSTRUC'FION ITItM# / WORKASSF_.SS~
Yes
No
a. What is the To~al Ama of the Project Parcels? 1 Will this Project Retain A~I Storm-Water Run-Off
(Indede Total A~ea of ell Parcels Ioneted within 0.4448 acres Generated by a Two (2') Inch Rainfall on Sin~?
Ihe Scope of Work for Proposed Constmc~on) is F/,*,~) (This Item will thclude all run-oi'f created by site X
b. What is the Total Ama of Land Cleating clearing anchor c~lstn~cUort activities es well as all --
and/or Ground Disturbance for the proposed 0.0 sq. ft. Site Improvements and the pem,,anent c~ea~ of
Imben~ous sun'aces.)
constmcUon acUvity? (s,~. I~) 2 Does the Site P|an and/or Survey Show All Proposed
PROVIDE BRIEF PRO]ECl' DESCRIPTION ~ ~ ,~ ..k~,~..~ Drainage Structures Indicating Size & Location? This X
item shall include all Pmpesed Grade Changes and
Applicant proposes to construct a '2"a-Story Addition Slopes ConlrollingSudaceWaterFIow.
'5~5.~5 square feet ±) atop the existing single-family 3 DoestheSitePlanandlorSurveydescrihetheerosion r-"-I
dwellin!~, re-construct the railing (56.0' L ±) to the andsndimentcontrolpmcflcesthatwillbeusedto X
attached rear deck to comply with the applicable building conlrolslteemslonandstormwaterdiscberges This --
code, remoYe the concrete padding {g, ~6o square feet ±) item must be malnlatned througheut the Entire
surrounding the dwelling and replace with native plantings ConstrdcUon Period.
{i.e., Cape American Beach Grass and Beach Rose) and 4 W~ll thls Project Requira any Land Filling, Gradingor
install a wood walkway {3~20 square feet +} from the ExcavationwheratheraisecbengeththeNatural 1__1 X
parking area, a]on~* the sOt. lthv, restern side of the dwelling, Existing Grade Involving rr~e than 200 Cubic Yards
of Material within any Parcel?
to the existing wood walk around the perimeter of the rear
attached deck. 5 WillthlsApplicatJonRequimLandDlsturbingActivilies r~
Encompassing an A~ea in Excess of Five Thousand X
(5,000 S.F.) Square Feet of Ground Surface?1~1 --
6 Is there a Natural Water Course Running through the [""1
Site? ls this project wlthth the Trustees jurisdiction
General DEC SWPPP Requirements: or within One Hundred (100') feet o1' a Wetland or
clisturbanceso[o~e(1)o~m~eac~s; Inctt~iogdisiurbance$oflessthanofleacmthat 7 Will there be Site praparaUon on Exis§ng Grade Slopes
am pa~ o! · larger c~mra~a plan that wll u#~mately dlsf:u~ o~e or more acres of ~and: Will ch Exceed Fifteen (15) feet of Vertical Rise to~1 X
treading Cens~uction ac~s ~ sea dtsiurbances of ~ess ~an o~e (~) acre ~ One Hundred (100') of H(xtzontal Dialance?
!. 33~e SWPPp shail dea~l)e the erosion and sediment oo~trel pnlctlo0~ anti ,*here 9Witl tilts ProJec~ Require the Placem~lt oi' N!atetial,
mqof~:l, post-co~sUuc~e storm water marmgemem prac~i:as Ihat w~ be u~d and/o~ Removal of VegeLation and/or the Construction of any 1__1 X
E'rATE OF NEW YORK, SUFFOLK
COUNTY OF ........................................... 8,5
BRUCE A. ANDERSON @ SUFFOLK
ENVIRONMENTAL CONSULTING, INC --. .. ~ ...... ·., ,. * .~ -
That l,. ....................................................................... ; ....... oemg (]my s 'om, oeposes aha says utat he/she ts mc applicant tot tomtit,
AGENT
And thai hdshe is thc ............................................ Cd;;,~;'~i~;~;'~'~;'~'c'i ................................................................
Owncr and/or rcprcscnlalivc o[ thc Ova]ct or O~mcrs, a~]d is duly authorized m pcrfom~ or have performed thc .said wink and t(~
make and l~lc this application; that all staicme[lta conLa~ncd in this application arc fmc to thc best of his kno~dedgc and Ix:Ilar; and
thai thc work will bc performed in thc maimer sci £o~I1~ in thc application t~lcd hc~
FORM - 06110
Qualified fr~ Suftolk County
Commission Expires January 22
FOUNDATION PLAN
<
0
r'~
GPRO] ECT NORTH ~
2ND. FLOOR PLAN
SCALE: 0.156" = 1'-0"
/~ _ ~,? _ / _ ? TOWN OF
FORMER
VL.
LAND
$OUTHOLD PROPERTY RECORD CARD
Vie ~
1/~ ,R, GE
N
IMP. TOTAL
t 9 o~o
:'~ / 0 0
,.C? o b /
NLOIV NORMAL
Farm Acre
Tillable 1
~illable 2
Tillable 3
Woodland
Swampland
Brushland
House Plot
Total
VILLAGE
DISTRICT SUB.
AC~,EAGE
S W TYPE OF BUILDING
FARM COMM. IND. CB. MISC.
DATE REMARKS
Value Per Acre Value FRONTAGE ON ROAD ~6 )~
.ULKH~O g (~ I
Est. Mkt. Value
W+"" E
S
.C::,URVE'T' OF LOT .5
"HAP OF= PI=CONIC SHOtP..J5..%"
FILED ~T 5, Iq24, FILE No. I1'1'
.~ITUATE.- PEC.,ONIC,
TOI,'IN.-
5UF=FOLK Gl'Y, NY
5URMET'EO OEC,. I,D, 2011
PROPOSED ADDITION SEPT. 2.5, 2012
E~JFFOLK COUNTY TAX #
I000 - ~"'/ - I - -/
MI(XIAEL ~. ~
J-IMHNA P. MARTINHS
A(~ ABSTRACT (X)RP.
.rl'Y NATIONAL -rtlLB
COMPANY OF NEW YORK
NOTES=
GAPPED REBAR FOUND
PIPE FOUN~
TOPO ELEVATIONS P..EF. N~X/'D '2~f DATI)t'4
®RAPHIC E::~. AL E
FEIHA PLOOP ZONES AS .?:~FIOI.'~ ON FEFIA
PIpjvl E~10~-.O1¢21 FI DATED ~=PT. 25, 2OOq
COASTAL EFEO~ION HA. ZAP. E;' LINE A5 E~FIOI, flN
OF COASTAL EERO~ION HAZAFEO AP-.EA HAP c..541EET "/ OF 4ct'
AREA TO LON® 15LAN~
HIC.~H Y, IATER =
JOHN C.
6 EAST MAIN STREET
R1VERHEAD, N.Y. 11901
SURVEYOR
N.Y.S. LIC. NO. 50202
369-8288 Fax 369-828'/
REF:C:\UserskJohn\DropboxXl 1 \11-190.pro
Town of Southold, New York - Payment Voucher
V~lo~ Nam~
t
i Vendor No.
TERRy CONTRACTING & MATERIALS, INC. 1146 OSBORN AVE., RIVERHEAO, NY 11901
Vendor Te.l~hoac Numbva-
631-727-0170
Vendor Comact
ROBERT TEP~y
60,900.00
1 7/23/201:
60,900.00
l',~ha~ Order
l~=iptioa of Goods or $~wic~s
LONG CREEK DRAINAGE
=========================== ::5::::::::::
Payee Certification
The undemgaed (Claimant) (Actiag on behalf of rig above named clalmam)
does h~'eby certify that the foregoiag chim is mu: and cor/~ct, that no ixlrt has
be~n pa~d, eacept as tl~x~n stated, that the balanc~ therein stated is actually
due and ov~ng, and that taxe~ from which thc Town ~ exempt al~ e~tcludccl.
Coml~nyNameTERR¥ CONTRACTING&MATERIALS ~ 7f23/20t~
Department Certification
I he~.t ~'"ify that th~ m~rials abov~ s~cificd hav~ b~a m:.eivnd by rr~
APPLICATION AND CERTIFICATE FOR PAYMENT AUk DOCUMENT G702 PAGE i OF 2
APPLICATION:
Disl~ibu~to:
FROM (CONTRACTOR);
Tar/¢xxll/~;tir~ & Materials, Ir~.
Long Creek Drainage Projects
v~ (Eng~near):
Southold Town Engineaing
CONTRACT DAT~: 5/29/2012
[ ] ENGINEER
[ ]CONTRACTOR
CONTRACTORS APPLICATION FOR PAYMENT
CH,a~N GE ORDER SUMMARY
;hange Orders approved in ADDmONS D~U~N8
xe~s ~s by ~
TOT~
The undemigned Contractor certlBe~ that to the best of tim Contractor's knowledge,
informa~:m and belief the Wo~ covered by ~3e Application for Payment tam been
completed in accordance v,4th the Contract Documents, that all amounts have been
paid by the Contractor for Work for which previous Certh3ustes of Payment were
issued and payments received from the Owner, and that ci~"rent payment ai3own
CONTRACTOR: Tern/Contracting & Materials, Inc.
ENGINEER'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Documents, based on on-site observations and the
data comp~lg the above application, the Er~ineer ce~ to the owner that to the
best of lbe Engineer's knov~dge, Information and belief the Work has progressed as
indicated, the quelity of Ihe Work is in accordance wffh the Contract Documents, and
the Contractor is entJtJed to payment of the AMOUNT CERTIF,,~Di~ A MCCLA¥£
NOTARY PUbLIC-STATE OF NEVi YORk
.......... 36
Qualified In Suffelk County
My Commission Expire~ Mulch 12, 20 ! 5
Application is made for Payment, as shown below, in connection wittt the Contract.
Continuation Sheet, AUk Document G703, is at~ched.
1. ORIGINAL CONTRACT SUM PLUS OPTION A
2. Ne{ change by Change Orders
3. CONTRACT SUM TO DATE (Line 1 + 2 )
4. TOTAL COMPLETED & STORED TO DATE
(Column G on G703)
5. RETAINAGE:
a:_5% of Comple{ed Work
(Col umn D + E on G703)
b:__5 % of Stored Material
(Col umn F on G703)
Total Retainage (Line 5a + 5b or
Total in Column I of G703
6. TOTAL EARNED LESS RETAINAGE
(Line 4 less Line 5 Total)
7. LESS PREVIOUS CERTIFICATES FOR
PAYMENT (Line 6 from prior CeCdflcate)
8. CURRENT PAYMENT DUE
9. BALANCE TO FINISH, PLUS RETAINAGE
(L~ 3 ~,s~ Une S)
State o(: New Yotlt County
AMOUNT CERTIFIED
(Attacl~lanation if~mount ce~tif'~d diffem from lbe amount applied for.)
ENG, R:
C eTfl~lca ' - lED is payable en~, to the
' Con~cto*- named herein, Issuance, payment and acceptance of payment are with-
ol~relu~lice lo any rights of the Owner or Contractor under this Contract.
$0.00
$0,00
$0.00
$0.00
$60~g00.00
$0.00
CONTINUATION SHEET ~ DOCUMEm G703
AIA Doc~ir, eF,~ G702, APPUCATION AND CERH~-K;ATE FOR PAYMENT, containing
Contractor's signed Certification is attached.
In tabulations below, amounts are stated to the nearest dollar.
Use Column I on Contracts where variable retainage for line items may apply.
PAGE 2 Of 2 PAGES
APPECATION NIJMUeK: 1
APPECATION DATE: 7/23120112
PERIOD TO: ~'15/2012
ARCHITECT'S PROJECT NO:
A S C D I IE ~ e . ,
ITEM I~ES~R~' ! I~N OF ~RK SCHEDULED WORK COMPLE~D MATERIALS TOTAL % BALANCE RETAINAGE
NO. VALUE FROM PREVIOU~ THIS PERIOD PRESENTI.Y COMPLETED (G C) TO FINISH
APPLICATION STORED AND STORED (C - G)
(D + E) (NOT IN TO DATE
DORE) (D~'E+F)
I Drainage conl/oiPro~ect #1Lo~ Creek D~ive 23,400.00 $23,400.00 I $23,400.00 100% $0.00 $1,170.00
2 Drainage control Project #2 Laurel Avenue 18,500.00 $18,500.00 $18,500.00 100% $0.00 $925.00
3 Drainage co~lxol Project ~ Long Creek Drive 19,000.00 $19,000.00 $19,000.00 100% $0.00 $950.00
Total $60~900.00 $0.00 $60~g00.00 $0.00 $60,900.00 $0.00 $3,045.00
U.S. Depar~'h-i&nt of Labor P~ROLL
Employment Standards Adminis~ration
Wage and Hour Division (For Contractor's Optional Use; See Instructions, Form WH-347 Inst.)
OMB No.: 1215-014
TERRY CONTRACTING 1146 OSBORNE AVE RZYERNEAD NY 11901 F. xpires: 04/30/20d
PAYROLL NO. FOR WEE~ ENOliq~ PROJECT AND LCCAllON
I 06/09/[2
N,~d~E, ADDRE~.S. ANO I [40N FUR WE£ rHU FRl SA' ISUb
SOC~.SECURITYI~UM~ER WOR~ ~5 4 5 6 .~. U ~O~SS W~
~NOZ GARC[A,JOEL E 3OURNEYHAN °
PO BOX 333
R~VER~EAD.NY LIgOL ~-LABORE~ ~ ~.5 45.57 31.67 .60 69L.84
X~-~-~R~ 4.5 36.65 37.00 114,~
GARC[A,~[L[ H O~RNE~ o
45 JT 8LVO I 71.06: 65.10 .60 91[.82
R~V~HEAD. NY 1~901 ~-~ORERS s 5.0 .0 %0 6.5 25.5 36.65
XXX-XX-Z22t ' 209.00 345.76
~ONES.~Z~AEL N gOURN~N o 1.5 1.5 106.96 ~29~
23 SEASHORE AVE 0
E QUOGUE,NY 11942 OR-EXCAVATOR s ~.0 8.0 .0 8.0 8.0 40.( 53.~ [34.39 146.65 ~60 1567.75
~-XX-2853 /'2378.39 529 .~ 810 .~4
RAMN~RZNE. VAL ~OURN~AN o
PO 80X 541 0
~HNAR[NE,VAL ~URNEYHAN o; 9~
PO BOX 541 0 75.50 71.41
E HAR[ON.NY 11939 OP-ASV DOZER ~.( 2.0 49.99
X~-XX-8025 247.~ 394.51
SAYERS.CHARLES JOURNEYMAN 7~
43 BUCKSKIN LANE 0
SELDEN.NY 11784 LA-LABORERS , :.0 59.93 53.03 .60 828.24
X~-XX-Z910 ~s 2.0 36.65 119.00 232.56
~060 · 80
TERRY,~H~ ~ gOURNEY~N o
39 ACO~ OR[VE
E NORTHPORT. NY 1173~ LA-LABORERS S.7 ~.0 '.0 7.0 6-~ 82.93 78.87 .60 1014.33
XXX-XX~350 s 34.2 36.65 ~451 · 83 276.~ 437.50
Du~'b"ent e~ Labor (nOL) Regulations 29 CFI~ Part 5.5(a)(3)(~0 require confzactom to aubmA ~u a ~..,.. ............. dY a ~'~""i~m,i w~h respect to the ~aagea paid each employee dudng the
..... · '""r"'~"w~.u,au~me~'aaermagencycc~d.,actJngforor fthaacingUlecanstruclionpmJecLaccompaniedby
~ sGned "Statement o~ C,~mp~ance" indicating thai the payrolls are correct and complete and that each laborer or mechamc has been paid not ~eaa ~an the proper
DOL and [ec~eral oontrac~g agenaes receiving thrs mrbrmalJon renew[he Informa~n to detarrnifle Lhal employees ~ave received I~a~ required wages and fdnge benefi[e.
(Name of Signatory Par[y) (Title)
do hereby state:
(1) That I pay or supervise the paymenl al the penml~ employed by
onthe
~ . .~ (Conb~gr,~jJbcontmctor)
~ (Buil~ing or Work) ~) '
a~ p~o~ e~ye~ on said p~ have ~ ~1~ the ~ ~ekly ~ges ~med, that ~ m~t~ h~
b~n or ~ ~ ~ elth~ dlm=lN or ~d~e~ to or ~ ~haF ~
(Con~cl~ ~ Su~nt~or)
(4] That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED pLANS, FUNDS, OR PROGRAMS
the above refemncad psyroll, paymenls of fringe benefits as listed r~ the conffact
employees, except as noted Irl Section 4(e) balow.
.J
(b) WHERE FRINQE BENEFITS ARE PAiD tN CASH
as Indk~ted on Ihe payroll, an amount not lem~ than the sum of the appqeal~e
in ~ha con treot, exoept as noted in Sectfon 4(0) bekn~.
EXCEPTIONS
EXCEPTION (CRAFT) EXPLANATION
U.S. Depart~rent of Labor ~OLL ; ! ~
Employment Standards Adminlstra[ion ~'
Wage anti Hour Division (For Contractor's Optional Use; See Instructions, Form WH.347 In~LI ~
OMB ~.: 12~14
TERRY CONTRACTING .ZZ46 OSBOREE AVE R[VERHEAD NY ZZ90~ ~: ~0~
PA~OL L NO. F~ WE~ ~O[NG P~ ~O L~ON ~E~ ~ ~ NO.
2 06/[6/~ 195 LON~ CREEK S.H,
OF E~L~E ~ WORK mT~ ~TE A~T ~ STATE LOCAL
HUNOZ GARC[A,OOEL E 30URNEY~N o
45 ~T BLVD
n~ U*$. Departmem of Labor (DOL) RegutaUons 29 CFR Part 5.5(aX3)(ii) requke contractem to sub~ w~. a ~, ^f .. ............ ~ith respect Io Ihe wages paid each employee du~ng ~e
DOL and tederaJ contrac~ng agenaes receiving tbs mformatJan review the reformation to delerm~e that emp~yees have received legally required wages and ~nge benefits.
(Name of 81gnelo~/Pedy) (TIIle)
(1) That I pay or sup~wlse the pa~ent of ~ pa~o~ emp~y~ by
~ (Building ~ W~) I ' '
pemons e~loyed on a~d proJe~ h~e ~en ~ ~e ~ ~ek~ ~ eam~, ~al on re.res
(Con.clot m Su~n~cl~)
(4) ~h.t:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
~he above referenced payroll, payments of f~nge benefits as listed In the con~ract
employees, exespt as noted in Section 4(0) below.
(b) WHERE FRINOE SE-2,1~FI*rS ARE PAID IN CASH
[]- Ea°hlaborer~'mechanlclistedl~theaboveteferencedpayro~hasbeenpald.
as Indicated on [he payroll, an amount tm(lams than the sum of the apptlcable
(o) EXCEPTIONS
EXCEPTION (CRAFT/
EXPLANATION
U.S. Departh~,?t of Labor P~OLL
Employment Standards Administration
(For
Contractor's
Wage and Hour Division Optional Use; See Instructions, Form WH-347 Inst.)
TERRY CONTRACTING 1146 OSBORNE AVE RZVERNEAD OMB No.: 1215-01,~
I NY 11901 ~'~; 04/30/20C
PAYROLL NO. FOR WE~( ENDING PROJECT AND LOCA11ON
3 06/23/12 195 LOk~ CREEK S,H. PROJECTORCOm'RAcrNo.
[1) (Z) (3) (4) OAY ~o OATE (5) (6) (7)
~ CON TUE ND THU FR1. SA~ SUN O~OUC'nONS
soc~ S~CURITY NUMSE~ ~ WOR~ $ TOTAL P~TE AMOUNt' HOLO~NG STATE LOCAL TOT~.
OF F-J~PLOYEE CL.~.~SlRCAIION HOURS WORKEO E~CH OAy ~ OiC PAY EA.~NED FICA TAX TAY TAX OTHER )EITJOIION$ nOR WEE~
GARCIA~WUILI H dOURNEYMAR °
48 ..IT 8LVO 1 '~u7 4~.75 31.65 .60
RIVERHEAD, NY ~90~ LA-LABORERS 3.0 3.fl 38.68
~Y~(-XX-1221 OS ,00 189.00
JORES,HICHAEL ii JOURNEYMAN o
23 SEASHORE AVE 0~:7 84.32 8L.48 .$0 1040.0(
E QUOGUE,NY 11942 OR-EXCAVATOR ~ 2,0 3.1 5,0 53.48
×XX-XX-2853 286. O0 452.40
/ 1.492. ~0
NEJIA,ROBERTO A .30U RN E',pAA N o
121. MOET §RYVE O;'7 38.38 29.05 .60 B24.4;
RYVERHEAD, RY 11901 LA-LABORERS si 3.0 3.0 30.05
XXX-XX-3927 87,.00 155.03
/ 679.45
TERRY.ROBERT W ~OURNEYMAN
$0 WEST NECK RD. !a~ 58.98 $1.29 .60 776.6~
XXX-XX-2SLsSOBTNAMPTON'NY LA.g68 LA-LAOORER5 3.0 3.O 30.60 1043.53 186.00 266.80
'~ERRY,HATTHEW ~1 30URNEYMAN
39 ACORN OR'rVE 0~'u7 45.67 37.36 .60 609.7{]
)OZX-X×-43soE NORTHPORT, NY 1173! LA-LABORERS 3.0 3.0 36.65 / 808.33 1L6.00 199.63
DOL and ~ederat contracting agendes receiving th~s ~nform~on review the mforma~n 1o determine that employees have received legacy required wages and gnge benefits.
(Name of 81gnato~ Party) (Title)
do hereby' slate:
(1) That I pay or supen, ise the peymenl of the persons employed by
(~uil~ng or W~
aa pemons smpbyed on s~d proJe~ have ~en ~ld ~e ~ ~ek~ ~ges ~med, thai ~ m~s have
(~n~cl~ or Su~mm~
3 (~ C~ Subtitle A), issued by
That any peym]ls other/~se under ~his conl;a~ requVed to be aubm~ted for [he eboye period are
app~cable wage rotes contained in any t~ge 'deternflnatlon Inco~led in~o the ~ntmot; that the
(3) That any apprentices employed In the above period are duly registered In a bone fide
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVEO PLANS, FUNDS, OR PROGRAMS
the above retemnced payroll, payme~6 of fllnge beneilts as ~Jsted In the contract
have been or will be made lo eppmpdete programs for the benefit of such
employees, except ae noted In Sechon 4(o) below.
('o) WHERE FRINGE BENEFITS AR~ PAID IN CASH
in Ihe contract, except as noted In Secffort 4(0) below.
(o) EXCEPTIONS
EXOEPTION (CR~FT) EXPLANATION
U.S. Depart~,ent of Labor r~w~ r~OLL
Employment Standards Administration
Wage and Hour Division (~;0[ contractor's Optional Use', See Instruc[ions, Fo~
o~ E,~,.O~E ~i TOTAL ~ATE n~,~oUtCT HO~.DING STATE LOCAL TOTAl. PAiD
The Copeland Aa 140 U.S.C. 3145) requires co,& .~.t~ ~ and su~..~,, educe, perf~lng work on Federa
V th rinse requ~'nents ~s mandatory DOL and federal contracting agencies rece~ng this reformation re~wthe mforma~ ~ ~rne ~at ~plo~ ~e mc~ ~y r~u~ ~ a~ ~nge ~n~s,
(Name of Signatory Party) (Title)
do hereby state:
(1) That I pay or supervise the payment of the per~ons employed by
0 (Building or Work) ~ ' ~
ali pemolls employed on said project have been paid Ihe full weekly wages earned, that no rebetas-I~ave
been or will be made either dlreotly or Indirectly lo or on behalf of said
(Contmcto~ or Subcontraclor)
from the Mil wages earned by any pemon, other then permloslbta deduefiona as defined I~1 Regulations, Part
3 (29 CFR Subtitle ^), Issued by the Se0rela~J of Labor under the Copeland ^or, as amended (48 Slat. g48,
63 Start. 108, 72 Stat. 967; 76 sial 357; 40 U.S.C. 276c), and described below
(4) Thai:
employees, except es noted tn Section 4(0) below.
.J
(b) WHERE FRINGE BEREFITE ARE PAID IN CASH
[]- Eacetabererormecbenic~tadththeebeverefem~medpayrcehasbeenpatd,
in the co~lrao~, exoept ~s noted In Seotlon 4(e) below.
(c) EXCEPTIONS
(CRAFT)
EXPLANATION