HomeMy WebLinkAboutTR-10909A Glenn Goldsmith,President d-o SUfFOC,�Ctk Town Hall Annex
A.Nicholas Krupski,Vice President �� �,,� t. 54375 Route 25
Eric Sepenoskiy a P.O.Box 1179
Liz Gillooly 0 fyt Southold,NY 11971
Joseph Finora "�",� QQ�'Y:' Telephone(631)765-1892
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
1 st day of construction
Y2 constructed
Project complete, compliance inspection
Glenn Goldsmith, President ®F soU�y Town Hall Annex
ski,Vice President �� ®� 54375 Route 25
Nicholas Kru
P � ® P.O. Box 1179
Eric Sepenoski J� Southold, New York 11971
Liz Gillooly G Q Telephone(631) 765-1892
Joseph Finora Fax(631) 765-6641
MUNTV,N�
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Permit No.: 10909A
Date of Receipt of Application: January 12, 2026
Applicant: Summit Estates Homeowners Association Inc.
SCTM#: 1000-38-7-12
Project Location: Parcel "D", Shipyard Lane, East Marion
Date of Resolution/Issuance: February 11, 2026
Date of Expiration: February 11, 2029
Reviewed by: Board of Trustees
Project Description: As-built 12' x 12' gazebo.
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
survey prepared by Young Associates, received on January 12, 2026, and
stamped approved on February 11, 2026.
Special Conditions: None.
Inspections: Final Inspection.
If the proposed activities do not meet the requirements for issuance of an
Administrative Permit set forth in Chapter 275 of the Southold Town Code, a
Wetland Permit will be required.
This is not a determination from any other agency.
f
,a
Glenn Goldsmith, President
Board of Trustees
I
SUMMIT ESTATES
EAST MARION, NY 11939
SCTM# 1000-38.-7-12
E0 EIVE
��4
W
,. r north fork modern home
12'-11 3/8
design•draft•build
' -, Sr�tl�viu lutiat�
* ,
Board of Trislers
huck hirsch 646.416.4096
[IX6 TREX DECKING]
00 2X6 FLOOR JOIST 12"O.C. PROJECT OVERVIEW:DRAW PLANS FOR"AS BUILT"GAZEBO ON
j - - (TECO TO RIM JOISTS) SUMMIT ESTATES HOME OWNERS'ASSOCIATION PROPERTY AS
�--
---- - ------ DOCUMENTATION FOR FILING ALL NECESSARY APPLICATIONS TO
f. GET A BUILDING PERMIT. NOTE:STRUCTURE DRAFTED AS BUILT.
ew-
1
,_. N
r,r -
--- (2)2X6 RIM JOIST
GAZEBO(see survey for exact location)
14"SONOTUBE PIER
MIN. 36" BELOW GRADE
., ON 24X24X6 PC FOOTING
F- i
6X6 TYPICAL NO.2 PINE POST
OWN lr-"Irow
(ANCHOR BRACKET)
GENERALNOTES
1.All work shall conform to the requirements of the Residential Code of New York
State,County and Town Department Regulations,Utility Company requirements
and best trade practices.
2.Before commencing work,the Contractor shall file all documents required by
SUMMIT ESTATES GAZEBO - P LAN the Building Department,pay all fees required by local agencies and obtain all
3 required permits.
Scale: 1/4"-1'0" 3.The Contractor shall visit the site and verify all dimensions and the existing
conditions affecting the work prior to construction.Any discrepancies which would
preclude satisfactory completion of the work described herein shall be reported
to the Contractor or property owner.Do not start work until such conditions have
been examined and a course of action mutually agreed upon.Failure to notify the
SUMMITE S TAT E S GAZEBO - AS BUILT owner or Contractor of unsatisfactory conditions will be construed as acceptance
4 of the conditions to properly perform the required work.
Scale: NTS 4.All work is to conform to the drawings and specifications of the contractor and
engineer consultants.
5.The Contractor is to maintain a complete and up-to-date set of plans on the job
site at all times.
6.The drawings are not to be scaled under any circumstances.
7.It shall be the Contractor's responsibility to ascertain all prevailing procedures
including storage and toilet facilities,protection of existing work to remain,access
to work area,hours of permitted work,availability of water and electric power,and
all other conditions and restrictions for this particular location in order to execute
the work in a careful and orderly manner with the least disturbance to the public.
8.The Contractor shall make the necessary arrangements to utilities and services
temporarily disconnected while performing the work as required.
_ 9.The Contractor shall provide all dimensions and cutouts for other trades.10.The Contractor shall provide proper shoring and bracing for all remaining
structure prior to removal of existing structure.
11.Plumbing,electrical,HVAC and similar work shall be performed by licensed
persons who shall arrange for and obtain all required inspections.The General
Contractor shall be responsible for scheduling all other inspections as required.
12.The Contractor is solely responsible for construction safety and shall hold the
f owner and draftsperson harmless from litigation arising out of the Contractor's
failure to(provide construction safety means and methods.
CONSTRUCTION NOTES
1.All footings shall rest on undistrubed soil at a minimum of 36"below fin.grade.
2.Poured concrete shall have a minimum psi of 2800 at 28 days unless noted.
3.Sill plates shall be preserved,treated wood and be installed above a 16 oz.
copper termite shield.
4.Shingle siding shall conform to ASTM D 3679 and be installed in accordance
with the New York State Building Code and manufacturer's specifications.
5.Pilings shall be installed by a licensed contractor to a depth bearing agreed
upon by an engineer and certificates shall be issued stating same.
ll.s r• ,, ;�. { i t 6.Foundation designed for a soil bearing capacity of 2 TSF and grade less
F. than 5%.All fill beneath Concrete slabs to be compacted to 95%relative density.
l -_ .:` �, , T i?rTr ,r-r, f,/ 7.Unless otherwise noted all framing and structural wood components shall
It _ _ be#2 or(better Douglas Fir.
1.jv" .12-' ' r `t 8.All framing techniques and methods shall be as prescriptive design based on
Pt � s�9� -t�°� AF&P Wood Frame Construction Manual for One and Two Family Dwellings
T. t (WFCM)or as specified in R 301.2.1.1.
9.All building envelope components shall comply with Chapter 6 of the Energy
_ �_ ""'A� Conservation Code of the State of New York.
10,Firebllocking shall be provided in all wood frame construction in accordance
1 ---- << SUMMIT ESTATES GAZ B O - 3 D VIEW with NY5 Code R 602.8 to form an effective fire barrier between stories and
between the top story and roof space.
Scale: 3/8"=1'0" 11.Protective panels shall be provided for lazed openings in accordance with
3 t � NYS Code R 301.2.1.2 if they are required.
P P 9
12.Proviide flashing at all roof breaks,exterior doors,windows,decks,etc.
1 -- -- ---- ------- - - - 13.All window and exterior door headers to be(2)2x8 unless noted otherwise.
7 - TYPICAL HIP ROOF CONSTRUCTION 14.All interior wall partitions to be typical:2x4 @ 16"O.C.with standard GWB;
�' LL..1_ TIF i♦
19.Sr°A]-E e;
E
7 9 T7iOOB Ia ' ._
J 4 pow a
Reofty c or 2x6 @!16"O.C.with standard GWB for walls with plumbing,as drawn.
tormef'' GAF ASPHALT SHINGLES
"� W re 15.All portions of the new structure are designed to comply with local geographic
§I rb R n now or forme. Ii
SYNTHETIC UNDERLAYMENT and climate criteria as specified in the following table.
�rM,JP +! pa
fleightsCo- I 3/4n PLYWOOD SHEATHING
2x8 RAFTERS @ 16"O.C.
COV*FIANTS•R9TaTC1gNPA
_ (HURRICANE STRAPPING PER)
'o�iv ..R.e.*•m 5 3657'1Z'E r,aii.�p_. � ��g
a Ci
ooe n•cSaar _ _ E06.96" `�� FF OI.K A7Y OE'-4Gf-t1I
e "¢ i _S_e staEn 4 r T tao a 1 c 'ew•nr �8 t1�9
oI L Iy '3@75Acr w 0 __
area t �'a-
1L. \ - SP, o t B 1� rtnawu
'`aw„ N 3657 72�ry --_ / 3'o' Q v e apm_ea w tM*Dave date.PMQ Wit
4a'<2`w m-"- ._ -- •, 3 CaNru u'tiwl sLfderd�n e*cf A•ne tdMt
6 FASCIA
SC.90 �? iiEu 75H.07 GEOGRAPHIC AND CLIMATE DESIGN CRITERIA
cOGssd +Is,u1F I.'ed wrn iM C,uadY JrM1
'�_ •o Iryd t Ca:se taM t-ry LPN•IDr t�#t
tt tIM Ott a D.
- F2)2X10 HEADER NE
GROUND SNOW LOAD 45 PSI
W h .ice awe-N-.Mn d trs
-
� MPH
g WIND SPEED 130
SEISMIC DESIGN CATEGORY B
�...� I.I�ECt(r.Ui- a Enn-.:
------- --- p 'pl WEATHERING SEVERE
Z 90° METAL BRACKET
* * FROST LINE DEPTH 36"
^' io A y� TERMITE THREAT MODERATE TO HEAVY
�L )
Future Secfion'3 's o4
noN'or tcrmeriY Gusm I o.� ._
r DECAY SLIGHT TO MODERATE
n WINTER DESIGN TEMP. 11
eo,ty Corp. � s moo. ��<3.
r 2X4 CORNER BRACE �" _
owQ ,E.�w�,NE FLOOD HAZARD AS NOTED
a 3
All, 77006
rY1 'b+n.fy 1 921 ��i_ c^ 9^(� wo Q�r
_ 6X6 TYPICAL NO.2 PINE POST
-�� -� � '��FESSIONP
�9 -�J� ra y �. wQd* 1
per• no. no 'J 4.
1X6 TREX DECKING
S n °ryeMc I ~� �o°-y ' Crey�Mt.React,C
oa q
1 r a NwrFR„�. 8 P� _ DRAFTED:10/11/23
2X6 RIM JOIST REVISED:
it 01•' --
REVISED:
---t
1
.art l "� U":t ANCHOR BRACKET REVISED.
SUN r1..re•
GRADE
N,asD NOT OKLARAT110%OF COVENANTS ArO RWR ICT�O NS A
((NAS BEEN FLED IN THE SUFFOLK COUNT(CLERKS
OFFICE MNCN CTS LOTS 1�111S SUBDIVISION l
--- 14 SONOTUBE PIER
""`"` "''' 'N LL417A CP� MIN. 36" BELOW GRADE CONTACT INFORMATION
ON 24X24X6 PC FOOTING
MIKE AGNONE,HOA PRESIDENT (516)532-3648
FLAVIO YANZA,BUILDER (631)949-5376
LOUIS SCHWARTZ,ENGINEER (631)839-4824
e I HUCK HIRSCH,DRAFTSMAN (646)416-4096
2 SUMMIT ESTATES GAZEBO - SITE PLAN 4 SUMMIT ESTATES GAZEBO - ELEVATION :t. , j. 1 s I
Scale: NTS Scale: 1/4"=1'0"
DATA _ -0 -
- - A_ l
i "AS BUILT"
i
O UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW.(2)DISTANCES SHOWN HEREON FROM PROPERTY LINES TO EXISTING STRUCTURES ARE FOR A SPECIFIC PURPOSE AND ARE NOT TO BE USED TO ESTABLISH PROPERTY LINES IOR FOR ERECTION OF FENCES.(3)COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY.(4)CERTIFICATION INDICATED
]HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY,GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON,AND TO THE ASSIGNEES OF THE LENDING INSTITUTION.CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDIIIONAiL INSTITUTIONS OR SUBSEQUENT OWNERS. (5)THE LOCATION OF WELLS(W),SEPTIC TANKS(ST)6 CESSPOOLS(CP)SHOWN HEREON ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS.
400 Ostrander Avenue, Riverhead, New York IIQOI
tel. 631.-72-7.2303 fax. 631.72-1.0144
00,' adminoyoungengineering.com
S
•
4to
Howard N. Young, Land Surveyor
t, Thomas 0. Nolpert, Professional Engineer
3 ! v Douglas E. Adams, Professional Engineer
Daniel A. Weaver, Land Surveyor
N / x SITE DATA
Lot
34 r AREA = 1.7779 ACRES
No „Summit Fs d'v'sion- r
a=� Suff co File No l�ti°n 3„ r r ,�
/
�69 r Lot
1 r * SUBDIVISION-"SUMMIT ESTATES,SECTION P FILED IN THE OFFICE OF/ THE CLERK OF SUFFOLK COUNTY ON NOV.4,1993 AS MAP NO.9426
_ Sub v-
Cleave di lsiot7-
/ s !
I � ! \_ s3 ; Suff. Co FP e�OManor„ rr r
6-51'12„F 11624 Lot,2SUb I l
„Cleaves plvrslpn
1 1 Lot 3
s7-ONE 1_ __\ ` Su fir Co, bile No 1�6�„ ! „C/eavubd vrs°n- r
�1 4 / es P /
m `'_ CMF S oint
RCF BBC `\ rr tiff. Co F!l a N0 11624 rr „C/ Subd v s o r
'\ 60697,
o69 IR�F / Suff.�o�llent Manor„ l
\ r No.
11624 rr
fgsF E '� ____ Subdiv si Parcel 'CR r o
EN SkO _ r on_ „SummOpen Space 5o0p, SPF S36 51'Iz„E I
ON Fs a 200,0 r
`\ RFD MAP OF -5� t t Section 0
r
MMr-- ` °� p 50.0p,
S"C�z NQ' ¢n�L op O 57pNf H f�f 31I.1 SPF
12395 CA 939)
_ FRAME C SHfO
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RCF
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Subdivision_ „ Lot 3.3
uni
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Stiff. Co- File states 5. Section 4„
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4 � 7
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SURVEYOR'S CERTIFICATION
i A C ', /{ 9:� �...�'. ., y r• $MtRg ILJOCIp(f3
� JT r l._ *WE HEREBY CERTIFY TO SUMMIT ESTATE HOMEOWNERS
��- Jq� 1 `� t�l' ii �,>F� ASSOCIATION INC. THAT THIS SURVEY WAS PREPARED IN ACCORDANCE
< Pq WITH THE CODE OF PRACTICE FOR LAND SURVEYS ADOPTED BY THE NEW YORK
<°A ° TQ"r� N OF- �����ri'? �i�� STATE ASSOCIATION OF PROFESSIONAL LAND SURVEYORS.
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s�PoC, ' e� ?Al �Il { � R�Fl�v£y0Z IA
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(10
r^ 2,3;
M E T A"r1'V' T1 _
HOWARD W.YOUNG,N.•. L.S.NO. 893 ��` 45 ��'
DANIEL A.WEAVER,N.Y. .L.S.NO. 771
D S
os1 6a SURVEY FOR
h
��Py 0�"', �r�A'2 SUMMIT ESTATES HOMEOWNERS
PQ��oOa
�r ASSOCIATION INC.
PARCEL 'D', PARK & RECREATION AREA,
"SUMMIT ESTATES, SECTION 1"
E 3 1at East Marion, Town of Southold
o� Suffolk County, New York
M CERTIFIED SURVEY
i
r, .r._,......_.
> LEGEND
0
BBA = BELGIAN BLOCK APRON County Tax Map District 1000 Section 38 Block 07 Lot 12
oS BBC =BELGIAN BLLOCK CURB FIELD SURVEY OCT.24,2023
CLF =CHAIN LANK FENCE MAP PREPARED OCT.27,2023
CMF =CONCRETE MONUMENT FOUND
CMS =CONCRETE MONUIMENT SET Record of Revisions
CID =CONCRETE PAVEMENT REVISION DATE
OL =ON PROPIERTY LINE
PVCF =I PVC FENCE
RCF =REBAR Q C:AP FOUND
SPF =SPI:KE FOUND
SPS =,SPIKE SET
WIF =W:IRE FENCE
WSF =WOOD STAKE FOUND
WSS =WOOD STAKE SET v
xX =L7IGHT POLE
m • =END OF DIRECTIONADISTANCE
60 0 30 60 120 180
Scale: V = 60'
JOB NO.2023-0201
DWG. 2023_0201_cs 1 OF 1
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TH15 NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN:TRSUSTEES.OFFICE,TOINN OF.'SOUTHOLD
EE"--S-
SOUTH! OL* D' TRUST
"
OUTHOLD, NY. 11971 --
TE L..: '76.5-1892 ;.
Glenn Goldsmith;Prey ��o��SUFFO(,�cOGy Town Hall Annex
A.Nicholas Krupski,Vice President :`c 54375 Route 25
Eric Sepenoski P.O.Box 1179
Liz Gillooly �y O� Southold,NY 11971
Joseph Finora � ��� Telephone(631)765-1892
Fax(631)765-6641
Southold Town Board of Trustees
Field Inspection Report
Date/Time: Completed in field by: ��� ✓�
SUMMIT ESTATES HOMEOWNERS ASSOCIATION INC requests an Administrative
Permit for the as-built 12' x 12' gazebo. Located: Parcel "D", Shipyard Lane, East
Marion. SCTM# 1000-38-7-12
Type of area to be impacted:
✓Saltwater Wetland Freshwater Wetland Sound may
Part of Town Code proposed work falls under: rapt. 275 Chapt. 111 other
Type of Application: Wetland Coastal Erosion Amendment
✓Administrative Emergency Pre-Submission Violation
Notice of Hearing card posted on property: Yes No ✓ Not Applicable
Info needed/Modifications/Conditions/Etc.:
Present Were: G. Goldsmith N. Krupski ---"E. Sepenoski
L. Gillooly J. Finora
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OFFICE LOCATION: ��oF soUryo MAILING ADDRESS:
Town Hall Annex ,`O l0 P.O. Box 1179
54375 State Route 25 Southold, NY 11971
(cor.Main Rd. &Youngs Ave.) N Telephone: 631 765-1938
Southold,NY 11971 G 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: February 5, 2026
Re: LWRP Coastal Consistency Review
SUMMIT ESTATES HOMEOWNERS ASSOCIATION INC, SCTM# 1000-38.-7-12
This application is for the as-built 12' x 12' gazebo.
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 INCONSISTENT
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.
y.
The proposed plan includes actions which are inconsistent with the "Administrative
Permit" requirements of Chapter §275-2 A of the Wetlands Law of the Town of Southold
which do not 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, or(I) Decks.
In this case, the as-built structure is not associated with a single-family dwelling and the
structure does not meet the definition of a "deck" in Chapter §275-2 which defines a
deck as: "A structure and/or platform without a roof that is either freestanding or
attached to a building supported by pillars and/or posts constructed of various
materials."
The proposed action has been reviewed to Chapter§268, Waterfront Consistency
Review of the Town of Southold Town Code and the Local Waterfront Revitalization
Program (LWRP) Policy Standards.
2
�a 5
Scott A. RussE__ °S` '� S"a JRM'V AVER
SUPERVISOR
MANAdGrIEM}ENT ,
SOUTHOLD TOWN HALL-P.O.Box 1179 r
SS09,5 Main Road-SOUTHOLD,NEW PORK 11971 Town of
Southold
CHAPTER 236 - STORMWATER MANAGEMENT REFERRAL,FORM
( APPLICANT INFORMATION TO BE COMPLETED BY THE APPLICANT _
ONLY FOR PROPERTIES ONE ACRE IN AREA OR LARGER. ) fit
APPLICANT: (Property Owner, Design Professional, Agent, Contractor Other)
� NAME: h�Di4 �2rzs, ,
tm 1.L_ 4M NX�i_ Date:
�t Contact Information: —-Ar-ra � �„ �,
f# Q:-Mad&1elepham NumW)
Property.Address / Location of Construction Site: it
f . ,t1 nA M IT- RSa tag riS 1�4�6. o�vANZA S.C.T.M. #: 1000
i District
Ono _< <
!I ���Ipn Adl Q rJ v
d Section Block Lot
d
i TO BE COMPLETED BY SOUTHOLD TOWN ENGINEERING DEPARTMENT
!
Area of Disturbance Is less than 1 Acre, No S.P.D.E.S. Permit is Required!
Project does Not Discharge to Waters of the State. No S.P.D.E.S. Permit is Required! o
�] - .Area of Disturbance is Greater than 1 Acre&Storm-water Runoff Discharges Directly
i t to Waters of the State of New York. THE APPLICANT MUST OBTAIN a S.P.D.E.S. Permit ;(
DIRECTLY From N.Y.S. D.E.C. Prior to Issuance of a Building Permit.
Area of Disturbance is Greater than 1 Acre& Storm-water Runoff Flows Through Southold
E' li Town's UIS4 Systems to Waters of the State of New Mork. THE APPLICANT MUST OBTAIN
41
jo# a S.P.D.E.S. Permit through the Southold Town Engineering Department
Prior to Issuance of a Building Permit.
l del ,
if
ai+l ��� Date: .3 l
Re��leH�ed by:
Fr1R M • CMr P-Tr1C o_tnhPt 7n in
C V �
y
Glenn Goldsmith,President ®F S®(/I� Town Hall Annex
A. Nicholas Krupski,Vice President ,`O ®�® 54375 Route 25
P.O. Box 1179
Eric Sepenoski Southold, New York 11971
Liz Gillooly G Telephone(631) 765-1892
Elizabeth Peeples Fax(631) 765-6641
co
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
This Section For Office Use Only
ff ffJ�.
Coastal Erosion Permit Application
Wetland Permit Application
' Administrative Permit r~ 9
J A N 1 2 zoo
Amendment/Tran sfer/Extens io
Received Application: I/ 0- a- — --.
Received Fee: $ Soo • o c S:)Atnlo To�vn
Soary o`Fruslees
Completed Application:
Incomplete:
SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec.
Lead Agency Determination Date:
Coordination:(date sent):
�( LWRP Consistency Assessment Form Sent:
CAC Referral Sent:
�C Date of Inspection: [k-t' (,
Receipt of CAC Report:
Technical Review:
�( Public Hearing Held: OL h 1
Resolution:
Owner(s) Legal Name of Property (as shown on Deed): SO d►l WL t i -SY6c1rT�,S ��
Mailing Address: '17, O , i�>o K 7 7 9 64-5q—
Phone Number: — (�IL) S-,-U—34.!�b ��<C�
Suffolk County Tax Map Number: 1000 - v gi -- 07 /Z
Property Location: IbAfi (Z L. 1)
(If necessary, provide LILCO Polle/#, distance to cross streets, and location)
AGENT (If applicable):
Mailing Address:
Phone Number: Email:
Lrd of Trustees Applicati-
GENERAL DATA
Land Area(in square feet): 4C. &J
Area Zoning: C f ^I 7 7 9 A.C,Rd,S
Previous use of property: PAAkl 4- (?,6_0 lZk A-r-C o J
Intended use of property: )
Covenants and Restrictions on property? Yes No
If"Yes", please provide a copy.
Will this project require a Building Permit as per Town Code? Yes No
If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review
and Elevation Plans will be required.
Does this project require a variance from the Zoning Board of Appeals? Yes No
If"Yes", please provide copy of decision.
Will this project require any demolition as per Town Code or as determined by the Building Dept.?
Yes �J _No
Does the structure (s) on property have a valid Certificate of Occupancy? Yes_1)(_No
Prior permits/approvals for site improvements:
Agency Date
No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency? No Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
ird of Trustees Applicati
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: + (uZ `k toji
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? Y—No Yes
If yes, how much material will be excavated? --" cubic yards
How much material will be filled? cubic yards
Depth of which material will be removed or deposited: 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):
d�
61 Z20
Appendix B
Short Environmental Assessment Form
Instructions for CompletinjZ
Part l -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses
become part of the application for approval or funding,are subject to public review,and may be subject to further verification.
Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully
respond to any item,please answer as thoroughly as possible based on current information.
Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful
to the lead agency;attach additional pages as necessary to supplement any item.
Part 1 -Project and Sponsor Information
Name of Action or Project:
Project Location(describe,and attach a location map):
Brief Description of Proposed Action:
Name of Applicant or Sponsor: kE-Mail:
elephone: 3-L—3L�t
•h,L KXL �W i7'*�i
Address:
City/PO: State: Zip Code:
tz A'T- /-N) C M 3�
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. Check all land uses that occur on,adjoining and near the proposed action.
Urban ❑Rural(non-agriculture) ❑Industrial [—]Commercial El Residential(suburban)
❑Forest ❑Agriculture El Aquatic ❑Other(specify):
b&arkland
Page 1 of 4
5. Is the proposed action, NO YES N/A
a. A permitted use under the zoning regulations? El ❑
b.Consistent with the adopted comprehensive plan? ❑ 9 ❑
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: ® ❑
8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES
b.Are public transportation service(s)available at or near the site of the proposed action? 40
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 1/1 7 ❑
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: El
10. Will the proposed action connect to an existing public/private water supply? NO YES
If No,describe method for providing potable water: [A ❑
11.Will the proposed action connect to existing wastewater utilities? NO YES
If No,describe method for providing wastewater treatment: ❑
12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES
Places?
b.Is the proposed action located in an archeological sensitive area? ❑
13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES
wetlands or other waterbodies regulated by a federal,state or local agency? ❑
b. Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑
If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres:
14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply:
-Shoreline ❑Forest Agricultural/grasslands ❑Early mid-successional
❑ Wetland ❑Urban ❑Suburban
15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES
by the State or Federal government as threatened or endangered? ( ❑
16.is the project site located in the 100 year flood plain? NO YES
17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES
If Yes, " ❑a.Will storm water discharges flow to adjacent properties? ❑NO DYES
b. Will storm water discharges be directed to established conveyance systems(runoff and storm drains)?
If Yes,briefly describe: ❑NO AYES
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: ( V-AJ.- -,AJ-0,4 Date: I d>1+ /ZS'
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?
3. Will the proposed action impair the character or quality of the existing community? ❑
4. Will the proposed action have an impact on the environmental characteristics that caused the ❑
establishment of a Critical Environmental Area(CEA)?
5. Will the proposed action result in an adverse change in the existing level of traffic or ❑
affect existing infrastructure for mass transit,biking or walkway?
6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑
reasonably available energy conservation or renewable energy opportunities?
7. Will the proposed action impact existing:
a.public/private water supplies?
b.public/private wastewater treatment utilities?
8. Will the proposed action impair the character or quality of important historic,archaeological, n
architectural or aesthetic resources? 1_J
9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑
waterbodies,groundwater,air quality,flora and fauna)?
Page 3 of 4
No,or Moderate
small to large
impact impact
may may
occur occur
10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage �j ❑
problems? Li�!k
11. Will the proposed action create a hazard to environmental resources or human health?
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.
❑ Check this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action may result in one or more potentially large or significant adverse impacts and an
environmental impact statement is required.
Check this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
Town of Southold-Board of Trustees
Name of Lead 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
and of Trustees Applicatj
AFFIDAVIT
BEING DULY SWORN
DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN
ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT
ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION
AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES.
THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE
BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES
AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF
GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE
TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE
CONSERVATION ADVISORY COUNCIL, TO ENTER ONTO MY PROPERTY TO
INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION,
INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF
TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE
COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL
EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM
OF THE PERMIT.
Signature of Property Owner Signature of Property Owner
SWORN TO BEFORE ME THIS DAY OF , 20
Notary Public
APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of
this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is
necessary to avoid same.
YOUR NAME: A,, (��Q �il. ►"7�4V� �'
(Last name,first name,qiiddle initial,unless you are applying in the name of
someone else or other entity,such as a company.If so,indicate.the.other
person's or company's name.)
NAME OF APPLICATION: (Check all that apply.)
Tax grievance Building �.
Variance Trustee
Change of Zone Coastal Erosion
Approval of plat Mooring
Exemption from'plat or official map Planning
Other
(If"Other',name the activity.)
Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship.with any officer or employee
of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business,
including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation
in which the town officer or employee owns more than 5%of the shares.
YES _ NO
If you answered"YES",complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of Southold
Title or position of that person
Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check
the appropriate line A)through D)and/or describe in the space provided.
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply):
A)the owner of greater than 5%of the shares of the corporate stock of the applicant
(when the applicant is a corporation);
B)the legal orbeneficial owner of any interest in a non-corporate entity(when the
applicant is not a corporation);
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this day of 200_
Signature.
Print Name
Form TS l
Town of Southold
LWRP CONSISTENCY ASSESSMENT FORM
A. INSTRUCTIONS
1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for
proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This
assessment is intended to supplement other information used by a Town of Southold agency in
making a determination of consistency. *Except minor exempt actions including Building Permits
and other ministerial permits not located within the Coastal Erosion Hazard Area.
2. Before answering the questions in Section C, the preparer of this form should review the exempt
minor action list, policies and explanations of each policy contained in the Town of Southold Local
Waterfront Revitalization Program. A proposed action will be evaluated as to its significant
beneficial and adverse effects upon the-coastal area(which includes all of Southold Town).
3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will
affect the achievement of the LWRP policy standards and conditions contained in the consistency
review law. Thus, each answer must be explained in detail, listing both supporting and non-
supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and
conditions,it shall not be undertaken.
A copy of the LWRP is available in the following places: online at the Town of Southold's
website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all
local libraries and the Town Clerk's office.
B. DESCRIPTION OF SITE AND PROPOSED ACTION
SCTM# - & '? - I —U�-
PROJECT NAME CA Z VX,-0 su�,tin A `,--r
The Application has been submitted to(check appropriate response):
Town Board ❑ Planning Board❑ Building Dept. IN Board of Trustees
1. Category of Town of Southold agency action(check appropriate response):
(a) Action undertaken directly by Town agency(e.g. capital ❑
construction,planning activity, agency regulation,land transaction) ❑
(b) Financial assistance(e.g. grant, loan,subsidy)
(c) Permit, approval, license,certification: ❑
Nature and extent of action:
Location of action:
Site acreage: �,11 q
Present land use: Q A-(l-)Z- PK ACA L 'b GIRO"(O 1!l
Present'zoning classification: Pf4l S Q-ge—'
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: 1- t-t-ffke2A-- "V--i cD N i,
(b) Mailing address: ` Q,
(c) Telephone number: Area Code( , )
(d) Application number, if any: N
Will the action be directly undertaken,require funding, or approval by a state or federal agency?
Yes ❑ No ICI If yes, which state or federal agency?
C. Evaluate the project to the following policies by analyzing how the project will further support or
not support the policies. Provide all proposed Best Management Practices that will further each policy.
Incomplete answers will require that the form be returned for completion.
DEVELOPED COAST POLICY
Policy 1. Foster a pattern of development in the Town of Southold that enhances community character,
preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and
minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation
criteria.
❑YesO—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
❑ YegNo ❑ 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 F�ot 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&�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 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.
❑ ❑ K
Yes No Not AL gable
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 XNot 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 of 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.ElYe n No�ot Applicable
Attach additional sheets if necessary
WORKING COAST POLIO'_
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 ❑ No Not Applicable
Attach additional sheets if necessary
Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic
Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria.
❑ Yes ❑ No 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�ot 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 DATE