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HomeMy WebLinkAboutTR-9064A _ f i *ZF SO Michael J. Domino, President � yQIO Town Hall Annex John M. Bredemeyer II1,Vice-President 54375 Route 25 P.O. Box 1179 Charles J. Sanders Glenn Goldsmith Southold,New York 11971 � � O ® �� Telephone(631) 765-1892 A. Nicholas Krupski l,Y��UPJT�,� 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 1St day of construction Y2 constructed Project complete, compliance inspection r a Michael J.Domino,President O�'�zf S®UlTown Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Charles J.Sanders Southold,New York 11971 Glenn GoldsmithG ® @ Telephone(631) 765-1892 A.Nicholas Krupski '® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9064A Date of Receipt of Application: July 14, 2017 Applicant: David Thorn & Alice Leiner SCTM#: 1000-44-1-25 Project Location: 56525 C.R. 48, Greenport Date of Resolution/Issuance: August 16, 2017 Date of Expiration: August 16, 2019 Reviewed by: John M. Bredemeyer, III, Trustee Project Description: To construct a proposed ±22.5'x29' deck over garage with railings and stairs to ground. 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 David Thorn, received on July 14, 2017, and stamped approved on August 16, 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. o Michael J. Domino, President Board of Trustees c y VOLS 1Z. t - Sri 0&IZ FF elk a . APPROVED BY 4 RD OF TRUSTEILIMAAW' - TOWN OF SOUTHO EAS- LEL - DATEv�v sT' rt 2017 6 D ECC V JUL 1 4 2017 Southold iotivn oT e 16 1 s a Ilk it E � r a JUL 14 2017 . " Southold Town r of s e Michael J. Domino, Pre OQSQFFO(1(COG Town Hall Annex John M. Bredemeyer I11,Vice-President �� y� 54375 Route 25 Charles J. Sanders cm P.O.Box 1179 Glenn Goldsmith Southold,NY 11971 A.Nicholas Krupski p! Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: �� / l ��- /� Completed in field by: DAVID THORN & ALICE LEINER requests an Administrative Permit to construct a proposed ±22.5'x29' deck over garage with railings and stairs to ground. Located: 56525 County Road 48, Greenport. SCTM# 1000-44-1-25 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of aring 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/standa ds: 14 Present were: /J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 OS®� tfFOj�C�� Town Hall Annex Michael J. Domino,Pre z John M. Bredemeyer III,Vice-President �� 54375 Route 25 Charles J. Sanders o P.O.Box 1179 Glenn Goldsmith o Southold,NY 11971 A.Nicholas Krupski ,,�� Cpl ,t Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: DAVID THORN & ALICE LEINER requests an Administrative Permit to construct a proposed - ±22.5'x29' deck over garage with railings and stairs to ground. Located: 56525 County Road 48, Greenport. SCTM# 1000-44-1-25 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 SC,TN H0. olsmcT IDDD S[cf0N.AI BLOCK I LOt(s)?5 _N 16 Ot O 0 NKppO • -L C�SiK Lpa9AA N J O. O ,tape e aNc - m 9IY k0t nw a Its I t` srY ;no lWu m $ g 9] m •�� y�� dddEEE 'Z CP CS� SWi e4Y 4:b m ' b MIDDLE ROAD C.R.48 (NORTH ROAD) tN£WAIER SUM r.B£uS EWrNf7e5 AND elssPaOL LOCARONS SHOWN ARE A1ON ItEtO 1R,SfAVAMANS AND OR DATA OBTARg3 FROM O1W£RS AREA:28,000 SQ•FT. or 0.89 ACRES CLIVAnOV DA4A1,-_- 0NANMWt12ED ALMRARW OR AaLUOV TO RRS SURWr IS A W&APaV Cr ZCNav A20R or Noy NCW rax SIA1C LOUCARLW LAW DUPrtS Of IM$SURVfr NAP NOT$£AMNO 01£LAND SURv£rOWS£NMUD SIAL SHAD N01 St C6VWPCD tO BE A MV AKIN COPY DUARAINIM;1RDWAAD W*(4W$HALL RNR Of r r0 RXRWSON FOR OW THE 5UR6£Y 15 PRMWD AND ON HA 8CHA0 10 RNC Rrit 4WANY,60WRNMtN7AL ACENCr AHD CCNOWC WSRRtBON US1£D IXACON.AHD f0 RAE ASWAVf£S OF 7W LOOM WSFIAMV,4UARAN1ta ANI£NOT MAN50£RADL[ 1AY&FSEIS OR Ow£Nsays SHOIWN HFRCON FRW W PRaPV?tr'LVKS 10 Mt STRUCtURtS ARE fW A SPMOC PURPOSC AND UV"PtFWT DPCY AR£ not AMENDED 10 NONUW.Nt TN£PNtOPD?tY LINES OR W CVA£tH££RECKON OF FCNCCS.AMWVAL SMUCtEWS OR AND 004M MMOHwMIS. EASEWN7S ANDIM SIMIRFACE S7RUCIUR£S ACCORDED DR DNRCCOWW ARI NDr a7URmrao UNLESS PNYSICALLr rwmwr am RL'PRLLISCS Ar IHI RNC Or$RWY SORVtV OF:DESCRIBED PROPERTY CERTIFIED TO DAVID LYMAN THORN; NAP or ALICE DOROTHEA LEINER, FILCO• FIDELITY NATL TITLE INSURANCE COMPAW- SItUA110 At CREENPORT Tom OF.SOUTHOLD KENNETH_M NOYCHUK LAND SURVEVINO. PLEC SUFFOLK COUNTY,NEW YORK * Protooslcnal Land Surveying and Deatgn P.O. Bas 193 AqueboQue, NOW York 11931 FILE 117-3D SCAtE�1-w30 OAPZ MARCH 20, 2D17 pNaNE 031121111-16" EAX(eal)epe-leen Of S LISC Na 050857 mNlhwb R.•—4.N 0—1.1`--•6ww6 V••1skd, nn E Env JUL 1 4 2017 t SoljUmld Town Baard of Trus e s ti i l 12_ 9 (-Pao k +-owcsd � 12/201�L- �� ^ �+fA C 1Cty)ak (7 t� r James F.King,President �0 SQ(/Ty Town Hall Jill M.Doherty,Vice-President OOl0 53095 Route 25 Peggy A.Dickerson l P.G.Box 1179 Southold,New York 11971-0959 Dave Bergen en _*W Bob Ghosio,Jr. '� i0 Telephone(631) 765-1892 COU Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 6922A Date of Receipt of Application: July 2, 2008 Applicant: John & Marianne Clarke SCTM#: 44-1-25 Project Location: 56525 North Road, Southold Date of Resolution/issuance: July 23, 2008 Date of Expiration: July 23, 2010 Reviewed by: Board of Trustees Project Description: Replace the existing deck over the garage. 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 Bob Bohn, last dated August 18, 1998, and received on July 23, 2008. 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. /N--, o j5r James F. King, President Board of Trustees JFK:eac MC7� [� - -- - ---i I' OCCA of 61 >� J& AP FES AT N SM 9 AM TO 4 PM FOR THE p� I'�t APjDF ED BY FOLLOWM �' S7�R I coNcr&W D a�i�sT21��"Z BOARTRUSTEES a FINAL . , TOWNOUTHOLD - CONSTRUCTION Must„ SATE � 0BE OOMq UC FOR CO. - ./'ALL CO?NSTRUCTIONSHALL MEET° •THE REpUIREMENTS OF THE N.Y. `vOCCUPANCY OR � / STATE CONSTRUCTION & ENERGY USE IS UNLAWFUL CODES. NOT RESPONSIBLE FOR �►■ DESIGN OR CONMUCTION-ERitORS y�THOUr CERTIFICATE of OCCUR p E C E d E - ► �.. � � 1pC> 4 u�.n� J U L - 2 2008 5x-i�(a,.a,d N q 114 7 1 So,+',,dc(" N'.3 li471 Souihhold Town Board of Trustees FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. CERTIFICATE OF OCCUPANCY No. k..Mq............. Date ...............................` ....... THIS CERTIFIES that the building located at ......................................... Street Fishers Is. Estates Wilde tress Point Map No. ...................... Block No. ...................... Lot No. .......................x'15 =35..•3ik�t .... •• � conforms substantially to the Application for Building Permit heretofore filed in this office dated .....................................Oat..........9........... 19...6.7 pursuant to which Building Permit No, .30%. dated ................QC t..........9.0................, 19.67.., was issued,and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ........ .....Pkinto..Quo...fay:.AW.011111a.......................................................................................... The certificate is issued to .... aQn ?,3 A aY3 .....................!NA'?y............................................. (owner, lessee or tenant) of the aforesaid building. Building Inspector § § ell SOJA / I COUNTYOF SUFF51 / I a0 0�t 'lc ,04A I / O 0 FOR PCL NO SEC EC NO EE9, $ A I � I oar / s\� CD , 0 I t COUNTY 31 75 4A COUNTY OF SUFFOLK • SC\y 6, u mo LO 48•s\ 43 g•,T� 0 9 \ \\ 7�. 4d1,1o\ m ^ — 3 Y 'g MATCH LINE t '4\ SEE SEC NO 053 0 T � \ ,g 3 Nxo,m 9 SECTION NO COUNTY OF SUFFOLK © a.n� of soumoLo r. ti.�.._,;__ �...,•_`-.v �". �.-_`. _ -_ - _ _ __ -- —_ - -- ___ - -_ _ _ _ (- Real Proper.rry T.ax Se gency .a.o v 44 -- - � f y a �®F SO!/l�, OFFICE LOCATION: MAILING®�® MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) Southold, NY 11971 ® a� Telephone: 631 765-1938 C®UfVT�,� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: August 11, 2017 Re: Local Waterfront Revitalization Program Coastal Consistency Review for DAVID THORN & ALICE LEINER SCTM# 1000-44-1-25 DAVID THORN &ALICE LEINER requests an Administrative Permit to construct a proposed ±22.5'x29' deck over garage with railings and stairs to ground. Located: 56525 County Road 48, Greenport. SCTM# 1000-44-1-25 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is EXEMPT from LWRP review pursuant to: §268-3. Definitions. MINOR ACTIONS items `71"which states: ll. Additions to an existing building or rebuilt residential structure which results in no net increase in ground area coverage, except where'the parcel is located in a coastal erosion hazard area; The action is not located within the Coastal Erosion Hazard Area. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. �� <� 54:375 Main K03d Michael J. Domino, Vice-President F P O. Box 1179 Jarnes I= Feng. Trustee ` Sd` ld. New York 11971-0959 Daae Bergen-Trustee Telephone (631) 765-1892 Cliarles J. Sanders.Trustee fly Ea..•c(631) 765-6641 BOA-.ID OF TOWN" TRUSTEES D TOWN OF SOUTHOLD JUL 1 7 2011 To- Southold-Town Building Department Re: Verification of Building Department Permit Requirements BiTI ' T®W1�1 OFSODEPTUTH®LD •, SGTM#: q Property Owner(Mame: r ��OM) p�L� � �a, �� Date Sent to Bldg_ Dept_: The Office of the Board of Trustees is forwarding the above referenced applicatioa for verification of the Building Depart-inent's permitting requirements stated below: --YES NO Will the proposed project require a Building Permit? Will the proposed project require a variance determination from the Zoning Board of Appeals? - Wi[I any-part of this application be considered as Demolition as 'described under Town Code? COMMENTS: l I W Signature of eviewer Date �Z¢ so��y Michael J.'Domino,President �O� OlTown Hall Annex 0 John M.Bredemeyer III,Vice-President 54375 Route 25 im P.O.Box 1179 Charles J.Sanders N --Ibc Southold,New York 11971 Glenn Goldsmith ® Telephone(631) 765-1892 A.Nicholas Krupski' ®l�`OUM Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extension ReceivedApplication: Received Fee: $ 100MU 2 E p // Completed Application: E C'p ll Incomplete: SEQRA Classification: Type I_ Type H Unlisted JUL 14 2017 Lead Agency Determination: Coordination:(date sent):� ,�LWRP Consistency Assessment Form Sent. Southold Town CAC Referral Sent: Board,of u Date of Inspection: < < Receipt of CAC Report: Technical,Review: Public Hearing Held: a/ Resolution: Legal Name of Property Owner(s): N j3 1 F;caAl Atj iD 4-L-i l iyX9, Mailing Address: 4006 ,� S47: '=C41 UC4- q%t Phone Number: aOG 62-'A 1(4,470 Suffolk County Tax Map Number: 1000':- 44 -° i ­ z s— Property Location: ` �1� '"�1� co (If necessary,provide LILCO Pole 4, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: oard of Trustees Appli.cai' n GENERAL DATA Land Area(in square feet): C 0 Q Area Zoning: Previous use of property: Intended use of property: Covenants and Restrictions on property? Yes ZNo 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 requir any demolition as per Town Code or as determined by the Building Dept.? Yes J No Does the structure-(s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No Yes If yes, provide explanation: Project Description(use attachments if necessary): ek--J v% 9 ' 22. s its�� iI C-0.0e e-,r \q tnS �1 Jk j\ �;L��t� '12-2.,S a n t, WDA 425115- Z 1 SSupP 04 �4 I bard of Trustees Applicat n WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: S�� square feet Percent coverage of lot: -?)0 % Closest distance between nearest existing structure and upland ��a C,M- E�N e i C0 edge of wetlands: 6 feet Closest distance between nearest proposed structure and upland edge of wetlands: b-0 feet Does the pro' ct involve excavation or filling? �J 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): �6 617.20 Appendix B Short Environmental Assessment Form 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 l 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 Name of Action or Project: 4,0 9 ® CC-L Project Location(des r e,and attach a aation map): C3ii r-a ao a- t ac ®cC+- 5 kt&%ir 5a cc" aV34th saLhC�-Qcg%g, -2`S' Brief Descri tion of Proposed Action: 0, c do,iQS 1 t ' ;roY23w CQ OVee Name of Applicant or Sponsor: FEail: phone: ®G � o 1 MCA Address: City/P� ,a � State: ��ICode:, � 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that ❑ may be affected in the municipality and proceed to Part 2. If no,continue to question 2. Leff 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO AS If Yes,list agency(s)name and permit or approval: ❑ 3.a.Total acreage of the site of the proposed action? S7 I acres b.Total acreage to be physically disturbed? t!::) acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? ° 5-9 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial 2<esidential(suburban) ❑I;orest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. is the proposed action, NO YES N/A a,A permitted use under the Toning regulations? F] ? ❑ b.Consistent with the adopted comprehensive plan? El 1:1 17 6. Is the proposed action consistent-with the predominant character of the existing built or natural NO YES landscape? -T-1—sthe siteof the proposedactionlocated in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify- N/ 1-1 A— 8. a.Will the proposed actionresultin a substantial increase I in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? UF] c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? F] 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: I I.Will the proposed action,connect to existing wastewater utilities? NO YES If'No,describe method for providing wastewater treatment: 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? F] 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;i federal,state or local agency? El Z b. Would the proposed action physically alter,',or encroach into,any existing wetland or waterbody? LZ If Yes,identify the wetland or waterbody and extent of alterations in square feefor acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply- 0 Shoreline 0 Forest 0 fidulturallgrasslands 0 Early mid-successional El Wetland El Urban Vsuturban 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 XS If Yes, r--V a. Will storm water discharges flow to adjacent properties? ❑NO [:]YES- I V1 b, Will storm water,discharges be-directed to established conveyance systems(runoffandstorm drains)? If Yes,briefly describe: FINO EIYES, Page 2 c)F 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: ❑ 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: B ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO As 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/spo name: OCA `� � Dat 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 El Elregulations? 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? E ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the El 1:1establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El 1:1affect 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 El ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ 1__J architectural or aesthetic resources? 1__J 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, 1:1 Elwaterbodies,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 1:1 E]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. F] 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. ElCheck 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 API'L.ICANT/AG&Y'f/Rrl'RESY,'NTA'rlvE TRANSACTIONAL DISCL,OSURIT;FORM ;L�'I':inn ufsautho}d's C'oIe of Ednti�eattJ h s r+Qim aC:�t^rc;tnn ijts;,�tt_OS1ft5YD,4A1£t s Anil emnJuverc 7'ht rttur�,ro_r.!?$ this tato;is W uravidr nJf4tp1 +con which epn sltrt IJl�;4u.1}nt rucrihJe ulntitcMvfinicr�tt t+<tdl w Jt to n- vJuet v�a��j fryessJryyn avod,Fnmt, , YOUR RAMP-_,'��L4_5.�3.�/__� (Lost mume,first name,oudJi'inihai,am_ yvo areF—n~j}':g fit uarAe of s»m.one ciSa vt atltat rnthy,saeh:u a tampatt}'.If So,mJuate U,a other }+crsoa's nrwm}nnv's Dame.) NAME OY APPt.ICATION (Cheat idt that opp},v,) Tcrt+;nevuwn i)udJmg Variwwg (costae rlmnge ofTmne Ymston Approval of rlat _._.___.._,._ bfornng , —..•____.... rwoption frons Plow vm�tal loan �. . Planning Other ft6 you per%nrily for d,mugh your company,spoune,siblinf:,parry or rhdd)havo a rclahonship with Any ottioer or emoloyce of the Taw,of soothntdl•`Rclmianship'hmledet b}hlwnl,niaa Sage.,r buumass inures:,"fsysfrn^ss}nwrest"+w-e a busin<ra t oluJiog a pwmrinp,it,rluch dm tatvn officer oP tmfiloyea ha evcnaprritaJ vwocr Jsq,of{aremptoymtnr by}scamsration in wti+ch the Io%a atLCrt nrcmpluyte owns mora than 5".0 of shams, YES W) Iron nn cm,d"YP%'t4n,f,iero the b.,lant.e or dsts ionm and date u.1sip wt..indi-rod. }Lena of}carrot cinplayrJ by 3:t'rnits,of S,r,tehold _ IJtsenha the rclaTwasfup txlaczn yourx;iftdra n1+pb:tos4'agrnr,'rcpraarntaiival re?d the town uil7rcr or ciaplaycu^E;ittur check the appropriate fine A)tn,ough U)andor dw,It,,sn it.,space frovtdcd the town officer or cog+mycc or hta or her;,pou^c,5tbhn8,Wrt jt,or r1nW is(cJ+ctic all;fia(apply). - A)the o+vner of grwater than 5%(If 11w slums of the corptato,luck of the appjl�nt (}then the apphcan(rs a corporatfor0. the loyal or Ixrrfterul o,tnerarruty rntmrst m a uon-rrarl wrate"try(wfma the opphrnnt v;not a rolpomnon) C}an"Ricer,duoctor,poruter,or emplo)xe of It e apphc to Of _«�D)lira actual apphai:t. DLSCRtrnn1,s or•REJ,<j JONSI lip' subathted this dax`of X04 Signator Trent Name Form ISI AIDr ;I I i Board of Trustees Application AFFIDAV17 A /1 ' 1 vie v- -!�—e—1t, Le- BEING DULY SWORN DEPOSF,S,ANDAFFIRMS rll/VflifU,�IE isnlu APPLICANTFOR TnEABOVE I)FSCRIBVD PERMIT(S)AND THAT ALI-STXFE11VjrNTS CONTAINED 11BREI.N ARE TRUE TO THE BEST OF HISIllyl?KNOWLEDGE 13 F D, LLI F,AN THAT ALL WORK WILL BE DONE IN Tilt MA-,NrR SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD TAIL TOWN OF'SOUTHOLD AND THE BOARD OffRUSTEP-S HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE,OF SAID PERMIT(S),IF GRANTED. IN COM&FTING THIS APPLICATION,I HEREBY AUTHORIZE THE TRITSTEE'S,THEIR AGENT(S)OR REP)RFSFNTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY 7'I) IINSPEC'I'THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPLCTION. I FURTHER AUTHORIZE Tlfl&i 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,TRUST BPS DURING THETERN OF TILE.PERMIT. SWORNTO BEFORE-Mli.THIS,JA DAY OF 4) 2o DAVID PLETCHER Notary Public Notary Public State of Washington My Appointment Expires Aug 29,21020 3oard of Trustees Applica n AFFIDAVIT Dqv �eo - I- cats 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. L� Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF J L , 20_Q_ otary Public 6�" - JEAWMRIE ODDON Notary Public,State of New York No,01 OD6261238 Qualified in Suffolk County Commission Expires November 1h,20 f � APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The puroose 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. YOUR NAME: t+<3 y%V_.% L (Last name,first name,ipiddle 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 ll g (If"Other',name the activity.) tau IS�`('g1s;'i �l�.�l Gh S—AcN'1 ' Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of th hares. 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 Jk Submitted Pis-4Z day of Signature Print Name ®aq %C:- -_,E-Aso Form TS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS I. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. -Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# PROJECT NAME (C)fn -e_$(5+-(v7 C&C'e_ CV-C, e. The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees r 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: P Location of action: tj� Site acreage: Present land use: C �,� �,��,_ t� ( W Present zoning classification: La,5 f cLewh d 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: VCA%4I CnJ AA Cc! (b) Mailing address: 0 K--C, �� (c) Telephone number: Area Code (d) Application number,if any: Will the action be di undertaken,require funding, or approval by a state or federal agency? Yes ❑ No If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ NoNot Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Pol' ies Pages 3 through 6 for evaluation criteria 11 Yes 1:1 No Not Applicable Yes No Not)_ ilicable 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 37APplicable aluation criteria. Yes [:] No No Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. 1:1 Yes ❑ No _ 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 outhold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. 1:1n Yep--1 No Not Applicable Attach additional sheets if necessary 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 zy'. ❑ No ❑ Not Applicable Ce k a ► ,2�= Cs!! Va 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 PaVr8 through 16 for evaluation criteria ❑ Yes [ No [�rNot 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 throu 21 for evaluation criteria Yes ❑ No YNot 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 evaluatio criteria. ❑ ❑ • WORKING COAST POLICI,' J Policy 10. Protect Southo 's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See RP Section III—Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes F-1NoNot Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town w ers. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes El 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 eva dation criteria. ❑ Yes 1:1 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; P es 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED BY UA d r ` TITLE �� �� __ DATE 2�l