HomeMy WebLinkAboutTR-10965A MIFFat
Glenn Goldsmith,President �0 �'� Town Hall Annex
A.Nicholas Krupski,Vice President �� �y� 54375 Route 25
Eric Sepenoski y Z P.O.Box 1179
Liz Gilloolyy, Southold,NY 11971
Joseph Finora ?,h ®!"�Y' Telephone(631)765-1892
Fax(631)765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES
72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN
APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO
SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE
PERMIT.
INSPECTION SCHEDULE
Pre-construction, hay bale line/silt boom/silt curtain
1 st day of construction
% constructed
X Project complete, compliance inspection
Glenn Goldsmith,President �®f S0!/r Town Hall Annex
54375 Route 25
Nicholas Krupski,Vice President hOV� ®Ie
P.O. Box 1179
Eric Sepenoski l Southold, New York 11971
Liz Gillooly Telephone(631) 765-1892
Joseph Finora Fax(631) 765-6641
®lyCOU ,�
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Permit No.: 10965A
Date of Receipt of Application: May 1, 2026
Applicant: Maryanne Kelley & Dianne McKenna
SCTM#: 1000-99-4-19
Project Location: 1775 Naugles Drive, Mattituck
Date of Resolution/Issuance: May 13, 2026
Date of Expiration: May 13, 2029
Reviewed by: Board of Trustees
Project Description: Remove imploded bungalow.
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 Maryanne Kelley, received on May -1, 2026, and stamped
approved on May 13, 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
S.C.T.M. NO. DISTRICT: 1000 SECTION: 99 BLOCK: 4 LOT(S):19
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SOuthold Town IHE WATER SUPPLY, KUS DRYMFLLS AND CESSPOOL
+ LOCATIONS 940HTV ARE FROM FIELD O�RVATIONS
iDARD OF Board of Trustees AND OR DATA 0STANED FROM ORAERS
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�. AREA: 48,269 SOFT. or 1.11 ACRES Ec£vanoN DATUM:
LWAUTHORI2ED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY
MAP NOT BEARING THE LAND SURVEYOR'S EMBOSSED SEAL SHALL NOT BE CONSIDERED 70 BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN
-yr•� A ONLY TO THE PERSON FOR MHOM THE SURVEY IS PREPARED AND DN HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION
` A/1 �� � ' �O LISTED HEREON,AND TO THE A59GNEES OF THE LENDING INSTITUTION, GUARANTEES ARE Nor TRANSFERABLE.
7N£OFFSETS OR DIMENSIONS SHOMN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE
NOT INTENDED 70 MONUMENT INC PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS
"-` - -' AND/OR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE DME Or SURVEY
SURVEY oF:DESCRIBED PROPERTY of NEW CERTIFIED TO: J. KELLEY,
MAP OF: SN M. W02r0'P
FILED: °j 211
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SITUATED AT:MATTITUCK Y F ¢
Tom OF:SOUTHOLD o �
SUFFOLK COUNTY, NEW YORK ��'s Dsoae2 p KENNETH M WOYCHUK LAND SURVEYING, PLLC
oe J Profeeeionel Land Surveying end Design
N P.O. Box 153 Aquebogue, New York 11931
FILE#222-93 SCALE:1"=40' DATE:JULY 25, 2022 KY,S.LISC.NO. 050882 PHONE(e31)29e-13ee FAX(e.91)299-15aa
R"US. EES
SOUTHOILD .T T
No. ' �oal 65 A
Ma��cnn2 KeUe��r rj�l3 �e�L
Issued T Date
Address. 114S KaIA51e..� br:Ve, )qQlN I I %ACK
THIS.NOTICE MUST BE DISPLAYED DURING. CONSTRUCTION
.TOWN TRUSTEES OFFICE TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765.1892
Glenn Goldsmith,Pr' ,_ at o��SUFFO(,y�o Town Hall Annex
r�
A.Nicholas Krupski,Vice President < 54375 Route 25
Eric Sepenoski P.O.Box 1179
Liz Gillooly �y�® �O��N Southold,NY 11971
Joseph Finora Telephone(631)765-1892
Fax(631)765-6641
Southold Town Board of Trustees
Field Inspection Report
Date/Time: Completed infield by:
MARYANNE KELLEY & DIANNE McKENNA request an Administrative Permit to
remove imploded bungalow. Located: 1775 Naugles Drive, Mattituck. SCTM# 1000-
99-4-19
T a of area to be impacted:
y7 Saltwater Wetland Freshwater Wetland Sound Bay
Part of Town Code proposed work falls under: 'sChapt. 275 Chapt. 111 other
Type of Application: Wetland Coastal Erosion Amendment
Administrative Emergency Pre-Submission Violation
Notice of Hearing card posted on property: Yes No Not Applicable
Info needed/Modifications/Conditions/Etc.:
Present Were: G. Goldsmith N. Krupski E. Sepenoski
L. Gillooly J. Finora
S.C.T.M. NO. DISTRICT: 1000 SECTION:99 BLOCK: 4 LOT(S):19
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AS DETERMINED BY k x k x x k k k k
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MILL ROAD
THE WATER SUPPLY, HELLS DRrN£LLS AND OFSS°OM
_ LOCATIONS SHOWN ARE FIRM F7ELD OBSERVATIONS
,�'.I # AND OR DATA OBTAINED FROM OTHERS.
IL'L��� FEMA MAP 36103C0143H
1 AREA: 48,269 SOFT. Or 1.11 ACRES ELEVATION DATUM: NAV088
T
UNAUTHORIZED ALTERATION LW ADDITION TO THIS SURVEY IS A NOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY
j! MAP NOT BEARING THE LAND SURVEYOR'S EMBOSSED SEAL SHALL NOT BE CGNSDER£D TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN
ONLY 7D THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BENALF TO THE TITLE COUPANY,GOVERNMENTAL AGENCY AND LENDING INSDTUTION
' ��`` LISTED HEREON,AND TO THE ASSIGNEES OF THE
LENDING INSTITUTION,GUARANTEES ARE NOT TRANSFERABLE.
MAY 202[J THE OFFSETS OR DIMENSIONS SHORN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE
NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES ADMI70NAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS
AND/OR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EMOENT ON THE PREMISES AT THE TIME OF SURVEY
µ,
SURVEY oF:DESCRIBED PROPERTY OF NET, CERTIFIED TO: J. KELLEY;
Southold Tw—n
NAP OF: g!�N M. *Da'FILEc=DpJ
Board of Trustees I SITUATED
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LaTUATEO ar:MATTITUCK
TonN oF.SOUTHOLD �� '
�"' KENNETH M NOYCHUK LAND SURVEYING, PLLC
SUFFOLK COUNTY, NEW YORK d'8 05088 Professional Lend Surveying sad Design
N P.O. Box 153 Aquebague, New York 11531
FILE 1222-93 scALE:1"=40' DATE:JULY 25. 2022 NY.S LISG NQ O5GB82 PHONE(501)29e-1588 FAX(e51)M-155e
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OFFICE LOCATION: ��OF SO yo MAILING ADDRESS:
Town Hall Annex �� lO P.O.Box 1179
54375 State Route 25 Southold, NY 11971
(cor.Main Rd. &Youngs Ave.) N Telephone: 631 765-1938
Southold,NY 11971 G.A • Q
LOCAL WATERFRONT REVITALIZATION PROGRAM
TOWN OF SOUTHOLD
To: Glenn Goldsmith, President
Town of Southold Board of Trustees
Cc: Honorable Lori Hulse, Attorney
From: Heather Lanza, AICP, Planning Director
LWRP Coordinator
Date: May 12th 2026
Re: LWRP Coastal Consistency Review
MARYANNE KELLEY& DIANNE McKENNA, SCTM# 1000-99.4-19
This application is to remove imploded bungalow.
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 Chapter§275-5 (B)(2)(b) Removal of any material or structure,
provided that a project limiting fence and a silt fence with hay bales is installed to
contain disturbance if deemed necessary and provided that such operations 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
Glenn Goldsmith,President Town Hall Annex
54375 Route 25
A.Nicholas Krupski,Vice President P.O.Box 1179
Eric Repenoski jW
Southold,New York 11971
Liz Gillooly rh Telephone(631) 765-1892
Elizabeth Peeples Fax(631) 765 6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
This Section For Office Use Only
Coastal Erosion Permit Application ® `=
Wetland Permit Application
Administrative Permit r✓/
Amendment/Transfer/Extension L MAY 1 2026
Received Application:
Received Fee: $ Southold Town
Completed Application: Board of Trustees
Incomplete: . .
SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec..
-Lead Agency Determination Date:- - - - - -
Coordination:(date sent):
LWRP Consistency.Assessment Form Sent:
CAC Referral Sent:
Date of Inspection:
Receipt of CAC Report:
__Technical Review:
Public Hearing Held_:
Resolution:,
Owners)Legal Name of Property (as shown on Deed): M�XCVIVXA
Mailing Address: I 341 1 W OL L12-Ue., `A w; Q 4--
Phone Number: 201 - 4'A 5 -U 54 0.:_......... CC 1 J 01 - 8 9 8 -a ,39 I
Suffolk County Tax Map Number: 1000- �
Property Location: . 9 rl 5 . a Y 1 a L ( 5 2'
(If necessary,provide LILCO Pole#, distance to cross streets, and location)
AGENT(If applicable):
Mailing Address:
Phone Number: Email:. -
Board of Trustees Application
GENERAL DATA
Land Area(in square feet): _ I /3 acre �
Area Zoning:
Previous use of tY:ro er
P P ..
Intended use of property:
Covenants and Restrictions on property? __❑_Yes KNo
If"Yes", please provide a copy.
Will this project require a Building Permit as per Town Code? Yes _nNo
If"Yes",be advised this application will be reviewed by the Building.Dept.prior to a Board of Trustee review
and Elevation Plans will be required.
Does this project require a variance from the Zoning Board of Appeals? Yes No
If"Yes",please provide copy of decision.
is project requirq 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=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): Te.CL d o �::r) -c-Ln
tffiulo...&A
eJ
... .. . . . cx .. "r . u
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Y
Purpose of the proposed operations: VYl!1\/ I W O� ' 4ISSUMME C
f r
him
aloes. . t is. aa tosk
3acetv ,
1
Area of wetlands on lot: square feet
Percent coverage of lot: .
Closest distance between nearest existing structure and upland edge of wetlands: 7—iJ feet
• Gtl+�r�f.
Closest distance between nearest proposed structure and upland edge of wetlands:_�feet
Does the project involve excavation or filling?' ® No Yes
If yes,how much material will be excavated? .cubic yards
How much material will be-filled?. A cubic yards
Depth of which material will be removed or deposited: N .A feet
Proposed slope throughout the area of operations:_'N LA
Manner in which material will be removed or deposited: N
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.Comnleting
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 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 believewill be needed by or useful
to the lead agency;attach additional pages as necessary to supplement any item.
'Part 1=Project and Sponsor Information 1,.,
Name of Action or Project: ;
Project Loca bn(describe,and attach a location map):
Brief Description of Propose Action:
l� caJrc�o �•4.�n cA rim VC cdl,&A summer Vouq3nJokA
C v-r.��ntl it t
:.- I o,n t n alp n�:� bG rs el X,c, v-Ar\/
9 � .
NMary
aAme of Applicant or Sponsoorr: r Telephone: .?6 _ S—(GSA�I E v
1 V 1 a r A"in f'�e k 1e E-Maid:�IP � +2 ti �:.(� j .
{ c'M
Address:
wi tcta
City/PO: State:_ Zip Code:
1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES. -
administrative rule,or regulation?
If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that
maybe 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 governmenfal Agency? NO YES
If Yes, list agency(s)name and permit or approval:
ry
3.a.Total acreage of the site of the proposed action? X awes-
b.Total acreage to be physically disturbed? ,��j,a L x i 1.3. am& '> one- bL�Lr-,r l ow
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? %, /. acres
4. Che I land us j at occur on,adjoining an ar the prop action.
Urban L�JRural(non-agriculture) Ljlndustrial Commercial ❑Residential(suburban)
Forest ❑Agriculture ❑Aquatic ❑Other(specify):
Parkland
Page 1 of 4
5. I s the proposed action, NO T YES N/A
a. A permitted use under the zoning regulations? Gi�L-}� I$Sqi i2.
b.Cons CUBistent with the adopted comprehensive plan? SC�r'Y1�G�1t t CA �Je—lv x
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: _ _ _ _ j[� :❑
LAI
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? It
0.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? fY0 ..YES
If No,describe method for providing potable water:
11.Will the proposed action connect to existing wastewater utilities? NO. YES,.
If No,describe method for providing wastewater treatment:...
12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES
Places?
b.Is the proposed action located in an archeological sensitive area?
13.a.Does any portion ofthe site of the proposed action,or lands adjoining the proposed action,contain
wetlands or other waterbodies regulated by a federal,state or local agency?
b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody?
If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres:.
14., ntify the typic bitat types that oc n,or are likely to be found on t roject site. Check all That apply:
Shoreline Forest Agricul tural/grasslands Early mid-successional
Wetland Urban Suburban
15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO... .YES
by the State or Federal government as threatened or endangered?
]6.Is the project site located in the 100 year flood.plain? NO YES. ..
17.Will the proposed action create stone water discharge,either from point or non' sources? NO:. ..
If Yes,
a. Will storm water discharges flow to adjacent properties? �1O ❑YES
b.Will storm water discharges be directed to established conveyance systems ff an 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: El
19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES
solid waste management facility?
If Yes,describe: . . . - ❑
20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES'
completed)for hazardous waste?
If Yes,describe:
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE.BEST OF MY
KNOWLEDGE -7
Applicant/sponsor name:..M( Af^ InnQ:: l 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 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. W'i{I the proposed action create a material conflict with an adopted land use plan or zoningFSA
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. W ill the proposed action have an impact on the environmental characteristics that caused the ❑
establishment of a Critical Environmental Area(CEA)?
S. Will the proposed action result in an adverse change in the existing level of traffic or
El
affect existin infrastructure for mass transit,biking or wal .kway
g i �
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/ rivate wastewater treatment utilities?
8. W ill the proposed action impair the character or quality of important historic,archaeological, I ❑
architectural or aesthetic resources?._ �X
9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, . �.
waterbodies,groundwater,air quality;flora and fauna)?
Page 3 of 4
No,or Moderate :
small to large
impact impact
may may
occur occur
10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage
problems? �.
11. Will the proposed action create a hazard to environmental resources or human health?
Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every
question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular
element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3.
Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by
the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact
may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring,
duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and
cumulative impacts.
Check this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action may result in one or more potentially large or significant adverse impacts and an
environmental impact statement is required.
Check this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
Town of Southold-Board of Trustees
Name of'Lead Agency Date
President
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer)
PRINT Page 4 of 4
Board of Trustees Application
BEING DULY SWORN
DEPO ES AND AFFIRMS THAT HE/9=IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERAW(S)AND THAT ALL STATEMENTS CONTAINED HEREIN
ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT
ALL WORK WILL BEDONE 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($),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 TIRE PREMIISES 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.
Signaftui of Property Owner:. Signature of Property Owner
SWORN TO BEFORE ME THIS ( _DAY OF . ..20All
ATotary Public
MEN• : ki�IZ21
Notary Phi.- . .r:of l4aaN Jere®Y
• �M Gar���
MEL'�cA R.LIBR=
pWry PUNuL.'•'htA.Of N"J'31M
won disc_ 43030
urd of zmateea Application
AFFIDAVIT
BEING DULY SWORN
DEPOSES AND AFFIRMS THAT BFISM IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMT(S)AND THAT ALL ffrATE=NTS CONTAINED KWIN
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 TILE
BOARD OF TRUSTEES HARIYII,ESS AND FREE FROM ANY AND ALL DAMAGES
AND CLAIM ARISING UNDER OR BY VRt=OF SAID PEgMiTM IF
GRANTED. IN COMPLETING THIS,APPLICATION,I HEREBY AUTHORIZE THE
TRH T AGENTTM OR ATTVEsy IIITGLUDING THE'
CONSERVATION ADVISORY COUN CK.,TO ENTER ONTO MY PROPERTY TO - -
INSPECT THE PREMISES IN CONJUNCTION W1TH THIS APPLICATION,
INCLUDING A 19NAL INSPFrCTION. I.RURTHFR AUTHORVZ THE BOARD-OF
TRIISTEES TO ENTER ONTO MY PROPERTY AND AS REQUMED TO fi%M
COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL `
EROSION PERMIT ISSUED By THE BOARD OF TItUSPESS DURING THE TERM
OF T=Pl3t IIT.
a
Signature of Propeity Owner- : Side of Propmy Owzw
SWORN TO-BEFORE ME THIS � DAY OF . 20
Notary Public
AND
9o0o ilATTIE SACKIC14
XE OF NEW
NOIARNOBI2-01SA60850 2
"P'L C66IN QS ON GXP REST
DECEMBER 16'2026
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
New York,hereby authorizes
to act as my agent and handle all
necessary work involved with the application process for permits) from the Southold Town
Board of Trustees for this property.
Property Owner's Signature Property Owner's Signature i
SWORN TO BEFORE ME THIS, DAY OF , 2Q,
Notary Public
APPLICANUAGENUREPRESENTATIVE
TRANSACTIONAL DISCLOSURI�FORM
The Town of Southold's Code of Ethics arohibits'conflicts of interesf on the•nart'oft6wn officers:arid:emoloWees.The nuroost of
this form:is to tirnvide infermation'which can:alcrt the Town of possible conflicts of inteii�gf and allow it to fake whatever action is
nectssatytb a-did samee.YOUR NAME I V/�
aryAn n c
(Last name,first name,1riddle initial,unless ydif are applying iri.the name of
someone else or other entity,such as a company.If so,indicate the other
person's or company's name.)
NAME OF APPLICATION: (Check all that apply.) ,
Tax grievance Building
Variance Trustee
Change of Zone Coastal Erosion
Approval of plat Mooring
Exemption from plat or official map Planning
Other l'4
(If"Other`,name the activity.) tLt feet lYk i('I(in
( �O ZCtilr�Lta��')I 1'?Z 1'YlG`+f� �rn p�pC�ZC�
Do you persono,yjor through.yogr.company,spousei sibling,Pareht-dr,child)have a.relationship*ith•ariy bf edr;oT employee
of the Town ofSouthgid?-"Relationship"inciddes-by blood;:m4maap,or, usidcss it-tcr&A "Business irNsiesC'•means.a.busipess, _
including a.partnership,in which the town officer or employce has eve :a partial ownership of(or.emp.0ymeritby,)a corporation
in which the town officer or employee owsns more than 5PA of the shares.
YES :._w 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):
f1A)the owner of gteatcr than 5"10 0#tith.shares of the cdrpbatc stock o[ihe apple;uat .
fj (when the appliaant is a d6"4*ion);
B)the legal or beneficial owner of any interest in a non-corporate'entity(wb6n.the
applicant is not a corporation);
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant y
DESCRIPTION OF RELATIONSHIP
•
` Submitted this day of 20 Z(
Signature
Print Name b&jv'1'Q Ayw
Form TS I
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 nroaiosed action will be, evaluated. as to. its signif cant t
beneficial aiid averse effects upon the coastal area(whirl includes all of Southoid 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,.-listinLr both supporting:and non-
supportingfacts. If an action cannot be certified as consistentwith the LWRP policy-standards and
conditions,,t-shal1not be undertaken.
A copy of the LWRP is available in the following places: online at the Town of So
uthold'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
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: El
Nature and extent of action: "
�:. z .�
en, i�i'z�l
. t :... _.._... c�'f-
' k
Location of action: 0 Ka Llo I es b r. U3 hL C A 957.
Site acreage: Q Cre S
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 appiiaant ga
. (b) Mailing address:
(c) Telephone number:C (,1 /4 4 ,.:'�5 4 o
Will the action be directly undertaken,require funding,or approval by a state or federal-agency?
Yes 1_J No fV 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,
1.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
LVM Section III—Policies Pages 3 through 6 for evaluation criteria
[I Yes ❑ No ® Not Applicable
Attach additional sheets if necessary
Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See
LWRP Section III—Policies Pages 6 through 7 for evaluation criteria
❑ Yes ❑ No Not Applicable
Attach additional sheets if necessary
NATURAL COAST POLICIES
Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP
Section III—Policies Pages-8 through 16 for evaluation_criteria- - -
+ - Yes [] No IF-Y-i Not Applicable
-77
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 5dNot 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 0 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 134 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.
0 Ye❑ 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
Attach additional sheets if necessary
Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic
Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria.
❑Yes ❑ No� Not Applicable
Attach additional sheets if necessary
Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III—Policies; Pages
62 through 65 for evaluation criteria.
❑Yes ❑ No Not Applicable
.....
Attach additional sheets if necessary
Policy 13. . Promote appropriate use and development of energy and mineral resources. See LWRP
Section III—Policies; Pages 65 through 68 for evaluation criteria.
❑Yes No Not Applicable
PREPARED BYAnn, TITLE a " LO11 e r DATE
John F Kelley
14 Wilda Lane
Waldwick,NJ 07463
(H)201-445-6540 (C)201-888-2391
jfhell_ey2O6&Mail.com
April 27,2026
Town of Southold Board of Trustees:
I am writing to formally request immediate approval for the teardown and removal of the summer
vacation bungalow located at 1775 Naugles Drive Mattituck NY.While this structure measures
approximately 24.2'L x 17.3'W,it is no longer a viable building;it has suffered a structural failure
(implosion)and currently poses a severe risk to public safety.
Current Situation:
This request is not a matter of wanting to,but having to tear down the bungalow since it is a critical safety
issue.The bungalow has partially collapsed and is currently leaning directly onto the neighboring
property.The structural integrity is non-existent,and the building is in a state of active failure.
Points of Concern:
• Public Safety:The structure is unstable and represents a significant safety hazard.I am deeply
concerned that a trespasser could be seriously injured or killed if the remaining walls shift
further.
• Pro pea Damage:The building is currently infringing upon and possibly damaging the
neighbor's property.Delaying the removal increases the risk of further liability and structural
damage to the neighboring property.
• Emergency Status:Because the building has already imploded,it cannot be"shored up"or
repaired.Demolition is the only responsible course of action to mitigate the hazard.
Request for Action:
I am prepared to begin the removal process immediately.I respectfully request that the Board or the
Building Department expedite the necessary permits or grant authorization to proceed with the teardown
and removal to ensure the safety of the properties and the neighborhood.I have attached photographs of
the current state of the bungalow to illustrate the urgency of this matter.I am available to discuss this at
your earliest convenience.
Thank you for your immediate attention to this situation.
Sincerely, ® C E 2
MAY 1 2026
John F.Kelley
(On behalf of Maryanne Kelley and Dianne McKenna, owners) Southold Town
Board of Trustees