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Home My WebLink AboutTR-11011A , zzra-- Glenn Goldsmith, President o��gOfFQ( Town Hall Annex A.Nicholas Krupski, Vice President ty'� rig- Route 25 Eric Sepenoski y = P.O. Box 1179 Liz Gillooly N. Southold,NY 11971 Joseph Finora ?� pl.,�0 Telephone(631)765-1892 �Ol �a Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1st day of construction % constructed XProject complete, compliance inspection Glenn Goldsmith,President �QF S0!/r Town Hall Annex 54375 Route 25 Nicholas Krupski,Vice President ,`off ®�® P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly G Q Telephone(631) 765-1892 Joseph Finora • a0 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 11011A Date of Receipt of Application: August 26, 2026 Applicant: Howard & Lisa Koff SCTM#: 1000-70-12-32 Project Location: 1380 Oakwood Drive, Southold Date of Resolution/Issuance: September 16, 2026 Date of Expiration: September 16, 2029 Reviewed by: Board of Trustees Project Description: Raise the permitted 4' high pool enclosure fencing along the eastern side of the property by two feet by adding extenders on the existing posts and using chain link fencing on the extended portion to achieve a 6'-6'5" high chain link fence. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Howard & Lisa Koff, received on August 26, 2026, and stamped approved on September 16, 2026. Special Conditions: None. Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. 411— A" Glenn Goldsmith, President Board of Trustees I Aug 07 20,12:41 p Harold Tranchon Jr.P.C. 6319291426 p.1 i LOT AREA 30,308 SO. Fr. 0.696 acres OAKWOOD DRIVE j N 83'05'30"E 110.00' opron FD i FC MON 11{0.6'W � cn � v , O ' z m :n �1 U' c, 22.9. bfg n blk .•JP G pc:ovrch curbing O I 116 N m I i z 3 Il � 36.2' o uo 21-0' - v I p ' �_2 STY FR DWELU. ti 32-6 O A 3 �D B 1 m x' � — porchp �x cC x � �, roo36deck' 17.5' 0.5 w BOARD OF TRUSTEES s<nm� b1T 2nd 2.7'r 10.2' —bcbove TOWN'OF SOUTHOLD DATE i 2 \Cm ec- x i -- y/ bulkhead7 7- �1.D'w 2 bulkhead onLA s6. 2 6 2026 I' Lr� e�4 i 4P 11 dock °a �FC0.5'N 1 G ram,x4' �9 �0.2'W I 0I 14'rS terGe ;0uth01d Town IQar'^tsN e o $j1ard of Trustees i C" floating dock �— 20'x6' _( E02l�ER0- ! bulkhead QR H THE CCS7ENCE 09 RIGHT OF WT5 AND OR EASEENIS 1.7'N V1 k\\ a=RECORD.IF ANY.Nor SHORN ARE NOT CEMUNr®. C.� S TE b�sm(m�ENSCHs)sna—.0moN Rr OY THE SrtiULR1AiE5 To THE PPROPEWT LINES ARE FOR A SPECIFIC PURPOSE AND USE AND TREMYORE ARE NOT I JOB No. 20-166 STOLE No. 1041 F INTENDED TO OLME THE ERECTION OF FENCES RETAINING WALLS,PDO 06,LS.PAT t PLlNRNG AREAS.AfXATGN To Mb XZ!S OR ANr OTHER CONSTRUCTION. SURVEYED FOR HOWARD & LISA KOFF UNWINCRIZED AITFTATIGN OR ADDITION TO THIS SUR.EY 6 A NCLATIOH OF sEC1I0IE 7209 OF THE NEW YORN STATE EbuGTON IAf_ CWPAYiFEs xldwED NFAEOtt SEVEI,Rui LNIY T1 THE PHiSbI FOR WON THE 4 SGINEY Is PREPARED,AND ON HIS eDUUF TO THE— Y.COWM OOYUMIENTAC : SITUATED AT SOUTHOLD ALFJ.C1'ANTI LENDINGUfI NO UIS7RTN LISTED I>ffEW.AND 70 ME ASUCNEES OF THE LENDING INSTIMN,N.GUARANTEES ARE TW TwvEF�IE TT AmraNk nimrtmms i TOWN OF SOUTHOLD, SUFFOLK COUNTY,N.Y. - 09 gmSEOU0n mom I COPIES OF TNOS SUMTY NAP Na SEARING THE uM suR%EYWS WED SEAL PR � SCALE 1" = 40' DATE 7-31-2020 EHBOSSED SUL 91NL NOT EE CONSIDERED TO RE A VALID TRUE COPY. FILED MAP No. DATE CERTIFIED ONL'( TO: TAX MAP No-1000-70-12-32 DISK 2020 HOWARD & LISA KOFF MADISON TITLE AGENCY LLC HAROLD F. TRANCHON JR. P.C. STEWART TITLE INSURANCE COMPANY LAND SURVEYOR WELLS FARGO BANK, N.A. I P.O. BOX 6 f6 1 f i 1866 WADING RIVER-MANOR RD:WADING RIVER, ET' NEW YORK, 11792 11 LIC.No.048S92 HAROLD F.TRANCHON JP,. NN.LIC.No.21S-E 631-929-4695 l SOUTHOLID ' .TRUSTEES No. A Issued To- NoWarA A- Us5o. Ko� P Date Address 1M6o CUaKw000l br : ve , Sok;ll-solg THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION .TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765-1892 Glenn Goldsmith,Pre;. �0�� CO�� Town Hall Annex A.Nicholas Krupski,Vice President < 54375 Route 25 Eric Sepenoski y ,?, P.O.Box 1179 Liz Gillooly Southold,NY 11971 Joseph Finora ��l �� r Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees p� Field Inspection Report Date/Time: ( Completed in field by: lzal(cd HOWARD & LISA KOFF request an Administrative Permit to install 6'-6'5" high chain link fence along eastern side of property. Located: 1380 Oakwood Drive, Southold. SCTM# 1000-70-12-32 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound ay Part of Town Code proposed work falls under: Chapt. 275 Chapt. 111 other Ty e of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Violat n Notice of Hearing card posted on property: Yes / No Not Applicable Info needed/Modifications/Conditions/Etc.: S&� YN t(tjAA Present Were: G. G/ith N. Krupski E. Sepenoski L. Gillooly J. Finora CEE SE. SES, ME SEC.NO.003 CME z ♦ ♦ x T_ C`" SDn4 99 ,"'I,11 1'IN.) , I IS oa _2 lol IV') uS) ,x, r 4-1 Nv ISss j 0 "NE X o2 31- 13 11K Sw A fl, V 'A", k4 14 si "T, lo.11 a J IS & Is IwO ",I 21 1-SQT nv s" RN, 25 I.Mw i 'E`o A qE 4 j� I Tom OF �A q� V 4, 3 lAtl.) ANN AO K�K - -i, 101 44 312 'A I k- - <N , •` 4 1 v, fP I ; - t. o - I W "15 o f,l 2 lz A2 I 2 AM0 4 v ti -IolON, 4, ,C A '0 K 4/ IS a 3 V 4 WTER t l J 'jlo, — A IS � t 13 si oo- v "1A ln,21 13 IJ4�ljl S, - ae V` Fig' n 2 '�N nS g� 'T �Z, IS- 4 QS"k 'A "A 7f42�- So N _R� yLI P�D.\70 \,S, ma" IS NX,�%n♦ n� 12 1 3cE ...... "pp 1p N ...... In n �i� M�x n_a�\ x n �41 COUNTY OF SUFFOLK(D N NOTICE MCTt.NO L Iwo EGE ------- Real�.ponyTh:,Si A y SOUT,OLD 070m A OFFICE LOCATION: ��OF So(/T�O MAILING ADDRESS: Town Hall Annex h0 lO P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) y -INCTelephone: 631 765-1938 Southold, NY 11971 G • Q 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: September 14, 2026 Re: LWRP Coastal Consistency Review HOWARD & LISA KOFF, SCTM #1000-70.-12-32 This application is to raise the permitted 4' high pool enclosure fencing along the eastern side of the property by two feet by adding extenders on the existing posts and using chain link fencing on the extended portion to achieve a 6'-6'5" high chain link fence. The proposed action has been reviewed under Chapter §268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is CONSISTENT with the policies of the LWRP as follows: Policy 6. Protect and restore the quality and function of the Town of Southold ecosystem. 6.3 Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction The proposed action of a chain linked fence is consistent with Policy 6.3.A, which states that actions must comply with the Southold Town Board of Trustees' laws and regulations. The use of extenders to increase the height of the existing fence will not have an adverse impact on the wetlands because there will be no ground disturbance. The action can be classified as an "Administrative Permit" pursuant to Chapter§275- 5B(2)(a) Construction, installation or removal of a split rail fence, open arbor, trellis or . other similar structure, provided that such operation will not have an undue adverse impact on the wetlands and tidal waters of the Town. The proposed action has been reviewed under Chapter §268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. 2 Lisa L. Koff 1380 Oakwood Drive Southold, NY 11971 917.838.7135 August 20, 2026 To the Trustees of the Town of Southold: We have a tree on our property that we'd like to remove. It is located just inside our chain link fence at the southeast corner of our property on the North Bayview side. I've attached a photo of the tree,which I believe is a Black Locust that is aging out. The photo was taken from outside the fence on North Bayview-and there's a ribbon on the post right by the tree at the corner there for ease of identification.We've already removed,with your approval, a number of Black Locust trees down at that end of our property. They are nasty and invasive. There's also another Black Locust just to the right of the tree noted above but just outside the fence that we would like to have removed. We request that you consider having the town take this tree down, or give us permission to take it down. It's unsightly and is also aging out, and it has already encroached our fence-growing inside the chain links!! Finally,we would like to extend the height of our chain link fence on the eastern side of the property up by two feet, so that it becomes a six-foot fence rather than a four-foot fence. We would put extenders on the existing posts and use chain link fencing on the extended portion, as well as a new rail across the top of the fence. We'd appreciate it if you could get back to us at your earliest convenience, and would be happy to answer any questions you may have. Best, Lisa Koff � Glenn Goldsmith,President O SQUT�j Town Hall Annex A.Nicholas Krupski,Vice President �0 �( 54375 Route 25 P.O.Box 1179 Eric Sepenoski l6 Southold,New York 11971 Liz Gillooly Telephone (631) 765-1892 Elizabeth Peeples y� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only rr Coastal Erosion Permit Application I! Wetland Permit Application R —A Administrative Permit AUG 2 6 2026 Amendment/Transfer/Extension � Received Application: — Received Fee: Southold Town Trustees Completed Application: Beard at Truste- 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: Owner(s) Legal Name of Property (as shown on Deed): A/S0. a Vtht Mailing Address: 3 r/Gt,D • /q(' Phone Number: Suffolk County Tax Map Number: 1000 - 70 Property Location: _Oa4 t, oo q ✓� e, Alq loo 2- (If necessary,provide LILCO Pole#, distance io cross streets, and location) AGENT (If applicable): Mailing Address: Phone Number: Email: jrd of Trustees Applicati - GENERAL DATA Land Area(in square feet): —�� -- — Area Zoning: l /) Previous use of property: & ),d-L4n 1 ) Y Intended use of property: kt5 Covenants and Restrictions on property? Yes FX-1_No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes _nNo 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. r 1 his project re any demolition as per Town Code or as determined by the Building Dept.? Yes No Does the structure(s) on property have a valid Certificate of Occupancy? Yes=No Prior permits/approvals for site improvements: Agency Date :fib z 1d�' ❑ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? No Yes If yes, provide explanation: Project Description (use attachments if necessary): 81i . -P Civde. Ord of Trustees Applicati WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: aJe' rV a- a,-.� 6k Area of wetlands on lot: square feet Percent coverage of lot: AZA % � / /S r Closest distance between nearest existing structure and upland edge of wetlands: feet 1)&1. 1 Closest distance between nearest proposed structure and upland edge of wetlands: _ feet Does the project involve excavation or filling? _�No 0 Yes If yes, how much material will be excavated? ® cubic yards How much material will be filled? 0 cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: 0 Manner in which material will be removed or deposited: Z A 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): �,re- fly, no wed 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 I 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: ` Pro• ct Location(describe,and attach a location map): Ilk— Brief Description of Proposed Action: cf✓a-��s ti 6 �2• S�-� • ZS�Z �� l5 Name of Applicant or Sponsor: Telephone:,? ! rrl. d 6 E-Mail: I O •c Co 71 Address: I 8 6 �a.>�z ago 0 �rr City/PO: St e: Zip Code: 50 I rlT. 1.Does the proposed action only involve the legislative adoption of a plan,local law,ofdinance, 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 sit f the pr posed action? c 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. Che I land us at occur on,adjoining an ar the prop action. Urban Rural(non-agriculture) Industrial Commercial Residential (suburban) Forest ❑Agriculture Aquatic QOther(specify): 5 Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? b.Consistent with the adopted comprehensive plan? 6. Is the proposed action consistent with the predominant character of the existing built or natural NO f YES landscape? 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 I YES Ifthe 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: FA ❑ 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: i—0 14. ntify the typic bitat types that oc n,or are likely to be found on tf�-project site. Check all that apply- Shore line Forest Agricultural/grasslands u Early mid-successional Wetland Urban PSuburban 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? O YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO FTM If Yes, a. Will storm water discharges flow to adjacent properties? �NO DYES b. Will storm water discharges be directed to established conveyance systems ff an m drains)? If Yes, briefly describe: NNO 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 name: lrvt� L 1sa I"V�IU Date: ��1 Signature: ` g OW 77 a-4-� 6 g/as�Zb 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 my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occu r occu r l. W ill 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? I 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 ❑ 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? �I 7. Will the proposed action impact existing: ❑ 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, �( architectural or aesthetic resources? J El 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, ( ❑ waterbodies,groundwater,air quality,flora and fauna)? I� 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? 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) PRINT7 Page 4 of 4 -,ard of Trustees Applicats AFFIDAVIT &-daAd-0- 1<ot� a-rd- 1 - - BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE 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. Signature of Property Owner Signature of Property O er SWORN TO BEFORE ME THIS DAY OF 0-- ,.20 4,6 OLEKSANDRASOROCHENKO Notary Public Notary Public-State of New York NO.01S00014709 Qualified in Bronx County My Commission Expires Oct 21,2027 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 purvose of .this form is to provide information which can alert the town of possible conflicts of interest and'allow itto'take whatever action is necessary'to'avo id same, YOUR NAME: t(5� (Last name,first nanfe,middle initial,unle s 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 i (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%dof 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): _nA)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 &4U4 20 Signature k 4 Print Name_ %t. Z . fi�1Q+1 b kd Forth TS 1 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 si ign frcant beneficiatand"adverse effects u on.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# PROJECT NAME ZAL t S CCP-U_ l The Application has been submitted to (check appr priate response): oC• 5 Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees R. 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: p rL 1 t art 0 n P�°� � Location of action: 13660 ram Y" aAd. Site acreage: , Present land use: . 41 r�aU Present zoning classification: &�e o:4-1-a�; _ 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:--L. aL—"A' k6 f (b) Mailing address:_��Q Y 7, s 9 �� l O0 (c) Telephone number: 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 1-1NoSi 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 Not 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 Not Applicable❑ Yes ❑ No 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 JondNot Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages 22 through 32 for evaluation criteria. ❑ Yes ❑No� Not Applicable 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 wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria. ❑ Ye❑ No® Not Applicable Attach additional sheets if necessary WORKING COAST POLICIIL 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 IA Not 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�l Not 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 IX Not Applicable PREPARED BY /l I S'a 1 ol7 TITLE eAj DATE 9 2—9ZZ16