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HomeMy WebLinkAboutTR-8736A John M. Bredemeyer III,President ®��®rf- S �®l Town Hall Annex Michael J. Domino,Vice-President ® 54375 Route 25 P.O.Box 1179 Glenn Goldsmith K= Southold,New York 11971 A. Nicholas Krupski �@ Telephone(631) 765-1892 Charles J.Sanders ���ic®UiVTY,� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1227C Date: June 3, 2016 TRIS CERTIFIES that the existing 19.5'x33.5' slate patio attached to existing dwelling; add 6 cubic yards of fill alongthe edge of the patio in order to create an on-grade patio; and vegetate area with pachysandra ground cover; At 3340 Oaklawn Avenue, Southold Suffolk County Tax Map#1000-70-5-54.1 Conforms to the application for a Trustees Permit heretofore filed in this office Dated January 22, 2016 pursuant to which Trustees Administrative Permit#8736A Dated February 17, 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 the existing_19.5'x33.5' slate patio attached to existing dwelling-, add 6 cubic yards of fill alongthe he edge of the patio in order to create an on-,grade patio; and vegetate area with pachysandra ground cover. The certificate is issued to ESTATE of DANIEL V. JENNINGS do TOM DUNLEAVY, EXECUTOR owner of the aforesaid property. Authorized Signature John M. Bredemeyer III, President ,���oSUFFO��=COG Town Hall Annex Michael J. Domino, Vice-President yam';, 54375 Route 25 Glenn Goldsmith �;y ? P.O. Box 1179 A. Nicholas Krupski ® Southold, NY 11971 Charles J. Sanders ` �1 ��°? Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DA-r-r- 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: CERTIFICATE OF COMPLIANCE: Ie John M. Bredemeyer III,President s 4'pF oujyQ' Town Hall Annex I '` : 54375 Route 25 Michael J. Domino,Vice-President • #I l t P.O. Box 1179 Glenn Goldsmith N Southold, New York 11971 A.Nicholas Krupski G % p � Telephone (631) 765-1892 Charles J. Sanders �� Fax(631) 765-6641 Sanders --- ���... iii 0 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8736A Date of Receipt of Application: January 22, 2016 Applicant: Estate of Daniel V. Jennings, do Tom Dunleavy, Executor SCTM#: 1000-70-5-54.1 Project Location: 3340 Oaklawn Avenue, Southold Date of Resolution/Issuance: February 17, 2016 Date of Expiration: February 17, 2018 Reviewed by: Michael J. Domino, Trustee Project Description: For the existing 19.5'x33.5'slate patio attached to existing dwelling; add 6 cubic yards of fill along the edge of the patio in order to create an on-grade patio; and vegetate area with pachysandra ground cover. 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 site plan prepared by Jerry Cibulski, received January 22, 2016, and stamped approved on February 17, 2016. Special Conditions: That a drought tolerant plant native to the northeastern United States be used in the landscaping. 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. J44— etAlog'"App,A7L. John M. Bredemeyer III, President Board of Trustees A 0 1 pl 'I�" E . (4)d N. t�a 58N. ,. Ire� ,� i . 3 ' ,,- n,01% i / qt sn .50.00* 3p �; no *- ...-..0. 4 i Ovls) 0 ..+. 0 hb i A oi, ,) 4 i 41:6C1 P N \,?, ,,, , • o n N /0 4:: .,050:4" .�• !S Pa 3 0 IY STT .•1 Q .y N .I: ki -. pm 4 Iva Hse JC ', a K um Y y ROLE pp terg1 c to atx� Ni V Vi �,, 1'. FR. N.E `Y�, . GAR � •� ~•' •ASPNAL T (• D�1V6:Lai QUI�I 0' ^� `P4 zur Li'l 0 ! . 0014 W U --- — — j5' rol.t ` oo°° a r Al -r N1iCiCON10 N 81•�2,pp' E o I F t •T o N E��_-�� Rp$t: w + IOIF X ,°o h �� oau0 N BION I h g. g�.32.00' W M. A S 1` 2 � L. NCO tots 'c 0.045 PINE NECK RD• 5 SURVEi' OF PROPERTY _ AI PINE NECK APPROVED B OWN OF SOUTHOLD UFF• K COUNTY, N. Y• :'ERTIFIED TO' BOARD OF TRUSTEES 100 - 70 - 05 - 54.1 /RST AMERICAN TITLE INSURANC, CALF 1" = 40' 'OMPANY OF NEW YORK TOWN OF SOUTHOLD APRIL 16, 1998 . DATE`Fektwki 17j 20/4, 'EA = 1. 3120 acres to tie Ur i.0 NEW j,,, %LTERATION OR ADDITION TO_THIS SURVEE Y�VIOLATION 54 o01.N .0 4110,, :TKIN 7209 OP NEW YORK STATE. TION LAW Ffs 4 T AS PER SE•CTICW 7209"SIyDDMSION 2.4t TIFICA�IONS �/�iata�F :; SIGNATUREI.AP OR N ARE V S BEAROR 7N1S�P SSED SSESAL OF T SUURVOF ONLY EYOR • 11�' i 1,'I� .Y.S. UC. N0. 496/8 ONALLY TO COMPLY IhTH SAD LAW THE TERM ALTERED BY• r-1 A I Y- J , P.c. • BE USEb BY ANY AND ALL SURVEYORS UTILIZING A COPY r .•r65,C,15• •7 S 0T_ SI:PTVEYOR'S P. SUCH M7TTLTED'AND t • ._ _---- -- 5 4e , c •s,; ;SIT ro-Da rE'ARE mor w o,�°LIaNC� r I i /2 , STREET L JAN 2 2 2016 ! sour • I, N.Y. 1197/ L.... I I 01- John M Bredemeyer Ill, President " SUff00xtee, Town Hall Annex Michael J Domino, Vice-President �� y�i4 54375 Route 25 Glenn Goldsmith 'y P 0 Box 1179 A. Nicholas Krupski �y �;' Southold, NY 11971 Charles J Sanders t\�j01 , �a f Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: }-t.- 1 1 ) ?-a / G / 5`Completed in field by: 711 Jerry Cibulski on behalf of ESTATE OF DANIEL V. JENNINGS, c/o TOM✓ DUNLEAVY, EXECUTOR requests an Administrative Permit for the existing 19.5'x33.5'slate patio attached to existing dwelling; add 6 cubic yards of fill along the edge of the patio in order to create an on-grade patio; and vegetate area with pachysandra ground cover. Located: 3340 Oaklawn Avenue, Southold. SCTM# 1000-70- 5-54.1 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual!? = "X" 1. Residence: 100 feet o'/=- 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet I 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Setback waiver required Part of Town Code proposed work falls under: SEQRA Type Ch. 275 Ch. 111 Type of Application: Pre-Submission ✓ Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N / Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completene s/comments/standa ds: /c • ,�,, j-La/4 V Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 OVFOLA- �� John M. Bredemeyer Ill, President 4", coo � Town Hall Annex Michael J. Domino, Vice-President e9,1 :-4 54375 Route 25 Glenn Goldsmith kv: ?a P.O. Box 1179 A. Nicholas Krupski y of*.4 Southold, NY 11971 Charles J Sanders �al ,0 '004 Telephone (631) 765-1892 rM� Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 414/ 6 6 Completed in Work Session by: ( f°I-A44" Jerry Cibulski on behalf of ESTATE OF DANIEL V. JENNINGS, c/o TOM DUNLEAVY, EXECUTOR requests an Administrative Permit for the existing 19.5'x33.5'slate patio attached to existing dwelling; add 6 cubic yards of fill along the edge of the patio in order to create an on-grade patio; and vegetate area with pachysandra ground cover. Located: 3340 Oaklawn Avenue, Southold. SCTM# 1000-70- 5-54.1 Ch. 275-12 - STANDARDS FOR ISSUANCE OF PERMIT MET=X or Comment=* A. Adversely affect the wetlands of the Town: B. Cause damage from erosion, turbidity or siltation: C. Cause saltwater intrusion in the fresh water recourses of the Town: D Adversely affect fish, shellfish or other beneficial marine organisms, aquatic wildlife & vegetation or the natural habitat thereof: E. Increase the danger of flood and storm-tide damage: F. Adversely affect navigation tidal waters or the tidal flow of the tidal waters of the Town: G. Change the course of any channel or the natural movement or flow of any waters: H. Weaken or undermine the lateral support of other lands in the vicinity: I. Otherwise adversely affect the health, safety and general welfare of the people of the Town: J. Adversely affect the aesthetic value of the wetland and adjacent areas: Ch. 111-9 - ISSUANCE OF PERMIT MET=X or Comment=* A. Is reasonable and necessary, considering reasonable alternatives to the proposed activity and the extent to which the proposed activity requires a shoreline location: B. Is not likely to cause a measurable increase in erosion at the proposed site and at other locations: C. Prevents, if possible, or minimizes adverse effects on natural protective features and their functions and protective values, existing erosion protection structures and natural resources: D. <_25% Expansion/Calculation Work Session Notes Application Complete SEQRA Classification Confirmed Coordinated Review Y/N Pos/Neg Declaration CAC: LWRP: Additional information on comments/to be discussed/Public Hearing: Date: Completed By: Present: 'I. Bredemeyer M. Domino G. Goldsmith N. Krupski r C. Sanders E. Cantrell D. Di Salvo Other Page 2 of 2 �- '\• i.� / ,1 , `';� , t. '� f rXIAN j00.1° .4 '14, tr s i . -7k9'? ' F :i N~� N `*rl.7r i " Ar ..\f►v '... ..—. ,,,,, -i• - , - • ;'•ilk.' ' 4 wc. t ' v 4.k �' F �It :r• /; 'i, .•.:',,\ { ,.��:_ spy ^ti w ,.. t- c. � �;,," '•`'o� A •Of: d„Y,�,k........Y..,. •��- , et ly., alk .,» ,,7 r,. 'Fri r .�,_ .5- ', `}`, a 7#�L.i.y1_s �..wJiwYfici�+. 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(21) ...� Ow-a- —_--— .-��-—_„_-- 5� Real Property Tax Service Agency reP nw1uc1or 070 E u-'�. _ .. �. — --- —- -— -ft. ——.—— m wzrtw,<. , M — N n.p...,. ——r—— ......4.mom:..--wx-- .ray... eux0an ¢ x ;P � m w >mmAP 05 0]a 0; PROPERTY MAP4....4..-.N., --.-- • //,,, iiii�__• #0'0 SO(ijy' OFFICE LOCATION: �''1#010 $ Ol MAILING ADDRESS: Town Hall Annex P.O.e Box 1179 54375 State Route 25 ; 1 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) va G Southold, NY 11971 @ P v Telephone: 631 765-1938 � �O ol4.00U� �1/ LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM ? '= ,F - 1 0 2016 To: John Bredemeyer, President Town of Southold Board of Trustees s ...., ' c . , ,f Tr From. Mark Terry, Principal Planner LWRP Coordinator Date: February 9, 2016 Re: Local Waterfront Coastal Consistency Review ESTATE OF DANIEL V. JENNINGS, c/o TOM DUNLEAVY, EXECUTOR SCTM# 1000-70-5-54.1 Jerry Cibulski on behalf of ESTATE OF DANIEL V. JENNINGS, do TOM DUNLEAVY, EXECUTOR requests an Administrative Permit for the existing 19.5'x33.5'slate patio attached to existing dwelling; add 6 cubic yards of fill along the edge of the patio in order to create an on-grade patio, and vegetate area with pachysandra ground cover. Located: 3340 Oaklawn Avenue, Southold. SCTM# 1000-70-5- 54.1 The proposed actions have been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is INCONSISTENT with the below Policy Standards and therefore is INCONSISTENT with the LWRP. • 6.3 Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction 1 Comply with Trustee regulations and recommendations as set forth in Trustee permit conditions. The existing deck was not constructed pursuant to a Board of Trustees Wetland Permit. It is recommended that a native, drought tolerant plant be used in landscaping. Pachysandra species are native to eastern Asia and southeast North America. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Jan 141612:08p C21 SH 631i B03 p.5 •°�*ti SOU/A:- Town Hall Annex John M. Bredemeyer HI,President �� �� �� t. 54375 Main Road Michael J. Domino,Vice-President ; P.O.Box 1179 James F.King,Trustee Southold,New York 11971-0959 Dave Bergen,Trustee �• I Telephone (631)765-1892 Charles J. Sanders,Trustee outiri Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Pe-mit Application ,Vdetland Permit Application i/Administrative Permit f _AmendmentTTrans.er%Extension Received Application: 2Z• ii, V Received Fee:$ 200.QD L Ass-13011,0 ' 1 Completed Application: I.7-2-//o --" Incomplete: iSEQRA Classific ion. JAN 2 2 2016 Type I Type Il Unli>ted Coordination:(date sent): 2.5,/(p TLWRP Consistency Assessment Form: — _CAC Referral Sent: 1 Date of Inspection: f o,/t'D _Receipt of CAC Report: Lead Agency Determination: Technical Review: Public Hearing Held:- �►I74 kO Resolution: Name of Applicant: y oy ^/tyi, DOW L lA( CF1�N j Mailing Address: J 7 VI 5Th - �(-- 11�fV 1 fit ) J 1 1 ) 3 Phone Number: 5-I 1.: (c3 1— `7b5-1-40 Suffolk County Tax Map Number: 1000- r96)-- Property Location: 3 Lib (Wei.At 41-F AVE •- VT6 (provide LILCO Pole#, distance to cross streets, and location) AGENT: it3oLs (If applicable) Address: 4faED Qr a - ,PO 6Ox �'' `i Phone: (.0 3 1-7/,5—3 Jan 14 1612:08p C21 SH 631-; B03 p.6 Board of Trustees Application GENERAL DATA Land Area(in square feet): 51 4C Area Zoning: Previous use of property: -Sl t7 r- A -L Intended use of property: —S 1 1:4-1T2Pri- 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 V. No If"Yes",please provide copy of decision. Will this project require y 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 TR-US-CW-7\S 3 I (94--91 ; - taut L-Dpi 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): l i 51P-A- YE PAT' cri P z 1 i E -3 3,.S f i L.e,?t (' l� 5 ,i- -p o ) ter- r -/- wireir P 4-ses - t_.(JlL Q 1b' P4 46E6 i_09-6-t'z-E - lam=-ops P Jan 1416.12:08p C21 SH 6317 303 p.7 Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: /-j , f t STP-A f r PC -t y �-UE 976'6 MaDVE _ h s - • 1 ■ri 1.4_-• • V. -1 '� Area of wetlands on lot: square feet Percent coverage of lot: (� Closest distance between nearest existing structure and upland edge of wetlands: SD feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? VNo Yes If yes,how much material will be excavated? C) cubic yards How much material will be filled? 0 cubic yards Depth of which material will be removed or deposited: v feet Proposed slope thrcughout 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): Jan 141612:08p C21 SH 631-4 B03 p.8 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 emnlovees.The purpose of this form is toprovide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. /�E:P,, � YOUR NAME: �� (3U LS12 I '. Ciat ) v (Las,name,first name,. riddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other pers m'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 thro.ieh 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",ccmplete 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)tbrcugh D)anddor describe in the space provided. The town officer or emplo2,ee 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 DESCRIPTIO OF RELATIONSHIP • Submitted this t day of 200j , Signature. Print Name �J OVLSI L Form TS 1 Jan 1416.12'07p C21 SH 6317 303 p.3 Board of Trustees Application AFFIDAVIT syrrr u ' J 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 ME 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 I'HE 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. /� ,/ - ec a ruli; I l?u f ree Signature of Property O weer SWORN TO BEFCRE ME THIS 15 DAY OF JAi4u4gy ,20 ih ; / No • Pub le DIANE SPIEGL Notary Public-State of New York NO.01SP6299259 Qualified in Nassau County My Commission Explretlul 7,2018 Jan 1416'12:07p C21 SH 631-d 803 p.4 Board of Trustees Application AUTHORIZATION (where the applicant is not the owner) I, 1-0/÷ti`s Ott—al residing at 1 v,m. 14,mic-e-cJ NY (print name o'owner of property) (mailing address) l gv3 do hereby authorize y 6 -Sk j (Agent) to apply for permit(s)from the Southold Board of Town Trustees on my behalf. (Owner's signator Jan 1416.12'08p C21 SH 631 803 p.9 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part I -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 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 Name of Action or Project: S AN-To A?— ,- f� Project Location(describe,and attach a location map): l 1\10/111-11.4-L--S7 �j l O f2- PIcIi CcP- Q.11-7}t{ Brief Description of Proposed Action: i ,"s NuL P lT r c—a PAnG— Ali -f1 t --e) f - sodari-1(:, `33;5 Name of Applicant or Sponsor. 0 1rd..- Telephone: T -Du t.4t‘41 FEslittTa 4r.-3 G4041,465E-Mail: Address: q 12iN p pl,cu Hy • 1 6es- City/PO: State: Zip Code: � �i-moiI f 11.3.-073 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 pf ❑ 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: ❑ rf 3.a.Total acreage of the site of the proposed action? I'3 ries b.Total acreage to be ph)sically disturbed? ("qt.,sit,p.'r 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 ❑neral(non-agriculture) El Industrial [I Commercial IlKs esidential(suburban) EForest DAg-iculture ❑Aquatic DOther(specify): ❑Parkland Page 1 of 4 Jan 141612:09p C21 SH 631; 603 p.10 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? n INA ❑ U.Consistent with the adopted comprehensive plan? I ' ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YE 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 111 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? ❑ ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES lithe proposed action will exceed requirements,describe design features and technologies. ❑ MA 10. Will the proposed actin connect to an existing public/private water supply? NO YES If No,describe method for providing potable water. Pi ❑ 1 I.Will die proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ 12. a.Does the site contai't a structure that is listed on either the State or National Register of Historic NO YES Places? Er ❑ b.Is the proposed actibn located in an archeological sensitive area? 0* ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other we terbodies regulated by a federal,state or local agency? El !L7`ll b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? M ❑ 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 ❑Agricultural/grasslands ❑Early mid-successional El Wetland ❑Urban 12rSuburban 15.Does the site of the prcposed 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 I 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, 1�/ Ela.Will storm water discharges flow to adjacent properties? ❑NO EYES b.Will storm water disctarges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ONO nYES Page 2 of 4 Jan 141612:09p C21 SH 631 603 p.11 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 ard size: __ k 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: O ❑ 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: - /' �1 I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsornam ^ `f Com' LS1.L AS A -4 ( Date: 1(— Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part l and other materials submitted by the project sponsor or otherwise available to the "eviewer. 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 I regulations? 2. Will the proposed acti)n 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 I /I ❑ establishment of a Cri.teal Environmental Area(CEA)? �/ 5. Will the proposed acti?n result in an adverse change in the existing level of traffic or ❑ affect existing infrastrActure for mass transit,biking or walkway? 6. Will the proposed actin-cause an increase in the use of energy and it fails to incorporate ❑ reasonably available eiergy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ a.public I private water supplies? b.public(private wastewater treatment utilities? 11 n 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, 171 l waterbodies,groundwater,air quality, flora and fauna)? Page 3 of 4 Jan 1416 12:10p C21 SH 631i 303 p.12 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed act on result in an increase in the potential for erosion,flooding or drainage {� problems? }" 1. Will the proposed action create a hazard to environmental resources or human health? lA n 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 a:tion 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 avo d 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. • ril l Check this box if you have determined,based on the information and analysis above,and any supporting documentation, ` I 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 environmentalYi paacts. Town of Southold-Board of 1 rustees D- 6 Name of Lead Agency Date era 4 -E- Cr— President Print or Typ ante of Respopsiltle 0 icer in Lead Agency Title of Responsible Officer attire of Resp ens.bl Officer in L Agen Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Jan 141612:10p C21 SH 6317303 p 13 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 .ist, 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# 7t) - 5' - PROJECT NAME Pte) The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees R 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: f/� /�Nt 4(S ?2*r77 u �.. �TSZ SATE- r -i?b M-Tr-A To THE- c F 1 J Le,l CC UJ1 qt D fO L LID FT L i P >4 C L rc - 13E. A-130 E s Ad3CSt.a P Jan 1416 12:11p C21 SH 631 303 p.14 Location of action: 3-7396 ©. e.i A 4t YJ4 A-v Site acreage: 113 iv :S Present land use: {�S f toak-CT)AI Present zoning classification: 2. If an application fox the proposed action has been filed with the Town of Southold agency, the following information shall be provided: [� �5CF (a) Name of applicant: l�� �✓(..4-41-- (b) Mailing address: "I V l SjTkRO &3 obi (c) Telephone number: Area Code( ) 7c.St (d) Application number,if any: Will the action be � directly undertaken,require finding,or approval by a state or federal agency? Yes ❑ No U If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space,makes efficient use of infrastructure, makes beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section III-Policies; Page 2 for evaluation criteria. �✓Yes No ❑ 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 �1 Yes ❑ No — Nat Applicable I . Jan 14 16 12:11 p C21 SH 631i 303 p.15 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 VI Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria Yes L No ❑ rot Applicable Attach additional sheets ifnecestary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 throw h 21 for evaluation criteria Yes — No Ell of 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. d n Al •. r Jan 1416 12:11 p C21 SH 631; 803 p.16 Yes No Not Applicable 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. [ l Yes No n 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. XYes ❑ 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. R Ye,0 No❑ Not Applicable Attach additional sheets if necessary y 6, • Jan 141612.12p C21 SH 631 803 p.17 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 n No I I No;Applicable Attach additional sheets ifnecessary 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. ViYes ❑ No P1 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 Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Sectio III—Policies; Pages 65 through 68 for evaluation criteria. Yes P No n Not Applicable PREPARED BY si 6{{3 x,,,1 ) TITLE DATE '1