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HomeMy WebLinkAboutTR-9336A Glenn Goldsmith, President �OOF so Town Town Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold,New York 11971 Michael J.Domino G Q Telephone(631) 765-1892 Greg Williams '0 Fax(631) 765-6641 C4UNT`l,Nct� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD ' CERTIFICATE OF COMPLIANCE # 1861C Date: October 5, 2021 THIS CERTIFIES that the removal of the existing landward 6'2"x24'1" deck and stairs and replace with new 5'x6':front pergola, entry door and 14'x16' stairs;replace or.repair 810sq.ft. of seaward side and westerly side decking, and second floor-7'x18' balcony; and-to replace deck and balcony railings(115 feet with new. At 3145 Main Bayview Road, Southold Suffolk,County Tax Map#1000-78-2-12.1 . " Conforms to the application for a Trustees Permit heretofore filed in this office Dated October 1, 2018 pursuant to which Trustees Administrative Permit#9336A Dated November 14, 2018,was issued and conforms to all the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the removal of the existing landward 6'2"x24'1" deck and stairs and replace with new 5'x6' front pergola entry door and 14'x16' stairs; replace or repair 810sq.ft. of seaward side_ and westerly side decking and second floor 7'x18' balcony; and to replace deck and balcony railings (115 feet) with new. The certificate is issued to Michael&Lori Minasi owners of the aforesaid property. Authorized Signature Glenn Goldsmith,President �QF so�jy Town Hall Annex A.Nicholas Krupski,Vice President ,`O l0 54375 Route 25 P.O. Box 1179 John M. Bredemeyer III Southold,New York 11971 Michael J. Domino N - Q Telephone(631) 765-1892 Greg Williams �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: INSPECTED'BY: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1St day of construction '/ constructed Project complete, compliance inspection COMMENTS: 3.3 CERTIFICATE OF COMPLIANCE: �`Q-- �nx O�S�FFD(KcoGy� Michael J. Domino, President Town Hall Annex John M. Bredemeyer, III, Vice-President < ; 54375 Route 25 Glenn Goldsmith N x P.O. Box 1179 A Nicholas Krupski �y • 0�� � Southold, NY 11971 Greg Williams �ol Telephone (631) 765-1892 ~ n ' 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 Whenjroect complete, call for compliance inspection; p i l Michael J.Domino,President �o��OE SOury®l® Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Glenn Goldsmith CA� Southold,New York 11971 A.Nicholas Krupski app Telephone(631) 765-1892 Greg Williams Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 9336A Date of Receipt of Application: October 1, 2018 Applicant: Michael & Lori Minasi SCTM#: 1000-78-2-12.1 Project Location: 3145 Main Bayview Road, Southold Date of Resolution/Issuance: November 14, 2018 Date of Expiration: November 14, 2020 Reviewed by: Board of Trustees Project Description: Remove existing landward 6'2"x24'1" deck and stairs and replace with new 5'x6' front pergola, entry door and 14'x16' stairs; replace or repair 810sq.ft. of seaward side and westerly side decking, and second floor 7'x18' balcony; and to replace deck and balcony railings (115 feet) with new. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Albis Architects LLC, dated September 28, 2018 and stamped approved on November 14, 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. _;�� A-ZewV�_ Michael J. Domino, President Board of Trustees - Michael J. Doniii esident Town Hall Annex John M. Bredemeyer III,- Vice-President 54375 Route 25 . Glenn Goldsmith y 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: A/, ,/ Completed in field by:, MICHAEL & LORI MINASI requests an Administrative Permit to remove existing landward 6'2"x24'1" deck and stairs and replace with new 5'x6' front pergola, entry door and 14'x16' stairs; replace or repair 810sq.ft. of seaward side and westerly side decking, and second floor 7'x18' balcony; and to replace deck and balcony railings (115 feet)_with new. Located: 3145 Main Bayview Road, Southold. SCTM# 1000-78-2-12.1 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet) 4. Septic Tank: 75 feet 5..-Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF'BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming-pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: 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: -I have read & acknowledged the foregoing Trustees comments: Agent/Owner: ,f Present were:- _.-J-B,r-e ecY'meyer`----- `-/..'Domino GN. Krupski Williams Other 11 11 11 � 11 � APPROVED BY BOARD.OF wI RUSTEES NEW ENTRY TOWN-OF SOUTHOLD STEPS BELOW DATE NOVeA P, 14-1-1 ?_o1g Bnfiit BEDROOM REPLACE NEW BEDROOM DECK RAILING WITH NEW EXISTING DECKING TO REMAIN AND BEDROOM BEDROOM NEW 5'-0" X BE REFINISHED 6'-O" ROOF op, Rrpzverb COVER ABOVE ENTRY DECK WITH DECORATIVE EXISTING ROOF HANDRAILS BELOW AROUND NEW STONE I VENEER ON EXISTING CHIMNEY - OCT 1 2018 __.__.____ ' I Sout4;nid iawn rd of it llsfeas 1 SECOND FLOOR PLAN The above drawings,specifications,designs,and ideas represented thereby are and shall remain in the property of the architect.NO part thereof shall be copied,disclosed to others or used in connection with any work or project rather than the specific project for which they have been prepared or reviewed without the written consent of the architect Q Copynght20l8 Allus Architects,LLC Project Name Date09/28/18 Albis Architects LLC RENOVATIONS TO Refer to Drawing 62 Broadfield Road 3145 MAIN BAYV I EW ROAD Scale: Hamden,Connecticut 06517 T 203.230.2821 D"'gTidr Number. www.albisarchrtects.com 2ND FLOOR PLAN A 1 02 i EXTEND EXISTING DECK SCREEN WALL REPLACE NEW DECK RAILING SIDE REPLACE WITH NEW DECK EXISTING DOOR WITH WINDOW EXISTING DECKING TO REMAIN AND I ILBATTU . BE REFINISHED I II IPF_Pllgf,EoKITCHEN REAR DECK i NEW ENTRY 1, ENMY STEPS I I I I I I NEW ENTRY DOOR AND D1N3CIZY SIDELIGHT I I I O I I I LINE OF i DINING EXISTING 2ND I I I FLOOR DECK I I I 5'-0" NEW 5'-O" X ABOVE i i ; LIVING 6'-0" ENTRY I I I DECK WITH FLAT ROOF COVER ABOVE I I 1 I UTI TV NEW STONE VENEER ON _EX RIO EXISTING DECK �a jl�ri i%I'^ Y f-E'X'TERIOR STAIRS i!Jj) A- ---=_ i AR AS THIS OCT ® 1 2018 1 FIRST FLOOR PLAN Boated ;Test 2s,� A101 1/e"=I'-0' The above drawings,specifications,designs,and ideas represented thereby are and shall remain in the property of the architect NO part thereof shall be copied,disclosed to others or used in connection wrth any work or project rather than the specfic project for which they have been prepared or reviewed without the written consent ofthe architect Qc Copynght20l8 Allns Archam LLC Project Name Date: 09/28/18 Albis Architects LLC RENOVATIONS TO - Refer toDrawkW. 62 Broadfield Road 3145 MAIN BAYV I EW ROAD Scale. 1/8"=1 1-01, Hamden,Connecticut 06517 T 203.230.2821 DwgTide. Number. www.albisarchitects.com 1 ST FLOOR PLAN A101 ti ---------------------------------------- -------- Tr�J LINE OF EXISTING DECK ° ° ° ° ° ° i// / STAIRS TO BE REMOVED LINE OF EXISTING DU K ° I j/j� ABOVE (NO CHANGES) I I I ° i I I LINE OF EXISTING ° I NON—CONFORMING ENTRY DECK ABOVE TO BE Z: REMOVED L--_7------r------ I I I I I I LINE OF I EXISTING DECK STAIRS ABOVE (NO CHANGES) OCT 1 2018 IL I ScuiP�cl-� tl;ot+m l"nard f Trustees 1 LOWER LEVEL PLAN 100 �/e•=��-o• The above drawings,specifications,designs,and ideas represented thereby are and shall remain in the property of the architect.NO part thereof shall be copied,disclosed to others or used in connection with any work or project rather than the specific project for which they have been prepared or reviewed without the written consent of the architect ©Copyright 2018 Albis Architecm LLC Project Name Date. 09/28/18 Albis Architects LLC RENOVATIONS TO Refer to Drawing, 62 Broadfield Road 3145 MAIN BAYV I EW ROAD Scale 1.011 Hamden,Connecticut 06517 T 203.230.2821 D`''grde' Number. www.albisarchitem.com LOWER LEVEL PLAN A100 GLENN ROAD zoN N 00 LAND NOW OR FORMERLY TRZCINSKI LAND NOW OR FORMERLY BRITTMAN TAX LOT 20 TAX LOT 11.3 PART OF FILE MAP LOT 2 I S 63053'30" E 206.06' ROW OF EVERGREENS (GENERALLY 1'-2' NORTH) I � I , I � p O� WOODED/NATURAL O O / Q M 00 o CLEARING LIMIT � I CATCH I 1 WEST CREEK _ BASIN I I - - - - - - - - - - - - - - - - - 5' WIDE DRAINAGE EASEMENT I LOT 2 c' — - - - - - - - — — — — — — — — — — — — — — — — — — — O II I STEPS -J FILE MAP LOT LINE K - - - - - - - - - - - - - - - - - - - - t` OIL FILL® J WOOD 3.3 24.5' LOT 3 t- I _W STEPS ` OVERHEAD 10.4' ~ TO GRADE \ ` - WIRES_ T UTILITY DECK 5'-6" CD 6.4' Q POLE ABOVE GRADE N 8.6' �� LAND NOW OR FORMERLY SIMON I 29.1 N 6.2' DECK 9'-0" \ 00 i W Y � 2 STY ABOVE GRADE TAX LOT 14�� w � FRAME 2ND STY ZLLJ C) Q N o RES. 7.0' DECKLLJ LLJ �\ —� > CO o #3145 , Q < I o0 0 35.3' 25.5' r6 �c� L- I (� z DECK 6'-7" STEPS WOOD P� O I N O ABOVE GRADE N W �- DECK z �' 3 7.4' Li , STONE APPROXIMATE WATER LINE AT TIME OF SURVEY 2/2/2018 10: 30 AM 00 RR TIES DECK 8'-0" DECK 10'-5 M ABOVE GRADE ABOVE GRADE p O / co I CD �} v I O Ln WOODED/NATURAL FOUND MONUMENT MASONRY HELD WALL MAS PIER MAS PIER N 6529'00" W 228.63' NW COR. 0.2' S SW COR. 0.2'N 0.2' W -- LAND NOW OR FORMERLY TOMAN OCT - 1 2018 TAX LOT 13 TOTAL PARCEL AREA= 37,375 SQ-FT.OR 0.86 ACRES UPLAND AREA=29,400 SQ. FT.+AOR 0.67 ACRES CERTIFIED TO: MICHAEL MINASI PROPERTY SURVEY LORI MINASI 3145 MAIN BAYVIEW ROAD FIDELITY NATIONAL TITLE INSURANCE SERVICES, LLC SITUATED IN SOUTHOLD (BAYVI EW) w,, TOWN OF SOUTHOLD,COUNTY OF SUFFOLK,STATE OF NEW YORK PFr,���P,� o � ' - x "UNAUTHORIZED ALTERATION OR ADDITION TO A SURVEY MAP PREPARED AND SEALED BY A LICENSED LAND OCon nor Petito � L . L . C .L . L . C . �� SURVEYOR IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW." 3' Land Surveying 27 Forest Avenue �M;�� � "COPIES FROM THE ORIGINAL OF THIS SURVEY MAP NOT MARKED WITH AN ORIGINAL OF THE LAND SURVEYOR'S ;1336"��Q, INKED SEAL OR HIS EMBOSSED SEAL SHALL NOT BE CONSIDERED A VALID TRUE COPY." "CERTIFICATION LOCUSt Valley, NY 11560 �Q LAhtO INDICATED HEREON SIGNIFY THAT THIS SURVEY WAS PREPARED IN ACCORDANCE WITH THE EXISTING CODE OF Civil Engineering (516) 676-3260 PRACTICE FOR LAND SURVEYS ADOPTED BY THE NEW YORK STATE ASSOCIATION OF PROFESSIONAL LAND SURVEYORS. SAID CERTIFICATIONS SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION. MAP WEST CREEK ESTATES,FILED 8/19/1963 AS FILE No.3848 DIST.1000 SEC. 78 BLK. 2 LOT 12.1 CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT OWNERS." 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Box 1179 54375 State Route 25 lx[ Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) y Southold,NY 11971 �Q Telephone: 631765-1938 olyCOU ,� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Michael Domino, President Town of Southold Board of Trustees From: Mark Terry, Assistant Town Planning Director _ LWRP Coordinator Date: November 9, 2018 Re: Local Waterfront Coastal Consistency Review for MICHAEL & LORI MINASI SCTM# 1000-78-2-12.1 MICHAEL & LORI MINASI requests an Administrative Permit to remove existing landward 6'2"x24'1" deck and stairs and replace with new 5'x6' front pergola, entry door and 14'x16' stairs; replace or repair 810sq.ft. of seaward side and westerly side decking, and second floor 7'x18' balcony; and to replace deck and balcony railings (115 feet) with new. Located: 3145 Main Bayview Road, Southold. SCTM# 1000-78-2-12.1 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the action is INCONSISTENT with the Policy Standards (Policy 6.3) and therefore is INCONSISTENT with LWRP. 6.3 Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction 1. Comply with Trustee regulations and recommendations as set forth in Trustee permit conditions. Wetlands appear to be larger in area than depicted on the submitted plan. Jurisdictional setbacks are not indicated. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Damon Hagan, Assistant Town Attorney Michael J. Domino, President �o�pSUFFO(�coy Town Hall Annex John M. Bredemeyer, III, Vice-President � 54375 Route 25 Glenn Goldsmith N P.O. Box 1179 A Nicholas Krupski • Southold, NY 11971 Greg Williams y��l , �ta�!_ Telephone (631) 765-1892 Fax (631) 765-6641 SOUTHOLD TOWN BOARD OF TRUSTEES D D OCT 1 0 2018 TO: SOUTHOLD TOWN BUILDING DEPARTMENT RE: VERIFICATION OF BUILDING DEPARTMENT PERMIT REQUIREMiMK5i 1'GDBIT. TOWN OF SOUTHOLD SCTM#: Property Owner Name: MAWS! • Date Sent to Bldg. Dept: 10�1o,1S' 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: &" Signature of Reviewer Date f i i l r - h Michael J.Domino,President ��oE SQUryO Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25P.O.Box 1179 Glenn Goldsmith CA Southold,New York 11971 A.Nicholas Krupski �pQ Telephone(631) 765-1892 Greg Williams ` uNr Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit �Amendment/Transfer/Extension Received Application: 16114 Received Fee: $ IOD,a�J Completed Application: 119 Id, Incomplete: SEQRA Classification: Type I Type 11 Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: ' � r� � i , ::]6Coordination-(date sent): I1,2 rlg �� �;_;_ _ WRP Consistency Assessment Form Sent::zt CAC Referral Sent: Date of Inspection: 11,Id �! ! OCT - 2018 1 Receipt of CAC Report: Technical Review: Sou!hcid Tr,,,vn Public Hearing Held: 111i t Boaid of Trulges Resolution: T 0 , Owner(s) Legal Name of Property(as shown on Deed): M 10111}El h 1 VV A-,-' 1 L O P-% 0) 1 W>qS 1 Mailing Address: IG CO W-YMA-) LAP>_ Phone Number: z!Z 0 3 - '12-7 Suffolk County Tax Map Number: 1000 - 76 —7- 12 0 1 Property Location: 3 / V-3' Wl j-+i N ?2 P,-jy i E L--) S6 tk'Tt-Ioi--0 (`l, . (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Board of Trustees Appl Ltion GENERAL DATA Land Area(in square feet): 37 i75- 5A, FT. Area Zoning: Previous use of property: Intended use of property: F-51 P 1E rJ T►►4t, I-10Yn F 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 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? Yes No Prior permits/approvals for site improvements: Agency Date rovals for site improvements. No prior permits/app Has any permit/approval ever been revoked or suspended by a governmental agency? /N Yes If yes,provide explanation: Project Description(use attachments if necessary): kEMoVe Aau-&A- ROAAi NC FRO NT DE-0K F S —01kS1�� z"x2��l�)APD f,�e?LAdetv►Ttk NE7w pT 3X6'Jr)c-i ec'o L A F,�TAY 17o�R e :%TAi'2.s (i Oft Al R6 1I'/XIb'JEli 4- 1)„REPJJV-F7®Q RESTt02E T to511Frt,oF AEC KiruC7olo�SilIM* -509- Rrak f READ- P-00 Flats A 7x 1 s3` 13 aL ebA2 , R E-PLk- b Ee- 9 A4�b/v Board of Trustees App ation WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 4-moVE No lu 0—ori Fb(Lm N cc F go NT Q E Cly F luo 6-rAri p,Np RE PLACE W IT14 Cori FoPLnn t"C-� �Rc�r�T rv'TRr�Nc PEP-CiOLA Pt,UQ 687"D RAIL-5 Oro QEnnA,0&G D ECk Ash S Ee-ow O FLOOR '�At e-00yo R,EPIAQF� Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: 29 feet Closest distance between nearest proposed structure and upland edge of wetlands: .6© feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? o cubic yards How much material will be filled? o cubic yards Depth of which material will be removed or deposited: p feet Proposed slope throughout the area of operations: 10 Manner in which material will be removed or deposited: Na D e pa 5 i T 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): Ago rJ F— a 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 Name of Action or Project: MF4 1 � Project Location(describe,and attach a location map): 3 / 4- (� 141 N 6 Ay v I C LJ R-D. 5,:5 UT H&L a N.Y, Brief Description of Proposed Action: lz' Yro l)1C poly-CoNF7'oRMtrv4t� FgarJT PFe_l, AP 19TAIA-5 rAvo P-CPLRCj�7 wiTH 0VfuFDAn\1 DC7- FPZot-lT 1rrVTRAr LF— PE: RC7r->LA ANO CNT►a-1 Dor R-, Rlt-ol.PF DECKING ANP 14ANORAlt-5 aN Dr'�LV-ICAPO 2Na F1-4e-p- (36" 5 Y. J�FPLt1d-E S 1D I N C-T. Name of Applicant or Sponsor: Telephone: 263- q 23 I e f-}I}CL ¢ 441 TY) I N 65) E-Mail: I N A51 i& Address: 1'8 COAMMIAPJ LANE City/PO: State: Zip Code: 14Ably I CT 0z"--x4- 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 R- F1 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: ❑ 19- 3.a.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? p 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. / E]Urban Elural(non-agriculture) ❑Industrial ❑Commercial MResidential(suburban) El Forest I�Agriculture F-1 Aquatic C1 Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ Q ❑ 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. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: 5� ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES L-1 ❑ b.Are public transportation service(s)available at or near the site of the proposed action? �( ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? u 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: ❑ Er 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? C" ❑ b.Is the proposed action located in an archeological sensitive area? [0 El13.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? _ff b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? I ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: " 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline El Forest ❑Agricultural/grasslands El 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 the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create stone water discharge,either from point or non-point sources? NO YES If Yes, –0, a.Will stone water discharges flow to adjacent properties? NO DYES 1J b.Will storm water discharges be directed to established conveyance systems' ru and stone drains)? If Yes,briefly describe: NO DYES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO I YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: R1 ❑ 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? I� � If Yes,describe: I,/ ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO I YES completed)for hazardous waste? If Yes,describe: 1�f n I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/spon me �prl Pvtl�•�! Date: � !7 2a!g Signature: Part 2-I pact 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 El 1:1regulations? 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 El 1:1establishment 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 El El available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: El El a.public/private water supplies? b.public/private wastewater treatment utilities? o El- 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ n architectural or aesthetic resources? 1J 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ Elwaterbodies,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 ❑ 0 problems? 11. Will the proposed action create a hazard to environmental resources or human health? El 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. ElCheck 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. ElCheck 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) PRINT Page 4 of 4 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 employees.The pumose of this form is to provide information which can alert the town of ppssible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: M 1 y\)" A . (Last nam ,first name,rpidd initial,unless you are applyin to the nage 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. DESCRIPTION OF RELATIONSHIP Submitted thi - da f 2001 Signature Print Name-/ Form TS I 1 Board of Trustees Appl' ation AFFIDAVIT Aegfia 6vo), ' A ram) . BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/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. �Kjnatu- re of rerty Owner Signature of Property Owner SWORN TO BEFORE ME THIS DAY OF . �f/ , 20 Notary Public MERITA DAUTI NOTARY KWIC STATE OF CONNECTICUT My Commissiorn Expires Feb 28 2022 , 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 employees.The purpose of this form is to Qrovide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: M, (Last nam ,first name,Vidd.16 initial,unless you are applym in the naAie 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 ofSouthold? "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. DESCRIPTION OF RELATIONSHIP Submitted thi . da r If 9 200 4-, Signature601 ''° Print NameJ_ IT('Ia/9 _ �'! 1. 1I9y Form TS I ' � f 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 PROJECT NAME. )NA N A-5'1 R-F-51 ©EN CE 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: (ZEmoo E EX 1!57 1 N!q Nay'- Caws RDRmiA;!5 F"vQT ,v'ftzti .D6c< ,qn,� R,ep4ee WIT 1+ S&:RQnkA a RCPJ-AAE O EcK1"a r, Nr�w,��P�i►-S 0ri Prr-7MAI)01W!n� D EeK5 AY-0 q EPLACAE s11NJ,6V r Location of action: -- 1 �- t.1 t3>� v E >Z�, 5OLITHna Q Site acreage: b. 8b Present land use: f),E5 I D F-b=)T iy�- Present'zoning classification: >R741 D E PJTi 14 Z- 2. 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: l C H A El- 0))ti IA- j (b) Mailing address: f 'zS Co P,e H m Ar-j )—Ai,,E' 3 ti A?J �. e-r.- 6&S'i�- (c) Telephone number: Area Code( ) 2 o 19-9 (d) Application number,if any: WA 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. ©'Yes ❑ No ❑ Not Applicable ��LI3 RENOUft'71DA1 GRRRVM ) ZVtipp-oyeS iF1RE;Tr1ETiC RESIoE/yClz- WI{II-1FDD EST N!3 17';4. '50 I/EAiZ DP -r1,OW BJ QF LACE I IV- 4wO REST®P-JN!6' DA1Y AQ913 ExT ERiD R C1 6*TIFRI.#4 .. . Z?SILL I nl T'[aRiQ 7M PRoVE Arlo E WkIS dt- tT. zrn PAe-'roas O&MMUNITY WARRtIERZ P91LE PApVIDINO, ITS OCCLAf'ANT5 U1-SE' OF iT-S eps- A . L.oeftT;op Lot-CSOWT pISR1A1>TINQ2 THE ENO1R6tJ1l6:z2J: Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III-Policies Pages 3 through 6 for evaluation criteria ❑ Yes 1No ❑ Not Applicable 3 --7741�5 Pep:lFcT ` DFS NoT Dj-- 2R X:r 6,9 !4-=rh:RACT 'TNE J?/z�PiERTiES W FTLA1VQ5 AMP DDES NDT PF-QLk kRE -rHr- IZEMOVFrL OF TO2E£5 QR %; EGETAf1,0 9 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 ❑ Not Applicable TUE Q&PAZIP10 13 P-5167NE2BV 19WMITECTS , 'THE A4'5'C OF A'9ZC-R1,;V5' :51j[45 j'To,V,E AWO 0EDAR, E21_1AvATF THE �t�NEs''h�'�QpL £LEir�Eiy7 &55oC lATFD W/rg PWR4Y �/oh7�5 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 ❑ Not Applicable /�9-A ,9 F 9V© E91Q51,0AZ 00,N7.?oL -'T/�UC►7W/?47- S TO . TNiS P2o�s'c7, 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 R Yes ❑ No ❑Not Applicable �� ,k 4t£ No 50Lr?,E-Vr 13AsFn 11667VN65 OR A7-- f3Fiv� a,sE-n ®.v %� ' L7ALL Cf /NS ® �q�yT iZl- BE Cf7F23195E7 4,yA1 ALLbLor::n To �6Tq�o 7151�!'1SE� QF X45 SdLinS c9lZ REC'YC'LED, 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. lid ❑ ❑ x 4 Yes No Applicable -f� iS x/2®3-4-T W1)-Z- 4�AV E ?EAD -Tr,) PACT OP FIs tl APO l)/)t n I IPE fF� I']'►9T Xl n�� W ETL/4 D1.7 l7 S, , 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. ayes ❑ No❑ Not Applicable -HERE FARE A1,0 TOXIC- A,'171c-,t'/AZL 5 /3E//I/Ki Gf 5.CD Civ 72Z/-6 49&ZrFeT _o7?H6'P- ley / 8 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 Applicable Apy GA5 POyEgEn -QU 1P1h4;0yT 1--,)1L RF PROPERII STORED .44tvn� E�VaJPMe-,QTC S fhoWEV,5 A,--n 7RiArn E'6L-5 AgF' BA Ir 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. YeO No❑ Not Applicable E4 Af,F- Ny --5T,E, J3jE/N6 T.9/CW-, -1 T -ImPiF0 E VlS o#1z Ad►/+-55 pj a n- -rat S-f 2eeT -m `TN,E 41A)TT 6/' OoosTA�Jzj e&-) ,:Lu E: P14 BJ 14, L-X)3-rI wo 2220 141 B)T V I EGy EXCEPT f--ROrh 141,QH ER Attach additional sheets if necessary WORKING COAST P, : [CIES 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. ❑ Not Applicable F1 Yes �No TA1S FR6_2FCT D ES Nn7 FFFFdT Wi4:r 97 R_ i�FPE_NDArjT VSPS 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 D/No ❑ Not Applicable ` Nis j-_-_)Ra-SFeT DoE5 luo-r TMRAdl 4zV1N§ AwK ti>^ RL5.2yEcCs, 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. 1:4Yes ❑ No❑ Not Applicable IRA N5 FFR -Mx 0,L 0-164), W19& 04,c FA,1TLy PA ID aT- m E d F c 44-5,IA1 i 2� F1 P o7E �/ �i Cil�T� �► ,44N,05 . 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 0 Not Applicable 4 v PREPARED BY ARIIII�2 414W,!' / TITLE DATE�2019