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HomeMy WebLinkAboutTR-9082A Michael J.Domino,President 0� so�ryo Town Hall Annex John M.Bredemeyer III,Vice-President ,`O l0 54375 Route 25 P.O.Box 1179 Charles J.Sanders Southold,New York 11971 Glenn Goldsmith _ Q Telephone(631) 765-1892 A.Nicholas KrupskiO Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1430C Date: December 7, 2017 THIS CERTIFIES that removal of existing;natural vegetation and expansion of existing lawn area seaward an additional 9,000 square feet; At 4298 Wunneweta Road, Cutcho ague Suffolk County Tax Map #1000-111-14-29 Conforms to the application for a Trustees Permit heretofore filed in this office Dated August 23, 2017 pursuant to which Trustees Administrative Permit#9082A Dated September 20, 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 removal of existing natural vegetation and expansion of existing lawn area seaward an additional 9,000 square feet. The certificate is issued to JULIE ANDERSON owner of the aforesaid property. Authorized Signature SOF S0 Michael J.Domino,President � 0�0 Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25P.O. Box 1179 Charles J.Sanders N Southold,New York 11971 Glenn Goldsmith �Q Telephone(631) 765-1892 A.Nicholas Krupski �'�C®UNFax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: ia/s-11) ✓Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 st day of construction % constructed Project complete, compliance inspection. INSPECTED BY: COMMENTS: I CERTIFICATE OF COMPLIANCE: i *pE SOUT Michael J. Domino, President � yQ�O Town Hall Annex John M. Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Charles J.Sanders u, Q Southold,New York 11971 Glenn Goldsmith o ® a0 Telephone(631) 765-1892 A.Nicholas Krupski Q�if'`+oUA� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1 st day of construction Y2 constructed Project complete,-compliance inspection 1 wf w Michael J.Domino,President � I S0!/lyolo Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O., Box 1179 Charles J. Sanders Southold,New York 11971 CA Glenn Goldsmith ® Telephone(631) 765-1892 A.Nicholas Kru ski ®�CoUfVTY, Fax(631) 765-6641 p � �� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9082A Date of Receipt of Application: August 23, 2017 Applicant: Julie Anderson SCTM#: 1000-111-14-29 Project Location: 4298 Wunneweta Road, Cutchogue Date of Resolution/Issuance: September 20, 2017 Date of Expiration: September 20, 2019 Reviewed by: Board of Trustees Project Description: To remove existing natural vegetation and expand existing lawn area seaward an additional 9,000 square feet. 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 landscape plan prepared by Creative Environmental Design, received on August 23, 2017, and stamped approved on September 20, 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 1 1 1 I 1 1 1 ANc)EP,50N LAN05CAPE PLAN NATURAL VEGETATION 1 NATURAL VEGETATION SCALE. -- 101,0099 ; DESIGNED BY: CREATIVE ENVIROW ENTAL DE51GN 1 ENL� GommoNNAmE , QTY GRAVEL DRIVEWAY FLOWER, PERENNIAL \\ CATMINT PER51AN DV E GC� G 5ALVIA NEMORO5A ` 'PD " SNOW HILL 9 � 1 � AUG 2 3 2017 5ALVIA 1 �V , 0ARA5 CHOICE 7 Southoid Town " ' 5wu5, L)Ecvuou-,,- 5FIPEAANTHoNy WATERER 4 G ! all- APPROVED ?�� 5PI JAP z ANES BI �=� -COL �Y - _ � - _ \+1� 5PIREA, 5CW STORM 2 . BOARD OF 1 t�USTEES F�P� •� _ ` ' iii _ _! i\ \ I TOWN OF SOUTHO EXISTING ; 5HRUB, EVERGREEN BROADLEAFADLEAF , . z� 2p�Z�1 GRA55 DATE 5 _�!_ _ 0: 131OXW0009 GREEN GEM 10 HOLLY, NELLIE 5TEVEN5 JAPANE5E FIER159 N/10UNTAINFRE NATURAL EDGED 5LUE5ToNE 5TEPPING 5TONE5® - _ - _ J!_ \ JAPANESE FER159 YAKU5HMA ( �'0 I \ 5KIMMIAq JAPANE5Eq DWARF (FEM) EDGE OF WETLAND5 /: \\ �P \���,,_ ���� TREE aCI[)UOU5 GARNET JAPANE5EOACER MAPLE CRAPEIVIYRTLE, CORAL PINK 1 EDGE OF HIGH WATER ; -\\1\� \�\\� \�\\�\ \\\� _ \\ Cjo -\ \ ! \� HORNBEA COLUMNAR \ _ !_ _ , _ ,_ - \ OAK RED EXISTING 2 \111 \1 / 1 --------- --- 1 RENOVATED AND NEW GRA55 C \\1/r_ \1\/i \\L/i --- , — NATURAL VEGETATION - __ - - \Ll1 1 1 J/— _0_ _111_ —111_ _11/_ _SII_ _SII_ J/— _111_ 1 X11_ \11_ moi\ IISIL IIL I , NATURAL VEGETATION,! J/- -\I/- J/- -0- J/- EDGE OF WETLAND5 1 I 1 1 1 EDGE OF HIGH WATER 1 ........... ......................................................................... 1 Michael J. Domino, Pris ht o�QS�FFO(,�COG . Town Hall Annex John M. Bredemeyer III, Vice-President 54375 Route 25 Charles J. Sanders y z P.O.Box 1179 Glenn Goldsmith Southold,NY 11971 A.Nicholas Krupski y ® p! Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 1,3 z Completed in field by: Creative Environmental Design on behalf of JULIE ANDERSON requests an Administrative Permit to remove existing natural vegetation and expand existing lawn area seaward an additional 9,000 square feet. Located': 4298 Wunneweta Road, Cutchogue. SCTM# 1000-111-14-29 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 f Hearing Card Posted: Y / N 1 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: Fee, � Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski '' C. Sanders Other Page 1 of 2 Michael J. Domino, Pr, Int O��SCOG Town Hall Annex John M. Bredemeyer I11,Vice-Fresident 54375 Route 25 Charles J. Sanders cz y z P.O.Box 1179 Glenn Goldsmith Southold,NY 11971 A.Nicholas Krupski ?� p! Telephone(631)765-1892 HCl �a Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: Creative Environmental Design on behalf of JULIE ANDERSON requests an Administrative Permit to remove existing natural vegetation and expand existing lawn area seaward an additional 9,000 square feet. Located: 4298 Wunneweta Road, Cutchogue. SCTM# 1000-111-14-29 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 REVISIONS: L 0- T C A U01 V r E R" Gv& I H I" B L E *v0jt% 1v1'mE rummA"I"A SITE AREA TOTAL: 48,810 5f SCTM # 1000-111-14-29 PROPERTY: 4298 Wunneweta Road 517E AREA UPLAND FROM ADDRESS Cutchogue NY 11935 TIDAL WETLAND BOUNDARY: 45,450 sf OWNER: Julie Anderson 333 East 30 th Street Apt 4M STRUCTURES EXI5TIN6 PERCENTAGE FROFO5ET7 PERCENTAGE New York NY 10016LU HOUSE: 1,511 sf 4.17 0 10861 5f 4.1196 SITE: 48,$10 SQ. FT- = 1.121 ACRES (TO TIE LINES y >- GARAGE: 436 sf 1.0090 456 sf 1.0090 WETLANDS: 5,380 SO. FT. = 0.12 ACRES 3: z PORCH: 56 5f 0.12 510, 56 5f 0.1296 1"mr DECKS: 251 sf 0.55°6 236 5f 0.5596 ZONING: R-40 TERRACE: 0 O 420 sf 1.090 ELEVATIONS ARE REFERENCED TO N.A.V.D. 1989 DATUM 0 TOTAL: 2,534 sf 5.596 2,853 5f 6.b296 Fm SURVEYOR: Nathan Taft Corwin 111 1586 Main Road "SITE AREA UFLAND FROM TIDAL WETLANDS BOUNDARY (NYSDEC Jamesport, New York 11947 z ADJACENT AREA AND TOWN OF SOUTHOLD BUILDABLE LAND)" LICENSE # 50467 DATED AUGUST 18, 2015 Q_ W UjEDGE OF WETLANDS , 0 A110 2 1 2017 Z CHANNEL WUNNEWETA POND TIE DATA ;_.. ..... _ 1. S 74'24'20" W 358.30' ,�Ir 2. N 58050'30" W 110.00' _ 3tttl.+- !__. _____.__--- EXISTING UNDERGROUND EXISTING `+ +_ 3. S 7fi'41'40" W 269.47' PUBLIC WATER LINE UNDERGROUND 92.86+ _ 4. N 88.18'20" W 176.73' V ELECTRIC, LINE 5. N 08.28'30" E 12.13' ., 7'03 E ,,I'- - -- - - -5, �--- 4 G, Z co 7a.5 16' R/C,4' 2 ----r ' 0 +�1C �'_ TOit� ROADWAY N 6 5$5� 16' RIGHT OF WAY - OF 1tiAY ELI' a. F"GO EXISTING TREES AND 7 ' 1 VEGETATION, TO REMAIN cn _ UNDERGROUND ;' ' ` PUBLIC N/01F a % S A ' - WATER LINE RICHARD ANDERSONUj 04 ICY APPARENT HIGH / � '��' EXISTING TREES AND VEGL'TATION, TO REMAIN 1 WATER - / LINE OF Z5 FT SETBACK FROM WETLANDS PROPOSED SILT FENCE DURING CONSTRUCTION SEE DETAIL 1, THIS SHEET %' >' :s LINE OF 100 FT SETBACK FROM WETLAND5 TIN& t DV VSA- - . EXISTING 1'LOATING il, �` r,;r 's;`r``,i' ; i. �S Z. DOCK, RAMP AND _ FIXED DOCK / /�r �- ;z;: ;;: m) A mQCD / G I r v F �ST"ING ` C N M - TINS PRE-CAST s'�Af ..1�:.`' ',`>'. ;"' :`,.•; LOCATION OF EXIS .7 -„I- 12 • ` ` r'':` ' — ANITARY 5Y5TEM ORIGINALLY y CONCRETE 5 W z w a APPROVED 5Y SGDHS FOR Erack THREE o dwa�ers / / t LL O J �r Cra �i ��oveyi' UJ• v UF �n RO BEDROOM RESIDENCElb 0 04 M ' FILTER CLOTH ti /� o� Q F-• u r E6 ��`' �'��'=�'•�'����� ••.�' � I ! LINE OF 100 FT SETBACK FROM WETLANDS ' G RAGE : • ' EXISTING TREES AND "•.. `, t, -� 436 5F .�.� . I , SURFACE ' VEGETATION, TO REMAIN t / ' ``~ ': " '' ' r D � � FILTER CLOTH MIN. RAI1�lAGE Pac n�csay /� b" 5ELOW GRADE ,FLOW �1� 4 GONG. _EDGE OF . W 5UWETLANDS . 'L � �� , LINE OF '75 FT SETBACK FROM WETLANDS 1 + sL �TC�G 20 b~ / -.T4 , a w cA,a ^i" C TEMPORARY STORM WATEREXISTING ELEGTRIG MTER / °w f � RUNOFF CONTROL MEASURE EROSION & SEDIMENT CONTROL DETAILS ,• /f� ' ' ` � , NO SCALE Z O. ' ST M: T., . OF FM EX�5T1 NG a { mtlr I I S R PROJECT NO. DEC!C 1508 1 � P wrn w WETLANDS �+ `EPS ` - It �t;. lip? �� � 1 T �� � 35, _ � ��.� �, T , , �, ,/ 000 o�w DRAWN BY: UT 1 -- � � EXIT� .004 CHECKED BY: TS R STEPS .�' f DATE: OPOSE6114117 P �� �/ NEW ? z --` - 1 - `EX a G SCALE: W � � � er � SHEET TITLE: APPARENT HIGH W ATER SITE PLAN TIE LINE ALONG ,t` 1 -� EXISTING TREES AND APPARENT HIGH WATER — ..�' / '�'(L- �- VEGETATION, TO REMAIN MARK ON AUGUST I$, 2015 99 0a. r '014 �ti1�,- - -= EDGE OF EDGE 0.- `'t'. t, ..�' •+ �iJ WETLANDS WETLANDS — alr, WETLANDS 356+ga S ? 6A.65 SHEET NO: N 85.43'0 i" W APPARENT HIGH 86.67' EXISTING TREES AND WATER TIE LINE ALONG APPARENT H16H WATER VEGETATION, TO REMAIN MARK ON AUGUST I8, 2015Q�j E SCALE: 1 It = 20'-0" WUNNEWETA POND TRUSTEES ` iv 04 SCTMH: 1000-111-14-29 AP 9/12/17 ' j;., � •1 Vis•`',. s.►r f jo 00 y i may' • -•ems f .,Y' �' f. _. '. fZ}" 1'/��• / r Wib _•lofl'j-'s�t� ��� •y'b'" '�� Y 3 Ilk— t., 's ' .i-. _I. vr' b. ♦�:'' ..rte ♦'. .I t•'�y -�: ,y.- . '+• � � � 1' �� "ate•� l I �� �! o .�„�� 0011, cit r 5 v r �"'" A w M OFFICE LOCATION: SOy®� MAILING ADDRESS: Town Hall Annex ® P.O. Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 �� Telephone: 631 765-1938 c®UN�9� ' LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: September 18, 2017 Re: LWRP Coastal Consistency Review for JULIE ANDERSON SCTM# 1000-111-14-29 Creative Environmental Design on behalf of JULIE ANDERSON requests an Administrative Permit to remove existing natural vegetation and.expand existing lawn area seaward an additional 9,000 square feet. Located: 4298 Wunneweta Road, Cutchogue. SCTM# 1000-111- 14-29 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 INCONSISTENT with Policy 6 of LWRP and therefore INCONSISTENT with the LWRP. The area to be converted to lawn appears to be located within a non-disturbance buffer as depicted on the approved plans. Minimizing the area of lawn fertilization, pesticide application and irrigation is beneficial to the function and values of wetland systems. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. �pF SOUTH, Michael J.Domino,President �O� Of4 Town Hall Annex John M.Bredemeyer 111,Vice-President 54375 Route 25 P.O.Box 1179 Charles J.Sanders Southold,New York 11971 Glenn Goldsmith ® �0 Telephone(631)765-1892 A.Nicholas Krupski ���©U�m��� Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application _,,0t_, Administrative PermitE p n,7 E 2 Amendment/TransfedExtensi n IS u V Received Application- Received Received Fee:$ l d®soo Completed Application: z��l AUG 2 3 2017 Incomplete:, SFQRA Classification: Type I_ Type II Unlisted southold Town Lead Agency Determination: ar f T us ee Coordination:(date sent): ��LWRP Consistency Assessment Form Sent: CAC Referral Sent: ^Date of inspection: T12,P Receipt of CAC Report: Technical Review. Pub11C Hearing Held- Resolution- Legal eld:Resolution•Legal Name of Property Owner(s): 1uhe_ Mailing Address: 33�; L&$rV 3a ' INI If�lL�,t� Dt"N, - V\�4 DO(k Phone Number: Suffolk County Tax Map Number: 1000- Property 000-Property Location: ff;L $ - IJ U��rM (If necessary,provide LILCO PoleV,distance to cross streets,and location) AGENT(If applicable):. 4W Creative Environmental Design Mailing Address: PO Box 160 Peconic,NY 11958 Phone Number: 1--13`i- '79 a Board of Trustees ApplicP3.0n GENFRAL DATA Land Area(in square feet):- t4�1$Imo' ,Area Zoning: Previous use of property: P, L(0 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 L/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 t/No If"Yes",please provide copy of decision. Will this project require an demolition as per Town Code or as determined by the Building Dept.? Yeslo 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? 1f/ No Yes If yes,provide explanation: Project Description(use attachments if necessary): Board of Trustees Application. WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: i t9 C' L yl�f Area of wetlands on lot: square feet Percent coverage of lot; Or % Closest distance between nearest existing structure and upland edge of wetlands: _feet Closest distance between Barest 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 filled9 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): Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) vwe, owners of the property identified as SCTM# 1000- <<<< 'a I in the town of New York,hereby authorizes C :( DC1"Oo LZ Creative Environmental Design P®B®x 1.60 to act as my agent and handle all Peconic,NY 11958 necessary work involved with the application process for pennit(s)from the Southold Town Board of Trustees for this property. 0/VA4W-o-- Pr.p rty Owner-'s,Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF 20 1 -1 t Notary AbliV MONICA LYNN HOWARD Notary Public-State of New York NO.01H06348491 Qualified in Queens County My Commission Expires Sep 26. 2020 Board of Trustees Application AFFIDAVIT J W r\ait- F d n BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SITE IS 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 DIY 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. Si ature of Property Owner Signature of Property Owner SWORN TO BEFORE ME TRIS DAY OF ,20 Notary Pub is Mat ICA LYNN HOWARD Notary Public-State of New York EVD.O 1 H06348491 ©ualified in Oueens Gounty My'Cornmission Expires Sep 26.2020 A]PIPEICANUAGENUREPRESENTATIV E TRANSACTIONAL DISCLOSURE FORM The'rown of Sonthold's Code of FIhics prohibits conflicts of interest on the part of town officers and cmnlovees.The lit"ose of this form is to nrovide infcirination which can alert the town of possible conflicic of interest and allow if to take whatever action is necessary to avoid same. YOUR NAME: Jj e /"i— -rnc-e � (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 ie _ Change of Zone Coastal Erosion Approval ofpiat Mooring Exemption from plat or official map Planning Other (If"Other,name the activity) Do you personalty(or through your company,spouse,sibling,parent,or child)have a reladonship.with any officer or employee of the Town of Southold? "Relationship"includes by blood,rparriage,or business intermt.`Business intcrest"'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 Ute town officer or employee owns more than 5%of the shares. YES NO If vdu answered"YES",complete the balance of this form and date and sign where indicated_ Name of person employed by the TovnbfSouthold Title br position of that person, Describe the relationship between yourself(the applicanttagemVr:presentative)and the town officer or employee.Either check the appropriate line A)through l?)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 tic applicant is not a corporation); _Q an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP 1° Submitted is 1;6 day of 200 Signature Print Na moi, L j`E "DElLSB Form TS I 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 purpose of this form is to provide inforination which can alert the town ofpossible conflicts of interest and allow it to take whatever action is necgssary to avoid same. = YOUR NAME: `i��t�!Vl l l G`Z �'�J•t° (Last name,first name,iriddle initial,unless you are applying in the nOoSive Environmental Design someone else or other entity,such as a company.If so,indicate the other PO Box 160 person's or company's name.) PecOnip,NY 11958 NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Tnistee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other,name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship''includes by blood ,igarriage,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 a shares. YES NO Ifyou answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner or employee of the applicant;or D)the actual applicant DESCRIPTION OF RELATIONSHIP Submitted is d Signature Print Name t r' Form TS 1 61 Z20 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 I 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: -S'ta`F— Project Location(describe,and attach a location map): 111-1 �a 4 1 -1 Brief Description of Proposed Action: � p �¢�� �� ��o� fix.� • �- P Name of ApplicantorSponsor: Telephone: , 3f or 06-v si' E-Mail EftViraftmentol -,- t �'S� 1-B C4 Address: P®Box 160 City/PO: State: Zip Code: 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. 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 F-1 Rural (non-agriculture) ❑Industrial ❑Commercial (Residential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ 12r ❑ b.Consistent with the adopted comprehensive plan? 1Z E] 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: M"' F]8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO J YES go b.Are public transportation service(s)available at or near the site of the proposed action? c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? P11 1:1 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: �`�( ❑ l l.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? 121 ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ ©/ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ,Ei—shoreline El Forest El Agricultural/grass lands El Early mid-successional Lv1 Wetland ❑Urban QSuburban 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, ❑ 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 AYES 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: 9 ❑ 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: F] I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE App Ii ant/spon n Date: r ``j r 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? I Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a.public/private water supplies? b.public/private wastewater treatment utilities? El- 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 i -1 / 1 No,or Moderate small to large impact impact may may occur, occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. FJCheck 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 impact .e / Town of Southold-Board of Trustees i ' Norte of Lead Ag Date I D0 f1/fu4t President Print or Type N$am of Re po ible er in Lead Agency Title of Responsible Officer Signature of Respons e Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 I Town of Southold I LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form,should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated. as to its significant beneficial and,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 2UIMned 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 The Application has been submitted to(check appropriate response): / Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees Imo" 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: � l�9v1 FLAG -r6�®V) C)V-��G 6 Ce�;ve� Gv�yticisrr, �lal ;�Pn Location of action: /`� LdR-RA Oe-1A- , Ltp—" d1 14 Site acreage: (a l a.t Present land use: R-LED Present zoning classification: K-HD 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: '-S1zV,O O (b) Mailing address: f&G� 2Z2& (c) Telephone number:Area Code( (d) Application number,if any: Will the action be ctly 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 LNVRP Section III—Policies; Page 2 for evaluation 7crite ' . Yes ❑ No F] Not Applicable Attach additional sheets if necessary Policy 2. Protect andp eserve historic and archaeological resources of the Town of Southold. See LWRP Section III=Po cies Pages 3 through 6 for evaluation criteria ElYes ❑ No Not Applicable Attach additional sheets if necessary Policy 3. Enhance,visual quality and protect scenic resources throughout the Town of Southold. See L7tion tion 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 Sectio —Policies Pages 8 through 16 for evaluation criteria F] Yes No ❑ 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 9YesE:1 No ❑Not Applicable sus'�ic,�,Aa Z -\ ADy C► '�- 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 throug 32 for evaluation criteria. ❑ ❑ Yes No NotI pplicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LVW Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes [:] No ot'Applicable Attach additional sheets if necessary Policy 8. Minimize en ironmental degradation in Town of Southold from solid waste and hazardous substances and wast See LNVRP Section III—Policies; Pages 34 through 38 for evaluation 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. ❑ YeLl No Not Applicable Attach additional sheets if necessary WORKING COAST POLfuiES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See L )AW 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 (Not rs. See MAW Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑Yes ❑ No 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 evalua on criteria. ❑ Yes ❑ No��ot 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 �t ���� _TITLE DATE