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HomeMy WebLinkAboutTR-8504A John M. Bredemeyer 111, President tlFFO(��o Town Hall, 53095 Main Rd. Michael J. Domino, Vice-President s Gym P.O. Box 1 179 James F. King y z Southold,NY 11971 Charles J. Sanders ��o� � Telephone(63 1)765-1892 Dave Bergen Fax(63 l)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 st day of construction '/ constructed Project complete, compliance inspection 0FSO 9 John M. Bredemeyer III, President OV��O uly�l Town Hall Annex O 54375 Main Road Michael J. Domino,Vice-President P.O. Box 1179 James F. King,Trustee C Southold, New York 11971-0959 Dave Bergen,Trustee • COQ Q Telephone(631) 765-1892 Charles J.Sanders, Trustee �'�CDUNTY,� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8504A Date of Receipt of Application: September 18, 2014 Applicant: Nancy Pearson SCTM#: 75-7-6.1 & 86-6-31 Project Location: 3258 South Harbor Road & 44332 Main Road, Southold Date of Resolution/Issuance: October 22, 2014 Date of Expiration: October 22, 2016 Reviewed by: Board of Trustees Project Description: For the as-built 8' high deer fencing installed along the landward side of the wetland boundary and along the side yards of the two abutting properties; and for a 10 Year Maintenance permit for the removal of invasive species along the shoreline. 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 Nancy Pearson, received on September 18, 2014, and stamped approved on October 22, 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. John M. Bredemeyer III OO President, Board of Trustees Nancy Pearson ti .. •4�. tw0/15114 � k411 J � 4 �� �: ..,• •.r�A hh -`` � 'R � it f • ""« w . 4. � � fit:•! ~� ,. r �py�.4 � + iiL .'^ �i': Y'F;,r .:. ice!'...T! 4 1 �.� �. � � _.. v ,►.. i '• ._( `.F 1 _ 't`.'�'�.� t.� , •1 re�N K� -_ Y11NA w • V•+'Ir ¢ w 14, , v � , . n r r a r , • �w ;�• Y, 1. �:'� • `. ^ •#w •, ftIF 4 1 to€ 4�r ?e, VA ? �iA &7.&-W44!hr,�� �• `s�,,,^'' �. ir'I� \r,�t + �.••. �ris'M� Nf °1;10! 1.5/2014 11 ' 54 16 0 John Bredemeyer, President °�QUFFott�o Town Hall Annex Michael J. Domino, Vice-President h° as 54375 Route 25 James F. King P.O. Box 1179 Charles J. Sanders • Southold, NY 11971 Dave Bergen 01 ,�, ya Telephone (631) 765-1892 Fax (631) 765-6641 Southold Town Board of Trustees Field InspectionMork Session Report Date/Time: NANCY PEARSON requests an Administrative Permit for the as-built 8' high deer fencing installed along the landward side of the wetland boundary and along the side yards of the two abutting properties. Located: 3258 South Harbor Road & 44332 Main Road, Southold. SCTM#'s 75-7-6.1 & 86-6-31 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 Notice of Hearing card posted on property: Yes No Not Applicable Storm Water Management Review: Yes No Not Applicable Info n nxh*& j!SZaCeJ_ 41-led 110k),41,*114 4;e q-J)7/4-1'#UV0LZ X- � " Modifications: I IV Conditions: ,��I ,�;,. � , ate,•.,, � o,� Present Were: v-J"Bredemeyer V/M. Domino _ King__!0_"C- Sanders ✓D. Bergen Bay Constable Other Form filled out in the field by Mailed/Faxed to: Date: Air- �' .e +tet � �•� ♦ ,� _ y. ir TRUSTEES c T SCOTT L. HARRIS John M. Bredemeyer, III, President Supervisor Henry P. Smith, Vice President ,,' Q Town Hall, 53095 Main Road Albert J. Krupski, Jr. ,� il `� John L. Bednoski, Jr. P.O. Box 1179 John B. Tuthill BOARD OF TOWN TRUSTEES Southold,Fax (5 6) 7 York23971 Telephone (516) 765-1892 TOWN OF SOUTHOLD Telephone (516) 765-1800 January 29, 1990 ........................... John and Nancy Pearson 3258 South Harbor Road - _. ...._.... ............ Southold, NY 11971 Re: App. No.11-3-89-75-7-6 Dear Drs. Pearson: ......... ... ...... __. ......... The following action was taken .by the Board of Town Trustees during its regular meeting held on January 25, 1990 regarding the above matter: WHEREAS, John and Nancy Pearson applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated November 14, 1989 and, WHEREAS said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and, WHEREAS, a public hearing was held by the Town Trustees with respect to said application on January 25,1990 at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW, THEREFORE BE IT RESOLVED that John and Nancy Pearson BE AND HEREBY IS GRANTED PERMISSION UNDER THE WETLAND ORDINANCE TO: Clear away multiflora and catbrier from area within 150' of Richmond Creek and replant undergrowth with oak, beech and hickory seedling, native shrubs and ground cover, such as bayberry, blueberry, kalmia, etc. , and cover all soil with leaves or hay until undergrowth is established. This permit will expire two years from the date it is signed if work has not commenced by said date. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. Very truly yours, John M. Bredemeyer, III President Board of Town Trustees JMB:jb __..._ .... ....._............. ..... cc: CAC File ♦' 0 i • ". -.. DECLARATION OF COVENANT f AND RESTRICTIONS T{IIS INDENTURE made this � 7 � day of MR/y 1982 by JOHN PEARSON and NANCY PEARSON, his wife, both residing at 542 E ast; Main Street, Riverhead, New :• York, hereinafter called the Declarants. WHEREAS, the Declarants are the owners in fe simple of a certain parcel of land situate in the Town of Southold, Suffolk Coun t ' , New York, and designated on the Suffolk County Tax Map as District 1000 / Section Ji5 / Block 7 and Lot `b containin g approximately 20 acres, being the same premises acquirOd by the Declarants by deed dated 012 T .`i / and recorded in the Suffolk County Clerk's Office on ,� � A ,.P� i n Liber l(',�' of Deeds....a.t.. a e. _ _ __. __. ..._ _ _ 9 S"�y . and referred I to herein as the "premises"; and WHEREAS, the Declarants intend to subdivide s id premises for residential Purposes and desire to subject said premises to certain conditions, covenants and restrictions in order to preserve the maximum open space, natural scenic beauty -and natural vegetation and to prevent overcrowding and to conserve the ground water resources of the Town of Southold; and WHEREAS, the Declarants have applied to the Panning Board of the Town of T. Southold for approval of the subdivision and development. of the premises as a Minor Subdivision, to contain not more than two (2) lots or paircels. NOW, THEREFORE, the Declarants do hereby declare that the aforesaid premises and every portion thereof is hereby held and shall be co iveyed subject to the conditions, covenants and restrictions hereinafter set forth, and th t every purchaser of said premises, or any portion thereof, by the acceptance of a deed thereto, covenants and agrees that the premises so purchased shall he held subj ct to the covenants, conditions, and restrictions hereinafter set forth. i 1 1 ji ,I I - No lot or plot as shown and designated onithe Minor Subdivision map approved by and filed with the Southold Town Planning Bard shall be further subdivided 2. That the covenants, conditions and restrictions contained herein shall be �i construed as real covenants running with the land ands all continue and remain in full ii force and effect at all times as against the owner of tie premises or any portion , thereof in perpetuity. Said covenants, conditions and estrictions shall be binding upon, inure to the benefit of and be enforceable py the,0eclarants, their heirs, successors and assigns; any owner of any portion of the aforesaid premises, their �.; heirs, successors and assigns, and the Town of Southold' and its successors and assigns, and the failure of any of the foregoing to enf rce any of such covenants, conditions and restrictions shall in no event be deemed a waiver of the right to do s.o. thereafter........,, IN WITNESS WHEREOF, this indenture has been e�ecuted the day and year first above written. onu,� �4uc�N STATE OF NEW YORK ` County of Suffolk I,Court of the State of New York in ARTHUR J. FELICE, Clerk of the County of Suffolk and Clerk of the Supreme Record) DO HEREBY CERTIFY that I haved for compared th Conn being a Co u of yy� annexed copy of 016 X77 x _ and that it is a just and true copy of such original /zz of the whole thereof. i and IN TESTIMONY WHEREOF,I have hereunto set my f and and affixed the of said County and Court this day of seal _ ... 19 '011, _ 10... Clerk, 14-!08 • I,V VuJ i ...v. ... i Mytor,, T°;1`•4" .ta • .t ;:rye Y01* Page 2 u i �e.E. ,vela] �,o-�o-" \ a,9i e,-2398 4a1, xnrcn -- — - b nz s \ t / \: a „RCN or rNE i �� 4r. ' M.WcI te.Mlq OPEN oaax ext5t 9 )H h E S ) a ). CEVEtow[MPrw ! 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FOR—NO C �2rDt 8b' Z,� CCC 5 Or5.0}OOpt Ors OrS060tt WE OreLr3C xO m-w m `*a'e M1N eA^ na of ioa,NUP 1 a W xxN. ]m 7 Qp1S' ,eNa �} a]r p.1 J xrvSl o N 11V 01 ,OS S •ol tw 06 T a ` 12 � A', �` e•e i 'S°nC, rtcoxc ury ,01 ,1 b -- ° � . v ., —1 r rz rsa• ]4wa „ � IF o I • r. o 'Awn 4L ew 1. m /ii sn CREEK — yN 1y{1 � qMN„. 43��P'/ WNO E.E SEC A 11Nc) jpF6. AAMeI su�c� —0112 Iliol 5S t.e O ,y{c1 r.] 'd ,iyLd a ,e t74 in r>A A 1. tl] roxRw SpPNa0 u ,m y1 A. A r, • � ° CP 1•] C FOR RCL.NO•--- —�.` ,�, , ' b� l-% Y.i .aNc) NO w,c. — ...ma.,5 _ SEESEG.N0.050 I`— SEE SEC NO OBB LW 4 R� E; •�� _ _ •� n rxti •• O �� — -- ...y -- NoricE o,>' .:'�g COUNTY OF SUFFOLK © E sourNan sEcrloN No _ _ ___ ____ Real Property Tax Serdce Agency E Mme— — a— ���----- n yM i;S ca.N�..,R,."....a.Nrtl,ol I M � 86 ' Fi:' �,r v FROPE—NAF OFFICE LOCATION: �O�*OF $�(/ryQl MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) CA Southold, NY 11971 �p Telephone: 631 765-1838 U0,Nc� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: John Bredemeyer, President OCT 1 f Town of Southold Board of Trustees From: Mark Terry, Principal Planner s . LWRP Coordinator Date: October 15, 2014 Re: Proposed Wetland Permit for NANCY PEARSON SCTM# 1000-75-7-6.1 & 86-6-31 NANCY PEARSON requests an Administrative Permit for the as-built 8' high deer fencing installed along the landward side of the wetland boundary and along the side yards of the two abutting properties. Located: 3258 South Harbor Road &44332 Main Road, Southold. SCTM#'s 75-7-6.1 & 86-6-31 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed actions are CONSISTENT with the Policy Standards and therefore are CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney James F_King,President *QF SO Town Hall Annex Bob Ghosio,Jr.,Vice-President ��� y�lO 54375 Main Road P.O. Box 1179 Dave Bergen Southold, New York 11971-0959 John Bredemeyer va G @ Telephone(631) 765-1892 Michael J. Domino �0 Fax(631) 765-6641 COUNTY,� BOARD OF TOWN TRUSTEES D EC E Q V TOWN OF SOUTHOLD To: Southold Town Building Department SEP 2 4 2014 Re: Verification of Building Department Permit Requirements BLDG.DEPT. TOWN OF SOUTHOLD SCTM#: Property Owner Name: n C V I eal-r 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 V Will the . / proposed project require a Building Permit? V Will the proposed project require a variance determination from the oning Board of Appeals? Will any part of this application be considered as Demolition as described under Town Code? COMMENTS: i.f ( -FC(r)C �— (;Lk vi-Du hd S 1 sir w4 � Z�. n�+ wv1 Signature of eviewer r Date 0 0 James F.King,President *QF SO Town Hall Annex Bob Ghosio,Jr.,Vice-President �� �� 54375 Main Road h O P.O. Box 1179 Dave Bergen Southold,New York 11971-0959 John Bredemeyer cis Michael J.Domino � Telephone(631) 765-1892 COUFax(631) 765-6641 BOARD OF TOWN TRUSTEES D E Cr` E Q U E TOWN OF SOUTHOLD To: Southold Town Building Department SEP 2 4 2014 Re: Verification of Building Department Permit Requirements BLDG. DEPT. C J TOWN OF SOUTHOLD SCTM#: 0 LC -11 Property Owner Name: rer_r's", Date Sent to Bldg. Dept.: TZ,y J/q 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/ Wi the proposed project require a Building Permit? Will the proposed project require a variance determination from t Zoning Board of Appeals? Will any part of this application be considered as Demolition as described under Town Code? COMMENTS: Signature ofa iewer Date • • John M.Bredemeyer III,President �� so�jiyo Town Hall Annex Michael J. Domino,Vice-President �� lQ 54375 Main Road AL 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 OI�COU Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application _Wetland Permit Application A-Administrative Permit 1 j' _Amendment/Trajsfer/ x ension SEP Received Application: 7 Received Fee:$ — i N- Completed Application _Incomplete _SEQRA Classification: Type I Type ll Unlisted Coordination:(date sent) -A—LWRP Consistency Assessment Form � o /� Date of Inspection: / _Receipt of CAC Report: _Lead Agency Determination: _Technical Review: -11-Public Hearing Held: Resolution: Name of Applicant NoLntmpwsoo Mailing Address 3a69 J O J f h 4bar Rd oa4hol k AW 1101 Phone Number:(��I Suffolk County Tax Map Number: 1000 - Property Location: po� A t0$ ro� -1{�t� - Ct' f�s�r�l yi�wH� 1���-h h�- 5 0v� J (provide LILCO Pole #, distance to cross streets, and location) ,G h r&v, �a r - AGENT: (If applicabl Address: Phone: *d of Trustees Application a r� GENERAL DATA Land Area(in square feet): l / 3K Area Zonai &(1t0JJvvrJ J- cc vt Previous use of property: Na if S Jvd 4TC e 1 d4✓ t ue J jc Intended use of property: Sawt 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.? _✓ ...No _ . Does the structure (s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: �0yolgen►S1115 Date1�S � 09Z 010 /��, � awiIKy 6jai V&S ! of 1 '? 46 11-7 /19q& " re(I) '7145a Z 701'r a A1973 �r03�,ee) (tac r_ 4 b 1 ren-4I-001- an ayT 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: Joy". �14nd h,��h�Gho��C �L�-vh�� (,i how rc nno�� I rn✓4s.ut, Project Description(use attachments if necessary)S1 De 4e nye 7 0 (D Jec+ &J, «t 4 S h r u bs rr '1(Jaltt J `rn� f (46 �a J ,�vre✓ 4 , e4 ✓ (fir l�try W"he P '� trope, �� c 1� A, a I fte w). With n ?(eJc n.4[ 4o4* 6 . a(t/�. .(�./ G• dk r►T'Y T vii -r.*Jrt OP) no Jqry.- Ifor" f si dee✓ +cMrei_ (4� / T k4 rh#o( p�c� ar -�►',tllcc /�,1�6� c� r ow �1 �-j„ �tnc�� Th- +1cc f���GKJ ry el QK m 1� ,� P - 1�1'�cv � -��� --� � �'l� :��,.�,au� .�c h w►�r Z carr ht��✓' y''�`a5V-I*i'L,f Bo* of Trustees Application 40 WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 0i'.1,4 60(-k/ Gr«. 4 Kd 194th d b&l 4e ✓ 4-ei�r x ion.. 31�r,,r3 e29 w�" y Cr` fefc --hese to&S ao pv wcY a th� y w4 ✓ �h G Vr�+'y rCi y pk'J,N�s �GJL �r�t�e �ti ��vrn�a(c.E. 'j�{11N� reCMc - c i R►^� / i ac �l t�� �✓�1�Gkd 1 G(of ;4 S�A )f✓vl Area of wetlands on lot: 30 0 square feet .a Percent coverage of lot: e % Closest distance between nearest existing structure and upland edge of wetlands: 0 11� feet ............... ............. Closest distance between nearest proposed structure and upland edge of wetlands: 3 0 feet 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 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): YIDS 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -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: Project Location(describe,and attach a location map): Brief Description of Proposed Action: r' 6 beer- 1-ence +0 pro—ra ripanur /JIGh1 ,�cp, a� /��+Jt leJ 3 �bile Ndi-hy too - ,?0() 1 � Qk r o � n tl t' GlPP r. Nam p of Applicant or Sponsor: Telephone: E-Mail: h rG f�e•C r�o-, � 1'►'1�� _ c a Address: �a� 8 Sou-14 &-100. City/PO: 3o v� o t stat y ji��-71 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: ❑ 3.a.Total acreage of the site of 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 tt z occur on,adjoining and near the proposed action. E]Urban M Rural(non-agriculture) ❑Industrial ❑Commercial ❑Residential(suburban) Forest 03Agriculture dAquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO ADD 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 YES landscape? al 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: n El 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? ❑ F-1- c. 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: ................... ❑ 10. Will the proposed.action..connect to.an.existing..pub.lic/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? El b.Is the proposed action located in an archeological sensitive area? pin 1 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 o►��► r are likely to be found on the project site. Check all that apply: ❑Shoreline [I Forest [9'Agricultural/grasslands ERIffarly mid-successional 914etland ❑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 If Yes, a. Will storm water discharges flow to adjacent properties? [3 NO []YES ❑ b. Will storm water discharges be directed to established conveyance systems(rupoff and storm drains)? If Yes,briefly describe: ]NO []YES Page 2 of 4 0 0 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: ❑ 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: ❑ 1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE ,D Applicant/spon k '� ✓ r1 Date y– y Signature......... ..... ..... . ... 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 l 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? 1:1 3. 3. Will the proposed action impair the character or quality of the existing community? ET LL❑] 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 ( F]affect existing infrastructure for mass transit,biking or walkway? U 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate 1:1reasonably available energy conservation or renewable energy opportunities? Ell 7. Will the proposed action impact existing: Q El a.public/private water supplies? b.public/private wastewater treatment utilities? ET 0- 8. Will the proposed action impair the character or quality of important historic,archaeological, E]architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, Elwaterbodies,groundwater,air quality,flora and fauna)? 1•� 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? 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. F1Check 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 Bo-O of Trustees Application County of Suffolk State of New York 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 THIS APPLICATION. Signature of Property Owner SWORN TO BEFORE ME THIS ISS _DAY OF ,201 L/ Notary Public CONNIE D. BUNCH Notary Public,State of New York No.01 BU6185050 Qualified in Suffolk County Commission Expires April .14,2Dj� 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 employees.The puroose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: da tir y (Last name,first name,ipiddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate,the.other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other'',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship.with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%!of�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' f of200_ Signature Print Name r-14 C Form TS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its sirup ficant 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. B. DESCRIPTION OF SITE AND PROPOSED ACTION crrL (10 3l SCTM# :2 5, —- --1 - !p. / PROJECT NAME DtCr rinVL The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees L✓� 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: E( Nature and extent of action: ( L�`S�� (�/ Location of action: oA so 4✓bq/ �. Site acreage: ( 3.J 5' 3 Present land use: 5 Present zoning classification: �G 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: J u)Ci H Cc, P45;YSc'e% (b) Mailing address: ? ' ��vNn ' r`w if fou 4-Po (c) Telephone number: Area Code (d) Application number, if any: Will the action be di ctly 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—Poli - s Pages 3 through 6 for evaluation criteria F-1Yes 1-1NoNot Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP ection 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 12 Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section 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. L"J ❑ ❑ Yes No Not Apiftable 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. dYes ❑ No❑ Not 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. 1:1 Yes 1No 1 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. ❑ Yep-n] No 4Not Applicable 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 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. 1:44Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages 62 through 65 for evaluation criteria. Yes ❑ No❑ 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 Not Applicable PREPARED BYkey TITLE DATE y tiG� L 0 \`�,.. Stync�ml fir© �► � �� _ ' (a rax fa OT 5.58'40'10"; BOARD OF I RUSTEES Or 1OVVW OF SOUTHOLD DATE D LSZcAT1 QCY,. 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