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TR-8926A
Michael J.Domino,President ��OE SO(/ryv Town Hall Annex John M.Bredemeyer III,Vice-President �� l0 54375 Route 25 Jae P.O.Box 1179 Charles J.Sanders Southold,New York 11971 Glenn GoldsmithG TeleP hone(631) 765-1892® i� A.Nicholas Krupski �® Fax(631) 765-6641 Ti BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1381C Date: August 16, 2017 THIS CERTIFIES that the existing 9'8"x11' (106sq.ft.) enclosed porch to be renovated and to become interior space of dwelling; At 175 Clearwater Lane, Cutchogue Suffolk County Tax Map#1000-118-5-2.2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated November 14, 2016 pursuant to which Trustees Administrative Permit 98926A Dated December 14, 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 existing 9'8"x11' (106sq.ft.) enclosed porch to be renovated and to become interior space of dwelling. The certificate is-issued-to Dennis Hickey owner of the afgre aid roper Authorized Signature k -) �pF S®(/l�, Michael J.Domino,President ��� �' Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O. Box 1179 Charles J.Sanders y Southold, New York 11971 Glenn Goldsmith �Q Telephone(631) 765-1892 A.Nicholas Krupski o�yC®UNFax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 6/4" Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction '/2 constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: 4, pPe Cr Por p/&Wy 01/- +a l zmie CERTIFICATE OF COMPLIANCE: SO fjf John M.Bredemeyer III,President �* Tiy� Town Hall Annex Michael J.Domino,Vice-President '`� l0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith JIB Southold,New York 11971 A.Nicholas Krupski G ® Telephone(631) 765-1892 Charles J.Sandersy�UUNT`I 0 Y 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/silt boom/silt curtain 1 st day of construction Y2 constructed Project complete, compliance inspection John M.Bredemeyer III,President �*of SoUjyO Town Hall Annex Michael J.Domino,Vice-President �� l0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G ® O Telephone(631) 765-1892 Charles J.Sanders O a Fax(631) 765-6641 couffN BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8926A Date of Receipt of Application: November 14, 2016 Applicant: Dennis Hickey SCTM#: 1000-118-5-2.2 Project Location: 175 Clearwater Lane, Cutchogue Date of Resolution/Issuance: December 14, 2016 Date of Expiration: December 14, 2018 Reviewed, by: A. Nicholas Krupski, Trustee Project Description: For the existing 9'8"x11' (106sq.ft.) enclosed.porch'to be j �: , renovated and to become interior space of dwelling. 4, 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 Samuels & Steelman;-Architects, dated November 9, 2016, and stamped approved on December 14, 2b1-6.-,, , . . 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 WIRE FENCE A/ FILTER CLOTH ,j /BOUND HAYBALE I SURFACE I DRAINAGE FILTER CLOTH MIN. k w k -SLOW WATERLA 6" BELOW 6RADE w ; ` 1A CLEAR F DIRT ROADWAY E �\ EDGE 0 UTILITY POLI ' METAL WIRE FENCE K/ R CUR�1E N # METER --,---FILTER CLOTH AND METAL 146- w R " POSTS 10' MAX SPACING LINE EGU1A I STONE PIER {I tt STONE PIER STONE PIER 0� \� O CTC PI ,► / / \ BASF -� 10 Uj10u ANGLE STAKE INTO Ilknfo �- ��07'50" E O PREVIOUS BALE g SURFACE DRAINAGE FLOW �6 �(i� / TIE LINE 174.24' Uj _ ._..........._.. _ _v_.._ .. _ ` tt 2" REBAR,5TEEL PICKETS �����\ o tt 0 z OR�2" X 2" STAKES 1-1/2" \ m y - 2 I N GROUND DRIVE I O , .. FLUSH W/ TOP OF BALES BOUND HAY5ALE5 (ABUT TO ADJOINING BALE TIGHTLY) `L1�$ I m k Z --i r HALL=BALI= TO BE EMBEDDED INTO 12 ! O SOIL MINIMUM OF 4 AND BINDINGS �/ I PLACED HORIZONTALLY \ \ WRAP SILT FENCE UNDER HAYBALE EXISTING AND DRIVE STAKE THROUGH. DRIVEWAY TEMPORARY STORM WATER / RUNOFF CONTROL MEASURE ° `\ W / 6 EROSION & SEDIMENT CONTROL DETAILS > ;= . NO SCALE \ O \ .......... / \�EXISTINGO .. . . / TRELLIS O\\ Uj APPROVED BY0 BOARD OF TRUSTEES Nj 0/F / EXISTING \ TOWN OF SOUTHOU) (� k POOL \ JOSEPH FLOTTERON III14 ` a o & NORA FLOTTERON ,�r�p/• 1 e . '»'POO EXISTING PERMANENT STORM WATER RUNOFF CONTROL L .. .. .:. MEASURE APPROXIMATE LOCATION OF EXISTING o >= >:':::>' DRYWELL FOR RAIN WATER RUNOFF FROM RUIDENCE �i 0 '> ` .' '> 14all \ O IS I T E DO V-m%T A EXISTING BUILDING STRUCTURE TO REMAIN, I I � SCTM # 1000-118-05-2.2 EXTERIOR FINISHES TO BE REPLACED WITH °� Z NEW FINISHES 16— EXISTING PROPERTY: 175 CLEARWATER DRIVE \ DRIVEWAY t I ,�Io ADDRESS CUTCHOGUE, NY 11935 Q• 0 '00/ � OWNER: DENNIS HICKEY -j m• o \ ` 0 12 `7 1 BUCKINGHAM COURT I � o ° LINE OF TRUSTEES JURISDICTION EXI5TING ST. JAMES, NY 11780 w —i• W Z W Q Z ° / SITE: 52,664 SF = 1.209 AC w. U1 DRIVEWAY • EXI5TIN6 PERMANENT STORM WATER RUNOFF CONTROL `,; Q N IN 61 5510 w ZONING: R-40 � MEASURE APPROXIMATE LOCATION OF EXISTING \ I J �. w. N = r DRYWELL FOR RAIN WATER RUNOFF FROM RE5IDENGE \ �o� 17.49 SURVEYOR: NATHAN CORWIN, LS ;�� - - �# PO BOX 16I— ?.__� JAMESPORT, NY 11947 i NOV 1 4 20'6 N cl)• LICENSE # 14 DATED 10/10/0749273 0%01073 I S �itiaid ^,, EXISTING ENCLOSED PORCH OF RESIDENCE / _E,ard_QfTrns�en� TO BE RENOVATED AND TO BECOME EXIST INTERIOR SPACE OF RESIDENCEDENCE 106 5F a'8"xl I' C OVERE PORCH Day NEIGHBORING TEMPORARY EROSION CONTROL MEASURE GARAGE «>> > < » NOTES: PROP05ED HAY BALES 6 SILT FENCE DURING CONSTRUCTION SEE DETAIL I-51PI ,�o / U 1 . ELEVATIONS ARE REFERENCED TO N.G.V.D. 1929 DATUM h % N/0/F .o OF EXISTING ELEVATIONS ARE SHOWN THUS. E N C W rL P <: '': ``? ?.:";.< �><' < : <�:. JOHN SPICER M <::::<: >:><::> :::::. EXISTING C 5 5 1s CONTOUR LINES ARE SHOWN THUS: & KATHLEEN SPICER P s { F.FL. FIRST FLOOR (/� ..,.,. ..,.. .. k<l:::• :>::•>:•:::•:;:>:::• G.FL — GARAGE FLOOR-27 e �s •STO,1 Y::T:R AI .: . >:.::: >:::.::. .. T.B. TOP OF BULKHEAD � . .i� cA 6.8. — BOTTOM OF BULKHEAD Y J F T.W. TOP OF W 0 S r pp�� ALL B.W. — BOTTOM OF WALL 1q \ � � ,3 \ \ \ \ ��.. : :::.;...:,...:.; ............................. 8350- O� �� _\ �■ \ EXIST 10 TERRACE FA3, LOCATION® MAP PROJECT NO: 1402 7 8�/� � \ \� � ,• , .;,,,; , s \ \ \ �� EXIST DRAWN BY: \ PATIO Mud 5` \ \ \ �.� Creek ro�oveters; /:;,' UT 4\ INE OF TRUSTEES JURISDICTION a /, CHECKED BY: T5 ---EDGE--OF WENDsFEe ' �� .•yh� o� DATE: c mac\ J.M.ONWIR0NMENTAL CO111/09/16 Ll ,� U p� e/ y a� %i \SERV\S ON\SEIPMM@I=\5�5 20 SCALE: cl 04 - 091 U� \ �4 /Peconic Bay %. H'ATf �AgCp G \\�\ conn SHEET TITLE: K ON 10/1 ARfIVT �\ \ \, XISTING PERMANENT STORM WATER RUNOFF CONTROL %�y /I/c/1 MEA5URE APPROXIMATE LOCATION OF EXISTING o \� 9 DRYAELL FOR RAIN WATER RUNOFF FROM RESIDENCE 41 SITE PLAN Q.. -W& a S 47.24'10" E S 87.58 09 15.00' 22.90' S 42.35'50" W �/ i;,. ,' %" SHEET NO: 9�� 7.70' N 81030'01 W �r N 71 59 3 W LLM zz 56.55' 51.49' Lel G 0O SCALE: 1 = 20'-Ovv APPROVALS John M. Bredemeyer III, Presid% ; UFFO(,��o M1' Town Hall Annex Michael J. Domino, Vice-President s e.-- 54375 Route 25 Glenn Goldsmith a P.O. Box 1179 A. Nicholas Krupski o Southold, NY 11971 Charles J. Sanders ��o ao�� Telephone (631) 765-1892 1 � Fax (631) 765-6641 �-rtzsrax BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: ��/�a/►� Completed in field by: tj'V44sk_' Samuels & Steelman Architects on behalf of DENNIS HICKEY requests an Administrative Permit for the existing 9'8"x11' (106sq.ft.) enclosed porch to be renovated and to become interior space of dwelling.- Located: 175 Clearwater Lane, Cutchogue. SCTM# 1000-118-5-2.2 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=� Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3'. Sanitary Leaching Pool (cesspool): 100-feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 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/comments/standards: NO �SSJz Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 John M. Bredemeyer III, Presid' "a Fat 0� Town Hall Annex Michael J. Domino, Vice-Presid'erit 54375 Route 25 Glenn Goldsmith o P.O. Box 1179 A. Nicholas Krupski o Southold, NY 11971 Charles J. Sanders l?�'y�j� a7, Telephone (631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: Samuels & Steelman Architects on behalf of DENNIS HICKEY requests an Administrative Permit for the existing 9'8"x11' (106sq.ft.) enclosed porch to be renovated and to become interior space of dwelling. Located: 175 Clearwater Lane, Cutchogue. SCTM# 1000-118-5-2.2 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: Date: Completed By: Present: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders E. Cantrell D. Di Salvo Other Page 2 of 2 a HICKEY RESIDENCE, 175 CLEARWATER DRIVE 4/10/14, 1 .20 pm, View East oAcLflseJ �oy-ck } r l♦ ol uq I • i HICKEY RESIDENCE, 175 CLEARWATER DRIVE 7/14/14, 10.00 am, View North HICKEY RESIDENCE, 175 CLEARWATER DRIVE 7/14/14, 10.00 am, View South r A RESIDENCE,HICKEY CLEARWATER DRIVE 7/14/14, , „ am, View West IlkA HICKEY RESIDENCE, 175 CLEARWATER ti. is I � • 4 r DRIVE 0-00am, OFFICE LOCATION: S®Ury®l® MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) ess ,e Southold, NY 11971 l ® aQ Telephone: 631 765-1938 Q Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM fjDECNVE D EC ® 9 2016 To: John Bredemeyer, President Town of Southold Board of Trustees Southall Taovn From: Mark Terry, LWRP Coordinator ard f Tru stues Date: December 9, 2016 Re: LWRP Coastal Consistency Review for DENNIS HICKEY SCTM# 1000-118-5-2.2 Samuels & Steelman Architects on behalf of DENNIS HICKEY requests an Administrative Permit for the existing 9'8"x11' (106sq.ft.) enclosed porch to be renovated and to become interior space of dwelling. Located: 175 Clearwater Lane, Cutchogue. SCTM# 1000-118-5-2.2 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 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. John M Bredemeyer [it. Presidepr, ��J" _ /�O town Hall Annex Michael J. Domino, Vice-Presider �` `� 1p 54375 Matn Road f' P.O. Box 1179 James F. King, Trustee 'Southold, New York 11971-0959 Dave Bergen, Trustee G 9 Charles J_Sanders, `I rustce p �O Telephone(631)765-1892 lye0t, � Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD D To: Southold.Towri Building Department J NOV 1 6 2016 Re--: Verification of Building Department Perm it"Requirements BUMI)INGDEP'P. SCTM#: �( I �,� TOWN OF SOiTTHOLD 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 Will the proposed project require a Building Permit? y ll the proposed project require a variance determination from Zoning Board of Appeals? ll any part of this application be considered as Demolition as described under Town Code? COMMENTS: Signature or e fewer Date r John M.Bredemeyer III,President Town Hall Annex �y�®�,�� ` �O�®ti„ 6437b Main Road ' Michael J.Domino,Vice-President _ James F.King,TrusteeSouthold,New York 11971-0959 Dave Bergen Trustee G' "tea' �►' _ ®' Telephone(631)765-1892 Charles J.Sanders,Trustee Olf� Fax(631)765-6641 BOARD OF TOWN TRUSTEES , TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit ApplicatiXAdministrative ; _Wetland Permit Application Permit _Amendment/Transfer/ xtension Received Application: _ Received Fee:$ /00, Completed Application _ _Incomplete f Vp E +�_l _SEQRA Classification: Type I Type II Unlisted ' �oordination:(date sent) , t/ LWRP Consistency Assessment Form J2��` NOV 1 4 2016 CAC Referral Sent: t Date of Inspection: 17, d _Receipt of CAC Report: Sotithold Town _Lead Agency Determination: �kard-0 TruS Technical Review: 1 Public Hearing Held: 17Z, < Resolution: Name of Applicant DENNIS HICKEY Mailing Address 1 BUCKINGHAM COURT,ST. JAMES,NY 11780 Phone Number:( ) Suffolk County Tax Map Number: 1000- 118-05-2.2 Property Location: 175 CLEARWATER DRIVE,CUTCHOGUE,NY 11935 Corner of Clearwater Drive&Nassau Point Road (provide LILCO Pole#, distance to cross streets, and location) AGENT: Tom Samuels of Samuels and Steelman Architects (If applicable) Address: 25235 Main Road Cutchogue,NY 11935 Phone: 631 734 6405 `3oard of Trustees Applbcat r GENERAL DATA Land Area'(in square feet): 52,644 S.F. Area Zoning:-- R-40 Previous use of property:: Residence- Single Family Intended use of property: Residence - Single Fad . Covenants and Restrictions on property? Yes X No If"Yes",please.provide a copy. Will this project require a Building Permit as per Town Code? X 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 X No If"Yes",please-provide copy of decision. Wi,11 this project require-any demolition as per Town Code or as determined by the Building Dept:? .,,Yes` X No Does the structure(s)on property have a valid Certificate of Occupancy?' X .Yes No Prior permits/approvals for site improvements: Agency Date usteGst and Permit 9/17/2DJ4 Southold Building Permit 12/5/2014 ermit 4/1501 S No prior permits/approvals for site improvements. Has any-permit/approval ever been revoked'or suspended by a governmental agency? X No Yes If yes,,provide.explanation: Project Description(use attachments if necessary); Existing.enclosed porch of residence to be renovated and to become interior space of residence, 106-sf, 9'8"x11'. Existing building structure to remain, exterior finishes to be replaced with new finishes. and of Trustees Applicatk' WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose'of the proposed operations: Existing enclosed porch of residence to be renovated and to become interior space of residence, 106 sf, 9'8"x11'. Existing building structure to remain, exterior finishes to be replaced with new finishes. Area of'wetlands on lot: 690 square feet Percent coverage of lot: 1.31 % Closest distance between nearest existing structure and upland edge of wetlands 37' feet Closest distance between nearest proposed structure and.upland edge of wetlands:- 72' feet Does the project involve excavation or filling? X 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': n. 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): None r APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL(DISCLOSURE FORM 1'he.Toe n of Soathold's Code of Ethics prghibits conflicts of interest on the part of town officers and emtrloyees.'17re moose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOURNAME: DENNIS HICKEY (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 X 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 Sotilhold? "Relationship"includes by blood,ntairiage,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,partnei,or employee of the applicant;or D}the actual applicant. DESCRIPTION OF RELATIONSHIP Submitte'th yJ�day o ( 200 Signature Print Nam IS HIC Form TS l Board of Trustees Application AUTHORIZATION (where the applicant is not the owner) DENNIS HICKEY residing at 1 BUCKINGHAM COURT (print owner of property) (mailing address) ST. JAMES,NY 11780 _ do hereby authorize (Agent) Tom Samuels to apply for permit(s) from the Southold Board of Town Trustees on my behalf. r ��Ow 's i tore) Board of Trustees Application County of Suffolk State of New York DENNIS HICKEY _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 re of roperty wn r SWORN TO BEFORE ME THIS_ DAY OF GL Iy 20 I ° 4Notarublic NANCY L NI!'L n 0,6ARAN NOTARY PUBLR. yl. QUALIFIED HbnU;;, ARK COMMISSION EXPIRES E NA ACIBL MELIL'0 BALABAN n�C STATE OF NEW YORKRICHMOND COUNTY81Cty� o�,1E467 ,:XF�lRES7 AUt3Ugr a j i� Board of Trustees Application AUTHORIZATION (where the applicant is not the owner) I, KATHY HICKEY residing at 1 BUCKINGHAM COURT (print owner of property) (mailing address) ST. JAMES,NY 11780 do hereby authorize (Agent) Tom Samuels to apply for permit(s)from the Southold Board of Town Trustees on my behalf. (Owne s signature) ' I I APPLICANT/AGENT/REPRESENTATIVF, TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Cade of Ethics prohibits conflicts of interest on the part of town officers and emRlovees.The purpose of this form is to provide information which can alert the town of o.sible conflicts of interest and allow rt to take whatever action is necessary to avoid same. YOUR NAME: KATHY HICKEY (Last name,first name,.yaiddle 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 X 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 interesf'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. I, Name of person employed by the Town of Southold Title or position of that person s Describe the relationship between yourself(the applicant/agpndrepresentative)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(wheh the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP I Submitted this50 day of ll 20jr/ Signature Print Name KAT HICKEY Form TS 1 617.20 Appendix B ,short Environmental Assessment Form Instructions for Completing Part I -Project Information. The applicant or project sponsor is responsible for the completion of Part]. 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 1 -Project and Sponsor Information DENNIS HICKEY Name of Action or Project: HICKEY RESIDENCE Project Location(describe,and attach,a location map): 175 CLEARWATER DRIVE, CUTCHOGUE,NY 11935 Brief Description of Proposed Action: Existing enclosed porch of residence to be renovated and to become interior space of residence, 106 sf, 9'8"x11'. Existing building structure to remain, exterior finishes to be replaced with new finishes. Name of Applicant or Sponsor: Telephone: DENNIS HICKEY E-Mail" Address: 1 BUCKINGHAM COURT City7PO: State: Zip Codes ST.JAMES NY 11780 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 Q. 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: Southold Town Building Permit, 3.a.Total acreage of the site of the proposed action? _J_209 - acres, b.Total acreage to be physically,disturbed? -..0_0"02_4 acres C.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? 1.209 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial [:]Commercial ®Residential(suburban) ❑Forest ❑Agriculture ❑Aquatic - ❑Other(specify): �. ❑Parkland- Page 1 of 4 5. is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ ❑ ❑ i b.Consistent with the adopted comprehensive plan? ❑ ❑ ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ ❑ 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: KI ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES ❑ ❑ b.Are public transportation service(s)available at or near the site of the proposed action? ❑ ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ❑ ; ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: ❑ ❑ 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: ❑ 10 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? ❑ X 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found.on the project site. Check all that apply: ®Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional ® Wetland El Urban MSuburban 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? FRI ❑ 16.Is the project site Iocated in the 100 year flood plain? NO YES X ' 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? [J NO ❑YES ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO ❑YES Page 2 of 4 18.Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: ❑ ,7 19. Has the site of the proposed action or an adjoining property been the location of an active or closed NO _ -YES solid waste management facility? If Yes,describe: ❑ ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe:. ❑ ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: Tom Samuels Date: 11/8/2016 Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the.following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to Iarge impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning F]regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ r 3. Will the proposed action impair the character or quality of the existing community? ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the- ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ reasonably available energy conservation or renewable energy op portunities? 7. Will the proposed action impact existing: El ❑ 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, ❑ waterbodies,groundwater,air quality,flora and fauna)`? 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 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. i J C eck this box if you have determined,based on the information and analysis above,and any supporting documentation, at 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 imps, t Town of Southold-Board of Trustees Name of Lead A ncy F bate President Print or Type ne of R nsibl fficer i Lead Agency Title of Responsible Officer Sign u of Res Bible Officer in Le Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 ' r - DENNIS HICKEY 1 Buckingham Court St: James, NY 11780 July 3, 2014 I hereby authorize Tom Samuels, of Samuels & Steelman Architects, at 25235 Main Road, Cutchogue, NY, to apply for all required permits from Southold Town, Suffolk County and New York State, for my project at 175 Clearwater Drive on Nassau Point in Cutchogue, NY. Sincerely, DENNISICKEY �,osU k Town of Southold N Erosion, Sedimentation & Storrn-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: s.C.T.M.ff: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A 1000 118 05 2.2 STORM-WATER,GRADING,DRAINAGE AND EROSION CONTROL PLAN s r c 3rect o — o-rr- —i.ot— CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTION ITEM# / WORK ASSESSMENT Yes No a. What is the Total Area of the Project Parcels? 52,664 S.F. I Will this Project Retain All Storm-Water Run-Off (Include Total Area of all Parcels located within 1.209 AC. Generated by a Two(2")Inch Rainfall on Site? the Scope of Work for Proposed Construction) (This item will include all run-off created by site b. What is the Total Area of Land Clearing 10(s.F./Acres)6 S.F. clearing and/or construction activities as well as all ElX and/or Ground Disturbance for the proposed 0.0024 A Site Improvements and the permanent creation of construction activity? impervious surfaces.) (S.F./Acres) Z Does the StPlan and/or Survey Show All Proposed — PROVIDE BRIEF PROJECT' DFSCRIPTION (Provide Additional Pe9aa as Needed) Drainage Structures ctures Indicating Size&Location?This Item shall Include all Proposed Grade Changes and Existing enclosed porch of residence to be Slopes Controlling Surface Water Flow. 3 Does the Site Plan and/or Survey describe the erosion renovated and to become interior space and sediment control practices that will be used to X control site erosion and storm water discharges. This of residence, 106 sf,.9r 8rr x11r. Existing item must be maintained throughout the Entire Construction Period. building structure to remain, exterior finishes 4 Will this Project Require any Land Filling,Grading or to be replaced With new finishes. Excavation where there Is a change to the Natural X Existing Grade Involving more than 200 Cubic Yards —of Material within any Parcel? rj Will this Application Require Land Disturbing Activities Encompassing an Area in Excess of Five Thousand X (5,000 S.F.)Square Feet of Ground Surface? — 6 Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Requirements: or within One Hundred(100')feet of a Wetland or Submission of a SWPPP is required for all Construction activities Involving soil Beach? disturbances of one(1)or more acres; Including disturbances of less than one acre that7 Will there be Site preparation on Existing Grade Slopes are part of a larger common plan that will ultimately disturb one or more acres of land, which Exceed Fifteen(15)feet of Vertical Rise to X Including Construction activities Involving soil disturbances of less than one(1)acre where One Hundred(100')of Horizontal Distance? the DEC has determined that a SPDES permit Is required for storm water discharges. (SWPPP's Shall most the Minimum Requirements of the SPDES General Permit 8 Will Driveways,Parking Areas or other impervious for Storm Water Discharges from Construction activity-Permit No.GP-040-001.) Surfaces be Sloped to Direct Storm-Water Run-Off ® X 1.The SWPPP shall be prepared prior to the submittal of the Not.The Not shall be into and/or in the direction of a Town right-of-way? submitted to the Department prior to the commencement of construction activity. 2.The SWPPP shall describe the erosion and sediment control practices and where 9 Will this Project Require the Placement of Material, required,post-construction storm water management practices that will be used and/or Removal of Vegetation and/or the Construction of any El X constructed to reduce the pollutants In storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder compliance with the terms and conditions of this permit.In addition,the SWPPP shall Area?(This Item will NOT Include the Installxaon of Driveway Aprons.) identify potential sources of pollution which may reasonably be expected to affect the quality of storm water discharges. NOTE: If Any Answer to Questions One through Nine is Answered with a Check Mark 3.All SWPPPs that require the post-construction storm water management practice In a Box and the construction site disturbance Is between 5,000 S.F.&I Acre In area, component shall be prepared by a qualiffed Design Professional Licensed In New York a Stonn-Water,Grading,Drainage&Erosion Control Plan Is Required by the Town of that is knowledgeable in the principles and practices of Storm Water Management Southold and Must be Submitted for Review Prior to Issuance of Any Building Permit. (NOTE. A Check Mark(4)and/or Answer for eadt Question Is Required fora Complete Application) I STATE OF NEW YORK, COUNTY OF........u! e .0...............SS i /fiat I,...DENNIS HICKEY being duly sworn,deposes and says that he/she is the applicant for Permit, ............................................. (Name of individual signing Document) Andthat he/she is the ................OWNER.........................................................................................................................I........ (Owner,Contractor,Agent,Corporate Officer,etc) Owner and/or representative of the Owner or Owners,and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his knowledge and belief;and j that the work will be performed in the manner set forth in the application filed herewith. i Sworn to before me this; .......................l..D�� ..........day of. ..Ale(lGll1 A�'( ...... ,,20.�� Notary Public: ' ......, ................................ LLO BALABAN (Slgnalure of A plicant) FORM - 06/10 NOTARY PUBLIC STATE OF NEW YORK QUALIFIED IN RICHMOND COUNTY UC,#01ME4673337 ADly COMMISSION EXPIRES AUGUST 31 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_ativerse'effects;u an'tlie coastal area vv}iich includes-all-,of-Southold oLmp 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. 'T'hu's; each answer must Ibc eicplAkM'itt-det3►il».listing`lioth suplao :tin :inti rto�t su�,pgrtina 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# 118 _ 05 .. 2.2 PROJECT NAME HICKEY RESIDENCE The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees I 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: Existing,enclosed porch of residence to be renovated and to become interior space of residence, 106 sf, 9'8"x11'. Existing building structure to remain, exterior finishes to be replaced with new finishes. Location of action: 175 CLEARWATER DRIVE,CUTCHOGUE,NY 11935 Site acreage: 52,664 S.F. 1.209 AC. Present land use: RESIDENTIAL Present zoning classification: R-40 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: DENNIS HICKEY (b) Mailing address: 1 BUCKINGHAM COURT,ST. JAMES,NY 11780 (c) Telephone number: Area Code( ) (d) Application number,if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes 11 No0 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. REVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space,makes efficient use of infrastructure,makes beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. ❑Yes No ❑X Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWR.P Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No El Not Applicable There are no historic or archeological structures on property. 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 Q Yes ❑ No ❑ Not Applicable ; Building structure is in keeping in style and scale of neighboring structures. 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 ❑' NoFX] Not Applicable Attach additional sheets if necessary Policy S. 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 0 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. ❑ ❑ ❑ 1 Yes No Not Applicable No development will take place in the"protected" or"natural indiginous environment". 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. X❑ Yes [:] No 0 Not Applicable The development will not add pollutants into the air. 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. 0 Yes 0, No ❑ Not Applicable Utilize the town's solid waste transfer facility in Cutchogue 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. - ❑ Ye�] No 0 Not Applicable No public land involved. Littoral access unimpeded. Attach additional sheets if necessary WORKING COAST POLICIES 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 0 Not Applicable There are no public or commercial activities or uses on site.Historically this property and neighboring properties are residential in use and will remain residential. 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 This project will protect and preserve the living marine resources by maintaining all rainwater discharge and sanitary flow from the residence on site by approved SCDHS sanitary system and drywells for rainwater runoff. 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 There are no agricultural lands on site. 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. Q Yes ❑ No ❑ Not Applicable The construction will be using equipment approved by the Federal government for energy usage.The residence will meet Federal standards for conserving_ energy "energy Star Program"and will use"NY State Energy Conservation and C ansirrtitioW Code"for construction of the residence. PREPARED By Tom Samuels. TITLE Architect DATE 11/8/2016