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HomeMy WebLinkAboutTR-9239A Michael J. Domini esident ��OF so Town Town Hall Annex L -1John M. Bredemeyer III,Vice-President �� l0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold, New York 11971 A. Nicholas Kru ski G p � � Q Telephone(631) 765-1892 Greg WilliamsyCDUNTT`1, O Fax(631) 765-6641 � ��' BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction Y2 constructed Project complete, compliance inspection. INSPECTED BY: 'ML.& IV COMMENTS: CERTIFICATE OF COMPLIANCE: t Michael J.Domino, President OF SQ(/T Town Hall Annex O�� y�l John M.Bredemeyer III,Vice-President 54375 Route 25P.O.Box 1179 Glenn Goldsmith 1 Southold,New York 11971 A. Nicholas Krupski Telephone(631) 765-1892 Greg WilliamsOla0 Fax(631) 765-6641 IrOUNT`l,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1611C Date: August 30, 2019 THIS CERTIFIES that the replacement of existingfencing with new 6' high fencing along both side yard lot lines; and install 3'-4' high fencing across the property, landward of the 10' wide non-turf buffer; At 1130 Glenn Road, Southold Suffolk County Tax Map#1000-78-2-29 Conforms to the application for a Trustees Permit heretofore filed in this office dated May 17, 2018 pursuant to which Trustees Administrative Permit#9239A Dated June 20, 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 replacement of existing_fencing with new 6' high fencing along both side yard lot lines and install 3'-4' high fencing across the property, landward of the 10' wide non-turf buffer. The certificate is issued to Reuben&Margery David owners of the aforesaid property. Authorized Signature 8la ��l� r s �/17 37� Ott 17 01- �IrL_t 3 2019SOME � v"� Michael J. Domino, President �o�p .00Town Hall Annex John M. Bredemeyer, III, Vice-President o 54375 Route 25 Glenn Goldsmith H z P.O. Box 1179 A Nicholas Krup ski �� • Southold, NY 11971 Greg Williams yOl , -�a°� Telephone (631) 765-1892 Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIES CHECKED OFF BELOW INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction Y2 constructed com liance ins ection Project completep p QF S0(/��, Town Hall Annex Michael J.Domino,President �� 0 John M.Bredemeyer III,Vice-President �� !O 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold, New York 11971 A.Nicholas Krupski r Telephone(631) 765-1892 Greg Williams Ol a cDUFax(631) 765-6641 yNT`1,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9239A Date of Receipt of Application: May 17, 2018 Applicant: Reuben & Margery David SCTM#: 1000-78-2-29 Project Location: 1130 Glenn Road, Southold Date of Resolution/issuance: June 20, 2018 Date of Expiration: June 20, 2020 Reviewed by: Board of Trustees Project Description: Install a 5'x10' dog run on south side of property; replace existing fencing with new 6' high fencing along both side yard lot lines; and install 3'-4' high fencing across the property, landward of the 10' wide non-turf buffer. 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 submitted by Patricia C. Moore, dated May 3, 2018 and stamped approved on June 20, 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. Michael J. Domino, President Board of Trustees SOFFO(�� Michael J. Domino,Preside' O�Q CSG" Town Hall Annex John M. Bredemeyer III,Vice-Pr.,a,UV'.it �� y,„q 54375 Route 25 Glenn Goldsmith z 'P.O.Box 1179 A.Nicholas Krupski Southold,NY 11971 Greg Williams ®!- Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD / Date/Time: �" Completed in field by: L Patricia Moore, Esq. on behalf of REUBEN & MARGERY DAVID request,an Administrative Permit,to install a 5'x10' dog run on south side of property; replace existing fencing with new 6' high fencing along both side yard lot lines; and install 3'-4' high fencing across the property, landward of the 10' wide non-turf buffer. Located: 1130 Glenn Road, Southold. SCTM# 1000-78-2-29 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 f Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: I II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: 3 t de�,� � qIZAn� e C � " ®rte . I have read & acknowledged the foregoing Trustees comments: Agent/Owner: / / Present were: J. Bredemeyer ✓ I M. Domino (SG. Goldsmith �' L N. Krupski /. Williams Other SITE DATA: SCTM # 1000-13-50-171 DESCRIPTION: SQ. FT. AREA: LOT COVERAGE: PROPERTY: 30705.6 SQ. FT. .70 ACRES �i PROPERTY WETLANDS: 7504.9 SQ. FT. .17 ACRES /6J BUILDABLE PROPERTY: 23200.7 SQ. FT. .53 ACRES V� y v / EXISTING HOUSE: 2253.3 SQ. FT. 9.8 % EXISTING DECK: 702.0 SQ. FT. 3.0 EXISTING PORCH: 56.0 SQ. FT. 0.2 EXISTING SHEDS: 256.9 SQ. FT. 1.1 % TOTAL: 3278.2 SQ. FT. 14.1 v 1 z 0 EL2 2 I APROXIMATE LANDWARD F LIMIT OF TITAL WETLAND O A O I10'NON-TURF P w EXhtING N f .. Z Z I BUFFER--- -- -�"`"'_-_GHE7R - � � to r-4 INro� 1 __ ® rte z I � I' ---- EL °• w • aoI -- YNO 7°5 ,59 W ..� a s o 00 284 9 7 C7 O '= A 20 �) 'v N rl EX.STONE WALKWAY �� V, 91.2' EX RECYCLE CENTER 12.3' L0 \,� 34.3' O �` GARAGE EXISTING ASPHALT D EWAY 00 \ o PROPOSFr)S'h- 4'h WIRE' 'NCE � ...__.._.._ ° /n 2.0' 1, �+� WEST CREEK EXIST. o DECK (DREDGED) ' EL.12.3 O N Z St�� MEETS & BOUNDS �•r EX. 1STY. op 70.6 HOUSE M EXIST. BY: YOUNG &YOUNG S , PORCH W �0., O DATED: AUG. 22, 19 1 O � 12 3' BASEMENT EL.8.7 00 A FsT Q S 1 1 O � w T�� 20.0'X6.0'EX, i - FLOATINGDOCK 1X. PROPOSED GATE :C,4PROPOSED :O - - EX.RAMP .DOCK's � N � � 45, 0 9 3 5.8' N 10.9' 12.7' 56.0' 8.0' 1�0 MAY 1 7 2018X9 1 1 CPI i -f' ,- 9 , . , f ra Ly \ -- _� 10' °FFERRF BUI S 16_°_1.5' 0" E 264.040' PROPOSED 6'h BLACK DEER FEND PROP')SED(7)0'w FENCE P'+l"L SECTIONS(6'h) \ (TO RCPLACE) 1 ' . I . , APROXIMATE LANDWARD SEL APPROVED BY 1 I LIMIT OF TITAL WETLAND 10 BOARD OF TRUSTEES I � EL SITE PLAN TOWN of SOUTHOLD 2 SCALE: 1" = 20'-0" DATE DRAWN BY: MH I 5/3/2018 SCALE: SEE PLAN CJ 5 CSD ER�r C;� SHEET NO: FO 0 502 A� ESSO-, _ 1a ■`.9. y F ;i 1i; ,J� ;•si 4W go i a .. - �� fes, - � �<• r� �;,, .. a,���• ..'+�.-,�.'" +� i •' R _''1 4 • 'i ' r 41 DAVID 1130 GLEN t, 1 .•r + P+ e F alai � �1 �• j r RD, rA,,-% r 66 AuL IF It f� a' - '�l .. ♦.. ,.+.-... f..�.• •s'•'�irn.iJif.,.a..was.�•e.p�a �'�+'� .- , } It 1�'.. it 1 , f 49 DAVID 1130 GLEN RD, r • Y7 ` ..-I ;..., .� .� r► !�' .. 5 wa���•. • . "�.�.�' ,��LI1Y 1r1�.• .,#� .. is .r SOUTHOLD e t R � 7 t• ",' r3- i ' ems +.�`4_; , il ip 1 L` , - _ _.�i..•.. � - 5t ++ ,+ y�,,p„.'art 1 +,, { . .J,. .� L • �. wli ' DAVID LD ,+�' ,+ i y Jf 1130 GLEN RDSSH0 °--•a i. ,. ��j�+* ;.� f � _, SCTM: 1000-13-50-171 1� cis a , t ;. y �* a r_ r x ;i+`rfar 7•'+ p, ai . ++ 'y _ 'lljl k t� s� IF ■• -4f it qr AM Mo 41 1 L Ir • e f tl N i. r, PW lN fA r.. eg , ■ M r �j. r tcDAVIDf 1130 GLEN RD, SOUTHOLD SCTM: 1000-13-50-171 r 1 4 �• t 1 j T it t � ."! �.•�� ieeeei.� ' � � � �.,: tib. rJy '�� T' t�! � /i4,��y �•- i. .. AV Lk e e ` � ��_ ." ,,. ., ;moi} � �+� • .ow ? l jr • y. �t . . '�� . ,, ■ � �f*. 111 1 ,e M A ` Jj iyi3�• der �� "s i �a.�•4•':!M!�. ; � .•. •,fir a a':, �+"•�:•'.d; •R ' C_ I �z• r•. � R { L .r 6 /•13/2018 13 ' 54 L oAir. ov �� F►+. . rsr►� sw.. 17-f? r v4 I 3 54 6 / 13 / 1 : H ' �s�' y�► ` Y'�i ..C. * .' �•yr .��lit'..3�E 3'e pk-t NoW. e . t wh ,' ��. Iw r T '� 1 i :. • i. . f• -'fir s.. 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(11) ...... --.-- e..u. --.-- SECTION NO �� x,ExcK>E .ea Real Property Tax Service Agency v �> E o..r_uu. ______ �„w, ... -- — -- -- 0ax+r tstar rw.nx.a,xr ntm 01 rm /un./ ®Ory + a 078 U ..rx` a ..�t3tN�.ta• u.a u. --.-- t4vu.--trr-- wwoErtrvwcErmccu;Excv ^ � AP x0 1000 ael PROPERTY MAP OFFICE LOCATION: ®��®F S® yO1 MAILING ADDRESS: Town Hall Annex '` ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (Cor.Main Rd. &Youngs Ave.) cn � ® �� Telephone: 631 765-1938 Southold, NY 11971 ® Fax: 631765-3136 lyc®UNTY,� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: June 13, 2018 Re: Local Waterfront Coastal Consistency Review for REUBEN & MARGERY DAVID SCTM# 1000-78-2-29 Patricia Moore, Esq. on behalf of REUBEN & MARGERY DAVID request an Administrative Permit to install a 5'x10' dog run on south side of property; replace existing fencing with new 6' high fencing along both side yard lot lines; and install 3'-4' high fencing across the property, landward of the 10' wide non-turf buffer. Located: 1130 Glenn Road, Southold. SCTM# 1000-78-2-29 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the action is CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Damon Hagan, Assistant Town Attorney .. �% so, r Michael J.Domino,President � Town Hall Annex John M. Bredemeyer III,Vice-President 54375 Route 25 <<,• ` P.O.Box 1179 Charles J.Sanders cis Southold,New York 11971 gr . Tenn Goldsmith yo Telephone(631) 765-1892 A. Nicholas Krupski �CDUNli Fax(631) 765-6641 s BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application D E V E Wetland Permit Application'Y Administrative Permit Amendment/Transfer/Extension MAY 1 7 2018 f Received Application: Received Fee: $ 100,Do ---- Completed Application: Seut+ d Torn ?�_: Tr�S:CrS Incomplete:, Board u SEQRA Classification: Type I_ Type II_ Unlisted - Lead Agency Determination: - �Coordination:(date sent): 10 LWRP Consistency Assessment Form Sent: 6.9a CAC Referral Sent: _ Date of Inspection: ~1 a Receipt of CAC Report: � /Technical Review: �/ Public Hearing Held: v Resolution: Legal Name of Property Owner(s): I\ 4 Mailing Address: jCIP�' C ((s 1_( `7 (4 - Cn 157 Phone Number: S _ c9t'-f1 -7 3 Z8 Suffolk County Tax Mar Number: 1000- die 9-2_Zj Property Location: . n n �r4 (If necessary,provide LILCO Pole#,distance to cross streets, and location) AGENT(If applicable): '7j�k Rf C C-R-0, C- _rOPOP-P, Mailing Address: _ C7 Z(0 -N_Ck t n 2,c)Ce Phone Number:` _ to - ( ^ : (e f- _-,(4 ��✓� t Board of Trustees Application GENERAL DATA Land Area(in square feet): 2>0i 7 0 S • 6, Area Zoning: — Li o Previous use of property: _�— (� ).5e— W/ . -Pem C-e' Intended use of property: H p U.-�,,c w/ V)-e�w Covenants and Restrictions on property? Yes X No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes A, No If"Yes",be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes No If"Yes",please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure(s) on property have a valid Certificate of Occupancy? X Yes No Prior permits/approvals for site improvements: Agency Date t -sz�1 3 oZ 36�/ 3 �oc� No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?_X_No Yes If yes,provide explanation: Project Description(use attachments if necessary):. S.1 tic 10 � rQn o (�U, 1,5 csi5 <vt _• 5tcsc1 '�' Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATI®N DATA Purpose of the proposed operations: etncS o s� G � r�, m 0.a�ol Area of wetlands on lot: ,, OOO square feet Percent coverage of lot: 3o % Closest distance between nearest existing structure and upland edge of wetlands: 1® ' feet Closest distance between nearest proposed structure and upland edge of wetlands: ! feet Does the project involve excavation or filling? X No Yes If yes,how much material will be excavated? K/on,_- cubic yards How much material will be filled? None_ cubic yards Depth of which material will be removed or deposited:_&c)6_<—.feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect, if any,on the wetlands and tidal waters of the town that may result by reason of such proposed operations(use attachments if appropriate): �dh� i i APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM Tlie'fown bfSouthold'e Code of 1 tfiics prohibits conflicts bf interest on the�arCtif#own bfliccrs and emnlovees.'Ihc nurnose of, this form is to iovicle inforindtion which can 6lert•tlie town bf„pbssible-cdiiflicts of interest and allow-at to'take.whatcvcr action is necesmy to av6id sante. YOURNAME: (Last name,first name,kiddle un initial, less you are applying n the am of someone else or other entity,such as a company.-If so,indicate the other person's or company's name.) I, NAME OF APPLICATION: (Check all that apply.) j 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 j,pu.personally(or through your company.-spouse; • 'child):hdive a relationship with any,officer.or e-1110oyee'' orthe"rown:of'Snuthold? "It'clatidriship"includes liy hhibd,.hjl riiage,"tar husiness;inte�st."Business interest"ineiins a•husiness, inclpiling'zi partsaecsl,p;iii wliiela theta}vnofflcer:-at enaployce i u*cven,a par`tial'owncrsliip' ftbr eitipldyment by)-ii corppration in iviaic Ahe•town officer or cmployee owns more thin 5%cif ilae shares. YES NO i 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 'i)esoribe the„relationship•between yourself(the appli'6ilt/agcnt/representative)and the town officer or employee,Either check `tile appropriate.line A)thro(Oi D)arid/or describe in the�spacc 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 o pprntc stock of the applicglit 1 (when the applicant is a corporation); B)the icgator Beneficial ow,rter of anyititcrest'in anon=c000rote entity(when.ft applicant is not a coicporttion ); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thi da 20`e y inataiaPA P _. Print Na Form TS 1 Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) I/We, CJV1 1-_Re.,sj owners of the property identified as SCTM# 1000- 1 "�5 50 r `T _ in the town of 1 New York, hereby authorizes _ ,-�V G Cmc,, C-01 0 rW — 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. Property Owner's Signature Property Owners igna re SWORN TO BEFORE ME THIS / ,DAY OF 0 ( ,20 -r-`�-- AXT Z7� y Public BETSY A.PERKINS Notary Public,State of New York No.01 PE6130636 Qualified in Suffolk Coun Commission Expires July 18G���`J� ' Board of Trustees Application AFFIDAVIT /, v�f(Yi ILI `1MY9 BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/ IIF IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF ' GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES,INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. °Signature of Property Owner Signature oQjopey Owner 2, SWORN TO BEFORE ME THIS DAY OF-rC__t19___j Nota lic BETSY A.PERKINS Notary Public,State of New York No.01 PE6130636 ,�'y, Qualified in Suffolk ly 18 Commission Exp 61 Z20 Appendix B Short Environmental Assessment Form 11i9tru€.tions dt,C.`obit}lethia 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. Part 1 -Project and Sponsor Information UGC-A�cl Name�of Action or Project: Project Location(describe,and attach a location map): I �U*tg6 `Brief Description of Proposed Action: Six It ' 8CD9 run 6r QU S�cQQ� pep(� 8 l Ce . � l Vns{� re- i r t NbYI= -`sr Name of Applicant or Sponsor: Telephone: n - 5-1 —02%{ X37 8, -Mail: - Address: Ci- City/PO- I State: Zip Code: A s7 1.Does the proposed action bnly 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 0/'may be affected in the municipality and proceed to Part 2. If no,continue to question 2. El 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: a 3.a.Total acreage of the site of the proposed action? 25— acres b.Total acreage to be physically disturbed? , 01 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 F-1 Rural(non-agriculture) F]Industrial ❑Commercial esidential(suburban) ❑1~orest ❑Agriculture El 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? ❑ (, r�i', ❑ b.Consistent with the adopted comprehensive plan? ❑ P ❑ 6. is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? 7. Is the site of the proposed action located in,or does it adjoin,a state listed'Critical Environmental Area? NO YES If Yes,identify: _ a,❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO 11 YES ❑. b.Are public transportation service(s)available at or near the site of the proposed action? I� c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? I❑1 9.Does the proposedaction meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: _ ( ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? b.Is the proposed action located in an archeological sensitive area? 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO ES wetlands or other waterbodies regulated by a federal,state or local agency? b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres 14. Ide ify he typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: S reline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species'of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? ❑' 16.Is tlie`project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, a.Will storm water discharges flow to adjacent properties? Q O []YES Era b.Will storm water discharges be directed to established conveyance systems(run and storm drains)? If Yes,briefly describe: ZNO ❑YES Page 2 of 4 ; 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: 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: Erti 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE GCS. G rP Date: Applicant/sponsornarne: 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? El 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action-cause an increase in the use of energy and it fails to incorporate 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 n problems? Ll. 11. Will the proposed action create a hazard to environmental resources or human health? EIq Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. DCheck this box if you have determined,based on the information and analysis abov and any supporting documentation7. that the proposed action will not result in any significant adverse environmentaallim aVa- Name Town of Southold-Board of Trustees 1(�of Lead A ency Date President Print or Type Name o Responsible Offi/ m Lead Agency Title of Responsible Officer Signature of Responsible`Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 a 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 slgnificant, tiealeficial.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'auswer.must be eti:¢ilained in detalil,.listintr.botlr supporting and non- simportim),facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not.be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# PROJECT NAME Q/V The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees Er 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: u` 1 O' ry el ' b n 6bufl,\ 5 cc- "-Ma-cee -c Ana --- -+n � c�-c°-e- e�lr e c411A wJZJ Q n-eek "tu- t dg s_:cw�c1 _ ,_. C�,�a;�t a�t,,1 '-- jy�(' J Location of action: Site acreage: Present land use: Present zoning classification: -q 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: e-0 6CVl (b) Mailing address: &—y' ),> 441 ) I , A / 7 t((� ^ (� I S7,57 ; (c) Telephone number: Area Code( ) (( a�- -7 33 8 (d) Application number,if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes El No Fi� 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. Poster 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 LVY'" Section III-Policies; Page 2 for evaluation criteria. Yes J—] No Not Applicable 12 iU ` Y Attach additional sheets-if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III-PoliciQsPages 3 through 6 for evaluation criteria Yes E 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—Polic' s Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Page through 16 for evaluation criteria ❑ Yes ,F] No 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 1 for evaluation criteria Yes �. No Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—PoIicies; Pages 22 through 32 for evaluation iteria. Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and w�Zplicable LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. 0 Yes ❑ No 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. Ye50 No Not Applicable Attach additional sheets if necessary WORDING 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. nw ❑ Yes ❑ No 19d Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III— Policies; Pages 62 through 65 forzNot n criteria. i 1:1 Yes El Nopplicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pa 5 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable PREPARED BY - - - TITLE DATE