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HomeMy WebLinkAboutTR-10929A SOfFO(�- Glenn Goldsmith,President 0�0 . COG Town Hall Annex A.Nicholas Krupski,Vice President may` yJ, 54375 Route 25 Eric Sepenoski H P.O.Box 1179 Liz Gillooly F Southold,NY 11971 Qv Joseph Finora Telephone(631)765-1892 �Clt �a 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 % constructed Project complete, compliance inspection Glenn Goldsmith,President QF S0 Town Hall Annex 01 Nicholas Krupski,Vice President ��� O1O 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly G Telephone(631) 765-1892 Joseph Finora Fax(631) 765-6641 coUNT'I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10929A Date of Receipt of Application: March 3, 2026 Applicant: Rudolfo David Cifuentes SCTM#: 1000-121-4-21 Project Location: 2035 Laurel Way, Mattituck Date of Resolution/Issuance: March 18, 2026 Date of Expiration: March 18, 2029 Reviewed by: Board of Trustees Project Description: Remove as-built retaining walls and fill; revegetate with native species. 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 Kehl Design Associates, Inc., received on March 3, 2026, and stamped approved on March 18, 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. Glenn Goldsmith, President Board of Trustees SITE PLAN N OF PROPERTY �'�?4� c7� KEIII DESIGN"SnTES AT LAUREL '� G N BRADLEYO JFBELZ 233I ��e.aa a a� 0 NC. PAD ;�, SHED JANET B BELZ FEN.END �� CMF a/ 1 T WN OF SOUTHOLD smF�, 00*" S UFFOLK COUNTY N. Y. T 2.4'S d s ,�Y�>»� �j• ���' SHED 2a 3 SPLIT RAIL-� I i m...a .nP ma�.aa•eUan. "w. 1000-121—04-21 0.2'S FEN. e* I FEN.END '�•°�°��" ^P'••"°•° c / j O 3.2'E s u". Fa�m.n ww SCALE: SEE BELOW sk .E o a �/ „,.,„�. �„.„�.,,,„Mw , aam TOTAL LOT SIZE _ .335 ACRE Re�9ecb4 T SHORE LINE 12•�p' ofSNED 1 � a/ Q Q o e 10'ffG Q UMo wi 1 OR 14,586 SQFT 5• Leo s N Gee o� / i 0 aorxeoFr Fins wr Far ff re+oa�.Four WETLAND AREA= 3253.65 S FT. CHIMNEY I• AC .� ,�, I Q I Fnr�eF"Feauan��uFu"sMooF�oaNsx Q - i,.;" WOOD 1`L' �% d I 0 4 SH ROM T WL KM A49oAtS+Ut.X W ff UPLAND AREA= 11,332.35 SQ. FT. ❑ UMM UNIT ' ;11'`?.° ' : �: CO STEPS E�'' �� / Y Q UMYV FdI WMM GE MW BFMCF "' UNDER GROUND I '"� ''`'' ='} Nc / CONC&BRICK I s 1 STY. FRAMED HOUSE :•' i-:?'°° d I Q `� ei R., ;. 9� �� 6 / UTILITY I a Ie.o.orw.a.yw.oFs.�wn�b CQ 'att +., Oy c ��, ��' ^ge ROOM—PUMP HOUSW i q W N'�d'w"aN'ii A TmWk .a. �� ' •al;?;'ti`•,w" OwWm4=FBN& Vot d COOK OWK J r r' Mll ij:c f r d , I .w npirb.r d mY.e.cr Ties 6x6 CCA Ties TO Be Removed , «:§. I OV T^: c iN?t+ate'' Z i Q iw/ O L.I..SHORE LINE �;, ;a `� QJ °F. w I o W ;.5: M PROPANE o w5f"" :sr:.•.,• r.. TANKS I FLAG LOCATION PROVIDED FOR �W. ��" `� u= {`t � Y 9 � ET INING �" 0 4 �,t �."....±: - �``• 0 WALL I (n BY THE D.E.C. J �c J, �S`, 2F, �\ : r. FLAG POINT LOCATION ONC. � o t LOCATION A B C D cK BLOCK BIN J _,, .�.... x.'!;*!x' :: ,F.:;3r�:: STEPS `c `+ 0 1 36.5 35.0 ,� �� �' •` -�. `':;_�; Via. , r 29•_ 2 9.4 30.5 w o00 oc 3 12.5 7.75 Q�P��° CMF q 5 37.1 33.1 Q �`L tK KEY fly 1�.;��'' _ ;'� = ;:? . 5 = NATIVE BUTTON BUSH (CEPHALANTHUS OCC/DENTALIS) +�� '' 0 '"'O¢,a --/ ` M ' ''�"r s "D' O 6+ 0 O, -J I • = SOFT RUSH (JUNCOS EFFUSUS), LURID SEDGE (CAREX L URIDA), PROJWT- ,���� e e� -%-- - - (0-') 2 �\�� SHORE LINE -�/- CIFUENTES TUSSOCK SEDGE (CAREX STR/CTA) \" , / 1 = BLUE FLAG IRIS (IRIS VERSICOLOR) rF: CATWALK rr'-�- „ N 0 _ p `�`� AMROG--LA -LA c ;' , RESIDENCE = SHADED AREA— LOCATION WHERE FILL ��CY 511•�p A��' 'fit ---=— t^` 2035 IS TO BE REMOVED TO NATIVE SOIL LAUREL WAY AND PLANTED AS NOTED ON PLAN r_`5232 °oGK CMF BOARD OF 1 RUSTEES MAR 3 ?, „ MATTITUCK,NY,11952 1 = DEC WETLANDS FLAG aN TOWN OF SOUTHOLD SCTM:#1000-121-04-21 Q = REBAR ^ CONDITIONS TO BE ® = WELL DATE�� I / �O g RESTORED AS NOTED = STAKE SHORE LINE MEMFf3f�ffi,F,aawxFFff7,fx At 0 RF1RfA"NIIXLM Ff�eFuuw F zwt : ac..ftsau LK F!"ffEbF7'FLO�Efa fLRt pa fw pIF�IIIN{ Fl A,11Fld � = TEST HOLE - � o�N � F y F °iiA�nismFens�r • = PIPE .__. ■ = MONUMENT SITE PLAN INFORMA77ON IS BASED S Y = WETLAND FLAG > > > > > > > > > > ' PREPARED BY PECONIC SURVEYOR , WK `�, = UnL/TY POLE 0 10 20 30 40 50 60 70 80 90 100 , P.O. BOX 909 - 12J0 TRAVELER STREET ,p 0 1 V SOUTHOLD, N.Y. 11971 OFESSI SP-1 (631) 765-5020 FAX (631) 765-1797 ELEVA77ONS REFERENCED TO AN ASSUMED DATUM. N.Y.S. L/C. NO. 49618 SURVEY DATED FEBRUARY 2, 2021 o®e,u®aeOSsoa+M. . .S TH'OLD R E ou . T IUSTI ES No. l oq a� A Issued T lk"AAO, baw:A C; �uesil"es Date Address JOSS .THIS. NOTICE MUST BE DISPLAYED DURING CONSTRUCTION .TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765-1892 Glenn Goldsmith,President ti S f OG Town Hall Annex A.Nicholas Krupski,Vice President �.�'`� �� 54375 Route 25 Eric Sepenoski N ?�j` P.O.Box 1179 Liz Gillooly 41, Southold,NY 11971 Joseph Finora �� �a � Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 34Z/26 Completed in field by: G. Gam, US,,,A RUDOLFO DAVID CIFUENTES requests an Administrative Permit to remove as-built retaining walls and fill; revegetate with native species. Located: 2035 Laurel Way, Mattituck. SCTM# 1000-121-4-21 Type of area to be impacted: Saltwater Wetland ,/ Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: Ahapt. 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.: OK 40 cea,o% ►1 a2g j "fall 0"A Present Were: -/ G. Goldsmith N. Krupski E. Sepenoski L. Gillooly J. Finora SURVEY OF PROPERTY AT LAUREL CERTIFIED T0: TOWN OF SO UTHOLI) RODULFO DAVID CIFUENTES STEWART TITLE INSURANCE COMPANY SUFFOL COUNTY, . Y. SALZMAN SETTLEMENT 1000-121-04-21 SCALE.• 1'=30 N/o/F BRADLEY J BELZ NOVEMBER 9, 2004 3�I JANET B BELZ FEN.END EL. 23 CMF FEBRUARY 2, 2021 �+ 2.4's _ 0 SHED �2$ SPLIT RAIL SHED FEN. I r FEN.END O 0 3.2' SHORE LINE SHED r o WOOD 0 w STEPS E DER GROUND Z CONC&BRICK CONC. �6 �L5 0<\ UTILITY ROOM-PUM I a CHIM. ^�01 HOUSE w 0 W ui S� O� !. z o vu J� 92 F �S� V, U- p �✓ SHORE LINE own\r't O �6 o I2� pl\s. PROPANE BRICK z 00 O 0. TANKS RETAINING I V N 2 �� ��\ a.y O\ �N' 91 WALL WOOD O X 06 Gy RAMP °'� �O p( CONC. � �" � �1 � BRICK F' BLOCK BIN �' ��1 WOOD F� , BRICK RETAINING LL �f \ PLAT/DOCK STEPS WALL Zg 0 = �p CMF SHORE LINE,,,,-- ' MAR 3 2026 CATWALK i�' ,+� N/O/F r +pQ NAMROG LAUREL LAKE INC KEY POCK REBAR __ S71 Sc,rc,f T i,t�cs = �5232 CMF ® = WELL / / - ® = STAKE ® = TEST HOLE SHORE LINE '" � ,'�� j�' ✓).�t'`� • = PIPE ,r. 0 ,� q1 i 14��(•y Zi� + +yi f• x ■ _ MONUMENT ve t = WETLAND FLAG rQ, = UTILITY POLE F ..s `,�r` . Y.S. LIC. NO. 49618 ELEVATIONS REFERENCED TO AN ASSUMED DATUM. U ORS, P.C. ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION. OF SECTION 7209 OF THE NEW (631) 765-5020 FAX (637) 765-179-7 YORK STATE" EDUCATION LAW. EXCEPT AS PER SECTION 7209—SUBDIVISION 2. ALL CERTIFICATIONS AREA 14,586 SQ. FT. P.O. BOX 909 HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF SAID MAP OR COPIES BEAR THE 1230 TRAVELER STREET Q IMPRESSED SEAL OF THE SURVEYOR WHOSE SIGNATURE APPEARS HEREON. SOUTHOLD, N. Y. 11971 04_28 0 sr, t Al C115- j I R mot'!' ,,yyam� ,:jy• "'•���r-.1 - t ei .V A J Pt • r it 1 r`.. •�• a.'ti � �� �"��}.h.•�i�'�ti � ,� ,sue,.f fe jy s y `► ��, •Tj� � :/.�� -i 1• 6' rR• Y, =fit`f- kol 14 4 of fp 1 r Y r '1 t 9 y, '-,w�s�tul ey S, •!1,.,ya'`4i y�`E,�f' 4 Y- 5 �'•i _.._.....+,�•— ",�,., �� �4 � `,�. �6 ..� «a 'w III Ilk lob o re pkit �• $F tlS.p 41 ti �w s f y iPt,er.1 OlAkd � p� ,;�M�1 "•Z rsSr "M. �� °Ii ►e 7�" e .yam , ` - �., ems'.''y.. •,ru.'v�., ,�P - r '` s�,'* • Y'. �. `' .- '„I�4,.tom., • j n �! •��• .�• try �` i ' ..'.!ry shy �. ti +. I. P +� f� + � •� 4 r��. (1;1�3 L r {.� 01. ti 'IN jw 1 • y 0t, R' +, oi` tom. Sent from my Whone mass \ asaaae \ mteA] � 6EE 9EC.MD.,13 PECgIN:IAHL IR T �,ot roR rci.NO. ma.m txima, - m.aaa ?wa owes. m,em t ii. p.res'� xux, eesem 19 ee460] a9\ �' a .e Aa a $aJ pvl �� �� ,.e O a.]e aw � tw`� � AVE m ata . A 31 ew ow mate ° as ,W E u zoe � ,a.nte arg vEcawc wo musr r] �0^ 3- „ 6.sr, u ,b/yrl taunt ^'W laMyc, 0.wo N aNE. .s 'uO Cam' COnMfr 6 ealFFgl( 54 \ u 2. \ •un own 102 } ,J ].1 \ • COUNIr Or SUFFOUt t 0.a \ > ® s eta \1 dsl' \ \y� `� `� O • CWMTY OF Q�O \\ SUFFOI,t ,l � ar \\ • iI t a mwNar sourno,n i ma e ^ �pp 11. wwxw[,veN I to$H r �� z \ cawTra surrouc I ,� ,s p ,.sn „ earF0.xCWNry I MMTERAUTHLRnY 14 \ N �2A ]a ' „ \ ant a.Nq Zz 0 x ran vu xo / . 3E�SE�NO ' e LAUREL LAKE IS e I wx NO. I sEEsEs—No. u Nma stE eEc,a.to -uE wTp aEe sEc.xo to sEE uNE sEc ra.ta Nonce 'tit COUNTY OF SUFFOLK © N v: a p sEcrax NO J � E E ,,_,,,� �,�, °,,,�� `Real Property Tax Service Agency r ,a wa w..NNr.nrns, ^,m 121 p v, m •,„,"° t� vxovearr unv � OFFICE LOCATION: � 0�SDUPyO MAILING ADDRESS: Town Hall Annex �� l0 P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) Southold, NY 11971 CAR • Q Telephone: 631 765-1938 olyc4U ,� 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: March 10, 2026 Re: LWRP Coastal Consistency Review RUDOLFO DAVID CIFUENTES, SCTM# 1000-121.4-21 This application is to remove as-built retaining walls and fill; revegetate with native species. 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. The proposed plan includes actions to restore an area of the property that was illegally filled by the applicant. Successful completion of this plan, including removing the retaining wall and all fill down to natural grade, followed by planting with the native species, will help to mitigate the damage caused by the applicant. As part of this permit, a permanent non-disturbance buffer should be established to prevent any further disturbance. 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. Hobson, Thomas From: David Cifuentes <rdcifuentes@aol.com> Sent: Monday, November 10, 2025 9:49 AM To: Goldsmith, Glenn; Krupski, Nick; Hobson,Thomas;Cantrell, Elizabeth; Peeples, Elizabeth Subject: Re:2035 Laurel Way, Mattituck Good day, I am writing you to inform you that the soil and wood removal at my home have been completed and the gradient has been brought to its natural level. Since the weather has turned, I will only be able to do the native plants planting in the spring of 2026. Please let me know if you have any questions. Warm regards, R David Cifuentes 2025 Laurel Way Mattituck NY 917-797-3172 Rdcifuentes@aol.com On Monday,August 18, 2025, 12:02 PM, David Cifuentes <rdcifuentes@aol.com>wrote: Dear Mr Goldsmith and trustees: It was a pleasure meeting you at my home in Laurel Lake. I will make sure that not native vegetation will be harmed during the removal of the retaining wall and fill material. My goal is to carefully start the removal of the fill first in order to not harm any surrounding native flora, and once the original grade has been reached, carefully remove the wall. The timeline should be to start the fill removal within the next 15 days and hopefully be done by the end of September, if not mid October. Once that has been accomplished, I will in proceed to plant some native flora species as recommended in the approved plans by_the NYSDEC, such as cotton bush, native ferns and native grass. This should be the second half of the restoration, hopefully will be done by November 1 st. If you have any other recommendations regarding the native species, I will be very happy to hear them. Sincerely, R David Cifuentes 917-797-3172 rdcifuentes@aol.com On Saturday, August 16, 2025 at 10:06:35 AM EDT, Goldsmith, Glenn <glenn.goldsmith @town.southo Id.ny.us>wrote: i 1 Dear Mr. Cifuentes, Thank you for taking the time to meet with the Trustees at your property (2035 Laurel Way, Mattituck) on August 6, 2025. 1 appreciated the opportunity to discuss the current site conditions and the necessary steps moving forward. As we discussed in the field, the retaining wall and fill material surrounding your house were installed without the required approvals, to the detriment of the wetlands and marine environment surrounding Laurel Lake, and must be removed. The area should be restored to its original natural grade and condition by removing the illegally built retaining wall and removal of all fill. During the removal and restoration process, care must be taken to ensure that no existing native vegetation is disturbed. Preserving the native plants is essential for the stability and ecological integrity of the area. Please confirm your proposed timeline for completing this work, and inform the Trustee office as such. Please contact the office if you have any further questions. Thank you for your cooperation. Sincerely, Glenn Goldsmith President Board of Trustees z Hobson, Thomas From: Cantrell, Elizabeth Sent: Friday,April 11, 2025 10:59 AM To: Hobson,Thomas Subject: FW:Wetland violation 2035 laurel way laurel Eliza6eth Cantrell Administrative Assistant Town of Southold Board of Trustees , Phone: (631)765-1892 Fax: (631) 765-6641 From: Krupski, Nick<nickk@southoldtownny.gov> Sent:Wednesday,April 9,2025 8:10 PM To: Cantrell, Elizabeth <elizabethc@town.southold.ny.us> Cc: rob.marsh@dec.ny.gov; Goldsmith,Glenn<glenn.goldsmith@town.southold.ny.us> Subject:Wetland violation 2035 laurel way laurel" Good afternoon, This house located 2035 laurel way in laurel sold a few years ago, at the time of sale the new homeowners cleaned up some of the walkways and made a parking space up by the road.The buyers were well aware that they purchased a very seasonal home that was surrounded and on top of the wetlands surrounding laurel lake. I Today on field inspections we noticed from the adjacent property that the homeowners had installed a retaining wall along the entire seaward side of the home, brought in enough fill and topsoil to level out the rear yard to the point where the existing catwalk over the wetland was no longer required and grass was planted., Liz- Please send the bay constables for clearing, and covering wetlands, retaining wall and fill without a permit ideally all separate violations.All of which should come out and a restoration should be completed. Rob I have cc'd you here so DEC can take a look. For a small site on a critical habitat it's pretty bad. Before and after photos below 1 r y w z Glenn Goldsmith, President so Town Hall Annex 54375 Route 25 Nicholas Krupski,Vice President ��Vu ®�® P.O. Box 1179 Eric Sepenoski AW Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Joseph Finora � �� Fax(631) 765-6641 C®UHlT`4,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application �•'- 4-- F � f ! Wetland Permit Application '; (—Administrative Permit Sf `�''� PEAR 3 2026 Amendment/Transfer/Extension d X Received Application: 313 _:____ X Received Fee: $ S 0 6 _ op oar(,of i os!eE Board ofinis!ees 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: 213), CAC Referral Sent: Date of Inspection: Receipt of CAC Report: Technical Review: k Public Hearing Held: Resolution: Owner(s) Legal Name of Property (as shown on Deed): ROAD L 0 Qlfj,k�' 0-cfu2(,,3%ems Mailing Address: Phone Number: 9l`7 - 717- -9172 Suffolk County Tax Map Number: 1000 - 141 - 0'1 - Z I Property Location: 2035' I_AUAML. WAY . omiT!i Uc.iL (If necessary, provide LILCO Pole #, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Email: rd of Trustees Applicatic GENERAL DATA Land Area (in square feet): �� S6 i 07,tL L.o k S,ZF Area Zoning: i NF y N i iN L- S1 rq 9.0 - FAA41 c-\-I Previous use of property: BSI W-,,r F I�- ��I�lC,i-e FILM t L`J Intended use of property: S 7 tNF Aj—j 1 A L S i N Ue FA Nei 1 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 _X _No If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure (s) on property have a valid Certificate of Occupancy? Yes X 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? X No Yes If yes, provide explanation: Project Description (use attachments if necessary): F -d of Trustees Applicat .o WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: —F0 �SMOVgr F 1 10 LAC_E-ts bi rrvA®u—, A PPP og Ass� &iJS �1 s 'PE-tz. 5Ul3�", �� F' I� Area of wetlands on lot: 31,7ZJ3,-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: NIR feet Does the project involve excavation or filling?. No X Yes If yes, how much material will be excavated? [® cubic yards How much material will be filled? N r'+ cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: 12 2 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 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 -P,ject and Sponsor Information f ,,Name of Action or Project! Project Lo ation(describe,and attach a location map). &-L_-- Brief Description of Proposed Action: Name of Applicant or Sponsor:` Telephone• r14 e7 Y E-Mail. �C 9' Ad_dres_i { 2 City/ 0 State: Zip Code: 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordina ce, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that N 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 Residential(suburban) ❑forest ❑Agriculture ❑Aquatic ❑Other(specify): ❑Parkland Page 1 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? ❑ ❑ ❑ 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? � ❑ 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: `1 ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: O ❑ 1 I.Will the proposed action connect to existing wastewater utilities? n f NO YES If No,describe method for providing wastewater treatment: _ F V ❑ ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? F.771 ❑ 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? ❑ LLV 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 El Early mid-successional 0 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? F ❑ 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 ❑YES 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: N ❑ 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: ❑ 1 AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE =/,O— ` Applicant/spo i (� Sig — Date: ` /2..� na 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 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning IV] ❑ 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 El 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? FV 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, f� ❑ waterbodies,groundwater,air quality,flora and fauna)? L�1 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? R I El Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail, identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration, irreversibility,geographic scope and magnitude. Also consider the potential for short-term, long-term and cumulative impacts. 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 Rrd of Trustees Applicati AFFIDAVIT EING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHt IS THE A PLICANT 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 r Owner Signature of Property Owner SWORN TO BEFORE ME THIS 2r DAY OF M O ►-d) , 2051(.0 CONNIE D.BUNCH Notary Public,State of New York No.01 BU6185050 Qualified in Suffolk County Notary Public Commission Expires April 14,2 (� 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. f YOUR NAME: ' V (Last name,first name,ipiddle itial,unless you are app ying in th me of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,Marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted t day Signatur Print Name �-- S Form TS l v 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# _-�"�- PROJECT NAME 'f \ ® qAvk �'U The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate'response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity, agency regulation, land transaction) ❑ (b) Financial assistance(e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nature and extent of action: Location of action: ZO 'JP1aJ__ /u-F, � Lx'lt Site acreage: Present land use: Present zoning classification: 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: (b) Mailing address: (c) Telephone number: Area Code( ) (d) Application number, if any: /) A Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No N If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. ,/, ❑Yes ❑ No j/� 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 11 Yes ❑ NodLSWI 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 D 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 XNot 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. ❑ ❑ Yes No 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 T�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 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. ❑ YesEl No Not Applicable Attach additional sheets if necessary WORKING COAST POLICIEa Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. I�ee LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No V11 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 ❑ NoX 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 ❑ NOX 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 `A Not Applicable TLE DATE PREPARED BY �� h,hJv-1