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HomeMy WebLinkAboutArevian, GayleJill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town H~lAnnex 54375M~nRoad 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.: 7425A Date of Receipt of Application: October 25, 2010 Applic~a. nt: Gayle Arevian SCTM#. 52-5-28 . Project Location. 165 Bayview Avenue, Southold Date of Resolution/Issuance: November 17, 2010 Date. of Expiration: November 17, 2012 Rewewed by: Board of Trustees Project Description: To install three leaching pools for the existing septic system. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Stanley Skrezec, III, received on October 25, 2010, and stamped approved on November 17, 2010. 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. Jill M. Doherty, President Board of Trustees JMD:eac Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction ¼ constructed Project complete, compliance inspection. Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. 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 Storm Water Runoff Trustee Matters Spring/Summer 2010 With the recent heavy rainfalls, we are reminded once again of the problems Southold Town has with storm water runoff. With over 1 O0 road ends terminating at creeks, bays, inlets, or Long Island Sound, as well as all of the lawns and homes lining our miles of shoreline, l O0's of thousands of gallons of storm water runoff enters our wetlands every year. Carrying sediment that prevents sunlight from reaching aquatic plants, nutrients from animal waste and lawn fertilizers that promote algae blooms detrimental to shellfish, and bacteria and other biologicals that in high doses can be harmful to swimmers, storm water runoff is one of the Trustees main public safety concerns. So important, in fact, that Southold has a Storm Water Management Code. Southold Town's Chapter 236 provides an outline for how people need to deal with storm water runoff from their properties. For example, new construction or renovation is required to contain any potential runoff to the wetlands from the construction by installing hay bales and silt fencing. This acts as a barrier and keeps our wetlands clean. Another example in Chapter 236 is that every building must have provisions to collect and disperse, ON-SITE, at least a 2 inch rainfall. This is usually handled by installing gutters, leaders and drywells to the home. The Trustees also have a standing policy of requiring pervious non-turf buffers along bulkheads and at tops of bluffs that help keep mn off from entering the wetlands and prevents erosion to bluffs. These are important measures to keep our wetlands safe and clean! Before deciding to renovate or build, the Town Trustees urge you to check our website and the other department's websites to make sure what you are planning to do meet the Town's Codes. These codes have been developed for the good of all citizens. And the wildlife all around us too! AFFROVED BY limed Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall. 53095 Main Rd. P.O. Box I 179 Southold, NY !1971 Telephone (631 ) 765-1892 Fax (63 l) 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 ½ constructed __ Project complete, compliance inspection. Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. 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 Permit No.: 7425A Date of Receipt of Application: October 25, 2010 Applicant: Gayle Arevian SCTM#: 52-5-28 Project Location: 165 Bayview Avenue, Southold Date of Resolution/Issuance: November 17, 2010 Date of Expiration: November 17, 2012 Reviewed by: Board of Trustees Project Description: To install three leaching pools for the existing septic system. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Stanley Skrezec, III, received on October 25, 2010, and stamped approved on November 17, 2010. 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. Jill M. Doherty, President Board of Trustees JMD:eac L OA~D OF TiLUS, ' ~L)WN OF SOUTH~'L, Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall, 53095 Main Rd. P.O. Box I 179 Southold, NY 11971 Telephone (63 I) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: Please be advised that your application dated Oc_il-~c~ c:25'~t o201© has been reviewed by this Board at the regular meeting of~£ I ?. QOIr'? and your application has been approved pending the completion of th~ following items checked off below. __ Revised Plans for proposed project __ Pre-Construction Hay Bale Line Inspection Fee ($50.00) __ 1st Day of Construction ($50.00) __ ½ Constructed ($50.00) J Final Inspection Fee ($50.00) __ Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee Js computed below according to the schedule of rates as set forth in Chapter 27§ of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTALFEES DUE:$-..~'~°'~° BY: Jill M. Doherty, President Board of Trustees Jill M. Doherty. President James F. King. Vice-President Dave Belden Bob Ghosio, Jr. John Bredemeyer P.O Box 1179 Southold. NY 11971 Telephone (63 I) 765-1892 Fax (631 ) 765-664 [ Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: ]l~ tO'lO Stanley Skrezec III on behalf of GAYLE AREVlAN requests an Administrative Permit to install three leaching pools for the existing septic system. Located: 165 Bayview Ave., Southold. SCTM#52-5-28 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 Type of Application: __ Wetland __Coastal Erosion __Administrative__Emergency __Pre-Submission __ Info needed: Sound __Bay __Amend ment Violation Modifications: Conditions: ~.Doherty Present Were: ~,_~J.King __ "~J. Bredemeyer __ B.Ghosio, ~-" D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: Date: D. Bergen__ SCTM 1000-52-05-28 soale ~" ~- 30' SCTM 1000~52-05-28 s~le ~" ~ 30' SCTM 1000,-52-05-28 scale 1" -- 3o' Re~oair .................... Red,oval .................... Demolition .................... Other Work (D~'~cribe) ........................ 4. Estimated Cost ....... ~....atr~.. ....................................... Fee .......... :.. ............................................................................. (to be paid on filing this application) 5. If dwelling, number of dwelling units .............................. Number of dwelling units on each floor ............................ If garage, number of cars ............................................................................................................................................. 6. If business, commercial or mixed occupancy, speci fy nature and extent ~h type of use ...... .~..!_~,~./ .......... 7. Dimensions of existi_ng structures, if any: Front....~....~.. .............. Rear ....... ~-! .................. Depth .....~.....~.....i ........... Height ...~..~,.*~,~...~., ......Number of Stories ......... ~ ......................................................................................... Dimensions of same structure with alteretions or edditions: Front ................................ Rear ................................ Depth ............... ~ ............ Height .......................... r..~umber of Stories ....... 7 .............................. ~' ! .................................... 1 1. Zone or use district in which pr~'mises ore situated ......... ~~...~. .......................................... 12. Does propased construction ~vio~e~any. z.~l~,,~r~---- ~:-.~-~ ordinonceor regulation? ...................................................... 13. Name of Owner of premises ~'g(.~&l.,~..~:~.~A. ddress ............................................ Phone No ..................... Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor .................................................... Address ............................................ Phone No ..................... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-beck dimensions from prc~perty lines. Give street and block numbers or description according to deed, and show street names and indicate whether interior or corner lot. STAT~ OF NEW~t'O~I~, ~ ) ~ ~ · COUNTY OF~J~IeY---~.....) ~'~' .......... ~.~....~ ...................................... ~ing duly swan, d~'and rays th~ he is t~e o~licant - (~ of l~ividual ~D~ e~licatim) ' ~e name. He is ~e ......... ~~ .................................................................................................................... . (C~tr~or, ag~t, co~omte officer, e~.) of ~id ~ner ~ ~, ~ is ~[y aut~riz~ to ~rfo~ or h~ ~rm~ the ~id work a~ ~ ~ke and file ~is ~l~ati~; that all st~ments c~ln~ in this ~licati~ o[e t~e to ~e b~t of his ~1~ and belief; a~ th~ ~e ~ will ~ ~rm~ in ~ manner set ~h fn the epphcation fil~ ~e~Jth. S~ ~ ~e ~ this ~ ~ T. ~ / ...........o, .................... ' N~o~ ~blic, ~.. , ~ (Signomr~licont) 60.~ 14.0A(c) 60.2 13.8A(c) ].2 3,0AIC) 1.1 NOTICE COUNTY OF SUFFOLK (~ Real ~ope~ty Tax Service Agency SDUTHOLD 1000 O52 Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer 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 Office Use Only Coastal Erosion Permit Application ~/etland Pemait Application __ Administrative Permit ' AmendmenffI'rans fer/Extension ,...~eceived Application~~ -.~'~eeived Fee:$_~-~ ~,ompleted Application_ 1131'~'0 r- - ~lncomplete __SEQRA Classification: Type I_ Type II Unlisted Coordinatien:(date sent)_ t~l ~'~ } ~ Consistency Assessment Form CAC Referral Sent: ~..D-ate of Inspection: ~ t O] tO Receipt of CAC Report: ~Lead Agency Determination: Technical Review: ~lic nearing nad:_ I \ [ !-3 !lO Resolution: Name of Applicant ~-aN Address ~(O ~'~ Suffolk County Tax Map Nmber: 1000 - Propmy Location:_[ ¢ PhoneNumber:((:~l) 2-C~.'2o -- ~'-~q 59_.- g - '?- (provide LILCO Pole #, distance to cross streets, and location) (If applicable) Address:_ ~'O ~ ~,[, ~:~c~. ~avxq ~__~Vee~ n~ t'~. N}- y' ~ Phone: , of Trustees Applica Land Area (in square feet): Area Zoning: GENERAL DATA Previous use of property: Intended use of property: ~, 6 I0 ~ ~T! ~ t_ Covenants and Restrictions: Yes )(x 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. Prior permits/approvals for site improvements: Agency Date Yes )(, No )(, No prior permits/approvals for site improvements. Has any permit]approval ever been revoked or suspended by a governmental agency? K No__ Yes If yes, provide explanation: Project Description (use attachments if necessary):. of Trustees Applic~ WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: ~0~ HE.~O L~AC~t~H~ Area of wetlands on lot:II ~ square feet Perc~t coverage of lot: ~ S % Closest distance between nearest existing structure and upland edge of wetlands: IOO feet Closest distance between nearest proposed structure and upland edge of wetlands: }IX> feet Does the project involve excavation or filling? No ~x Yes If yes, how much material will be excavated? ~' cubic yards How much material will be filled? /~' cubic yards Depth of which material will be removed or deposited:~ feet Proposed slope ~ou~out the ~ea of operations: M~er in which material will be removed or d~osited:~~CAq _Statement olde. 9ff~ect, if any, 0_n ~he wetlands and_ .tidal_ wa_ters of~ ~gwn that may_ r_9_s_ul[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 PART 1 - PROJECT INFORMATION ( To be completed by Applicant or Project Sponsor) 1. APPLICANT / SPONSOR 2. PROJECT NAME 3.PROJECT LOCATION: PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide mad IS PROPOSED ACTION: [] New [] Expansion [] Modification / atieration DESCRIBE PROJECT BRIEFLY: SEQR 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 IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) 10/DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ]Yes r'~No If yes, list agency name and permit / approval: 11. UU[~ ANY A~PP-(JF OF THE AC[iON HAVE A CURRENTLY VALID PERMIT OR APPROVAL? r-]Yes r--~No If yes, Fist agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? [~]Yes [~No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicanl / 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 Lend Agency)- A. C-,~_~ AC~ -rOH EXCEED ANy TYPE i ~HRESHOLD iN 6 NYCRR, PART 617.47 If YeS, eooedlnate the renew process and use ~e FULL EAF. B. WILL AC~ ~vE COORDINATED REVIEW AS PROVIDED FOR UNUSTED ACTION8 IN 6 NYCRR, PART 617.67 ff No, e negative C. COULD ACTION RESULT IN ANY AD~,= ~'rL-Cl ~ ASSOCJA'I~D WITH THE FOl..LOWING: (Answers may be ~ ~ ~) I INSTRUCTIONS: Foreach adve~e effe~lden6fied above, determiflevn, tether it is 8ebstanUa[. la~e. importantorolher4~se s~n~ ...... x, um~mnenm or mmmnce suppotlmg matedals, Ensure that explanatkms omlaln · ufl~kmt detnil, tn ~m~v Ilmt ~ relevant adveme Impac~ have been klen~d and adequately ~. If questiofl d of pad Ii was check~f EAF and/or prepare a poslb~e.de~aratkm. WILL NOT remd~ In any S~IR adve~e env~ronmer~d Impm~ ~ ~ o~ ,m.,.,-. ........... Board of Trustees Name of Lead Agency Jill M. Doherb/ * ' P~ or Type Name of Respo,asfjble O~oer in Lea~ A. genc~ President Date Title of Respoflsible Officer SignMum of Prepai~i (1~ different from mspons/ble officer) Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCA~OH: $.C.T.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM.WATEI~ GRADING~ DRAII~AGE AND EROSION CONTROL PLAH em.ct Beckon mock ~ CEkl~flstU BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPEOFWORK - PROPOSED CONSTRUCIION fl'EM# / WORK ASSESSMENT [ Yes No a. What is tho Total Area of the Project Parcels? (IncludeTotstAreaofallParsalslocatedwithin ~7jq~) .,~.. 1 WillthlsPmjectRetathAIIStorm-WaterRan-Off the Scope of Work for Pmposad Construction) Generated by a Two (2') Inch Rainfall on Site? b. What is the Tctal Ama of Land C~eadng (S.F. ~s) (This item will Include stl mn-off created by site cleadng and/or construction activities as well as all and/or Ground Disturbance for the proposed ~ ~'. Site Improvements and the permanent creation of construction activity? impervious surfaces.) (s.F.,~.) 2 Does the Site Plan and/or Survey Show NI Proposed PROV[DE, BRIEF PROJ-EC~ DESCg, E~'~ON P'~,~ad~'~P~#m.~,~) DmlnageStmcturesledlcatingSize& Location?This Item shall include all Proposed Camde Changes and ~ Pg.~J~ ~;~' t ~'% Pr~. ~F'~..~ Slopes Controiting Sudace Water Flow. and sediment control practices that will be asad to t control site erosion and steam water discharges. This item must be maintained throughout the Entire Construction Period. 4 Will this Project Require any Land Filling. Grading or Excavation where there is a change to the Natural Existing Grade Involving mom than 200 Cubic Yards .~' of Matedal within any Pamel? 5 VVill this Application Require Land Disturbing Activities Enc~mpasaing an Area in Excass of Five Thousand (5,000 S.F.) Square Feet of Ground Surface? 6 Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Reqst remen~s: or within One Hundred (100') feet of a WeUand or Subrr ~s!on of a SWPPP is required for all Construction activities involving soil Beach? disturbance$ofo~e(1)ormo~eacres; inciudingdisturbancesofiesslhano~eacre~hst 7 VVill there be Situ preparation on Existing Grade SIopes am part of a ~arger common p~an that will ultimate~y distur'o one or more acres of land; which Exceed Fifteen (15) faet of VerScal Rise to incfuding Cor~struction actlvifies invoNing so~l disturbartces of le~s than orte (1) acm wflere One Hundred (100') of Horizontal Distance? the DEC has detemflned that a SPDE$ permit is required for storm water discharges. SWPPP'$ Shall meet the Minimum Requlmmeofs of the SpDE$ General Permit 8 Wiil Driveways, Parking Areas or other Impmvious~ ~ for Storm WMer Diet, barges ~'om Const~uofton ect~ty. Peri. It No. GP-~.t 0-00t.) Surfaces be Sloped to Direct Storm-Water Run-Off 1. *l~e SWFPP shall pe pmpemd pdo~ to the sutxni~tal of the NOI, The NOi shall pe Into and/or in the direction of a Town ~ight.:~f-way? submk'tod to Ule Oepar tment prior to the commencement of consbuofkxl activity, ;TATE OF NEW YORK, COUNTY O1; ........................................... SS That ! ................ ~'r~*~'~'i~;,i';~i;~'~t')' ................... berg duJy swon't, deposes and sa. ys dtat be/sbe is ~be applicant £or And that hc/sbe is thc ............................................ Y~;~:'~;*~'~;;;~i ................................................................ Ovmcr and/or rcprcscnl~dvc etr thc Owner or Owners, and is duly anthodzed to ix:dorm or havc p~donncd thc sa~d work ;md to make and fiJc ~s applic;~on; that ail statcmcnts co.~a~ncd in th~s applicafio~ zrc ~uc 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; ............................................... ............................................. ..... Notary Public: .......................................................................................... FORM - 06/t0 of Trustees County of Suffolk State of New York BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOP, THE ABOVE DESCP, IBED 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 FPdSE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), 1~ GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIr, AGENT(S) OR REPRESENTATIVES(S), TO ENTEl{ ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signa~re SWORN TO BEFORE ME THIS DAY OF 20__ Notary Public Oct 24 10 08:55p Gayle Arevian Dc'r. ~S 203.0 t;':2:~Rl'1 ,3ET FRX p.2 i, · {~int AUTHORIZATION (where the applicant is not t-he owner) APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE. FORM Tho Town of Southold's Code of Ethics omhibits conflicts ofinterast on the cart of town Officers and emnlovces. The oumo~e of this form is to orovide information which can alert the town of oossible conflicts of interest and allow it to ~ce whatever action is ~e_.~.~'d same. (Last name, first nam ,~ ' · ' , ..... i 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 . e.~ Variance Trustee J Change of Zone Coastal Erosion Approval of plat Mooting 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 ~N 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 0r position of that person Describe the relationship between yourself(the applicant/agcot/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or dasctiho in the space provided. The town officer or employee or his or her spouse, sibling, parent, or ~hild is (cheek all that apply): ___A) tho owner of greater than 5% of the shares of the corporate stock of tho 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); ___C) an officer, director, partnei', or employee of the applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this ~day of Signature 200 Print Name Form TS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 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 si~ifieant 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~ listing both supporting and non- suooortin~ 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 wehsite (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 ACT SCTM# /~O - ,D~"Z - .~'- 2~5 ~ . ~ ~ 2010 PROJECT NAME The Application has been submitted to (check appropriate response): TownBoard ~ Planning Board ~ Building Dept. ~ Board ofTrustees Categoc~ 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: iN 5r/ l,c T o OF-- / 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 ( (d) Application number, if any:. ) (o3l q77 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 Southoid 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 At~ach 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 IH - PoliCies Pages 16 through 21 for evaluation criteria ~ Yes [] No ~Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. Yes No Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. Sec LWRP Section III - Policies Pages 32 through 34 for evaluation criteria. [-~ Yes [-] No [X~ 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 Southoid. See LW'RP Section III - Policies; Pages 38 through 46 for evaluation criteria. ~-~ Yes~ No ~ Not Applicable Attach additional sheets if necessary WORKING ¢ Policy 10. Protect Southoid's water-dependent uses and promote siting of new water-dependent ases in suitable locations. See LWRP Section III- Policies; Pages 47 through 56 for evaluation criteria. ~-~ Yes ~ No ~Z] Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section IIl- Policies; Pages 57 through 62 for evaluation criteria. 73 Yes ?3 No [] Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section Ill - Policies; Pages 62 through 65 for evaluation criteria. 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