Loading...
HomeMy WebLinkAboutTR-8857A John M.Bredemeyer III,President ��zf SO(/jgO Town Hall Annex Michael J.Domino,Vice-President h0 l® 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski Q Telephone(631) 765-1892 Charles J.SandersO Fax(631) 765-6641 OOUNT`1,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1291C Date: November 29, 2016 THIS CERTIFIES that the installation of 4' high fencing running along both side yard lot lines ending at the seaward edge of the lawn at the top of the embankment; At 505 Midway Road, Southold Suffolk County Tax Map#1000-90-2-29 Conforms to.the application for a Trustees Permit heretofore filed in this office Dated August 2, 2016 pursuant to which Trustees Administrative Permit#8857A Dated August 17, 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 installation of 4' high fencing running along both side yard lot lines ending at the seaward edge of the lawn at the top of the embankment. The certificate is issued to JESSE CLEMMENS owner of the aforesaid property. Authorized Signature T 1 1 ` I John M.Bredemeyer III,President ��QF S�UryO Town Hall Annex IN Michael J.Domino,Vice-President Az l0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 CIO A.Nicholas Krupski �� Telephone(631) 765-1892 Charles J.SandersFax(631) 765-6641 lyCOUNTY,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: d 2,� G VIZ Ch. 275 Ch. 111 INSPECTION SCHEDULE i Pre-construction, hay bale line/silt boom/silt curtain 1 st day of construction % constructed Project complete, compliance.inspection. INSPECTED BY: COMMENTS: 19 2 t CERTIFICATE OF COMPLIANCE: John M. Bredemeyer 111, President =opo cow',; Town Hall Annex Michael J Domino, Vice-President S L z�' 54375 Route 25 Glenn Goldsmith o 7" ;,� , P_O_ Box 1179 A. Nicholas Krupski Southold, NY 11971 Charles J. Sanders Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1St day of construction 1/2 constructed 7 Project complete, compliance inspection �pF sotlj John M.Bredemeyer III, President O� 1�l Town Hall Annex Michael J. Domino,Vice-President ® 54375 Route 25 d [ P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A. Nicholas Krupski ® a� Telephone(631) 765-1892 Charles J. Sanders ��`�C®UNT`IFax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8857A Date of Receipt of Application: August 2, 2016 Applicant: Jesse Clemmens SCTM#: 1000-90-2-29 Project Location: 505 Midway Road, Southold Date of Resolution/Issuance: August 17, 2016 Date of Expiration: August 17, 2018 Reviewed by: Charles J. Sanders, Trustee Project Description: To install 4' high fencing running along both side yard lot lines ending at the seaward edge of the lawn at the top of the embankment. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold -T-own Code. The issuance of an Administrative Permit allows for the operations as indicated on the project plan prepared by Jesse Clemmens, received on August 2, 2016, and stamped approved ,on August 17, 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 J - S.C.T.M. NO. DISTRICT: 1000 SECTION: 90 BLOCK: 2 LOT(S):29 ! ' -'Sl T7tc r r Aebo� NF � rrrr . �,2Q,, 9� A '/4 OjiIAr� rr ,� � ?' 1lY�, r r r EEL EDGE 0 LA K WN A r r r LOT 145 OF BAN .- 7 EL 7.6 2' 2ND 6R. TiMeFR r r r r S• OVERHANGS wACC 13�' _- \F-L 7.8 s r �FUH�4F EL 4.7 •11 r - -- -.? = -- .FC 5 4 ,,DC7 ¢f==:: DWFC RM. ::._=::.:_:_=_ &0: 0 ti FWjCFC/�yC :. - -:- N,OO ` EL 5.1 EL 4.6 14 4. Cb EL 9.6 EL 7.6 �� PCO LOT 144 H eh O �2g• �� ZONE AE(EL 6) d' 0 � EL 8.9 � � ~ ~ 4/0� - �§j EL 6.0 \ CQ lilo Ar' LAI LAI 71 a-0UlVDM �j O ZONE X - Is�. MON. - — 3� N70043 50 W 148.46 D/R71STONF TIMBER CURB TIMBER � CURB MON./P-,, MI \ DWAY (33') ROAD � � THE WATER SUPPLY, W UL .� RYWELLS AND CESSPOCL LOCA7101VS SHOWN ARE FROM FXqp 09SERVA71ONS — FIRM PANEL #36103CO169H AND OR DATA OBTAINED FROM 07HEr _ ,, —r -- MON. AREA: 12,803.24 S.F. OR 0.29 ACRES ELEVA170N DATUM: __NAVDSB------------- UNAUTHORIZED ALTERATION OR ADDInON TO THIS SURVEY IS A WOLA101V OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY j LOT D I LOT C MAP NOT BEARING THE LAND SURVEYOR'S EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN ONLY TO 174E PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE 777LE COMPANY, GOVERNMENTAL AGENCY AND LENDING INS777TJ710M J LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE. 7HE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE S7RUC7URES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE j� NOT INTENDED TO MONUMENT 7HE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES, ADDITIONAL STRUCTURES OR AND 07HER IMPROVEMENTS EASEMENTS i AND/OR SUBSURFACE SMUC/URES RECORDED OR UNRECORDED ARE NOT GUARAN7E£D UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE 77ME OF SURVEY { SURVEY OF: PART OF LOT 144 CERTIFIED To: JESSE PAUL CLEMMENS; MAP OF: CEDAR BEACH PARK JENNY MARIE BAKER; 1FAUG — 2 2016 FILED: DECEMBER 20, 1927 AS #90 FIDELITY NATIONAL TITLE INSURANCE CO., SITUATED AT: BAYVIEW I HOMEBRIDGE FINANCIAL SERVICES, INC.; t I , 4) outhold own TOWN OF: SOUTHOLD KENNETH M. WOYCHUK L.S. SUFFOLK COUNTY, NEW YORK Land Surveying and Design �9 j P.O. BOX 3 MATTITUCK, N.Y. 11952 IPHONE (831) 298-1588 FAX (831) 298-1588 FILE y 16-39 SCALE: 1 20'DATE APRIL 8, 2016 N. Y. 5, UC N0. 50227 maintaining the records of Robed J. Hennessy S5 - �t9 S.C.T.M.NR OmmCT.)0D0 SECTION:90 BLOCK 2 LOTca 29 rs¢Be2 i/yf r ,,••, r r r . � r .-Q,2pa—• .-•� .� r r .� r .— •�� .– polAt LOT 145 EL 7.62.2 fdtl g�yypp •- �3' ,� OVERRAN • �C �. r 1 7.8 De EL 4 j3B r js. • . EL&I EL 4.6 \ EL 9.6 ® E C E L .V L d �� EL 7. P/0 LOT 144 d� C 42�• ZONE AM 6) W L'i O //��Qp pp��++ EL B3 � M �•4 1i1Y17 �o�� EL BA��Rqy n D,qQ hR. y 2ONE X Southold Town it! SS MON o�r��i T�uste.s r N70e43'50"W loom CURB 148.46 Mon\L SNF narBrR CURB I MIDWAY (33') ROAD BE wAYM-%W tr, WMLk-MM .tS•AND CES-WOOL LOCARGVS SHOW ARE fRWf OB.SRVANONS FIRM PANEL #36103CO169H AND OR DATA O TAMM fRW!O _ _ _ T ._ -- ! — — u, AREA: T12,803.2424 S.F. OR 0.29 ACRES V-'%%RM VA Aft NAVD88 arm M.NRAnae AmIfOJ m nes sr r 6 A NDtInW OF 1EMW MW O 3W O&W IM SrAn;EMMO V IAK CW"W DO SM%tr LOT 0 I LOT C- I �,�rI ,wLL Hvrsm�ArAI�,AW� AZWW MM , : APPROVED BY warm nW RraLry faa rxev tAs sa�-r 6 R&PARLD off A15 NNW m-nrr W VAW Ny' VVAL AOTNDr AND NSDmA�V !!STPD IPZIIEpIi,MiD m nF A540VE>':S Dr ndT fFJMditD IXSNAInNI Rit2WiJ�5 ARf NOr IRANSfBPA�E nE RrglS Qt rraxrvs 9fD1N leFEW/nOU nla R90RR7Y 1avlS m nIE SiRrCnNa AN RYl A SPEbFC fvRIO.�AND eg TNLAfiq�IXtr ARF •,i,•:•- -- -� -�N - NOT NkIOED m 1RNW1llir Be A70PFR7r 1faES DA m OAeF BR OEC170pI�/DAgS ADpnp/AL SIRyCRQPLS OR MID OA(FR DDRON'A(�HlS EA�IIIJS ����((((qq)�ee (/.�)�. •• . t -, , Al vAw S sswAw SDdtN uns A'EmD W tl1e7ELmw AR£Nor OIARMNDa maw Rnseatr awwr OY THS RR1r Ar nN m w w SMNEY y eilr/ D_0 V t!- Titj T S' wmlr an PART OF LOT 144 CERTIFIED TO.JESSE PAUL CLEMMENS• _ uAn on CEDAR BEACH PARK JENNY MARIE. AKER Atme DECEMBER 20, 1927 AS #90 FIDELITY NATIONAL TI INSURANCE CO. :TOWN ©� �� D SRUAM A$BAYWEW - VI r - - , wm of SOUTHOLD RRNNBi)I Ir.ROYCNOI[ L.S. DATE svFEolx COUNTY.NEW YORK P.O.Box S man"=my. 1 /iob2 Fm i 16-39 sere:1=2O'oAm-APRiL 8. 2016 ron(m)m-leer on on)eoe-iae+ . acsuerasas r.rrrr.eo...�v.reroer= r I Town Hall Annex John M. Bredemeyer III, President SISFFD1,� Michael J. Domino, Vice-President- 4� ho� o°��� 54375 Route 25 Glenn Goldsmith . o ' P.O Box 1179 A. Nicholas Krupski o Southold, NY 11971 Charles J. Sanders 4,,jo'� Telephone (631) 765-1892 o� 01 Fax(631) 765-6641 xazaztr BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: i5 �, `yS�ri�✓1 Completed in field by: 0,A ej JESSE CLE MMENS requests an Administrative Permit to install 4' high fencing running,'alongboth side yard lot lines ending at the seaward edge of the lawn at the top of the embankment. Located: 505 Midway Road, Southold. SCTM# 1000-90-2-29 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=� 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: 10.0 feet 2. 'b riveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of H ring Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-SubmissionAdministrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/NWetland Line by: C.E.H:A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: I Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders Other 'Page 1 of 2 John M Bredemeyer III, Presiders �,OgUffat Town Hall Annex- Michael J. Domino, Vice-President a°�' �Gy� 54375 Route 25 Glenn Goldsmiths = ' P.O. Box 1179" A. Nicholas Krupskio Southold, NY 11971 Charles J Sanders �'tlj o� Telephone (631) 765-1892 �ti oaf` Fax (631) 765-6641 -Q71:YL1� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: JESSE CLEMMENS requests an Administrative Permit-to install 4' high fencing running along both side yard lot lines ending at the seaward edge of the lawn at the top of the embankment. Located: 505 Midway Road, Southold. SCTM# 1000-90-2-29 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 A A JA i ~ t ti :ti y i. '�•—���~ •qty t VIA d # j � 1 g.7 T YS � - „a 511; _ P 'nix o s� ,t _-� ~.:gam? - �•r _�,+`• W r v� / .,� S ,R t sA(cl , $ Opc1 Is l2 °w 9 �. p �a is TOWN OF souTNOLD M 83 -rof. O •.20 T 13 16 A 2 tm 23A(U Q7 O 6 sArmwra+ a A CEO AR isut �„� al PQ/� LPKESIOE •° nn ? p a n4, ________________ 6 12Me � / 6 nl / TONM OF _ 51 \ a O n CED d , �.ze OLDD 13 \ O� I IA R 3 :as AR POINT ..,T r TOWN OF SOUTN +3OLD n�q ) 20A(C) a ,n r to m lay wm W \r 1141, n 11 1 yl wEsr ' za - ID? ` a s n _ 23 0 LAKE O ' nw - 1 AR a 16 °° 191 19A(c N U v +5 ) _ a ,t w a t4 nal s 18 R 9 i�� TOMOF A \�� d' t - --- � � n.A am \f+l�� s m x SOUTNOLO mn ' 19 nm ' -`1 a 131 OR. E - a ---i 15 - 20 2122 '1'No 16 17 18 19 25 19 20 m SDR a wo - 1ZA(c) E W) - 21 22 22 2a r z u 5 6 2 3 n v & 1 1A(cy n w N nm nm, nui n� wn HOG I no NECK BAY � w - 7 LI ..,. ,.. - -- o...,... --�-- ^..,ate.. --•-- NOTICE '�ODU COUNTY OF SUFFOLK © K Om °� ° _ SOIRXOLD SECTION NO s° Real Property Tax Service Agency r 09S1N„°E°F 090 taunt .t R�rer6eal NY 11801 M 030 > ^^ AP 7-77- -s+.-.--we _ - — 'r• � Y M p mics NO 1000 PROPERTY M OFFICE LOCATION: ®� ®f ® MAILING ADDRESS: Town Hall Annex ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs,Ave.) Southold, NY 11971 a Telephone: 631 765-1938 c®U�TY,� LOCAL WATERFRONT REVITALIZATION PROGRAM - TOWN OF SOUTHOLD MEMORANDUM To: John Bredemeyer, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: August 9, 2016 Re: Local Waterfront Revitalization Program Coastal Consistency Review for JESSE CLEMMENS SCTM# 1000-90-2-29 JESSE CLEMMENS requests an Administrative Permit to install 4' high fencing running along both side yard lot lines ending at the seaward edge of the lawn at the top of the embankment. Located: 505 Midway Road, Southold. SCTM# 1000-90-2-29 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 furthers the policy to the extent practicable and therefore is CONSISTENT with the LWRP policies. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. <zxzJ- - p Sou k" John M.Bredemeyer III,President ' ''". Town Hall Annex Michael J.Domino,Vice-President 54375 Main Road P.O.Box 1179 James F.King,Trustee COO? [ Southold,New York 11971-0959 Dave Bergen,Trustee +�, �Y Charles J.Sanders,Trustee t',�r .M Telephone -6641 �'ou Fax(6311)) 65-1892 7 765-6 a BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only ` _Coastal Erosion Permit Application Wetland Permit Application DR�______ Administrative Permit / Amendment/Transfer/Extension 2 �o�� t Received Application: �oZ�I�i AUG Received Fee:$ 1 001, M Completed Application: �. outho4d Tovun _Incomplete: _SEQRA Classification: Type I Type II Unlisted - __/Coordination:(date sent): g� `r/ _LWRP Consistency Assessment Form: Co CAC Referral Sent: Date of Inspection: _Receipt of CAC Report: _Lead Agency Determination: Technical Review: Public Hearing Held: t 171 Resolution: � 6 Name of Applicant: e_3 5 C �- Mailing Address: Z�, P S &v, 6 r 6 a k/y fJ Al r i 1 Z 13- phone Number: g t q 3 d q 00 Suffolk County Tax Map Number: 1000- X, 8/0c'k 0 Z_ 401 C?zgi Property Location: 5®'S /42��c� A/' Rujcl/Ab l A N N 7( (provide LILCO Pole#, distance to cross streets, and location) AGENT: k✓IP- (If applicable) Address: 805 M1d VAY Opt , 'S'6vj- oil /j) y 1197 1 Phone: Et I L4 — Y8 " F Board of Trustees Appliaa >n GENERAL DATA Land Area(in square feet): -3 Area Zoning &s—se(R x-AA Previous use of property: (mot-e N i S Intended use of property: ( Q-K, /-k 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 yC 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 re uire 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?___X__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): C G (J t i �l �Nc� on s�,o-��, 1 d Q.,t p r�pa l� /'y�y�y e CA.to-rJ o-,4, GF kora 1 e,,J j `� ►--J&\. 'ftr pe nti to U la,e o-t QNX ®c l vJ bof f i ajV Q&k611-A/11 "R/4 (S,C Ajfk(, ,d f(A-N Board of Trustees Applica is WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: "" square feet Percent coverage of lot: < % Closest distance between nearest existing structure and upland edge of wetlands: Lq 0 feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No Yes If yes,how much material will be excavated? cubic yards How much material will be filled? 'P A cubic yards Depth of which material will be removed or deposited: N/A feet Proposed slope throughout the area of operations: A014 Manner in which material will be removed or deposited: /U/A 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): 9v0 � � 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1-Project and Sponsor Information Name of Action or Project: aS fv ,(W�, �wAkol� Y 11 7) Project Location(describe,ancittach a location map): 01 Brief Description of Proposed Action: 1 Gape,YUc�,orf � -C q 1 l o„l1 fel\L4 01\ ham env rjF Name of Applicant or Sponsor: Telephone: q t Ll 3 q L( 7q J Q5ts rACA E-Mail: jpS1e C(���'° EV Address: n 1 1J M &V vAVJL- k P'\A City/P0: L_ State: Zip Code: b��a '< piY I I i z 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: 3.a.Total acreage of the site df the proposed action? acres b.Total acreage to be physically disturbed? _�_acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) [:]Industrial ❑Commercial [Residential(suburban) ❑Forest ❑Agriculture El Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? [I IN ❑ b.Consistent with the adopted comprehensive plan? El ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ El 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? © Elc.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 requiremenntts,Aescribe 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: __.�fl ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: (ice El 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? ❑ El b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional ❑ Wetland ❑Urban (Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? � ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES 1f Yes, ❑ a.Will storm water discharges flow to adjacent properties? ❑NO YES b.Will storm water discharges be directed to established conveyance systemsoff and storm drains)? In 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: e 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: Al D 1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE e I� Applicant/sponsor e: �$� �l Date: Signature: Part 2-1'mpact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the,following questionsin Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑ ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? 3. Will the proposed action impair the character or quality of the existing community? E 4. Will the proposed action have an impact on the environmental characteristics that caused the El 1:1establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or Elaffect 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: ❑ ❑ 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, ❑ Elwaterbodies,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? ❑ F 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. L—I 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. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Board of Trustees Application AFFIDAVIT j' - t T v�Ar s j Ba V- eSSC- C j(!1MMC1jSBEING DULY SWORN DEPOSESTAND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE'DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S)OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. signature of Prop Owner SWORN TO BEFORE ME THIS DAY OF 20 h2/ ASHLEY 8 HU Notary Public-State of New York N0. 01 HU6286628 Notary Public Qualified in Kings County My Commission Expires Jul 29,2017 -~Board of Trustees Appliaa' in AUTHORIZATION }� (where the applicant is not the owner) I, residing at (print name of owner of property) (mailing address) do hereby authorize (Agent) to apply for permit(s)from the Southold Board of Town Trustees on my behalf. (Owner's signature) I APPLICANT/AGENTM-PRESENTATIVE 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 krovide inforination•Wbiieh can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. /� YOUR NAME: ' c(,-0-n"'w�iVS �Q` � ~ (Last name,first name,iaiddle initiaf,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 tion from plat or official map Planning ler ther",name the activity.) •:QyC SZ - GG A/S A) 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 Z� day of -TV')/ 200 Signature Print Name 7e ss2 C Fonn 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 a enc in making a determination of consistency. *Except minor-exempt actions including ildi g Permit 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 Townl. 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 detaih,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# 10 0 O D q _ 6i6-_k 02 1-04 O Z O) PROJECT NAME EQA c-AE 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: t s 14 Location of action: �'�i,�/iluF � J 0�'�' 1 Site acreage: g2 Present land use: Present zoning classification: 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: 'k55 (b) Mailing address: (c) Telephone number: Area Code( ) ® 3 CS 4 —Irl (d) Application number,if any: VJ I A, Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ Na® 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 Cl KgYj 1" -X13 t, I dV ^VAL 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 5r Yes ❑ No ❑ Not Applicable '11��rC► `�`°'ti f o nl f� p,8d'1- 0 y .I T� ��aJ �'l G 1�C,.r tk(V, ' Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No R 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 El NoNot Applicable OW f 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. qQ ❑ Yes No Not�_rrlicable r\,��- A N' Pvnc A(a of a-c z 1� s Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. Yes [:] No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation► criteria. ® Yes ❑ No VbNot 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. ❑ WE] No 0 Not Applicable Attach additional sheets if necessary WORKING COAST POLIC, i Policy 14. 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 f&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 E9 Not Applicable r 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 ❑ NNot 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 O'Not Applicable t Sc ole +� -71 Z t PREPARED BY TITLE DATE