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HomeMy WebLinkAboutTR-8462A 261 76th Street Brooklyn,NY 11209 June 3,2017 Town of Southold P.O. Box 1179 G� ' 4' Southold,New York 11971 Re: Permit No: 8462A +' JUN - 9 2017 Project Location: 215 Tarpon Drive, Southold T Applicant: George& Stavroula Protonentis Project Description: To construct a+/-20'x12' deck attached to dwelling We would like to renew our permit to construct a+/-20'x12' deck attached to dwelling. Attached please find a,check for$50.00. If you have any questions please contact us at 718-836-2951. Sincerely, Y George& Stavroula Protonentis n 1 UP Michael J.Domino, President SOF SOTown Hall Annex John M. Bredemeyer III,Vice-President 54375 Route 25 P.O. Box 1179 Charles J.Sanders C/, Southold,New York 11971 Glenn Goldsmith ® �9z Telephone (631) 765-1892 A.Nicholas Krupski �l`�'C®UNT`I Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 1- -')Uk,,t t /Ch. 275• Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction Y2 constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: CERTIFICATE OF COMPLIANCE: �oF SO(/�y Michael J. Domino,President ®�' ®�® Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 g P.O.Box 1179 Charles J. Sanders CASouthold,New York 11971 Glenn Goldsmith 9E "�aQ Telephone(631) 765-1892 A. Nicholas Krupski �'c®U ��. Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD June 21, 2017 George & Stavroula Protonentis 261 76th Street Brooklyn, NY 11209 RE: 215 TARPON DRIVE, SOUTHOLD SCTM# 1000-53-5-3 'Dear Mr. and Mrs. Protonentis: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, June 21, 2017: RESOLVED that the Southold Town Board of Trustees grants the Last One-Year Extension to Administrative Permit#8462A, as issued on July 23, 2014. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, Michael J. Domino President, Board of Trustees MJD:dd �pF SO!/Ty Michael J.Domino, President �o� ®�� Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Charles J.Sanders G @ Southold, New York 11971 Glenn Goldsmith �® Telephone(631) 765-1892 A.Nicholas Krupski Ol/l'CFax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1362C Date: July 17, 2017 THIS CERTIFIES that the construction of a+/-20'x12' deck attached to dwelling; At 215 Tarpon Drive, Southold Suffolk County Tax Map#1000-53-5-3 Conforms to the application for a Trustees Permit heretofore filed in this- office Dated June 20, 2014 pursuant to which Trustees Administrative Permit#8462A Dated July 23, 2014,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 construction of a+/-20'x12' deck attached to dwelling. The certificate is issued to George& Stavroula Protonentis owners of the aforesaid property. Authorized Signature John M.Bredemeyer III, President �O��oE S�UT/�®l® Town Hall Annex Michael J.Domino,Vice President 54375 Route 25 Glenn GoldsmithP.O.Box 1179 Southold,New York 11971 A.Nicholas Krupski ® Telephone(631) 765-1892 Charles J. SandersyCaUNT`13 a Fax(631) 765-6641 � �� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD June 22, 2016 George & Stavroula Protonentis 261 76th Street Brooklyn, NY 11209 RE: GEORGE & STAVROULA PROTONENTIS 215 TARPON DRIVE, SOUTHOLD, SCTM# 1000-53-5-3 Dear Mr. and Mrs. Protonentis: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, June 22, 2016: RESOLVED that the Southold Town Board of Trustees grants a One-Year Extension to Administrative Permit#8462A, as issued on July 23, 2014. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, John M. Bredemeyer III President, Board of Trustees JMB:dd zza- John M. Bredemeypr III, President6Id5UFFQik�:��, y Town Hall Annex Michael J. Domino Vice-President 54375 Route 25 Glenn Goldsmith o P.O. Box 1179 A Nicholas Krupski Io Southold, NY 11971 Charles J. Sanders y,- p� Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in field by: GEORGE & STAVROULA PROTONENTIS request a One-Year Extension to Administrative Permit #8462A, as issued on July 23, 2014. Located: 215 Tarpon Drive, Southold. SCTM# 1000-53-5-3 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 1 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: we— Present were: —J-Bredemeyer ("Mi Domino " G. Goldsmith . N.•Krupski C. S,aKers Other Page 1 of 2 26176th Street Brooklyn, NY 11209 May 12, 2016 Town Hall Annex P.O. Box 1179 Southold, New York 11971 Re: Permit No: 8462A Project Location: 215 Tarpon Drive, Southold Applicant: George&Stavroula Protonentis Project Description:To construct a+/-20'x12' deck attached to dwelling We would like to renew our permit to construct a +/-20'x12' deck attached to dwelling. Attached please find a check for$50.00. If you have any questions please contact us at 718-836-2951. Sincerely, George &Stavroula Protonentis D M(g[EGV[2 D MAY 19 2016 BUMD]ING DEPT. TOWN OF SOUTHOLD . . {F �►I i MAY 192016 i So�:thold Tc:�n � � John M. Bredemeyer Ill, President O�Ogu�Fp(,f-cO Town Hall,53095 Main Rd. Michael J. Domino, Vice-Presidents Gyp P.O. Box 1179 James F. King ti Southold,NY 11971 Charles J. Sanders y�©� �� Telephone(63 1)765-1892 Dave Bergen 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 1St day of construction '/ constructed Project complete, compliance inspection 0 • John M. Bredemeyer III,President �*0f SOUr/fiO Town Hall Annex Michael J.Domino,Vice-President �� l0 54375 Main Road P.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 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8462A Date of Receipt of Application: June 20, 2014 Applicant: George & Stavroula Protonentis SCTM#: 53-5-3 Project Location: 215 Tarpon Drive, Southold Date of Resolution/Issuance: July 23, 2014 Date of Expiration: July 23, 2016 Reviewed by: Board of Trustees Project Description: To construct a +/-20'x12' deck attached to dwelling. 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 Stavroula Protonentis, received on June 20, 2014, and stamped approved on July 23, 2014. 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. Michael J. Domino, Vice-President Board of Trustees -----SIN eorge&Stavroula Protonentis 15 Tarpon Drive,Southold CTM#53-5-3 /16/14 a r " r en .v r rb^'. s q,<.;.<.. '. ... •. dam' ie _ f. a d Y. � YW .r t� F. .r �� � -a� �„; � `�r � �.� .•�., ty �'�'''�I'1ST«�. II�� �,I� .R Air George&Stavroula Protonentis 215 Tarpon Drive,Southold ' SCTM#53-5-3 7/16/14 6 i John Bredemeyer, President �,� ��00Foco Town Hall Annex Michael J. Domino, Vice-President �� � 54375 Route 25 James F. King : P.O. Box 1179 Charles J. Sanders • Southold NY 11971 Dave Bergen f�'�i ,F �a°� Telephone (631) 765-1892 Fax (631) 765-6641 Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time:_07b f GEORGE & STAVROULA PROTONENTIS request an Administrative Permit to construct a +/-20'x12' deck attached to dwelling. Located: 215 Tarpon Drive, Southold. SCTM# 53-5-3 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound -_I/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 Notice of Hearing card posted on property: Yes No Not Applicable Storm Water Management Review: Yes No Not Applicable Info needed: Modifications: Conditions: t'�r-. Present Were: J. Bredemeyer t/M. Domino %,�.4ing Sanders C_0'Bergen Bay Constable Other Form filled out in the field by I Mailed/Faxed to: Date: �CK r�X ,2,0 )K tr .face- yG� A ?� III WVH BEEAE0.N0.ON YME 'mi6m — —_—Z2___ Q OLtia, Q• 8EE8EC x0.015 061a0, xiaa+ •; ,MTOH _ WE No fOR PCL � N sou,xao / w\ mm um -.rA �Sp� ¢ A PYH RwcPi No. ,e osawe / > I tM�lq I �E�.xO. Ob maam coxxr�ir auvroix � Ql -atv, 4 / mala TOW NEP saun,an ,��• ®asm / ,oxN OE eouma.o p� � �i mrz v]NG ��owr,,�naF �� 0i 13 3A •',' couxr aF SYENxx ��ourlxxc / j- ISA %ai nmg ,a ,a.a , • N of sourxno O r �•' yr u�"' cam bt z •i`v' >s• a Pt c ,s44 iii, B,AN) j,'�, s Q.. •'t 6� y� a, y y1 ♦ t � # - m 4 '>a h yY 1 b y� I2, h C "b ♦ y� '• 'P t��l, �` a . ya ♦ ♦ ye '' ♦ - kArl y' roA O • �� yp ♦ ♦ y� yam " I t va q� , • yv '•P ♦ ♦ •b ns ♦ '�`zae ,y p r u4 BEE EEC.NO. )>A �'P•� _—Z-uxE ems- ,p v y ME—xO.ml E - � _�_ �' __ �� _ NOT1cE " COUNTY OF SUFFOLK © E soUTWU) SECTION NO i..w..�w. _ �u _ _ W_ _ _ Real Properly Tax Service Agency v w .w1 x ___ 53 A c+�o '�• P �� PROPERTY MAP � OFFICE LOCATION: � 0� S�UryO MAILING ADDRESS: Town Hall Annex ,`O lO P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) Southold, NY 11971 G Q Telephone: 631765-1938 '.tet► �� Fax: 631765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM -- ; D EC w s To: John Bredemeyer, President JUL 2 1 2014 " Town of Southold Board of Trustees j From: Mark Terry, Principal Planner LWRP Coordinate Date: July 21, 2014 Re: Proposed Wetland Permit for GEORGE & STAVROULA PROTONENTIS SCTM# 1000-53-5-3 GEORGE & STAVROULA PROTONENTIS request an Administrative Permit to construct a +/- 20'x12' deck attached to dwelling. Located: 215 Tarpon Drive, Southold. SCTM#53-5-3 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the Policy Standards and therefore is 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 if SQury� Town Hall Annex Bob Ghosio,Jr.,Vice-President h0 l 54375 Main Road � P.O.Box 1179 Dave Bergen l Southold,New York 11971-0959 John Bredemeyer G Q Telephone(631) 765-1892 Michael J.Domino �� i0 F _ r COU �,..� ) � I11_� IAF— BOARD 1� BOARD OF TOWN TRUSTEES JUL - 1 2014 TOWN OF SOUTHOLD GI-G DEPT. To: Southold Town Building Department TONWj;OF onimojn Re: Verification of Building Department Permit Requirements SCTM#: SS -5---s Property Owner Name: C-f br fi -c4a V r b ukS Date Sent to Bldg. Dept.: The Office of the Board of Trustees is forwarding the above referenced application for verification of the Building Department's permitting requirements stated below: YES NO the proposed project require a Building Permit? Will the proposed project require a variance determination from �Will oning Board of Appeals? any part of this application be considered as Demolition as described under Town Code? COMMENTS: © 7 �7 Signature of ReViewer Date James F.King,President y Town Hall Annex Bob Ghosio,Jr.,Vice-President ��� 0� P375 Main O.Box 11?9d Dave Bergen > Southold,New York 11971-0959 John Bredemeyer G • Q Telephone(631)765-1892 Michael J.Domino yCv � Fax(681)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Applicatioly _Wetland Permit Application Administrative Permit AmendmentlTransficr./Extqnsion eceived Application: to 1.16) Ceceived Fee:$ ompleted Application _Incomplete D Q' _SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) JUN 2 0 2014 — WRP Consistency Assessment Form AC Referral Sent: ate.of inspection: _Receipt of CAC Repo Lead Agency Determination: echnical Review: Public Hearing Held: Resolution: Name of Applicant George 4 S-(ay ro u 1 a J r o+n n e n+ i f Mailing Address (O �r� } fc��k�y >1 + (� 112 09 Phone Number:019) t3 - d 9 5 I Suffolk County Tax Map Number: 1000- 5 3 — S — -Property Location: 15 TQr p o n r 2 SQ Lj+, .o 16 . N y 1 i q-7 (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: i d of Trustees Application i GENERAL DATA Land Area(in square feet): Area Zoning: r G S i c n Previous use of property: r'e-S ► d e n+ i a Intended use of property: Ire s ► 8 e n A-►'a 1 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/ny demolition as per Town Code or as determined by the Building Dept.? Yes V 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): Tn C-nn S±r-p CA Gt cl e C k i loc-, r L ou-6 . Bo of Trustees Application • WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: I i Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? V/ 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 Proposed slope throughout the area of operations: 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 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 t 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 Long+-rud ck- Name of Action or Project: C0 r\5"CAL Ck C4ecAk'_ Project Location(describe,and attach a location map): 2 15 Tai r-�✓� ��-� v�. �S��� o I � ►� ``' 1 1 Q—1 � Brief Description of Proposed Action: Q p . Name jof Applicant or Sponsor:: G 1 C �C)l'. G� Telephone: ►�(� 3 a 4 S 1 J V l�V-�Oi F-A-0 n e 1' s E-Mail: 01 3 C�1 ,(A A—_ Address: City/pO:C� Stater Zi Coded 1-OL) 1.Does the proposed 'on only involve the legislative adoption of a plan,local law,ordinance, NO T 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: ❑ 3.a.Total acreage of the site df the proposed action? acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial P Residential(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? ❑ ❑ 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? ❑ El 7. Is the site of the proposed action located in,or does it adjoin,a state Iisted Critical Environmental Area? NO YES If Yes,identify: � ❑ 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? ❑ 4.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: ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: Ei ❑ 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 0,0 YES Places? Elb.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? F] If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: uu 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 ❑Early mid-successional [TWetland 0 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-poi sources? NO YES If Yes, _9 a.Will storm water discharges flow to adjacent properties? NO .DYES ❑ b.Will storm water discharges be directed to established conveyance systems6NO and storm drains)? If Yes,briefly describe: OYES 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: 11 F-1 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/spo r name: 0-avrU L:en I t s Date: ib Signature: J' (-�21-01 `P 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 targe impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning 1-7 regulations? u 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 ❑ establishment ofa Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level.of traffic or 1" ❑ 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 rpmnably 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, ❑ architectural or aesthetic resources? LJ 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 n( problems? 9J 11. Will the proposed action create a hazard to environmental resources or human health? 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. F] 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. ElCheck 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 environmen al im acts. Town of Southold-Board of Trustees 11 / Name of Lead Agency Date G Ge ( T -Db, r",,,-- President e Printf or Type Name of ResponsibleOfficer in Lead Agency Title of Responsible Officer " _ Signature of Respo ible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Bc& of Trustees Application• County of Suffolk State of New York co r1110- u-h� n-e �, s - W Ay-r-o u 1 a, r o+U q P n f is 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 INXHIS 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 J-0 DAY OF ::3' u n1L ,20 i `' GEORGE L.DIACUMAKOS Nwry PvMk,State of New Vwk ws1n16oss9oa �� Qnlifled in Kinp Cam man Expires January 139 39f Notary Public APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM pa Toyrn of SM12ws CQ a of Ethics nro�(bits conflicts of interest on the part of(gym officers and empoy no purpose of thi to.,rovido conn ion which can alert town of possibly conflicts of interest and allow it to take whatever action is necessary to avoid same. y L YOURNAME ��0 1 D eP1 i S 4 C�y r o�.t.'Ch:. a Cj£ c7(_o � (Last name,fust name,jpiddle 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 Tice Change ofZone 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 iieterest"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 br position of that person Describe the relationship between yourself(the applicantlagenthepresentative)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 dist 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(whenthe applicant is not a corporation), C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thi 20 day of c•` ' 200 `f Signature Print Name r o - Form TS 1 � Oco ri Town of Southold • • LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a.determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to iits, significant beneficial and adverse effects upon the coastal area(which includes all of Southold TownZ 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. B. DESCRIPTION OF SITE AND PROPOSED ACTION ❑ N ;,_ ? ; E SCTM# JUN ? 0 7014 PROJECT NAME Lo n SA-ru A- A c c-k< The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ 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: Q R. E 1 • Location of action: Z L l o- p r l ci' Site acreage: Present land use: Present zoning classification: r Z S 1 de-A 2. If an application.for the proposed action has been flied with the Town of Southold agency, the fallowing information shall be provided: (a) Name of applicant: (b) Mailing address: (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? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space,makes efficient use of infrastructure,makes beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section III—Policies;Page 2 for evaluation criteria. Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Pol' les 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—ZAppficable ' Pages 6 through 7 for evaluation criteria F1 yes ❑ No 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 ❑ Na Pr7Not Applicable Attach additional sheets if necessary Policy S. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III -Policies Pages 16 throw 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. ❑ ❑ Yes No Not ApAle , 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[ONot 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 M—Policies; Pages 34 through 38 for evaluation criteria. F] yes 1:1 No U 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. � 11Ye� No E Not Applicable Attach additional sheets if necessary 'WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. Se WRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes [:1No 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 1:1 No 5Not 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 VNot Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; ages 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED BY *� 2, TITLE 1"T� d.� DATE G12-0 /y Lv��� S.C.TA%NAP NO. DIST.1000 SECT.53 BLOCK 5 LOT 3 FILE N0. 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Septic offsets, water line by applicant o)\1997\g8_720\d \FiNALdwg uws,rsr may,°ey, pq�,4 My.p,4.N 4°+W1M w S.sen>me M M I4.M 3nat° PROJECT: SAL LOCATION � ^^� FOR LOT 48 M/0 SOUTHOLD SHORES r,.p 4,n1°,s,^ p.eeuWwe s..n YsuYMle M Netlmd Ywwetl°is v w.wnl ewwe. al aY°ewr,M Ys4e M°el�/ipeef°W M/v MIlsM 4M M w°[N ww4✓M °�i.',r..4w7 w..,4..a.......w«w.n..a.nr w•>•a.w+r wo.. SITUATE AT: 30UTHOLD. NY DATE: OCTOBER 2005 SCALE 1"=30' ��Ne1W Y YWMye enf MM ea4x.M4^ CERWIED ONLY TO: Q W DAL i,C i� SURVEY DATE NOf'~ 7. 2005 MEA 21.000 SQ FT. FR.EO NAP NO.3rt51 _ — DATE BLED fx/29/1963 FaD 800M 107211 DATA OISC 1997\96-720 FN0.3/Q /05 IND.CONST. RNA.10/11/2095 y Na: S �� ® FFAWKWS WEBS JAEGER ASM P.0 b 1YIWAN L JAEGER I KY-S.UQ NO.0/8148 P PtAl1� 7m fNr ebeeM..qe.0/e�x,le'°'1l DESH27ED DRATAI RAO CKO. naue wv wenn•n o4s °.ra em a 4.es..e.s