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HomeMy WebLinkAboutTR-8719A //_l# John M.Bredemeyer III, President ��� ��of .®Ujy®l 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 %10 � yr e �� Telephone(631) 765-1892 Charles J. Sanders ®�ycoUNTY,� Fax Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1213C Date: April 28, 2016 THIS CERTIFIES that the berm cut in order to access the public road, and install an approximately 8 foot wide circular pervious driveway; At 105 Waterview Drive, Southold Suffolk County Tax Map#1000-78-7-9 Conforms to the application for a Trustees Permit heretofore filed in this office Dated December 10, 2015 pursuant to which Trustees Administrative Permit#8719A Dated December 16, 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 berm cut in order to access the public road, and install an approximately 8 foot wide circular pervious driveway. The certificate is issued to DOMINIC NICOLAZZI owner of the aforesaid property. Authorized Signature John M. Bredemeyer III, President ;a�oti�E , Town Hall Annex Michael J. Domino, Vice-President 4 2 r. 1., 54375 Route 25 Glenn Goldsmith y P.O. Box 1179 A. Nicholas KrupskiSouthold, NY 11971 Charles J. Sanders ,' 4,o! Telephone (631) 765-1892 Yr�y Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: '°/(,, Y Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1st day of construction 1/2 constructed Project complete, compliance inspection. INSPECTED BY: '7144 .;;--.) COMMENTS: CERTIFICATE OF COMPLIANCE: .-�: • I ,, "-,_ iii# S John M.Bredemeyer III,President �`�00 OUP/y® ' Town Hall Annex 0 A. , ,, ,. l® 54375 Main Road Michael J.Domino,Vice-President ��� ,,}}.�' P.O.Box 1179 James F.King,Trustee iNg ' . ^; '�f�"' Southold,New York 11971-0959 Dave Bergen,Trustee- L'1, z ;` S Charles J.Sanders,Trustee Telephone(631) 765-1892 Fax(631) 765-6641 • BOARD OF TOWN TRUSTEES ` TOWN OF SOUTHOLD Permit No.: 8719A Date of Receipt of Application: December 10, 2015 Applicant: Dominic Nicolazzi SCTM#: 1000-78-7-9 Project Location: 105 Waterview Drive, Southold Date of Resolution/Issuance: December 16, 2015 Date of Expiration: December 16, 2017 Reviewed by: Board of Trustees 1 Project Description: make a berm cut in order to access the public road, and install an approximately 8 foot wide circular pervious driveway. 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 Dominic Nicolazzi, received on December 10, 2015, and stamped approved on December 16, 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. '-' .i.a John M. Bredemeyer, Ill President Board of Trustees John M. Bredemeyer 111, President ,�� t}EFD(,Y Town Hall, 53095 Main Rd. Michael J Domino, Vice-President ,��� Gym; P.O Box 1 179 r i., N iv 11971 James F. King i ... ; Southold,, Charles J Sandersit, Telephone(631)765-1892 ,* Ol Dave Bergen Fax(63 l)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 1s1 day of construction V constructed t(s Project complete, compliance inspection it e:', y - NDIE ,t /:. /� / m. 1 ELEVATIONS ARE REFERENCED TO N G V D 1929 DATUM ` T l)V`1 1'. V .b // �/ �Oa EXISTING ELEVATIONS ARE SHOWN THUS-2.2 ,�,f I'(T�'1/ IJ ,//// - 2.PROPOSED SEPTIC S'STEY STRUCTURE SHOWN THUS ( (J I C 2 /� / 0 PROPO5E13 EXPANSION PDOI. - 0 urn r �� // / // /, PROPOSED LEACHING POOH _ so`J r^ / /% /,'(/////2 /j /// Q TIPROPOSED SEPTIC LANK TOWN O F S ", / S.THE LOCATION OF WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD TOWN IV O ^ I'I /// ; /�'t/ /j y THISP OBSERVATIONS ANOIN DATA OD7AINE0 EROY OTHERS N /l 4 THIS PROPERTY IS IN FLOOD ZONE AE(EL 8) SUFFOLK COUNT /1 FLOOD INSURANCE RATE NAP No 3610300166 G (� rA y /j/ / / // /''// . `Fio ZONE AE. BASE FLOSS ELEVATIONS DETERMINED S.C. TAX No. 101 .E� 5 11-E6-90 COASTAL BARRIER SCALE �-� g • p .s. FLODD INSURANCE NOT AVAILABLE FOR NEW CONSTRUCTION Jl." '1// /,/ // ,/ / 4*9.4A6,. .I OR SUBSTANTIALLY IMPROVED STRUCTURES ON OR AFTER 1 1/ // / Tr cN.f NOVEMBER 16, 1990^IN DESIGNATED COASTAL BARRIERS. 11�A.�1I A n 1//1 / / II /" , / T� 6 UPLAND AREA a 74,644 AN 11 .AI.i LLH4�_IA1L"Y-"`1 - / / / / / / PROPOSED HOUSE GARAGE IS 5,f 91 aq II OR 895%OF UPLAND AREA—` /1///// / '/' / / / _. JULY 18. 2002. AIME( /// /I ,/ 7 APPROXIMATELY SOO au.yd..OF FILL WILL NE NEEDED7 1 / / f / / / ////' / B HOUSE TO BE BUILT ON A CONCRETE FOUNDATION FFRRUAR't 12. 003 I // 1//21/Y////:// // ; a r/y///7/7 // ' // /// // / _ ,. AREA 235.6 /// / ,�/ /// / // // /% .T—�na< F-- . 4 (TO TIC UNE) 403 0. z //� 1/ j/ / / Joao . - _- i `tib� // / 14 �/ ///,; ///,/,// ', /, , % j . 11 I, °>;/ ',/7' //,-/,-/// //... // / , /% '/.///,% 'F30so,. '1, e DEC 1 0 2015 `-- G CER•rrr..LEP_I tel/ /////// I ,/, /', ////// /�/ / E 17jTos' i` 4 i • ESTATE 0( ,///////// '�AS/ , / / ///tom/// II N 1`�,,1 0 ' Si11,sa:C 1�TR.l�jj ` N • j jfE ////'� DEM11'�'�B�j j J////% II l i 'y,� dry —. '�^"- "3'?,4.J.-t-�f J ////' /r //// r / /A7 /� // // �_ , 0..I [� a / 1 �v , PROPOSED SEPTIC SYSTEMS' / ////,// ; /� // // / d Nuw,wal ////)// /r //j / 4/��j % / /• /e / , ds-4i3 ''';,I m i ,--,, '""--17--, �Q�'"orn*an yr ' { roa / //�//✓� �/ ` / /// 1118555 ' 4Vt�SS, / ' B ,ao's1 IIlI.I.MEM4t ; 111/ „/ /X /// / / ///ay / ttP-r ••qfp' j• 4�// / / 4 // /// // / '1 -, I.WOOL 742N.A.mu.r r..PRY.CT i.61.1or.o:m min®m m. =WV.wr.,a :.�: / / '/ / 7// , // . '{ 'it % am,eLLccrosomna Wa cmmnort. Lasa ren / /' // !/ // / /I / v / /'•u//,i LIE • I1 1i1 A ',up.`'w`r'W'®°a mwnn�'v an ate.ra wa.°".uuc,v.wsor.V•7 .u:':T u,kr,r`ai. / �//17• , /LSo_' _ /./ // , / ! -1:. 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PREPARED D+ACCORDANCE SUR WITH THE TABWRA ry W 4.6 .,� STANDARDS FOR DUE SURVEYS AS ESTABLISHED t7 r '� 0.0 ' Br THE LIA 5 AHD APPROVED r ADOPTED �'se SRBNOIC Eno fDR such E Of THE NEM/TORK SWE 1AND ��ZZ((,,,�, k- t - Board of Twain TITLE ASSOC ON _l_____an, rIN N a6.10'26' x. x 3111. - - -_a . Jay // URVEY OF PROPERTY 'CV ��V M 5 WOa 1 ELEVATIONS ARE REFERENCED TO NOVNGV 0 1929 DATUM 2•may/ G,/ / I �E%ISTING ELEVATIONS ARE SHOWN THUS-AD / /j/ SITUATED AT 2.PROPOSED SEPTIC SYSTEM STRUCTURE SHOWN THUS ,(/ el PROPOSER LEACHING POOL S 0 UTH 0 LD /1// /' //, // PROPOSED LEACHING POOL // I /1/ j/ , QTION CI, D6LLS Nx TOWN OF SOUTH0 D / 1`// 3 THE LOCATION CI WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD 0 M 1 //. I //1 /// OBSERVATIONS ANOiOR DATA OBTAINER FROM OTHERS rA 17,<// /// I/ ,/// // 4 THIS INSURANCE IS IAA ZONE AE 3C GTO S SUFFOLK COUNTY, NEW YORK V //' FLOOD INSURANCE RATE NAP No 3610300166 G / // 4— ZONE AE BASE F1-000 ELEVATIONS DETERMINER TAX No. 1 000_78_07--09 / / // • e, 2 5 11-16-90 COASTAL BARRIER S.C..7 TAX No. ll (J / J , /// // '1.// / / V:i1 FLOOD INSURANCE NOT AVAILABLE FOR NEW CONSTRUCTION SCALE 1"-5C' , / / 4 OR SUBSTANTIALLY IMPROVED STRUCTURES ON OR AFTER i //1 /// / -u NOVEMBER 16, 1990,IN DESIGNATED COASTAL BARRIERS I/,x,11 I [��/ Z �1 1 Z ///1///1 ' / / //j / 0 6 UPLAND AREA S]8 GARAGEA AG H ,_ _ .AhtLYW 0R1-i�T -?nQL_ 1 €/ /1 / ///, PROPOSER HOUSE A IS 5 191aq 11 OR 695X OF UPLAND AREA- ,I4 1 // / 7.APPROXIMATELY 500 as p3. OF FILL WILL RE NEEDED JULY 18, 2002 AODED PROPOSED WELL / F /✓ / / / 8 HOUSE TO BE BUILT ON A CONCRETE FOUNDATION FEBRUARY 12, 2003 REVISED SITE PLAN w / / /,;/ ;�///,//// ///%I /1///////j// - F /// to / '/// I ///// ///// / / I /r "..-`^ AREA - 235.614.84 sq. ft. G�,614 ,///iii I'�//2//, // / ' r, )Ec. E , „ El ( )TO TIE LINE 5.409 oc rtib ; //, 1 / // // , ' /, ��//� ,1:,; ,,/ / ' /// I//////// // / / // S,73p. .,,._,/ /, , •// ,//; •///r,',/,/,/,,,-/,/// Sip•, II s NOV 3 0 2015 / // / / % r CERTIFIED TO. //� //// /�/774-/-/-/-/-// //-i /-/ // / T�14S• ESTATE OF JULIUS ZEBROWSKI y�///////// GB�RR/// //e�', ///i N .I '� SO`J�'�oftl Town ry% //////j/ DIE9,%B/%/'/ / /// / iS '� f� �oardff Trustees - /// ,/// p//I, FZTB�,'� / ,///// T3 ////�// /f I - /////// 1 ' , / \ / f �' PROPOSED SEPTIC SYSTEM DETAIL / aumsw }\x43 j/ ',////'/ /�%�I /.Y y/ %/11/,f j//,$y'3o�//�// // I !F.. q an,:,1.4 J //'T +� %/ // l / l //� / /' / /'/�,g /; @@ _,4a;A�A - ,`1 m PROPOSED 7mrwaanc /1 ///////// I lY P v 1� IC.a Ps / ux m.v et —ray 1 / `f 17. ,:r//, /,`-'� °ATS eYPIc a't' 7 rarAu / / $ W/� I �l 3 t s_��`��/ Vsn m.r.at n , I w a-Tr ` ..,•- taiAn ///// //�//�y///i/,`....,4: --,::-::!'2,, ,,( ¢ / / ©,`�+�'f ' 1 Ilii toe f—r-1 fl, r 1 I..rr"'rl •a / /� / '•'�.t+ • 14. 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Ingegno rGw o �� ,t �6t ofI19� BY THE SA s ARO APPROVED AND ADOPTED `1' Rum TLU7L9� m SUCH .TEjON THE NEW YORK STATE LAND Land Surveyor .8x ,PHA !C (s` �y, ea'�: t^ -i- p Title Surveys-Subdrvrsrons - Sita Plans - Construction Layout GS. - p \'I i PRONE (631)727-2090 Fox(631)727-1727 Y o S 1 Q OFFICES LOCATED AT 'JAILING ADDRESS kNa -t,:a '-q4.A NYS I,c No 49668 1380 ROANOKE AVENUE PO Box 1931 4.-.j RIVERHEAD,New York 11901 Riverhead,New York 11901-0965 23-040 • -4.- ?c,....4.:,4, N , Y.. tr 4' +vF y,� a n 10, a•y ' ' ; ii* w 14. • *7' T£ �3 ''' 01" "1 ' r s• T` #, •tet , �" �.. ! .e.—.. 4r t 8 s X, ;;„3„ "C"- `�,p - '"" -s, ''• ' "Zr .� r i 'Ir +ate` ++ " `^t ,yam" ,,u'� , ,0.7- „°or yy"4^' -1 a, .0- t ,ar .., ±, yah iA'C”. .\. , k11rle, 4.". .1%,;',".'4..,-y,-.7, `' 'rr14i7.1 ,, wi. 7t0S1:41 IA l''' .-- 4k A 44' ' -1.4,44 ''-' ' 1 „a .4:' r sr ti veelart, l ^; '• a, AI- - F-61.<-1�1 G �1-S I NoQ c cf X19 T. ``' 1 e • - + `' •* - a ✓w!, 111 *', M' - .. _ - n € yr ye { . r i r .. a -. _ .. - #TMS " i'M P«s fi « aAlt, •, � w bra'°" ` • • . - • • I a • `'I• a!" 1. `-phi ,f, ,. 77 a111111" a or m • i a „,,,,.. .ya.:v. qM�FLi..• . . . . ... 1 - � H .... _ _ , . .. ,. ... ...4 t=RctN� 1J �2rrk�fST John Bredemeyer, President / ),suFFot, Town Hall Annex •Michael J. Domino, Vice-President ° A °°y'; 54375 Route 25• James F. King ;y s P.O. Box 1179 Charles J. Sanders o 47$ Southold, NY 11971 Dave Bergen =�'�i , , a°. Telephone (631) 765-1892 Fax (631) 765-6641 Southold Town Board-of Trustees Field Inspection/Work Session Report Date/Time: 1)&4--yi l r DOMINIC NICOLAZZI requests a Pre-Submission Inspection regarding a proposed berm cut and driveway expansion in order to create a circular drive. Located: 105 Waterview Drive, Southold. SCTM# 1000-78-7-9 Type f area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay . Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Viola 'n Notice of Hearing card posted on property: Yes No Ni Not Applicable Storm Water Management Review: Yes No Not Applicable Info needed: Modifications: . ti,.►„ � Conditions: . oc- ec,� 46' Present Were: I J. Bredemeyer . Domino'" J. Kin ID. Beren t'�" C. Sanders Y 9g Bay Constable Other Form filled out in the field by `--ts"- Mailed/Faxed to: Date: . . - 04-21 tra -V 11430.03 a .. c 11 2340 ± ar MATCH SEE SEC NO 070 5 gni' UNE r; 04.03.01 C " ) 7 E 7 E ,r'' „Jo ,..,, ,----i.___, 77 ----. .."-•-• , 0.9.13.01 ,,, 10.11 as - ... 0942411 '?> me / c. ..,-- .,„/ '•--.---. 01.1602 )7 4..!-C--' "--- ..,V.,' 08-02.02 SLEEPY OLLOW ','12- P , /-- . , ' ( ne-/E-0 1 -''''''''--.' ---. _....-- "..8 10-10-03 5.3440•,.... r.--- arra, \ 04-15.01 .0404 05-2.05 10-24-05 11.0945 11-22-CO 0 TOWN OF 05-11-09 a 11 20-09 * g cc s.... 09-3.11 1,0342 04-29.14 03-02 15 ,0 WO - rararara,rarraa, _ , / . It ihr a . inittflit I .1. . N , /1/ SEE SEC.NO On 0 r 11 coi lu7t/0 oF / , U 070 / l01440 . 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Town Hall Annex �� ® : P.O.Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 ` 4, 0 Telephone: 631 765-1938 ----a OLIO Alio I S LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: John Bredemeyer, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: December 11, 2015 Re: Local Waterfront Coastal Consistency Review DOMINIC NICOLAZZI SCTM# 1000-78-7-9 DOMINIC NICOLAZZI requests a Pre-Submission Inspection regarding a proposed berm cut and driveway expansion in order to create a circular drive. Located: 105 Waterview Drive, Southold. SCTM# 1000-78-7-9 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 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 IF ®F S®L/k4 _ John M.Bredemeyer III,President ��IQ� „,Nn• � Town Hall Annex 54375 Main Road Michael J.Domino,Vice-President 2111 • 414 P.O.Box 1179 James F.King,Trustee s Southold,New York 11971-0959 Dave Bergen,Trustee � r Telephone (631) 765-1892 Charles J.Sanders, Trustee ;lycoU ,*11.11• Fax(631) 765-6641 0'0 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application `Wetland Permit Application s Administrative Permit Amendment/Transfer/Extension (' if Received Application: 12►I® 15— Received Fee:$ I M DD ! ' ti Completed Application: iZ‘1045— DEC Incomplete: 2015 _SEQRA Classification: At Type I Type II Unlisted Soutt!c!u;ar�n Coordination:(date sent): .! fT LWRP Consistency Assessment Form: CAC Referral Sent: V Date of Inspection: 2-sq, _Receipt of CAC'Report: _Lead Agency Determination:_ Technical Review: Public Hearing Held: 12 / 7./5— Resolution: Name of Applicant: J b vsi/ i ae 3 Cot-a Z_Z1 Mailing Address: RS S T ��� =Ai Q t. s a .s Tito t•-0 Phone Number: 5'1 , G o7 -7 U 07 Suffolk County Tax Map Number: 1000- 76 - 7 _ 07 Property Location: C c 12_AIL a- o ,11,9nAf eft-'1 v 4 2 OF hitt 0 M " .rrytetea"i - i & , © 15 7 ��C "- COIL Al e o c , 4*s 8' (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: -mrd of Trustees Applicatirr GENERAL DATA Land Area(in square feet): 2 c ( `4 P 8 V Area Zoning: 2 ilciti'e PaS. rf' Previous use of property: 3/9-44€ °C.. Intended use of property: Steib►e_ Covenants and Restrictions on property? Yes a7 No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes ter'" No If"Yes",be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes V7No 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 So-;I4 r To /z469- No prior permits/approvals for site improvements. j 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): '5 WO v's_`-1,.'.y C.d P,C uL d9 sZ /Ai /Pry tL6 , g c.tL p3--6'� kAl Or it fiffildx `(6, ,e-r f-et r) 4:11,055 OdssV i ti-E t 0 _, =ord of Trustees Applicatii; -`• WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 0 Et S 3- f-2 a 1 t--011-0/570, f 7-0 *cow_ s9-A1GA4L _ Area of wetlands on lot: M /s'o,o e o square feet Percent coverage of lot: Closest distance between nearest existing structure and upland edge of wetlands: /0 0 feet Closest distance between nearest proposed structure and upland edge of wetlands: A/(4- feet o ST IL c5' (Ped Pd s Does the project involve excavation or filling? ;-/prNo 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: j C(A.,6_ exisTpvG L4 qOO q c atii e g 5. Manner in which material will be removed or deposited: 1.(-t/c.LL (it-tio9 II Er/V6- 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 I. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part l 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 'bo i'Ai lC IDOL azz- ( • Name of Action or Project: Project Location(describe,and attach a location map): (�Lt i J ?-Y c ovviANG- e F i wtficrc.a.0 : -✓ p a t i6 4-C4-05 5 F2ia WI-at? To 64441-CE. Brief Description of Proposed Action:• SP+t_ti R.v'6.eG-/L t, ;t_ &AIS g3-' (13 VI t ILL T4Ach- /9V`10 419 Jv CAR-55 AO—N 1--ths enddDtE Name of Applicant or Sponsor: Telephone: s-"!G G 07—7c0 7 vsni vcc r`Cdt-47-/Z--1 E-Mail: Ai,4SS0C- e Ffoa.Cc,bs? Address: /0'5- t.N 4'7-,.4 1/411 c4/ City/PO: State: � W Zip Code: 3aLT t, I.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 n ISI 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? 2 o o k.spv Ana/G. P(, ,./I2 00 sq. F r. b.Total acreage to be physically disturbed? o acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? 6,S acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial [Residential(suburban) ❑Forest DAgriculture ED 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? b.Consistent with the adopted comprehensive plan? ' 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? 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 El El 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: At/4 ❑ ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES A/i 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? b.Is the proposed action located in an archeological sensitive area? ® ❑ ® ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? El I-I b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? [5 ❑ 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 tForest Agricultural/grasslands ❑Early mid-successional 1-,;Wetland El 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? NO YES If Yes, Ela.Will storm water discharges flow to adjacent properties? ❑NO YES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: n NO nYES 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: n 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: J 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: (gip ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE ,� ! Applicant/sponsor n 11\ pc'+r►, t C �`V(.Cc!L.41.Z 2 ( Date: 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 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 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 (�.1 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? 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 El 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. NCheck 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 Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 --- ,Lrd of Trustees Applicatin AFFIDAVIT DOwn/" C- M 1CtO fl2, BEINGDULYSWORN DEPOSES AND AFFIRMS THAllfillE 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. Tn.,of Property©wner I SWORN TO BEFORE ME THIS DAY OF , 20 \C\ DANIELLE f3 !NTHWOHL, Notary PublIc Stare o;Slav'York No.9i W,zU87 17 t� n Queitfied in 5u olk Chau 2��� Commission Expires Notary ub - APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCI,1 SURE 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. n YOUR NAME: 1COC9i2 I 0e 4-n. stviC (Last name,first name,jJddle initial,unless ydu 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 t�r-- If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this / day of 0 e 200 5`" r Signature C f, ,✓' aA=i c-c)t,yr2 t Print Name t' A-1-7 Form TSI 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# tO o O - - _7 -- 7 PROJECT NAME N d Cc.)c-09- z ( Oi e t't c y The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. Board of Trustees kI 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 ti�s o /91°0-604 c Fait_ 7,9 .012-, et_e_U -&u (Ai N)9i /LE_ i Location of action: f=P-ati r" y'i¢-tO ©T /vs" wo-t s.0 r p - ✓7 /1-c( Site acreage: 3' Present land use: fa-t5( pr--?to) Present zoning classification: Z It S( /)f=7VI(//L_ 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: TO-^-s /r- c- Al(coc C;z-z z (b) Mailing address: j O S L.j e5-Tg i✓r 1,4-c-,./ 64. 54,1 T l a. ,-, /✓✓1 SI c i f (c) Telephone number: Area Code(() 6 07-70 0 7 (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 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. [3 Yes n No [4 Not Applicable e ©i2 1 U w d)-y 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' L=-1 Yes No I T 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 Fg Not Applicable ILL krt- 01. Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria Yes No Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria Yes No ©Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. 0 PA (^-'494-1 Yes No Not Apt_\ ble Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. Yes No Not Applicable 6o-f 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. YeJ No Not Applicable Attach additional sheets if necessary WORKING COAST POLICIE,; 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. ❑ Yes ElI '(I No 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® Not Applicable ,(f Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. Yes No ❑ Not Applicable v� QPfU4c4,64 . PREPARED BY cz 6-64-)1.7 ( TITLE DATE ,Z! /(S.-- 11 II i 1 tygois- 1l C r 2 c-,1-0!( 21 V el- 10 W T�r2�J j 4 w ,{dime , IIS 0 "J us ri u s-r&T 5 vifyiS i a v To Cb,-ane DA/ » Kms— C D iQ)P-E (Lt y v � ( r —- _'.- 14L ,v�,92 • 1 i —1:11791V(4- v Dr-v,C NI Cot.e-Z°2 I111 ,il Sid, ,- 07_ 7do 1 1111 E— E META i NOV 3 0 2015 a`` - . I! SoutivA Town - _,_____Board of Trustees I i i ' If • 1! •i1 p 1;1