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Home My WebLink AboutTR-8684A Michael J.Domino, President ��OF SyO Town Hall Annex John M.Bredemeyer III,Vice-President �� l0 54375 Route 25 P.O.Box 1179 Charles J.Sanders Southold, New York 11971 Glenn Goldsmith G Q � p Telephone(631) 765-1892 A.Nicholas KrupskiO Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1417C Date: November 14, 2017 THIS CERTIFIES that the modification of the existing driveway by removing the blue stone and replacing with asphalt, and install a dMyell for runoff; At 3600 Deep Hole Drive, Mattituck Suffolk County Tax Map #1000-115-17-8 Conforms to the application for a Trustees Permit heretofore filed in this office Dated September 15, 2015 pursuant to which Trustees Administrative Permit 08684A Dated October 21, 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 modification of the existing drivewa by removing the blue stone and replacing with asphalt, and install a dWyell for runoff. The certificate is issued to Joseph Zito owner of the aforesaid property. 6 Lai - Authorized Signature *V SO(/r Michael J.Domino, President � ®�® Town Hall Annex John M. Bredemeyer III,Vice-President t. 54375 Route 25 P.O. Box 1179 Charles J.Sanders v, Southold,New York 11971 Glenn Goldsmith Telephone(631) 765-1892 A.Nicholas Krupski O�y�9UNT 11 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: /gji 7 Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction 'z constructed /Project complete, compliance inspection. INSPECTED BY: G• C'u", � COMMENTS: 13 U Mto OXCO'c 0,0c e ov CERTIFICATE OF COMPLIANCE: X00,„ ileJohn M.Bredemeyer III,President ��I��of SOUr/yO Town Hall Annex ,`O l0 54375 Main Road Michael J.Domino,Vice-President _ • ' P.O.Box 1179 James F.King,Trustee .. "Wra Southold,New York 11971-0959 ih ,v.4,`, Dave Bergen,Trustee • G 4•. ,'A �� 1� Telephone(631) 765-1892 Charles J.Sanders,Trustee •` Fax Fax(631) 765-6641 eOUNV As BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8684A Date of Receipt of Application: September 15, 2015 Applicant: Joseph Zito SCTM#: 1000-115-17-8 Project Location: 3600 Deep Hole Drive, Mattituck Date of Resolution/Issuance: October 21, 2015 Date of Expiration: October 21, 2017 Reviewed by: Trustee James F. King Project Description: To modify the existing driveway by removing the blue stone and replace with asphalt, and install a drywell for runoff. 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 Joseph Zito, received on September 15, 2015, and stamped approved on October 21, 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. ,cam Michael J. Domino, Vice-President Board of Trustees SURVEY OF PROPERTY SITUATE NEW SUFFOLK AV . LI ,, ' '�; I----1n ' ,, I�J[A _ _ LUCK :,,, ,_.:::,:,:,' ,--k:.-'.?..p►PrPROVFD BY " TOWN OF SOUTHOLD t B`OARD OF` . ,:USTEES SUFFOLK COUNTYNEW YORK TOWN OF SOUTHOLD ® ,.., .`_ S.C. TAX No. 1 000- 1 1 5- 17-08 DACE= f �%7 20 %' , � SCALE 1 "=20' '4 . SEPTEMBER 2, 2011 Y, e)N L rr, L _ • {_: AREA = 10,714 sq• ft. • A .. °� (TO BULKHEAD) 0.246 ac. ° & L ORRAIN- FABR y CERTIFIED TO: A. FABRy JOSEPH T. ZITO • S 79000,00„ E ° . ° FENCE ''*� 0,7' 1 r o w O _•_'—., a a p srocKgD �•_ FLOOD ZONE NOTE: FENCE �'•--4 .�• 107.6 , FLOOD ZONE INFORMATION TAKEN FROM: 4 w FLOOD INSURANCE RATE MAP No. 36103C0482 H a in - 4-4.1.-.---".c7 iC4 ° a STO EIDE `� 9.7' ^�• � ZONE AE: BASE FLOOD ELEVATIONS DETERMINED FEN;E:1: 11.3-1 o27 s' ZONE X: AREAS DETERMINED TO BE OUTSIDE THE 0.2% ANNUAL CHANCE FLOODPLAIN. ° e °d 4' DIA. X 5' / ° SHED Eap• CONC. SLAB i`• • . BLKH B�LKHEAD 7 DEEP DRYWEL D 9'S. FOR ROOF RUN L o ►9 7 C e, ° til a ° ° ° vFF~-\ PLASTIC FEf t '4 STOCKADE 1 ? ° ;v . ° 1� MAS�NRY `, ' WOOD FENCE E O I t1L �l ° ° BLL' .TONE DRIV .., d ° II PATIO p�•OOF / RAMP r— ° ��— I.=•SLATE PATIOS O 111111 1 1_, 'Mill alliin 0 ° a r , _ - — w ° ° ° 28.5' , _ ___J10 X Q I Y 10' WIDE NON-TURF BUFFER W o °° G a ,. ° WW w MNZ MN pow Z Z tg�6 IZ1 O 4' e e 0'7 Q N 3y 8I I2 JwJ �W o� 4-4.I D<D C5 _ ° w 3� ° ° os N I 3 F'' i ti� ;-1 PREPARED IN ACCORDANCE WITH THE MINIMUM •° ° CY "�• o O v o CONC SLA6 0-6 z ti i ' : ; 1 I STANDARDS FOR TITLE SURVEYS AS ESTABLISHED ° 4 ° 0= n '�a z_, 4..—.< �. 1 •I t FORTSUCHI USE BYNTTHEPNEWVYORKNSTADOPLTAND �l TITLE ASSOCIATION. o LI i . ii ° ° Li ° a°° II�// N p� WOOD I _ SEP y G �j C • ��;;,,/� �e'A, '6 9' �^I BULKHEAD .�I DECK t 1 J 20�.F ' G F- ^N 1. Num ° ° ° vs.ji ARES • �� G ' 1, WOOD DOCK V w q�Su.�SLi ILtai� � iIwo Nom 8,! *.I' ' d ,° ° ° N- OVER °0 ° ° (2 UN TS CON LK e I I °°�1�i/// 1:1 ».. .,_..._..._.Boaru ?I tegi - T`i 5. G. f.- }s c CONC./WA ° I ° e p , . , ELi .� � §i fel ° e° ° o�' 1.;--c / ° CESSPOO di ° Z ail 0 L ° E..., 14: 1°°'° Q ° O .. N.Y.S. Lic. No. 50467 ° 0 a oENCE I a a ,-.�,-. A 0 N 3•N 2.TE ° , °' e UNAUTHORIZED ALTERATION OR ADDITION • ° ° N 79'0 ° d- TO THIS SURVEY ISA VIOLATION OF Nathan Taft Corwin III ° J ,� ST SECTION 7209 OF THE NEW YORK STATE ° O 0 OC�OE FENC a ° II 0 EDUCATION LAW W E _ ° Land Surveyor °4 1 (n COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR FENCE EMBOSSED SEAL SHALL NOT BE CONSIDERED /O/F 10 - 0 1'N TO BE A VALID TRUE COPY ,,,...--7,_ FRANKN MA 7.87' CERTIFICATIONS INDICATED HEREON SHALL RUN Successor To. Stanley J. Isaksen, Jr. L.S. y RT �[Z4T ORAN ONLY TO THE PERSON FOR WHOM THE SURVEY Joseph A Ingegno L.S J MAR'ORAN,A TITEIS REPAREDCOMPANY, GOVN HIS AGENCY, AND OERNMEN AL BEHALF CCYTHE AND LENDING INSTITUTION LISTED HEREON, AND Title Surveys — Subdivisions — Site Plans — Construction Layout TO THE ASSIGNEES OF THE LENDING INSTI- PHONE (631)727-2090 Fax (631)727-1727 V TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE J �- OFFICES LOCATED AT MAILING ADDRESS 1 µ _ THE EXISTENCE�OF^RIGHT OF WAYS -- John Bredemeyer, President Town Hall Annex Michael J. Domino, Vice-President °O°y�; 54375 Route 25 James F. King ti x 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: 061.- /016° JOSEPH A. ZITO requests an Administrative Permit to modify the existing driveway by removing the blue,stone and replace with asphalt, and install a drywell for runoff. Located: 3600 Deep Hole Drive, Mattituck. SCTM# 115-17-8 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay l Distance of proposed work to edge of wetland •/' - �® Part of Town Code proposed work falls under: Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment i7Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No 'ot Applicable Storm Water Management Review: Yes No Not Applicable Info needed: No Ai Modifications: Conditions: 7� f AG/GP- Present Were: J. Bredemeyer ' M. Domino J. King /D. Bergen C. Sanders Bay Constable Other • Form filled out in the field by ,/', /l/1e/ • Mailed/Faxed to: Date: rtsiet i• • 11 i . t {, „• jii��- vl , �, v ' ' Ism .y It . . y ' _ •.t' 1 Ary • a V ' f�.% t • `� ill op n • `r, 4 • fir ' ore, #Y.. , }� 4 %• os!' • •.. •r *a / • •` - •7. `• 4, . Imo '' r • Lo ..• r� •"� .aih ' + - , a . i,i_ilikt - ;' k • omit elik i $ 1 i • •I A ' i -. • .• ..••••• ' fkiriiiiitifiql. 0 I -okt4k1s _ —7_7.- _ •I ! r- ..,. . „1--,. _:..„450,i„ _ ___'. ... .., i _. _ _._ __. __..., -11 _ _ __ _._ _ _ _ ... _ __....____ _ _ _ .• _ . _ ...._____ _ .___ ._ _ __ __ , . _ . _. -iv...........__ - - _ .. ,. . .A„, _ : . ii.,..,- _. ...... ._ . _ _ ,. _ aril.o." 1 • f f •_ e''*OF sout - OFFICE LOCATION: ��/ ;?• Ol MAILING ADDRESS: Town Hall Annex �� ® P.O. Box 1179 54375 State Route 25 * Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) `. G aQ Telephone: 631 765-1938 Southold, NY 11971 ,c► CORM{,0" %es-s o'g LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM ` Y j �! OCT 162015 To: John Bredemeyer, President Town of Southold Board of Trustees Southold lam hay Iits'.. From: Mark Terry, Principal Planner LWRP Coordinator Date: October 16, 2015 Re: Proposed Wetland Permit for JOSEPH A. ZITO SCTM# 1000-115-17-8 JOSEPH A. ZITO requests an Administrative Permit to modify the existing driveway by removing the blue stone and replace with asphalt, and install a drywell for runoff. Located: 3600 Deep Hole Drive, Mattituck. SCTM# 115-17-8 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 recommendation that the proposed actions 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 I,„, //SI Vol __ C John M.Bredemeyer III,President ,,�I4 .., ,,,14, Town Hall Annex Michael J. Domino,Vice-President ��• O - l0 ; 54375 Main Road + ` P.O.Box 1179 James F.King,Trustee ; ; 41Ei Southold,New York 11971-0959 •Dave Bergen,Trustee G "„ �� mac► = �� ib Telephone(631) 765-1892 Charles J. Sanders,TrusteeC®U 0e Fax(631) 765-6641 poi BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD - - Office Use Onlyi5t g ti , 1 �1 _Coastal Erosion Permit Applicatior �.�J Wetland Permit Application V Administrative Permit _ L � / Amendment/Transfer/Extension SEP 1 5 2015 ;'" V Received Application: It/S-,/6 Received Fee:$ 100 00 V Completed Application qd/515 Southold Town _Incomplete —_----hard of frusteeq SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) fry R�!+� LWRP Consistency Assessment Form CAC Referral Sent: ✓Date of Inspection: /0./4,/6— Receipt 6Receipt of CAC Report: _Lead Agency Determination: Technical Review: ,/Public Hearing Held: /Ca 2-it 15— Resolution: Name of Applicant ) 5 -62/2/1 1 . L 0 Mailing Address `3 ep(J 9 e Phone Number: j 1 G - o cs? " t ( 8 Suffolk County Tax Map Number: 1000 - �° l , — Property Location: p---/'4-1 v (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: ] T-d of Trustees Applicatio , GENERAL DATA Land Area(in square feet): 464 Area Zoning: R-0 Fes. ; et,q2`Z +1 e / Previous use of property: /k.(2 5,&4 �/t V t Intended use of property: d.�'1`cf. r G/41 Covenants and Restrictions on property? Yes 7 No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes 4/Tho 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 X No If"Yes",please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes ‘. No Does the structure(s) on property have a valid Certificate of Occupancy? Yes dr 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? /No - Yes If yes, provide explanation: Project Description (use attachments if necessary): i tIL ' .Al - U ej 1, .; !y�//_`" �/° t// t) h`e kt 1 L ic,�... P , z _ - / 1 r% Bo of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: P11I1 417 Pil el V 4_14/6y Area of wetlands on lot: -4- 6/6 square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: O feet Closest distance between nearest proposed structure and upland edge of wetlands:10 I feet Does the proj ect involve excavation or filling? Yes If yes, how much material will be excavated? — cubic yards How much material will be filled? ri,44 q 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: /1,,. c7!n ,e_ 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): 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: *e/2/ fes( /-b Project Loc tion(describe,and attach a location map): 6-es /fes iii a—e C rief_ escription of Proposed Action: ) Name of Applicant or Sponsor: P Telephone:6 `' OZ q _Q6d eft( `�Z T/ Z E-Mail: Address: e oa P-e e,214/-ee lip I '/� -� City/PO: State: Zip Code: 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 �y n 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? P/3 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 D Rural(non-agriculture) ❑Industrial 0 Commercial CMesidential(suburban) ❑Forest ❑Agriculture ❑Aquatic DOther(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ G b.Consistent with the adopted comprehensive plan? ❑ 2 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? n 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? n n 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: ❑ F✓ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? / n b.Is the proposed action located in an archeological sensitive area? ❑ ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ® ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? f/ n 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: ❑Shoreline 0 Forest 0 Agricultural/grasslands 0 Early mid-successional ❑ Wetland 0 Urban 0 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? I- - ❑ 16.Is the project site located in the 100 year flood plain? NOYES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, Ela.Will storm water discharges flow to adjacent properties? RrNO nYES b. Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly escr'bei n NO 1'YES PI-44t€ a 5 l -/20-y a.,'e l( 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: 21 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: 7 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 Applicant/spons. nam " ° �� Date: ' r Signature: Part 2-Impact Assessmen The Lead Agency is esponsible for the completion of Part 2. Answer all of the following questions in Part 2 using the in ii ration-eontainedin Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur l. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or -71 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 l ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a.public/private water supplies? b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage J ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. • nCheck 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 environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. / Town of Southold-Board of Trustees / U') J 1 lN,ame o Lead A ency /� Date �,a I,1-. C; President Print or T. �:'Name of:esponsible Officer ih Lead Agency Title of Responsible Officer l nature of'Jr nsible Officer i •read Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 1`-' I' `rd of Trustees Applicatio_--- AFFIDAVIT JO sqh T. z I+6 BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE 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. ' a /t44; S.?ature . Prope/ I wner SWORN TO BEFORE ME THIS 15+h DAY OF a - 0C r , 20 15 TRACEY L. DWYER NOTARY PUBLIC,STATE OF NEW YORK NO.01 DW6306900 QUALIFIED IN SUFFOLK COUNTY • Jace,y ,61, COMMISSION EXPIRES JUNE 30,2a,_, Notary Public F 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. C1 YOUR NAME:j 'Qd �-s U 6 (Last name,first name,middle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of,Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO , If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant . (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thi day of 200_ Signature ¶- 4- Print Name/ " ' Form TS 1 -r--"-. ( ' Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# - - / PROJECT NAME 540,4 ` ' 2 (I t 6 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: ❑ P,,bj eco--clue veirfi` Nature and extent of action: ognienve / df h1ori 04'®n pg'0,42-( 4.1 � I Location of action: 0, Q V Site acreage: VI - Present land use: fl 8t14,7/I/9 / 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: d--0 3 '�l Z ( 't (b) Mailing address: 3 6® e /2/-!J v -( (c) Telephone number:Area Code 3/ a 9 - 0 0 O (d) Application number,if any: Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ri No If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. n Yes NI 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 No E 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 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 11 Yes No FE05 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 HI—Policies; Pages 22 through 32 for evaluation criteria. I - • Yes No Not Appiit;able 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. Ye4 No 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 No 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. YesNo 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 gNo 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 ids No Not Applicable PREPARED BY .«( /1/ i , TITLE ,0 1-44,11 DATE 4i-4i-iv f