HomeMy WebLinkAboutZupicich, Atilio (2) Michael J. Domino, Pre it O�QSVFFQLKCaG Town Hall Annex
John M. Bredemeyer III,Vice-President %. 54375 Route 25
Glenn Goldsmith y P.O.Box 1179 -
A.Nicholas Krupski 1_� � Southold,NY 11971
Greg Williams 4, �ap`r Telephone(631)765-1892
Fax(631)765-6641
BOARD OF TOWN TRUSTEES
/ TOWN OF SOUTHOLD
Date/Time: ®�� 7, �d Completed infield by:
East End Pool King on behalf of ATILIO ZUPICICH requests a Pre-Submission Inspection to discuss
tree removal and a proposed swimming pool. Located: 800 Glenn Road, Southold. SCTM# 1000-78-
2-26
CH. 275-3 - SETBACKS
WETLAND BOUNDARY: Actual Footage or OK=q Setback Waiver Required
1. Residence: 100 feet
2. Driveway: 50 feet
3. Sanitary Leaching Pool (cesspool): 100 feet
4. Septic Tank: 75 feet
5. Swimming Pool and related structures: 50 feet
6. Landscaping or gardening: 50 feet
7. Placement of C&D material: 100 feet
TOP OF BLUFF:
1. Residence: 100 feet
2. Driveway: 100 feet
3. Sanitary leaching pool (cesspool) 100 feet:
4. Swimming pool and related structures: 100 feet
Public Notice of Hearing Card Posted: Y / N
Ch. 275 ✓ Ch. 111 SEQRA Type: I II Unlisted Action
Type of Application: Pre-Submission Administrative Amendment Wetland
Coastal Erosion Emergency Violation Non-Jurisdiction
Surveys 5 years: Y/N Wetland Line by: C.E.H.A. Line
Additional information/suggested modifications/conditions/need for outside
review/consultant/application completeness/comments/standards:
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I have read & acknowledged the foregoing Trustees comments:
Agent/Owner:
Present were: . Bredemeyer �M. Domino G. Goldsmith N. Krupski
G. Williams Other
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SSD® G�AI.I D OPI C?, ;!LP Board of Trustees Ap�� �;cation
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AFFIDAVIT
Jkm' BEING DULY SWORN
DEPOS AND AFFIRMS T T HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRI ED PERM Y(S)-- -THAT ALL-STATEMENTS--CONTAINEI-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.
Signa a of Property OwneU Signature of Property Owner
SWORN TO BEFORE ME THIS 3 DAY OF � , 20
r �f
Notary Public
DIANE DISALVO
NOTARY PUBLIC-STATE Of NEW YORK
No. O1 D1475593
Qualified In Suffolk County
My Commission expires April 30, 20��
SURVEY OF
LOT 10
C• MAP OF
WEST CREEK ESTATES
FILE No 3848 FILED AUGUST 19.1963
SITUATE
CUTCHOGUE
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
y S.C. TAX No. 1000-78-02-26
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! NOTES Land Surveyor
1 ELEVATIONS ARE REFERENCED TO N G V D 1929 DATUM
EXISTING ELEVATIONS ARE SHOWN THUS:mJ
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OCT 1 6 2018
icafhalrl T,,:vn
( Board of Tnrlmcs }
_ l
East End Pool King September 121110111
P
P.0 Box 369
Peconic, NY 11958
I hear by grant Jennifer Del Vaglio and her husband as property agents for all Swimming Pool installation
and related activity and all tree removal and related activity for my property at 800 Glenn Road
Southold, NY 11971.
Sincerely,
i
^bm PASS
Marc Zupicich, Property Owner � $aL
� IIIIA t'lSaa94
800 Glenn Road Air�X I=MXn
Southold, NY 11971
917-566-3824
Board of Trustees Applic - .on
AFFIDAVIT
BEING DULY SWORN
DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S)—AND THAT ALL-STATEMENTS-CONTAINEITHEREIN-
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 ISUED BY THE BOARD OF TRUSTEES DURING THE TERM
OF THE PERMIT.
Signature of Property O ne Signature of Property Owner
SWORN TO BEFORE ME THIS DAY OF
Notary Pub
Abri
,90 01FA9108104
APP L.CAN T/ADEN T/REDRES)EI`:TATIVE
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: A
Last name,first nam ,middle initial,unless you are applying in the name of
someone else or other entity,such as a company.If so,indicate the other
person's or company's name.)
NAME OF APPLICATION: (Check all that apply.)
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,rrgarriage,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.
tl t
YES NO - • '
If you answered"YES",complete the balance of this forth and date and sign where indicated.
Name of person employed by the Town of Southold
Title br position of that person tii Fac
Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check
the appropriate line A)through D)and/or describe in the space provided.
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply):
A)the owner of greater than 5%of the shares of the corporate stock of the applicant
(when the applicant is a corporation);
B)the legal or beneficial owner of any interest in a non-corporate entity(when the
applicant is not a corporation);
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this day of 200
Signature
Print Name -
Form TS 1
Alan
®A 1 6108104
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