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HomeMy WebLinkAboutTR-9175A Glenn Goldsmith,President �QF sorry Town Hall Annex A.Nicholas Krupski,Vice President Q ��� 54375 Route 25 P.O. Box 11 John M. Bredemeyer III Southold, New York 11971 Michael J.Domino G Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 01 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1809C Date: April 23, 2021 THIS CERTIFIES that the increase by 38sq.ft. of a first floor bathroom within the existing building envelope,to be constructed under existing overhang;- At 375 North Parish Drive, Southold Suffolk County Tax Map#1000-71-1-4 Conforms to the application for a Trustees Permit heretofore filed in this office Dated February 20, 2018 pursuant to which Trustees Administrative Permit#9175A Dated March 23, 2018, was issued and conforms to all the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the increase by 38sq.ft. of a first floor bathroom within the existing building envelope, to be constructed under existing overhang. The certificate is issued to Maureen Benic owners of the aforesaid property. 4 41" Authorized Signature Glenn Goldsmith,President *QF SO(/TTown Hall Annex V� 0 A.Nicholas Krupski,Vice President ,`O l0 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold,New York 11971 Michael J.Domino cn ,c G @ Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 oly&UPM,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: INSPECTED BY: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale,line/silt, boom/silt curtain 1St day of construction constructed Project complete, compliance inspection COMM NTS: CERTIFICATE OF COMPLIANCE: k - OF SU(/T Town Hall Annex Michael J.Domino, President �o�� y�lO 54375 Route 25 John M.Bredemeyer III,Vice-President P.O. Box 1179 Glenn Goldsmith Southold,New York 11971 A. Nicholas Krupski e YD Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 �y00UN'i`I,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay,bale line/silt boom/silt curtain 1St day of construction % constructed Project complete, compliance inspection Michael J. Domino,President ��0f soy0 Town Hall Annex John M.Bredemeyer III,Vice-President h0 l0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold, New York 11971 A. Nicholas Krupski • Q Telephone(631) 765-1892 Greg WilliamsyCOU O Fax(631) 765-6641 l' M`I N� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9175A Date of Receipt of Application: February 20, 2018 Applicant: Maureen Benic SCTM#: 1000-71-1-4 Project Location: 375 North Parish Drive, Southold Date of Resolution/Issuance: March 23, 2018 Date of Expiration: March 23, 2020 Reviewed by: Board of Trustees Project Description: To increase by 38sq.ft. a first floor bathroom within the existing building envelope, to be constructed under existing overhang. 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 Eileen Wingate, received on February 20, 2018, and stamped approved on March 23, 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. 1 40----o Michael J. Domino, President Board of Trustees i FEB 2 0 2018 APPR©`� ED FY BOARD OF �_..____. 1 -� - TOWN O F ►�U;�{E E S S .:; U 1 F,OLD DATE I g �_ �►`� P- 1 •• o a • I aYv A-- o i i r —ao %..p loop By F"' V f a, C.. ca �•� r h7 Michael J. Domino, Presidei,, O�'SOFFO4-rc9' Town Hall Annex John M Bredemeyer 111, Vice-President h� y� 54375 Route 25 Glenn Goldsmith y z P.O. Box 1179 A.Nicholas Krupski ® Southold,NY 11971 Greg Williams y p! Telephone(631)765-1892 ��l �0 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in field by: Q Eileen Wingate on behalf of MAUREEN BENIC requests an Administrative Permit to increase by 38sq.ft. a first floor bathroom within the existing building envelope, to be constructed under existing overhang. Located: 375 North Parish Drive, Southold. SCTM# 1000-71-1-4 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required 1. Residence: 100 feet 2 Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4 Septic Tank: 75 feet 5 Swimming Pool and related structures: 50 feet 6 Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1 Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice/of Hearing Card Posted: Y / N Ch. 275 ✓ Ch. 111 SEQRA Type: 1 II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Surveys 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: I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski /G. Williams Other Page 1 of 2 Michael J. Domino, Presides O�QSUFFO(�COG Town Hall Annex John M. Bredemeyer 111,Vice-President y� 1 54375 Route 25 Glenn Goldsmith o ` P.O.Box 1179 v� z A.Nicholas Krupski Southold,NY 11971 Greg Williams 4,- �a0! Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by- Eileen Wingate on behalf of MAUREEN BENIC requests an Administrative Permit to increase by 38sq.ft. a first floor bathroom within the existing building envelope, to be constructed under existing overhang. Located: 375 North Parish Drive, Southold. SCTM# 1000-71-1-4 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. Causesaltwater 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 G. Williams E. Cantrell D. Di Salvo Other Page 2 of 2 � t C � U FEB 2 B 2018 SouthOd To'xn J i ,.. Bo ar f Truslao. 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Y., ,� n .. �.�.: �: . _ .. .. 4.�,.,. ..� ,y _ ., _,- ��; ___ -, t � „�,,,� -,� T . �. �*k�, � `` �, 4 ��� ...T 0.M k''tjk: �..; +'� Lr,. ,a�+t� ` 7 I�`� '.3 y j �{{ ;,5y` t ., � A ``b tet. nM N b .,e 71 b W.SMA SOUTHOLD MY /� fie°`'• �— fowxorlwlr«nn N.0).Y 21 f.u[q 5 a ] e o w n 12 13 � � ra 155afsN of:. g \ me.os '@ s _ O as faYc� 3 z OR 4 A1 P£ �R wlal uE � S w SEEM SQ NO N TCE men.+. wee. - Real Property T8,, ervice genoy 071 ]-2&05 OFFICE LOCATION: �0f SOUryD MAILING ADDRESS: Town Hall Annex ~� l0 P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) G AAC Southold, NY 11971 :,% � • �O Telephone: 631 765-1938 O Fax: 631 765-3136 ��DUNTY,�c� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From" Mark Terry, LWRP Coordinator Date: March 15, 2018 Re: LWRP Coastal Consistency Review for MAUREEN BENIC SCTM# 1000-71-1-4 Eileen Wingate on behalf of MAUREEN BENIC requests an Administrative Permit to.increase by 38sq.ft. a first floor bathroom within the existing building envelope, to be constructed under existing overhang. Located: 375 North Parish Drive, Southold. SCTM# 1000-71-1-4 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is EXEMPT from LWRP review pursuant to: § 268-3. Definitions. MINOR ACTIONS items "ll"which states: Additions to an existing building or rebuilt residential structure which results in no net increase in ground area coverage, except where the parcel is located in a coastal erosion hazard area; The action is not located within a coastal erosion hazard area. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination'regarding the consistency of the proposed action Cc: Damon Hagan, Assistant Town Attorney Ja,ncs r (Gni; Trustcc ° � S -1 11 Nc— York 11971 0959 x Oa,-e Bergen. TrLSlce G y <2. %clephonc (631),76S-1892 Cliarles J. Sarndcrs. Truscce � Pax (631) 765-6641 UN-N, B O ASCD OF TOWN TRUSTEES TOWN 0FSOUTHOLD To- Southold-Town Building Department Re_ Verification of Building Department Permit Requirements SCTM#: Property Owner Mame: Date Sent to Bldg_ Dept--- The ept_:The Office of the Board of Trustees is forwarding the above referenced applicadoo for verification of the Building Departrinent's permitting requirements stated below- NO elow:NO Will the proposed project require a Building Perrnit? Will the proposed project require a variance determination from he Zoning Board of Appeals? _ = Wil[ any-part of this application be considered as Demolition as described under Town Code? COMMENTS: AA St r ®r e 611 Date D FEB 2 6 2018 BUILDING DEFT. TOWN OF SOUTHOLD SO/ Michael J.Domino,President Town.Hall Annek 54375 Route 26 John At. Bredemeyer 111,Vice-President *., P.O. Box,1179 Charle&J.Sanders. Southold, NeW York 11971 Glenn Goldsmith Telephone.(631) 765-1892 A; lixuu poska BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD .TI.: hic Fvp n.m.1- Coastal.Erosion Permit Application Wetland Permit Application Administrative Permit ), DID . /.Amendin.ent/TransferAExtension Received Application: /00,VV� * . Received Fee: Completed Application: FEB 2 0 2018 Incomplete: _SEQkA Classificationt,Type I Type 11 Unlisted Sntlirld-mvvn aad.Agen4y-Detetrnination: Board of Tms±,?�'L-------j Coordination:.(date sent): LWRP Consistency Assessment Form Sent:. CAC Referral .Sent:. Receipt of CAC Report: Technical Review: V--public'Heafing Held: .,', ,:5,244 Resolution:. Legal Name of Property.Qwnef(s):. AI Mailing Address- LJQU)% LAIIE:b RXA.Ly", S T 1V. LL50-7 . Phone Number: 151U 5.0 2-A Q11"olk Crmnftr Tnx Man Number- _11100- Property Location: �.. ...Yt�R�Sf4 DR Ikk (jf. 'necessary, provide LILCO,Pole#,,disha.nce to cross.streets, and-location) A Mailing Address:_ UJ44 Phone Number- �_e2 Board of Trustees Applic__lon GENERAL DATA Land Area.(in square feet): Area Zoning: p Previous use of property:.I ,�Ly� ,� Intended use of property: r;;; �,.,....a �W �• .�..� ter..,. ,,�� If"Yes", please provide a copy: Will'this project require a Building Permit aper 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.Planswill.be required. L.Jvu ilii 3.!!l.`fiJ\iiYC iva1 i;iil v'u �Aiicuit,v"ii viii Cii�.iuViiiii�ii,Vui ci vi h�iY�:uiS: i v5 �iVv If".Yes",' please provide copy of decision. Wilt this:project..require any-demolition as per Town.-Code:or..as_determined.by.the Building.Dept:? Ye's Does the structure(s)on property have a valid Certif cate of Occupancy?_X_Yes No Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revolted or suspended'by a governmental agency? X No Yes If yes,provide explanation:. Project Description(use.attachments if necessary):,I kcaeh5e my a S qLjoge, r-T 1 IST F'I.DORL&I. {tbi M,_nWa Bu L DIMC, E'�WEI.OP to M comemgro ( moEg. e-its-1LIC-t MtR�A�IC9 Board of Trustees Applic__ion WETLAND/TRUSTEE LANDS APPLICATION-DATA �tij�l'1JC Vl`LfIC'.p1V�lilJ�ii V�lG1QL1V11S. (, •�� �(,��� w Area of wetlands on lot:..... _ square feet. Percent coverage of lot: . . . % Closest distance between nearest existing .structure andupland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge.of wetlands: feet Does the projecuinvolve 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: 4et proposed fi i rp. ^f:nAmfi . tv 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): WO 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 Part 1-Project and Sponsor Information Ur— fwelc)EMM� Name of Action or Project: Project Location(describe,and attach a Iocadon map): Jon-wTqnn Brief Description of Proposed Action: C (-ir5 1 n"OPI T 0" t,1,9J - f fit�C� 80 V0411 um4ftwq - LA)M+1�! x Cisfi�l.Ca rAl t .CJ1a-1 P!)OT PRIt Name of Applicant or Sponsor: Telephone: • Q_ E-Mail: t Zan Address: MIA 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? Jf Yes,attach a narrative description of the intent of theTroposed action and the environmental resources that V F 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? M 15 acres b.Total acreage to be physically disturbed? 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. QU.rban ❑Rural(non-agriculture) ❑Industrial ❑Commercial We0sidential(suburban) LIForest UAgriculture ❑Aquatic ❑Other(specify): ❑Parkland Pagel of 4 5. ls:the propose&action, NO YES N/A a.A permitted use under the zoning regulations? ❑ k ❑ b.Consistent with the adopted comprehensive plan? ❑ ❑ ❑ 6. NI N --- LIli ..........iii l'J"�UIV V VJL.U,act ion L.VIIJIJLL.IIII IIl41U141 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. R7]] no. J 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public•transportation services)avanabie 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,d scribe design features and technologies: WILL Ml>�� 't c:�. ❑ 0 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 theproposed action connect to existing wastewater utilities'?' NO YES , If No,describe method for providing wastewater treatment: ❑ �[ 12, a.Does Lite site cuntain a structure tiiaL is iisieu un cii11e1 Lite PLUM ur i'4aiivuai i:egIsici UI i-iisiUric NO ES Places? (� ❑ b.Is the proposed action located in an archeological sensitive area? L 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? f;z;l ❑ 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 ❑Agricultural/grasslands 'DEarly mid-successional, El Wetland El Urban Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the QtatP nr FP.r1Prn1 onvPrnmPnt aq thrPntPnPti nr Pnd2mvered;? � ❑ 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, ,F-1 F] , a. Will storm water discharges flow to adjacent properties? P<NO [:]YES b.Will storm water discharges be directed to established conveyance systemsnpffand storm drains)? If Yes,briefly describe: NO L(YES Page 2 of 4 18_Does the proposed'action include construction or other activities that fesuIt In the Impoundment of `NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: ❑ 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe- 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES rmmnli-Ind)far ha?ardnaje; •agt�? If Yes,describe: ❑ ]AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: 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 I 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? M El ?v Will t4+p n.v nn. !orl art:n..ror. lt iri o r•1,gnno in_tho neo nr intra cihof nco nF lonrl9 - I—1 U U 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(CEAj? 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: ❑ ;1: public/private water supplies? b.public/private wastewater treatment utilities? F1 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 ft,or "Moderate small to large impact impact may may 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage problems? LA' EJ 11 Will thevproposed 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-tern and cumulative impacts. F1Check 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. nCheck 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 imps Town of Southold-Board of Trustees Name of Led A..gency Date CN�[e -VVL jLD President Print or Type Nam WofRponsi eficer in Lead Agency Title of Responsible Officer pnatnra of Racnr) Le Offinnr in I P,?(l Ananry Cionnti�ra of PrPna-rPr(if different frnm ResnonSihle Officer) ,y PRINT Page 4,61'4 APPLICANT/AGENTmEPRESENTATIVE TRANSACTIONAL DISCLOSURE FORINT Thr Town of%uthold's CQft of Ethics vrohihits conflicts of Interest on the oars of townofficers and ems.The tttrmse'of this form is to RMdde inforination which can alert the town of moble conflicts of km=and allow it to tah,�Avow action is nog=to avoid sante. La j m a, q� YOURNAME U,00BG"Cl 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 C Variance Trustee Change of Zone Coastal Erosion A ,yat of plat Mooring Etcemption from plat or official map Planning Other (If"Other",name the activity.) Do you.personally(or throw 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 S%of the shares. 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 applicmtt/egeat/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 empfoyee or his or her spouse,slbfing,pa=4 or crud is tciiecit ail-ti.appiyj: A}the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corpomdonk 6)the-legal orbene6cial owner of any interest in a non-corporate entity(whenethe applicant'is not a corporatloa); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP SttbmiIt) Si PrintNwne,& [ /'egn .Z( Sp I c- - Form TS l Board of Trustees Applici _ -on AUTHORIZATION (Where the applicant is not the owner) UWe, tel,y r e e A e-/1 1 �C `r ,Cy r I s 1 ee4� C owners-of the property identified.as SCTM# 1000- in the town of e ' New York, hereby authorizes / '�'e4f h � to,act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees'-for this-.property. W Property Owner's Signature P perty Owner's Signature SWORN TO BEFORE ME THISr, t DAY OF 2L401 0 _ lvj� xr :n_ �t• 1.4 r LAAk COLLEEN KEMMESAT Notary Public, State of New York Registration#01 KE6322637 Qualified In Nassau County Commission Expires April 6, 2019 Board of Trustees Applica ,�,,n AFFIDAVIT C(f,r) '2 �h �' <- (,BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES., THE APPLICANT AGREES TO HOLD 1'HE'I'OWN OF SOUTHOLD AND HE 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 TRUSTEESDURING THE TERM., OF THE PERMIT, _/X l� f Signature of Property Owner Si lure of Property Owner SWORN TO BEFORE ME THIS_!Z DAY OFIWUL&" , 24AL_ p ( I Notary Public COLLEEN KEMMESAT Notary Public, State of New York Registration-#01 KE6322637 Qualified"In Nassau County Commission Expires April 6, 2019 Town of Southold LNM 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 exept actions including Building Permits . and other ministerial permits not located within the Coastal Erosion Hazard Area. . rieIOre answering the que�iions in Section C, d r, prcparer of this form should review u1C CXCinpt .minor action"Hst, policies and explanations oi'each policy contained in the T own of Souinoiu L Ui�l Waterfront Revitalization Program. A. 'proposgd acctia� will be ev�l�}ated a� to !is -sitnuficant e cial'and a dverse:cIfectstipon the cogtal area(which.inc1udes-a]1,of fiouIiold 10 Vn2. 3. If any question in Section C on this form is answered "yes" or "no"; then the proposed action will i affect the achievement of the LWRP policy standards and conditions contained in the consistency rgvie_.w law. Vine- .rneb macs;'rr mngt he in.deftit_ fiRtinn hnth.san-in:f ro and rr»- Tf ark artier. rannnt hP r.FrtifiPr� aC (:!1!1_^2^.P•:F.�r�l•.41,vT\I TUU—nliinr c.4n-A6rAo onA 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.northfoik.net)-' the Board of Trustees Office, the Planning Department,-all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# � PROJECT NAME C e The Application has been submitted to(check appropriate response): n ., �.� ' 1'�i!DUiII-ll L.�J I'ltlLWil�'DVA1 Y l�J lluiiuiiis iic�ia. iJ yvaiii vi i i'iiSii:ra Lei 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) El • (1�\ Tiinonniol acoietonno(ort rtrart lean ciilteir��) (c) Permit,approval,license,certification: El Nature and extent of-action: ^_r% . T MCI U4 T Location of action. QQ r Site acreage , Present land un: 311J►Eal � 1.�5 �.---- -- — 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: i'Si,i ivam�ri„»eai;;•s�s�+s; �1'eQ0/1 �- �1/f1/» (b) Mailing address: JZh.D5E� ILl. 9 H .1U (c) Telephone number: Area Code(4:;IJQ• C.Z- QQ. (d) Application number, if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes N4 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 1;n.: 1 Ti,nn}nv.n ..r.K:..... ..f rle�rnln�►rhnnt vn *16o Tnaain AF`nly*1tn1�1 ±hof•nnhampoe nnwnmvsini/v nhur.�ntpr Pow_- _ .._._ _ .. .... ... ..._-----• --_> ... ,..... ....... .. .___. _ . - . . .. . . _.-. . - .- . - _.,. _-- preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section III–Policies; Page 2 for evaluation criteria. Yes No Not Applicable Attach additional sheets if necessary • �} D...,L....L .....7 w....nnwsn 1.in�nvin ^"A nwn1knnn1nninn1 vnontfs•nnp ^f f•16n Tnnrn of Cnn+Hn1A Can LWRP Section III–Policies Pages 3 through 6 for evaluation criteria 0 Yes o.No,) Not Applicable J Attach additional sheets if necessary 'II S`.II.,....... �.:..._..' .....:•.:�. .___.• . .• rr -A, n • •• n .s Vll�r' J. L'rs"n"llG Twu"'' 4uAliL, Allo t%1 Viva.a OviiUii. i iNVU!%,%iO %U1 VUSMUMi iLG 1 VT/U l/L $JUUa U%pl". UVW LWRP Section III—Policies Pages 6 through T for evaluation criteria Yes.[] No Not Applicable Attach additional.sheets if necessary NATURAL COAST POLICIES POIAVY !!. 1V11UU1UUC IU33 V1 MCI 3L1 MAW w) uuu Halm ai i cavus I.cO as vuA alvvuaur, auu ci vaavu. IJGF L VV X%A Section III—Policies Pages S through 16 for evaluation criteria 0 Yes 0 No,%Not Applicable Atlnrh aA.44irna1 Sheet,if nece&Wy Policy 5. Protect and improve water quality and supply in the Town of Southold. See.LWRP Section III �Z?.�1in�nn Dn.�nn 1L �1...n..r�3. 71 Fn..mrnb.sn+IAM nsi4ns•in Yes o No �K 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 ffi—Policies; Pages 22 th--E-vugh 32 sur cnackin. i a EJ 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 thhri ugh ear ilii iiu "J'i iiTi �'r•iiii«TiiiJlL G.i LLiri aii• Yes No�g Not Applicable Attach additional sheets if necessary Policy'8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. FT v r F1 Y w • INUO;capkpax%s"Lp� 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 c..:a,,.:;.. .wa ate• -- n w-- i�v=� i�vi ra�rYia�.sivaQ Attach additional sheets if necessary WORI{ING 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 waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. Yes 0 No Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III Policies; Pages -V",1"- iii. V. V.w.iial'A" CA21' ria. 0 Yes No Not Applicable Attach additional sheets if necessary "Policy 13. Promote appropriate use and' development of energy and mineral resources. See LWRP .QA"+9 n" TIT_VAMDiBa t. pRahx.13. n 4$ fh 99 owls ir...].'01n fl l ---.- ,. [� �,_/y__��yaaaaau__L-�' :a itfw'rl'd. ., t l t7.._ i 1 1►r_ K 1 AT_. a PREPARED B TITLE—j `7""" DATE