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#8098-Mattituck Plaza (Walgreens) ZBA application
FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT SOUTHOLD,N.Y. NOTICE OF DISAPPROVAL DATE: July 11, 2025 RECENED TO: William C. Goggins (Mattituck Plaza LLQ JAN W 2026 PO Box 65 Mattituck, NY 11952 ��QQNG BOARD OF APPEAL-S Please take notice that your application received November 17,ST33' For permit to: Construct alterations to an existing storefront at: Location of property: 10095 Main Road Mattituck, NY Mattituck Plaza Wl Teens County Tax Map No. 1000— Section 142 Block 1 Lot 26 Is returned herewith and disapproved on the following grounds: The 12roposed construction alterations to an existin sho in center storefront on this conforming 8.65 acre lot in the General Business fB District is not pennitted pursuant to Article XI. Cho ter 280-4 A(2),[dl,which states: "Buildings containin a drive-through or drive-up window are prohibited. The drawin s show a proposed drive up,Dick up window and canopy on the harmac facade. Authorized Signature Note to Applicant: Any change or deviation to the above referenced application may require further review by the Southold Town Building Department. CC: file, Z.B.A. 9f Page 4—Use Variance Application,Revision Nov.2023 a API LICATION TO THE SOUTHOLD TOWN ZONING BOARD OF APPEALS USE VARIANCE Received House No. 10095 Street: Main Road Hamlet: Mattituck 2 2026 SCTM 1000 Section 142 Block 1 Lot(s) 26 Lot Size 8.7ac Zone B oni of Appeals I(WE)APPEAL THE WRITTEN DETERMINATION OF THE BUILDING INSPECTOR DATED Julv 11, 2025 BASED ON SURVEY/SITE PLAN DATED June 28, 2023 Applicant(s)/Owner(s): Mattituck Plaza, LLC Mailing Address: P.O. Box 1256, Mattituck, New York 11952 Telephone:631.298 818 _ Fax:631.298.4214 Email: gogginslaw@gmail.com NOTE:In addition to the above please complete below if application is signed by applicant's attorney,agent, architect,builder,contract vendee,etc.and name of person who agent represents: Name of Representative: William C. Go gins for�) Owner ( )Other: MailinAddress: g P.O. Box 65, Mattituck, New York 11952 , Telephone: 631,298.4818 Fax: 631.298.4214 Email:__Rogginslaw@gmail.co Please check to speck who you wish correspondence to be mailed to,from the above names: ( ) Applicant/Owner(s), k) Authorized Representative, ( ) Other Name/Address below: WHEREBY THE BUILDING INSPECTOR REVIEWED SURVEY/SITE PLAN DATED June 28 2023 and DENIED AN APPLICATION DATED 11/16/23 FOR: kX) Building Permit ( ) Certificate of Occupancy ( )Pre-Certificate of Occupancy ( ) Change of Use ( )Permit for As-Built Construction ( ) Other: Provision of the Zoning Ordinance Appealed. (Indicate Article,Section,Subsection of Zoning Ordinance by numbers.Do not quote the code.) Article: XI Section: 280-48A(2)(d) Subsection: A prior appeal (X) has, ( ) has not been made at any time with respect-to this pro eLty,UNDER AVP XXXXXXXXXXXX III ',See, below . (Please be sure to research before ' File Numbers•309, 29 ✓, 2576 2 3.SE, 1689, 28 , 12 1250, 6635 1715, 2530, i/ �� Page 5—Use Variance Application,Kevision Nov.2023 REASONS FOR USE VARIANCE: An applicant for a use variance MUST demonstrate unnecessary hardship by satisfying ALL of the following four tests: (Please consult your Attorney before completing, attach additional sheets as needed, and submit related docurnentatiorl4easked, 1. The applicant cannot realize a reasonable return, for each and every permitted use under AW11182026 regulations for the particular zone district where the property is located, as demonstrated by substantial and competent financial evidence because: The issue is not to increase r of Appeals realize a reasonable return. It is to dispense prescriptions "for residents in accordance with the Americans with Disabilities Act. 2. The alleged hardship relating to the property is unique and does not apply to the majority of parcels in the same zoning district or neighborhood because: it is a drug store serving the residents of Southold Town inclusive of handi—capped people living in our community. 3. The requested use variance, if granted,will not alter the essential character of the neighborhood because: the application merely provides access to a limited part of society, and will have a de minimus effect on the charactor of the neighborhood. 4. The alleged hardship has not been self-created because: the need is to give access to those who have difficulty ambulating, and the less fortunate among us with physical limitations. In addition to the above,standards the Board of Aopea.ls must also find that: 5. The requested relief is the minimum relief necessary to avoid unnecessary hardship, while at the same time preserving and protecting the character of neighborhood and the health, safety and welfare of the community because: the health, safety, and welfare of handi—capped people will he enhanced by easy access to prescription pick—up 6. The spirit of the ordinance will be observed, public safety and welfare will be secured, and substantial justice will be done because: all people should have equal access to services available in the community. By signing below, I certify all information is true and correct to the best of my knowledge„ Signature of Applicant or Authorized Agent (Agent must submit written Authorization from Owner) William C. Goggins Print Name Sworn to before me this day of •� ,20 71t� otary Public) BRIAN A. ANDREWS Notary Public, State Of New York No. 02AN5014509 Quakfied In Suffolk County Commission Expires 07/15/ k1 Page 6—Use Variance Application, Kevision Nov.2023 Zoning Board of Appeals APPLICANT'S PROJECT DESCRIPTIONReceived APPLICANT: Mattituck Plaza LLC SCTM No. JAW FITUM 1. For Demolition of Existing Building Areas Please describe areas being removed:_ _N/A Zoning Board of Appeals II.New Construction Areas (New Dwelling or New Additions/Extensions): Dimensions of first floor extension: KIA Dimensions of new second floor: Dimensions of floor above second level: Height(from existing natural grade): Is basement or lowest floor area being constructed?If yes, please provide height(above ground)measured from natural existing grade to first floor: HI. Proposed Construction Description (Alterations or Structural Changes) (Attach extra sheet if necessary). Please describe building areas: Number of Floors and General Characteristics BEFORE Alterations: one Number of Floors and Changes WITH Alterations: one IV. Calculations of building areas and lot coverage,GFA,sky plane(From Surveyor,Design Professional): Existing square footage of buildings on your property: _ $ 000 s . f . Proposed increase of building coverage: no increase Square footage of your lot: 8.7 _acres Percentage of coverage of your lot by building area(lot coverage) N/A no change. _ Gross Floor AreaGFAI of single family dwelling including the attached garage and/or habitable detached accessory structure: (Please refer to Chapter 280,Section 280-207 of the Town Code): N/A For Residential lots, is project within the allowable Sky Plane? (Please refer to Chapter 280, Section 280- 208 of the Town Code): N/A V.Purpose of New Construction: Install 53.5"by 40"bi—parting window with canopy. VI.Please describe the land contours (flat,slope %, heavily wooded, marsh area,etc.) on your land and how it relates to the difficulty in meeting the code requirement(s): Describe on separate page if needed: Please submit 8 sets of photos,labeled to show different angles of yard areas after staking corners for new construction,and photos of building area to be altered with yard view. 11/2023 Page 7—Use Variance Application,&evision Nov.2023 QUESTIONNAIRE ��C�IV� FOR FILING WITH YOUR ZBA APPLICATION A. Is the subject premises currently listed on the real estate market for sale? JAN 12 2026 Yes XX No Appeals Zoning Board of B. Are there any proposals to change or alter land contours? XX No XX Yes,please explain on separate sheet. C. 1.)Are there areas that contain sand or wetland grasses? No 2.)Are those areas shown on the survey submitted with this application? 3.)Is the property bulk headed between the wetlands area and the upland building area? 4.) If your property contains wetlands or pond areas, have you contacted the Office of the BOARD OF TRUSTEES for its determination of jurisdiction? No Please confirm ftatus of your inquiry or application with the Board of Trustees; If issued, please attach copies of your permit listing conditions of approval with a copy of the approved survey. D. Is there a depression or sloping elevation near the area of proposed construction at or below five feet above mean sea level? No E. Are there any patios, concrete barriers,bulkheads or fences that exist that are not shown on the survey that you are submitting? No If any of the aforementioned items exist on your property,please show them on a site plan. F. Are there any construction projects currently in process on your property? No If yes, please submit a copy of your building permit and survey as approved by the Building Department and please describe scope of work: G. Please attach all pre-certificates of occupancy and certificates of occupancy for the subject premises. If none exist,please apply to the Building Department to obtain them or to obtain an Amended Notice of Disapproval. H. Do you or any co-owner also own other land adjoining or close to this parcel? No If yes, please label the proximity of your lands on your survey and identify the Suffolk County Tax Map No. I. Please list present use or operations conducted at your property, and/or the proposed use retail J. (examples:existing single family,proposed:same with garage,pool or other) September 2, 2-25 Authorized signature Date � F � TOWN OF SOUTHOLD—BUILDING DEPARTMENT Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959 " Telephone (631) 765-1802 Fax (631) 765-9502 hLtp ://www. outliol townn . o ecoived Date Received t APPLICATION FOR BUILDING PERM�IT JAN 12 2026� 1 Ziralp ,®ard� f appeals For Office Use Only "' 4 PERMIT NO. Building Inspector. AON Applications and forms must be filled out in their entirety. Incomplete applications will not be accepted. Where the Applicant is not the owner,an Owner's Authorization form(Page 2)shall be completed. Date:November 16, 2023 OWNER(S)OF PROPERTY: Name:Mattituck Plaza, LLC SCTM# i000-42-1-26 Project Address:10095 Main Road, Mattituck, New York 11952 Phone#:631.298.4818 Email gginslaw@gmail.com Mailing Address:P.O. Box 65, Mattituck, New York. 11952 CONTACT PERSON: Name:William C. Goggins Mailing Address:P.O. Box 65, Mattituck, New York 11952 Phone#:631,298.4818 Email:gogginslaw@gmail.com DESIGN PROFESSIONAL INFORMATION: Name: Mailing Address: Phone#: Email:. CONTRACTOR INFORMATION: Name: Mailing Address: Phone#: Email DESCRIPTION OF PROPOSED CONSTRUCTION ❑New Structure ❑Addition RAlteration ❑Repair ❑Demolition Estimated Cost of Project ❑Other $ Will the lot be re-graded? ❑Yes ONo Will excess fill be removed from premises? ❑Yes ®No 1 T PROPERTY INFORMATION Existing use of property:cOmmercial Intended use of property:COmmercial Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to Business this property? ❑Yes RNo IF YES,jWj!Rr7@ZPPY. ❑ Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and to water issslyMS p � Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Buil At pursuant to th uiiding Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law. William C. Goggins Application Submitted By(prime : WAuthoriZed Agent ❑Owner Signature of Applicant: Date: November 17, 2023 STATE OF NEW YORK) SS: COUNTY OF SUFFOLK William C. Goggins being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, Attorney/Agent (S)he is the (Contractor,Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief;and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this 16th November 23 day of 120 Notary Public PROPERTY OWNER AUTHORIZATION R M.NWER �Pul�il , (Where the applicant is not the owner) o ojpAW0718 w �iii�cl i 5�� Alan A. Cardinale Cutchogue, New York commission Expims ba,� I, residing at William C. Goggins do hereby authorize to apply on my behal to the Town of Southold Building Department for approval as described herein. November 16, 2023 Owner's Signature Date Alan A. Cardinale Print Owner's Name 2 "oor off`Appeals � MSouthold TownReceived, MAIN ROAD- STATE ROAD 25 S❑LJTH❑LD, L.I., N.Y. 11971 TEL JAN 1 RECEIVED AND FILED BY ACTION OF THE ZONING BOARD OF A P", SOUTi30LD TOWN caftning Board of Hppeaks Appeal No. 3029 DAM/;1/111,�J HOUR 3',56 Application Dated August 26, 1982 TO: Abigail A. Wickham, Esq. for NORTH FORK 'BNK & �� Main Road, Box 1424 own Clerk, n�weo ou Mattituck, NY 11952 At a Meeting of the Zoning Board of Appeals held on NOVemmber 18, 1.982 the above appeal was considered, and the action indicated below was taken on your [ ] Request for Variance Due to Lack of Access to Property New York Town Law, Section 280-a [ ] Request for Special Exception under the Zoning Ordinance Article , Section [�{ ] Request for Variance to the Zoning Ordinance Article VII , Section 100-71 [ ] Request for The public hearing on this application was held on October 21, 1982. Upon application for NORTH FORK BANK AND TRUST COMPANY, by Wickham, Wickham & Bressler, P.C. , Main Road, Mattituck, NY for a Variance to the Zoning Ordinance, Article VII, Section 100-71 for permission to construct drive-in banking facility with canopy extending into the frontyard area at the Mattituck Shopping Center, North Side of Route 25, Mattituck, NY; bounded north by Bethany Cemetery Association; west by Factory Avenue; south by Ardprop Inc. and Main Rd. ; east by New Bethany Cemetery; County Tax Map Parcel No. 1000-142-1-26. The board made the following findings and determination: By this application, appellant seeks permission to construct a 27-foot canopy attached to a proposed drive-in banking facility at the old Grants Building in the Mattituck Shopping Center. Appellant states that the 27-foot extension will not be a solid structure, but rather a "floating canopy" and is needed to protect the customers during bad weather when transacting business. Appellant proposes a reduction in landscaping necessary for the two-lane 12-car stacking area to avoid traffic problems and a proposed new curb cut for bank-customer egress at the southeasterly corner of the premises. Ingress is proposed at the proposed new curb cut for deliveries into the loading area of the old Grants Building only. In considering this appeal, the board determines that the variance request is not substantial; that the circumstances are unique; that by allowing the variance no substantial detriment to adjoining properties will be created; that the difficulty cannot be obviated by a method feasible to appellant other than a variance; that the relief requested will be in harmony with and promote the general purposes of zoning; and in view of the manner in which the difficulty arose and in consideration Of all the above factors, the interest of justice will be served by allowing the variance. On motion by Mr. Sawicki, seconded by Mr. Doyen, it was RESOLVED, that the relief requested in Appeal No. 3029, applica- tion for NORTH FORK BANK & TRUST COMPANY for permission to construct floating canopy extension from the proposed banking facility with a setback from the front property line at 14 feet, as shown on the site plan revised October 29, 1982, be and hereby IS APPROVED SUBJECT TO THE FOLLOWING;. - (CONTINUED ON PAGE TWO) DATED: December 13, 1982. CHAIRMAN, SOUTHOLD TOWN ZONING BOARD OF APPEALS Form ZB4 (rev. 12/81) Page 2 - Appeal No. 3029 Matter of NORTH FORK BANK & TRUST CO. P+ ,� Decision Rendered November 18, 1982' Received 1. Review by the Suffolk County Planning Commission pursuant to JAN 12 2026 Sections 1323, et seq. of the Suffolk County Charter; 2. Approval by the Southold Town Planning of the site plan. Zoning Board of Appeals Vote of the Board: Ayes: Messrs. Goehringer, Doyen, Douglass and Sawicki. (Member Grigonis was absent.) This resolution was unanimously adopted. APPROVED ChalrMan Board hl Ajgl"alb TOWN OF SOUTHOLD,NEW YORH DATE ,J4n94]:Y„?, 1969 ACTION OF THE ZONING BOARD OF APPEALS Appeal No. 1226 ' Dated December 12, 1968 ACTION OF THE ZONING BOARD OF APPEALS OR THE TOWN OF SOUTHOLD ReCeIV" ' To Cassella Builders, Inc. - "°` Appellant 504 Walt -Whitman Road JAN 12 2026 ......__]U=t1R9t9A 6tation, at a meeting of the Zoning Board of Appeals on January 2, 1969 the appeal ,Zoning Board Of Appeals was considere&and the action indicated below was takt)n on'your Request for'variance due to lack of access to-property ( ) Request for a special Axception under the Zoning Ordinance $}Q Request for a variance to the Zoning Ordinance - - AA a 4 ) 1. SPECIAL EXCEPTION. By resolution of the Board it was determined that a special exception ( ) be granted ( ) be denied pursuant to Article .__............... Section ,,,.•............... 8trbsection paragraph ............... of the Zoning Ordinance, and the decision of the Building Inspector ( ) be reversed ( ) be confirmed because 8:G0 P,M. (E.S.T.), -upon -application offl M.T. Caesella Builders, Inc., 504 Walt Whitman Road, Huntington Station, New York, for a variance in accordance with the Zoning Ordinance, Article IV, Section 440-6 as it, applies to Article IV, Section 400-1. for reduction in- landscape area-and increase -in -parking area for proposed Mattit-uck Shopping Center-.D-Location of property: north ed-st corner--of Factory Avenue and Route 25 (Main-•Road), Mattituck, New( York, boxiinded north by Bethany Cemetery Assoc., east by Bethany Cemetery Assoc., south by Main Road, west by Factory Avenue. 2. VARIANCE.By resolution of the Board it was determined that (a) Strict application of the Ordinance (would) (would not) produce practical difficulties or unnecessary hardship because SEE REVERSE (b) The hardship created (is) (is not) unique and (would) (would not) be shared by all properties alike in the immediate vicinity of this property and in the same use district because SEE REVERSE (c) The variance (does) (does not) observe the spirit of the Ordinance and (would) (would not) change the character of the district because SEE REVERSE and therefore, it was further determined that the requested variance ( ) be granted ( ) be denied and that the previous decisions of the Building Inspector ( ) be confirmed ( ) be reversed, APPEPi1VED \v y969 V NING BOARD or AF"I7I14,I FORM ZB4 ih l sett N viile, Secretary After investigation end inspection the Board finds that the applicant requests a reduction in landscaped area and increase in parking area for proposed Mattituck shopping Center, in accordance 's with the Zoning Ordinance, Article IV, Section 440-6 as_ it applies Received to Article IV, Section 400-1. The Board finds that the -present parking layout of the proposed shopping centiter may be obselete due to the present population, growth, and summer tourists. The Shopping JAN 12 2026 Center layout will presently accomodate 387 cars as required by the Town Ordinance. I£ the Ordinance can be amended by the Board applicantZoning Board of Appeals seek to gain 150 to 250 additional parking spaces. Therefore alleviating any possibility of inadequate parking, and avoiding any congested parking on the public streets. A perimeter reduction of 40 ft. sn the northerly property line. The Board finds that strict application of the Ordinance will produce practical difficulties or unnecessary hardship; the hardship created is unique and would not be shared by all properties alike in the immediate vicinity of this property and in the same use district; and the variance does observe the spirit of the Ordinance and will not change_ the character qf. the, cistrict. Therefore-a it was RESOLVED that Caseella Builders, : c,, 504 Walt Whitman Road,--Hu tington Station,, New. Fork,, .be GRANTED a.... reduction in landscape area-and increase- In parking ,area as applied for on -property located on north east corner of Factory Avenue & Route 25 (MaiR Road), Matt-.tuck, New, York. - ) From: 'Toth,Vicki"<vlcki.toth®town.southold.ny.us>6? Subject: matt plaza Date: February 7,2013 3:24:15 PM EST To: <williamgoggins@yahoo.com> miv hmenl,38 KB JAN 12' � «156fi1-Z.pdb> Zoning Board of Appeals FORM NO.4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold,N.Y. Certificate Of Occupancy No.. VA119........ Date ., October 1, 1967 THIS CERTIFIES that the building ....R.4S a P..21 C 4F e................ «.....,. LoatianofProperty Rt. '2S & Factory Ave. Itattitucl: m»„ moor No County Tax Map No.1000 Section ....!A?.....Block ..o!...........Lot...26........... Subdivislon.Store.6.19...................Filed Map No. ........Lot No. ............. conforms substantially to the Application for Building Permit heretofore filed in this office dated San. 29, 198....., pursuant to which Building Permit Ne. .,,i.... 1 .,......._.. dam . Feb: 3 t. 9 8 7........... . was Issued,and conforms to all of the requirements of the applicable provisions of the law.The occupancy for which this certificate is issued is ......... RETAIL DRDG STORE--GBNOVBSE DRUGS, INC. ...i ....................«..... .............,«.... The certificate is issued to .,GENOVESE DRUG STORES, INC. fl�tt .tanant! µA. CARDINALE-owner of the aforesaid building. Suffolk County Department of Health Approval ..... N{A................................„ UNDERWRITERS CERTIFICATE NO............. N79609b March 12, 1967„ „.... PLUMBERS CERTIFICATION DATED: N/A Buildinpeot� r<",tnt RECEIVED FEB.2 8 2013 BOARD OF APPEALS Received From: "Toth,Vicki"<vicki.toth@town.southold.ny.us>Lf Subject: matt plaza JAN 12 202 Date: February 7,2013 3:26:38 PM EST To: <wllliamgoggins®yahoo.com> Zoning <<12073-Z.pdb> FORM NO.a TOWN OF SOUTHOLD BUILDING DEPARTMENT office of the Building Inspector Town Hail Southold,N.Y. Certificate OF Occupancy No.. 1.Zg 4......... Date ......July.33................ ..190. THIS CERTIFIES that the building ...,..,»....................1...»M.,.» �. ....... 10g05 State Road 25 Diattituck Location of Property i t 66..................... sn it Har+eisi 06 County Tex Map No.1000 Section ...,14?.....Block .. ...........Lot.....`.........»» Subdivision...x..........................Filed Map No. X Lot No. .I.......... conforms substantially to the Application for Building Permit heretofore fried in this office dated pe c gmb er 6,,,,,.,19 82.pursuant to which Building Perrnit No. 120T 3, Z....,..,..., dated ,,.pppArl"r,_15............1952.,was issued,and conforms to ail of the requirements of the applicable provisions of the law.The occupancy for which this certificate is issued is......... a drive—up banking facility for North Fork Bank.A Trust Co: The certificate is issued to .....NORTH FORK••. .••BANK b TRUST CO. foie iicM:e:riiwnt% of the aforesaid building. Suffolk County Department of Health Approval AMA 20A......................,, UNDERWRrMS CERTIFICATE NO......... N.6 0.4.0.8 0......... .....„.„..,,, .,. Building Inspector Rw.r/a1 RE EI1?E FEB S 8 2013 BOARD OF APPEALS Received From: "Toth,Vicki"<vcki.toth@town.southoid.ny.us>B JAN 12 2026 Subject: matt plaza Date: February 7,2013 3:20:07 PM EST Zoning Board of Appeals To: <wi1liamgoggins0yahoo.com> 1 Attachment,38 KB «21068-Z.pdb> FORK NO. 4 Tom OF SOUTHOLD BUILDING DEPARTlBM Office of the Building Inspector Town Nall ry' Southold, H.Y. CERTIFICATE OF OCCUPANCY No Z-22178 Uatg„ THIS CERTIFIER that the building ALTERATION Location of Property House No. 1 2 House No. AMTZTITUCUC H. Street Hamlet County Tax bap No. 1000 Section 142 Block 1 Lot 26 Subdivision Filed Hap No. lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated 29 993 rsuant to which Building Permit No. Z1068-Z dated b 1g2 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancY for which this certificate is issued is CxM811MUC2i FULL SERVICE BANK tM -THRU �•ST SBO The certificate is issued to A- temrmer} of the aforesaid building. SUFFOLK COUNTY DEPARTlR= OF HEALTH PPROYAL A UNDERWRITERS CERTIFICATE NO. RY 25 1993 pLMMERS CERTIFICATION DATBG3 �1J Building neptr RECEIVED Rev. 1/81 FEB.2 8 2013 BOARD OF APPEALS Page 8—Use Variance Application,?tevision Nov.2023 AGRICULTURAL DATA STATEMENT ZONING BOARD OF APPEALS TOWN OF SOUTHOLD Received g WHEN TO USE THIS FORM: Thisform must be completed y the applicantfor any spe t, p permit site plan approval, use variance area variance or subdivision approval onproperty1 fill Zoz� 1 p PP PP an agricultural district OR within 500feet of a,farm operation located in an agricultural dis gic"d of Appeals All applications requiring an agricultural data statement must be referred to the Sli �t un,y, Department of Planning in accordance with Section 239m and 239n of the General Municipal Law. 1. Name of Applicant: Mattituck Plaza. LLC 2. Address of Applicant: 10095 Main Road Mattituck New York 11952 3. Name of Land Owner(if other than Applicant): 4, Address of Land Owner: 10095 Main Road, Mattituck, New York 11952 5,, Description of Proposed Project: Handica Prescri tion Deliver Access 6. Location of Property: (Road and Tax map Number) same as above 1000-142.00-01.00-025.000 7. Is the parcel within 500 feet of a farm operation? { } Yes {X } No 8. Is this parcel actively farmed? { } Yes {X} No 9. Name and addresses of any owner(s) of land within the agricultural district containing active farm operations. Suffolk County Tax Lot numbers will be provided to you by the Zoning Board Staff, it is your responsibility to obtain the current names and mailing addresses from the Town Assessor's Office (765-1937) or from the Real Property Tax Office located in Riverhead. NAME and ADDRESS 1. N/A 2. �. 4. 5. 6. (Please use the back of this page if there are additional property owners) 09 / 02 / 2025 Signature of Applicant Date Note: 1. The local Board will solicit comments from the owners of land identified above in order to consider the effect of the proposed action on their farm operation. Solicitations will be made by supplying a copy of this statement. 2. Comments returned to the local Board will be taken into consideration as part as the overall review of this application. 3. Copies of the completed Agricultural Data Statement shall be sent by applicant to the property owners identified above. The cost for mailing shall be paid by the Applicant at the time the application is submitted for review. Received JAN 1.2 2026 Board of Zoning A _eala A lieafia Zoning Board of Appeals AUTHORIZATION (Where the Applicant is not the Owner) I, Mattituck Plaza, LLC residing at p 0 Box 1996 (Print property owner's name) (Mailing Address) Mattituc, New York 11952 do hereby authorize William C. Goggins (Agent) to apply for variance(s)on my behalf from the Southold Zoning Board of Appeals. Z wner's Signature) Alan Cardinale (Print Owner's Name) Page 11 —Use Variance Application,Revision Nov.2023 AGENT/REPRESENTATIVE ReceIVE)d TRANSACTIONAL DISCLOSURE FORM JAN12 .202b The Town of Southold�'s Code of Ethics prohibits conflicts of interest on the part of town officers and empi The Purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whalever a necessary to avoid same. zoning YOUR NAME : Goggins, William C. (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.) TYPE OF APPLICATION: (Check all that apply) Tax grievance Building Permit Variance X Trustee Permit Change ofZone Coastal Erosion Approval of Plat Mooring Other(activity) Planning 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 X 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 that 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) Q an officer,director,partner,or employee of the applicant;or D)the actual applicant DESCRIPTION OF RELATIONSHIP Submitted this Zhuday ofS�embei b 2025 Signature V/ Print Name William C. Goggins APPLICANT/OWNER Feceive TRANSACTIONAL DISCLOSURE FORM GI JAN 122026 hi icts oft torMt 913 The 12111 of..tgw—q oftga Mnd eMDloyjM'Tbc gurligAl or e n o whir o f on t ail and ,allow it t w peals Sams, Zoning e YOURNAME: Alan Cardinale (Last name,first name,middle initial,unless you are applying in the name of someone else or other eatity,such as■ company.if so,indicate the other person's or company's name.) TYPE OF APPLICATION:(Check all that apply) Tax grievance Building Permit Variance X Trustee Permit Change of Zone Coastal Erosion Approval of Plat Mooring Other(activity) Planning 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 x 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 applicantiagent/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 that 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 2nd dayofSeptember 25 Signature Print Name Alan Cardinale ceived Town of Southold Re LWRP CONSISTENCY ASSESSMENT FORM JAN 2026 A. INSTRUCTIONS honing goarci o§ ApPeals 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", then the proposed action may affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, the action should be analyzed in more detail and, if necessary, modified prior to making a determination that it is consistent to the maximum extent practicable with the LWRP policy standards and conditions. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shallLiot 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# 142 - 1 - 26 The Application has been submitted to (check appropriate response): Town Board 11 Planning Dept. D Building Dept. W Board of Trustees El 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) r (b) Financial assistance (e.g. grant,loan, subsidy) (c) Permit, approval,license, certification: 3H Nature and extent of action: Install Handica Prescri tion Deliv:r Access Location of action: IQQ25 Main Mattituck, New k ReQe1�� Site acreage: 8.7 acres 2026 Present land use: Commercial og ,appeals Present zoning classification: Business District 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: Mattituck Plaza, LLC (b) Mailing address: P.O. Box 1256 Mattituck, New York 11952 (c) Telephone number:Area Code O 631-298-4200 (d) Application number,if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes El No 0 If yes,which state or federal agency? 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 LVVR.P Section III—Policies; Page 2 for evaluation criteria. Yes No © Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria ❑ Yes © No ❑ Not Applicable Attach additional sheets if necessary • Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria Q Yes © No Not Applicable Fleceived .( `b a4 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 G No ® Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria Yes E' No ®Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. i Yes [E No© Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See L III — Policies Pages 32 through 34 for evaluation criteria. AW6 ❑� Yes R No3M Not Applicable JAN 1.2 Zoning Board of ApPeRls 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. El Yes ❑ No 9 Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ YesO No Pi Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III—Policies; Pages 47 through 56 for evaluation criteria. D Yes 0 No ka Not Applicable ..................... rl Attach additional sheets if necessary and f ��f,: Ma&. Policy 11. Promote sustainable use of living marine resources in Long l 191 %%uncP tie Pecon c Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. El Yes ❑ No iii Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ No La Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. Yes ❑ No Not Applicable Created on 5125105 II:20 AM AN \` °\ \ \j \\ \= - Y \\\ \ \ I ,\ al \ i - u CD a � Ml 10� ems , ) . � t � _ � ' ! T _��, ��-_ � � � . . �. ° :§ ~ ��_�y -��: . : - ...: y d ��—». .: ���:�a�y�v�������«��d�����\�����a�%vim \ . . ° < w � �� a���������:���6��«. . . . � ...�««» . < .< , � . ti ��, SCTM # - - �QQO� TOWN OF SOUTHO101 PROPERTY RECORD CARD Ot NtR STREET ��Q� VILLAGE DIST. SUB. LOT - (�+, a S 1�jatt�fitter - ACR. g .� REMARKS TYPE OF BLD. 4 33 n 11 t (fission �rA PROP. CLASS AND IA TOTAL DATE �, c Q) Z o ea ' n- P - ,CAR# 37a GEZv 1p13 - z FRONTAGE ON WATER HOUSE/LOT - _ - E i BULKHEAD TOTAL 3 �( TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER STREET VILLAGE DIST. SUB. LOT ai n _ ACR. REMARKS 15 TYPE OF BLD. ) � � PROP_��ASS oZ�a T Aftif) or •on r - - LAND IMP, .E TOTAL DATE a ! s B P- k a�1�30 mi nor_ ' lce� rn h 3 3)o) 4 UrL.lN Ska B z Z 0,1 l -ia o a Shac k sure 6 i .RA 3PS54 i n slue- • � W FRONTAGE ON WATER TILLABLE FRONTAGE ON ROAD WOODLAND DEPTH MEADOWLAND BULKHEAD HOUSE/LOT TOTAL - k r � v TOWN OF SOUTHOLD PI(OPERTI' RECORD CARD -STREET ! VILLAGE - DIST. SUB. LOT FOAMEA OWNER - N E S w TYPE OF BUILDING I ! l{./p/ Ott , JL. 8 l.Lft"! RES. SEAS. VL. - FARM COMM. - ND IMP. TOTAL DATE REMARKS// & 7 - . - /' C' rw l / # =k '� T �a�,°..' i.•:.;n: (. to / .' �`' �' pl�C Q'� �l! �, ' -_ m . a N h rho y JI �5 j({1�o #mac -- ilo la!� ek e� �y�, /lV -r Sid �.3 Sf i3 - a 65_ It - � =-coyon let - 7 ,1 10 ( / • , G? (4 Weed TILLABLE TAGE , ROAD O LAND - - c/ .:ice Fr M W N .- . .c E £ - SA Ht 1 OT -Co oa P- l,1 b P L n I . 0, N r*' .'; �r.� " 10,000 WF-20 . 3P o�(c 'Cn ri 5+o" • Wn, L - - �_ . . .. a i 7-7 77 3 COLOR AF- I s TRIM - c M. Bldg. �e i Foundation Bath Dinette' 171 'Aderal /� �V :.- ✓�1 Sa ; n "1" . ? Basement Floors K. Ext. Walls Interior Finish LR. E z 3 ;2 .4 o�rsp Fire Place Heat DR. ,, . Z. Type Roof Rooms i st Floor BR. Porch Recreation Room Rooms 2nd Floor FIN. B. Porch Dormer - - ------------- - Breezeway Driveway q Garage / $ Patio 0: B. 1/L 7,4 - Total - _ -- • _ io UAMUNw— `STREET VILLAGE DIST. -FHB:- LOT va RMER OWNERN ,� y/ j� E� ACR. DD . a S W TYPE OF BO ILDfN t° KZ14Q . # �. t�Jog cioR vE - �/PDP�Pa�' 4 Z. r y S. S. 0 VL. FARM CO CB. gMISC. Mkt. Value Q D cclM G TOTAL DATE REMARKS 3 '�� / 3 0o v Q 11,M - 0�. f -� I DlT N � � �'0 $ �` r= - .7Ar� � r'e .16109 er Va ue d creZ,7 - �' A-�&�-- FZW 2 Noodland 37!o Q y a e-,p t' V �- A iwamplarid FRONTAGE Ot irushfand . S RONTAGE ON ROAD _ a -louse Plot - DEPTH : ' - �- BULKHEAD , 'otal DOCK g r , s TOWN -OF SOUTHOLD* PROPERTY RECORD CARD S•t EET - VILLAGE- DIST. _ SUB. LOT 11A Qp , 0 N E AC .-2- - S W TYPE OF BUILDING Jd eill WZ SFAS. VL. FARM COMM. CB. MILS. Mkt, Value C x 7- 1J.-,: ,WD , IMP TOTAL DATE REMARKS - �•Y' S'/ 74 4 7 God 3 �.7d D /tl1F 9.3 C.,. /LJ Lltka1Aa/C. 8 6 ' 2 .S�i dJ / �'/ 7 9 C'd G r e,? o�r �` I -17S,rI Z Q;7 31, 5 l : 3�G _Aj /G/SAD L A, 9ta `C .,. .'. � .��a3 ,7•��� �, ,��' �,-'�•, z-/xn , ,., ��1� 7 .P, p r� � z a,�o� ..5"�rf � �''`. �C ` �'-'� '; f OYGs � .� ; o , 5/- 7 6-0 3� o- v r'o .3 o-p �3a Y c ° °/ '• 9 j �J.� 'm + ) �g �+ J {' 1 yam•/� L .rP ��•a � Ld ._ t ilJ/ [1�`�4'GL if �•���l ^Jf _ �1', WSJ�t 7� e ��, Q Ef} `� N=�s• La Sfsi,•� l�lPSr'S/ r 1 d' AU�� .Ca�vrrf Sorted 1-Pcfaarnn/. C. / i 'illobla , s - 4f '� fj /o o-o-d w ti� 1t I Voodla»d �/ louse Plod _ � . a r � —o d 'Owl U jl#.;87 AW 1646 ., C ..i C�{) .:'12`i`.. n . i7 h,}s• V P t. xt .. :•� 47, COLOR � � TRIM Q ..� o - - e _ - - .� cc o +1 44.—� —7—————————— ° y E _ M. Bldg I Extension 1-7-44T Extension _ ! n( y S Extension :�74 foundation-. v- Bath y S Dinette Porch Basement � Floors �L� K. 5wh ,• ; '.' Ext. Wells i Interior Finish LR. i s r S a Fire Place Heat DR. e Gara / - - 9 i Type Roof Rooms I st Floor BR, Patio Recreation Room Rooms 2nd Floor - FIN. B O. B. Dok{ner Driveway - Total .. ( �P s COLOR TRIM t U 0 Bldg. q sox 7 Extension Extension N q Extension R x /a /a-�1 n` Foundation S L'-' 6 Si Dinette Porch Basement Floors y Q 4n` Ext. Walls l Interior Finish LR, Breezeway Heat b f /t t 3 O ,A �..� s'<a yPe Roof Rooms 1st Floor BR. z c q'.3 - - - - > 2 G S Recreation Room Rooms 2nd Floor FIN. B� 'at:3s �� U° � �_. l 5p ormer Driveway r Total I �l y i/ �'o . .7 F° —r/' j�.l a fx :s — t { 1 a s ,s s F 6' z f 142.1-26 3/08 M. B Id f Extension :. - � L ; S'5 a 1 s Extension L. 3 It e, - _ a - a. qaa Foundation Both. Dinette 4 Basement ` - Floors Porch o Ext. Walls Interior Finish LR. 3reezewayc'3?x ': 8 Fire Place. - Heat DR. act D type Roof Rooms 1st Floor BR. >otio Recreation. Room Rooms 2hd Floor FIN. B ; I B. Dormer Driveway Total a An official website of New York State. - Here's how you know NEW YT ATE y( De aartment of State Division of Corporations EntityInformation --Received Return to Re sults Return to Search A1H1^N 12 2026 Zoning Entity Details Board of Appeals ENTITY NAME:MATTITUCK PLAZA LLC DOS ID:2751294 FOREIGN LEGAL NAME: FICTITIOUS NAME: ENTITY TYPE:DOMESTIC LIMITED LIABILITY COMPANY DURATION DATE/LATEST DATE OF DISSOLUTION: SECTIONOF LAW:203 LLC-LIMITED LIABILITY COMPANY LAW ENTITY STATUS:ACTIVE DATE OF INITIAL DOS FILING:04/04/2002 REASON FOR STATUS: EFFECTIVE DATE INITIAL FILING:05/01/2002 INACTIVE DATE: FOREIGN FORMATION DATE: STATEMENT STATUS:PAST DUE COUNTY:SUFFOLK NEXT STATEMENT DUE DATE:04/30/2022 JURISDICTION:NEW YORK,UNITED STATES NFP CATEGORY: ENTITY DISPLAY Service of Process on the Secretary of State as Agent The Post Office address to which the Secretary of State shall mail a copy of any process against the corporation served upon the Secretary of State by personal delivery: Name: MATTITUCK PLAZA LLC Address: 10095 MAIN ROAD,UNIT#4,MATTITUCK,NY,UNITED STATES,11952 Electronic Service of Process on the Secretary of State as agent:Not Permitted Chief Executive Officer's Name and Address Name: Address: Principal Executive Office Address Address: Registered Agent Name and Address Name: Address: Entity Primary Location Name and Address Name: Address: 617.20 Appendix A FlecE)Ne State Environmental Quality Review FULL ENV I RON M ENTA L ASSESSM ENT FORM JAN 12 �026 A eals Purpose: The full EAF is designed to help applicants and agencies determine, in an orderly manner, 7b�ingr p9K0cpbr aeon may be significant. The question of whether an action may be significant is not always easy to answer. Frequently, there are aspects of a project that are subjective or unmeasurable. it is also understood that those who determine significance may have little or no formal knowledge of the environment or may not be technically expert in environmental analysis. In addition, many who have knowledge in one particular area may not be aware of the broader concerns affecting the question of significance. The full EAF is intended to provide a method whereby applicants and agencies can be assured that the determination process has been orderly, comprehensive in nature, yet flexible enough to allow introduction of information to fit a project or action. Full EAF Components: The full EAF is comprised of three parts: Part 1 : Provides objective data and information about a given project and its site. By identifying basic project data, it assists a reviewer in the analysis that takes place in Parts 2 and 3. Part 2: Focuses on identifying the range of possible impacts that may occur from a project or action. It provides guidance as to whether an impact is likely to be considered small to moderate or whether it is a potentially-large impact. The form also identifies whether an impact can be mitigated or reduced. Part 3: If any impact in Part 2 is identified as potentially-large, then Part 3 is used to evaluate whether or not the impact is actually important. THIS AREA FOR LEAD AGENCY USE ONLY DETERMINATION OF SIGNIFICANCE-- Type 1 and Unlisted Actions Identify the Portions of EAF completed for this project: El Part 1 Part 2 Part 3 Upon review of the information recorded on this EAF(Parts 1 and 2 and 3 if appropriate), and any other supporting information, and considering both the magnitude and importance of each impact, it is reasonably determined by the lead agency that: A. The project will not result in any large and important impact(s) and, therefore, is one which will not have a significant impact on the environment, therefore a negative declaration will be prepared. EIB. Although the project could have a significant effect on the environment, there will not be a significant effect for this Unlisted Action because the mitigation measures described in PART 3 have been required, therefore a CONDITIONED negative declaration will be prepared.* EDC. The project may result in one or more large and important impacts that may have a significant impact on the environment, therefore a positive declaration will be prepared. *A Conditioned Negative Declaration is only valid for Unlisted Actions Handicap Prescription Delivery Access (HPDA) Name of Action Zoning Board of Appeals Town of Southold Name of Lead Agency 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) website rate Page 1 of 21 PART 1--PROJECT INFORMATION Prepared by Project Sponsor NOTICE: This document is designed to assist in determining whether the action proposed may have a significant effect on the environment. Please complete the entire form, Parts A through E. Answers to these questions will be considered as part of the application for approval and may be subject to further verification and public review. Provide any additional information you believe will be needed to complete Parts 2 and 3. It is expected that completion of the full EAF will be dependent on information currently available and wil n e new studies„ research or investigation. If information requiring such additional work is unavailable, so indicate and specify each instg . Name of Action Handica2 Prescri tion Delivery Access HPDAZona , Location of Action(include Street Address, Municipality and County) 10095 Main Road, Mattituck, New York Name of Applicant/Sponsor Mattituck Plaza , LL Address 10095 Main Road, Mattituck, New York 11952 City/PO Mattituck State NY Zip Code 11952 Business Telephone 631 .298 .8494 Name of Owner(if different) Address City/PO State Zip Code Business Telephone Description of Action;. Installation of a window to provide handicap prescription delivey to handicapped people needing access . Page 2 of 21 Please Complete Each Question--Indicate N.A. if not applicable A. SITE DESCRIPTION Physical setting of overall project, both developed and undeveloped areas. 1. Present Land Use:-7 Urban El Industrial Commercial Residential (suburban) Rural (non-farm) Forest El Agriculture M Other w ;,nin9 Board of 2, Total acreage of project area: ?`-q- acres. APPROXIMATE ACREAGE PRESENTLY AFTER COMPLETION Meadow or Brushland (Non-agricultural) acres LO acres Forested acres acres Agricultural (Includes orchards, cropland, pasture, etc.) O acres acres Wetland (Freshwater or tidal as per Articles 24,25 of ECL) 0 acres L� acres Water Surface Area -acres O acres Unvegetated (Rock, earth or fill) `f acres acres Roads, buildings and other paved surfaces �• i acres o�� acres Other (Indicate type) N acres acres 3. What is predominant soil type(s) on project site? a. Soil drainage: Well drained 100% of site El Moderately well drained % of site. Poorly drained % of site b. If any agricultural land is involved, how many acres of soil are classified within soil group 1 through 4 of the NYS Land Classification System? acres (see 1 NYCRR 370). 4. Are there bedrock outcroppings on project site? Yes No a. What is depth to bedrock (in feet) 5. Approximate percentage of proposed project site with slopes: 0-10% % 10- 15% % M 15% or greater-% 6. Is project substantial) contiguous to or contain a building, site, or district, listed on the State or National Registers of Historic Places? Yes No 7. Is project substantially contiguous to a site listed on the Register of National Natural Landmarks? Yes No 8. What is the depth of the water table? (in feet) g. Is site located over a primary, principal, or sole source aquifer? DYes l o 10. Do hunting, fishing or shell fishing opportunities presently exist in the project area? Yes �No Page 3 of 21 11. Does project site contain any species of plant or animal life that is identified as threatened or endangered? ,Yes No According,to: TTTTTT"" Identif each species: eC,61 P�7 30 2 �025 12. Are there any unique or unusual land forms on the project site?(i.e., cliffs, dunes, other i �rr�ffii '? ° ❑Yeson n9 o 9 Describe: )gN 13. Is the project site presently used by the community or neighborhood as an open space or recreation area? rYes KN0 If yes, explain;° 14. Does the present site include scenic views known to be important to the community? Yes No 15. Streams within or contiguous to project area: at a. Name of Stream and name of River to which it is tributary 16. Lakes, ponds„ wetland areas within or contiguous to project area: + Ali— b. Size (in acres): Page 4 of 21 1-7. Is the site served by existing public utilities? RYes D No a. If YES, does sufficient capacity exist to allow connection? Yes No b. If YES, will improvements be necessary to allow connection? ElYes No 18. Is the site located in are agricultural di trict certified pursuant to Agriculture and Markets Law, Article 25-AA erection 303 and 304? Yes �No 19. Is the site located in or substantially c tiguous to a Critical Environmental Area designated pursuant rt�l lathe ECL, and 6 NYCRR 617? Yes No ` Zonin9 Board of 09'eals 20. Has the site ever been used for the disposal of solid or hazardous wastes? 0 Yes KNO B. Project Description 1. Physical dimensions and scale of project (fill in dimensions as appropriate). a. Total contiguous acreage owned or controlled by project sponsor: O'� acres. b. Project acreage to be developed: (0,U acres initially; Ojoacres ultimately. c. Project acreage to remain undeveloped: � � � acres. p d. Length of project, in miles: r"l - (if appropriate) 'QjV1 d KI E e. If the project is an expansion, indicate percent of expansion proposed. 0 f. Number of off-street parking spaces existing qo U ; proposed qq "Q g. Maximum vehicular trips generated per hour:-5(40L�—(upon completion of project)? h. If residential: Number and type of housing units: V1 4— One Family Two Family Multiple Family Condominium Initially A—. Ultimately i. Dimensions (in feet) of largest proposed structure: height; width; length. j. Linear feet of frontage along a public thoroughfare project will occupy is? ft. 2. How much natural material (i.e. rock, earth, etc.) will be removed from the site? ®�� tons/cubic yards. 3. Will disturbed areas be reclaimed E]Yes RNo N/A a. If yes, for what intended purpose is the site being reclaimed? b. Will topsoil be stockpiled for reclamation? E]Yes No c. Will upper subsoil be stockpiled for reclamation? .' Yes M-No 4. How many acres of vegetation (trees, shrubs, ground covers) will be removed from site? acres. Page 5 of 21 5. Will any mature forest (over 100 years old) or other locally-important vegetation be removed by this project? 0 Yes tNo two/_ 1 6. If single phase project: Anticipated period of construction: s, (including demolition) 7. If multi-phased: r I a. Total number of phases anticipated (number) G b. Anticipated date of commencement phase 1; month year, (including dem i e`v c. Approximate completion date of final phase; month % year. JpN d. Is phase 1 functionally dependent on subsequent phases? ED Yes In No honing hoard 0` ;�;,� •• 8. Will blasting occur during construction? r7l, Yes //�� o 9. Number of jobs generated: during construction 0 ;0 ; after project is complete 10. Number of jobs eliminated by this project . 11. Will project require relocation of any projects or facilities?ID Yes No If yes, explain: 12. Is surface liquid waste disposal involved? E]Yes ONO a. If yes, indicate type of waste (sewage, industrial, etc) and amount b. Name of water body into which effluent will be discharged 13. Is subsurface liquid waste disposal involved? E]Yes M No Type 14. Will surface area of an existing water body increase or decrease by proposal? Yes PNo If yes, explain: 15. Is project or any portion of project located in a 100 year flood plain? Yes qNO 16. Will the project generate solid waste? E:] Yes o a. If yes, what is the amount per month? tons b. If yes, will an existing solid waste facility be used? 0 Yes M No c. If yes, give name ; location d. Will any wastes not go into a sewage disposal system or into a sanitary landfill? Yes 11 No Page 6 of 21 e. If yes, explain: 17. Will the project involve the disposal of solid waste? E]Yes No ec a. If yes, what is the anticipated rate of disposal? tons/month. 3AN b. If yes, what is the anticipated site life? years. Zoning Board �� F�?�i�'��`' 18. Will project use herbicides or pesticides? Dyes h No 19. Will project routinely produce odors (more than one hour per day)? Yes t&O 20. Will project produce operating noise exceeding the local ambient noise levels? YesVNo 21. Will project result in an increase in energy use? Fl Yes FAPO If yes, indicate type(s) 22. If water supply is from wells, indicate pumping capacity gallons/minute. 23. Total anticipated water usage per day 0 gallons/day. 24. Does project involve Local, State or Federal funding? OYes No If yes, explain: Page 7 of 21 25. Approvals Required: Type Submittal Date City, Town, Village Board Yes No City, Town, Village Planning Board Yes ® No �1 City, Town Zoning Board Yes Lj No City, County Health Department Yes No Other Local Agencies E]Yes No Other Regional Agencies Yes No State Agencies Yes No Federal Agencies Yes Mr No C. Zoning and Planning Information 1. Does proposed action involve a planning or zoning decision? Yes E] No If Yes, indicate decision required: Zoning amendment qT-special oning variance New/revision of master plan E] Subdivision Site plan use permit Resource management plan ® Other Page 8of21 2. What is the zoning classification(s) of the site? V1 3. What is the maximum potential development of the site if developed as permitted by the present zoning? 4. What is the proposed zoning of the site? ^ of 7-onin9 Board 5. What is the maximum potential development of the site if developed as permitted by the proposed zoning? / �'' 6. Is the proposed action consistent with the recommended uses in adopted local land use plans? E]Yes No 7. What are the predominant land use(s) and zoning classifications within a '/4 mile radius of proposed action? 8. Is the proposed action compatible with adjoining/surrounding land uses with a 1/4 mile? Yes No 9. If the proposed action is the subdivision of land, how many lots are proposed? a. What is the minimum lot size proposed? Page 9of21 10. Will proposed action require any authorization(s) for the formation of sewer or water districts? Yes No 11. Will the proposed action create a demand for any community provided services (recreation, edu ,� µ protection? Yes No BAN �,2 2026 Board ei ApPeats a. If yes, is existing capacity sufficient to handle projected demand? .Yes bolo 12. Will the proposed action result in the generation of traffic significantly above present levels? Yes No el a. If yes, is the existing road network adequate to handle the additional traffic. Yes No D. Informational Details Attach any additional information as may be needed to clarify your project. If there are or may be any adverse impacts associated with your proposal, please discuss such impacts and the measures which you propose to mitigate or avoid them. E Verification I certify that the information pro ided above is true to t e best of my knowledge. /A 2 — Applicant/Sponsor Name j Date Signature Title If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment. Page 10 of 21 PART 2 - PROJECT IMPACTS AND THEIR MAGNITUDE Responsibility ofiLead Agency General Information(Read Carefully) I In completing the form the reviewer should be guided by the question: Have my responses and determinations been reasonable? The reviewer is not expected to be an expert environmental analyst. The Examples provided are to assist the reviewer by showing types of impacts and wherever possible the threshold of magnitude that would trigger a response in column 2. The examples are generally applicable throughout the State and for most situations. But,for any specific project or site other examples and/or lower thresholds may be appropriate for a Potential Large Impact response,thus requiring evaluation in Part 3. The impacts of each project,on each site, in each locality,will vary. Therefore,the examples are illustrative and have been offered as guidance. They do not constitute an exhaustive list of impacts and thresholds tcpteCeWWtfestion. I The number of examples per question does not indicate the importance of each question. In identifying impacts,consider long term, short term and cumulative effects. JAN �026 Instructions(Read carefully) a. Answer each of the 20 questions in PART 2. Answer Yes if there will be any impact. Zoning gpard of k��aalt. b. Maybe answers should be considered as Yes answers. C. If answering Yes to a question then check the appropriate box(column 1 or 2)to indicate the potential size of the impact. If impact threshold equals or exceeds any example provided,check column 2. If impact will occur but threshold is lower than example, check column 1. d. Identifying that an Impact will be potentially large(column 2)does not mean that it is also necessarily significant. Any large impact must be evaluated in PART 3 to determine significance. Identifying an impact in column 2 simply asks that it be looked at further. e. If reviewer has doubt about size of the impact then consider the impact as potentially large and proceed to PART 3. f. If a potentially large impact checked in column 2 can be mitigated by change(s)in the project to a small to moderate impact, also check the Yes box in column 3. A No response indicates that such a reduction is not possible. This must be explained in Part 3. 1 2 3 Small to Potential Can Impact Be Moderate Large Mitigated by Impact Impact Project Change Impact on Land 1. Will the Proposed Action result in a physical change to the project site? NO YES Examples that would apply to column 2 C Any construction on slopes of 15%or greater, (15 foot [] Yes D No rise per 100 foot of length), or where the general slopes in the project area exceed 10%. C Construction on land where the depth to the water tableEl 1:1 0 Yes 0 No is less than 3 feet. C Construction of paved parking area for 1,000 or more 0 El Yes M No vehicles. C Construction on land where bedrock is exposed or n E] Yes 0 No generally within 3 feet of existing ground surface. C Construction that will continue for more than 1 year or Yes E]No involve more than one phase or stage. C Excavation for mining purposes that would remove Yes 0 No more than 1,000 tons of natural material(i.e., rock or soil) per year. Page 11 of 21 1 2 3 Small to Potential Can Impact Be Moderate Large Mitigated by Impact Impact Project Change c Construction or expansion of a santary landfill. 0 0 DYes 0 No c Construction in a designated floodway. 0 0 DYes ONo c Other impacts: 0 0 DYes 0 No 2. Will there bean effect to any unique or unusual land forms found on � the site?(i.e., cliffs,dunes, geological formations,etc.) Rec� >� ®NO YES N c Specific land forms: Yes, ONO :.� Zoning boa Impact on Water 3. Will Proposed Action affect any water body designated as protected? (Under Articles 15,24,25 of the Environmental Conservation Law, ECL) ®NO OYES Examples that would apply to column 2 c Developable area of site contains a protected water body. 0 0 Yes ❑No c Dredging more than 100 cubic yards of material from channel of 0 0 Yes No a protected stream. c Extension of utility distribution facilities through a protected water 11 El 0 Yes 0 No body. c Construction in a designated freshwater or tidal wetland. 0 Yes 0 No c Other impacts: 0 Yes 0 No 4. Will Proposed Action affect any non-protected existing or new body of water? 0 NO OYES Examples that would apply to column 2 c A 10%increase or decrease in the surface area of any body of Yes O No water or more than a 10 acre increase or decrease. c Construction of a body of water that exceeds 10 acres of surface El 0 Yes No area. c Other impacts: ❑ DYes 0 No Page 12 of 21 1 2 3 Small to P ti:aI Can Impact Be Mpd g'e Mitigated by Imp a c Impactt Project Change 5. Will Proposed Action affect surface or groundwater quality or 3PA quantity? of Zoning �Oard �NO YES Examples that would apply to column 2 C Proposed Action will require a discharge permit. ! ©I Yes No C Proposed Action requires use of a source of water that does not __1 r-7 Yes No have approval to serve proposed(project)action. C Proposed Action requires water supply from wells with greater 17 �_ Yes No than 45 gallons per minute pumping capacity. C Construction or operation causing any contamination of a water Yes No supply system. c Proposed Action will adversely affect groundwater, ©_i Yes 177 No C Liquid effluent will be conveyed off the site to facilities which El r-7- Yes El No presently do not exist or have inadequate capacity. C Proposed Action would use water in excess of 20,000 gallons M Yes E]No per day. c Proposed Action will likely cause siltation or other discharge into Yes [D No an existing body of water to the extent that there will be an obvious visual contrast to natural conditions. C Proposed Action will require the storage of petroleum or rl U __j Yes Do chemical products greater than 1,100 gallons. C Proposed Action will allow residential uses in areas without Li Yes 1:1No water and/or sewer services. C Proposed Action locates commercial and/or industrial uses El Yes 17 No which may require new or expansion of existing waste treatment and/or storage facilities. C Other impacts: Yes 1:1No Page 13 of 21 1 2 3 Small to Potential Can Impact Be Moderate Large Mitigated by Impact 6 Project Change ec 6. Will Proposed Action alter drainage flow or patterns,or surface water runoff? 0 NO ElYES �ir��3 �oevd 01 Examples that would apply to column 2 C Proposed Action would change flood water flows 0 DYes 0 No C Proposed Action may cause substantial erosion. 0 0 DYes ONo c Proposed Action is incompatible with existing drainage patterns. 0 0 DYes 0 No C Proposed Action will allow development in a designated 0 0 0 Yes 0 No floodway. C Other impacts: 0 OYes ONo IMPACT ON AIR 7. Will Proposed Action affect air quality? ONO F1 YES Examples that would apply to column 2 c Proposed Action will induce 1,000 or more vehicle trips in any 0 DYes No given hour. c Proposed Action will result in the incineration of more than 1 ton 0 0 Yes 0 No of refuse per hour. c Emission rate of total contaminants will exceed 5 lbs. per hour 17 OYes 1:1No or a heat source producing more than 10 million BTU's per hour. c Proposed Action will allow an increase in the amount of land El El OYes 0No committed to industrial use. C Proposed Action will allow an increase in the density ofEl El Yes No industrial development within existing industrial areas. c Other impacts: 0 OYes No IMPACT ON PLANTS AND ANIMALS 8. Will Proposed Action affect any threatened or endangered species? ONO DYES Examples that would apply to column 2 C Reduction of one or more species listed on the New York or 0 Yes No Federal list, using the site, over or near the site, or found on the site. Page 14 of 21 1 2 3 Small to Potential) Can Impact Be Moderate Large Mitigated by Impact Impact Project Change C Removal of any portion of a critical or significant wildlife habitat. INJZ Yes C No C Application of pesticide or herbicide more than twice a year, Yes 0 No other than for agricultural purposes. w JAB C Other impacts: C C Yes CNo D"t g. Will Proposed Action substantially affect non-threatened or non- endangered species? 0 NO M YES Examples that would apply to column 2 C Proposed Action would substantially interfere with any resident �Yes 0 No or migratory fish, shellfish or wildlife species. c Proposed Action requires the removal of more than 10 acres of C El Yes 1:1No mature forest(over 100 years of age)or other locally important vegetation. c Other impacts: El DYes ONo IMPACT ON AGRICULTURAL LAND RESOURCES 10. Will Proposed Action affect agricultural land resources? ❑ NO 0 YES Examples that would apply to column 2 c The Proposed Action would sever,cross or limit access to 0 Yes 1:1No agricultural land (includes cropland, hayfields, pasture,vineyard, orchard,etc.) C Construction activity would excavate or compact the soil profile of Yes C No agricultural land. C The Proposed Action would irreversibly convert more than 10 E]Yes 11 No acres of agricultural land or, if located in an Agricultural District, more than 2.5 acres of agricultural land. Page 15 of 21 1 2 3 Small to Potential Can Impact Be Moderate Large Mitigated by 1 Impact Project Change c The Proposed Action would disrupt or prevent installation of �0 1:1Yes 0No agricultural land management systems(e.g., subsurface drain 1 lines, outlet ditches, strip cropping); or create a need for such �A measures(e.g. cause a farm field to drain poorly due to � �,ar� d ` ` y a increased runoff). 7-06ng B C Other impacts: El El E]Yes No IMPACT ON AESTHETIC RESOURCES 11. Will Proposed Action affect aesthetic resources?(If necessary, use the Visual EAF Addendum in Section 617.20,Appendix B.) F1NO riYES Examples that would apply to column 2 c Proposed land uses, or project components obviously different El Yes 11 No from or in sharp contrast to current surrounding land use patterns,whether man-made or natural. C Proposed land uses, or project components visible to users of E]Yes 0 No aesthetic resources which will eliminate or significantly reduce their enjoyment of the aesthetic qualities of that resource. C Project components that will result in the elimination or 0 0 ;Yes 0 No significant screening of scenic views known to be important to the area. c Other impacts: E]Yes . No IMPACT ON HISTORIC AND ARCHAEOLOGICAL RESOURCES 12. Will Proposed Action impact any site or structure of historic, prehistoric or paleontological importance? NO YE,S Examples that would apply to column 2 C Proposed Action occurring wholly or partially within or 0 Yes No substantially contiguous to any facility or site listed on the State or National Register of historic places. C Any impact to an archaeological site or fossil bed located within r E]Yes 1:1No the project site. C Proposed Action will occur in an area designated as sensitive E] Yes 0 No for archaeological sites on the NYS Site Inventory. Page 16 of 21 1 2 3 Small to Potential Can Impact Be Moderate Large Mitigated by Impact Impact Project Change c Other impacts: E]Yes E]No IMPACT ON OPEN SPACE AND RECREATION a 13. Will proposed Action affect the quantity or quality of existing or future � �ppa open spaces or recreational opportunities? td o 171 NO 0 YES 7-onln9 'ac,a Examples that would apply to column 2 C The permanent foreclosure of a future recreational opportunity. Yes No C A major reduction of an open space important to the community. 0 D Yes No C Other impacts: El 0 Yes No IMPACT ON CRITICAL ENVIRONMENTAL AREAS 14. Will Proposed Action impact the exceptional or unique characteristics of a critical environmental area (CEA)established pursuant to subdivision 6NYCRR 617.14(g)? NO MYES List the environmental characteristics that caused the designation of the CEA. Examples that would apply to column 2 C Proposed Action to locate within the CEA? EJ Yes EI No C Proposed Action will result in a reduction in the quantity of the 0 El Yes EI No resource? c Proposed Action will result in a reduction in the quality of the 0 Yes r7No resource? C Proposed Action will impact the use,function or enjoyment of the E]Yes M No resource? C Other impacts: 0 Li 0Yes -- No Page 17 of 21 1 2 3 Small to Potential Can Impact Be Moderate Large Mitigated by Impact d Project Change IMPACT ON TRANSPORTATION 15. Will there be an effect to existing transportation systems. ,; ,• rl NO 0 YES Examples that would apply to column 2 C Alteration of present patterns of movement of people and/or Q Yes No goods. C Proposed Action will result in major traffic problems. 0 Yes Q No C Other impacts: ❑ Yes E No IMPACT ON ENERGY 16. Will Proposed Action affect the community's sources of fuel or energy supply? NO r7YES Examples that would apply to column 2 ❑ ❑ c Proposed Action will cause a greater than 5% increase in the Yes LRDNo use of any form of energy in the municipality. C Proposed Action will require the creation or extension of an QYes Q No energy transmission or supply system to serve more than 50 single or two family residences or to serve a major commercial or industrial use. C Other impacts: 0 Yes _ No NOISE AND ODOR IMPACT 17. Will there be objectionable odors, noise, or vibration as a result of the Proposed Action? ®NO E]YES Examples that would apply to column 2 C Blasting within 1,500 feet of a hospital,school or other sensitive QYes 1:1No facility. C Odors will occur routinely(more than one hour per day). 0 Yes 0 No c Proposed Action will produce operating noise exceeding the 0 E]Yes 0 No local ambient noise levels for noise outside of structures. C Proposed Action will remove natural barriers that would act as a Q Yes ❑No noise screen. C Other impacts: 0 0 DYes 0 No 1 2 3 Small to Potential Can Impact Be Moderate Large Mitigated by Im adt Impact Project Change IMPACT ON PUBLIC HEALTH 18. Will Proposed Action affect public health and safety? I , a "° NO DYES ; c Proposed Action may cause a risk of explosion or release of Oo � � Yes No hazardous substances(i.e. oil, pesticides, chemicals,radiati "n, etc.)in the event of accident or upset conditions,or there may be a chronic low level discharge or emission. C Proposed Action may result in the burial of"hazardous wastes" _.; DYes No in any form (i.e.toxic, poisonous, highly reactive, radioactive, irritating, infectious,etc.) C Storage facilities for one million or more gallons of liquefied El El Yes DNo natural gas or other flammable liquids. c Proposed Action may result in the excavation or other DYes No disturbance within 2,000 feet of a site used for the disposal of solid or hazardous waste. c Other impacts: DYes —]No E : IMPACT ON GROWTH AND CHARACTER OF COMMUNITY OR NEIGHBORHOOD 19. Will Proposed Action affect the character of the existing community? NO ElYES Examples that would apply to column 2 C The permanent population of the city,town or village in which the 0 El DYes 0 No project is located is likely to grow by more than 5%. c The municipal budget for capital expenditures or operating __1, El Yes 0 No services will increase by more than 5% per year as a result of this project. c Proposed Action will conflict with officially adopted plans or 0 0 DYes 0 No goals. c Proposed Action will cause a change in the density of land use. 0 DYes DNo C Proposed Action will replace or eliminate existing facilities, 0 DYes 0 No structures or areas of historic importance to the community, C Development will create a demand for additional community 0 []Yes 0 No services(e.g. schools, police and fire,etc.) Page 19 of 21 1 2 3 Small to Potential Can Impact Be N1 Moderate Large Mitigated by Impact Impact Project Change C Proposed Action will set an important precedent for futiA�1 n El ©Yes E]No projects. �9�t a C Proposed Action will create or eliminate employm��nq V0 © r7 Yes ®No C Other impacts: 13 Q iYes ®No 20. Is there,or is there likely to be, public controversy related to potential adverse environment impacts? 0 NO YES If Any Action in Part 2 Is Identified as a Potential Large Impact or If you Cannot Determine the Magnitude of Impact, Proceed to Part 3 Page 20 of 21 Part 3 - EVALUATION OF THE. IMPORTANCE OF IMPACTS Responsibility of Leach Agency Part 3 must be prepared if one or more impact(s) is considered'to be potentially large,even I �im`pact($ rnws be mitigated. � c'b Instructions (If you need more space, attach additional sheets) " Discuss the following for each impact identified in Column 2 of Part Z 1. Briefly describe the impact. 2. Describe(if applicable) how the impact could be mitigated or reduced to a small to moderate impact by project change(s). 3. Based on the information available, decide if it is reasonable to conclude that this impact is important. To answer the question of importance, consider: t The probability of the impact occurring I The duration of the impact I Its irreversibility, including permanently lost resources of value I Whether the impact can or will be controlled I' The regional consequence of the impact I' Its potential divergence from local needs and goals I Whether known objections to the project relate to this impact. I Page 21 of 21