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TR-8826
i erg SO(/T Michael J. Domino,President h�� 9plo Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Charles J.Sanders Southold,New York 11971 Glenn Goldsmith ® yo Telephone (631) 765-1892 A.Nicholas Krupski lyA�UNTV I Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: \'A `NQ C 1� r Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 st day of construction / Y2 constructed V Project complete, compliance inspection. INSPECTED BY: C3 v I ai , 5 COMMENTS: 'c - C C& 1i CERTIFICATE OF COMPLIANCE: C Michael J.Domino,President ®'�'QF SQ(/I�Ol Town Hall Annex John M. Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Charles J.Sanders Southold,New York 11971 Glenn Goldsmith G ® Telephone(631) 765-1892 A. Nicholas Krupski Q Fax(631) 765-6641 �ycOUNT`1,� ' BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1380C Date: August 15, 2017 THIS CERTIFIES that the construction of a 27.6'x24' wood timber frame barn on full frost wall and slab; At 1255 Goose Creek Lane, Southold Suffolk County Tax Map#1000-78-8-9 Conforms to the application for a Trustees Permit heretofore filed in this office Dated May 23,2016 pursuant to which Trustees Wetland Permit#8826 Dated June 22,2016,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 construction of a 27.6'x24' wood timber frame barn on full frost wall and slab. The certificate is issued to STEPHEN MILGRIM owner of the aforesaid property. Authorized Signature ._ ._-SSUFFQthI`-- John M Bredemeyer III, President :ro�o �o� Town Hall Annex Michael J. Domino, Vice-President 54375 Route 25 Glenn Goldsmith � 'J ? ` P_O. Box 1179 A_ Nicholas Krupski �, o� ; Southold, NY 11971 Charles J. SandersTelephone (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 1" day of construction '/ constructed Project complete, compliance inspection BOARD OF SOUTHOLD TOWN TRUSTEES SOUTHOLD, NEW YORK PERMIT NO. 8826 DATE: JUNE 22, 2016 ISSUED TO: STEPHEN MILGRIM PROPERTY ADDRESS: 1255 GOOSE CREEK LANE, SOUTHOLD SCTM# 1000-78-8-9 AUTHORIZATION Pursuant to the provisions of Chapter 275 of-the Town Code o,f the Town of Southold and in accordance with the Resolution of the Board of Tria"S'tees adopted at themeeting fieldonJune 22, 2016, and in consideration of application fee in the sum of 250.00 paid Stephen Milgrim and subject to the Terms and Conditions as stated in the Resolution, the Southold Towfi'B O*ard'of Thistees authorizes and permits the 01 following: a - Wetland Permit to construct a 27:6'x24' wood timber frame,barn on full frost wall and II., ' " "'last slab; and as depicted on the survey of Nathan' Cbriwin'll ta!ndSuiirveyor, 1A dated on May 19, 2016,_and stamped approved on June 22,,;916. said 0 of rustees r y,cause is Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Boar of this date. Sa- C* TERMS ANIS CONDITIONS The 1v elllltltlIo+V Stephen Milgrim, residingat 1255 Goose Creek Lane Southold,, p e York, as part of the consideration for the issuance of the Permit does understand and prescribe to the following: 1. That the said Board of Trustees and the Town of Southold are released from any and all damages, or claims for damages, of suits arising directly or indirectly as a result of any operation performed pursuant to this permit, and the said Permittee will,at his or her own expense, defend any and all such suits initiated by third parties, and the said Permittee assumes full liability with respect thereto,to the complete exclusion of the Board of Trustees of the Town of Southold. 2. That this Permit is valid for a period of 24 months,which is considered to be the estimated time required to complete the work involved, but should circumstances warrant, request for an extension may be made to the Board at a later date. 3. That this Permit should be retained indefinitely,or as long as the said Permittee wishes to maintain the structure or project involved, to provide evidence to anyone concerned that authorization was originally obtained. 4. That the work involved will be subject to the inspection and approval of the Board or its agents, and non-compliance with the provisions of the originating application may be cause for revocation of this Permit by resolution of the said Board. 5. That there will be no unreasonable interference with navigation as a result of the work herein authorized. 6. That there shall be no interference with the right of the public to pass and repass along the beach between high and low water marks. 7. That if future operations of the Town of Southold require the removal and/or alterations in the location of the work herein authorized,or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstruction to free navigation,the said Permittee will be required, upon due notice, to remove or alter this work project herein stated without expenses to the Town of Southold. 8. That the said Board will be notified by the Permittee of the completion of the work authorized. 9. That the Permittee will obtain all other permits and consents that may be required supplemental to this permit,which may be subject to revoke upon failure to obtain same. 10. No right to trespass or interfere with riparian rights. This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. John M.Bredemeyer III,President �0�X\f3f SOc��yol� Town Hall Annex Michael J.Domino,Vice-President 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski Yp� Telephone(631) 765-1892 Charles J.SandersFax(631) 765-6641 COUNVI BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD June 22, 2016 Stephen Milgrim P:O. Box 1696 Southold, NY 11971 RE: STEPHEN•MILGRIM 1255 GOOSE CREEK LANE, SOUTHOLD SCTM# 1000-78-8-9 Dear Mr. Milgrim: The Board of Town Trustees took the-following action during its regular meeting held on Wednesday, June 22, 2016 regarding the above matter:, WHEREAS, STEPHEN MILGRIM applied to the Southold Town Trustees-for a permit under the provisions of Chapter 275 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated May 23, 2016, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator for their findings and recommendations, and, WHEREAS, the LWRP Coordinator issued a recommendation that the application be found Consistent with the Local Waterfront Revitalization Program policy standards, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on June 22, 2016, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the•surrounding area, and, 2 �4 WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies withh the standards set forth i�h� Chapter 275 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees have found the application to be Consistent with the Local Waterfront Revitalization Program, and, RESOLVED, that the Board of Trustees approve the application of STEPHEN MILGRIM to construct a 27.6'x24' wood timber frame barn on full frost wall and slab; and as depicted on the survey of Nathan Taft Corwin III, Land Surveyor, last dated on May 19, 2016, and stamped approved on-June 22, 2016. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of$50.00 per inspection. (See attached schedule.) Fees: $50.00 Very truly yours, Jo . Bredeme er III President, Board of Trustees JMB/dd SURVEY OF PROPERTY (� a SI T UA TE BAYVIEW ,LVA 0 2 3 TOWN OF SOUTHOLD ti,AY 2016 f t SUFFOLK COUNTY, NEW YORK 3.0 S.C. TAX No. 1000-78-08-09 SCALE 1 "=20' 4 '-' MARCH 30, 1994 �� '` R. ti�'� MARCH 3, 2016 UPDATE SURVEY �� l 2 0 MAY 19, 2016 ADD PROPOSED BARN REE 7 LOT AREA = 18,751 sq. ft. C 1 " y. O S b 1 E /� FONc. MON. lit G GOO" N /-70 53 50 / RAIL FE 6.3 't .431 ac. 40�I� S �` ND N/ b / 5.\ y p0� 5j "w 1'25 O EXISTING LOT COVERAGE o►' ou zh 1 �`� of � o.4;s• CONC. �' � DESCRIPTION AREA X LOT COVERAGE �OGF, ENCS 0.4 W OST do FAIL FENCE \ QY. �k �8 U7 a HOUSE 1,858 sq. ft. 9.9% FOUND CONC. FE / N' I 4.5 F05W• M° / I � E �9 FRONT DECK W/ STAIRS 425 sq. ft. 2.3/. 62.20 0.7 S. o.6C . u4 REAR DECK 520 sq. ft. 2.8% 0.3'W. / OUTSIDE SHOWER 38 sq. ft. 0.2% o I / O� SHED 146 sq. ft. 0.7% W6 TOTAL EXISTING 2987 sq, ft. 15.9%. I / I PROPOSED LOT COVERAGE ; �►{� DESCRIPTION AREA X LOT COVERAGE J HOUSE 1,858 sq. ft. 9.9% / I / l / ; - 'AR D BY L I 6 I / X-.. FRONT DECK W/ STAIRS 425 sq. ft. 2.3% /�� ' y 'CA�D F USTEES ' REAR DECK 520 sq. ft. 2.8% OF OLD OUTSIDE SHOWER 38 sq. ft. 0.2% PROPOSED BARN 660 sq. ft. 3.5% 5.4 ' 8.9 /x TOTAL EXISTING 3501 sq. ft. 18.8% o I' ' / / / /I / "•�•'` � TORMWATER MANAGEMENT NOTES: 1. ANY WORK OR IS MATERIALS SHALL BE CBSTORAGEANCE, AND ONFINED TO THEOTION LIMIT OF CLEARING ,� / AND/OR GROUND DISTURBANCE SHOWN ON THE APPROVED PLANS. x saw I I \ e�"�95 I / I= 2. PRIOR TO THE COMMENCEMENT OF ANY CONSTRUCTION ACTIVITIES, A CONTINUOUS LINE OF SILT SCREEN (MAXIMUM OPENING OF z Z I 1 \ ys �'y p � U.S. SIEVE #20) SHALL BE STAKED AT THE LIMIT OF CLEARING O CONC. COVE AND> I % y AND GROUND DISTURBANCE SHOWN ON THE APPROVED PLANS. 7. x THE SCREEN SHALL BE MAINTAINED, REPAIRED AND REPLACED AS �.� tri OFTEN AS NECESSARY TO ENSURE PROPER FUNCTION, UNTIL ALL 6 a � P� tin DISTURBED AREAS ARE PERMANENTLY VEGETATED. SEDIMENTS TRAPPED THE SCREEN SHALLAY FROM SCREEN TOYAN APPROVED UPLANDELOCATIIONDBEF/0 E THE THE SCREEN IS REMOVED. JRg 11 jo x 4.8 STEEL OR WOOD EXTRA STRENGTH FILTER FABRIC POST (TYP.) / 5. I O3� I F• ►C �-. REO'D. WITHOUT WIRE MESH SUPPORT I LAWN wN 8.3 e a°, 1 �y SF' o.a'0.4'E. '~ 10' MAX. O.C. SPACING� �\� W/ WIRE SUPPORT FENCE 6' MAX. O.C. iL SPACING W/O WIRE SUPPORT FENCE T. I DLp� c G• p� o � , I 4. I �5�°Q FLOW I6. \ I I ATTACH FILTER FABRIC SECURELY 1P TO f I I o TO UPSTREAM SIDE OF POST 0 I I 4^n ��/��/��\��j \ SILT FENCE DETAILS NOT TO SCALE `fYyO i o�G -j NOTES: SILT FENCE SHALL BE PLACED PARALLEL TO SLOPE CONTOURS TO MAXIMIZE PONDING EFFICIENCY. INSPECT AND REPAIR SILT FENCE AFTER EACH STORM EVENT AND REMOVE SEDIMENT WHEN NECESSARY. REMOVED 1 0� f D�A y titi' I 6.9 SEDIMENT SHALL BE DEPOSITED TO AN AREA THAT WILL NOT ALLOW OFF-SITE TRANSPORT. 2 '�y ' �p�' I I x-t'�'.`•' TREES 1 25., 0.9'E. p X119 I 11 36" HIGH POLE (MAX.) �n Fx I OAK TREE STEEL OR WOOD POST fi Y q v�s ►v i FLOW 1 b 1VRYWELL I ' I\ Q (P � 1 w 1 RooO PROPOSEDppR g�Ro 42 m 05 O 9.4 12.2 7 w�a0. :. ; x- 2 / I� :. �.r:r. 'i}:i' ':. :.'Y ��\ /� /�� 4" X 6" TRENCH �:..::..\ \\ __ \ /� � / COMPACTED EXISTING BDo:::SiiES3: --- \�. BACKFILL b RE oVEDI 9 w,4r�:.... ::: a 425 N :."... ui Q \ IND Co NC SON TRENCH DETAIL PRO Fo LED 10-0 o ::. :.::.:::X 9. aTa 1-� rj. \'*� (NOT TO SCALE) 'T FENCE �'� ` � � 7.� PROPOSED 51 i FO ND s A 1 \ li /? 1 CONS• M N. VV ' \ ` S 05 � 9 ��o NOTES: 1 . ELEVATIONS ARE REFERENCED TO N.G.V.D. 1988 DATUM _ 3 EXISTING ELEVATIONS ARE SHOWN THUS:XXX - - - - - - 8 7 ` EXISTING CONTOUR LINES ARE SHOWN THUS: x - PROPOSED ELEVATIONS ARE SHOWN THUS: x.x �70 FA.� �2pNF PROPOSED CONTOUR LINES ARE SHOWN THUS: JOHN NG )KE20`* F.FL. - FIRST FLOOR G.FL. - GROUND FLOOR °= X 2. FLOOD ZONE INFORMATION TAKEN FROM: FLOOD INSURANCE RATE MAP No. 36103CO187 H ZONE AE: BASE FLOOD ELEVATIONS DETERMINED �-- ZONE X*: AREAS OF 0.2% ANNUAL CHANCE FLOOD; AREAS OF 1% ANNUAL �► CHANCE FLOOD WITH AVERAGE DEPTH OF LESS THAN 1 FOOT OR 1 WITH DRAINAGE AREAS LESS THAN 1 SQUARE MILE; AND AREAS 20NE X* PROTECTED BY LEVEES FROM 1% ANNUAL CHANCE FLOOD. All, ZONE . , ZONE X: AREAS DETERMINED TO BE OUTSIDE THE 0.2% ANNUAL AE (EL 7) CHANCE FLOODPLAIN. PREPARED IN ACCORDANCE WITH THE MINIMUM 3 1 - STANDARDS FOR TITLE SURVEYS AS ESTABLISHED BY S.LAI 3.1 FORTHE SUCHI USE BYNTTHE NEWVED YORK STAADOPTEDTE LAND TITLE ASSOCIATION. PDGf aF 3.1 FRrSHWgW T� 3.1 , ,DS \r TYPICAL STORMWATER UNIT (TOP TO BE TRAFFIC BEARING) (NOT TO SCALE) ah, j �• FINISHED GRADE 6" THICK REINFORCED CONC. COVER f B" TRAFFIC BEARING SLAB (max) A. Lic. No. 50467 '�-- PIPE FROM ROOF GUTTERS S-O" 8'-0" S-0" (min.) 0 4" (min.) UNAUTHORIZED ALTERATION OR ADDITION Nathan Taft Corwin "' WRAP LEACHING SECTIONS LEACHING RINGS TO THIS SURVEY IS A VIOLATION OF REINFORCED PRECAST CONC. WITH FILTER FABRIC SECTION 7209 OF THE NEW YORK STATE 4000 PSI o 28 DAYS EDUCATION LAW. CRUSHED 3/4" - 1-1/2" STONE Land Surveyor ALL AROUND COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR E EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VAUD TRUE COPY. GROUND WATER CERTIFICATIONS INDICATED HEREON SHALL RUN Successor To: Stanley J. Isaksen, Jr. L.S. ONLY TO THE PERSON FOR WHOM THE SURVEY Joseph A. Ingegno L.S. HE DRAINAGE SYSTEM CALCULATIONS: T E COMPANY GOVERNMENTAL AGENND ON HIS BEHALF CY TAND Title Surveys - Subdivisions - Site Plans - Construction Layout LENDING INSTITUTION LISTED HEREON, AND PROPOSED BARN ROOF AREA: 660 Sq. ft. TO THE ASSIGNEES OF THE LENDING INSTI- PHONE (631)727-2090 FOX (631)727-1727 660 sq. ft. X 0.17 = 113 CU. ft. TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. 113 cu. ft. 42.2 = 2.7 vertical ft. of 8' Glia. leaching pool required OFFICES LOCATED AT MAILING ADDRESS / g P q THE EXISTENCE OF RIGHT C WAYS 1586 Main Road P.O. Box 16 AND/OR EASEMENTS OF RECORD, IF PROVIDE (1) 8' dia. X 3' high STORM DRAIN POOL ANY, NOT SHOWN ARE NOT GUARANTEED. Jamesport, New York 11947 Jamesport, New York 11947 �"✓1�FFdt "" . John M Bredemeyer III, President r;�'o��S �coG Town Hall Annex Michael J_ Domino, Vice-President '�� ��, 54375 Route 25 Glenn Goldsmithz P.O. Box 1179 A. Nicholas Krupski y ® ySouthold, NY 11971 Charles J. Sanders 01 , ���?`" Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD WV 4.991, Ila TO: LPH�II( Please be advised that your application dated MAY 23( 201(o has been reviewed by this Board at the regular meeting of V%' .22,2011o, and your application has been approved pending the completion of the following items checked off below. Revised Plans for proposed project Pre-Construction Hay Bale Line Inspection Fee ($50.00) 1St Day of Construction ($50.00) o / Y2 Constructed ($50.00) 1✓ Final Inspection Fee ($50.00) Dock Fees ($3.00 per sq. ft.) The Permittee is required to provide evidence that the non-turf buffer condition of the Trustee permit has been recorded with the Suffolk County Clerk's Office as a notice covenant and deed restriction to the deed of the subject parcel. Such evidence shall be provided within ninety (90) calendar days of issuance of this permit. Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $ 150i6D BY: John M. Bredemeyer III, President Board of Trustees iAmjEwcAN OUNTRYBARNS 5tephen Milgrim - CLASSIC TIMURFRAAIEBUIIJANG� American country Sams bq East Street 27.5' x 24' Monitor Barn Bethlehem, GT 06751 800-7q-BARNS w/ Half L oft (800-7q2-2167) 7,iM Engineer: Structural and Architecturalngineering 3 2016 L-' DeStefano& Chamberlain 50Thcrpe5rraet j 06tl2A3725 { Tel 203 31 t Fax 203 254-0254-02 63 Southold Town Customer: Stephen Milgrim 1255 Goose Greek Lane Southold, NY 11971 - Mailing Address: ® ® P.O. Box 1696 Phone: (631)765-6285 Gell: (631)834-8782 smilgrim@optonline.net ------------ P�3 Print on: TABLOID 11" x 17" Date: February 4, 2016 GAD Work: February 4, 2016 March 10-11, 2016 March 22-25, 2016 March 26-30, 2016 April 1, 2016 April 5-6, 2016 Project Manager: Mark Calabro American country Bams Criteria Southold New York *ALL 5TRUGTURAL MATERIAL 15 EASTERN HEMLOCK UNLE55 OTHERWI5E NOTED. �of"E6r (800)792-2767 EXT:512 H~Y a6 Y�r Ground Snow Load Obs per sci ft) 20 - w Wind 5 eed (mph) 120 CUPOLA SUPPLIED BY OTHERS. ��° Computer Design: Weathering 5EYERE .ISP III Frost Line Depth 42" �c American Country Barns Termite moderate to heavLA THIS DRAWING OR THE UNDERLYING DESIGN CANNOT BE COPIED OR USED TO BUILD AN IDENTICAL OR SUBSTANTIALLY SIMILAR STRUCTURE, Ver,aw slight to moderate REGARDLESS OF CONSTRUCTION METHOD,WITHOUT AMERICAN Winter Design Tem (degrees farenhei ht) ? COUNTRY BARNS.LL05 WRITTEN PERMISSION. Page: ACB - 1 COPYRIGHT 0 2016 AMERICAN COUNTRY BARNS,LLC AM EWCAN COUNITKYBARNS Ci uuC in tr,1'tt Fi N4 rSU d INGS American Country Barns 69 East Street Bethlehem, GT 06151 800-19-BARNS (800-192-2"1b1) Engineer: Sttuctural and Archithltectural Engineering DeStefano& Chamberlain 50TarpcldST Fan(Id" 0682A 5725 TeL 203 254.7131 Fax 03254-0� Customer: Stephen Milgrim 1255 Goose Greek Lane Southold, NY 11911 J Mailing Address: FRONT GABLE ELEVATION 2 REAR GABLE ELEVATION P.O. Box 1696 e0113 Phone: (631)165-6285 Scale: 1/8 in. = 1 ft. Scale: 1/8 in. = 1 ft. Cell: (631)834-8192 smilgrlm@optonline.net Print on: TABLOID 11" x 11N Date: February 4, 2016 GAD Work: February 4, 2016 March 10-11, 2016 March 22-25, 2016 March 26-30, 2016 April 1, 2016 ® ® Apel 5-6, 2016 Project Manager: Mark Calabro American Country Bams pF NE:y^ (800)192-2167 EJCT:512 qqP ES&o0s4,9p 4 3 LEFT EAVE ELEVATION 4 RIGHT EAYE ELEVATION computer Design: A05-2 _ AGB" Scale: 1/8 in. = 1 ft. .iSP III Scale: 1/b in. 1 ft. American Country Barns THIS DRAWING OR THE UNDERLYING DE516N CANNOT BE COPIED OR USED TO BUILD AN IDENTICAL OR SUBSTANTIALLY SIMILAR STRUCTURE, REGARDLESS OF CONSTRUCTION METHOD,WITHOUT AMERICAN COUNTRY BARNS,LLC'S WRITTEN PERMISSION. Page' AGB - COPYRIGHT 0 2016 AMERICAN COUNTRY BARNS,LLC John M. Bredemeyer III, President p511Fj o Town Hall Annex l Michael J. Domino, Vice-President 54375�y� 54375 Route 25 Glenn Goldsmith a P.O. Box 1179 A. Nicholas Krupski o ® Southold, NY 11971 Charles J. Sanders '�,fj o� Telephone (631) 765-1892 Fax (631) 765-6641 �-zzrrxx="" BOARD OF TOWN TRUSTEES ICS TOWN OF SOUTHOLD Date/Time: I Completed in field by: STEPHEN MILGRIM requests a Wetland Permit to construct a 27.6'x24' wood timber frame barn on full frost wall and slab. Located: 1255 Goose Creek Lane, Southold. SCTM# 1000-78-8-9 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or K=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 / N Ch. 275 Ch. 111 SEQRA Type: 1 II 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: Present were: J. Bredemeyer VM. Domino Goldsmith N. Krupski C. Sanders Other Page 1 of 2 John M. Bredemeyer III, President o�oSOFFO o Town Hall Annex Michael J. Domino, Vice-President = y�q 54375 Route 25 Glenn Goldsmith o P.O. Box 1179 A. Nicholas KrupskiSouthold, NY 11971 Charles J. Sanders 4, _ ao�a Telephone (631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: STEPHEN MILGRIM requests a Wetland Permit to construct a 27.6'x24' wood timber frame barn on full frost wall and slab. Located: 1255 Goose Creek Lane, Southold. SCTM# 1000-78-8-9 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. s25% 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 ISO ' .� �. •fir -+, 40 -�. ..r lull 91 s now 10 Z 1 oil M• . rpt - ., "�.. .M'y �-�'� I /� -I ,y`. •� �� d s — t,• r 44 r lk:' � .o- a � L 1 ,s•; y OFFICE LOCATION: ®��®E S®(/jMAILING ADDRESS: Town Hall Annex ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) c� Southold, NY 11971 ® �� Telephone: 631 765-1938 ®lyc4U�,� 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: June 16, 2016 Re: Local Waterfront Revitalization Program Coastal Consistency Review for STEPHEN MILGRIM SCTM# 1000-78-8-9 STEPHEN MILGRIM requests.a Wetland Permit to construct a 27.6'x24' wood timber frame barn on full frost wall and slab. Located: 1255 Goose Creek Lane, Southold. SCTM# 1000-78-8-9 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. � 1 Peter Young,Chairman Town Hall,53095 Main Rd. Lauren Standish,Secretary P.O.Box 1179 Southold,NY 11971 Telephone(631)765-1889 Fax(631)765-1823 Conservation Advisory Council Town of Southold At the meeting of the Southold Town Conservation Advisory Council held Wed., June 15, 2016.the following recommendation was made: Moved by John Stein, seconded by Jack McGreevy, it was RESOLVED to SUPPORT the application of STEPEHN MILGRIM to construct a 660 sf. barn for storage of yard tools and kayak. Located: 1255 Goose Creek Lane, Southold. SCTM#78-8-9 Inspected by: John Stein The CAC Supports the application with the Condition gutters, leaders, and drywells are installed to contain the stormwater run-off. Vote of Council: Ayes: All Motion Carried John M. Bredemeyer III, President ��o� SOUTyo Town Hall Annex O l 54375 Main Road Michael J. Domino,Vice-President d P.O. Box 1179 James F. King,Trustee JW Southold, New York 11971-0959 Dave Bergen,Trustee G Q Telephone(631)765-1892 Charles J.Sanders,Trustee OIyC�UIdTY Fax(631) 765-6641 BOARD OF TOWN TRUSTEES - TOWN OF SOUTHOLD J To: Southold Town Building Department MAY 2 4 ft Re: Verification of Building Department Permit Requirements WELDING DEM TOWN OF SOUTHOLD SCTMff: Property Owner Name: ' MIL6-rglM Is Date Sent to Bldg. Dept.: S'CD4 (� The Office of the Board of Trustte s is forwarding the above referenced application for verification of the Building Department's permitting requirements stated below: YES NO ill the proposed project require a Building Permit? Will the proposed project require a variance determination from Zoning Board of Appeals? Will anypart.of this application be considered.as Demolition as described under Town Code? COMMENTS: t Signature of R fewer Date John M.Bredemeyer III, President ���®f Town Hall Annex Michael J.Domino,Vice-President54375 Main Road P.O.Box 1179 James F.King,Trustee Southold,New York 11971-0959 Dave Bergen,Trustee ® i0 Telephone(631)765-1892 Charles J.Sanders,Trustee 010W.", Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD _ Office Use Only r, D _Coastal Erosion Permit Application j Z Wetland Permit Application I _ DD Administrative Permit / MAY 2 3 2016 Amendment/Transfer/Extension ( V Received Application. 4(p t Received Fee:$2$®t60— S4°tthcid Tann Completed Application: 5,2-U. l Tr Incomplete: _SEQRA Classification: Type I Type II Unlisted Coordinatiow(date sent): �LWRP Consistency Assessment Form: 61'74 CAC Referral Sent: ;e`_ DateofInspection: -(a`��/� _Receipt of CAC Report: _Lead Agency Determination: Technical Review: Public Hearing Held: 67,7-7--j&_ Resolution: Name of Applicant: ,S "GtA Mailing Address: -pa jUt:, t k(^6 . toLD, N Y \\°1'11 Phone Number: Suffolk County Tax Map Number: 1000 - Property Location: \255 j!;qoaSE. C.V, L t-�N�� YFCL.D N`t' 119-1 ►-1►-. -�.�. 1255-�.�. '%y VA,\It.� -0 N.'sAYy W34 Hbu 5X-_ OVA t_&V--T (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) Address: �Qc� Phone: V �� Mrd of Trustees Applicatir� GENERAL DATA Land Area(in square feet): _I IS I Sq, . Area Zoning: M, g R- LAc> Previous use of property: &3�YG Intended use of property: der FAtA%% Covenants and Restrictions on property? Yes _ _No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? _ Yes No If"Yes",be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes k No If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes )�—No Does the structure(s) on property have a valid Certificate of Occupancy? _Yes No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? )!� No Yes If yes,provide explanation: Project Description(use attachments if necessary): Gv�1S- LT V..04 (2'l f z X VA I Yc\gb'h) 'StPe to r-o4. 5'Cb'�Pr�f COF ` kP k 'R _S 1E-�` ky- , wcx�p 'RY S4*-_f 014 1:0Lt— yard of Trustees Applicati( WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: -1�b!JJ�IG�� S-�LYjp�c11 -LUb�,S go Area of wetlands on lot: square feet Percent coverage of lot: !7, % -rtn� C-o\V%WA = Closest distance between nearest existing structure and upland edge of wetlands: 110 feet Closest distance between nearest proposed structure and upland edge of wetlands: y5 feet Does the project involve excavation or filling? No X Yes If yes,how much material will be excavated? 32 cubic yards How much material will be filled? 16 cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: ►D�'( Manner in which material will be removed or deposited: '6PvC.Y�1-}O� P�0�1b st1��_ 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): 61 Z20 Appendix B Short Environmental Assessment Form Instructions for Completing Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 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 l -Project and Sponsor Information Name of Action or Project: IAIL-kf'l1-k SP�ftl�� Project Location(describe,and attach a location map): m55 5 kc,05E G 1.AcC�� 5 o �ot.�� t•�`t \1�'l'[ ��� `1' Q Brief Description of Proposed Action: (o 6 oP-Npct- S'CDf�P oto► Lo1.1cgCE-J� V=F-OST v3AvL_J_ p."T, e, ,,,r , e-0L-- 1 MQ L-Acle 11� *gAf- Kkt�D of s\rcc «Y 'P-���p�w Name of Applicant or Sponsor: Telephone: 631 S'rW"*tA 1_k1L_&14 \fk E-Mail: SYllll��lK ��`C�l�l.•lN� . Address: SSS 4_P� t..lv�. 4t--1 City/PO: 7179%? e: Zip Code: i! 0e>U ROt—�1? 140 k 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: ��� ❑ la.Total acreage of the site of the proposed action? 0.1131 acres b.Total acreage to be physically disturbed? O 16 115 acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? 0AVA acres 4. Check all land uses that occur on,adjoining and near the proposed action. Urban ❑Rural (non-agriculture) ❑Industrial ❑Commergial U�Wesidential(suburban) ❑Forest ❑Agriculture ❑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? F] �vZ ❑ 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 ® ❑ 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: 1AAA, '�11 ® ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ��A SZDC—_ 'tel ❑ 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? ® ❑ 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 F-1 Forest ❑Agricultural/grasslands ❑Early mid-successional ❑ Wetland ❑Urban ELSuburban 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 TTI K 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? V&LNO E]YES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: KNO ❑YES Page 2 of 4 t i 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: F I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: — Date: �►(� Signature: –AW AM 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 I. Will the proposed action create a material conflict with an adopted land use plan or zoning ® 11regulations? 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 F-1affect 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 ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: El 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 ® 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. 1ZCheck 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 environmentalimpacts. Town of Southold-Board of Trustees ��,ii � Name o ead Agency Date Jbh N pi ,n�9M� President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signatt e f Respons blefficer in Lea Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 John M. Bredemeyer III�.resident �1o�oS1F0[x�o� ` r Town Hall Annex Michael J. Domino, Vice-President t�'a� ,} $��, 54375 Route 25 Glenn Goldsmith y m 1 P.O. Box 1179 A. Nicholas Krupski y ® o�� `` Southold, NY 11971 Charles J. Sandersh Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD --------------------------------------------------------------- In the Matter of the Application of STEPHEN MILGRIM COUNTY OF SUFFOLK STATE OF NEW YORK AFFIDAVIT OF POSTING TO BE COMPLETED AFTER POSTING REMAINS IN PLACE FOR AT LEAST SEVEN DAYS PRIOR TO THE PUBLIC HEARING DATE I, 164-1 EM!= q%1 N ,residing at/dba 125;S AAX�SS G4tdctL L.M•� being duly sworn, depose and say: That on the' 7 May of 3UN W , 206,, I personally posted the property known as 1259 L-ik ti So UTNAM.M. 1.1 Y \td-71 by placing the Board of Trustees official poster where it can easily be seen, and that I have checked to be sure the poster has remained in place for eight days prior to the date of the public hearing.Date of hearing noted thereon to be held Wednesday,June 22,2016. Dated: im f 1-Th(v (si ature) Sworn to before me this IN day of.TVW 201& 4W Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. O1 D1475593 Qualified in Suffolk County my Commission Expires April 30, 2019 t- s ® 1 ®e ® •® � 0 n o I ® A em D r ® 00 C, ru ruLnSOU �fOC0 Y Ill'! 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Sworn to before me this Day of 20 Notary Public PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK residing at I ZSS t oo SE LFl � 1�ty S oQCV} �k.D'V41 being duly sworn, deposes and says that on the 1 day of , 201 L, deponent mailed a true copy of the Notice set forth in the Board of Trustees Application, directed to each of the above named persons at the addresses set opposite there respective names; that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment roll of the Town of Southold; that said Notices were mailed at the United States Post Office at \1O\"I \ , that said Notices were mailed to each of said persons by CERTIFIED MAIL/RETURN RECEIPT. i Sworn to before me this /31 Day of �V , 20� i I Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. O1 D1475593 Qualified In Suffolk County ,0 My commission Expires April 30, 200 NUTILt: UF Ht:-ARING NOTICE IS HEREBY GIVEN that a Public Hearing will be held by the Southold Town Board of Trustees at the Town Hall, 53095 Main Road, Southold, New York, concerning this property. OWNER(S) OF RECORD: STEPHEN MILGRIM SUBJECT OF PUBLIC HEARING : For a wetland Permit to construct a 27.6'x24' wood timber frame barn on full frost wall and slab. Located: 1255 Goose Creek Lane, Southold. SCTM# 1000-78-8-9 TIME & DATE OF PUBLIC HEARING : Wednesday, June 22, 2016 — at or about 5 :30P. M . If you have an interest in this project, you are invited to view the Town file(s) which are available for inspection prior to the day of the hearing during normal business days between the hours of 8 a.m. and 4 p.m. BOARD OF TRUSTEES * TOWN OF SOUTHOLD * (631) 765-1892 J I rd of Trustees Applicatio,___ AFFIDAVIT Sy SActJ N� BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) 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. r!0_aiure"'o?P'r_operty Owner SWORN TO BEFORE ME THIS �2" DAY OF � � , 20r(P DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No, O1 D1475593 awWfl d In Suffolk County p otary Public My Commission Expires April 30, 20jo 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. YOUR NAME: (Last name,first name,middle 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 Y, — Ifyou 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 Submitte th* �� a of 20(1(0 Signat fe y PrintIla Form TS 1 3rd of Trustees Applicatii, AFFIDAVIT 5' T--P}1e41A BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS)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. 4'0�2 Ors-ignapkfe A Property Owner SWORN TO BEFORE ME THIS �3 DAY OF , 20A� Notary Public MARINA K®KK@N®S Notary Public o State of New YoFk No. 01 K06191941 (Qualified in Suffolk County My Commission Expires Aug.a5,2016 APPLICANUAGENUREPRESENTATIVE 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 Dossible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: PAj%_�l M �s"� �'� K (Last name,first name,griddle 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,rnarriage,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 V 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�fi Kea 2041. Signature Print Name K1 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 sigr4cant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3: If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# `18 - 0 8 011 _ PROJECT NAME MILGAf-1M JLk� 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 and extent of action: C€4.4,t7 1J IF6R S-o e'F qA'f--t) 'Tc�ok.S po--XO P � Location of action:_ 12.SS Gkoc$r= C �.-A�+ z S k-ItNW Ub, '-f XM\ Site acreage: O-IA51 Present land use: 511aht C-- Present zoning classification: C� 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: SfiG ►�V µ\L(,��,\� (b) Mailing address: 'PO 'Sbcq- (c) Telephone number:Area Code( ) 6'5N --"T 65 167-255 (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 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies' Page 2 for evaluation criteria. ❑Yes ❑ No ® Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ 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 El 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 ®Not 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 Apph -a-We 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 lel 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 19 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 LVVRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ YeF- 1 No® 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. ❑ Yes ❑ No ® 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 ❑ No® Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III—Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ No® Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No ® Not Applicable PREPARED BY !\ TITLE_AP?I—VA-t4f/ 14WG— DATE SZ-> I O wNew�