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HomeMy WebLinkAboutTR-9062A �oS�FFQc�-Co Michael J. Domino, Preside � Town Hall Annex John M. Bredemeyer III,Vice-President ��� Gy 54375 Route 25 Glenn Goldsmith o P.O.Box 1179 crs x A.Nicholas Krupski W_ � Southold,NY 11971 Greg Williams Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD I(-�I� r Date/Time: �' Completed in field by: N+ Compliance Inspection of JAMES & KAREN SPEYER for the location of the two permitted 12"x12" signs within the property lines near the beach. Located: 2100 Jackson Street, New Suffolk. SCTM# 1000-117-10-18.1 & 18.2 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 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: /ger CaY file I r `ce-°r l I have read & acknowledged the foregoing Trustees comments: Agent/Owner: / Present were: 1/ J. Bredemeyer M. Domino G. Goldsmith N Krupski ' ,/G. Williams Other Michael J. Domino,President OF S®UTyO Town Hall Annex John M.Bredemeyer III,Vice-President �O i lQ 54375 Route 25 P.O.Box 1179 Charles J. Sanders Southold,New York 11971 Glenn Goldsmith G O Telephone(631) 765-1892 A.Nicholas Krupski �COUNTI, �O Fax(631) 765-6641 � �� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1388C Date: September 61 2017 THIS CERTIFIES that the seasonal installation of two (2)posts with 12"x12" signs on the beach at least six feet above average mean high tide and placed landward of the easterly and westerly property lines; each sign is to be removed in October and replaced in May of each year; At 2100 Jackson Street,New Suffolk Suffolk County Tax Map #1000-117-10-18.1 & 18.2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated July 20, 2017 pursuant to which Trustees Administrative Permit#9062A Dated August 16, 2017, 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 seasonal installation of two (2) posts with 12"x12" signs on the beach at least six feet above average mean high tide and placed landward of the easterly and westerly property lines; each sign is to be removed in October and replaced in May of each year. The certificate is issued to JAMES & KAREN SPEYER owners of the aforesaid property. Authorized Signature w �1 a r - - - ,�s r <x 4f•� ti 0�. " f'• i 39 + a •a t r �'�. �� ♦IT..,! ��� � �;` §� � "fes #.r to � _ .,. ., Ilk 1, 1 '.flet1c ` PIP �y �A v4. � 1 71 M t� � tt 1 •v E V 17 om SpA �l� r y � f S x. S3 r+ �♦ .k } s 4 EAC Ilk T . a w y.•F � F7+M S n 4A, e l y,01 i Ay ,r 4 C � � t � - � s ,44 ♦� '. ♦ W �'�,-,- � �� yo- ... �` ,- ♦',fig-' ..�� � �° Y -.�►, - iR 1 r1 - - Michael J.Domino,President � Ol0 Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O. Box 1179 Charles J.Sanders CA Southold, New York 11971 Glenn Goldsmith � ® aQ Telephone (631) 765-1892 A.Nicholas Krupski F"ZCOUN11v� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: (J7 6/, Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction ,'/z constructed Project complete, compliance inspection. INSPECTED BY: IV, KaYPA COMMENTS: KevzwJ �1���,- P Ao✓fe- 0� ',cam,. CERTIFICATE OF COMPLIANCE: *Qf S®(/jy t Michael J.Domino, I _dent Town Hall Annex� Ol0 John M. Bredemeyer III,Vice-President 54375 Route 25 Charles J.SandersP.O.Box 1179 Southold, New York 11971 Glenn Goldsmith �l Telephone(631) 765-1892 A. Nicholas Krupski if'�+®UN 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 % constructed Project complete, compliance inspection 1- r Michael J.Domino,President Of SO�fy Town Hall Annex John M.Bredemeyer III,Vice-President �®� Ol0 54375 Route 25 P.O.Box 1179 Charles J. Sanders Southold,New York 11971 Glenn Goldsmith G ® O Telephone(631) 765-1892 A.Nicholas Krupski 'Q Fax(631) 765-6641 �yC4UN�1,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9062A Date of Receipt of Application: July 20, 2017 Applicant: James & Karen Speyer SCTM#: 1000-117-10-18.1&18.2 Project Location: 2100 Jackson Street, New Suffolk Date of Resolution/Issuance: August 16, 2017 Date of Expiration: August 16, 2019 Reviewed by: Board of Trustees Project Description: Seasonally install two (2) posts with 12"x12" signs on the beach at least six feet above average mean high tide, and placed landward of the easterly and westerly property lines; each sign is to be removed in October and replaced in May of each year. 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 James Speyer, received on July 20, 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. 0 Michael J. Domino President Board of Trustees Michael J. Domino, PresidE; y� O�Q V�FQt40A Town Hall Annex John M. Bredemeyer III,Vice-President ,� �� 54375 Route 25 Charles J. Sanders Cz z P.O.Box 1179 Glenn Goldsmith w ^�f Southold,NY 11971 A.Nicholas Krupski ©4Sy1.ol plf Telephone(631)765-1892 1. ' Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in field by: JAMES & KAREN SPEYER request an Administrative Permit to seasonally install two (2) posts with 12"x12" signs on the beach at least six feet above average mean high tide, and placed landward of the easterly and westerly property lines; each sign is to be removed in October and replaced in May of each year. Located: 2100 Jackson Street, New Suffolk. SCTM# 1000-117-10-18.1 & 18.2 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 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: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 Michael J. Domino, Preside - ;� �Q gyEFD(��'� + � Town Hall Annex John M. Bredemeyer III,Vice-President �`3C' Gy54375 Route 25 Charles J. Sanders cm P.O.Box 1179 at Glenn Goldsmith d ® , Southold,NY 11971 A.Nicholas Krupski ?,�0 apl� Telephone(631)765-1892 l Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: JAMES & KAREN SPEYER request an Administrative Permit to seasonally install two (2) posts with 12"x12" signs on the beach at least six feet above average mean high tide, and placed landward of the easterly and westerly property lines; each sign is to be removed in October and replaced in May of each year. Located: 2100 Jackson Street, New Suffolk. SCTM# 1000-117-10-18.1 & 18.2 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 JACKSON STREET I (vueuC WATER W STREET) S 85'22'00" E fOF P•n>.rm I _E SPEEv UiOr--->' SURVEY OF PROPERTY 1-1Y =1 sRPSloov 61 120-21' SON 202.21' I, SITUATED AT -T 4 =a� m 8200' a" NEW SUFFOLK F =1 t0 CNK I TOWN OF SOUTHOLD ,y �� •. �a ,;""°" _ ml ,n 110 SUFFOLK COUNTY, NEW YORK — — °nr to S.C. TAX No. 1000-117-10-18.1 ' 101• .�• Tr FRAME U) To- �° aARacE I "' , S.C. TAX No. 1000-117-10-18.2 o SCALE I"=40' �R - ��� I JANUARY 28 2005 1`aATrR 0 2 STORY FRAME HOUSE " 9"KER ✓ ,-S F DECEMBER 9, 2005 ADDED WETLANDS BOUNDARY ar 44 JULY S. 2006 FOUNDATION LOCATION Ke• Ina aa1Nv r nr � maCKoero I y 1 JUNE 6, 2017 UPDATE SURVEY 8 ry 9 S^ ♦ 1"1�NE " CK n1 IT AREA DATA Kom rnaN1 o. 227 S.C. 00-117-10-18.1 43`0 992 acct. •,,• �I S.C. TAX No. 28,394 sq. ft. 1000-117-10-18.2 0.652 ac. I TOTAL 71.1 (TO TE UNE) 1.644 aC rt 1311 I E- E- E-, 'E-,12� : g � 5 X I JUL 2 0 2017 •a - BOARD OF _ � _ ,, "• - Southold Town , Z-RUSTEES ' r of Trustees TOWN-idP SOUTH4LU ®ATE � - I F-� -'__ . .- .. ls• . __ , • " PREPARED IN ACCORDANCE WITH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABLISHED BY THE L I• - I TORE ASH ATS E 14. OI STATEOPLAND A -•.. _- 11 j.�c- L� ��Iv� a ,r'N Y S U. No 50467 • UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE 0 3 �+ EDUCATION LAW Nathart� afit� ` drwin iii COPIES OF THIS SURVEY MAP NOT BEARINGTHE LAND SURVEYOR'S SEAL OR •�.�---�•""' go 12!?(1?—" O O EMBOSSED SEAL SHALL INOTD ` BE CONSIDERED Land Surveyor TO BE A VALID TRUE COPY. 3 6a—r-O f�6— Z N CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY •� �,p,E uaxc,p,,,,a,,, �Ah1 D41 )21(v l �) IS PREPARED,AND ON HIS BEHALF TO THE Successor To Stanley J Isaksen, Jr LS TITLE COMPANY, GOVERNMENTAL AGENCY AND Joseph A Ingegno LS LENDING INSTITUTION LISTED HEREON, AND -c""A'o"w+K or'wO1,uxc aa, +�I ,�' w.t*, e �,a TO THE ASSIGNEES OF THE LENDING INSTI— Title Surveys — Subdivisions — Site Plans — Construction Layout S 89'33'32" W 123.01' N 82,17 35 W m,T PHONE `�{l7F V 1� /�ArFvC'Y1/1 TUTION CERTIFICATIONS ARE NOT TRANSFERABLE / 631/727-2090 Fax (631)727-1727 THE EXISTENCE OF RIGHT OF WAYS 79.02' AND/OR EASEMENTS OF RECORD, IF OFFICES LOCATED AT MAILING ADDRESS GREAT PECONIC BAY ANY, NOT SHOWN ARE NOT GUARANTEED. 1586 Main Road P 0 Box 16 Jamesport, New York 11947 Jamesport, New York 11947 f t 5d OFFICE LOCATION: �®F S® y® MAILING ADDRESS: Town Hall Annex �® l® P.O.Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) e!s Southold, NY 11971 ® �� Telephone: 631 765-1938 ®l�OWN,� 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 14, 2017 Re: Local Waterfront Revitalization Program Coastal Consistency Review for JAMES & KAREN .SPEYER SCTM# 1000-117-10-18.1 & 18.2 JAMES & KAREN SPEYER request an Administrative Permit to seasonally install two (2) posts with 12"x12" signs on the beach at least six feet above average mean high tide, and placed landward of the easterly and westerly property lines; each sign is to be removed in October and replaced in May of each year. Located: 2100 Jackson Street, New Suffolk. SCTM# 1000-117- 10-18.1 & 18.2 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 proposed action is EXEMPT from LWRP review. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Town Hall Annex John M.Bredemeyer III,President ' �� 54375 Main Road Michael J.Domino,Vice-President � �- \\\ -, P.O.Box 1179 � � James F.King,Trustee Southold,New York 11971-0959 Dave Bergen,Trustee Telephone(631) 765-1892 Charles J.Sanders,Trustee ` �i;) Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application 7 Wetland Permit Application Administrative Permit —_Amendment/Transfer/Extension ��Received Application: 7.26&(722pReceived Fee:$ 100,6® D l�J E u V E DD Completed Application: , _Incomplete:__._,,_ _SEQRA Classification: J U L 2 0 2017 Type I Type II Unlisted Coordination:(date sent):_ _ �� LWRP Consistency Assessment Form: Southold Town CAC Referral Sent:__ of Trustees Date of Inspection: �,0 _Receipt of CAC Report: _Lead Agency Determination: Technical Review: Public Hearing Held:�7 � Resolution: Name of Applicant: Mailing Address;_ �Qd J �' zs' _� 'in /� New ff-A /1) `` T' Phone Number: f - `�-� �� ��l 3 -7 -SG Suffolk County Tax Map Number: 1000- L g���- I 1 1 --l��I `t 3�' 'y 1 I�- ]a d " Property Location: G�% (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): t 00-0 Area Zoning: �S Previous use of property: 51 Intended use of property:, pit:c f rN -� Covenants and Restrictions on property? Yes _� No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes;_No If"Yes",be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. ; Does this project require a variance from the Zoning Board of Appeals? Yes No If"Yes",please provide copy of decision. Will this project requir 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?-Y---Yes No Prior permits/approvals for site improvements: Agency Date t No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?_'�V No Yes If yes,provide explanation: Project Description(use attachments if necessary): — - Purpose of the proposed operations: lc Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: la ( � �� 1--4 Area of wetlands on lot: 2� square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: -u 2-cc feet Closest distance between nearest proposed structure and upland edge of wetlands: feet s Does the project involve excavation or filling? No Yes If yes,how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect, if any,on the wetlands and tidal waters of the town that may result by reason of such proposed operations )I(use attachments if appropriate): /V C7 Poe L(f+ m�t � S f2.&v4 c)V e Rµ 0 C e� i' 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 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 1 -Project and Sponsor Information Name of Action or Pro ect: G n m w,f%,e � Icvv�t'„� S 1ci� S C It� C�� J -a6f Project Location(describe,and attach a location map). t t P a�A,G_ 1 yI"r- sQg�- 4� Brief Description of Proposed Action: S7" Name of Applicant or Sponsor: Telephone:�.3/ L/ D� t t -i4 me, �(n �- •E-Mail 1,SA tv/er 1'9 ✓oCY 47 Address: �t- 2 ins 5�0 �— City/PO: State: Zip Co e: GI�5 1.Does the proposed action only involve the legislative adoption of a plan,local law,brdinanc , 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. 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: ry 3.a.Total acreage of the site of the proposed action? acres �S b.Total acreage to be physically disturbed? acres—�,40--qC 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. 1-�F, C-]Urban El Rural(non-agriculture) ❑industrial ❑Commercial (rtesidential(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? 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: � ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO 'VE '❑ b.Are public transportation service(s)available at or near the site of the proposed action? n E] c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? L.�.1 U: 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:, n ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? 1-1 F] b.Is the proposed action located in an archeological sensitive area? LLl 13.a.Does anyportion 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? EJ 1LS ; 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: _ t_Ct 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 ❑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 u 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES 1f Yes, 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: E]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: © ❑ 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 n e:, S Pr e Date: I �� 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 I. Will the proposed action create a material conflict with an adopted land use plan or zoning a regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? 3. Will the proposed action impair the character or quality of the existing community? o ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? LLJJ 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? (�J 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ reasonably available energy conservation or renewable energy opportunities? c 7. Will the proposed action impact existing: ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? ❑ 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, (� waterbodies,groundwater,air quality,flora and fauna)? LJ 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 a j� problems? L-1 11. Will the proposed action create a hazard to environmental resources or human health? Y Part3-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,insufficient 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,wilI 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. s Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 J Board, ot Trustees ,Application AFFIDAVIT ,0CS 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 THEMANNER 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 ANDTHE 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 TRIS 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 TEAM OF THE PERMIT. Signature f P ope`ty Owner SWORN TO BEFORE ME THIS DAY OF U-I _._,w„_.,;,-20 - 4 - ','Notary is CM STIE ASE Notary Public;;;,itate of Np Registrati6n-#01 LE6.;.;79 Qualified In Nassau Countx� Commission'Expires Feb.29,20 Board of Trustees Application AUTHORIZATION (where the applicant is not the owner) I, residing at (print name of owner of property) (mailing address) do hereby authorize (Agent) to apply for permit(s)from the Southold Board of Town Trustees on my behalf, (Owner's signature) APPLICANVAGENTIREPRESEN T,A.TIVE TRANSACTIONAL,DISCLOSURE FORM Thee owmof Southoldis Code of Ethics prohibits`conflicts of interest on the lLart of town offcrrs'and etn*yees.Thppurpose of tt,i form is I'nirrivide itrforination'whiclt icts of interest and allow it to take whaieyer,action is necessary to avoid same. YOURNAME: _ "��2 W "j keV' \ (Last name,first name,.tpiddle 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 l MS (If"Other",name the activity.).--v) 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 busirtess.interest_"BilSiness 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 q If you ansivered"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%,ofthe shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP -------------- Submitted this '� 20orL�7- Signature Print Name �t S L• Form TS l Town of Southold LWRP CONSISTENCY ASSESSMENT FOM 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 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, listingboth supportu19 and'non- supportine 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# 1[` PROJECT NAME The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity,agency regulation,land transaction) ❑ (b) Financial assistance(e.g. grant,loan,subsidy) (c) Permit,approval,license,certification: Nature and extent of action: n Location of action: 9- Site Site acreage: Present land use: Present zoning classification: 2: If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: kov e--L., Sze yeV (b) Mailing address:—;, (c) Telephone number: Area Code �7, �l � 03 - (d) Application number,if any: Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes EI No'R If yes,which state or federalagency?-' 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. Pq Yes No Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria F Yes 11 No L_J-, Not Applicable i 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 —Policies Pages 8 through 16 for evaluation criteria Er Yes ❑ Nol❑ 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 �Kot 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 J 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 Noof 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 1:1No E3,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'YeO No❑ Not Applicable rA d �� b r N V r o e-v- V d1n f�'I cam Attach additional sheets if necessary 1 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 of Applicable Attach additional sheets if necessary Policy 11. -Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No 1;6--of 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�Not criteria. ❑ Yes ❑ Noplicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pa es 65 through 65 for evaluation criteria. F1'Yes ❑ No Not Applicable PREPARED l �� TITLE 5 wt,u-1 DATE J