Loading...
HomeMy WebLinkAboutTR-8872A John M.Bredemeyer III,President of S0(/T�,� Town lull Annex Michael J.Domino,Vice-President h0 0. 0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski ® Telephone(631) 765-1892 Charles J.Sanders Fax(631) 765-6641 �yCOWN,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8872A Date of Receipt of Application: August 19, 2016 Applicant: Thomas Frenz SCTM#: 1000-104-9-4.2 Project Location: 1260 Broadwaters Road, Cutchogue Date of Resolution/Issuance: September 21, 2016 Date of Expiration: September 21, 2018 Reviewed by: A. Nicholas Krupski, Trustee Project Description: To install an approximately 875 sq.ft. pervious outdoor patio with a fire pit on-grade. , Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Creative Environmental Design, dated August 2, 2016, and stamped approved on September 21, 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 John M Bredemeyer III, President :'o�� - Com':; Town Hall Annex Michael J. Domino, Vice-President Y < ', 54375 Route 25 Glenn Goldsmith o z `' P_O. Box 1179 A_ Nicholas Krupski �:o ® .` Southold, NY 11971 ` �r o� =� Charles J. Sanders ,` ol �a;;r 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 Y2 constructed Project complete, compliance inspection i moo I POO moo Poo 00 F-ROP05FD Phbumowe 05LE PAT-0 Aff IR- EF- T EDGE OF WETLANDS A5 PER EN—CON5ULTANT5 5 _ -- --- - ----- - ------ 52' 0" PERMEABLE PAVER INSTALL DETAIL PERb7FABLE PAVER 8 �_1"aLLEsra�E scrc�r�s 4"ro 6' caM'Ac(ED GRIbWI n NATWAI.5r6tE 10 r 12 - 1 875 S.F� '' I N �. 1 1 1 . 1. 1 1 LEGEND 1 COIvMON NAME QTY - 1 LOWER, GRA55 1 1 Kv. FOREST GRA55, GOLDEN JAPANESE 3 GRA55, DWARF FOUNTAIN 7 FLOWER, PERENNIAL ' CATMINT, LITTLE TITCH 4 1 SALVIA VERTICILLATA PURPLE RAIN' 10 SHRUB, DECIDUOU5 . ABELIA, CANYON CREEK DRUB, EVERGREEN BROADLEAF 10 BOXWOOD, GREEN MOUNTAIN 3 1 THOMAS & PATRICIA FRENZ R b b APPROVED BY 1260 61 0 n, A /ATER5 LOAD BOARD OF 1 RUSTEES /VJ V V TOVM OF SOUTHOLD u �l .J CUTCHOGUE, NY 11935 I AUG 1 9 2016 211201b Soufhcld iown f SCTM# 1000-104-9--42 Revision #: Landscape Plan : 8-2- 16 Date: 8/19/2016 Frenz , Scale: Landscape Design by: Dave Cichanowicz 1 = 10' Creative Environmental D f � of 4e, .1 John M. Bredemeyer III, Presider �, , Ir'pS �'e, Town Hall Annex Michael J. Domino, Vice-President' �r�4� �Gy 3, 54375 Route 25 Glenn Goldsmith y P O. Box 1179 A Nicholas Krupski o F,It Southold, NY 11971 Charles J. Sanders ��jo ao� Telephone (631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 14100 91'Sl`,� Completed in field by: tj Creative Environmental Design on behalf of THOMAS FRENZ requests an Administrative Permit to install an,approximately 875sq.ft. pervious outdoor patio with a fire pit on-grade. Located: 1260 Broadwaters Road, Cutchogue. SCTM# 1000-104-9-4.2 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary,Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet J Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: r 1 S2 Ff&A oeflood. fo c�ri��l� GQ f eaboas 1 Present were: J. Bredemeyer M. Domino G. Goldsmith "� N. Krupski C. Sanders Other Page 1 of 2 John M. Bredemeyer III, Preside �Og�yFF04eo� Town Hall Annex Michael J. Domino, Vice-President tido Gy 54375 Route 25 Glenn Goldsmith o P.O. Box 1179 A. Nicholas Krupski o t Southold, NY 11971 Charles J. Sanders y�, o�� Telephone (631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: Creative Environmental Design on behalf of THOMAS FRENZ requests an Administrative Permit to install an approximately 875sq.ft. pervious outdoor patio with a fire pit on-grade. Located: 1260 Broadwaters Road, Cutchogue. SCTM# 1000-104-9-4.2 Ch. 275-12 - STANDARDS FOR ISSUANCE OF PERMIT MET=X or Comment=* A. Adversely affect the wetlands of the Town: B. Cause damage from erosion, turbidity or siltation: C. Cause saltwater intrusion in the fresh water recourses of the Town: D. Adversely affect fish, shellfish or other beneficial marine organisms, aquatic wildlife & vegetation or the natural habitat thereof: E. Increase the danger of flood and storm-tide damage: F. Adversely affect navigation tidal waters or the tidal flow of the tidal waters of the Town: G. Change the course of any channel or the natural movement or flow of any waters: H. Weaken or undermine the lateral support of other lands in the vicinity: I. Otherwise adversely affect the health, safety and general welfare of the people of the Town: J. Adversely affect the aesthetic value of the wetland and adjacent-areas: Ch. 111-9 - ISSUANCE OF PERMIT MET=X or Comment=* A. Is reasonable and necessary, considering reasonable alternatives to the proposed activity and the extent to which the proposed activity requires a shoreline location: B. Is not likely to cause a measurable increase in erosion at the proposed site and at other locations: C. Prevents, if possible, or minimizes adverse effects on natural protective features and their functions and protective values, existing erosion protection structures and natural resources: D. 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: I f Date: Completed By: Present: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders E. Cantrell D. Di Salvo Other Page 2 of 2 � Fv UP�DP,• B °�O f£ct£c wn on wiul wl.. • d b G9 A __LZ P - O p A P '' •� B a \ � ••� LI1T1E CREEK l0 Ile1 • Awt'.So J' � „ �yt `$", 4 � � 1.04 ��� ��M1 T Zy. j6 a Fti. M O .0 3 "�•+��, ri \r \1°' 'T ,md„4 \, 3pP11 O , t`'�:,•" "F` ." `a+m P• to.. wo 'end\T 21 tB ••M1 A T t4 \B ae l A d M 9 t0 t\'� l°'n •y 61 $ G1 d \9 d" a.\9 w ,�? 77.2 • SBIyc)� �. PVE- 4 weer A 13Ill MRK ms 1 S t 3 1• �, �...m m � \ `OP " A • 9 " v © 1 t\ QFL •n `B O A \_ BROADWATERS COVE \ E \ m 33 e` OPS°�y °p e tB • +y" P 9 / TOWN OF SOUTHOLD 14 `ryt OP• " N 9 •�•mmnrenww ) �. 1 INC) ♦� t0 '° sM10 12 W •P�� � O �5 � '~�� � 31ank1 4 \ M1" CoQ \O r � _ tdao) .` 'o' sit '� /„nk) ae•'""'s tt '',A• a � gO '2g11°"l1 1 B � ' ro o � • 9 W \ - 2]n c) I 4 'ay I s °° i`8 ✓ D 0 B tint\� �,. d p fli B2 - p„ 9I'�l 4 S '+ •'�Bq �wa �; � \5 • t °' N9g 1 NAYWATER COVE ®" /s al OQ-pP�,P J O � �® /_• �J`. � ♦9 c � 10.9 ° ,yC"` •fit eP 0 8 '"10 ' O 9\ ```�.c dP ♦5 101 C� a� 9-'' t\P - �» `.� `..1.` =a'\ t .�• __".i4,-_ _ r=.'.,s::rw. G...:�-..<=�T'__ •1 - .l.t;;; a''�i^;:` -=r=t_' — � _1.°i'•w':y,r:r,�a,*. ,„.Nonds // COUNTY OF SUFFOLK C 1e � souTllolo SECTION No _ ':sr•;da'.'#?r.:xs i:'tia.SQi-t.r+' � � :r��v_�`T,a':_�� ,,..."5 :.:n±. +..+'.�^f','sr4 b".', - O ��. --i ....;.vC.1 - ,...�...�-a-.,.. �`..�y";�~=v_.:'.:::.. 'o.�. G----S`•.- —��-.� .:.��Pra��µe�.�:� �"�i�:�° 'Real'RroPertY'tTa'115ervIciT A9er1 r .-i `=e'-�«'--.....: ,�.�.....�.�.�' `�`'"•�d+i=.�-„"L.'"'".'. .-,f 3= � "".+�;P' �'•� - °�'•Y;<.»ke»W..,_K_. ..t '104 �ti'ir��`^.w... 1�,v } v�o-wr��,ew�•ew.• � :1.r .. - .:wo� - =.s "`J�+;�r�-r. r,.uy �,�,ry�l,,w�:„.i� .T us:,,> .� 7• '” •.�., _ .ac .'sl+r :�::' �.,��« i:L'�`7.t.�;�'i�.•..."�2">.�`s:.w'y�%'s'vol, .,�;=•'�•sj., y.`'?�.r`'4'2``,.�;;, i��',4*�'��.<.t.., .r '�a.�* ' 'fi 'txY::yy,-}cw. i.; 'SS :�..' ;�'. •.-""',:r.�=�..�. „+.k.PP,y.�+3�e^;;? y�l�f*(]y,',g.;'tt;�::" r:3•y',.P�a�.ty.�-..%�.�:;. - nys� a..:��s.. ti'_�:fY :4 v. .<\.r„ i 't- .G+ 'tFn f.,P. 4•.+<.:w...,+1-i.a'''. p. .Rr. ;'M1 C�-+._•f�.e c� ^t... ,.y Y^x v�st�v;,.e. -�-�{.v�. �£F..'w' v.'a]"e= .:ds'• +;.a','a- .'t r.�, .t, `t ., s,'..'s, 6.. ,1 .��.§ .•4.,. `ti.t'.'r•. �if,r S"K •'it' `e,4'r' %.Mt='�.r3::, ..'k 0+�. -P�e _ �f • •i f1,:• �4- y _ ,, u�.��.,,,,.;g,_,;:.::�.;.r.'"_.i.-..:'t'i�'7�r'��ay.=°„�g��..:i:•P..-u,'.::.t;`.�:uta.�:.. �.::G`.`.,=:_'v'm..}�.:�.. '"` �rw'r`-iza•n�a�:\.r Y3'^ �:.'.."tri'a.�ni±::�; .�':^�i•'"i�'tt��`F:a mss•., - ,� i I OFFICE LOCATION: ®��OF SO(/r � MAILING ADDRESS: Town Hall Annex '` ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) co, S ® �®� Telephone: 631 765-1938 Southold, NY 11971 O Fax: 631 765-3136 COU01 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: John Bredemeyer, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: September 19, 2016 Re: LWRP Coastal Consistency Review for THOMAS FRENZ SCTM# 1000-104-9-4.2 Creative Environmental Design on behalf of THOMAS FRENZ requests an Administrative Permit to install an approximately 875sq.ft. pervious, outdoor patio with a fire pit on-grade. Located: 1260 Broadwaters Road, Cutchogue. SCTM# 1000-104-9-4.2 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the ,Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the'records available to me, it is my recommendation that the action is CONSISTENT with the below listed Policy Standards and therefore is CONSISTENT with LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. / John M Bredemeyer 111, Pre ' ��,0v SQ�/Tiyp Town Fall Annex O l 54375 Main Road Michael J- Domino, vice-President `� O P.O- Box 1179 James F- King,Trustee Southold, New York 11971-0959 Dave Bergen,Trustee G_ Telephone(631)765-1892 Charles J. Sanders, Trustee p �ycoUFax(631) 765-6641 BOARD OF TOWN TRUSTEES D TOWN OF SOUTHOLD D To- Southold Town Building Department AUG 2 9 2016 Re- Verification of Building Department Permit Requirements BUILDING DMT. TOWN OF soum®LD SCTM#: Property Owner Name: Date Sent to Bldg. Dept_: The Office of the Board of Trustees is forwarding the above referenced application for verification of the Building Department's permitting requirements stated below: YES NO ill the proposed project require a Building Permit? Will the proposed project require a variance determination from the Zoning Board of Appeals? Will any part of this application be considered as Demolition as described under Town Code? COMMENTS: 5 ure of i6z6lewer Date P © "SoUT John M.Bredemeyer IN,President �'� �� Town Hall Annex Michael J.Domino,Vice-President 54375 Main Road ; P.O.Box 1179 James F.King,Trustee , CIO Southold,New York 11971-0959 Dave Bergen,Trustee a-�o Telephone(631)765-1892 Charles J.Sanders,Trustee �'C �. F�' Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOtiTHOLD Office Use Only _Coastal Erosion Permit Application Wetland Permit Application tAUG Administrative Permit / AmendmentfTransfer/�extension VReceived Application: I"WX9 2016 _ Received Fee:$ 100,0_cr , �'. Completed Applieati^ on: YWTV ____incomplete: Southold Town __SEQRA Classification: Type I Type U___ Unlisted _ /Coordination:(date sent): 9,2'j(o V LWRP Consistency Assessment Form: CAC Referral Sent: V/ Date of Inspection: _Receipt of CAC Report: Lead Agency Determination: Technical Review: Public Hearing Held-- r � Resolution: Name of Applicant: p 1(v��� 5 Z Mailing Address:� j0� �� Gt„ � LA�uz—, Phone Number: Suffolk County Tax Map Number: 1000- �,D 14 --�—�r Property Location: (provide LILCO Pole #, distance to cross streets,and location) AGENT:- �1�; (If applicable) _1Crea6Ve Envir®mmen a esign PO Box 160 Address: Peconic,IY 11958 Phone: -- Board of Trustees Application GENERAL DATA Land Area(in square feet): Area Zoning: L40 Previous use of property: Intended use of property:. Covenants and Restrictions on property? Yes ��No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes No If"Yes",be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review and Elevation Plans will be required. / Does this project require a variance from the Zoning Board of Appeals? Yes No If"Yes",please provide copy of decision.. Will this project require y demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure(s)on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency Date ; No prior permits/approvals for site improvements. Has any pennit/approval ever been revoked or suspended by a,governmental agency? No__,.,—/Yes If yes,provide explanation: Project Description(use attachments if necessary): ?e-V-V"off Ori Hoard of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations; Area of wetlands on lot: o�J� 1 a(7 square feet Percent coverage of lot: / % Closest distance between nearest existing structure and upland ` edge of wetlands: w feet Closest distance between nearest proposed structure and upland edge of wetlands: 5-all feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? _ _ _ cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: 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): 617.20 Appendix B Short Etrvironrnetrtal Assessment Forte Instructiotts for Comnleting 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 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 item. Part I-Project and Sponsor Information Name of Action or Project: - Project Location(describe,and attach a location map): Brief Description of Proposed"Action: w E Name of Applicant or Sponsor: Telephone: Creative EnvJMMental Address: PO BOX 160 Peconic11958, City/PO: State: Zip Code: I.Does the proposed action only involve the legislative adoption of a plan,ioeaf law,ordinance; NO YES administrative rule,or regulation? -0` 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 of the proposed action? ay.- b. b.Total acreage to be physically disturbed? $7-5 �"05 c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? __ g j� Cres 4. Check all land uses that occur on,adjoinidg and-near the proposed action. (]Urban El Rural(non-agriculture) ❑industrial []Commercial desidential(suburban) ❑Forest ❑Agriculture ❑Aquatic Q01her(specify): ❑Parkland Page I of 4 5. Is the proposed action, _ - NO YES .N/A a.A permitted use under the zoning regulations? ❑ 0 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? ET -7.-Is-the'site ofthe proposed action located in;or does it adjoin,a state listed Critical'Environmentat Area?_ NO YES If Yes,identify: _ S.- 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? F-1- c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ❑ 9.Does the proposed adtion meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: I0. Will the proposed action connect to an existing public/private water supply? NO/ YES j If No,describe method for providing potable water, .. 1""�l ❑ 11.Will the proposed action connect to existing wastewater utilities? NO :I(Eg If No,describe method for providing wastewater treatment;, ( i 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 NOJ 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 tvaterbody? ; 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 ❑ gricuttural/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 ygg 17.Will the proposed action create storm water discharge,either from paint or non-point sources? NO _ YES . If Yes, a.Will storm water discharges flow to Adjacent properties? dNO ❑YES ❑ b.Will storm water discharges be directed to established conveyance-systems(run ff and storm drains)? If Yes,briefly describe: NO DYES 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: • _ �j 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: = ;ice 20.Has the siteof the pf6posed action or an adjoining property bcen'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 B;ST OF MY ` KNOWLEDGE II�1 / Applicants ons me: tc9` 7_ Date:= l 1. 66 r 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 i and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to Inrge impact impact may may _ _occur occur 1. Will the proposed'action create a material conflict with an adopted land use plan or zoning' _ ((��`` regulations? ❑ L l 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ f z 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 oftraftic 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? 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, ( "I waterbodies,groundwater,air quality,flora and fauna)? �—J Page 3 of 4 i — 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 problems? 11. Will the proposed action create a hazard to environmental resources or human health? a Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation;" that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. 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 environmenta'impa ts; Town of Southold-Board of Trustees � Name:of lead Ag? ey Date ' 'ter President Print or Type Name f Responsib a Officer'n Lead Agency Title of Responsible Oft icer " Signature_ esponsible Wc6r in Lead Agency Signature of Preparer(if different'frorn Responsible Officer) PRINT Page 4 of 4 Board of Trustees AppliMticft AUTHORIZATION (where the applicant is not the owner) e rsidingat o 3rwil, ),M, (print owner of property) (mailing ad ess) Y.' David Gichanot4icz, Pres. o hereby authorize (Agent) Creative Environmental Design- to apply for Permit(s)from the Southold Board of Town Trustees on any behalf. (Owner's signature) - -card of Trustees Application County of Suffolk State of New York 1-'4 17L I C'i dlC- R_e_Y_-7, BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE'ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE ! TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORD ; 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 TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING i UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR � REPRESENTATIVES(S),TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION., s Signature 3 AAI { SWORN TO BEFORE ME THIS c��l _DAY ® 1�O PATRICIA L. BIRNEY Notary Public, State of New York No. 01916996688 Notary Public - V Qualified in Nassau County Commission Expires November 1); 2011 F i { i i Board of Trustees Application County of Suffolk State of New York 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 TOWN 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(S),TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. _ - Signa - SWORN TO BEFORE ME THIS �h DAY OF xi ,?0 J-(P— GIAKAW SUPPER Notary Pubuc=Sttle of Near York NO.OISU6326564 Qualified In Suffolk County RAY Commission Expires Aug.3,2019, Notary Public i Board of Trustees Application AUTHORIZATION (where the applicant is not the owner) 1,%e 9ygx %:eCWZ- - -residing at /-4 40 (print owner of property) (mailing address) _� _ _�/P.�,$�__ __.do hereby authorize David Cichanowicz, Pres. (Agent) ,Creative Environmental.Design to apply for permit(s)from the Southold Board of Town Trustees on my behalf. (Owner's signature) 'APPLICANUAGENI REPIIFSENTA.TI'VF TRANSACTIONAL DISCLOSUR14G FORM The'rnvn ofiSoutlinld's Code of T thics prahiliifs'cariflietc`of iittorest ort tho hart of town iifficers and,emolovees:The nttrnos of" -chis form is to"provide in orinniiciri witiclt c u ici t'tfte"town ofpossihle eottflicts of interest anti a W%v_tt tp tale wltatcver action t( necessary!to avoid same. YOUKNAME: ���/� a• (Gast name,"test name,jpiddle 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 1/ Variance Trustee Change of Zone Coastal Erosion Approval of plat ^_ Mooring Exemption from plat or official map - __ Planning Other (lf"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 applicantlagont/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in thespace provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all,that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation),, C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of Sf- .Zoo Siguatit �?' Print Name ---- Form TS 1 APPLICANT/AGENT/REPRF,SENTATTVF TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The pumose of this form is to provide information which can alert the town ofMssible conflicts of interest and allow it to take whatever action is necessary to avoid YOUR NAME: (Last name,first riame,.rniddle initial,unless you are applying in the name of someone.else or other entity,such as a company.4f so,indicate&'.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 emoloymerit by)a corporation in which the town officer or employee owns more than 5%of the sh es. YES NO V If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space-provided. The town officer or employee or h&or her spouse,sibling,parent,.orchild is(check all that apply): A)the owner of greater than 5%of the shares of the corporate-stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any-interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,-partner,or employee of the applicant;-or D)the actual applicant. DESCRIPTION OF-RELATIONSHIP Submitte thi 206 Signature- Print Name Form TS I F 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 HazardArea. 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 siificailt 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 ansiv+ef must he fex lained'in detail listing,both supporting and non" sup ortin 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-met), the Board of Trustees Office,the Planning.Department, all local libraries and the Town Clerk's office, t B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# Lo PROJECT NAME 7—o 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: COQ0 Qa4? - - a Location of action: `?)QQ`A CS . A, r C�(,-M—UL, V ((93 Site acreage: I �� 3 3 Present,land use: NOG ,ti 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: �TD Z (b) Mu ling address: �i �GrGt (e) Telephone number:Area Code(,B) --ate t - (d) Application number,if any: Will the action be di tly undertaken,require funding,or approval by a state or federal agency? Yes ❑ No If yes,which state or federal agency`. ` C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Rest Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. x DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, mares 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 trite es ❑ No ❑ Not Applicable AM6 additional sheets if necessary Policy 2, Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III-=pplicable ages 3 through 6 for evaluation criteria Yes ❑ No 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 JjYes No Q Not Applicable f Attach additional sheets if necessary NATURAL COAST POLICIES ' r Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages through 1b for evaluation criteria t. , f T 0 Yes O No U/Not Applicable Attach additional sheets if necessary Policy 5, Protect and improve water quality and supply in the Town of.Southold.See LNVRP Section M. -- Policies.Pages 16 through 21 for evaluation criteria V► Yes '� No ❑Not Applicable s0 NI 1 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 In—Policies; Pages 22 through 32 for evaluation iriteria, U v ` Yes, No Not Applicable Attach additional sheets if necessary 1 Policy 7. - Protect and improve air quality in the Town of Southold. See LWRP Section M — Policies Pages 32 through 3=licable ion criteria.' 11 Yes E]No Attach additional'sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances----and wastes. ec LWRP Section III—Policies;Pages 34 through 38 for evaluatiop criteria. Yes U No of 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 LWIti.'Section.III—Policies;Pages 38 through 46 for evaluation criteria. Yeo No VNot Applicable Attach additional sheets if necessary WORN ING COAST POLICIES Policy 10: Protect Southold's water-dependent.,uses and promote siting of new water-dependent uses in suitabl ''cations. See LWBP Section IH—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 Dong Jbland Sound, the Peconic ' Estua and Town waters:See ILWRP Section III—Policies; Pages 57 through 62 for evaluation criteria.' Yes ❑ No❑ Not Applicable Attach additional sheets ifnecessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III--Policies; Pages 62 through 65 for evaluation.criteria. ❑Yes Not�iApplicable 3 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 n, No Not Applicable PREPAREID BY7�7 'u�L aAWkY-`z TITLE IRATE b-1 ,