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HomeMy WebLinkAboutTR-9097A Michael J.Domino,President �\\rjf SU(/Tlyo Town Hall Annex John M.Bredemeyer III,Vice-President �� l0 54375 Route 25 P.O.Box 1179 Charles J.Sanders Southold,New York 11971 Glenn Goldsmith G p Telephone(631) 765-1892 A.Nicholas KrupskiO Fax(631) 765-6641 �yCOUNV I BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1416C Date: November 14, 2017 THIS CERTIFIES that the demolition of the two existing garages located landward of the dwelling; At 1425 Pine Neck Road, Southold Suffolk County Tax Map#1000-70-5-40 Conforms to the application for a Trustees Permit heretofore filed in this office Dated September 6, 2017 pursuant to which Trustees Administrative Permit#9097A Dated October 18, 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 demolition of the two existing garages located landward of the dwelling. The certificate is issued to Elizabeth& Salvatore Pennisi owners of the aforesaid property. a Authorized Signature �zf S0 Michael J. Domino,President � yOIO Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Charles J. Sanders N Southold,New York 11971 Glenn Goldsmith • aQ Telephone(631) 765-1892 A.Nicholas Krupski ��`yC®UNTY,Nc Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Its. [� 0 y t l Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction V2 constructed Project complete, compliance inspection. INSPECTED BY: ��O�V��1' �\ ���,� a✓S COMMENTS: © A :�b kgL'vk CERTIFICATE OF COMPLIANCE: Michael J.Domino, .sident ®� S®(/�yol cr Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 , P.O.Box 1179 Charles J.Sanders 'U0 Southold,New York 11971 Glenn Goldsmith ® yo Telephone(631) 765-1892 A.Nicholas Krupski Olif'COUN11 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 % constructed 7Project complete, compliance inspection 1 Michael J.Dominc'�'. __sident �\\,of S®Urjy� Town Hall Annex John M. Bredemeyer IIl,Vice-President �� lO 54375 Route 25 P.O.Box 1179 Charles J.Sanders Southold,New York 11971 Glenn Goldsmith G ® Telephone(631) 765-1892 A. Nicholas Krupski 'O Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9097A Date of Receipt of Application: September 6, 2017 Applicant: Elizabeth & Salvatore Pennisi SCTM#: 1000-70-5-40 Project Location: 1425 Pine Neck Road, Southold Date of Resolution/Issuance: October 18, 2017 Date of Expiration: October 18, 2019 Reviewed by: Board of Trustees Project Description: To demolish the two existing garages located landward of the dwelling. 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 survey prepared by John C. Ehlers Land Surveyor, received on September 6, 2017, and stamped approved on October 18, 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 Michael J. Domino, Presid` O�pS�FFUC�coO _ Town Hall Annex John M. Bredemeyer III,Vice-Pr6siaent yJ, 54375 Route 25 Charles J. Sanders w z P.O.Box 1179 Glenn Goldsmith Southold,NY 11971 A.Nicholas Krupski Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES 1 TOWN OF SOUTHOLD /� Date/Time: �® �G�! ,f Completed infield by: _ r�b'G' ELIZABETH & SALVATORE PENNISI request an Administrative Permit to demolish the two existing garages located landward of the dwelling. Located: 1425 Pine Neck Road, Southold. SCTM# 1000- 70-5-40 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: 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: Present were: �redemeyer M. Domino /G-. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 J 5URVEY OF LOT -1 , "MAP OF PROPERTY OF N J. NELL$ PH I LL I P5 r .locks Greek FILED NOVEMBER 6, 1909, MAP No. 247 y 51TUATE: FINE NECK -- - � TOWN: 50,UTHOLD S J'UFFOLK COUNTY, NY tie line olon � + SURVEYED 04-01-2008 S8e�e high >ester ,,�p�*Br p +_05 _ F� r E V E SUFFOLK COUNTY TAX # -I 1000 - 70 - 5 - 40 _ _ -� wood bul gad _ - _ ` _ - - -� 6 2011 - - -w- - - - —; - - - - �y Southold Town COMMONWEALTH LAND TiTi.B - -e- x=xl T INSURANCE COMPANY ; - ' �; - _ x it x a 3°9• x I Story i F Qme 1- House Fr X � p w.� APPROVED BY BOARD OF TRUSTEES Fr `d TOWN OF SOUTHOLD w she � , °1 ,DATEo t M�2 t 9! � ala t - / � t� + l Lot ` l Lot 7�`�� Lot 6 S —20 I , ° 1 � I I I 10 I I , SY I I , a I I ON I I � o I 1 , I 1 , O I I I I a* P4�a I 0, I 1 N8503p'g0"W8.7$ \N8401S,Op„W,gl, I I 899't , �\ 1tu,G,aH[W olFwotian a adeltbn b°wlv.y 9 of p \ xap e,aortg a nc.i- 01%x v.yOrf 2, b o avement w at en ar..atl.n noes,M.Ed on z,m ma ' fl.w York 9bb EOucatbn 1a.1 NOTES: o mu:a`f-1 gtth or 4,..1.1.'Nir. y d W- `MONUMENT FOUND ��� 1\�j�,�p� �® °b p•a...I w wm e.r.e b wuW... I Neck ll/lL/ 1h�I cops®.• , /��t� w-c ..os' prrod t acoraancinRh tt oft .�. elf, y th G.a..r rratic.fm LaN 5wsy.ooaaooppt.a O PIPE FOUND byllr xa.Yark Slab A,.aal.tbn.fprob.e and Laid sw.ya'..sale a.RtticaGMa.hall M, Iyy b tlu p.rwn for ream tn..wry V propae4 and on hb b.lnlf b tti Gtb tgfpa. bl ayalWf dle I.Mtg WGWtI.n Ila:.d:l.ro.a,W CONTOURS REFERENCE NGVD '29 DATUM ""� "� Con.ar.rot tronl.th.LI t.ZION—;wGtutbro Area = 46,516 S. F. JOHN C. EHLERS LAND SURVEYOR Area = 1.0679 Acres 6 EAST MAIN STREET N.Y.S.LIC.NO.50202 GRAPHIG SGALE 1"= 40' RIVERHEAD,N.Y. 11901 - 369-8288 Fax 369-8287 REF.\\Compagserver\pros\08\08-130 TOPO.pro Michael J. Domino, Presic, ` o�pSVFFQ1�COG , Town Hall Annex John M. Bredemeyer III,Vice-President 54375 Route 25 Charles J. Sanders N z P.O.Box 1179 Glenn Goldsmith 0 ^� Southold,NY 11971 A.Nicholas Krupski 4& pl� Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: ELIZABETH & SALVATORE PENNISI request an Administrative Permit to demolish the two existing garages located landward of the dwelling. Located: 1425 Pine Neck Road, Southold. SCTM# 1000- 70-5-40 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. 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Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) Southold, NY 11971 �� Telephone: 631 765-1938 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: October 16, 2017 Re: LWRP Coastal Consistency Review for ELIZABETH & SALVATORE PENNISI SCTM# 1000-70-5-40 ELIZABETH & SALVATORE PENNISI request an Administrative Permit to demolish the two existing garages located landward of the dwelling. Located: 1425 Pine Neck Road, Southold. SCTM# 1000-70-5-40 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the action is CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. �pE SO(/ly Michael J.Domino,President Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 Charles J.Sanders P.O.Box 1179 C/> Southold,New York 11971 Glenn Goldsmith ® �� Telephone(631) 765-1892 A.Nicholas Krupski ®lif'couVFax(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/Ext, in Received Applic tion: �` 7 E E V E Received Fee: 15' �D���r7 Q v ►—Completed Application: < ID Incomplete: / SEP ®.S 2017 SEQRA Classification: Type I_ Type H ✓ Unlisted Lead Agency Determination: Coordination:(date sent): outholdTown LWRP Consistency Assessment Form Sent: 10`x' CAC Referral Sent: ; Date of Inspection: Receipt of CAC Report: Technical Review: Public Hearing Held: 10119,17 Resolution: Legal Name of Property Owner(s): L,'z� �e � -� S✓t-���a-f-o✓c� (/ ,� .�i� Mailing Address: e w e C_k /U '+k.1 Phone Number: 3 / — 7 2 y ?z 3 3 Suffolk County Tax Map Number: 1000 - ?0 Property Location: /`-Io2 PI;nye yv e-c/L /ZcJ So L'+L' d 1 cl (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Board of Trustees Application GENERAL DATA Land Area (in square feet): ��r, S/G Area Zoning: 2 e s"Ot e'i-fi'A-1 /— yb Previous use of property: /C CSS-G Q n A%d Intended use of property: 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 s project require any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure(s) on property have a valid Certificate of Occupancy? ✓ 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): %o e�,., o Ii-�'oJ J Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: -F,9 p—emoye ,1 ggAA g= i� S 4htd -J,9 Qtp 41 IV ,6 o-ooA e:�e n�-" Area of wetlands on lot: O-0 0 square feet Percent coverage of lot: 0/0 Closest distance between nearest existing structure and upland edge of wetlands: 7 o feet Closest distance between nearest proposed structure and upland edge of wetlands: Vo V-7L feet Does the project involve excavation or filling? No Yes If yes,how much material will be excavated? cubic yards How much material will be filled? J0 cubic yards Depth of which material will be removed or deposited: d -feet Ir Proposed slope throughout the area of operations: i✓D ��O,O e— Manner in which material will be removed or deposited: O . 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): AZ/0 l lrirge-k -' � Y . l i 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 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 l -Project and Sponsor Information Name of Action or Project: A!-0/Ws, G '�XOA/ Project Location(describe,and attach a Idgation map): Brief Description of Proposed Action: 6��Afc'rf le 46C by Ai4_2 Name of Applicant//or//Sponsor Telephone: Th �V6�-0%�ie Qi ��/�/�$ E-Mail: �-t�zAd. Address: / �.Si✓� &ck City/Po-State: Zip Code: /C �! 1197 ) 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. 0 11 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? A acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural (non-agriculture) ❑Industrial [:]Commercial residential(suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page I 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: RT n' 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ 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? ❑ r�t 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline ❑Forest ❑Agri cultural/grasslands ❑Early mid-successional ❑ Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, ❑ ❑ a. Will storm water discharges flow to adjacent properties? NO YES b.Will storm water discharges be directed to established conveyance systems(rungff and storm drains)? If Yes,briefly describe: NO YES Page 2 of 4 � r 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: Rr�❑ 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 PRPjVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Sa r vr4'fort r We ei wJ 1So APPlicant/s on r name: -Lt7 ! L�A — Date: / 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 �y ❑ regulations? u 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? 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 E]reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: 1:1a.public/private water supplies? PT b.public/private wastewater treatment utilities? Fr 1:1 IV 8. Will the proposed action impair the character or quality of important historic,archaeological, architectural or aesthetic resources? 00, 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, waterbodies,,groundwater,air quality,flora and fauna)? MOO, 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 ❑ 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. ElCheck 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 impacts1670 Town of Southold-Board of Trustees Q Name of Lead Agency Date President Print or Ty e Name of Res onsibl Officer in Lead Agency Title of Responsible Officer Signature of Respons' le Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Board of Trustees Application AFFIDAVIT 3n/yp-7 4-cive J'emw S a BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE 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 MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. % Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF � � , 20 V A;4 Notary Public DIANE DISALVO NOTARY PUBLIC-STATE OF NEW YORK No. OID1475593 Qualified in Suffolk County Q My Commission Explles April 30, 20 V 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 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: fie'.n '.1y t&,Q E_�,Q -- (Last name,firs ame,iniddle 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: a(Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other",name the activity.) \09.,,VJVi 7// 0 / 1 7 ,0 O f A�i�-.LCL C-r J 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 the shares. 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 Submitted th' day of Seoo% 200[7 Signatur Print Name Form TS 1 y Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and 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# /QOO - -7O-S - ' o PROJECT NAME �Gl�n isi (.Ta.�e `D�jy�O�. �j O.✓ The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. 1?f 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: 4g' d " _ n -I"-- ae is O O Location of action:/IQ 57 / /WQ_ ��44,91 Wy,,�CJ Site acreage: X Present land use: AgSi O� CI-) .t Present zoning classification: ��s'j�✓v��j�/ l ' 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: / - _ / `– i (b) Mailing address: A;/OL A /e- Ar9el �-fLAo/d /✓ y // gi 7- / (c) Telephone number:Area Code, ,A – 7 (d) Application number,if any: Will the action bb�edirectly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No EdiIf 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. ErYes ❑ 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 ElYeseNo [- Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria 121*'Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP >, Section III—Policies Pages S through 16 for evaluation criteria ❑ Yes ❑ No [ZNot 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 ug ❑ Yes ❑ No 1 21 Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ ❑ � y Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy S. 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. 1:1Yes ❑ No LTJ 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. ❑ YeO No 1? Not Applicable Attach additional sheets if necessary ti 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 Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town wat rs. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes 1:1 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 forevaluation criteria. 1:1Yes ❑ No[1 Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No I r1 Not Applicable PREPARED BYg�11zEW6e 24-A ��, ,;s,' TITLE Oj,Uj✓ DATE G —�