HomeMy WebLinkAboutTR-8535A ',,,�
John M.Bredemeyer III,President
°•,,I�pf. S®U74,- Town Hall Annex
54375 Route 25
Michael J.Domino,Vice-President /����,,, ® P.O.Box 1179
Glenn Goldsmith ; '"+" Southold,New York 11971
A.Nicholas Krupski `.' �' }���1�, Telephone(631) 765-1892
Charles J.Sanders = eOUNit Fax(631) 765-6641
... i°�
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
# 1206C Date: March 7, 2016
THIS CERTIFIES that construction of a 22.2'x25.9' two-car garage; construction of a
14'x25'addition to dwelling; new dormer; and construction of a 19'x14' deck attached to
dwelling,
At 4210 Ole Jule Lane, Mattituck
Suffolk County Tax Map#1000-122-4-28
Conforms to the application for a Trustees Permit heretofore filed in this
office Dated-October 3-1-, 2014 pursuant-to which Trustees Administrative Permit#8535A
Dated December 17, 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 22.2'x25.9' two-car garage; construction of a 14'x25'addition to
dwelling; new dormer; and construction of a 19'x14' deck attached to dwelling.
The certificate is issued to MARIE&ERIC MUNTNER owners of the
aforesaid property.
15944- Jct.-% etkoloor
Authorized Signature
John M. Bredemeyer[ff,President ,,,c0IFFOL4-
Town Hall,53095 Main Rd.
P.O. Box 1179
Michael J. Domino,Vice-President Gy
'o Southold,NY 11971
James F.King cn z
Dave Bergen `.y Telephone(631)765-1892
-*O �d��i' Fax(631)765 664 I
Charles J. Sanders 1 4( *..•
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
0. 2(16
DATE OF INSPECTION:
Ch. 275 Ch. 111
INSPECTION SCHEDULE
Pre-construction, silt fence
1st day of construction
1/2 constructed
Project complete, compliance inspection.
•
INSPECTED BY: Glenn Go •
idsrrn 4 ,
COMMENTS: q a
?cc,, G� coM 9‘e-tedlgg Accoc�a Q1 co to F3�rc t- 0 K.
Dcyvie Ws acs . �D
CERTIFICATE OF COMPLIANCE:
John M. Brederneyer 111, President , g1IFF0( Town Stall,53095 Main Rd.
Michael J. Domino, Vice-President 0 `�0° ®G¢ i P.O. Box 1179
James F. King "i _ Southold,NY 11971
Charles J. Sanders OT ++ Telephone(631) 765-1892
Dave Bergen Fax' ' 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
®z constructed
Project complete, compliance inspection
I,,,,it i tee—
John M. Bredemeyer III, President 11//��®� S®u�® Town Hall Annex
lel A® <, : 54375 Main Road
Michael J. Domino,Vice-President ` P.O.Box 1179
James F.King, Trustee % Southold, New York 11971-0959
Dave Bergen, Trustee 1
* 1 Telephone(631) 765-1892
Charles J. Sanders, Trustee �._ 1
/s Fax(631) 765-6641
p 011
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Permit No.: 8535A
Date of Receipt of Application: October 31, 2014
Applicant: Marie & Eric Muntner
SCTM#: 122-4-28
Project Location: 4210 Ole Jule Lane, Mattituck
Date of Resolution/Issuance: December 17, 2014
Date of Expiration: December 17, 2016
Reviewed by: Board of Trustees
Project Description: To construct a 22.2'x25.9' two-car garage; construct a
14'x25' addition to dwelling; new dormer; and construct a 19'x14' 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
survey prepared by Harold F. Tranchon, Jr., Land Surveyor, last dated December
9, 2014, and stamped approved on December 17, 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.
i
Jo n M. Bredemeyer Ill (
President, Board of Trustees
ikk
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•CTM#122428 a
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John Bredemeyer, President Town Hall Annex
Michael J. Domino,
Vice-Presidenti'�° �qOG 54375 Route 25
James F. King s 3 P.O. Box 1179
Charles J. Sanders :o 474 Southold, NY 11971
Dave Bergen ' 01 # �cst Telephone (631) 765-1892
Fax (631) 765-6641
Southold Town Board of Trustees
Field Inspection/Work Session Report
Date/Time: , u I 2 ,/ 7 3°®
MARIE& ERIC MUNTNER requests an Administrative Permit to construct a 22.2'x25.9'
two-car garage; construct a 14'x25' addition to dwelling; new dormer; and construct a
19'x14' deck attached to dwelling. Located: 4210 Ole Jule Lane, Mattituck. STM# 122-
4-28
Ty :-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: ?°
Conditions:
Present Were: J. Bredemeyer M. Domino J. King C. Sanders D. Bergen
Bay Constable Other
Form filled out in the field by
Mailed/Faxed to:
Date:
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I
James F. King,President of/� qSOUi Town Hall Annex
.
0° r® 54375 Main Road
Bob Ghosio,Jr.,Vice-President O l
,� ,. O %� P.O.Box 1179
Dave Bergen i , Southold,New York 11971-0959
John Bredemeyer , �c ��
G, e Telephone(631) 765-1892
N.=Michael J.Doinino : �` 1
1� ®l� Y��� Fax(631) 765 6641
L �� i - COUNTY,* E•if� ¢ �� �
�i iii .� , SIS ��� I�� I�.� �i ��'' 1�� ).
NOVii
BOARD OF TOWN TRUSTEES I i 1; }
►, L } NOV - 6 2014 1
TOWN OF SOUTHOLD � ,
__I
To= Southold Tow Building Department St DC- F,Err.
M. �C'�'r: ;F ilei n . .�
Re: Verification of Building Department Permit Requirements
SCTM#: / . — _c2SO
Property Owner Name: / i c £ 6.&ec-- M h-ler
Date Sent to Bldg. Dept.: ii /O//`/
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
Will the proposed project require a Building Permit?
Will the proposed project require a variance determination from.
th oning Board of Appeals?
Will any part of this application be considered as Demolition as
described under Town Code?
COMMENTS: .
f ' ' //
7/77/7/4
Signature o Reviewer Date
/274 , i,
OFFICE LOCATION: wr 0® MAILING ADDRESS:
Town Hall Annex i °�® �® P.O.Box 1179
54375 State Route 25 Southold, NY 11971
(cor. Main Rd. &Youngs Ave.) cic,c tTelephone: 631 765-1938
Southold, NY 11971 +�® ® " P
C®UNTY,* Pi"
LOCAL WATERFRONT REVITALIZATION PROGRAM
TOWN OF SOUTHOLD
MEMORANDUM
67r
To: John Bredemeyer, President NOV 1 �'
Town of Southold Board of Trustees
From: Mark Terry, Principal Planner
LWRP Coordinator
Date: November 17, 2014
Re: Proposed Administrative Permit for MARIE & ERIC MUNTNER
SCTM# 1000-122-4-28
MARIE & ERIC MUNTNER requests an Administrative Permit to construct a 22.2'x25.9' two-car
garage; construct a 14'x25' addition to dwelling; new dormer; and construct a 19'x14' deck attached
to dwelling. Located: 4210 Ole Jule Lane, Mattituck. STM# 122-4-28
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 provided that the Board considers the following recommendation:
1. Require storm water controls pursuant to Chapters 275 and 236 of the Southold Town
Code.
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
ee,
01#1 1112; Town Hall Annex
John M.Bredemeyer III,President tl 4, 80 'le
54375 Main Road
Michael J.Domino,Vice-President P.O.Box 1179
James F. King,Trustee t Southold,New York 11971-0959
Dave Bergen,Trustee
4, Telephone(631) 765-1892
Charles J.Sanders,Trustee f'ie •01 Fax(631) 765-6641
eOUNTO Al°
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
r • - .
,Office
-
Office Use Only
Coastal Erosion Permit Applicatio - T
OC 3 1 2014
Wetland Permit Application V Administrative Permit
Amendment/Transf r/Extension
_ Received Application. id / :Ov
$/. .Received Fee:$/da
V Completed Application/0/3 VP-/
Incomplete
SlEQRA Classification:
Type I Type II Unlisted
Coordination:(date sent)
VLWRP Consistency Assessment Form /P-i
_CAC Referral Sent:
VDate of Inspection: 1 .2,
Receipt of CAC Repo
Lead Agency Determination:
_Technical Review:
VPublic Hearing Held: Hp 9/14/
Resolution:
Name of Applicant M 1912 le 4 g- kz_ C- (In i T r,d1
Mailing Address LI 6 A C) U Y NJ L AN E s-r i3 U 12, 161-1, NY
73 Phone Number:OA 6 4D - 6 I e q
Suffolk County Tax Map Number: 1000 - 2 2 U ,qg
li
Property Location: t' a( I (-J OL J-1,4 L6 G_R
(provide LILCO Pole #, distance to cross streets, and location)
AGENT:
(If applicable)
Address:
Phone:
rd of Trustees Applicatic
. , .
GENERAL DATA
Land Area(in square feet): i9 i 4 0 6
? Area Zoning: CIC
Previous use of property: SIN& L6 rpm I L `( 1-to rY) e:
Intended use of property: ( &)Cr t & rilmIL ( 14-0K) L-----
Covenants and Restrictions on property? Yes j. 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 V No
If"Yes", please provide copy of decision.
Will this project require,any demolition as per Town Code or as determined by the Building Dept.?
Yes .\/ No
Does the structure(s) on property have a valid Certificate of Occupancy? V Yes No
Prior permits/approvals for site improvements:
Agency Date
rot,),J or, s-oLtri-fro447 (3LD 6 00,-- -
, -# 1 Y q -- 9&-C K-
E C, (Cyl Alin-C1-160) 101 )-01
oe c- I fl- q-73x - 6) 01- Lt-7/000O -3 - Y(ca ( ?7 - P6Gic,
OICPf OF 'Oa viv‘,/ itt to6P - 11,0- 0 37 3o _ q Id ,/ 19q - 00c K..
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):
c'A c,n rc_ G og_14G-C Do[co) e I' l< i-R-1-1 c-:-0 4
PEC K 04.4 yailici ' /X—Ik-,44–'
Bo of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: IJ L-i1 R G E 5i t\i L.
Vf' ri) 1LA Hv11 C-;--
Area
=
{
Area of wetlands on lot: A-4,$r 1-,J a O square feet
B
Percent coverage of lot: '�- 4%
o
r Closest distance between earest existing structure and upland
V , edge of wetlands: clL feet
( Closest distance between warest proposed structure and upland
edge of wetlands: 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? 0) cubic yards
Depth of which material will be removed or deposited: 3 feet
Proposed slope throughout the area of operations: 4 et/
Manner in which material will be removed or deposited:
1)6 Doo roc
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):
i
M0NJ
617.20
Appendix B
Short Environmental Assessment Form
Instructions for Completing
Part l -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 I -Project and Sponsor Information
Name of Action or Project:
5L A /n 1 kbNo ✓170/
Project Location(describe,and attach a location map):
4 10 1,1 TT c(C , „y. fli
Brief Description of Proposed Action:
13Ui
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? f1
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:
1-1
8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES
El
b.Are public transportation service(s)available at or near the site of the proposed action? El
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? rA
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:
El IA
10. Will the proposed action connect to an existing public/private water supply? NO YES
If No,describe method for providing potable water: ❑ E
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 LI
b.Is the proposed action located in an archeological sensitive area?
13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES
wetlands or other waterbodies regulated by a federal,state or local agency? El N
b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody?
If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres:
14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply:
0 Shoreline 0 Forest 0 Agricultural/grasslands ❑Early mid-successional
0 Wetland 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?
16.1s 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? VINO (1YES I`
b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)?
If Yes,briefly describe: NO NYES
.51-0/2411 I /a-( !til
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:
)4/
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: =r I I
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
Applicant/sponsor I C Cr)lJ ✓71/41<f L /OWN7U677_ Date: (O f z7 l
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 1 and other materials submitted by the project sponsor or
otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my
responses been reasonable considering the scale and context of the proposed action?"
No,or Moderate
small to large
impact impact
may may
occur occur
l. Will the proposed action create a material conflict with an adopted land use plan or zoning
It El
regulations?
2. Will the proposed action result in a change in the use or intensity of use of land? -
3. Will the proposed action impair the character or quality of the existing community?
4. Will the proposed action have an impact on the environmental characteristics that caused the
establishment of a Critical Environmental Area(CEA)? 1 ,/I
5. Will the proposed action result in an adverse change in the existing level of traffic or
affect existing infrastructure for mass transit,biking or walkway? I-J
6. Will the proposed action cause an increase in the use of energy and it fails to incorporate (
21 �
reasonably available energy conservation or renewable energy opportunities? 1-1
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?
9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands,
waterbodies,groundwater,air quality,flora and fauna)?
Page 3 of 4
No,or Moderate
small to large
impact impact
may may
occur occur
10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage
problems?
Nr\f‘t
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.
•
n Check this box if you have determined,based on the information and analysis above,and any supporting documentation,
f J that the proposed action may result in one or more potentially large or significant adverse impacts and an
e vironmental 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 environment impacts.
Town of Southold Board of Trustees /1 ) b/ i a
Name of Lea Agency Date
SID H 6a ( President
Print or. ype Name of Responsible Officer in Lead Agency Title of Responsible Officer
At �/
°
. attire of Sponsible Office i Lead Agency Signature of Preparer(if different from Responsible Officer)
PRINT Page 4 of 4
!,,111111/I,•,,,'
Town of Southold
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Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM
O - ,.
PROPERTY LOCATION: S.C.T.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A
\''al)�j �}-,`•� STORM-WATER,GRADING,DRAINAGE AND EROSION CONTROL PLAN
�•7fr,,,'' ism Wi Block —of t CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK.
SCOPE OF WORK - PROPOSED CONSTRUCTION ITEM# / WORK ASSESSMENT YesNo
a. What is the Total Area of the Project Parcels? 1 Will this Project Retain All Storm-Water Run-Off
(Include Total Area of all Parcels located within ( r� 1''
the Scope of Work for Proposed Construction) ..,
I i 9 5 1 Generated by a Two(2")Inch Rainfall on Site?
(S.F./Acres) (This item will include all run-off created by site 0
b. What is the Total Area of Land Clearing clearing and/or construction activities as well as all
and/or Ground Disturbance for the proposed ,g a-. Site Improvements and the permanent creation of
construction activity? impervious surfaces.)
(S.F./Acres)
2 Does the Site Plan and/or Survey Show All Proposed
PROVIDE BRIEF PROJECT DESCRIPTION (Provide Additional Panes as Needed) Drainage Structures Indicating Size&Location?This I 111
Item shall include all Proposed Grade Changes and —
°, CAW—z G. `r D o iLM�— Slopes Controlling Surface Water Flow.
s� 3 Does the Site Plan and/or Survey describe the erosion
K. 1i - --k 'f d. 9 E'..-7_, K. and sediment control practices that will be used to `a—f/
control site erosion and storm water discharges. This
item must be maintained throughout the Entire
Construction Period.
4 Will this Project Require any Land Filling,Grading or
Excavation where there is a change to the Natural
Existing Grade Involving more than 200 Cubic Yards
of Material within any Parcel?
5 Will this Application Require Land Disturbing Activities
Encompassing an Area in Excess of Five Thousand
(5,000 S.F.)Square Feet of Ground Surface?
6 Is there a Natural Water Course Running through the
Site? Is this Project within the Trustees jurisdiction
General 'DEC SWPPP Requirements: or within One Hundred(1001 feet of a Wetland or
Submission of a SWPPP is required for all Construction activities involving soil Beach'?
disturbances of one(1)or more acres; including disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes
are part of a larger common plan that will ultimately disturb one or more acres of land; which Exceed Fifteen(15)feet of Vertical Rise to '–
including Construction activities involving soil disturbances of less than one(1)acre where One Hundred(100')of Horizontal Distance?
the DEC has determined that a SPDES permit is required for storm water discharges.
(SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit 8 Will Driveways,Parking Areas or other Impervious
for Storm Water Discharges from Construction activity-Permit No.GP-0-10.001.) Surfaces be Sloped to Direct Storm-Water Run-Off 111 j
1.The SWPPP shall be prepared prior to the submittal of the NOI.The NOl shall be into and/or in the direction of a Town right-of-way?
submitted to the Department prior to the commencement of construction activity.
2.The SWPPP shall describe the erosion and sediment control practices and where 9 Will this Project Require the Placement of Material,
required,post-construction storm water management practices that will be used and/or Removal of Vegetation and/or the Construction of any
constructed to reduce the pollutants in storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder —
compliance with the terms and conditions of this permit.In addition,the SWPPP shall Area?(This item will NOT Include the Installation of Driveway Aprons.)
identify potential sources of pollution 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 Cheek Mark
3.All SWPPPs that require the post-construction storm water management practice in a Box and the construction site disturbance is between 5,000 S.F.&1 Acre in area,
component shall be prepared by a qualified Design Professional Licensed in New York a Storm Water,Grading,Drainage&Erosion Control Plan is Required by the Town of
that is knowledgeable in the principles and practices of Storm Water Management. Southold and Must be Submitted for Review Prior to Issuance of Any Building Permit
(NOTE: A Check Mark(4)and/or Answer for each Question is Required for a Complete Application)
STATE OF NEW YORK
, CS'
�aCOUNTY OF SS
That I,... &k. being duly sworn,deposes and says that he/sl is the applicant for Permit,
(Name of individual signing Document)
And that he/she is the 0W fJ c,F it
(Owner,Contractor,Agent,Corporate Officer,etc.)
Owner and/or representative of the Owner or Owners,and is duly authorized to perform or have performed the said work and to
make and file this application;that all statements contained in this.application are true to 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 m e this;
m
r dayof 6611)6 20. . `;
Notary Public: ..... t aw ARVINDLALL
���a ..yr
(Signature of Applicant)
Nat
FORM - 06/10 Comelery Publicesien wee.:t5 5 ofeNg1k i°
Bc 1 of Trustees Application
County ofl4
State of New York
EPIC, rivet 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.
Signature o' Pro y Owner
SWORN TO BEFORE ME THIS e DAY OF 6c1Oacit ,20 /
4
Af. #
Not. Public
AnVIN®LAU.
Wary P ile,VZIong T
oni
OidkiiiigtllnWawa Cate 2011
4i 1i lit1 a1 a*Not t9i etiI It.
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 purpose 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: tq VI d✓ I L g- I C— 4- in U
(Last name,first name,puddle 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 the shares.
YES NO
If you'answered"YES",complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of Southold
Title or position of that person
Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check
the appropriate line A)through D)and/or describe in the space provided.
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply):
A)the owner of greater than 5%of the shares of the corporate stock of the applicant .
(when the applicant is a corporation);
B)the legal or beneficial owner of any interest in a non-corporate entity(when the
applicant is not a corporation);
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this Al day,pf (9 6,0),:0- 20$rA-
Signaturec r
Print Name J t[G. 1 j in Alt-I C /' c) 011°
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 significant
beneficial and adverse effects upon the coastal area(which includes all of Southold Town).
3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will
affect the achievement of the LWRP policy standards and conditions contained in the consistency
review law. Thus, each answer must be explained in detail, listing both supporting and non-
supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and
conditions,it shall not be undertaken.
A copy of the LWRP is available in the following places: online at the Town of Southold's
website(southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all
local libraries and the Town Clerk's office.
B. DESCRIPTION OF SITE AND PROPOSED ACTION
SCTM# 02 - c''/a
PROJECT NAME UWL u 1u- 1\J L
The Application has been submitted to (check appropriate response):
Town Board ❑ Planning Board❑ Building Dept. Board of Trustees ix
l. 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:
15u I Ld, c 1st0G-6, 1)Dia) M ,
K <-rz d- ����
Location of action: 14d, 1 0 (AL 3-1u,l% )f3 lin f 1 I C I< f J t-i I g 5 a
Site acreage:
Present land use: Si o( % I-rnrn ( NV
Present zoning classification: A, ~ l)
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: (Y) A (t I l: a- C I L t ' u O-r-u
(b) Mailing address: 14-() u u d4 IJ L-t3
� s n jG(I Nom( [ li3 -
(c) Telephone number: Area Code(S11' ( - (g
(d) Application number,if any:
Will the action be directly undertaken,require funding, or approval by a state or federal agency?
Yes ❑ No v . 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.
n Yes n No 1%1 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—Policies Pages 3 through 6 for evaluation criteria
❑ Yes No Not Applicable
Attach additional sheets if necessary
Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See
LWRP Section III—Policies Pages 6 through 7 for evaluation criteria
Yes No k Not Applicable
Attach additional sheets if necessary
NATURAL COAST POLICIES
Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP
Section III—Policies Pages 8 through 16 for evaluation criteria
Yes ❑ No ` 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.
Yes ' No Not App_-__'ble
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 n NolA 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.
Yes No {21 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.
YeE No M Not Applicable
Attach additional sheets if necessary
WORKING COAST POLICIEL
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 Fl 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 No12 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 l! 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 171 Not Applicable
PREPARED BY (c fil t a rN eot TITLE Obi Cit DATE 121/
14-145
LOT AREA = 17,799 SQ. FT. 14-273
ERNEST PAUL WILSBERG de DONNA WILSBE
ANITA PAARTINELLI (enoiling)4095 OLD JULE LA.f
4005 OLD JULE LANE (physical)3547 OLD JULE IAG.
WILLIAM M.
SR & MARYANN GREMLER MATTITUCK, N.Y. MATTITUCK, N.Y.
3905 OLD JULE LANE 1000=1225-24
PAATTITUC4t, N.Y. i1000-122-5-23.5
1000-122-5-25
DWELLING/WELL DWELLING/PUBLIC WATER
DWELLING/PUBLIC WATER
hyd
• ® ELEV. TOP OF
® existing water main HYDRANT=
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�sk ' " ' ` OLE LANE
(8.2)� PV:'' 'APPROVED B
JULE
(8.0)
o.00` X40
T { 0 S
-90
N 56®27 1 (�"� 10 _ __ ,Q
edge of pavement Pole
•
® 786.87'
ca3 01
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' 11' ® Z
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® o masonry [„p
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® ® (8.2 stoop (8.1) O
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a 14.1' mom prop porch o, 'I 6.4' CO _
CA 36.7r '_ a , > I
CA / 26.0'
ry 1 STY FR DWELL 0, t ® O 73
wd picket N pr" & FEL ELEV=10.5
CO fence co a•1-.0° BASEMENT=2.6 I�
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® 0 0 2.2' X111 25° ce 20.5° O
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in addition "eC' '1
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® G? Q W 6 14.0'x22.9 shed til W I '
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OD �C� x \z®A,e (6.6)x L 6:6 C e' c�
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P� C) Z 0 (5.6) (6.2) 6 shed r
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TIDAL WETLANDS as FLAGGED by 5
/ THOMAS W. CRAMER, ASLA, ON JULY B. 2014
4.X 5 fIa # 5
C flag 8 flag 7 flag 11 6 f'o. 4 flag 1 X(4.5)
(4.3) flag flag 2 I0.3°E
X (3.9r (qX)
r1
...'' itidal X11' -_...� w wd walk
we#lands 'no high water bLolkheading
79.1C
S 53°48 24 Vd
- -cIn��l
wood dock _ ®pprox. low voter C (8 1
4'x2. wood ramp CANAL 22.70'
CANAL 3x14°
' wood floating dock
6'x20'
LOT COVERAGE
EXISTING, BLDG.,DECK,STEPS and ',.SHED = 1451 SQ. FT.
PROPOSED ADDITIONS 1287 SQ. FT.
TOTAL = 2,738 SQ. FT.
LOT UPLAND AREA = 17,400 SQ. FT.
12-9-2014 REVISED PROPOSED ADDITION 2,728 / 17,400 = 15.7%
6-25-2014 REVISED ZONE LINE
7-29-2014 REVISED, ADDED WETLAND FLAGGING,LOCATED MEAN LOW WATER and
ADDITIONAL NOTES AS REQUESTED
4-4-2014 ADDED HEALTH DEPARTMENT INFORMATION r DATUM N.G.V.D. >,1929
THE OFFSETS (OR ) SHOWN HEREON FROM THE SIDUCIURES TO THE
PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND USE AND THERWORE ARE NOT JOB No. 13-298 FILE No. 955 F
WENDED TO GUIDE THE EREGTON OF FTS, REMIND WALL POOLS; PAATIOS.
PLANTING AREAS, ABOITION TO d3UBLCBBdGS OR ANY OTHER CONSTRUCTION.
NOTE: SURVEYED FOR
Location o f water mains 2ED ALTERATION OR ADDITION TEl THIS SURVEY IS A VIOLATION OF SECTION
7208 OF THE NEW YORK STATE EDUCATION LAW.
Sc adjoiners water supply
by others and are not OUARAAREES INDICATED RENON LL RUN ONLY TO THE PERSON FOR WHOM THE
guaranteed. SURVEY Is PREPARED,AND ON IRS BEHALF TO THE TITLE COMPANY, 00VERNMENTN. SITUATED AT MATTITUCK
AGEPBd:'Y AND LENDIND HanlImm LISTED HEREON,AND TO THE ASSONEES OF THE
.0LtmonTEs ARE NOT TRANSFERABLE To ADOMONAL iNsuninoms TOWN OF SOUTHOLD, SUFFOLK COUNTY, N.Y.
OR SUBSEQUENT OWNERS.
CONES OF DAIS SURVEY MAP NOT BEARING THE LAND SeRVEYOet`S BAH4ED SEAL OR SCALE 1" = 30' DATE 12-3-2013
EMBOSSED SEAL SHALL NOT RE CONSIDERED TO BE A VAUD TRUE COPY.
FILED MAP No. DATE
CERTIFIED ONLY TO: TAX MAP No. (REF ONLY) 1000-122-4-28 DISK 2013
HAROLD F. TRANCHON JR. P.C.
LAND SURVEYOR
P.O. BOX 616
1866 WADING RIVER-MANOR RD. WADING RIVER,
fi,---c_c1 . NEW YORK, 11792
HAROLD F. TRANCHON JR. PENN.LIC. No. 211159E 631-929-4695