HomeMy WebLinkAboutRomanelli, Paul & Boyle, Theresa Glenn Goldsmith,President �00f SDUTyOI Town Hall Annex
Michael J.Domino 54375 Route 25
P.O.Box 1179
John M.Bredemeyer IIIc Southold,New York 11971
A.Nicholas Krupski G Telephone(631) 765-1892
Greg Williams O �� Fax(631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
November 9, 2020
Tom Samuels
Samuels & Steelman
25235 Main Road
Cutchogue, NY 11935
RE: PAUL ROMANELLI & THERESA BOYLE
1750 BEEBE DRIVE, CUTCHOGUE
SCTM#: 1000-103-3-5.1
Dear Mr. Samuels: '}
The Southold Town Board of Trustees reviewed your letter received in-this office on
October 28, 2020 and the survey prepared by Nathan Taft Corwin Land Surveyor, last
dated June 18, 2019, and the site plan prepared by Samuels & Steelman Architects,
dated October 7, 2020 and determined that the proposed renovations and additions are
out of the Wetland jurisdiction under Chapter 275 of the Town Wetland-Code and
Chapter 111 of the Town Code. Please be advised that a silt fence/haybale line
should be placed at the 100' mark.
Therefore, in accordance with the current Wetlands Code (Chapter 275) and the
Coastal Erosion Hazard Area (Chapter 111) no permit is required.
Please be advised, however, that no clearing, no removal of vegetation, no cut or
fill of land or removal of sod, no construction, sedimentation, or disturbance of
any kind may take place within 100' landward from the top of the bluff, or seaward
of the tidal and/or freshwater wetlands jurisdictional boundary or,seaward of the
coastal erosion hazard area as indicated above, without further application to,
and written authorization from, the Southold Town Board of Trustees pursuant to
Chapter 275 and/or Chapter 111 of the Town Code.
—It Es your-responsibility--to-ensure-that all-necessary-pr-ecautions-ar_e_taken-to_preventany
sedimentation or other alteration or disturbance to the ground surface or vegetation
2
within Tidal Wetlands jurisdiction and Coastal Erosion Hazard Area, which may result
from your project. Such precautions may include maintaining adequate work-area
between the tidal wetland jurisdictional boundary and the coastal erosion hazard area
and your project or erecting a temporary fence, barrier, or hay bale berm.
This determination is not a determination from any other agency.
If you have any further questions, please do not hesitate to call.
Sincerely,
t�t
Glenn Goldsmith, President
Board of Trustees
GG:dd
SURVEY OF
LOTS 1 & 2
MAP OF MINOR SUBDIVISION
OF PROPERTY SURVEYED FOR
JOHN BEEBE
ANTLER LANE APPROVED BY PLANNING BOARD TOWN OF SOUTHOLD APRIL 30, 1990
SITUATE
CUTCHOGUE
TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
S.C. TAX No. 1000-103-03-5.1
S.C. TAX No. 1000-103-03-5.2
SCALE 1 "=30'
NOVEMBER 22, 2016
JUNE 18, 2019 UPDATE SURVEY
S s,. TgAIL AREA DATA
`314 00,, MO 0 S.C. TAX No. 50,340 sq. ft.
F - 1000-103-03-5.1 1.155 ac.
; S.C. TAX No. 46,070 sq. ft.
Ny19 ?7 x' OCT 2 8 2020 . l ! 1000-103-03-5.2 1 .058 ac.
C 1
TOTAL 6,410 sq. ft
71.2
`•t TIE LIN BE aDp �'. . I (To E) 2,213 ac.
o
F ES 315.98 e N I ,
N/OI JONto x I \N I
G
RICHADcYAllA x\, o '24.2' ;.!• ; \�� \�.� \ _ \
`\ I \ \ w /I I N FRRAGEN cii ` . . -. -
\ \ GAa� \ LO
\\ I \ \ \ / a I N 11.6 \` i \ 13.0
NOTES:
x \ r \ \ 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM
\ j \ �" %ry EXISTING ELEVATIONS ARE SHOWN THUS:AU
/ I x�W000 ."r',';.' n / c .
/� SfEPS 3 x \ m�•' ► \ / EXISTING CONTOUR LINES ARE SHOWN THUS: XX-----XX
CE \\ I I 34.1 ii' \ g� tQ F.FL. - FIRST FLOOR
./�'pFptiCE
G.FL - GARAGE FLOOR
FENCE d
N 7e 43 �� f �pp5Cfw- f �� Dt -_--_--_- 1 -- II \ \I I \\I\ \ ;II 1I/ I11 0 Ion �' ;;:: BsATYEPs / / t\ \\ \ \• . I
BULKHEAD
- BOTTOM OF BULKHEAD
T.W. - TOP OF WALL
PpST G N B.W. - BOTTOM OF WALL
Aro x- x 2. FLOOD ZONE INFORMATION
TAKEN FROM:�p
IRM 10.16FLOOD INSURANCE RATE MAP No. 36103
COl 64 H1z f ly \
ep5T N \\\ \ y\N \ \ \ M R ; vnNDo i\ \ \ \ �" ZONE AE: BASE FLOOD ELEVATIONS DETERMINED
o-rFENCE t O \Co� \ 34.1' / 12.8
wppD DpCK t ; \ \ 9 \ \ \ \ \ W 2t „ / / x \ I I ZONE X AREAS OF 0.2% ANNUAL CHANCE FLOOD; AREAS OF 1% ANNUAL CHANCE FLOOD
t\ \ \ \ CMN '''CELtIE \ I I \I WITH AVERAGE DEPTH OF LESS THAN 1 FOOT OR WITH DRAINAGE AREAS LESS THAN
i9�, t \ * \ \\ �$\2c,\ Ett "'` I { 1 SQUARE MILE; AND AREAS PROTECTED BY LEVEES FROM 1% ANNUAL CHANCE FLOOD.
x- \\ \ \� °4� \ �K D _ _____ �F \ I � x 12.3 \"^ ZONE X: AREAS DETERMINED TO BE OUTSIDE THE 0.2% ANNUAL CHANCE FLOODPLAIN.
DE £ \�0\F k+x x9 \ g1.9$
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;\ x i \ Zx I POND \ c xB. \ t D /
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LOT \ , 1 \ \ \ \ x METEF?
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\ X N°. �p00 03�0g.5• `�jP , \\ \ RE /t (���� �� /�\ -__ x1Q.�
$.C,SAX N°• � \\ \ �PR� ioyr�+ t2,3'� \ x °
TIE LINE ALONG SEAW S 71�36,50 S ��` \\ \\ \�WooD K 10.3' w*+-C Qr N 12 wE� \
ARD EDGE OF \k 18.5' Jz l T fit„ No T'n 0 \ EDGE OF LAWN \ O i
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\
?j/O/OUTHOLD
\\ TOWN OF
li�61 ,50" VAI LOT 53
77°36VAP OF
5 SUDDAqSENCOVE 11 o f SUFE Zg0 oouNn
E OFFItt CEOO Jg60 A5 F11.E N°' 3
FILED IN ON A0605
PREPARED IN ACCORDANCE WITH THE MINIMUM
STANDARDS FOR TITLE SURVEYS AS ESTABLISHED
BY THE L.IA.LS. AND APPROVED AND ADOPTED
FOR SUCH USE BY THE NEW YORK STATE LAND
TITLE ASSOCIATION.
N.Y.S. Lic. No. 50467
UNAUTHORIZED ALTERATION OR ADDITION Nathan Taft C o r
TO THIS SURVEY IS A VIOLATION OF
SECTION 7209 OF THE NEW YORK STATE
EDUCATION LAW. Land Surveyor
COPIES OF THIS SURVEY MAP NOT BEARING
THE LAND SURVEYOR'S INKED SEAL OR
EMBOSSED SEAL SHALL NOT BE CONSIDERED
TO BE A VALID TRUE COPY.
CERTIFICATIONS INDICATED HEREON SHALL RUN Successor To: Stanley J. Isaksen, Jr. L.S.
ONLY TO THE PERSON FOR WHOM THE SURVEY Joseph A. Ingegno L.S.
IS PREPARED, AND ON HIS BEHALF TO THE
TITLE COMPANY, GOVERNMENTAL AGENCY AND Title Surveys - Subdivisions - Site Plans - Construction Layout
LENDING INSTITUTION LISTED HEREON, AND
TO THE ASSIGNEES OF THE LENDING INSTI- PHONE (631)727-2090 FOX (631)727-1727
TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE.
THE EXISTENCE OF RIGHT OF WAYS 0MCES LOCATED AT MAILING ADDRESS
AND/OR EASEMENTS OF RECORD, IF 1586 Main Road P.O. Box 16
ANY, NOT SHOWN ARE NOT GUARANTEED. Jamesport, New York 11947 Jamesport, New York 11947
DRAINAGE CALCULATIONS NYSDEC "ADJACENT AREA" TOWN OF SOUTHOLD "BUILDABLE LAND
AREA OF RESIDENCE (DW-A) SITE DATA
DRY WELL AREA x RAINFALL x RUNOFF FACTOR LOT COVERAGE TABLE LOT COVERAGE TABLE SCTM # 1000-103-03-5.1
(DA-A) 1,158 SF x (2/12 FT) x 1.0 = Ia0 GU. FT.
USE: (I) 8' DIAMETER x 4' HIGH POOL SITS AREA TOTAL: 50,340 sf 1750 BEEBE DRIVE
(1) 8' X 4' STORM DRAIN RING = 168A CU. FT. SITE AREA TOTAL: 50,340 sf CUTCHOGUE, NY 11935
USE: (1) V DIAMETER x 4' HIGH POOL UPLAND SITE AREA FROM SITE AREA UPLAND FROM OWNER: PAUL ROMANELLI & TERRY BOYLE
(I) 6' X 4' STORM DRAIN RING = 8a.5 Gu. FT. TIDAL WETLAND BOUNDARY: 28,-110 sf
PROPERTY: 90 Bridle Ct
PROVIDED REGUIRED TIDAL WETLAND BOUNDARY: 28,'710 sf ADDRESS Cutchogue, NY 11935
258.2 GU. FT. > I410 GU. FT.
AREA OF RESIDENCE (DW-B) AREA GALGULATIONS FOR SITE AREA AREA GALGULATIONS FOR SITE AREA 50,340 sf= 1.155 ac
DRY WELL AREA x RAINFALL x RUNOFF FACTOR STRUCTURES EXISTING PERCENTAGE PROPOSED PERCENTAGE STRUCTURES EXISTING PERCENTAGE PROPOSED PERCENTAGE
(DA-5) 1,5011 5F x (2/12 FT) x 1.0 = 252 CU. FT. HOUSE: 1,2-71 sf 4.42% 2,40cl sf 8.5Ci% Nathan Taft Corwin III
USE: (I) 8' DIAMETER x 4' HIGH Pool HOUSE: 1,271 sf 4.42% 2,40�f sf %0.
% SITE: 1586 Main Road
DETACHED GARAGE: 555 sf 1.86% O sf 0% GARAGE: 535 sf 1.86% O sf % sort, New York 11947
(1) 8' X 4' STORM DRAIN RING = 165A GU. FT. o o ZONING: M p 50467
USE: (2) V DIAMETER x 4' HIGH POOL DECK: 554 sf I.q3/ 554 sf I.Cf 5/ DECK: 554 sf I.q5% 554 sf %
COVERED PORCHES: O sf 0% 65 sf 0.22% SURVEYOR: 6/18/19
(2) 6' X 4' STORM DRAIN RING = 178.6 GU. FT. COVEREID FORGOES: 0 Sf 0% 63 Sf %
PROVIDED REGUIRED STONE WALKWAYS: 588 Sf 2.055yo 56cf sf 1.2of516' TOTAL: 2,360 sf 8.21% 3,026 Sf 10.54% ELEVATIONS ARE REFERENCED Y
54-1.5 GU. FT. > 252 GU. FT. PAVED DRIVEWAY: 2,4a4 sf 8.65% 0 sf 0% L�NN$�. . 1988 DATUM = �
AREA OF DRIVEWAY (DW-C) TOTAL: 2,701 sf cl.40% 5,51 f 5 sf 12.52% DRYWELLS FOR 5TORMWATER DATED O
DRY WELL AREA x RAINFALL x RUNOFF FACTOR RUNOFF (4x(b) SEE DETAIL I-SP LOOD ZONE LINE FLOOD ZONES: I
(DIN-0) :2,555 !5F x (2/12 FT) x 0.7 = 2aa GU. FT.
USE: (2) 8' DIAMETER x 4' HIGH POOL PROPOSED S) T FENCE )PROPOSED NEW ZONE AE: BASE FLOOD ELEVATIONS O
(2) VX W STORM DRAIN RING = 55'7.8 CU. FT. WALKWAY DETERMINED
DURING CONSTRUCTION Uj W
PROVIDED REGUIRED SEE DETAIL 2-5P XISTING GARAGE TO ZONE X* : AREAS OF 0.2% ANNUAL CHANCE Z
55'1.8 GU. FT. > 2aa GU. FT. BE REMOVED - FLOOD; AREAS OF 1% ANNUAL
fn
XISTING BELGIAN STABILIZED CONSTRUCTION CHANCE FLOOD WITH AVERAGE Z
EXI5TIN6 SANITARY BLOCK CURB ENTRANCE 5EE DETAIL 5-5P
SYSTEM To REMAIN DEPTH OF LESS THAN 1 FOOT OR O
N/O/F FOOD ZONE LINE EW BELGIA EW DRIVEWAY ENTRY WITH DRAINAGE AREAS LESS
RICHARD A. M. JONES t BLOCK CURB ROPOSED SILT FENCE THAN 1 SQUARE MILE; AND AREAS Uj
XISTING WOOD DOCK DARCY GAZZA ` DURING CONSTRUCTION PROTECTED BY LEVEES FROM 1%
AND RAMP TO REMAIN 1000-105.-5-15 3 4 5 6 7 8 9 10 11 12 13 SEE DETAIL 2-5P ANNUAL CHANCE FLOOD.
�N 76 4340 E \ _ \ 315 98 772 '40'\E 1 1119.27' \ � MOOSE ZONE X: AREAS DETERMINED TO BE Q
OUTSIDE THE 0.2% ANNUAL
CHANCE FLOODPLAIN. 06
TRAIL
118'- ` 11.4 i ---- O 13
TNS ? TLANDS SETS, OK p 4xe - \ (/�
1.0 �I►, 'L _4
FLAG #1 I i R� N ��__ -�y .--`t f Z
L D&E OF ( NEW 2 A �� _ O
z I EXISTING I I / STORY I �' ��` Rte, I / ;-
I LAWNxb �I ADDITION I ' ,�� ' : LA .,
w ANDWARD EDGE OF TIDAL _ _____ 1
100' LGARAGE SLAB 1-1T= __„ p ,tQJ I X15TING UTILITY POLE OCT 2 8 2020
WETLANDS AS LOCATED BY G. I / LE7+-r.�' �, - ` +-�`\ANDER �s {��' �(i u\ I $ GUY WIRE
,till, OUTHOLD TR ---- > C'
o- = JUST - JMO ENVIRONMENTAL STEES W TLA D SETBA 0' �n �, DR41/•E`W Y ``,.\� �� �, I
CONSULTING ON JUNE 14, Zola I K 34.1 - ,15 0' �` ' o / W BELGIAN BLOCK CURB O
/ 1 DW A I/F 11' ! o DR1i'WELL5 W/ METAL INLET Z
I, SALT MEADOW F OD ZONE O / --I� EXISTING 6 ', , 1, / 4"8 ��" ' m G ATE FOR 5TORMWATER W
2. I L M \FLOO1 1 0
2 STORY w - �� I NOFF (4x8) SEE DETAIL I-SP
FLAG #2 E (EL 6) V I0 z NE X '�� HOUSE °' Y
PUBI I STING BELL 1 AN 0
I I 7 w L TER LINE FLR ELEV +15.7 i i L _ 12 B OGK CURB
0INE OF LIMITED WAVE ACTION A K� 6 1, / -E ISTING WATER METER
ISTING OVERHEAD WIRES
I►' X00 WE �. \ 10.2 34.1'
22_8 / \ I I / EX STING DRIVEWAY. REMOVE ASPHALT.
N
11_0 FLAG #3 \ SOV \ �10� ---- -' / 1 PROVIDE PERMEABLE, CRUSHED STONE
\ 4x6 \ 50 I DR VEWAY ON EXISTING 5UB-BASE
I I ELS+ 5.5 LE , „ , I 2pN O� FLOOD \ FRO 5m TBT AGK I I I
DE OF I ' lN� ZONE X
TIE LINE ALONG `3\ \ EXISTING I / POSEAI /
OF SALT MEADOW ED&E \ 1 .3 \ 1 LAWN / \ FL D rn I °' B E E B E
\ ZON X pI N N / v I otf Z
FLAG #4 2.__`4 1 / \ rn ' D RIVEIU 0 a.
_
S 77 36'50" W � J M
3 4 5 / � \ 361. 8' \ I � '
• °a o
FLOOD ZONE LINE 7 $ 9 10 11 1 12 : I °P Ao J. °� r
EXISTING POND uGENEgRO W 2 Z w a
EUGENE ' S CREEK "/°'� TO REMAINU.
PAUL ROMANELLI PROPOSED SILT FENG LOOD ZONE LINE I �� a W � w
1000-105.-5-5.2 DURING CONSTRUCTION Lo to
XISTING m m 00
0
(EAST CREEK) SEE DETAIL 2-SP ROfi�OSD NV�I UTILITY POL j T°o g W. a N
COTTAGE BU I LD I NC5 ADD I T I N o
WELL m°p s o
XISTING 5U1 (5 TO XISTING � Mo E N y.
SECONDARY
P0'
. � FpWN
REMAIN AND RENOVATED NEIGHBORING 51-M �, N� N RWoo
SCALE: 1 " = 20'-0" ENTRY SITE D R
GARAG SHED SHED
c E�°A
°p0 C0 r-OF N,
EAST
C.
50' MIN COMMERCIAL A �R'9VF T CREEK 0
pp5 SOp
50' MIN REIDENTIAL
STABILIZED CONSTRUCTION ENTRANCE NOTES: '-O"
EXISTING EXISTING
PAVEMENT XISTING
GROUND o
1. Stone size -use 2 inch stone, or reclaimed or recycled NEIGHBORING
concrete equivalent. BUILDING -
STRUCTURES i
2. Length - not less than 50 feet(except on a single residence lot where 30 T 1- 1-1111 1=,11 I TT PROJECT NO:
foot minimum length would apply). 1 704
\�_FILTER MOUNTABLE BERM DRAWN BY:
3. Thickness - not less than six(6) inches. 2" STONE OR PROFILE CLOTH (OPTIONAL) TEST HOLE UT
RECYCLED CONCRETE
4. Width -twelve (12) foot minimum, but not less than the full width at points NO SCALE ELEV. + 5.5 CHECKED BY:
where ingress or egress occurs. Twenty-four(24)foot if single entrance to TS
site.
so' MIN COMMERCIAL1.5 FT LOAM OL DATE:
5. Geotextile -will be placed over the entire area prior to placing of stone. 50' MIN REIDENTIAL TOP of EXISTING GRADE 0/7/20
CAST IRON PRAMS AND COVER TO MEDIUM TO - SCALE:
6. Surface water-all surface water flowing or diverted toward construction GRADE (AS RE TRAREWIRED
AFFFIC, SLAB (SEE 4.5 FT COARSE SAND SP O
entrances shall be piped beneath the entrance. if piping is impractical, a PLANS FOR LOCATIONS) -
mountable berm with 5:1 slopes will be permitted. O
WATER IN SHEET TITLE:
= 11 FT I COARSE SAND SW
7. Maintenance-the entrance shall be maintained in a condition which will COMMENTS: WATER ENCOUNTERED
prevent tracking or flowing of sediment onto public rights-of-way, all - O
` d5 4.5' BELOW SURFACE, ELEV 1.0'
sediment spilled, dropped,washed or tracked onto public rights-of-way ® ® ® ® ® ® ® ® ® SITE
® ® ® ® ® ® ® ® ® DRAINAGE BASIN FOR
SIZES 5EE 5 L
must be removed immediately. ,} ., ' ® ® ® ® ® ® SHE ITE P AN5
EXISTING SSE
} ® ® ® ® ® ® ® ® ® WIRE FENCE YV/ PLAN
8. When washing is required, it shall be done on an area stabilized with GROUND ;.'' `�' �+ 0 z° R' BACKFILL MATERIAL
n into an approved sediment trapping device. . : • y °`' z ® ® IS ® ® ® ® ® E TO BE GLEAN SAND FILTER CLOTH
stone and which drains t pp pp g �` +`: ''`' Z 0 ® ® ® ® ® ® ® ® E ANO GRAVEL FILTER CLOTH MIN. 6" SURFACE
' ,, .., • • �.. ® lam ®
9. Periodic: inspection and needed maintenance shall be provided after each �! ® ® ® ® ® - BELOW GRADE _DRAINAGE
FLOW
X • z SHEET NO:
rain. ADJAGENRT ROAD WIDTH MATCHM � p W -
GROUND WATER
PLAN PERMANENT STORM WATER RUNOFF CONTROL MEASURE TEMPORARY STORM WATER RUNOFF CONTROL MEASURE
STABILIZED CONSTRUCTION ENTRANCE STORM DRAINAGE RING TYPICAL (D ���ION ER & SEIMENT CONTROL DETAILELEN
10' MIN.
REGULATORY APP" ROVAL
Glenn Goldsmith,President QF S0(/ry f Town Hall Annex
Michael J.Domino,Vice-President ,`O� ��� 54375 Route 25
P.O.Box 1179
John M.Bredemeyer III Southold,New York 11971
A.Nicholas Krupski G Q Telephone(631) 765-1892
Greg Williams �O �� Fax(631) 765-6641
�yPs.uNvi
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
NON-JURISDICTION INSPECTION
-DATE OF INSPECTIOhf:
INSPECTED BY:
Ch. 275 C,h.`1:1i1,=- >'• F`.
COMMENTS:
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APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics prohibits conflicts of interest on the pan of town officers gnd cmplones.The puMgse o
this forin is to p_rQdde information which can alert the town of p2asible conflicts of jnteMgd allow' e wha
Itycraction-is
necessary to avoid same.
YOUR NAME: Vw ISG l S
(Last name,fust name,griddle 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,marriage,or business interest."Business interest"means a business,
including a partnership,in which the town officer or employe has even a partial ownership of(or employment by)a corporation
in which the town officer or employee owns more than 5°/u f 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 day of���Z99
Signature_ - '
f Print Name Y-42 f4.4- SAA P
Form TS 1
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COUNTY OF SUFFOLK y wa
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S A M U E L S &
S T E E L M A N �'
October 22, 2020 ;' ,i V !� )
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Board of Trustees I :
Town Hall Annex , OCT 2 $ 2020
PO Box 1179
Southold, NY 11971 Southold Town
Eoard of T ustoes
Re: ADDITION AND RENOVATIONS TO THE ROMANELLI RESIDENCE
1750 Beebe Drive, Cutchogue, NY 11935
Dear Staff and Board of Trustees,
I hereby request a Letter of Non-Jurisdiction for the above referenced project. All work is
significantly beyond the one hundred foot setback from wetlands. There needs to be no work
within the limit of your jurisdiction. For your review, I submit the following documents:
1. Two (2) stamped SITE PLANS
2. SURVEY
3. Owner/Agent Authorization Letter
4. Affidavit
5. Three photos project site
6. Check for$50.00
Please get back to me with any questions, or if we can provide additional information. If this
application is complete and when it is approved, please send me a Letter of Non-
jurisdiction.
As always, thank you.
Sincerely,
%x"y"t,6411-
Tom Samuels, RA
enclosures
ARCHITECTS
25235 MAIN ROAD
CUTCHOGUE,NEW YORK 11935
(631)734-6405
FAX(631)734-6407
Board of Trustees AFj cation
lZATLION
(Where the applicant is not the owner)
owners of the property identified as SCTM# 1400- in the town of
New York, hereby authorizes ®IIYI• G�
to act as my agent and handle all
necessary work involved with the application process for permit(s)from the Southold`i'own
Board of Trustees for this property.
Property® er' S°gnature Property Owner's Si e
j°W UJ:UN 1 U 1�Zr t-).KrC 1VIZ L rU F9 `�a� i iA°i %JL- � c
Notary Public
ALICIA WALKER
Notary Public State of New York
No.OIWA6153064
Qualified in Suffolk County
Commission Expires Sept.25, .E
AFFIDAVIT
I'
F "r(ld..6LGCSL , LL�..6.h.."'� �O "e �a•�'7� YegTg pr vei Ttt as A_T
DEPOSES AND AFFIRMS THAT I ISH�IIE 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 APP207VIED BY THE SOUTHOLD T0VV,-r4 BOARD 017 TRUSTE
T HE A P F L 1 CANT AGREES T O HOLD i HE T O W iNi OF sO .l 'HOLD AiA%8'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
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
EROOKON PERS QT ISSUED BY THE BOARD OF TRUSTEES DURING TITE TERM
iiF'g riE P�;Rivl�T'.
Signature of Propert wner (Signature of Pr e nerT
SWORN T O BEFORE ME THIS V\ DA x Oi
ALICIA WALKER
notary Eubim,State of New York
No.O 1WA6153064
nuagwin su6fdl County --
Coanrtnassoq�� CZ't' ya='-
J
a swans'are tiTIr/E
—
'I'ItANSAcTIONAL IDISCLOSURE FORM
The'Toi vn of S6utli dfs Cade of _ ffie and a tovees:Ethics roaibi ,con1fowrosofcThe u ose 6f
a , iirr r ,o ride 1,66 -imp w 6 can alkr't the trx+:0: ssible ednfl Lsof interest and allow it tci to a ivh' era tianis
YOURNAME.. �name,�qiiddle
name,firnless 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 Or A PLrICATION; (Ciaeck all that apply.)
Tax grievance Building
Variance Trustee
Change of Zone Coastal Erosion
Approval of'ptat Mooring
Exemption.front plat or official map Planning
Other
(it'`:;titer'",t^au,.,e LOU U'U'..:i:y- —
1?o,'ou persoaaily(or through your compan),,spouse,,sil3fing;parent,oir'chiild)'ha'.ie it relalions_h o,owith`anyr officer or employee
of'tlae'Town of-Southold?. "Relationship"includes 6y blood,`nt iwiage,or Whim interest.`'Business interest'.,means a busine's,
igcludiiag u pactsaersliip,in which the town ofCcerar efnjaloyc4 lass evesa,a;pariial ownership°of(or'entploytaient liy).a cogiacation
In which the,toWn officer-or employee owns loon thuf `54/Q,Utlie shares.
YES NG
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_ . -
Ve:.c il.v the Ecla_ionship&hvuer y Dur- ,f ithe ar�alic to ng t;t rep��sentativel and the town officer or employee.Either check
lllu 21pyl VVI AOL,idle iij u :i`s�'ii-%j - --- --,-- - as u.v - ..•.•--- ,
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): i
A)thqowner ofgrettter than.5%of Nie shares of the corporate stock of the applicont
(when Nae applicant is i co'poratlon);
F3}the legal or.heneftalal owner of any.Interest in anon-corporate entity(whetr the
r.:nlin3nijc rata rnrrwimdcnni_ -
C)An officer,'director,partner,orejhpioyec.of-the,applieant;or
D)the actual applicant.
DESCRIPTION OF RELATIONSHIP
" Submitte this day of � _ 2U�
S i;nature
p�rittt N?at:1e
Form T5 1
A T'41r?'r- 71"A rWt"a ff' 3,
TRANSACTIONAL DISCLOSURE FORM
lite`t nV--t—1 P,-4. FEttWes rot%nik conflicN,of intcres-t—Aftnijof tow 6 ic a dem I
o
Of int OP07 � IC RM
tw M�
wn or southold's coftl—oal�
W- -CLn-8—W*"01,
,tp
YOURNAME'
na ,
roadie,roadie, memevi 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.)
Tax grievance Building
Variance Trustee
Change of Zone Coastal Erosion
Approval of plot Mooring
frost',plat or official man Planning
00 you pci-sonally(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,mofflage,or business interest."Business interest"means a business,
including a partnership,in which the town officerix employeebas even a partial ownership of(or employment by)a corporation
In which the town officer or employee owns more than 5%of the shares.
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
In; re��
te,Either Ch
M-- 1 Y
the zrp-p—ioprimc line A.;-thrm-go V;aiftU
e-Ur
The town officer or employee or his or her spouse,sibling,parent or child is(check all that apply):
the owner ofgreater than 5%of the shares Of the corporate stock of the applicont
(when the applicant is a corporation):
*� q,
4..e4 .4 awl-Dogo
dw�kga'= of axl-v natc en--tv
an'"i director,pminer,or employee of the applicant;or
— it aitii;a,Lnrrt:ieiiiitiq�;
C) o i
the actual applicant
DESCRIPTION OF RELATIONSHIP
Submitted is da of
Signature�
Funn TS 1