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HomeMy WebLinkAboutTR-8523A John M. Bredemeyer Ill, President o�ogUFFQ( -co Town Hall,53095 Main Rd. Michael J. Domino, Vice-President �� Gy: P.O. Box 1 179 James F. King N x Southold,NY l 1971 Charles J. Sanders � �� 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 1 st day of construction '/ constructed Project complete, compliance inspection 0 0 John M. Bredemeyer III, President O��QF S�ujyOl Town Hall Annex Michael J. Domino,Vice-President ~ 54 Main Road P..O.O. Box 1179 James F. King, Trustee C Southold, New York 11971-0959 Dave Bergen, Trustee Telephone (631) 765-1892 Charles J. Sanders,Trusteeli"COU ,� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8523A Date of Receipt of Application: October 8, 2014 Applicant: April & Norman Wenk SCTM#: 31-16-2.2 Project Location: 415 Huckleberry Hill Road, East Marion Date of Resolutionlissuance: November 19, 2014 Date of Expiration: November 19, 2016 Reviewed by: Board of Trustees Project Description: To add approximately 100 cubic yards of clean fill, and re- grade area to restore the eroded slope of the bluff. 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 April & Norman Wenk, received on October 8, 2014, and stamped approved on November 19, 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. 'M ohn M. Bredemeyer III President, Board of Trustees 0 0 John Bredemeyer, President �SUFFO(,r 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 y�o! ,� �a°! Telephone (631) 765-1892 Fax (631) 765-6641 Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: 1/'I, l lo APRIL & NORMAN WENK request an Administrative Permit to add approximately 100 cubic yards of clean fill, and re-grade area to restore the eroded slope of the bluff. Located: 415 Huckleberry Hill Road, East Marion. SCTM# 31-16-2.2 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 needed: Modifications: r Conditions: L✓� n �� Present Were: / J. Bredemeyer rM. Domino,�f J. King`' C. Sanders D. Bergen Bay Constable Other Form filled out in the field by �l Mailed/Faxed to: Date: Ck _V7 a f"y ____._ us ��� ro ,rA,5 l.• v 1 V 'e, illi i tvt � .. 111 ,,,pr�. 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W. o1r p N.59 08' E: / \ UNAUTHORIZED ALTERATION OR ADDITION rO THIS SURVEY IS A VIOLATION OF SECTION 7:09 OF THE NEW YORK STATE # G_ 1 pp \ E^:l::ATION LAW. CCrITS Cf 7f'1S SU2VZY eSAP NOT SEARING �._._._,• _ .s - T THE LAIT) X `J.0 SIAL OR �� �_ �I EP1E;'.` ^ �.._•,. B°CONSIDERED I /J TOS: AFF D .. OCT - 8 2014 6�,,a CL1Av T A :i SHALL; E Sd"EY i V i 11 r A. s Azo ;o T►E ITLt C o, 6 N AL ri:a�:-Y AND { f sOUthn �7�1n ttEASSn.-A A n iT TXAWlESA::..' I Bq�r 01�rUStE f S- _-� W c1v<A\AL��.�i�,lOa6 OR SUSS"'QQ1 N 40 -5,�A L F. w -- - � T Q AREA F. d T 1 1,E NO. 107- 5 261AG Lo I �,AT 7 p- � t C �' :,<.! t �,t_ . 1C: . k* rillG ~•1 ;.'.q�tlr,•��^1•I T►T�E lNSi. >�fa� ta. U. 0 0 OFFICE LOCATION: �O�*Of S�(/ryQl MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 [ [ Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) cn 41r Southold, NY 11971 �� Telephone: 631 765-1938 01 it LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM r� To: John Bredemeyer, President ? Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: November 17, 2014 ; a Re: Proposed for an Administrative Permit for APRIL & NORMAN WENK SCTM# 1000-31-16-2.2 APRIL & NORMAN WENK request an Administrative Permit to add approximately 100 cubic yards of clean fill, and re-grade area to restore th^ded slope of the bluff. Located: 415 Huckleberry Hill Road, East Marion.�_SCTM# 31-16-2.2 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 �sorry Town Hall Annex Bob Ghosio,Jr.,Vice-President 5437.Main Road �� � P.O.Box 1179 Dave Bergen l 4 Southold,New York 11971-0959 John Bredemeyer ip Telephone(631)765-1892 Michael J.Domino O Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Applicatio _Wetland Permit Application Administrative Permit Amendment/Transtf /E ension as pt iiab n n eceived Application: ai Received Fee:$ 6,.ede vv>ey _Completed,Application IL-J) Incomplete OCT ' 8 2014 _SEQRA Classification: i Type I Type Il Unlisted ' _Coordination:(date sent) South ntv;i ]�,�,WRP Consistency Assessment Form CAC Referral Sent: Date of Inspection: 2 _Receipt of CAC Report: Lead Agency Determination: Zechnical Review: ublic Hearing Held: Resolution: Name of Applicant 1 �1 Ytit� Cc� Mailing Address A?-- W e-t bov+0 N ltg3t �' Phone Number:(Q6) 7y N Suffolk County Tax Map Number: 1000-0 31 —1 to- 2—- � Property Location: S 30U"���11 kanMQ.• AKA `tl�- 1ju ;Kc,&- G4G4A f 'L' L^ ma<i on . Nkk- 119 30 (provide LILCO Pole#, distance to cross streets, and location) AGENT' (If applicable) Address: Phone: 10/20/2014 11:46 5163498389 ACM PAGE 02/04 • • Board of Trustees Application GENERAL DATA Land Area.(in square feet): q! `t o o Area.Zoning: Previous use of property: RL t �� Intended use of property: Covenants and Restrictions on property? Yes No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes INo 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 �Nv If""Yes",please provide copy of decision. Will this project require any demolition as per Town.Code or as determined by the Building Dept.? E No Does the structure(s)on property have a valid Certificate of Occupancy? V"Y' es No �^ 1 Prior permits/approvals for site improvements: G i Agency Date No prior poT nits/approvals for site improvements. i Has any permit/approval ever been revalued or suspended by a governmental agency? o yes If yes,provide explanation: Project Description(use attachments if necessary): ' 9A st7bc- or PLdctit r.- 9LU t= Folo-d Mf T3 To f s m4 S (A Irox 100 el 1012012014 11:46 5163498389 AC&M PAGE 03/04 Board Of Trustees Application WETLANDITRUSTEE LANDS APPLICATION DATA, Purpose of the proposed operations:Rf`"P,& A A,6,A W*-s FS-�- d V-1 (3� j: 04&r&0)b 1-401 /b E- cr ref! &A y ,J3 LU F r= FA#M � o 13 to Ll</t6A� IP mt- 0 F a EASY s i"-- 1_9TRA_A- eA) OF Sc.o�G- �N l3l.C?r�' F►L c. -Tv P 6 A'��Q J 04b 6�� Area of wetlands on lot: 2 41 1 L40 0 square feet (15W�o x_ flu c K 43cv") Percent coverage of lots % (S- ,+vb 8- 2 0 Cl< (3 6A-C44} Closest distance between nearest existing structure and upland t-G -P y4 r s1vk-.• edge of wetlands: "' o feet i-r�:o r � W&AJ ( Closest distance between nearest proposed structure and upland edge of wetlands: feet N a {Rd t o.s e] Does the project involve excavation o filling? No tomes If yes,how much material will be excavated?__Q Cubic yards How much.material will be filled? cubic yards Depth of which material will be removed or d ( feet /a. rA eke ; i' Proposed slope throughout the area of operations: Manner in which material will be:reiuovedr 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): /VOL ." 617.20 Appendix B Short Environmental Assessment Form i' Instructions for Completing i 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 s respond to any item,please answer as thoroughly as possible based on current information. f 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 I -Project and Sponsor Information R , 1 ovv d O ver wk.- _ �o t Wn tr t Name of Action or Project: r4 /A Project Location(describe,and attach a location map): AKA �i V(1 L,- 6-ft" (4-1 1,t, it I Sou -n LA/Vif Brief Description of Proposed Action: out l u )�ke'e"d Name of Applicant or Sponsor: Telephone: S� .. y 1—� ' �gl 0 Y�4 �D ww" W C'4A,C� E-Mail: W& (S SCA1 S , 60 M Address: Ci /PO: State:( Zip Code: 6 1� 0-30 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? id 1:1If 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? . o acres b.Total acreage to be physically disturbed? so-I;—acres c.Total acreage(project site and any contiguous properties)owned J or controlled by the applicant or project sponsor? •Q� acres i 4. Check all land uses that occur on,adjoining and near the proposed action. / ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial ®Residential(suburban) ❑Forest ❑Agriculture El Aquatic ❑Other(specify): .. ❑Parkland .Page 1 of 4 4 i i , f i 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 IRr 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: FO ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO 1 YES 0 ❑ 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? Q ❑ 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: ❑ EJ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ 11.Will the proposed action connect to existing wastewater utilities? I NO YES If No,describe method for providing wastewater treatment: A/ ❑ ❑ 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? i 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? i If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: I 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 ❑ Wetland ❑Urban ❑Suburban Al I t 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? (�' ❑ t;J s. 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, �( i a Will storm water discharges flow to adjacent properties? EdNO ❑YES LJ ❑ j b.Will storm water discharges be directed to established conveyance systems(runoand storm drains)? If Yes,briefly describe: 4O QYES Page 2of4 i s k- 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: © ❑ i i.. 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 THXINF MATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGEApplicant/sponsor nam1 IV��n1GM �(�U Date: �� 1 Signature j 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?" i No,or Moderate small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? ❑ 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ 3. Will the proposed action impair the character or quality of the existing community? F1 D I. 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑ establishment of a Critical Environmental Area(CEA)? S. 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? i 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, ❑ E]architectural or aesthetic resources? 9_ Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, EJ ❑ waterbodies,groundwater,air quality,flora and fauna)? t Page 3 of 4 I I( I i 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 ® a 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, j duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. i•. i I. i i . j. i IJCheck this box if you have determined,based on the information and analysis above,and any supporting documentation, t the proposed action may result in one or more potentially large or significant adverse impacts and an nvironmental 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 'mpacts. Town of Southold-Board of Trustees i, I W l () i Nam f Lead Agency Date -D h h C. � e I^1 a �'/ President Print or ype Name of Responsible Officer in Lead Agency Title of Responsible Officer gnature of Res nsible Officer#Lead Agency Signature of Preparer(if different from Responsible Officer) I PRINT Page 4 of 4 i UVUVTown of Southold Erosion, Sedimentation A Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATtON S.C.TALM: THE FOLLOWING ACTIONS NIAY REQUIRE THE SUBMISSION OF A Is-be p3 1 -11L I Y Z STORM WATER,GRADING,DRAINAGE AND EROSION CONTROL PIAN MMW- Sdb. -gam- -ar-- CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK SCOPE OF WORK - PROPOSED CONSTRUCTION TEEM# / WORK ASSESSMENT Yes No a. What is the Total Area of the Project Parcels? gOn 1 Will this Project Retain All Storm-Water Run-Off (Include Total Area of all Parcels located within s.f 01 Wa Generated by a Two(2')Inch Rainfall on Site? lir/A the Scope of Work for Proposed Construction) —/* (S.F h�) (This item will include all run-off created by site b What is the Total Area of!and Clearing f o c clearing and/or construction activities as well as all — and/or Ground Disturbance for the proposed S.f• ,Q 2 Site Improvements and the permanent creation of ; construction activity? (S.F.f Aaas) impervious surfaces.) )✓,A I BRIEF PROJECT DESCREMON M-4"Aam�eeeh Paq-a N-dwl) 2 Does the Site Plan and/or Surrey Shaw All Proposed PROVIDE — Drainage Structures Indicating Size&location?This j item shall include all Proposed Grade Changes and �; O rl ��GV4 d �d S Slopes Controlling Surface Water Flow. N A e V 3 Does the Site Plan end/or Survey describe the erosion �Q and sediment control practices that will be.used to ❑ p control site erosion and storm water discharges. This av f b J I I�kla,d Item must be maintained throughout the Entire ilmit- 40 ,IW`c Construction Period. . 1 lr a 4 Will this Project Require any Land Filling,Grading or Excavation where there is a change to the Natural ❑ Existing Grade involving more than 200 Cubic Yams of Material within any Parcel? �j Will this Application Require land Disturbing Activities / Encompassing an Area in Excess of Five Thousand �/ (5,000 S.F.)Square Feet of Ground Surface? 6 Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction General DEC SWPP Requirements- or within One Hundred(100')feet of a Wetland or Submission of a SWPPP is required for al Construction actvides Involving sol Beach? disturbances of one(1)or moreease; including disturbances of less than one ace that are Wil there be.Site preparation on Existing Grade Slopes / 1 are pan of a larger rwnxhmon plan that Will ultimately disturb one or more saes of hand; which Exceed Fifteen(15)feet of Vertical Rise to —/ trhctuding Construction ectirides involving sol disturbances of less than one(1)acre where One Hundred(100')of Horizontal Distance? the DEC has determined that a SPOES perut is required for storm water discharges. (SWPPP's Shall meat the Minimum Requirements of the SPDES General Permit 8 Will Driveways,Parking Areas or other Impervious / for Storm Water Discharges tram Construction actvtty-Permit Na GP-0+10-001t Surfaces be Sloped to Direct Stonm-Water Run-ON 1.The SWPPP shall be prepared prior to the submittal of the NOI.The NOI shall be into and/or in the direction of a Town right-of-way? — � submitted to the Department prior to the commencernent of construction act*. 2.The SWPPP shall describe the erosion and sediment control practices and where 9 Will this Project Require the Placement of Material, required,post wri struction si mn water management practices that will be used and/or Removal of Vegetation and/or the Construction of any constructed to reduce the Wutarft in storm water discharges and to assure Item Within the Town Right-af-Way or Road Shoulder — oomptance with the terms and conditions of this pertNt.In addition,the SWPPP shall Area?(mra Item win NOT inNude the bouna on of Driveway 4ramis.) identify potential sources of polutbn which may reasonably be expected to affect the quality of storm water discharges. NOTE: If Any Answer to Questions One through Nine Is Answered with a Chock Mark in a Box and the construction she dkWrbanee Is between 3,000 S.F.31 Acre In area, 3:Al SWPPPs that require the post�onstrhxdion storm water mahmgement practice In Sionn-Water,Grading,Drainage&Erosion Control Plan Is Required by the Town of comporemt shall be prepared by a quallfled Design Professional Licensed in New York Southold and Must be Submitted for Review Prior to issuance of Any Building Permit that b knowledgeable in the Principles and practices of Storm Water Management (VOTE: A peck Mark(4)andror Answer for each oueseton is Required for a Complete ApMcd-) S1A.TE OF NEW YORK, C _ COUNTY OF...........................................SS That IAvA 1 .`!�!.t L.-N 0(N M kolk---being duly swom,deposes and says that he/she is the applicant for Permit, (Name of individual stgrft Document) I: And that he/she is the .................... (owner,conG;tor,Agent,Caipoiale OfScer,etc.) Owner and/or representative of the Owner or Owners,and is drily authorized to perform or have performed the said work and to make and file this application;that all statements contained in this.application are true to the best of his knowledge and belieF,and that the work will be performed in the manner set forth in the application filed herewith. Sworn to before me this; LP TFday,of...OC( .......... ....... .... 201. Notary Public: ....1......!.-� ....... n, . ... ... (Signature d Appswrhl) iUNL FORM - 06110 Mtlttry Public, State of Now York i Req. No• 485'.3571 i Qualff)ed in Nassau Countya p l Commission Expires May 19,�,- • • Board of Trustees Application i County of Suffolk State of New York I yiQJ- pv,.,ck ' Jo(M&y\ BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN.THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES(S),TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. .. ignature of Property Owner SWORN TO BEFORE ME THIS DAY OF 0 GT 1201 f Notary Public Notary Fundic. State of Now York Req. No. 4859357 Qualified In Nassau Countya t)f Commission Expires May 19, I j l APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Townof 5 thold's Code of Ethics prohibits conflicts of interest on the pert of tgy n of lets and em loovees Tk nuroose of this form is to provide inforinglion which can alert the town ofymlhle conflicts of interest and allow it to take whatever action is j ngcomm to avoid same. YOUR NAME: (Last name,first nalne,q»ddle 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 Q�van Variance e TTrustee 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, f 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%o the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person I 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. I 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 I (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of 200_ Signature___.:._ Print ignature - Print Name Form TSI Town of Southold LWRP CONSISTENCY ASSESSMENT FORM _ A. INSTRUCTIONS i 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 significant beneficial and adverse effects upon the coastal area(which includes all of Southold Townl. 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. i 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 l local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# 1000 -D3l - 16— 2.2 OCT — 8 PROJECT NAME IJ o k. The Application has been submitted to(check appropriate response): s 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) ❑ i_ (b) Financial assistance(e.g.grant,loan,subsidy) t. (c) Permit,approval,license,certification: 2/ Nature and extent of action: d� n l W PF �.�d r 6vI khaj -6 � r C, j )RA- Location of action: -SOV LAMt I &S,� v-A 9 3 Site acreage: -02- OLUe Present land use: Present zoning classification: I 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: AQ 11 K6WVK W&WL i I (b) Mailing address: ZWt I Itj I, (c) Telephone number:Area Code(n�) (d) Application number,if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? i 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. l 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 i i Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LVVRP Section III—P oli Pages 3 through 6 for evaluation criteria El yes ❑ No j r i Attach additional sheets if necessary i 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 [3/Not Applicable i i i I 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 Pa es 8 through 16 for evaluation criteria ❑ Yes ❑ No Not Applicable I' i (i Attach additional sheets if necessary f 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 F] Yes ❑ No Not Applicable i e Attach additional sheets if necessary i Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including 4 Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages.22 through 32 for evaluation criteria. Yes No Not Applicable I� Attach additional sheets if necessary I 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 Not Applicable i 'i 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. ElYes 11No la'Not Applicable ' I. i PUBLIC COAST POLICIES I I Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public j resources of the Town of Southold. See LWRP Section III-Policies; Pages 38 through 46 for evaluation i criteria. 1 ❑ Ye�-] No U Not Applicable i f Attach additional sheets if necessary E ;f k WORKING COAST POLICIES 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 I i 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. j ❑Yes ❑ Nola Not Applicable r i i I i 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 forevaluationcriteria. El Yes ❑ No u Not Applicable I I F Attach additional sheets if necessary i I Policy 13. Promote appropriate use and development of energy and mineral resources. 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