HomeMy WebLinkAboutDonadic, Steve Michael J. Domino, President �0 SO-Town Hall Annex
John M. Bredemeyer III,Vice-President '`� l0 54375 Route 25
P.O.Box 11
Glenn Goldsmith J�t
Southold,New York
11971
CA
A. Nicholas Krupski Telephone (631) 765-1892
Greg Williams �CoUFax(631) 765-6641
I �,�`t.'`
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
March 28, 2018
Steve Donadic
180 Bayview Road
Manhasset, NY 11030
RE: 1071 BAY HOME ROAD, SOUTHOLD
SCTM# 1000-56-5-37
Dear Mr. Donadic,
The Board of Trustees office received an application submitted by Twin Fork Landscape
Contracting, Inc. on February 5, 2018 for an Administrative Permit to eradicate dead
debris and cut all of the bamboo down by hand on the property mentioned above.
The Board reviewed the application and determined that a permit cannot be issued to
clear vegetation on an undeveloped property without first obtaining a Town permit for a
primary structure and/or a site plan approval.
As the Board has determined to not move forward on this application, a refund is being
issued in the amount of$100.00 under Town check #1164 which is the total fee amount
that was submitted for the Administrative Application.
Sincerely,
Michael Domino, President
Board of Trustees
Encl. - Town of Southold Board of Town Trustees Check #1164
2M SNEER=.
TOWN OF SOUTHOLD
1164
BOARD.OF TOWN TRUSTEES
P.O.BOX 1179::'',
SOUTHOLD,W'11971'`: 50-666.214
DM mo? s'
PA7'[07MORDEROFOn $ /v0� 0z).
e s DOLLARS.
Brldgehampton National Bank
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54070 MAIN ROAD
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Cantrell, Elizabeth
From: Cantrell, Elizabeth
Sent: Friday, March 09, 2018 3:S5 PM
To: Twin Fork LC (twinforklc@optonline net)
Subject: RE: Donnadic -Administrative permit
Attachments: 20180309141753.pdf
John,
As per our phone conversation earlier,your application for the property located at 1071 Bay Home Road, Southold
(SCTM# 1000-56-5-37) was reviewed and unfortunately it was determined that the application would not be able to be
heard due to Town Code Ch. 280-136—Land Clearing, and a Zoning Board of Appeals determination issued September
30, 1998. It appears that removal of vegetation on a vacant parcel is prohibited without first obtaining any permits or
approvals where required. I have attached the two documents for your reference.
If the property owner would like to try to proceed with getting Town approvals, they should first talk to the Planning
Dept. and possibly apply for an approved site plan.
As this had been determined prior to the Board of Trustee's formal review, a full refund of$100.00 will be issued to Mr.
& Mrs. Donadic.
I apologize for the inconvenience this may have caused.
Sincerely,
Elizabeth Cantrell
Senior Clerk Typist
Town of Southold
Board of Trustees
From: DiSalvo, Diane
Sent: Thursday, March 08, 2018 10:17 AM
To: Cantrell, Elizabeth
Subject: FW: Donnadic - Administrative permit
See below—maybe this will help when you contact them tomorrow.
Diane
From: DiSalvo, Diane
Sent: Tuesday, February 27, 2018 11:50 AM
To: 'Jon Fabb'
Subject: RE: Donnadic - Administrative permit
I do have all the forms completed now and the file is on the shelf slated for the March 21, 2018 hearing.
At this point I have all that I see that I need—but technically the files have not been reviewed by the Trustees yet.
Diane
1
From: Jon Fabb [mailto:twinforklcaoptonline.net]
Sent: Tuesday, February 27, 2018 11:01 AM
To: DiSalvo, Diane
Subject: Donnadic - Administrative permit
Hi Dianne,
Just want to be sure we are all clear on the Donnadic Administrative permit
Property tax map 056.00—0.500-037.00
1071 Bay Home Rd
Is their anything else you need and when is that meeting and time we have to attend?
It is the whole lot as illustrated in the drone picture.
What is the next step if you could let us know?
Ok let us know thanks so much .
Greatly appreciated.
Best,
Jen
TFLC, Inc
2
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APPEALS BOARD MEMBERS Southold Town Hall
y 53095 Main Road
Gerard P. Goehringer, Chairman q s
P.O.Box 1179
James Dinizio,Jr. Southold,New York 11971
c2 ,.• .
Lydia A.Tortora - _" "
"•��::.,:_ ,O!': ,: ZBA Fax(516)765-9064
Lora S. Collins Telephone(516)765-1809
George Horning ~
BOARD OF APPEALS
TOWN OF SOUTHOLD
BOARD OF APPEALS DETERMINATION
TOWN-WIDE INTERPRETATION
MEETING OF SEPTEMBER 30, 1998
Appl. No. 4597YNG DOEPAl iMEt .bEdward EorreSter, {
0.j r of*,-Code i fotw_n t . <; .
LOCATION OF PROPERTY: Town-Wide, Town of Southold
DATE'OF PUBLIC HEARING: September 24, 1998
SECTION QF CODE INTERPRETED: 100-259 Land Clearing
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: . .�fo�'��r�:I11�'.RET:��TiON o
the
: .. . . .
Y � or not This
-, a *mon 104�4?;59"fid C.`( lh :to d�'; ::trig thki
tnc all zoo and
...,:
::vac�ntlart�'` n9
is
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WHEREAS, after due notice a 1public hearing was held by the Bxl>of Apls on `
In the R 1 ;;Town Hall, 53095 Main:Rpa�tpi Id, New York t
mb` ',
:....
to:,cG std the_6Uil ing D "" air re[t!�SSep
VM
.. on; and
WHEREAS, at said hearing all those who desired to be heard were heard and their
testimony recorded, and
WHEREAS, all testimony has been carefully considered; and
WHEREAS, Section 100-259"Land Clearing"of the Zoning Code reads as follows:
07:5 ;'l;ard.deade .&8= 99 Ey'L;L:;N0:.13;-�: 9I
9;,
:,',
orit::land` c�eart i:ii?clidjr r�din ctat'lr ;'cutng
N per shall uncle faik darty.'.. 9,; first h gvi
11 ..exca
Ke or
ha or:titee remov�it.assodat :t1l with,:.w flout:' ng.,o
n9 :
,.,:'a Iifiairi�i sl.: .
I, Wei garcCeriit�g;moi+ving and-thefve.prunfrt9:off vegettjon;:.or:selective;
plan a:prova._.. ... . . : ,. -
cul tng;gF iiiseased pr head °:trams: st aff rioti;,t a ln'duiW'� fi ii. Alny:Iandowrier Und:.gulitY. of
Site
Oil
an a rovat shall'
violatltag:thls secttonstiaif be flried.up to fCv�'i ous�nd ..-,. .:pP
tie wlthi�o "uhdl and tmless:_a :plant, restoration :pl rt:"for tt at site ed:,b foie.F lannir-9
Board.
On motion offeredby Member Homing, seconded by Member Collins,
IT IS RESOLVED, that the question of the Southold Town Building Department is hereby
ANSWERED as follows: Yes.-Sectlori I00 259 Land C1anq does apply to'vacant IAM..
Pagd 2--September 30, 1998
Appl. No.4597—Building Department
S.Quthold Town Board of Appeals
cf,
VOTE OF THE BOARD: AYES, ,M-ember.s,.Goehr.!,nyeri,!,Di,.nizio, T.ortor-a Morning-, and
Collins. This Resolution was duly adopted (5-0)-.-
GERARD P4. GOEHRINGER , 'CHAIR. ......
-t-Approved for Fili.ng.# 1
Ali
Town of Southold,NY https://ecode360.com/print/SO0452?guid=5163437
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Town of Southold NY
Thursday,March 8,2018
7
Chapter 280. Zoning
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Article XXIV. Site Plan Approval
§ 28o-136. Land clearing.
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[Added 8-8-1995 by LL No.17-1995111;amended 8-8-2006 by LL No.12-2006]
No person shall undertake or carry out land clearing, including grading, clearing, cutting and filling,
excavating or tree removal associated therewith, without first having obtained any appropriate
approvals or permits where required. Weeding, gardening, mowing and the selective pruning of
vegetation or selective cutting of diseased or dead trees shall not be included herein. Any person in
violation of this section shall be subject to a fine not to exceed$5,000. }
[1] Editor's Note.This local law also provided as follows:"The purpose of this ordinance is to allow owners to
take advantage of the existing vegetation on-site when developing a landscaping plan as part of site plan I
approval,and to prevent clear cutting of properties prior to site plan approval."
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DESCRIBED PROPERTY + LAND SURVEYING
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SCTM: 1000-056-00-05-00-037.On0 EAST ISLLP, N.Y. 11730.
AREA: 21.823.40 Sq.PL TEL, 631-277-3605
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SURVEY OF DATE: JUNE 27, 2017 QUILKIN
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SCTM: 1000-056.00-05.00-037.000 EAST ISLIP, N.Y. 11730
AREA: 21,823.40 Sq.Ft. TEL: 631-277-3605
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DERED TO DEATRUE.VALID COPY.OLSTANCFS SHOMN FROM PROPERTY LINES TO EXLSTINC STRUCTURES ARE FOR A SPECIPIC PURPOSE AND USE,AND ARE NOT INTENDED TO CUIpE Di T[iE ERECTION OF
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ASSIGNEES OR TILE LF.NDINC INSTITUTION.CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDITIONAL.INSTITUTIONS OR SUBSEQUENT OWNERS.
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Michael J. Domino,President ��� yplo Town Hall Annex
John M. Bredemeyer III,Vice-President 54375 Route 25
P.O. Box 1179'
Charles J. Sanders Southold,New York 11971
Glenn Goldsmith • iQ Telephone (631) 765-1892
A. Nicholas Krupski 1�0+ im Fax(631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
This Section For Office Use Only
Coastal Erosion Permit Application
Wetland Permit Application !nrl �l` 1 e.
_Administrative Permit I�_•r``�.--_ _..._ ,
Amendment/Transfer/Extension
Received Application:r ±? FEB - 5 2018
Received Fee: $ 0 _
Completed Application:
Incomplete:
SEQRA Classification: Type I_ Type H Unlisted
Lead Agency'Determination:
Coordination:(date sent):
LWRP Consistency Assessment Form Sent:
CAC Referral Sent: _
Date of Inspection: l3i
Receipt of CAC Report:
Technical Review:
Public Hearing Held:
Resolution:
Legal Name of Property Owner(s): L C`
Mailing Address:1� "& IVlAvi 11G�c� ,t-- w"✓L 0
(�
Phone Number: `"G 1-]" -0 9 8(a 2—S--
Suffolk
SSuffolk County Tax Map Number: 1000 - 0 5-6 n — 0 •S a 0 — b�J�• �y
Property Location: 1071 gu'l'l /Y1- '3 u5td A 'Cl /HCl W
(If necessary, provide LILCO Pole#, distance to cross streets, and location)
AGENT (If applicable):—T—SJ) IJ F::C�V— L6� tb�Ae6
Mailing Address: P0
Phone Number: 631 ' 73 L4
Board of Trustees Appl - tion
GENERAL DATA
Land Area(in square feet): �,�$Z. • `"�D S4F-1—r
Area Zoning: S t D4:-IU t-7 AL—
Previous use of property: D P_N T? /-l_
Intended use of property: l ��n fl�
Covenants and Restrictions on property? Yes No
If"Yes",please provide a copy.
Will this project require a Building Permit as per Town Code? Yes _,X 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.?
YesIr _No
Does the structure�(s) on property have a valid Certificate of Occupancy? Yes J No
Prior permits/approvals for site improvements:
Agency Date
No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency? No Yes
If yes,provide explanation:
Project Description (use attachments if necessary): 2! 1QUAX 7&/& IYllh SCC i��Gµ-t T
Dft Dt8046 4 &vnt56D 4-o Guy'
-S "wed wr(r of IW,r�-c_ Ali-6� 's C6
DETAILED REQUEST: 1071 BAY HOME RD, SOUTHOLD NY 11971
TO: TRUSTEE'S Southold Town
ADMINISTRATIVE PERMIT FOR: STEVE DONADIC
TAX MAP #: 056.00-05.00-0347..000
DATE: 1/31/18
We are requesting a 10-year maintenance/administrative permit to eradicate by
hand, the over grown Bamboo and dead debris as illustrated in the attached (6)
overhead drone pictures taken 1/24/18 and emailed to Trustee's.
To Eradicate the Bamboo, it will be HAND cut to 12". All dead debris and bamboo
will be removed from the lot area highlighted in yellow on the attached survey
copy.
Board of Trustees App] "-ttion
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
Area of wetlands on lot: WK square feet
Percent coverage of lot: 1 ' %
Closest distance between nearest existing structure and upland
edge of wetlands: Ile feet
Closest Fdit�nce between nearest roposed structure and upland
edge of s: feet
Does theproject 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: 1'S`J
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):
NCS
61Z20
Appendix B
Short Environmental Assessment Form
Instructions for Completing
Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses
become part of the application for approval or funding,are subject to public review,and may be subject to further verification.
Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully
respond to any item,please answer as thoroughly as possible based on current information.
Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful
to the lead agency;attach additional pages as necessary to.supplement any item.
Part 1 -Project and Sponsor Information -STPO'D 6N�-/P'rDl C,
Name of Action or Project:
Project Location(describe,and attach a location map):
1071 P24� Home- ka , sov�wtd NI-1 l( �2
Brief Description of Proposed Action:
e e 4'vC�-11tj cr 10� ee-w �tGc,k dcr.a ��— �r eyt t-f 'dn �(tZa�C.
Name of Applicant or Sponsor: Telephone: //1
l � /1 L t_II�jC6L e__ l e �Z/I E-Mail:�'w Lz
Address:
W6�_61*LAni
City/PO: Po w q 1po State: Zip Code:
J ( �a
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 41 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:
TXC_ r
aJ.
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 /ytp✓
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 ❑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? ❑ ❑ 1:16. 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: VMart�*— Kf0L*Z e F cm_rl6'i"' ❑
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? FVr ❑
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? O YES
If the proposed action will exceed requirements,describe design features and technologies: MLZSLJ El
10. Will the proposed action connect to an existing public/private water supply? NO YES
If No,describe method for providing potable water: 0 ❑
11.Will the proposed action connect to existing wastewater utilities? NO YES
If No,describe method for providing wastewater treatment: ❑
12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES
Places? ❑
b.Is the proposed action located in an archeological sensitive area? ❑
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? ❑
FRI
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:
[A-Shoreline ❑Forest ❑Agricultural/grasslands El Early mid-successional
Wetland ❑Urban ❑Suburban
15.6oes 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? NJ ❑
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, ® Ela.Will storm water discharges flow to adjacent properties? �NO [:]YES
b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)?
If Yes,briefly describe: QNO DYES
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: ❑
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: X 1 -1
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE —11-i 1 N F-�fc- L -t- 5 G ^ fsrApplicant/sponsor n e: 7rl1 Dnar -
V
Signature:
Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following
questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or
otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my
responses been reasonable considering the scale and context of the proposed action?"
No,or Moderate
small to Large
impact impact
may may
occur occur
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? ❑
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 El
existing infrastructure for mass transit,biking or walkway? �y
6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑
reasonably available energy conservation or renewable energy opportunities?
7. Will the proposed action impact existing: ❑
a.public/private water supplies?
b.public/private wastewater treatment utilities? ❑
"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
occur occur
10 Will the proposed action result in an increase in the potential for erosion,flooding or drainage Elproblems?
IL Will the proposed action create a hazard to environmental resources or human health? F1
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.
F] 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)
t
PRINT Page 4 of 4
•,M . Board of T-rustees Application
AFFIDAVIT
1)(2N)k9 1C BEING DULY SWORN
DEPOSES AND AFFIRMS THAT BE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED P.ERMIT(S)"AND THAT ALL STATEMENTS CONTAINED HEREIN
ARE TRUE TO THE--BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT
ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION
AND AS MAY BE APPROVED BY THE SO,UTHOLD TOWN BOARD OF TRUSTEES.
THE.APPLICANT AGREES TO HOLD THE TOWN OF`SOUTHOLD AND THE
BOARD OF TRUSTEES HARMLESS AICD FREE FROM ANY AND ALL-DAMAGES
AND CLAIMS ARISING UNDER OR.BY VIRTUE OF SAID PERMIT(S),IF
GRANTED. IN COMPLETING THIS.A.RPLICATION,I HEREBY'AU THE
TRUSTEES,THEIR.AGENT(S)OR REPRESENTATIVES,INCLUDING7HE
CONSERVATION-ADVISORY COUNCIL,TO ENTERoONTO MY PROPERTY TO
INSPECT THE-PREMISESIN 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 WITHANY CONDITION OF ANY WETLAND OR COASTAL
EROSION•PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM
OF THE PERMIT.
t
S
Si tore of Pro'erty-Owner Signature-of Property Owner
..._� ;
SWORN TO BEFORE ME THIS DAY OF 2018
t" BARBARA Z+CH� 4 ".t• 4'1-
mm
Notary Publl"tate of m Yelic
No.OIZY6205445 �;
i Notary Public Qualified in,Queens County
Commission hires May 11 2OZ1, 4� =1 R~+
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Board of Trustees Application
AUTHORIZATION
(Where the applicant.is not the owner)
I/We,
owners of the property identified as SCTM# 1000- 05(P.000,5D0 03'• in the town of
5o(1n�bL,o ,New York,hereby authorizes "TW t 1U.
.LA-10t> � WE 6 WTeA?,TlrluCC I K)C-. to act as niy agent and handle all ,
necessary work involved with the application process for permit(s)from the Southold Town
Board of Trustees for this property.
Property Owner's Signature Property Owner's Signature
SWORN TO BEFORE ME THIS Z6L*'� DAY OF 20 106
BARBARA ZYCH
Notary Public-State of New York
No.01ZY6205445
Notary Public Ca misssdin Queens County
Expires May 11.202 i
Board of Trustees Apr dation
AFFIDAVIT
S TE;1/C rn A-r-c A-- ID61"A-D i C 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 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.
a
Signature of Property Owner
SWORN TO BEFORE ME THIS Z DAY OF , 20 )9
J
BARBARA ZYCH �y ;
Notary Public-State of New York
No. 01ZY6205445
!--
Qualified in Queens County
Commission Expires May 11,2001 �.
Notary Public
•I
n '
Board of Trustees Application
AUTHORIZATION
(Where the applicant is not the owner)
I/We, 51-EVE- �'I(M4 kV 1aA DC)Mb'<i
owners of the property identified as SCTM# 1000- 05(Q -00705-00-037 in the town of
GOU'hipuo New York,hereby authorizes 'rW!#,j Fbr- --
LPrNt>5tN iF 60TOOVNk to act as my agent and handle all
o.
necessary work involved with the application process for permit(s) from the Southold Town
Board of Trustees for this property.
Property Owner's Signature Property Owner's Signature
SWORN TO BEFORE ME THIS DAY OF 20__
BARBARA ZYCH
.00 Notary Public-State of New York
No. 01ZY6205445 ;�:• _�
Qualified in Queens Coun
Notary Public ty f
Commission Expires May 11,2021
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APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of fithics nLhihits conflicts gfintcr� ton the part of town ollican and emnlgyices The namosc gl
this form is to nmvide infomhntion which can-alert the rown of r&«iblc conflicts of interest rind nllow u'to lake whrilevcr nctign is
necoTinry to nygitl snme.
YOUR NAME: YMKyrz—(k L�6-rjk D t G
(Last name,first name,irpiddle 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 comp6ny's name.)
NAME OF APPLICATION: (Check all that apply.)
Tax grievance Building
Variance Trustee
Change of Zone Coastal Erosion
Approval of plat _ Mooring
Exemption from plat or official map Planning
Other
(If"Other',name the activity.)
Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee
of the Town of Southold? "Relationship"includes by blood,nt'�inge,or business iWerest."Business intemst^incnns a business,
including a partnership,in which the town officer or employce has even n partial ownership of(or employment by)a corporation
in which the town officer or employee owns more than 5%of the shares.
YES NO _
I f 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 descrjbe 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 tlhe shares of the corporate stock of the applicant
(when the applicant is n corporation);
D)the legal or beneficial owner of any interest in a non-corporate entity(when the
applicant is not a corporation);
C)an officer,director,partner,oremployec of the applicant;or
D)the actual applicant.
_—� DESCRIPTION OF RELATIONSHIP
Submitted this day of VC-6 204
1t Signature I
Print Name
.... ............_. .---------Form TS-1--------------------------�------------_..------ _� . _1�. _ ..--------- - --
:d
APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE•FORM
The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and emplovees.The purpose of
this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is
necessary to avoid same. Fe ki�Z{r a r- `fd /�'l N
LfiNDSeowe
YOUR NAME: C6MMAC 7� /A•
(Last name,first name,.tpiddle 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
Change of Zone Coastal Erosion
Approval of plat Mooring
Exemption from plat or official map Planning
Other
(If"Other'',name the activity)
Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship.with any officer or employee
of the Town of,Southold? "Relationship"includes by blood,marriage,or business interest"Business interest"means a business,
including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation
in which the town officer or employee owns more than 5%of the shares.
YES NO
If you answered"YES",complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of Southold
Title or position of that person
Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check
the appropriate line A)through D)and/or describe in the space provided.
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply):
A)the owner of greater than 5%of the shares of the corporate stock of the applicant
(when the applicant is a corporation);
B)the legal or beneficial owner of any interest in a non-corporate entity(when the
applicant is not a corporation);
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant.
DN OF RELATIONSHIP
Submitted zw
Signature r
Print Name 411 V, %-qwn
Form TS I Pvb)I C- v7p Iv&W q�+
MEtANM V BROWN
(Votary Pubtlo,State of Now YQ*
No.ol BR4908712 �1
Cualffled In Suffolk County
*WaftlEt� a V'
n w October 1%.!L ..�) -
Town of Southold _
LWRP CONSISTENCY ASSESSMENT FORM
A. INSTRUCTIONS
1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for
proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This
assessment is intended to supplement other information used by a Town of Southold agency in
making a determination of consistency. *Except minor exempt actions including Building Permits
and other ministerial permits not located within the Coastal Erosion Hazard Area.
2. Before answering the questions in Section C, the preparer of this form should review the exempt
minor action list, policies and explanations of each policy contained in the Town of Southold Local
Waterfront Revitalization Program. A proposed action will be evaluated as to its sign ificant
beneficial and adverse effects upon the coastal area(which includes all of Southold Town
3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will
affect the achievement of the LWRP policy standards and conditions contained in the consistency
review law. Thus, each answer must be explained in detail, listing both supporting and non-
supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and
conditions,it shall not be undertaken.
A copy of the LWRP is available in the following places: online at the Town of Southold's
website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all
local libraries and the Town Clerk's office.
B. DESClR_IPTION OF SITE AND PROPOSED ACTION
SCTM# �JtO
PROJECT NAME
The Application has been submitted to(check appropriate response):
Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees
1. Category of Town of Southold agency action(check appropriate response):
(a) Action undertaken directly by Town agency(e.g. capital ❑
construction,planning activity, agency regulation, land transaction) ❑
(b) Financial assistance(e.g. grant, loan, subsidy)
(c) Permit, approval, license,certification:
Nature and extent of action: WC "a f1 l-j ' O-
-nom 83a w i yx �.ert d�n�d bc� 1�a v PYA.
Location of action: 10-7 6at4
Site acreage: v
Present land use: l �L—
Present zoning classification: I� �Z-
2. If an application for the proposed action has been filed with the Town of Southold agency, the following
information shall be provided:
(a) Name of applicant:
(b) Mailing address:
(c) Telephone number: Area Code ( )
(d) Application number,if any:
Will the action be directly undertaken,require funding, or approval by a state or federal agency?
Yes ❑ No�Q If yes, which state or federal agency?
C. Evaluate the project to the following policies by analyzing how the project will further support or
not support the policies. Provide all proposed Best Management Practices that will further each policy.
Incomplete answers will require that the form be returned for completion.
DEVELOPED COAST POLICY
Policy 1. Foster a pattern of development in the Town of Southold that enhances community character,
preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and
minimizes adverse effects of development. See LWRP Section III—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
L VI)P Section III—Policies Pages 3 through 6 for evaluation criteria
PYes ❑ No Jf 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
❑ Yes ❑ No 0
Not Applicable
Attach additional sheets if necessary
NATURAL COAST POLICIES
Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP
Section III—Policies Pages 8 through 16 for evaluation criteria
❑ Yes ❑ No P
Not Applicable
Attach additional sheets if necessary
Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III
—Policies Pages 16 through 21 for evaluation criteria
❑ Yes ❑ No of 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.
Yes No ]: Applicable
Attach additional sheets if necessary
Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies
Pages 32 through 34 for evaluation criteria.
❑ Yes ❑ No;4 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.,
❑ Yes ❑ No Ix Not Applicable
PUBLIC COAST POLICIES
Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public
resources of the Town of Southold. See LW" Section III—Policies; Pages 38 through 46 for evaluation
criteria.
❑ YesEl No Not Applicable
Attach additional sheets if necessary
WORKING COAST PC--CIES r
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 0 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 ❑ No of Applicable `
Attach additional sheets if necessary
Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages
62 through 65 for evaluation criteria.
❑ Yes ❑ NM Not Applicable
Attach additional sheets if necessary
Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP
Section III—Policies; Pages 65 through 68 for evaluation criteria.
❑ Yes ❑ No Not Applicable
PREPARED BY 1/v TITLE ( � f DATE ��