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HomeMy WebLinkAboutTR-9270A Michael J.Domino,President F SO(/Jy Town Hall Annex John M.Bredemeyer III,Vice-President �O� ��� 54375 Route 25 P.O.Box 1179 Glenn Goldsmith 1 [ Southold,New York 11971 A.Nicholas Krupski G Telephone(631) 765-1892 �� Greg Williams Fax(631) 765-6641 Q cOUNT`t,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1547C Date: December 26,2018 THIS CERTIFIES that the installation of a hot tub placed on a 6"high concrete slab; 15'1" towards the dwelling but not moved past edge of dwelling with waste water to-drain to remain; hot tub and slab total dimensions are 94"x94", At 500 Hippodrome Drive Southold Suffolk County Tax Map #1006-66-2-13 Conforms to the application for a Trustees Permit heretofore.filed in this office dated June 21, 2018 pursuant to which Trustees Administrative Permit#9270A Dated July 18, 2018,was issued and Amended on December 12,2018 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 installation of a hot tub placed on a 6"high concrete slab; 15'1"towards the dwelling but not moved past edge of dwellingwithwaste water to drain to remain;hot tub and slab total, dimensions are 94"x94" The certificate is issued to Ora&Elliot Heath owners of the aforesaid property. r - i Authorized Signature - i 11011 -T7 Al - - aoA�4-D Of i XSTEEs - ocT 2 2A T' OEOIJTHOL® I ' I I i i i (�outhold Tq�n a o T s ae f f '4�'? - ' +t-6 Michael J.Domino,President ��0f soyo Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G Q Telephone(631) 765-1892 Greg Williams Q �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD December 12, 2018 North Fork Pool Care 9700 Main Road Mattituck, NY 11952 Attn: Jason Peters RE: ORA& ELLIOT HEATH 500 HIPPODROME DRIVE, SOUTHOLD SCTM#: 1000-66-2-13 Dear Mr. Peters: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, December 12, 2018: RESOLVED that the Southold Town Board of Trustees APPROVE.the Administrative Amendment to Administrative Permit#9270A to,relocate the hot tub 15'1"towards the dwelling but not move past edge of dwelling with waste water drain to remain; and as depicted on the project plan prepared by North Fork Pool Care, received on October 2, 2018, and stamped approved on December 12, 2018. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, Michael J. Domino President, Board of Trustees MJD/dd SOFFocx Michael J.Domino,Preside' 0�0 Co0 ,Town Hall Annex John M. Bredemeyer III,Vice-President �� �� j 54375 Route 25 Glenn Goldsmith , CD w P.O.Box 1179 A.Nicholas Krupski Southold,NY 11971 Greg Williams Telephone(631)765-1892 Fax(631)765-6641 i BOARD OF TOWN TRUSTEES TOWN'OF SOUTHOLD Date/Time: ��` Q Completed in field by: North Fork Pool Care on behalf of ORA & ELLIOT HEATH requests ani Administrative Amendment to Administrative Permit#9270A to relocate the hot tub 15'1" towards the dwelling but not move past edge of dwelling with waste water drain to remain. Located: 500 Hippodrome Drive, Southold. SCTM# 1000-66-2-13 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3.1 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 J Ch. 111 SEQRA Type: 1 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: I have read & acknowledged the foregoing Trustees comments: Agent/Owner: / Present were: -✓ J. Bredeme er M. Domino G.-Goldsmith ✓ N. Kru ski _ / Y , p v G. Williams Other r Michael J.Domino, President ��0� S�UTyO Town Hall Annex John M.Bredemeyer III,Vice-President �0 l0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold, New York 11971 A. Nicholas Krupski • �Q Telephone(631) 765-1892 Greg Williams O Fax(631) 765-6641 01 AE fP% BOARD OF TOWN TRUSTEESI I TOWN OF SOUTHOLD OCT — 2 2018 Saufhold Toven a a This cP APPLICATION FOR AN AMENDMENT TO A WETLAND PERMIT DATE f140101 OWNER &VU, t qA PHONE Ca I (O(P MAILING ADDRESS "5'000, rwc AGENT C �--C. PHONE (0 PHONE ��-o o `Co'`'t ADDRESS q_l�b I-A rlJ RJ L OV 11 PROPERTY LOCATION 500 �1�drw-t,?_ I✓r. TAX MAP NO. r M - ((0 - c3L- 13 (,�rurjL I/We I �r,K Po OC CR-rz request an Amendment to Permit# I Q _70 p to s'x. -c 6— CAko') ®F I)'D� k6 1, 1 Ii r�S r 05�t JSP�1 �..Q )�A L31 j Signed By: ' - u r� 1005L co}c a Michael J. Domino, President Town Hall Annex 54375 Route 25 John M. Bredemeyer, 111, Vice-President Glenn Goldsmith P.O. Box 1179 A Nicholas Krupski Vol T Southold, NY 11971 Greg Williams elephone (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 I't day of construction 2constructed Project complete, compliance inspection; Michael J.Domino,President OF SOUTTown Hall Annex John M.Bredemeyer III,Vice-President h0 l0 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski �p� Telephone(631) 765-1892 Greg Williams �COU Fax(631) 765-6641 NTY�`� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9270A Date of Receipt of Application: June 21, 2018 Applicant: Ora & Elliot Heath SCTM#: 1000-66-2-13 Project Location: 500 Hippodrome Drive, Southold Date of Resolutionlissuance: July 18, 2018 Date of Expiration: July 18, 2020 Reviewed by: Board of Trustees Project Description: To install a hot tub placed on a 6" high concrete slab; hot tub and slab total dimensions are 94"x94". Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the project plan prepared by North Fork Pool Care, Inc., received on June 21, 2018 and stamped approved on July 18, 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 Michael J. Domino, Pr(' it SUFFO(�-Co Town Hall Annex John M. Bredemeyer 1II,Vice-1'"resident ,� Gym 54375 Route 25 Glenn Goldsmith o 1 P.O.Box 1179 zz A.Nicholas Krupski Southold,NY 11971 Greg Williams yy�O �apl Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: > / Completed in field by: 1� North Fork Pool Care, Inc. on behalf of ORA & ELLIOT HEATH request an Administrative Permit to install a hot tub placed on a 6" high concrete slab; hot tub and slab total dimensions are 94"x94". Located: 500 Hippodrome Drive, Southold. SCTM# 1000-66-2-13 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=� Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 1'00 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 v 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: o 4tAkQj, 61t I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredeme er �/ M. Domino G. Goldsmith /- N. Kru ski Yp G. Williams Other Wil _FT7 - 1 - -I I -I I i J , 41, 77 -j3- ed S31S'f1�1 �® ®fib'®9- j I L[ I I - I �i (!I.L-I i I. -1 1 1 1 1 1� r r r� M JUN 2 1 2018 11 SouthTo O * q� WPM BIEBTBUY l <. TWILIGHT SERIES 8.3 E EFeent TWILIGHT SERIES 8.2 EFficieent Seating Capacity 6 Seating Capacity 6 Dimensions 94"x 94N 38"(239 cm x 239 cm x 97 cm) Dimensions 94"x 94N 38" (239 cm x 239 cm x 97 cm) Gallons 385(1,457 L) Gallons 380(1,438 L) Weight(Dry/Full) 1,115 lbs(506 kg)/5,440 lbs(2,468 kg) Weight(Dry/Full) 1,065 lbs(483 kg)/5,345 lbs(2,424 kg) Pumps 3 Pumps 2 Number of Jets 50 Jets(2 Master Blasters) Number of Jets 44 Jets(2 Master Blasters) Water Features 3 Water Features 3 Filtration EcoPur®Charge Filtration EcoPur®Charge LED Lighting Orlon Light System'" LED Lighting Orion Light System' Noise Reduction System Standard Noise Reduction System Standard Premium Options Fusion Air Sound System Premium Options Fusion Air Sound System Wi-Fi Module Wi-Fi Module QuietFlo Water Care System" QuietFlo Water Care System' Mast3rPur'"Water Management System Mast3rPur"Water Management System Afterglow Jet Package Afterglow Jet Package Dream Lighting Dream Lighting Vac-formed ABS Pan Bottom Vac-formed ABS Pan Bottom The Twilight Series 8 2 has been repeatedly recognized as a "Best Buy"by Consumers Digest MASTERSPAS.COM 40A al. qP S. I�nYt ice TWILIGHT SERIES 8.25 nt TWILIGHT SERIES 8.35 EF�icle Seating Capacity 7 Seating Capacity 7 Dimensions 94"x 94"x 38" (239 cm x 239 cm x 97 cm) Dimensions 94"x 94"x 38" (239 cm x 239 cm x 97 cm) Gallons 400(1,514 L) Gallons 395(1,495 L) Weight(Dry/Full) 1,170 lbs(531 kg)/5,805 lbs(2,633 kg) Weight(Dry/Full) 1,100 lbs(499 kg)/5,690 lbs(2,581 kg) Pumps 3 Pumps 2 Number of Jets 53 Jets(2 Master Blasters) Number of Jets 47 Jets(2 Master Blasters) Water Features 2 Water Features 2 Filtration EcoPur®Charge Filtration EcoPur®Charge LED Lighting Orion Light System- LED Lighting Orion Light System- Noise Reduction System Standard Noise Reduction System Standard Premium Options Fusion Air Sound System Premium Options Fusion Air Sound System Wi-Fi Module Wi-Fi Module QwetFlo Water Care System" QwetFlo Water Care System" MaSt3rPur'Water Management System Mast3rPur""Water Management System Afterglow Jet Package Afterglow Jet Package Dream Lighting Dream Lighting Vac-formed ABS Pan B Vac-formed ABS Pan Bottom 7 - t)UR'VEY OF LOT #S, BLOGK 4 ll MAP OF BEIXIDON E5TATE5 ,, N FILED MARCH I6, K146 A5 # 14120 icy 51TUA�TE: SOUTHOLD �p� VP 00•d TOWN: LD ��o evc ` s 5UFFOLK COUNTY, NY 2� SURVEYED 01-31-01 PROPOSED ADDITIONS 03-2q-2001 WETLAND LOCATION 06-15-2001 y 10' VAN TUYL CONTOUR ADDED 08-23-2001 O�c a ��yi �(, cy PROPOSED 06-06-2008, 01-24-200805-2-7-2005 0 G A,y- Z)2 ��10 �o ado SUFFOLK COUNTY TAX n �" i��c�d�,c\� i�d°epi #1000 - 66 - 2 - 13 N\c � Y� ¢ CERTIFIED TO: Oj 0��oq I 'kilo a °P �, ORA JEAN HEATH �O ��04�Z- :PROP.2STORY! ELLIOT BRUCE HEATH 111 �P'0�d, ADDITION rc � ° PROP.2nd _ do 0'� J�' sroRY t}ALcoN a• SITE DATA' ���° �° ��. - v 5 °9y\ �'�� \1KA 0�N�a DESCRIFTIOId: AREA: I M'COVERAGE ♦♦ /♦♦ PROP.PtRc o ` �\� o -=;i iiti0 �O pid' ♦ AND PaT10 > PROPERTY: LANDWARD OF WETLANDS 11.601 S F. ♦♦ ♦♦ I ` � p,2C,)o� ♦ ,rj, ♦♦ _ �k y�P \0�, EXISTING & PROPOSED HOUSE: 1, 414 S F. 12.19% ♦ Q ♦ ` `�� `° 0 PROP 2nd srarrADVrnoaO 5E rnax PROPOSED PORCH. STOOP, PATIO 239 S.F. 02.06% �♦ @ -' �, SHEDS 272 S.F. 02.34% ♦♦♦ �� ♦`♦ ��! ' \\ i 6 cy s \ \ APRDTION STORY EXISTING & PROPOSED LOT COVERAGE. 1, 980 S.F. 17.06% ♦♦♦ �E ` �(- O S ` / �Fco ��� \� `�� - PROP.2nd ♦♦ ` 00 aO' \ \ �♦ 9�o-k5 STORY BAL(-O DEC ADJACENT AREA BETWEEN WETLANDS AND ♦ G� \\ \\ �0� i PROP.ENTRY PORCH VAN TUYL 10' CONTOUR LINE OF 1982 8. 400 S.F. ` �. `\ �1 kh _ AND STEPS Q- \ ♦ -,-•a.". Sr Q h S 2 Di - ; MASONRY WALK ��,J T.,OFFSE7 EXISTING IN DEC ADJACENT AREA 5 S.F.' 0.06% ADDITIONS IN DEC ADJACENT AREA 219 S.F. 1.95% r S' "yes\ ro V T` \\ \ cE \ \ ♦ `` 0 oyc \ `• d� NOTES: $/ ♦ \' f�i- : (C - --_,/C `� �7 iJ� tE, EE !i v MONUMENT FOUND p �n PIPE FOUND L, e ♦♦� JUN 2 1 2018 STAKE FOUND - lineve �`� `�; �`♦ `� � •�__ - ,dcP�o��,d C/(.'�` \^ i�t� t`yti��cc,¢-<. Southold Town LOT AREA TO MAP LINE 15,113 S.F. OR 0.35 ACRE '��\ ♦` �,` `j'�tiro 0W,6, 1 Board,o Trustee ELEVATIONS REFER TO M51- NOVO '2q ,�`s <o. O o tiro PARCEL RESIDES IN ZONE R-40 �V •`1 <oo�Z ->O, F NE PRE-Ec15nN� IN6 oN� „ P��O W yo IO'SIDE YARD--TOTAL 25' '4F �� O + ALLOhIS 35 FRONT YARD i� � C., REAR YARD 55' 8 O dy ra« -�M frau Ib d tl,[s mvkeG rJth U a—of Yee bb Wveyo.b xmpnn xa aon ee c�t�da b be.Ww true -�. No CHANE IN wrt$ER of s>=DRoorls os>=D DRAINAGE CALCULATIONS: , w v s D E c by ttn Ibn-r r sk ROOF (DWELLING) J AS PER-TERMS O O s,. , -, 5nb ,b �� "" bum W RMefatoriol DWELLING ROOF AREA 1414 S.F. WD OF /(� b `w- ad on Ib tMNt b Ib tAb rmpmy Mreorl ab TIDAL hE7tAND BOUNDARY AS DELINEATED BY EN-CONSULTANTS, Inc. 1414 X 0.11 X 1.0 = 241 G.F: i 3ERWT NO 00 C-"7 U U C7d3 /S' Sv ON 5-21=2007 AND LOCATED AND SHOWN HEREON BY SYM30L Z 241 / 4224 = 5.6q V.L.F. REQUIRED )ATE; PROPOSED IO'WIDE +NON,URF BUFI�2 TO BE PLANTED W2 8'-ODE NATIVE V SETATION V JOHN C. EHLER AND SURVEYOR 2 8b" DIA. X 3'-0" DEPTH DRAINAGE POOLS 6 V.L.F. PROVIDED 6 EAST MAIN STREET 369-8288 Fax 369-8287 N.Y.S.LIC.NO.50202 GRAPHIG 50ALE i"= 30' RIVERHEAD ADW PROP05ED DRYWELL ,N.Y. 11901 REF.-CADocuments and Set ings\OwneADesktop\heath\01-247 proposed house.pro 000 �' ffN T .- L 7 l./P, ,ITION �vWrl � s IN o1q. JF � \ � � of ` • / �Q/ ` �. ��%�, \ \ . \ \ �` � -off •� �. �, � Fa-..t. a ! >:.•... n � -i,. _—I +....-..,. •—- I nr..�:wxi:,. _.w._._ " _ _ ._..^ _..._ � .. Y� ?,7 _ _ _—_ µ7 1 i:.�e' rt'. t I _ .___ cantn3x>t ouF rr m• ;" SEE SEC NO.OSE wtCM uHE N P W SEF INTCN Z—FOR PCL NO. P SEE SEC,NO. 1� � 5J 0 LL566SOO1.J 3 �J .�t l5 n.zvcl �0'(OJ f Amt Cwt E� \O ¢O/ BA n't 5 E5 � r'- ,2��, ti fi _ C� •PE a �.+ p I d, N l +^ Rd 3 y ty NO akc) 41. .419 d Sj 0 4b 0 A V $ � d r NOTICE COUNTY OF SUFFOLK © K m Or M,TNO- SECTION NO Real Property Tax Service Agency v a. CQ Mai to VV A NN V oarEict uo to1E PROPERTY MAP OFFICE LOCATION: S® y®l MAILING ADDRESS: Town Hall Annex ® P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) G Telephone: 631 765-1938 Southold, NY 11971 ® O P � Fax: 631 765-3136 ®I�C17UNV LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, LWRP Coordinator Date: July 12, 2018 Re: Local Waterfront Coastal Consistency Review for ORA & ELLIOT HEATH SCTM# 1000-66-2-13 North Fork Pool Care, Inc. on behalf of ORA & ELLIOT HEATH request an Administrative Permit to install a hot tub placed on a 6" high concrete slab; hot tub and slab total dimensions are 94"x94". Located: 500 Hippodrome Drive, Southold. SCTM# 1000-66-2-13 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 CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP. Clarify the setback distance from the hot tub to the regulated feature. 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 f Michael J. Domino, President o\AsUFFo(,��oG Town Hall Annex John M. Bredemeyer, III, Vice-President �� y1 54375 Route 25 Glenn Goldsmith y P.O. Box 1179 A Nicholas Krupski Southold, NY 11971 Greg Williams X01 , �a� Telephone (631) 765-1892 Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIREMENTS SCTM#: 66-9-1-3 D [ECIEU'v[2 D Property Owner Name: HEA- UN 2 5 2018 Date Sent to Bldg. Dept: - f 8 BUMDYNO DEPT. TOWN OF SOUTHOLD The Office of the Board of Trustees is forwarding the above referenced application for verification of the Building Department's permitting requirements stated below: YES NO Will the proposed project require a Building Permit? Will the proposed project require a variance determination from the Zoning Board of Appeals? Will any part of this application be considered a Demolition as described under Town Code? COMMENTS: -MA'na S ( d -e--- r6l6 C R cl h w &�- CS 1 ')2aa_ce . Irf-1 oca=W (r(An+ /' ignature of Reviewer Date Michael J.Domino,President �O��O� S�UTiy�IO Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O:Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 cou BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit rc 1!j 1 6Amendment/Transfer/Extens l� j� y �_, I;� {; �,. l� Received Application: Received Fee: $ 100, �! Completed Application: Z5 JUN 2 1 2018 1 Incomplete: SEQRA Classification: Type I_ Type H Unlisted Southold Twrrn Lead Agency Determination: ( Boar i of T.nstsns ICoordination:(date sent): 7i�Y`V LWRP Consistency Assessment Form Sent: CAC Referral Sent: Date of Inspection: - Receipt of CAC Report: Technical Review: Public Hearing Held: 7,119 Resolution: Ldgal Name of Property Owner(s): � Mailing Address: �� nt) r��l� Phone Number: CO'� Suffolk County Tax Map Number: 1000 - (A(D Property Location: SQ® ' - (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): Qo 1 r_r-I—Por)L .CA �—c Mailing Address: 27oo HOW LAO 41lj t' k bj V/1q Phone Number: (9 3 t (__,,,Board of Trustees Applim- ',on GENERAL DATA Land Area(in square feet): ® � Area Zoning: Rk,6 di 11 0.1 Previous use of property: ISI ok Intended use of property: K610* lU 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 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 A No If"Yes", please provide copy of decision. Will this project requir y demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure (s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency Date U0 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): 1 Dj r4obe r :6 bL pteaJ o � ,e C 41Stnb, m0i kk) - Board of Trustees Applici on WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 0.�, n540b) 91' X 9�/ " C30 C If I-e, .JCL -(�i� I Area of wetlands on lot: square feet Percent coverage of lot: 1-7,0(D % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: . (0 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: d feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Oderl A0 e c,111 bv. OXPpj fJkJ Ce_)-f e C1 wAvJ-C IW rr Ya -ter a Is ( Li[ rC !A OLXJ, , 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): ot)� b ocls r- 7/_Qa� 617.20 Appendix B Short Environmental Assessment Form Instructions 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 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 Qw F L Name of Action or pProject: Project Location(describe,and attach a location map): oo �� O l7f Brief Description oflPrbpos&d Action: place-A OJT qt u A gg11 D�C� . 51a� m ��d♦ eV b-P- .»d 4 (0 11 410,k, Name of Applicant or Sponsor: Telephone: 031- aT [46/ 66J3 � E-Mail: 0— Ad ress: f� ,) p�L['0-Jt.�,�' qlbo a►>J a City/PO: State: Zip Code: CI -).Ja6c� 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: N ❑ 3.a.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? A- acres c.Total acreage(project site and any contiguous properties)owned ? or controlled by the applicant or project sponsor? P -5 acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial hResidential(suburban) ❑Forest ❑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? ❑ ❑ b.Consistent with the adopted comprehensive plan? ❑ ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ 7. 1s the site of the propospd ation locate i ,or do s it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES rIVI b.Are public transportation service(s)available at or near the site of the proposed action? F-1- c. c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? FVLA ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: FM ❑ 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 JNOYES Places? ❑ b.Is the proposed action located in an archeological sensitive area? 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies-regulated by a federal,state or local agency? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? rK;;1 ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional 0%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 the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, F-1a.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: ❑NO ❑YES Page 2 of 4 18.Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: `,ty ❑ 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: ( 711 I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsorDate: ' Signature: rd 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 l and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? N/, 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? F] 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 1__l reasonably available energy conservation or renewable energy opportunities? &ILJ 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, F]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 ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsiblefor 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 Iead 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 Abcoymino Date Michael J. President Print or Type Name of Responsibi Officer in Lead Agency Title of Responsible Officer Signature oT Resposible'llfficer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Board of Trustees Applic on AUTHORIZATION (Where the applicant is not the owner) owners of the property identified as SCTM# 1000- X/® PR/1)15 in the town of New York, hereby authorizes X--JP60,j �!I 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. X Property Owner's Signature � erty er's gnature SWORN TO BEFORE ME THIS DAY OF , 20 o Not Public 13NNIE1.DOROSKI Notary Public,State Of New York No. O1D06095328,Suffolk County Term Expires July 7,20 r ' Board of Trustees Applia- ` ,.on AFFIDAVIT Z�t,` � BEING DULY SWORN DEPOSES AND AFFIRMS THAT. /SHE 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. X ✓r�% >C Signature of Property Owner igna e of Pro caner SWORN TO BEFORE ME THIS DAY OF 20to�L_ otary Public BONNIEJ.DOROSKI Notary Public,State Of New York No 01DO6095328,Suffolk unty Term Expires July 7,20 APPLICANT/AGENUREPRESENTA.TIVE TRANSACTIONAL DISCLOSURE.FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the nartof town officers and emnloyees,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. l YOUR NAME: /7• x/7-GLJ � (Last name,first name,- aiddle 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,narne 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,rnarriage,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); ]3)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. DESCRIPTION OF RELATIONSHIP Submitted this day of�u/✓E ZO�j SignaturcK t Print Name Form TS 1 �"�1•�'a -r �lw/� � ,i APPLICANT/AGF,NT/REPRESENT.A.TIVE TRANSACTIONAL DISCLOSURE]FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees The uuMose 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. YOURNAME: jpyi°�� (Last name,first name,middle 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 br 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. DESCRIPTION OF RELATIONSHIP Submitted this day of xjU 1v C, 200 Signature Print Name rj Form TS 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 significant 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. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# f W ) - C0�- I Z 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: nE 4�'' - n�-) 94'` A c�q `' C60c � 51ab. • a ' Location of action: OQU Site acreage: , 3� Present land use: I� s up 11,3 Present zoning classification: RP-5 �y l O� . 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: BB (a) Name of applicant: p Rrk POL CA m��. 107-5,))3 Rhrst9. (b) Mailing address: q`7DO PQJ �Cy. (c) Telephone number: Area Code C43 f (d) Application number,if any: / Will the action be directly undertaken,/require funding; or approval by a state or federal agency? Yes ❑ No 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. F1 Yes No ® Not Applicable b be, iji4ded o d @, 10 C_ 0-W 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 ElYes ❑ No Ivl Not Applicable Q,S(�Q�-► -r�l� 1 aC �r 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 NJ Not Applicable ® 6 l-1 -4L1—J 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 LIN Yes ❑ No ❑ Not Applicable -0L 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 F] No UrX]Not A p icable C,.4 .P e 1~ AJ2 UJ J 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 Not(j,_`;plicable <<' L.,- lI d -1% ®p 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 X Not Applicable 14b� Ajb ru)--G ()t,3 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 ❑ Not A plicable 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. ❑ YeX No❑ Not Applicable t. 1- - - 113+" IIJ am apro Alit �. Attach additional sheets if necessary WORKING COAST POLhr-J"S 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 K No . Not Applicable V 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 ® Not Oplicable ` I w-e_1I 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 ❑ No 41 Not Ap licable I t7ug Ams HSHe0a, ahc_ (*0. PPj I GRA Q . 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 [X Not Applicabl ® U -C, PREPARED BY TITLE ll. t'• DATE_a/ t