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HomeMy WebLinkAboutTR-9601E Property width 66 feet 9--- cl�j 3 O iia = 10 Sand bag wail width 66 feet TYPICAL, SAND BAG � I nrlw 1 ■ 1--1 C\/A-Irl Pl existing grade V rMLL. %-A-L Y A■ -1 A. estimated eroded slope Scale: one inch =5 feet estimated unconsolidated Notes loose sloughed soil Sand bags:36"x 36- x 40" H {First row fully buried to grade approx_line for relocated 2nd and 3rd rows staggered as shown loose soil behind sand bag wall Returns: 3 bags deep behind front wall 1- \ Estate of Mark Warfel existing grade &R(1 Thn Ctrwn.i 1 wno, FMc± Mwl-;nn Temporary Sand Bag Wall TYPICAL SAND BAG to Protect Distressed Slope Return at'12it-overall RETURN ELEVATION Scale:one inch=5 feet By: M. A. Kimai ck Dated: Nov. 19, 2019 Qfa ' ' J a� alG 6 a _l +`?P1 , \O0 GP `p. 0+ ) aE� co r- D� 06 ` rt '9A -- ti G f T: os \ n aPGy�i �;,5- ti o mor fls aH,,v _ _ ,pp.. "* oo• 0707, 4'�,u• j �—'1y j6 2B50"W _ 3B i 1r I a,`9aS a 5`lv as 'Oi ag APL f 0 s, AG c's's, P'.600 Ohl � Y- , 5 SU"OlA COUNTY HEALTH DEPARTMMT SURVEY FOR ABOSTOLOS SKAPERDAS - NOV 1_!I,Q7R Y.. D. RE . ;_ `7-.Sc-[ G LOT 130 "PEBBLE BEACH FARMS 20. 979 AT EAST MARION DATE DECT 8,,1978 l t,an r+.c t:Dn TOWN OF SOUTHOLD SCALE I =so' L,-- + :LV-na'd four)0 SUFFOLK COUNTY, NEW YORK NO 78-809 ' -� •I -' ''t\+�,J,,•._aa� "�' "� a.t MUNAUTwOR11ED A-1(RATION OR ADDIT.01•0 rni5 1♦ ✓�L'aE� 1 %�a r,� T�•i 111111 iS A VIOIA•ION OF SECTION 7109 OF•nE OF N Chlef of Geneml Engineering ` NEW ISSN SATE EDUCATION I AW tptE f(y. K COPIES OF'"SURY"NOT BEARING rH(L ANO S fiU ly `U4 SeiN1CB8 SURVf rORS.NFt L SEA LC RIMBOSSC D Sf AL SHAII �[' �- ,7 NOT BE CONSIDERED•0 BE ♦A110'PLE CCR• `u1ARANTEFS Ira-I'Allr HERION_"AIL RUN Urvl. OG HEALTH DEPARTMENT-DATA FOR APPROVAL TO CONSTRUCT THE PERSON fop W..ON r.E SU"C iS PNEPARED 2 AND ON HIS BEHALF TO THE TILE COMPANr,GOVERN 1 '�<!0 �' NNEAREST WATER MAIN MIS *SOURSEOF WATER PflIVATE PUBLIC: MENTdL AGENCYANO LENDING INSTITUTION.15TE0 ```I MI % *3VFF CO TAX MAP 01ST SECTION BLOCK LOT HEREON ANO•G THE ASS+GNEES OF THE LENDING t<�al_5 *THERE ARE NO DWELLINa4 WITHIN 100 FEET OF THIS PROPERTY INSTI•UrION GUARAN TEE ARE NOT TRANSFERABLE ' OTHER THAN THOSE SHOWN HEREON t0 ADDITIONAL INSTIN TIONS OR SUBSEQUENT I r *THE WATER SUPPLYANDSEWAGE DISPOSALSYSTEM FORIHISRESIOENCE OWNERS ! 'G 4S£93 WILL CONFOR M TO T N E STANDARDS OF TH E SUFFOLK COLIN TY DEPARTMENT �I DISTANCES NOES SHOWN HEREON FROM PROPERTY L-NES C OF HEALTH 3ERVIC E9 0 E%IS TING STRUCTURES ARE FGR A SPECIFIC 'Jf6 APPLICANT PURPOSE AND ARE NOT TO BE LSEO i0 ESTA RUSH (A D PROPERTY LINES OR FOR THE ERECTION OF FENCES ADDRESS --- TEL --- YOUNG a YOUNG 400 OSTRANDER AVENUE RIVERHEAD,NEW YORK ■=MONUMENT 13 STAKE SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK OF ALDEN W YOUNG,PROFESSIONAL ENGINEER SUFFOLK COUNTY ON JUNE 11,'1975 AS FILE NO 6266 AND LAND SURVEYOR NYS LICENSE NO 12845 p THE LOCATION OF WELL(W1,SEPfIC TANK(ST19CO3PppL3(CPI3NOWN HEREON HOWARD W YOUNG,LAND SURVEYOR dRE FROM FNLD OBSERVATIONS dXOOR DA TA OBTAINED FgOM OTYER9 NYS LICENSE NO 45893 Michael J.Domino,President rjF S0!/TTown Hall Annex John M.Bredemeyer III,Vice-President ,`O� ��� 54375 Route 25 P.O.Box 1179 Glenn Goldsmith [ Southold,New York 11971 A.Nicholas Krupski G • Q Telephone(631) 765-1892 Greg Williams 'gyp Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No.: 9601 E Date of Receipt of Application: November 20, 2019 Applicant: Estate of Mark Warfel, c/o William Donald Warfel, Executor SCTM#: 1000-30-2-85 Project Location: 680 The Strand, East Marion Date of Issuance: November 22, 2019 Date of Expiration: 90 Days From Date of Issuance Reviewed by: Trustee John Bredemeyer Project Description: To construct a sand bag wall approximately 66 feet in width to property lines with two (2) 12 foot returns; first sand bag course fully buried with two (2) courses above (staggered) for a height above grade of approximately 6 feet; relocate sloughed unconsolidated soil at base of distressed slope laterally behind new sand bag wall as material allows, to help stabilize toe and sand bag wall; and to remove all storm debris from beach to protect sand bags. Findings: The project meets the-requirements for issuance of an Emergency Wetlands Permit as determined by the Board of Trustees. The issuance of an Emergency Wetlands Permit allows for the operations as indicated in the application received on November 20, 2019. 1 Special Conditions: A full Wetland Permit must be obtained within 90 days in order to conduct any further activity on or around the bluff. This is not a determination from any other agency. Michael J. Domino, President Board of Trustees I T US S SOUTHOLD R TEE No. -g6o1 E- 6""ftc4yAn%;+ Es�}e of rfd, Issued T0 & wd6ft3mftw Date.�I� Address 68-D flu S4r*iJ,, Comi A&rodbn THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765.1892 Michael J. Domino PresidentSOFFD(� b�(1 COG ,.,;` r' Town Hall Annex John M. Bredemeyer III,Vice-President` ,�� �,� 54375 Route 25 Glenn Goldsmith C= P.O.Box 1179 A.Nicholas Krupski Southold,NY 11971 Greg Williams p� Telephone(631)765-1892 �( *0 ' Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in field by: Michael Kimack on behalf of ESTATE OF MARK WARFEL, WILLIAM DONALD WARFEL, EXECUTOR requesting an Emergency Permit to construct a sand bag wall approximately 66 feet in width to property lines with two (2) 12 foot returns; first sand bag course fully buried with two (2) courses above (staggered) for a height above grade of approximately 6 feet; relocate any sloughed, unconsolidated soil at base of distressed slope laterally behind new sand bag wall as material allows, to help stabilize toe and sand bag wall; and to remove all storm debris on beach to-protect sand bags. Located: 680 The Strand, East Marion. ,SCTM# 1000-30-2-85 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___V/ Ch. 111 SEQRA Type: I II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland -Coastal Erosion Emergency Violation Non-Jurisdiction Survey <_ 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: At 4 „ v' of 'Azz,G.5f s 4ZjJri P4 le) �/r!'t2 %,r O-V' `” JY G2 rW— C y- Y(P I I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other MP V` + ,.w F' oo• = r tr lip '1 _ ,ori.-r• ,.. NOV 2 0 2019 Southold Town Tr ^ s j r s 7 A .� :— .ji�r ,�h I+ `1 ;11 amu• ��S �`,.. 1 v e A AL 1 1 iMINy _ 1 �....:.- ,,;�. ,,•,. .:..:.=h.., ��' fMln-�,L!r::'"$�'g"_'rr'"Y`'.r.� '�•.,^w�+•'°s��.M.,.m,, _. a, 'SEE"SEC NO 021 O 90 ,«I MATCH— UNE w N358082 92 p S 89 '3 nn b l'x FOR PCL.N ✓A 1 a ■ I1°) 93 �1 6 SEE SEC NO. \ 1,1A po N 5 Im 021.05.02294 C1 6 n) y'' nwl p 1i s) 2 85 87 �•m, 1y11 95 \ u') 1.2A / O e12A(t) m)� 4 96 yP w 6 5 // ///3 u°I ' 78 81 0 98 \ g 4 � a g9 � I") 80 I❑q .R 73 w 7(3 00 70 � 69 0 86 4 Or 72 (VEN SPACE) 31.8A 100 '0' 65 Gj 71 .� Ial P '§, 5.9A (OPEN SPACE) 34 68 7 1.1A 67 '¢ a 101 32.4A � a) 4° RI)2 1.2A/ 5 )� S 6 11� 9 'PII (OPEN SPACE) 113 'P° W) $ / / 9 s 114 10 ala) ba M) .. 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U SEE SEC.NO. 035-02-017.1 FOR PCL.NO k J 035.02.001 SEE SEC.NO �3 03502.012 °X39 c1 ---------�-- LINE 4 �° MATCH UNE V SEE SEC,NO.035 NOTICE COUNTY OF SUFFOLK © K mI TOWN OF SOUTHOLD SECTION NO MAINTENANCE,ALTERATION,SALE OR E Real Property Tax Service Agency r SUFFOLK COU TYTA PORTION O THE VILLAGE OF w O SUFFOLK COUNTY TA%MAi'IS PROHIBITED �^ Coanry tinier RIYEmn.d,N Y 11901 030 03I Vi W TROUT V.NITTEN PERMISSION OF THE _ .4y`� 2 O SCALE IN FEET. M REAL PROPERTY TAX SERVICE AGENCY Y1`v'• G_7—'-- 2m 4w m' P DISTRICT NO 1000 w5 PROPERTY MAP CONVERSION DATE'Ap 16,2012 -.. Y� #6 "eF—"tea ..rte.. �.. i �. 1<. fir! tx �,.� �^F`rt0�fR1Y MAP ter,.. - -...u.... OSI1@ we 83 FOR PCL N\ .. xaa �\ y�n a av msaa m m os m 3 1. l n je' EE a 4 / ► n u w O n n � � 11A % N 0.x tot � a ax.0 E � ex IOFwa,nal na t.xA / ■ n n° M IS 12 0 ITS CRESCENT w toc 1fD m ,m ao s 10x �c n 'E Ia FOR L.. / �• >0 s r 10. 10. 'N �^ BE SEC.NO. //' aF A la mt-0toot.a Ze x1 �j a m EN e ,xe I x • a dP ' ./ •,/ FOR—NO TO BEE SBC NO. ° W6R-0161 // POR PCI III 0.eE llC.wNO. - � �I FOR PCL NO. X01 ¢ U B0.dC MQ / SEE SEC.N0. BEE 8EC N0. 0.0.a0.0.�T 1 fOR PCL.NO P 3 OabOt-0x6 0]60x —---- —BeQa6�E41� -001 c1 — Z---- _SE N! COUNTY OF SUFFOLK © R a BOOI„Ol.p SECTION NO Real Property Tax Service Agency v M 30 UP rwc*w 1EM PROPERTY MM Michael J. Domino, President i� ��till �i> (1 Town Hall Annex John M,Bredemeyer III, 'V'ice-President 64376 Route 26 Glenn Goldsmith � l P,0, Box 1179 P,, Nicholas Ks'upski Southold, New York 11971 Telephone (631) 766.1892 Greg Williams v tA��Iq(� Fax (631) 766-6641 xEan-� BOARD OF TO'INN TRUSTEES TOWN OF�SOUTHOLD L_ Emergency Permit t�ppii ThiionSection For Office Use Only e,` _-Coastal Erosion Permit Applicsation Wetland Permit Application _Administrative Permit NOV 2 0 2019 YAmend ment/Transfer/Extens ic,m Received Application;�4� -'___Re,oP,lved Fee; $ Southold iasm C/ _Completed Application; /1 47- Board ofhasiees lnoomplete; SEQRA Classification; Type f�_Type ll� � Unlisted Lead Agency Determination; _Coordination;(date sent); _LWRP Consistency Assessment Form Sent; CAC Referral Sent; Date of Inspection; v Receipt of CAC Report; Technical Review; Public Hearing Held; __,Resolution; _ �t1��Ji4/l DarU.�Il1� W�i�fEG Legal Name of.Property Owner(s); ,6>C,ECVTOR Mailing Address; STi ,4NP Z,4.)V4 �4'Sr ? 9�Mv �J/y l/959 Phone Number; W&(�AJ�'1 7/7 ,S72 6Z 8Z Suffolk County Tax Map Number; 1000 . Property Location; __6_&O _ Me_J'T.� r 1112A�d�(/ /V y �l f�3 G (If necessary, provide LILCO Pole #, distance to cross streets, and location) �! AGErNT(If applicable); Mailing Address; _ Phone Number: .. Hoard of Trua•t;iaea Applicat GrENERAL DATA Land Area(in square feet); Area Zoning; --- Previous use of property; Intended use of property; Covenants and Restrictions on property? ___Yes „��No If"Yes", please provide a copy, Will this project require a BulIding Permit as per Town Code? __Yes ��No If"Yes", be advised this application will be reviewed 1)),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 Cade or as determined by the Building Dept,? --- Yes X -No Does the structure (s) on property have a valid Certificate of Occupancy? X Yes No Prior permits/approvals for site improvements; Agency Date No prior permits/approval; for site improvement j Has any permit/approval ever been revoked or suspendedby a governmental agency? X No Yes If yes, provide explanation; Project Description (use attachm(;ij.ts if necessary); o`zvo(z) /--; ����11,Pr1oS. F-1�; •.�r��'..�6':�:�f�11_�' CL,Y��/�l,S/� dF 4,ORRaV, 6 A-r:T. 5'01<.. .4r,66145Z of ��•'� 5'S► i� .rX e R=— •.4«Oays- To � U� DPWD r QVO IW4 CIV P,GI a7XE eI-5-14 d Z W OSI Board of Truawl:,aes WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations; :'�L2���F -z�p� ��y bid.. e1 Area of wetlands on lot; . �_ square feet Percent coverage of lot; Closest distance between nearest existing structure and upland edge of wetlands; feet Closest distance between nearest proposed structure and upland edge of wetlands; Al feet Does the project involve Oxcavation or filling? .,,--No Yes If yes,how much material will be excavated? cubic yards Al How much material will be filled? cubic yards ,�l, , Depth of which material will be removed or deposited: feet, feet �0 Proposed slope throughout the area of operation;,;,_._,F Manner in which material will be removed or deprasite:d; �`�N� ,�4('_' G1!2_4 r,4 VZ7-)641 ,8.y Statement of the effect, if;any, on the wetlands and tidal waters reason,ofsuch proposed operations (use attachments if appropriate): of the town that may result by --------------- - _____ :3oard of TrustE:c�sPplication COASTAL EROSION APPLICATION DATA Purposes of proposed activit p �'f;� / IV ^ Are wetlands present within 100 feet of the propof►ed activity? No Yes Does the project involve excavation or filling? No � Yes If Yes,how much material will be excavated? ' _ (cubic yards) 0 How much material will bc. filled? .I (cubic yards) UNAfT' P�-J//I/A� Manner in which material will be removed or deposited,; ---------------- Describe the nature and extent of the environrnenttil impacts to the subject property or neighboring propetlies rea,ianably anticipated resulting ftom i:rnplementation of the project as proposed, including erosion increase or adverse efafr-cts on natural protective features. (Use attachments if necessary) z-AeA� --- . NV/ 0 �"i9L sv 6.�r ,tJ,_ }30urd 01; TrL'st(:138 APPliaat:ion �1LI.l���t�N�LJ�t� EL .L`t.U ra DEPOSI,;S AND AFS+' , � `' -- ^�" ',BEINCr DULY SWORN DESCRIBED PERN[lT S S )~HAT rSz<'951 3±, Zt!, IHE APPLICANT FOR THE ABOVE t ) AND THAT ALL' BTATEM 'NTS CONTAINED HEREIN ARE TRUE TO THI!; BEST OF HIS/lIER "•'TJC)WLEDG ALL WORK WILL B-It, DONE IN TIME Ma�,1VNE E AND BELIEF, AND LCAT AND AS MAY BE API'?RC�YED BY'I'HE,S(;tl;l'I'HOLD TOWN BOARD IOF TRUSTEES.N TIM I APPLICANT At31 +'ES TO HOLD THr",TOWN OF SOUTHOLD AND THE BOARD OF TRUSTRE,,S HARMLE,238 ANIS FR1+; r11'{n 'f;LAIMS ARI5TN(y y, E,FRUI�I ANY AND ALL DAMAGES GRANTED, � UNDER ON, BY r GR 1'LI!, U1< SAID PI;RMIT(S), IF IN CO3NlPl ETnNG THIS APPLICATION, I HEREBY AUTHORIZE THE TRL'S'I'EES, THEIR A( , INCLUDING THE =EiV:C(S) ORREPIid.�3la?�'TA'IIVE,` CONSERVATION AD'VISORY COLINCII.;'7'0 Elti"IE12 ONTO iYIY PROPERTY TO INSLUDI THE PREM'[SE,g.IN CONJUNCT.CO?� WI'I'ZI THIS APPLICATION, i'V(=I,CiDING A FINAL It�I;�I'ECTIC)Py', I F11I�THE.R AUTHORIZE r TRUSTEES TO ENTRY;,, ONTO TI N, I Fll.la THE BOARD Or COXPLIANCE WITH .ANY C;pNUI'I'TON t;:1;'TX A7~{I} AS REQUIRED TO INSURE COASTAL EROS1 ON PERMIT I`;yiUlt"D BY TI 1)i BOrk,(!.DAOF?RUS'T.EE SDI NG THE TE1ZM Or THE PERMIT. Sigr,alure or'Property Owner „ ______________ v�1CG�%�-j Do�,de:.p �,Q � y�gr�atttre of Property Ov�r,er SWORN ORB 1V)s a O)v'�i TO BEF 20 l Q N�ry ,o?i MICHAEL A.KIMACK Notary No 02Kl State5 o Now York Carmiiorn Expires Nassau ,2022 r Boaxd of Tr;u;7 ::E3E5$ Appa,ioation A,IJ'TTICT IIA ION (Where the ap'Aice,,ixt is not the owner) i;lVe, owners of the propertyidc; , „ ----•-.' nti�ed as 5C1'M# IUUC. in the town of _•:�i4�'/y - � �-•—_._._.., New Yc)rlc. hereby b y authorizes to act as my agent and handle all necessr:ry work involved with the appliontion pJ"acess for pBr'rlit(s) from the Southold Town Board of Trustees for this prof;erty f r� �rUpc;riy C-MleCs 3 , 5 ' gnatu:e w![GrrZ/y .001V4C,6) Propuart Oy wner s S1 na g lure Sl�'Qrt,N TO 13SF,,01Z8 Ml.s' TII:ts OF Cy, ---- '� � vtart' Pu, MICHAEL A. KJMACK Notary Public,State of New York No.02KI5056U3 Qualified in Nassau County Commission Expires March 11,2022 f17 XT UCANT/AG1%,NITREPRj StNTATIVL; 'X ANSACTIONAL DIS(:LOSkIR�, poRj�j ;hi�C�ua:�U2.1tL12Y,�s•I n f' r tl�1�2r 11 J:�t�r I U�'�.s�r,`D�:JLr Uv c �'innl..�i!1i2��1li-vAll.11).Cl(.l)IA.S(L�.$1�A[!1 P�S5.l.�(L'.IJ�II,nIU,(.,Q,)'.i�];.17r4 nhri7r,}�n1oYC0,S r c •.51151.,.QII1F, •.Ail�a.(�1QRir11lr.L(i• 'F'n E1.:11115�: `llll4t_1VJ! '' '"T-1-�Rt�tR2.U_:= YOUR NAME: ------ t2lr�e ill ,vt7'C�ii417_l_ (Ctrs!nam, ft or olhor rlijoy c In(f!ai, ui oy;,y ou are npplyln In LST me of someone ;Ills or olller ontl!y•such as a company, if so, Incliontar(f1a other porson's or oompany's narno,) "•lAt,48 OP APPLI CAT10N; X lal;k a i(I)a(apply;, rR>grle:,:nw Chaq**-orunr � 1 1. Irllllg - ^Pp;cvelcr,!cc --.�__._.__•__._••. 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(Leer or ui7•,Inycc wh'oh thn tnwrt ofticrrror/o7npbs•I:ctaw;7oflieer or tmie!oycts'ln'r a.vc,rt,P.+rtla9•pwnc intvresl' i:,oa,7s•a businn,., 8 morc•Ihn:;'4/0 ol'tltd b)Inrol, r I11P•of'fdr orn)laumen't 11y.)n eo-,-4rn(lol v r` "YBS". complete >,I�j .._..!.t_._......, 11+e balance 0('thts '':)7m and all nod sign svhero 7r,alcrind, '-'amt of ocrson crnotoyed by Il7e T'„vn or;Joutholti 16 tr pJSI,!0,7 if t},al DCniOn ".-...���,..,.•. t3cccrl�,,tr,,:raln!!onship beh�reen ,,,, .•....._._--_-_,..___,___---. 1Fne A)throe h D !(V()[ rFall'(the nppl)ennl!.r enWrat se a!1 8 )a a 7 nr descr lt>y In.,';spoor pr'n,Idea. t lo7'in of!ccr or omp(oyea, 131tnar Ohl, lh:by n oriiccr 0 Cmol o e or Ills or her spovso,sib!1ng,parol,t, :,,child is{shook nli'thra apply); _�,)i u c tr;7ur vfgronivr that,:7%VC111t;Simms C!(N. S(oak or iha ni>h(Icant (,r tea ibu np1711can(Js n ct,7)sorv(lor7); fkPPLICANT'/AGENI'IPJ PRE',SENTA.TIVE TRANSACTIONAL DISCL0SL1P4 FORM `llho To��54f,�o.titllcrld!s Codi;'oP��biun.prnlrlbil�:coIIJXJ'cl�.ni',In►��;t ,�g.�Ztrr4�f•iny�n,b,(�,afir,�-n��;•r��4.y��,�'Clte_,rntrmose c�(' thrs,form Js;to nrovl�pjn'Pprfn111hn_►Hhl§[t inn n[rr4 tltig ; L ' �l�li� !] 1a Y af.inlC 'tltrr I�o��r.i(fo.lnkr,wlintcvrr•nollon.is I1CCa�9aN tvdfd.s'nmc, YOUR NAME; (Lust name, first name, lddle uliflal,unlou you are npplying-in the name of someone else.or other wily,such as a company,If so, Indlonto the olhcr person's or company's name,) NAME O1'APPLICATION; (Check all that apply,) Tax grievance _ Building Vorlence _ Trusice Change of7_•one , W - Coastal Erosion Approval of plat Mooring L-aomptlon from plot orofficlal map Planning - R Other (If"Other•",name the activity.)_-- __� •���__ p'o you:porsorwlly(Qr tfi,rough.you.r•,company,,spouso,s1611ngrpttran►,o'r ahlld)'havc a,rclritlonahl'p.with any orTlcar orunfplayco ofiho Town-ofSouthold7 "ReintWimbi»"hiclutics tly blood,ltlatviag'o,orbusltraas:IhtorvsC",puslncysJntvrrst'+irxsnns•n businoss, Inalut1fnb.a partnorsli�p,,,In vllilehjIwtown oFrjpt;r pr empioyeo han evcnwportlnl owner hip.oP(6r nnl}ilayr»enY!3y)a•corporntlon In whloh-Wi town olflct r•or vmpluycc.oavns moro•tiian'M,,///o,oi lhd is!Wt. YES NO _--x Irydu answered"YES",complete the balance or this form and date;and sign where Indicated. Name of perspn employed by the Town of Southold Title br position of that person Describe the relationship between yourself(the appilcant/ngGnVrepresentative)and the town o,fllcer or employee, Either check (tic appropriate line A)through D)and/or describe In tho space pr ,•lded, The,town Weer or employee or hiar or her spouse,sibling, parent,dr child is(chock all•Ihal apply); A)tho ownor of•grcdtor Wan 3%of,'lha sh ros of the orporntC stack of the appilcon( (whoa lllo i1ppllcortt Is a carparation•); B)the logal'nr'ben0101M owner crtnhylnlor�al In•a notProrlYorntc cntfty(,Nyhan the oppficont•ls not ri oorporhtltirt); G)tut offlu'or,61motor,porbiiey,onomployee,of•11tc uppllctull,or ' D)the actual applicant, DESCRIPTION OF RELATIONSHIP Submitted this a day of 2QG//9 S 1'gn a'tu re;_ Print Name �_� �• l Form TS I '