Loading...
HomeMy WebLinkAboutTR-10871A Glenn Goldsmith, President �OF SO Town Hall Annex A. Nicholas Krupski,Vice President �O� ��� 54375 Route 25 P.O. Box 1179 Eric Sepenoski l Southold, New York 11971 Liz Gillooly G Q Telephone(631) 765-1892 Elizabeth Peeples • �O Fax(631) 765-6641 ooUiVT`l,� BOARD OF TOWN TRUSTERS TOWN OF SOUTHOLD Permit No.: 10871A Date of Receipt of Application: October 29, 2025 Applicant: Mazi Holdings LLC SCTM#: 1000-86-7-7.1 Project Location: 530 Broadwaters Road, Cutchogue Date of Resolution/Issuance: November 12, 2025 Date of Expiration: November 12, 2028 Reviewed by: Board of Trustees Project Description: Demolish existing two-story dwelling with crawl space, including foundation; all demolition material to be removed from site; regrade site to match surrounding grade. 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 Adragna Designs, LLC, received on October 29, 2025, and stamped approved on November 12, 2025. 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. Glenn Goldsmith, President Board of Trustees Town Hall Annex ©� sou� 54375 Route 25 Glenn Goldsmith, President ®� p p. Box 1179 Vice President �® Southold, New York 11971 A Nicholas FCrupski, * 1592 Eric Sepenoski Telephone (631) 765 Liz Gillooly Fax (631). 765-6641 ;�� • a® Elizabeth Peeples ffl U0 BOARD OF TOWN TRUSTEES TOWN OF SOUT HOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUST OFFEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ,4.CTIVITIES BELOW INSPECTION SCHEDULE _ Pre-construction, hay bale line/silt boom/silt curtain 1 s' day of construction '/z constructed mp lete, call for compliance inspection, When project co r SOUT HO LD TRUSTEES No. Issued T is LL4 Date, Addr 'ess '530 ,6ro&aw&-Iecs' ' coveI C%Zrclnog..e THIS NOTICE MUST BE D15PLAYED, DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765.1892 I Q) co c0 CO co � / co \\ I - - \ \\L— \\ \\ ��`IMIT OF SILT C>= _—� — - - �, �i /_/ 0 4A \ I EXISTING 1 \ c0 I II 11 I \6HED TO BH \ \ \\\ \ \ \ ` \ ♦ WETLI'AND ETSACK "d / // (!� Cz �-+ 1 2 REMOVED I \ \ \ \1 \ Ii c� O O - --------t---m----------- I \ \ \ \ \ i \ f\ l" O O O J� \ -------- � Ra _ _ \ \ I i I - \ --- - T{Zl1GT10N EXIT "� \ \ GRAVEL I - IN EXISTING I 1_''` DW LLING Q Cd x GRAVEL DRIVEWAY 1 I v2 \ \ I 1 I 1 \ I I C''J N N O N TO BE, REM01fED / r STFk/s _.-_`� '----------- I 1 I I I I I I \ 1 $�NF LNG i Ln Q Z Id 7� Sign E Seal: co/ \ 0�/ \ h' \ 1 ► - I ----- \ ICE CD LIMIT or �A TUReaNCE i Q0 �C) CO %- r^ N S 23'Q(�° UJ �\ ` \ 3"(fd.� t*a 19 1, ge.Ta a c}o unlessactmg ' \ \ rider Ind n of ense arch ct,to alter I \ \ (QQ� a :.�:6 a be i�t e seal of an gyp\\\ \\\ \ \\ ar IT al red,Ehe�alterl �dehlectsha!I affix to his 1 e e lhI 7tk, a i !1'ered b followed by his ya a �e e bfy�ch alteration,and a �`CP� / I r, �rortrdit��lets' yl vQ� specific c al ation. \ \ \\\ \\ \\ \\\ m _ I Architect: \ \ I \ xl eITEE f=LAN SCALE . P = 20'-011 01 DIVERSION RIDGE REQUIRED EXTRA STRENGTH FILTER FABRIC \ WHERE GRADE EXCEEDS 2% 2 OR GREATER NEEDED WITHOUT WIRE MESH SUPPORT STEEL OR ROADWAY \/ \ c WOOD POST /�\/,�/\/��//\i�/�\/,( ATTACH FILTER FABRIC FILTER FABRIC SECURELY TO UPSTREAM SIDE OF POST „ECTION A—A -- 17 FLOW NOTE: STRAW BALES, SANDBAGS, SPILLWAY USE SANDBAGS, STRAW BALES •'�— OR CONTINUOUS BERM OF OR OTHER APPROVED METHODS :�` . ' ''''•' AD RAC NA EQUIVELENT HEIGHT TO CHANNEUZE RUNOFF TO BASIN AS REQUIRED. 10' MAXIMUM SPACING WITH SUPPLY WATER TO WASH // //\ �/j WIRE SUPPORT FENCE DESIGNS L LC WIRE SUPPORT WHEELS IF NECESSARY \\\�\�/\\i \ /\ / AXIMUM PACING FENCE WITHOUT _ A2ARCH 1 6@GMAIL.COM STEEL OR WOOD POST A P a`�'o`�i � a-I� E a� (516) 289-2461 FLOW FLOW 36 HIGH MAX. BOARD OF ) r,USTEESFLOW _r7 40 0 0 0 b o . 0 0 -d- TOWN OF SOUTHO .D • { J•.._�.j I k Project Title: tfCt X t I e e op= 4 0o PONDING HEIGHT PONDING HEIGHT 530 B r o a dw a t e r s Rd A I A 2"-3" 3/4" MIN. DRAIN ROCK /� r }r� COURSE AGGREGATE vo 12' MIN. FLOW 9" MAX DJ1T �� ! , rj I t •' OCT 2 Q 20255 11 MIN. 6" THICK -- 6• t V O V, / I �� STORAGE HT. CUtChogue, NY �e Az_t' Nv DIVERSION RIDGE 12" MIN. �\ \�'��"\\\��\\ 12" MIN, _-____ Drawing Title: 50' MIN. x6" TRENCH \/\ PLANNTH COMPACTED �\��� D E M 0 BACNOTES: TRENCH DETAIL INSTALLATION WITHOUT TRENCHING SITE PLAN 1. THE ENTRANCE SHALL BE MAINTAINED IN A CONDITION THAT WILL PREVENT NOTES: TRACKING OR FLOWING OF SEDIMENT ONTO PUBLIC RIGHT—OF—WAYS. THIS MAY REQUIRE TOP DRESSING, REPAIR AND/OR CLEANOUT OF ANY MEASURES USED 1. SILT FENCE SHALL BE PLACED ON SLOPE CONTOURS TO MAXIMIZE TO TRAP SEDIMENT. PONDING EFFICIENCY. 2. WHEN NECESSARY, WHEELS SHALL BE CLEANED PRIOR TO ENTRANCE ONTO 2. INSPECT AND REPAIR FENCE AFTER EACH STORM EVENT AND REMOVE PUBLIC RIGHT—OF—WAY. SEDIMENT WHEN NECESSARY. 9" MAXIMUM RECOMMENDED STORAGE Project#: Scale: 3. WHEN WASHING IS REQUIRED, IT SHALL BE DONE ON AN AREA STABILIZED HEIGHT. 1000-104-10-4 As Noted WITH CRUSHED STONE THAT DRAINS INTO AN APPROVED SEDIMENT TRAP OR 3. REMOVED SEDIMENT SHALL BE DEPOSITED TO AN AREA THAT WILL SEDIMENT BASIN. NOT CONTRIBUTE SEDIMENT OFF—SITE AND CAN BE PERMANENTLY STABILIZED. Date: Sheet#: TEMPORARY GRAVEL CONSTRUCTION October 26. 2025 x of x ENTRANCE/EXIT DETAIL SILT FENCE DETAIL Sheet' SCALE: NTS SCALE: NTS D - 100 . 00 Glenn Goldsmith,President "✓Y��O' OG Town Hall Annex A.Nicholas Krupski,Vice President ai�� y�'` 54375 Route 25 Eric Sepenoski * P.O. Box 1179 Liz Gillooly �y ® 0� Southold,NY 11971 Elizabeth Peeples � � � Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report l� lo�z� �;1�� Date/Time: Completed in field by: MAZI HOLDINGS LLC requests an Administrative Permit to demolish existing two-story dwelling with crawl space, including foundation; all demolition material to be removed from site; regrade site to match surrounding grade. Located: 530 Broadwaters Road, Cutchogue. SCTM# 1000-104-10-4 Typ of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: J Chapt. 275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment .� Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: /Yes No Not Applicable Info needed/Modifications/Conditions/Etc.: Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples S.C.T.M. N0. DISTRICT: 1000. SECTION: 1:04 BLOCK:- TO L-OT(S):`4 BR:OADWATER COVE TIE.LINE . S 74'30'05" E. ;.:.. 70.60' SyORFC/Nf . INTERTIDAL MARSH. O' m OTHERWISE PROTECTED " L 1.2 AREA BOUNDARY, --MHW NOV. 16. '199T ZONE AE(EL 7) 2 ECK TIDAL'WETIAND PIPE � :ENUCONSU11,,��fUVTS ►0110N �62:1... WF ZONE AE(EL 7) -A— LOT 184.' LOT 186 �'�:LOF 185 �p0. ZONE X 0.2f CHANCE ANNUAL FLOOD 2ND FIR. DECK . r5.3 ZONE:X. !I 0 11 7�,'/ 2Np ,�T f�A110 00 jam/ i 9'�' � �'' •: l ." W / / BRL� o /. 2NND e.t .... .... .tJ.P.' ..� .. / W 17r O 1 i Iyy — ---- —00 -a5,— �, 14�' .GRAVEL p _48- 17 I. \ le \ APE 2'N 4 NLINK Jw�',/ % \�20 a:. .. .. OCT 29 2025 N r ; "20— Southold Towri 3 %'910N. s�6 23, Board of Trustees U. fOCF Do pgMFNT � � EDGE OF. V z. . FIELD: INSPECT/UPDATED 03-22-23 ADD •TOPO 1-0`'28-24 THE'WATER.,SUPPLY, WELLS DRYWELLS AND,CESSPOOL FEMA MAP.#361'03CO1 64H I1:Pfy LOCA77ONS :SHOWN ARE FROM FIELD OBSERVATIONS AND OR DATA' OBTAINED FROM OTHERS AREA: 28,70-1 SQ.FT. or 0.66 .ACRES ELEVARON DATUM: :NAVD88 UNAUTHORIZED AC7ERA77ON:OR ADDITION`'TO THIS SURVEY IS.A:VIOLA17ON OF SECTION 7209 OF THE NEW: YORK .ST47E EDUCATION LAW.'" :COPIES-OF. THIS SURVEY MAP NOT BEARING::THE LAND SURVEYOR'S. EMBOSSED SEAL, SHALL•NO.T,BE•CONSIDERED TO BE A. VALID,.'TRUE COPY.'' GUARANTEES INDICATED HEREON SHALL:RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON'HIS BEHALF TO THE •77,TLE COMPANY, GOVERNMENTAL-AGENCY AND.LENDING INST77UT70N LISTED HEREON, -AND TO 774E ASSIGNEES OF THE"LENDING INS77TU770N,' 'GUARANTEES ARE NOT TRANSFERABLE. " 774E OFFSETS OR DIMENSIONS SHOWN HEREON FROM -THE'PROPERTY'LINES TO THE STRUCTURES ARE.FOR A.' SPECIFIC PURPOSE AND-USE THEREFORE 7NEY ARE NOT INTENDED' TO MONUMENT THE.PROPERTY LINES OR 'TO: GUIDE THE EREC77ON OF FENCES, ADDIT70NAL STRUCTURES OR AND OTHER, IMPROVEMENTS. 'EASEMENTS. ; AND/OR SUBSURFACE'S7RUMRES,RECORDED OR UNRECORDED ARE NOT GUARANTEED' UNLESS PHY51CALLY•EV/DENT ON.'THE'PREMISES.AT.THE• TIME OF SURVEY SURVEY OR LOT t85 of NEB, CERTIFIED TO: MAZI.: HOLDING'S LLC; ': �� M. J% CORE TITLE :SERVICES LLC;: (No.CORE27951) MAP OF:AMENDED 'MAP A -OF NASSAU POINT �� �N �o �,�; FILED:AU..G 16, 1922 No. . 156 �. SITUATED AT: CU'TCHO.UGE Y a TOWN OF:SOUTHOLD: KENNETH M .WOYCHUK `LAND SURVEYING, :PLLG . . .SOFFOLK COUNTY;- NEW YORK BLS _Professional Land -Survey.ing and. Desi n, 050882 JQ, . g P.O. Jul Box*:153 Aqueb gue, New York 11931 0 N PHONE:.(831)298-1588 FAX (831)- 298-1588. FILE #221 =193 SCALE: 1 "=40' DATE: OCT.. 1:5, 2021. N.YS. 'LISC. 'NO. 050882: maintaining the records 'of Robert J. Hennessy & Kenneth M. eoychuk Ba,..90 - aY� OS11A8 111P0 1 � p qe �ac Tot a +a ♦1y � .CuEEI( 942]-0I '�u 1 'O' 0 6„6 W�A• roM p,p.,. m ..` �`y ;�� e¢`'9Cr' ` ,r.e ++�' Po`1 1s' ♦'^'`a^ +n''c T a`.',"'- - 3 yzsw t i. � $ � ` ♦s,,3?'s t+ ay 'I ,.^Ap B'a+ 3 ,yty�ll ?x\ N 2Al reoa _ y 5 O., oT-21-IT �^+g3 1 �� ,3�;'fj b10 � ° 18 m ,+'y`�,♦yp W�fi � p i -' ' v ,1l n ♦ vm m v 10 wN,s txeSl� d LL O 09aoe1rycr -,._�I a a,raauE ryopl s,A3y 0P♦ ,0� 31t"l1 `� +oP s 9 t m�� 6 lam.♦c� yap \ , � e \ + -\ BROADWATERS COVE \ '\ - a TOWN OF SOUTHOLD �e4 25 i A"sue a+ b a •[®/✓", to ` - ♦3+ 2 a„ a - HAYWATER COVE . 1�-... ' E (21) NOTICE .a+��v'�y COUNTY OF SUFFOLK © E av gppTMOLp SECTION NO c $f' Real Property Tax Service Agency Yc E --w-- cpnry O,rox WnrOmC,NT,1001 M 704 p as n a n,Nm>uu o.a� __r__ o�,�—_r.__ Y,YYus' a A rx,cr xo P 7000 PROPERTYMAP OFFICE LOCATION: QF.$Q(/j�Ol MAILING ADDRESS: Town Hall Annex P.O.Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) CA G � Telephone:631 765-1938 Southold,NY 11971 ;�• . • y0' LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD Glenn Goldsmith, President ;' T ,r .,Town of Southold Board of Tru`stees '- iJ Cc: Honorable Lori Hulse, Attorney:"" = From: Heather Lanza, AICP, Planning Director LWRP .Coo'rdinator-_ . `� .�:11'. �"�'I Date: November 10, 2025 Re: LWRP Coastal Consistency Review MAZI HOLDINGS LLC, -,.SCTM# 1000-104.-10-4 ` This'application.is.for an Administrative Permit to demolish existing two storY dwelling with crawl-space, including foundation';`alI demolition material to be removed from site; regrade site to match surrounding gratle:•. The proposed action has been reviewed to Chapter,268.,.,Waterfront-Consistency - ;,; , i °• , .. a . .,t 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 proposed action is CONSISTENT with the policies of the LWRP as follows: J The plan includes actions which are consistent with the "Administrative Permit" requirements of Chapter 275-2 A. of the Wetlands Law of the Town of Southold. 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. 2 Glenn Goldsmith,President � .; Town Hall Annex . *� 543752oute 25 A Nicholas Kru.pski,Vice President . 1179 P,O .Box Eric$epenoski k Southold,New York 11971 Liz Gillooly . 01 lel-eAone(631) 765-:1892 Elizabeth Peeples YqiF(6 6 .. OCT 29 2025 BOARD.OF TOWN.TRUSTEES . TOWN OF SOUTHOLD �'thbT i oar o Trustees This Sect<on For Office Use Only OC 2 9 0 Coastal Erosion Permit Application T 2 25 Wetland.Permit Application fx' Administrative Permit. } Southold Town f Amendment/Transfer/Extension Board of Trustees Received Application Received Fee: Completed Application Incomplete - SEQRA Classification. Type I Type II Unlisted Negative Dec Positive Dec Lead Agency..Determination,Date: Coordination:(date sent):;. L.MW Consistency Assessment Form Sent:: :CAC Referral Sent: . Date of Inspection: Receipt of CAC Report Technical Review: . Public Hearing Held Resolution: Owners Leal aly (a Name of Pro s shown on.Deed ;: ' L Z- g . P . ) Mailing Address: ' �/ .7��Smr�S ° /P.+� [�v� / X Phone.Number: 7 ,,�� , / / Suffolk County Tax Map Number: 100011.9 -�� `- Property Location AU (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable):`: , Mailing Address`; Phone.Number: Email ward .of Trustees ApplicatJ—, GENERAL DATA Land Area_(in.square feet). _ Area Zoning Previous use of property Intended use of property: 'a ..Covenants and Restrictions.on property? . Yes No If"Yes",please .provide a copy : Will this ro'ect require a Buildin .Permit as er.To,wn Code? Yes ._a llo project �1 g P _. 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.Appeais? ` YesNo P q .If"Yes";please.provide copy.of.decision. s:project re 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: . /L// c d Agency Date ❑ No prior permits/approvals for site.improvements: Has anyermit/a royal.ever been revoked or suspended b a overnmental agency?�NoL Yes P . PP �P y . g If yes,provide explanation: ' a )..roJect Desc P riPtion(use attachments if necessy 44 V,AM10 J2 17 �:.402 av j4 LA 44 q -.-.,ard of Trustees Applicat�,r` WETLAND/TRUSTEE LANDS APPLICATION DATAF. Purpose of the proposed operations:' 240 Area of wetlands on lot ;square feet Percent.coverage.of lot % Closest.distance between nearest:existing structure and upland edg&of wetlands: - . . feet Closest distance between nearest proposed structure and.upland edge of wetlands feet Does.theJ project involve excavation or fillip 9 El No Yes P g• _: . If yes,how much material will be excavated?— .cubic yards. How much material will:will:be filled?_ ­9 _cubic yards. Depth of which material will be removed or deposited: ..:: ' ..feet Proposed slope throughout the area of operations:-. :o Manner in which material will be removed or deposited::. '�. e Statement of the effect, if any, on:the wetlands and tidal waters of the town.that may result by... reason,of such 'operations (use`attachments if appropriate): � � / 7 .61 Z20 . Appenaiix B Short Environmental Assessment Form Instructions torcomnleting Part 1 -'Project Information. The.applicant or project sponsor.is responsible-for the completion of Part 1. Responses become part ofthe application.for approval or funding;:are subject io public review,and may be subjectto further Verification. Complete Part 1 based on information currently available:..if additional:research or investigationwould 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 youbelieve Will be needed by or.useful to the lead agency;attach additional pages as necessary to supplement any item: Part"1 -Projec and Sponsor fo a 'on Name of Actio .o .roject: Project Loca io?q�c nbe; d att c a 10 ation map Brief.Desc"ph n of Proposed Action, Or ems Al � ry Name of Applicant or Sponsor Telephone l l.G. E Mail Address 77 City/PO: State: Zip.Code. 1 Doe t e p oposed action only involve the legislative adoptiorrof 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' 1f Yes,list agency(s)name and.pennit or approval- la.Total.*acreage of the site of the proposed action? :. acres b.Total acreage to be physically disturbed? s4. acres c.Total acreage(project:site•and any contiguous properties)owned. or controlled by the applicant or project sponsor'? w acres .4. Che I land us at occur on,adjoining an ar the prop action.: Urban Rural(non=agriculture) : Industrial Commercial., Residential(suburban) Forest �P►griculture Aquatic QOther(specify) Parkland Pagel:of 4 5. Is the proposedact,on, 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 ;landscape?, 7. Is the site of the:proposed action located:n,ordoes it.adjoin,a state list6&Critical Environmental Area?: :. If Yes,identify El 8. a.Wilf.the proposed action result in a substantial`increase in trafi c above present levels? NO YES' b.Are public transportation service(s)available at or near the site of the proposed action? c.Are any pedestrian accommodations or bicycle routes available on or near site of the`pr posed action? 9.Does the'proposed action meet or exceed the state energy code regmrements?. NO. . If the proposed action will exceed requirements,describe design features and technologies . if Will the proposed action connect to an existing public/private water supply N.O,.. YES , If No,describe method for providing potable water; l 1:1N�11 the proposed aohon,connect to existing wastewater utilities? �/�/ NO. YES`; If No,describe method for providing wastewater treatment 11 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,ofthe proposed action,or lands adjoining the proposed action,contain NO:: ;.YES.` wetlands:or otherwaterbodies: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 insquare feet or acres,:: 14: nti the tc bitat es that oc n,or are like] to be found on tiro ect site Check ail that a I fy typ h'p Y u J pp 9 Shoreline Forest riculturai/grasslands Early mid-successional Wetland Urban. Suburban S.Does the site of the proposed action contain any species'of.animal,or associated habitats;listed NO.: ES., by the State or Federal;government as threatened or endangered? I6:tithe projectsite.loeated in the T00 year flood pla�n� . " N YES:. 15.Will the proposed action create storm water discharge,either from point or non-po t sources :. `NO If Yes, a.Will storm water discharges flow to adjacent.properties? O:_. ES b.Will storm water discharges be directed to established conveyance systems f an drains)? If Yes,brieflydescribe . . I, ��►�10:. ES Page.2 of 4 18.Does the proposed action_include construction or other activities that result to the impoundment of NO YES water or other liquids(e.g.:retention pond;-wastes 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 Eq 20.I as the site of the proposed action or an adjoinm propeiiy been the subject of remediation(ongoing or NO YE..S complet6d).fbr.hazardous waste? If Yes,describe ,I AFFIRM THAT.THE INFORMATION.PROVIDED ABOVE IS TRUE AND ACCURATE TO THE:BEST OF MY..; KNOWLEDGEJA . - ApplicandsPo Date: Signatu Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all ofthe;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 reviewerahould be guided by 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? El El 2. . Will the proposed action result in a change inthe use or,intensity of use of land? 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed Action have an impact on the environmental characteristics that caused the. establishment of Critical Environmental Area(CEA)? a. 5. Will the roposed action result in an adverse change in the existing level of traffic or AMectexistinginfirastructure for mass transi biking or walkway? 6., Whi-the proposed action cause an increase in.the use.of.energy and it fails to incorporate reasonably.avai)able energy:conservation or renewable.energy.o ortunrties? � ❑ 7. Will the proposed action impact existing: a..public].private water supplies? - a ❑ b.public/.private.wastewater treatment utilities? .. . ❑ �. S. Will the proposed action impair the character or quality of important historic,archaeological, El architectural.or,aesthetic;resources?,. 9.: Will the proposed action result in an adverse change to natural resources(e.g.,wetlands; El waterbodies,groundwater,air quality,'flora,and fauna)? a Page 3 of 4 No,or Moderate small to large .impact = impact may may. . occur occur. l0. Will the proposed action result in an increase in the potential for erosion,flooding or drainage problems? El 11. Will the proposed " tal actioncreate a hazard to environmen resources or human health? ❑, Part 3-Determination ofsigriificance: The Lead Agency is responsible for the completion of Part-3. For every question An.Part that was'answered"moderateao large impact may occur",or.if there is a nee&to explain why a"particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part3.. Part 3 should,in sufficient detail,identify the impact,including any measures or des'ign.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.inipact 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 requited. 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 .�.,...-..mow.,;.;. Name of Lead Agency ,,.. 'bate President Priht or Type Name of Responsible.Officer'in Lead`Agency Trt1e of.Resp Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer). PRINT Page.4:of 4 of :Trustees Applicat!", 1 AFFIDAVIT,. BEING:DULY SWORN'. D OSES�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 PE'RMIT(S);IF GRANTED. IN COMPLETING THIS APPLICATION,I;HEREBY AUTHORIZE THE TRUSTEES THEIR.AGENT(S) OR REPRESENTATIVES,,,INCI:UDING.THE CONSERVATION ADVISORY COUNCIL;T.0 ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING.A.FINAL INSPECTION. I FURTHER AUTHORIZE THE:BOARD OF TRUSTEERTO ENTER ONTO MY PROPERTY AND AS REQUIRED.TO INSURE COMPLIANCEWITH ANY CONDITION OF ANY WETLAND`OR COASTAL. EROSION PERMIT ISSUED BY.THE BOARD OF TRUSTEES DURING.THE-TERM OF THE PERMIT. ar ignature Property: r Signature ofTroperty.Owner SWORN TO BEFORE MFTHIS . A9 `h DAY_OF 20^a CONNIE D.BUNCH Notary.PublicNotary.Public,State of New York No.01BU6185050 Qualified in Suffolk County Commission Expires April 14,2� Board 'of Trustees Appli.catzozx AFFIDAVIT V _1 �_i_..� ._ ._ I3EII�G.DYIG'�' SWORN: D,PO$ES,AND,' ' FIAIMS THAT RENT It IS TIIE,APPLICANT`FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL STATEIYIENTS CQNTAINEI) HEREIN' A R,E TRITE TO THE.BEST OF HIS/HER;,XN-OWLEDGE.AND BELIEF,,AND)THAT ALL VVO.IM,WILL BE.DONE:IN THE MAn111ER SET:FORTH IN:THIS APPLICATIONAND"AS MA BE APP'I20'VED.DY THE SOUrl1OLD TO.W`N 80A"OF`TRUSTEEK, THE APPLICANT:AGREES TO BOLD T TOWN OF SOU AND THE BOAT OF TItUS'I EES HARIVILES ATD'FREE—ROM ANY A3'!D:PERMAT.L TIAiY[AGES AND CLAIMS ARISING UNDER OR B VIR Y` TLFE OF SAID T(S},IF CR.ANTED. IN COMPLLETING"THIS APPEICAI`L ON,,I HEREBY AUTHOR.I7E TH TRUSTEES,THEIR AGENTS) OR`REPRESENTATIVES,INCLUDING THE' CONSERVATION ADVISORg COUNCIL,TO ENTER ONTO,MY'PROPERT TO INSPECT THE PREMISES"IN CONJUNCTION:'WITH:THIS=APPLICATION,, INCLUDING A FINAL INSPECTION; I FURTHER,AUTHORIZE THE.DDOARD'OF TRUSTEES:TO ENTER ONTO MY PROPERTY AND AS. REEQU=IRED TO INS RE: COMPLIANCE WITH.ANY CONDITION OF"ANY WETLAND OR COr TAL ExOStON RENT° ISSU'JI) Ii TIIE I3t)ARi3 CliF TRUSTEES D:URIN,G THE TERM OF THE-PERMIT: (231 Ua v L:W signature of opert� Owftr Signature o,lProperty Owner S WOR.�1 TO.BEIi QFZE ME'THIS 00 DAY-C) ` OVDbe.2 Nota6 pijbl e Ifl/MACOL.ATA PARRINO Notary Publ;<,Mate of New York No.(i 1 PA6182092 Qualil icd in Queens County Commission Expires February 19, 2924 `hoard of Trustees Applsca� ° -,,n AFFIDAVIT ( lv) AA LJ S �`t BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SITE 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 TER,'VI OF THE PERMIT. Si nature of Pr ertv Owner Sig to e of uperty Owner SWORN TO BEFORE ME THIS 3A , DAY OF �e�-��{' -- , 202.S -ct P_c�2,!/1 Notary Public HEATHER R.LANCI Notary Public,state of New York No.01LA6373692 Qualified In Nassau County Commission Expires April 16,20 !gyp Board of Trustee's A.pplica, n ti AFFIDAVIT RALIA POLECHRONIS CHRISTOPHER POLECHRONIS BEING'DULY SWORN? DEPOSES AND AFFIRMS THAT HEISHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT,(S),AND THAT ALL STATEMENTS GONTAINEWHEEREIN 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 ,AN!)AS MAY BE.APPROVED BY THE 8OUTHOLD TOWN BOARD-OF"TRUSTEES. THE APPLICANT AGREES.TO HOLD THE TOWN OF SOUTHOI D AND`T:HIE BOARD OF TRUSTEES HAR LESS'AND,FREE FROM ANY AND.ALL,DAMAGES AND CLAIMS ARISING UNDER OR,BY VIRTUE OF SAIYD 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'TH15 APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE,BOARD OF TRUSTEES TO ENTER.ONTO MY PROPERTY AND.AS REQUIRED:TO.INSURE COMPLIANCE WITII ANY CONDITION OY ANY WETLAND OR COASTAL- EROSION PERMIT ISSUED IIY TH`E'BOARD`OF TkUSTEE DURING THE TERM. OF THE PERMIT: Signature.o Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS 2N D DIY QF ,..2. 25 .. State of Florida County of St Lucie AC►3QJD Sworn to (or affirmed) and subscribed before me by Notary Public °Y means of_Physical Present, or X Online Notarization, AotoinedwRobinsan „ Notary Public-State of Horida + a Comm,Eitpirm 09-07-2028 this 2nd day of NOV, 2025 by RALIA POLECHRONIS Commission#HIB26405 - - Notarized Online mdthNotaryLive.rom CHRISTOPHER POLECHRONIS who provided identification of NY DL LA is Notarized by: ANTOINETTE ROBINSON Time: 2025-11-03 02:56:33 UTC URL: https://notarylive.com/tu/cdp/T7F7KT Access ID: T7F7KT %dew Pin: 59HK7J APPLICANT AGENT/REPRESENTATIVE. TRANSACTIONAL DISCLOSURE FI1RM h The'T o 50 1a' C E";i :. bi;. ., is o f.n ... .' lie f n o ce d em e , of this form is to provide information which can elehe fQwg of ne3sible conflicts of ra�ere -and allow it t;o ake wharerachq Is nececsary to avoid same:: te YOUR NAME (L,ast name,first nameviddle mifial,.unless you are applying to the name of someone else or other;entity;such as a company.If so,indicate the other .. petson'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 plaf or official map: planning ..Other • (if"Other•;:.name.the activity.), Dy llyn (or through you company,s mnor chidfiWM a sa0"' 'withyoffpu cer or employee ofthe'Town ofS'uthold? "Relationship"Includes by blood,marriage,or... ... . interest"Business mietesf'means a busErless, including a partnership,m which the town offrecroremployce hasieven a . rhal ownershi of or em to ent )a.co Pa P:. ( P yin by rporaGon in whkk thG:town officer or:employee owns more than 5%of t ' 'shares '.; YES' NO if,'you answered"YES",complete the balanc a ofthtsfoim and date•andsign where in -vied. . Name of person employed by the Town of Southold Titleor position of that'person Describe the relationship between yourself(the.apphca►t/agent/representatiye)and the town officer or employee.Either check• the appiopnate line A)through D)and/or describe in the space provided. .:: The town offreer or employee-or his or ki spouse,sibling,parent,of child`is(check alltliat apply): �A).*q owner of gn ater thaw S%:of the shaves of the corporate stock of the iipplicant:. (when the ap0,W%ht,is a corporation); B)the legal or lieneficial owner of arty interest in,a non-corporate entity(when the applicant is not'a corporation); _Q an officer,director,partner.or employee of the applicant,or D)the.actual applicant.' DESCRIPTION OF RELATIONSHIP Submitted this ay of. 20 Signature Print Nam a .4�DI�MM�S 'GLc ,J .. Form:TS'_I Town of'Southold LWRP CONSLSTENCY ASSESSMENT FORM A. INSTRUCTIONS 1: All applicants for emits* including Town:of.Southold ncies, shall coin lete this CCAF for. P � P . proposed actions:that.are subject to the Town of Southold VVater&ont`Consistency Review Law. This assessment _is intended' t0 supplement other: infOnnation used by a:Town of Southold agency in making a deterannation of consistency: *Except:mirwr exempt actions in ludmg Buildrng Permits. and other ministerial permits not located.within the.Coastal Erosion fitazard 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 actfon will be evaluated as to .its si can beneficial`and adverse effects;upon the coastal areaiwhch includes all of Southold Town) 3 If any question in Section C onabis form is answered "yes";or"no them the Pi+oposed action will affect the achievement of the:LWRP policy standards and conditions contained m the consistency review.law Thus, each answer.must e, exmained In detai4 hsfm$ both sunporhng and non: suoporfine facts If an action cannot be..certified as consistentwiththe VWRP 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# : - p PROJECT NAME Tile Application has been submitted.to(check appropriate response): Town Board ❑ Planning Board❑ Buildwg Dept. ❑ Board of Trustees 1 Category of Town of;Southold agency.action(check;appropriate response): (a) Action undertaken direcd by Town agency(e.g.capital.. ❑ constiuctton,:planning acttvitY,agency regulation,land Iransaction)` Financial assistance(e.g•grant,loan,subsidy) . (c) Pemut,:approval,license,certification Nature and extent of actin Location of action. :rgn�z2 �y */1., Site acreage • S Present land use: Present zoning classification: n_ 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, .. ro) Mailuig address. (c) Telephone number: Will the action be .`fly undertaken,require funding,or approval by a state.or federal agency? Yes No; If yes;which Mate or federal agenco. C. Evaluate the project to the following policies.by analyzing.how the project..Will further support or not support the policies. Provide all proposed Beat:Management Practices.that will.further each:pohcy. Incomplete answers.will require that.the form be returned for completion DEVELOPED COAST P:ULICY .Policy 1. Foster a pattern_of development in the Town of Southold that enhances'vommunity-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. l. Yes Ni Not Applicable - . Attach additionalsheeb if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See . LWRP Section III-Poli ' s Pages 3-through b,for evaluation criteria Q Yes l.h No Not Applicable 4. Attach additional sheets if,necessary Policy 3. Enhance visual quality and protect scenic resources.'throughout the Town of:Southold. See LWRP Section III--Polic es Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No Not Applicable 71 Attach ditional 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 P 8 through.16 for`evaluation,;criteria Yes ❑.:No ..:. . Not Applicable 7. _ y Attach additional shee d ec is n essary Policy 5: Protect and improve water equality and supply An the Town:of,Southold.See LWRP Section III —Policies Pages.16 tzotApplicable. 21 for-evaluation criteria Yes ❑ No . 777777777777 Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant.toastal Fish and Wildlife;l3abitats and wetlands. :See LWRP Section.III=Policies;Pages.22 through 32 for.evaluation riteria.; Yes o Not Applicable, Attach additional"sheets ifnecessary Policy`7. Protect and improve air quality in the Town of:Southold See LWRP Section III Policies Pages 32 through 34 for:evaluation criteria. YesNo Not Applicable_ 0: 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 PUBLIC.COAST POLICIES Policy 9.. Provide,for public access.to,and recreational use:of, coastal waters, public ands, and public resources.of the:Town of Southold. See.LWRP:Section III-Policies;Pages 38 through 46 for evaluation criteria. 0 Ye .J No Not Applicable arY Attach additional sheets if necess WORKING COAST POLIO Policy 10. Protect Southold's water-dependent uses and promote siting.of new water-dependent:uses in suitable locations. S.ee'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 wat rs. See MW Section III-Policies; Pages 57 through 62 for evaluation criteria: Q Yes :� No . Not Applicable . Attach additional'sheeis itnecessary Policy 12. Protect`.agricultural.lands:in the Town .of Southold. See LWRP Section III,-Policies; Pages 62 through 65 for:evalu hon criteria. . Yes ❑ No Not Applicable Attach additional she if necessary Policy 13. Promote appropriate. use and development of energy and mineral resources. See.LWRP: Section III—Policies; ges 65 through 68`for.evaluation criteria. Q . Yes ❑ 'No Not Applicable PREPARED BY �.i'y/Tr (�? ,�_ A"/,�L��f'�1S ;.. TITLE