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HomeMy WebLinkAboutTR-8305A John M.Bredemeyer III,President //��pf O1ir*O , Town Hall Annex Michael J. Domino,Vice-President ��� 1. ° l0 54375 Main Road P.O. Box 1179 James F.King,Trustee 4111 Southold,New York 11971-0959 Dave Bergen,Trustee - Q Charles J.Sanders,Trustee O ����� Telephone(631) 765-1892 lij' e Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0977C Date: May 6, 2014 THIS CERTIFIES that the installation of a±3' high two-rail split-rail fence along the full length of the eastern property line and along the western property line from road end landward At 32625 Main Road, Orient,New York Suffolk County Tax Map# 14-2-25 Conforms to the application for a Trustees Permit heretofore filed in this office Dated September 27, 2013 pursuant to which Trustees Administrative Permit#8305A Dated October 16, 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 installation of a±3' high two-rail split-rail fence along the full length of the eastern property line and along the western property line from road end landward. The certificate is issued to ORIENT ACRES LLC C/O EVA MALLIS owner of the aforesaid property. Authorized Signature • 0 John M. Bredemeyer III,President �,�''OgWFO(A, Town Hall,53095 Main Rd. Michael J.Domino,Vice-President t,+''z- CMG¢= P.O.Box 1179 James F. King y Southold,NY 11971 Dave ;Bergen O . �� Telephone(631)765-1892 g .4;* `ail*, Fax(631)765-6641 Charles J.Sanders 1 4 ,' ) BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 6619 /s 1 Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1st day of construction A constructed Project complete, compliance inspection. • INSPECTED BY: J I grQ41("4-4?-4---g/ COMMENTS: 012- i-p j if v-4_, 0)Z_ iJ CERTIFICATE OF COMPLIANCE: 93 • James F. King, President Ofd r~'O Town Hall, 53095 Main Rd. Bob Ghosio, Jr., Vice-President lly P.O. Box 1179 Dave Bergen Southold, NY 11971 John Bredemeyer ~d 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 15t day of construction _ % constructed Project complete, compliance inspection James F. King, President O~~QF S0Town Hall Annex Bob Ghosio, Jr., Vice-President 54375 Main Road P.O. Box 1179 Dave Bergen * Southold, New York 11971-0959 John Bredemeyer G Q 'Q • ~O Telephone (631) 765-1892 Michael J. Domino 00UNT'1, Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8305A Date of Receipt of Application: September 27, 2013 Applicant: Orient Acres, LLC C/O Eva Mallis SCTM#: 14-2-25 Project Location: 32625 Main Road, Orient Date of Resolution/Issuance: October 16, 2013 Date of Expiration: October 16, 2015 Reviewed by: Trustee John Bredemeyer Project Description: Install a +/-3' high two-rail split-rail fence along the full length of the eastern property line and along the western property line from road end landward. 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 Eva Mallis, received on September 27, 2013, and stamped approved on October 16, 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).," 0 J r James F. King, President Board of Trustees gUFFOLk James F. King. President COG P.O. Box 1179 Bob Ghosio, Jr., Vice-President Southold. NY 11971 Dave Bergen Telephone (631 765-1892 John Bredemeyer G a Fax (631) 765-6641 Michael J. Domino `F y'yo! ~ ~aor Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: /0- ?-13 ORIENT ACRES, LLC, c/o EVA MALLIS requests an Administrative Permit to install a +/-3' high two-rail split-rail fence along the full length of the eastern property line and along the western property line from road end landward. Located: 32625 Main Road, Orient. SCTM# 14-2-25 Type of area to be impacted: -Saltwater Wetland -Freshwater Wetland -Sound -Bay Distance of proposed work to edge of wetland P of Town Code proposed work falls under: _Chapt.275 Chapt. 111 -other Type of Application: Wetland -Coastal Erosion -Amendment 4Administrative_Emergency Pre-Submission Violation Info needed: Modifications: Conditions: of Prese ere: J. King _B. Ghosio D. Bergen, J. Bredemeyer Michael Domino D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: Date: 3c2 & D EC 9.V ~iC1 G! N G- ~i~S r Al S EP 2 7 40 •1'. t F y • . w 711!! i / y N A?- '.aP .`qe Al 010 .wa ..rw ~ R y mum j µo ~ PD ra i, q w~_eww~ ~ f!1 W - ]MI M O .mp n • V ~J~ e llffl~ .w+ y' ax s x.u .n _ _ _ mna WU OFSUPPO © ..unoc acc,c. xo wn PmpMPTU SrAO?pvwY _ 14 _ mi _ p ^^a r• a~..~nu • .s-+~ °T -uiwrsa.a~r. QQ1 P n. - wn_e~^w Ito i • 0 OFFICE LOCATION: OF SO(/jyO MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 # l~ Southold, NY 11971 (cor. Main Rd. & Youngs Ave.) Southold, NY 11971 G~ C Telephone: 631 765-1938 i~ Fax: 631765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM LOT To: Jim King, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: October 15, 2013 Re: LWRP Coastal Consistency Review for ORIENT ACRES, LLC, c/o EVA MALLIS SCTM# 1000-14-2-25 ORIENT ACRES, LLC, c/o EVA MALLIS requests an Administrative Permit to install a +/-3' high two- rail split-rail fence along the full length of the eastern property line and along the western property line from road end landward. Located: 32625 Main Road, Orient. SCTM# 14-2-25 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 EXEMPT from LWRP review pursuant to: § 268-3. Definitions. MINOR ACTIONS item "Z" which states: Z. Split rail fences or fences used to control nuisance wildlife that do not interfere with the public's rights of passage along the foreshore; 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 ~OF so~Ty Town Hall Annex Bob Ghosio, Jr., Vice-President 64875 Main Road P.O. Box 1179 Dave Bergen l~ * Southold, New York 11971-0959 John Bredemeyer °p Telephone (631) 766-1892 Michael J. Domino Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD - - - r=~'GL 1L~afIIS Office Use Only I-S ~?Cz~-I-(~.. 11 E Y Coastal Erosion Permit Applicatio 1 -Wetland Permit Application Administrative Permit G l Y I C VT I _Amendmentrrransf/Cxt ion eceived Application. 17 AC re S LL C eceivedFee:$ for) , T'Cl, n --Completed Application a 27 J 3 IIunU'I'/ -Incomplete _SF.QRA Classification: L i p I;~ V y I I Yl ES Type I_ Type IIUnlisted 4 6 I oordinatiow(date sent)___ -~71'WRP Consistency Assessment Form CAC Referral Sent-.. _ ~1 VC (l~ C Cc=ilCn /Date of Inspection: Receipt of CAC Report: V71~L~ lead Agency Determination:__ 'technical Review: Public Hearing He1 i3 Resolution: - Name Name of Applicant ORIRW 7- A--G124-S L.LG Mailing Address IJOX 7/ 16,. /f~9,eR/J OA,'. N Y, /OSZ - T Phone Numberl/J/ - aZ T-O6 651 l o ice) Suffolk County Tax Map Number: 1000- Property ' Location: 3.26 Z S /w4--v Al R-b 0./2/6-/V7 74 ` ykAe.. Very cjoja 7`V Lpryler t9T QicAt Rd. ~fi)suh 12W. OrieO' (provide LILCO Pole distance to cross streets, aWd location) AGENT: LL.L F-, r?v/Ly ?2, PiQdJ-,0A 'f7-/t/'r ' (If applicable) f}7/En/v~ Address: S )E70fZES7- yb N• y 10r eQ Phone: [ t°J 9•ZS = ~(rfJ - O 7r77-Q 1 Ord of Trustees Application. GENERAL DATA Land Area (in square feet): y;Z.Z~ 2/!/ Area Zoning: 12eSiden?f-v,-L R-RE) Previous use of property: 12C41o1e* -A-^k _ Intended use of property: /Z di`Glt.~ ti 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 y' 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? s No Yes I If yes, provide explanation: - Project Description (use attachments if necessary): 6. DESCRIBE PROJECT BRIEFLY: f I^0.,! / S ~rrx~as~o„ ~b i,1a~3•lJ a- ~ ~P ~ Gee wo,det like f-ehe.c~ 3 -1~ t ~`+~9~- ..Iorg ~,(o e,~~'•~ p~s~`~ t ro !~n a J5~ / n ve ~ I"1'7'o•i /Zd ~s~/ OIL. rP /t0 e-/y,{ QfD [.ina. o ~u r w~~ &J Bca of Trustees Application • WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: A/OT 1009- Area of wetlands on lot: O square feet Percent coverage of lot: O % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? ? No Yes If yes, how much material will be excavated? cubic yards I How much material will be filled?__ -cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: I. Manner in which material will be removed or deposited: I i 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): I II 617.20 SEAR PROJECT ID NUMBER 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 ' k' rrf.¢L S OR/E/~AGRES L L F~;NG 3.PROJECT LOCATION: .$fJF'FO~i~ Municipality (Doel ENT County 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc or provide man ii 9r7 3.2 17;?-S- m*iti o2,Fn~; /V-)/ ler-q S4-0 b. IS ROPOSED ACTION : evi Exp nsion Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: Wt wo„t/d /ike ~~'•rtissioN 7b iks~wJf a a-re./~ spl~1~ r~i~ Prpon„L wlon y~ P~1 s -)o 14,v Wai.•t Rd. late//D~~ ~or vno~s~rv n~v¢ ~ C.G.r¢-ate 7~0 7~-/~P tJ7~+^~r ~j~' e g OvQQt Q 1~~' . L /Q.f.D L/~rt~ D sur !Jr ~t Hi~~,de GK7 Olt. rP /'lOQ7 6../y, t. Ai:tOUNT OF LAND AFFECTED: _y-• 6^71 / Initially acres Ultimately acres 6. VVi PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? Yes ? No if no, describe briefly L. 9. %Iv I IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) Residential Industrial 0 Commercial ?Agricultura Park / Forest / Open Space Oliver ~(describe) I. I 10.'DOES ACTION INVOLVE A PI_RMIF APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Fedcm State or Locao Yes No if yes, list agency name and permit /approval: j "11-WES- ANY "ASR~ CT"OF-THE-7iCTIOW IIAVE A--CURRENTLY-VALID PERMIT-OR APPROVAL? ?Yes t - i If yes, list agency name and permit / approval: 12. AS A RE4lJ)rP'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 i Applicant / Sponsor Name,(,{/,., Dale: j Signature.----- 2, ~/-'27 If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment i PART It - IMPACT ASSESSMENT o be co (eted b Lead A en .A, Does AC um r=XCEED ANY TYPE t THRE s"= IN 6 t4ycRR, PART e1T.47 If yes, coordrtsk the review process and use the FULL EAF. 0 Yes. Q No EL Wlll ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 HYCM PART 617.6? If No, a negative declaa'asort may be w4mrseded by another imrolved agency. El Yes Q No C_ COULD ACTION RESULT W ANY ADVERSE EFFECTS ASSOCIATED VVIH THE FOLLMN6: (Answers may be tmrdwdlten, 9legme) . C1. Eidserp air qudty, surface or groundwater quaflty or quantity, noise keels. erdstktg tafac patlem; soad waste pmducgon or disposal, polorKlel far erosion, drainage or flooding probleriw? Egtiakl bttear CP- Aftltm o,;;G; urak ardmeologi al, tttsWk or aster nokador cuftal resbu ms, or a dtarader? 6nkM CS. Vegetsom or fauna, ash 'or spedes. significant habads, or etreatenedw;TZ gered spedes? g;Z briefly. C4. A oommunily's edsting plans or goals as ofidasy adopted. ors change. M use a lo easily of use oP or Dater nalwd resources? Fxplakt brfelly. Cs. Growth. subsequent development, or related activities likely to a utduoed by the proposed action? E.,oaid briefly: C6. long term, start term, mmurative, of other effects not identified in Cl-CS? EWain bdeay: C7: Qthat knpaCffi cha in use of salter papa or type c(mwW 0. VNLL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABusWENT OF A CRITICAL ENVIRONMENTAL AREA 7 Q Yes Q No E. 18 THERE. OR IS THEME Y TQ - RELATED TO POTENTIA(. ADVERSE AL &W K . -O Yea [am PART IN-OET73IIHIM7 fdOF800MV11CEgobe0"ple6edtwA~ R187ia JOTtONSx FWeadtadvwaedfeatldet0WmboNa,deblttAnawhelfl6Tklati kf9e,WVwttaRtorotltenvFaesiagtilfk~Rf Eadt elAotsttordti be ewaeNed in Dora etft uM Ties W sa ft (I& abort or mg* go pmbdit etosourfYyF (Cl d m&K IQ imeveratl", (e) er~taf deWIQShW99iatdMW4rdmWmekmaddormbowNSWwWW OrreklaWaftgwA*@fnms eta Eneaeffid0fplarlW*9 otdWd yea gfedeierftl4ta6ortofsl~nlfbertoemuctevad pr>beatlaAkfpadaFMlePraposedaatlortea rid oflheCFA Chock 96boxIfyaftmf06d 0*;loneorawre powlsilivismeorN4tillk0tadVaraeyapadawifk MAYotxta-Then EAF arldlorpropao a positive dedlarasm. prodaeddkecaytotlte Check Mttc boa #yw4mvie4dermkmd, based on ate ktfa udm and analysts abase and terry allpporetig dopntrxda6m, that the proposed acft WILL NOT rests in ary sWOC&MN adverse en*wnental knpads AND provide, orattad mends as nece determktatim. scary, the reasons stPPorTm9 ati Board of Trustees p j e r l~ 2-0/7 Name /of Lead Agency Date Mp)ef President C Print or Type Name of Responsible O r ;n Lead Agency Title of Responsible Officer God Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM I PROPERTY LOCATION: SM.T.N.a: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A T . A ORADI AOE AND EROSION CONTROL PLAN ~lOl - S 0 -51ii-VEF -5--- iiiii -g gym- -TUt- C Y RO ONAL IN T STATE OP NEW YORK SCOPE OF WORK - PROPOSED CONSTRUCPION ITEM # / WORK ASSESSMENT Yes No ! a. What is the Total Area of the Project Parcels? i Will this Protect Retain All Storm-Wafer Rum-Off (Include Total Area ad Parsed boated within S Q Generated by a Two (2) Inch Rainfall on Site? the Scope of Work for Proposed Construction) (This item will include all run-o0 created by site (S F. r Ara) b. What Is the Total Area of Land Clearing Z2,5 clearing and/or construction activities as well as all j andfor Ground Disturbance for the proposed d2,r o Site Improvements and the permanent Creation of construction activity? Impervious Surfaces.) i (S.F.I AVma) 2 Does the Site Plan and/or Survey Show All Proposed ? PROVIDE BRIEF PROJECT DESCRIPTION (P,ada A,taimw P.s.r.,Nawae> Drainage Structures Indicating Size 8 Location? This L1 i Item shall Include all Proposed Grade Charges and ~0 YI O .E Slopes Controlling Surface Water Flow. L 3 Does the Site Plan and/or Survey describe the erosion ' T7 and sediment control practices that will be used to V lu{ control site erosion and storm water discharges. This j v SU/' Item must be maintained throughout the Entire I A . Construction Period. R?t A6e eyl- J 074 Will this Project Require any Land Filling, Grading or Excavation where there is a change to tie Natural yep u J,t O../' N Fisting Grade Involving more than 200 Cubic Yards of Material within any Parcel? 5 MI this Application Require Land Disturbing Activities ? / Encompassing an Area in Excess of Five Thousand (5,000 S.F.) Square Feet of Ground Surface? 6 is there a Natural Water Course Running through IM ? Site? Is this Project Within the Trustees jurisdiction general DEC SIAPPP ReoulrrrreMC: or within One Hundred (100') feet of a Wetland or Submission of a SWPPP Is required for all construction adiNaea iwaimg soil Beads? divurbenoaa of ono (t)ar mom saes; Irrd,dFg disturbances of loss man ore acre Met 7 Will there be Site preparation on Existing Grade Slopes I are pad of a lemorcomhron plan that wit ultimately disturb one ormore acres of land; which Exceed Fifteen (15) feet of Vertical Rise to induding construction activities Involving soli disturbances of leas then are (1) sae wiwre One Hundred (1(0') of Horizontal Distance? the DEC has detenrined Mo a SPDES permit is required for atom water discharges. ( SWPPP's Shalt moat the Minimum Requirements of the SPDES general Permit 8 Will Driveways, Parking Areas or other Impervious ? for Stoma Water Discharges from Construction acUvrb - Permit No. CIPA-10-0(1.) Surfaces be Sloped to Direct Storm-Water Run-Off 1. The SWPPP shall be prepared prior to the submidal of the NOL The Not shell be into and/or in the direction of a Town dght-of-way? sUbmdlod to the Department prior in the commencen got of construction activity. 2. me SWPPP shall dmaibe the amsiun and sediment control pmctbee and wham 9 Will this Project Require be Placement of Material, required, poet x nsbuaon store wlermenagenNm[ practices that WE be used endfor Removal of Vegetation andfor the Construction of any wnsWUtal to reduce the PoWlerne in storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder - complfancewimthetemaandcvnd0lomofthis permit. In addition. to SWPPP shall Aree?tihYe lWrsvrln NaTlrcido tie bumlamnmadre,Fpreml I identify Potential sources dpagulbn which mar, reasonably be eyected booed the NOTE rf krrY Mawrb Wrtlona OnatMOUgh MM iAnawa.drdma Chack Nara qually atom wet (WIN, , the posl 1n a eex and the mnsamc4sa aim diturbwrwa IN beisie r 8,000 a 1 Aga in err, on All SWPPPS that repa MC crostrudbn slam valor nrrwgemem Padlee a StomNWarr. Grading, Dmiosge A Erosion Control Plan Is Requited by the Torre or mponord shag be prepared by a quaNad Design Professional Licensed in New Yank that is knnovladgeeble in the pMClpM and pmtlkas of Sturm Water Managomont Southold anti Mort be Subnpbdtor Review Polo b haeNbe of Any ndlAng Permit (NOTE: AOrwk Mark (,I) erdir Amaw for vin oueOOn is Reakad fora LbnFRene AWSomeon) ! STATE OF NEW YORK, A/FSTC#fFST~, pp COUNVI' OF .........................::-SS That I, /'/7 • `ys being duly sworn, deposes and says drat he,/she is the applicant for Permit (Nano of Individual d0nkg Dooanent) . .......Oil..VAl'~....~ .........................1.4 --.r!9....... And that he/she is the L L- L E- ..(Orrter. Conapta. Ageal. Capaale Omeet. aloj Owner and/or representative of the Owner or Owners, and is duly authorized to periorni 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 befieF, and that the work will be perfomud in the manner set forth in the application filed herewith. Sworn to before rile this; ..............d of.........._ .20 Notary Public; ..JD A{ A.-R"So............. o Public State FORM - 06110 Quailfied in Dutchess County Certified in Westchester County No.01RU6225091 '1,1 My Commission Expires 07.19-20 _ B& of Trustees Application • County of&n€fakk- I/v~TC State of New York 1VlA- ALL s 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 AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signature of Property Owner SWORN TO BEFORE ME THIS 25- DAY OF ~ 120if i ublic JOHN A. RUSSO Notary Public, State of New York Qualified in Dutchess County Certified in Westchester County No. 01RU6225091 My Commission Expires 07.1940 i APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM i The Town of Southold's Code of Ethics prohibits conflicts of interest on the pmt of town officers and emn(ovees The nuroose of this form is to provide inforination which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: 4'I S~ ?4 (Last name, first name, /piddle 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.) I Tax grievance Building Variance Trustee - j Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning other (1f "Other", name the activity.) E/?G ~/?ILL Ltr9-T/ O 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 offices' or employee has even a partial ownership of (or employment by) a corporation - i ' in which the town officer or employee owns more than 5% of the shores. YES NO If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the'1'own of Srmlhold _ Title or position of that person i Describe the relationship between yourself (the applicant/agcol/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. I I The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): ~A) the owner of greater than 5% of the shares of the corporate stock of the applicant (when the applicant is a corporation); j B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a corporation); C) an officer, director, partner, or employee of the applicant; or ^D) the actual applicant. j DESCRivrioN OF RELATIONSHIP - ! I Submitted this day of 200 _ Signature. Print Name Form TS I 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 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 exi lained in detail. listine both supnortina and non supportine 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# D~ v o --~=a S- PROJECT NAME 0/2JFAlr- 19-e.2k7:5 Lt r Fdn/G,F- The Application has been submitted to (check appropriate response): Town Board ? Planning Board D 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) ? j (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: I Nature and extent of on: rI.1 ICA7Le¢ 401--Oit-4 /00,k-Drt9ArrJ~ ku s as /n01; L r Location of action: e/ r0 ~iito baaJ fei1l Ji ~ee- Site acreage: G `poi 7A/ t~,/'t t'. Present land use: ~ i 40 T+ s11.x- Present zoning classification: e o 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: EtIA- AV,4- L- 4-,' (b) Mailing address: 7S'e2 )0 2~-sT fyy~ , Ryi=, A/- y, 0 1'8 0 (c) Telephone number: Area Code l9x y Z> _ (o (p (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes El No 1 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 E] Not Applicable t' 'G e Zvi c r ' tau Attach addiu 1 sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III - Polici ages 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 L WRP Section III - Policies Pages 6 through 7 for evaluation criteria Yes ? No ? Not Applicable ZIP ;Ce"tiLs- wi e- o f S c. y o.oe n w p Aw u s H.% 7 A-0 Z A. D V !n- a AAX W JJ 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 U Not Applicable I I 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 [O Not Applicable i 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 evil natio riteria. ? ? Yes No /Not Appable • 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 [9Not 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 Not Applicable PUBLIC COAST POLICIES L 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. 1:1 YXJ No 1=--I Not Applicable I Attach additional sheets if necessary WORIONG 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 }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 171 No l 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 I~ Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III - Polic=Not 65 through 68 for evaluation criteria. ? Yes ? No pplicable PREPARED BY TITLE OR/,F_A7 A l2tU1_4CDATE SURVEY OF PROPERTY _ SITUATE: HAMLET OF ORIENT TOWN: SOUTHOLD SUFFOLK COUNTY, NEW YORK SUFFOLK GOUNTY TAX # 1000- 14-2-25 'S'S8 SURVEYED: MARGH II, 2008 ~2A REVISED: NOV. 5, 2008 "F<2 r CIEIEY=ll1'IlKD: ~^G~ l OR= ACRES LLC LOT b ' \ \ \ ~ .Y_ O ~66030,4 - - - J ~ - \ \ FF 2 {9c \ I\ p, Poe, Y( IEi F c -4i LOT l 'All ~ s V F \ !~u k 'oRW ~e ~ I V~ 5tl _ mss _ )rl k~ O ti aroa~v i waY ('9 LOT 8 iy r Y ~Q Fa u,,Fi~ 9 0 N ~p Z Op U y~ N ry \+1 O 0 u^9 T~ ° I_oT a e,21 U J r ti J] U Q Q ~ nor io 00 9 2 a~ z oa No fs7ggiplsn3 ~ Q ~ 31V410S d0 Nmo, al d0 4av AObddV U~i 1 ~ s, 6le) ~ cal! 4e a~~es Vill/ JJ Z../ y~ .aas 1;. eo 1p aMal pia~~llan ti. e~az [ a d3s m J Q a3A1 a a r, m ~t e ~ T ;h• O E ~ V /H O d T 0 b~ e t~ 8 0~ y ~ a J pal 1 - ~ dl P~Pos{®[ Fence - a rwl , s ra7l OF NEW Y d it Notes: ¦ MONUMENT FOUND 0 PIPE FOUND JOHN C. EHLERS LAND SURVEYOR Area = 422,214 5. F. 50- 6 EAST MAIN STREET N.Y.S. LIC. NO. 50202 RIVERHEAD, N.Y. 11901 ( Area = q.6g2-1 Acres GRAPHIG 5&f-ALE 150' 0 5(0 100 150 150 369-8288 Fax 369-8287