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TR-8735A
SUFFour John M. Bredemeyer Ill, President ;�a�o oo Town Hall Annex Michael J. Domino, Vice-President 4 r t y�'r, 54375 Route 25 Glenn Goldsmiths N 04 1rz ' P.O. Box 1179 A. Nicholas Krupski ''2 ;; Southold, NY 11971 Charles J. Sanders �`�� Y Telephone (631) 765-1892 �. 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, hay bale line 1st day of construction 1/2 constructed 1/ Project complete, compliance inspection 1 l //'II John M.Bredemeyer III,President ��� ��®� SO ry®l Town Hall Annex Michael J. Domino,Vice-President � �, 54375 Route 25 P.O.Box 1179 Glenn Goldsmith � G . . , Southold, New York 11971 A. Nicholas Krupski .c� -4��� Telephone(631) 765-1892 Charles J.Sanders : COUNT Fax(631) 765-6641 O BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8735A Date of Receipt of Application: October 28, 2015 Applicant: Brian Parker SCTM#: 1000-78-5-15 Project Location: 305 Williamsberg Drive, Southold Date of Resolution/Issuance: February 17, 2016 Date of Expiration: February 17, 2018 Reviewed by: Board of Trustees Project Description: To install four(4) 12'x14' floating platform upwellers (FLUPSYS) against the existing bulkhead for raising juvenile shellfish. Findings: The project meets all the requirements for issuance of an Administrative Permitset 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 Brian Parker, received October 28, 2015, and stamped approved on February 17, 2016. Special Conditions: The screening of equipment should be greater than or equal to ten feet off of all property lines and should also be greater than or equal to ten feet landward of an existing non-turf buffer; and that if a fence is used for such an enclosure it should be located in the side or rear yard and not exceed the Town Code limitation of 6 % feet in height. The project is limited to no more than three (3) FLUPSY units. The FLUSPY units are to be attached solely to the bulkhead, with no nets, lines or tackle suspended from the seaward side of the structure which side is at the public interface; as same would inhibit the harvest of wild shellfish in the canal. Wash down of equipment is limited to be within the screened enclosure. Said enclosure should include a pad and a drywell to handle the wash down of the equipment. There is to be no future expansion of the project without approval by the Board of Trustees. Inspections: Final Inspection. r 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. ,f.: John M. Bredemeyer III, President Board of Trustees ( << John Bredemeyer, President ,0\01FFot Town Hall Annex Michael J. Domino, Vice-President '�°� , —tire.,-„, 54375 Route 25 Glenn Goldsmith y # s , P.O. Box 1179 A. Nicholas Krupski ate ,' Southold, NY 11971 Charles J. Sanders -•:._,/,„1 ,� i,7;„.. Telephone Telephone (631) 765-1892 Fax (631) 765-6641 Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: ®6 f 6 , BRIAN PARKER requests an Administrative Permit to install four (4) 12'x14' floating platform upwellers (FLUPSYS) against the existing bulkhead for raising juvenile shellfish. Located: 305 Williamsburg Drive, Southold. SCTM# 1000-78-5-15 Type 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: P7-rw1 _ " iS 7- Present Were: J. Bre " meyer V M. Do ino G. Goldsmith N. Krupski C. Sanders Bay Constable , Other Form filled out in the field by Mailed/Faxed to: Date: John Bredemeyer, President •�'•saFFu� Town Hall Annex Michael J. Domino, Vice-President � � �cO ; 54375 Route 25 . James F. King ;,�ti P.O. Box 1179 Charles J. Sanders Southold, NY 11971 Dave Bergen 'yo! * $a°!�'� Telephone (631) 765-1892 " Fax (631) 765-6641 Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: BRIAN PARKER requests an Administrative Permit to install four (4) 12'x14' floating platform upwellers (FLUPSYS) against the existing bulkhead for raising juvenile shellfish. Located: 305 Williamsburg Drive, Southold. SCTM# 1000-78-5-15 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Storm Water Management Review: Yes No Not Applicable Info needed: Modifications: Conditions: Present Were: J. Bredemeyer M. Domino J. King D. Bergen C. Sanders Bay Constable Other Form filled out in the field by Mailed/Faxed to: Date: SURVEY Of PROPERTY N SITUATE: SOUThOLD TOWN: SOUThOLD „J . ......._ w .---. E SUFFOLK COUNTY3 NY 1.4, SURVEYED 05-05-2014 . SUFFOLK COUN1Y TAX# yr 117'0 . S 1000 - 78 - 5 - 15 OA ... CERTIFIED TO: ENO BRIAN PARKER V STEWART TITLE INSURANCE COMPANY , I...LCD (a- ,/kJ "J I g...."6./ ••'. ..t.,v . •61 4.) - c•• •/,. • icst$ A, Nr) T , n......0 il•. ..... fp'"S All ry.tV- .....,s,""c flY `‘,..) • le O Lm Olt, .... "....J 4,-, .- die, 140> 4,f,t fe 040 \..' • J r7ciN • 0„ift „„,....... AtiC\1 Li A ' • et0 ,.... ,,.. - ...../ -- -"--07.. 9P, • ........., ,.,.. ,, Vt ..9 , • vKii- is...., . ,... - (..1 .10 •_... ....„` v .e ...•• ‹._ 7-0 re) . '\ 'll'i// /../ i ')-- 6.\.• ... . .... .... 1/4.....Pe. ".. 1 ,. . . .. ,:',.:i' ' V...;...;';,.''-;,';',, ',..„',',.?3;;,,j''A''',: ','•;.',7,t,.4",0:;!:",,:ir,. .'„,-,2,, -,--2i'r'''' ' ;,"' ,,_:-'-•:'1,- IjV , ' _- — — --JP-- - -- ni Sis,-,AIC A.0.\\!, A 'a PROVED 8irz •.... ;4,, so „. i7,,,..0 •,9; -,/?, _ k..-) - . .".J.- 2.''':.fi• RD OF TRUSTEES .6\ I v.- -ka. - t5p44 c,, ..,,, ,e.., oF&callow • . ..„ , ,p et ,,C - i - -q.... /// • ,. . . , . ?... .. . .- , .. .• '' -...> .• • , , • , ,, i'= '-', -• FreialitO 1726V_ '''' ' . .• .1 r. .:p;Z.;1''',',',:7',,i,,;,.,,,•.a: , ( e , , . . ' .• 'x -< ' : - ''' — gie.. ..', . _ ..,.. . 0 , . ,... • r ‘,...., • ' , , ••, ,,, - --,:::. 1:::), 0 , , - — ,,,-„, "• .-7.77---, ,-• --,•,-,;---.u.:, :- 0 .)? -PA. ''''.2 '''y,c, * t. II '4/1 ii•7" I i...‘ Qij, e '• Eth 42:-3- 'V.I.- ' I id, • de,_0A,cs ' - - I 7 J, 11 i A lit ' L I- </< ,.e Stilly A 1' :44,i:<9 <,0, 40/N., (.0 ., ,_ ....„ ..IT ,,iki ., . - &.(...,<"1/ '()- '' • '1'' ' •••...1 '-'1 OCT 2 8 2015 .....,x A, , .., ,,,,,. 0 o c3 .., :T. , •dr••••3• .. ,,. . . • ;, •,''''',, 1 - Southold / \e..A•CI?), 1 ri: "1 , , IT Town / ...../ L.,..._. J3..onigtTrugw......._...., ,.....1 , , • _ , • , i . • /A 41V :' `r4b. /:- ;'• ,,1* f ' rrleI, 'Unauthorized alteration or addition to o survey i• - i ?// " P/ 4 •••••,.... ' °C) IV E W.- - .... map bearing a licensed land surveyor's seal ts a violation of section 7209.sub-division 2.of the . . • i ., 9/ - 4 o 4'... f' C E 4P 4. " ,2.40 • itkkg,01: Zug '' ''Yr -... '034 .1. , '10 40 4 ti e,,iii 0 ,,--i, I '' ' '‘7-''.'i: fiftip . ', *i i . 4K. ,* it;;;,, t-Ver SrNew York Stole Education Low." Only copies from the ovrgwal of the survey marked with on originol of the land surveyor s stomped seal shall be considered to be valid true copes" "Certifications Indicated hereon signify thol this survey was prepared in accordance with the err- . . . 1 .- - • r'i 'i i ,..„.. . „ ,, isting Code of Practice for Land Surveys adopted by the New York Stote Association of Professional v. ,. • `....\:\, • 0,,, Lond Surveyors. Said certiflcoltans shall run only . 93) / el ,,,,,, ,,, to the person for whom the survey is prepared. , /7/t s i. 0 6i2 2 4 e(/f and on his behcdf to the title company.governmen- . 2 NOTE5: Qn••• rVlr) 11) tol agency ond lending institution listed hereon. and 4 ,ANt.)^-• ll to the assignees of the lending institution Certifico- - • --.,,,,r• 3r#11f ' (Ions ore not transferable to additional institutions 4?0111\/ No, 75 11' v1) • MONUMENT FOUND ..-.1 ilil e • STAKE 5ET JOI-IN C. EI-ILERS LAND SURVEYOR ,A.,. 0 STOCKADE FENCE . 0 SPLIT RAIL FENCE 6 EAST MAIN STREET N.Y.S. LIC. NO. 50202 50 Area = 14,726 Sc. Ft. RIVERHEAD, N.Y. 11901 369-8288 Fax 369-8287 1-131( Area = 0.338 Acree a b CelliblA loncystancilancisurveyor.com GRAPH C SC LE 1"= 0' 14-141 9 3/)//6 . 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Telephone (631) 765-1892 ' Fax (631) 765-6641 Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: it/iiyi ; BRIAN PARKER requests an Administrative Permit to install four (4) 12'x14' floating platform upwellers (FLUPSYS) against the existing bulkhead for raising juvenile shellfish. Located: 305 Williamsburg Drive, Southold. SCTM# 1000-78-5-15 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound 41/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: /�, ,�1.1W Present Were: /Bredemeyer LAI. Domino ✓J. 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Southold Schoi . • Parker,Brian Roll Year 12015 Curr Yr 1 Family Res Land AV 1.200 -` '�q40.rift''rl' 305 Williamsberg Rd Land Size 0.35 acres Total AV. 4,600 L.] Parcel 73-5-15 Owner 1 Tax Bill Mailing Address 1 3rd Party Address l Bank 1 ' Li History --- Assessment Total 1 Owners;.To oven. click the aoorooriate row fRioht Click to Addl SpecDistfs) r _lrr , i i 1; 7,4r :a -1:' 01 __.___---__-� ' Li Description gar O wner(s) ' Li Images Li Gis Last Name/Company First Name- Ml Jr.,Sr,etc ;_:.i Site(1)Res ,Parker _w ;Brianr 1� i=t Li Sale05J14/14 Attention To/In Care Of: Additional Address: ' :J -Site[1)Res - Street No: Prefix Dir: Street I Rural Route: St Suffix. Post Dir. UnitName: Unit No. 305 1 . Williamsberg (Rd 711 - iL.jI ' Po Box_No. City/Town. State Zip Code: r jSouthold -- —;NY +.1111971- J Country enter if not 11USA" Bar Cd Ownership e.g.Life Use Owner Type I--- — r-- f l I f =Primary T Owner's Primary Residence l -1 4 1 •��� �p SO(j y- , OFFICE LOCATION: 0 O- Ol MAILING ADDRESS: Town Hall Annex ��� ' \ P.O. Box 1179 54375 State Route 25 t * * % Southold,NY 11971 (cor. Main Rd. &Youngs Ave.) ` � Southold, NY 11971 \ �Q/1% Telephone: 631 765-1938 =43 l�C4UNTy,N ii°, 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: November 12, 2015 • Re: Local Waterfront Coastal Consistency Review BRIAN PARKER SCTM# 1000-78-5-15 BRIAN PARKER requests an Administrative Permit to install four(4) 12'x14' floating platform upwellers (FLUPSYS) against the existing bulkhead for raising juvenile shellfish. Located: 305 Williamsburg Drive, Southold. SCTM# 1000-78-5-15 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed actions are CONSISTENT with the Policy Standards and therefore are 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 Ir. ,„ ,„ • 4 NOV 1 2 2015 i r L .- Southold Town �,���t*®F S0114, John M.Bredemeyer III,President ,00 $4 A ,. Q Town Hall Annex Michael J.Domino,Vice-President �10 ®4 �® : 54375 Main Road James F.King,Trustee t : P.O.Box 1179 �, ,, e Southold,New York 11971 0959 Dave Bergen,Trustee ; ar O 0 %:'Q ~ .:� • '' a 0 Telephone(631) 765-1892 Charles J.Sanders,Trustee - Fax(631) 765-6641 = OLIO,�,0 to Fax BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application Wetland Permit Application XAdministrative Permit -_ VAmendment/Transfer/Extension 11:;), k is.. i; v e , I Received Application: !L'`2&&I5 ! ` / Received Fee:$ 106e()® I Completed Application: 10,Zg<I5 j OCT 2 2 11-11,Incomplete: _SEQRA Classification: ! d Type I Type II Unlisted !i Southold Town 0 Coordination:(date sent): ... _ _,_?oagd_gf Trj _��y= LWRP Consistency Assessment Form: «'�'`if CAC Referral Sent: Date of Inspection: ll'/O.(5- Receipt of CAC Report: Lead Agency Determination: Technical Review: Public Hearing Held: 11,(g,15 ' Resolution: Name of Applicant: 'j@. / K Mailing Address: .30S— i 1/ 14141)j/ 9 g bighitF SOW/VOW Ai y Phone Number: (6a) --..5,844.V. ' ,8 V Suffolk County Tax Map Number: 1000- 0 78 A9--95e 0 0 — O/ST O 0 0 Property Location: 9Q i//19/Lf }� • p,fZ IXe sL % 0L-_.) ,API /1r7 ) . (provide LILCO Pole#, distance to cross streets, and location) AGENT: A /I, (If applicable) 10 Address: A/ Phone:b 101 312c ` 19 p fV1 - ADMINISTRATIVE PERMIT APPLICATION Aquaculture Project Corey Creek Brian Parker 305 Williamsburg Dr. Southold, NY 11971 Project Description: Deploy 4 floating upwellers(FLUPSYS)at existent bulkhead located at 305 Williamsburg Drive,Southold. FLUPSYS will be used to grown small oyster seed to juvenile size;then moved to Peconic Bay County lease site. FLUPSYS are 12'W x 14'L floating platforms. FLUPSYS will be attached to bulkhead pilings via dock slides. "ward of Trustees Applicat, GENERAL DATA Land Area(in square feet): / Area Zoning: ie4pi Previous use of property: le F/14 4", Intended use of property: 9A,(Q /ice✓/ I AYEA-c—ci 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 X 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? j 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): YsTra2 4, 5 a ge-erirkteD a al 24 ��� 0 i►�' -- Zrd of Trustees Applicati - WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 4'-00/9- LWiik7 — 4i2 0 LA-)f 5M4// 621172— J ✓ Area of wetlands on lot: 1, square feet Percent coverage of lot: 0 % Closest distance betwe nearest existing structure and upland edge of wetlands: R feet Closest distance between nearest proposed structure and upland edge of wetlands: ,NYAL 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): Aftwi 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1, You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item.)) Part 1 -Project and Sponsor Information /52-419A-) PrfrZ/1 to WI ( "L/� ; PA o f�—vr- Name of A tion or Project: 39r OWilvDdk r-7 ,)✓zihte )o47voL3 Ai Y I 191e Project Location(describe,and attach a location map): Brief Description of Proposed Action: Peet-oyi& 77 - . i1tCtileri ONAll-442--051-4 i 't 0/J-it St-EZ Names, of Applicant or Sponsor: Telephon �, �ii> ,_// ted IJJO , � d/a. JAM S�/V t E-Mail: e/tIO1.�9(k O c. Address: ,; a 11ONLOW DOW'We 504740 ) City/PO: State: Zi Code: City/, 7. t .o 24) l Y Yiyil ].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 may be affected in the municipality and proceed to Part 2. If no,continue to question 2. r ,' 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: P 4r� - DEC Ah13bEC 3.a.Total acreage of the site of the proposed action? iA acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial 0 Commercial lgfResidential(suburban) ❑Forest DAgriculture krAquatic ❑Other(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? N,..0z YES b.Are public transportation service(s)available at or near the site of the proposed action? 154 ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? pi, n 9_Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed equirements,describe design features and technologies: A./ .A 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: f 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: 1► • 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ri b.Is the proposed action located in an archeological sensitive area? r;‹,d, 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? ri b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: x 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline El Forest 0 Agricultural/grasslands DEarly mid-successional D Wetland 0 Urban EJ 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? 15-1 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, a.Will storm water discharges flow to adjacent properties? 4I NO I]YES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: n NO [-YES vs rw 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: • 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: I I I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor tame: /30,4Date: Jo) Signature: �f AIL 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 . 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? PFA 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or affect existing infrastructure for mass transit,biking or walkway? 1, 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: Fl 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 0. Will the proposed action result in an increase in the potential for erosion,flooding or drainage 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. • Check this box if you have determined,based on the information and analysis above,and any supporting documentation, 11 that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. mi Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees `0' ' if Name of Lead Agency Date �Q A 1^- Eic4 047 et/c President Print or Type;.me of Res.() -.le Officer in Lead Agency Title of Responsible Officer / Sig/re of Res...." e Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINK Page 4 of 4 p hard of Trustees Applicat Sf_-', AFFIDAVIT B? , � ?frt-16) BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. 1)Sign tore of Property Owner SWORN TO BEFORE ME THIS MI DAY OF © ,20 15 ') ' IfkAtat- Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. 01D1475593 Qualified in Suffolk County it, My Commission Expires April 30, 2010 i • APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same.3 it (0t,�— YOUR NAME: °Ci (Last name,first name,. Liddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring • Exemption from plat or official map Planning Other (lf"Other,name the activity.) • Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest"Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or-beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); " C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this .a, CI 200 Signature 'r / �. Print Name t Pima Form TS 1 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 ANDBPROPOSED ACTION SCTM# a r (3 a 00- 03;0 - g f r 00 0 PROJECT NAME C 0/0.1 t- A. /-w 1211AW The Application has been submitted to (check appropriate response): Town Board Planning Board Building Dept. Board of Trustees g 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) I I (b) Financial assistance (e.g. grant, loan,subsidy) (c) Permit, approval, license,certification: Nature and extent of action: atio-)r/ dF " kiG Location of action: �/ 1 14MS B(xi m o Site acreage: 1 0: Present land use: 11 1iK te F Present zoning classification: etcI 0701\i 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: 7(L. (b) Mailing address: 17200 t WAS Jul DA/uut S.irvirAIVAP (c) Telephone number:Area Code( Jj 6 4 (d) Application number,if any: Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes m-No If yes,which state or federal agency? X1 YfDt-C_ 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 Sout i i I 1 . 1 •• : . ' '. aracter, 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 2 Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies�jPages 3 through 6 for evaluation criteria I Yes I I No gl Not Applicable ly 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 9 Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria Yes No '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 I Yes No .tNot 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. Yes No Not Apj, Able r ) Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. Yes No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. Yes No )(Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. YeJ No Not Applicable Attach additional sheets if necessary WORKING COAST POLICII' _�' 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 KNot 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. iYes No fl 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 kNot Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. Yes I I No Not Applicable i PREPARED BY/f , / - TITLE 0 DATE °II I h 1 I F ,i I