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HomeMy WebLinkAboutTR-8306A James F. King, President ~g1lff0!¢ Town Hall, 53095 Main Rd Bob Ghosio, Jr., Vice-President h~4 lly P.O. Box 1179 Dave Bergen Southold, NY 11971 0 John Bredemeyer y~ Telephone (631) 765-1892 Michael J. Domino ~Ol 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 tat day of construction _ % constructed Project complete, compliance inspection James F. King, President ~a0f SO(/Ty~ Town Hall Annex Bob Ghosio, Jr., Vice-President lQ 54375 Main Road y P.O. Box 1179 Dave Bergen Southold, New York 11971-0959 John Bredemeyer A C Michael J. Domino 1 Telephone (631) 765-1592 lyFax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8306A Date of Receipt of Application: September 9, 2013 Applicant: Denise & James Martin SCTM#: 123-4-11 Project Location: 2740 Deep Hole Drive, Mattituck Date of Resolution/Issuance: October 16, 2013 Date of Expiration: October 16, 2015 Reviewed by: Board of Trustees Project Description: For a (10) Ten Year Maintenance Permit to hand-cut the Common Reed (Phragmites australis) to not less than 12" in height on an as needed basis. 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 Kathleen Neumann, received on September 9, 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. )Xo"~ 0. '~5r James F. King, President Board of Trustees Denise & James Martin 2740 Deep Hole Drive, Mattituck SCTM# 123-4-11 10/9/13 c x,~ I f ~d Job L - ~Y - e F SURVEY OF PROPERTY SITUATe MATTITUCK TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK DEEP HOLE DRIVE S.C. TAX No. 1000-723-04-11 S 83'2D'a0_E SCALE 1"=30' 21.12 R=1 4].35" . DECEMBER 9, 2010 N: a xo ut aaos o oJSE FOR FITT r... FRANNA ;A Am, 25 L?60 89 ' u rvlwr 5[ oae ro' 10AS1IINLAI STAR o e o ~l. N. AI. 1 IN P71 TOTAL LOT /ARE1 93 746 39. 11. L Uo IN LINO 1119 oc- o 11LA11 ,RE.L _ 66.610 W av 1 So 1 N C4R \ N. Eruxo A, = e. , . 1. Q' - 2. 5 11 moo: .YESES: RE q I • 1 1. FLE'DD ZONE XrORONN TAKEN ITROM: VRANCF RATE e. 361011OAI WAR :ib 'I R 1 \ -1 1,00 : N:,A, A...R." ZOU_ ~I 11 1 OASIAL iL All R LE p"ERS' (AN' ITT Ou. x~Nr 5 CnY 1. E. ENE uw[0 RI Oc ¢ P E R RN wI o1;rr.s o~ Less N. ,II k5 Y EA ,ti wNA:,A Niz Lis q ZONE NoO SERIES PROTECTED - oLLAEA 1 Lxz .,.,u 1-11 u~ow.-. 1 1 C£R J EP_L e/ N` \ AMES P. MARTIN Y y,~C _ _ DENISE N. MARTIN 4' FIDELITY NATIONAL TRLE INSURANCE COMPANY \11 1 TITLE No. 10-9,104-90114-SUFF 5 1 1 9W \ 4Y 4' ~QE _IV E~ SEP - g J ti ~ 1R ` aa. E 4 Lµ. i.16 8 t _ SEPP/C SYS E tlE L..NC£e -11 w.., ' x TIRE II TIRE I 1. No A, (9 No, nT oo - aR6 W" 1 i r_ a ER ' IT IS. (~i " ~ do Y';v ~115T I IN, I", 7 N \ im . \\\\,S JS Ya 14' g]B OA S 55•33'4e" wr AN, Ef' HALF CjP;F VII I AN INSU .w ypF'~:. -Al Nathan Taft Corwin III Land Surveyor 11 111 ALI., -1 1. 11 TI I AS I'l, IF, A 'R I IT OERE / 3 ,_x190... _ _ _ _n.. N.EI.,, Al NIA 1E Lr l'A ....IN A ALA _ 1" -1 ,NR,. IT .R1 4 .nLR 1-1 11 gyFFO( James F. King, President P.O. Box 1179 Bob Ghosio,.lr, Vice-President y Southold. NY 11971 Dave Bergen ? Telephone (631 765-1892 John Bredemcyer T Fax(631)765-6641 Michael .1. Domino y `F Southold Town Board of Trustees Field InspectionMork Session Report Date/Time: /0- / - /3 Kathleen Neumann on behalf of DENISE & JAMES MARTIN requests an Administrative Permit for a (10) Ten Year Maintenance Permit to hand-cut the Common Reed (Phragmites australis) to not less than 12" in height on an as needed basis. Located: 2740 Deep Hole Drive, Mattituck. SCTM# 123-4-11 Type of area to be impacted: -Saltwater Wetland -Freshwater Wetland -Sound -Bay Dis nce of proposed work to edge of wetland Part of Town Code proposed work falls under: _Chapt.275 ChaA5t. 111 -other Type of Application./ - Wetland -Coastal Erosion -Amendment _Administrative_Emergency-Pre-Submission Violation Info needed: Modifications: Conditions: Press Were: J. V, : g /B. Ghosio D. Bergen, !J. Bredemeyer_ _ Michael Domino D. Dzenkowski other Form fille utjn th f1 J by Mailed/Faxed to: _ Date: 7 le t~AT-WUII- J I w ~c, n S (11s fil,c~ ~u- nG (c c.'Z r FSEP d I~a ~ 1 d y 1y - TArI<Pn-u~u1~ -~AUY>7[ T 010 4wfe, Ere cti. ~,I tips, Ic~~~~ LXn~~,e~~a. a1 C ~ ~ 11 II nT lLeo-) Bar r w -47 S'OJT k- ~ ~ ~F~? ~ c;~. ~ ~ pew ~ yi ~ ~ ~ f ne L h,JJI W' ld" WdA- Ilk ~ r t Y I,~, ~ rl I a y~ qqIt y 3 ' J ~1 E ~ V'~` d nr ~~l r4a 9~ I ~ i t Yv4Y~ ~ y~~~ ~Strtb~ le rte p r ~d , ii u, r 6; a r 9.''.~,~ r v , 1)~l, yr V I ~ f.i p , r. ,.gy S t { ~J. 1~ Yn -~i Yy 11 G ~f .r v ~ ~ t t'. ~ i , Al {~r ! ~ ~4~ r •s,'~14A itl J ~ v+ aF`;1 ` s rl s V ~r~~, S ri ~~i ,v a,~r 1~'l tTf~ taw r~ V Sid >I~fi' y fv ~r. b , M a1~~ 1 i~l , p ? ,y (l. ' S/sRrirry~~, It le~: ~ s4gi~~~ r~, G 7~P~ ~•'~t 1. i~ 4~~~}^~i.,~ d { ~ I' , v ~y ~`a~~~~'+'f t r "'4. ~,~fr~ \~Ft~, yu~t~n l-inf. ~'SL~~~ 1 { ' ! 1 / I 1 ~)7 I ~i"\ IVC,I E- 110-1 ~ ~t .t ~ir~~Lv, (I G„CC LSt clC-/ um y i ry nsa ~ • + .u + d a _wa ~ n ~ ,o.aw wn Ewa ,mm a q f f a `x. 0 ~ I ~ f 1 ~V ? y, ~ a,. ? w ,lw pe . ice/ • ~ M • a a r w .v+ ~ FA T~ _i' a `y r i. © GD~~- 0 :rte f r ~ _ i' rr D. f 1 r ~ i C • /s i Dr ~ COUH OFMMMK ® _ on,m cTwx 0-- -__s _ ~ RrlPgpwty TU Semw Ke~K`Y e OFFICE LOCATION: ~~OF $vuryo MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 * Southold, NY 11971 (cor. Main Rd. & Youngs Ave.) Q Telephone: 631 765-1938 Southold, NY 11971 co iZ3 Fax: 631765-3136 OOUNi I I LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM F._I_V. ~ OCT 1 5 2013 ID To: Jim King, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: October 15, 2013 Re: LWRP Coastal Consistency Review for DENISE & JAMES MARTIN SCTM#1000-123-4-11 Kathleen Neumann on behalf of DENISE & JAMES MARTIN requests an Administrative Permit for a (10) Ten Year Maintenance Permit to hand-cut the Common Reed (Phragmites australis) to not less than 12" in height on an as needed basis. Located: 2740 Deep Hole Drive, Mattituck. SCTM# 123-4- 11 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed actions are CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney James F. King, President • ISO pry ~ Town Hall Annex Bob Ghosio, Jr., Vice-President 54375 Main Road P.O. Box 1179 Dave Bergen l~ * Southold, New York 11971-0959 John Bredemeyer CA Q ~p Telephone (631) 765-1892 Michael J. Domino r7 Fax (631) 765-6641 OOUNTI, BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only -Coastal Erosion Permit Application -Wetland Permit Application Administrative Permit Amendment/Tr / tension DGe f~VlS e S`S eceived Application: IV D 4Received Fee:$ ompleted Application 3 SEP 9 ZQ~3 -Incomplete _SEQRA Classification: Type IType II_Unlisted _ oordination:(datc sent) oulh d own LWRP Consistency AssesBment Form e - CAC Referral Sent Date of Inspection: .3 Receipt of CAC Report: Lead Agency Determination: Technical Review: Held Public Hearing : 1~3 Resolution: - R I Se, 11 It Name of Applicant M ' n nq -jq b Mailing Address (j 1 ac k N 1 1 I W)_Phone Number:((?t) 8- l y Suffolk County Tax Map Number: 1000 - 12 S - - 1 Property Location: 1.k:g&0<A P 'CV% V e,~ x (provide LILCO Pole distance toy cross streets, and location) AGENT:- 1j 1 wM0.ncl (If applicable) Address: 'C1 L~ l~~ h l~ Phone: l D 1 V rd of Trustees Applicatiob GENERAL DATA Land Area (in square feet): 2 1p S~ Area Zoning: Z- 40 Previous use of property: 1C S1.Si ~M Intended use of property: Covenants and Restrictions on property? Yes _X 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 req ire 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: 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): /v Uedz~ R/n`-C4, Cn C,~- fijd, m, f ~S lj eC~c~e~ (Y Bo of Trustees Application • WETLAND/TRUSTEE LANDS APPLICATION DATA M h~ Purpose of the proposed operations: C' f S (1 Area of wetlands on lot: C.0 ~J -0 square feet Percent coverage of lot-1-0/0 Closest distance between nearest existing structure and upland edge of wetlands: S-5 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? y A cubic yards How much material will be filled?_ N__cubic yards C Depth of which material will be removed or deposited: 2 feet J Proposed slope throughout the area of operations: °l d-k Manner in which material will be removed or deposited: 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): 617.20 FROJECT ID NUMBER • PENDI • SEAR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 • PROJECT INFORMATION ( To be completed by Applicant or Project Sponsor) 1. APPLICANT / SPONSOR 2. PROJECT NAME 3.PROJECT LOCATION: - 1- 1 Municipality kA~ tT~C.L County 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map Z-7 q0 l`7QJO~p eke '0C, l, 5. IS PROPOSED ACTION: ? New Expansion Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: , Initially acres Ultimately acres 6~. ~WIL~/L PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? 7V es ? No If no, describe briefly: 19. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) 14 Residential 0Industrial ? 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 ?No If yes, list agency name and permit / approval: OA5yec PERMIT O APPROVAL? _TT_DOES_ ~ ~Y~VLQI U~ 111t ACTION HAVE A CURRENTLY VALID ?Yes No If yes, list agency name and permit / approval: 12, AS A ESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? ass No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor N me Date: Signature 6al- v'L W1.5 If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART It - IMPACT ASSESSMENT o be Completed b Lead' Agencyl A, GOES AC11 EXCEED ANY TYPE f TNRESHgD IN 6 NYCRR, PART 61T.47 H yes. ommlitude the review prooass and use the FULL EAF. ? Yes Q No S. W(t t, %4CTTON RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRP, PART 617.6? It No, a negative dada luaw may be superseded by another krvoved agency. . Yes © No C_ COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED VWM THE FOULOVMG: (Answers may be handwritten, If legible) . C7. Exissm air glaaty. surface or wourldwater quality or quantity. nose levels, mdstiog balGC pollens said waste pmducbn or disposal, potential tar emsim dwhage of lkodkg problems? Expleh blleay. C2 Aestlletl4 agrbuttks+i, aldaaalopler4, or atlhar nahsatnradbxal reaMaaes; of or charadeN 6q" C3. Vegetation of fish, 'or swedes. Qgdfaad habitats. or dwedeneda endangered species? E>rptaln briefly: C4. A eorrmxmity's edslkg plans or goals as y adopted. a a-dm W-1n use or endy of use of nd nr other n durat resources? Explain bdelfy. C5. Growth. 4ubsequenl development; or related activities likely lo' be induced by the proposed action? Explain briefly. C6. Long, lens. stwd lam, cumulative, or other effects not identified' in C1-C57 Explain briefly: C7: Claw aebl 22g2ft change h use of either Quantity or type of energy? O. VALL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL EMMONMENTALAREA ? OYes ON- E. ISTHOW-ORIS YTCT RQ.ATBOTOPOTENnAL ALIMP 4(mewtvin: Yes Q No . PART IM - DeTsumiATM OF SMROANOE (To be aallpleled by gge rico tis18T>>MlOZ10f/8s FofaahadvrLaeaRaatiden9fledaboae debfffLNlewlleglaritlasWtbatlal lei9e,kflpmMK(WagLeavlMSIatlMOWt ESdt efsotahouNl bs sues9e m(ed~^bpealttaaB,gn wigs Me (s) salMllg (Le. wfwfl a LulaQ: (b) PlobedfMi{Y t>f t>oamYl~ QcI dulaMaC illaeefabipb: (e) >tldMOlNkdetlMbilwlnalR~llbYpMid r add 8M8dvnmft ofae{blMleesuppoift Ale 1 11" Enitimthat NQfIMIIMoflb corAlyl_ kll a*havebowk1loo fwd and ade"*11yedclemoved. If*m loaddPadMwaadield ed yes, thede0aLm11laMaL afabLLMbulee rtwatevrMLadellLe pobMid kllpadafMlaplvposedac6oll enMroemAaofilLellglldtraablteMos afgte CFA CladlMbbOgWynnbiNSW NMWOtganarePOWnl iylatpaorsWMIcK dko*jolheFULI le aw ardor pspsre s posit dederaPon. Clock bat Myoulmvadelommiked, based all the kdalmafiw and almlysb above and any slppol" dom m itatiM 8mt the pmposed acft WILL. NOT resit in any sigriicard adverse M*mmwntal knpacts AND provide, on' altacimlelds as necessary, the reasons suppor6ry . delertnkhadon. Board of Trustees p Q~T L/ ZD /3 Name of Lead Agency Date V)sq H1 hr- f A' X/ ~J6- President t7 P" or_ Type Name of R~e/sponsible Officer in Lead Agency Title of Responsible Office, 0o, 0911"Zt Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M.fi THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A '4( y0'r 1 ~~'~7~ QL-{ STORM-WATER. GRADING, DRAINAGE AND EROSION CONTROL PLAN F' "S.cBon ~I""Gx It CERTIFIED BY A DESIGN PROFESSH)NAL N 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? (Include Total Area of all Parcels located within Will this Project Retain All Inch Rainfall on Generated by a Two (2') Inch Rainfall on Site? ? the Scope of Work for Proposed Construction) 121 hLL0-9 (s.r. r Aces) (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 Greund Disturbance for the proposed Site Improvements and the permanent creation of construction activita- Impervious surfaces.) ~IIOC" (S.F. / Agas) PROVIDE B WirROJECT DESCRB'IIO tPierNe Aampahr Petee n nerdwl 2 Does the Site Plan and/or Survey Show All Proposed _ Drainage Structures Indicating Size & Location? This Item shall include all Proposed Grade Changes and Q/ Slopes Controlling Surface Water Flow. LC/ $ Does the Site Plan and/or Survey describe the erosion N r~ c,n ~j p, 'C' 7tP.~,~i„( and sediment control practices that will be used to conbd she erosion and storm Water discharges. This hem must be maintained throughout Sre Entire Construction Period. 4 Will this Project Require any Land Filling, Grading or Excavation where there is a change to the Natural ? Existing Grade Involving more than 200 Cubic Yards of Material within any Parcel? rj Will 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 the ? Site? Is this Project within the Trustees jurisdiction x, General DEC SWPPP Requirements: or within One Hundred (1 DO') feet of a Wetland or Submission of a SWPPP is required for all Construction ac Miss involving soil Beach? disturbances of one (t) or mom arms; Including disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes am pan of a larger cannon pan that will ultimately disturb one or rnom aces of land; which Exceed Fifteen (15) feet of Vertical Rise to ? K Including Construction activities involving soil disturbances of less than one (1) acre where One Hundred (100') of Horizontal Distance? the DEC has determined that a SPDES permit Is required for slam water discharges. ( SWPPP'e Shall meet the Minimum Requlmmnds of that SPDES General Parrett 8 Will Driveways, Parking Areas or other Impervious for Storm War Diseherges from Construction so" - Permit No. GP.0.10-001.) Surfaces be Sloped to Direct Storm-Water Run-Off ? 1. The SwPPP chat be Papered Prior to this suMaOa Of the Not. The Nis anal be into and?or In the direction of a Town right-of-way? submitted to the Department prior to ram camhencannenl of construction activity. 2. The SWPPP shW describe the emakhn and sadknem control Practices and Wiens 9 Will this Project Require the Placement of Materiel, required, post-construction stem water management practices that will be used anOla Removal of Vegetation and/or the Construction of any conabucted to reduce the Pollutants In storm water discharges and to seem Item Within the Town Rightof--Way or Road Shoulder compliance with the coma and conditions of this penmen. In addition, Me SWPPP shall Areal (htr lam Mn Nor p,wpud, raw b.wprhw, elhxh.aay Awww.l identify potential sources of pollution which may reasonably be expected to affect the quality of storm water discharges. NOTE: If Any Meurer to Questions Om through Nine is Answered wBh a Cheek Mark 3. Al SWPPPs that require the p st-odnsbuclbn sbrm water management practice In a Box and the construction sib disturbance Is between 5,000 S.F. a 1 Aura in nee, component shell be prepared by a gwNOed Design Professional Licensed in Nev, York a Stom-Wrar, Grading, Drainage a Erosion Control Plan Is Required by on Town of that Is knowledgeable In Its prindpes and practlcas of Stone Water Management Southold and Must be Submitted for Review Prior to Issuance of Any SuIMbg Pa re t (NOTE: AChrk Ma*(.f) aM/a Amex Maedhawmma RepYed fora C,gft Ppplkalim) STATE OF NEW YORK, COUNTY OF 5. SS That 1, A-e.#'. . of 1.!! /?7 "f being duly sworn, deposes and says that he/she is the applicant for Permit, (Name of iriaVwd a Doaiment) And that he/she is the (Qwwr, Coneapor. eel, Coparete Olflcer, Na) 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 ht9 before me this; zz ~....2 ..................11.n^........ day of `10.. ~.J Notary Public:.....`..y...)~J' MEU1t9E V. w1mk C! 3 ~IDt fy mull k SIW of NSY/ Ph 49MIR (Spgnaturaf Appicant) FORM - 06/10 tad in SulbAl Ot11R1y t;vmr ilia) l Ey#n Od.19, 2_,2) -7 Bo* of Trustees Application • County of Suffolk State of New York DZnks" 0my * k n 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__ '7_DAY OF ,20 Notary Public kftw V. Mom NdvY R60. &W of thw Yak ?b.49WI2 Q dhd b fiulbk County ow""mBON OCL ts, -m 1-7 Bod of Trustees Application • AUTHORIZATION (where the applicant is not the owner) IOS fAecjoj 13(u <'r 1 ^ t \ property) residing at pnnt owner r of propeerty) (mailing address)f 11 ' (9 S L do hereby authorize- 1 11 ~ o lM L (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. `s^ ~I N~-- (Owner's signature) APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Towrt of S th Id' Code of Ethics prohibits conflicts of interest on the part of town officers and employees The purpose of this form is to provide information which can alert the town of poasible conflicts of interest and allow it to take whatever action is nceemarv to avoid same.`\ YOUR NAME: Q Q.I.) r1l~Glin Y CA Q I S?i " (Last name, first name, ipiddle 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 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 Print Name Form TS I Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS I. All applicants for per mits* 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 supporline 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. IE: V B. DESCRIPTI ON OF SITE AND PROPOSED ACTION SCTM# JQ~Z-I 9 2013 PROJECT NAME The Application has been submitted to (check appropriate response): Town Board ? Planning Board El Building Dept. E] 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: C-~h(~Qc "t Location of action: !DQL,40 A a2 Ty k I j~ Site acreage: Present land use:_ al Present zoning classification: AL- 40 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be pgrov~iided: \ (a) Name of applicant: ,yIL V (Y~o n r~ (b) Mailing address: 214C) -DQ is D fko Dr. Ua'J'-"i~UL (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 ? If yes, which state or federal agency? -DC. 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 IJW kee e-,., - 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 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 S through 16 for evaluation criteria Yes ? No ? Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section HI - Policies Pages 16 through 21 for evaluation criteria Yes ? No ? Not Applicable N:.A,Q n4.faP,-,~ TT 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. F-1 7 Yes No Not Apple • o. 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. 01Yes ? NooNot 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. ocki Yes El No Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation criteria. ? YeO No~ Not 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 LW" Section III Policies; Pages 47 through 56 for evaluation criteria. ? Yes ? No VNot 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. ZYes ? No ? 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 ? NogNot 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 i PREPARED BY "h [~'~a( LP- h ~ TITLE ~ ~ ~ DATE_46~3 CITE DATA L!J ~EN ns o. ~mXw.m. ff rnmX, E.: m m O ~n a X _ Y! r 1t ExE '~RIY~IO~K . MUN.. O' REE OE N~ L ~ ~ ~ yX.M ~ SVXVEYOP= X.MnT~ICOrnFIY pp~X~1111 1 _ \\W 4 0 Nl niEmnN~uw°unXY 11M W UEENS. 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