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HomeMy WebLinkAboutTR-9177A r Michael J.Domino,President ��OF SUy� Town Hall Annex John M.Bredemeyer III,Vice-President ,`O l0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold, New York 11971 A. Nicholas Krupski G Q � O Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 y�4UNTY,Nc� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1475C Date: May 30, 2018 THIS CERTIFIES that the as-built 7'x7.7' hot tub located on existing seaward side deck; hot tub drainage connected to existing_drywell on southwest corner of dwelling; At 880 Deep Hole Drive, Mattituck Suffolk County Tax Map#1000-115-12-13 Conforms to the application for a Trustees Permit heretofore filed in this office Dated February 6, 2018 pursuant to which Trustees Administrative Permit#9177A Dated March 23, 2018, 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 as-built 7'x7.7' hot tub located on existing seaward side deck; hot tub drainage connected to existing drywell on southwest comer of dwelling; The certificate is issued to David Krupnick owner of the aforesaid property. Authorized Signature Michael J.Domino,President 0f SUUTyO Town Hall Annex John M.Bredemeyer III,Vice-President �� lQ 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G • Q Telephone(631) 765-1892 Greg Williams Ol cDUm, Fax(631) 765-6641 �� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 5.430/1 S' Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction / % constructed V Project complete, compliance inspection. INSPECTED BY: COMMENTS: or G S C CERTIFICATE OF COMPLIANCE: c � Michael J.Domino,President �o��V SO!/j Town Hall Annex y�lO 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 �COUFax(631) 765-6641 � NI`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 I ar Michael J. Domino,President QF soTown Hall Annex O�� /yOl 54375 Route 25 John M. Bredemeyer III,Vice-President '` P.O. Box 1179 Glenn Goldsmith Southold,New York 11971 A. Nicholas Krupski • Q Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 COU BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9177A Date of Receipt of Application: February 6, 2018 Applicant: David Krupnick SCTM#: 1000-115-12-13 Project Location: 880 Deep Hole Drive, Mattituck Date of Resolution/issuance: March 23, 2018 Date of Expiration: March 23, 2020 Reviewed by: Board of Trustees Project Description: As-built 7'x7.7' hot tub located on existing seaward side deck; hot tub drainage connected to existing drywell on southwest corner of 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 site plan prepared by Mark Schwartz & Associates, received on February 6, 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. e � Michael J. Domino, President Board of Trustees . , S ,� j._ Michael J Domino, Presid �ffO( O�Q ,Town Hall Annex John M. Bredemeyer III,Vice-President �� yJ, 54375 Route 25 Glenn Goldsmithy z P.O. Box 1179 A.Nicholas Krupski • Southold,NY 11971 Greg Williams y p! Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: ,�/,��g 3'-,Zr2 Completed infield by: G• Go��s,�.` DAVID KRUPNICK requests an Administrative Permit for the as-built 7'x7.7' hot tub located on existing seaward side deck; hot tub drainage connected to existing drywell on southwest corner of dwelling. Located: 880 Deep Hole Drive, Mattituck. SCTM# 1000-115-12-13 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,Presid, O�QSIIFFOIAI. , Town Hall Annex John M. Bredemeyer III,Vice-President y� 54375 Route 25 Glenn Goldsmith o r` P.O Box 1179 W z A.Nicholas Krupski 0 Southold,NY 11971 Greg Williams A ® p! Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in Work Session by: DAVID KRUPNICK requests an Administrative Permit for the as-built 7'x7.7' hot tub located on existing seaward side deck; hot tub drainage connected to existing drywell on southwest corner of dwelling. Located: 880 Deep Hole Drive, Mattituck. SCTM# 1000-115-12-13 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 G. Williams E. Cantrell D. Di Salvo Other Page 2 of 2 NEW SUFFOLK AVE LAND NOW OR FORMALLY CONSTANCE 6 PAUL ry CONNOR EL 4 EL 6 EL 8 S 87"19'20"E 212.28' EL 10 EL 10 0 el 6 \ZR, I1 Q,1,/- TURF B W an O \ �.O 1 r 11 / BUFFFR CH 62.9' Y / 43.8' _ 55.2'Tq(JON TURF BUFFER o z I1 / O HOLE II 22.3' g w C R E E K EXISTING 1 STORY PORCH O I HOUSE 'ice^l, ' 59.114 -!Tu BUF ER T DOCK .i y "e. \ \ b®, � 18.8' W aim :(i,�i; .b•\ \\ \ \ 7b" N�Z a s I BASIN W U 76.4' LL 40.3' w Z61 prr�i cid 44.0'TON N TURF B R y V I— / r CONC.WALK Q \-� q N 87"19'20"W 18711N\ SLB a UNDERGROUND PIPE Ie LAOWWMLLY SITE PLAN SCALE:1"-10'-0' STORM WATER MANAGEMENT DETAILSU N.T.S. SITE DATA: ICTM aaoousr:.0 W oucwvraN� w.rr.•urw wrcovcaAce L APPROVED BY x BOARD " OF TRUSTEES j TOWN OF SOUTHOLD FEB — 6 2018 '`JJ '/ _ _'—��.._.__ _ -DATE- _ _ MFEff 6 BOIMDS A-kct{- 3 201 �: aONa _ - - .....o`er ._.��._.._ DATE IYl 2 / g 1 o•rzo oszi.xm� 1 Vv 40 S-1 - a,irr_c..S i 5URVEY OF PROPERTY N 51TUATE: MATTITUCK NEW SU s TOWN : 5OUTHOLD FFO�K AVENUE W E 5U FFOLK COUNTY, NY 11"r SURVEYED 1 2- I 1 -2014 S SUFFOLK COUNTY TAX # 1000 - 115 - 12 - 13 I �0 CERTIFIED T0: i Q0 David Rrupnick LAND Now OR FORMERLYbF: Lowell T. Blumenthal CONSTANCE A. CONNOR Bank of America. N.A. PAUL J CONNOR � First American Title Insurance Company 58701 9120T 87o19,2O,iE w Advantage Title Agency, Inc. 21228 Lu 0t 10-— \ , r➢it �� :E ————' FE. 1.9'5 j c� C.E. �0 ��� ^ 4 ,'I1 Q I' CHIM. Q W t ' 3 UO•O 0IIX W 43.8 - - - - - - — GZ� _ — - - - — - O LU ` V Z O LU t O l \-- O v W rr tn� kO h � r 6 �WQ ! 22. Q ca" +� I —90 3 W 1— r--`, - - - - l - -Z`z�- - - - �'^ -z ODOCK `, 21 ' I o O u ! l 8 R` t BA51N 1p 4 \� o �m �yPNPUj 0 N rr 'z t N Al t (I i 'i'7 1..;� , • :\ 29.5 LU LLJ >� . N I O FEB 6 2018 + ' - ' �IQ LLJ ' o S^;i,o!; o� ����GG I �2�u� l (O o 1 Boa'I+ r"rr!1-i ' -� O UNERAINROPE D I �\ 187. 1 I 8 -- Z LAND NOW OR Fop ` RLYtpF• WETLAND FLAGS SHOWN THUS PSET BY LORRAINE WENDT SURVEYOR AT EDGE OF VEGETATED WETLANDS II ON 0"5-14 UTIU51NG BACCHARIS BUSH AS IDENTIFIER i if LEVATIONS REFERENCE'N.G.V D. 1929 DATUM ; FLOOD ZONE ANNOTATED FROM F,I.R.M. 3G 103C0482H NOTES: "Vnoulhoriyed alteration or addition to a survey map Dearing a licensed,and,arve,w,,eat is a ADJACENT AREA ® MONUMENT FOUND O HN C. >W d vimol ion of section 7209, sub-division 2, of the —a---- WOOD FENCE E H LE R5 LAND 5 U RVEYO R �'0.EHE New York Stale Education Lan. COVERAGE CALCULATIONS � �^ L�� � "Only copies Iron the original of this survey ti^ marked with al e on °"dland%Id EXISTING HOUSE= G2G Sed. Ft. PROPERTY ZONE R-40 stamped gem shalt original considered Of the to be �lidyoue I .:0 ft�;fQ� � copies EXISTING STOOP= G 1 Set. Ft. 6 EAST MAIN STREET N.Y.S. LIC. NO. 50202 —:_ {� "Certifications Indicated hereon signify that this EXISTING CONC. WALK= 152 Sg. Ft. _.,�C it I g1,� survey v/ag prepared in accordance rich the e.- Area = 21,05G S Ft. RIVERNEAD is .9 ng Cotle of Practice fo Lond Surve ado ted a N.Y. 1190 I 369-8288 Fax 3G9-8287 r ! ,. Dy the New York Stale Assocation of Pno,e„ono, TOTAL COVERAGE. 839 Sq. Ft. Area = 0.483 Acres �- „= � Ci Land Surveyors. Said certiltcations shall run only ADJACENT AREA= 8,87 ! Sq. Ft. GRAPHI SCALE °_ 'Ion ISlandlandsurve or.eom <� ; `°`his"`behalfp"'° `°`""°m `"le °arvey is Prepared, I 30 9 Y �`' °lot agency and lending Institution Fsed he eon,antl TOTAL COVERAGE= 9.5% ��` •1 1 f- J J�-,�,!+ o the msignees of:he lending institution. Certiftcn- .y`'/' !tons aro not ansfer to additional inglitu tions 14-134 I i y _kk - _.. 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F 7' ^ 4 13 �' 122E-0SU01 r 221(C) SEE SEC NO. w ♦ e y � tMTCR t1t1E s MArc1t uNE o ,� `' .," �a a Ye1O1 '"`� R SEESEC.NO.Ia 15" ,♦ t3 * 12 ,u,pl r�1Ma Qi�)3 0YC 11aE - NOTICE p0°� COUNTY OF SUFFOLK © e 1O a m oe n SOUTHOLD SECTION NO Q �� " �� ,,, ��� •'F^ e�rEM* <+ Real Property Tax ServiceAgency r 115 ..d a D r�,it Naly au u• -_- y.u. --r-- tr�r--rw-- V' +" tt"y5'� A wo 1aDs PROPERTY MAP -- -- cv"avtnx N.taaR r OFFICE LOCATION: �QF soyO1 MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) C Q � � �p Telephone: 631 765-1938 Southold, NY 11971 Fax: 631 765-3136 COU� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To Michael Domino, President Town of Southold Board of Trustees From Mark Terry, Principal Planner LWRP Coordinator Date: March 18, 2016 Re: Local Waterfront Coastal Consistency Review for DAVID KRUPNICK SCTM# 1000-115-12=13 DAVID KRUPNICK requests an Administrative Permit for the as-built 7'x7.7' hot tub located on existing seaward side deck; hot tub drainage connected to existing drywell on southwest corner of dwelling. Located: 880 Deep Hole Drive, Mattituck. SCTM# 1000-115-12-13 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 INCONSISTENT with the Policy Standards (Policy 6.3) and therefore is INCONSISTENT with,LWRP. 6.3 Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction. The as built hot tub does did not receive the benefit of Board of Trustees review or a Wetland Permit. 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 Michael J.Domino,President Town Hall Annex, �Q�� y�l �• 54375 Route 25 John M. Bredemeyer III,Vice-President !xR P.O.Box 1179 Charles J.Sanders N Southold,New York 11971 Glenn Goldsmith Telephone(631) 765-1892 A. Nicholas Krupski Fax(631) 765-6641 ; UNV _ } BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only } Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extensio 2, � .Received Application: Received Fee: $ M.00 `P>U1L7 FEB - 6 2018 - Co _._mpleted Application:-, 7, Incomplete: SEQRA Classification: Type I_ Type H Unlisted Lead Agency Determination: Coordination:(date sent)-- j LWRP Consistency Assessment Form Sent. . 4_ CAC Referral Sen t: Date of Inspection: .. ... Receipt of CAC Report: . - _--. Technical Review: Public Hearing Held:. ,21 W ' Resolution:- -- ; Legal Name of Property e Owner(s): 1�/'J_/ L a.0 cd - ru. go � ►;�/_ nna r 1 sem. Mailing Address:, Phone Number lo-51- Suffolk County,Tax Map Number: 1000-. Property Location: . �� .I7��.. �l.✓`e 'V la �(�%K- I V Vl �� /Jr� (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) Area Zoning: .. V d uk_fi�j Previous use of property:. Intended use of property: . ... Covenants and Restrictions on property? Yes No { If"Yes",please provide a copy. i 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. i Does this project require a variance from the Zoning Board of Appeals? Yes.. No If"Yes",please provide copy of decision. Will this projectrequire any demolition as per Town Code or as determined by the Building Dept.? f _-Yes Yes _N0 f Does the structure(s)on property have a valid Certificate of Occupancy? Yes No 1 j Prior permits/approvals for site improvements: t Agen y Dat ; Boa-VA,OfT— sf u1 ( CvvNu� til a 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):,. SFS. bLlt 611 `-ex/sfi _ var GLC . ". -Ogg ep a4d a U)" s�. Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: TO kLKW�f e)� l _ __ Area of wetlands on lot: 'J square feet Percent coverage of lot: Jam— % Closest distance between nearest existing structure and upland edge of wetlands: ,"( feet Closest distance between"ne est 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 j 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): APPLICANT/AGENT/REPRESENfiATIVE TRANSACTIONAL DISCLOSURE.FORM The Town of SoutNold'`s'Code of Ethics oioh'ibits conflicts of interest on thepart"oftown affoers rind emolovees' e-pumose of this foiin is to ptgviile"information which can iilertthe town of paible conflicts of interest and allow it. take'whtttever action is; necessurv'io-avoid same: /n YOUR NAME: ` (ran -(Last ndmd'first name,ipiddle initial,unless you are applying irr.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.) 'y i Tax grievance Building Variance Trustee Change of Zone =_ Coastal Erosion ; Approval of plat Mooring Exemption from plat or official map Planning _ - t Other (If"Other*,name the activity.) Do you personally,(6r'dt�r6iigh=your•compAny;;spouse-si1?lin;g;;Pni'ent pr child)'have u reladbnshi'p.with miyoftccr or employee, oF,tlie Town of,Soiitholtl? "Relntitinship"mclu.;dcs bybloo(,m�rriage,.or busiries§anterest "]3usiness Interest iiieriris a liusiiitieS includinga partnership,.in ayhicli the town.officecor,eiitployeeaias curb a partial ownership.of(oreniploympnt;by)„a cdrporafiorn i in;wliicli die tatvn,,t) ce:r or employee.ownsrho re;th'n15%oftheshares: 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. i 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 orbeneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); " C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this r da of Print Name o4__- . Co1 i1% n/C Form TS l Board of Trustees Application AFFIDAVIT v BEING DULY SWORN D_EPOSES 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 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 L F 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 B7THE 77TRS U DURING THE TERM OF THE PERMIT. r i -�r Signature of Property Owner SWORN TO BEFORE ME THIS S DAY OF CU-O-.r ,.20 Notary Public BARBARA H.TANDY Notary Public, State Of New York No. 01 TA6086001 Qualified In Suffolk County Commission Expires_01/13/20 61Z20 Appendix B Short Environmental Assessment Form Iristructibns;for-.Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification: Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. i Part 1 -Project and Sponsor Information r i { 1 Name of Action or Project: - i Project Location(describe,and attac a location ma ); . s � Brief Description of Proposed Action: 0 Vl U Name of Applicant or Sponsor- Telephone: FEMail: Address:- fff0 1� 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 an permit or approval: 3.a.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? __ _ acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. Urban ❑Rural(non-agriculture) ❑Industrial []Commercial residential(suburban) ❑Forest ❑Agriculture El Aquatic ❑Others ecif ( P Y)" _ y ❑Parkland Page l 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? EF. S' ❑ 6. is the proposed action consistent with the predominant character of the existing built or natural NO YES. landscape? i 7. Is the sife of the proposed actio-n-located in,"or does it adjoin,a state Iisted'Critical Environmental Area? NO NES If Yes,identify: . El 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 tiie proposed action meet or exceed the state energy code requirements? - O 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 . s VIf No,describe method for providing potable water: - - t 11.Will the proposed action connect to existing wastewater utilities? NO- YES s If No,describe method for providing wastewater treatment: j� 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES } Places? z 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 f 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? i If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres..—. _-_ El ; 14. Identify the typical habitat types that occur on,or are likely to be found on the project site.-Check all that aPp1Y= ❑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? - 16.1s'66 project site located iiithe•l00'yeai'f!6 dpiain? _ .__._..__.-.._ ..._ NO YES `m 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 `a b Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: E]NO ❑YES Page 2 of 4 19.�bocs the proposed action include construction or other activities that result in`tlie impoundment of NO YES water or other liquids(c: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 YES- solid waste management facility? ' If Yes,describe _ 20.Has the sited the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? _ If Yes,describe: ........:......... ) f I AFFIRM THAT THE INFORMATION PROVIDED ABOVE 1S TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/spon n -: ��t -1-�I� ► 6:�1: _,. Date:.:-- 6- - -- — - -/i Signature:., �_`1---� Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the,following questionsin Part 2 using the information contained in Part I and other materials submitted by the project sponsor or s otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my i responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact F may may occur, occur 1. Will"the proposed action create-a material"conflict with an adopted land use plan or zoning regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? - a 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 a 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 energyconservation or renewable energy opportunities? _ 7. Will the proposed action impact existing: a.public/private water supplies? ! b,public/private wastewater treatment utilities? '" 8. Will the proposed action impair the character or quality of important historic,archaeological, .architectural or aesthetic resources?_.-_ _....-. 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 .' � ' � No,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 � ate a hazard to environmental resources or human health? 11. Will the roposed action cre Part 3'Determination vfsignificance. The Lead Agency is responsible for the completion oKPart 3. For every / ' question inPart 2that was answered"moderate mlarge impact may ouou,",o,ifthere iouneed mexplain why uparticular � element o[the proposed action may o,will not result inusignificant adverse environmental impact,please complete Part 3. Part]should,insufficient detail,identify the impact,including any measures o,design elements that have been included hy i the project sponsor toavoid orreduce impacts. Part 3should also explain how the lead agency determined that the impact / may o,will not hevigni§oontS�hpo�nndu| impvo�ohouN�nuum,oyodoou,id�,in&imy�uing,pmhu6i|i!yoyo��unin&. � ! duration,irreversibility,geographic scope and magnitude. Also consider the potential for ohort-tenn.long-term and � cumulative impacts. / � ElCheck this box if you have determined,based on-the inf6rm'atio-n and a"nalysis above,and any supporting docu'inentation,' 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,, � i ' < � ' � ` > / � � � . ^ . � ` ' ` ' - � ` ^ Town of Southold-Board of Trustees Name Lead ATy Date President OM Lead Agency Title of Responsible Officer Print or TypeName of Respo_nsi e., icer in ff if different from Responsible Officer) PRINT Page 4of4 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 -,wilt be evaluated a&.Aa ;its-.s_i _nifccant fal area'(wl icl the udes aofSoithold`T6Lialandadveffet 'h.beneficeesu one.eoas 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will z affect the achievement of the LWRP policy standards and conditions contained in the consistency z review law. Thus,.each answer.must_be explained rin_detail; listinw-both,.supporting�and:non supportiri` .fg acts: If an action cannot be certified asconsistent with the LWRP policy standaiiis and 1 conditions;-it shall:':notbe`-underiakeri: 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. s B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# PROJECT NAME - r- -+-_ The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ElBoard of Trustees 1. Category of Town of Southold agency action(check'appropriate response): (a) Action undertaken directly by Town agency(e.g. capital 0!. -- 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: _ ----- --- - -'I lI -« _ - T _h Auk-, h'-flame. 4-6. -_SA_ . r_v r d&USe Location of action:. .. OV Site acreage:_-,., Present land use:. Present zoning classification: Y�S Gc�► l T7 i 2.. If an application for the proposed action has been filed with the Town of Southold agency, the following f information shall be provided: f (a) Name of applicants, tau �d �u.� ���� (b) Mailing address.: ��� IvAr IaEk mv t (c) Telephone number: Area Code( .SqO :.Dago .J���Q.y�v ��14 f (d) Application number,if any: .. Will the action be directly undertaken,require funding, or approval by a state or federal agency? ' Yes-:0 No: If yes,which state or federal agency? 1 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. 2 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. la Yes E] No \0 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 Yes 0: No 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 Q Yes ❑ No Not Applicable r -- y - _ 1 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 8 through 16 for evaluation criteria ? C-1 Yes .0 No Not Applicable r S Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria Yes E]' No PNot 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. F n' I Yes No Not Applicable Attach additional sheets if necessary . i Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. E Yes Q No Not Applicable R 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. t 0'Yes E No Not Applicable . 4 ------------- 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. YXI No Y�f Not Applicable Attach additional sheets if necessary s 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. 9,Yes :0 No Not Applicable 1 Attach additional sheets if necessary r 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. F T] Yes Q No Not Applicable i Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages } 62 through 65 for evaluation criteria. r 0 Yes No Not Applicable Attach additional sheets if necessary T . 'Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. Yes �No Not Applicable 0 PREPARED BY aU id �C ryl i �- TITLE IMA6 Oi✓/DATE o2LoZ--LS