Loading...
HomeMy WebLinkAboutTR-8844A OF S0V& John M.Bredemeyer III,President �� Town Hall Annex Michael J.Domino,Vice-President �® l0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski • Telephone(631) 765-1892 Charles J.Sanders �OOUNT(, O Fax(631) 765-6641 � N� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFI"CATE OF COMPLIANCE # 1273C Date: September 22, 2016 THIS CERTIFIES that the reinforcement of footings to existing deck attached to dwelling; and to install an 86"x86"07"hot tub onto existingdeck; At 1890 Arshamomaque Avenue, Southold t, _ Suffolk County Tax Map#1000-66-2-46 Conforms to the application for a Trustees Permit heretofore filed in'this office Dated June 28, 2016 pursuant to which Trustees Administrative Permit#8844A Dated July 20, 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 reinforcement of footings to existing deck attached to dwelling; and to install an 86"x86"07"hot tub onto existing deck. The certificate is issued to THOMAS &BARBARA BALL owners of the aforesaid property. Authorized Signature Ejc'n APPROVE® BY BOARD OF I RUSTEES. 0 '6 ' PROVI 0 �21' '�D F 7 -TOWN A<x- --T, 'qF SC VOF SOUTHOLD b DATE -TILl 2-0 tl(vwfok N.IE am Co Pla '471 :IX 12 CCAep oST5 3c \v John M_ Bredemeyer III, President �0. Town Hall Annex Michael J_ Domino, Vice-President y�� y<'=, 54375 Route 25 Glenn Goldsmith = N z P.O. Box 1179 A. Nicholas Krupski Southold, NY 11971 Charles J. Sanders `•,�'�1 , ���?✓4 T elephone (63 1) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: P Ch_ 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction '/ constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: 0-z� toGa ; e CERTIFICATE OF COMPLIANCE: John M. Bredemeyer III, President opo coG'; Town Hall Annex Michael J- Domino, Vice-President :° yam'' 54375 Route 25 Glenn Goldsmith bio " ,� ,z P.O. Box 1179 A. Nicholas Krupski " � o�;, Southold, NY 11971 Charles J Sanders of �a; Telephone (631) 765-1892 Fax (631) ?ES-6541 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1St day of construction Y2 constructed Project complete, compliance inspection r �O�®F S®U�iy�® Town Hall Annex John M.Bredemeyer III,President � � Michael J.Domino,Vice-President 54375 Route 25 Glenn GoldsmithP.O. Box 1179 Southold,New York 11971 A.Nicholas Krupski ® app Telephone(631) 765-1892 Charles J.Sanders ��yC®UN11 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8844A Date of Receipt of Application: June 28, 2016 Applicant: Thomas & Barbara Ball SCTM#: 1000-66-2-46 Project Location: 1890 Arshamomaque Avenue, Southold Date of ResolutionlIssuance: July 20, 2016 Date of Expiration: July 20, 2018 Reviewed by: Charles J. Sanders, Trustee Project Description: To reinforce footings to existing deck attached to dwelling; and to install an 86"x86"x37' hot tub onto existing deck. 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 project plan prepared by Thomas Ball, received on June 28, 2016, and stamped approved on July 20, 2016. Special Conditions: None. Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. John M. Bredemeyer, III President Board of Trustees �ST� NG H ou5 rP PROVE® BY BQARD OF TRUSTEES , 13 7 29 TO SOUTHOLD jDATE Tftj 2-0 • / � 3� --' • ' r .,`'i,fi:ralr';�'Ir••t lr�t:.' : Mr�yl,.;:" '� l0 j I•' t�'f.�c.iftis_!�•��::..i,',,`�r1t::F{>:.'b't:, 1 r --_ �r .: t ie'�.'�if�l i �.!"i•�'i.�'Vj;��i�:) ry.': ;i#..L.11lf{•�i'7J1S�'j ' ', •i� •,•, rrrl'.f0.;st f:{a7t;�;`il��<i k�:'�F$�:l�:L �,�•�Fr! d•� �,_.,. , :.'y; � ..r .� �S}.;.1' .. �' Z'.,1 ra I' r s P to �w �•�}�''rn� r'f::�'•''' ,:,:I: : a•::r ,,` �,,. ;,;r• ;�'= E' t:'�IT �, r tir,'n1,,.:: „�� ..pT..'.)• ..r. ,• ��.�• :r;•, ,• •'ry r;• .'�.,:�4• !dy E.� 'Y,lr�' �iAr�'t C"` .f••�•��' '49 q t{..',r_[� �, yr+9'rq, {�' ^r J��?:Y:'n ,;���'' �.,' ':' 'r! ',�•!, t �..i�r,,.:l. , •,,��r: r':r'�' :Id'rH'i ��+Y/:.�:: •,•" ` :�'f��`�.. C�My+:Q�l+li� �IY��Y�H �A:�'.�'•;r},FIR Aac^ ,.}•', ... :(,'I •' t:�t,•if'. .'�irL:'',' ..r ,,'r'.. v'. -'� i•1R 4• e�(;.ahi��AP •�i � 6`S'R+'R'E'..t•:��q• '•r� 'r'!� -.'� � .'u , iy' ..'S t(I',�iP;�r.'; , :n C C Y 7-11 ax 12- • c5� Y, �/,� ., rte!' �y`'< <O T1 L �o CCA ?0ZTS L11 �t John M. Bredemeyer III, President6�05� FF UCq Co { Town Hall Annex Michael J. Domino, Vice-President ���o 2;k 54375 Route 25 Glenn Goldsmith o ` P.O. Box 1179 A. Nicholas Krupski o ^r Southold, NY 11971 Charles J. Sanders 4, m o� Telephone (631) 765-1892 dal Fax (631) 765-6641 `�ztYz'z7• '.. BOARD OF TOWN TRUSTEES TOWN OF-,SOUTHOLD Date/Time: �'��� o `�SP�'I Completed in field by: p THOMAS & BARBARA BALL request.an Administrative Permit to reinforce footings to existing deck attached to dwelling; and to install an 86"x86"x37" hot tub onto existing deck. Located: 1890 Arshamomaque Avenue, Southold. SCTM# 1000-66-2-46 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q 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 i Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: 141 Present were: J. demeyer M. Domino G. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 John M. Bredemeyer III, President �OofFOi4ell- Town Hall Annex Michael J. Domino, Vice-President ��o Gym, 54375 Route 25 Glenn Goldsmith o '` P.O. Box 1179 A Nicholas Krupski o Z Southold, NY 11971 Charles J. Sanders 4-, ® o�� Telephone'(631) 765-1892 Fax (631) 765-6641 -T271= BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: THOMAS & BARBARA BALL request an Administrative Permit to reinforce footings to existing,deck attached to dwelling; and to install an 86"x86"x37" hot tub onto existing deck. Located: 1890 Arshamomaque Avenue, Southold. SCTM# 1000-66-2-46 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. :525% Expansion/Calculation Work Session Notes Application Complete SEQRA Classification Confirmed Coordinated Review Y/N Pos/Neg Declaration -CAC: ,LWRP: Additional information on comments/to be discussed/Public Hearing: Date: Completed By: Present: J.-Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders E. Cantrell D. Di Salvo Other Page 2 of 2 11 J-VIOPOk-F 1VYCv HOT TL/103 -ON 1—=Y, IS 7-1 N DEC/< o JUN 2 8 2016 L Southold Town Trustee 12" Block (ode-I 2RC Height 7 5/8' Width 115 D0,/6/-/F .2 ,<G 1/8 Lenght 15 5/8" Weight 28.1 lbs _j 72 in a cube ill L. G-R A D� 3 RX Ik APPROVED BY 900D POL"646 2- x 10 '7- /C (:�C OF IRUSTEES bFOUTNOtD FES% let Rs' 0 6'5'j q f-,4. L cj� 0, S-C a 70 X F�c) 4 r rr a mvm4�jle toe .-j Q v OU-- - .rs HIPPODROME DR. n `' E � V E II 1' JUN 2 8 2016 LOT 3 cp f ) (UWELLIN0 ) 1? 'r 1 Southold Town ( N.600201g011E_ P LE-3 1 41 .831 f„, jLa ( DWELLING ) �( PUBLIC WATER) 14.8 15' WIDE ASPH. PAVT. I SURVEY OF EASEMENT L 0 T 4 /Z, U) A (1) MAP OF BEIXEDON ESTATES S BLOCK 7 co I I o FILED MAR. 16 , 1946 FILE NO. 1472 LOT 4O AT A R SHAMOMAQUE TOWN OF SOUTHOLD CV I I T.H LOT 5 I I I 0 'j7 SUFFOLK COUNTY , N .Y . 140 IN- I I I — p 1000 - 66 02 - 46 (DWELL(NG) N Q SCALE I" = 30 ' MAR 3 , 1987 �) I Ire/ 13.0 ( DWELLING ) FEB. 5, 1988(FINAL-) 13.s 13.2 _ SEPT. 26 ,1989 ( BULKHEAD) ' I I U) I - I-,�! ��;;•vs, ` O� CERTIFIED TO AMERICAN TITLE INSURANCE CO. LONG ISLAND MORTGAGE CORP. THOMAS BALL v.)iY 24.5 p BARBARA BALL STOR I MA1,4L HOUSE jAt & S.8 GARAGE -- `F 22.7' 3 Il 1 a.a' ri O O TEST HOLE N tri b ' I ��C - 1 kri tl 0 M - Q/atvn 113.8 o b ref I I 10.. .r110 Grey,ih N I If U 1, �td brown z I i w�,t� 99.9 /an.� I �j STOCKADE I 1 �� " cy) Pale FEN CE i%f i /Op f I 0 r 0) co care / I W00D BULKHEAD I cV so/701 ,1 I I vi TIE LIFE ALONG H.W. M. 1 I2q' 11.W.M. -- 99.83' II.W M. 9/28/89 S 59° 04' 51" W) �ale b r'o 1vr? Coa/'s N +1 +1 aana IT 0` t� co in 0) TOWN -HARBOR (r' i SHORELINE AS PFR FILET) MAP AREA p 21 , 071 SQ . FT. o`�" , ! Fc �,,� 1 u to tfe line ° ��� j �.�0 4986'j !Z' Y. S. LIC . NO . 19668 FLOOD Z0NE C ' 14' int ---- - --- -� �- ,RECONIC YOR S 81 ENGINEERS, P.C . /( 516 )• 76 5 - 5020 ELEVATIONS ARE REFERENCED R46V/.5,oq 7- S' �` 7 / P. 0 . BOX 909 TO U. S. G S. Found. 10c 6- /v-87 MAIN ROAD �1e1e-7 S-OUT1-IO LD , N,Y. 11971 BEV/mss r o�� FORM NO. 4 - TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-26014 Date: 10/09/98 THIS CERTIFIES that the building ADDITION Location_ of Property:-- 1890 ARSHAMOMAOUE AVE SOUTHOLD _ (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 66 Block 2 Lot 46 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated AUGUST 13, 1996 pursuant to which Building Permit No. 23708-Z dated SEPTEMBER 30, 1996 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is DECK ADDITION TO EXISTING ONE FAMILY DWELLING AS APPLIED FOR & AS PER ZBA #4415 The certificate is issued to THOMAS J & BARBARA BALL (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. N/A PLUMBERS CERTIFICATION DATED N/A a- ,— Building Insp ctor Rev. 1/81 Hot tub Project - Thomas & Barbara Ball 1890 Arshamomaque Ave. Southold -- View from South Err View from North 45w ken 2--11 2-01 fie: 3 z PM +h View from West , . • View from East1 i 2--112-0 16 Drainage for Hot tub Dry well located ° u =% a 12 feet off , V � PI \ NE corner of house and 116 ft. from the bay zA.. l Mr 4 foot drywell ' has a capacity 1 :t -pho+o maker) of 375 gallons2-0 - •i--'� •_��...�..'�APiT��' lam. 1 •�'.. �.. _ M' - .. -:I;_ �.t71 gEns iNo iZ _ s. !V t PROPERTYMAP t _ {'�T `gfi1 } w ux[ SEE SEC NO - xxnxex" MATCN •- ccc sE4 xo ase yPmg.. _—_ 7 ---_ --__— z —_—_OPIE r xxv xez G8� .�• FOR PCL NO SEE SEC NO J �ryh m 5A ^'e 0560SWt3 P m � y N a r N ym�,,+)p 41A(c) S3a�y�s61 6 v.s ,' 2715 2A(0) a66 (a) �'' yyc 6z•? n Nnnn.�z eL^ O Q� / a ; m .n° a ps qty 1! fi s r �a5fi NY ' Zl � w M1 b n 'rye 5• mid' c„ 1 eA(al '2A(.) °M1�9 0'e,9'•6.a a$ `` 4 g e`` �` "\ 4 I � n F gPd ;� ♦° �W pe d` Zoe o.n. o r F, -sem �. 'S R'P J' •'�p��gA t�.m �$ � y � a5 at S 9 a my � kms a u N O A� a62� - - f NOTICE +m@COUNTY OF SUFFOLK © K owx or SOOTHOLO SECTION NO E E ------ x — -- — •-- Real Property Tax Service Agency v N - --• w —_— — — -- -- °"' q�JJ coemr unmr a..meaa.Nv 11so1 v �uuz or ss ..�vasnle1m1z1n w:m. ssiraua„n wr M m ° �byz�i>P p ran xo too° PROPERTY MAP .��.,-:-fir. _c--�.-..-.-�.-�__ "-`•.-:,..._.--r __ _ ._ ___ .... -s.c_e,+-_..a-s,.. -- ..-._.>.-_...:.._e - .. __`.az_ -- r e i 1 OFFICE LOCATION: S®(/jyOl MAILING ADDRESS: Town Hall Annex ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) cn Southold, NY 11971 • aQ Telephone: 631 765-1938 ®lyC®U ,� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOL•D MEMORANDUM To: John Bredemeyer, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: July 18, 2016 Re: LWRP Coastal Consistency Review THOMAS & BARBARA BALL SCTM# 1000-66-2-46 THOMAS & BARBARA BALL request an Administrative Permit to reinforce footings to existing deck attached to dwelling; and to install an 86"x86"x37" hot tub onto existing deck. Located: 1890 Arshamomaque Avenue, Southold. SCTM# 1000-66-2-46 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 actionis EXEMPT from LWRP review pursuant to: § 268-3. Definitions. MINOR ACTIONS items "CC and which states: CC. Structures less than'250 square feet in size that are accessory to existing permitted primary structures, and which accessory structures are greater than 50 feet from a boundary of a natural protective feature and freshwater or tidal wetlands; Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. i �f John M. Bredemeyer III, President ®��®F S®(/TyQ� Town Hall Annex Michael J.Domino,Vice-President ~ O 54375 Route 25 P.O.Box 1179 Glenn Goldsmith CA Southold, New York 11971 A. Nicholas Krupski ® �O Telephone(631) 765-1892 Charles J. Sanders ®:?" 110 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Applicatio _Wetland Permit Application V Administrative Permit _Amendment/Transfer/Extension Received Application: (O Received Fee:$ I00t o o Completed Application 7,57s/U _Incomplete I i� _SEQRA Classification: JUN 8 2016 Type I Type II Unlisted Coordination:(date sent) QQ ? LWRP Consistency Assessment Form 71 a'�� Southold Town L.-- E1rF rd of TnisteEs J CAC Referral Sent: - — V?71]Date of Inspection: _Receipt of CAC Report: _Lead Agency Determination: Technical Review: Public Hearing Held: 7'2011 Resolution: Name of Property Owner(s) Th e)mn S j Bar-ba ca J PU l Address I 9DhQmow1nu (le . _PD _6pX 1 -10<? GDLk 'ho 0 Phone Number: �)3 I Suffolk County Tax Map Number: 1000 - — o Z — V40 I Property Location: 1 `890 ASha O q, 7T� � pole 4 1 `t L4er5e4bn j 14,'p podro m e �C- (provide LILCO Pole#, distance to cross streets, and location) 3 Q . AGENT: (If applicable) Address: Phone: Applicant: Thomas Ball 1890 Arshamomaque Avenue, Southold, NY 11971 PROJECT DESCRIPTION FOR HOT TUB TO BE INSTALLED ON EXISTING DECK The hot tub will be placed 5 feet from the bayward side of the deck or 50 feet from the bulkhead. The 86"x 86"x 37" hot tub holds approximately 375 gallons,weighs 705 lbs. dry and 3700 lbs. wet. (see attached sheet). The deck is going to be reinforced with new footings and support structure as per attached diagram.The existing deck is 41 inches above grade. Drainage for the hot tub will be provided by a 4ft. drywell that is located 116 ft. landward from the Southold Bay and is 12 ft. off the northeast corner of the house. The drywell is capable of holding 375 gallons. The hot tub has an ozonator which will help reduce the amount of chlorine required in the water. Pictures enclosed show: View of project facing South View of project facing North Sideview of project showing elevation of deck(West) Location of 4 foot drywell (12 ft.from NE corner of home) 3oard of Trustees Applica in GENERAL DATA Land Area(in square feet): ao,re l���►'OK d Z d DOO gq '' II O Area Zoning: T D Previous use of property: Ros' Oen-`a Intended use of property: kosiden�a Covenants and Restrictions on property? Yes L,�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 ✓ No If"Yes", please provide copy of decision. Will this project require ny 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? Zyes No Prior permits/approvals for site improvements: Agenc —dou c d _ Clo� FA. 4� iJJi n aj 66u+14-01d -To-tbyi De_c� addl�ko V) AI?b 'BOdrd 0--� &Ppealr- - 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): C1Yl '36 X S& x 3 7 z n e_c is- , n q de,c.k 3oard of Trustees Applical n WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: W UI'7�� ere Area of wetlands on lot: square feetu b( ,heal Percent coverage of lot: % D-�- b �g6��x8(o���c 3>�� LU o �- Iqc ►� ���'n C' �C Closest distance between nearest existing structure and upland `� SIS edge of wetlands: feet A5 �r � d�ApP e nClo ' P-a4 Closest distance between nearest proposed structure and upland edge of wetlands: E O feet Does the project involve excavation or filling? V/ No Yes If yes,how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): A�1 t� 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part I -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part l based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Pro'ect: - o7�" b i k95� 141-i'©r 6 h e>c1:5Ar_�_ _ deck _ Project Location(describe,and attach a location map): /`d la Ar5hgmom c use. 4VV-e So ,(4)or� Brief Description of Proposed Action: JCi57y0 L�e� w� 1 l �-P- re5G e P-4 �r 5 �� 8 6 )e� g 6 //X 3 7'� Name of Applicant or Sponsor: / L Telephone: �1 �h0!/YIQS 'Pa J Jc$Nrk�1rQJ 8QI(> 'E-Wil:46A b P6_ nIi0eeh Address: 1Sg0 AVIShayy,ovy, G _ue __ ,4v� , v t�o� l76 City/PO: State: Zip Code: 01,41 o I d I Irl / I T-/I 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 F] 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: OoLA4)o Id Tou-)Y-) t l 1 Y-) , 3.a.Total acreage of the site of the proposed action? acres +Lc b w I J b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. - ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑CommercialResidential(suburban) ❑Forest ❑Agriculture ❑Aquatic []Other(specify):: ` ❑Parkland Page 1 of 4 \ 1 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: M ❑ 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: M 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?�[ n NO YES If No,describe meth9d for roviding Vy�astewater treatment: / �� GCJe �` �°ZgC'.U:><'Tl L'4 ct 7lQ a�. �ee i5fr' 4 well 6ac IZ o �, ❑ 12. a.ffoeLs the site contain a structure that is listed on eith&t'he'gtiate or National Register of Historic NO YES Places? FVr ❑ 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 ❑Forest ❑Agri cultural/grasslands El Early mid-successional ❑ Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed JNO YES by the State or Federal government as threatened or endangered? El16.Is the project site located in the 100 year flood plain? YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, F]a.Will storm water discharges flow to adjacent properties? ❑NO [—]YES 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: -_ _.____ _ ❑ I9.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 " I f Applicant/sponsorn e: l N1Odl?QS� _ I _. �0. ElY'�J__ �I Date: Signature: _ Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the,following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" -- - --- - -- -- - -- - --- - - --- - -- No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a inater"ial conflict with an adopted land use plan or zoning ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ 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? - --- -- --- - - -- - ---- -- -- - 7. Will the proposed action impact existing: (3 a.public/private water supplies? u b.public/private wastewater treatment utilities? E ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, architectural or aesthetic resources? �J 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 F]problems? 11. Will the proposed action create a hazard to environmental resources or human health? El 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 en ironmental impact statement is required. [:] eck 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 environmenta imp /tss.. Town of Southold-Board of Trustees " Name of LAgenc Date U /A *; President Print or Type Na of Responsib i er iq gead Agency Title of Responsible Officer Signatur esponsib icer in Lead Ag cy Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 ,oard of Trustees Applicat',, ,i AFFIDAVIT S rAL PQ►-UArZL J Bek L 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. Sigfiature of Property Owner SWORN TO BEFORE ME THIS o DAY OF U , 20� h Notary Public CONNIE D. BUNCH Notary Public,State of New York No.01 BU6185050 Qualified in Suffolk County Commission Expires April 14,i—Q 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. / f�� YOURNAME: �hoM a-s J & !I �i�T rr barq �J 84 6// (Last name,first name,xpiddle 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 02 VdAay of I�It� 0& Signature Print Name TYIDwW5 j 5a L r6,t at! Form TS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS I. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# /000 - (60 PROJECT NAME The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. X1 Board of Trustees 1A I 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 acti n: �:Vn_51-a 11 g 6 iii S (� �rx 3-1 -/Li 0 ( 11 Location of action: !p 7 TIy �7�'1 G 1�Y18►/1'1 Q�, uej/';� X70[,tP� Site acreage: Present land use: Ae 5%CI eyl-A4 Present zoning classification: /�- 7 O 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: f- (a) Name of applicant: -7-ho Y!4 /S �1 B4 11c4- �G{�DC7�"l� J JJ (b) Mailing address: -70 13OX l-/n 9 (c) Telephone number: Area Code( ) J!- 76 5 7'3 5 (d) Application number,if any: Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No 9 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 X 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 1:1No VN Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section HI —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 IH—Policies; Pages 22 through 32 for evaluation criteria. ❑ ❑ NA Yes No Not A%icable 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 x 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 Y 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. nn ❑ YesF] No V Not Applicable Attach additional sheets if necessary WORKING COAST POLICIr.a 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 9 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 P 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 X Not Applicable PREPARED BY /3Z/( TITLE 0 w n e DATE arbQra a t 1