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HomeMy WebLinkAboutTR-10983A Glenn Goldsmith,President N,dO�.S CG Town Hall Annex G� A.Nicholas Krupski,Vice President �� yam _ 54375 Route 25 Eric Sepenoski z P.O. Box 1179 Liz Gillooly Southold,NY 11971 Joseph Finora 't' pl, ' 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 ``�f3f S0l�r Town Hall Annex Vv ® 54375 Route 25 Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski l l Southold, New York 11971 Liz Gillooly G Telephone(631) 765-1892 Joseph Finora • a0 Fax(631) 765-6641 COUNI`1,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10983A Date of Receipt of Application: July 9, 2026 Applicant: The Stirling Eastern Shores Association Inc. SCTM#: 1000-33-1-3.1 Project Location: 3550 Sound Drive, Greenport Date of Resolution/Issuance: July 15, 2026 Date of Expiration: July 15, 2029 Reviewed by: Board of Trustees Project Description: Install five (5) 12" x 12" signs along property boundary line. 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 Rick Herbst, received on July 9, 2026, and stamped approved on July 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. Glenn Goldsmith, President Board of Trustees S.C.T.M. N0. DISTRICT: 1000 SECTION: 33 BLOCK: 1 LOT(S):3.1 / �S O�Yp��o tiQ\� o S -'BOARD OF 'j RUSTEES 7OW►y OF SOUTHOLD ,yp 3q�b DATE ETA GRAVEL lam. WALKWAY 7 09 .._ LAND NIF OF 'FE=CE7 LAND NIF OF EENCE STIRLING EASTERN PETER J GROSSMAN SHORES ASSOC INC f REVOCABLETRUST x lV 2 / / �001, 5�•hpa / j STK. S\c\03 / 235 / GUY \\ g GAS Up. / \ STK. \ .r \0O\ GRAVEL Or GRIVEWgY Vl LAN N!F OF \ SUFFOLK COUNTY s / MOH. / \\ 1 u.R. SB�Op \\ ; "OP00"W \\ U.P. c\ / 14 011 50`' U.R.I.( �, SOUND?Arcrti°, �\ DRIVE IV6' 1001 \� 0 o \� / LAND NIF OF b � SUFFOLKCOUNTY D E C E I E L 9' 0 61 JUL 9 2026 „w 0 a� o• Southold Tomi Board of Trustees THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL -- -- LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS. AREA: 52459.49 Sq. Feet or 1.20 ACRES ELEVATION DATUM. _ _ ________ UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW COPIES OF TVIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL"AGENCY AND LENDING INSTITUTION LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE. THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE THEY ARE NOT INTENDED TO MONUMENT 7HE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES, ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS. EASEMENTS AND/OR SUBSURFACE STRUMRES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME OF SURVEY SURVEY OF: DESCRIBED PROPERTY 0F�w CERTIFIED TO: STERLING EASTERN SHORES MAP OF: EASTERN SHORES SEC. 4 �4� �� "' vo �Qp ASSOCIATION INC.; FILED: MARCH 7, 1966 No.4586 li�1� G Mz. SITUATED AT: GREENPORT � o TOWN OF: SOUTHOLD � �• OWN O COUNTY, NEW YORK � KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFs� 015088 - JQ- Professional Land Surveying and Design n N ` P.O. Box 153 Aquebogue, New York 11931 PHONE (631)298-1588 FAX (631) 298-1588 FILE # 225-253 SCALE: 1"-50' DATE: APRIL 5, 2026 N.YS LISC. NO. 050882 rro. � o5S3 A SOUT HOLD TRUSTEES Issued To Address.SS5o Sound Drvei Green4o= .THIS. NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765.1892 x N c) Tr .. i4l, lx� R R Glenn Goldsmid sident ; �O��gpFF� OG Town Hall Annex A.Nicholas Krupski,Vice President tit* 54375 Route 25 Eric Sepenoski N ? P.O. Box 1179 Liz Joseph nol ra@ � � Tele Southold, ( )hone 631 765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: Completed in field by: THE STIRLING EASTERN SHORES ASSOCIATION INC. requests an Administrative Permit to install five (5) 12" x 12" signs along property boundary line. Located: 3550 Sound Drive, Greenport. SCTM# 1000-33-1-3.1 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: Chapt. 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 Glenn Goldsmith,Prey;.__ p' ryoti� CO 's Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 Eric Sepenoski U P.O.Box 1179 Liz Gillooly y • 01� Southold,NY 11971 Joseph Finora �1 Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 7 g/2r Completed in field by: I - (n U ne, L, THE STIRLING EASTERN SHORES ASSOCIATION INC. requests a re-Application Site Inspection to discuss fencing options on beach. Located: 3550 Sound Drive, Greenport. SCTM# 1000-33-1-3.1 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: Chapt. 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.: e4 Idsmith " N. Kru i E. enoski Se Present Were. G.Y lc p L. Gillooly J. Finora S.C.T.M. NO. DISTRICT: 1000 SECTION: 33 BLOCK: 1 LOT(S):J.1 i ^5. 5 z. �0� o ,gyp gb Y \�q GRAVEL WALKWAY 0� j LAND N/F OF PGSTANRE LAND N/F OF STIRLING EASTERN PETER J GROSSMAN STK. SHORES ASSOC INC REVOCABLETRUST / 2 / �001, STK C., 23 .6' / GUY �\ py5 U.P. \ Y GPSE \ \F STK � U. �o GRAVEL O� DRIVEWAY LAND N/F OF SUFFOLK COUNTY / s �\ \\ 1 MDN. SBOo / U.P. 00, \ ; /0�00,00 0„W \� U.P. g8 0, SOh h\ uP / SOUND / DRIVE ti8 0 N� 0 00, ® E E j LAND N/F OF SUFFOLK FFOLK COUNTY JUL 9 2026 ,.w ob Southold TowIl Board of Trustees -- THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS. AREA: 52459.49 Sq. Feet or 1.20 ACRES ELEVATION DATUM.- UNAUTHORIZED ALTERAT70N OR ADDITION TO THIS SURVEY IS A VIOLA77ON OF SEC77ON 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM 7HE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TIRE COMPANY, GOVERNMENTAL AGENCY AND LENDING INS77TUT70N LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INS777U77ON, GUARANTEES ARE NOT TRANSFERABLE. THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE THEREFORE 7HEY ARE NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECT70N 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 77ME OF SURVEY SURVEY OF: DESCRIBED PROPERTY of NEO/ CERTIFIED TO: STERLING EASTERN SHORES MAP OF: EASTERN SHORES SEC. 4 P �N M 'v��:o� ASSOCIATION INC.; CO FILED: MARCH 7, 1966 No.4586 ���� 9 SITUATED AT: GREENPORT cr o TOWN OF: SOUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC SUFFOLK COUNTY, NEW YORK 0, 050882 JQJ Professional Land Surveying and Design IN P.O. Box 153 Aquebogue, New York 11931 FILE # 225-253 SCALE: 1"=50' DATE: APRIL 5, 2026 N.Y.S LISC. N0. 050882 PHONE (631)298-1588 FAX (631) 298-1588 OFFICE LOCATION: ��OF S�!/P�,O MAILING ADDRESS: Town Hall Annex ,`O l� P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) G • �Q Telephone: 631 765-1938 Southold, NY 11971 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: July 13, 2026 Re: LWRP Coastal Consistency Review Sterling Eastern Shores, SCTM #1000-1000-33.-1-3.1 This application is to post five 12" x 12" signs along the property boundary. 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 action of five 12" x 12" signs along the property of the proposed parcel is consistent with Policy 6.3.A which states compliance with the Board of Trustees' jurisdiction and complies with Town Code Chapter§275-11 B(4)(d) under Fences as a minor action. 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 Y , Glenn Goldsmith,President . � � Town Hall Annex 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 Coastal Erosion Permit Application �1 Wetland Permit Application6 Administrative Permit --Amendment/Transfer/Extension EJUL9 2026 Received Application: Received Fee: $ SoulholdTown Completed Application: Board of Trustees Incomplete: . SEQRA Classification: Type I__ Type I1 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: Owner(s) Legal Name of Property (as shown on Deed): Mailing Address: ?� C).Pj Du 6�6,0 PoA ,d L/ �! 7 Phone Number: l� Suffolk County Tax Map Number: 1000- SSG lJoJ 3-3 _�aGf� L•vCJ) 1 Property Location: vv'�'f ,,11t�'�e2S.✓ (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): dZV_-14_ e I S Mailing Address: Phone Number: rjc�U r 2 (�,(k Email: i L 4(fT � ~ Board of Trustees Application GENERAL DATA Land Area(in square feet): _ Area Zoning: Lf Previous use of property; Intended use of property: � `� Covenants and Restrictions on property? =Yes _ _No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? ElYes JRNo 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 _R_No If"Yes", please provide copy of decision. his project re 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?_n No Yes If yes, provide explanation: Project Description(use attachments if necessary): To s ,�l x f 2` y 12,E 'S I Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA r r o Purpose f the proposed operations: r Area of wetlands on lot: square feet Percent coverage of lot: / .. Closest distance between nearest existing structure and upland edge of wetlands t/L�i� feet Closest distance between nearest proposed structure and uplan 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? cubic yards Depth of which material will be removed or deposited: r 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): 617.20 Appendix B Short Environmental Assessment Form Instructions for:.eompleftnR 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 1 Project and Sponsor Information Name of Action or Project: Project Location(describe,and attach a location map): Brief Description of Proposed Action: Name of Applicant or Sponsor: Telephone: 5�s fi—LiA)&I �5 (4$fOC � E-Mail: Q Addres City/PO: State: Zip Code: el 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? 1 ❑ 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? Z 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 I land us at occur on,adjoining an ar the prop action. Urban Rural(non-agriculture) Ljlndustrial Commercial Residential(suburban) Forest ❑Agriculture Aquatic ❑Other(specify):; arkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? b.Consistent with the adopted comprehensive plan? -Ila 9 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? 7. 1s the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO J 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 YES If No,describe method for providing potable water: © IFI 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? e/ 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 NO YES, wetlands or other waterbodies regulated by a federal,state or local agency? S 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. Td4ntify the typic bitat types that oo` n,or are likely to be found on tll=,roject site. Check all that apply: Shoreline Forest Agricultural/grasslands U Early mid-successional Wetland Urban Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats, listed NO YES by the State or Federal government as threatened or endangered? 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO If Yes, a. Will storm water discharges flow to adjacent properties? 121NO ❑YES El b. Will storm water discharges be directed to established conveyance systems ff an m drains)? If Yes,briefly describe: MNO �'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 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:.,..w.� ... �-�- - -�-w-- ----- I AFFIRM THAT THE-INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY, KNOWLEDGE d Sd�� ��< i Applicant! orname:.� C� l'��. � ��C� .. �149�s /'t Date: � Signature:, ,��.� '�1 L trele� Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the,following -- questions in-Part 2 using the information contained in Part I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur I. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑, regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? El 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑. establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or (�j ❑ 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 a reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a.public/private water supplies? - b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ 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 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 ZE 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 AFFIDAVIT. Sf4n2G5 / bSSoG�'/p '✓f,LBEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS TH APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S),IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE-'PREMISES-IN C N W ONJUNCTIOITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS v�r J DAY OF wo Notary Public CONNIE D.BUNCH Notary Public,State of New York No.01131.16185050 Qualified in Suffolk County Commission Expires April 14,2 � APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits"conflicts of interest on the Part of town officers and,emaloyees.The purpose of this forth is to provide"information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOURNAME: (Last name,first name,griddle initial,unless you are applying in name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) <1 -Do y_ou-personally(or_throughyouurcompany,spouse;-siblingi parent;or-child),haveta M:itionship:with-any ofhcer or employee of the Town of Southold? "Relationship"includes-b"y 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 wnsore than 5"!o o ie shares. YES n o mNO _ 1 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): _nA)the owner of greater than 5%of the shares of the corporate stock of the applicant � (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate;entity(when-the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of tom` 20 Zb Signature F� ) -C 1.l-,�,.( 6 Lj!. Print Name Form TS 1 lrece s,re 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_.:niotiosed action will :be evaluated. as to::is sipufcant beneficial-and adverse effects.uyon the coastal area(wM6"in"eludes-all of Southold Town): 3 If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions'contained in the consistency review law. Thus.:each answer.,must:be-explained in detail,.listink both supporting and non-. suppotting facts. If an action cannot be certified as consistent with the LWRP policy standards and -Conditions.itshall=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 t 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 ❑ C onstruction,planning activity,agency regulation,land transaction) (b) Financial assistance(e.g.grant,loan,subsidy) (c) Permit,approval,license,certification: E Nature and extent of action: ` ' J! 6-1Vco-,O 0V 6 4ea ALocation of action: -500 n/a e-,oar Site acreage: �� Z Present land use: < �f-C(4 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: F (a) Name of applicant: CL�t��' (�// +��°"J SC �t�S S:`�•�-►�a -�.�-< (b) Mailing address: (c) Telephone number: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes ❑ No Rr If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED:COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ No Ftl 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—P licies Pages 3 through 6 for evaluation criteria ❑ 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 Pi Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss-of life, st1-uctures, and_natural-r-esources-from-flooding-and-erosion: See-LWRP -- -- section III—Policies Pages 8 through 16 for evaluation criteria Yes No Not Applicable _..... . ... ._.. .. � d....� . .,,_ . 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 throw h 21 for evaluation criteria ❑ Yes E.] No Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ Yes ❑No E?rNot 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❑ 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 0 No'2Not 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. ffNot ❑ Yef No 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 1�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 ZNot 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 0 Not Applicable PREPARED BY` a AIL �. G� S 1 TITLE DATE P� �6