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HomeMy WebLinkAboutTR-8952A Michael J.Domino,President �QF SOUrTown Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 h O P.O.Box 1179 Glenn Goldsmith t Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD April 17, 2019 Luckyfront LLC 333 Central Park West#106 New York, NY 10025 Attn: Barbara Becker RE: 38015 ROUTE 25, ORIENT SCTM# 1000-15-2-15.8 Dear Ms. Becker: - The following action was taken at the Southold Town Board of Trustees regular meeting held on Wednesday, April 17, 2019: RESOLVED, that the Southold Town Board of Trustees APPROVE the request for a --- — -- Transfer of Wetland Permit#8952A from Amelia Mendoza to-Luckyfront LLC, as issued - on February 15, 2017 with the condition to no longer remove any more trees without Trustee permits, and all vegetation permitted to be trimmed be trimmed to no less than 3' in height. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. If you have any questions, please contact our office at (631) 765-1892. Sincerely, Michael J. Domino, President Board of Trustees MJ D/dd Michael J.Domino,President SQUTjsi Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 CA A.Nicholas Krupski y Telephone(631)765-1892 Greg Williams fif. Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD R APPLICATION FOR A TRANSFER OF A W'E'T6'XN-D' -P'E- FEB 2 1 2019 0 DATE LVC,K�rX0,Vr 61,C, OWNER PHONE MAILING ADDRESS AGENT PHONE ADDRESS (- PROPERTY LOCATION 0 TAX MAP NO. 0 2 2 1 S7 I/We request a Transfer of Permit# '?CK2- A- from, Signed By: Board of Trustees App,"Cion r 1 AFFIDAVIT GC.I''barot . BEING DULY SWORN DEP SES AND AFFIRMS THAT HE/SHE W THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. afore of Pro rty O.- er Signature of Property Owner i SWORN TO BEFORE ME THIS DAY OF. r✓_GC f_- 20� IhAllso' %11 ' 'QyP�N'CY,yc Notary Public ,�€ a MARY ANN LYNCH v'J;:,PUgtt�'�O Notary Public,State of New York qTF 0F'N�� r No.01LY4826838 mrmemn� Qualifled In Nassau County Certiitcate Filed In New York County Commission Expires May 31, aL2. APPLICANT/AGENT/REPRESENTATM TRANSACTIONAL DISCLOSURE FIRM Af � i n tr uth Id' - -bl tere d tl it to t w e ibiso v .n o • at'o w le neg ary to avald same. YOUR NAME: ' a vein � (Last name,first name, addle initial I unless you ape applyrng 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 Trasteo Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning 1 Other (If"Other",name the activity.) Do you personalty(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,rrtarr'iage,or business interest."Busirt0Ss interest''means a busrnrndess, 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. 4 ( YES — NO ._ ifydu 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 applicanttagentlt'cpresentative)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)tho owner of greater than 501*of the shares of the corporate stock of the applicant (when the applicant is a corporation); $)lite 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 ofthe applicant;or D)the actual applicant, DESCRIPTION OF RELATIONSHIP �2,�o�c/ . Submitted this Z.0 day o dr 20 [�_ Signature f ✓, Print Nam Form TS 1 ~ Michael J.Domino, President 0f S0Uly0 Town Hall Annex John M.Bredemeyer III,Vice-President h0 l0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G � O Telephone(631) 765-1892 Greg WilliamsO Fax(631) 765-6641 OOUNT`1,� 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 Y constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: e () Moke CERTIFICATE OF COMPLIANCE: °k i ' :'fir. , '� ns s �< � .. .. �,.; ,- `' '.°'"-_ �� ,. . . �. � - F- :. ..�_.�„� .., �; � �\� . . . > I I.. q 1 *)1# i , " �r • f� 7 �. lot, , r �F r 44��/' ►�. �'T • + � �^ 17.1 x � ��•T, + � ,� - �,1 � 1 - ' Or �f �� •rr d•_ is "�� {T R' "� 1 f�i•• � ���di�. 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SandersO Fax(631) 765-6641 Cow,� 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 1St day of construction Y2 constructed Project complete, compliance inspection Michael J.Domino,President ® SOujyOl Town Hall Annex ® 54375 Route 25 John M.,Bredemeyer III,Vice-President P.O.Box 1179 Charles J.Sanders N $ Southold,New York 11971 Glenn Goldsmith ® �� Telephone(631) 765-1892 A.Nicholas Krupski l�C®U Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 8952A Date of Receipt of Application: February 1, 2017 Applicant: Amelia Mendoza SCTM#: 1000-15-2-15.8 Project Location: 38015 Route 25, Orient Date of Resolution/Issuance: February 15, 2017 Date of Expiration: February 15, 2019 Reviewed by: John M. Bredemeyer, III Project Description: For a Ten (10) Year Maintenance Permit to hand-prune the vegetation landward of the top of bluff to not less than 3' in height with hand removal of invasive autumn olive and multiflora rose without ground disturbance. 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 Jeffrey Standish, received on February 1, 2017, and stamped approved on February 15, 2017. 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. Michael J. Domino, President Board of Trustees II x,z1.asu es LK mAvwc=TD wav,D. Lt2i ou11u SURVEY & TOPOGRAPHICAL SURti'EY OF PROPERTY 03sr0!G,QxvAl0,0 Ma•i1tam?H=xr. L==w GGwm a tam An sw.,nros SITUATED AT I MWAM Tim rJ/AC "ti.s W0000n 4Quw a faDO cAuxtm ORIENT 1 TAW4 Y DY.,•-0•MP *WW*A)W LLAODc SYMO rpt A s MOMM 1f0M 0 500-q M 20DEWAU ANEL TOWN OF SOUTHOLD r ro0+ 1A' ow,s•aa: SUFFOLK COUNTY, NEW YORK $r LrAcaroa S.C. TAX No. 1000-15-02-15.1 Ione mmrwm T" sr-ALE 1'=100' A.TM LDCAT70A CO MU AM=W'=l 91v,111 HMO"Of MOU MD 09MAT100 At0/M(TATA MMW ROM MMM OCTOBER 11, 2001 L ftD002010:wor"f*TAMrxov% %OVDA N 29,2001 ADOm TOPOMOWAL SLWM RD00 11'WIAIK.[RATL Y✓1Y••,.SMSM067 0♦ALO]NON G WT 14,200=ADOM HC FLM Nc Ar va A000 tiidumm orrvwm 7 MAY M 200=AMCD U)A FASDIfAR IIAr K cwt L nwa r vasa Y MDAD C."ALTpx); UKZ FL=vz"c4m CETE" 117 TDTAL AMA. 1.162.MA0 A. M. 201K X. AYL4S 01 A00-YDA RDao.v d Ioo-.rAt1 limo r r»r•v+tct (fe n tn4 24APO xs. 0m1x p ua rw,t t mat ca vnM PW-"M9M LLT N" 1 3"K YlL AN ARRA P+OPEM tr L"n ntcw t00-mO rLwo 2D•4! /CAS cEromm=A RL CLIO=900-fDA ILOWkAk ' ►rvloerYrunT R �O RD OF . UISTEESf�'� P4a1a D.A., n 2.W TO N OF SOU.;T HOLD 501r1 M DATE �i�A �j is, zol 7 S�T`D •� -� ��.;ti__--_ G ON r'A LA' � � +—i• twfC [p r I �.,,t •`� It ��3y i000n. �•n` ! j p�•C• t �/ 2• S 1� TtO L�� '• tl'?'9 Va \ 'HK 1 �� �. d. `1''ti as 9' \ �• ONO o MfY --' � E � x,u •1..-til 1 `, �;3 ,., r } FEB p 1 2017 11 itii1��,�Y�CI a l.�r••, ` l , � �` •'L _ � ,� YW / x1°• • f `lb d7 -oP 62 FEB - 32016 - - -Board fTrustoes Michael J. Domino,Presid, J ,( �O U���l� Town Hall Annex John M. Bredemeyer III,Vice-President �j, 54375 Route 25 Charles J. Sanders co P.O.Box 1179 Glenn Goldsmith Southold,NY 11971 A.Nicholas Krupski Telephone(631)765-1892 � x Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in field by: AMELIA MENDOZA requests an Administrative Permit for a Ten (10) Year Maintenance Permit to hand-prune the vegetation landward of the top of bluff to not less than 3' in height with hand removal of invasive autumn olive and multiflora rose without ground disturbance. Located: 38015 Route 25, Orient. SCTM# 1000-15-2-15.8 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: I 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: See ti n '310ec e-ler F /cl Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 Michael J. Domino,Presid, j O���UFFOL/(�,oG t Town Hall Annex John M. Bredemeyer III,Vice-President r��` �j, 54375 Route 25 Charles J. Sanders cm a P.O.Box 1179 Glenn Goldsmith Southold,NY 11971 A.Nicholas Krupski ?,�Q fid! Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: AMELIA MENDOZA requests an Administrative Permit for a Ten (10) Year Maintenance Permit to hand-prune the vegetation landward of the top of bluff to not less than 3' in height with hand removal of invasive autumn olive and multiflora rose without ground disturbance. Located: 38015 Route 25, ,Orient. SCTM# 1000-15-2-15.8 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 ;, �t� f � '1 F r I' r , � u,s, �.. � ��i���,-�� � . .y,� S � �� � �� ���� � � a . ,, ,. � F. .'�. ��� ,�, � � ` ' ,�,rc e r 1 ._ �y '.{• _ �`--,�M4 9)1�. .A�`�-.� i, ''t��.. ,� � r:c�� r�,��� ���� t�tfr r y�. � �r� � �� l�r� 3 � ( /�fi. i ll '. - _ �..,4 '3 ,,ti 1•<.��>�_.,.t � i"�' as�•:Ys+ � .y_ �� ;•� I ��' s„:� � 1 �' 1j ... ,� `�v Z_--_ .r; ,. � r&'. �R .,t sTah "t w'',ki' � �4` � ��P � v:r,;tY. ry. �J' f�. �%�'•'g. '. � . 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Y tQs "a s 2 NOTICE COUNTY OF SUFFOLK © K tb ovmo, SOUTHOLD SECTION NO "iw.•u.-,--_ je"."' _Fi:`, a$,:y _ '+a.- -- —— _ - - ""'"'E"""`e""•,"a",a,,; Real Property Tax Service Agency v .,•,......,015 •-te�a x'Me - '.ax 1-. ;K;= �:[,}.:: _.,c-aw-'r. �•yy. .' ,.w r+.y,: "'siS;. tea."` �[ r,,,`47 - .}t _�,fi,d�,', Z�:.f '3•, ,`i'^.r'7� q WI _ '°4S - hH" - ,5yy�w�,^^* .3.c=.icy ?, y'`+..]^ ti.. .zzct'.4-pyo .1,'s```"Yfi•`ds t .� .'w,.• ",4• "cc ti. s>,'1.�.�..Ug.i� '�*��rf ke' Qq . `t �G?t` a«.5i- -4, mss,:,+t"?.'4»a' ...e q �y�i.�,yp :3 _,t•'}a`)".Tr. ,y� ;F .'$>:.�... T.z{, .y3.+'a+a' ,ari.-.r..,'��:.�,�-c,, •v a...µ�` r-., � .,�; �,{ c'.L�'`g' ,` �,.�.,. i�, ..x. •:Y H'_f'fii'S :rt - ?4' ':,�.' ,`*c•. ��.-.1. T -�:•,. �? _�Y.�,s t , -.y. .„ ;,im::Y .;� -:'.u :1na ::F.Zi,..:� il•. -t'...,F.2; .it.a 3... ,.. - - .•� .. u._ ':�. ,.91r`• .2' '3.,�'.iT.-rc,: ',i.,� ,•� �.r.f°"-�;.., t4;,k„ .;�.. �1;'<r:; r:��:,-,!,.:'r rsi.- ..:r+r` t^• .v,+�•r., � �•. -.. 2 '._,.,.4{x - •.?'w'..�Y ".:V�:.'.•;. i*�'"a3` 3'•rt:".':.r: :'?i's^Y'.s`r'rS-""a: ii:ze:.j�h:lfit£�r-`.r.''>b+-t (.}"'-4^%-•'�:';n'x.Y>f•.rtY .., .. OFFICE LOCATION: ® MAILING ADDRESS: Town Hall Annex P O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) � Southold, NY 11971 ® aQ Telephone: 631 7654938 O Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: February 8, 2017 Re: LWRP Coastal Consistency Review for AMELIA MENDOZA SCTM# 1000-15-2-15.8 AMELIA MENDOZA requests an Administrative Permit for a Ten (10) Year Maintenance Permit to hand-prune the vegetation landward of the top of bluff to not less than 3' in height with hand removal of invasive autumn olive and multiflora rose without ground disturbance. Located. 38015 Route 25, Orient. SCTM# 1000-15-2-15.8 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 INCONSISTENT with the below listed Policy Standards and therefore is INCONSISTENT'with LWRP. 6.3 Protect and restore tidal and freshwater wetlands. A. 'Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction A Wetlands Permit (5834) was issued to restore 4900 square feet of an area "within the seaward edge of the limit of clearing and disturbance and landward edge of top of bluff" following a violation in 2003. The permit follows. The vegetation in this area contributes to soil stabilization and bluff integrity. The proposal lacks plans and details. : � ` . . U Age Board Of �So'uthold Tom Trustees . 11 ..we' SOUTHOLD, NEW YORK PERMIT No. 4 DATE: --Nov-- 20031 P4r&uant to the proyisions of Chapter 615 of the Laws of the State of Now York, 1893-9 and Chapter 404 of the Laws of the State of Now York 1952; and the Southold Town Ordinance en- fitled ."REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and fhe REMOVAL OF SAND, GRAVEL-OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;" and in socordance with the Resolution of The 86ard adopted at a meeting held on Nov. 2003 id by ­.., and in consideration of the sum.of Pat Terms and 'Conditions risfed on the reyerse s1de hereof, of Southold Town Trustees authoeizes and permlits t6 fodowiing: Wetland Permit to re-vegetate 4000 sq. feet of disturbed are within the seaward edge of limit of clearing and disturbance and the,landward edge of top of bluff witb Rosa rugosa (2- gailon pots). 'a in acc�idanee with the defa&d specWicafions as presented to IN WITNESS WHEREOF, The said Board of Trustees hare- by causes ifs C�c"rate Seal to 6e affixed. and "o presenfs to be subscxiibed bya majority of fhe said Board as of this defa. ClAt eL4 Nv AL NOW 2_093.m PRIT Pursuantto Chapter 268, the Board of Trustees ohmU consider this recommendation in preparing its written determination regarding the consistency of the proposed action. John M.Bredemeyer III,President q,SlkfG� Town Hall Annex Michael J.Domino,Vice-President lG� 54375 Main Road P.O.Box 1179 James F.King,Trustee Southold,New York 11971-0959 Dave Bergen,Trustee Charles J.Sanders,Trustee .�O Telephone(631)765-1892 CQu ,� �i Fax(631)765.6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application _Wetland Permit Application Administrative Permit / Amendment/Transfer/Extension _ Received Application: Iz( QC �-aReceived Fee: QQ y�Completed Application: 2.1, r � _Incomplete: FEB - 1 2617 `", _SEQRA Classification: Type I Type II Unlisted Coordination:(date sent): i ZI.WRP Consistency Assessment Form: �'«t 17 Southold Taw CAC Referral Sent: L-ILO-ald T uS!EnQS __J Date of Inspection: 3•I o _Receipt of CAC Report: _Lead Agency Determination: Technical Review: Public Hearing Held: 3A ZZ-17 Resolution: Name of Applicant: a ml?t(a Mailing Address: p _ ^��,� ��- �,( �]�L? Phone Number: Suffolk County Tax Map Number: 1000- Property 000-Property Location: Sgoi m, a T (ol Q Ulf (provide LILCO Pole#, distance to cross streets,and location) AGENT: (If applicable) Address: Phone: Board of Trustees Application GENERAL DATA Land Area(in square feet): OCO S Area Zoning: — _ Previous use of property: Intended use of property: 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? 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 any demolition as per Town Code or as determined by the Building Dept.? Yes _ No Does'the structure(s)on property have a valid Certificate of Occupancy?___4 Yes No Prior permits/approvals for site improvements: Agency Date rt 4SWX l I )-V10 9L 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) U eW Mk1-*ena nC- kcn R -AD Q ire,- I (\ lar*M-W ot- -gyp n�- -C�' -+D Nffifiky7, rb JW- X44 .Vd Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATI®N DATA Purpose of the proposed operations: Wand �YU�1 d. (7����1'1 L0 0'1 11z dLlZ��'Ibcmce. 40 Vol- n LCWSpr b-g f; err mpl( mqh Area of wetlands on lot: square feet Percent coverage of lot: 7� Closest distance between nearest existing structure and upland edge of wetlands: ©UPW I Od I 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: -tars nnwino btu bad 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): 1`��o r✓� —P use t®win, ho a miy M Ay boa m , u� I 617.20 Appendix B S/:ort Environmental Assessment Form Instructions for CompletinIz 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): M m pyl e,l+ 1'! -a-I g Brief Description of Proposed Action: Name of Applicant or Sponsor: Telephone: ksla E-Mail: Addre s• City/PO: State: Zip Code: 1,Does the proposed action only involve the legislative adoption of a plan,local law,ord—irIce, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that EI 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? acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial [:]Commercial (Residential(suburban) ❑Forest KlAgriculture ❑Aquatic ❑Other(specify): ❑Parkland Page I of 4 I 5. is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ 191 ❑ 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? ❑ M 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: FV] I.-1w ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES a ❑ b.Are public transportation service(s)available at or near the site of the proposed action? IM ❑ 91 c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 10 ❑ 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: Q_._— El 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: n�t9� ! n ❑ 12. a.Does the site contain a structure that is listed on either the State or National Registei of Historic NO YES Places? b,Is the proposed action located in an archeological sensitive area? -� ❑ LAJ IT 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? F] b. Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ® El 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 El Forest E&Agricultural/grasslands ❑Early mid-successional Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? � ' ❑ 16.is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, k a.Will storm water discharges flow to adjacent properties? ❑NO YES ❑ ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO OYES Page 2 of 4 18.Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: E 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: © ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: I v 1' I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/spsor name: t�t'1 Date:. //3��17 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 large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? IzI EL 3. Will the proposed action impair the character or quality of the existing community? l� 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 r Ll 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? 2 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, F]waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 e i Fi 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? Q 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 76& acts Town of Southold-Board of Trustees y Name of Lead Agency Date President Print or Type Name of Responsi e Officer in Lead Agency Title of Responsible Officer Signature of RespUsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of r ' Board of Trustees Application AFFIDAVIT 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 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 Property Owner SWORN TO BEFORE ME THIS DAY OF Joc nUa 201] Notary Pubfic LAUREN M. STANDISH Notary Public,State of New York No.01 ST6164008 Qualified in Suffolk County Commission Expires April 9.2019 Board of Trustees Application AUTHORIZATION (where the applicant is not the owner) I, a ft ia VYIQ,ml m residing at P0 A _ (print name of owner of property) (mailing a dress) Cd ao� � N I I qC,,.r) do hereby authorize (Agent) to apply for permit(s)from the Southold Board of Town Trustees on my behalf. (Owner's signature) APPLICANUAGENUREPRESENTATI'E TRANSACTIONAL DISCLOSURE.FORM The Town of Southold's Code of Ethics"prohibits cbnflicts of intorest on the,in,rt of tow»officers and•emnloxees The,purpose of this form is'toprovide informntioawhich can alert_tlte town of possible conflicts of-interest and-allow it to take whatever action is necessary to avoid same. ,r n,,,��� YOUR NAME: k_k Ualk.�1L�/" (Last name,first name,piddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance _ Building Variance Trustee ✓ Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other",name the activity.). Do you personally(or through your company,spouse,sibling,parent,or child)have a.rcihtionsltip with any officer or employee of the Town of Southold? "Relationship"includes by blood,niarriage,or business interest.`tBusiness interest"means a business, including a partnership,in which the town officer or employee has even a partial,owncnhip of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO q,/ I . If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by tite own�o�f,S�uthold ,( 5h — Title or position of that person–� v� +UQ* xZ Describe the relationship between yourself(the applican age�Y? and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the spa 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); F3)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 this3� day of� 20�� Signature t Print Name yAA4 c! /./1 Form TS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for pennits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal areatwhieh 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 supportinh and ilon- 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# PROJECT NAME AM LM a1+d,)D 7U The'Applieation 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 U construction,planning activity,agency regulation,land transaction) ❑ (b) Financial assistance(e.g. grant,loan,subsidy) (e) Permit,approval, license,certification: LAJ, Nature and extent of action: s Location of action: UP Site acreage: Present land use: ����+n, 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: C V� (b) Mailing address: No (c) Telephone number: Area Code O ' (d) Application number,if any: Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No Q If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not 'support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space,makes efficient use of infrastructure,makes beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section III--Policies; Page 2 for evaluation criteria. F]Yes F-1 No Z 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 1-1Yes 0, No Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary NATURAL, COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages S through 16 for evaluation criteria Yes [] No FQ -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. Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. Yes [:] Nor 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 evaluatiop criteria. ❑ Yes ❑ No 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. n(� 1:1 Yes Nol�,Not Applicable Attach additional sheets if necessary, k; J NVORIUNG 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 "7C 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. 1-1 Yes F] 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 1:1No 1� 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 TITLE DATE 3 JL-A2