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HomeMy WebLinkAboutTR-8258A James F. King, President so~Tyo Town Hall Annex Bob Ghosio, Jr., Vice-President 54375 Main Road P.O. Box 1179 Dave Bergen Southold, New York 11971-0959 John Bredemeyer H Q ~O Telephone (631) 765-1892 Michael J. Domino Fax (631) 765-66441 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0911 C Date: October 2, 2013 THIS CERTIFIES that the replacement of the existing sanitary system in-place At 20 Third Street New Suffolk, New York Suffolk County Tax Map # 117-10-19 Conforms to the application for a Trustees Permit heretofore filed in this office Dated July 31, 2013 pursuant to which Trustees Administrative Permit #8258A Dated August 21, 2013, was issued and conforms to all of the requirements and conditions of the applicable provisions of law. The project fpr which this certificate is being issued is for the replacement of the existing sanitary system in-place. The certificate is issued to NICK DE CROISSET owner of the aforesaid property. yxp"' 0 Authorized Signatu •e • • James F. King, President O~gAfFA(,t Town Hall, 53095 Main Rd. Bob Ghosio, Jr., Vice-President P.O. Box 1179 Dave Bergen Southold, NY 11971 John Bredemeyer 'by Telephone (631) 765-1892 Michael J. Domino Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: (0~f /,u V Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 151 day of construction _ % constructed Project complete, compliance inspection. INSPECTED BY: - e, e- A v~ COMMENTS: r-- CERTIFICATE OF COMPLIANCE: James F. King, President g~fF014- Town Hall, 53095 Main Rd. Bob Ghosio, Jr., Vice-President P.O. Box l l79 C4 Dave Bergen d°+ Southold, NY 11971 John Bredemeyer Telephone(631)765-1892 Michael J. Domino 1 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 1 at day of construction % constructed Project complete, compliance inspection James F. King, President so~lyo~ Town Hall Annex Bob Ghosio, Jr., Vice-President 54375 Main Road Dave Bergen P.O.Box 1179 Southold, New York 11971-0959 John Bredemeyer CA Michael J. Domino • ~O Telephone (631) 765-1892 1y00UMY Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8258A Date of Receipt of Application: July 31, 2013 Applicant: Nick de Croisset SCTM#: 117-10-19 Project Location: 20 Third Street, New Suffolk Date of Resolution/Issuance: August 21, 2013 Date of Expiration: August 21, 2015 Reviewed by: Trustee Dave Bergen Project Description: To replace the existing sanitary system in-place. 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 Mark Boeckman, received on July 31, 2013, and stamped approved on August 21, 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. o7- James F. King, President Board of Trustees i r gpFFO(k James F. Kin-, President O~ C P.D. Box 1179 Bob Ghosio, h., Vice-President Y2y Southold, NY 11971 Dave Bergen WTelephone (631 765-1892 John Bredenreyer G Fax (631)765-6641 Michael ) . Domino 4, ~aa Southold Town Board of Trustees `Field Inspection/Work Session Report Date/Time: h V, P Mark Boeckman on behalf of NICK de CROISSET requests an Administrative Permit to replace the existing sanitary system in-place. Located: 20 Third Street, New Suffolk. SCTM# 117-10-19 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: Modifications: c7 - Conditions: h o Present Were: J. King _B. Ghosio !67 Bergen, J. Bredemeyer Michael Domino D. Dzenkowski other Form filled out in the field by ft Mailed/Faxed to: Date: M~ q ~ .~,n a I I p , - i ) f ,yfsl CUICiIGGUE inn w Fr, a ar ~ ..wn „ s R vwuO a , infer o,' xwv, o' ,'va mr enro fwe - ,m PA. Be f° W J - vECGR~ _ _ tuna COOT' OF SUFFOI ~ s° v~muu mortnrv urv Y°~ u -O_ _ m u.wn.mmmn Reel` TmSemm ApezY Y OFFICE LOCATION: OF SO(/TyOI MAILING ADDRESS: Town Hall Annex p 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 ~~OOUNTV LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM R nEQ IVE5 2013 fTrustees id own toes To: Jim King, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: August 13, 2013 Re: LWRP Coastal Consistency Review for NICK de CROISSET SCTM# 1000-117-10-19 Mark Boeckman on behalf of NICK de CROISSET requests an Administrative Permit to replace the existing sanitary system in-place. Located: 20 Third Street, New Suffolk. SCTM# 117-10-19 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the LWRP provided that the Board considers the following: 1. The parcel is located in the VE and AE 6 FEMA Flood Zones (Figure 1.) It is recommended that the Board locate the septic system out of the VE Flood Zone and maximize the distance of the new septic system from the water body to the greatest extent practicable. Figure 1. Subject parcel and FEMA Flood Zones. 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. ~q so • Town Hall Annex Bob Ghosio, Jr., Vice-President ,`O~ Ol0 54375 Main Road P.O. Box 1179 Dave Bergen JI~1 * Southold, New York 11971-0959 John Bredemeyer H Michael J. Domino Telephone (631) 765-1892 O~'Fax (631) 766-6641 , COU~ BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only -Coastal Erosion Permit Application -Wetland Permit Application Administrative Permit Amendment/Transfer/Ex erasion eceived Application: 311 3 Z: 7 fi= D -Received Fee:$ rr Completed Application Incomplete SEQRA Classification: Type I Type llUnlisted U L 3 ?013 Coordination:(date sent) ~ZLWRP Consistency Assessment Form "q CAC Referral Sent: ,~TDateoflnspection: Ydlah-Receipt of CAC Report: I -Lead Agency Determination: Technical Review: Public Hearing Hel Resolution: Name of Applicant m i Cy, (it°_ c,.cO t s<se,4 Mailing Address Q0 -1lna 4~3~t-(Cje~r ~eW cJ \ tJ~ j \es'(5 & Phone Number:(gty) cm ' 73 o~S Suffolk County Tax Map Number: 1000 - ) 1'-7 - 1 p - 19 ZO "0 wwr^^ Property Location: A}e v~ ~JU\K (provide LILCO Pole distance to cross streets, and location) AGENT: (If applicable) Q Address: /4 /n`0, A+,.43 ^W z()( 1453 0.t U q_5 Phone: %~j~ - 0~ - 6 3 9 m-ard of Trustees Applicati~ . GENERAL DATA Land Area (in square feet): 1011. 00 Area Zoning: 'R-40 Previous use of property: V.?eY~'MC< <"qe Intended use of property: ~rr1 cY'1G~ Covenants and Restrictions on property? Yes -J~_No If "Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes V"~`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 any 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: Agen y Date jt~I. +ceS I- 3\ - IM 71 Ftam tr bt BL,orr ma or 3ao* No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? X No Yes If yes, provide explanation: Project Description (use attachments if necessary): /y ~q,~`\ l T e!!AA Bo d N of Trustees Application • WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: S3T I L-t~ 6 T_ Area of wetlands on lot: (q y d square feet Percent coverage of lot: Closest distance between nearest existing structure and upland edge of wetlands: 1 b feet Closest distance between nearest proposed structure and upland edge of wetlands: © feet Does the project involve excavation or filling? NoX_ Yes If yes, how much material will be excavated?o~ubic yards How much material will be filled? 40 4--,cubic yards Depth of which material will be removed or deposited: ~j feet Proposed slope throughout thearea of operations: N.d Manner in which material will be removed or deposited: t~' ;Ke44}ewyr,,_ 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): PROJECT ID NUMBER APPENDIX • X C • SEAR 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 ~5 3.PROJECT LOCATI"ONE~: Municipality eloo County S \ 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map ac -06va 4E~r«G-k 5. IS PROPOSED ACTION : ? New ? Expansion 5610odificallon / alteration 6. DESCRIBE PROJECT BRIEFLY: ~Ir T AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? WYes ? No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) W Residential ? Industrial ? Commercial ?Agriculture ? Park / Forest / Open Space ? Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) Yes El No If yes, list agency name and permit / approval: PERMIT APPROVAL? Yes 191 No If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? Dyes ~ No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Spons me Date: PT I Signature 1 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 o born leted b Lead A en A. OOES ACTION EXCEED ANY TYPE ITHRESHOID IN 6 NYCRR, PART 61T.4? If yes, coordinate (he review process and use the FULL EAF. El Yes Q No B. VWJ- ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNUSTED ACTIONS tN 6 NYCf1R, PART 617.6? If No, a negatve declaration nay be superseded by another kwo(ved agency. Yes a No C. COUW ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING (Answers may be handwtittea, If Iegibie) C1- F)batng air QuaIlly. surface or groundwater quality or quantdy, noise levels. eA*V traffic POM sold waste production or disposal, potetl681 for erosion. drainage of flooding problems? E plaAh briefly, - C2. Aestltedo. agrkWtura4 alnirraealogiifxl, or otlher nadrNor dAaral resoueoes: a or rdaradefl Fxplakf . CS. Vegetation "fauna, fish shetfa ac wtd species. sigrdfhcard habitats, or drestened of endangered spades? Wn briefly. C4. A commuaify's exhaling plans or goals as oflhdaty adopted, or achaage in use or in enity of use of landor other nalwal vesoufces7 c Explain Mieay F C5. Growth. $ubs;;Uent development, or related activities likely la i,duced by (he proposed action? Explain briefly: C6. Long term. short term, cumulative, or Omer effects not identifiedin Cl C5? Explain briefly: C7. Qthetimpacts (Inctuding dean es in use of ether uanri(. or type of a air ixiefl. 0. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL; explain ENVIRONMENTAL AREA ? s Q yes 'no, "a E 18 THGRF- OR IS THBtE UKELY TQ RELATED TO POTF.N IAL SAL WACTS? lf. 0 Yes pi No L- PAKFM-DETEMMTIMOFSKU&90ANGE(robeGxnpwwbyAgenaA k1 TRUCiKM: ForeadladverseelfootIder sibm dowllattewheowl(Islalbstaa6allmoo,iotpatttattofothetwkesigniflcahlt Eadt belied should be ameSSad In Minecdoin vrl(fl ins (a) setting (Le. Mbar or rump; (b) probali ft of oooutlrMrg; (0) dtaa0on: ((Q imeve ; (e) v GOOM attd (f) onaviftKI& if neoflssmY, add altadatletlts or rellanance suppoltlllg ma6ttfals Enwm duet elgrltatagotts coatab - wAf(darAdetaAWdiawthatdrelevantathetaeYt havebeenFledwWadeglaftlyad~ jfgt Si1oaddpartliwasdmdred yes, tlleddetemdlta6ortdslgnifirsmtaamustl:vablatetllepdea6a11mpadefthepreposedaoBon onNte~IdlaladeA36csdiheCEA Check glbboxllyouhsYeidanaadOleOfmarepalfvl1dylargeorsi¢dficantadversabpacts;%fthMAYoccur Then Wooeeddractylothe FUU EAF ardW prepare a poAw dedaratorL Check ttk box ayw4ki a deteaMned, based on the kdomafion and analysis above and any stppoltng doarneldatim that the proposed acft dWILLLNO result In any sigrAtraM adverse ~l knpads AMC) provide, on'stfadmlends as necessary. the reasons supporting thi . Board of Trustees y Z O 3 Name of Lead Agency ' Date j # OF S F IZI~ President ~ Print or Type Name of Responsible Officer m Lead -Agency TMe of Responsible Officer C4 P! - ear Town of Southold Erosion, Sedimentation t& Storm-Water Run-off ASSESSMENT FORM 1b PROPERTY LOCATION: s.C.T.M. a: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A Q(~ y - STORM-WATM GRADING, DRAINAGE AND EROSION CONTROL PLAN TWEIW" ft-S -1116W- Tr- CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTION ITEM # / WORK ASSESSMENT Yes No a. What is the Total Area of the Project Parcels? I Will this Project Retain All Storm-Water Run-Off (Include Total Area of all Parcels located within Generated by a Two (2') Inch Rainfall on Site? the Scope of Work for Proposed Construction) is F l) (This item will include all runoff created by site ? 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? Impervious surfaces.) (S.F.IAgaa) (RerMe aaadon+vw.... rw.aa) 2 Does the Site Plan and/or Survey Show All Proposed PROVIDE BRIEF PROJECT DESCREMON ? Drainage Structures Indicating Size & Location? This l Item shall include all Proposed Grade Changes and i .,a- t _ ~r\ Q SL Slopes Controlling Surface Water Flow. ].c~+?~ + 3 Does the Site Plan and/or Survey describe the erosion ? _10y'lie SCl16A%_%C_ and sediment control practices that will be used to control site erosion and stone water discharges. This ~L (D cAxb p\A st-i ~ f? Item must be maintained throughout the Entire Construction Period. Sy ' 4 Will this Project Require any Land Filling, Grading or Excavation where there is a charge to the Natural ? Existing Grade Involving more than 200 Cubic Yards T/ of Material within any Parcel? rj Will this Application Require Land Disturbing Activities ? / Encompassing an Area in Excess of Five Thousand -LI (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 Gomm] DEC SWPPP Requirements: or within One Hundred (100') feet of a Wetland Or Submission of a SWPPP is required for all Construction activities involving sou Beach? disturbances of one (1) or more aces; Including disturbances of Was than one acre that 7 WIII there be Site preparation on Existing Grade Slopes ? am pan of a larger co men pan that will ultimately disturb one or more acres of land; which Exceed Fifteen (15) feet of Vertical Rise to Including Construction actidties Invobing sol disturbances of less men one (1) acre where ..LL the DEC has deterined that a SPDES permit Is required for storm water discharges. One Hundred (100') Of Horizontal Distance? ( SWPPP'e Stall meet the Minimum Requirements of the SPDES Geneml Permit 8 Will Driveways, Parking Areas or other Impervious for Storm Water Discharges from Construction actlviry . Permit No. GP-0.10-001.) Surfaces be Sloped to Direct Storm-Watw Run-Off 1. The SWPPP shall be prepared prior to the submittal of the Not. The Not shall be Into and/or in the direction of a Town rightof-way? subm7led to the Department prior to the mmreraxtrnent of construction acthlty. 2. The SWPPP shall describe the erosion and sediment control precaces and where 9 Will this Project Require the Placement of Material, ? required, post+.onesuction storm water management practices that will be used andlor Removal of Vegetation and/or the Construction of any coratructed to reduce Bit pollutants in storm water discharges and to mum Item Within the Town Right-of-Way or Road Shoulder compliance with the terms and conditions of this perm. In addition, the SWPPP shall Area? (feu ram win NoT r,wnaha m. mswuwier, of dlwway Aerom.) Identify potential sources of pollution which may reasonably be expected to effect the quality of storm waterdischxrges. NOTE: N Any Mew to Questions One through Nina is Answered with a Check Mark 3. An SWPPPs that require the postconsuuctkvr storm water management practice I. a Box and the construction site disturtumi, Is brAween 3,000 S.F. a 1 Am in arr, component shall be prepared by a gmallled Design Professional Licensed in New York a Stonn4vabr, GtWiny, Drainage i Erosion Control Plan Is Requited by the Town of that is knowledgeable in the prinolples and practices of Storm Water Management. (NOTE: AantiChedMorMustk(be./Suarx tor Review Polar to b eq e of Any wVling Pernift. (NOTE: )endVw /arMexerbreadrQuearbrihRaWlrMbraCmgNteApPiAppkmgan) C'Q~14t= r) R1 INCH SPATE OF NEW YORK, Notary Public, State of New York COUNTY OF......`J... SS No.01BU6185050 Qualifiod in SOTToIk t:&ur,P/ That I, bedui swum, de Cos"Kai ;spires April ttt 2 (Nam.e of k;*Qual agning D6o;. op being y poses and says a 1ie?s a 1s the applicant for Permit, And that he/she is the (Owner, Contractor, Again, Corporate Officer. etc.) 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 are true 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; J.~.. day of 20.1 / II Notary Public:...... V" .Y.....C........ r. (Sign ure of Applicant) FORM - 06110 Board of Trustees Application AUTHORIZATION (where the applicant is not the owner) I, t3 jr F CRO scb i' residing at / 3 C W:SC Z,°`~ 5J- (print o ~wner of property) (mailing address) ~ )`y N ~1 1 L do hereby authorize (Agent) 0 (L _~~OEG UGM~~) to apply for permit (s) from the Southold Board of Town Trustees on my behalf. 4 (Owner's signature) 8 B of Trustess ApplicsticsraCq I Count} of Sutblk StateafNew York ~V t w 6 1. s P G R o S 5 f -BEING DUTY SWORN DEPOSES AND APF Obd THAT HEZIIE IS THE APPLICANT FOR THE ABOVE DBSCROED PEWIT(15) AND THAT ALL 9Tt.TEi48M CONTAINED HEREIN ARE TR'FJH To', M BEST' OF HIStFtW KNOWIXI)G AND,13F_LIB8. AND THAT ALL WORK WILL: BE DONE IN THE MANNER SE MKTbI W TM API? LWA111ON: AM AS MAY BE A"R:O"VED By THE SOFJT6IOLD-TO BOA= OF TkU 9 LEES. THE APPLICANT AGREES TO HOLD THE TOWN- OF SD'G"1 HOLD AM T14Y TO9+ N TRUST- 0s HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIPa•I.S ARISING UNDER OR BY VIRTUE OF SAID FERMIT(S), IF Ga24NTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTA'I NES(S), TO ZYM ONTO MY PROPERTY TO INSPECT THE PR.wvnsES IN coxR ` cTI'Oh WITH RFv]EW OF THIS APPLICATION. xt?~~ C / Siwature of Property Owner S WORN -10 BEFORE METH S I'r-F DAY OF I ~ 61 S 71 20 otary Prtuli~: DANIELLE MARIE PARIAS NOTARY PUBLIC 11 OW STATE Of TEXAS G:ONIr. EXPIRES 02.0.9017 "N TARY WITHOU XLMAT WITH Ai' UNT STAMWENT~ State of TEXAS ss. Catnty oPHARRiS Sx Attached Document (Nowy to cross out lince 1- 1.1 below) ? See Statement Belaw (Linn. 1 - I1 io be complemd only by doormen signer(s), not-il>e Notary) L 2. - y. - I0. SiFpatvmatboertmeat.5lgrarsNo.l $igax=ofDontaim'SiperNo.2(j{urry)~ 5ubsexibod and swan to (or Mbrmed) Wort; me this Data Sh motarh ?'-1'u~C Year ear 0 . nor ~wp (i) !r/!'co "4 c fir c f Npoe of 8igaoda) ` °01 t7 g, xeme of figm:*) sipaturs of Notary P*ric _ OMOMAt, TAeugh the AyarmoWon below isawt r¢qukred by law, it rnoy provt miuobL- Mo permw relyvq on the deenwd and could pm, emJfaU&lem renMal and raauaehmeiu W:his form m another documem. Further Dweripdan of Any Attached Document 1 Mrle or Type o£ Lk+cuutedDa~e: l ~I~ -_Nmber of Pages: : ignc,s) Otbar rffim \ um d ,tmam~Nmnumuryneaa APPLICANUAGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM 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 =vide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid some. BOe. V t a ~ 1 <K YOUR NAME: de G fo~?%~~" P* ~r '~\~e 0\GS (Last name, first name,itiddle 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 X - 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 thi d v L200 _L~> Signature Print Name Form TS 1 Town of Southold . • LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS I. 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 significant 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, listine both supportine 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 ffCE V ( Ir SCT # 11 `7 -IUl 3 1 2013 PROJECT NAME T 'r a oMn The Application has been submitted to (check appropriate response): Town Board ? Planning Board El 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: dbouyyle -;fie aS c *A S=Z 4 M+.~ Location of action: • • Site acreage: Present land use: lZiRsy i I>C -,ate Present zoning classification: • 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: N1 L tL N>ce- C1 tS V,:-T-7- (b) Mailing address: ZC- l -5 f~ Sf f'AJS V SO (c) Telephone number: Area Code( ) 1 q ~J ZS (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ? No Rr 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 Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III - Policies Pages 3 through 6 for evaluation criteria ? Yes ? No CJ 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 E] 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 IJ 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 El No u 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. ? ? 42 Yes No Not Ap*ble • Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies Pages 32 through 34 for evaluation criteria. ? Yes ? No V 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 I r i 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.0 No [KNot Applicable Attach additional sheets if necessary WORKING COAST POLICIEO Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria. ? Yes ? No [Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. ? Yes ? No IVNot 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 Z 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 0 Not Applicable PREPARED BY X 21! 'E!:bV CM A,) TITLE DATE :Z ' I ~ JACKSON STREET I - N° a/o;F SURVEY OF PROPERTY W oT:jOMn' S M. ldART! N a 1' N a & JAYNE P. MARTIN SIT A TL ~I m _o NEW SUFFOLK A rt/~ 90.00' i S'U 5 I. I FOUND HUNT i N ,aL , 00" C 5c I I ° I pip, 35.0' WOOD T CAPPED REBAR FENCE COML. MON. TL ^7WN (^i F Sum I ^ i T ~C N 4 3 Pas ~RNL FENCE U. SU, I OLK COUNTY, NEW YORK z S.C. TAX No. 1000-1 17-10-19 B BLK. ~ SCALE "NE FRAME SHED C 1 "=20' STO ~ POLE :'4R"c""' - ° , JANUARY 2008 2, 2008 ats• ~ ~ ~ ~ V ~ JANUARY 20, 2008 VERIFIED HIGH HIGH WATER MARK O a' O xh r[ MAY 9, 2009 STAKE PROPERTY LINES "i ? m a , NOVEMBER 19, 2009 UPDATE SURVEY gJANUARY 6, 2013 ADDED 1st FLOOR EL. & FLOOD ZONE WROOOD R JUL 3 1 2013 AREA = 11.105 sq. ft. "eo ~a I~ S-FMnAAEE OUTSIDE 'k b ,re suLKHEAD) 0.255 cc. \ ~ g 1B3• m _ a a o utfiTldTown CEP.TIFIED TO: Board of Trustees I NICOLAS DE OCROISSET B r ° P" a 7 f a AMERICAN TITLE INSURANCE COMPANY OF NEW YORK D' f y N • _xa a n NOTES: :1t Pc°~ ro:r y 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM ,a' IU I- Ul F m m b 2. THIS PROPERTY IS IN FLOOD ZONE VE (EL 8) AS SHOWN ON m y FLOOD INSURANCE RATE MAP No. 3610300501 H 1i - ZONE VE: COASTAL FLOOD WITH VELOCITY HAZARD (WAVE ACTION); BASE FLOOD ELEVATIONS DETERMINED 9.3' 29.6' FLAG -S~ -w - _ - BU, POLE 1.4'W. ROOF OVER ~57.3~ ~j x1. l~•r.,.dn1c_ial G+'-; '~.~i n: CONC. PATIO UNAUTHORIZED CONC. ? ! - C yL(- ~ APPR TO THIS SURVEY ALTERATION VIOLATION ADDITION A OF NEW YORK STATE S siEP plI°- y , APPROVED BY SECTION. 7209 OFISTHE EDUCATION LAW. FOUN MAXWEAD MAIL D w°aT BOARD OF TRUSTEES COPIES OF UTHIS RN SURVEY AMP NOT BEARING LAND OR SE SURL SMAS INKED O SELL SI SLKIL WOOD BULKHEAD THE S ,aw. STEPS EMBOSSED SEN. RUE CNOOPY. T BE CONSIDERED _ TOWN OF SOUTHOLD TO A VNJD T C g • CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY hJ - V ~x7T I IS PREPARE, AND ON HIS BEHALF TO THE DATE O I Q M11 LL J I LETITLE NDING LINNS71TUfIOON LUSTED HEREO SAND TO THE ASSIGNEES OF THE LENDING INSR- -APPNTENT HIGH WATER MART( AS OF 01 /20/08 TUITION. CERTIFICATIONS ARE NOT TRANSFERABLE PE UNE N 89628'30" W 89,47' THE EXISTENCE OF RIGHTS OF WAY AND/OR EASEMENTS OF RECORD, IF ~ Q ~ 1A ~ ANY, NOT SHOWN ARE NOT GUARANTEED. GREAT PREPARED IN ACCORDANCE YS THE MINIMUM STANDARDS FOR RT TITLE SURVEYS AS °STABUSHEO Nathan ~~7T} Corwin III BY THE L.I ANDT APPROVED AND ADOPTED ASSOCIATIONUCH ~ THE NEW YORK STATE LANG ° TIRE S USE Land Surveyor Title Surveys - Subdivisions - Site Plans - Construction Layout PHONE (631)727-2090 Fox (631)727-1727 OFFICES LOCA7D ar MAILING ADDRESS 1586 Main Road P.O. Box 16 N Y 5 Uc No 50467 Jamesport. New York 11947 'Jamespart, New York 11947