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HomeMy WebLinkAboutTR-8325A James F. King, President Q~@gQEfO( rcO Town Hall, 53095 Main Rd. Bob Ghosio, Jr., Vice-President P.O. Box 1179 Dave Bergen Southold, NY 11971 John Brederneyer 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 1't day of construction % constructed. V Project complete, compliance inspection James F. King, President qf soUryo Town Hall Annex Bob Ghosio, Jr., Vice-President 'lam 54375 Main Road P.O. Box 1179 Dave Bergen Southold, New York 11971-0959 John Bredemeyer Telephone (631) 765-1892 Michael J. Domino (yCOUfm Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8325A Date of Receipt of Application: October 28, 2013 Applicant: Lucie Harris SCTM#: 70-6-12 Project Location: 305 Private Road #3, Southold Date of Resolution/issuance: November 13, 2013 Date of Expiration: November 13, 2015 Reviewed by: Trustee Michael Domino Project Description: To remove five (5) dead/dying oak trees around the existing dwelling and power lines; re-vegetate areas with various plantings and add garden fencing. 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 Lucie Harris, received on October 28, 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. 1111~ 0.'d James F. King, President Board of Trustees gUFFO(K James F. King. President p~ C P.O. Box 1179 Bob Ghosio. Jr., Vice-President vd Southold, NY 11971 Dave Bergen t Telephone (631 765-1892 John Bredemeyer ,r T Far (631) 765-6641 Michael J. Domino X01 * ,~ao* Southold Town Board of Trustees "Field Inspection/Work Session Report Date/Time X't-y- l', a.-o/3 LUCIE HARRIS requests an Administrative Permit to remove five (5) dead/dying oak trees around the existing dwelling and power lines; re-vegetate areas with various plantings and add garden fencing. Located: 305 Private Road #3, Southold. SCTM# 70-6-12 Type of area to be impacted: -Saltwater Wetland -Freshwater Wetland -Sound ? Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: _Chapt.275 _Chapt. 111 -other Type of Application: _ Wetland -Coastal Erosion -Amendment -Administrative-Emergency Pre-Submission Violation Info needed: Modifications: Conditions: A,,,,4 ,~?,k.n,.e ~k' - Present Were: J. King'_B. Ghosio D. Bergen, J. Bredemeyer ? Michael Domino D. Dzenkowski other Form fill d o/ut in the field by Mailed/Faxed to: Date: CONSULT YOUR LAWYER BEF RE IGNING THIS INSTRUMENT-THIS INSTRUMENT SHOULD BE USED BY LAWYERS ONLY THIS INDENTURE, made t e 7 %day of September, 2013 BETWEEN LAWRENCE MARKS and MARION MARKS, both residing at 305 Private Road #3, Southold, NY 11971 party of the first part, and LUCIE HARRIS, residing at 521 Sixth Avenue, Brooklyn, NY 11215 party of the second part, WITNESSETH, that the party of the first part, in consideration of TEN and no/10$0) dollars aid by the party of the second part, does hereby grant and release unto the party of the second part, the heirs or successors and assigns of the party of the second part forever, SEE SCHEDULE "A" ANNEXED HERETO AND MADE A PART HEREOF BEING AND INTENDED TO BE the same premises conveyed to the parties of the first part by deed made by Robert Wheeler and Richard Wheeler, as Co-Executors of the Last Will and Testament of Mary M. Wheeler, deceased dated April 10, 1982 and recorded in the Suffolk County Clerk's Office on April 19, 1982 in Liber 9170 Page 49. TOGETHER with all right, title and interest, if any, of the party of the first part in and to any streets and roads abutting the above described premises to the center lines thereof; TOGETHER,with the appurtenances and all the estate and rights of the party of the first part in and to said premises; TO HAVE AND TO HOLD the premises herein granted unto the party of the second part, the heirs or successors and assigns of the party of the second part forever. AND the party of the first part covenants that the party of the first part has not done or suffered anything whereby the said premises have been encumbered in any way whatever, except as aforesaid. AND the party of the first part, in compliance with Section 13 of the Lien Law, covenants that the party of the first part will receive the consideration for this conveyance and will hold the right to receive such consideration as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same first to the payment of the cost of the improvement before using any part of the total of the same for any other purpose. The word "party" shall be construed as if it read "parties" whenever the sense of this indenture so requires. IN WITNESS WHEREOF, the party of the first part has duly executed this deed the day and year first above written. 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NO, $ZI ra I~v,G _ ~g oo1G~aA a~ 1/ Zr LP cf CA [ , M 4g E T ~UCENSEgiflEGISTMTIONNUMBEA 10 101 3 Z Iu' (7 D STATE T~ OF LICENSE MTE E1(PRiES DATE OF BIRTH OPEAATOR O C 1 2 1 2013 Z! - / p F p %p JAY OWNS VEHICLE L{ ?m ?ND THE OPEAATgi OR MGI5I EAED VNNER OF VFHIgE DESCRIBED BELOW RATE NO. DATE FJtPIRES SGUtliGiG lGWa STATE PUTS TVPE ? KY. ? NJ. ? N.Y. ? N.J. ? ? PASS ? COMM ? VEHICLE MAKE ? DODOE ? BVICK ? CHEV ? LPgUAC ? PONMC ? FORD ? qD4 ? RYM - ? TOYOTA ? WJIHs ? BODY ? Fpfl ? 4DA ? Bus ? MCY ? S.W. TYPE ? TRUCK ? T UR ? VAN ? _ WN NUMBER THEPERSONDESC MWABOVEISC GEDASFIXLOW3 PLACEOFOCCURfl PCT 30Y +03 rl~ V 1V 7'7'%3 POE ° 0 ]-?r~~/q HVAIET SUFFWICgMTNY W WOIAIgN dF SECTOH SUED, aF THE?VEHICLE AIM)TViflC UW OF THE STATE OF NEW VgiK 571- ?O.S. ?cBm ?BUS ?H tj / 5 DEF VEH I ? MPHSPEEpN6 OTHER OFFENSE/J INA mm;rONE No et'--4 +l L MIBDEMEAN011 ? FACT PARTLNOT"O /J THE mNMJEDOFFEII NTgDgJ STgTEDDATE.IIMEANDRACE C~~' Mf2 wl _ tu~tSO~')yh 1KF FaWNV iOUN~eny~ PAAN SSCHEgAJORNE6 CONTACT COURT? THE PENBOH DESCRIBED ABOVE 138UMMONEO TOAPPFM AT SgTIHOID TOWN JVBTICE CglflT, 6]846 RWIE E6, SOUTHgD, NY 119]1 G VMPFMVCEOWT FORT'1 ON ZD .I -.j FNSEBTAlt111FNN181piBNIAERM6WBlEASAtlA44AM16CEMEANgi%AM{MNITOSFCIICNp10A6CFTEP.LNYb. COMPLAINANT DAM BADGE S COURT COPY m. em" Oj • ~ " Y y y 4 alb " ~ ~ mxnmeomud ^J, T y p p• n F' u J aWM • , S+° \ ~ pQ p E1PEe '"R N -^nlVrl ~ e ` ^ u ? y am n e ` p , b u " p eOUmfaYb4l>nsim • .O O qJj` J " y ~ w I e u 91 r+ n / • 1 °r10a °w"a • i " e ! I S ,aw ,ivn " ,.?w ,ru ,vya ti...i. y r u " I ..w 11 9v m 9 Pv zTw J . ~ ~"~J 4 ~ l- u~ .^e~.. • 3 ~re° P " P'e I `am"v° •em 1 s +s Yy yo yr 1 p? a ~f? 1y/'f ~ e.em, e ~ P 6 W 9a ° a fY bi y4 _ N O ° fY9 d Y _d . e' ° Y J° f r +y f•L 1P ~ .v " m ~ A ~l a " ~ ay "o i~ p 1 9~+y^ " C S J ° _ y ~ r 8AP y .ice v? ~ v PexxF' " • n s A 9 S " ^ P _ " I1..' 'z ,rq ~u 9i€ _ _ y ~ em.^vy~ .wmuc y f ® a[ n •w t as • : • A" ° 9 -,.w-1~ im'~~~~?~Y__~~ IYe: a, _ xo•w[ COUNiY OF SUFFOLK © a m uuiNaLO racnoxxo L AM, 70 James F. King, President ~OF SOpr~, • Town Hall Annex Bob Ghosio, Jr., Vice-President 54375 Main Road P.O. Box 1179 Dave Bergen !~I Southold, New York 11971-0959 John Bredemeyer C02 G p~ Telephone (631) 765-1892 Michael J. Domino '~0 Fax (631) 766-6641 ~~OOUNTI BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extension Received Application: 13 Received Fee:$ Completed Application RD Incompl ete _SEQRA Classification: OCT 2 8 2013 1 Type I ACA Referral ,al S11 Unlisted entWRP Assess ent Form ZDate of Inspection: f 1 /3 -Receipt of CAC Report: -Lead Agency Determination: Technical Review: Public Hearing Held: Resolution: i Name of Applicant Luc j e ~-~arr S I Mailing Address SZ I ~P ' 6rv&~ t) tYq 11-2-15- Phone Number:(-118) 142 8 Suffolk County Tax Map Number: 1000 - 70 1 cc*_ b , Lc 12 ~I Property Location: ZO 5- ya 44 3 I Svtti(lo "A 14 11 ky I e # 3 (provide LILCO Pole distance to cross streets, and location) AGENT: (If applicable) I Address: I Phone: >rd of Trustees Application GENERAL DATA 7` 1 Land Area (in square feet): lOI /O 3, I D 31 1 Area Zoning: X Previous use of property: Pest JtA'tW de4~~ Intended use of property: Yt 51 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 No If "Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes -_No Does the structure (s) on property have a valid Certificate of Occupancy? 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? x No Yes If yes, provide explanation: I Project Description (use attachments if necessary): rGVhDV M 5 dy!~l o r de'. Oak +rfes -1rn t4ere 4Y'aw(n5 iyj~ -r&t dect or ouerharrY~ cu'~1 ~nu~`5 ` t hoUsz and e~dric I;"es V)e are iDlarrfcrY,na)~~~ ~lowcrs}veyelab~- ~e~eYta+tcA xvJ loosl~,5 rvi -Wa area tAer- iCe-I-rees were ?emov4. Boi of Trustees Application • WETLAND)TRUSTEE LANDS APPLICATION DATA t Purpose of the proposed operations: {-a A pd n~ k t/ I~~011 'a ~ ~ s reb~aC~~ lle~8 o?i I~ Area of wetlands on lot: Z 5-" square feet Percent coverage of lot: ~3 .3 0/0 Closest distance between nearest existing structure and upland edge of wetlands: feet H t JVC k , 7At h1* 6e s ctprv )y- rtIHnd s ?roc rcMOU:I oyn Closest distance between nearest proposed struc a and upland ~ab~U~ From AkA edge of wetlands: a t feet T. ~rorh L~ D Gk t WC+1end s Does the project involve excavation or filling? No Yes If yes, how much material will be excavated?_~ cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet f Proposed slope throughout the area of operations: P Manner in which material will be removed or deposited:: f P- 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): nRP r~i ~n~ . ~ ~2eu r,A ~ nv~t o(~e~z~r bc~ . Y(ef We Af.'c 617.20 Appendix B Short Environmental Assessment Form Instructions for Comoletine 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 I 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 I. 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 i - Project and Sponsor Information Name of Action or Project: Project Location (describe, and attach a location map): I~0 3 Gia Q 305- Brief Description of Proposed Actir t. ~~Gtd2o et ovrtl7f+r~f dour '11t.t an.e o< Zd~. `FC.e ~ o~~ n.e-n~n.i ~tu+sl ~fb-wc.fsa v~cy~f~t~es uf.~~„~N;i Name of Applicant or Sponsor: Telephone: Lv,U Arl~ E-Mail: ZNcrc~. a7is /t c.rr,Coht Address: 51- 1 lei City/PO: State: Zip Code: &LOV A n 1-( IIZ1 S_ 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. 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: ~T'1 rK54QeS 3.a. Total acreage of the site of the proposed action? . 2_3 acres IJ b. Total acreage to be physically disturbed? W acres c. Total acreage (project site and any contiguous properties) owned or controlled by the applicant or project sponsor? 23 acres 4. Check all land uses that occur on, adjoining and near the proposed action. Urban [-]Rural(non-agriculture) []Industrial []Commercial M Residential (suburban) []Forest []Agriculture []Aquatic ?Other(specify): []Parkland Page 1 of 4 5. Is the proposed action, NO YE N/A a. A permitted use under the zoning regulations? ? ? b. Consistent with the adopted comprehensive plan? ? ? 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YE landscape? ? 7. Is the site of the proposed action located in, or does it adjoin, a state listed Critical Environmental Area? NO YES _ff F-1 If Yes, identify: 8. a. Will the proposed action result in a substantial increase in traffic above present levels? NO YES a El 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? ? 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: ? M 10. Will the proposed action connect to an existing public/private water supply? NO YES If No, describe method for providing potable water: [A ? 11. Will the proposed action connect to existing wastewater utilities? NO YES If No, describe method for providing wastewater treatment: E ? 12. a. Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ? 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 YE 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: ?Shoreline ?Forest ?Agricultural/grasslands ?Earlymid-successional M 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? ? 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 _ff If Yes, ? El a. Will storm water discharges flow to adjacent properties? NO YES b. Will storm water discharges be directed to established conveyance systems (ru ffand storm drains)? If Yes, briefly describe: NO YES 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: _ I ? 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: 1~1 ? 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: ? 1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsorne: Lycie 4Aft (S Date: (O~ZgI~3 Signature: t4 ciy 1~6-y-W . 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 I 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 1. 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? ? 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 I~ ? establishment of a Critical Environmental Area (CEA)? u 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? 8. Will the proposed action impair the character or quality of important historic, archaeological, 171 ? architectural or aesthetic resources? u 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? E 11. Will the proposed action create a hazard to environmental resources or human health? M 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 NO aJ ) 3 Name of Lead Agency- Date J19 H r s (L - IL IIO President Print or Type Name of Responsible O rcer in Lead Agency Title of Responsible Officer n -01, / Si ature of Responsible Officer in ead Agency Signature of Preparer (if different from Responsible Officer) PRINT Page 4 of 4 Town of Southold ® Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM $ PROPERTY LOCATION: S.C.TA. r. THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM-WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN j '%'IF eT ialrx; -m5EF- ToE- CERTIFIED BY A DESION PROFESSIONAL N THE STATE of NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTION rfEM # / WORKASSESSMENT Yes No a. What is the Total Area of the Project Parcels? - (Include Total Area of all Parcels located within 1 Will this Project Retain AN Stone-Water Run-Of the Scope of Work for Proposed Construction) r Z 3acTf5 Generated by a Two (7) Inch Rainfall on Site? ? (s.F. /A ) (This Item Will include all run-off Created by site b. What Is the Total Area of Land Cleating cleating and/or construction activities as well as all and/or Ground Disturbance for the proposed A e- irk Site Improvements and the permanent creation of construction ac W impervious surfaces.) (S.F.IAa+) ? 2 PROVIDE BRIEF PRO.)FIT DESCREMON tPreaa, Aaamn+Pages rll Does the Site Plan end Survey Show All Proposed Drainage Structures Indicating Size d Location? This A rA~ ! Item shall Include all Proposed Grade Changes and (y~ Yet)J2~ QRRa( 0( - 1 ~Lk ~tge S Slopes Controlling Surface Water Flow. .L1 3 Does the Site Plan and/or Survey describe the erosion ? kAt U/tAL s LEt!:5 .(;Lh JAA )i?CW7" and sediment control practices that will be, used to /I({~ -l~ -u control site erosion and storm water discharges. This F+- tn iwr ~821~~ 10 Y 0 ~eY, ink)"` Item must be maintained throughout the Entire - h-T ( Construction Period. lticua( .,A W yu_ , ' Q nk"y 4 Will this Project Require any Land Filling, Grading or Y) ` L 1 cn Excavation where there is a change to the Natural ? 4 d} d U.t,wlt«~? Existing Grade Involving more than 200 Cubic Yards li tt - l.rL1,r ~t.¢ M-D~t l e r of Material within any Parcel? equire Land Disturbing Actinides I J(' 5 Will this Application Require rvwu 5 Q f _.b1ap WIt>,,,r..n.f Encompassing an Area in Excess of Five Thousand / (5,000 S.F.) Square Feet of Ground Surface? El ,V- 6 Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction j General DEC SWPPP Requirements: or within One Hundred (100') feet of a Welland or Submission of a SWPPP Is required for all Construction actNitiea InvoMng soil Beach?. disturbances of one (1) or more acres; Including disturbances of less than we acne that 7 Will there be Site preparation on E isdng Grade Slopes are pan of a larger common plan that will ukimetey disturb one or more aces of land; Induding ConsWctbn activities involving soil disturbances of lass than one (1) acre where which Exceed Fifteen (15) feet of Vertical Rise to F the DEC has determined that a SPDES permit Is required for storm water discharges. One Hundred (100') of Horizontal Distance? (SWPPP's SMII meet time Minimum Requirements of the SPOES General Permit 8 Will Driveways, Parking Areas or other Impervious for Storm Water Discharges heat Construction activity -Permit MD. GP440L01.) Surfaces be Sloped to Direct Storm-Water Run-Off 1. The SWPPP shag be prepared prior W the subtotal of the Nit. The NOI shag be Into and/or in the direction of a Town right-Of-way? subn-Med to this Department prior to the commencement of construction activity. 2. The SWPPP shag describe the erosion and sediment control practices and whore 9 Will this Project Require the Placement of Material, required, post-construction storm water management practices that will be used and/or Removal of Vegetation and/or the Construction of any 1-16 constructed to reduce the pollutants In storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder compliance with the term and conditions of MIS permit In addition, the SWPPP shag Area?phv, aua we Nor hadu6 tlh, mnetWYbnaarbeway Apr„s) identify potential sources of pollution which may reasonably be expected to affect tre quary of storm water discharges. NOTE: If Any Answer b Quwtons One thmnh Nine la Answered with a Cheek Mark 3. AN SWPPPs Hurt require the postconstmclbn stone water management practice in a Box and f construction she disturbance is between 5,000 S.F. a I Acm in area, component shag be prepared by a qualified Design Professional Licensed in New York a Stone-Water, Grading, Drainage a Emlon Cordrel Plan is Required by the Town of that is knowledgeable In the principles and practices of Storm Water Management Southold and Must be Submitted ter Review Prior to isawnce of Any Building Para L (NOTE: ACMd Mark (!)and/or MSxer for each Ouerion lr RagBed lore 0arp4b Applnam) S1'A1EOFCOUN'l O~ , F......SO... ....LfCr............SS 17rat I, l k!^?...L.~' ^'0 being duly sworn, deposes and says that he/she is the applicant for Permit, (Name of be Ivldual signing Document) And that he/she is the .............$W :ti................................. (Owner, Cpntracbr, Agent. Corycats OMcer, eta.) 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. Swom to bef re me this. I da of (,1AG.1 2013 Notary Publir....LN~h r L 1 ..1..'!......................._................_ MELANIE DOROSK1 (Signature of Applicant) FORM - 06/10 State o NEW No. Ot D04634870 Oualified in Suffolk County Commission Expires September30,c~b A 'il BOW of Trustees Application • County of Suffolk State of New York I 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 j 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. dl 6'' Signature of Property Owner SWORN TO BEFORE ME THIS_ 4DAY OF 20(--A I ti t Notary Pub MELANIE DOROSKI NOTARY PUBLIC, State of Newyork No. 01D04634870 Qualified in Suffolk County Commission Expires September 30, 11Sy I, Boj# of Trustees Application • AUTHORIZATION (where the applicant is not the owner) I, R 64i ~4 V Y S residing at 5- 2 (print owner of property) (mailing address) I PyLO , u 1 2 do hereby authorize h (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf (Owner's signature) i I i I II APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE, FORM Tti Town of e bolds Code of Ethics prohibits conflicts of interest on the part of town officers and employees The puroose of , ion cancan can alert the town of possible conflicts of interest . and _ allow it to take whatever action is his fon^ is to n:nVe.,_ .•_a~_...„„n-_,.: necessary to avoid same. YOUR NAME: Gt ~t t ie (Last name, first name, Middle initial, unless you are applying to 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 r! 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 - k 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 i 4 I Submitted this 2-f' day of &a- MMti'i Signature Z 1 yvy - Print Name -e, 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. I 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, listing 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. LOCT B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# 2013 PROJECT NAME POLVLio 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: oak /t e y~py ~.~1 5 /tee y zOW Acad r-, c[c4 L L iKad W<nr ~n n~ ~^c i ~0 ttce plc c dr a-yt4 he r N- e `Il~4 ~~'u.Q.Q ~ L~r~u~ vUa- R QnA R/~ I B+ v~l u o r y,. ceti t c sC ~~e ft r wee .4,0,~d ,4~,A 4.-C s d YkL~e{µt~lo.~u/.F{~c~rS . Location of action: 39S JeS -0 3 ? & CL t Site acreage: 3 Present land use: i1 e 9~G1~ ~1 Present zoning classification: X 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: II /I (a) Name of applicant: L U ax-, far rJ (b) Mailing address: S2/ ~!b Pho jiy?t (c) Telephone number: Area Code Q11 (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes El No 12( 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 i teria. Yes ? No ~ Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See L Section III - P licies 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 8 through 16 for evaluation criteria L Yes El 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 thrr ugh 21 for evaluation criteria ? Yes ? No u Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. F-1 El F' Yes No of Ap le • 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 1~ Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wast See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. ? Yes ? No 7NOt Applicable PUBLIC COAST POLICIES j i 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. I ? Ye~] No Not Applicable I Ali Attach additional sheets if necessary WORKING COAST POLICIE* Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locationsgS LW RP Section III - Policies; Pages 47 through 56 for evaluation criteria. ? Yes ot 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. I ? Yes ? No EI'Not Applicable f I 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 ev luation criteria. ? Yes ? No Not Applicable ~I Attach additional sheets if necessary I 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 j I PREPARED BY /-Vct;, TITLE_ n4f DATE (o &I~3 S C.T M. N0. DISTRICT-. 1000 SECTION'. 70 BLOCK' 6 LOT(S)'. 12 FILM JOCKEY CREEK I pE Q,~ rryD D OCT 2 8 2013 RZ-~ 45 ; IF ~ ~ 'ram Y ..Yn.:x:. ~ e. ~Vsnuxo?o m ~ Im ZI n w luxa/e. S APPROVED BY i~`` eAVIV OARD OF TRUSTEES 2°52 z~ c oto 77 A.F OWN OF SOUTHOLD o °°2s9~ x DA 'R 13 I3 L7 _ R ~ m • 1 r ~q I~ ~ Ix 1 y n I u w mH ! ma. w. C avo 82°42'00"W lo;~ffMxl - soo - "D ~ussn? 260'"IR' A. (5~o swil , w~ X Y`N~(vaCR~~ _ Q rIPV PANEL 166H VAP REVISED SEPT. 28, 2009 Q' O A iER SaFPt Y. w£u E, ORYWELLS AND CESSPOGt 0I TOWN ARE FROM FIELD OBSERVATIONS AND AND OR IY Oa TA 06TAlNCO FROM OTHERS AREA: 10,103.10 SOFT . or 0.23 ACRES LLe. LION DATUM: - UNAUTHORIZED A6TERATOY OR ADDITION TO RIIS SURVEY IS A NOLARON OF SEC,,,R 7209 OF THE NEW YORK STATE EDUCATION LAW COPIES OF THIS SURVEY MAP NOT REARING THE LAND SURVEYORS EMBOSSED SEAL SHALL Nor BE CONSIDERED TO RE A VALID TRUE COPY GUARANTEES INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WW THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TIRE COMPANY. GOVERNMENTAL AGENCY AND LENDING INSiiTUAOv LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSRTURON, GUARANTEES ARE NOT TRANSFERABLE. ]PE OFFSETS OR DIMENSIONS SHOWN HEREON FRW THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO MONUMENT ME PROPERTY LINES OR TO GUIDE THE ERECTION Of FENCES, ADOITIOITAL STRUC!L'RES OR ANO OTHER IMPROVEMENTS. EASEMENTS ANO/oR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME DIE SURVEY SURVEY DT: DESCRIBED PROPERTY CERTIFIED I0, LUCIE HARRIS; MAP of FIDELITY NATIONAL TITLE INSURANCE: FILED EVERBANK; SITUATED AT SOUTHOLD TOW Dr: SOUTHOLD KENNETH M wOYCHUK LAND SURVEYING. PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design (4:p,,,Q` P.O. Eox 153 Aquebogue, New York 11831 FILE / 13-82 SCALE I"= 30DATE: MAY 29, 2013 PHONE (631)29B-1588 FM (031) 290-1580 NY, LBO NO 050882 I.mmo IS....om..1111 T. H.oo...r a r.ee.m Y. a.ymw