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HomeMy WebLinkAboutTR-8722A Michael J.Domino,President o�*QF SOUTyO� Town Hall Annex John M. Bredemeyer III,Vice-President O 54375 Route 25 l l�[ P.O.Box 1179 Charles J.Sanders CA Southold,New York 11971 Glenn Goldsmith O �� Telephone(631) 765-1892 A.Nicholas Krupskilif COU Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1359C Date: July 12, 2017 THIS CERTIFIES that the installation of a 4' high fence along the western side property line ending approximately 20' landward from top of bluff, At 695 Pettys Drive,Orient Suffolk County Tax Map#1000-14-2-23 Conforms to the application for a Trustees Permit heretofore filed in this -•- office Dated December 17,2015 pursuant to which Trustees Wetland Permit#8722A Dated January 20,2016,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 installation of a 4' high fence along the western side property line ending gpproximately 20' landward from top of bluff. The certificate is issued to PAUL&MARGARET KOBALKA owners of the aforesaid property. e Authorized Signature T I ®F SO(/Ty Michael J. Domino, President �0� ®l0 Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25p.0.Box 1179 Charles J.Sanders C, Southold, New York 11971 Glenn Goldsmith ® a� Telephone (631) 765-1892 A.Nicholas Krupski OIi�C�UI Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Ch. 275' Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction % constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: O)Z— 46 CERTIFICATE OF COMPLIANCE: r� John MA. Bredemeyer Ili, President p�ogUFFO(,�c Town Hall, 53095 Main ltd. �G P.O Box 1179 Michael J. Domino, Vice-President o James F. King z SvLiihvid,i��i 1.1971 Charles J. Sanders Telephone(631)765-1892 Dave Bergen 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 John M.Bredemeyer III,President of SO y®� Town Hall Annex O 54375 Route 25 Michael J.Domino,Vice-President P.O.Box 1179 Glenn Goldsmith COO Southold,New York 11971 A.Nicholas Krupski Telephone(631) 765-1892 Charles J. Sanders ®l�COWN� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8722A Date of Receipt of Application: December 17, 2015 Applicant: PAUL & MARGARET KOBALKA SCTM#: 1000-14-2-23 Project Location: 695 Petty's Drive, Orient Date of Resolution/Issuance: January 20, 2016 Date of Expiration: January 20, 2018 Reviewed by: Trustee John M. Bredemeyer, III Project Description: Install a 4' high fence along the western side property line ending approximately 20' landward from top of bluff. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the project plan prepared by Paul Kobalka, received on December 17, 2015, and stamped approved on January 20, 2016. Special Conditions: None. Inspections: Final Inspection.- If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. John M. Bredemeyer, III President Board of Trustees r TEST HOLE DATA SURVEY OF (TEST HOLE DUG BY McDONALD GEOSCIENCE ON NOVEMBER 8, 2007) LOT EL 197' 0' MAP OF O0ODO DARK BROWN LOAM OL 1. PETTY'S BIGHT PALE BROWN SILT ML FILE No. 5859 FILED JANUARY 26, 1973 3 SITUATED AT n4 BROWN SILTY SAND SM ORIENT 7' TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK BROWN FINE TO COARSE SAND SW S.C. TAX No. 1000-14-02-23 10 SCALE 1"=40' a n JULY 30, 2004 BROWN SILTY SAND SM JUNE 25, 2007 ADDED PROPOSED HOUSE \ JULY 25, 2007 RELOCATED PROPOSED HOUSE NOVEMBER 2, 2007 ADDED ADDITIONAL WELL & CESSPOOL LOCATIONS S' �O 16' NOVEMBER 24, 2007 REVISED PROPOSED WELL LOCATION Sl BROWN FINE TO MEDIUM SAND SP DECEMBER 3, 2007 ADDED TEST HOLE M EL 27' t7' DECEMBER 12, 2007 ADDED LOT COVERAGE Tt� JANUARY 9, 2007 SET LATH FOR SITE INSPECTION N FEBRUARY 4, 2008 REVISED SEPTIC SYSTEM M \ WATER IN BROWN FINE SEPTEMBER 15, 2008 RELOCATE PROP DRYWELL 50' FROM PROP WELL F TO MEDIUM SAND SP JULY 16, 2014 UPDATE SURVEY JANUARY 21, 201515 ADD PROPOSED HOUSE � MARCH 5, 2015 REVISE PER S C D H S NOTICE 03/03/2015 MAY-19, 2015 FOUNDATION LOCATION A 23' _JULY 22, 2015 STAKE PROPERTY LINES °tiF<ro AREA = 38,131 sq. ft. G<�q<o Q (TO TIE LINE) 0.875 ac. CER TIFIED TO PAUL KOBALKA MARGARET KOBALKA FIDELITY NATIONAL TITLE INSURANCE COMPANY w ULSTER SAVINGS BANK, ITS SUCCESSORS AND/OR ASSIGNS f 00 CN 13.5 F►2o Pop v A! W CIOq rOA EXISTING--, ,e e<G,,, �O ! 1 CESSPOO - DEC 1 7 2015 y. on Off, EXISTING ( O2 / g CESSPOOL 1 / y pti <G,� F — / 03 hq?4p� 143 -4 !! 144 `\ x142 J� � v a x1 ..1 w � x H HOUSE m ysax LpT O / \ mix 4 jp1F (pE VERGRpw - - - - /,g/ � to RIODICgLLY h MOW D) 4/ 3 W / \ O x 18.3 � y 3t 17.7 o CD ^9 38 3, 0 O r ?0' 79S m zj0 0 \ a x183 M 17.4 o, ` 194 " N C01V \ o-12 3 b yC/ �� 37`•__ ^ roPRUjE F zj4 �= u (^ 2 NQ9n oUNdq j� 128 1 _ x1999 a / 00, 4ON I w EXISTING ` i WELL •0 01 a y o 1e.s 195x� TEST HOL CONC 2?0' 19 7 I 78.4 FXis // lap e2,C ANO U 00,00,E M/ / z x , o 6 00, HOUSE AFPR®V BY x Al o h � - ry�// 00 � TC / o BOARD OF 1 RUST N rPq� w r� _ l bFNr/ OI EXISTING z 4•I�'^T ��,�•'� o�, V©�� [/m / T 1N',,SgFPaR, CONC Cu CA x 723 ` CESSPOOL x RB�P X 20 �o/ 1 (� S<r39,o7 /V Leo aq 6j.43 O �y 166' ' 1 7 (O %, D 0', •, 1 ' R_ZQ•OO' EXISTING WELL RA Ja�C�-��_l x4z1111 r,. 00' J V PREPARED IN ACC Ej�1���ppRpppIII1IV� IMU P�pE• 'J '4C STANDARDS FOR6PITLET S CI ED s ANT FBY OR SUCH A15�E�b`"'Qry[yRRAApNE ED p y TITLE ASSO 1AT1�6Y��T ANEWST�0 t�'/ O C4 NOTES 1. !7+ z F 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM EXISTING ELEVATIONS ARE SHOWN THUS:103 2 2. FLOOD ZONE INFORMATION TAKEN FROM: FLOOD INSURANCE RATE MAP No. 36103CO069H ZONE VE COASTAL FLOOD WITH VELOCITY HAZARD (WAVE ACTION), BASE FLOOD ELEVATIONS DETERMINED w. N Y L,e N 50467 ZONE X AREAS DETERMINED TO BE OUTSIDE THE 0 2% ANNUAL CHANCE FLOODPLAIN UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF 3. COASTAL EROSION HAZARD LINE TAKEN FROM COASTAL EROSION SECTION 7209 OF THE NEW YORK STATE Nathan Taff HAZARD AREA MAP PHOTO No. 47-655-83 EDUCATION LAW COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR Land Surveyor EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED,AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND Title Surveys - Subdivisions - Site Plans - Construction Layout LENDING INSTITUTION LISTED HEREON,AND TO THE ASSIGNEES OF THE LENDING INSTI- TUTION CERTIFICATIONS ARE NOT TRANSFERABLE PHONE (631)727-2090 Fox (631)727-1727 THE EXISTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OF RECORD, IF OFFICES LOCATED AT MAILING ADDRESS ANY, NOT SHOWN ARE NOT GUARANTEED. 1586 Main Road P Box 16 R Jamesport, New York 11947 Jamesport, New York 11947 34-139E John Bredemeyer, President �oguFFotTown Hall Annex Michael J. Domino, Vice-President 54375 Route 25 Glenn Goldsmith ti ; P.O. Box 1179 A. Nicholas Krupski �y • ! Southold, NY 11971 Charles J Sanders �o! ,� �a° Telephone,(631) 765-1892 Fax (631) 765-6641 Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: 4116 6 � PAUL & MARGARET KOBALKA request an Administrative Permit to install a 4' high fence along the western side property line ending approximately 20' landward from top of bluff. Located: 695 Petty's Drive, Orient. SCTM# 1000-14-2-23 Tyg� of area to be impacted: ,/ Saltwater Wetland Freshwater Wetland Sound Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion 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: rl�' Present Were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders Bay Constable Other J_'Form filled out in the field by �re �e✓ Moiled/Faxed to: Date: r f u S i i '��. �� / � i j ��/ � i / L, 1 AM °fir- 2, •y„/�y�1 ( /,. ♦t'� ':/� ti�i� �' � � S grar ; ”.. R pr,i/�-,p ` 1K, B� � �•) � � Fah'./ Gft 'xi � �_' � 1 Ar i •i' `�� lame = a'"- i\pi,�'- t; ' _ _. Y r - ,r ♦0 PROPERTY MAP PD.65 AP 18 +eN<I tANq q6 IA /_gyp c� f tNc) 3.,e 1n to 1.ONc) 5mc) nn w vs19 ,1A1 <) f t0 320 113 ,9 seN<) `3 nNc) 17 i seN0 ^ 321 y`I 114 0 11Hq Qp 5� fpra 11s ,m ASt.1A0 /?� /60 M 119� \ ,wuix MU wrcnaMl MO 1�) 3.35�R11 A 7.2 9 ^ /p O J2A m Y 23 \ 9pew• p 2 21 Z 7.] M�WI 1e 9N<) 1za 3.n o t A 3N<) 21.4.1 1� ' FOR PCL NO ,r,[r✓„rraEm�t+vw.i 5. 133 a2 WE SEC.ND. .ANq 4 maol-09zz ue \ t aqq m a n to N 1 3oA s104011 o zf w 1INc) 29a ( , &"0 + c) 117 20y O 303 130 m m S I �i _ MA O / wm 1 a 139 12 19 762 302 I.7Nc) FOR PCI.NO, FOR PCL NO FOR PCL NO. f+ 12 e 1 SEE SEC.W. SEE SEG NO. SEE SEC.NO. yWn 12 _S: 11 X01-001.9 MAIN OLD MAIN 19Nc) to RD R� 13 ^ p u ns —� _ sEE SEG No.mg � /Qtj 15 y =A SEE SEG NO 019 16 171 S.R.25 ft Y G --Z-- �..�. lot, ^ —O-- w�� --p-- e, --^-- NOTICEA COUNTY OF SUFFOLK © E T— SDunaLD SECTION NO 1. E ^�^�— --^-- ^�,---w*-- ,, Real Property Tax Service Agency Y pm .4 014 Pata 9rmcr rq 1000 PROPERTY MAP mmv,wor�mr[wn,4 xw t r ' OFFICE LOCATION: S® y®l MAILING ADDRESS: Town Hall Annex ® P.O. Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 • �®� Telephone: 631 765-1938 ®l�C®UNT�,� 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: January 14, 2016 Re: Local Waterfront Coastal Consistency Review PAUL & MARGARET KOBALKA SCTM# 1000--14-2-23 PAUL & MARGARET KOBALKA request an Administrative Permit to install a 4' high fence along the western side property line ending approximately 20' landward from top of bluff. Located: 695 Petty's Drive, Orient. SCTM# 1000-14-2-23 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 the action is recommended as 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. i rg SOn John M.Bredemeyer III,President �� �® Town Fall Annex Michael J.Domino,Vice-President 54375 Main Road " k P.O.Box 1179 James F.ging,Trustee Southold,New York 11971-0959 Dave Bergen,Trustee y9z Telephone(631)765-1392 Charles J.Sanders,Trustee l,�'C®� �, Fax(631)765-6641 ]BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD - - - - Office Use Only - - _Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendmentfrransfer/Extension i/ Received Application:a ` Received Fee:$ 00,'0-- Incomplete: __ _ 4 ___SEQRA Classification I Type I Type II Unlisted i o coordination:(dtate sent): � {DEC 1 1 2015 � • - LWRP Consistency Assessment Form: s CAC Referral Sent: l f Date of inspection: 1,11F, Switlidd la rpt _Receipt of CAC Report: ------- j Lead Agency Determination: Technical Review: —Public Hearing Held: P a Resolution: Name of Applicant: Pate / A r,y j re-¢ ISG Mailing Address /70 o�r en�, Al, y /19,r7 Phone Number: 3/-o7,0 Suffolk County Tax Map Number: 1000- Ll-d-7,_ Z3 Property Location:-__ _ �J fez!`y r /J r; ✓r° , (provide LILCO Pole#, distance to cross streets,and location) AGENT: (If applicable) Address: Phone: r Board of Trustees Application GENERAL DATA Land Area(in square feet): 3 F / Area Zoning: Previous use of property: Intended use of property: Covenants and Restrictions on property? Yes No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? __ _Yes -✓_No If`Yes",be 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 ✓ 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 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): 7l- ���� )�Ld?<o ed Board of Trustees Application WE'IPI[.AND/'1['atgTSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: square feet Percent coverage of lot:- 3 0 �/ % Closest distance between nearest existing structure and upland edge of wetlands: /06 " feet Closest distance between nearest proposed structure and upland edge of wetlands: *' .7,0 ' feet Does the project involve excavation or filling? No Yes If yes,how much material will be excavated?_ cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited:_ _- _ feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect,if any,on the wetlands and tidal waters of the town that may result by reason of such proposed operations(use attachments if appropriate): Nv-1-t--' - 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 I based on information currently available. Ifadditional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based an 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: - — -- - - L fie4 Fey-re Project Location(describe,and attach a location map): Brief Description of Proposed Action: N e of Applicant or Sponsor. / Telephone: /�CL E-Mail: Ctl� /J Address: 0- City/PO: Q Siate:, Zi Code: ; l.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, IVO' YES- administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that I,1 F 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: I✓ 3.a..Total acreage of the site df the proposed action? acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action--.- []Urban .❑Urban ❑Rural(non-agriculture) ®Industrial ❑Commercial ®Residential(suburban) ❑Forest OAgriculture ❑Aquatic ❑Other(specify): _ ❑Parkland Page I of 4 5. Is the proposed action, - - - -- NO YES 'N/A a.A permitted use under the zoning regulations? El E b.Consistent with the adopted comprehensive plan? ' Q 0 11 11 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 soubstantiai increase in traffic above present levels? 11 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? f I I Q 9.Does the proposed action meetor exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: M - - - - ' F] j 10. Will the proposed action connect to an existing public/private water supply? NO ( YES If No,describe method for providing potable water: _ I I_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? �✓ b.Is the proposed action located in an archeological sensitive area? U.a.Does any portion of the site ofthe 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? [—jf If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: UU�att l_1 14, identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply- EgShoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional ❑ Wetland ®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? f 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm waterdischarge,either from point or non-point sources? NO I YES If Yes, �YES Q a.Will storm water discharges flow to adjacent properties? [�NO b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ONO []YES Page 2 of 4 18.Does the proposed action include construction or other activities that result in the impoundment of NO _ YE$ water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size; 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO 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- j YES completed)for hazardous waste? If Yes,describe: _ __ _ _ _ _ _ _ _ = P,, Q H AFFIRM THAT THE INFORMATION PROVIDEID ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponso n c f I I'�0�J�I/� _-- -- Date,:, I��� Signature: Part 2-Impact Assessment. The Dead Agency is responsible for the completion of Part 2. Answer all of the.following questions in Part 2 using the information contained in Part I 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? u 12. 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 Critical Environmental Area(CEA)? u 5. Will the proposed action result in an adverse change in the existing level of traffic or affect existing infrastr•ueture for mass transit,biking or walkway? El 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? L-1 CJI T. Will the proposed action impact existing: - - - - -( a.public/private water supplies? IJ b.public/private wastewater treatment utilities? Q 8. Will the proposed action impair the character or quality of important historic,archaeological, a architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, F,71i 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_ L_1 i nj 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 aparticular 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. ElCheck 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 ifyou 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. j 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 J Page 4 of 4 Board of Trustees Application. AFMAVIT /WIW d— BEING DULY SWO RN DEPOSES AND AMRMS THAT HEAHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARIE TRUE TO THE BLEST OF HIS/HER KNOWLEDGE ANIID BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER STET FORTH IN THIS AIPIPILIICATIION AND AS MAY BE APPROVED BY THE SOUTIHIOILIID TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD LN1D ANIlD THE t BOARD OF TRUSTEES HARMLESS AND]F>IBIEIE]FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OIF SAID,IPIEII8IFlIi IIT(S),IF GRANTED. IN COMPLETING NG THIIS APPLICA-TION,b HEREBY EIBY AIIT HOJRI Z E THE 7RUSTIEIES,THEM ADIENT(S)OR.IRBIPR ESIENTAT]WES,INCLUDING THE CONSIEIRVAMION ADVISORY COUNCIL,TO ENTER ONTO IY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. II FURTHER AUTIHIOIRIIM THE BOARD DIF TRIIJSTIEEs TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO UNSURE (COMPLIANCE WrT HI ANY CONDITION OIF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OIF 'IRIU >ES IIIIRItNtG THE TERM OF THE PERMIT. -- ature of Property Owner SWORN TO BEFORE ME THIS DAA'OF aC-20-A9 21 Y 20 /5- Notary Public DONNA M.PALMER i4otary Public,State of New York No. 01 PA5069978,Suffolk Counter, Commission Expires December 9, AP PILIICANVA SENT 'E-lPRESIENTATW +� T RANSA.MONAL DISCLOSURE.FORM ORM The Tasv<taFSdaifinLOU lramc �wthe Vartaf(0-ma,61HOMand,cnn±faycr, Tfx,tzu sc_a_G UYis fuunr is tit pPtrvidd iriE�tmarixr«[tick c<ia Put(ire fn�crt afixossiLtTi:conlliefC of mtt rttatrd�Illtav tt to tsho whaf'ma acrzorr r�, necessary to avoid same. / -YOURNAME. O 6�Q���w / GC L(-/- /� d l��t O'�/�_!" ai r e7� (Last name,fi-trimmer,(riddle initial,unless you am applying in the ndne 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 Trust _ Change ofZone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other �I (If"Other,name the activity.)- Do you personally(or through your company,spouse,sibling,parent,or child}trace a relaiiar>sfiup with any officer or employee of the Town of Southold? "Relationship"includes by blood,rgarriage,or bushier:-ih&ae c"business interest"means a business, including a partnership,in which the town officer or employee has even a parW4 mvct�Sltilt e�(ar employment by)a corporation in which the town officer or employee owns more than 51/16 of the shares. YES NO If you answered'YES",complete the balance of this form and date and sign where indicated. i Name of person employed by the Town of Southold _ Title or position of that person Describe the relationship between yourself(the applicantlagent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officeror employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner ofgreater 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 J7 dw of �CewLao915 Signature- d Print Name y, Form TS 1 I Town of Southold LWRP C®NSILST ENCX ASSESSMENT FORM A. INSTdRUCT]IONS 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 infonnation 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 HazardArea. 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). 3e 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. -Thal, da&answer witst.he e.Nnlaiubed in dettil� listing Heade sduplFRrfinsi and non: sun gorting 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. DESCRfMON OF SIS AND PROPOSED ACTION SCTM /®00 / --i}2— PROJECT NAME Gl1 e The A ppNeation has been submitted to(check appropriate response): � Town Board ❑ Planning board❑ Building Dept. ❑ Board of Trustees l=I L 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) FT (b) Financial assistance(e.g.grant,loan,subsidy) (c) Permit,approval,license,certification: ❑: Nature and xtent of act. X2 2A Location of action: _� OZA�� Site c`LpG_ gr Present land use: Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing address:- _ (c) Telephone number:Area Code (d) Application number,if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes E] No 1' If yes,which state or federal ageacy? C. Evaluate the project to the following policies by analyzing how the project wig further support or mot support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require Haat 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,mares beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section ffi—Policies;Page 2 for evaluation criteria. '1'Yes Q No [71 Not Applicable Attach additional sheets ifnecessary 1Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See I.MP Section �M—Policies Pages 3 through b for evaluation criteria Fl Yes 1-- No 12'Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scene resources throughout the Town of Southold. See ILMW Sectioen HI—Policies Pages 6 through 7 for evaluation criteria : Q, Yes Q,leo H Not Applicable Attach additional sheets if necessary - - NATURAL COAST POLICIES Policy 4. Minimize floss of life, structures, and natural resources from flooding and erosiou. See ILWR? Section M—]Policies Pages S through 16 for evaluation criteria El files,Q No 0 Not Applicable Attach additional sheets if necessary - - - -- -- - - : ]Policy S. ]Protect and improve water quality and supply in the Town of Southold. See LWRP Section ffi —Policies pages 16 through 21 for evaluation criteria F-11 Iles Q No ®Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Souttbold ecosystems unclad mg Sigoaifacant Coastal Fish and Wildliffe Habitats and wetlands. See 1VVRP Section ffi—Policies;Pages 22 through 32 for evaluation criteria. F1 Q u! yes No NotApplicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LNM P Section M— Policies Pages 32 through 34 for evaluation criteria. Q� yes Q No Not Applicable Attach additional sheets if necessary Policy S. Aflni size environmental degradation in Town of Southold from solid waste and hazardous substancesandwastes. See LNVRP Section M—Policies;Pages 34 through 38 for evalaatioga criteria. Q Yes Q� No ® Not Applicable PUBLIC COAST('POLICIES Policy 9. Provide for public access to, and irecreatiomaR use of, coasta8 waters, public lands, and public resources of the Town of Southold. See g,MW Section M—Policies;Pages 38 through 46 for evaluation criteria. I71 YeD No Z Not Applicable Attach additional sheets if necessary / y t C WORKNG COAST POLICIES Policy 10. Protect Southold's wateir-depeadient uses and promote siting of new water-dependent roses in suitable locations. See LMW Section M--Policies;Pages 47 through 56 for evaluation criteria. E]Yes No Q Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in hong Island Sound, the Peconic Estuary and Towns wagers. See LWRP Section M—Policies;Pages 57 through 62 for evaluation criteria. : Q.Yes n No® Not Applicable Attach additional sheets if necessary - -- - -- - - - ------ -- - Policy 12. Protect agricultural lands in the Town of Southold. See LNVRP Section M—Policies; Pages 62 through 665 for evaluation criteria. Yes 11 No 10 Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRF Section M—Policies;Pages 65 through 68 for evaluation criteria. Q Yes El No ® Not Applicable IPIIEPAlIFfl➢BYf G�e 'I'II'PYX d,&� DATE 0_ 471-5--