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HomeMy WebLinkAboutTR-8323A John M. Bredemeyer III, President �O�k S�UjyOlO Town Hall Annex Michael J. Domino,Vice-President 54375 Main RoadP.O.Box 1179 James F.King,Trustee Southold,New York 11971-0959 Dave Bergen,Trustee G Q Charles J.Sanders,Trustee Telephone(631) 765-1892 �IiYCOU � Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1054C Date: October 8, 2014 THIS CERTIFIES that the replacement of the decking and railings on the existing ±34'2"x11'9"deck At 2125 Pine Tree Road, Cutchogue,New York Suffolk County Tax Map#98-1-13 Conforms to the application for a Trustees Permit heretofore filed in this office Dated October 29, 2013 pursuant to which Trustees Administrative Permit#8323A Dated November 13, 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 replacement of the decking and railings on the existing±34'2"xl 1'9" deck. The certificate is issued to ESTHER MATELLI owner of the aforesaid property. Off"` Authorized Signature John M. Bredemeyer 111, PresidentO�OgQFFU(,f CO Town Hall,53095 Main Rd_ Michael J. Domino,Vice-President P.O. Box 1179 o � James F. King y Southold,NY 11971 x Dave Bergen a Telephone(63 t)765-1892 Charles J_Sanders y�01 � Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE F INSPECTION: ( � 65-( l`{ Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction %Z constructed Project complete, compliance inspection. will INSPECTED BY: 1� ��r e re-cnwe L Per Owhe.( COMMENTS: AQ CERTIFICATE OF COMPLIANCE: _ James F. King, President ~pp1~ Town Hall, 53095 Main Rd. Bob Ghosio, Jr., Vice-President P.O. Box 1179 Dave Bergen Southold, NY 11971 John Bredemeyer °yo Telephone (631) 765-1992 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 1s' day of construction %constructed Project complete, compliance inspection James F. King, President ok *OF SOUjyol Town 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 ,~j • ~O Telephone (631) 765-1892 Michael J. Domino O Fax (631) 765-6641 ~'~OOUMV BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8323A Date of Receipt of Application: October 29, 2013 Applicant: Esther Matelli SCTM#: 98-1-13 Project Location: 2125 Pine Tree Road, Cutchogue Date of Resolution/Issuance: November 13, 2013 Date of Expiration: November 13, 2015 Reviewed by: Trustee Dave Bergen Project Description: To replace the decking and railings on the existing 34'2"x11'9" deck; and to remove one tree located within the existing deck. 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 submitted by Esther Matelli, received on October 29, 2013, and stamped approved on November 13, 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. /Pgpl" cz'~5r James F. King, President Board of Trustees ~gUFfOZ c lames F. Kin., President Bob Ghosio. Vice-President Southold, NY 11971 Dave Bergen gen ? John Bredemeyer Telephone (631 765-1892 ; Michael J_ Domino O Fax (631) 765-6641 y~01 ~ ,#,DOp Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: ( r a ESTHER MATELLI requests an Administrative Permit to replace the decking and railings on the existing +/-34'2"x11'9" deck; and to remove one tree located within the existing deck. Located: 2125 Pine Tree Road, Cutchogue. SCTM# 98-1-13 Type of area to be impacted: -L,Baltwater 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 ~dministrative_EmergencyPre-Submission Violation Info needed: Modifications: Conditions: Present Were: J. King _B. Ghosio 1 D. Bergen, _J. Bredemeyer Michael Domino D. 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Irk 11 x Su. p 1,ik `~t~f 11' ulr i. _ - N r ~ ~ ~ ~ J "!A, ,.'q`ty ~~ti ; M ~ ~ l'r ~ 1 J Ago* L~1. ~ f. T7 Ti271f, arf~_27 ~ *[_..n 9r~ Srf. ,nTi R Z~ t~ w r,WY v -27 4%, i o.owx, ea PY " %6tR>4eb4~9va VC, ur Ow +.wv 13" rd: P e v~~~S , ^ ° p • N j~ ~ ~I ~O e m o Yp ro f rc. ro.~a i tr e Y m, Y ~m I j pl~ 14 i ~yy I V C ~WV 0 Y' OOUNtt OF SUFFOLK © o wnm ssrnax xo OFFICE LOCATION: 16 SOUjyOI MAILING ADDRESS: Town Hall Annex O P.O. Box 1179 54375 State Route 25 l~ Southold, NY 11971 (cor. Main Rd. & Youngs Ave.) H NY 11971 Telephone: 631 765-1938 Q Southold, Fax: 631765-3136 OOUN% LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Jim King, President Town of Southold Board of Trustees NOV - 7 2013 From: Mark Terry, Principal Planner ,y LWRP Coordinator Date: November 6, 2013 Re: LWRP Coastal Consistency Review for ESTHER MATELLI SCTM#1000-98-1-13 ESTHER MATELLI requests an Administrative Permit to replace the decking and railings on the existing +/-34'2"x11'9" deck; and to remove one tree located within the existing deck. Located: 2125 Pine Tree Road, Cutchogue. SCTM# 98-1-13 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 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 "B" which states: B. Replacement, rehabilitation or reconstruction of a structure or facility, in kind, on the same site (inplace), including upgrading buildings to meet building or fire codes, except for structures in areas designated by the Coastal Erosion Hazard Area (CEHA) law where structures may not be replaced, rehabilitated or reconstructed without a permit and shoreline erosion control structures (including, but not limited to, groins, jetties, bulkheads, filled piers) located within Great Peconic Bay, Cutchogue Harbor, Little Peconic Bay, Hog Neck Bay, Noyack Bay, Southold Bay, Shelter Island Sound, Pipes Cove, Orient Harbor, Gardiners Bay, Long Island Sound, Fishers Island Sound and Block Island Sound (excluding all creeks); The proposed action(s) are not located within the CEHA. 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 0 James F. King, President at SUl/Town Hall Annex Bob Ghosio, Jr., Vice-President 54375 Main Road P.O. Box 1179 Dave Bergen l~I # Southold, New York 11971-0959 John Bredemeyer COO Michael J. Domino Telephone (631) 765-1892 O~~COU' Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD I Office Use Only I~ 1 o q ,z -Coastal Erosion Permit Application -Wetland Permit Application )L_ Administrative Permit D Amendment/Transfer/Extension u u Received Application: LOC 9 Received Fee:$ Completed Application Soutj' i7 icwn -Incomplete SEQRA Classification: tees Type IType IIUnlisted Coordination:(date sent) TLWRP Consistency Assessment Form 1 I -CAC Referral Sent: YDate of Inspection: I / -Receipt of CAC Report: Lead Agency Determination: Technical Review: r Public Hearing Held: 11 13 I -Resolution: Name of Applicant r Ac c 6i Mailing Address ~1 a- 0 R 3~ 4*P, FWS~1 t tl y /J 3Sg Phone Number:( Suffolk County Tax Map Number: 1000 - 9 8 ( 3 Property Location: 2l S i, e 'Frc G Ito C v+(A o g o e, (provide LILCO Pole distance to cross streets, and location) AGENT: (If applicable) Address: Phone: Wd of Trustees Applicatio* 7 GENERAL DATA Land Area (in square feet): - t~ I * S r. Area Zoning: r t° St 8 e- x1 l at 1 Previous use of property: Intended use of property: Covenants and Restrictions on property? Yes No If "Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes No If "Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes 2S 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.? X Yes No Does the structure (s) on property have a valid Certificate of Occupancy? -X -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: I IC 1 I ) Project Description (use attachments if necessary): bQ LoO& d e cA< (3L4 r`p "e -Y [oo ~eM oV e -~ree. ti, Qetrnoyo~ ain.c~ rq61r-- /JO Boa of Trustees Application • WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: ~J O d square feet Percent coverage of lot:--q-(/)O Closest distance between nearest existing structure and upland edge of wetlands: ct o feet Closest distance between nearest proposed structure and upland edge of wetlands: O' feet Does the project involve excavation or filling? X No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? MA 10 cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: er4 ' 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): ~oru>? 61220 Appendix B Short Environmental Assessment Form Instructions for Completing Part I - Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding, are subject to public review, and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item, please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency; attach additional pages as necessary to supplement any item. Part 1 - Project and Sponsor Information Name of Action or Project p~ry~ 0 t/ e!.- r 4e4110lC, Apor,2,4 rails 0'r~ T eh`s-kri dccA k&p)etc_e_ s&we, corvrf 4,t _X0 Project Location (describe, and attach a location map): oil a s P .tax 12~Q N j 9 35- Brief Description of Proposed Action- L 'rte- Name of Applicant or Sponsor: Telephone: uJ 1, 1t~~I Ul E-Mail: Address: I ~;L-D ?2d. City/PO: Stale: Zip Code: him hen Iv 1~ 113sf 1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance, NO YES administrative rule, or regulation? If Yes, attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no, continue to question 2. IN 11 2. Does the proposed action require a permit, approval or funding from any other governmental Agency? NO YES If Yes, list agency(s) name and permit or approval: f"Rr ? 3.a. Total acreage of the site of the proposed action? i to V acres b. Total acreage to be physically disturbed? O acres c. Total acreage (project site and any contiguous properties) owned or controlled by the applicant or project sponsor? . 6 V acres 4. Check all land uses that occur on, adjoining and near the proposed action. .r~ []Urban ?Rural(non-agriculture) []Industrial []Commercial RrdResidential(suburban) []Forest []Agriculture []Aquatic ?Other(specify): ? Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ? IL-N-1 El b. Consistent with the adopted comprehensive plan? ? ? ? 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ? 7. Is the site of the proposed action located in, or does it adjoin, a state listed Critical Environmental Area? NO YES If Yes, identify: [XI ? 8. a. Will the proposed action result in a substantial increase in traffic above present levels? NO YES © ? b. Are public transportation service(s) available at or near the site of the proposed action? ? c. Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 5(1 ? 9. Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements, describe design features and technologies: 11 Pyl 10. Will the proposed action connect to an existing public/private water supply? NO YES If No, describe method for providing potable water: ~ ? 11. Will the proposed action connect to existing wastewater utilities? NO YES If No, describe method for providing wastewater treatment: ? 12. a. Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? [ij ? b. Is the proposed action located in an archeological sensitive area? ? 13. a. Does any portion of the site of the proposed action, or lands adjoining the proposed action, contain NO YES wetlands or other waterbodies regulated by a federal, state or local agency? b. Would the proposed action physically alter, or encroach into, any existing wetland or waterbody? © ? If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply: (gShoreline ?Forest ?Agricultural/grasslands ?Earlymid-successional (,'Wetland ?Urban ?Suburban 15. Does the site of the proposed action contain any species of animal, or associated habitats, listed NO YES by the State or Federal government as threatened or endangered? [2111 El 16. Is the project site located in the 100 year flood plain? NO YES 17. Will the proposed action create storm water discharge, either from point or non-point sources? NO YES If Yes, a. Will storm water discharges flow to adjacent properties? ? NO ?YES 12 ? b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)? If Yes, briefly describe: EJNO AYES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids (e.g. retention pond, waste lagoon, dam)? If Yes, explain purpose and size: [xf ? 19. Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes, describe: ? 20. Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or NO YES completed) for hazardous waste? If Yes, describe: ® ? I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/spon;ornyme: Date: /DAs/~ „J Signature: GGos/Lll~_~ Part 2 - Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept "Have my responses been reasonable considering the scale and context of the proposed action?" No, or Moderate small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning © ? regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? F\71 ? 3. Will the proposed action impair the character or quality of the existing community? ~ ? 4. Will the proposed action have an impact on the environmental characteristics that caused the ® ? establishment of a Critical Environmental Area (CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ? affect existing infrastructure for mass transit, biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ? reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a. public / private water supplies? b. public / private wastewater treatment utilities? r_J 8. Will the proposed action impair the character or quality of important historic, archaeological, I ~/1 ? architectural or aesthetic resources? ~J 9. Will the proposed action result in an adverse change to natural resources (e.g., wetlands, ? waterbodies, groundwater, air quality, flora and fauna)? Page 3 of 4 No, or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion, flooding or drainage ? problems? 11. Will the proposed action create a hazard to environmental resources or human health? El Part 3 -Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered "moderate to large impact may occur", or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact, please complete Part 3. Part 3 should, in sufficient detail, identify the impact, including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant. Each potential impact should be assessed considering its setting, probability of occurring, duration, irreversibility, geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts. Check this box if you have determined, based on the information and analysis above, and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined, based on the information and analysis above, and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold - Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from Responsible Officer) PRINT Page 4 of 4 • • Op Town of Southold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M[A.- THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A - STORM-WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN 'Samar ~ CERTIFIED BY A DESIGN PROFESSIONAL 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? 1 Will this Project Retain All Storm-Water Ri eEl (Include Total Area of all Parcels located within Generated by a Tiro (2e) Inch Rainfall on Site? the Scope of Work for Proposed Construction) (S.F. I Acres) (This Item will include all runoff created Ii 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 She Improvements and the permanent creation of Constmdion activity? impervious surfaces.) (SF. I Acres) 2 Does the Site Plan and/or Survey Show All Proposed PROVIDE BRIEF PROJECT DESCRIPTION (PpovN. Addtlonrl Papas WMe Drainage Structures Indicating Size & Location? This 9 - t~ Item shall include all Proposed Grade Changes and - Slopes Controlling Surface Water Flow. 3 Does the Site Plan and/or Survey describe the erosion and sediment Control practices that will be used to Control site erosion and storm water discharges. This Er i Item must be maintained throughout the 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 General DEC SwPPP Requirements: or within One Hundred (109) feet of a Welland or Submission of a SWPPP is required for as Construction acOWlles involving sag Beach? disturbances of one (1) or more acres; including disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes are part of a larger cemnon plan that wig uMmataly disturb one or more acres of land: which Exceed Fifteen (15) feet of Vertical Rise to including Construction activities involving sol disturbances of less than one (1) acm where One Hundred (100') of Horizontal Distance? - the DEC has determined that a SPOES permit is required for storm water discharges. (SWPPP's Shall mast the Minknum Requirements of to SPDES General Permit 8 Will Driveways, Parking Areas or other Impervious i~ for Storm Water Discharges from Construction activity. Parmm No. GP-0.10401.) Surfaces be Sloped to Direct Slam-Water Run-Off ? I. The SWPPP shag be prepared prior to the submitted of the NOT. The Nor shag be Into and/or in the direction of a Town right-of-Way? submitted to to Department prior to the cmmsncement of construction activity. 2. The SWPPP shall describe the erosion and sediment control practices and where 9 Will this Project Require the Placement Of Material, required, postconsauUlon storm water management practices that will be used and/or Removal of Vegetation and/or the Construction of any constructed to reduce the polulanis kin atoms water discharges and to assure or Road Shoulder - comptianee with the terns and conditions of this pemit. In addition, the SWPPP shag Item Item Wmwithin mm the ToWN Nor wn i Right-of-Way r Road Sh Shoulder identify potential sources of pollution which may reasonably be expected to effect the Am? quality of storm water discharges. NOTE: N Any Answer to Qusstuns One through Nina is Answered will, a Check Mark 1 AN SWPPPs that require the poalccnstructlon storm water management Practice in a Box and the consbucgon age disturbance Is behvaen 5,000 S.F. a 1 Ass In area, component shag be prepared by a quashed Design Professional Licensed in New York a Storm-Wamr, Grading, Drainage & Erosion Control Plan Is Requited by On Town of that is knowledgeable In the principles and practices of Storm Water Management Southold and short be Submitted for Review Paw to Issuance of Any Building Ponart (NOTE: AChxk Maki!) emdlar Ansxerfmr each OueNimhRePaed fwaCmpkia Appgngon) Andrew Kegut STATE OF NEW YORK, Notary Public State of N.Y. COUNTY OF VASs .'?:5~n SS No. 01 K06124303 That 1, ..1.r...~:.Y. " ~IJ.i being duly sworn, dCpoQuSaahif~'ed in Nassau County for Permit, signing liOf11R1155f /a /w_1 (Name of Individual signing Doaarrent) And that he/she is the ...................................JDW .I. (Owner, Contractor. Agent, 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 die best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed herewith. Swom to before me this; 1 11 1................. day of ......Q.. Cis yc J'. `20...3 , Notary Public: . (sgmawre or APp~mt FORM - 06/10 Boo of Trustees Application w County of Suffolk State of New York es4i c(L ' ~6jd (t 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. Signat&e of Propert Owner SWORN TO BEFORE ME THIS a l DAY OF O e-- L4 r 2013 Not Angre No o~blicStateOOfN Y Qualifie K06124303 Notary Pubb Qommission/E pa esao Qoonry s 03/28/201 BOW of Trustees Application AUTHORIZATION MM (where the applicant is not the owner) r 1 ~s A6-A (I residing at 17,)-01 3;)Ax@-~ I-~JSv1 1135 (print owner of property) (mailing address) do hereby authorizer ~v~JK~S (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) Andrew Kogut Notary Public State of N.Y. No. 01 K06124303 Qualified in Nassau County t ~_Gnmmission Expires 03/28/201' APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold 's Code of Ethics prohibits conflicts of interest on the part of town officers and emplovees The pun= of this form is to provide information which can alert the town of possible conflicts of j=mst and allow it to take whatever action is neces_wrv to avoid same. YOUR NAME: " ' ' vp 1'rL e1`' (Last name, first name, diddle 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 \~1 n (If "Other, time 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 th' 1da of b G I 200 Signature- PrintName E5"Cr Mi j-Q 1'1 Form TS I 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 supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold ' s website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# (DO 0 p( Z 1 PROJECT NAME a` 017 U t ~1 C i P r Q 1`.C - 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: a~a~ Pty. ~~a2 • N 1~g3~' Location of action: I Site acreage: N G-~cJ1 p ' n n Present land use: ~~1U Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: f~ (a) Name of applicant: `iST ? e4z- Mold (b) Mailing address: I ? a. `a4 3 r N 13 S$ (c) Telephone number: Area Code (15~ b O 3 (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ? No R1 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 gNot 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 Rl 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 2 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 S~ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III - Policies Pages 16 through 21 for evaluation criteria ? Yes ? No 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. N.P~ . Yes No Not Apple 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 gNot 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 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. ? Yer-1 No KNot Applicable Attach additional sheets if necessary WORKING COAST POLICIES it 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 El No KNot 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 ?al 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 K-Not Applicable PREPARED BY I k t y' TITLE a, Q DATE o ao ~3 C LOOT-Q ' A4A- ~ OCT 2 9 "M 5oaUTu~6 :can" Board of Thatem OD Neap APPROVED BY j~ecK ~R~E F Q° BOARD OF TRUSTEES j q' TOWN OF SOUTHOLD i DATE 3 3 P o STd2--- _ I t o { M T Scale' 1 t n„ R- J, oard f li swes (LOAD ° ZEDvAr'Joc PC.:..E _ dC 330 Fo l~ e ' FLOAT RAMP a ~o WL -7, ~lA,, - - - - - f BIN i. ti~o~~•\9 I S7'v. FR. N0. 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