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HomeMy WebLinkAboutTR-10946A Glenn Goldsmith,President s10foc�- ��0 COG Town Hall Annex A.Nicholas Krupski,Vice President =� y� 54375 Route 25 Eric Sepenoski y a P.O.Box 1179 Liz Gillooly • Southold,NY 11971 Joseph Finora 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 1st day of construction % constructed Project complete, compliance inspection Glenn Goldsmith,President QF S0(�T Town Hall Annex 01 Nicholas Krupski,Vice President ,`�� �I® P.O. Route 25 P.O. Box 1179 Eric Sepenoski J l Southold, New York 11971 Liz Gillooly G Telephone (631) 765-1892 Joseph Finora • a0 Fax(631) 765-6641 olycOU ,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10946A Date of Receipt of Application: March 30, 2026 Applicant: Paul & Joan Kustek SCTM#: 1000-76-3-5 Project Location: 1540 Smith Drive South, Southold Date of Resolution/Issuance: April 15, 2026 Date of Expiration: April 15, 2029 Reviewed by: Board of Trustees Project Description: As-built irregular shaped wood deck. 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 PJM Land Surveying, PLLC, received on March 30, 2026, and stamped approved on April 15, 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. '4- W. ip" Glenn Goldsmith, President Board of Trustees CERTIFICATIONS HEREON SIGNIFY THAT THIS PLAT OF PROPERTY IS A TRUE AND CORRECT REPRESENTATION OF A RECENT SURVEY MADE UNDER MY DIRECTION IN ACCORDANCE WITH THE EXISTING CODE OF PRACTICE FOR LAND SURVEYORS BY THE NEW YORK STATE ASSOCIATION OF PROFESSIONAL LAND SURVEYORS. SAID CERTIFICATIONS SHALL RUN ONLY TO THE PERSON WHOM THE SURVEY WAS PREPARED AND ON THEIR BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON.THIS CERTIFICATION IS ONLY FOR THE LANDS DESCRIBED HEREON, ITS NOT A CERTIFICATION OF TITLE, ZONING, _ OR FREEDOM FROM ENCUMBRANCES. CERTIFICATIONS ARE NOT NOT TRANSFERABLE TO ADDITIONAL OR SUBSEQUENT OWNERS. . 0.00 i 001 L�40' .",BOARD OF "! DUSTEES FE FE JO.WN. OF SOUTHOLD O.L.N/S O.L.E/W " 0.2'E °F FE DATE r 0.5'N , 5 ao1 ON N �� N VE M� O 00 9� o •• CqR•� 7 v oBLDG.2 x 2.9'N P/02 OT zq� 29 31 za, SHED 8 IA'S o P/O LOT .. SHED e W 41 FRAME O.L.N/S N o SI-IEDS /49• .61 3 zss, .h 1 STORY FRAME D WELLIN N N P/O LOT 42 P/O LOT 7 00 41 W LANDW N I• .,' BUFFER SIDE OF PROPER ES ZIGNMENT WjON TURF \ ` MAR 3 0 2026 ADJACENT eUCCAD 3 APPROX• HIGH Southold Town WATER Board of Trustees FLOATING r DOCK `'� 47-00,00pr uJ 13ULKF1EAD — � 12/7.S0, THE OFFSETS OR DIMENSIONS SHOWN FROM THE IMPROVEMENTS TO THE PROPERTY LINES ARE FOR A SPECIFIC PURPOSE AND USE,AND THEREFORE ARE NOT INTENDED TO BE USED AS A GUIDE IN THE ERECTION OF FENCES, WALLS, POOLS, PATIOS, BUILDINGS,ADDTIONS TO BUILDINGS OR ANY OTHER IMPROVEMENTS. SUBSURFACE AND ENVIORNMENTAL CONDITIONS NOT SHOWN. PROPERTY CORNER MARKERS WERE NOT SET AS A PART OF THIS SURVEY. EASEMENTS AND OR RIGHTS-OF-WAY OF RECORD, IF ANY, NOT SHOWN. PJM LAND SURVEYING, PLLC UNAUTHORIZED ALTERATION OR 132 CLYDE STREET/SUITE 16 ADDITION TO THIS SURVEY IS A WEST SAYVILLE, NY 11796 VIOLATION OF SECTION 7209 OF PHONE 631-563-0400 NEW YORK STATE EDUCATION LAW. FAX 631-563-5808 PJMSURVEYING AOL.COM LOT:P/O 41 &42 REVISIONS MAP OF: GOOSE NECK DECK ONLY 03/21/26 REVISED 03/28/26 FILED: NOVEMBER 22, 1948 NO: 1663 COUNTY: SUFFOLK SITUATE: BAYVIEW, TOWN OF SOUTHOLD COPIES OF THIS SURVEY MAP NOT CERTIFIED TO: TITLE NO-- ------ BEARING THE LAND SURVEYOR'S EMBOSSED SEAL AND SIGNATURE SHALL NOT BE CONSIDERED A TRUE AND VALID COPY PROJECT NO.:2015-58A DATE: 05/18/18 DRAWN:PM CHECKED BY:PM SCALE: 1'=40' DISTRICT: 1000 SECTION: 76 BLOCK: 03 LOT(S): 05 SOUTHOLD TRUSTEES No. 10 q 4 (a X Issued T&% Date Address ISLIO Srin ;�;. Dom:ve So,�i1r, , � o,�ti1,o I d THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION ,TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.:' 765-1892 Glenn Goldsmith,President ��o��S�FEOCk�OGy� Town Hall Annex A.Nicholas Krupski,Vice President a < 54375 Route 25 Eric Sepenoski w ? P.O.Box 1179 Liz Gillooly �y 0�� Southold,NY 11971 Joseph Finora � ��, Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: l �� Completed in field by: ��/U� PAUL & JOAN KUSTEK request an Administrative Permit for the as-built irregular shaped wood deck. Located: 1540 Smith Drive South, Southold. SCTM# 1000-76-3-5 Type area to be-impacted: V Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: k/Chapt. 275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: _ZYes No Not Applicable Info needed/Modifications/Conditions/Etc.: fS�, G� e hMr►i Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly A_,-'�J. Finora ,_ "--� _-.=---,_. I t/J _ us°''� /`•i 1 .-i�11 1 i•a.a �11'y;1� t�a�. i= �fk��'� " \r:--�• l; � -•`--,.,._ l r' " _—_Jy ` en •�. \�t> �\ ��� ____--�� - '`'< �. : I a 1 1 L� N. .-( \.y •� n1 yam\., � �� , as I 1 -fir ;. ! a ;� -../ � a ',• N•\ ' ; \r^\\�,> \' '��\ t � \t" �'. I ....1-_ ..! 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Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold,NY 11971 G • O Telephone: 631 765-1938 COU 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: April 13, 2026 Re: LWRP Coastal Consistency Review PAUL & JOAN KUSTEK, SCTM# 1000-76.-3-5 This application is for the as-built irregular shaped wood deck. 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 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)(d) Remodeling or renovation of a wetlands-permitted structure, provided that such activity will not have an undue adverse impact on the wetlands and tidal waters of the Town. 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 f` 1 Town Hall Annex Glenn Goldsmith,President 54375 Route 25 A.Nicholas Krupski,Vice President P.O.Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly Telephone(631).765-1892- Elizabeth Peeples Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only - r' Coastal Erosion Permit Application Wetland Permit Application gLill _Administrative Permit MAR 3 0 2026 1J .._Amendment/Transfer/Extension !c Received Application: Southold Town Received Fee $ © .. 06 _ Board of Trustees Completed Application:..::. _- Incomplete: SEQRA Classification: Type'! Type II Unlisted.: Negative Dec. Positive Dec_..., ._..., Lead Agency Determination Date: .... __Coordination:(date sent):.._ X— LWRP Consistency-Assessment Form Sent: 3 .sr ;u CAC Referral Sent: ........ k Date of inspection: fL _ ... Receipt of CAC Report:_ _Technical Review: X Public Hearing Held::.,Ll. [ S . -Resolution: ... Owner(s)Legal Name of Property (as shown on Deed): Paul and Joan Kustek Mailing Address: 743 Flowerdale Dr Seaford, NY 11783 Phone Number: 516-906 9306 Suffolk County Tax Map Number: 1000 -section 76..­block,03.-;lot 05 (PO..Lot 41...&.42) Property Location: 1540 Smith Dr. South, Southold, NY 234.5W south of Williams Rd (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT-(I-f-applicable): ` ......_ . . .,:.. Mailing Address ... Phone Number: Email.paulkustek@gmail.com. . Board of Trustees Application GENERAL-DATA Land Area(in square feet): 20,473.2 Area Zoning: .. _ _. ... . . . . Previous use of property:Single family residential Intended use of property: Single family residential Covenants and Restrictions on property? Yes =No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? JaYes ]allo If"Yes",be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review .and Elevation Plans willbe required._ Does this project require a variance from the Zoning Board of Appeals? =Yes _Z_No If"Yes",please provide copy of decision. is project re any demolition as per-Town Code or as determined by the Building Dept.? YesNo Does the structure(s) on property have a valid Certificate of Occupancy? Yes=No Prior.permits/appprovals 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?fl NoE Yes I_f.yes,provide explanation: Project Description(use attachments if necessary): A S ' u��� . .....t�� y v,�r^r- Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the roposed operations: FreJ/TF/f /l ` ilC' F P _ _.: .. ..... . ...... 641K 6 C IM 7 4PVc ` SQL. /0y en Area of wetlands on lot: square feet Percent coverage of lot:. .. . . ... .... _:;.% Closest distance between nearest existing structure and upland edge of wetlands: ..86 feet Closest distance between nearest proposed structure and upland edge of wetlands: 86 feet Does the project involve excavation or filling? LJ 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): 61-Z20 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 I 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]-Pr ct arty-Project and Sponsor Information Name of Action or Project: Refurbish existing permitted wood-deck Project Location(describe,and attach a location map): north and east side of existing building structure Brief Description ofProposed Action: Remove and replace all existing deck boards and replace with new. Remove steps in some areas and-replace with railings. Finish-deck off to-house on north side. Name of Applicant or Sponsor: Telephone: Paul kustek E-snail:pauikustek@gmail.com Address: .. _. Mailing: 743 Flowerdale Dr. ' City/PO: State: Zip Code: Seaford NY 11783 l.'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: Fv 3.a.Total acreage of the site of the proposed action? .47 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 11 land us at occur on,adjoining an ar the propqse4 action. Urban Rural(non-agriculture) Industrial Commercial 1 Residential(suburban) Forest ❑Agriculture HAquatic QOther(specify):.. Parkland Page 1 of 4 5, Is the proposed action, N.O 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 ofthe proposed action located in,or does-it adjoin,a state listed Critical Environmental Area? NO YES. If Yes,identify:. .... El El 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: .10. Will.the proposed action connect to an existing public/private water supply? :.NO If No,describe method for providing potable water: ✓ IF 11.Will the proposed action connect to existing wastewater utilities? NO YES.; If No,describe method for providing wastewater treatment.,... 1?. 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? Ell If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14.Kwetland ntify the typic bitat types that oc n,or are likely to be`found on tl}e�roject site. Check all that apply: Shoreline Forest Agricultural/grasslands uEarly mid-successional 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'' sources? NO . q, If Yes, a.Will storm water discharges flow to adjacent properties? ✓❑NO OYES b.Will storm water discharges be directed to established conveyance systems ff an�m drains)? If Yes,briefly describe: ✓ NO 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 solid waste management facility? If Yes,describe .-RIFT 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:. _.. Date:. .. 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 1 and other materials submitted by the project sponsoror 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 l_ 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? U 3. Will the proposed action impair the character or quality of the existing community? EJ 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of 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? ET 1:1 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? a ..... 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ architectural oraesthetic resources? 9_ Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, waterbodies,.groundwater,air quality,flora and fauna.)? Ef El 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? 1 l. 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'Uai d Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 Board of Trustees Application AFFIDAVIT 1 _ ... .: ... . . ..._. ................ . ........_.......__.. .. .. ..BEING DILLY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS)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. a THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLDAND 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_P.REMISES 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. Sig6#e of Pro erty Owner Signature of:Property Owner SWORN TO BEFORE ME THIS 3Q DAY OF Al—C 1.1 2Q CAROLINE M MACARTHUR Notary Public-State of New York M NO.01MA6384635 Notary Public Qualified in Suffolk County y Commission Expires Dec 17,2026 Board of Trustees Application AUTHORIZATION (Where the applicant is not the owner) I/We, owners of the property identified as SCTM# 1000-. _.____ in the town of f .New York,hereby authorizes to act as my agent and handle all necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for this property. Property Owner's Signature Property Owner's Signature SWORN TO BEFORE ME THIS'.., DAY OF .,.20. _..Notary Public APPLICANT/AGENPREPRESENTATIVE TRANSACTIONAL DISCLOSURE-FORM The,owir of Southold's;Code of,Ethics orohibits�conflicts ofinteri§0i rthe Dart of offi town cers artd embloyees The nurvose:of ' whichnet he,t wn wtakewhateveracfio `isthurfomis to ovide nforination pecessarvlto avoid_sane: YOUR NAME: (Last name,firs name,gii dle itial,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 PIanning Other F (if"Other'',name the activity.) ........ Do you personally ,(or through yow;company,spouse;sitiimg,parent or.child)have`a relattorish�p with any officer or'ein oyee of the Town of Southold? "Relationship includes b%'blood marriage,or biismess Criterest "Baseness interest'means a<bustrtess, including a.partnership in which the Gown officer or employ has eve4.n.a;partial ownership of(or employment y)a coipotaii in which itk iown officer or employee owns more than.Wa ofal arcs. YES n.. 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 betweenyourself(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,of child is(check all that apply): —EIA)the owner of gieatec than'30/oof the shares of the corpotatc;stoek oftbe•applicant EL (when-the applicant-is a corporatioh); B)the legal or beneficial owner of any interest in a non-coiporate:entdy(when the EIapplicant 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 o / 20 Signature -PrintName e Forth TS 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 .oroposed. action .will be :evaluated. as.to...its sianifeant beneficial and adverse effects;upon.the coastal area(which includes a11..of gouthold.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 detains bstin both.suoporfine.and uon-. supaortina facts. If an action cannot be certified as consistent with the LWRP policy'standards and conditions,;tsliall not.be.undertakdn. 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. i B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# o� -PROJECT NAME The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees LJ 1. -Category of Town of-Southold-agency action(check-appropriat6response): (a) Action undertaken directly by Town agency(e.g.capital ❑ construction,-planning activity.,agency regulation,land tansaction) _❑ (b) Financial assistance(e.g.grant,loan,subsidy) (c) Permit,approval,license,certification: Nature and extent of action: _ ' r Location of action: / 0® 7'�/ ' /1 ` %U"�' al /" /�l Site acreage: Present land use: Present zoning classification:_1 /� T/'�'L . . 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 ofaPpl,eant vLA 1/ . . , (b) Mailing address: (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? s 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.G:OAST 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 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 LJ 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 S through 16 for evaluation criteria ❑. Yes ❑ No Not Applicable Attach additional sheets if necessary Policy S. Protect and improve water quality and supply in the Town of.Southold. See LWRP Section HI —}P'olkies Pages 16 through 21 for evaluation criteria IJ Yes LJ No Not Applicable Attach additional sheets if necessary Policy b: 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 FlNo FNot 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 G Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous r substances and wastes. See LWRP Section III—Policies;Pages 34 through 38 for evaluation criteria. ❑Yes ❑ No IJ 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. ❑ Yet. l No L_I Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III--Policies; Pages 47 through 56 for evaluation criteria. Yes ❑ No E!fNot Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long~Island Sound, the Peconic Estuary and Town wa rs. 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 eval ation criteria. ❑Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; ages 65 through 68 for evaluation criteria. Yes ❑ No 2 Not Applicable PREPARED BY — L AVk6 TITLE bG'��O Zj.. .4,DATE