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HomeMy WebLinkAboutTR-8658A S®(/ry Michael J.Domino,President \QF Town Hall Annex�� John M.Bredemeyer III,Vice-President ~ O 54375 Route 25 0 P.O. Box 1179 Charles J.Sanders Southold,New York 11971 Glenn Goldsmith G Telephone(631) 765-1892 A.Nicholas Krupski ®UNil Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE - AMENDED # 1182C-Amended Date: July 12, 2017 THIS CERTIFIES that the installation of a 612 ft high fence along the eastern side of property line and to end approximately 20' away from top of bluff; At 695 Pettus Drive,Orient I Suffolk County Tax Map#1000-14-2-23 Conforms to the application for a Trustees Permit heretofore filed in this J office Dated August 3,2015 pursuant to which Trustees Wetland Permit#8658A I dated August 19,2015,was issued and Amended on May 17,2017 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 installation of a 6 %2 ft. high fence along the eastern side of property line and to end approximately 20' away from top of bluff. The certificate is issued to PAUL&MAJIGARET KOBALKA owners of the aforesaid property. Authorized Signature *pF SO(/T Michael J.Domino, President �0� yolO Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Charles J.Sanders N Southold, New York 11971 Glenn Goldsmith • �� Telephone (631) 765-1892 A. Nicholas Krupski o�yCou Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TO OF SOUTHOLD DATE OF INSPECTION: f' / t-� Ch. 275' Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 st day of construction '/2 constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: `' ' t l7 CERTIFICATE OF COMPLIANCE: �oF s0ur Michael J.Domino,President �o� y®�� Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O. Box 1179 Charles J. Sanders N Southold,New York 11971 Glenn Goldsmith ® a@ Telephone(631) 765-1892 A.Nicholas Krupski ®lf�`+ou Fax(631) 765-6641 BOARD OF TOWN TRUSTEES May 17, 2017 TOWN OF SOUTHOLD Paul & Margaret Kobalka 695 Petty's Drive Orient, NY 11957 RE: 695 PETTYS DRIVE, ORIENT SCTM#: 1000-14-2-23 Dear Mr. and Mrs. Kobalka: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, May 17, 2017: RESOLVED that the Southold Town Board of Trustees APPROVE the Administrative Amendment to Administrative Permit#8658A to extend the existing 6'6" high fencing along the eastern side property line an additional 20' seaward; and as depicted on the project plan prepared by Paul Kobalka, received on April 28, 2017, and stamped approved on May 17, 2017. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, Michael J. Domino,,President Board of Trustees MJD/dd SURVEY OF ;- LOT 5 APPROWEr BY MAP of BOARD OF CKUSTEE PETTY'S BIGHT � S , FILE No. 5859 FILED JANUARY 26, 1973, i." TOWN OF SOUTHOLD SITUATED AT ORIENT TOWN OF SOUTHOLD DATE *A� 17 Z�L SUFFOLK COUNTY, NEW YORK I'= S.C. TAX No. 1000-14-02-23 1•' � SCALE 1"=40' ' v� JULY 30, 2004 JUNE 25, 2007 ADDED PROPOSED HOUSE \ JULY 25, 2007 RELOCATED PROPOSED HOUSE NOVEMBER 2, 2007 ADDED ADDITIONAL WELL & CESSPOOL LOCATIONS NOVEMBER 24, 2007 REVISED PROPOSED WELL LOCATION A6. � DECEMBER 3, 2007 ADDED TEST HOLE M DECEMBER 12, 2007 ADDED LOT COVERAGE \ JANUARY 9, 2007 SET LATH FOR SITE INSPECTION N \\ \2,, j FEBRUARY 4, 2008 REVISED SEPTIC SYSTEM SEPTEMBER 15, 2008 RELOCATE PROP DRYWELL 50' FROM PROP WELL F C. JULY 16, 2UPDATE SURVEY �� JANUARY 21, 201515 ADD PROPOSED HOUSE MARCH 5, 2015 REVISE PER S C.D H S. NOTICE 03/03/2015 MAY 19, 2015 FOUNDATION LOCATION JULY 22, 2015 STAKE PROPERTY LINES Dae DECEMBER 1, 2015 FINAL SURVEY JANUARY 16, 2016 ADD POOL EQUIP, WALL & CORRECT NOTES PER HEALTH DEPT. },sol FEBRUARY 4, 2016 CORRECT WELL TIE DISTANCES c \ AREA = 38,131 sq. ft. y°ti;\\ O (TO TIE LINE) 0.875 ac. \ y� \ CERTIFIED T0: PAUL KOBALKA 20 MARGARET KOBALKA FIDELITY NATIONAL TITLE INSURANCE COMPANY ULSTER SAVINGS BANK, ITS SUCCESSORS AND/OR ASSIGNS F < -10, ,J O 20N�P / �9j1 0 n 9 o m C'0 7bq �04f qs o of a, r4C ESOOL CSP Exlmnc OOSi CESSPOOL O O`L/ F ` NoOsf / os°F / ei,c,y` 1 -004 �CkI / L°' O �o �U��` 2a �- J 5 RYqrH,e(SH� �� tiF F/t �t T-p PDo(zqphi��, w j Qoo" yhoaj4 // y J SEPTIC SYSTEM TIE MEASUREMENTS 0 w 0o a co°.-� ° / yo3in HOUSE HOUSE yh4 o�j ry�'oi p CORNER ® CORNER08 Stepp � SEPTIC TANK 25.5' 34.5' a 154' p q o // ,� COVER O 16, ( LEACHING POOL 795 m 27p / W,po poo h�p COVER 1 45' S4' M S7Fap LEACHING POOL iV =Nro 2 �2d a pop y COVER 2 48' 34.5 m y ST £Cir 37 3,__oQ OU y FR M 2T•a _28.7_ WELL TIE MEASUREMENTS �o 10 & 04 R4 F B HOUSE HOUSE �° O u w CORNER © CORNER�D zo Exlw Qoo ���� �u b G WELL 40.5' 62.5' y y1P 0p- °l B okq y Yu COA,a Ara p0 223, -� 3 N /sn (Poll ; ; 3 Ra NO wE2 fie(( co 00' I�_� boa z a el yOUse O 1 cyN ho// N 6�.43100,. T`0C , OpFN�(R9Te/tN W b Ar e /N 0 O��P �SWf (` Y�CESSPOOL R_Z0.00' APR 2 8 2017 La3,.42 1�j� ExIWELL i Southold Town �`i Board of Trustees ��`��y�OF�+��' �8�00• o OV PRE IN.I`CGA&Ed1�9Iki MINIMUM pip f 'a qC STAN�OR TITLEAND SU E E �BPTED h� qNT BY E ALS AND APPROVE AbO ISHE w FO SOCIAE N. EW YO ATE LAND \U NOTES: El 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM EXISTING ELEVATIONS ARE SHOWN THUS: o 2. FLOOD ZONE INFORMATION TAKEN FROM: FLOOD INSURANCE RATE MAP No. 36103CO069H ZONE VE COASTAL FLOOD WITH VELOCITY HAZARD (WAVE ACTION), BASE FLOOD ELEVATIONS DETERMINED N.Y.S Lic. No. 50467 ZONE X AREAS DETERMINED TO BE OUTSIDE THE 02% ANNUAL CHANCE FLOODPLAIN. UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF 3. COASTAL EROSION HAZARD LINE TAKEN FROM COASTAL EROSION SECTION 7209 OF THE NEW YORK STATE Nathan Taft Corwin III HAZARD AREA MAP PHOTO No. 47-655-83 EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR Land Surveyor EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED,AND ON HIS BEHALF TO THE TITLE COMPANY,GOVERNMENTAL AGENCY AND Title Surveys - Subdivisions - Site Plans - Construction Layout LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTI- TUTION CERTIFICATIONS ARE NOT TRANSFERABLE PHONE (631)727-2090 Fax (631)727-1727 THE EXISTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD, IF OFFICES LOCATED AT MAILING ADDRESS ANY, NOT SHOWN ARE NOT GUARANTEED. 1586 CE Mom Rood P 0. Box 16 R Jamesport, New York 11947 Jamesport, New York 11947 /`\\ 34-139f -cS - Michael J. Domino, PresidO�O COG Town Hall Annex John M. Bredemeyer III, Vice-President ,�� �j, 54375 Route 25 Charles J. Sanders P.O.Box 1179 Glenn Goldsmith Southold,NY 11971 A.Nicholas Krupski > � pl '` TelephoFaxne (631) 765-6641-192 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD // �B '� v Date/Time: / �� Completed-in field by: PAUL & MARGARET KOBALKA request an Administrative Amendment to Administrative Permit #8658A to extend the existing 6'6" high fencing along the eastern side property line an additional 20' seaward. Located: 695 Petty's Drive, Orient. SCTM# 1000-14-2-23 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback W Iver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice off Hearing Card Posted: Y / N Ch. 275 ' Ch. 111 SEQRA Type: 1 II . Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: / i Present were: �redemeyer M. Domino G. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 Michael J. Domino Presid+ U�Fdj� Town Hall Annex John M. Bredemeyer III,Vice-President 4`y` �� 54375 Route 25 Charles J. Sanders P.O.Box 1179 Ze Glenn Goldsmith Southold,NY 11971 A.Nicholas Krupski ?� p! Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: PAUL & MARGARET KOBALKA request an Administrative Amendment to Administrative Permit #8658A to extend the existing 6'6" high fencing along the eastern side property line an additional 20' seaward. Located: 695 Petty's Drive, Orient. SCTM# 1000-14-2-23 Ch. 275-12 - STANDARDS FOR ISSUANCE OF PERMIT MET=X or Comment=* A. Adversely affect the wetlands of the Town: B. Cause damage from erosion, turbidity or siltation: C. Cause saltwater intrusion in the fresh water recourses of the Town: D. Adversely affect fish, shellfish or other beneficial marine organisms, aquatic wildlife & vegetation or the natural habitat thereof: E. Increase the danger of flood and storm-tide damage: F. Adversely affect navigation tidal waters or the tidal flow of the tidal waters of the Town: G. Change the course of any channel or the natural movement or flow of any waters: H. Weaken or undermine the lateral support of other lands in the vicinity: I. Otherwise adversely affect the health, safety and general welfare of the people of the Town: J. Adversely affect the aesthetic value of the wetland and adjacent areas: Ch: 111-9 - ISSUANCE OF PERMIT MET=X or Comment=* A. Is reasonable and necessary, considering reasonable alternatives to the proposed activity and the extent to which the proposed activity requires a shoreline location: B. Is not likely to cause a measurable increase in erosion at the proposed site and at other locations: C. Prevents, if possible, or minimizes adverse effects on natural protective features and their functions and protective values, existing erosion protection structures and natural resources: D. :525% Expansion/Calculation Work Session Notes Application Complete SEQRA Classification Confirmed Coordinated Review Y/N Pos/Neg Declaration CAC: LWRP: Additional information on comments/to be discussed/Public Hearing: Date: Completed By: Present: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders E. Cantrell D. Di Salvo Other Page 2 of 2 r� Paul&Margaret Kobalka 695 Pettys Drive,Orient •SCTM: 1000-14-2-23 ..- ;�' 5/9/17 Jl- i 1 ..-..� y ti J f J x r w ti - -'> �����;rS. • far j'.�� , � i { i _ �y � 3P x _ .`jE„ � A a -tlLw ,ti:: d�.,r,,,�s �F� �+x�;r;a�, #r,:. or •:y • �-�F -. ,� �y a � r � � ''rp1� 144A Ak y�yy + e fji� mR t ��►'! t ,.�,•�L^"�y. x ' _ off.. .1i+ .� �. 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( �};S l,1' rill//-�ft';i� - 11 'x; c� 1,� �� .� :*P; , � — .f'4 r 'Vp Ow � �. agw LAW 1 �"���Y !aamtt ,1 ��4 t�� �r/►��1r W � AMA` 2�p :liA S R, /rte F., % r ��111tr � VvQQ rr •Srt did ` �i� �r � .y� i f rs i i AMR 77. 1 Ji,} p w ;'0 - .��. 1 i - r �+Y�..�'. �� _ �• "". �il �,. .yr.. ��i i � i� iii 1�, i gyp£ l i y , i 4. ,rpt�a s r1 - / ,1V,.) i .✓' r ;��..V tc. �' , ���� , �.,, �..., '� � '.i � li 'Iii i; i i 1� �i �q. �i. , - �: ✓ r.: _ _4fi �`, �� —tis f�F�,, ��. t i t i}.r �� � v�% �� h � �. .i... .y.� �..• •fi,, fi ��r�. k V\, � �1 - �.� r �'.?1� �, .�f `r.ifs {{ .� �ti� �i,. �7 i'i � �� I� � ��>•�4_. �"AF V� cee /<p Mew MAY — 3 2017 lohn M.Bredemeyer III,President �Ogu�FUL�-C Town Hall,53095 Main Rd. Michael J.Domino,Vice-President ��� �¢y P.O.Box 1179 James F.King y Southold,NY 11971 Dave Bergen y Telephone(631)765-1892 Charles J. Sanders �Ol �0� Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, silt fence. 1St day of construction % constructed Project complete, compliance inspection. YO INSPECTED BY: �� V1 a C �J COMMENTS: j 11 A111 I� CERTIFICATE OF COMPLIANCE: �/ John M.Bredemeyer III, President ,,�QF S jSrO Town Hall Annex Michael J. Domino,Vice-President '`� l0 54375 Main Road P.O. Box 1179 James F.King, Trustee JW Southold, New York 11971-0959 Dave Bergen,Trustee G �► ® y0 Telephone(631) 765-1892 Charles J. Sanders,Trustee 0� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1182C Date: November 2, 2015 THIS CERTIFIES that the installation of a 6 %Z ft:high fence along the eastern side of property line and to end approximately 20' away from top of bluff, At 695 Petty's Drive, Orient Suffolk County Tax Map#1000-14-2-23 Conforms to the application for a Trustees Permit heretofore filed in this office Dated August 3, 2015 pursuant to which Trustees Administrative Permit#8658A Dated August 19, 2015,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 installation of a 6 %2 ft. high fence along the eastern side of property line and to end approximately 20' away from top of bluff The certificate is issued to PAUL&MARGARET KOBALKA owners of the aforesaid property. Authorized Signature a t TO: Town of Southold, southoldtownny.gov ttx X 5(6 yi Board of Trustees POB 1179 Southold NY 11971 FROM: Madeline Droege, POB 162, Orient NY 11,957 6313233540 madi111 @optonline.net DATE: 9/23/15' Re: Permit for Fence at wetlands I am the owner of 885 Pettys Drive, 'Orient Point NY 11957, 1000-14-2-24. New construction is going up in the vacant lot, 695 Pettys Drive, 1000-14-02-23 next to my house by Paul & Margaret Kobalka. Both lots are .y on the wetlands with backyards at the sound. Have the Kobalka's received a permit for a proposed fence on their easterly border? Initially the property sticks were placed at the easterly property line and matched my 3 surveys taken over the past 10 years, Just recently new stakes were planted that resulted in a new property line that encroached 2+ feet over onto property. There is no longer a pipe marking the point of their property line at the street on the east as indicated by their survey. The Kobalka's stated to me that the new line is correct and they are installing a . x 6' solid fence. I am under the understanding that only a certain type of fence can be used at the wetlands permitting small animals to continue to traverse, is made of wood logs with post holes like the fence that was installed by my neighbor to my east, and can only extend a certain distance to the high water tide mark. I would like to know if they received a permit and if it conforms with the rules. Thank You. f> SEP 2 3 2095 t 4 Southold Town ®� (�P�, John M.Bredemeyer III,President ®� S® ' Town Hall Annex 54 Main Road Michael J.Domino,Vice-President P.O..Box 1179 James F.King,Trustee Southold,New York 11971-0959 Dave Bergen,Trustee ® �@ Telephone(631) 765-1892 Charles J.Sanders,Trustee ����OUNTY,� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8658A Date of Receipt of Application: August 3, 2015 Applicant: Paul Kobalka & Margaret Kobalka SCTM#: 1000-14-2-23 Project Location: 695 Pettys Drive, Orient Date of Resolution/Issuance: August 19, 2015 Date of Expiration: August 19, 2017 Reviewed by: Trustee John Bredemeyer III Project Description: Install 6'/z ft. high fencing along the eastern side of property line and to end approximately 20' away from_the top of 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 Paul Kobalka & Margaret Kobalka, received on August 3, 2015, and stamped approved on August 19, 2015. Special Conditions: None. Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. John M. Bredemeyer III, President Board of Trustees John M. Bredemeyer 111, President guFFO(,�-c Town Hall,53095 Main Rd. 49- P.O.Box 1179 Michael J.Domino, Vice-President James F. King y Southold,NY 11971 o Telephone 631 765-1892 Charles J. Sanders y � �� P ( ) Dave Bergen O 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, silt fence 1St day of construction %2 constructed XProject complete, compliance inspection SITE PLAN FOR TEST HOLE DATA PAUL & MARGARET KOBALKA (TEST HOLE DUO DT MCDONALD GEOSCITJCE ON NOVEMBER S 2007) PAIGE 1 OF 2 7 g LOT 5 9009°p DMR SROM LOAN OL MAP OF PALE BRO-9LT NL PETTY'S BIGHT 3 FILE No.5859 FILED JANUARY 26,1973 aROIVN BLIT SAND SM SITUATED AT ORIENT 7 TOWN OF SOUTHOLD BRorm TIRE ro cDA SE sam sv SUFFOLK COUNTY, NEW YORK 0 S.C. TAX No. 1000-14-02-23 SCALE 1"=40' _ BROM SILTY SMD SM JULY 30, 2004 .� JUNE 25.2007 ADDED PROPOSED HOUSE S Q 16 JULY 25 2007 RELOCATED PROPOSED HOUSE NOVEMBER 2,2007 ADDED ADDITIONAL WELL&CESSPOOL LOCATIONS °1 \4C, �//��.. FL 27 FINE iD MEDIUN SAND SP NOVEMBER 24,2007 REVISED PROPOSED WELL LOCATION V." 17 DECEMBER 3,2007 ADDED TEST HOLE of ECEGARY 9. 12.SET ADDED LOT COVERAGE M \ \��' MIER IN fiRDP81 FINE JANUARY B,2007 SET LATH FOR SITE INSPECTION f` .�' FEBRUARY 4 2008 REVISED SEPTIC SYSTEM ST 10—_SAND SP SEPTEMBER 15,2008 RELOCATE PROP.DRYWELL 50'FROM PROP WELL �j. JULY 16.2014 UPDATE SURVEY JANUARY 21 2015 ADD PROPOSED HOUSE A y 4 AREA=38,131 ;q.ff. X41 Do HE LINE)0 875 CERTIFIED TO PAUL KODALKAA .� MARGARET KOBALKA FIDELITY NATIONAL TITLE INSURANCE COMPANY 'r �� /SOS LOT COFERACE OVER LOT AREA LANDWARD } \ OF THE COASTAL EROSION HAZARD LINE (AREA=24.438 sq.ft.) DESCRIPTION AREA x LOT COVERAGE �O4'4f r� 1\ HOUSE&COVERED 2,790 sq.ft. 11 4% PORCHS ?Oat' AJ o ? ° POOL 720 sq if. 3.09 O4.ffC N DRIVEWAY 815 sq ft. 3.3X TOTAL 4.325 sq ft. 177% 00, a'q, 4 V � 'If .\ .tA2 Ink .JAI •�+ � S cA �r ROUSE LOQ �p +° �t?� `y'�.,T '�`•� Teo• �'Ih, ,Pi tOa �� Y»s _L_' LLa `fP yam,���Pp Too y j•f Is�.N0=_ MDIYLD) TC—ILE Vo I ( Ij1 .ago ,�� � 3 C.� ;f AUG - 3 201 hAi 7' o J N = T ` 57' �Op_F����v,9� �onoSEo L70' sOL OZ� b�O �1 fI P 'J DRY P*q:pBF�OR R,2 Ccz60.Op. (38 .00 I N / �4g- n" o roro$I m OOe rn 0114, IF �Y E NOTES. I1539. 1.ELEVATIONS ARE REFERENCED TO NA-V.D. 1988 DATUM ,� EXISTING ELEVATIONS ARE SHOWN THUS:— v314 1J 2.FLOOD ZONE INFORMATION TAKEN FROM ../� FLOOD INSURANCE RATE MAP No 3610300069H ,ONE VE. COASTAL FLOOD WITH VELOCITY 1W2ARD(WAVE ACTION), BASE FLOOD ELEVATIONS DETERMINED MINED TO ZONE X AREAS DETERBE OUTSIDE THE 02%ANNUAL CHANCE RCOOPLAN rI. Cl' rRpvaFa w Mrop°v%F eitR IRE �J Y slMmams 1°R TmL'.semis rs m 3 COASTAL EROSION HAZARD LINE TAKEN FROM COASTAL EROSION ti O °r THE uwLS AND APmwm AND roro0n HAZARD AREA NAP PHOTO No 47-655-83 /}T� FAO LS 4.THE LOCATION OF WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD OBSERVATIONS ANO/OR DATA OBTAINED FROM OTHERS. S.MINIMUM SEPTIC TANK CAPACITIES FOR 6 BEDROOM HOUSE IS 1,500 GALLONS. 1 TANK;8'DIA.5' LIQUID DEPTH 4.&YMMUM LEACYBH6 SYSTEM FOR 6 BEDROOM HOME IS 400 sq ff S/DIEWAEL AREA. 2 POOLS;8' DEEP.8'df. Iffill PROPOSED(EXPANSION POOL PROPOSED LEACHING POOL NYS Lc No 50467 PROPOSED SEPTIC TANK iD'�L1W°5 05UR�.£Y0'1VGIAt°Rlmr�°i'1g11 04 NAC cYCTRM CAMT107 ME SIAM Nathan "haft Corwin III DRNEWAY AREA.614;%11 DM6 aF 116 SIINET NAP MT[GMYwc 814 w n.k an=138 a.R W—SURft a NODI DAL°i Land Surveyor 136 a,.N./422 c 1l wmM 6,of W 6a.Inonvng Pool 1"ga"ed T�fl v m na <�i 06 PROVIDE(1)it 41a x 4•NIGH sTORY ORAD!POOLS panRulnrs wnarrn 14AFM sINL RDN aWf Al293=ro H d6Y ro mE PfRsm1 TDR vxc6 111E SURJfl' 2021 W-11QI7 u 480,.v.It• IS PPEPAIaD AXa ON 165 IxNNF i0 R£ am R/422=11 3 rvflcnl H of 8'41a.ba Ring paoi rtGWroE r111E COPMY W19w101IK 1CMCT Aw Mk$ulve -SyEpnas"vnv-S7e Pons- CPnsrNCtnn L.".1PHI PRovmE(2)R mn.z s•NIgR sr6RM DRAm Pools 1F10Wa wsnluno+lslm ROa:aN.Nm ro n¢As9a.RFs aF TRE LFt°%1D 8'ORan- �-�1 lunox m+rttxAllara Na:NOT tRN5HRA61E. PHONE(631)727-2090 FD%(631)727-1727 PfI0Po5fD B'DIA.Y 6'DEEPORl'NEUS FOR ROOF ROTI-OFF ARE SHOWN 111U4;� ME OIWf OF RIGHT OF WAYS L'OOA.k 4 DEEP ORTYAl15 FOR ORPIEVAT RUN-OFF ARE SHOWN THOS' •WD/ON FASEOF S OF RECORD IF PROPOSOFFICES LOUIID AT MVUNC ADDRESS Oi i J+ ANY.NO SHOWN ARE NOT Lt1ARAXtaD. 1596 Yam Road PO Bax 16 Jo—op,,,Npv York 11947 Jamcspory Nev Yank 11947 04-1 A TEST HOLE DATA SURVEY OF (TEST HOLE DUG BY McDONALD GEOSCIENCE ON NOVEMBER 8, 2007) LOT 5 EL. 19.7' 0' MAPOF O 0 O O DARK BROWN LOAM OL PETTY'S BIGHT PALE BROWN SILT ML FILE No. 5859 FILED JANUARY 26, 1973 3' SITUATED AT a ORIENT BROWN SILTY SAND SM TOWN OF SOUTHOLD 7 SUFFOLK COUNTY, NEW YORK BROWN FINE TO COARSE SAND SW S.C. TAX No. 1000-14-02-23 10' SCALE 1"=40'• JULY 30, 2004 ° BROWN SILTY SAND SM JUNE 25, 2007 ADDED PROPOSED HOUSE JULY 25, 2007 RELOCATED PROPOSED HOUSE \ NOVEMBER 2, 2007 ADDED ADDITIONAL WELL & CESSPOOL LOCATIONS S NOVEMBER 24, 2007 REVISED PROPOSED WELL LOCATION 16 DECEMBER 3, 2007 ADDED TEST HOLE M \ 2 EL 2 7' : BROWN FINE TO MEDIUM SAND SP DECEMBER 12, 2007 ADDED LOT COVERAGE JANUARY 9, 2007 SET LATH FOR SITE INSPECTION N \\ FEBRUARY 4, 2008 REVISED SEPTIC SYSTEM M \ \ �J' WATER IN BROWN FINE SEPTEMBER 15, 2008 RELOCATE PROP DRYWELL 50' FROM PROP. WELL F TO MEDIUM SAND SP JULY 16, 2014 UPDATE SURVEY JANUARY 21, 2015 ADD PROPOSED HOUS MARCH 5, 2015 REVISE PER S C D H S- NOTICE 03/03/2015 \ MAY 19, 2015 FOUNDATION LOCATION \ JULY 22, 2015 STAKE PROPERTY LINES oyF4 z3 a AREA = 38,131 ft. Q� (TO TIE LINE) 0.875 cc. da pgoA� CERTIFIED TO PAUL KOBALKA hqr MARGARET KOBALKA ��,��\\ 'S• FIDELITY NATIONAL-TITLE INSURANCE COMPANY w ULSTER SAVINGS BANK, ITS SUCCESSORS AND/OR ASSIGNS Q to F F , �o APPROVED BY . 1F J o °"F` IR N , BOARD OF TRUSTEES s .-TOWN OF SOUTHOLD t„ x,13.2 C,Oq`rrq( raAo�°t o,r ,ti CESSPOIOL�� a tpoISTNG CESSPOIOL� `/ O� h TO, (�N 14.4 \ F `\ x1£2 ?as � W \ V (, 2 1�0 ru u yr x in /IOUs,, x GOr O L&ix �� i�s�ceI Ie� ��o OVeRG (PERIODI A�Ly MOWED) / z N /6 ¢ y o3 1 yq 5,WI / o'w 17'I 4 _ to x1§..1 O �8=`gypp0, I9S of 2j•0 0 \ Q x78.3 M J74 0) h DOA, �12 3 G .2 z8 1 z a FOU 4q°oO4 TjO I s 128.1' x 19.9 0.o b �i w \ I o n w �J EXISTING a Fa WELL D, Ci .Ili9 19.Sx� 0) C TEST HOL v GNC ?2.p• 79.7 to Bac te•a I fk/syy // I a a- 23' :k01/ - G�200.00,�`I 6 00, ' x o• / N / M" bo" Nth/ (p _ AIS ((yLc((.OV(;Okf((, l f N x,N O�SRfavR� CGNC CU C P x 1s 7 (` i _CESSPOOL ep CESSPOOL k e5r j r� ' 11S3eifolB�gG?/t�yR 6 .43 h 166 i s%� A�ZO•G ' x,I�� 'V EXISTING Li{ `ii.,,,� L.g1.42 .��11• "�J - WELL ? AUG - 3 2015 x Amy - � , 0 0, ®� a PREPARED IN ACCOBDANCE`WNH-SF,L MINIMUM p�pf qq N AOgAT At BYATHERDS FOSSS LE AlJ$VfYS ASESTABLISHED TFOR ITLE SUC OCt6�i0 Y Rp�FttPP�V � O� NOTES. ��. a COQ 1 Z 2 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM ZZ EXISTING ELEVATIONS ARE SHOWN THUS:120 , f� o 2. FLOOD ZONE INFORMATION TAKEN FROM: FLOOD INSURANCE RATE MAP No. 36103CO069H ZONE VE COASTAL FLOOD WITH VELOCITY HAZARD (WAVE ACTION), BASE FLOOD ELEVATIONS DETERMINED r N S L,c No 50467 ZONE X AREAS DETERMINED TO BE OUTSIDE THE 02% ANNUAL CHANCE FLOODPLAIN UNAUTHORIZED ALTERATION OR ADDITION ., F- TO THIS SURVEY IS A VIOLATION OF , 3. COASTAL EROSION HAZARD LINE TAKEN FROM COASTAL EROSION SECTION 7209 OF THE NEW YORK STATE HAZARD AREA MAP PHOTO No. 47-655-83 EDUCATION LAW' Nathan Win III COPIES OF THIS SURVEY MAP NOT BEARING �..`„�-�r,,..�' THE LAND SURVEYOR'S INKED SEAL OR Land S u r v e y o r EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY CERTIFICATIONS INDICATED HEREON SHALL RUN _ ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED,AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND Title Surveys - Subdivisions - Site Plans - Construction Layout LENDING INSTITUTION LISTED HEREON,AND TO THE ASSIGNEES OF THE LENDING INSTI- TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE PHONE (631)727-2090 FOX (631)727-1727 THE EXISTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD, IF OFFICES LOCATED AT MAILING ADDRESS ANY, NOT SHOWN ARE NOT GUARANTEED 1586 Main Road P 0 Box 16 Jamesport, New York 11947 Jamesp, York 11947 34-139E I John Bredemeyer, President �ogUFFOt� Town Hall Annex Michael J. Domino, Vice-President 54375 Route 25 James F. King y z P.O. Box 1179 Charles J. Sanders • Southold, NY 11971 Dave Bergen 01 ,� �a°! Telephone (631) 765-1892 Fax (631) 765-6641 Southold Town Board of Trustees field Inspection/Work Session Report Date/Time: - , PAUL & MARGARET KOBALKA request an Administrative Permit to install"6Y2 ft. high fencing along the eastern side of property line and to end approximately 20' away from the top of bluff. Located: 695 Pettys Drive, Orient. SCTM# 14-2-23 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 o - pplication: 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: (!!!2 Present Were: --"X Bredemeyer �M. Domino J. King/ D. Bergen C. Sanders Bay Constable /Other Form filled out in the field by Mailed/Faxed to: Date: : � r TOWN OF SOUTHOLD BUILDING DEPARTMENT Y1`' TOWN CLERK'S OFFICE SOUTHOLD, MY BUILDING PERMFT (THIS-PERMIT MUST BE KEPT ON THE PREMISES 1(ItrITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit#k 39682 Date: 41151 O 15 Permission is hereby granted to: Kobalka, Paul &Kobalka,Margaret 170 Oysterponds Ln Orient,NY 11957 To: Construction of a new single fancily dwelling as applied for per ZBA.and SCHD approvals. At premises located at.- 695 t:696 Pettys Or,Orient SCTM#f 473889 SedBlock[Lot#14,�2-23 Pursuant to application dated 3/31/2015 and approved by the Building Inspector. To expire on 1011412016. 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FOR PLI NO 1 4 1z �z\i 3D] SEC NO SEE SEO.NOE UI C.N0. 11 !s.'eANq 5 a" Rp a .er+^ o,2n.au.: oxa101 alis I� AA MN ,.Wcl ,o1Nc1 31, OBD iMA1N ^ le l; RD QO 13 Iw 5 z __--Z---.— ---_Z_ _—__!_--- wnTc f 1, na LANE AEE SEc.No m9 16 � ®B,LN• SEE SEC NO 019 y n, S.R.25 ta] 3 E � � w~ w m °A` a '" —"-- NOTICE COUNTY OF SUFFOLK © K S or SOUTNOLD SECTION NO G F.w.., —� (21) -- Reel Property Tax Service Agenpy v E --� µ--- °� M 1 �E� 014 p..��. a .. ,z,N waA�N•I ___ ...v. _—,-- a.u.--�'-- . w. s A69 1 P% Rin+1 1000 PROPERTYMAP J ' OFFICE LOCATION: S®UjyQ�® MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) �a Southold, NY 11971 �p� Telephone: 631 765-1938 COU LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM .J ' I AUG 1 2 2015 � s To: John Bredemeyer, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: August 12, 2015 Re: Local Waterfront Coastal Consistency Review for PAUL & MARGARET KOBALKA SCTM# 1000-14-2-23 PAUL & MARGARET KOBALKA request an Administrative Permit to install 6Y2 ft. high fencing along the eastern side of property line and to end approximately 20' away from the top of bluff. Located: 695 Pettys,Drive, Orient. SCTM# 14-2-23 The proposed actions have 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 John M.Bredemeyer III,President ®;_ Town Hall Annex Michael J.Domino,Vice-President, 54375 Main Road P.O.Box 1179 James F.King,Trustee T - Southold,New York 11971-0959 Dave Bergen,Trustee ® . .� Telephone(631)765-1892 Charles J.Sanders,Trustee Fax(631)766-6641 BOAM OF TOWN TRUSTMS TOWN OF SOUTHOLD - _ Office Use Only _Coastal Erosion Permit ApplicationL� !f Wetland Permit Application L = � V Administrative Permit Amendment/Tram tension J } AUG Received Application / 3 2015 ' 1 Received Fee:$ d ompleted Application - __ - , Incomplete _SEQRA Classification: —— _mac+ i'-L"'L--._._ Type I Type II Unlisted Coordination:(date sent): �LWRP Consistency Assessment Form: CAC Referral Sent: Date of Inspection: - l� Receipt of CAC Report Lead Agency Determination: Technical Review: :ublic Bearing Held: Resolution: Name of Applicant: ��'} 0 ko_d ,kll_« - ✓ )'� i_I-e f l(0 6 1/ 1c4 Mailing Address. / '7O O%S-fe r^ PO,? c(r L,�'I e , Oti r'e#�,_ Y_lW-J>' Phone Number: Suffolk County Tax Map Number: 1000- /q © — Property Location:- --� ,c� ��I((Yf---��'i Ver (provide LILCO Pole#,distance to cross streets,and location) ACCENT: (if applicable) - ---- Address: Phone: Board. of Trustees Application G ENTERAL DATA Land Area(in square feet): 3K, 1 3 Area Zoning: --_ Previous use of property: 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 _ No If`Yes",be advise 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 o 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? Yes No Prior permits/approvals for site improvements: Agency Date No prior pem3its/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): - 1? �,e n C(� ����. (� L ���1 )g-/CJ r9�� EI7 d tC'Y%/ 5 '�f Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION CA7 ION ADAT Purpose of the proposed operations: 40P � t�`r��s.'i✓_ — - - Area of wetlands on lot: square feet Percent coverage of lot:_ 3C) 6 % Closest distance between nTest existing structure and upland edge of wetlands: O a feet Closest distance between nearest proposed structure and upland edge of wetlands: 41 Zo ` feet Does the project involve excavation or filling? ✓ No Yes If yes,how much material will be excavated? _ cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited:_ feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect,if any,on the wetlands and tidal waters of the town that may result by reason of such proposed operations(use attachments if appropriate): 0rt 617.20 Appendix B Short Environmental Assessment Form Instructions foar Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I 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 - Project Location(describe,and attach a location map): ,!+ ��FJ�PY>V ��r.�ti' `�'n/'v��i;'� �-/ova l✓.'�j1�✓1j��' I�y� Brief Description of Proposed Action_ mew L: tv bled/ h,ec" �i����' ,��►�/ hod /oar Foe,*' Name of Applicant e&Spe"aar. Telephone. ko�i e/C E-Mail://�/C/9�9 G fa 4 ar ✓e' Address: / %� V}�fi<('✓1 �f9:7Kf �/�'i?� ' City/P0: S I v Zip od �Yt 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, No- YES- administrative rule,or regulation? - If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that ® F 7 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: 11M Q 3.a.Total acreage of the site df the proposed action? acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining-and near the proposed action. - Urban F1 Rural(non-agriculture) []Industrial ❑Commercial [Residerttial(suburban) ®Forest ❑Agriculture ®Aquatic []Other(specify):_ ®Parkland Page li of 4 I ,5. is the proposed action, __ - - - - NO-YES N/A a.A permitted use under the zoning regulations? b.Consistent with the adopted comprehensive pian? Q Q -_ 6_ is the proposed action consistent with the predominant character of the existing built or natural NO YES I landscape? /l1 Q I� 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 -8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? c.Are any pedestrian-accommodations or bicycle routes available on or near site of the proposed action? FT Q 9.Does the proposed action meetor exceed the state energy coderequirements? NO I YES If the proposed action will exceed requirements,describe design features and technologies: Q I1 10. Will the proposed action connect to an existing public/private watersupply? NO YES If No,describe method for providing potable water: _ /VA I I_Will the proposed action connect to existing wastewater utilities? NO- YES- If No,describe method for providing wastewater treatment; �^ A//f 12_ a.Does the site contain a structurethat is listed on either the State or National Register of Historic L NO YES Places? IV7 < b_Is the proposed action located in an archeological sensitive area? .0 1 13.a Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES g wetlands or other waterbodies regulated by a federal,state or local agency? F-1, {� b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ,� IV,_�I 1 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: 0Shoreline )]Forest ❑Agricultural/grasslands ❑Early mid-successional Q Wetland []Urban []Suburban IS.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? Q i 16•Is the project site located in the 100 year flood plain? NO YES IT Will the proposed action create stone water discharge,either from point or non-point sources? NO I YES If Yes, a.Will storm water discharges flow to adjacent properties? Q NO OYES �I b.Will storm water discharges be directed to established conveyance systems(runoffand storm drains)? If Yes,briefly describe: Q NO AYES Page 2 of 4 ! t I S.Does the proposed action include construction orother activities that result in the impoundment of NO JI YES- waterorother liquids(e.g.retention pond,waste lagoon,dam)? j If Yes,explain purpose and size;. 19_Has the site of the proposed action or an adjoining property been the location of an active or closed NO 11 YES solid waste management facility? If Yes,describe: _ - - -- -_ - 20 Has the siteof the proposed action or an adjoining property been the subject ofremediarioii(ongoing or LL -NO YES completed)for hazardous waste? t IfYes,describe: d AMRM TUAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE 9EST OF MY j KNOWLEDGE ; Applicant/ 7nam : � � al` ��f��- Date,; - F. Signature:7 - - - — - -- Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the:following questions in Part 2 using the information contained in Part l and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" - - - --- ---- -------- — --•,No,or Moderate small to large impact impact ; may may occur____ occur 1. Will the proposed action create i materiaPconflictwith an adopted land use plan orzoning I s l regulations? ' Z Will the proposed action result in a change in the use or intensity of use of land? Q G 3. Will the proposed action impair the character or quality of the existing community? Q 4. Will the proposed action have an impact on the environmental characteristics that caused the rJ( El establishment of a Critical Environmental Area(CEA)? ( �J l--_ !� 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? f G. Will the proposed action cause an increase in the use of energy and it fails to incorporate -- reasonably available energy conservation or renewable energyopportunities? 7. Will the proposed action impact existing: - a.public I private water supplies? b.public/private wastewater treatmera utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, architectural or aesthetic resources? �l 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, i waterbodies,groundwater,air quality,flora and fauna)? F11, F1 Page 3 of 4 -- - -- No,or Moderate small to targe impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage t problems? ,A 1. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for thecompletion of Part 3. For every question in Part 2 that was answered"moderate to targe impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project-sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant_Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude_ Also consider the potential for short-term,long-term and cumulative impacts. Check this box ifyou have determined,based on the information and analysis above,and any supporting documentation; that the proposed action may result in one or more potentially large or significant adverse impacts and an E�fenvironmental impact statement is required. Check this,box ifyou have determined,based on the information and analysis above,and any supporting documentation, 1 that the proposed action will not result in any significant adverse environmental i)pa .. r Town of Southold-Board of Trustees `� /J _ Name of Lead A' cy - - - - _ - Dates -- (� President Print Type NanVnof esponsible Office iia Lead Agency Title of Responsible Officer v Lure esponsible Officerih Lead Agency Signature of Preparer(if different from Responsible Officer) Page 4 of 4 1 Board of Trustees Application AFMAVIT lNr 4z/ e, bA �FW-ct/ v�� '/ BEING DULY SWORN F DEPOSESSAND AMM&THAT HEASH E IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER II04OWLEBDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MANY BE APPROVED BY TH ESOIJTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTTHOL D AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND-CILAIIRMS ARMUNG tUTDIER OR BY VIRTUE OF SAID PERM7T(S),IF GRANTED. IN COMPLETING THIS APPLICATION,II HEREBY ANTHORM E THE TRUSTEES,THEIR AGENT(S)OTR REPRESENTATIVES,INCLUDING THE. CONSERVATION ADVISORY COUNCBBI,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A II?'BNAIL INSPECTION. II FURTHER AUTHORIZE THE BOARD OF TRIUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WBTIHI ANY CONDITION OF ANY WETH,ANID OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE IPIERIUT. /y e ature of PiiFj Owner._ __-- SWORN TO BEFORE ME THIS , - �^ _DAY OF .1 - _ 4 20 /S_ C � 7W AA� _ --- Notary Public -- ----- -- DONNA M.PALMER Notary Public,State of New York No.01 PA5069978, Suffolk County / -Commission Expires December 9, 0 F APFUCANVAGENTMPRESENVATNE TRANSACTIONAL DISCLOSU=FORM T, hi6lt�cesattfctsnFiRi an thc{+:s+taftacvrierili M1d'emnlova,ti�Ttlennm�asea r{ii.Cumr is to�ce i�id infJnii iii to{t%c3iuirr aCwt ffieto�err of aa�csi{fv c ntlici csfittGr >tar dk"V rttritat a wfYadt:c�c�actrtnt r nicogk to avoid same. YOURNAME: Ko 64 (Last name,firstnam6„#fiddle initial,unless you areapplying to 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 ofplat - - - - Mooring Exemption from plat oro fficial map_ Planning — Other E-r e ct_�e h c Naito+0ece G z 4//U•`J ,C4 f�S r P✓td Irl (If"Other',natne the activity-) � _ _ ,�/��: yL;nP > Do you personally(or through your company,spouse,sibling,parent or childf favc with any officer or employee of theTown of Southold? "Relationship'-'includes by blood,rgarriage,orbusina�iiiwes t:'BtEsiness interest"means a business, including a partnership,in which the town otficeroremployee has even apai 1,aivtU:[gjiltaQaremploymentby)acorporation in which the town officer or employee owns more than 5%ofthe shares. YES NO If you ansivered"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 applicanVagenitrepresentative)and the town officer or employee.Either chectc the appropriate line A)through D)and/or describe in the space provided. The town offrceror employee or his or her spouse;sibling,parent or child is(check all thatapply): A)the owner of greater than S%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(wheel 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 �D daJy of 20d 5' Signature Print Name/n.,z Fortin TS I . f � Town Of Southold LVMP CONSISTENCY ASSESSMENT FORM A. INSTRUMONS I. .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 ooasta[area.twhich includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or`Sno",then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. `u` ra : each ad ef-gi ist fire e:rfti ted'ua detgit,-Iigtihg,lbo€h Muportig:aiid itgrxr - mpoafin 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 SrM AND PROPOSED ACTION Scna loco /yrOZ�i Z3 PROJECT NAME -_��s� S%c1e y Lr,ie -�e4ee The Application has been submitted to(check appropriate response): Town Board. ❑ Planning Board❑ Building Dept. ❑ Board of Trustees E�1. 1. Category of Town of Southold agency action(check appropriate'response): (a) Action undertaken directly by Town agency(e.g.capital ❑, construction,planning activity,agency regulation,land transaction) (b) Financial assistance(e.g.grant,loan,subsidy) - (c) Permit,approval,license,certification: ❑. Nature and extent of action: _ e _ P Location of action: A?��Yr-- v OY,P y � /C✓�� J �,��' Site acrpgp;� Oc`i! - - Present land use: 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: (b) Mailing address: i (c) 'Telephone number:Area Code( _--_ __-- ----- (d) Application number,if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes No if yes,which state or federal , C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Fest Management practices that will furthefr each policy. f[ncomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Poster a pattern of development in,the Town of Southold that enhances community character, preserves open space,makes efficient nese of infrastructure,makes beneficial use of a coastal flocationn,and mnhnimizes adverse effects of development. See lLWRF Section M-Policies; Page 2 for evaluation criteria. lyes F- No FJ Not Applicable Attech additional sheeis if necessary PoRey 2. Protect and preserve historic and archaeological resources of the Town of Southold. See L WRP Section M-Policies Pages 3 through 6 for evaluation criteria 1_J! Yes EI'No No ® Not Applicable r r' Attach additional sheets if necessary ]Policy 3. Enhance vbuaa quality and ]protect scenic resources throughout the Town of Southold. See ILWIIPIP Section MflI—]Policies]Pages C through 7 hr evaluation criteria QYes Q No 0 Not Applicable Attach additional sheets ifnecessary NATURAL COAST POLICIES Policy R. Minimize floss of flife, structures, and natural resources from floodi mg and erosiom. See ILWR? Section ffi—Policies Pages S through 16 for evaluation criteria Yes t—I No ® Not Applicable Attach additional sheets if necessary - Policy 5. Protect and improve water quality and suuppRy in the Town of Southold.See ILS Section M —Policies Pages 16 through 21 for evaluation criteria Ell Yes Q No ®Not Appl3icalbRe Attach-additional sheets if necessary Policy 6. ]Protect and restore the quality and ftnetiohn of the Town of Southold ecosystems incitadmg Signi;taica mt Coastal IPish and Wildlife Habitats and wetlands. See ILVYI P Section ffi—IPoUcies; wages 22 through 32 for evaluation criterk. r] Q Nd yes No Not Applicable f Attach additional sheets if necessary Policy 7. Protect and improve air quAty in the Town of Southold. See SLWR P Sections M — Policies Pages 32 through 34 for evaluation criteria. F11 Yes Q No NJ Not Applicable Attach additional sheets if necessary ]Policy 8. Minimize environmental degradation in Town of Southold[ from solid waste amd hazardous substances and wastes. See IL IP Section M—Policies;Pages 34 through 38 for evaluxatiop criteria. Q.Yes �� No ® Not Applicable PUBLIC CAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public Hands, and pudic resources of the Town of Southold. See ILWR P Section M—]Policies;Pages 38 through 46 for evaluation criteria. Q YeD Xo Not Applicable Attach additional sheets if necessary - - - - W®REING COAST POLIS }Policy 10. Protect Southold's wateir-dependent uses and promote siting of new water-dependent eases in suitable locations. See 1WRP Section M—Policies;Pages 47 through 56 for evaluation criteria. Yes E1,No V\I 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 I VvW Section I —Policies;Pages 57 through 62 for evaluation criteria. I� Yes No® Not Applicable F Attach additianal sheets if necessary- -- - - Policy 12. Protect agricultural lands in the Town of Southold. See LNVRP Section M—Policies; Pages 62 through 665 for evaluation criteria. Yes l NO� - Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use anal development of energy and mineral resources. See 1LWRP Section M—Policies;Pages 65 through 65 for evaluation criteria. Yes No ® 1 Not Applicable PREPARED By-9j M a-f2C-r 4 aT= 0 W n e r DATE ,9/2--©/5