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Home My WebLink AboutTR-8786A John M.Bredemeyer III,President �� SO �vO Town Hall Annex Michael J.Domino,Vice-President �® l0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G ® @ Telephone(631) 765-1892 Charles J.Sanders �� Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1298C Date: December 19, 2016 TRIS CERTIFIES that the existing irregularlyped f280sq ft on-grade brick patio and to expand it an additional f320sq ft for an overall t600sq.ft. (22.5'x34.5' outside dimensions) irregularly shaped on-grade brick patio; and install a 14"high stone wall to act as-planting bed edging; At 100 Knoll Circle, East Marion Suffolk County Tax Map#1000-37-5-20 Conforms to the application for a Trustees Permit heretofore filed in this office Dated April 28, 2016 pursuant to which Trustees Administrative Permit#8786A Dated May 18, 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 the existing irregularly shaped f280sg ft. on-grade brick patio and to expand it an additional f320sq ft for an overall±600sq.ft. (22.5'x34.5' outside dimensions)irregularly shaped on-grade brick patio; and install a 14"high stone wall to act as planting bed edging. The certificate is issued to MICHAEL Di LEO owner of the aforesaid property. Ave— Authorized Signature QF SOUj Town Hall Annex John M.Bredemeyer III,President tio�� yplo Michael J.Domino,Vice-President 54375 Route 25 Glenn GoldsmithP.O.Box 1179 Southold,New York 11971 A.Nicholas Krupski G Q �► ® �O Telephone(631) 765-1892 Charles J. Sanders �l�•COW N Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: cs l� Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 st day of construction _Y2 constructed Project com lete, comPliance inspection' . INSPECTED BY: O�Y'I�C�.S � S~G" �C,V S COMMENTS: CERTIFICATE OF COMPLIANCE: i r, UFFO( John M. Bredemeyer III, President roes ��o� Town Hall Annex Michael J. Domino, Vice-President ,,v y� 54375 Route 25 Glenn Goldsmith �;N � P.O. Box 1179 A. Nicholas Krupski � o�_V Southold, NY 11971 Charles J. Sanders k ol , �`�� 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 Y2 constructed Project complete, compliance inspection � Souly John M.Bredemeyer III,President Q� Town Hall Annex®� ®� Michael J.Domino,Vice-President ® 54375 Route 25 P.O.Box 1179 Glenn Goldsmith CASouthold, New York 11971 A.Nicholas Kru ski G p ® �® Telephone(631) 765-1892 Charles J.Sanders ol�f'`,oUN Fax(631) 765-6641 , BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8786A Date of Receipt of Application: April 28, 2016 Applicant: MICHAEL DiLEO SCTM#: 1000-37-5-20 Project Location: 100 Knoll Circle, East Marion Date of Resolution/Issuance: May 18, 2016 Date of Expiration: May 18, 2018 Reviewed by: Trustee Charles J. Sanders Project Description: For the existing irregularly shaped ±280sq.ft. on-grade , brick patio, and to expand it an additional ±320sq.ft. for an overall ±600sq.ft. (22.5'x34.5' outside dimensions) irregularly shaped on-grade brick patio; and install a 14" high stone wall to act as planting bed edging. 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 Nancy Dwyer Design Consulting, Inc., received on April 28, 2016, and stamped approved on May 18, 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 CLI DiLeo \ z Q Addition to Existing Patio 0 F,a , �+„ � ,"� y �� ,.�✓�1 � �:,� � e �b i'�c ,g,��'ixc�, Ili 1 � aye. j .� ; i { � '4 �`yJ P' rv}-.4 ! h.i'k:a;r � - �, -�_`e�;;.• �� # �, !�,1 �*,��"r�"`/�• '�'�. � ,"�� rw�� :'''kgp'.�I i�'_ a� ""' °�j�a r" .4 �' . �,: � ,F `did �,�`..��`� FF1 i a��,a��:��' `�"'�.�.•pII'rs•,�((�, �Jhl�^'.„`. `+��''d a s,�.. ,�" �. 4, �tE ,��t&'*,^� .��'�` `.'�'�a ,, �R �ti �.� �. ''•:+�g• I� _ nn .'' .5..'a:.rah'.. aTX ty +e #' y."".� �` L 2 t � APR 2016 n'''it o,� 't'" �M .:,r �f§- ^gw :i! s. -bw ^>•w —".+,.0 ...,. a o-, O Z4 � ... r+• A �5i :h'" i-s `1w•�w�_ x'"'�,�`''j:a� f� S 1 .."'�+a"'= '�6'h SPRING POND CL`�a q � `+�3, -„ ��!>'ffi�'„"'tea. �'• ..:..d' i t'"�'"; a� (CANAL) ' � .�i '��t �_ �� `` ��ri^„+4 ak i3" S S .u.'»" .�",�'""��U"'^♦ .� �rY� `'t 'r'T p4�• Y _ - rlr,`�'� tl'r r'+ � �k`_�.' <: ±�` � ^ `• AV w.+A ,F y r i +R, _ p_.; �11� .J Q V� U��pPp NG WOOp WP�K OOp 6 v �\ px1g��NG W w 60 O N' 0 NEIGHBORING YARD zA � o _ N ,. k,',APPROVED BY ; 0 N ^ WARD OF TRUSTEES " , .. -TOF SOUL SITE PLAN EXISTING WOOD STEPS Q) SCALE: 3 " = I '-O'i OUTLINE OF SILT PATHWAY TO REMAIN DATE. M�4�( ($ 2D�G" , o 32 go°,o' FENCING TO CONTAIN Q U z N 1a1_0" Max. C. to C. SCTM: 1000-37-5-205q,3�5z'So� ' - � � �=-< ' CONSTRUCTION AREA Information taken from 'L o jrve dPOSED G"�e u- m KennethM. Woychuk, L.S. WAL FOR NDSCAPING _ w _ EXISTING WOOD o @ o ° w Mattituck, New York STEPS TO HO SE BEDS w J dated March 23, 2012 TO REMAIN MIN. PROPERTY AREAS: REG R SHAPE O � _ r 9„ z s1CZ Existing Lot ar6a: 9,424 s ft �N APPR t EXISTING, w O �O House (existing): 1809 sq. XISTING BRICK CON RING AROUND ~ Q Existing lot coverage: 10. 1 % ATI RE TRE SHRUBS 6 u PERSPECTIVE VIEW Existing patio on grade: 3205cl.ft. EXISTING HOUSE (320sq.ft.+/- NEI N0 o Proposed patio addition: 2805c1.ft. TO REMAIN P F OSED ADDITION (2ao5a.ft.+/-) 7- Total patio Size: 0005CI.ft. ^�� _ T XISTING PATIO; BRICKS 3G" MINIMUM 2 x 2 TOTAL LOT COVERAGE: /19. 1 % �r GRADE TO MATCH w/ FENCE POST d R EGULAR SHAPE EDGES WOVEN WIRE FENCE (G x G - 1O / 10 WWF) FILTER CLOTH o W U lo S O 0 EXISTING SPLIT RAIL O Z U � LGpF FENCE TO REMAIN W s D � � G b zN EMBED FILTER CLOTh O MIN. G" INTO GROUND U z z W08 4" t9 rn NOTE: S ego MAXIMUM DRAINAGE AREA 57703 Ill OW 124.Go' a „ 112 ACRE / 100 LINEAR FEET a SECTION DETAIL KNOLL CIRCLE U z SILT FENCE DETAILS - NTS z J 0 � ro z � O � U m z u W (� z r W 0 U z Q z PAGE: I UNAUTHORIZED ALTERATION 09 ADDITION TO THIS DRAWING AND RELATED DOCUMENTS 15A VIOLATION OFSEC. 7209 OF THEN.Y.S.EDUCATION LAW S.C.T.M. NO. DISTRICT: 1000 SECTION: 37 BLOCK: 5 LOT(S):20 0 o .6 NN z �Q 3� 4.4"W MON. N66.40 91 O-E 69.3g' O A �Q MON. I O� CQT to � 24.2' Go CL a STONE GARAGE I DRIVEWAY Z W CL- 0 tO a 2.5'W U M r' ,O 6.0' w o Taj 2.0' 10.2' Cf 2 STY FRIt7. 3 3'W BRIC DWELLING #700 r r zo O v z ® �Lo � 23.4' 36.4' I �� 0� 0J o 4'X8' N 46 00'UTDOOr r a WOOD SHOWERR STOOP 50, BRICK `r �p PATIO of O -1 6 MON. 4.2'W S7 �x c,' a. v 4.VS I ��3I 4YpOQ o_t4�N' �� J Z . 80. �G APR 2 8 2016 a 6 THE WATER SUPPLY, WELLS AND CESSPOOL LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS REVISED LOT LINE ALONG BULKHEAD 04-06-12 AND OR DATA OBTAINED FROM OTHERS. AREA: 9,423.94 SQ.FT. or 0.22 ACRES ELEVATION DATUM, ------------------------- UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY GUARANTEES INDICATED HEREON SHALL RUN MAP NOT BEARING THE LAND SURVEYOR'S EMBOSSED ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE. THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES AITIONAL RE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE AND OTHER ENTS N OF FENCES, ADD NOT INTENDED TO MONUMENT �7URESPR�CORDEDLINES OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLYREVID AND/OR SUBSURFA ENT ONUCTURES RTHE PREM SES APROF�ti1TIME OF SUR EYTS SURVEY OF: P/O LOTS 36, 37 & 38 INCL. CERTIFIED TO. MICHAEL DiLEO; MAP OF: GARDINERS BAY ESTATES SECTION 2 AUDREY MORRISON DiLEO; FIDELITY NATIONAL TITLE INSURANCE FILED: SEPT. 23, 1927 No.275 SERVICES, LLC; SITUATED AT: EAST MARION CITIBANK, N.A.; TOWN OF: SOUTHOLD KENNETH M. WOYCHUK L.S. SUFFOLK COUNTY, NEW YORK Land Surveying and Design P.O. Box 3, Mattituck, New York, 11952 PHONE (631) 298-1588 FAX (631) 298-1588 FILE # 12-35 SCALE: 1 =20 DATE: MARCH 23, 2012 N. Y. S. LIC N0. 50227 maintaining the records of Robert J. Hennessy John M Bredemeyer III, President �QSI1GFUt�-c Town Hall Annex Michael J Domino, Vice-President ,�° �y�� '� 54375 Route 25 Glenn Goldsmith o P.O. Box 1179 A. Nicholas Krupski ^ Southold, NY 11971 Charles J. Sandersyjot Telephone e (631) 7656664892 BOARD OF TOWN TRUSTEES TOWN OF-SOUTHOLD Date/Time: d L e PrM Completed in field by: Nancy Dwyer Design Consulting, Inc. on behalf of MICHAEL DiLEO requests an Administrative Permit for the'existing irregularly shaped ±280sq.ft. on-grade brick patio, and to expand it an additional ±320sqft for an overall ±600sq.ft. (22.5'x34.5' outside dimensions) irregularly shaped on- grade brick patio; and install a 14" high stone wall to act as planting bed edging. Located: 100 Knoll Circle, East Marion. SCTM# 1000-37-5-20 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required 1. Residence: 100 feet 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 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y /0 Ch. 275_z Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-SubmissionAdministrative Amendment Wetland _L Coastal Erosion Emergency Violation Non-Jurisdiction I Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/cohsulta�t/application completeness/comments/standards: Rue-S u V\- l V1 7ij a. C n✓ v , s :1 Y Present were: 7J. edemeyer M. Domino G. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 John M. Bredemeyer III, President Town Hall Annex Michael J Domino, Vice-President �� Gyq 54375 Route 25 Glenn Goldsmith o ` P.O. Box 1179 A. Nicholas Krupski o Southold, NY 11971 Charles J Sanders y�j 5�vTelephone (631) 765-1892 ti Fax (631) 765-6641 -tczrrrr� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: Nancy Dwyer Design Consulting, Inc. on behalf of MICHAEL DiLEO requests an Administrative Permit for the existing irregularly shaped ±280sq.ft. on-grade brick patio, and to expand it an additional ±320sq.ft. for an overall ±600sq.ft. (22.5'x34.5' outside dimensions) irregularly shaped on- grade brick patio; and install a 14" high stone wall to act as planting bed edging. Located: 100 Knoll Circle, East Marion. SCTM# 1000-37-5-20 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: 1. 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 I 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. :525% 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: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders E. Cantrell D. Di Salvo Other Page 2 of 2 1 .r ., �• � a ,�'4 • ,� 1 � � �' few I= � � �+. Vk TV 10 - •� - ::. r'7 � fr �/1 • Amory �'�A r r .',' I• ti s ' a AL 16 400 JA -• �w t I tl • Y *3s fit , 1. _ 1 / �w ` , it `' .; � � � rI'�� '.� � 'rte � • ,*' f`/ „ I •� . lie -OA Mob If OF (lw y _ -1 .{ e do 10 ; r t ,fit . _ ,� } r.. r � .• � ,� � 1:: ••��t•. ` YX •+`.rri �� .. �i•�~ �,'.a - 'kyr•+ /- � �"+�J/ / c Y v / -� i _ jj �. •fie -S. K4 ` "' � - ;, : 1.�� .. V '�_ �'.� - J � .� �W I v� _y - yam.:. l.. _ - � • ' m INN— r kph"' sk- • A ♦ r� (sem' ;? `•�.• � .. fp•,4 , ♦ � �_. Jb!!l r�{ �•� .� �� « `•,49Fvw / vt I; �, � �• ..� - 40riY. +l�• lw :'mow • Jv 41 .000 YW r� aj 4• 'M w T • r .I • r �a , � r r n r r�i •, ,'.�•�n 4 .�� 111 1 / •� -fir? i�� ,r1 _ •y r. � '.1� * t• �r ol dir may" � �, T � y ..• ♦ '.� i .•.' ` - . r �t 4 14 Ar lk low in t n J7 �f^ n `f. t - •', `�� / - - �+�' � - spa► f r Y•V _ . i • r .. w st ► ,. <a P P P � ,t, � t,,^'�Y '� �. � •max a �+ to 24 Fri •a, o -- -i- 23.2 RAMOR lee ORWNT � s VL- jz a �S� K --- OF SUFFOLK CCD x� 't t � f OFFICE LOCATION: S MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) Southold, NY 11971 a� Telephone: 631 765-1938 C UAV 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: May 12, 2016 Re: Local Waterfront Revitalization Program Coastal Consistency Review for MICHAEL DiLEO SCTM# 1000-37-5-20 Nancy Dwyer Design Consulting, Inc. on behalf of MICHAEL DiLEO requests an Administrative Permit for the existing irregularly shaped ±280sq.ft. on-grade brick patio, and to expand it an additional ±320sq.ft. for an overall ±600sq.ft. (22.5'x34.5' outside dimensions) irregularly shaped on-grade brick patio; and install a 14" high stone wall to act as planting bed edging. Located: 100 Knoll Circle, East Marion. SCTM# 1000-37-5-20 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with.the LWRP policies and therefore 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. ` 'of � 1 Annex John M.Bredeme er III,PresidentQ Town Hal Ann y � - - 54375 Main Road Michael J.Domino,Vice-President • - 7 P.O.Box 1179 James F.King,Trustee ,, ' "r: Southold,New York 11971-0959 Dave Bergen,Trustee yp Telephone(631)765-1892 Charles J.Sanders,Trustee �o �a Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application __,/Wetland Permit Application Administrative Permit / Amendment/Tranfer/Extension 1/ Received Application: ��•�� .-- -,.,, ,"` � -- . F1 Received Fee:$ 1DO►� �� Completed Application: 2�� '. i _Incomplete: _SEQRA Classification: a APR 2 8 2016 1`~ Type I Type II Unlisted VCoordination:(datesent): } ,, LWRP Consistency Assessment Form: Sett. is�n CAC Referral Sent: Date of Inspection: _Receipt of CAC Report: _Lead Agency Determination: jjam�--Technical Review: Is_Public Hearing Held: l Resolution: Name of Applicant: Mailing Address: 10D 164q011 C4 r �. Cis ��►ova Phone Number: Suffolk County Tax Map Number: 1000- Property Location:_ ,00 k,4,Lo 11 (24�C _ S� AA a r on (provide LILCO Pole#, distance to cross streets, and location) AGENT: O a kifl t)wqt Y De_S �)K UQ Y15 A n'e!t (If applicable) Address: 100 f✓p)G (o �a— �,'ay o i d Phone: and of Trustees Applicati `' GENERAL DATA Land Area(in square feet): �70? `� 4f- 7ek: Area Zoning: „ 9- Previous -Previous use of property: sI��e �i r�S� -�- ��JQI�-ho Intended use of property: Covenants and Restrictions on property? Yes _/>0 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 -;,�o If"Yes", please provide copy of decision. Will this project requ're 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? L/ Yes No Prior permits/approvals for site improvements: Agency Date 0 1AA I0 0 1.72 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): OU rr k-,aS byw*- ivL41p 6n 4(-,ot�c, R 120toX 2270 N OZ a? Jxgq-4e-�f. (I rr�vl&tr). otos fro 1 is -)v �6 Svrrov�^ u�l �1 -- D✓P�r�,��'lj��,�v�51� �iA.A ��®�5 l cl' h 1 J At s)'a-te- a-��o wA,c,:1L,1</() �P/� and of Trustees Applicati WETLAND/TRUSTEE LANDS APPLICATI®N DATA Purpose of the proposed operations: T11 I nG rZASQ- _—111 qra,,o(Q hw e4e oX S2 o �� L� 2 a� /-Z-/ 1J I Ifa' 00 c ar"' hrtie," o U.5 'x 3 6 114 em f r rgq v Area ofwetlandson lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: �?/,o? ' feet Closest distance between nearest proposed structure and upland edge of wetlands: ' 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): 2- 7/6 Pe/o0L �0 41nv L SC J2_ Go�s/il �G�� G'oit l a � d� 1�t2�5 A, 0kJ 4A_e,,(A--,� 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: I L9,0 l2e S !it e___ - Project Location(describe,and attach a ll(o�c�ation map): Brief Description of Proposed Action: r row JL _ 1 s �t. 6 tZ�L k- 'pig-f` o, �P o0_0 �• , O r/1 5 r -51 oleo cx. PrcoR- f ro f o 5_e.s -� tee.J-,A- Vv 1� `cJ1� wov I d- 19,9 prz- _ �� x �� Yt, d AP, � r� v (aV- PC- Name of Applican Sponsor: Telephone: POGA % �,� e✓�✓l ��gl� E-Mail:d�G lil Address: mac) ��k City/PO: State: Zip Code: o v 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources thatkL ❑ may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: ❑, 3.a.Total acreage of the site of the proposed action? . b.Total acreage to be physically disturbed? res 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. � E]Urban E]Rural(non-agriculture) ❑Industrial ❑Commercial 21 esidential(suburban) ❑Forest ❑Agriculture El Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations9 ❑ ❑ 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: [�J ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES U_ ❑ 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 If the proposed action will exceed requirements,describe design features and technologies: Oq__ F1 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: N ` ' ❑ ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: 1'S D ❑ 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? ❑ F-1- 13. 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ 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 ❑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? ❑ 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? JO EJYES b.Will storm water discharges be directed to established conveyance systems(runo and storm drains)? N If Yes,briefly describe: NO [-]YES 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: 19,TJ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor a OC- PX Date: '44/115 11�o 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 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate - -- -- -- - - - - - - - -.small --- to-large _ - impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning El ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? E 4. Will the proposed action have an impact on the environmental characteristics that caused the El 1:1establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or F-1 ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate El El available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? ❑ 11 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ _ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. W ill the proposed action result in an increase in the potential for erosion,flooding or drainage ❑ 1:1problems? 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, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. EICheck this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 • —oard of Trustees F•pP licat a i I i AFFIDAVIT BEING DULL'SWORN DEPOSES AND AFFI S THAT�HE/S�HESTHE APPLICANT FOR THE ®� REIN DESCRIBED PERMITS)AND THAT ALL STATEMENTS NCONTAINED THAT ARE TRUE TO THE BEST OF HIS/HER]KNOWLEDGE AND BELIEFALL WORK WILL BE DONE IN THE MANNER SET $ T D APPLICATION � AND AS MAY BE APPROVED BY THE SOUTHOLD TUWN o� OF TRUSTEE N OF OLD AND THE THE APPLICANT AGREES TO HOLD THE'r®E FROM ANY HAND ALL DAMAGES BOARD OF TRUSTEES HARMLESS AND FRE AND CLAIMS ARISING UNDER OR APPS ATION,TUE OF SAID PERMIT(S)5 IF I HEREAUTHORIZE THE GRANTED. IN COMPLETING THIS TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTIONER AUTHORIZE WITH THIS APPLICATION, BOARD OF INCLUDING A FINAL INSPECTION. I FURTHER i TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL i EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM j I OF THE PERMIT. I Signature of Property Owner i J 0 SWORN TO BEFORE ME THIS l — DAY OF / 20` Notary Public DIANE C.GIRARDI NOTARY PUBLIC,State of New York No.01 G16058753 Qualified in Nassau County Commission Expires May 14,0 6'�Di A PPLICANT/AGENT/REPRESENTATWE TRANSACTIONAL DISCLOSURE,FORM 1119DAI-1 of dot 101d'g Cock of I'tn the of town officers and employices 'Che n11 .cif 111i$ b W-11 X, c incQm1allon IV " can al e w si eco icts o int and allow rt to tako whatever actio rs Iteceasary to avoid satM- YOUR NAMI?• (Lust name,first name,viddle initial,unless you are applying to the name of someone else or other entity,such as a company.If so,indicate thb other person's or company's name,) NAME OF APPLICATION: (Check all that apply.) Tax gricv:uicc Building Variance Trustee Change ofzoue _ Coastal Erosion Approval of plat Mooring l emptiou from plat or official map Planning Mer (if"Other,name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a Pelationship 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 Woership,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 shales. YES —_.- NO iryou 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 applicantlagent/representative)and the town officer or employee.Either check the appropriate tine A)through D)and/or describe in the space provided. 'rite 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 appllcent (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,pattnei or employee of the applicant;or _p)the actual applicant, 1)ESCRIP1'10N OF RELATIONSHIP Submitted this v3-> daoolt 200 Signature Print Name ; APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE,FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the hart of town officers and employees.The puroose 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. A , YOUR NAME: �_D w yex-, (Last name,first name,")piddle 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 L�— Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other",name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest'means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO 1/ -" ---If-you-answered-"Y-ES",-complete-the balance-of this_form_and date and sign-where indicated.___ Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thi v7 day of 200 Z�o Signature Print Name c- Form TSI__+_ � Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail', listing both supporting and,non- s_upportina facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website(southoldtown.northfork.net), the Board of Trustees Office,the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# PROJECT NAME 'D! L" Pzsi c k,& The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity,agency regulation,land transaction) ❑ (b) Financial assistance(e.g. grant, loan,subsidy) (c) Permit,approval, license,certification: Nature an_d extent of action: AL1 h mioLl b4t cilc-5 �o k e— I ge, 12�h a � d_�rA t e . &a"2 O ;�4A- a-P v A470 V& /S Location of action: /0 C) not re,, ..e 44a r i en Site acreage: Present land use: s1(1--,)1-C -( IIW r(irk rL S 1 44LCe__ Present zoning classification: 12- o 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: 00, n WInc SI n-�. (b) Mailing address: �2- 50v-I�- (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 ❑ No If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy.I. 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 LW1tP 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 ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III-Policies Pages 6 through 7 for evaluation criteria ®' Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III-Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III -Policies Pages 16 through'21 for evaluation criteria ❑ Yes ❑ No �ot 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-andl wetlands,_Sce-LW1tR_Section_III_^P_olicies;_Pages 22 through 32 for evaluation criteria. 1-1 F] 191 Yes No Not Ap_, ,,'able Attach additional sheets if necessary Policy 7. Protect and improve air quality in the,Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. Yes [—] No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances andwastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. Q.Yes-❑-No Ek7 of Applicable - - - -- - -- - -------- PUBLIC -------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. Ye Dn n No GJ'Not Applicable Attach additional sheets if necessary WORKING COAST POLICIP 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 �ot 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. 1:1 Yes 1:1No `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. ElYes F] No[['Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No R;� Not Applicable PREPARED BY TITLE /�5� // DATE /