HomeMy WebLinkAboutTR-8855A John M.Bredemeyer III,President *rjf SOUr-®l® Town Hall Annex
Michael J.Domino,Vice-President 54375 Route 25
P.O.Box 1179
Glenn Goldsmith Southold,New York 11971
A.Nicholas Krupski ® app Telephone(631) 765-1892
Charles J.Sanders �CDU
l Fax(631) 765-6641
NT`(,��
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
# 1288C Date: November 14, 2016
THIS CERTIFIES that a Ten(10)Year Maintenance Permit to remove Japanese knotweed,
weeds and poison ivy cut back bushes; trim Montauk daisies; and when the knotweed dies off,
plant salt tolerant plantings in order to maintain the shoreline;
At 759 Orchard Road, Southold
Suffolk County Tax Map#1000-66-2-11
Conforms to the application for a Trustees Permit heretofore filed in this
office Dated July 26, 2016 pursuant to W'hich,Trastees Administrative Permit#8855A
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 a Ten(10)Year Maintenance Permit to remove Japanese knotweed, weeds, and
poison ivy cut back bushes; trim Montauk daisies; and when the knotweed dies off, plant salt
tolerant plantings in order to maintain the shoreline.
The certificate is issued to VIVIAN V. EYRE owner of the aforesaid property.
Authorized Signature
1
1
®F sOUr Town Hall Annex
John M.Bredemeyer III,President tio�� /y�lo
Michael J.Domino,Vice-President 54375 Route 25
P.O. Box 1179
Glenn Goldsmith
Southold,New York
11971
A.Nicholas Krupski G
Telephone(631) 765-1892
Charles J. Sanderscousm Fax(631) 765-6641
e
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
DATE OF INSPECTION:
Ch. 275 Ch. 111
INSPECTION SCHEDULE
7
Pre-construction, hay bale line/silt boom/silt curtain
1St day of construction
% constructed
Project complete,'compliance'inspection.
INSPECTED BY:
COMrLYvS:
-1
CERTIFICATE OF COMPLIANCE:
John M Bredemeyer III, President �o�� ooG ; Town Hall Annex
Michael J. Domino, Vice-President :` ��- 54375 Route 25
Glenn Goldsmith o z `= P.O. Box 1179
A. Nicholas Krupski `moo ® -� Southold; NY 11971
Charles J. Sanders '; al , �� :' 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
'/2 constructed
Project complete, compliance inspection
/rte 1 r
John M.Bredemeyer III,President ®��®f 3®(/ry�l Town Hall Annex
Michael J.Domino,Vice-President ® 54375 Route 25
P.O.Box 1179
Glenn Goldsmith Southold,New York 11971
CA
A. Nicholas Krupski Telephone(631) 765-1892
Charles J. Sanders ®1/0 CO
N Fax(631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Permit No.: 8855A
Date of Receipt of Application: July 26, 2016
Applicant: Vivian V. Eyre
SCTM#: 1000-66-2-11
Project Location: 759 Orchard Road, Southold
Date of Resolution/issuance: August 17, 2016
Date of Expiration: August 17, 2018
Reviewed by: Michael J. Domino, Trustee
Project Description: Ten (10) Year Maintenance Permit to remove Japanese
knotweed, weeds, and poison ivy; cut back bushes; trim Montauk daisies; and
when the knotweed dies off, plant salt tolerant plantings in order to maintain the
shoreline.
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 Vivian Eyre, received on July 26, 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
AVIA- ✓ �yam"
63i - 765-3 463
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,
SURVEY OF PROPERTY
AT SOUTHOLD JUL 2 6 2016
t11 r O 11/ O
TOWN OF SOUTHOLD TO t\
SUFFOLK COUNTY N. Y. q° o
t Southold Town Lp 6°. °'
1000 - 66 - 01 - 11c�r 1S Ley 2
SCALE 1" = 30' _-_ boa,.• f use o N r+•
MAY 1, 2003 ,
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APPROVED BY
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BOARD OF TRUSTEES vo `sA° �\ �� . �°``" °° -vo
TOWN OF SOUTHOLD \
O (r� 3a °q0
DATE s Z D vo�
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CERTIFIED RO
BARRY LIP MAN
AB \015 \Aa2 Nom. �IQQ
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NOTE, LOT NUMBERS ARE REFERENCED TO
a _
MAP OF BEIXEDON ESTATES BLOCK 4
FILED IN THE SUFFOLK COUNTY CLERK'S �e 4`s A$A` is `�m�Nc, ifs OF Nflyy
OFFICE ON MAR. /6, 1946 AS MAP NO. 1472 \ t p�0 1.Me,
PROVED B
ANY ALTERATION OR ADDITION TO THIS SURVEY 1S A VIOLATION
P
OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. �
EXCEPT AS PER SECTION 7P09-SUHOMSION 2.ALL CERT1f'KATIONS P E O� `, � 'fit I STEE
HEREON ARE VALID FOR THIS MAP AA9 COPIES THEREOF ONLY 1F �M Q -
SAO MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR /� pE; yA' �D O
WHOSE StGNA TUR£APPEARS HEREON. SV 18
ADDITIGWALLY TO COMPLY WITH SAID LAWTERM'ALTERED BY
Mvsr BE USED By ANY A+»ALL sLwv£roRs urrL¢iNG A COPY 7,65 5020 FAX 1631)=765 1!19 7
OF ANOTHER SURVEYOR'S MAP. TERMS SUCH'WSPECTED -AND --
BROLGHT- TO-DATE'ARE NOT 1N COMPLIANCE WITH THE CAW,
AREA = 18,919 sq.11nnI�� — ' 1AVeAFe91-51REET '
197/
03.—,168
A N1�/ jqpp4j*C.4-4iL)A/ -6R LiAUG
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John M. Bredemeyer III, Preside gUFF04,r b Town Hall Annex
61
Michael J. Domino Vice-Preside G + 54375 Route 25
4�
Glenn Goldsmith o P O. Box 1179
A. Nicholas Krupski
41�* Southold, NY 11971
Charles J. Sanders �'�1 ao�� Telephone (631) 765-1892
n' Fax(631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Date/Time: G ` Completed in field by:
VIVIAN V. EYRE requests a Ten (10) Year Maintenance Permit to remove Japanese knotweed,
weeds, and poison ivy; cut back bushes; trim Montauk daisies; and when the knotweed dies off, plant
salt tolerant plantings in order to maintain the shoreline. Located: 759 Orchard Road, Southold.
SCTM# 1000-66-2-11
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 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:
4_�
Present were: J. BredemeyerM. Domino G. Goldsmith N. Krupski
C. Sanders Other
Page 1 of 2
John M. Bredemeyer III, Preside �oS�FFO(�eo Town Hall Annex
Michael J. Domino, Vice-President ,`.to Gy�a 54375 Route 25
Glenn Goldsmith o '` P.O. Box 1179
A. Nicholas Krupskio ® S Southold, NY 11971
Charles J. Sanders y�j� ao�� Telephone (631) 765-1892
Fax(631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Date/Time: Completed in Work Session by:
VIVIAN V. EYRE requests a Ten (10) Year Maintenance Permit to remove Japanese knotweed,
weeds, and poison ivy; cut back bushes; trim Montauk daisies; and when the knotweed dies off, plant
salt tolerant plantings,in order to maintain the shoreline. Located: 759 Orchard Road, Southold.
SCTM# 1000-66-2-11
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. :5256/o 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
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OFFICE LOCATION: ®� S®Ur�®� MAILING ADDRESS:
Town Hall Annex °` ® P.O. Box 1179
54375 State Route 25 Southold, NY 11971
(cor.Main Rd. &Youngs Ave.) CA
Southold, NY 11971 ® a� Telephone: 631 765-1938
enupm
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 VIVIAN V. EYRE
SCTM# 1000-66-2-11
VIVIAN V. EYRE requests a Ten (10) Year Maintenance Permit to remove Japanese knotweed,
weeds, and poison ivy; cut back bushes; trim Montauk daisies; and when the knotweed dies off,
plant salt tolerant plantings in order to maintain the shoreline. Located: 759 Orchard Road,
Southold. SCTM# 1000-66-2-11
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 provided the following:
1. The removal of vegetation is limited to invasive species. Native vegetation should remain.
2. The method of removal is described. Will herbicide be applied to the plants?
3. The applicant identifies the spacing and species of planted vegetation.
Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its
written determination regarding the consistency of the proposed action.
1
John M.Bredemeyer III,President ®��QF SO(/T�pl Town Hall Annex
Michael J.Domino,Vice-PresidentO 54375 Route 25
P.O.Box 1179
Glenn Goldsmith CA Southold, New York 11971
A.Nicholas Kr upski Telephone(631) 765-1892
Charles J. Sanders ®l�f'`,oUNTi Fax(631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
_Coastal Erosion Permit Applicatio
_Wetland Permit Application Administrative Permit
/ Amendment/Transfer/Extension
Z Received Application: -2G•1(0
Received Fee:$ 100,0 yr. ,.- ----�
e_Completed Application 7r.2-� L ' E L, 'E V
_Incomplete
_SEQRA Classification:
Type I Type H Unlisted JUL 2 6 2016
Coordination-(date sent)
LWRP Consistency Assessment Form
CAC Referral Sent: Southold Town `
Date of Inspection: <
_Receipt of CAC Report:
_Lead Agency Determination:
Technical Review:
Public Hearing Held: c 171 149-
Resolution:
Name of Property Owner(s) VNIAIJ V C..Y
Address )00 R-04P0-S ��(� / f. 0• gdX 1055—
PhoneNumber:631) 7b..50' 34L 3
Suffolk County Tax Map Number: 1000 - q-'7 3 9 8 C ' -66 -a."
Property Location: 759 QAaM__x.d 1'�2 OA J
(&t" a00 R:xie s g a )
(provide LILCO Pole#, distance to cross streets, and location)
AGENT:
(If applicable)
Address:
Phone:
1
, _`3oard of Trustees Applical- ,,n
GENERAL DATA DA,T.A
Land Area(in square feet): LD r'' tes,37 ,I(k 41415 6 g 7a
Area Zoning: 2W Zz A L.
Previous use of property: Amrc4 e le--m Pry to r
Intended use of property: l&4m>
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 __,k/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 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 V No W/A
Prior permits/approvals for site improvements:
Agency Date
49M&Ud dF /dw,v Tl&ffees e'/9 /20157
SC-rM -4 46 —,2--I1
No prior permits/approvals for site improvements. /
Has any permit/approval ever been revoked or suspended by a governmental agency? V No Yes
If yes,provide explanation:
Project Description(use attachments if necessary):
/0 YeAP, MAIA46VAMSF� s 7- D-40() I.J- 9-
ZV,A-,f,S e. K.A/dTyy`eQiC (1,V VA S-1 V& '4,4/a7E__A g Qa 0 IV y /-4eIna VA I-i
y" 6,4ct5. 6vs4.& . /N lL ' '
U/k-f--W le-A.0T wC ie S, tV Z_AnrT _51,4Z_ ' -fv L-E7OkN T P&4t/TNS S
* of*t nAkt j SA vUr'Z_1*eU6-
_,3oard of Trustees Applicw�'^ -`;n
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: dip �Afl/bVeSe.9AAraeobGA.104DVP0
/u#a/07 AdlsoM tw
wccd Aft T;y ks4a. !tl kt/ 4 d ;Mwb r wV S,*I r
T lam 7'0 ^4wflfrN 540/W11W
�"d1'A�. /oS.37► T c6-Blvd- to T r*L 6$,7L
Area of wetlands on lot: square feet J
Percent coverage of lot: r %
Closest distance between nearest existing structure and upland
edge of wetlands: 1010 feet
Closest distance between nearest proposed structure upland Sr LTJ��
edge of wetlands: PIA- feet //C f�OS
Does the project involve excavation or filling?
No ✓ Yes
,M111Au*L CVAr *R-0rb �VA A7r 1
/GvoTu�
If yes,how much material will be excavated? cubic yards
How much material will be filled? cubic yards
Ale M aw T
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:
4oaydso7e, 7-4iL/L �u c4tcT- 6oi!, jtma
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):
Description of Site&Proposed Action
Owner: Vivian Eyre
631-765-3463
200 Rogers Load& 759 Orchard Road
Southold,NY 11971
Property Location: 759 Orchard Road(Lot behind 200 Rogers Road)
On Beixedon Estates Site Map Lot 10
On Tax Map: 473889-66-2-11
The following request is for a 10 year maintenance permit to remove Japanese knotweed,and
invasive species that is spreading and eroding the shoreline of Hippodrome Pond.
In addition,the purpose of the permit will be to allow ongoing maintenance to the area such as
removing weeds and poison ivy,trimming/cutting back flowering bushes. Part of this project
will be implemented by the owner and part through Chris Mohr Lawn&Landscape.
Background
My first permit to remove the Japanese knotweed and maintain the area was issued by the Town
on August 22,2012. Four years later,I'm still trying to remove the Japanese knotweed. My
method is to cut it back to about a foot in the spring and early fall. I feel as if I'm losing the
battle. The knotweed is eroding more of the shoreline, and is spreading to south.
Recently Chris Mohr was advised by the Town,to try cutting back the knotweed in November
(as well as the spring). So this new permit would allow me to follow the Town's advice in that
regard. If the Town has any additional advice about how to eliminate this invasive species, it
would be greatly appreciated.
Thank you.
Vivian Eyre
July 26,2016
t
I t
617.20
Appendix B
Short Environmental Assessment Form
Instructions for CompletinI4
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 1 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 ite.ey)qCCAf 19, .C4714
Part 1 -Project and Sponsor Information
1-"Y le 6- - #i PP 1D R o MU.' PAld 7J e-- ' f 14VVJ�S ��v
Name of Action or Project:
Project Location(describe,and attach a location map):
Brief Description of Proposed Action: /0 Y q. /1l 4tN ray /( ,M t294C, i tT >V d 4
a p>4r�se ,el-1.0r`veeb (r vms/(A ') 1410 a, MAI sysAcs
�O�NSS 77�-T Wi /1 /��trtiTl�av 71rc SY? d�L.r'evC
Name of Applicant or Sponsor:Vi
LE-Mail:
elephone:6��,,,
�/ Y I/V /QE Wl 1411 . 17 vq IV
Address:
-2a0 /Ro. /05r
City/PO: State: Zip Code:
Soci 7�4I cd �Nv //? W
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: [i? ❑
3.a.Total acreage of the site of the proposed action? acres 7.�� sl��'/h
b.Total acreage to be physically disturbed? acres
AP
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? Y2, acres
4. Check all land uses that occur on,adjoining and near the proposed action. �
❑Urban ❑Rural(non-agriculture) ❑Industrial [:]Commercial L Residential(suburban)
El 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? ❑ ❑
6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES
landscape? ❑
IT
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: 9 ❑
8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES
00
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? IJ ❑
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: N ❑ ❑
11.Will the proposed action connect to existing wastewater utilities? NO YES
If No,describe method for providing wastewater treatment: 0 ❑
12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES
Places? NO 6rg4G fv�' F-1�/
b.Is the proposed action located in an archeological sensitive area? E, r F-113.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO" YE
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? RL r_1If 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 El Forest ❑Agricultural/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 NO YES
by the State or Federal government as threatened or endangered? ❑
16.Is the project site located in the 100 year flood plain? NO YES
17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES
If Yes, [VNLTJ
�j
a.Will storm water discharges flow to adjacent properties?
O DYES ❑
b.Will storm water discharges be directed to established conveyance systems(run and storm drains)?
If Yes,briefly describe: WNNO AYES
Page 2 of 4
1
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: 11 ❑
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: ❑
1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE � 4
�J
Applicant/sponsornarne: -P Date:
Signature: j(A*15! ' V . g
Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following
questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or
otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my
responses been reasonable considering the scale and context of the proposed action?"
No Moderate
-09to large
inert impact
"Wr may
oetTv occur
I. 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?
4. Will the proposed action have an impact on the environmental characteristics that caused the ❑
establishment of a Critical Environmental Area(CEA)? u
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:
a.public/private water supplies?
b.public/private wastewater treatment utilities? 0
8. Will the proposed action impair the character or quality of important historic,archaeological, (� ❑
architectural or aesthetic resources? L✓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
fc
Moderate
to large
t impact
may
occur
10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage �/ ❑
problems? u
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.
F1Check 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
`Board of Trustees Applica�, ,n
AFFIDAVIT
v r
XV I IW• !�E BEING DULY SWORN
D POSES 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.
Signature of Pro erty Owner
SWORN TO BEFORE ME THIS 2"' DAY OF �U( , 201
DIANE DISALVO
l f NOTARY PUBLIC-STATE OF NEW YORK
No. O1 D1475593
Notary Public Aualifled in Suffolk County p�
My Commission Expires April 30, 20_10
k i t
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 s�a�me.
YOUR NAME: V 1 V,&A, V.
(Last name,first name,diddle 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 X
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 tJks da of-
Signature
Form TS 1 f
Print NameVi tJiA�/ V ' eYAW
Town of Southold
LWRP CONSISTENCY ASSESSMENT FORM
A. INSTRUCTIONS
1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for
proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This
assessment is intended to supplement other information used by a Town of Southold agency in
making a determination of consistency. *Except minor exempt actions including Building Permits
and other ministerial permits not located within the Coastal Erosion Hazard Area.
2. Before answering the questions in Section C, the preparer of this form should review the exempt
minor action list, policies and explanations of each policy contained in the Town of Southold Local
Waterfront Revitalization Program. A proposed action will be evaluated as to its significant
beneficial and adverse effects upon the coastal area(which includes all of Southold Town).
3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will
affect the achievement of the LWRP policy standards and conditions contained in the consistency
review law. Thus, each answer must be explained in detail, listing both supporting and non-
supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and
conditions,it shall not be undertaken.
A copy of the LWRP is available in the following places: online at the Town of Southold's
website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all
local libraries and the Town Clerk's office.
B. DESCRIPTION OF SITE AND PROPOSED ACTION
SCTM# to tv - A - I
PROJECT NAME 6) pRC— O,ob DipeM PcH✓n( /tcl.E L- k-:- 1AQtAAC A100
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: /0 \/& 1hA 1A4-9W tivt. T- -f0
oyow, . wjgAyesir rcadl'w�� GN✓�s���� u�_ cr�T Bq�,E~./t�i�
Y 116
fu5�. W kai vk-A0W d 640. 44ce tolh sw r 75-1e *ryr
VLA-Al IAICI s will !W 17Le ,�h01ZC4 IC
' , 1
_ I ' f
Location of action: 7s A4x fY '/RQ6 I s a,) Tho L d
Site acreage: A-?PAOk 31q OcAt'
Present land use: -M p T\ G l S/ DO
Present zoning classification: "clElV 11 A L
2. If an application for the proposed action has been filed with the Town of Southold agency, the following
information shall be proovided:r
(a) Name of applicant: //k'V eygg:
(b) Mailing address: P.d. Go)S /0 s�
50fjV .eI AJ
(c) Telephone number: Area CodeW -3 6 .�
(d) Application number,if any:
Will the action be directly undertaken,require funding, or approval by a state or federal agency?
Yes ❑ No V 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 d 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 V 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
Sectio III—Policies Pages 8 through 16 for evaluation criteria
47
Yes 0 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 HI
—Policies Pages 16 through 21 for evaluation criteria
Yes El 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.
y
Yes No Not Al,r ,`cable
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 YNot 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.
1:1 Yes ❑ No 11 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.
❑ YeO No Not Applicable
Attach additional sheets if necessary
WORKING COAST POLICIt
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 14ot 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 1;7
ation criteria.
F] yes ElNoNot 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
u
PREPARED 13Y
TITLE( t//tl DATE -�`/