Loading...
HomeMy WebLinkAboutTR-8230A James F. King, President OF S0Town Hall Annex Bob Ghosio, Jr., Vice-President 54375 Main Road P.O. Box 1179 Dave Bergen # Southold, New York 11971-0959 John Bredemeyer os • ~O Telephone (631) 765-1692 Michael J. Domino r/ Fax (631) 765-6641 ~yoouim,~ BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0914C Date: October 9 2013 THIS CERTIFIES that the redirection of the drainageepine from the bluff into the existingddrywell on the p opertv At 55255 County Road 48, Greenport, New York Suffolk County Tax Map # 44-1-9 Conforms to the application for a Trustees Permit heretofore filed in this office Dated June 3, 2013 pursuant to which Trustees Administrative Permit #8230A Dated June 19, 2013, 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 redirection of the drainage nine from the bluff into the existing drvwell on the nronerty. The certificate is issued to MISAK TERJANIAN owner of the aforesaid property. Authorized Signature L L i t I I 4L e*~ r . x~.{k A 4~"~, y. I ...;~~ST"`r r+s ~ N~KyrF~'`t ~ ~ ~ "1t~7 y~l~fc~• ~ i Ir .01 Nk, ~ ?~.N, 3 . I lam! ~ ~~I? 7 "rrrPPPrrrr 9. ~t h~ Y~F "f {.ljflF ki, .tin' 14 14, - T. 1, t 1• err 'b ~ 1',y ' .r ~1•° , , 7 r ! r t~ 'j Jy rte' w?~: _ '31- •~4vn ~~_~~~1•Y~~`'~V R. I T.Y..^:~~ s ~ -~'ry~ + _ r wy, -°F: ~ca~~ ~a Ai~ i- left- L opt s. , :•!Y•r' l .I .Iva..'. .,.p, x ° _~r'?# ' ~ e t ~ ~ • .,ISM rf ~ ~ r i fem. ~f f`i`r°s, rY ' ` ~•I M tl . All '.7C'}'4ti'Ff-~{lssiT~%~'~~!~[~"~r'41~. aA'~~1*~~~1~f~lM.-'i~11 10 Misak Terjanian 10 6 Louis street East Hanover, New Jersey 07936 n ee Q OCT - 4 2013 Nafd at U„ September 30, 2013 Permit # 8230A Enclosed please find pictures of completed project which redirects drainage pipe from the bluff into the existing drywell on property. I cannot provide pictures of project during construction, because I was not requested to do so prior to the start of project. If additional information is needed you can contact Peconic Cesspool. Sincere)y, Misa-kTer'a 1 / i 0 James F. King, President O~vAfF0(,tco Town Hall, 53095 Main Rd. Bob Ghosio, Jr., Vice-President P.O. Box 1179 Dave Berger ; Southold, NY 11971 John Bredemeyer O !~c Telephone (631) 765-1892 Michael J. Domino 'j Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE F INSPECTION: R - (Z ~r3 Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 st day of construction % constructed 7 Project complete, compliance inspection. INSPECTED BY: &A COMMENTS: CfSyS - /tJp 6y~ ~ov.u~ d CERTIFICATE OF COMPLIANCE: ~lL ` • 0 James F. King, President %gk*FO(rc Town Hall, 53095 Main Rd. Bob Ghosio, Jr., Vice-President ~~O filly P.O. Box 1179 Dave Bergen # Southold, NY 11971 John Bredemeyer 'y Telephone (631) 765-1892 Michael J. Domino! 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 % constructed Project complete, compliance inspection James F. King, President ~OF soUry Town Hall Annex Bob Ghosio, Jr., Vice-President 54375 Main Road P.O. Box 1179 Dave Bergen l~( Southold, New York 11971-0959 John Bredemeyer d+ ac Michael J. Domino G • O Telephone (631) 765-1892 ~COU'Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8230A Date of Receipt of Application: June 3, 2013 Applicant: Misak Terjanian SCTM#: 44-1-9 Project Location: 55255 County Road 48, Greenport Date of Resolution/Issuance: June 19, 2013 Date of Expiration: June 19, 2015 Reviewed by: Bob Ghosio, Vice President Project Description: To redirect drainage pipe from the bluff into the existing drywell on the property. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the project plan prepared by Misak Terjanian, received on June 3, 2013, and stamped approved on June 19, 2013. 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. )X*_" cz, , r James F. King, President Board of Trustees gUFFO(~ James F. King. President P.O. Box 1179 Bob Ghosio, .Ir.. Vice-President Southold, NY 11971 Dave Bergen M, Telephone (631 765-1892 John Bredeme%er Fax (631) 765-6641 Michael J. Domino yyo1 # ~y0~' Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: ( ~i ` MISAK TERJANIAN requests an Administrative Permit to redirect drainage pipe from the bluff into the existing drywell on the property. Located: 55255 County Road 48, Greenport. SCTM# 44-1-9 Type of area to be impacted: -Saltwater Wetland -Freshwater Wetland "Sound -Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: _Chapt.275 Chapt. 111 -other Type of Application: Wetland -Coastal Erosion -Amendment -Administrative-Emergency Pre-Submission Violation Info needed: .A- Modifications: Conditions: K?C~ I cC- X ~ r LIAJ ~i Present Were: J. King 1--B. Ghosio D. Bergen, J. Bredemeyer Michael Domino D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: Date: g PECONIC CESSPOOL INC. Main Road PA Box 487 Laurel N.Y. 11948 Phone(631)727-0115 (631) 298-9658 Fax (631) 727-7564 May 20, 2013 Terjanian Michael 55255 CR 48 Southold, NY 11971 This is certify that the above mentioned property has 10' deep cement blocks drywgll on north-east corner house. Pool in good condition. No income pip6~in the pool. PECONIC SSPOO Cc' Les n - president Suffolk County License Number - 43857-LW TE 7CE IVE 32013 old Town oard of Tru<___ t~___. q~ ~4Aa JxJ / YIP ~./ad SJ ' ~ eta I I / I O I a0 / ~ O rte. - ' I3 Q1 I c ccr ~ ~ ~ I n 3 I ~ I ' ~ Y w.imvwn'u % O O I ' O I v raeECxar n « ~ 1 _ _ ipmms COWNTY OF SUFFOLK © •-ti nEC.~w xJ cimn RW PRwtY ~SmVi. p1 / s a„ [ r.. r.. unrmrx.wr • V x w r, N ' v.r w.. .m.verra. r sAar[mr .111,0,111me pr 1, oil 11 OFFICE LOCATION: OF SO(/lyO MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. & Youngs Ave.) Southold, NY 11971 Telephone: 631 765-1938 Fax: 631765-3136 OOUNV,~ LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM EDO To: Jim King, President JUN 1 3 2013 Town of Southold Board of Trustees outhold Tn, ar f Tni~ ces From: Mark Terry, Principal Planner LWRP Coordinator Date: June 12, 2013 Re: LWRP Coastal Consistency Review for MISAK TERJANIAN SCTM#1000-44-1-9 MISAK TERJANIAN requests an Administrative Permit to redirect drainage pipe from the bluff into the existing drywell on the property. Located: 55255 County Road 48, Greenport. SCTM# 44-1-9. 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 actions are CONSISTENT with the Policy Standards and therefore CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney James F. King, President *zf SOply Town Hall Annex 54375 Main Road Bob Ghosio, Jr., Vice-President l0 P.O. Box 1179 Dave Bergen l~I 4 Southold, New York 11971-0959 John Bredemeyer • Telephone (631) 765-1892 Michael J. Domino Q Fax (631) 765-6641 ~~MUNT1,~ BOARD OF TOWN TRUSTEES E C E I V TOWN OF SOUTHOLD 1i1~ ,llS D Office Use Only 11 li JUN - 3 2013 -Coastal Erosion Permit Application -Wetland Permit Application X Administrative Permit Southold own xtension T _Amendment/Trana3;1_3 lReceived Application: `Received Fee:$fZ_ Completed Application -Incomplete _SEQRA Classification: _ Type IType II_Unlisted _Coordination:(date sent) _LWRP Consistency Assessment Form CAC Referral Sent: Date of Inspection: VLAII -Receipt of CAC Repo t: _Lead Agency Determination: -Technical Review: Public Hearing Held:_ Resolution: , l S flt¢) Name of Applicant ~ ailing Address V J-e,~5 PhoneNumber:(~')~ p ~~~~~1 Suffolk County Tax Map Number: 1000 - Property Location: 6_5CQ SS I 0_11 11 So Cj_-R-+ b)L-71 jkl 1I r 7I (provide LILCO Pole distance to cross treets, and location) AGENT: (If applicable) Address: Phone: Ord of Trustees Applicaticle GENERAL DATA Land Area (in square feet): Area Zoning: / I 5. I `v" Cd Previous use of property: L51 ae r I / oar Intended use of property: R CS1 C" Covenants and Restrictions on property? Yes No If "Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes /No If "Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No If "Yes", please provide copy of decision. Will this project require y demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure (s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? /No Yes If yes, provide explanation: Project Description (use attachments if necessary): Ldkfe- J AMAX ~~e JP -eydA J "44 BC& of Trustees Application` WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: --o Area of wetlands on lot: OZ- square feet Percent coverage of lot-~-)°/u Closest distance between nearest existing structure and upland edge of wetlands: 14D feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does th/e project involve excavation or filling? No Yes If yes, how much material will be excavated? cubic yards How much material will be filled?_ N___cubic yards Depth of which material will be removed or deposited:- feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: /v 74 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): n C) uz-~- 617.20 PROJECT ID NUMBER SEAR APPPENDI ENDIX 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 j I ~AiJIA-rJ YZ~}yJ)ft~J 3.PROJECT LOCATION: 77~~ 1. ~_r Municipality S V LL 1 1 1 0 Ll~ County ~Ul-r }~V LK 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc - or provide map -gS a ss ~ tL--N T J . Modification I alteration 5. IS PROPOSED ACTION : M New F-1 Expansion F] 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres & ~WI/LL, PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? - i r es ? No If no, describe briefly: 9 W AT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) 10 Residential ?Industrial 0Commercial Agriculture Park/Forest/Open Space Other (describe) 10.' DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Fede , State or Local) Yes No If yes, list agency name and permit / approval: VALID PERMIT R APPROVAL? ?Yas No If yes, list agency name and permit / approval: 1II2~. AS A RE LT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? LJ*es No I CERTIFY THAT THE MATION PRO ED IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Date: e ~j Tr Signature a U the actio s a Costal Area, and you are a state agency, complet the Coal al Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To completed b Lead Agency) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. Yes 0 No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. ? Yes a No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly: C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Longterm, short term, cumulative, or other effects not identified in C1-C5? Explain briefly: C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? 11 Yes z No If Yes, explain briefly: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? E] 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 I I was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. Checkthis box ifyou have determined, based on the information and analysisabove and anysupporting documentation, thatthe proposed action WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting this determination Board of Trustees Ju,~ /9 z.~1.3' Name o Lead Agency Date ?~Af 17-f Z~ President ~Prrriinntt(oor Type Name o Responsible Officer in Lead Agency rile of Responsible O cer / Signature o Responsible Cifficer in y Agency Signature o reparer (If different from responsible o r) B*d of Trustees Application. County of Suffolk State of New York 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 AGE (S) OR REPRESENTATIVES(S), TO ENTER ONTO PROPERTY TO INSP THE FT IS APPL PREMISES IN CONJUNCTION W#RE ~tv f Prope wn er SWORN TO BEFORE ME THIS _:!:I_ DAY OF ~ _,20 Notary Public MARSHALL N CpyEpT Nowy $ Rm C tlon E S" is, 207 4 B•d of Trustees Application* AUTHORIZATION (where the applicant is not the owner) 1 residing at (print owner of property) (mailing address) do hereby authorize (A ent) to apply for permit(s om the Southold Board of Town Trustees on my behalf. (Owner's signature) i l~ APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and emplovees The puroose 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.A 5A-K NAME:/ (Last name, first name, apiddle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If "Other', name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, marriage, or business interest- "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of (or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO V If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): A) the owner of greater than 5% of the shares of the corporate stock of the applicant (when the applicant is a corporation); B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a corporation); C) an officer, director, partner, or employee of the applicant; or D) the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of 200 Signature p Print Name - 4i `sock, Form TS I e~k Town of Southold ® Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM $ PROPERTY LOCATION: s.C.T.M. a: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A y~ - STORM-WATER, GRADING, DRAIIIAGE AND EROSION CONTROL PLAN mrwu- -Siawn- -uwT -u r- CERTIFIED BY A DESION PROFESSIONAL N THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTION TI'EM # / WORK ASSESSMENT Yes No a. What is the Total Area of the Project Parcels? 35 Will this Project Retain All Storm-Water Run-Off (Include Total Area of all Parcels located within S • F Generated by a Two (2') Inch Rainfall on Site? / the Scope of Work for Proposed Construction) (This item will include all runoff created by site ? ($.F. /Aces) b. What is the Total Area of Land Clearing clearing and/or construction activities as well as all and/or Ground Disturbance for the proposed / Site Improvements and the permanent creation of construction activity? (S.F. / Acres) impervious surfaces.) ? Z PROVIDE BRIEF PROJECT' DESCRIPTION (P AEeabna Pays a Na i Does the Site Plan and/or Survey Show All Proposed Drainage Structures Indicating Size & Location? This Item shall Include all Proposed Grade Changes and ,g' - no Slopes Controlling Surface Water Flow. r 3 Does the Site Plan and/or Survey describe the erosion ? and sediment control practices that will be used to to -P-1 control site erosion and storm water discharges. This r item must be maintained throughout the Entire CODSWCU00 Period. 4 Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Natural ? - Existing Grade Involving more than 200 Cubic Yards of Material within any Parcel? 5 Will this Application Require Land Disturbing Activities ? - Encompassing an Area in Excess of Five Thousand (5,000 S.F.) Square Fast of Ground Surface? 6 is there a Natural Water Course Running through the ? - Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Requirements: or within One Hundred (100') feet of a Weiland or Submission of a SWPPP is required for all Construction activities involving sol Beach? disturbances of one (1) or more acres; including disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes are pan of a larger common plan that will ultimately disturb me or more acres of land; which Exceed Fifteen (15) fast of Vertical Rise to including Construction activities Involving soil disturbances of lass than we (1) acre where One Hundred (100') of Horizontal Distance? - the DEC has determined that a SPDES permit is required for storm water discharges. ( SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit 8 Will Driveways, Parking Areas or other Impervious ? - for Storm Water Dscharges from Construction activity -Permit No. OP-040-001.) Surfaces be Sloped to Direct StMm-Water Run-Off 1. The SWPPP shall be prepared prior to the submittal of the NOT. The NOI shall be into and/or in the direction of a Town right-of-way? submitted to the Department prior to Me camnerxenient of consbuctbn activity. 2. The SWPPP shall describe the emslon and sediment control practices and where 9 Will this Project Require the Placement of Material, required, pcstconstnwilcn storm water management practices that wit be used and/or Removal of Vegetation andlor the Construction of any constructed to reduce the pollutants In stom water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder - - compliance with the term and conditions of this portrait In addition, the SWPPP shall Area? frNa lam wpl xar I,MUMaw ImanMan eronv.,.yp,o,..l Identify potential sources of poRrtlon which may reasonably be expected to affect the quality of storm water discharges. NOTE: If Any Answer W Questions one through Nine Is Answered wiM a Check Mark 3. M SWPPPs that require the postcroshudbn skim water management prectice in a Box and the construction she disl,vbanu is beavseh 5,000 S.F. a I Asa in area, component shag be prepared by a qualified Design Professional Licensed in New York a Stsmn-Water, Grading, Drainage a Erosion Control Plan Is Required by the Town of that Is knowledgeable in the prlnd*s and prectices of Skim Water Management Southold and Must be Submitted for Review Prior W Issuance of Any Building PermlL (NOTE AChw kM (.F) anN>AmvwrfaaarAOuatbnb RegdWiwe0ao Aepimam) STATE OF NEW YORK, COUNTY OF ..........................d................ SS That being duly swum, deposes and says that he/she is the applicant for Permit, (Name of YMivBuel signing Dowrnenl) • And that he/she is the 0......ti e (Oawr, Canbacton Agent. Coparea Omcer, elcJ Owner and/or representative of the Owner or Owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application arehue to the be f his knowledge and be ' ; and that the work will be performed in the mariner set forth in the application filed herew th. Sworn to before me this; 1.1... ...................1.11. Notary Public. ZZ~I HALL N COVIM 'gnalure of AppF q FORM - 06/10 nnCo,IrRYMM[ mitivi son? Town of Southold • LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its sigfi cant beneficial and adverse effects upon the coastal area (which includes all of Southold Town). 3. 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- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# ' I - - PROJECT NAME The Application has been submitted to (check appropriate response): Town Board ? Planning Board ? 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: j I 10-1-o- ~L~AIifC1 Arru?1GL L ( 1/ lie Location of action: 3 SSA ~Jut' sbc-at 6 L Site acreage: Present land use: ( l~2Cf Present zoning classification: 1G~-1 G.X 2. 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: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ? No El If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III - Policies; Page 2 for evaluation criteria. ? Yes ? No t&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 El 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 KNot 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 S through 16 for evaluation criteria ? Yes ? No M Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III - Policies Pages 16 through 21 for evaluation criteria ? Yes ? No P 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 HI - Policies; Pages 22 through 32 for evaluation criteria. ? ? 171 Yes No Not Applicable 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 E] No 14 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. 1:1 Yes El No a t1 Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. ? Ye~:] No 0 Not Applicable Attach additional sheets if necessary J • 0 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 4 Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. ? Yes ? No P Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages 62 through 65 for evaluation criteria. ? Yes ? No 1~ Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III - Policies; Pages 65 through 68 for evaluation criteria. ? Yes ? No "Not Applicable PREPARED BY ~L4 dN I~4k TITLE DATE 5~~3 APPROVED BY E BOARD OF TRUSTEES TOWN OF SOUTHOLD DATE I q I-7outhEE 3 c~55 ~ o V E 3 2013 ol own of Tiuxtres MINIM a07-Nnr f 1 3AI303 a oQ\%p. 'OWN OF GU Ha t'LU ^J. Y, All ~Q 4j \ ~ lk r ao A 1~ W t l 4 I! O•q ~t.EPR• ; o 3 g < 2 5CALE-30 -I l Pc"?t. LL d AaA : o,565 AC .PTO TV E wl NE)l t o y T ~ 0rMoNUM E--N. ~ i AF~+tQTMtr,NT f I j Woo i i ~ac~t~wc~. m'• ~ ~ i - - 5.7 '29 0°W w C7R.lT ! '"tom tM rl pwl"5 re+rrPo ^r iM"i!! ~t !~1 sp gY~'Tr#AaKAi. t Y. ro M!^ ra wM k r virk.fleP et y i cW W%Y. k,itidfc 0F'ALt6LQIV01W.X9i LA. r°"r,PnooofwenorYork SUM meson Low. 1 V r~:r cef eF Yrt? VA" rrrr erc tent rlpvg41t'e k+6at1 e41cdor , 41m8~e41ed raM rhUf Mt b to b:~ r. wek^.lltle rrVr• GurrenCe. beAera41nara MILE (:.z4 ROAD onto tltc errs is 41Anet •t41 M tuo+wr2. exd 41e Nt Oeltrlf M tkh. cow"If. 96-mumod IcnCinF, iPCtIerN4111 Nood 11~ to the rcr„WtrrR 411 thr W"1100" ta'.tM. Gv,lWtow INFO IM lltltrAtOttlm 1 .ID :(!:l:~iePei 1f141t1&Ilt41flr K """'IT' of NEW 5' FT CU TAY MAP UA-Mi;JU ? ~ 1.9. o K VR SKY L_