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Sheehan, Diane
James F.King, President V��Of S0(/r 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 G Q • �O Telephone(631) 765-1892 Michael J. Domino O Fax(631) 765-6641 UNT`1,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD NOTICE OF DISAPPROVAL — ADMINISTRATIVE PERMIT Applicant: Dianne Sheehan Date of Receipt of Application: October 29, 2013 SCTM#: 59-1-1 Project Location: 1200 Leeton Drive, Southold Date of Resolution: November 13, 2013 Reviewed by: Board of Trustees Project Description: To install a snow fence along the beach dunes. Findings: The project does not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code as the Board determined that there would be no,benefit to the surrounding dune area or help with erosion control in or around the subject property. A. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. 8l James F. King, Pre' dent Board of Trustees J FK/eac gUFFO(,�- James F.King,President �q� C� P.O.Box 1179 Bob Ghosio,Jr.,Vice-President S Southold,NY 11971 Dave Bergen y Telephone(631 765-1892 John Bredemeyer u. Fax(631)765-6641 Michael J.Domino O 'F Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: �� � V Quarty Construction on behalf of DIANNE SHEEHAN requests an Administrative Permit to install a snow fence along the beach dunes. Located: 1200 Leeton Drive, Southold. SCTM# 59-1-1 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 Ty of Application: Wetland _Coastal Erosion Amendment _A dministrative_Emergency Pre-Submission Violation Info needed: Modifications: f Conditions: Prese Were: J. Kig9' �Ghosio D. Bergen, J. Bredemeyer l Michael Domino D. Dzenkowski other Form filled out in t fiel by Mailed/Faxed to: Date: __ ,�M, � I �l� 1:- �' � � _ , � ��, .. _• -, _ �� ..i � .a.y.... �� ;.f', _ —.�rr- �' _ -- ,, j , •,� ,_ -_ .. aii� r .r �.�' ., '.."� ., .., � ".�'.y„... ���,,,,. y� `k' �, � �� �! I r � � ��� � „ � _. ` � � I j �, �' � j � ' �IIIr � - • � i ' - w Y � �r 1 5URVEY OF PROPERTY 51TUATE: 5OUTHOLD TOWN: 5OUTHOLD 5UEEOLK COUNTY, NY SURVEYED: 03-25-2011 Q SUFFOLK COUNTY TAX # t 1000 - 59 — I — I �1 CERT=TO: OCT 2 9 2013 5Q m LQ�g 34e B and fTuste '41 An , AL 4' �q I `-------6'- 6..>.r✓ I;� BO fTOM BANK--- r 1� l coP OF BANK z� \ 10,-, I ➢rat\p ZW 1� O Q _ dArn o° 45�'�d 1 ➢� - �G� i T rnrn� T AAA �WR. -� RA6B � ..• .. T =34� SIP. N I mo 70 it A rn ib 115�1 �Ao II c VO--O— rrAA 5' Onw (�J�V\• S4 � edge of pQ�ernent NOTES: OF NEW ■ MONUMENT FOUND Un thw ied olteretion o eaa tiara to a>�ray O mop he .9 O I1-6 Intl sweyorS xol Is O CONTOUR LINES REFERENCE N6VD '2a DATUM a�/ '(� s L �Y- a E—tbn L—' j( !4- * 'only copte>from the orlg'ml of Nis—9 �•� ,.,.,,�.,- — le morkea nith on or'of the brad e�.eyor§ �,i- >tonyea xoi ynn ae corc;�aerea eo ao�ard.tr.e FEMA FLOOD ZONE ANNOTATED FROM FIRM �b MAP # 36103G0154 G DTD MAY 4, 1998 0� �C-ttf.ot —.tea nere�n siq ly wn --y—prepared,n occorao.ee.nth the ex- (r',�•� ,t � btirg Lode of -pt.d COASTAL EROSION HAZARD LINE ANNOTATED FROM Yak State Polo btbn o Poe»anl \, '�_� - J�2 t.am fey .Q k+cerlrceot ey P,,.Po.d DEG PHOTO # 56-566-83 SHEET 6 OF 4a DTD 8/29/88 ��\�vp 5 g f`e`,t`W`� tol jerky ord lend j Imtiwllon IQ'b[eG M�car,and [O the Os9k]k'es of lne leritl'og VntfWtbn. Gerti(ko- t(ore ore rot lrms(erolNe to oaalknal Nsti[ufldn AREA = 16,-A5 S.F. OR 0.3810 ACRE JOIN C. EHLLERS LAND SURVEYOR GRAPHI G SCALE 1"- 30' 6 EAST MAIN STREET N.Y.S.LIC.NO.50202 RIVERBEAD,N.Y.11901 369-8288 Fax 369-8287 RERC:\Documents and Settings\Owner\My Documents\My Dropbox\l 1\1 1-1 14.pro SUR` Y OF PROPERTY 51TUATE: 5OU114OLD TOWN: 5OUTHOLD SUf:FOLK COUNTY, NY SURVEYED: 03-25-2011 -� SUFFOLK COUNTY TAX # 1000 - 59 — I — I CERTfFMD TO: JAbM T.MOLLOYY 0 CT 2 9 2013 -y- "r� �O Ord �51 and — SFr— rn `UU IIIUI'J \11` �r�J Long 4s qm dTrII qto - �1GNl -' r�11GH BOTTOM BANK--- r d..,.. 1•� `p !OP OF BANK J z W Z ` A� r OUT _ =w 5"WR = yTORY = -75 n 34 4 S A N � ` 9 I$ c� Q A rn ;b ' o o-�o- ,� ��,®ffiedge of pQ�ement , NOTES: pp NEW Y ■ MONUMENT FOUND C. Ey(�cn O� A wt a izee°leerauon a aamnaa ° ey . � `O •,.'t� '� moP beQYg°Ikeme°Intl nweyorb x°I�i o i v I°Iation or xcuon l]09.sW-aNiflon�,or len I,York 5lale EO.,catlon Lorv.• CONTOUR LINES REFERENCE N6VD '2Q DATUM is j? .a y cop',,r—l„e �keA nllh on oriylral of llie land svrveyorb FEMA FLOOD ZONE ANNOTATED FROM FIRM >eoed�aI Sholl�e aaakered to °°d, e MAP # 36103GO154 6 DTD MAY 4, IG98 _r o� li ate ahQelCda^e� r�119NI9`.t F. bti VGode or Pra'ka ror Loa 5„rve otlaptetl COASTAL EROSION HAZARD LINE ANNOTATED FROM GJ!a h,n YIX k55o, A»oclatbn or t,p-—d. La,d P r«.10a,om rtro°xlr°.iOayOaPo°A°a DEC PHOTO # 56-566-83 SHEET 8 OF 4Q DTD 8/2q/88 <<=;fvU V/ and as �e„alr t°l„e Ntle°«tea. nee- taI a:a m,one lena�g In9nwNon rneea rarean,and to eta[roek)aee of the lendbg mtlt V.,eortlfl - [lom are rot trororerobl.to od°itk l betUtlon, AREA = 16,5g5 S.F. OR 0.3810 AGRE JOHN C. EBLERS LAND SURVEYOR GRAPHIC 5GALE I III= 30' 6 EAST MAIN STREET N.Y.S.LIC.NO.50202 RIVERHEAD,N.Y.11901 369-8288 Fax 369-8287 REF.CADocuments and Settings\Owner\My Documents\My Dropbox\11\11-114.pro i OFFICE LOCATION: �OF SO(/ry� MAILING ADDRESS: Town Hall Annex h0 l0 P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) Southold, NY 11971 G Telephone: 631 765-1938 a0 Fax: 631 765-3136 Counm,��' LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM [ C L Y .E NOV - 7 2013 To: Jim King, President Town of Southold Board of Trustees :.. Souti?�iti�aYJ From: Mark Terry, Principal Planner —Loa-ri�F Trustee LWRP Coordinator Date: November 6, 2013 Re: LWRP Coastal Consistency Review for DIANNE SHEEHAN SCTM#1 000-59-1-1 Quarty Construction on behalf of DIANNE SHEEHAN requests an Administrative Permit to install a snow fence along the beach dunes. Located: 1200 Leeton Drive, Southold. SCTM# 59-1-1 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 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 SOUTH, Town Hall Annex Bob Ghosio,Jr.,Vice-President ,`Q`� Old 54 Main Road P..O.O.Box 1179 Dave Bergen Southold,New York 11971-0959 John Bredemeyer Michael J_Domino '.� ® �� Telephone(631) 765-1892 O Fax(631)765-6641 Uffrt,� BOARD OF TOWN TRUSTEES D �. a r'� i' ti 13' -a TOWN OF SOUTHOLD Office Use Only OCT 2 9 2013 Coastal Erosion Permit Application Wetland Permit Application Administrative Permit —Amendment/Transfer/Extension B Received Application: v d,' /3 received Fee:$ c-• °- ompleted Application Incomplete _SEQRA Classification: Type I Type H Unlisted _Coordination:(date sent) LWRP Consistency Assessment Form _CAC Referral Sent: Date of Inspection: Receipt of CAC Rep oft: _Lead Agency Determination: _Technical Review: Public Hearing Held: Resolution: Name of Applicant-'.It)i'GCr�e S h ee#lv" -„ -- Mailing Addres,� 3 �' �'� �h�e sseC Al Phone Number:( 5_14 Suffolk County Tax Map Number: 1000- 7 _ 1 Property Location: 124) k i v 25� (provide LILCO Pole#, distance to cross streets; and location) CurzAGENT; (If applicable) Address: /qiVY aa��1z Phone: �s � n^ird of Trustees Appl.icatip— i GENERAL DATA i Land Area(in square feet): 00 Area Zoning: I P Previous use of property: Intended use of property:; r1"G�;, z�� ,� f Covenants and Restrictions`on property? Yes E/ No If"Yes",please provide a copy. Will this project require a Building Permit as per Town Code? Yes No If"Yes",be advised this application will be reviewed by the Building Dept.prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes 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 �D No Does the structure(s)on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: /Agency �Date n No prior permits/approvals for site improvements. Has an ermit/approval ever been revoked or suspended by a governmental agency?_�e No Yes l\ If yes,pro 'de explanation: Prr Ject Description (use attachments if necessary): S��Uc✓ ��s�.e, I BAa-rs3 of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: �S'f- rc.✓ Area of wetlands on lot: Jd square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands:_ Apa /air feet Closest distance between nearest proposed structure and upland edge of wetlands:&pp If2v f 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): 61 Z20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: / Project Location(describe,and attach a location map): f ad rvi-�ev--�-? Brief Description of Proposed Action: s� Name�oATplicant or Sponsor: Telephone: E-Mail: Add ess: ity/PO• State: Zip Code: 1.Does the proposed action only involve the legislative adoption of a plan,local law,or nance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: ® ❑ 3.a.Total acreage of the site of the proposed action? 4 U acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial fo Residential (suburban) ❑Forest ❑Agriculture ❑Aquatic ❑Other(specify): El Parkland Page I of 4 5. Is the proposed action, NO YES N/A a.A permitted use under the zoning regulations? ❑ 12 ❑ b.Consistent with the adopted comprehensive plan? ❑ ❑ ❑ 6. is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? I ❑ 0 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: ❑ 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? ® ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: p ❑ 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: y�� VI ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: ��/; ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ❑ b. is the proposed action located in an archeological sensitive area? ❑ ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: VP Shoreline El Forest (Agricultural/grasslands El Early mid-successional ❑ Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, ® ❑ a.Will storm water discharges flow to adjacent properties? NO ❑YES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: �]NO ❑YES Page 2 of 4 18.Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: ® ❑ 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: ® ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: r-;3 ❑ I AFFIRM THAT THE 7INFOR ON PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/s me: Date: &A11/` 0/7 Sign atur : T- Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning ❑ regulations? Ef 2. Will the proposed action result in a change in the use or intensity of use of land? Rr 3. Will the proposed action impair the character or quality of the existing community? Fl ❑. 4. Will the proposed action have an impact on the environmental characteristics that caused the ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? Efl 8. Will the proposed action impair the character or quality of important historic,archaeological, El or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, © Elwaterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage Elproblems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees ��/�/� 3 Name of Lead Agency Date //�(yr S F• �c 4)tY President Print or Type Name of Responsible Offi�e;in Lead Agency Title of Responsible Officer 44 Signpiure of Responsible Officer in V ad Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 PROJECT ID NUMBER 617.20 SEQRAPPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 9 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1.APPLIC9DIT/SPONSO 2.PROJECT NAME S 3.PROJECT LOCATION: Municipality (f County 4.PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map S.IS PROPOSED ACTION: New Expansion I—vlod�cation!alteration 6.DESCRIBE PROJECT BRIEFLY: l�l ?.AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? �as ❑ No If no,describe briefly: 9.WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) [PResidentiai 0 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 Wo If yes, list agency name and permit / approval: A CURRENTLY VALID P RMIT OR APPROVAL? { Yes F]No if yes, list agency name and permit / approval: 12. AS A UF.PULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? QYes WNo I CERTIFY THAT TH INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Spons ame l/yam u`�j �J ��� �rprr�/y��V`��t 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 APPLICANT/AGENT/REPRESEN TATlVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits 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. YOUR NAME: c (Last name,Xst name,-n»ddle 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 ofZone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) S"l ow—;94 e2-e 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 ttiat 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 0/1 Signature. .- Print Nam Form TS I Bc I of Trustees Application County of Suffolk State of New York c BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE S THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND AT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS 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 of Property Owner SWORN TO BEFORE ME THIS DAY OF © �/� ,20 f3 Notary Public ANTV 40N� A. `l Coal DO NOTARY P F� � C4 4'���York; Come EP. ��--3 of Trustees Application I AUTHORIZATION (where the applicant is not the owner) I, blayk, S�eZh a yl residing at 6-3 Ac 11 dec l(--- � A,-,V 1/D 3 D (print owner of property) (mailing address) do hereby authorize 1D1n Q (Agent) to apply for permit(s)from the Southold Board of Town Trustees on my behalf. ((Ywner's signature) C 2,0 0 L e&-hk l r� � l�(7 a�� k Town of Southold Erosion, Sedimentation A Storm-Water Run-off ASSESSMENT FORM o ,� PRopefriY LOCATION. s.Csl►t.#: THE FOLLOWING ACTIONS MAY REQUIRE THE SUBMISSION OF A Ol STORM WATER,GRADING,DRAINAGE AND EROSION CONTROL PLAN rs� worm "$loeTc —ur-- CERTIFIED BY 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? Will this Project Retain Al Storm-Water Run-Off (include Total Area of all Parcels located within /� o the Scope of Work for Proposed Construction) all 3 Generated by a Two(2)Inch Rainfall on Site? b. What is the Total Area of Land Gearing (S.F./Acres) (This item will include all run-off created by site ❑ 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? `XP4 impervious surfaces.) (S.F.i Aces) PROVIDE BRIEF PROJECT' DESCREMON (—do A-"Pages as Needed) Drainage Does the Site Plan and/or Survey Show All Proposed Drainage Structures Indicating Size&Location?This � ❑ Item shall include all Proposed Grade Changes and Slopes Controlling Surface Water Flow. 3 Does the Site Plan and/or Survey describe the erosion / ❑ and sediment control practices that will be used to r/ 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 N 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 ❑ (5,000 S.F.)Square Feet of Ground Surface? 6 Is there a Natural Water Course Running through the Site? Is this Project within the Trustees jurisdiction General DEC SWPPP Requirements: or within One Hundred(100')feet of a 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 including Construction activities involving soli disturbances of less than one(1)acre where One Hundred(100')of Horizontal Distance? the DEC has determined that a SPDES permit Is required for storm water discharges. El (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.GP440401.) Surfaces be Sloped to DirectStoml-Water Run-Off ❑ 1.The SWPPP shall be prepared prior to the submittal of the NOL The NOt shall be into and/or in the direction of a Town right-of-way? subrr rued to the Department prior to the commencement of construction activity. 2.The SWPPP shall describe the erosion and sediment control practices and where 9 Will this Project Require the Placement of Material, required,post-consruction storm water management practices that will be used and/or Removal of Vegetation and/or the Construction of-any — constructed to reduoe the pollutants In storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder compliance with the terms and conditions of this permit in addiNon,the SWPPP shag Identify potential sources of peg ution which may reasonably be expected to affect the Area?Mft item vdn Nor include the Instanation ororlveway Aprons.) quality of storm water discharges. NOTE: If Any Answer to Questions One through Nine is Answered with a Check Mark 3.'Ag 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 shag 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 Stan is knowledgeable in the principles and practices of Sto Water Management. Southold and Must be Submitted for Review Prior to issuance of Arty Building PemriL (NOTE: 'A Check Mark(**)andlor Answer foreach question Is Required fora Complete Application) S'I ATE OF NEW YORK, t c'Q UN1`Y OF.: _ 43.�:F.s(.J.. ..SS That 1, Al.m.. ...... ...........................................being duly sworn,deposes and says that he/she is the applicant for Permit, ( me of lndrua, fining DoDo-cument)� And that he/she is the l..1/. .. ... .. ........................................ �(17wiier,Conirsctor,Agent,Corporate OBice,etc) ""' 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 fide this application;that all statements contained in this.application are true to the best of his knowledge and belief;and that the work will be performed in the manner set forth iri the application filed herewith. Sworn to bi 5fore a this; ................. ....... . ........:.....day of.. .. 11 1 .....,20. 3 % �...! t-.!.... ..Notary Public: .... .. ....._. .. .. ......................... t ,-;' (Signature of Applicant) FORM - 06/10 NotaN No.01'06070081 Qualified iri Suffolk Coun r(, Commission Expires "� 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 six if t 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. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# 0�'__ 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: Nature and extent of action: ��- Location of action: © ZV-Z V,0h Dvi� oz 1 Site acreage: 14i yU Present land use: 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: �" (b) Mailing address: (c) "Telephone number:Area Code( ) ,t�-7j (d) Application number,if any: Will the action be directly undertaken,require funding,or approval by a state or federal agency? Yes ❑ No® If yes,which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space,makes efficient use of infrastructure,makes beneficial use of a coastal location,and minimizes adverse effects of development. See LWRP Section III—Policies;Page 2 for evaluation criteria. [:]Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III=Policies Pages 3 through 6 for evaluation criteria ❑ Yes ❑ No E4 Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section M-Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No . -T Not Applicable i Jdr/ Oliyt,..e/ 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 Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of.Southold. See LWRP Section III -Policies Pages 16 through 21 for evaluation criteria Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III-Policies; Pages 22 through 32 for evaluation criteria. ❑ ❑ F Yes No Not Ap 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 Not-Applicable 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 ❑ 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. ❑ YeO No UNot 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 L Policies; Pages 47 through 56 for evaluation criteria. Yes ❑ No RNot 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 1Not Applicable ` Attach additional sheets if necessary Policy 12. Protect agricultural lands-in the Town of Southold. See LW RP Section III —Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes El No � Not Applicable PREPARED B 7 TITLE DATE / a3 2 4. A, $EE SEC.NO.SL NNE ° m.zsse \\JJ w-N-at /♦/ � eA � ° Olep�tlr � t tool S y B `° a `Yl 128., tds &u Q T° 7° j�v 'yYS A T.BA / ,y 25 FORPCL 19, ESE SEC.No. ?�d A nt iCYM OP 60NTHONJ h °�' a +,�^d Patf mwtmt5 CR ATPONO a � ° Ji �� hf r � A � •^y+A .�/ � a,H Aa�f „� ` A9¢4°` min +' ' 6 1 L1 a y? I SCFFOII! t AW vr\ so�N 21 A Sao �r I \ h e 1ju x a ^ N S6nlq Av0 mvci uv tax acrrt9 A A u.En(q 'bT r \` Sw-) t20A(c) 6 ry \ FOR PCL NO. � \ GEESE- - ' --------z-------. .. .. .. .. .._�—NNE NNE N MATCN SEE=,o.m. //^\\ SEE SEC.NO. 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