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HomeMy WebLinkAboutTR-7880A James F.King,President `�QF S0!/TTown Hall Annex Bob Ghosio,Jr.,Vice-President ,`OOl0 54375 Main Road P.O.Box 1179 Dave Bergen Ji Southold,New York 11971-0959 John Bredemeyer ® p� Telephone (631) 765-1892 Michael J.Domino O Fax(631) 765-6641 COU BOARD OF TOWN TRUSTEES V� �TOWN OF SOUTHOLD Permit No.: 7880A t Date of Receipt of Application: June 21, 2012 Applicant: Vito & Dina Moles SCTM#: 54-4-3 Project'Location: 4200 Kenny's Road, Southold Date of Resolution/Issuance: August 22, 2012 Date of Expiration: -August 22, 2014 Reviewed by: Board of Trustees Project Description: To install a post and rail fence along the west side of the property from the concrete walkway seaward, to be no more than 52' seaward of the northwest corner of the existing deck. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the application prepared by Vito & Dina Moles, received on June 21, 2012, and stamped approved on August 22, 2012. 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. 0 s James F. King, President Board of Trustees James F.King,President p� OG� Town Hall,53095 Main Rd. Bob Ghosio,Jr.,Vice-President P.O.Box 1179 Dave Bergen � ae Southold,NY 11971 John Bredemeyer $,y • Telephone(631)765-1892 Michael J.Domino �o,( , �,`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 1 st day of construction % constructed Project complete, compliance inspection M 04=397 BOAR • .d - OF TRUSTEES '°ry - TOWN OF SOUTHOLD DAX zoi So N G . 1SL,N oo3 WATER F NIOK a8,s5• 1 P z 4� 31.�03.1 E N '36�1' ZE N 4 9 a5 et 0 0 �a da O tj ..CGI N' deck _ er?cl ► rt 7. porch rn 0 �n +� S7Y`FR cv FR .S f C� 0111 I 32.5' x8 vi oL s�' d to give .:fir 2� 137•0 . Pp' S 3 24 0 0 MERLY �b OR FOR ..NO $� I. KATHERINE' w'`TRA JUN 2 1 •2012 . Southhold Town Board of Trustees. DRNE N0RTNsEA nKioa ra0o�jUiWSWIM IieMw . ct�iY.ma smxquan m TMc',. iwiar'aAe:+a�t:!I�tW c'nritro�e ANO 0,0 U.NOW A war wipcnicaaarpr°oF-. .Mcrrrw+q,wt�.rocs-Am= 'JOB No. 03�485: FILE No. .. 824 F r rw iwoMr,rmi�gw io.aurn�m aw A*MM UXWMJMVK SURVEYED FOR RINA MOLES NNYlItiO D%AUE1�Q 'OII::/ppllidl'm,Sff6 8Y(OE7f•MA VM40 N OF 9=04 f1LL:R1N'OM]70'7FM''Pk7lIO -FW-MNOM:•TW :.aaMnc: lIIdIY�1�iM�`q�,ems.tow►;zo"n�:mu m�w+r,:as awom� SITUATED AT.SOU7HOLD. ,`vr"`'+:*T�' +Aoe16'C ND.WOIO'•1fR11irt101F:L1f�;1�k�AlO=19:,Sfi IM�p�.t.OP'•7FE '. , nacs,AK'wor:?wwraAKt ao ma►moK umnmom• 001 OF SOUTHOLD, SUFFOLK COUNTY N.Y. 'g oa SCALE 1' _ So' DATE 9-21-2004 sv r.'wa++at rip tr+e wa ai wx amposqs WC.mW:.`wr s`qpmDiMm 79 K A WIV YNX aWV. . ,. MAP FILED No. DATE CERnFIED..ONLY-TO: TAX 'MAP No.(REF oNLY) 1000-54--4-3' DISK 2D03 ALLSTATE.:ABsiRliCr roRP. WAROLD F. TRANCHON JR. P.C. .T F7ftSi'AMERICANS Tf[tE' INS: CO. OF NI:YV'..YORK LAND SURVEYOR �, s.y P.O. 80X 616 1866 WADING RN ER-MANOR RD..WADING_RIVER, NEW YORK. 11792 N LiC_ No. 048992 631-929-4695. 4::. ,, -•"NA ROLD F..T RA NCHON JR. PENN. LIC.'No. 2115—E James F.King,President *DF S0 Town Hall Annex Bob Ghosio,Jr.,Vice-President ,`O� Ol0 54 Main Road P.O..Box 1179 Dave Bergen i[ Southold,New York 11971-0959 John Bredemeyer G p@ Telephone(631) 765-1892 Michael J.Domino Fax(631) 765-6641 �yCOUNT`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 7880A Date of Receipt of Application: June 21, 2012 Applicant: Vito & Dina Moles SCTM#: 54-4-3 Project Location: 4200 Kenny's Road, Southold Date of Resolution/Issuance: August 22, 2012 Date of Expiration:August 22, 2014 Reviewed by: Board of Trustees Project Description: To install a post and rail fence along the west side of the property from the concrete walkway seaward, to be no more than 52' seaward of the northwest corner of the existing deck. Findings:,The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The-,- issuance of an Administrative Permit allows for the operations as indicated on the application prepared by Vito & Dina Moles, received on June 21, 2012, and stamped approved.on August 22, 2012. 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. James F. King, President Board of Trustees 1 �����11FFQE�-LPG James F.King,President o 40 Town Hall Annex Bob Ghosio,Jr.,Vice-President w 54375 Route 25,P.O.Box 1179 Dave Bergen Q�'. �' Southold,NY 11971 John Bredemeyer �'d1 ��bQ Telephone(631)765-1892 Michael J.Domino Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: M06 Please be advised that your application dated has been reviewed by this Board at the regular meeting i and your application has been approved pending the co pletion of the following items checked off below. Revised Plans for proposed project Pre-Construction Hay Bale Line Inspection Fee ($50.00) 1 st Day of Construction ($50.00)' '/z Constructed ($50.00) k 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: rlylcd 17WsY, Fee 1, 06D S9 TOTAL FEES DUE: $Sav BY: James F. King, President Board of Trustees 07/26/2012 15:07 6 "76=1893 LI FINEST HOMES P r Bargain and Sale Decd,with covenants against Grantor$Acts �• !tJ L 2 6 2012 CONSIILT YOUR LAWYER BEFORE SIGNING THIS INSTRtlWNT-THIS INSTRUMENT SHOULD BE USED BY .:. LAWYERS ONLY. THIS INDENTURE, made the 20`r'day of October Two thousand and four "'`..,c,,;,llol:l ;own :. BETWEEN _ ��_�F'u;,id of Trustees — JOHANNA TSOURIS,as surviving tenant by the entirety,residing at 25 Maymont Lane,Stonybrook,New York; 11790 party ofthe first part,and DINA MOLES,as to one-third interest and VITO R.MOLES,as to one-third " interest,both residing at 7 Klarman Court,South Huntington,New York 11746,and CHRISTOPHER KIDERIS,as to one-third interest,residing at 43 Barnum Avenue,Plainview,New York 11803. party of the second part, : WITNESSETH,that the parry ofthe first part,in consideration of teli dollars and other valuable ' consideration paid by the party ofthe second part,does hereby grant and release unto the party ofthe : second part,the heirs or successors and assigns ofthe party ofthe second part forever, ALL that certain plot,piece or parcel of land with the buildings'and improvemefs thereon erected, situate,lying and being at Southold,in the Town of Southold,County of Suffol d State of New York; BEGINNING at a point on the Easterly side of Kenney's ad distant 225.00 feet Northerly frorn the corner formed by the Easterly side of enney's Road and the : Northerly side of North Sea Drive; RUNNING THENCE North 40 degrees 53 m' utes 00 seconds West 109.99 feet to the highwater mark on 11/6/03 of the Long Islal Sound, RUNNING THENCE North 41 de s 31 minutes 03 seconds 29.85 feet;' RUNNING THENCE North 3 degrees 01 minutes 47 seconds Ease 88.65 feet;' RUNNING THENCE S lth 50 degrees 36 minutes 00 seconds Ease 109.42 feet; RUNNING THE E South 39 degrees 24 minutes 00 seconds West 137.02 feet to a . point on the E rly side of Keruley's Road being the point and place of BEGINNING. Said Premises is known as by 4200 Kenneys Road,Southold,New York. Said premises being the same premises conveyed to the party of first part by deed dated 1/27/1971 recorded 1/29/1971 -in Liber 6877 Page 537 .in the Office ofthe County Clerk, Suffolk County,New York. : TOG ETHER with all right,title and interest,if any,of the party of the first part in and to any streets and roads abutting the above described premises to the center lines thereof; TOGETHER with the : appurtenances and all the estate and rights ofthe party ofthe first part in and to said premises; TO HAVE AND TO HOLD the premises herein granted unto the party ofthe second part,the heirs or successors and assigns ofthe party ofthe second part forever. ' AND the party ofthe first part covenants that the party ofthe first part has not done or suffered anything whereby the said premises have been encun-ibered in any way whatever,except as aforesaid. AND the party ofthe first part,in compliance with Section 13 of the Lien Law,covenants that the party of the first part will receive the consideration for this conveyance and will hold the right to receive such consideration as a trust fund to be applied first for the purpose of paying the cost ofthe improvement and — will apply the same first to the payment ofthe cost ofthe improvement before using any part ofthe total of :. the same for any other purpose. The word"party"shall be construed as if it read"parties"whenever the sense of this indenture so requires. , IN WITNESS WHEREOF,the party ofthe first part has duly executed this deed the day and year first above written. IN PRESENCE Of ' V^� JOI ANNA TSOURIS r - . 07/26/2012 15:07. 6- 76-1893 LI FINEST HOMES PAGE 02 EW�PORK : STATE OF TiRW YORK STATE OFT! YG COUNTY OF�SuMil ss: COUNTY OF Suffolk ss'; On the 20t4 day of October 2004' On the........day of - ''before me,the undersigned personally ' ..before me,the undersigned,personally-. : --appeared JOHANNATSOURIS appeared t ,e personally known to me or proved to me on the ;.personally known to me or proved tome on the'' ' basis of sahsfactory.evidence to be the `,,'basis of satisfactory evidence to ba thG l indivrdual�s)whose name(s)is(are)subscribed ''individuals)whose tratt1.ie(s).irs(zue)subscribed, to;the wrthm instrument and acknowledged to to the within instnumentd"(eclnowledged ;'- me that ii(she6ey executed the same in his/her me that he/shehhey ex ei ated the sand in his/her Ytheie.capacity(les),and that by his/her their /their capacity(ies) and'that by hrs/{►er the¢ ' signatures(s)on the instrument,the individual(s), signatures(s)on the Wit,thata'dtvrdua•1(s), or the person;upon behalf of which the or the person..upon bchalfwptch the' mdi �dual(s)awed,executed the instrument. individua(s)acted,J. exec fire* natL t a c s t, T r TIFFANY ANNUN23ATA ..Notary Public,State of Neer Yak ; No.01AN6048300 Qualified in Suffolk County Commission Explres September 25,200 .Bargain and Sale Deed SECTION 054 BLOCK 4 LOT 3 :. -COUNTY SUFFOLK RECORD AND RETURN TO: .....;..: :. Aichael Carlomusto,Esq. ,;<` : ::;;-: •:•:': :1065 Old'County Road,Suite 204 ;. '-Wt' tb'r 'New York 11590 � a+ .07/26/2012 15:07 631-671 93 LI FINEST1HOME5 P�1GEir'03.: 4 ! 1 F } ` •I f i r i Ali l° .. � ) `I Py � i A►LL STATE ABSTRACT COrRP f } ! x�{de'NO 7680,65415J'"N-i�gl_ � dttM1�ifJ x -'{,t ys i 1?s'��•� ¢ l f5t ' . Y;i S C H RRU L E A :5 l i , �'� .Z�,',•,) �'."I r..: ` I C�.•t ii _ xr�DIVL, gleC�r Il�r � .el of(1�W�.�"f1 "s„ #'�=`"` h ✓afYsrt ), + '1 �• y. •- iR1. EI ' F �.¢ i I •{ , t! i • { f" s. >'i. i �ak�" t '' t fro nr;>ierected, situate,F.Iymg aqd be ao *ax 1 Ii /� �$ , _ r J " 4 r 1 a s r Ih • '., '"¢1G°1 {3 'a! f ti w a{xf�Sa of Suffol$andi;State:a New,}Yorg� _ � ,Y� a�},C}�'�: 1�i�i"����: " + ` .•. } } ,. f `I _ 1 .. I SE*d f 1 ; C � 8(4 �§ i7' r !.�• >..�7 � - BEGINNING,at; apoint on the Easterly side of+Kenney's { Northerly3 tithe corner formed by the yssterly side ofeiaae ' Road and'tbie'` ,w t Northerly(s"�'of.NO�rth'Sea I)I1Ve; ! t � :: f 3F ! �, t i a �. .'•. I' , , " ' �! �3.N" 1k� , rt;3't6t "'S � r'Ti���r ry t ^� � !' I '+' R[fNNING: f CE North 40'd 53 . . '..., o agrees.. the highwaterjtnark on'11/6/03 of the Long Island Sound, ' RUNNING THENCE North 41 degrees 31 minutes 03 seconds'East 29.85 feet; -RUNNING!TH�TCE North 38 degrees 01.minutes 47 seconds East,8&.0 feet;. 'RUNNING'TIENCE,South:.50 degrees 36 nunntes 00 seconds East IQ942 feet, ;RUNNING' THENCE South 39 degrees 24 minutes 00 se6iids!West 137 02`feet to a point on tithe ;Easterly side of; Kenney's Road ;being the paint and place of . I BEGINNING; * 3 c • ,f ..I • t y. y ��,�., .-. �' E 8 I. f'. tr 3�1:�`.n 2, .;.''� 4YG�w'^ l't + ' ' LJ "• l'.Ile-7 A�i �f 1... n��r�C, . '•�t {. r « t ' "I"' . oP by o 'be lsssi tin' this :report' will insure the t Ab,such buad`uigs arid: FOR .F improyements erected on the premises which by law constitute:real property. CONVEYAl�IC1NG ON Y�. TOGETHER,with all the right, title and.interest of the party-of.the first part, of, iwand,to ,r the lends tying in the street in front of and!adjoining said premises pSUf F9Zk James F.King,President P.O.Box 1179 Bob Ghosio,Jr.,Vice-President �� y� Southold,NY 11971 Dave Bergen coo - Telephone(631 765-1892 John Bredemeyer O Fax(631)765-6641 Michael J.Domino !� Southold Town Board of Trustees Field Inspection[Worksession Report Date/Time: /711C- /,} / �_ 3 0 Rescind Resolution dated July 18, 2012 and Amend Resolution to read as follows: RESOLVED, that the Southold Town Board of Trustees APPROVES the Administrative application of VITO & DINA MOLES to install a post and rail fence on the west side of the property no more than 70' in length beginning from the concrete walkway seaward. Located: 4200 Kenny's Road, Southold. SCTM# 54-4-3 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 Administrative_Emergency Pre-Submission Violation Info needed: Modifications: �� , �'�''y��- /f� GL��✓'�/, der012,Q i.y G. 7V Conditions: Present Were: J. King B. Ghosio D. Bergen, J. Bredemeyer Michael Domino D. Dzenkowski other Form filled out in the field by Mailed/Faxed to.- Date: SUFFO(�- James F.King,President Q�� C4G P.O.Box 1179 Bob Ghosio,Jr.,Vice-President �� y Southold,NY 11971 Dave Bergen Telephone(631 765-1892 am John Bredemeyer 0 Fax(631)765-6641 Michael J.Domino 4,ol Southold Town' Board of Trustees Field InspectionMorksession Report Date/Time. //2— VITO & DINA MOLES request an Administrative Permit to install a post and rail fence on the west side of the property no closer than 10' to the mean high water line. Located: 4200 Kenny's Rd., Southold. SCTM#54-4-3 T>r e 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 Typpes� of Application: Wetland _Coastal Erosion '_Amendment /--"Administrative_Emergency Pre-Submission Violation Info needed: Modifications: Conditions: ��`�''� s �C 1j.1jV/e-- J t Presgnt Were: ,'---J. King'— B. Ghosio / D. Bergen, J. Bredemeyer Michael Domino D. Dzenkowski other Form filleout in t field by Mailed/Faxed to: Date: Vito&Dina Moles 4200 Kenny's Rd., Southold SCTM#54-4-3 8/1512012 T Aqm*'Iqk,6. - ..- r.: �, - - r y� ~ - .� . _ +-...��.." •_ elf`"�_ - �T ., -' -•-a - .� �r-;Rim -�a.� s., � ,`- •J... , �� S..Ir ,�-�. ` -.�.,.. 1r�. - u..� '+_N`'._ �-'�. �. maw aw. 01 ,ram •yiy� r A j• • �-3" ,. w ►.' Iv RUN- _..� 'F _ mom:-' . `tiv.�..,Ti t ^� `Si - •�. •:r.41� i' _ o f �, �y'•� i .! � �is�'`�' 'y; •' � i mxiae g � sw mosw �� w �• 4 Vr e / JD a ? a 'aa �aJ re e O 4 j ro q ttJ Tovm of +�{'q SOUrnCtD e J., ,'o �z b r d, � r �• w � �ZY do h ,b a � •ze. '' °r °'1 Wqa'® ,� �as�mm. s iUul ® �e SECYION NO _ __ _ __ __ ,,,,a.,�,....a...p..e NOTICE COUNTY OF SUFFOLK © x ____ °�� __,__ Real Property Tax Service Agency Y r ,, 54 E rr�s —�� " (21) „ O w.wu �— u..runwraw,r.nYmn Y P m.we.wa,wma^ iROPERTYMM O u,,,u ww.0 rru OFFICE LOCATION: ��OF SO(/jyO MAILING ADDRESS: Town Hall Annex ,`O l0 P.O.Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold, NY 11971 G Q Telephone: 631 765-1938 Fax: 631 765-3136 oou�m,��' LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD D E MEMORANDUM JUL 1 7 2012 SOUthhold Town Board of Trustees To: Jim King, President Town of Southold Board of Trustees From: Mark Terry, Principal Planner LWRP Coordinator Date: July 17, 2012 Re: Proposed Wetland Permit for VITO & DINA MOLES SCTM#1000-54-4-3 VITO & DINA MOLES request an Administrative Permit to install a post and rail fence on the west side of the property no closer than 10' to the mean high water line. Located: 4200 Kenny's Rd., Southold. SCTM#54-4-3 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 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 i James F.King,President *0 SOUj Town Hall Annex Bob Ghosio,Jr.,Vice-President ,`O� �' 54375 Main Road P.O.Box 1179 Dave Bergen l [ Southold,New York 11971-0959 John Bredemeyer - . N 4 G p@ Telephone(631) 765-1892 Michael.J.Domino 'O Fax(631)765-6641 lycoorm,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application _Wetland Permit Application _ Administrative Permit J U N 2 1 . 2012 Amendment/Transfer/ xtension Received Application: 6161111d, Southhald Town Received Fee:$., Board of Trustees �Completed Application _Incomplete _SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) _✓LWRP Consistency Assessment Form (n xct((:r "CAC Referral Sent: mate of Inspection: 1(((y _Receipt of CAC Report: _ Lead Agency Determination: f _Technical Review: Public Hearing Held: Resolution: Name of Applicant VI;T-0 Address K LA7kMk J LITQ a*0TaQ VEW y0a I d-I Ll� Phone Number: W70'3�'113 C'ell rai l Suffolk County Tax Map Number: 1000 - 15 V - ' ,3 Property Location: 42DO 1�"Me (provide LILCO Pole#, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: Bcl- i of Trustees Application GENERAL DATA Land Area(in square feet): I�s S2.0 S Area Zoning: Previous use of property: 19Stde-K (,te Intended use of property: 0-es; n C-e Covenants and Restrictions: Yes No If"Yes",please provide copy. Does this project require a variance from the Zoning Board of Appeals Yes No If"Yes", please provide copy of decision. Will this project require 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 ZYes No Prior permits/approvals for site improvements: Agency Date �►rt-�n(d �� �03 � t� Co No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended y a governmental agency? o Yes If yes, provide explanation: Project Description(use attachments if necessary): Q DF � �ArkLo� � � ��� . Bc; ' 'L of Trustees Application I WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: square feet Percent coverage of lot: % i Closest distance between nearest existing structure and upland edge of wetlands: feet I Closest distance between nearest proposed structure and upland I 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: 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 SEAR 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.APPLICANT/SPONSOR 2.PROJECT NAME 3.PROJECT LOCATION: 17� /IfV( (�, Municipality CkJ*0 � County �� " 4.PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map 5.IS PROPOSED ACTION: RT New ❑Expansion ❑Modification/alteration 6.DESCRIBE PROJECT BRIEFLY: r� ?kCPMy FrOm C -M t�qk vI,q l� Lt �4 7.AMOUNT OF LAND AFFECTED: Initially a".11l d acres Ultimately a acres.- 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? Yes ❑ No If no,describe briefly: 9.WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) Residential ❑Industrial ❑Commercial ❑Agriculture ❑Park/Forest/Open Space ther (describe) V,e inn 's V0,-­! '-r S 1 W 10.'DOES ACTION INVO AIT-APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) Yes ❑No if yes, list agency name andpermit / approval: 7 CUR CURREN VALID PERMIT OR APPROVAL? ❑Yes moo` If yes, list agency name and permit / approval: LAR 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? ❑Yes NINo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Spo orrNNa 92 Date: Signature If the action is a Costal Area,and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment B(;' -,I of Trustees Application County of Suffolk State of New York 670 /VdDto 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/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 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 REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signature SWORN TO BEFORE ME THIS DAY OFI/A-0, ,20 ! d- Jonas Justin Wagner Notary P, ' State of New York �. WA6213636 N ry Public uu in Suffbik County ..uission Expires 11/16/20LZ B, d of Trustees Application AUTHORIZATION (where the applicant is not the owner) I, y © residing at 7 12J1&oft & sl$' N (print owner of property) (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) APPLICANUAGENUREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics rohibits conflicts of interest on the part of town officers and employees.The numosd 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 necessary to avoid same. '2 YOUR NAME: 7 �e (Last name,first name,.rpiddle 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%oft a shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater 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 10 day of ,�NGS 20yf�?r Signature cc � Print Name Form TS l r 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 area(which 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. DESCCRfIPTION OF SITE AND PROPOSED ACTION SCTM# J 7 - -3 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: LX Nature and extent of action: L ��.G� � ojc - - - M Location of action: ./ fur /pit Site acreage: f 95 Present land use: Iscd� ia t 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 applicant: Y d T® /40165 (b) Mailing address: 7 �/ )�U A97A)&7DAU S—t* (c) Telephone number: Area Code(4 k (d) Application number,if any: Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No[4� 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 VNot Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III-Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No 9 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 WNot 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 RFNot Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No of 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 Aph;__., ble _ 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 of 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 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. 0YeLl No❑ Not Applicable Attach additional sheets if necessary WORKING COAST POLICIE_ 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 5rNot 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 ONO 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 0 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 BY 1,7V TITLE�w��� DATE