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HomeMy WebLinkAboutTR-8785A John M. Bredemeyer Ill, President r"o�Qs t Town Hall Annex Michael J. Domino, Vice-President _ ry i -4,, y� , 54375 Route 25 Glenn Goldsmith At'" �' P.O. Box 1179 ri A. Nicholas Krupski , o ? Southold, NY 11971 y w � w Charles J. Sanders ;'hod *,(1-7 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 V Project complete, compliance inspection ie,„................... ' John M. Bredemeyer III,President ',g®,�� - soot,: - Town Hall Annex Michael J. Domino,Vice-President �� ~ ,yam' , ` 54375 Route 25 P.O.Box 1179 Glenn Goldsmith % ; Southold,New York 11971 A.Nicholas Krupski ''' .. �Q��1�1 Telephone(631) 765-1892 Charles J.Sanders _'.'-..' I Fax(631) 765-6641 yCOUNTY,* � ,�, - -... 'I , BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8785A Date of Receipt of Application: May 2, 2016 Applicant: Tom & Sandy Psarros SCTM#: 1000-88-5-61.2 Project Location: 575 Watersedge Way, Southold Date of Resolution/Issuance: May 18, 2016 Date of Expiration: May 18, 2018 Reviewed by: Board of Trustees Project Description: For the existing 18'x24' on-grade patio against the seaward side of dwelling; construct an 18'x24' flat roof over patio for a 2nd story deck; and construct a ±10'x15.2' and a ±10'x20.6' open trellises running along both sides of the patio. 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., dated April 21, 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. dm& gvN 4:— r : , John M. Bredemeyer Ill, President Board of Trustees 1272 John M Bredemeyer Ill, President cr• •,'QgUFFOC,��, Town Hall Annex Michael J Domino, Vice-President : ��� o` Town 54375 Route 25 Glenn Goldsmith -74j P.O. Box 1179 A. Nicholas Krupski o �a Southold, NY 11971 Charles J. Sanders # o� Telephone (631) 765-1892 �0� ..)411:• 7 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES / TOWN OF SOUTHOLD Date/Time: /I ) 6 Completed in field by: /In- TOM & SANDY PSARROS request an Administrative Permit for the existing 18'x24' on-grade patio against the seaward side of dwelling; construct an 18'x24' flat roof over patio for a 2nd story deck; and construct a ±10'x15.2' and a ±10'x20.6' open trellises running along both sides of the patio. Located: 575 Watersedge Way, Southold. SCTM# 1000-88-5-61.2 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK='l 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 qr 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 Ch. 275 ' Ch. 111 SEQRA Type: I I I Unlisted Action 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 completeness/comments/standards: 1 ti ✓ / - > Present were: V reeme er IM. Domino G. Goldsmith t/ N.� Y Krupski l�J. d C. Sanders Other Page 1 of 2 John M. Bredemeyer Ill, President ( ! ,,�gpFFO(��, Town Hall Annex Michael J. Domino, Vice-President ',��°� w �� 54375 Route 25 Glenn Goldsmith o , P.O. Box 1179 A. Nicholas Krupski : Southold, NY 11971 6. Charles J Sanders • #4f • °�. Telephone (631) 765-1892 �� ` Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: TOM & SANDY PSARROS request an Administrative Permit for the existing 18'x24' on-grade patio against the seaward side of dwelling; construct an 18'x24' flat roof over patio for a 2nd story deck; and construct a ±10'x15.2' and a ±10'x20.6' open trellises running along both sides of the patio. Located: 575 Watersedge Way, Southold. SCTM# 1000-88-5-61.2 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. 5.25% 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: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders E. Cantrell D. Di Salvo Other Page 2 of 2 ...,--..--- —,..—. OZ 11-1 rsarros Residence o >- o z z APPROVED B • vi- red Patio and Trellis 5: tO ** BOARD OF TRUSTEES - , TOWN OF SOUTHOLD FA 1......„. Lo ::• , _ _ DATE. MA-V' ( ( 2016, : c.i MAY - 3 2016 N i.11P 'VW i , 1AIIIIIIIIII.111111111 1 , : . 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E � o O SITE PLAN ;...: ,, m_ .., . m-,11---- , SCALE: 3 11 = I i—On o o a o 1 s *1 t. a .1,. 1 ..1 .� 32 A + ---`mm-''''''' i Z • SCTM: 1000-88-5-6 I .2 , 1 5'-9 1/2" :•4•,. : • a 0 Information taken from , ' + x ¢ �= - I-� 1 1 1 1 1 1 .l 15 I/2 (L survey prepared by • - it i i i i I I III I , I I i /11 I I I III III ¢m , ; o II I I I I I I I I I I I I I I 23 8 11 I I I I I I I I I I II 0 Pat T. Seccafico, L.S. • b . I . w Q 111IIIiiiiiiiiii ' I 11111111111III • Center Moriches, New York • - li I I I I I I I I I i i i i i i II I I I I I I I I I III • O 111 dated March 3 l , 201 5 • I i i I i-i i I .I .,i I_� i-_ II I I I i_I I I I I i s '• > J �, ''1; • 20'4" I _ 15' 211 ,, y • • U E— PROPERTY AREAS: • i I © tt• I i • Existing Lot area: 17,333 561„.ft. PRO.-OSED OPEN T IELLIS L�._._—_—°1— _._ house (existing): 2420 5 ol.ft. ON , IT1ER SIDE OFL ATIO Patio (existin ): 355 s 58'-3 I/2" g cl Existing lot coverage: 16.0% ' EXISTING PATIO ON - Y s : GRADE TO REMAIN; Z_ Deck over patio on grade: 355sct.ft. • Proposed trellis addition: 350sc�.ft. PROPOSED ROOF OVER • PHOTO 3 PHOTO 4 Ix Total new area: 350sc1,.ft. • AS UPPER DECK • W Q+ TOTAL LOT COVERAGE: 18.0% • • • E~ril i F, OUTLINE OF F SI T z ,gF F." I-ENCING TO CONTAIN z Z g-� Zo CONSTRUCTION AREArt- 0 CP CA •••.1 z ' . ' .'e': 1)00. .Le jr7 c,,A . • di" TO .) ' , -i,:, ;p' iNM • - ,rte J • Ln 0 6 ‘\ (t) OD BULKHEAD �'A. �'.'.��' •, '` O EX TING .i '. ''``..- '`.---,. - .... ....... . . u w •.r 'ems `�..,.. • ........., ... ...• .�- ..«..,.✓-^`"'.......a. ,.-::-::: , Z5502'23"W '`.. ``.:� f_ w W 3BEACH AREA „.,.....:... ..... `'' .. - ~. p z W`n;r 0 N70°06'55"U/ 93 r '" .-"•� a • N N z _ "3s. ''''''''.".":".*'\. ,mow.+.:''"„"' a /� PHOTO 5 PHOTO 6 Z HOG NECK BAY Z PAGE: 2 UNAUTHORIZED ALTERATION OR ADDITION TO rH/S DRAWING AND RELATED DOCUMENTS 15 A VIOLATION OF SEC. 7209 OF THE N.Y.S.EDUCATION LAW SURVEY OF DESCRIBED PROPERTY '� SITUATED AT • \ - . SAJFIrY 4I TOWN OF YORK S.�T.M. NO. 1000-88-5-61,2 WA�'.�RS DGE WAY �,� O UPLAND AREA = 17,333 SQ. FT.' (50' WIDE) �� CERTIFIED•T0: �r/,p GRAVEL ��v?•o SANDY Pmt 3SARROS &•sy sy* APRON " L7 8 l 'per TUE SECURITY TITLE GUARANTEE CORPORATION S 68®22'10"E 80.0 ' N 88'22'10"}Y OF BALTIl470RE SCTIC INC. (TITLE NO. 33094-8394) 559.02' FIRST PRIORITY BANK, ITS SUCCESSORS AND OR ASSIGNS, ATIMA, 2 W. LIBERTY BLVD, STE.104, 71 V MALVERN, PA 19355 . ci, 121 \kil i GUARANfEM OR CERTIFICATION ARE NOT TRANSFERABLE UNDERGROUND URURES TASEITENTS Nor SHOWN AND MUTT POLE LaCATDRIVEWAY RAE OFFSET DIMENSION SHOWN HEREON FROU WEN ARE NOT GUARANTEED. DRNENAS S1RUCTURES T 17 THE PROPERTY UNES ARE FOR SPEED-IC PURPOSE AND USE THEREFORE ARE NOT INTENDED TD GLADE THE C ERECTION OF FENCE!,RETORTING WALE POOLS PATEN,PLANERS ARMS,_ A�ffON N ADDITION TO BUDAING5 AND OTHER CONSTRUCTION. THE DDETENCE OF RIGHT RP OF WAYS R'WETLANDS AND/OR EASEMENTS OF RECORD, ANY HOT SHOWN c CSL�RP' III A 6E.5' 1 8' ARE NOT GUARANTEED , DTUNAUINORLZED ALTERATION OR ADDITION 717 THIS SURVEY IS A VIOLATION OF 'A.. SECTION 7209 OF THE NEW YORK SATE EDUCATION LAW. COPIES OF DOS SURVEY LoP Lea. NOT BE LDERED A TRUE W1UNor BEARING THE LAND D SIGNATURE AND RED INK OR EMBOSSED SEAL SHALL 29.0' O t.\i Di. E;o iv ALL=AVM OF AND DISTANCES TO WELLS AND CESSPOOLS ARE BY LOCATIONS L'' CO 1 Lb 2 STy aS FROM HDMEOI4WERS,FIELD OBSERVATIONS AND/OR INFORLNRON OBTAINED FAME It 4 i m DWG.. al 4 2 OTHERS SINCE MOST ARE NOT MILE THESE LOCATIONS AND DIMENSIONS CANNOT q DE CERTIFIED. 0 II l te p, ,H.2• a 14.7 tit~ s., Ls. s _ It��\.-.-Hi, 1 `!,'! T►Doo P ; _ PAT T. SECCAFICO IOW 745 . If �g — 3 Zol� a`1LL� - u auiica�Aa PROFESSIONAL LAND SURVEYOR, P.C. MAY :15:Z11414 = G - SUCCESSOR TO - R ' - DONALD TASE; LS. io Mail AREA A� RICHARD WILHELM AND ASSOCaTEs NORTSwthGld Toldt} TataCANAUZTAR SURVEYING, P.C. yy Oa.N. RI IGH gATER LINE _—----^ PAUL T. CANAtJZO, L5, ROBERT A. KART, L.S. 0` d G{T1UStL$S___ �_ ___-_-J :;u� N 70'DB'bLS'1T DtT.OD /1771/1GOOD GROUND SURVEYORS, P.C. La 328A Main Street Hampton Atrium Unit 0-4 L._....Cs. N i Center Moriches, NY 11934 186 W. Montauk Highway xOG ��� Hamptonhone8.1) 2 53 60 Phone: (631) 878-0120 Phone: 631)) 728-5330 �j Fax: (631) 878-7190 Fax: (631) 728-6707 PSECCAFICO®OPTONLINENET _ N.Y.S. UC. NO. 049287 FILE' NO. T61054 SCALE: 1" = 30' DATE': 03/31/2015 COPYRIGHT - 2015 PAT T. SECCAFlCO P.LS., P.C. 111111. Tom&Sandy Psarros 575 Watersedge Way,Southold SCTM#: 1000-88-5-61.2 5/11/16 • Ae • 6111i • • • • w. ir- • om&Sandy Psarros 575 Watersedge Way,Southold SCTM#: 1000-88 -5-61.2 ---11,110 iir 5/11/16 IIIIr. 4111). - otut r r•, J. i0 yam_ -.- A ... -rte Mb fillimaill w a 1 1 .41"14 !,I _ A. y 1 •�y. / Y ! " SOU OFFICE LOCATION: ��� .1;1/ MAILING ADDRESS: Town Hall Annex �� �® P.O. Box 1179 54375 State Route 25 21Ig Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) . ss� Telephone: 631 765-1938 Southold, NY 11971 :="Z't. ®0. A-, r P c®UNTI,� .• 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 13, 2016 Re. Local Waterfront Revitalization Program Coastal Consistency Review for TOM & SANDY PSARROS SCTM# 1000-88-5-61.2 TOM & SANDY PSARROS request an Administrative Permit for the existing 18'x24' on-grade patio against the seaward side of dwelling; construct an 18'x24' flat roof over patio for a 2'd story deck; and construct a ±10'x15.2' and a ±10'x20.6' open trellises running along both sides of the patio. Located: 575 Watersedge Way, Southold. SCTM# 1000-88-5-61.2 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 provided the following is required for further Policies 5 and 6. 1. Require a vegetated non-turf buffer landward of the bulkhead planted with native, salt tolerant vegetation. 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: Stephen Kiely, Assistant Town Attorney „. _ , jso7John M.Bredemeyer III,President t r ,, O Town Hall Annex Michael J.Domino,Vice-President t� 54375 Main Road i JV , i P.O.Box 1179 James F.King,Trustee t '' 1/ g Southold,New York 11971-0959 Dave Bergen,Trustee ` 1 &F AY Telephone(631)765-1892 _1/r Charles J.Sanders,Trustee = 11 V• Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application Wetland Permit Application V Administrative Permit / Amendment/Transfer/Ext nsion i::7. • -, ✓/Received Application: S;2`/� % V Received Fee:$ 100100 _ _ i ✓✓_Completed Applicata : '5 3 If ;( , —Incomplete: MAY a 2 2016 r . ! P 1 _SEQRA Classifica on: Type I Type Unlisted L. - -- Coordination:(date sent): ` Sr{”�'r'``� inn V LWRP Consistency Assessment Form: S-164/lam L........ ----- '-.���-'ti-'D.141::.-.w . _ JCAC Referral Sent: Date of Inspection: -6-411/Lo. Receipt of CAC Report: _Lead Agency Determination: Technical Review: Public Hearing Held: S 4 Ilii/1 Resolution: Name of Applicant: 1 OA Sc 11.11 Sao r 0 S Mailing Address: Phone Number: _ — v.,,- Suffolk County Tax Map Number: 1000- &S- 6/ Property Location: _5-7 c Wet je,,r5 ----6/1.e...- 1'04 v� So u Id .590.2 ' V &Mb/€ /(provide LILCO Pole#, dista- cross streets, and location) AGENT: p,h I -fir Th51 5a/!Sv /iiiri1 /it . (If applicable) J • Address: 0 Ian 6 33- S0 UT ke, I cL Phone: 24,S-8g0,5" E rd of Trustees Applicatio GENERAL DATA Land Area(in square feet): /7, 3 53 Area Zoning: e_ `/0 Previous use of property: S 41 IL -atm I e )cJe4'LGe_ to 17 V Intended use of property: S4ivA.e, k)/ Cede, .e ° ra-b0 4 ir&1'115- Covenants and Restrictions on property? Yes X No If"Yes", please provide a copy. ____:x2 Will this project require a Building Permit as per Town Code? Yes No If"Yes",be advised this application will be reviewed by the Bui eding 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 requi e 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? XYes No Prior permits/approvals for site improvements: Agency Date 61,x.1 17er+- Nis I qq5 0 j rUS{-c 71Na r /q,, 7 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): Tl-/e— HoUSG C 'rrik itti hetS ezr► /S x 2_,/ .,-ti o o n l retJz. -iv we.16v5i cLe o C house,. e 4 froj 's J (L J K -hut_ ii to w a. _r , . r -Q1 a _• J ci oar a.-cdA 6 S x 2q) i As-- & A_ O Pew. -I r-g.11 IS /0 o-q ho-c,/__ '6"C I^- sem- h- CUvt t2-ti,`-ai p 6o L s/c e_s ,4i e.,>cr s h, a. e.,Sf s, -kre,11 r s i a prr'd> /D,c 2 0 12-a- . ,s-1- sf d er la p/eo)C /6)c/S a-ei: B :d of Trustees Application• WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations:.% croutr 01-110 /1 S ra-L - w / �(& ioo-C froL 2 -010-sor mak. I gPte'. 'IAA- o re/k- - �-(( s OLIO p(Z-0)‹. 16 )( go re-a-- ( 0 d( D kl S -iv 119L. 0r Area of wetlands on lot: square feet Percent coverage of lot: 0 Closest distance between nearest existing structure and upland edge of wetlands: / 7 feet Closest distance between nearest proposed structure and upland edge of wetlands: 71. 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: P 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): L/ -k(f n o e,f o f? tvo./-ja pmt s- 51)J- -0'v kLa p f ✓l leper _ 71v cep,5 i7 u i o,'1 r 4 a- PI L-(-4441- J4 a ( tra_a_5 Ore 0-1(' d -A i s. 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 I. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 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 Name of Action or Proct: ibl Set_y✓oS .-0-gi c1441. O.� Project Location(describe,and attach a location map): 515 k/A4,rs e-dqe— Lz 1a vj ,, v l cL Brief Description of Proposed Action: Goin✓ j 51 vj / c -/IS P io 4 n io-I.e ex.// 4. -A a,-1- r or)-1) S�'r'a C I-V Ce_ vi)k r C/IA rtir I I ) 269(-- e1vo . cLe -k--. Ad of aa/L. 0 pal. -&2. h 1 i5 itA4C-e -'L4. Aou s eV) el 1-k_e_r sib o 16 pot/01 (LIP P20)e /0x d o aA /e-(! Sim- ; ( /0x /vim ort rt .5L+ Sick-_ or .e))41 sl• Peh--'l O. Name of Applicantl�lior1Sponsor: ri ,-1 / Telephone: 7 5- (579.0s' dd Q vti ��/v Q,Y �J� 515!1 Lr7/I Sv,7, E-Mail: /I R ii cti 0 chi ye,r d esiSei S. /Let Address: 1 / r0 rho,. 6 30-- City/PO: aCity/PO: State: Zip Code: SO0-o(d kJ 1197) 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 that 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: n SOI 1 of!X1.43fQir&t,t L-V lbw vl ?fy `® (6 ❑ Y 3.a.Total acreage of the site of the proposed action? /7/ 93 aeres -� b.Total acreage to be physically disturbed? c'O© awes- c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? _ a acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban 0 Rural(non-agriculture) 0 Industrial ID Commercial residential(suburban) ❑Forest DAgriculture 0 Aquatic ❑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? NO YES LL ❑ . 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: ❑ ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: �-%'' ❑ ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: -) c:•<, ❑ 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? L 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 0 Agricultural/grasslands ❑Early mid-successional i 'etland 0 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? L ❑ 16.Is the project site located in the 100 year flood plain? NO YES 1X 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, jAl a.Will storm water discharges flow to adjacent properties? NO DYES 14 b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? 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: 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 1 � Applicant/sponsor .. `RC j • ;� e a Date: `)'i^I —I Signature: at,vlij� (�J� 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 I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate -- - -- small to large_ impactimpact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning1. regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate reasonably available energy conservation or renewable energy opportunities? i 7. Will the proposed action impact existing: a.public/private water supplies? b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage problems? IL 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. • Chec this box if you have determined,based on the information and analysis above,and any supporting documentation, tha he proposed action may result in one or more potentially large or significant adverse impacts and an vironmental 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 enviro men al impacts. Town of Southold-Board of Trustees t. 9 / Name of Leel Agency Date JC2)..-v President Print or Type N.me of Resj.i ib e Of icer in Lead Agency Title of Responsible Officer Sig . e of Respon'-ble Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 E. rd of Trustees Applicatia ,i AFFIDAVIT 64ctoc h'OS (_ iotiios aid 6.04, i"T 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. Cs.Y Som-- a ncu1?e ignature of Property Owner SWORN TO BEFORE ME THIS a#4 DAY OF 4fs. I 20 if l� COMMONWEALTH OF PENNSYLVANIA Notarial Seal Brandon R.Bartholomew,Notary Public North Whitehall Twp.,Lehigh County My Commission Expires Jan.23,2017 MEMBER,PENNSYLVANIA ASSOCIATION OF NOTARIES Notary Pum E rd of Trustees Applicatio,, AUTHORIZATION (where the applicant is not the owner) I, 5+omcchos cidPi wtoS residing at a Coq Sylvca- Lane (print name of owne1 of property) (mailing address) \\nim , P R ( 101 'V do hereby authorize No f1C'f Ow\-r( (Agent) 1)e S15n Con si\Al ) 1 vlc • to apply for permit(s)from the Southold Board of Town Trustees on my behalf. es, (Owner's signature) 6-1-ancrho s Pson'S X15 Wa+crsed Wa (Ml + �U( a)i-W-)68. 1 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold''s code of Ethics prohibits coOflicts of interest on the Dart of town.lifters and(emolovees..The purpose of this form•isto-provide intorination which can alert•the-town of possible conflicts of interest and allow it to take-whatever action is necessary to avoid same. pp 1 i ' YOURNAME: PSo(()S) J'1C(YIohOS't G. Quid ?SQ(IQ-S,JCY)O(� (Last name,first name,j fiddle 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 (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 , If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold . __ - Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check ' the appropriate line A)through D)and/or describe in the space provided. , The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant - , (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); • C)an officer,director,partner,or employee of the applicant;or . D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of 200_ - Signature - Print Name Form TS l 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. CbYOUR NAME: C'L( (Lame,f kme,iiddle initial,unibss 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 - 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 this day o 0�s /i 200 /62 —f Signature , • EP/ Print Name Art 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-SIT-I AND-PROPOSED-ACTION SCTM# )000 - jP - 5 PROJECT NAME "Tom k SCLr di c rcc The Application has been submitted to(check appropriate response): n Town Board Planning Board Building Dept. Board of Trustees l 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ri construction,planning activity, agency regulation,land transaction) (b) Financial assistance(e.g. grant, loan, subsidy) (c) Permit, approval, license,certification: L� Nature andt extent of action: - -- nue.,( Phi G-11 1 I 6)e Z`f 0 0, f e. t"Bot 54kruc,4-v r - ic/k i GIS ut( l (O¢. �. 2 tom{ -t�1 a�✓L 4./ or, 4_ R.1&- cfeN\ ti icnekoko0s . a n a ' r o iC t90- oaffi� ° ) O)C JD k .64 IC /5' 4_1) • Location of action: 6 '1,C Site acreage: l ' 333 mer. . Present land use: olYe cE3,_\ ‘1 eWz c,e. Present zoning classification: - —LA 0 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:(J\\CCF c p-er ©mac kin 0=801 (n c (b) Mailing address: PCS &y. C 2 C`J�� d k te-t r (c) Telephone number: Area Code( ) 7(g — 4,0 (d) Application number,if any: Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No Ek 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 n No [ . (ot Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See -----LWRP SectionIIT Poil/cies Pages 3 throngli 6 for evaluation cri is n Yes No of Applicable i..f 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 I I 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 11 Yes No 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 Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including ._.___.._Significant_CoastaLEish_and_Wildlife Jiabitats_aand_ etlands._.See..LWkR_Section IIITPolicies;_Pages_22___.__ through 32 for evaluation criteria. • • Yes No Not Applit_.. 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 n Noot'Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes.a�s.� See LWRP Section III-Policies; Pages 34 through 38 for evaluation criteria. H-Yes- No-U''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 ,"e�/Not Applicable Attach additional sheets if necessary 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. Ft Yes n No P'Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III-Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes Noot 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 a-mot 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 Not Applicable PREPARED BY JCt1A eir TITLE .tcIDATE - )4/lb 4