HomeMy WebLinkAbout#8130-deBruijn ZBA Application Jttz-
FORM NO. 3 Received
TOWN OF SOUTHOLD
BUILDING DEPARTMENT MAY 0 6 2026
SOUTHOLD,N.Y.
Zoning Board of Appeals
NOTICE OF DISAPPROVAL
DATE: January 5, 2026
REVISED: April 29,2026
RENEWED: April 29,2026
TO: Johannes de Bruijn
150 W 82nd St lK
New York, NY, 10024
Please take notice that your application dated November 7, 2025:
For permit to: construct an accessory pool louse and construct an accessory swimming
pool to an existing single-family dwellin= at:
Location of property: 2625 Bay Shore Road Green port NY
County Tax Map No. 1000— Section 53 Block 4 Lot 21
Is returned herewith and disapproved on the following grounds:
The proposed construction on this non-confdnning 8,612 s .ft. parcel in the R-40
residential district, is not permitted pursuant to Article X III Section 280--124 which
states lots measuring less than 20,000 square feet in total size require a maximum lot.
coverage of 20%.
The survey shows a calculated lot cover& e of 22.39%.
Additionally, the accessog pool and pool house are not ermitted pursuant to Article III
Section 280-15 which states:
In the case of a waterfront parcel, accessory buildings and structures may be located in the front
yard, provided that such buildings and structures meet the front yard principal setback
requirements as set forth by this Code and the side yard setback requirements for accessory
buildings in Subsection B above.
"1'he survey shows the pool house to have a front yard setback of 21 feet. MAY 0 6 2026
The survey shows the pool to have a front and setback of 9 feet
Zoning Board of Appeals
O
Apt �orize �.
d ignatu
Note to Applicant: Any change or deviation to the above referenced application may
require further review by the Southold Town Building Department.
CC: file, ZBA
MAY 0 6 2026
Zoning Board of Appeals
APPLICATION TO THE SOUTHOLD TOWN BOARD OF APPEALS Wo
n AREA VARIANCE
House No.2�O1� Street , Hamlet
SCTM 1.000 Section: b Block: Lots) 12J.0 Lot Sipe: d Zone - 40
I(WE)APPEAL THE WRITTEN DETERMINATION OF THE BUILDING INSPECTOR
DATED BASED ON SURVEY/SITE PLAN DATED
Owner(s):
Mailing Address: 1 " QA d k- `: tQ1 b o '
Se 6,ru.N, &n42 s"0,Lk . c,om
Telephone: ". Email:
NOTE:In addition to the above,please complete below if application is signed by applicant's attorney,agent, r
architect,builder,contract vendee,etc.and name of person who agent rresents:
low
Name of Representative: ) _C for Owner Other:
Ad ress: l a� d
Telephone: Fax: Email: ,.�I�" ,�.�' � �^�,'�
Please check to s ecif who you ivdsh correspondence to be mailed to,from the above names:
( )Applicant/Owner(s), authorized Representative, ( )Other Name/Address below:
WHEREBY THE BUILDING INSPECTOR REVIEWED SURVEY/SITE,
PLAN
DATED S and DENIED AN APPLICATION DATED' FOR:
uilding Permit
( ) Certificate of Occupancy ( )Pre-Certificate of Occupancy
( ) Change of Use
( )Permit for As-Built Construction
( )Other:
Provision of the Zoning Ordinance Appealed. (Indicate Article,Section,Subsection of Zoning Ordinance
by numbers.Do not quote the code.) e""J S—
Article: Section: ::,28 ),2y Subsection:
Type of Appeal. An Appeal is made for:
(�A Variance to the Zoning Code or Zoning Map.
( )A Variance due to lack of access required by New York Town Law-Section 280-A.
( )Interpretation of the Town Code,Article Section
( ) Request for Reversal or Overturn the Zoning Officer's Denial
Other
A prior appeal( ) has, I , has not been made at any time with respect to this property,,
UNDER Appeal No(s). " Year(s). �r�
(Please be sure to research before completing this question or call our office for assistance)
Received
Page 2, Area Variance Application MAY 0 6 2026
Revised 6/2023
Zoning Board of Appeals
REASONS FOR APPEAL
(Please be specific,additional sheets may be used with preparer's signature notarized):
1.An undesirable change will not be pro LIced in the CHARACTER of the neighbor or a detriment to
nearby properties if granted,because Ck)&
2.The benefit sought by the applicant CANNOT be achieved by some method feasible for the applicant to
pUrStIC,other than an area variance,because: ,, - -4-
3.The amount of relief requested is not substantial because:,
'-pa-weA A �4rnoqexi 44� PrOPOLe,d
kiz� 'i 00(1� (Lo"
,e 4�1
/-or ez.,,4elo-ge.
4.The variance will NOT have an adverse effect or impact on the physical or environmental conditions in
the:neighborhood or district because: --rKp,
e- 6)ape-
5 Has the alleged difficulty been self created? Yes,or No Why:--At c4- 6rrio-
• Are there any Covenants or Restrictions concerning,this,land? No Yes(please furnish a
copy)
• This is the MINIMUM that is necessary and adequate,and at the same time preserve and protect the
character of the neighborhood and the health,safety and welfare of the community.
By signing this document,the PROPERTY OWNER understands that pursuant to Chapter 280-
146(B)of the Code of the Town of Southold,any variance granted by the Board of Appeals shall
4
become null and void where a Certificate of Occupancy has not been procured,and/or a subdivision ,
map has not been filed with the Suffolk County Clerk,within three(3)years from the date such
variance was granted. The Board may,upon written request prior to the date of expiration,grant
an extension not to exceed three(3)consecutive one(1)year terms. IT IS THE PROPERTY
OWNER'S RESPONSIBILITY TO ENSURE COMPLIANCE WITH THE CODE REQUIRED
TIME FRAME DESCRIBED HEREIN.
Signature ofllApp-ridnt or Authorized—Agent
(Agent must submit written Authorization from Owner)
Sworn to before me this 0�q day Kim E.Fuentes
Notary Public,State of New York
of Qualified in Suffolk County
LIC.#01 FU4811709
Commission Expires Agril
Notary tublic
Zoning Board of Appeals Received
APPLICANT'S PROJECT DESCRIPTION
MAY 0 6 2026
APPLICANT: . x - " SCTM No. d 2 1
Zoning Board of Appeals
1.For Demolition of Existing Building Areas
Please describe areas being removed:
II.New Construction Areas (New Dwelling or New Additions/Extensions):
Dimensions of first floor extension: ry, (4
Dimensions of new second floor:
Dimensions of floor above second level:
Height(from existing natural grade): Col
Is basement or lowest floor area being constructed?if yes,please provide height(above ground)measured from
natural existing grade to first floor:
C9
III.Proposed Construction Description(Alterations or Structural Changes)
(Attach extra sheet if necessary). Please describe building areas:
Number of Floors and General Characteristics BEFORE Alterations.
Number of Floors and Changes WITH Alterations; C)j,c......
IV.Calculations of building areas and lot coverage,sky plane(From Surveyor,Design Professional):
Existing square footage of buildings on your property: "
Proposed increase of building coverage: 5.
Percentage coverage of our of b building area Square ..footageY 2—
g g Y Y g rea(lot coverage) � � . -�„ G ( ;"�� � �. ,39
ross Floor Area(GFA) of single family dwelling including the attached garage and/or habitable detached
accessory structure: (Please refer to Chapter 280, Section 280-207 of the Town Code):.
For Residential lots, is project within the allowable.Sky Plane? (Please refer to Chapter 280, Section 280-208 of
the Town Code):
V. Purpose of New Construction: �.
VI.Please describe the land contours(flat,slope %,heavily wooded,marsh area,etc.) on your land and
how it relates to the difficulty in meeting the code requirement(s): Describe on separate page if needed:
° � [''
Plea le submit 8 sets of photos,labeled to show different angles of yard areas after staking corners for
new construction,and photos of building area to be altered with yard view.
11-A Ni
QUESTIONNAIRE liqLm ilved
FOR FILING WITH YOUR ZBA APPLICATION MAY 0 6 2026
A. Is the subject prcrni es currently listed on the real estate market for sale?
Yes No Zoning Board of Appeal-,
B. Are there any pr osals to change or alter land contours?
-Ni Yes,please explain on separate sheet. .V "_ M f
.ham\�� cl � �r �
C. 1.)Are there a s that contain sand or wetland grasses? N0
2.)Are those areas shown on the survey submitted with this application?
3.)Is the property bulk headed between the wetlands area and the upland building area?
4.) ffyour property contains wetlands or pond areas,have you contacted the Office of the
BOARD OF TRUSTEES for its determination of jurisdiction?
Please confirm status of your inquiry or application with the Board of Trustees: '-
If issued,pleas=atac&h'c0`pies of your ermigstin conditions s of p with py f �\S`
p g of
the approved survey.
D. Is there a depression or sloping elevation near the area of proposed construction at or
below five feet above mean sea level?
E. Are there any patios,concrete barriers, bulkheads or fences that exist that are not shown
on the survey that you are submitting?
If any of the aforementioned items exist on your property,please show them on a site
plan.
F. Are there any construction projects currently in process on your property?
If yes,please submit a copy of your building permit and survey as approved by the Building
Department and please describe scope of work:
G. Please attach all pre-certificates of occupancy and certificates of occupancy for the subject
premises. It'none exist,please apply to the Building Department to obtain them or to obtain an
Amended Notice of Disapproval. o
H. Do you or any co-owner also own other land adjoining or close to this parcel? '
If yes,please label the proximity of your lands on your survey and identify the Suffolk
County Tax Map No,
I. Please list present use or operations conducted at your property, and/or the proposed use
J. (examples existlsrr"Allgle f�m ,proposed:sam
e ''t, garage,pool or other)
Authorized sign
g ture Date
Ott Town of Southold 11/3/2017
53095 Main Rd
Southold,New York 11971
�flAY 0 6 2026
PRE EXISTING Zoning Board of APPea
CERTIFICATE OF OCCUPANCY
No: 39326 Date: 11/3/2017
THIS CERTIFIES that the stracture(s)located at: 2625 Bay Shore Rd, Greenport
SCTM#: 473889 Sec/Block/Lot: 53.4-21
Subdivision: Filed Map No. Lot No.
conforms substantially to the requirements for a built prior to
APRIL 9, 1957 pursuant to which CERTIFICATE OF OCCUPANCY NUMBER Z- 39326
dated 11/3/2017 was issued and conforms to all the requriements of the applicable provisions of the law.
The occupancy for which this certificate is issued is:
wood frame one family famfly dwelling with enclosedporch.*
Note:BP 1793 addition COZ-1476w BP 8953 addition COZ-8042-BP 25352 addition and alteration COZ-26600•BP
24220 interior alteration COZ-26599.
The certificate is issued to DwyerBarth Revoc Fam Trt
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
*PLEASE SEE ATTACHED INSPECTION REPORT.
O (T
` d Signature
FORM NU. 4
TOWN OF SOUTHOLD Vv
BUILDING DEPARTMENT Received
Office of the Building Inspector
Town Hall MAY ® 6 2026
Southold, N.Y.
Zoning Board of Appeals
CERTIFICATE OF OCCUPANCY
No: Z-26599 Date: 07/28/99
THIS CERTIFIES that the building ALTERATION
Location of Property: 2625 BAY SHORE RD GREENPORT
(HOUSE NO. ) (STREET) (HAMLET)
County Tax Map No. 473889 Section 53 Block 4 Lot 21
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 3, 1997 pursuant to which
Building Permit No. 24220-Z dated JUNE 25 1997
was issued, and conforms to all of the requirements of the applicable
provisions of the law. The occupancy for which this certificate is issued
is INTERIOR ALTERATION TO EXISTING ONE FAMILY DWELLING AS APPLIED FOR.
The certificate is issued to JOHN B & ALBERTA DWYER
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL, CERTIFICATE NO. N-492370 06/25/99
PLUMBERS CERTIFICATION DATED N/A
Building Inspec or.
Rev. 1/81
rerun Nu, �
TOWN OF SOUTHOLD 9- ecei
veci
BUILDING DEPARTMENT
Office of the Building Inspector MAY 0 6 2026
Town Hall
Southold, N.Y. Zoning Board of Appeals
CERTIFICATE OF OCCUPANCY
No: Z-26600 Date: 07/28/99
THIS CERTIFIES that the building ADDITION & ALTERATION
Location of Property: 2625 BAY SHORE RD _ GREENPORT
(HOUSE NO. ) (STREET) (HAMLET)
County Tax Map No. 473889 Section 53 Block 4 Lot 21
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated APRIL 3, 1998 pursuant to which
Building Permit No. 25352-Z dated NOVEMBER 23 1998
was issued, and conforms to all of the requirements of the applicable
provisions of the law. The occupancy for which this certificate is issued
is 12' X 20' ADDITION & ALTERATION TO EXISTING ONE FAMILY DWELLING AS
APPLIED FOR AND AS PER ZBA #4587.
The certificate is issued to JOHN B. & ALBERTA DWYER
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. N-492370 06/24/99
PLUMBERS CERTIFICATION DATED N/A
Building Ins ctcr
Rev. 1/81
1
FORM NO. 4
TOWN OF SOUTHOLD �Ieoelved9t, o
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE MAY 0 6 2026
SOUTHOLD, N. Y.
Zoning Board of Appeals
CERTIFICATE OF OCCUPANCY
No. ..2;...WO........... Date ................... =Qbfix..23.............. l 9. ..
THIS CERTIFIES that the building located at ........... Street
PeconiO Day Rstatex:
MapNo. ......*............. Block No. .... ?ti? .......... Lot No. si.................................................................
conforms substantially to the Application for Building Permit heretofore filed in this office dated
.„»„.......,.J7 3n�3.., `1.... ,,..,.».. ........... .. 19.. r.00 pursuant to which Building Permit No .........7a..1�` 3
dated ........allPA-.27.............................• 1942... was issued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is ........
....... " ', ...�,.. G +71V0...... ................................................................................
The certificate is issued to ...NXAr...JK...Q'.!:CQA:D=.►...Q!4LeX........ ......»s., .......... ....... ..........I........
(owner, lessee or tenant)
of the aforesaid building.
... . .....r.. ....... ... ....... .........
.. Building Inspector
APPEALS BOARD MEMBERS ea Southold Town Hall
53095 Main Road
Gerard P.Goehringer,Chairman P.O. Box 1179
James Dinizio,Jr. " Southold, New York 11971
Lydia A.Tortora ," ZBA Fax (631)765-9064
Lora S. Collins �d Telephone (631)765-1809
George Horning
BOARD
OF APPEALS
TOWN OF SOUTHOLD MAY 0 6 2026
FINDINGS, DELIBERATIONS AND DETERMINATION Zoning Board of Appeale
MEETING OF OCTOBER 5, 2000
Appl. No. 4857— ROBERT t AZiZOLAt O N ZOUMAS 1000-78-9-5.1
STREET & LOCATION: 750 Cedar Dri ,
DATE OF PUBLIC HEARING: September 14, 2000
FINDINGS OF FACT
PROPERTY FACTS, The subject property is an unimproved lot on the east side of Cedar Lane in
Southold, measuring 200 feet on Cedar Lane and 120 feet in depth. The lot area is 24,000 sq. ft.
Applicant Zoumas proposes to build a house for J. and R. Gazzola, the prior and prospective
owners of the property.
BASIS OF APPEAL: Building Inspector's Notice of Disapproval dated August 16, 2000, denying a
permit to build a house on the subject property for the reason that the proposed front yard (38 feet)
and rear yard (45 feet) are less than required by Code section 100-244B (40 feet and 50 feet,
respectively).
RELIEF REQUESTED: Applicant requests a variance to locate a house, as proposed, with a front
setback of 38 feet and a rear setback of 45 feet.
REASONS FOR BOARD ACTION DESCRIBED BELOW: On the basis of testimony presented,
materials submitted and personal inspection, the Board makes the following findings:
(1) Applicant testified that the prior and prospective owners of the property, J. and R.
Gazzola, have selected a specific house design, and that this house cannot be built on this lot
without the requested variance.
(2) The requested front yard variance is modest, entailing a reduction of 2 feet from the
required 40 feet, and a rear yard reduction of 5 feet from the required 50 feet. Applicant submitted
evidence showing that the proposed 38-foot front setback is consistent with the existing houses on
the block. For these reasons, grant of the requested front yard variance will not produce an
undesirable change in the character of the'neighborhood or detriment to nearby properties.
(3) The requested rear yard valance entails a reduction of 5 feet from the required 50 feet.
The Board believes that a lesser reduction —that is, a greater rear setback— is feasible by means
of a minor change in design.
(4) A property owner to the rear of the subject property expressed concern about drainage
onto his property. Because of this, the Board imposes a condition on the variance granted below,
limiting the clearing of the land at rear of the property.
i
I
Page 2—October 5, 2000
ZBA Appl. No. 4857—R. Gazzola/J. Zoumas
Parcel 1000-78-9-5.1 at Southold
MAY ® 6 2026
Zoning Board of Appeals
(5) The action set forth below is the minimum necessary and adequate to enable applicant
to build a house of the desired design while preserving and protecting the character of the
neighborhood and the health, safety and welfare of the community.
RESOLUTION/ACTION: On motion by Chairman Goehringer, seconded by Member Dinizio, it was
RESOLVED, (1) to GRANT the requested variance for the front yard setback, and (2) to
DENY the requested variance for the rear yard setback and ALTERNATIVELY to GRANT a
variance authorizing a rear setback of 47 feet, subject to the following CONDITIONS:
(A) The natural vegetation shall remain undisturbed, and maintained as a buffer in good
condition, for 20 feet inward from the rear property line;
(B) Roof gutters shall drain into drywell(s);
(C) The Board reserves the right to inspect and review the final plan for drainage, or to
consult with the Town Engineer upon completion of the project as to whether the pitch or other
preventive action may be necessary regarding on-site water drainage in his opinion.
VOTE OF THE BOARD: AYES: Members Goehringer (Chairman), Dinizio, Tortora, and
Horning. NAY: Member Collins (because a reasonable house an be pro y without
the need for any variance). This Resolution was duly adopt (4-1),/`
GERARD P. GOEHRINGER, CHAIR.
IJW
'ECEIVED AND FILED BY
W Tovm Clark, To;irn of $'_3 out :tol
AGRICULTURAL DATA STATEMENT (' 5�'
ZONING BOARD OF APPEALS
TOWN OF SOUTHOLD MAY 0 6 202
WHEN TO USE TI3IS FORM: This form must be completed by the applicattfo all 87 , pear
permit,site plan approval, use variance, area variance or subdivision approv o I
an agricultural district OR within 500 feet of a farm operation located in an agricultural district.
All applications requiring an agricultural data statement must be referred to the Suffolk County
Department of'Planning in accordance with Section 239m and 239n of the General Municipal
Law.
1. Name of Applicant: �_ f 11L
a C �",
2. Address of Applicant: '3
3. Name of Land Owner(if other than Applicant): C ?
4. Address of Land Owner:
t
5. Description of Proposed Prol ect: ° =.
6. Location of Property: (Road and Tax map Number) \ � �� �- C)?A
7. is the parcel within 500 feet of farm operation? "des WNo
S, is this parcel actively farmed? f ") Yes No
9. Name and addresses of any owner(s)of land within the agricultural district containing active
farm operations. Suffolk County Tax Lot numbers will be provided to you by the Zoning Board
Staff, it is your responsibility to obtain the current names and mailing addresses from the Town
Assessor's Office(765-1937) or from the Real Property Tax Office located in Riverhead.
NAME and ADDRESS
[.
2.
3.
4.
5.
6.
(Please use the back of this page if there are additional property owners)
y
Signature of Applican Date
Note:
1.The local Board will solicit comments from the owners of land identified above in order to consider the
effect of the proposed action on their farm operation. Solicitations will be made by supplying a copy of
this statement.
2. Comments returned to the local Board will be taken into consideration as part as the overall review of
this application.
3. Copies of the completed Agricultural Data Statement shall be sent by applicant to the property owners
identified above. The cost for mailing shall be paid by the Applicant at the time the application is
submitted for review.
617.20
Appendix B
Short Environmental Assessment Form
Received
Instructions for Completing
PAY 0 6 2026
Part 1-Project Information. The applicant or project sponsor is responsible for the completion of art 1. Responses
become part of the application for approval or funding,are subject to public review,and may be subject to fuurther ven i ation.
Complete Part 1 based on information currently available. If additional research or investigation As t Weals
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:
hoc,\ ►ax 2-A a � 1-21
-
Project Location(describe,and attach a location map):
Brief Description of ProposedAction:
a x 1 (p
�
Name of Applicant or Sponsor: \�., �- Telephone:
'E�-ST �/...�C1 = I Ill C� ` I L�� � E-Mail:
Address:
City/PO: State: M
QJ
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? o ) ' 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 VAquatic ❑Other(specify):
❑ Parkland
Page 1 of 4
5. is the proposed action, NO YES N/A
a.A permitted use under the zoning regulations? U '
b.Consistent with the adopted comprehensive plan? 20�6
6. Is the proposed action consistent with the predominant character of the cxistin Wit or natural NO YES
landscape? 5t G:`
7. Is the site of the proposed action located in,or does it adjoin,a state list a al Environmental Area? NO YES
If Yes idcn ofy. &A� � �' ? �1, .-'� '
8. a. Will the proposed action result in a substantial increase in traffic above present levels? •Lull,,(_h to-:;11 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:
m
10. Will the proposed action connect to an existing public/private water supply? NO YES
k �r providing potable water:
If No,describe method for
11.Will the proposed action connect to existing wastewater utilities? NO YES
If No,describe method for providing wastewater treatment: X
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
F—Wetland ❑Urban ',;Suburban
15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES
Y endangered?
16. is the project s to located in the 1I111 year floodplain?� F ,
b the Stag or Federal ovt°r�arttent'as threatened or
p l o m rR c' NO YES g'� r�o}
Will the. r
17 proposed action create tort-water d schargc„either from point or non-point sour es? NO YES
If Yes,
a.Will storm water discharges flow to adjacent properties? NO ❑YES X
b.Will storm water discharges be directed t (runoff
Y o established conveyance systems(runo n storm drains)?
If Yes,briefly describe: ❑ NO YES
'J n_
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 d O YES
solid waste management facility? A 0 6 29
If Yes,describe:
ZoningBoard of, AP4 1
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: X
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
Applicant/sponsor name: Date: lalz
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 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
1. 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? a
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 u
reasonably available energy conservation or renewable energy opportunities? l`l
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,
architectural or aesthetic resources?
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
ReCeive No,or Moderate
small to large
Mgs 2�2� impact impact
may may
occur occur
10. Will the proposed action result in an increase in the potential for e ,9lcq'9 oN rai ge
problems? _X
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.
Name of Lead Agency Date
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)
Page 4 of 4
E �
Board of Zoning Appeals Application Received
MAY 0 6 2026
OWNER'S AUTHQR1Z&T10N
(Where the Applicant is not the Owner) Zoning Board of Appeals
f �'1
residing at..,t')' ��<i
(Mailing ( CC
(Print property or�,yn s name ,���
( g Ad4lress) ! C) ��Y,'
do hereby authorize bc� ��
(Agent)
+ to apply for variance(s)on my behalf from the
Southold Zoning Board of Appeals.
By signing this document,the Property Owner understands that pursuant to Chapter 280-
146(B)of the Code of the Town of Southold any variance granted by the Board of Appeals shall
become null and void where a Certificate of Occupancy has not been procured,and/or a
subdivision map has not been filed with the Suffolk County Clerk,within three(3)years from
the date such variance was granted. The Board of Appeals may,upon written request prior to
the date of expiration,grant an extension not to exceed three(3)consecutive one(1)year terms.
"'" `]:HE PROPERIV_OW ER'S!RE PON IBILIT TO ENSURE!90-MPLIANCE WITH
THE CODE RE QUIRED TIME_FT�AM DESCRIBED UJEREIN.
(C ner's Signature
(Print Owner's Mum;
- tin c1►'(�p bc� 4121
Received
APPLICANVOWNER MAY
TRANSACTIONAL DISCLOSURE FORM
The-Inn PAs-aillMd's Code of Q1110 pt9hibits on i t5 of interest on thii!!iiiar(of town fcer at d guml tt)ry s -
this Lorin Is to wide m Inroration which can alert th town of possible conflicts of'inte rest and allow it to t e rlfa ever action i B hC
rree+ sarvta�avoid e. r
te S
75
YOUR NAME :(Ls"�..� �," Initial,unless you areapplying In the�(Last name,first name middle
y name of someorre else or other entity,such as a
company.If so,indicate the other person's or company's name.)
TYPE OF APPLICATION: (Check all that apply)
Tax grievance Building Permit
Variance Trustee Permit
Change of Zone Coastal Erosion
Approval of Plat Mooring
Other(activity) Planning
Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer
or employee of the Town of Southold?`Relationship"includes by blood,marriage,or business interest."Business
interest"means a business,including a partnership,in which the town officer or employee has even a partial
ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the
shares.
YES NO
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/agelit/representative)and the town officer or employee.
Either check the appropriate line A)through D)and/or describe in the space provided.
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply)
A)the owner of greater that 5%of the shares of the corporate stock of the applicant(when the applicant is a
corporation)
B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation)
C)an officer,director.partner,or employee of the applicant;or
D)the actual applicant
DESCRIPTION OF RELATIONSHIP
Submitted this Q daw°
Signature
Print Name
Received
' MAY 0 6 2026
APPLICANT/OWNER
Zoning Board of Appeals
TRANSACTIONAL DISCLOSURE FORM
The Town qf S9tithold's Code of tit hilstt .o is o int art f officers a to a s.T ur os of
this form is to rovide informa ioll W ich can alert he town of possible conflictsof interest and allow it to,_lohg)_vItalever action is
neee sory to avoid sante.
YOUR NAME:
(Last name,fIrst name,middle Initial,unless you are applying In the name of someone ild or other entity,such as a
company.If so,indicate the other person's or company's name.)
TYPE OF APPLICATION: (Check all that apply)
Tax grievance Building Permit
Variance Trustee Permit
Change of Zane Coastal Erosion
Approval of Plat Mooring
Other(activity) Planning
Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer
or employee of the Town of Southold?"Relationship"includes by blood,marriage,or business interest.f°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 that 5%of the shares of the corporate stock of the applicant(when the applicant is a
corporation)
B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation)
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant
DESCRIPTION OF RELATIONSHIP
Submitted this day of ()
Signature
Print Name.
is
l
AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM Received
The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose
thia fam s!2 Ruxl9tinformation which can alert the town of uggi0jo gglIflictsof i ter0t and allway
action is necessary to avoid same.
YOUR NAME :w "O akr Z/Onlnca Board of peEft
(Last nam rrsi name,middle WI 4 unless you are applying in the name of someone else or other entity,such as a
company.if so,indicate the other person's or company's name.)
TYPE OF APPLICATION: (Check all that apply)
Tax grievance Building Permit
Variance Trustee Permit
Change of Zone Coastal Erosion W
Approval of Plat Mooring
Other(activity) Planning
Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer
or employee of the Town of Southold?"Relationship"includes by blood,marriage,or business interest."Business
interest"means a business,including a partnership,in which the town officer or employee has even a partial
ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the
shares.
YES NO
If you answered"YES",complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of Southold
Title or position of that person
Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.
Either check the appropriate line A)through D)and/or describe in the space provided.
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply)
A)the owner of greater that 5%of the shares of the corporate stock of the applicant(when the applicant is a
corporation)
B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation)
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant
DESCRIPTION OF RELATIONSHIP
Submitted this �D day of 4'"
Signature
Print Name
Town of Southold 0
LWRP CONSISTENCY ASSESSMENT FORM
Received
A. INSTRUCTIONS MAY ® 6 2026
Zoning ggo
1. All applicants for permits* including Town of Southold agencies, shall complePe li ' tar
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).
1 If any question in Section C on this form is answered "yes", then the proposed action may affect the
achievement of the LWRP policy standards and conditions contained in the consistency review law.
Thus, the action should be analyzed in more detail and, if necessary, modified prior to making a
determination that it is consistent to the maximum extent practicable with the LWRP policy
standards and conditions. If an action cannot be certified as consistent with the LWRP policy
standards and conditions, it 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# ' D ,- 5 � - (-1 02- .T)
The Application has been submitted to(check appropriate response):
Town Board 7 Planning Dept. er Building Dept. A 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:
""
' I "' ')P
Location of action: Recesved
Site acreage:
MAY 0
Present land use:
Zoning Board of Appeals
Present zoning classification: e---4c)
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:
Will the action be directly undertaken,require funding, or approval by a state or federal agency?
Yes $4No E] If yes,which state or federal agency b or Q5Z
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 Not Applicable
; o
14" .
-Ina�
C
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
r Yes No 0Not Applicable
Attach additional sheets if necessary
Policy 3. Enhance visual quality and protect scenic resources throughout the Toux of gautgo6 . See
LWRP Section III—Policies Pages 6 through 7 for evaluation criteria Hec
Yes []' No Not Applicable MAY ®6 2026
Zoning Board of Appeals
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
D� Yes F-� No R Not Applicable
Attach additional sheets if necessary
Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III
—Policies Pages 16 through 21 for evaluation criteria
0 Yes 0 No $tNot 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 Ea No of Applicable
Attach additional sheets if necessaryOf
w
Policy 7. Protect and improve air quality in the Town of Southold. SeeZtJWRID(MAioon — Policies
Pages 32 through 34 for evaluation criteria.
R Yes D No Not Applicable
Attach additional sheets if necessary
Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous
substances and wa . See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria.
Yes El 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.
1E Ye�4 No® 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 Not Applicable
Board of Appeal
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 1:1No Not Applicable
Attach additional sheets if necessary
Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP
Section III—P'olici s; Pages 65 through 68 for evaluation criteria.
Yes 0 No Not Applicable
Created on 5125105 I1:20 AM
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