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TR-1614
James F.King,President g�FFO(,�c Town Hall,53095 Main Rd. Bob Ghosio,Jr.,Vice-President �� OGy� P.O.Box 1179 Dave Bergen Co. ; Southold,NY 11971 John Bredemeyer 'VA 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 1st day of construction % constructed Project complete, compliance inspection James F.King, President o��OF S0!/Tyal Town Hall Annex Bob Ghosio,Jr.,Vice-President h O 54375 Main Road P.O.Box 1179 Dave Bergen Southold,New York 11971-0959 John Bredemeyer G Q • �O Telephone(631) 765-1892 Michael J.Domino �yC4U Fax(631) 765-6641 NT'Y,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD May 15, 2013 Ms. Regina Cartselos Latham Sand & Gravel PO Box 608 Peconic, NY 11958 RE: 1120 BROADWATERS ROAD, CUTCHOGUE SCTM# 104-9-2 Dear Ms. Cartselos: The following action was taken at the Southold Town Board of Trustees regular meeting held on Wednesday, May 15, 2013: RESOLVED, that the Southold Town Board of Trustees APPROVE the request for a Transfer of Wetland Permit#1614 from Eugene Bolter to Marilyn Sferrazza, as issued on March 4, 1981, and BE IT FURTHER RESOLVED, that the Southold Town Board of Trustees APPROVE the Administrative Amendment to Wetland Permit#1614 for the existing 3'x72' fixed catwalk; 3'x14' ramp; and floating dock with four 8" diameter batter piles, with the condition the floating dock be downsized to 120sq. ft. and must be done within 60 days, and as depicted on the project plan prepared by Latham Sand & Gravel, received on June 5, 2013 and stamp approved on June 7, 2013. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. If you have any questions, please contact our office at (631) 765-1892. Si rely, r James F. King President, Board of Trustees r James F.King,President ti Town Ball Annex Bob.Ghosio,Jr.,Vice-President w 54375 Route 25,P.O.Box 1179 Dave Bergen �.fi Southold,NY 11971 John Bredemeyera1yo Telephone(631)765-1892 Michael J.Domino Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD ,w S"d + Cnavel Ar.MAnlyin S4e-r,—MZ2—d-- Please be advised that your application dated 0343 has been reviewed by this Board at the regular meeting of 5 [S . . 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) YZ Constructed ($50.00) Final Inspection Fee ($50.00). v 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: Vi n0.1 Tin sfec--h'on -12 -RSb, bb DbGk-(ees : Ca. wa-1 k C 3'x I8')r- S-4 sq,,A x $'3.bo Ix� Sq F��_ �O 2 •vb rQrnrn do-/) � SI,-f_ . x f 3.bo er- SQ_, �_=4 (g Ob a -� bah 9 C [ Z- � [( J = Z4-SZL � , 3 -7 2 66 TOTAL FEES DUE: $ 3 D , bb BY: James F. King, President Board of Trustees suFF Z/r James F.King,President pp� CGp P.O.Box 1179 Bob Ghosio,Jr.,Vice-President j y Southold,NY 11971 Dave Bergen y Telephone(631 765-1892 John Bredemeyer u.. ��, Fax(631)765-6641 Michael J.Domino 'F Southold Town Board of Trustees Field Ins ection/VUork Session Report Date/Time: 0 7 Latham Sand & Gravel on behalf of MARILYN SFERRAZZA requests a Transfer of Wetland Permit#1614 from Eugene Bolter to Marilyn Sferrazza, as issued on March 4, 1981; and for an Administrative Amendment to Wetland Permit#1614 for the existing 3'x72' fixed catwalk; 3'x14' ramp; 10'3"x16'3" floating dock with four 8" diameter batter piles. Located: 1120 Broadwaters Road, Cutchogue. SCTM# 104-9-2 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: 7Chapt.275 Chapt. 111 other Type of Application: Wetland _Coastal Erosion XAmendment Administrative_Emergency Pre-Submission Violation Info needed: L c� r 3 Nc 7 Z C� -Z �- Modifications: Conditions: Press t Were: Kin Ghosio D. Bergen, J. Bredemeyer Michael Domino D. Dzenkowski other Form filled out in the field by Mailed/Faxed to: Date: Mari lyn S-Pe rr o.zut SC TM # 104 _ - f 'fit. �..-. .��� ��.��r \\�•. _ •--- q `I 7 r d.�7.I' "t: - ��L i•i�'iV>1:...'"i_J �:r W .�7fi:a.."i:.�l•k�lJ.�L. •,•i lJ:i�.�L' �r 1J lA�.. k J AL , DCC:S' H1 L7 -Bi-L.ZH :ABS..—MUST DIS;✓.7,.Z4 . ViS!Bt- I� • ' � �- .����i4�r• =��%;�tis� �ie�'�w.�- .. �.�-t� ✓`f�, _,k��w- r�'�l'�z,�`�- �•�;,s�•:i=+ �+� ����_ - ,„,:r. - .:'t'�.rti r.�Nv "' J.. ... . ..e}^�y �.. .-•; oj•^. ta. +=-e�y.'v..•. S+: , -+�.;.■Y;•=:.• �.p�',•;:a.5•., .: f�� `:, r,,:.•; 7�''. _'.iY.' ``��-y.=_ .t +'_`c.�•r,.� :1 t• ..,�i,,r.�. •l`{. e... . ��'l•. :i r' '.�+^� .i.i .i-<^S•!-.`- �::' � •fri' .••,tr v F`:. -�. .{C...7Nyv/,,;/!!. .j -•�,1�• •C ..c. �.;E,;.Y:`� d' .:`! +mod`;�! „"_ o H.�1 �m.o3�.•/'7 ,�. `t _ .:�•Y�... r�-:.t'.._. .:r wr.+. F '-r.nZ�•, .v':!i . ry.. •. f'•.J' �_.'. :J•• .•a_w.`�J'' ': ^L�tJ't:..: ..L: ..'-j,:I4;i Y,:a �J(i�i•.tc: J.. tS.r.�••i ..7< y,�'• .. � ��: � �� ?+=.= ;`+'•ni._' ter.' 'y�.•;.r:M,.`�` i^ri�.tT'ti.l: T.'!sa�:>r.;.ti�. r "-. •Lr"'" <�`, 4:.�.: .+ ''� <<•^�-•�•f..-[y. `y •i( ,^a-'.f� _ - 'a�'.:.'•>�.:.a-+�ti_- -'1Y� ��-���ait�.:1_ - .'�.ti.�'' ' ,l>'a :r:.`'.�w _„`:i!;�� :•iF,r =.�Sr.:::..1-..`.,.rrrrr.:}.`_�...:._+',.._!��5•� -- .i - i. � w; -..�• '•�f• .i1 J, J - _.;-y.' �....•s -i�._ . �..Sri.— . --•�,M�-�•t.,r- `A_-c-. ._ .K. ..- .-an�.ir�.�. ��1..•-'.:S.Lt. • �c r�' !"1 •� rye ^1 }!� Ott /t'�'� -•7�-r.f 1 E-:•l••`�� ,�,`!i b� ".�' GI .J{J itl iol'U i ow I 1 1 IiS PA Jt` i ^• �`r „ �" SCUT HOLD,.NEW YORK NG �. `� •.; PCR�lI March 4, 19$1 ' r:i < i NO. DATE:'.. •- +: tSUEI7: _.....pants for 'E_u ene. Ealte,r 4 ,ter r� ...... 7y fi:+r •�. �r?^./�`a�'!•7 1�`�r•]� ti� ,� ��t` '�'..�t�t'�� f .�`1.. jfff —A. ,W :v r :x. < r,- • r . ` , 645 . LawsPursuant. to: # sof CateF r o -fh of �,ii✓a :,�t��i� fhe'State of. I�Iew..YoA� I;$°'3, and::Chao?er 0:='of }iie. Laws o;f Fie �ti� .Ycrx[ I§'S2;>.a:nd she So:uinold .Tb,wvn Ordirra' cr'en- titled RcGULATING ANR THE PLACING OF OBS T RUCTIdNS. •�'•. IN .AND ON TOWN 1tlATE:RS APED PUSL'IC .L'ANRS. aril the �•J�3 �3 �<' r ' _ RE4fOY,A Qr" SA?vD, GAVEL..CR 4'T;:;E, : i,4TEFiLS•F`rZOM yR . -, L.&INDS.. TOW EJ;NRrR N' WATE�S;" �.nd. [n .acrord�nce witty.:the •x_•-T�w'�i -j % '•'' ResoIuiion of The Boar ed aT a masting,heEd o M rch t:`• �'1:_F 19....81:� .and in: consider P! ,.,i a Sum Ci aid.b ~r" ,• ram;;. 3 on of h 4,103 00 P y j /.<':. '\� �i�i ..._.._..___....._._.....__.._......_.._�it7.43�X1:�....Fa.S2.3,t-.e�'......................_._......................._...._._...... • . .c� 4. 14G, of .._ _C t l?gJt?e .....«_..°:.:............................ .. N. Y: .arid .sunje.�t to the d '"' Iistad on tFse reverse.. <side hereof , Terms: an C:crcr,�nn.s' of Southold Town Trustees. aufinari:es 'and.:peritm.i;s the foilow.ia :. ''•" <' ` °>.!� Approved to construct a timber dock, . fixed. cat— AI «- W� ';�� walk,. hinged ramp 'and .float .plus associated pilings subject to: See .hevers�: side for provisians of wX alp1hrTA. ance with o o t., ', tSe derail d :sP.ecificatioris as`present d ins'.;_ f 15 tNv the originating application_ [`:'� ' .•: •,a;�'. IN:WI- cS .ti —t rvstees here [�::• �`� �N' S VHERECF The.said Board of ±i; '.b cau'ses.iis Car orirTe .SeJ31 0 sae affixed J3nd these reserits,.to � Y p. t F is�~! < '' =� • E`.i` be. suLscr16ea' by: a majori?y of the said _:Ii:oard as ox this dale. .} •<:�.� _� ; wit• ^'�s:"-e"':.\G.O�_ '�t1.. ,rri ••.):�� Ma+�'. .. �' ..�., �p:'r��:= C/�'~.'� _ _��"�� ��71.,, •�t� fit. —i war. . ins:` x-.J• it / •f.:...� .:�\�iN:� '�� ... 2G .. - �r mar•-�+--c _�.:•-_ *.,--t J�V ' :_..•rJ i� �:f�� � �� � iF-'��f•�!..l:.ram.......'-: _ _� .. •s-.ei�1•..r �I -f,.. __ .�.5_"�e'.t' ."�'KJI ` -�. •r; i+s _ ''•v' j'C~, rT^� yr�T.^ti�~-jam^.-�".�.r=T� ,"-a' ��' :'f �_ .� ''>'`o *ice rii .-Lei:j c�_�l- �'-"« ,5�.er,J}.iCi1.171��;�1' `yti�-'^,e`:. ' u� :/:q1•��. aw •��' -'Y". 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'�' �� j"...L.., ';�.';"..1" .Ai c ''i" _1:4q4a� - . OS,t�80 N —�- 4 P � 06a�2 M F e , d u d P c 0\Bs •,e, Ri."4n 1c cl43�_�FR.3b�```7�LD.4 ./. 10a10 F .'d ' ♦ 0'"'y °2� Y 1 Q 0 � '0 '''' '���'�.+•d^'ZC '���""r",,,e a 10 1 a.-'; ,iiy Bata .. oazsae e4e• . .p O,'�' �9,ti:'• P •b 7 nantc) a �E ':� BROAOWATERS COVE TOWN OF SOUTHOLD12 1 Op . ♦.. F e q •� t � ,a ,� of �e{' °Y�nB,•r 0 ° ,.tN`' 0 • 0©•PP O r � b{el r $`.•a+ f P JJ� Ru„`kD m / " ',� P`g ids'. HAYWATER COVE W n T L •�.•�• �� " �• — -- �^^� --'O1— r --^-- NOTICE mar COUNTY OF SUFFOLK © K m a^ SOIIiKpID SECTION NO c _--�_ _-- Real Property Trslc Service Agency v .1 E "..`, r ___ r CewnYMmv�N•r.mr+C.NV H/ot M la 'IQQ' vu un N t m M n .. - -:. •_- .:..�....� _.-unw_ .��—..._�—_..�_�.._:��,r_ —r -.—.:. � _ _ J _ _ _ _ pPERTVMM • .. -F FT - �. -:R.Y.. 'T%FiP�ff .`�k. � - � awF .gl°' .'i''..�C•� 1., OFFICE LOCATION: ��OF SOUT�o MAILING ADDRESS: Town Hall Annex 01 P.O. Box 1179 54375 State Route 25 Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) y Telephone: 631 765-1938 Southold, NY 11971 Fax: 631 765-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM To: Jim King, President EG` E � VC �+ Town of Southold Board of Trustees MAY 1 4 2013 From: Mark Terry, . Principal Planner LWRP Coordinator Southold Town Date: May 14, 2013 oard of Trustees Re: Proposed Wetland Permit for MARILYN SFERRAZZA SCTM#1000-104-9-2, Latham Sand & Gravel on behalf of MARILYN SFERRAZZA requests a Transfer of Wetland Permit #1614 from Eugene Bolter to Marilyn Sferrazza, as issued on March 4, 1981; and for an Administrative Amendment to Wetland Permit#1614 for the existing 3'x72' fixed catwalk; 3'x14' ramp; 10'3"x16'3" floating dock with four 8" diameter batter piles. Located: 1120 Broadwaters Road, Cutchogue. SCTM# 104-9-2 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 actions are 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 James F. King,President *0 SO!/jyo Town Hall Annex Bob Ghosio,Jr.,Vice-President ,`O l0 54375 Main Road P.O. Box 1179 Dave Bergen Southold,New York 11971-0959 John Bredemeyer A Michael J. Domino �Ol �� Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES APR 3 0 2013 TOWN OF SOUTHOLD S. Southol Town APPLICATION FOR A TRANSFER OF A WETLAND PERMIT DATE OWNER m� 5ferjrj--i2Zj1fj:1 PHONE 51�o W-4-61 S MAILING ADDRESSr2�5 Pond Ufec_3 Dr l�f�-� ��SJ,��� �Ol� rlu AGENT_zeC InaCar_+so_ PHONE (b3)-734- 6 00n"'r C.A-fh�n �anol+ Grp,✓'sz . ADDRESS 3S 180 TZF- 49 'Tb -Box 608 1�26or)i C PROPERTY LOCATION -Pro,9 wow' 3rS -L?4 av-�C WC fI TAX MAP NO. Uwe (n13rJu n '14�_2r'CR27A ,I,��y'InFA Cyr- � j5 request a Transfer of Permit# 1 from Eugene- Eot4e( f Signed By: James F.King,President �QF SO!/Ty Town Hall Annex Bob Ghosio,Jr.,Vice-President ,`O`� Ol0 54375 Main Road P.O.Box 1179 Dave Bergen Southold,New York 11971-0959 John Bredemeyer G p@ Telephone(631)765-1892 Michael J.Domino 'Q Fax(631) 765-6641 �yC4Uwl C E � V E D BOARD OF TOWN TRUSTEES APR 3 0 2013 TOWN OF SOUTHOLD outhold Town TrusteesBoard gf APPLICATION FOR AN AMENDMENT TO A WETLAND PERMIT DATE OWNER(p f4r► �'erft PHONE S 16- 944 ADDRESS S �Onc� l/let�l QC1 Jf -'PaK4-(jr-j4 I n4-/oo. (fig 11 oso AGENT l(X�Cer � PHONE �Z��- �og� Lo4hom Sond+ Girt/ ADDRESS,�56-180 IZ+ 4 A -PO 'Bo K (o0g lPae—rY) 1 C PROPERTY LOCATION //ram _660f)�ffi442E,- Td aldOg(1p TAX MAP NO. 104 - % • a— I/We Mpe lUn 5krjj,, ,94 Cr-kr a. quest an Amendment to Permit# �6 /4- to QC I.4i rq 3 i x 7c9 t Ca-1c.OR!/C, 3+-)( I f t r-ano /0�,� x )(or.3 ' F)Off+ t F ?(X� wr#-) 4er i Imo. Signed By: V� awl 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 022f) I z l� C -4SCI 3.PROJECT LOCATION: ed too -aropl_-'� Municipality County 4.PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map 5.IS PROPOSED ACTION: ❑ New ❑Expansion Modification/alteration 6.DESCRIBE PROJECT BRIEFLY: 7"AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8 WI 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 ❑Other (describe) I 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Feder , State or Local) ❑Yes No If yes, list'agency name and permit / approval: i 11.DOES A Y ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes o If yes, list agency name and permit / approval: i S A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? es ❑No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE i Applicant / S onsor Name 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 PART 11 - IMPACT ASSESSMENT Te: . rom leted by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL EAF. Yes 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. Yes 0 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. Long term,short term,cumulative,or other effects not identified in C1-05? Explain briefly: C7. Other impacts(including changes in use of either quantity or type of energy)? Explain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA(CEA)? El Yes ❑✓ No If Yes,explain briefly: E. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes No If Yes,explain briefly: 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 of significance must evaluate 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 or significant adverse impacts which MAY occur. Then proceed directly to the FULL 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 action WILL NOT result in any significant adverse environmental impacts AND provide,on attachments as necessary,the reasons supporting this determination Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer) 01_n From: latham gravel<lathamg ravel @optonline.net> Subject: Trustee forms Date: April 30,2013 2:43:14 PM EDT To: lynns@optonline.net 2 Attachments, 528 KB Hi Lynn, Here are the forms that we spoke about. If you could sign them and overnight them back,that would be great Latham Sand&Gravel P.O. Box 608 Peconic, NY 11958 Thanks, Regina Board of Trustees Application ALTTHORIZAWOIK (where the applicant is. not the.-owner) residing at4�. w ✓J �� grin owner of property) (mailing address) "y` IIOJ do hereby authorize (Agent) �429'/ R Cr-w-4S60S to apply for, permits) from the Southold Board of Town Trustees on my behalf. (Owner s s' ature r From: latham gravel<lathamgravel@optonline.net> Subject: Trustee forms Date: April 30, 2013 2:43:14 PM EDT To: lynns@optonline.net 0- 2 Attachments, 528 KB Hi Lynn, Here are the forms that we spoke about. If you could sign them and overnight them back,that would be great Latham Sand&Gravel P.O. Box 608 Peconic, NY 11958 Thanks, Regina Board of Trustees Application AUTHORIZATION (where the applicant is. not the -owner) residing at /lam AKA e / (print[owner o property? (mailing address} �c��c Cs�r� /17/ do hereby authorize !.� I (Agent). Qar4 sql S to apply for permit(s) from the Southold Board of Town Trustees on-my behalf. t. . (owner's si n re) Board of Trustees Application County of Suffolk State of New York BEING DULY SWORN .DEPOSES#ND-AFFIR10 THAT HEfSHE IS THE APPLICANT FOR THE A13OVE - DESCRIBED PERIMT(S);AND:THAT ALL STATEMENTS.CONTAINED HEREIN ARE TRUE T011M BEST OF TIISfi0-KNOWLEDGE AND BELIEF,AND THAT ALL WORK " :WILL:BE DONE-IN THE MANNF_R.SET FORTH-IN-THIS APPLICATION.AND,ASMAN BE'APPROVED.BY THE SOUTHOLD TOWN BOARD OF TRUSTEES, THE APPLICANT., AGREES TO HOLD THE TOWN OF SO.UTHOLD AND THE TOWN TRUSTEES - AARMLESS`AND FREE.FROM ANY AND-ALL DAMAGES AND CLAIMS ARISING. xUNDER:OR-BY VMTUE OF SAID'PERAdT(S),IF,GRANTED.AN COMPLETING THIS' APPLICATION,I HEREBY.AUTHORIZE THE TRUSTEES,THEIR AGBN'T(S)OB. REPRESENTATIl E (S) TO..ENTER ONTO MY PROPERTY TO INSPECT.THE -PREMISES W CONJUNCTION WITH REVIEW OF THIS APPLICATION: Sin r SWORN TO BEFOR&ME THIS DAY OF r REGINA L. CARYSELOS Notary.Public-State of New'York -- tary Pulilic No.01 CA61.98908 Qualified in Suffolk County " My,Commission Expires January 5,2017. t APPLICANT/AGENT/REPRESEN'TATI" TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The nuroose of this form is to provide inforination which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same.YOUR NAME:12Qyfne?- 6y46oj,2S < nl-F)r,11 Il J FN (Last name,first name,griddle 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 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 day of r- 20 A Signature Print Name -FS21 Form TS 1 f Town of Southold i. LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS i 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 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 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. i 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 I6 G E I V E SCTM#104- 9 - ' APR 30 2013 , PROJECT NAME Southold Town i The Application has been submitted to(check appropL Trustees 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) ❑ ; I (b) Financial assistance(e.g. grant, loan,subsidy) (c) Permit,approval, license,certification: Nature and extent of action: 'x wpf 'x 14' Camp Location of action: f ��, B-(ndL&)4ers Site acreage: Present land use: Present zoning classification: j 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: i (a) Name of applicant: n4n ( Q Q�� I (b) Mailing address: J� I (c) Telephone number: Area Code (d) Application number, if any: I I If Will the action be directly undertaken,require funding; or approval by a state or federal agency? j Yes ❑ Noz If yes,which state or federal agency? I j i i 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 4 Policy 1. Foster,a pattern of development in the Town of Southold that enhances community character, f 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 � i Yes F1 No Not Applicable II 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 ❑ N Not Applicable ' I li i I Attach additional sheets if necessary it 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 ❑ Not2�j Not Applicable i Attach additional sheets if necessary f l NATURAL COAST POLICIES II 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 ❑ NohNot Applicable , i i I II Attach additional sheets if necessary ! i 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 ❑ NoKNot Applicable j i 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 i through 32 for evaluation criteria. � i Yes No XNot Applicabl. I i !i Attach additional sheets if necessary I Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. I Yes ❑ No)gr Not Applicable t i f I . ! I Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wa�stes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ NoCe Not Applicable I � i I• I PUBLIC COAST POLICIES I 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�:] NoN Not Applicable Ir Attach additional sheets if necessary ' 1 i i WORKING COAST POLICIES i 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 2Q Not Applicable f , I ' I . . I Attach additional sheets if necessary I Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III-Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No�Not Applicable i � f � I ' I 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 ( ❑ NoN Not Applicable Attach additional sheets if necessary Ii 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 TITLE ce( r 9�r DATE 3 ) j