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HomeMy WebLinkAboutTR-8905A �pfr SO(/T Michael J. Domino,President �0� y®�O Town Hall Annex John M. Bredemeyer III,Vice-President 54375 Route 25 Charles J.SandersP.O. Box 1179 cn ac Southold,New York 11971 Glenn Goldsmith �@ Telephone (631) 765-1892 A.Nicholas Krupski �lif100 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Ch. 275• Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction % constructed Project complete, compliance inspection. INSPECTED BY: J 6"Q) 1G�JC� COMMENTS: CERTIFICATE OF COMPLIANCE. SOF SO!/jg, Town Hall Annex Michael J.Domino,President John M.Bredemeyer III,Vice-President ® 54375 Route 25 Q P.O.Box 1179 Charles J.Sanders CA Southold,New York 11971 Glenn Goldsmith G ,ems a0 Telephone(631) 765-1892 A.Nicholas Krupski li}�`,oUff Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1364C Date: July 18, 2017 THIS CERTIFIES that the installation of an 8'x12' storage shed onto the property in the rear yard and 10' away from side yard lot line; At 695 Petty's Drive, Orient Suffolk County Tax Map#1000-14-2-23 Conforms to the application for a Trustees Permit heretofore filed in this, office Dated October 24, 2016 pursuant to which Trustees Administrative Permit#8905A Dated November 16, 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 an 8'x12' storage shed onto the property in the rear yardand 10' away from side yard lot line. The certificate is issued to Paul &Margaret Kobalka owners of the aforesaid property. Authorized Signature } �� �F SO Town Hall Annex John M.Bredemeyer III,President /y® 54375 Route 25 Michael J.Domino,Vice-President P.O.Box 1179 Glenn Goldsmith w Southold,New York 11971 A.Nicholas Krupski ® Telephone(631) 765-1892 Charles J.Sanders , O Fax(631) 765-6641 COUN�1,� 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/silt boom/silt curtain 1 st day of construction Y2 constructed Project complete, compliance inspection 1 UT John M.Bredemeyer III,President f SOTown Hall Annex®� yol Michael J.Domino,Vice-President 4 54375 Route 25 Glenn GoldsmithP.O.Box 1179 Southold,New York 11971 A.Nicholas Krupski app Telephone(631) 765-1892 Charles J.SandersV Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8905A Date of Receipt of Application: October 24, 2016 Applicant: Paul & Margaret Kobalka . SCTM#: 1000-14-2-23 Project Location: 695 Petty's Drive, Orient Date of Resolution/Issuance: November 16, 2016 Date of Expiration: November 16, 2018 Reviewed by: John M. Bredemeyer, III, President Project Description: To install an 8'x12' storage shed onto the property in the rear yard and 10' away from side yard lot line. 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 Paul Kobalka, received on October 24, 2016 and stamped approved on November 16, 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 SURVEY OF LOT 5MAP OF _ PETTY'S BIGHT g o FILE No. 5859 FILED JANUARY 26, 1973 �Il SITUATED AT F) I LH D11) ORIENT { OCT 2 4 2016 11 TOWN OF SOUTHOLD l SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-14-02-23 SotltholdToWn I r SCALE 1"=40' Baaftl�f hu�te�s _ �) JULY 30, 2004 JUNE 25, 2007 ADDED PROPOSED HOUSE \ JULY 25, 2007 RELOCATED PROPOSED HOUSE NOVEMBER 2, 2007 ADDED ADDITIONAL WELL & CESSPOOL LOCATIONS s O� NOVEMBER 24, 2007 REVISED PROPOSED WELL LOCATION \Sl6,� DECEMBER 3, 2007 ADDED TEST HOLE 7,1 \ ,2 DECEMBER �- 12, 2007 ADDED LOT COVERAGE \ Y+ JANUARY 9, 2007 SET LATH FOR SITE INSPECTION N FEBRUARY 4, 2008 REVISED SEPTIC SYSTEM SEPTEMBER 15, 2008 RELOCATE PROP. DRYWELL 50' FROM PROP. WELL JULY 16, 2UPDATE SURVEY ��\ JANUARY 201515 ADD PROPOSED HOUSE CH \ MAR5, 2015 REVISE PER S.C.D H S NOTICE 03/03/2015 .� MAY 19, 2015 FOUNDATION LOCATION JULY 22, 2015 STAKE PROPERTY LINES °aFP DECEMBER 1, 2015 FINAL SURVEY JANUARY 16, 2016 ADD POOL EQUIP, WALL & CORRECT NOTES PER HEALTH DEPT. rye°y FEBRUARY 4, 2016 CORRECT WELL TIE DISTANCES ° \ AREA = 38,131 sq. ft. (TO TIE LINE) 0.875 cc. CERTIFIED TO: � S� W \ PAUL KOBALKA MARGARET KOBALKA FIDELITY NATIONAL TITLE INSURANCE COMPANY ULSTER SAVINGS BANK, ITS SUCCESSORS AND/OR ASSIGNS �F< rsJ lOy� /J O 0 r Y 9 9 m CIO $A X04, 4'F9 EXISTING W gsT4` °A�YG 9�G� CESSP°OL� EXISTING O / Z CESSPOOL 1 `/ PpSy pti y / V a � O44' P004 LOT DR KS A OAS Bq p� P604tp '-ser s4ke Ha. m2 0 o�or / 7 SEPTIC SYSTEM TIE MEASUREMENTS HOUSE HOUSE CORNER QA CORNER[g] LLJ - 3" l TFpO • SEPTIC TANK Tia o 0o A 0 / / COVER 25.5' 34.5' O m 16' Ck // 4pro�elC/ LEACHING POOL 45' 54' .pIgS m 2j•0 wp0 OO / .r COVER 1 LEACHING POOL ehi m• p H'op } r7'Z I .Sti?r-yr COVER 2 48' 34.5 / 2 ti &r cRq 27 S�< WELL TIE MEASUREMENTS s Zo C apo• �ARgGE @ HOUSE HOUSE CORNER © CORNER[ ti EXISTING--,,,. WELL 40.5' 62.5' tj �N �P oor CON, 4 a 22.J• _ 0 .00 MO O 3 A' R� G'wit 3 OR fC( b ,.'i.�` �_ 3 4 ��s� " O 00 00' ��"' AS' 26 00 ooh 61.43, 1\0f1 pF�t o^ NN z P 00'' CRA)FTh v7 _ (at�MNr F AP <,N p f 7y°aYfpaR) CBOLEX STING lVf ` r— CESSPOOL ��F� 7S C I � NC a0 x� 0 ,( RB T - OF T�t 'f ES 17,5 WOOD p� 3g� tyR 43 oO„ zo.00' �� W , Rm31.42Exlweii OF lye 4, ^� 0, PRE I MATE NIMUM STAN TITLE SUR pF LI BY ALS.AND APPROV A'PTEDO h FO SOC SE Yo TE LAND �V NOTES: m ; ,., a' i 2 ti 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM ti EXISTING ELEVATIONS ARE SHOWN THUS: _ o 2. FLOOD ZONE INFORMATION TAKEN FROM: FLOOD INSURANCE RATE MAP NO. 36103CO069H ZONE VE. COASTAL FLOOD WITH VELOCITY HAZARD (WAVE ACTION); BASE FLOOD ELEVATIONS DETERMINED N.Y.S Lic. No. 50467 ZONE X. AREAS DETERMINED TO BE OUTSIDE THE 0.27. ANNUAL CHANCE FLOODPLAIN. UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF 3. COASTAL EROSION HAZARD LINE TAKEN FROM COASTAL EROSION SECTION 7209 of THE NEW YORK STATE Nathan Taft Corwin III HAZARD AREA MAP PHOTO No. 47-655-83 EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING Land Surveyor THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED,AND ON HIS BEHALF TO THE TITLE COMPANY.GOVERNMENTAL AGENCY AND Title Surveys - Subdivisions - Site Plans - Construction Layout LENDING INSTITUTION LISTED HEREON,AND TO THE ASSIGNEES OF THE LENDING INSTI- TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE PHONE (631)727-2090 FOX (631)727-1727 THE EXISTENCE OF RIGHT OF WAYS OFFICES LOCATED AT MAILING ADDRESS ANY,, NOT SHOWN ARE NOT GUARANTEED. ANDEASEMENTS OF RECORD, IF 1586 Main Rood P.0 Box 16 N Jamesport, New York 11947 Jamesport, New York 11947 34-139f John M. Bredemeyer III, Presi i 'OSOFFO(kC' Town Hall Annex Michael J Domino, Vice-Pres"id"eni joy �Gy� 54375 Route 25 Glenn Goldsmith o P.O. Box 1179 A. Nicholas Krupski o ^ Southold, NY 11971 Charles J. Sanders Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in field by: PAUL & MARGARET KOBALKA request an Administrative Permit to install an 8'x12' storage shed onto the property in the rear yard and 10' away from side yard lot line. Located: 695 Petty's Drive, Orient. SCTM# 1000-14-2-23 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 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/comm nts/standards: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 John M. Bredemeyer III, Presi yoSUFFOC�co Town Hall Annex Michael J. Domino, Vice-Presiaeni =moo Gy< 54375 Route 25 Glenn Goldsmith o P.O. Box 1179 A. Nicholas Krupski o ® Southold, NY 11971 Charles J. Sanders �y Sao Telephone (631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: PAUL & MARGARET KOBALKA request an Administrative Permit to install an 8'x12' storage shed onto the property in the rear yard and 10' away from side yard lot line. Located: 695 Petty's Drive, Orient. SCTM# 1000-14-2-23 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 ' /0/ Z3/ 20/;C r l . ! If f • 1 F -1 i S` =Q i?° ,.an+�� .,, - Y.. "4.+,•C" . e, SAN• _ fx �.,4 y�Y •yM� v3 r �A i +LL• , .� � �':;1 r1^"� y meq, kr L� IT � ��tib! 4 1 �lL�. j ^•ai'd Y-, ,+.f ,",�'" "r X' ,.; yJ .a ,,y,ry ^..-ems• ( -d � � . �G � .F r."� •t � .d .,�,,:?� �Bsi�,,,;+P' *le 'r.• � � ,q• �y�Y ;L .?' " °Y� G^::y �� :.,ter �f4�.4`�.t at• "'' `," sx �r. 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Vinyl sheds have vinyl windows Door opening height on 7ft walls 80" with 5/8"PT plywood *96"roll-up door only fits on 12'gambrels Concrete block supports PT 4x4 beam under 12'wides only Note: Some options may not be available on all sheds.Call your Distributor or Sheds USA for more information. Please refer to our specific instructions&dimensions before beginning any slab, sonotubes (piers), gravel pad or other site preparation. Shed-Cutaway-Diagram-HD_classic.doc Version: 02/10/2012 rn• P agEDS USA The Home Depot V11-U Shed Roof 512 , OPTIONAL VENTS 24/12-5/12 Gambrel Roof Pitch only 12 - 2x4 trusses 24"on center 8ft 2in tall (8ft 4"with 2x6 joists) 241 _- _-_ - -_ -_-__ - `� N Choice of roof shingle color r OSB Roof sheathing Vents are OPTIONAL-> ®®® i I 1cli I I Wall Framing I I I I I 14 2x4 studs 24"on center 47"sidewall height End walls are truss-plated 2x4s l„ o I I 1 92 st R.O. 1 I I Wall Siding options 11 1 or 53�' -3/8"engineered&pre-primed SmartPanelTM siding by L-P -_-_ - 1x4 Pine Trim- Rake, Fascia & Doors 96 wide only 1x4+ 1x3 pine Cornerboards -Vinyl clapboards over 7/16 OSB Vinyl wide-flange &J-channel trim Door 40" Double Door on gable end only-upgrade to 54" clear opening: 39'/2"wide x 66'/"tall, or 53%"wide x 66'/"tall o doors are SmartPanel if SmartPanel sided doors are solid vinyl slabs if vinyl sided g Zinc plated T-hinges Chrome Keyed T-Handle Lock (2) Barrel Bolts inside left door half 9 Bullnose (threshold) is standard CN Ramp is OPTIONAL 3 Choice of 4ft long or new heavy-duty 6ft Floor 96"across gable ends Sidewalls length: nominal 8ft long = 92" M MA (See Exact Outside Floor Dimensions for other sizes) OSB Flooring 2x4 PT floor joists, recommend upgrade to 2x6s. Optional Tough Floor II: upgrades to 2x6 joists 12"on center upgrades to PT plywood floor RAFT S & STUDS 24" O.C., TYP Anchor Kit option: Includes Strongtie®H2.5A hurricane clips for rafters and four arrowhead ground anchors with cable that goes over gable ends. Recommended or required in many areas to meet hold-down requirements for wind resistance. 2-year Limited Warranty standard, optional upgrade to Lifetime Limited Warranty. SIDE WALL FRAMING Please refer to our specific instructions& dimensions before beginning any slab, sonotubes(piers),gravel pad or other site preparation. Revised 112613 If OFFICE LOCATION: ®��rq S®Ury®l MAILING ADDRESS: Town Hall Annex ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) CIO N Southold, NY 11971 ® �Q Telephone: 631 765-1938 ®� C®UNTY, Fax: 631 765-3136�� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUMr]D , E NOV 1 4 2016• To: John Bredemeyer, President Town of Southold Board of Trustees so�t��cd iovm Board of Trustees From: Mark Terry, LWRP Coordinator Date: November 14, 2016 Re: LWRP Coastal Consistency Review for PAUL & MARGARET KOBALKA SCTM# 1000-14-2-23 PAUL & MARGARET KOBALKA request an Administrative Permit to install an 8'x12' storage shed onto the property in the rear yard and 10' away from side yard lot line. Located: 695 Petty's Drive, Orient. SCTM# 1000-14-2-23 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 the LWRP., Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. e F SOF SOOT John M.Bredemeyer III,President 0� y0l Town Hall Annex Michael J.Domino,Vice-President d 54375 Route 25 Glenn Goldsmith P.O.Box 1179 Southold,New York 11971 A.Nicholas Iirupski � O �� Telephone(631) 765-1892 Charles J.Sanders �l� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Applicatio Wetland Permit ApplicationV Administrative Permit AmendmenvTran fer/1�yxtynsion Received Application: 10 J-q d Received Fee:$100, Completed Application Incomplete �D _E � � U 3EQRA Classification: Type I Type II Unlisted �Coordination:(date sent) LWRP Consistency Assessment Form fir'�` OCT 2 4 2016 CAC Referral Sent: LDate of Inspection: < out old Town Receipt of CAC Report: Boa _of Trustees j Lead Agency Determination: Technical Review: Public Hearing Held: n, ___Resolution: Name of Property Owners) Pikct l Mj#ve f Address_ (o Is- l e ��yJ h-;V' 0)-: e it f /V Y �l f �3i Phone Number:( ) Suffolk County Tax Map Number: 1000- I// — C3-Z 3 Property Location: �c_ Pe e C y_r U?_, ve . Q r;V%?� l e y //F S 7 (provide LILCO Pole#, distance to cross streets, and location) AG (I£applicable) Address: Phone: Board of Trustees Appli -ion GENERAL DATA Land Area(in square feet): 3 Area Zoning: ?- Yo Previous use of property: 90;�qN Intended use of property: ffv,9oJel j X%2' r, kip .r/?e� Covenants and Restrictions on property? Yes V' No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes V 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 V No Does the structure(s)on property have a valid Certificate of Occupancy? V/ 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): f �P V fWe,?iy /0" fnept of (e;w 1',Je a L•a� f J Board of Trustees Applk :ion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: k;�c� l,orf // r' -VYZ;' h ei,( ON th,e i'4-riern S;clf c� Y,e4r al kogje Area of wetlands on lot: D square feet Percent coverage of lot: Closest distance between nearest existing structure and upland edge of wetlands: 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? 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): No e Meet- 1 l 61Z20 Appendix B .Short Environmental Assessment Fortn Instructions for Completing Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 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): �'�1� e� �o Gt.S�' R 1•>rerh S«/� /©` ero n, foe (y Brief Description of Proposed Action: /,(I-Dif4// 6- /g , X./z syc/ ell V/7 e4 tY /0' FlEaM �ro�ertay L_%"rP Name of Applicant or Sponsor: Telephone: p�u� k��•�/k ill- ,fee k0AA-11CI- E-Mail: Address: p19 K/9y ® 0 ti rl'/q rn. /V c't' FTotal O: 0 State: Zip Code: 3�, e f /V Y �� 9 S-7 s the proposed action only involve the legislative adoption of a plan,local law,ordinance, inistrative rule,or regulation? NO YES attach a narrative description of the intent of the proposed action and the environmental resources thatr_n affected in the municipality and proceed to Part 2. If no,continue to question 2. s the proposed action require a permit,approval or funding from any other governmental Agency? NO YES list agency(s)name and permit or approval: al acreage of the site of the proposed action? oo 7'ys— acres tal acreage to be physically disturbed? q�Sal acreage(project site and any contiguous properties)owned --'acresontrolled by the applicant or project sponsor? 0- Y7 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑industrial ❑Commercial gResidential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page I of 4 5. [s the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ ❑ b.Consistent with the adopted comprehensive plan? F-1 El ❑ 6. is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ ❑ 7. Is the site of the proposed action located in,or does it adjo If Yes,identify: in,a state listed Critical Environmental Area? NO YES — M ❑ Fa.Will proposed action result in a substantial increase in traffic above present levels? NO YES 10 11 lic transportation service(s)available at or near the site of the proposed action? c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? © ❑ 9.Does the proposed action meet or exceed the state energy code requirements? ❑ ❑ If the proposed action will exceed requirements,describe design features and technologies: NO YES ❑ ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ JEJ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? p� b.Is the proposed action located in an archeological sensitive area? 1 v 1 ❑ F y portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES IT s or other waterbodies regulated by a federal,state or local agency? ❑the proposed action physically alter,or encroach into,any existing wetland or waterbody? I"� ❑ y the wetland or waterbody and extent of alterations in square feet or acres: 5a 14. Identify the typical habitat types that occur on,or are likely to be found on thero'ect site. Check.all that apply: ®Shoreline ❑Forest p pp y ❑Agricultural/grasslands E3 Wetland ❑Urban ❑Eazly mid-successional ❑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? ® El16.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, a.Will storm water discharges flow to adjacent properties? ❑NO ❑YES 0 ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO ❑YES Page 2 of 4 F es the proposed action include construction or other activities that result in the impoundment of NO YES ter or other liquids(e.g.retention pond,waste lagoon,dam)? ,explain purpose and size: R-1 F] 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: [2�1.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? Yes,describe: ® ❑ 1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE r Applicant/sponsor name: 4 e 0iI1-/" Date: /o% / A ep/6 Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the,following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" 7hMnJPact1mpact Moderate to large mayoccur 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? (� g 4. Will the proposed action have an impact on the environmental characteristics that caused the :t: : LJ establishment of Critical Environmental Area(CEA)? ❑ 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate :0r, reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ a.public/private water supplies? F-1- 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, F1waterbodies,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 ❑ ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. 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 Applic _ `ion AFFIDAVIT k4c,I �i-"r� IK�eo-11YO/1,6,� EEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL, TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of Proper wn SWORN TO BEFORE ME THIS Z DAY OF ®� ,20/& f Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. O1 D1475593 Qualified in Suffolk County My Commission Expires April 30, 20�� APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of j=n 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 ye whatever action is necessary to avoid same. / YOUR NAME: KU�4-11C-4 , IC K/ 1<0 �f/C�ff6r,0ref (Last name,first name,ipiddle initial,unless you are'applying to 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,trlarriage,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 a y day f 20016 Signature .XPi Print Name ,9y/ft �� /yJQ o Form TS l `� • 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 nronosed 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# /(20® _ /LI __ O PROJECT NAME The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees LJ 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: Probi'd ' .S,�r U� /d���l� �d� anon, �°�✓�r,� S'./� lit� .vel��'�iv� Location of action: Site acreage: 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: (b) Mailing address:_-- `�� /�-c ffY/ (c) Telephone number:Area Code O G 3/ a 4 91116` ^� (d) Application number,if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? If yes,which state or federal agency? Yes ❑ No 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 Hi—Policies; Page 2 for evaluation criteria. ❑Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No M 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 Q Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No a Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No ©Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ ❑ o Yes No Nf�,' ,applicable Attach additional sheets ifnecessary 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 Z 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 0 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. Q YeO No W Not Applicable Attach additional sheets if necessary WORKING COAST P0—, ,.,!'IES 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 2 Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No ® Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III—Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ No© Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑Yes ❑ No ® Not Applicable PREPARED BY � 'l TITLE DATE ✓01.2 y �6