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HomeMy WebLinkAboutHansen, Cheryl N/ O,y, ravs v19 OAT FAG/NG ~k e/ 12 •4•,y'4 G ~OC~ e17.4 n~araeev erAOe .i17./ ~c 8 ~ - /Dio jOrPiL 6F9G~N ~gTVpi ,e 4• ~ ~ noo sAL. r APpR PiE ~ ~ ~~y/,~ "4~~ If iJ sPnc Tiwc /E .,E.f4 .'_S'-i J ~~0 "i c's.~!// +"q 'QO O Ara ~ ?,i r cw. ~ RPM o Gp' G.7 / ~ Tip ~F0 'f' we~lG r eJ /•7 awrnt Q~ f7vE G 6 ~~p-sv~~ root czu~sra P~,pES ~ st'`~t '~y Q ~6 ~ "''G ~s9 ~ro°~ ~w"~a~iAroe ~°1~ '/v . f01~ J v: C v ` y~ t`s," ~ ~O°. ~QO .0 ~hD w"a°rr aF ".w ai°wun e~.w m sun r i rv. a StF , ~ • r. r - s ~ ~ g3~ ~ ;CROSSECTIO,N -SEPTIC SYSTEM g ~ 5'1' ~ c..S ' S ~ ~ ~2 ~ Q SUBSUPFACE SF_WAGE U/SPOSAL g2 ~ do ~ Q. SYSTEM GF_S.IGN 1~ ~ ~ ~t% / 4 ~ O BY' JC•SFr'h' F(SCHF. ril, P.E. es41 t° d ,V HOdAr~ R~~AG P~ c~ ~ n~ ~,~.s - SOUT~''~~~ P?.;•". ;,'971 \F'y~ ° . ~ ~ (E:37 t 5 - 2;'54 \ ~°j6•J ~90~ ~ 5:~~..~jW~~d~P11~ ~ sil~~ l: ~'~iPa~°.~ - ~ b~ s ~e`T~ 1h -s- o,, P~ ~ ; , , , , I , ~ SUR VEY OF A°o°• ° 5 ~ 13'~ ~ ~ ~3~.j ~ ~ PROPERTY auc 2 D ~P A T BA.YVfEW a Z°°9 0 G ~ •3~ ~ \F ~ ~ - - - ; TOWN OF SOUTHOLD ~e~"~, ~~Z ~ Q,~ ~~o o s~~FoLK courrrv nr,~a, ,1~~ ~1,~F ~ ~r3, 7 i SUFFOLK COUNTY, N. Y. '9 ' ~ g~~~=_~ t~~u~4©v, , ~ 1000-78-05-17 ~ e /110 os-OLOD DEC. 29, Zoos pF N yy <a. s•T~B Oi. i E Z l 5 p'6 ?ANI9, zoo6 ~f~g r ~9 \ V . 6 ~s, ~ w AREA = 14,547 SQ.FT. ~t~.s e YEA :°'tr~t u~ ~ er aaP4+,,,,~~. ~ ~ IESrMOCE ' s?o~~~ ~,g vniae er~,,oawALOaEOS~povcf oA/N enorN yaw a- - --r ` elvorr ~ ANY AL T£RAT10N OR ADO/T/ON TO TH/S SLN7VEY /S A VIOLAT/ON • OF SECT/ON T209 OF Tl~ NEW YORK STATf EDUCATION LAW. •~~Of flE~.yY rA nF N ypM' QAYEY Snrr sc EXCEPT AS PER SECT/ON 7209 - S(/BDIVISION 2..9/1 rcnrc;,CA T/0NS FLOOD ZONE'AE (er'.81 - - r HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF FIRM 36/03C0/66 v 5/04/98 5~ ~Tlc 'Q.F- r rA~ 0.AY ~ SAID MAP OR COP1E5 BEAR THE IMPRESSED SEAL OF THE SURVEYC4 ' WHOSE SIGNATURE APPEARS IiEREON. - IAnF N di0/N qA YEY SANU SG / - - o• lam lamiliar with fhe STANGAROS FOR APPROVAL NO 4 6/8 AND CONSTRUCT/ON OF SUBSURFACE SEWAGE The locations a/ weds ertd cesspools DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES shown hereon are tram lield observallons ECONIC NA /EN N TALE e/torr FINE SANG sP and will abide by the conditions sef lorlh (herein and on. -!he and or tram data obtained /ram others. (6311 765 - 50 ~ 6 / 797 perm./1 to construct. P. O. BOX 909 1230 TRAVELER S ELEVATIONS AR£ REFERENC£0 TO fI,G.V.O. SOUTHOLD~ N. Y. ll9 m ' OG n AC James F. King, President ~~0~ SU~r~ Town Hal) Jill M. Doherty, Vice-President ~Q P O Z~ ute 96 Peggy A Dickerson ~ Southold, New York 11971-0959 Dave Bergen Bob Ghosio, Jr. Telephone (631) 766-1892 Faa(631)766-8641 BOARD OF TOWN TRUSTEES ~~t ~r ) -TOWN OF SOUTHOLD Please be advised that your application dated GU has been reviewed by this Board at the regular meeting b and your application has been approved pending. the com letion of the follow/ing items checked off below. V Revised Plans for proposed project S~~' bw~~ 0.~`i~1~ ~ ~ Sp'.~aM l~y~,alesw~lhs~l~~-enc~nN'~o~! (ti~-ers~ Pre-Construction Hay Bale Line Inspection Fee ($50.00) ~~k' / 9 d~ywells on duaellincf 1St Day of Construction ($50.00) Constructed ($50.00) Final Inspection Fee ($50.00) Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below acxording to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $ BY: James F. King, President ~I,~ ~ ~b, Board of Trustees I • '`°~~Or~ James Eckert, Chairman Town Hall, 53095 Main Rd. Lauren Standish, Secretary yj ~ P.O. Box 1179 Southold, NY 11971 Telephone (631)765-1892 Fax (631)765-6641 Conservation Advisory Council Town of Southold At the meeting of the Southold Town Conservation Advisory Council held Wed., September 16, 2009, the following recommendation was made: Moved by Jack McGreevy, seconded by Doug Hardy, it was RESOLVED to SUPPORT the Wetland Permit application of CHERYL HANSEN to construct asingle-family dwelling, driveway and sanitary system. Located: 405 Williamsburg Dr., Southold. SCTM#78-5-17 Inspected by: Jack McGreevy, Doug Hardy The project was not staked, however the CAC Supports the application, as applied for. Vote of Council: Ayes: All Motion Carried i ~ 5yfF0i,~ James F. King, President ~cqy P.O. Box 1179 Jill M. Doherty, Vice-President ~ i Southold, NY 11971 Peggy A. Dickerson ? Telephone (631) 765-1892 Dave Bergen ~ ~ Faz (63 q 765-6641 Bob Ghosio, Jr. ~~a Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: ~ U CHERYL HANSEN requests a Wetland Permit to construct asingle-family dwelling, driveway and sanitary system. Located: 405 Williamsburg I)r., Southold. SCTM#78-5-17 Typ of area to be impacted: altwater Wetland -Freshwater Wetland -Sound -Bay Distance of proposed work to edge of wetland Part f Town Code proposed work falls under: ~apt.275 _Chapt. 111 -other Type of Application: Netland -Coastal Erosion -Amendment _Administrative_Emergency-Pre-Submission Violation Info needed: Modifications: Conditions: Present Were: .King `~J.Doherty ~ckerson "D. Bergen_°'B.Ghosio, D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: l Date: I i I YP ~ ' e ra Q w>m • o r • a.. s P s r.. y rrav a. rsw.m O 3t ' e 7 ~ w n _ Yf~ . O L ~ ..W _ • Y 4 e _ ~ ` r y e<e< e a • / ~ • ° P 'y v Y ~7 ~ 0 A• • P r ~ • III P+° ° ~ ? • w • s • v • Y , ~ F . C, I y n • v • r O~ v P • L yb' a ~ r e.A • ~ ~ w ~ • • v y r ° • ~ • • • L .y • • s " r n P P a~pY s Oq ~ 'w, • • . ~w • • • • 'r a • • N ~ a • w • • n. J•tl ? • P tl M A ~ ~ #Y • Y • ~ P y w P P PP n • • O ~ ~ ,'r V ~ • ~ _Jy • 'y • • ~ y` '.b P1b n • • n ~ ~p w y y,~ v w L L • °s0 s « • _ r • v Y w ~d.. Y ~ ~ 4 • • • Yy ~ •PAY • • • w~ r e • r~ X Yl f ~ ~Y b ~ 11 • Y Y n S = w . / w Pc - ~ . ~ ~ CdInY OF SIFFnIt { moi ie t ~ ~ o .Y~a.~v.m• M~Prapsy la Srvb kK7' 4 ® yr ~78 F... ~•~sb>s ~f! M ~ _ ~ ~ _ wr - ~ aiw ~m~•1~ si dY~bYM ~ W! p rw. • _ e_s rs ~ . ~ ~ OFFICE LOCATION: SU(/ry0 MAILING ADDRESS: Town Hall Annex ~0 6 P.O. Box 1179 54375 State Route 25 # # Southold, NY 11971 (cor. Main Rd. & Youngs Ave.) Southold, NY 11971 ~ Telephone: 831 786-1838 Fax: 831 786-3138 ~'~OOUN1'(,~ LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM D ~ ~ ~ ~ l/ SEP ~ 8 2009 To: Jim King, President Town of Southold Board of Trustees Southhold T Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: September 16, 2009 Re: Proposed Wetland Permit for CHERYL HANSEN SCTM#78-5-17 CHERYL HANSEN requests a Wetland Permit to construct asingle-family dwelling, driveway and sanitary system. Located: 405 Williamsburg Dr., Southold. SCTM#78-5-17 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Watertront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the below Policy Standards and therefore is CONSISTENT with the LWRP provided that the below best management practices are required. Policy 6. Protect and restore the quality and function of the Town of Southold ecosystem 6.3 Protect and restore tidal and freshwater wetlands. It is recommended that perpetual. landscaped buffer be required landward from the wood bulkhead. An example definition follows: LANDSCAPED BUFFER a land area of a certain length and width which is planted with indigenous. drought tolerant. vegetation similar to that found within the immediate proximity of the parcel. Vegetation shall be installed in sufficient densities to achieve ninety-five (95) percent ground cover within two nears of installation. Survival of planted vegetation shall be (ninety) 90 percent for a period of three nears. Maintenance activities within the buffer are limited to removing vegetation which are hazardous to life and property. trimming tree limbs up to a height of fifteen feet (15') to maintain viewsheds, replanting of vegetation and establishing a four foot (4') wide access oath constructed of pervious material for access to the water-bodv. Further, to further Policy 5, Protect and improve water quality and supply in the Town of Southold" and protect and improve the water qualfiy and supply in the area; the following, hest management practices are recommended: 1. Require the installation of gutters, leader and dryweBs. 2. Require that the driveway be constructed of previous materials. 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 ~a0f ~l/j Town Hall Jill M. Doherty, Vice-President ,`O ~ 53096 Route 25 P.O. Bo: 1178 Peggy A. Dickerson ~ ~ Southold, New York 11871-0959 Dave Bergen Bob Ghosio, Jr. Telephone (631) 766-1882 Faa (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OIP 30UTHOLD Otilce Use Only Coastal Erosion Pemnt Application 1 Wetland Permit Application _ Administrative Permit _AmendmentlTranaf Extension V Received Application: 8~ O ~lteceived Fee:$S~ D ~ ,Completed Application 6 -Incomplete q D _SEQRA Classification: Type I_Type II_Unlisted_ AUG ~ 4 Coordination:(date sent) ~LWRP Consistency Assessment Form _.eAC Referral Sent:~~ T ate of Inspection: q 191~~~- -Receipt of CAC Report: -Lead Agency Determination: Technical Review: ~c Hearing Hel~~ Resolution: Name of Applicant n E/E. l/ ( ~/~5//~~(/ Address 30S [t~l/UAS(9~ d,P/?C, /7/2LlNG~'tJN H"6-TS dP9[~J ~ Phone Number:(~y3,SO7-3Sa~/r9y7-~/~/-SSA/ Suffolk County Tax Map Number: 1000 - 'J$ - mss' - / Property Location: /~(7S /LL/A-MS /3 U2!i- ~ ~ ~ MFG nF f~1f]-iu /~fl~/y/r`r.~ S'rJuTH-oL/S (provide LILCO Pole distance t co loss street, and location) - AGENT: (If applicable) Address: ~ Phone: • ~rd of Truateea Applicati~ GENERAL DATA Land Area (in squar~e/feet): /S". Sam/ ~ C C~u~~C~ GE Area Zoning: /C ES/ Bt ivT ~l~L / Previous use of property: (~A-L' /fit/ T f-.~/-,V 4 Intended use of property: S/~Z~~ ~ Tip/ N~/L ~1 4 u/ ~ L L /NG- Covenants and Restrictions: Yes No If "Yes", please provide copy. Prior pemuts/approvals for site improvements: Agency Date 3uF~« ~uu,w~y /den-ter/,~ /-9-09. ~-~-oho Ac.;C ~NCu/ HULK/fE~4~1 9-/7-O'~ Q/WN ( ~ .3 ~Di D~~ ~tFr,ust I3c.r~Cr ~~/wvnt~ y-/o-od TAN ~U3TEES ~ C9S No prior permits/approvals for site improvements. Has any permiUapproval ever been revoked or suspended by a governmental agency? ? No Yes If-yes, provide explanation: Project Description (use attachments if necessary): S/NG.L ~ FILM/L pR-~cvnJ r~~y ~u~y6~1 • ~rd of Trustees Applicati~ WETLAND/TRUSTEnE LANDS APPLICATION DATA. Purpose of the proposed operations: w/ST.Q.UC~.~ f~ Area ofwetlands on lot: o,tl L square feet Percent coverage of lot: N H Closest distance between neazest existing structure and upland edge of wetlands: Nf1- feet Closest distance between neazest proposed structure and upland edge of wetlands: ~J9 feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? /'I'7 cubic yards How much material will be filled? cubic yazds Depth of which material will be removed or deposited:~_ feet Proposed slope throughout the azea of operations: Manner in which material will be removed or deposited:~j U ~ A 0 Z b K 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): ~rd of Trustees Applicati~ COASTAL EROSION APPLICATION DATA Purposes of proposed activity: Are wetlands present within 100 feet of the proposed activit}r? No Yes Does the project involve excavation or filling? No Yes If Yes, how much material will be excavated? (cubic yards) How much material will be filled? (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) ' PROJECT ID NUMBER 81720 SEAR APPENDIX C STATE ENVIRONMENTAL pl1ALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 -PROJECT INFORMATION (To be completed by plipM a Praiect Sponsor) 1. APPLICANT/SPONSOR 2. PROJECT NAME ~ S c=/t/ 3.PRQIECT LOCA ON: M~+aaar J 6V L cpllmy .p U OL 4. PRECISE LOCATION: Street Addasa antl Road Interaee8ona. PromkleM rks etc -or provide map ~d 0.S ~ LI Z-t46~TlF L/4/VC 5 vtrr*~0 /l/Ev~~~ - T/f/~-D le!(rtfT OFF d~ rH~-l~ C3~yv.~Ewq-~Fr~~e sT Pty-T~~e,~ C~~fr~R- 5. IS PROPOSED ACTION : ? New ? Expanabn ? ModiBcatlon / aaerotion 6. DESCR//IB~~E PROJECT BRIEFLY: ~%D/USTR,,I/C*/cam or s/N~-cc_ ~~-~/Ly ~wE<[./,uG wiT~ G~~v~~ D,e,lv~w?~ y 7. AMOUNT OF LAND AFFECTED: InitlaAy acres Ultlmate scree B.~~H-AL~~/L PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~]QYes ? No N no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as marry as appty.) ~esitlentlal ? Iraustdal ? Commerdal ?Agdarhuro ? Park / Forost / Opan Space ? Other (describe) 10. DOES ACTION INVOLVE A PERMR APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Lacel) f I /es ?No If yea, Net agency nanre era permh / approves ~E/O/~K.'J-~~T dG ~T~~TH S PIZV I e ~S f}'N ~ ~EPAk-T'M~J/Y' o~ Eif/v iQeiAV Al E,orHL C~A4l15671-Vi9-7"/0/lI 11. D~O,E/S ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? l fires ?No H yes, list agency name and permft /approval: A,~-P,a-lu-~sur v~ f~~i~~r~ S ~ ~ ? c ems Aav A h ~ 1 . AS A R ULT OF PROPOSED ACTION WILL EXISTING PERMR/ APPROVAL REQUIRE MODIFICATIONS es No 1 CERTIFY THAT TnHE INFORM/ATION PROVIDED A"B~OVE IS TRUE TO THE BE3T OF MY KNOWLEDGE Applkant /Sponsor Name C ffL=2u L ~"IQ-/1/$ G /v / Date: 8 _ ~0 q S' lure / ff the actbn is a Costal Aroa, and you an a state agency, complete the Coastal Assessment Fonn twforo proceeding with this assessment PART 11- IMPACT ASSESSMENT o be eom Ntted b lead A nc A. DOES ACTION IXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? Hyes, coordktate tlts revbw praxss antl use the FULL EAF. Yes ~ No B. WILL ACTION RECENE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? N No, a negative dedaretion may be superseded by another InvoWed agency. Yes ~ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be harMwdtlen, H legibl9) C1. Existlng air quality, surface a groundwater quetlty a quaMky, ndse bvels, ezbtlrg traffic pattern, sdkl waste productlon a dbposal, potentlal for erosion, drehtpe or flooding protNamsT Exphh txbfly: C2. Aesthetlc, agricultural, archaeologkal, hlstork, a otltsr rmW or cuHurel reswross; a community a neighborhood droredeR EtglaM bdefly: C3. Vegetatlon a fauna. flah, ahelHislt a wsdNfe spades, habitat, a lhreaMned or endargxed spades? Fxp~in Mblly: C4. A commun(tya existlng plans a goals as omdaay adopbd, a a change in use a hNsmNy of uw of knd a other natural roeourees? Ezpkin brMflY C6. Growth; subsequent tlevelopmem, or related adlvitku likely t0 be krdUGed by the proposed BCtloflT Explain briefly: C6. Lag term, short term, cumulatlve, or ottlar effects nW klentlfied fn Ct-C6? Explain briefly: C7. Other im indWl the es in use Of efiher w a d sne in D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA CEA 7 If N bri Yes ~ No E. IS THERE, OR IS THERE LIKELY TO BE CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? H ex kt: Yea ~ No PART IN -DETERMINATION OF SHiNIFICANCE (TO be completed by Agency) INSTRUCTIONS: ForealitadverseefledidertWiedabove,determinewhettterHissubslanfial,large,imporfantorotftervdeesignificant Eech effect ahadd be assessed in connection with Hs (a) sotfirtg (i.e. urban or ruraq; (b) probebHHy of occurring; (c) duration: (d) kreversidlily; (e) geographic scope; and (f) magnitude. If necessary, add aCachmenb or reference supportlng maleriak. Ensure ttrot wp4nationa contain suffident detail to show that all relevant adverse hnpacb have been identified and adequately addressed. If queatlat d dpart N was dledted yes, the determinationofaignificance must evaluate the potential impadofthe proposed actlott on the environmenMl dteracMristkaofthsCFA. Check Ws bar Hyou have identified ore a more potantlaey larye asigMfiartt adverse knpacta wMdr MAY otxxs. Thsn proceed directlyto tlts FUL E/1F antl/a prepare a poaHiva daclaretlon. Check this box H you have tlelemtMed, basal on tlta kdorntatlon arM anaysis above and any supportlng dactunentatlon, tlua the proposed a WILL NOT reautt in any significant adverse emironmeMal Impede AND provide, on attachments as neasaary, the reaeoro supportlrtg determination. Name of Lead Agency n a ype erne apona e r n TPoe of Reapomibb Olf~er nature o capon r n enq parer ( d rent re ~ard of Trustees Applicat• County of Suffolk State of New York CI'~G~f~ l ~G?~$aln 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/f~R KNOWLEDGE AND BELIEF, AND THAT ALL WORK WII,L 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, THEIIt AGENT(S) OR REPRESENTATTVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. /Jr.22y~/ ign ure SWORN TO BEFORE ME THIS o~~_DAY OF 2009 otary Pu ooil~ NO~o T RY PUBUC 8hbutk3kMlbAt No.OtLA60592a1i ~ua~Hied In Sufbik County Commissk~nExpkenMq ,l0~ ' APPLICANT/AGENT/REPRESEN'TATiVE TRANSACTIONAL DISCLOSiJRi+; FDRM 'rl.- Tow ~ of 5;~~1~'•'Q ode of prohihits Dossiers of imenst al the Hatt Of town otBcera and erenbwma The O@^n?a of 1.. Como L L nrovlde inforinatiao ' h can start thn town of mssibk ceo~ of istenet and stlow it to talm whatever action is necessary to avoidsame. / / - - YOUR NAME: ~A-/U t E/V ~/-r• E2V (Last parse, fast n e, tpiddk initlel. q u Y~ ~ ~PIYmB is the name of someone else or other entity, such a, a company. If so, indicate the other person's or cempany's nerrre.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Varimrce Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If "Other", name the aMivityJ Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer oremployee of the Town of Southold? "Relationship" includes by blood, rgarriage, or business interest "Business interest" nrearrs a business, including a parurership, in which the town officer or employce has even a partial. owrrerstrip of (or employment by) a corporation in which the town officer or employee owns mote than 3%of the shares. YES NO If you answered "YES", complete the balance of this form end 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 applicartlagentltepresentative)and the Wwn officer or empbyee. Either check the appropriak line A) through D) and/or describe in the span provided. The town officer or employee or his or her sparse, sibling, parent, or child is (check all that apply): A) the owner of greater than S%of the shares of the corporate stock of the applicant - . (when the applittam is a corporation); _B) the kgal or ~be~cial owner of any interest in anon-corporate amity (when the applicant is nM a corporation); _C) an officer, director, partrrer, or employee of the applicam; or _D) the actual applicant DESCRIPTION OF RELATIONSHIP Submiaod this o~`1 day of Ca-t15T 200 Signatttro Print Name r L / E~II Form TS 1 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 malting 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 prtparer 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 oroposed actiaa will be evaluated as to its simificant beneficial and adverse effects upon the coastal area (which includes all of Southold Townl 3. If any question in Section C on this form is answered "yes" or `~o", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained is the consistency review law. Thera each answer must be ezu~ed in detail listin¢ both snneortiu¢ and non- - suonortin¢ facts. If an action cannot be certificd 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# - DS PROJECT NAME L~J/LL / ~4-1r1 S bU2-G A2 [ ?G ~D dS The AppticaHon 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) Pemvt, approval, license, certification: Nature and extent of action: St nl f~ i Lu 6 Cy F LL I,~ G-xF1lL. ~S'19-n~ i U W ~ Ti-~ 1 N T N ~ L`NY/ EL D P ~ ~ ~i ~l d i1/ Location of action:_ _ ADS LtJ /L[./KI-1rtS K3Ui2G- d~ l V c Site acreage: /~3 ~-C/2-~ Present land use:_ - ~ /¢{r_ /¢/1J ~ Present caning classification: ~ ~ S 1 p 6= NT ! A- L- 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: ~."~E,Ps/L f-t-~-NSc N (b) Mailing address: ~ D S c~. W DS 0/e d ~ V~ l4at/ruo-~n~ t~c,-mss. ~ L rQcx~o ~l (c) Telephone number: Area Code ( ) 8 N 1-S" 7 7 - 3 Sa ~ 8 4 7 - ya / -S Sg / (d) Application number, if any: Will th~eyaction be directly undertaken, require finding, or approval by a state or federal agency? Yes L"J No ? If yes, which state or federal agency? j~S i~ P u A L f/ ~ d L-~." l9-cv ~ p e P~4,2r~ an/r p F fF~~?-~ rl-f ~ t cES 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. Incomph~te 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 apace, makes efficient use of infrastrnctnre, makes beneficial use of a coastal location, and miaimizes adverse effects of development. See LWRP Section III -Policies; Page 2 for evaluation criteria. QYea ? No ? NotApplica e dlli~ Attach additional sheds if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III -~Po~li/cies Pages 3 through 6 for evaluation criteria ? Yes ? No LJ 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 ? Yea ? No u Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water gnality asd supply in the Town of Southold. See LWRP Section III -Policies Pages 16 through 21 for evaluation criteria ? Yes ? No u Not Applicable Attach additional sheets if necessary Policy 6. Protect sad restore the quality and function of the Town of Southold ecosystems inclndmg Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III -Policies; Paga 22 through 32 for evaluation criteria. ? ? No Not App~able • Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III -Policies Pages 32 throngh 34 for evaluation criteria. ? Yes ? No ?v Not Applicable Attach additional shcets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wa~stes~See LWRP Section III -Policies; Pages 34 through 38 for evaluation criteria. ? Yes ? No L~ 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 ~ Not Applicable Attach additional sheets if necessary WORIONG COAST POLICIE~ • Polity 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. ? Yea ? No Not Applicable Attach additioml sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Towu~wat~ers. See LWRP Section III -Policies; Pages 57 through 62 for evslnation criteria. ? Yes ? No t~ 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 fore-valuation criteria. ? Yes ? No U Not Applicable Attach additional sheets ifnecessary Polley 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III - Policies;/Pages 65 through 68 for evaluation criteria ? Yea ? No LvI Not Applicable PREPARED BY~ /L~ ~ N S ~N TITLE DW,vE~C' DATE R ~ 0 9