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Home My WebLink AboutTR-8655A John M.Bredemeyer III, President ®F S0 Town Hall Annex�® Michael J.Domino,Vice-President �O �® 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski Telephone(631) 765-1892 Sanders d �1 X Fax(631) 765-8641 Charles JT. an ers BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1263C Date: September 11 2016 THIS-CERTIFIES that a Ten(10)Year Maintenance Permit to hand-cut Common Reed(Phragmites australis) to 12"in height by hand, as needed. At 130 Midway Road, Southold - - Suffolk County Tax Map#1000-90-1-8 Conforms to the application for a Trustees Permit heretofore filed in this- office hisoffice Dated August 3, 2015 pursuant to which Trustees Administrative Permit#8655A 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 a Teri(10) Year Maintenance Permit to hand-cut Common Reed(Phramites australis)to 12"in height by hand, as needed. The certificate is issued to HENRY KAMINER owner of the aforesaid property. IVV\ o� Authorized Signature John M. Bredemeyer III, Presidentoo�' Town Hall Annex Michael J. Domino, Vice-President "yam y<': 54375 Route 25 . Glenn Goldsmith � P.O. Box 1179 A. Nicholas Krupski ® Southold, NY 11971 ire -�r 4 one Charles J. Sanders '. �1 , �� Y elep�gone '63 65- oyc } Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: V Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction Y constructed ;7 Project complete, compliance inspection. INSPECTED BY: ` COMMENTS: c 44- CERTIFICATE OF COMPLIANCE: h0�oF Uly John M.Bredemeyer III,President soI. 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 a® Telephone (631) 765-1892 Charles J. Sanders,Trustee ��yCOUN11, Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8655A Date of Receipt of Application: August 3, 2015 Applicant: Henry Kaminer SCTM#: 90-1-8 Project Location: 130 Midway Road, Southold Date of Resolution/Issuance: August 19, 2015 Date of Expiration: August 19, 2017 Reviewed by: Michael J. Domino, Trustee Project Description: Ten-Year Maintenance Permit to hand-cut Common Reed (Phragmites australis)to 12" in height by hand, as needed. - -Findings: The project-meets-all-the-r_equir_ements.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 submitted by Henry Kaminer, received on August 3, 2015 and stamped approved on August 19, 2015. § 275-5 Permit procedures. (i) Cutting of common reed (Phragmites australis) to within 12 inches of the soil surface landward of the wetland boundary. This does not include mowing to ground level. Special Conditions: Do not disturb native vegetation during the hand cutting of Common Reed (Phragmites australis), including but not limited to; Eastern Red Cedar(Juniperus virginiana), Northern Bayberry (Myrica pensylvanica), Marsh Elder(Iva frutescens), and Groundsel Bush (Baccharis halimfolia). The approved operations must be commenced within two (2) years from the date of the resolution. The permittee is required to provide the Trustees with before and after photos of the area within this time period before any further maintenance is conducted. 2 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 Town Hall,53095 Main Rd. �G P.O.Box 1179 Michael J. Domino, Vice-President 4V y� James F. King y Southold,NY 11971 Tele hone 631 765-1892 Charles J. Sanders y « !� P ( ) Dave Bergen �Ol 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 '/ constructed Project complete, compliance inspection STREET ADDRESS: 130 MIDWAY ROAD SC0HS Ref. # RIO-'04-0083 SURVEY . OF PROPERTY , N LOT NUMBERS REFER TO MAP OF CEDAR BEACH PARK FILED /N THE SUFFOLK COUNTY CLERK'S OFF/CE ON AT BA YVIEW DECEMBER 20, 1927 AS FILE NO. '90. TOWN OF SO UTHOLD 'ELEVATIONS ARE REFERENCED TO-NGVD. APP BY SUFFOLK COUNTY, N. Y. " .BOARD OF''TRUSTEES j] • b. 1000-90-01 SOU ' 'TONY N OF SOUTHOLD •d SCALE: 1'=30' MAY 5, 2004 -A7 15, ,A MAY 19, 2004 (PROP. SEPTIC CONNEC77ON) �•r,�j. OCTOBER 29, 2004 (ADDITION) JANUARY 17, 2008 (TOPOGRAPHIC SURVEY, WETLAND FLAGS) '1 Feb. 15, 2008 (0441floAs) I� I'� �� a MARCH fl 2008 ( STA VS B '?RCH AbD/T.) ✓ULY 1 X008 ILOT COVERaGEI Y AUGUS� 25, 2008 (revislons) �� 7 �// ••S>O•�3, - JAN. 5, 2008 (revisions) O 50~ O� MARCH 31, 200'•9 (ADDITIONS! F I39 APRIL 15, 2009 (REVISIONS) AP21j'19, 2010 (lam re*CC) 1670�O l Yeo gip; Cb �O'4nN A �� Y7. �t� j► �G rre, 22j �� - +{f AUG ® 3 2015 °� Y>•• 40 Pv T/1�0 �'' w Z � �� °�4 ��s, 0 ' _ :•t�Lti:"L=ani"_� J .� � k ,• 8 / � X13 �,�. � _ � � �jcUYo�. , �•� p��►� -- - cR LOT COVERAGE °R/WK,ACO r\ Fs ry' AREA OF UPLANDS r 18,877 sq.fl. TEST BOR/NG L� / C +r' ?°' r' I CO 2125109 11+38 AM ��►y�s� m \ SQUARE FOOTAGE OF EXISTING STRUCTURES HIGH TIDE TIME /JC / 0 0 / eRi O�' BY SUFFOLK \ 3 2850 sq.fl. ENVRO. CONSULT.Z , / g�� m ?o• SQUARE FOOTAGE OF PROPOSED STRUCTURES D• c poo .� `b� r ® sq.ft. TOPSOIL o.3s ,�. l b <�l� �' j COMBINED SQUARE FOOTAGE OF EXISTING AND 0.4' PROPOSED STRUCTURES = 292.0 sq.fl. SILTY CLAY /�/jO• 'fNL EZ v?�, �Q o pO�ST j �, % ,LOT COVERAGE OF EXISTING STRUCTURES 2.4 OH 4`3SOp `\ p, rHsF� �' '• / f�Q 2850,f)8877 - 15% • SIL TY SA)JD8 cX,9N►�k �£ oo Io q COMBINED % LOT COVERAGE OF EXISTING AND ' 4.5' GRAVEL GM EL IP �✓N \X \ 14 PROPOSF-D -2920'/18877 = 15.504 lO.l 6R0[AJD MATER B NOIy _ N�\kms h �I 10 MEDIUM TO Y s�ARD Fo Ill I COARSE SAND N(/q Oak GF O �O `�'s oe• -9 !7' SP Ry•� ooe'�pN,yF�TT` T �4J 06;V SP rNgy pcTge� 1�I 4 �VT. '4/ '9NOS L'ON T/A,G, Q° J I 'PPTL rcT? IU,;s N'SU�r�NG oF�/rVF /T�y'`7RgrgFC4 AGF?3L 1 , A�� _0` f' r0 /�Vc gTFO rY A0, ,f ON �NTF,?oR 0Ul*vey poi gERI�4l� I �y c� ,O/1 AREA=22,622 SQ. FT `-�� ``.�••Nper..,5 LIC. N0. 49618 TO TIE LINE 1 ANY AL7FRA77ON OR ADDITION TO THIS SURVEY IS A WOLA77ON OF SEC77ON 7209OF THE NEW YORK STATE EDUCATION LAW. (631 J ' (631) 765-1797 ■=MONUMENT EXCEPT AS PER SE0710N 7209—SUBDIVISION 2. ALL CER77FlCA770NS P.0. BO HEREON ARE VALID F'OR 7741S MAP AND COPIES 7NEREOF ONLY IF •=PIPE SAID MAP OR COPIES BEAR 7HE IMPRESSED SEAL OF THE SURVEYOR 1230 TRAVELER STREET 04-145 A=WETLAND FLAG WHOSE SIGNATURE APPEARS HEREON. SOUTHOLD, N. Y. 11971 John Bredemeyer, President �osuFFnt� Town Hall Annex Michael J. Domino, Vice-President 54375 Route 25 James F. King y = P.O. Box 1179 Charles J. Sanders • Southold, NY 11971 Dave Bergen y�o! �a°� Telephone (631) 765-1892 Fax (631) 765-6641 Southold Towyn Board of Trustees Fiel Inspection/Work Session Report Date/Time: HENRY KAMINER requests an Administrative Permit for a Ten (10) Year Maintenance Permit to hand-cut the Common Reed (Phragmites australis) to not less than 12" in height by hand, on an as needed basis. Located: 130 Midway Road, Southold. SCTM# 90-1-8 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound __L/Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: �Chapt.275 Chapt. 111 other Typeof f 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: 1) 1 Present Were: X/ J. Bredemeyer ✓ M. Domino ✓ J. King W. Bergen Ac. Sanders Bay Constable Other Form filled out in the field by )1A Mailed/Faxed to: Date: IMG-1166JPG https:Hmail.goog] n/Jscs/mail-static/Jjs/k=gmail.main.e... z> AUG - 3 2015 3v 20 / j ✓1 - CO-h 1 of 1 7/30/15,9:48 AM IMG_1167JPG https://mail.googi ►/_/scs/mail-static/_/js/k=gmail.main.e... k. lir • Ami • f.„p.. . aa 41 41 • ' Mfe .r�y y * ,,• rT • 1�, s y ► " 1 ,•�Y a I- • t I.4r � �. �� :► T 1�!•� i I�rll _ >. 3 2015 3a '3 2-ol� l C- C)L 1 of 1 7/30/15,9:50 AM IMG_1169JPG https://mail.gooi m/—/scs/mail-static/_/js/k=gmail.main.e... �waf�..�r 8 •r i d j ,a �T AUG — 3 2015 _ a c � c J 1 of 1 7/30/15,9:51 AM >z+ax $, • { w, x t IV SOD,nDiO 13 b e cEDgR � POIryT rd+ ' a a m b s ------------ X11, - / ,D-o, - ________0.1_______-- J O i C60gR A0wr tOwN eF Sg1TNOlD ,,. > iWq .% P n _-' W. I n s 9 a +41:51' 8 ,w b • `• n ---------- E.--- E. 4 LAKE u n ms e i „wc, f HOG NECK BAY L •r..+n,.. un n ,.. -----_ a..u. --+a-- w --.-- . K aoY a SECT N0 n t ... rmncE COUNTY OF SUFFOLK C or soun,o,o _� Real Property Tax Service Agency v 090 OFFICE LOCATION: ®� S®Ujy0l0 MAILING ADDRESS: Town Hall Annex P.O.Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) N � Southold, NY 11971 • �O� Telephone: 631 765-1938 coutmi LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM � AUG 12 2015 To: John Bredemeyer, President i Town of Southold Board of Trustees From: Mark Terry, Principal Planner t LWRP Coordinator Date: August 12, 2015 Re: Local Waterfront Coastal Consistency Review for HENRY KAMINER SCTM# 1000-90-1-8 HENRY KAMINER requests'an Administrative Permit for a Ten (10) Year Maintenance Permit to hand- cut the Common Reed (Phragmites australis) to not less than 12" in height by hand, on an as needed basis. Located: 130 Midway Road, Southold. SCTM# 90-1-8 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 determination that the actions are EXEMPT from LWRP review pursuant to: § 268-3. Definitions. MINOR ACTIONS item "FF" which states: FF. Cutting phragmites to greater than 12 inches and vegetative restoration, provided that native wetland vegetative species are not affected or disturbed in any manner; 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 �� SQUry John M.Bredemeyer III,President Town Hall Annex�� Michael J. Domino,Vice-President O 54375 Main Road P.O.Box 1179 James F.King,Trustee Southold,New York 11971-0959 Dave Bergen,Trustee O� Telephone(631)765-1892 Charles J. Sanders,Trustee CotfffrN Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application Wetland Permit Application ' (A Administrative Permit Amendment/Transf r/Extension Received Application: __93)15 ? S Received Fee:$ (/ L Completed Application: AUG - 3 2015 ; _Incomplete: f _SEQRA Classification: L_ Type I Type II Unlisted -- Coordination:(date sent): ctrl rf 7r' `ca 'FLWRP Consistency Assessment Form: 7 3— CAC Referral Sent: Date of Inspection: KI W / _Receipt of CAC Rep _Lead Agency Determination: _Technical Review: Public Hearing Held: Resolution: Name of Applicant: ��AY 14�4 M S V NL�Q J Mailing Address: ` �� 1 v o l 30 ILI l U aAY Phone Number: Zo l 2-S 22Z* . cla Suffolk County Tax Map Number: 1000 - Property Location: 3 Itil ( (7 4J,Ay 2!� S o �Ili o L I� (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: B4 d of Trustees Application GENERAL DATA C L2, Land Area(in square feet): �c c1 �} c 7 sio np nn Area Zoning: Previous use of property: �, S d �` O Intended use of property: �2 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 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 ___(::�� If"Yes", please provide copy of decision. Will this project requir molition 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? es No 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? QNo _Yes If yes, provide explanation: - Project Description(use attachments if necessary): Z V € �� B d of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: R GAM GL cC�QG G t— � �FM1Tr,- Vrt1,-n4c± -tAf Area of wetlands on lot: fi square feet Percent coverage of lot:; m % Closest distance between nearest existing structure and upland edge of wetlands: ! c,,—feet Closest distance between nearest proposed structure and upland edge of wetlands: /0-c) feet N Does the project involve excavation or filling? 61;) 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): r�C��s , c _ 1, C,14 c 61Z20 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 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 1 -Project and Sponsor Information Name of Action or Project: \ A Q Co :Ego L_ av�Plt 0w 4 F �" 'GM Project Location(describe,and attach a location map): (c4 Brief Description of Proposed p tion: �,Q W l vl ! ►� ►�P I(a�Vk 1 S N. C�L�✓ cL t ►'� Co J IA-C 0_1_K—f Zlc� Cf Name of Applicant or Sponsor: cic hone: to ( E-Mail: Address: 1 136 ; l' �-s ,-�lvc f City/P0: I �f State: Qp Code: CA'Lv0 1.Does the proposed action on y involve the legislative adoption of a plan,loca aw,ordinance, NO administrative rule,or re . n? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources tha ` may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: ❑ ❑ 3.a.Total acreage of the site of the proposed action? ( acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial []Commercial El Residential(suburban) ❑Forest ❑Agriculture ❑Aquatic t�Other(specify): / ❑Parkland \ es 1 �( y Page 1 of 4 5. Is the proposed action, NO AYE N/A a.A permitted use under the zoning regulations? ❑ F-1b.Consistent with the adopted comprehensive plan? ❑ lE 6. Is the proposed action consistent with the predominant character of the existing built or natural landscape? ❑ , 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? ul ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: �A ❑ ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: El ElN 12. a.Does the site contain a structure that is listed on either the State or National Register of HistoN ONO YES Places? Al ❑ F]b.Is the proposed action located in an archeological sensitive area? I" El El 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? El Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 011 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline F-1 Forest ❑Agricultural/grasslands El Early mid-successional MWetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? ® ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? O YES If Yes, ❑NO k ❑ a.Will storm water discharges flow to adjacent properties? YES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO AYES 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: V F-1 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: I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE _kj 2A� sQ r Applicant/sponsornarne: 1X � l-` 1� ^pate: � 64. �-�"! fib/g Signature: S� 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 1. Will the proposed action create a material conflict with an adopted land use plan or zoning 11regulations? 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? r 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate (� ❑ reasonably available energy conservation or renewable energy opportunities? Lit 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, V ❑ architectural or aesthetic resources? J 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 1::1problems? 11. Will the proposed action create a hazard to environmental resources or human health? FT I F, I Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an nvironmental impact statement is required. ExCheck 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 environmento impacts. Town of Southold-Board of Trustees AI Name of Lea gency Date President Print or Ty ame of�Zes onsible Officer in Lead Agency Title of Responsible Officer ature of Responsible Officer in ead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 B d of Trustees Applicatio= AFFIDAVIT I 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 BOARD OF 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, INCLUDING THE CONSERVATION ADVISORY COUNCIL, TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signatu a of Property Owner SWORN TO BEFORE ME THIS " ""° DAY OFFyL� 520 DIANE DISALVO P NOTARY PUBLIC-STATE OF NEW YORK d �Jg No. OID1475593 Qualified in Suffolk County yp Notary Public Commission Expires April 30, 2®(b B;" d of Trustees Applicatiox AUTHORIZATION (where the applicant is not the owner) I, residing at (print name of owner of property) (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) i 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: P, (Last name,first name,qiiddle 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,rgarriage,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 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 godayof 200 ®� Signature Print Name Form TS l `�,-e h`� t 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, listin$t 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# 9 0 . k9t,— 0 1- ® e PROJECT NAME ao k 1 `1 V 0 L— Ffl 94 EN i TY-5 The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity, agency regulation,land transaction) ❑ (b) Financial assistance(e.g. grant, loan, subsidy) (c) Permit, approval, license,certification: Nature and extent of action: A car try 7 �� • ,` -.... ' V ✓� � V -'�A ,(�- J l 1. _�.r �� G Location of action: Site acreage: Present land use: Present zoning classification: 0 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: 14-e. N el VS, (b) Mailing address: e �� ,�� --%I- 11L � n� �c�'I� rU`l lG� /TA (c) Telephone number: Area Code( ) 2 0► 2� 2�- (d) Application number,if any: Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No JV 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 Tot 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 J F. Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section HI—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No [N 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 F-1No �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. ❑ ❑ ALJ • t Yes No Not Appli ''e 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 [:] 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 ❑ No ❑ 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. ❑ YesE] No❑ Not Applicable Attach additional sheets if necessary • WORKING COAST POLICIES z 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 A 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 ❑ No UN�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 IR 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 I Not Applicable PREPARED BYTITLE 1 6 Cv y� DATE l