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Home My WebLink AboutTR-9142A Michael J.Domino,President ��0� S�Uryo Town Hall Annex �O l0 54375 Route 25 John M.Bredemeyer III,Vice-President P.O.Box 1179 Charles J.Sanders Southold,New York 11971 Glenn Goldsmith • �O Telephone(631) 765-1892 A.Nicholas Krupski �yCouNT`1, � 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 7 complete,lete, compliance inspection p Michael J.Domino,President o��OF S0!/Iyol Town Hall Annex 54375 Route 25 John M.Bredemeyer III,Vice-President P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski Telephone(631) 765-1892 Greg Williams cUUFax(631)765-6641 yNT`I,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9142A Date of Receipt of Application: November 28, 2017 Applicant: Ronald R. Schwalb SCTM#: 1000-126-6-6 Project Location: 3105 Sigsbee Road, Mattituck Date of Resolution/Issuance: January 17, 2018 Date of Expiration: January 17, 2020 Reviewed by: Board of Trustees Project Description: Remove existing 4' high fencing and install 6' high fencing beginning at the existing retaining wall and extending landward along the westerly property line. 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 Ronald R. Schwalb, received on November 28, 2017, and stamped approved on January 17, 2018. 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. s Michael J. Domino, President Board of Trustees SURVEY OF PROPERTY A T MA =UCK $AVID• TOWN OF SO UTHOLD $AY SUFFOLK COUNTY, N Y ep CoNi'c 1000-126-06-06 PESCALE• 1'-20' JULY 22, 2010 OCTOBER 7, 2016 ol GR Ar � s 9 p0"s v� id'i 6 059 N6 -�� pnuly0►� �5F o.Z E ° M, O nP n p z O � o C". °° g, ZONE X , `- 1.4E sgo w ZONE AE \ 9�'S 26 \(EL.6 Feet) Ros � s 6 �Y+ � 24- c'A y� FL000 .ZONE lip O NOV 2 8 2017 ZONE AE n°"Bow °5 ,E (EL.8 Feet) 0.5 Board of Trus eo BE�N 0 CERTIFIED T0: RONALD SCHWALB BUU� VNO YAP" ADVOCATE'S ABSTRACT, INC. 06o STEWART TITLE INSURANCE COMPANY BZ6E� /3�"� t►E CAPITAL ONE, N.A. 5620 o�0�1 �0 :E ■ =MONUMENT J N FLOOD ZONE FROM FIRM 36103CO481H LOT NUMBERS REFER TOJ "AMENDED MAP OF PROP. OF MAT77TUCK PARK PROPER77ES INC." FILED IN TRE SUFFOLK COUNTY CLERK'S OFFICE AS FILE NO. 801. ANY ALTERARON OR ADD177ON TO THIS SURVEY IS A WOLA77ON NO. 49618 OF SEC77ON 7209OF THE NEW YORK STATE EDUCA77ON LAW. CONIC EXCEPT AS PER SEC77ON 7209—SUBDIVISION 2. ALL CER70CARONS (631) 765-5 1) 765-1797 HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF AREA=9,351 SO. FT. P.O. BOX 909 SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR TO TIE LINE 1230 TRA i/ELER STREET WHOSE SIGNATURE APPEARS HEREON. 10-17� SOUTHOLD. N. Y. 11971 SURVEY OF PRO RT Y AT MATTITUCK $LVA• TOWN OF SOUTHOLD $A� SUFFOLK COUNTY., N. Y. SIC 1000-126-06-06 ;o- °�sa SCALE. 1'--�20' JULY 22, 2010 / OCTOBER 7, 2016 sol / ullu� 1 �nvv� X6'29 °, \ •5g+��5 dP� /� CtA f DO E \ Pn of �� \ -_�� O• 0 col zrloo O O \ wcp x co so Fe 4E \ ZONE X owe pEd� o � 19 4 2' , \ TY. w FR• N ZONE AE X9'5 2.0 (EL.6 Feet) 5r ps Q \' � c FLOOD ONE Nom\ P01-*Z� ,I 0 I \• ZONE AE NOV 2 8 2017 5� ,� (EL.B Feet) AP,P-R_OVED BYct Souihcl�i Imran 1 , ,, Board of iiusBOARD `OF 1 RUST o icn _ ` TOWN,'OF SOUTHOLD �1ns, PATE- CERTIFIED ,z ` � 5 I I CERTIFIED TO: \\ / RONALD SCHWALB BU , VAt � YaP" ADVOCATE'S ABSTRACT, INC. STEWART TITLE INSURANCE COMPANY _ 8�6E CAPITAL ONE, N.A. _ % Z9� P ®�iGL S6Z "" i` 0 s r Q Lj ® =MONUMENT J L n� � N FLOOD ZONE FROM FIRM 36103C0481H LOT NUMBERS REFER TO ND "AMENDED MAP OF PROP. OF MAT 77TUCK PARK PROPER71ES INC." FILED IN THE SUFFOLK COUNTY CLERK'S OFFICE AS FILE NO. 801. NO. 49618 ANY ALTERATION OR ADD17ION TO THIS SURVEY IS A WOLA77ON CON/C OF SECTION 72090F THE NEW YORK STATE EDUCA77ON LAW. EXCEPT AS PER SEC77ON 7209—SUBDIVISION 2. ALL CERT7F7CARONS (631) 765-5 31) 765-1797 HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF AREA=9,351 SQ. FT. P.O. BOX 909 SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR TOTIE LINE 1230 TRAVELER STREET WHOSE SIGNATURE APPEARS HEREON. 110-178 ¢SOUTHOLD. N. Y. 11971 Michael J.Domino,Presid'�� gUFFQ(�C ~" Town Hall Annex John M. Bredemeyer III,Vice-Pr iucnt �� G�� 54375 Route 25 Charles J. Sanders y z P.O.Box 1179 Glenn Goldsmith Southold,NY 11971 A.Nicholas Krupski �' p! Telephone(631)765-1892 hod �a Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: c/i r 80:25 Completed in field by: C, aouS'.,"4 RONALD R. SCHWALB requests an Administrative Permit to remove existing 4' high fencing and install 6' high fencing beginning at the existing retaining wall and extending landward along the westerly property line. Located: 3105 Sigsbee Road, Mattituck. SCTM# 1000-126-6-6 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=� Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y. / N Ch. 275 / Ch. 111 SEQRA Type: I II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: LOA;ns ) 'TO Gain 1-1A R&—oGf 1s� otune 4�4 ®C-► 4 NJ I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino v/ G. Goldsmith N. Krupski C. Sanders Other Page 1 of 2 Michael J.Domino Preside' SVFFQj'( �0 C� Town Hall Annex John M.Bredemeyer III,Vice-Presiaent �y� G�� 54375 Route 25 Charles J. Sanders CZ CZ) z P.O.Box 1179 Glenn Goldsmith Southold,NY 11971 A.Nicholas Krupski ?� ® p!� Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: RONALD R. SCHWALB requests an Administrative Permit to remove existing 4' high fencing and install 6' high fencing beginning at the existing retaining wall and extending landward along the westerly property line. Located: 3105 Sigsbee Road, Mattituck. SCTM# 1000-126-6-6 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. s25% Expansion/Calculation Work Session Notes Application Complete SEQRA Classification Confirmed Coordinated Review Y/N Pos/Neg Declaration CAC: LWRP: Additional information on comments/to be discussed/Public Hearing: Date: Completed By: Present: J. Bredemeyer M. Domino G. Goldsmith N. Krupski C. Sanders E. Cantrell D. Di Salvo Other Page 2 of 2 t NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Diviaion of Environmental Parmita,Region 1 SUNY;co Stony Brook,50 Circle Road,Stony Brook,NY 11790 P;(631)444-0365 I F;(631)444-038Q WWWA@C'ny'Q0V PERMIT MODIFICATION November 2, 2017 Mr. Ronald R. Schwalb 30 E 40th St., STE 1102 New York, NY 10016 Re: Permit#1-4738-04007100002 3105 Sigsbee Rd, Mattituck SCTM# 1000-126-6-6 Dear Mr. Schwalb: The Department of Environmental Conservation (DEC) has reviewed your request to modify the above referenced permit in accordance with the Uniform Procedures Regulations (6NYCRR Part 621). It has been determined that the proposed modifications will not substantially change the scope of the permitted actions or the existing permit conditions. Therefore;-the-permit'is'-hereby modified to authorize:-Gonsti u b-an-of an additional 15' for bulkhead return on the western side of the parcel listed above. All work must be in accordance with plans by DKR Shores ; (sheets 1 & 2) last revised on 10-23-2017 and stamped,NYSDEC approved on 11-2-2017. This letter is a modification to the original permit and must be available at the job site whenever,authorized work is in progress. All other terms and conditions remain as written in the original permit. AA an Administrator cc: marine DKR Shores file _�N,W voom Department of 4k3164„Y Environmental Conservation • t • t e 'w • 14 r e r&I•.` 00 • w _ i s �.i` h.e-��' s'{,5r� � -�° �` Tti'.w. � .(. ��` l K.".h.° ��f Y -• �. �S :N ;. •� r_ ` - ._ �,•�r �•`r•• !�i •t• tom' - - 1 R SEE SEC NO 114 397x^° r /-a �9EESEG NO ttd 1 1 g�1MTCN UNE 1 @a 24 UA 7.99 20A Ky � ry4 •//��( cap RM>I� 4 w NABOR g O 3 1w-� SEE SEGNo IJNE172Sol m9Tc _ 11 - LINE— 1T trC shy StA(cl F � PARROISTF /I MATRRiC Fj PMR 5 OIST e h, 42 �O �aP,/. ♦p.a 216Mc1�, W N b v / ^R NAltF1E �F ,a a ^0 e N 9 10.2 101 11 12 13 11 sMc) `�.0.2ap<B' E ♦, ,° ®'� 3� ^0 u s 14 r ♦NK(On LR k 40( 1 °9♦0 9 F��AF 6 A�p b 1�' J / 49A(c) Q SEE SEG N013 , � N� `' p M 9 r 1, ^' •`°'•' �/ �' a a: � / 2�`' . �°"♦ per`♦♦ �a .6 b ,�•.�C� .p eF/� , P FOR PCL NO r F a SEE SEC NO p ° 'CB t• „s 1 1250402433 FOR SEEN. 1 P 123r� 601-- .0 O 4 14 rA 29M-) .a / FOR PCL NOm two-•� SEE 13 19MQ / � f 2 ~ i 3�f FOR PGL NO 5 t i ,. 1 E2r,,.0y-02421 n'^'•P w NffiF` FOR POU NOSEC NO ---_�— LINE ,n / .4 ryy.z ,wX F.�•:i`:: : :s.-. .'�.q .,,:— .: ., uv{ _ ) _ 4UTCNE�N04 tm f c^:S 1' •J3.' .b. 1 _t;' .,,�,s a�•F{)N pp'$""1 7`(LLbFPkKCrlox a'FOR- _ _ 1 OFFICE LOCATION: ®�®f MAILING ADDRESS: Town Hall Annex ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 Q ;= a� Telephone: 631 765-1938 Fax: 631765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: January 17, 2018 Re: LWRP Coastal Consistency Review for RONALD R. SCHWALB SCTM# 1000-126-6-6 RONALD R. SCHWALB requests an Administrative Permit to remove existing 4' high fencing and install 6' high fencing beginning at the existing retaining wall and extending landward along the westerly property line. Located: 3105 Sigsbee Road, Mattituck. SCTM# 1000-126-6-6 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 below listed 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. �QF so Michael J.Domino,President ` Q�Gf Town Hall Annex John M.Bredemeyer III,Vice-President [ P.O.Box 1179 54375 Route 25 Charles J.Sanders CA,. Southold,New York 11971 Glenn GoldsmithQ .�� Telephone(631) 765-1892 A. Nicholas Krupski � �a®U F'ax(631) 765-6641 130ARD OF TOWN TRUSTEES TOWN OR SOUTHOLD This SectionForOffice Use®oily, Coastal Erosion Permit Application D E E � �`�� Wetland Permit Application _Administrative Permit NOV 2 8 2017 Amendment/Transfer/Extension Received Application: U109-1-11 '/' Received Fee: $ 1004,60 - Southold Town a of r Ste Completed Application: �•1 Incomplete:, SEQRA Classification: Type I_ Type R Unlisted Lead Agency Determination: -rCoordination:(date sent): I �� LWRP Consistency Assessment Form Sent: ,—CAC Referral Sent:, (z.20�1 " Date of inspection: Receipt of CAC Report: '�`��Technical Review: 1/ Public Dearing Held: I " Resolution: Legal Mame of]Property Owner(s): Mailing Address: c�Q �J L_ ° ' � �U�'�� ' l U 6 16" r Phone Dumber: 2 l/ Suffolk County Tax Map Number: 1000-. �4;�j Ll A2 C, Property Location: J/0 S Slake 606 � �vc� Z�Jt.S2 (If necessary,provide LILCO Pole#,distance to cross streets, and location) AGENT(If applicable):_ Mailing Address: Phone Number: ird of Trustees Applicuti( GENERAL.DATA Land Area(in square feet): s O(Pp r "��,.p j f)�r Area Zoning: Previous use of property: G e/-- J � Intended use of property: Covenants and Restrictions on property? Yes _No If"Yes",please provide a copy. Will this project require a wilding Permit as per Town Code? Yes __I/No If"Yes",be advised this application will be reviewed by the Building Dept prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes _,/No If"Yes",please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes ✓ No Does the structure(s)on property have a valid Certificate of Occupancy? ✓Yes No Prior permits/approvals for site improvements: Agency Date i✓G��!^�6/C(a� l� �/7/r� ✓7, !�jr Gii✓u" <o✓ /� / 'cJV✓✓h '�✓ �J No prior permits/approvals for site improvements. Has any perQnit/approval ever been revoked or suspended by a governmental agency? No Yes If yes,provide explanation: Project Description(use attachments if necessary): %7 h��or b r��- ✓ e f"v' / -^ If y, O h fl 1 °i It I- Com+ rc lj A Mrd of Trustees Applicatis' J WET e'.AND/TR€TS'TEE LANDS APPLICATION DATA Purpose of the proposed operations: J/2CT6/1-r 'Vz Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No Yes If yes,how much material will be excavated? cubic yards How much material will be filled? __ cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 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): 61 Z20 Appendix B Short Environmental Assessment Form bisi:ructibns for Completing Part I -Project Information. The applicant or project sponsor is responsible for the completion of Part 3. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part l based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part I -Project and Sponsor Information Name of Action or Project: Project Location(describe,and attach a locations ap): Brief Description of roposed Action: 1� G� ITZ, o1h _ /& _` Joh `v I�-, h-,('G•, Name of Applicarif or Sponsor: Telephone: 6 Y7 "' a/ E-Mail: !j ! we b Gni Address: 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: EJ 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? C9 acres 4. Check all land uses that occur on,adjoining and near the proposed action. L []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? ❑ 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: �!r _�6 r �,0 c �, � ��6;,.� 8. a.Will the proposed action result in a substantial increase in traffic above present levels? N® (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: EX El 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 IIY..__E��S Places? b.Is the proposed action located in an archeological sensitive area? ❑ 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? 1❑`J 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 ❑Agricultural/grasslands []Early mid-successional ❑ Wetland ❑Urban MSuburban 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? M ❑ 16.Is the project site Iocated 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? CSKNO ®YES d ❑ b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: [ C 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: IV F1 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: (q( I AFFIRM THAT THE INFORMATION PROVIDED ABOVE 1S TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE / Applicant/sponsor name: OLVo/ V ��D11 Date: Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of fart 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 regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? Q (� 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 FV__1 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 op rtunities? I--1 7. Will the proposed action impact existing: a.public/private water supplies? b.public/private wastewater treatment utilities? L Q 8. Will the proposed action impair the character or quality of important historic,archaeological, f�u1 ('�7 architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, rM waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage � 1"� problems? E.l 11. Will the proposed action create a hazard to environmental resources or human health? L Jr Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental 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) ��°�� Page 4 of 4 I -'rd ®f Trustees Applicati.cp Al MAVIT BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBE®PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER]KNOWLEDGE AND BELIEF,AND THAT ALL WORD 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 00 DAY OF M .20 1 Notary CARLOSJ RAMIREZ Notary Public—State of New York N0.01 RA6354253 Qualified in Bronx County My Commission Expires Feb 6,2021 APPLICANUAGENUREPRESENTATIn TRANSACTTONALDISCLOSURE.FORM The Town of Southold's Code of Ethics prohibits con€liets of interest on the part of to6 iB jors and cmnloyces.1he unrnose of this form is to nrovi a inforinat ion which can alert the tom of nosslW conflicts of interest anti allow it'to Utke whcttevet cation is' neeessary to avoid same.j� YOUR NAME: - - (Last name,first name,.ghiddle 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 )C 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,sibihig,parent,orchild),Irave a relationship with any ohicer or employee of the Totivin of Soudio�Id? "Relationship"includes by.blood,hnarriaf c,or business interest."Business interr:st"means a business, including a partnership,ihi which-the town officer-orempiUyeG has even a partial ownership of(or employment by),a corporation in which theimvin officer oretnptoyee owns more than 5%of the sharel. 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(wheel the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIP'T'ION OF RELATIONSHIP Submitted this 7 day o _ d200 /17 Signature— Print Name Forth TS l I 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 tim4thin the Coastal Erosion HazardArea. 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 Devitalization Program. A proposed action will be evaluated as to its sianificatat beneficial and adverse of epts upon the coastal area C1 hi ch hacluj dei 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 au-debtil fistine, both supporthig and non- sup 6rting faets. 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): �y Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees !LI 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: Location of action: (? cl ®r%F ✓ol' 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) Naive of applicant: (b) Mailing address: -� U (c) Telephone number: Area Code( },26' Id - (d) Application number,if any: Will��t-h--e--{{action be directly undertaken,require funding,or approval by a state or federal agency? Yes 6,_,.t' No o 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 foram 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 LVVRP Section M—Policies; Page 2 for evaluation criteria. 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 i-_l Yes Q No Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LSection M—Policies Pages 6 through 7 for evaluation criteria Yes No '7�� Not Applicable LA Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWR? Section M—Policies Pages 8 through 16 for evaluation criteria -7 C1 Yes 1:1 No L/21 Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold.See LNVRP Section III Policies Pages 16 through 21 for evaluation criteria DYes [] No Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section M—Policies; Pages 22 through 32 for evaluation criteria. El [A it Yes leo Not Apj Bnekble Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See llWRP Section M — Policies Pages 32 through 34 for evaluation criteria. Yes No Not Applicable Attach additional sheets if necessary Policy 8. Agnimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section M—Policies;Pages 34 through 38 for evaluation criteria. El Yes 0 No E-N�Not Applicable PIIBUC COAST POLICMS 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 M—Policies; Pages 38 through 45 for evalvati6n criteria. YeO No Tart Applicable Attach additional sheets if necessary - - WORMING COAST POLICIES Policy 14. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LVVRP Section III—Policies; Pages 47 throw 56 for evaluation criteria. El Yes � No LNot Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living amarine resources in Long Island Sound, the Pecornic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. L Yes No Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LNVRP Section III—Policies; Pages 62 through 65 for evaluation criteria. U Yes El No Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. Yes D No Not Applicable PREPARED BY /c 42A o �� h w-/,//—TITLE DATE