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HomeMy WebLinkAboutTR-7918A gUfFO(,� James F.King,President p� �'pG Town Hall,53095 Main Rd. Bob Ghosio,Jr.,Vice-President P.O.Box 1179 Dave Bergen a g w Southold,NY 11971 John Bredemeyer .4 • Telephone(631)765-1892 Michael J.Domino 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 Y2 constructed Project complete, compliance inspection James F.King,President �QF SO(/ry Town Hall Annex Bob Ghosio,Jr.,Vice-President ,`O� ��� 54 Main Road P..O.O.Box 1179 Dave Bergen t Southold,New York 11971-0959 John Bredemeyer G pQ Telephone(631) 765-1892 Michael J.Domino 'p Fax(631) 765-6641 OUNT`I,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 7918A Date of Receipt of Application: September 7, 2012 Applicant: Kathleen Milne SCTM#: 107-9-4 Project Location: 3875 Wickham Avenue, Mattituck Date of Resolution/Issuance: October 17, 2012 Date of Expiration: October 17, 2014 Reviewed by: Board of Trustees Project Description: To fill in an area of land to prevent further erosion using clean fill and topsoil and re-establishing the lawn area. 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 project plan prepared by Kathleen Milne, received on September 7, 2012, and stamped approved on October 17, 2012. Special Conditions: Fill for creek-side of depression to be at grade, not to exceed elevation of the bank 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 EFO4�O James F.King,President - Town Hall Annex coo at Bob Ghosio,Jr.,Vice-President - 54375 Route 25,P.O.Box 1179 Dave Bergen .f• Southold,NY 11971 John Bredemeyer �lQ1 �'aa Telephone(631)765-1892 Michael J.Domino Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD [�2+h TO: leeo M IrIVIL Please be advised that your application dated 7 M I has been reviewed by this Board at the regular meeting of D and your application has been approved pending the completion of He 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) % Constructed ($50.00) VFinal 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: �'r�al Z�tspechav�- � 5D•D© TOTAL FEES DUE: $ J 00 BY: James F. King, President Board of Trustees t) la/12- � s «a • 1 11Y Y �r 1 #; .is �" `�� •�' ,'.� � � � �•� , . .r'`� `� �'� `'+�,�.�,, 'f1; ., �rh � � `• k' r J # ?�� •,M ,fit� ��..rr�l``l s r " ��• 1 ' •NAY', � .. - _ _ � � -�".. �, i .-1'�•... �+ , � • -'�' .t t,' ��,yWiL�`�/}� �.� .vim+�' 1 •/, � ��t•. c ,, •J } ij i tiq - t f t c wF ' SURVEY OF PROPERTY CREEK SITUATE ��1� s „ E MATTITUCK ,70 WOOD POST N 8 3 9.0 8'1 7TOWN OF SOUTHOLD N 890 27'42" E >> 6 "46. 11 — — — — SUFFOLK COUNTY, NEW YORK ° i - - ` 5�•/ '// °E's ii� E C E E TAX No. 1 000- 107-09 -04 —H GHI WATER MARK 41E ALONG APPAREN A��jo SCALE 1 —3 0 It .l SEP - 7 2012 ! ;1 MARCH 7, 2000 6 DISREPA DocK / 'AY 18, 2012 STAKE EAST & WEST PROPERTY LINES A/ WN IR L 0' Southold Towp <1\ Board of Trustees AREA = 36,188.40 sq. ft. (TO TIE LINE) 0,831 ac. '� �4^- CERTIFIED TO: ` � _ COMMONWEALTH LAND TITLE INSURANCE COMPANY CORNER TITLE No. RH-80001053 ��� SUFFOLK COUNTY NATIONAL BANK s �oP� ��, KATHLEEN MILNE ti NOTE: 00< ,,j/ 6°, 9� S.C.D.H.S. REFERENCE No. 91 —SO-89 � h C a'i 4�3/.5' � G & Wp\ Fyn 10- 46, F SEPT/C /'F ( p 4 o \ TA K S k O S .. e e• ti �p/0!r• n v N ��? / �' Jo0 5�0 S/ti i ��:' ::• - �E�� op CEP 1 �/ o<S APPROVED •� 1 a�; :e �� ;a, •.'. `e' c�QR� Gp\N ��tPc PREPARED IN ACCORDANCE WITH THE MINIMUM 7 STANDARDS FOR TITLE SURVEYS AS ESTABLISHED �� ��V `� y�GS a • o%• �,1 IFRPM °, ''{ �FFy, G2 APROED AND FORBY T HE SUCH USE BYNTHEPNEWVYORK STATEOPTED LAND F ,2oGS N�vs !� 9� TITLE ASSOCIATION ® NE(/y . cIF 8 . • moo o ?ATE 17 �ZN��vD . ' A• ' o _ C'a� \o fo yc> �oP \ GVY WIRE E Y.S. Lic. No. 504E Vv 2 �� DOE QP�F 5 a4.85 Nathan Taft Corwin III UNAUTHORIZED ALTERATION OR ADDITION �O P a ?C. Land Surveyor r0 THIS SURVEY IS A VIOLATION OF ,,R� SECTION 7209 OF THE NEW YORK STATE CDUCATION LAW. FCJ�C� a'•.a+ COPIES OF THIS SURVEY MAP NOT BEARING \��C\�' rHE LAND SURVEYOR'S INKED SEAL OR �\Y Successor To: Stanley J. Isaksen, Jr. L.S. :MBOSSED SEAL SHALL NOT BE CONSIDERED Qo��a�o`' � Joseph A. Ingegno L.S. r0 BE A VALID TRUE COPY. CERTIFICATIONS INDICATED HEREON SHALL Title Surveys — Subdivisions — Site Plans — Construction Layout �P o� 1nnv Tn TWW croon& mR Wunu TUC CI I RUN A\IN .G./ �Q niinur /ez+\�n� nnnn r.... /c7+\7n-7 +-71)-7 su>:Foc�- James F.King,President �� �O P.O.Box 1179 Bob Ghosio,Jr.,Vice President ] G� Southold,NY 11971 Dave Bergen y Telephone(631 765-1892 John Bredemeyer Fax(631)765-6641 Michael J.Domino ro e� Southold Town Board of Trustees Field InspectionMlorksession Report Date/Time: 9c7-/ 0 2-91 7i 17,, KATHLEEN MILNE requests an Administrative Permit to fill in an area of land to prevent further erosion using clean fill and topsoil and re- establishing a lawn area; and requests a Pre-Submission Inspection in regards to rebuilding the existing dock and retaining wall. Located: 3875 Wickham Avenue, Mattituck. SCTM# 107-9-4 Type of area to be impacted: ✓Saltwater Wetland Freshwater Wetland Sound Bay Distance of proposed work to edge of wetland - L o 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: F N e-7— 7-z' x c� Modifications: 1) C,5S NON- 9V_f�9— Conditions: Present Were: �J. King . Ghosio +�D. Bergen, .,--J. Bredemeyer t/ Michael Domino D. Dzenkowskl other Form filled out in the field by )elk) Mailed/Faxed to: Date: � �� '_ •'.`yam � � ' L .y di rf t� iF ma r jl. ' •3 } I,P t PROPERTY MFP 0 ^ OB-x}gg _0. 1�W SEE SEL.ND.,m •SEE SEC xD.tm 6Y34B9 N)ro.ea°1 u of 6 Y' YP MATCN—ZT--_ LINE � MATCN—___-Z--___ � ——— ,�-- UNE ry %x699 OfFOR PLL NO ] @ 0636W N Yy ,.A 5.5A °} EEEEEO.NO. 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C 'es ''4� SEE SEC o.rll p O . , nsaza5z, I I/ / ` •5M1 'a, �� e '9s 9 � "` ,;�''// Yp'I r°" _r4r '°9', � p9' m ,^.w4 4 I •\s 0� Y" ,5 _.i Be F ,S a b.r '� � W� oFmrnww Sa P�, �ru•mvrnorn / \ \ t 'p r}a M e 'Rxxac Q•?e"4� a Y Q //,� ICJ I \#,n q QP ,a 2° '0a • y C� 61 L°'v'Qw r� ?°°_=a `�axre�p �e^� y ,��e � � e+' l r l 'E. i MATLN^K UNE a t0 ry - s¢Sm W>w SEE SEC NO.114 ' _ e 1 � \♦ L"....sr.. r,� .. ... _ —_ �v --mr-- r...r.. --x-- qm NOTICE COUNTY OF SUFFOLK © K cK SOUTHOLD SECTION NO E u µme-- 109 —O2 �µ —_—" w —_—� .., Real Property Tax Service Agenq M, mr °f L rL.A1.1w.m aNY„rc, 107 0.e.r. 21 .� 1.1Nx"12'A r"' —_-- �r --•-- _ ""--..-- wuraor[mviAKSEmncSAaxcT. Q4 " P 11]t,^ U" °ENO ,000 PROPERTY MAP I OFFICE LOCATION: ��OF S0(/ryO MAILING ADDRESS: Town Hall Annex 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: 631765-3136 ��y��UNT1,Nc� LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM C � � � ' fII! To: Jim King, President L OCT 1 6 2012 Town of Southold Board of Trustees 'From: Mark Terry, Principal Planner srutNial, roi(fan Bae,rr, of irastees LWRP Coordinator --�- �� Date: October 16, 2012 Re: Proposed Wetland Permit for KATHLEEN MILNE SCTM#1000-107-9-4 KATHLEEN MILNE requests an Administrative Permit to fill in an area of land to prevent further erosion using clean fill and topsoil and re-establishing the lawn area. Located: 3875 Wickham Avenue, Mattituck. SCTM# 107-9-4 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 action is CONSISTENT with the Policy Standards and therefore, 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, 10 SEPTEMBER 2012 THE SOUTHOLD TOWN TRUSTEES MAIN ROAD 2} ; i���r— L� SOUTHOLD, NEW YORK SEP 1 1 20i2 RE: DOCK PERMIT # NY 5524 AA { — & RETAINING WALL Scatne!�I To;'n ECBiC C7 I''L'Sf' PS 3875 WICKHAM AVENUE MAZTITUCK, NEW.YORK GENTIJJ MLN: THE UNDERSIGNED WOULD APPRECIATE YOUR OPINION ON THE CHANCES OF OBTAINING A PERMIT TO REPAIR AND/OR RESTORE THE EXISTING DOCK AND RETAINING WALL. MANY THANKS. SINCERELY, e KATHLEEN MILNE 3875 WICKHAM AVENUE POST OFFICE BOX 1707 MATTITUCK, NEW YORK 11952 I I I James F.King,President �QF O� SDUryQI Town Hall Annex - 54375 Main.Road Bob Ghosio,Jr.,Vice President � � P.O.Box 1179 Dave Bergen Southold,New York 11971-0959 John Bredemeyer G � �pQ Telephone(631)765-1892 Michael.J.Domino 'Q Fax(631) 765-6641 �yc4UN1Y,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Applicatio W� U Imo_ y Wetland pp 1 nd Permit Application Administrative Permit _ ✓ Amendment/Transf /E tension E. Reei Z i SP 7vePPlication: 2012 j �. Received Fee:$ WOO j 7Completed Application f - _Incomplete Southold Town _SEQRA Classification: = board of Trustees Type I Type II Unlisted Coordination:(date stint) 7_LWRP Consistency Assessment Form CAC Referral Sent: —Date of Inspection: Receipt of CAC Report: _Lead Agency Determination: Technical Review- Public Hearing.Held: 10111 Resolution: Name of Applicant [�GC ��-eI/1 � Q Address ;6� to.161&a/V1 AV'21ALCQ Wffitckj kQw qo rv, Phone Number:( Suffolk County Tax Map Number: 1000 40-1" 0q—K Property Location: ` Sr7 S wl c-O m mu-c f (provide LILCO Pole#, distance.to cross streets, and location) AGENT: (If applicable) Address: Phone: f f Boa.-4 of Trustees Application GENERAL DATA Land Area(in square feet): 3 cot Area Zoning: Previous use of property:Intended use of ro ert : ��AWAA P P Y 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 Yes No Prior permits/approvals for site improvements: Agency Date V6CiL P�� ev1 CCU I Jko Oce aazf No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No Yes If yes,provide explanation: Project Description(use attachments if pecessary): ASS , Boar' >f Trustees Application - WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: I Area of wetlands on lot: square feet j Percent coverage of lot: % 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 I 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? (00 cubic yards j Depth of which material will be removed or deposited: feet i i Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: I i 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): i Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: fttz O Wt IA b SLdn Are wetlands present within 100 feet of the proposed activity? No Yes 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? &Q (cubic yards) Manner in which material will be removed or deposited: c ibe the nature and extent of the environmental impacts to the subject roperty or neigh properties reasonably anticipated resulting from im entation of the project as proposed, inc g erosion increase or adverse effe�qral protective features. (Use attachments if neces r sa-6 * f 617.20 SEAR PROJECT ID NUMBER APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM i , for UNLISTED ACTIONS Only PART 1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1.APPLICANT/SPONSOR 2.PROJECT NAME WmatI4 V� 3.PROJErLOCa( Municipality �(� y County 4.PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map �15 talc agvv\ 4KuAa , d ``� ley 2Jg 5.IS PROPOSED ACTION: 1�9 New ❑Expansion ❑Modification/alteration 6.DESCRIBE PROJECT BRIEFLY: t WwL't M &ts s 7.AMOUNT OF LAND AFFECTED: Initially acres . Ultimately acres 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? Yes ❑ No If no,describe briefly: I I i 9.WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) 99 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: I I 11.DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes MINo If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? ❑Yes IR No I CERTIFY THAT THE INFORMATION PROYID D ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant ! Sponsor Name 1 K`� G� Date:q ' Signature C • I I If the action is a Costal Area,and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment I i PART II- IMPACT ASSESSMENT To be completed by Lead Agency). A. DOES ACTION EXCEED ANY TYPE t THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL EAR Yes Q.No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration may be superseded by another involved agency. El Yes [Z 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 pattern,solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly: C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly: C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly: .... ....... .. 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: C5. Growth,subsequent development,or related.activities likely to be induced by the proposed action?Explain briefly: C6. Longterm,short term,cumulative,or other effects not identified in C1-05. Explain briefly: C7:Other impacts(including chap es in use of either quantity or!Xee of ener ? Explain briefl :'-- - _ D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA(CEA)? If .es,explain briefly: Yes a No E. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes ex lain: ❑ Yes M No PART III-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it is 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;(c)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 ofsignificance must evaluate the potential impact of the proposed action on the environmental characteristics ofthe CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur.Then proceed directly to the FULt EAF and/or prepare a positive declaration. Check this box Ifyou 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 thi determination. Board of Trustees / Name of Lead Agency Date J )g M r-s CJ/A) President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer S' nature of Responsible Officer 1 V6ad Agency Signature of Preparer(If different from responsible officer) Town of Soutnold Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM PROPERTY LOCATION: S.C.T.M.t►: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A 01j STORM-WATER,GRADING,DRAINAGE AND EROSION CONTROL PLAN D sTfcT- Section -locTc- Lot 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 Will this Project Retain All Inch Rainfall on the Scope of Work for Proposed Construction) Generated by i Two(all Inch Rainfall on Site? (S.F. Acres) (This item will include all run-off created by site 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? impervious surfaces.) (S.F./Acres) 2 Does the Site Plan and/or Survey Show All Proposed PROVIDE BRIEF PROJECT DESCRIPTION (Provide Additional Pages as Needed) Drainage Structures Indicating Size&Location?This Item shall include all Proposed Grade Changes and t et- �k Slopes Controlling Surface Water Flow. d qJ n k 3 Does the Site Plan and/or Survey describe the erosion O and sediment control practices that will be used to control site erosion and storm water discharges. This item must be maintained throughout the Entire 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? 5 Will this Application Require Land Disturbing Activities , Encompassing an Area in Excess of Five Thousand ❑ n/i� (5,000 S.F.)Square Feet of Ground Surface? / j i 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 Wetland 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 r �(�including Construction activities involving soil disturbances of less than one(1)acre where `l One Hundred(100')of Horizontal Distance? — the DEC has determined that a SPDES permit is required for storm 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-0-10.001.) Surfaces be Sloped to Direct Storm Water Run-Off 1.The SWPPP shall be prepared prior to the submittal of the NO).The NOI 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, ip I. required,post-construction storm water management practices that will be used and/or Removal of Vegetation and/or the Construction ofconstructed any ❑ /vCJr conscted to reduce the pollutants in storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder j compliance with the terms and conditions of this permit.In addition,the SWPPP shall Area?(This Item will NOT include the Installation of 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 Chedc Mark(4)and/or Answer for each Question is Required for a Complete Application) STATE OF NEW YORK, 5 EL C(<. /COUNTY OF............. C�.........................SS That I, ��a��"" . "� .........being duly sworn,deposes and says that he/she is the applicant for Permit, ................................................................... (Name of Individual signing Document) Andthat he/she is the ........... . .............................................................................................................. (Owner,Contractor,Agent,Corporate Officer,eta) Owner and/or representative of the Owner or Owners,and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his knowledge and belief;and I that the work will be performed in the manner set forth in the application filed herewith. Sworn to before me this; E I I r Notary Public:Public: ........... qri `........ . ..... ................... VT� (Signature of Applicant) FORM - 06/10 No.01 061 0696 i Qualified in Suffolk County Commission Expires July 28,2 j Board-of Trustees Application County of Suffolk State of New York to 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. (0 � I U--� 7wvm (14 Signature SWORN TO BEFORE ME THIS 1A DAY OF �d , I�CJC.t Notary Public VICKI TOTb Notary Public State of New York No.006190696 Qualified in Suffolk Coun Commission Expires July 28,Z0 I 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 purpose of this form is to provide information which can alert the town of Rqssible conflicts of interest and allow it to t0kewhatever tion is necessary to avoid same. �' (�( YOUR NAME: tc m` V rp�)—N, (Last name,first name,-middle 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.) -�c[e��► 4��N 'Tax grievance Building Variance Trustee 9i Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other,name the activity.) I Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship.with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. - I 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 br_position of that person f� 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. I DESCRIPTION OF RELATIONSHIP • i S bmitted this day f r 200_ Signature'! Print Name "f . e2✓l 1 Form TS 1 `i I I I ` I Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt f minor action list, policies and explanations of each policy contained in the Town of Southold Local i 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 Towne, 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. i B. DESCRIPTION OF SITE AND PROPOSED ACTION I SCTM# (5Q-04 i PROJECT NAME h The Application has been submitted to(check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 0 I. Category of Town of Southold agency action(check appropriate response): I (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity,agency regulation,land transaction) ❑ (b) Financial assistance(e.g. grant, loan,subsidy) (c) Permit, approval,license,certification: Nature and extent of action: � I i Location of action: -' i Site acreage: ®0 Present land use: 1 � ^ l � Present zoning classification: 'I 2. If an application for the proposed action has been filed with the Town of Southold agency, the following i information shall be provided: j r__ jl (a) Name of applicant: K.Q. (b) Mailing &%WL 1�arl g address: LLT5 (c) Telephone number:Area Code (0?5I� I I (d) .Application number,if any: i 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? f 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. I Incomplete answers will require that the form be returned for completion. I 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. I ! ❑Yes ❑ No Not Applicable i i I' 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 Not Applicable 'i 4 I Attach additional sheets if necessary Policy 3:.. Enhance visual quality and protect scenic resources throughout the Town of Southold. See j LWRP Section III—Policies Pages 6 through 7 for evaluation criteria j ❑ Yes ❑ No 0 Not Applicable I. j i I I Attach additional sheets if necessary I i i 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 l 10 Yes ❑ No ❑ Not Applicable f. I �I 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 j i Yes ❑ No Not Applicable C f - i I Attach additional sheets if necessary I 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. i ❑ ❑ I I Yes No Not Applical` i i i 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 i I 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 RNot Applicable l 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 j criteria. ❑ YeZ] No VNot Applicable i i i Attach additional sheets if necessary i f WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in .I suitable locations. See LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑Yes ❑ No4t�] Not Applicable 1 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 U Not Applicable f Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages j 62 through 65 for evaluation criteria. ❑ Yes ❑ No,IyNot 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 ❑V Not Applicable PREPARED BY cUfG NEVI V'--� TITLE USA DATE�'�� i