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HomeMy WebLinkAboutTR-10898A DENIS NONCARROW Town Hall,53095 Main Road P.O. TOWN CLERK OF SQU Box 1179 Southold,New York 11971 Fax REGISTRAR OF VITAL (631) 765-6145 Telephone(631) STATISTICS MARRIAGE OFFICER 765-1800 RECORDS MANAGEMENT www.southoldtownny.gov OFFICER FREEDOM OF �� INFORMATION OFFICER l��dlPt'1IY,�c OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO.2026-471 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MAY 20,2026: RESOLVED that the Town Board of the Town of Southold hereby authorizes a refund to the following applicant. The Board of Trustees has requested a refund as the applicant has withdrawn their application. Cutchogue-New Suffolk Park District $100.00 Administrative Amendment to P.O.Box 311 Administrative Permit#10898A Cutchogue,NY 11935 Denis Noncarrow Southold Town Clerk RESULT: Adopted MOVER: Councilwoman Doherty SECONDER: Councilman Mealy AYES: Councilman Mealy, Justice Stevens, Councilwoman Doherty, Councilwoman Smith, Councilwoman Suess, Supervisor Krupski, Jr. NAYES: None Page 78 of 99 Cutchogue New Suffolk Park District I - PO Box 311 � �(�U S�S �j S Gc.tSS���✓�Southhold Toy Cutchogue,NY 11935 � i� Gn U Town Hall And � !Tc 543 75Rt 25 South Southhold,l� I- -- - - Re: Dave Allison Park Dear Mr. Goldsmith I am in receipt of your approved permit#10898A and I thank you for your quick action on the application. Unfortunately, unforeseen conditions were discovered, (underground water pipe), and we must alter our shed location. Enclosed is a copy of our survey with the new proposed location for your review. The CNSPD will be most grateful if you can wave any additional fees for the revision. Very truly yours, Xavier Fleming, Commissioner eta a,L JXfCNxf4- E>,y/hzIL Coin C E � W E APR 22 20M Southold Town Board of Trustees -- -- ----- - ---- ------ - or ca CASH Date 05971Uj Received From O LA� eW S U� ' is IPG r-K b ` CC Oz N Address t z5o5z Dollars$ 0 p 06 O For rr1 (Y1� (Y)e A 0 3 ACCOUNT03, HOW PAID C? 0: AMT.OF CASH " ('� ^ Q ACCOUNT v ' V ® AMT.PAID CHECK l V Q - BALANCE rr,,``ll MONEY ORDER El By DUE V V CREDIT CARD El FFO r Glenn Goldsmith,Prds:.:a it ea Town Hall Annex A.Nicholas Krupski,Vice President Qo < 54375 Route 25 Eric Sepenoski 21 , � P.O.Box 1119 %Liz Gillooly ty • p�VY Southold,NY 11971 Joseph Finora l Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: S 2__1 Completed in field by: LI a� CUTCHOGUE-NEW SUFFOLK PARK DISTRICT requests an Administrative Amendment to Administrative Permit#10898A to move location of previously approved shed. Located: 55 West, Road, Cutchogue. SCTM# 1000-110-7-13 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: Chapt. 275 Chapt. 111 other T pe of Application: Wetland Coastal Erosion V�Amendment Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable 1. Info needed/Modifications/Conditions/Etc.: CO V(CeY Yb.s�(✓m i+ r r�` t �o C S Present Were: G. Idsmith N. Kru ski I,/E. Sepenoski L. Gillooly �J. Finora r-1 S.C.T.M. NO. DISTRICT: 1000 SECTION: 110 BLOCK: 7 LOT(S):13 n [JJ '„ AP 22 20 Southold Tovdn Board of Trustees EDGE OF PAVEMENT WEST ROAD W,%°W.°V. MO N. N 64e47'00"E i 0.4'S 0.7•E 0.5'S 4'ESTATE FENCE U.P. 16S.13' Q GATE 0.3•S 0U.P. SIGN. A e? FLAG O N z POLE a � m CATCH BASIN m m SAND PLAY AREA m M N. W F M N. h 0 w 0 r� T �"N CONC. W GANG. DAVE ALLISON PARK 1-'U.P. Y S:1�dl 0 4W ? e Z �C- orJ ASPHALT I�-I,I�1 I 1 oiiiCONO.:i;i 1.3e N 1° 4D,• ° O a DRAIN �° W000 L m `` 0• . 0.5' *dO9�' �� FENCE A �°+ CATCH BASIN TOP OF BgryK � 7.3'E GU.gRO E W0 ( ZONE X DECK00 TOE OFK Q� F0000 ZONE BOUO Y_ C 4 ZONE V saz 9) UM?OF BEACH GAS b b 'NFL'H/GH WATER S68°45'S4"w _ 93.38' CT rTC 'BE UN- 'ON' FEMA MAP#36103CO164H ROGUE HARBOR THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL LOCATIONS SHOWN ARE FROM FIELD OBSERVA77ONS EFFECTIVE 09/25/2009 AND OR DATA OBTAINED FROM OTHERS. AREA:37,942.71 SQ.FT. or 0.57 ACRES ELEVA77ON DATUM: UNAUTHORIZED AL TERA770M OR ADD177ON TO THIS SURVEY IS A VIOLA 77ON OF SEC770N 7209 OF THE NEW YORK STATE EDUCA77ON LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEYS PREPARED AND ON HIS BEHALF TO THE PRE COMPANY, GOVERNMENTAL AGENCY AND LENDING INS77TU77ON USTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE. THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE EREC77ON OF FENCES, ADD17IONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS AND/OR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE 77ME OF SURVEY SURVEY OF:DESCRIBED PROPERTY CERTIFIED TO: MAP OF: CUTCHOGUE NEW SUFFOLK PARK DISTRICT; FILED: SITUATED AT:CUTCHOGUE TOWN OF:SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design 01* tO5O882 P.O. Box 153 Aquebogue, New York 11931 FILE #222-156 SCALE:1"-30' DATE: DEC. 2, 2022PHONE (631)298-1688 FAX(631) 298-1688 N.Y.S. L/SC. N0. melntalning the record.or Robert J.Henneaay&Kenneth M.Boychuk Glenn Goldsmith,President haO�pS�fFO(�-COG Town Hall Annex A.Nicholas Krupski, Vice President �� y1� 54375 Route 25 Eric Sepenoski y x P.O.Box 1179 Liz Gillooly �rY Southold,NY 11971 Joseph Finora 4 'l' p�Ar Telephone(631)765-1892 . ClrY, Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1st day of construction % constructed Project complete, compliance inspection Glenn Goldsmith,President ® OF SOU� Town Hall Annex V` 54375 Route 25 Nicholas Krupski,Vice President e` ® P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly G Q Telephone(631) 765-1892 Joseph Finora Fax(631) 765-6641 C®UM BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD( Permit No.: 10898A Date of Receipt of Application: December 11, 2025 Applicant: Cutchogue New Suffolk Park District SCTM#: 1000-110-7-13 Project Location: 55 West Road, Cutchogue Date of Resolution/Issuance: January 14, 2026 Date of Expiration: January 14, 2029 Reviewed by: Board of Trustees Project Description: Install a 10' x 14' shed. 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 Xavier Fleming, received on December 11, 2025, and stamped approved on January 14, 2026. Special Conditions: No tree removal. 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 S.C.T.M. N0. DISTRICT: 1000 SECTION: 110 BLOCK: 7 LOT(S): 13 EDGE OF PAVEMENT WEST ROAD W.V. 0 0 W.V. MON. N 64047'00"E 0.4S 0.5'S 4' ESTATE FENCE �U P 0.1'E 165.]3' GATE d 9U.P.0.3'S N SIGN. 1A'W °o-� FLAG m o N POLE (A - tv m °N°° ® m CATCH �� O V� m BASIN m ED By SAND PLAY AREA BOARD OF •I RUSTEES M N. U W TOWN. OF SOUTHOLD _g A ~ DATE J G uG r M N. 14 �oa� 0 CONC. CONC. DAVE ALLISON PARK � U.P. Ul W Id Id M.H. �► ASPHALT t� o STYiii ONC. ::: Q c� w ^tia DRAIN RA1L WOOD FENCE CATCH BASIN TOP OF BANK ss s 1.3E GUgR WOOD D R4�L ZONE X DECK °� � —TOE OF BANK �, � '� FLOOD I ' c o LONE BOU NARY— � ZONE + _ LIMITrfff BEAC VE(EL g)OF H GRASS DEC 1 1 2025 SOUthold Town MEAN HIGH WATER Board of Trustees S 6 045'54"W _ (77E LINE ALONG MHW) 93.38' CUTCHOGUE HA - FEMA MAP#36103C0164H HARBOR THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS EFFECTIVE 09/25/2009 AND OR DATA OBTAINED FROM OTHERS. AREA:37,942.71 SQ.FT. or 0.87 ACRES ELEVATION DATUM- ------ ______ UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SEC77ON 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT 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 77TLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INS77TV77ON LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE. THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES, ADD177ONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS AND/OR SUBSURFACE STRUMRES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE 77ME OF SURVEY SURVEY OF:DESCRIBED PROPERTY CERTIFIED TO: MAP OF: CUTCHOGUE NEW SUFFOLK PARK DISTRICT; FILED: SITUATED AT:CUTCHOGUE TOWN OF:SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design P.O. Box 153 Aquebogue, New York 11931 PHONE (631)298-1588 FAX (631) 298-1588 FILE #222-156 scALE:1 "=30' DATE: DEC. 2, 2022 N.Y.S. LISC. NO. 050882 maintaining the records of Robert J. Hennessy & Kenneth M. Woychuk SOUTHOL.D TRUSTEES No. o$qg A Issued TO C%Xc-l%*r%%^r- New S..vm1K Qanc Date. I I'`' /a L Address S5 We sY Ro� C �l� , -T c► o � que. THIS. NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765.1892 Glenn Goldsmith,Presid ��o�OSpFFO(,�c t Town Hall Annex A.Nicholas Krupski,Vice President �� s.� 54375 Route 25 Eric Sepenoski y , P.O. Box 1179 Liz Gillooly �y ® o�� Southold,NY 11971 Joseph FinoraOKa¢� Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: IZA Completed in field by: /V, CUTCHOGUE NEW SUFFOLK PARK DISTRICT requests an Administrative Permit to install a 10' x 14' shed. Located: 55 West Road, Cutchogue. SCTM# 1000-110-7-13 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: /Chapt. 275 Chapt. 111 other Typ'9,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.: op, A00�+ ,flu f ajJ '1Y('V a/P T im0%/ , . Present Were: G. Goldsmith J N. Krupski E. Sepenoski L. Gillooly E. Peeples F y •w Y , IN i w s, ���I� e �f 1Sc.� wj w. f �1tc• �t ✓'.'f'. F'Y .. ♦ n�♦ / � •+'��.� + 1:I�! rj� �r/�2�• •: f:'.fi �".• .0 jr- �`r Yl 77 40 JJ� rF F: - � ._.. <� -.?.-i'�- ••�� J�._. - -r yam.a _ •V•��+.k,�♦t,y,` .Yti_ �.f�' - -r�• . .. ,.- � a:'r - .ems. - »s ♦ .._. r i. a '-(\ _ y".. s�sc.w. t¢ "5 .,N"Y S �, � ,a �t S 1#". �s/R.. ♦6� `y.... d c "'-a xiz err:.+t ♦ 9 m .�m /r( $S J�/�e /P y �e d,' ♦/Fa '-'ji+t ,'i; 9,,t „ g f, a e+NT Sr'� j�p",3. Y v'Y va4! a °' Z .ns 101 z1\Y' ,e�jAt '° «:v sourRo L \ eii. ,^1 " a,/''% j�.,``y t` 'p` ♦ c• ^� y a^ �? p0 51 sot. OZ � l3 ......m-- \`` �I.� q f�✓'e9� �"..�p 4 '��>♦ ,p y�a,',"�+\�`, a Y J� '� >aw. li,,., s" '..v, \ \ t�`� • :�`.f>,?�f '< e^.r/ �/,�8 � A\a\iu�� '? '� q� \�\tp• pp Al IV y w F v ,Vi _ ent�i 6PE SEG.NO. c . oB-06-0932 39� m �fl 6 fI�-5 FOR `F 6EE 9EC.NO_ 16.M1q � � "z"c" Rr E *_�a9._K.p•�.�__ .__mw_ —>— e� O moo.. --� F COUNTY OF SUFFOLK c) N -T icE • ,,,�..w moo __ U.rF, u ...� ..� __.__ .. ., Real P,.Pr t T r, iti. Nre«rE kteuvmN J.�Eaa v T wee e° a unr w�«JaEn M - 110 a — — M�iN(>•,rt�F P "FeRC o OFFICE LOCATION: so yo MAILING ADDRESS: Town Hall Annex P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) N Telephone: 631 765-1938 Southold, NY 11971 • Q LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: Glenn Goldsmith, President Town of Southold Board of Trustees Cc: Honorable Lori Hulse, Attorney From: Heather Lanza, AICP, Planning Director LWRP Coordinator Date: January 9, 2026 Re: LWRP Coastal Consistency Review CUTCHOGUE NEW SUFFOLK PARK DISTRICT, SCTM# 1000-110.-7-13 This application is to install a 10' x 14' shed. The proposed action has been reviewed to Chapter §268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the policies of the LWRP as follows: Policy 6. Protect and restore the quality and function of the Town of Southold's ecosystem. 6.3. Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction. D. Provide adequate buffers between wetlands and adjacent or nearby uses and activities in order to ensure protection of the wetland's character, quality, values, and functions. The proposed 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 which qualify under §275-5 (8)(2)(e) Construction of accessory structures for existing single-family dwellings, provided that such activity will not have an undue adverse impact on the wetlands and tidal waters of the Town and the setback is no less than 50 feet. The proposed new shed is greater than 100ft from the MHW mark in Cutchogue Harbor. 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. Glenn Goldsmith,President + Q ( Town Hall Annex ski,Vice President 54375 Route 25 A. Nicholas Kru P "`*+ P.O.Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 Cot"a BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only ---- l Coastal Erosion Permit Application 'Iu Wetland Permit Application X Administrative Permit DEC 1 1 2025 _ Amendment/Transfer/Extension � _Received Application: Southulo To_ wn Received Fee: $ S o Board ofTristees Completed Application: Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: _Coordination:(date sent): '0 [AK LWRP Consistency Assessment Form Sent: _CAC Referral Sent: x Date of Inspection: _ l Receipt of CAC Report: Technical Review: _Public Hearing Held:jh-�U6 Resolution: Owner(s) Legal Name of Property (as shown on Deed): C� Mailing Address: Phone Number: Suffolk County Tax Map Number: Property Location: 4F re L) , (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): Mailing Address: Phone Number: Email: foard of Trustees Applica n GENERAL DATA Land Area(in square feet): --- Area Zoning: K " LID Previous use of property: Intended use of property: �'� Covenants and Restrictions on property? Yes _E_No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? E-Yes -P;7No If"Yes",be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes _2_No If"Yes", please provide copy of decision. YTis project regmp 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 F-1_No Prior permits/approvals for site improvements: Agency Date gNo prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency?,El-No-a Yes If yes, provide explanation: Project Description(use attachments if necessary): loard of Trustees Applica in WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: � � x Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: _ feet Does the project involve excavation or filling? ❑ No ❑—Yes If yes, how much material will be excavated9 cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part l based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part I -Project and Sponsor Information Name of Action or Project: p / Project Location(describe,and attach a location map): Brief Description of Proposed Action: 17 ,_ 5L (( IJ 'y- Name of Applicant or Sponsor: Telephone: S«f ;� < E-Mail: P ItTL Go„� DJ, art Address: Pz) 3 1( City/PO:: State: Zip Code: / 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that ❑ may be affected in the municipality and proceed to Part 2. if no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes, list agency(s)name and permit or approval: ❑ 3.a.Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Che l land us at occur on,adjoining an ar the prop ffj action. Urban Rural(non-agriculture) Industrial Commercial PResidential (suburban) Forest Agriculture HAquatic QOther(specify): Parkland Page I of 4 5. is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? b.Consistent with the adopted comprehensive plan? _IELH: 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? 7. is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: ❑ ❑ S. a.Will the proposed action result in a substantial increase in traffic above present levels? NO I 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 proposed action? 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: ❑ ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: © ❑ 11. Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: © ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO I YES Places? b. Is the proposed action located in an archeological sensitive area? 171-1.171. 13.a. Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? b. Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. ntify the typic bitat types that oc n,or are likely to be found on tFMroject site. Check all that apply: Shoreline Forest Agricultural/grasslands Early mid-successional Wetland Urban Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats, listed NO YES by the State or Federal government as threatened or endangered? —a Li 16.is the project site located in the 100 year flood plain? NO YES TrFT 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO If Yes, � ^ ❑ ❑ a. Will storm water discharges flow to adjacent properties? 0 ES b. Will storm water discharges be directed to established conveyance systems ff anm drains)? If Yes, briefly describe: ' NO Iu�ES Page 2 of 4 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids (e.g. retention pond, waste lagoon, dam)? If Yes,explain purpose and size: _ - ----- ❑ 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: F vl e-. �� ,,, (� G,_P i Date: Z -t 2-.2 O 2-5- Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? El 11 3. Will the proposed action impair the character or quality of the existing community? El 4. Will the proposed action have an impact on the environmental characteristics that caused the ® ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic of ❑ affect existing infrastructure for mass transit, biking or walkway? 6.. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ reasonablyavailable energyconservation or renewable energyopportunities? 7. Will the proposed action impact existing: Q a. public/private water supplies? b.public/private wastewater treatment utilities? a 8. Will the proposed action impair the character or quality of important historic,archaeological, o architectural or aesthetic resources? EL 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, Q a waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage problems? 11. Will the proposed action create a hazard to environmental resources or human health? IE Part 3- Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail, identify the impact, including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration, irreversibility,geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts. ElE !! Check this box if you have determined,based on the information and analysis above,and any supporting documentation, the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. LJ Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT .__...�....... Page 4 of 4 )ard of Trustees Applicat AFFIDAVIT XA u�P ��eon 5) /C-"- BEING DULY SWORN DEPOSES AND AFFI THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. 7 Z4�2- /-6� Signature of Prop y Owner Signature of Property Owner SWORN TO BEFORE ME THIS l r DAY OF ew. , 20 -2 1— Notary Public KAMRAN H KHAN Notary Public-State of New York NO.OIKH6438355 Qualified in Queens County My Commission Expires Aug 8,2026 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southoid's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose o this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action i§ necessary to avoid same. YOUR NAME: v�/il l, (Last name,first name,griddle in' al,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (lf"Other",name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood, marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%ofthe shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): fjA)the owner of greater than 5%of the shares of the corporate stock of the applicant � (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this / L d 20 2 Signature_ ZfY Print Name Fonn IS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus each answer must be explained in detaih listing both supporting and non- supporting f tL. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall g9t 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# .J - 7 - 1 3 PROJECT NAME 1 ,.- -:d ,Q 01QC, A (/r j o&j �� I K The Application has been submitted to (check appropriate response): Town Board ❑ Planning,Board❑ Building Dept. ❑ Board of Trustees ❑ I. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g.capital ❑ construction,planning activity, agency regulation, land transaction) ❑ (b) Financial assistance(e.g. grant,loan,subsidy) (c) Permit, approval,license,certification: ❑ Nature and extent of action: Location of action: A) -5 f 5' ��'s ce a s --r Site acreage: E ?,7 Present land use: i'n 1k Present zoning classification: F 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: A. Ic /1 fC LOY y4✓act (b) Mailing address: If2-31"' (c) Telephone number: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes ❑ No❑ If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location,and minimizes adverse effects of development. See LVV" Section III—Policies; Page 2 for evaluation criteria. Yes ❑ No 1� 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 E� 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 ❑ Yes ❑ No ❑ Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No R 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 ❑ No E Not Applicable Attach ad itional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ Yes ❑No P. Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes ❑No 5 Not Applicable 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 D 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. ❑ Ye❑ No� Not Applicable Attach additional sheets if necessary WORKING COAST POLICI .,, Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III—Policies; Pages 47 through 56 for evaluation criteria. ❑Yes ❑ NoElNot Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑Yes ❑ No B 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 0 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 PREPARED BY TITLE 1 J;/hi/ S !J; DATE j L -/Z -2j-