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HomeMy WebLinkAboutRuggiero, Henry Glenn Goldsmith,President y���SUFF �`D Town Hall Annex A.Nicholas Krupski,Vice President v3�� Gyp 54375 Route 25 Eric Sepenoski y P.O. Box 1179 Liz Gillooly �y • p_ Southold,NY 11971 Elizabeth Peeplesl '1�¢'0 Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: 1 cj 25 Completed infield by: L•6111tt 00 1 HENRY RUGGIERO requests an Administrative Permit for the as-built ±506' of 4'-6' deer- fencing and chain link fencing around perimeter of property (excluding bulkhead). Located: 425 Calves Neck Road;Southold. SCTM# 1000-63-7-29.1 Typ f area to be impacted: Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code ro osed ork falls under: ✓Cha t. 275 Cha t. 111 other P p P p Ty of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Info needed/Modifications/Conditions/E c.: h C -F' 1> l wo Present Were: GjGdsmith N. Krupski E. Sepenoski. Gillooly E. Peeples N SURVEY OF PROPERTY A T SOUTHOLD TOWN OF SO UTHOLD SUFFOLK COUNTY ; N. Y. 1000-63-07-29.1 aG� ry' ��N frig, • Olt h NI CT • � � '�'�/lam BU � cs-y�go QJ�� G o`� �1r G ?ry \ INI •` \ �`�, INI ` 3 3 .CS P Fq cd \ 2� r r� NI HALT 2f3+ 1 O A 2.0 — o �2 24 p. 81' 73 0 CF �3 S E P 1 2 2025 IPA b Southold Town Board of Trustees FLOOD ZONES FROM FIRM 36103CO166 G 5104198 Ruggiero N,4,1,2Q.w Property Fencing ' r so.o0•t� �, 425 Calves Neck Road, ROWD PAS'£"r Southold, NY 11971 AREA-29,558 SO. FT. _ -- TO TIE UNES- LEVA 710NS ARE REFERENCED TO N.G. V.D. Fencing Layout Date: Sept 7, 2025 SURVEY OF PROPERTY N A T SO UTHOLD TOWN OF SO-UTHOLD SUFFOLK COUNTY, N. Y. 1000-63-07-29.1' SCALE. 1'=30' FEBRUARY 27, 2006 O `P�d'O�j��g '9N h��y�y R • � eG�yFgO J�O� V� O \� 'Pell O x QV z cam S�S G .��O� �•�p` \ � � \ � � �opo�`F IGyEJ• ^ Oc• \ o Fo � "Iz pl q \ 6Q0 2 0 S � O 18- "4;7o j 20� ASPHA� Z 5` 2.0 JC I 12a � m fL 24,0, 81' 139, 43 6. Q� N ` IPA N N - � h S E P 1 2 2025 4 2 Southold Town Board of Trustees FLOOD ZONES FROM FIRM RFB�R 36103CO166 G 5104198 H74:?, R 6000. ?3,5•f0 OF PAVEMENT gP�S�,M EW�O A►REA-29,558 SO. Fr. TO TIE LINES ELEVA 77ONS ARE REFERENCED TO N.G. V.D. /�// � �, O. 49618 ANY AL TERA 77ON OR ADDITION TO THIS SURVEY IS A VIOLATION P CONIC UR B U OF SEC77ON 7209OF THE NEW YORK STATE EDUCATION LAW. (631� 765-502 ��� —1797 EXCEPT AS PER SECTION 7209—SUBDIVISION VISION 2. ALL CERTIFICA 77ONS P.O. BOX —5 ```� HEREON ARE VALID FOR 7NIS MAP AND COPIES THEREOF ONLY IF SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR 1230 TRAVELER STREET WHOSE SIGNATURE APPEARS HEREON. SOUTHOLD, N. Y.. 11971 06-128 WN.OF SOI7THO.LD APPEARANCE TICKET #7061 rh- Southold,New York, 11971 - 1 Issued to:, } commr_ ssion.of the offense,,of . �4 Fir St Narlie st me U ) J *�C ep 1 t. ''v: (� ' 1VLI' 1 . Nur tuber and Street f t a / _ s CAyorT6wn State r g s�ej EI i 4w To o e pr is of contrary_t th_ ov ons { YOU ARE HEREBY directed to appear at the Justice Court; 'y jr (St Town of Southold,(Town,H Section. all)53.095 Mam Road o - (State out 25); S'outhold, New York 11971,,. f the code ofthe Town of Southold �3 n Dated at On the f 4_ Y . _ �_ - 20 Issued-and subscribed'b :F: `'. { 1 o at . �,C o'clock in the.. Y ! t nc � � ` Name 1Z L5t ; _ in connection with your.alleged {% Title �jL X iS IF. YOU FAIL TO APPEAR ON,THE:DATE,AND TIME'INDICATED A CRIMINAL SUMMONS OR WARRANT FOR YOUR ARREST.MAY BE ISSUED.: 1 INjDic AR REST SScn VEp, -� v o rn � 0 0 I Q- fV CD N I - (D (,n FIR —:�vVly OF S,OUTH.OLD APPEARANCE TLCKET #7062 Southold,New York, 11971 Issued,t0! rl' - commission of. he>offen e of- ii Last Na ne T Firstp.ame -- s Number and-,Street, = y , }. City w State or To Zlp �w i `11 t��+ti i , �i l` f • N'�jrt� . V �rcontrary to the provisions of # T YOU"ARE HEREBY directed to appear,at the Justice Court; g i Sect ion, ' (S Town of Southold(Town Hall) 53095 Main Road - i` (State Route 25), 5outhold,:New York 1197 L. de of the T.wn of -of thc.,co : 'o Southold at On:the ..' day of 20 Dated: yF.. a_nd subscnbed by: I in c o'--clock in the M., e sued= � o Nate in connection with your alle_ed Title a AV > �8S f IF YOU FAIL TO:APPEAR ON THE DATE AND TIME INDICATED; A-.CRIMINAL SUMMONS:OR':WARRANT FOR,YOUR ARREST MAY BE ISSUED: k RHO C ± RREST_ a� �SSVEp, M 0 cz 0 0 �!Q rQ 1 0 (D 0 63 r : . y. - Southold New York l THLD , T,OWN�OF SOU APPEARANCE TICKET 1.97.1 D #706:0 E• Issued to: v , - s. - i �,� eo offense fco commission th o Last-N emsa _ - �y ti 4 � j� '4. � b `W...i -.� � f� First Name l.�. _ �:• f _ t r M.I., 1 t�I�11`�; �; Number and Street: r� r' 1�7rtt �,i sJ 1 Yam.{ � � f� � ,�r ��.. c'""• - -- '... ..w � +..� � �t L� � _ _ _ �t� 4 '' Cite Town - Mate Zip ° r��, � contrary to the provisions of YOU ARE HEREBY dtected to appear at.the Justice Court r Town of Southold.(Town Hall) 53095.Main Road; Section , (State.Route 25), S'outhold, New York 1'1971. of the code of the Town of Southold Dated.• .X On the r. day r € . / 20 ~' Issued and subscribed by.. q-. , at P .r.. o clock i r� n the � f- J #i i - �. M ,. Name D in.connection with 4. .. your alleged - Title �'� �`� ' - 4-4 NA o C/) cr) IF`YOU' FAIL TO APPEAR ON THE.DATEAND'TI o ^' ME fNDICAT -n A CRIMINAL.SUMMONS`.OR'WAR'RANT FOR YOUR ARREST MAY BE, ISSUED. 0 o �Cf) ry (D o _ " I vWN OF SOUTHOLD APPEARANCE TICKET #7063 Southold,New York, 11971 Issued to.: j {� r commission of the offense of: Last Na me, First/NameM.I. —� Vol %• t i;'.fi,,y ?U``i�.�d, tt �S�S Jar'. '•,�,s �f �`� �.,?mow,. Number and Street ,._ —7 a/i i'; C' 1, '4 3 _ 1 City or Tow t>n State zip I contrary to the provisions of I To , YOU ARE HEREBY directed to appear at the Justice Court, f Section o�-� - -�} (St Town of Southold(Town Hall) 53095 Main Road J� (State Route 25), Southold, New York 1.1971. of the code off hewn of Southold On ! ru.`F Dated: ' `. < at On the day of ; 'j 20 y; Issued andsubscribd_by: at in cod `' G� o'clock in the .. M. Name j in connection with your alleged - Title IF'YOU.FAIL TO APPEAR ON THE DATE.AND TIME INDICATED, A CRIMINAL SUMMONS OR WARRANT-FOR YOUR ARREST,MAY,BE ISSUED. - ST'WAY BE ISSUECo D . F2�� cnm No t (n ��E a w• �� f�. a y � � 1 x. d ,.� 's �.�� ����� a g +r�. '3� , K .. � `�T- `�^ .- _ ,'-• !" :(� ~-. AW 1 4 ��.��, � � `� - �; ..-�,�•��'`' was." "��� � _.. Ov- ZIP lw AWe jr MA y7 { NC. Y r��� ►t ., {, Y ` �� ri �r�' �� � v, '\i� Yt 1 Y I +, �� ,� �,,iH/-' :y: �M ? !tea`�1t�'• r+{y� !'. ,/,_ ,� ,1/�' �� j � '�' I '�'� � z- ...-yam".. �� s.•-� �'*�� Y � ♦ �i �t y.. _ `Y fly ,,,"..ia 14 -01 At Ir R , ��•w/1 t,J,r��j 11 ,. '~� I ,�'f vry,.a p� .. y ' 63 23 Ss _ zoo 2 OM 0 a' ��- F•'h94`- 0.$ � "yY�� 1�` M1 Y^"``� 15 xasa "1f fi Gf'. L. 3 1f L ` 15lycl aS3 � f ''�� ;m`,. iWa) ,?•.gyp:• �.�43P1 M c. Oa3)-0) 35.E a. rw 13 yap T NO�� alOArfiwn ,`? )A 'zl tE i AlcP4v. 5 Nc12 M�. .yy 66t'09 d OEv6luwenT5lsviy P¢ o } W-x0.0s Vt' ��.' T.TMcf 4� � ♦ i M1 89Mc1 n A Oaao-Os ° n r'' e. s '2,8 0.•, 5yN` , 1 .'i'' 112 b. D)zato: z zsA y' x�vx.r..e;.oxoovaNw � _ 2 _ 12.apt3 ' -" .: �..�... AwfwwnFn, y � °� •tj v 'sy s 6 .,. tldE ,'s ♦. 6 �1HMc1 fh) .:S¢2 3.6Mci 3y -. ssff - .`a :e's ,. y.`;,� c•' ,. ' ipp,q +6A{cf oszo-a _ .rs s 1a3 z3n a>r..lcw,w6u A a H ta`A - 6AMn) L Z ol„ " W �5 ' v C - ka 121 SSA 1 0 �! da+mP�amc wp.aemarMr♦ ', sea ' _ 23wo M1 .6 1 r ) al v: - •,«,o.'.' ..: ,"' ....." ^- ...:. COUNTY OF SUFFOLK O No3we K we*w. teoe sE-TI. c. o �._ _ A✓_ �-�_ .,.�.�.w ..i R I&perry i o x 1g v u_ E �oF 063 pl � SWTNIXA eu_ [61WNIflw `. � .,E w • � s1iFOuc Lc. • A S s Glenn Goldsmith, President *®F S®Ury Town Hall Annex A. Nicholas Krupski,Vice President ,`®V� ��® 54375 Route 25, P.O. Box 1179 Eric Sepenoski J J�L Southold,New York 11971 Liz Gillooly cs� Telephone(631) 765-1892 Elizabeth Peeples ��� a� Fax(631) 765-6641 c®u��,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD October 23, 2025 Henry Ruggiero 61 Marshall Avenue Lynbrook, NY 11563 RE: 425 CALVES NECK ROAD, SOUTHOLD SCTM# 1000-63-7-29.1 Dear Mr. Ruggiero; At the October 15, 2025 Hearing, the Board of Trustees approved your Administrative Permit application with the following conditions: 1) The proposed fence must be pulled back 20 feet from the bulkhead per Town Code, Chapter 275. Pull fence back to the top of the bank. In order to get your Administrative Permit, you must provide 2 sets of revised plans showing the fence pulled back 20'from the bulkhead to the top of.bank. Feel free to contact the office at (631) 765-1892 with any questions. Sincerely, ,b a Glenn Goldsmith President, Board of Trustees OFFICE LOCATION: _ '4�_ O „ MAILING ADDRESS: Town Hall Annex P.O.Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) cis i ae•' ii Southold,NY 11971 G•. �` Telephone:631 765-1938 '�►O • ��0;' ,• LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: Glenn Goldsmith, President Town of Southold Board of Trustees Cc: Honorable Lori Hulse, Attorney From: Heather Lanza, AICP, Planning Director LWRP Coordinator Date: October 14, 2025 Re: LWRP Coastal Consistency Review RUGGIERO, SCTM# 1000-63-7-29.1 This application is for 4'-6' deer-fencing and chain link fencing around perimeter of property (excluding bulkhead). 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, it is my recommendation that the proposal is a MINOR ACTION pursuant to Town Code §268-3 Z, and is not subject to review for LWRP consistency. 4 Glenn Goldsmith,President �i�f S0/�� Town Hall Annex A. Nicholas Krupski,Vice President ®� 54375 Route 25 Eric Sepenoski P.O. Box 1179 ,® Southold, New York 11971 Liz Gillooly cf-I Elizabeth Peeples Telephone(631) 765-1892 COWN, 0 E BOARD OF TOWN TRUSTEES SEP 12 2025 TOWN OF SOUTHOLD luvvtl c, + This Section For Office Use Only Board of'Trustees Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extension Received Application: Received Fee: $ Completed Application: Incomplete: SEQRA Classification: Type I Type II Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: —Coordination:(date sent): LWRP Consistency Assessment Form Sent: CAC Referral Sent: Date of Inspection: Receipt of CAC Report: Technical Review: Public Hearing Held: Resolution: `� � 1 Owner(s) Legal Name of Property (as shown on Deed): #'e rry Tongaan' V Mailing Address: 41 M4 is4,6J/ A LypXr.ak /V. Phone Number: — 2d 7— 76(cPo 0, Suffolk County Tax Map Number: 1000 - „�a�f - .1 Property Location: ,f-. '�!a t/e-S Ale_Ek Rd AW 1117-71 (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): Mailing Address: Phone Number: Email: Dard of Trustees Applicat GENERAL DATA Land Area (in square feet): Area Zoning: aE Jel /"'d AIV Previous use of property: A/ A Intended use of property: A/A _ / Covenants and Restrictions on property? V Yes No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes __V//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 _�,�N0 Does the structure (s) on property have a valid Certificate of Occupancy? VYes No Prior permits/approvals for site improvements: Agency Date 51 g'2- l/ ©7 No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? V!�No Yes If yes, provide explanation: Project Description (use attachments if necessary): J Dard of Trustees Applicat WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: V-aer Area of wetlands on lot: . square feet Percent coverage of lot: 2-5-- % Closest distance between nearest existing structure and upland edge of wetlands: /c?,5 feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? AIA cubic yards How much material will be filled? 94 cubic yards Depth of which material will be removed or deposited: &A feet Proposed slope throughout the area of operations: AIA Manner in which material will be removed or deposited: AM 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 orProject:.r . Project Location(describe,and attach a location map): Brief Description of Proposed Action: F'e'��0 Name of Applicant or Sponsor: Telephone: lie r a-AVc e E-Mail: G' R� ITT - i �l D •C4-9 Address: Q AtarsAodl Ave. City/PO: State: Zip Code: I.Does the proposed action only involve the legislative adoption of a plan, local law,ordinance, 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? N■O�1 YES If Yes, list agency(s)name and permit or approval: ❑ 3.a. Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned r� or controlled by the applicant or project sponsor? 7 ' acres 4. Check all land uses that occur on, adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial [Residential (suburban) ❑Forest ❑Agriculture El Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 i 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ [-j} ❑ b.Consistent with the adopted comprehensive plan? El ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ 7. Is the site of the proposed action located in,or s it adjoin,a state listed Critical Environmental Area? NO YES s;? [f Yes,identify: 01_ ❑ 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: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: X ❑ 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? I1 ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: Y�,I 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: Shoreline ❑Forest ❑Agricultural/grasslands ❑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 1 f Yes, rn�J ❑ a. Will storm water discharges flow to adjacent properties? ]NO OYES b. Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: A 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: ® ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Q Applicant/sponsor n e: ie r Rv. / ro Date: 7 /�OZ2— Jl Signature: k! 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 1 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 illy 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? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? ❑ ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the El ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El ❑ 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: El 1:1 a.public/private water supplies? b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, El ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ❑ waterbodies,groundwater,air quality,flora and fauna)? El 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 ❑ ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? 1:1 El 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 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) PRINT Page 4 of 4 oard of Trustees Applicat AFFIDAVIT `1� 'c &'nr-1 'PUAilercl BEING DULY SWORN DEPOSES AND AFFIRMS TIAXT 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 BOARD OF 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, INCLUDING THE CONSERVATION ADVISORY COUNCIL, TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. e oTTp rty n r Signature of P operty Owner SWORN TO BEFORE ME THIS 1 2— DAY OF 6er , 20 o1S Not ry ublic \\`ooS�ATErp i- Dawn Johnson INOTAR`/., %Notary Public,State of New York *: rueuc a"a No 01J®6349053 'N..... [c., Qualified in Suffolk County rrnrni�noo Commission Expires 10/11/203--o 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 possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: Ale-'a rV P11PI _4 (Last nam ,first na e,'rniddle initial,unless you are applying to 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 AMC f ��®°C• 200;S_ C+ Signature Print Name n Form TS 1 t �� Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# 3 • �' - a o PROJECT NAME Aej ry �u le-ra 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: I ITC c eat^ 1 Location of action: ��-�' ed/V19s Alf&k , d Site acreage: g Present land use: Rks 1 dk n°f / Present zoning classification: FfiesI d�aa*q 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing address: (c) Telephone number: Area Code ( ) (d) Application number, if any: Will the action be directly undertaken,/require funding, or approval by a state or federal agency? Yes ❑ No Vr 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 J?T 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 V Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No VNot Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No 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 VNot 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. ❑ ❑ [je/1 . Yes No rNot�ppiic.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 Vr Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No WNot 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 XNot Applicable Attach additional sheets if necessary WORKING COAST POLICthS 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 VrNot Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Lang Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No VNot Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ No N/Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No VNot Applicable LiZ �� '" v ;OrV TITLE d�w�7�ef D ATE i IO PREPARED BY 4 �`