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HomeMy WebLinkAboutTR-7398A Jill M.Doherty,President �QF S0 Town Hall Annex James F.King,Vice-President ,`O� ��� 54375 Main Road P.O. Box 1179 Dave Bergen J Southold,New York 11971-0959 Bob Ghosio,Jr. y ,c John Bredemeyer �Q Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 7398A Date of Receipt of Application: August 31, 2010 Applicant: Mo Ahmadzadeh SCTM#: 54-4-11 Project Location: 925 North Sea Dr., Southold Date of Resolution/Issua.nce: September 22, 2010 Date of Expiration: September 22, 2012 Reviewed by: Trustee Bob Ghosio Project Description: To modify the existing plantings by adding native species. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of-an Administrative Permit allows for the operations as indicated on the application received on 8/31/10 and survey stamped approved on 9/22/10. Conditions: 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. Jill !.Doherty, i en Boa of Trustees SURVEY OF PROPERTY A T SOUTHOLD TOWN OF SOUTHOLD LON°` ISLAND SOUArD SUFFOLK COUNTY, MY 1000-54-0411 SCALE. 1'=30' N43 46'03"E nE uN JUNE 5, 2008 _ _E _100.29 MfAN RICH WA� JUNE 26, 2008 (revisions) — - - - - —6— EDGE OF BEACH Ln O (,1 (.1 O O p o — r1 ' —ff�OBE Q` HAYBA(ES ,,// —� — /NbTALJ—N-r'D4 '9F /Y+i l✓F- � r'l V77 13) O F I-V►q A r Gizow� � I3c� I-F PL,)nt-- OSED DECK � a R� , LOT- COVERAGE r- �,� 13...5 `` i I ��ur rr, AREA = 26950 sq./1. to beach a y cG EXISTING HSE. & DECKS =.2994 sq.11 I 36.4' 1 Z. DECK 123' i,(i .05HED = l80 sq./1. 2 1.D' jJ,J 3/74/26950 3/74 sq./1. 8 '2 AFTER CONSTRUCT/ON = 3625 sq !;, 1 STY \,— x 3625126950 =13.5 % FR. HSE. w o p I I F.F. EL. 10.4' ��00 AREA TO COASTAL EROSION HAZARD 22.6' LINE =4500 sq./1. k +s.5' +6.6' LOT COVERAGE = O LX X—X— 12.2' DECK 122 5. • Z Co) .14 d CONCRETE PROPOSE DECK COVERS COASTAL EROSION ONE AE HAZARD , �, U (er 11) +6 s AUG 3 l 2010 °875.00' 1 Southhold Town Board of Trustees S3924'00"W 100.00' +7.8' OVERHEAD WIRES +7.7' EDGE OF PAVEMENT NORTH SEA DRIVE COASTAL EROSION HAZARD LINE FROM PUBLe WATER w STREET COASTAL EROSION HAZARD MAP. PHOTO # 56-566-83 FLOOD ZONE FROM FIRM MAP NO. J610JC0154 G MAY 4, 1998 ELEVA TIONS REFERENCED TO N.C. V.D. AREA=30,085 SO. FT. c VC. NO. 49618 ANY ALIFRA77ON OR ADDI77ON TO THIS SURVEY IS A WOLA77ON CONIC Sd YORS, P.C. OF .SEC77ON 7209OF THE NEW YORK STATE EDUCATION LAW. EXCEPT AS PER SEC77ON 7209—SUBDIVISION 2. ALL CER77FICA77ONS (631) 765-5020 FAX (631) 765-1797 HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONL Y IF P.0. BOX 909 SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR 12JO TRAVELER STREET WHOSE SIGNATURE APPEARS HEREON. SOUTHOLD, N. Y. 11971 08-142 Jill M.Doherty,President ti - Town Hall,53095 Main Rd. James F.King,Vice-President ,a.. P.O.Box 1179 Dave Bergen dr, �` Southold,NY 11971 Bob Ghosio,Jr. Telephone(631)765-1892 John Bredemeyer a '� Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-.CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE - Pre-construction, hay bale line 1st day of construction % constructed i/ Project complete, compliance inspection. Jill M.Doherty,President q Town Hall,53095 Main Rd. James F.King,Vice-President ,y� F. P.O.Box 1179 Dave Bergen �► ` Southold,NY 11971 Bob Ghosio,Jr. �v � Telephone(631)765-1892 John Bredemeyer ' ' Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: ►`) h cx�{�o,4Lo It Please be advised that your application dated $ 1 10 has been . reviewed by this Board at the regular meeting of a a and your application has been approved pending the completion of the following items checked off below. Revised Plans for proposed project Pre-Construction Hay Bale Line Inspection Fee ($50.00) 1st Day of Construction ($50.00) '/2 Constructed ($50.00.) Final Inspection Fee ($50..00) Dock Fees.($3.00.per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. -You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $ r BY: Jill M. Doherty, President Board of Trustees Jill M.Doherty,President �p� CQ P.O.Box 1179 James F.King,Vice-President G� Southold,NY 11971 Dave Bergen y Telephone(631)765-1892 Bob Ghosio,Jr. ,y. Fax(631)765-6641 John Bredemeyer y !� Flo` Southold Town Board of Trustees Field.Inspection/Worksession Report Date/Time: 0 �® Creative Environmental Design on behalf of MO AHMADZADEH requests an Administrative Permit to modify the existing plantings by adding native species. Located: 925 North Sea Dr., Southold. SCTM#54-4-11 Type of area to be impacted: _Saltwater Wetland Freshwater Wetland Sound Bay Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: _Chapt.275 Chapt. 111 other Type of Application: Wetland _Coastal Erosion _Amendment Ad min istrative_Emergency Pre-Submission Violation Info needed: Modifications: Conditions: Present Were: _J.King _J.Doherty_J. Bredemeyer D. Bergen_ B.Ghosio, D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: Date: OTo301 J - � 6 tF q l.la 5 l.y<r w 'll e a e oe.I6.0 a pvroo y . N r i w ` r4 `♦ &nai an F F I-T)OG w La'c J V)1 w II 12 \ —N— aJ v w aya¢• r _ J � ' L & 2 TIJ S� 9 J , J: pSI a) J w r I! Tl.l h SOUrx11D L r'4cr r •': ' a ♦ ,r r s 'WI '�. ° t2rr L ♦ t yr w q a roa pn.Na ziu I �. `33 LJ Ir ) � �°. Q• J� � ,v a !P SFE)�Ol 65 a . B� SECTION NO NOTICE COUNTY OF SUFFOLK © E 0A° SOUTHOLD mpp __ wm w{snroum wean Real Property Tax Service Agency Y0 054 E m r O _ _ _ ) ooipwlw s pr pmfor Ir]If p G Cam Center Poverneaq 1 N T 1 190 Y E amn m N==—� w L♦f04 WYIY rY urp 6 PbO1Ep 4,�1 YYE.mlE A 061Ptt i0 _ tm+rw -- W,f ipliM 1pnr5)OI Or M y)�p P lOOO 1211 tY PROPERTY YAP 0 i.nr T]�-. ��IT.1 atm pr iT.L�' �_ —_ ,srr mw[I In— —_ Hll W6Eeii iai S£PVR arMr. r Ym rjf so OFFICE LOCATION: P MAILING ADDRESS: Town Hall Annex h0 l0 P.O. Box 1179 54375 State Route 25 Southold,NY 11971 (cor. Main Rd. &Youngs Ave.) cn 4AC Telephone: 631 765-1938 Southold,NY 11971 0� Fax• 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Jill Doherty, President Town of Southold Board of Trustees _ From: Mark Terry, Principal Planner f`:! ' SEP 1 6 2010 LWRP Coordinator '0 L-; Date: September 16, 2010 soul odd To c Board of Trustees Re: Proposed Wetland Permit for MO AHMADZADEH SCTM# 1000-54-4-11 Creative Environmental Design on behalf of MO AHMADZADEH requests an Administrative Permit to modify the existing plantings by adding native species. Located: 925 North Sea Dr., Southold. SCTM#54-4-11 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 denoted following Policy Standards and therefore is CONSISTENT with the LWRP. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney �L���yFFO�,�Cl1 Jill M.Doherty,President ti - Town Hall,53095 Main Rd. James F.King,Vice-President P.O.Box 1179 Dave Bergen �► `� Southold,NY 11971 Bob Ghosio,Jr. �0 � Telephone(631)765-1892 John Bredemeyer �' Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application _Wetland Permit Application dministrative Permit �- _Amendment/Transfer/E ension V E eceived Application: � 1 Q Received Fee:$ ,)u ompleted Application r3 1:(1 ( _ + AUG 3 1 2010 _Incomplete SEQRA Classification: Type I Type II Unlisted Soutl?hold Town Coordination:(date sent) _ Board or Trustees - WRP Consistency Assessment Form LV c,.,CAC Referral Sent: PA 0-- Date of Inspection: Receipt of CAC Report: _Lead Agency Determination: Technical Review: Public Hearing Held: Resolution: Name of Applicant Address Jos k1vd,-zt7 5� N.y 1 d0(3 Phone Number:( ) Suffolk County Tax Map Number: 1000 - Property Location: 9Z� �UC�r �PC� i6t/,e swt o�(Y (provide LILCO Poe#, distance to cross streets, and location) AGENT: �A ClC�k-4&,6wtC-2 . coc�vo (If applicable) J� Address: �d✓� Z�. �y (60 \/G�&JL C 9Q Phone: B, d of Trustees Application GENERAL DATA Land Area(in square feet): .9,50 10 beo-A Area Zoning: �S , Previous use of property: �ES Intended use of property: Covenants and Restrictions: Yes VINO If"Yes",please provide copy. Does this project require a variance from the Zoning Board of Appeals Yes L,- If"Yes";please provide copy of decision. Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspende y a governmental agency? No Yes If yes,provide explanation: Project Description(use attachments if necessary): 0►71 ' A.� F ST, lay w�i�, ti n Lc ed 1✓ v� E -d of Trustees Applicatio WETLAND/TRUSTEE LANDS APPLICATION DATA. Purpose of the proposed operations: C', t sT, Area of wetlands on lot: o square feet Percent coverage of lot: C2 % Closest distance between nearest existing structure and upland edge of wetlands: J'�C> feet Closest distance between nearest proposed structure and upland edge of wetlands: /S� feet Does the project involve excavation or filling? S- No Yes If yes, how much material will be excavated? cubic yards. How much material will be filled? cubic yards 'Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by_ reason of such proposed operations(use attachments if appropriate): PROJECT ID NUMBER 617.20 SEQR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1.APPLICA T/SPONSOR 2.PROJECT NAME ctc(I A (C2 MID Ar0;y0*�, ) zA7 C-1 &PROJECT LOCATION: 2S WOO Sew. �� S Munic County t�0 4.PRECISE LOCATION: Street Addes9 and Road Intersections, Prominent landmarks etc -or provide map l s-b e"5"s a F L)0-vTfdq 5.IS PROPOSED ACTION: ❑ New ❑Expansion B?� ification/alteration 6.DESCRIBE PROJECT BRIEFLY: LL�� �� `� wi.v Gi -� A-ITA-c ►// ��i/�i JAI d 7.AMOUNT OF LAND AFFECTED: Initially ,0 acres Ultimately i d acres 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? Yes ❑ No If no,describe briefly: 9.WH,A57, IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) Residential ❑Industrial ❑Commercial ❑Agriculture ❑Park/Forest/Open Space ❑Other (describe) 10.'DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal State or Local) ❑Yes No If yes, list agency name and permit / approval: OF IHI:= ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes No If yes, list agency name and permit / approval: 12. AS A RES OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? Oyes No I CERTIFY THAT THE`INFORMATION PROVIDED //ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / nsor Name ( ►(� C I L}t+4�?d1,v�G2 l QC (vIJV� ��S iCi 1, ' Date: Signature vl ion is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II- IMPACT ASSESSMENT(To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617A? if yes,coordinate the review process and use the FULL EAR Yes [0 No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.E7 If No,a negative declaration may be superseded by another involved agency. E] Yes a No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,If legible) C1. Existing air quality,surface or groundwater quality or quantity,noise levels,existing traffic patter,solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly. No . C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly: No C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly: No C4.A community's existing plans or goals as officially adopted,or a change in use or Intensity of use of land or other natural-resources?Explain briefly: No C5. Growth,subsequent development,or related activities likely to be induced by the proposed action?Explain briefly: No • C6. Long term,short term,cumulative,or other effects not identified in C1-05? Explain briefly: No C7. Other im acts,(including changes in use.of either quandty or type of energy? Explain briefly: 'No D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA CEA 7 If Les,explain briefly: Yes 21 No E. IS THERE,OR IS THERE LIKELY TO BE CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If es ex lain: Yes No PART III-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS; For each adverse effect Identified above,determinewhether His substantial,large,important.or otherwise significant. Each effect should be assessed in connection with its(a)setting(i.e.urban or rural),(b)probability of occurring;(o)duration;(d)irreversibility;(e) geographic scope;and(f)magnitude. If necessary,add attachments or reference supporting materials. Ensure that explanations contain sufficient detail.to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes,the determination of significance mustevalua(e the potential Impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have Identified one or more potentially large orsigri ficant adverse impacts which MAY occur.Then proceed directly to the FUL EAF and/or prepare a positive declaration. Check this box If you have determined,based on the information and analysis above and any supporting documentation,that the proposed actin WILL NOT result in any significant adverse environmental impacts AND provide,on attachments as necessary,the reasons supporting thl determination. Board of Trustees Name of Lead Agency pate Jill M. Doherty President Zor Type Name of Responsible Officer in Lead Agency Title of Responsible Officer vi - 6�' � - Signature of Responsible OCpf in Lead.Agency Signature of Preparer(Ifdifferent from responsible officer) dos� � Town of Southold Erosion, Sedimentation .& Storm-Water Run-off ASSESSMENT FORM �o PROPERTY LOCATION: S.C.T.M.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A STORM-WATER,GRADING,DRAINAGE AND EROSION CONTROL PLAN District Sectloh grock, -T�-- CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK. SCOPE OF WORK - PROPOSED CONSTRUCTION ITEM# / WORK ASSESSMENT Yes No a. What is the Total Area of the Project Parcels? (Include Total Area of all Parcels located within Q � Will this Project Retain All Storm-Water Run-Off the Scope to Work for Proposed Construction) s- �4 Generated by a Two(2")Inch Rainfall on Site? (S. ./Acres) (This item will include all run-off created by site I/ El — b. What is the Total Area of Land Clearing clearing and/or construction activities as well as all and/or Ground Disturbance for the proposed �� �� Site Improvements and the permanent creation of construction activity? ( .F.I Acres) impervious surfaces.) 2 Does the Site Plan and/or Survey Show All Proposed PROVIDE BRIEF PROJECT' DESC1tIPIION (Provide Additional Pages as Needed) Drainage Structures Indicating Size&Location?This ( _ Item shall include all Proposed Grade Changes and MODi N r CIS i. Vge e�'kTi0 tit Slopes Controlling Surface Water Flow. fjII 3 Does the Site Plan and/or Survey describe the erosion ❑ A �1 Al W fF 1 de CL Q-e r and sediment control practices that will be.used to control site erosion and storm water discharges. This A—,--�- � 4 06 item must be maintained throughout the Entire A Construction Period. 4 Will this Project Require any Land Filling,Grading or Excavation where there is a change to the Natural — Existing Grade Involving more than 200 Cubic Yards of Material within any Parcel? j Will this Application Require Land Disturbing Activities / Encompassing an Area in Excess of Five Thousand ✓ (5,000 S.F.)Square Feet of Ground Surface? — 6 Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Requirements: or within One Hundred(100')feet of a Weiland or Submission of a SWPPP is required for all Construction activities involving soil Beach? disturbances of one(1)or more acres; including disturbances of less than one acre that 7 Will there be Site preparation on Existing Grade Slopes are part of a larger common plan that will ultimately disturb one or more acres of land; which Exceed Fifteen(15)feet of Vertical Rise to Including Construction activities involving soil disturbances of less than one(1)acre where One Hundred(100')of Horizontal Distance? — the DEC has deteimined that a SPDES permit is required for stone water discharges. (SWPPP's Shall meet the Minimum Requirements of the SPDES General Permit 8 Will Driveways,Parking Areas or other Impervious for Storm Water Discharges from Construction activity-Permit No.GP-040-001.) Surfaces be Sloped to Direct Storm-Water Run-Off ❑ 1.The SWPPP shall be prepared prior to the submittal of the NOI.The Not shall be into and/or in the direction of a Town right-of-way? submitted to the Department prior to the commencement of construction activity. 2.The SWPPP shall describe the erosion and sediment control practices and where 9 Will this Project Require the Placement of Material, required,post-construction storm water management practices that will be used and/or Removal of Vegetation and/or the Construction of any constructed to reduce the pollutants in storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder — — compliance with the terms and conditions of this permit In addition,the SWPPP shall Area?(This Item will NOT Include the Installation cf Driveway Aprons.) identify potential sources of pollution which may reasonably be expected to affect the quality of storm water discharges. NOTE: If Any Answer to Questions One through Nine is Answered with a Check Mark 3.All SWPPPs that require the post-construction storm water management practice in a Box and the construction site disturbance is between 5,000 S.F.81 Acre in area, component shall be prepared by a qualified Design Professional Licensed in New York a Storm Water,Grading,Drainage&Erosion Control Plan is Required by the Town of that is knowledgeable in the principles and practices of Storm Water Management. Southold and Must be Submitted for Review Prior to Issuance of Any Building Permit (NOTE: A Check Mark(4)and/or Answer for each Question is Required for a Complete Application) SPATE OF NEW YOM COUNTY OF...........................................SS - That I, .....being duly sworn,deposes and says that he/she is the applicant for Permit, (Name of individual signing Document Andthat he/she is the ............. .>1 ............................ ... ....... .... ........ ...... ....... (Owner,Contractor,Agent,'Corporate Officer,etc.) Owner and/or representative of the Owner or Owners,and is duly authorized to p&#M%.MMDj3brmed the said work and to make and file this application;that all statements contained in this.application 1tcd=12(61 th b t i01 I �$f�3wledge and belief;and that the work will be performed in the manner set forth in the application filed h v' `it Suffolk' Sworn to before me this; PU a i7 in Suffolk Coup$ Co ion ............ .� .....................day of.. ...........................,20/0 Notary Public: ..?....". .. .�.............. .............. ............................ (Signal i nt) FORM - 06110 Board of Trustees Application County of Suffolk State of New York 1 pcv t C t c_ °"^d""` `Z BEING DULY SWORN ..DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/BER 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 TOWN 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 Y REPRESENTATIVES(S), TO ENTER ONTO M PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF TION. Signatur SWORN TO BEFORE ME THIS f*�57'- DAY OF (9AS)i ,20Go LAUREN M.STANDISH Notary Public,State of New York Qualified m Suffolk0Count�yy Commission Expires April 9,20L n ry Public Bo&L_ .3f W slte" hpplicatics 11Il�lT1G� (where the applicant is not the owner) remidina at (print owner of property) ass � 'l-4fl�fl N kl 1.117 I do hereby authorize 1 wl�.1.1111 1■ 111� (Agent) DNQ C'iC—�C9AJ i C2 to apply for permit(s) from the Southold Hoard of Town Trustees on my bahalf. (owner' s a gmture nr APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The puipose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is nece,ss=to avoi ame. YOUR NAME: A-j t Cl G l-F J w c yZ (Last name,first name,ipiddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the.other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship.with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial.ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the tires. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,of employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submi 30 a of - 2040 Signature. Print Name ` Form TS 1 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other•information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form.should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal arealwhich includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non-. supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# - - j PROJECT NAME Mo The Application has been submitted to(check appropriate response): / Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate'response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity,agency regulation,land transaction) ❑ (b) . Financial assistance(e.g. grant, loan,subsidy) (c) Permit, approval, license,certification: ❑ Nature and extent of action: _ M Location of action: 1)R4 ifs �o✓'"`a`"� - Site acreage: Present land use: Present zoning classification: - L(O 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 ❑ No❑ 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 ONot Applicable Attach additional sheets if necessary Policy 2. Protect and pr rve historic and archaeological resources of the Town of Southold. See LWRP Section III=Po ' ies 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 O<Ot 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 Pa s 8 through 16 for evaluation criteria Yes No Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of.Southold. See LWRP Section III —Policies Pages 16 throw 21 for evaluation criteria El Yes ❑ 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 evaluatio 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 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. No❑ Yes ❑ No t 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. ❑ 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 L RP 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 wat rs. See LWRP Section III-Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III— Policies; Pages 62 through 65 for eval tion 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; P ges 65 through 68 for evaluation criteria. ❑ Yes ❑ No Not Applicable ('D PREPARED BYP�,G1 CCG Rq-j a W C2 TITLE DATE / 3J /�