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HomeMy WebLinkAboutLomangino, AnthonyI 3 peUf1`0 Bob,G os o,Jr., Vice -President nt �� C4G� P.O. Box 1179 `Southold, NY 11971 James F. King ,\ Telephone (631 765-1892 Dave Bergen U&- , Fax (631) 765-6641 Jolm Bredemeyer G '`F Southold Town Board of Trustees Field InspectionMorksession Report. Date/Time: Inspect the property of ANTHONY LOMANGINO and review therevised plans submitted by Briarcliff dated November 22, 2011 for consistency with the approvals granted on October 19, 2011 — Administrative Permit and Wetland Permit pending approved plan. Located: 8925 & 9105 Bay Ave., Cutchogue. SCTM#104-3-15&18.1 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 fails under: _Chapt.275 . Chapt.111 other Type of Application: Wetland _Coastal Erosion _Amendment —Administrative—Emergency Pre -Submission Violation Info needed: Modifications: Conditions: Present Were: J. Doherty j. King B. Ghosio J. Bredemeyer D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: Date: .D. Bergen, hony Lornangino 5 Bay Avenue, Cutchogue M# 104-3-15 9/2011 '�* - "1 '-7- MIMI or Apo o It JA k k. WL' —Mach, %x Anthony Lomangino 9105 & 8925 Bay Avenue, Cutchogue v SCTM#'s: 104-3-18.1 & 104-3-15 16 _ ,Jr 3a• 1�"gad lt+4.', , Anthony Lornangino 9105 & 8925 Bay Avenue, Cutchogue SCTM#'s: 104-3-18.1 & 104-3-15 11/9/2011 j,- - Peter Young, Chainnany Town Hall, 53095 Main Rd. Lauren Standish, Secretary d P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631) 765-6641 Conservation Advisory Council Town of Southold 'At the meeting of the Southold Town Conservation Advisory Council held Wed., October 12, 2011, the following recommendation was made: Moved by Jack McGreevy, seconded by Audrey Horton, it was RESOLVED to SUPPORT the Wetland Permit application of ANTHONY LOMANGINO to landscape; install Belgian block curb; reset existing walk and patio; create mulch walking. path; Belgian 'block apron; clean out and enlarge existing pond; plant evergreens around existing shed; install putting green; horseshoe pits; bocceball court; 'install paved driveway and drywells. Located: 8925 Bay Ave., Cutchogue. ;SCTM#104-3-15 Fnspected by: 'Peter Young, Jack McGreevy, Derek Bossen The CAC Supports the application, however, questions whether the "cleaning-out" of a pond is a permitted activity. Vote. of Council: Ayes: All 'Motion Carried Jill M. Doherty, President osu�Fo�,� Q� 4 Bob Ghosio, Jr., Vice -President James F. King Dave Bergen y - John Bredemeyer Gy viol � ,hyo Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: P.O. Box 1179 Southold, NY 11971 Telephone (631765-1892 Fax (631) 765-6641 ANTHONY'LOMANGINO requests a Wetland Permit to landscape; install Belgian block curb; reset existing walk and patio; create mulch walking path; Belgian block apron; clean out and enlarge existing pond; plant evergreens around existing shed; install putting green; horseshoe pits; bocceball court; install paved driveway and drywells. Located: 8925 Bay Ave., Cutchogue. SCTM#104-3-15 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 —Administrative—Emergency Pre -Submission Info needed: Modifications: Conditions: Present Were: J. Doherty B. Ghosio J. King J. Bredemeyer D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: Date: Amendment Violation D. Bergen, lip i6 4A. C jo JV -4 14 0 I in N9an5 41.-88 f� Qf 08-0 B) eexe[Cxo Oa 411.03 - p4BSYB ♦ , � p 1 Lrl'T[E '�� �Cjfl 11'. ( 43600 } N A ^.� ✓ \ , 1 » CREEK 5�- � ` � . 10.40 % '' s to • t Ne` w\1 t�ix t • � .,�. \ 4x)-01 0 ♦� `� �' ? F : . m -09o1 e f�" � 1 .® ty i cP g' ti g^ -* ♦i iAF r, -0�, m - �..�J +pat -0) yy S � ♦�.' 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N° . i. ♦p i i x F _ _ __ --w-- ue:r --x-- NOTICE tea' COUNTYOFSUFFOLK © K ® n fi00TNOtD SECTION NO G ...�.W6. _— e ntl m O ��-- -- $ Real Property Tax Service Agency v04 _ sx Iloaa+P x]owgx, w.9 0, er �, ... -.- x.a.o.x a• .�.0 w s°:f�swxm:c+nu.x..i�wo m.m raumr ramoa.emma.xrnnt M E a r,x.. ,•----••-� ,r�r, a e.nu. __— uro.x:.. __.__ .��u..u�__.__ vuexieee _ +v .. _ .. -: w m .rvs w+wOrwcnexwf.vcmlar+�c m s m ® A Office Use Only _Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Tran Mension Received Application: eceived Fee:$ p'l _Completed Application_ jncomplete 'SEQRA Classification: Type I Type H Unlisted _Coordination:(date sent) Vii: WRP Consistency As essment Form -<A- C Referral Sent:. 'M mate of Inspection: _Receipt of CAC Report: Lead Agency Determination: _Technical Review: vfulilic Hearing Held: Resolutiofi,- Named Applicant D C Q U ?, SEP - 8 2011 Southhold Town Board of Trustees v Address �� ��j is coo n aaA, M leach r,"arAn (_Phone Number:( Suffolk County Tax Map Number: 1000 - I nq Profierty Location: (provide LILCO Pole #, distance to cross`<treets, and location) AGENT:.���-� L--�•sC 5�--Urk- Lafi (If applicable)`'' n :Address: `TMJ C'�--5F'E�o►rL LC� S� Phone: �% (D '' 12_ Z� B, �d of Trustees Applicatio3 GENERAL DATA Land Area (in square feet): 0&51 --7/ -(n br Area Zoning: L41D Previous use of property: les, 0-1, Intended use of property: 1 Covenants and Restrictions: Yes is No If "Yes", please provide copy. Does this project require a variance from the Zoning Board of Appeals Yes No If "Yes", please provide copy of decision. Prior permits/approvals for site improvements: Agency Date No prior permits/approvals.for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No Yes If yes, provide explanation: Project Description (use attachments if necessary):. r 1'D � (..-e- b e-1- 4 �-,S�, b i,nS�-l�'� ��f ��.{--E;-►'lG, P�lCis'fi'Zq t,�a-1 o`li'1, -en S i tli.. YYl U1 -pal-11" )wS b.i ( block �`���e � o �d � ���i--z�►-e�-��.-� s aro � ��-e-tc�s-�fi � sl�c� lfv s�- -i ne-e-a, 1q -s> 11 horseshLw ��-s, 'tr�s�el bocce �1 �v& P B' -d of Trustees Applicati.oi WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: CoYbS f ?V ron s' d-e� o dt a -v 4 P.4q(� ►'c�► 2 p�C iSi-i �G� �O HCl, c I nS-b l a Di .l h n o, nrce-41. h064Sl� nits . bDaC Area of wetlands on lot: 00 0 square feet Percent coverage of lot: O % Closest distance between nearest existing structure and upland edge of wetlands: 100 feet Closest distance between nearest proposed structure and upland edge of wetlands: 100 - 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 r Proposed slope throughout the area of operations: n0 cl� Manner in which material will be removed or deposited: We p(, --In ova aeb6s -ern -1X- Pr-W'oos PLOner ;n an area, TV -e- prcl ioo-s owner u6 -ed( 2�S 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): h0 e PROJECT ID NUMBER 617.20 SEQR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PAK I 'I - F'KUJtL; I INt-UKMA I JUN ( i o De compietea oy Hppncanl or rrojecl oponsor/ 1. APPLICANT/ SPONSOR 2. PROJECT NAME g :�rz�-rte( f � sc e_ l (� Ld- 3.PROJECT LOCATION: su Municipality ` L'L `Ko U',—:P' County 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc - or provide map Modification / alteration 5. IS PROPOSED ACTION: L-J`J New Expansion El 6. DESCRIBE PROJECT BRIEFLY: LSc� CU rb S rov-tS c ll� Cl -e o u f` a � D 1 , IY � (� `�-'-� l ° 1 LA_ l 1 , A� 8 1 L.1 (qhs �l � n-zAi -e M u, l ck .w��„Ja-1 �L 7. AMOUNT OF LAND AFFECTED: Initially �.� 5 ,� acres Ultimately sy acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? WYes No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) V-7-1 Residential Industrial Commercial []Agriculture El Park / Forest /Open Space Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) FYes � No If yes, list agency name and permit / approval: 11. DOES . ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ElYes NNo If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? Dyes 'R] No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Cry�.a.q�}� Applicant /Sponsor Name /� �� Date: ql ill/ Signature If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART If - IMPACT ASSESSMENT (To be completed by Lead Aqencv) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. Yes a No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by -another involved agency. Yes a No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:.(Answem may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: II- .. I ..... 1.j C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly: C5. ....... ..... ...................... . Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain -briefly: C6. Longterm, short term, cumulative, or other effects not identified in C1-05? Explain briefly: C7. Other impacts (including changes in use of either quantity or type of energy? Ex Iain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? If es, ex Iain briefl : Yes 0✓ No E. IS THERE, OR IS THERE Q Yes a No LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If es ex Iain: PART 111- DETERMINATION OF SIGNIFICANCE (To be completed by Agency) . INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial,large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part 1i was checked U It; UUMIS i i m IduUn i ui mynwa:di nz n iubUavdwdUa Una puUanudr nnpdUa v► Una prvpobaa acuUn vn ura anvnvrnnanxar urdrdcUar 1buUs yr Urra L'am. Check this box if you have Identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed actio WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. Board of Trustees Name of Lead Agency Date Jill M. Doherty 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) SUFFQ/rTown. of Southold y Erosion, Sedimentation & Storm -Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M. # THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A y01 �j Yea- STORM -WATER, GRADING, DRAINAGE AND EROSION CONTROL PLAN Distnct Section -90ck- Lot. CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTION I ITEM # / WORK ASSESSMENT Yes, No PROVIDE BRIEF PROJECT DESCRIPTION (Provide Additional Pages as Needed) ids aq w k , oof eh lac G gh,/kc too 1056110 _PtLtbo, g i -r fri , horst �i tc� j' I tp ) bou'eba tl l ou P I i 1'it1Al(,EI ICL �i(i1 l fte) -1%OiYh General DEC SWPPP Requirements: Submission of a SWPPP is required for all Construction acfrvities involving soil disturbances of one (1) or more acres; including disturbances of less than one acre that are part of a larger common plan that will ultimately disturb one or more acres of land; including construction activities involving soil disturbances of less than one (1) acre where the DEC has determined that a SPDES permit is required for stone water discharges. ( SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit for Storm Water Discharges from Construction activity - Permit No. GP -640-001.) 1. The SWPPP shall be prepared prior to the submittal of the NOI. The Not shall be submitted to the Department prior to the commencement of construction activity. 2. The SWPPP shall describe the erosion and sediment control practices and where required, post -construction storm water management practices that will be used and/or constructed to reduce the pollutants in storm water discharges and to assure compliance with the terms and conditions of,this permit. In addition, the SWPPP shall identify potent(atsources of pollution which may reasonably be expected to affect the quality of stone water discharges. 3. All SW PPPs that require the post -construction storm water management practice component shall be prepared by a, qualified Design Professional Licensed in New York that is knowledgeable in the principles and practices of Storm Water Management. SPATE OF NEW YORK, 5����k COUNTY OF ......:.................................... SS Will this Project Retain All Storm -Water Run -Off a. What is the Total Area of the Project Parcels? (Include Total Area of all Parcels located within 6.1 the Scope of Work for Proposed Construction) Site Improvements and the permanent creation of b. What is the Total Area of Land Clearing and/or Ground Disturbance for the proposedr (S.F. / Acres) ' construction activity? ' El Item shall include all Proposed Grade Changes and (S.F. / Acres) PROVIDE BRIEF PROJECT DESCRIPTION (Provide Additional Pages as Needed) ids aq w k , oof eh lac G gh,/kc too 1056110 _PtLtbo, g i -r fri , horst �i tc� j' I tp ) bou'eba tl l ou P I i 1'it1Al(,EI ICL �i(i1 l fte) -1%OiYh General DEC SWPPP Requirements: Submission of a SWPPP is required for all Construction acfrvities involving soil disturbances of one (1) or more acres; including disturbances of less than one acre that are part of a larger common plan that will ultimately disturb one or more acres of land; including construction activities involving soil disturbances of less than one (1) acre where the DEC has determined that a SPDES permit is required for stone water discharges. ( SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit for Storm Water Discharges from Construction activity - Permit No. GP -640-001.) 1. The SWPPP shall be prepared prior to the submittal of the NOI. The Not shall be submitted to the Department prior to the commencement of construction activity. 2. The SWPPP shall describe the erosion and sediment control practices and where required, post -construction storm water management practices that will be used and/or constructed to reduce the pollutants in storm water discharges and to assure compliance with the terms and conditions of,this permit. In addition, the SWPPP shall identify potent(atsources of pollution which may reasonably be expected to affect the quality of stone water discharges. 3. All SW PPPs that require the post -construction storm water management practice component shall be prepared by a, qualified Design Professional Licensed in New York that is knowledgeable in the principles and practices of Storm Water Management. SPATE OF NEW YORK, 5����k COUNTY OF ......:.................................... SS Will this Project Retain All Storm -Water Run -Off Generated by a Two (2") Inch Rainfall on Site?- ite?(This item will include all run-off created by site (This clearing and/or construction activities as well as.all Site Improvements and the permanent creation of impervious surfaces.) 2 Does the Site Plan and/or Survey Show All Proposed Drainage Structures Indicating Size & Location? This El Item shall include all Proposed Grade Changes and Slopes Controlling Surface Water Flow. 3 Does the Site Plan and/or Survey describe the erosion and sediment control practices that will be used to 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? rj 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 ❑ or within One Hundred (100') feet of a Wetland or Beach? 7 Will there be Site preparation on Existing Grade Slopes which Exceed Fifteen (15) feet of Vertical Rise to yr One Hundred (100') of Horizontal Distance? — L` 8 Will Driveways, Parking Areas or other Impervious Surfaces be Sloped to Direct Storm -Water Run -Off into'and/or in the direction of a Town right-of-way? E:1 7�- 9 Will this Project Require the Placement of Material, Removal of Vegetation and/or the Construction of any ❑ — Item Within the Town Right -of -Way or Road Shoulder Area? (This item will NOT include the Installation of Driveway Aprons.) NOTE: If Any Answer to Questions One through Nine is Answered with a Check Mark Ina Box and the construction site disturbance is between, 5,000. S.F. & 1 Acre in area, a Stone -Water, Grading, Drainage & Erosion Control Plan is Required by the Town of Southold and Must be Submitted for Review Prior to Issuance of Any Building Permit (NOTE: A Check Mark (.(I ) and/or Answer for each Question is Required fora Complete Application 1'hat I, ..:.1::........�- I�ZN6w0 irrt2 � ................................... being duly sworn, deposes and says that he/she is the applicant for Permit, (Name of individual signing Document) Andthat he/she is the...........:..................................................................................................................... (Owner, Contractor, Agent, Corporate Officer, eta) Owner and/or representative of the Owner or Owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the. best of his luiowledge and belief; and that the work will be performed in the manner set forth in the application filed herewith. Sworn to before me this; . ......................... day of 3.ep NotaryPublic: (R, ........�...................................................................................••- nn� r�r r. u, (Signature of Applicant) FORM - 06/10 Notary Public, State of New York No. 01 C04863757 Qualified in Suffolk County Commission Wires 10/20/201 M Jill M. Doherty, President Bob Ghosio, Jr. , Vice -President James F. King Dave Bergen John Bredemeyer BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of ANTHONY LOMANGINO COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax(631)765-6641 I, residing at/dba 7 � ��[� v1 r) a Ttet1� being duly sworn, depose and say: That on the q day of Dc. -D19 -e' , 2011, I personally posted the property known as o x Par= by placing the Board of Trustees official poster where it can easily b6 seen, and that I have chec to be sure the poster has remained in place for eight days prior to the date of the public hearing. Date of hearing noted thereon to be held Wed, October 19, 2011 on or about 6:00 PM. Dated: Sworn to before me this qpk day of ca* 20 t I Notary I SHARON L. C©UW- Ut4 Notary public, State of Naw York No. 01 Co4863757 Qualified in Suffolk County 111 Commission E*Ires `10/20120: 7 of (signature) c" PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Postal Address:; CERTIFIED MAILT. RECEIPT Name: ; or • . deliveryFor Uv� *#1`9 . � I `ID Postage $ $1.28 117 (� Certified Fee $2.� ;�i% '' C� A � ;, •0 m i C3 Return Receipt Fee ;' LA Here r n (Endorsement Required) $0.00 Q Restricted Delivery Fee 0 .� p (Endorsement Required) $0■00 �\ Er C3Total Postage & Fees $4.13 Sent To ---------- ---------�D---- ---- - -- -- - ----- -- - - CI Street, Apt. No.; 3 �� r`- or PO Box No. City,to - - - --- - -o.......-- - -.......... --=-- ------- city, stere, zrP --- - STATE -OF NEW YORK 'PS Form 3800, COUNTY -.OF SUFFOLK . on LOm� q I 0_0 residing at, 11-7q-3 -15el�aaoinna Talm -Be�h C-� ms's � �3y r g, being duly sworn, deposes and says that onLj.the j _ day of %-,- , 20 . L I , deponent mailed a true copy of the Notice set forth -in the Board of Trustees Application, directed to each of the above named persons at the addresses, set opposite there respective names; that the addresses set opposite the names of said persons are the address of said persons as. shown on the current assessment roll of the Town of Southold; that said Notices were mailed at -the United States Post. . Office at n ( G .N `f , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to before me this Day ofl1C LIz, 20 .�L Notary Public SHARON L.06UQHUN Notary Public, State 01 New York No. o1 Cp4863757 Qualified in Sluifolk C0n01 _ cbmmission Exp' I'I , residing at, 1I -7y3 �e ka cTna Ct• 6�arcZens VL 33y i 5., being duly sworn, deposes and says that on, the t day of De -r" ,'20 d 1 , deponent mailed a true copy of the Notice set forth- in the Board of Trustees Application, directed to each of the above named persons at the addresses. set opposite there respective names; that the addresses .set opposite the names of said persons are the address of said persons as. shown on the current assessment roll of the Town of Southold; that said Notices were mailed at.the United States Post. Office at �o� �- `� , that said Notices were mailed to each of said .persons by' (certified) (registered) mail. f Sworn to before me this1 Day of 20 Notary Public SHARON L. cOUGHLIN Notary pLoc, State of New York No. 01004863757 Qualified in Suffolk.COunty Commission Expires 1020201-, PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Postal Service,. CERTIFIED IA.�IL,,,_RECEIPT Name: Address:. o • . - Lrl For delivery information visit .I ur website at www.us�sxoma Er l g . � - Er Postage $ $1.28 C r =i Certified Fee $2.85 of C) •,• Postmark M Return Receipt Fee L-3 (EndorsementRcegwred) $0.00 , . � re C1\;,1, e1-3© Restricted Delivery Fee $0.00 C3(Endorsement Required) Er ' Total Postage & Fees $ $4.13 09/26!2011 M Sent To Q C` or PO Box No. / V -----/-- • City, State, ZIP+4 STATE -OF NEW YORK - '" COUNTY OF SUFFOLK I'I , residing at, 1I -7y3 �e ka cTna Ct• 6�arcZens VL 33y i 5., being duly sworn, deposes and says that on, the t day of De -r" ,'20 d 1 , deponent mailed a true copy of the Notice set forth- in the Board of Trustees Application, directed to each of the above named persons at the addresses. set opposite there respective names; that the addresses .set opposite the names of said persons are the address of said persons as. shown on the current assessment roll of the Town of Southold; that said Notices were mailed at.the United States Post. Office at �o� �- `� , that said Notices were mailed to each of said .persons by' (certified) (registered) mail. f Sworn to before me this1 Day of 20 Notary Public SHARON L. cOUGHLIN Notary pLoc, State of New York No. 01004863757 Qualified in Suffolk.COunty Commission Expires 1020201-, Bc I of Trustees Application County of Suffolk State of New York l C'A jllcpj Aloe BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) 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 SWORN TO BEFORE ME THIS DAY OF ,20 Notary Public 0. SMRON L. COUWM Notary Pubk State of NOW Yak No. 01004863757 Qualified in Suffolk County Commission Expires 101201201_ 'd of Trustees Applicatioj', AUTHORIZATION (where the applicant is not the owner) I, C YI LOm IW esiding at 1 13 LI3 3? eA (,,( V_ aL C+ (print owner ot property) (mailing address) Tab �BeB 6&dpi5 , FL 33q C do hereby authorize (Agent) �I 6 SGL [ 4 Ln.-,Mn� o apply for permit(s) from the `j Southold Board of Town Trustees on my behalf. 'lop (Owner's sig tune) APPLICANT/AGENT/REPRESENTATM 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 t' �(Lastme, hist �nWe,,pMddle tial, less 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 Variance Change of Zone Approval of plat Exemption from plat or official map Other (If "Other", name the activity.) _ Building Trustee Coastal Erosion Mooring Planning 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 day of 200 Signature. Print Name Com. Gn ti .S Form TS l 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 posed 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, listin4 both sunuortinL, 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#(J Do PROJECT NAME The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board ❑ Building Dept. ❑ Board of Trustees W 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: Nr, Nature and extent of action: 1�.,�s� al�nn��q�, ova- �c�`ng : b���t��►-� bloc cork Ili 1-1 16106- f ea.1 oaf' av, isfi 'ant �8seens ,�.�1� �c�si�rt� S1�c r ins bu T PcA-tT;/L1� ►i5 boc�ei�l C�Xf, i rls fail Arc �I lS �Dr d ' h-6,01 C'1 av Fes, horsest7o e clr+�y Location of action: Site acreage; aEIr-e—S Present land use: -.es i je,&q 4� at Present zoning classification: 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: LO ✓Yl t c /I (b) Mailing address: 117 g ,-S 1�4I d- ooh Cf, -TIJ r,-, I-eack roen 5, (c) Telephone number: Area Code `T 1 g .(d) Application number, if any: Will the action be directly undertaken, require funding; or approval by a state or federal agency? Yes ❑ No)n"7J' 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 — Policies Pages 3 through 6 for evaluation criteria ❑ Yes 11 No LP 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 NNot Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources fxom flooding and erosion. See LWRP Section III — Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No VN 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. El 0 Yes No Not Appl le Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LNVRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ 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. ❑ Yes ❑ NoTeNot 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. ❑ Ye�j Nob Not Applicable Attach additional sheets if necessary WORKING COAST -POLICIES • . . , - Policy 10. Protect Southold's water -dependent uses and promote siting of new water -dependent uses in suitable locations. See LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ NoWNot 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 ❑ No< R1 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 Kot 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 BY JOS C C_ 6ri ©tit (� TITLE LQn& � 1J-01 DATE 7 �� CERTIFIED T0, 8925 BAY AVENUE, LLC THE KEL SE COMPANY CONESTOGA TITLE INSURANGIE! COMPANY S87'01'20 -W I BA Y AVENUE I I ANY AL TERATION OR ADOI nON TO THIS SURVEY IS A VIOLA 77ON AREA --- 201,270 SQ. FT, or OF' S£CnON 7209OF THE NEW YORK STATE EDUCATION LAW. EXCEPT AS PER s£cnON HIS MAP ON 2. ALL CERFTjnCAONLY nANs 4 6205 ACRES(TO T1 �' LINES'HEREON ARE VALID FOR TIi/S ANAP AND CC✓'lES 7N£REOF ONLY 1FSAID MAP OR COPIES BEAR TH£ IMPRESSED SEAL OF THE WRWEYOR • WHOSE 9CNATURE APPEARS HEREON. 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