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HomeMy WebLinkAboutMott, Eugene ! James F. King,President OF so Jill M. Doherty,Vice-President y Town Hall 53095 Route 25 Peggy A. Dickerson P.O.Box 1179 Dave Bergen u, Southold,New York 11971-0959 Bob Ghosio,Jr. �O Telephone-(631) 765-1892 00UNT1,N Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Southold Town Board of Trustees Field Inspection/Work session Report Date/Time: EUGENE MOTT requests an Administrative Permit to mow the phragmites and plant native wetland grass. Located: 360 North Oakwood Dr., Laurel. SCTM#127-8-8.3 Type of area to be impacted: _Saltwater Wetland Freshwater Wetland _Sound Bay Distance of proposed work to edge of above: �Cchapt.275 of Town Code proposed work falls under: _Chapt. 111 _other Type of Application: _Wetland_Coastal Erosion_Amendment administrative _Emergency Pre-Submission Violation Info needed: S Modifications: Conditions: Present Were: _J.King _J.Doherty_P.Dickerson D. Bergen B. Ghosio, Jr H. Cusack D. Dzenkowski Mark Terry other Mailed/Faxed to: Date: r Environmental Technician Review �-�a, o1z,is S n,..+ x n�hJc o".sS Or ti amt,-{A4rnr-i AT-Jwe-, IM 1I _yaw s�c..1 Fv l�,-� ih�,� 1 r�yc�ig•.t b�, P farts. +Y-Vr ��fi I s � h���{�� �� �5 I- ? 6,J,- � Fw�� ' B SUR VE Y OF P/0 LOT 38, LOT 39& P/0 LOT 40 P/0 LOT 40 IN 254. 06' r MAP OF LAUREL PARK 40" E SI TUA TF FD STK 109.81 FD cn LAUREL, STONE MON. LQ TOWN OF SOU THOL D ON LINE S 0.2' w � SUFFOLK COUNTY, N. Y. LOT 40 EARTH U' DRI VEWA Y C)- SURVEYED SURVEYED FDR EUGENE MOTT q b PATRICIA MOTT i Q44 2 STORY ty j WOOD o ►— j LLJ STONE 0 4.2' FRAME , 't o WELL RES. CA TM 1000-127-08-08.003 162.2' 2.0 6 DEC ( 0 (_Ad FM # 212 W/RAILING a FILED OCT. 5 1921 SURVEYED 11 MARCH, 1999 M STONE , �� 0V SCALE 1"-40' TH D,RI VE WA Y CHIMNEY 20' e v �O AREA= 42,123.051 SF ® s )T 38 / 4A io , �-�- � 0.967 ACRES GUA RAN TEED TO FD N 1.1' EUGENE MOTT STONE MON. O O 164.5' � O• PATRICIA MOTT » '" 270.59' � FIDELITY NATIONAL WILE INS. CO. 3 i40 W �P,CKET FE. TOWN OF SOUTHOLD S 4.t P/0 L 0 T 38 RD ,r Unauthorized alteration or addition to this SURVEYED DY' Guerantpes indicated hers on shall t�.ir► ;,rv�y is a violation of Secfi:an 7209 of only to the person For whom the survc:;+ t STANLEY J, ;S%�KSEN; JR. R 2 7 2007 he New York State Education Low, is prepared, and on his behalf to the P.O. hOY.. Z94 BAY til;^ core:x c;. Goverr,ental Agency, I SonthholdTown BOULEVARD ,• NEW _c_�,=SLK` rIr >>s lcrc;;; ir;,,..t::n, i' luted hereon, cnd �1" -i;i,4--583 Board of Trustees {a ilt;: c t,:,noos of ii,2 lording in:,{itution, Copies of this survey map not bearing �-- Guvtc ntees c�.a r.--t hansierable to the Land Surveyors embossed seal shall 77,3 odditional institutions or subsequent ownem not be considered to be a valid tru€a "�LICE Fci;�NoYOR eopy= NYS LIC'. NO 4„, ' V P/0 LOT 40 254.06' N 69' 08' 40" E � 109.81 FD LLJ ' , 11 FD 100.00 FD STK STONE MON. � �1 CM. ON LINE S 0.2' W s a 1 Qn P10 LOT 40 EARTH • U Q DRI VEWA Y o� �v 2 STORY N 4.4' _ LQ WOOD - 0 LOT 39 STONE p N2 FRAME --\ o �s WELLRES. o W O 162.2' 2 0 6. 00 DECK Q W/RAIUNC STONE �. N TH 0 1 VEWA Y CHIMNEY 20' N R / ® � h f 0 Q) P/0 LOT 38 /! 4A 10 N aCO / b b FDL 1.1'FD FD N 0.3' STONE . PIN CM E 7.7' 164.5 ON LINE IA/ � 270.59' Z , ®® S 69° 08' 40" YrPICKET FE. FDS 5.00 � � s 4't R� � � oIn I lP E 3.11 FD S 4.8' V jED O o STONE'E 6.7' PCO L O T 38 N MON. APR 2 7 2007 liJ Guarantees indicated here on shall runt Unauthorized alterction'or addition to .+rv:�y is a viciction of Section 7209 Southhotd Town only to the person for whom the survey is prepared, and on his behalf to the the New York Stcte Education Law, Board of Trustees PECONIC BAY BOULEVARD tiYl^ ccr;]rr.;: Covermental Agency, lf:r,c„ng i; a„.t;cn, if listed i rreon, and to tl;ry c st:c;nees of ii,2 !e rJin,, institution. Copies of this survey map not beari Guercn:.Cs Ure nct tiansicial;la to the Land Surveyors embossed seal sl additional ins!"auticns ur sLbs�3quent ownem not be ecnsidered to be ca valid tris copy. Town of Southold -A ' 4800 Suffolk County, NY The People of the State of New York us. LAST E(DEFENDANT) FIRST NAME MUX+�La INITIAL �✓ �\ V STRE ADDRESS NO CITY STATE zip Ic p ) UCENSE OR REGISTRATION NUMBER STATE TYPE OF LICENSE DATE EXPIRES SEX DATE OF BIRTH OPERATOR IT NTH 7 Y ('5A OWNS VEHICLE Al Jt 10TT OYES ONO_ THE OPERATOR OR REGISTERED OWNER OF VEHICLE DESCRIBED BELOW PLATE NO DATE EXPIRES STATE PLATE TYPE ❑N Y ❑N J ❑N.Y. ❑N J ❑ ❑PASS ❑COMM ❑ VEHICLE MAKE ❑ DODGE ❑ BUICK ❑ CHEV ❑ CADILLAC ❑ PONTIAC ❑ FORD ❑ OLDS ❑ PLYM ❑ TOYOTA ❑ VOLHS ❑ BODY ❑ 2 DR ❑ 4 DR ❑ BUS ❑ MCY ❑ SW TYPE ❑ TRUCK ❑ TRAILER ❑ VAN ❑ VIN NUMBER THE PERSON DESCRIBED ABOVE IS CHARGED AS FOLLOWS PJACE OF OCCURRENCE PCT y �AJE FOFF NSE AM TIME PM CI N.VILLAGE OR MLET SUFFOLK COUNTY NY N VIOLA ON OF SECTION SUBD OF THE❑VEHICLE AND TRAFFIC LAW OF THE STATE OF NEW YORK "ETHER(SPE .7-7'-- � • ❑O S ❑COM ❑BUS ❑HAZ 0 4'�. DEF VEH MAT ❑ SPEEDING OTHER OFFENSE MPH IN A MPH ZONE MISDEMEANOR❑ FACTUAL PART(NOT FOR TVB) , THE ABOVE NAMED DEFP4DANT DID ON jHE STATED DATE,TIME AND PLACE w�. /s �✓= t�4a� � ,c-erwt � The Foregoing a based on(personal knowledge)and/or(information&belie0,the source being the attached mom deposition(s)of dated PARKING SCHEDULED FINE$ CONTACT ONCOURT❑ THE PERSON DESCRIBED ABOVE IS SUMMONED TO APPEAR AT • /v SOUTHOLD TOWN JUSTICE COURT,53095 ROUTE 25,SOUTHOLD,NY 11971 DATE OF APPEARANCE(NOT FOR NB) !((rl NOR- 1 Agency �.-- 2-1 7,,7,:.,,T,, New York State 3 ORI 4 0 Ong 5 Case No 6 Inudent No i INCIDENT REPORT NY s "f ❑ Supp 1 7Report Day 8 Date/ 9 Report Time Occurred 10 Day 11 Date r�t 12 Time Occurred 13 Day 14 Date �7 15.Time r C' ✓ o. ° /'r. onr }9 T--► '' 'S .1 j� < F 16Incident Type f ,� 17 Business Name 18 Weapon(s) A O V 19 Incident Address(Street No,Street Name,Bldg No,Apt No /! 20 City,State,Zip(f❑C F] T E]V) 21 Location Code B f z 2C � _^✓'1�L it»� rC f 22 OFF NO. LAW SECTION SUB CL CAT DEG ATT NAME OF OFFENSE CTS 23 No of Victims C 2 24 No.of Suspects ` 3 25 Person Type:CO=Complainant OT=Other PI=Person Interviewed PR=Person Reporting WI=Witness N1=Not Interviewed VI =Victim 26 Victim also complainant ❑Y❑N E TYPE/NONAME(LAST,FIRST,MIDDLE,TITLE) Date of STREET NO.,STREET NAME,BLDG.NO,APT NO,CITY, STATE, ZIP Telephone No Birth 16AF W '��' �,'`., 'r;'J✓'�. r^ 7.'3S i C'C' ®°Tr..`�.�-a }'`'� j�oc,✓'"?"�l�.y r<,`"�'' RESIDENCE i- 0 EST..Lhf£3F.4Sl/— G V BUSINESS H O V1 RfSIDENCE Q 3ES5 I RESIDENCE 27 Date of Birth 28 Age 29 Sex 30 Race 31 Ethnic 32 Handicap 33 Residence Status ❑Temp Res -Foreign Nat. v Mo 0�y yr ❑ M ❑ F ❑ White❑ Black❑Other ❑ Hispanic❑ Unk ❑ Yes ❑ Resident ❑Tourist❑Student❑Other 1 > ❑U []Indian❑Asian❑ Unk ❑ Non-Hispanic ❑No ❑Commuter❑Military ❑Homeless❑Unk 34.Type/No 35.Name(Last,First,Middle) 36 Alias/Nickname/Maiden Name(Last,First,Middle) 37 Apparent Condition K z ❑ Impaired Drugs ❑ Mental Dis ❑Unk. O TABLF O ❑Impaired Alco ❑InJ/III ❑App Norm cc Lu 38 Address(Street No,Street Name,Bldg No,Apt No,City,State,Zip) 39 Phone No [I Home 40 Social Security No L FO ❑ Work z tJ Fw- wILA 41 Date of Birth 42 Age 1 43 Sex 44.Race 45.Ethnic 46 Skin 47.Occupation Nw €no Da Yr ❑ M ❑ F ❑ White❑ Black❑Other C] Hispanic❑ Unk E] Light C]Dark ❑Unk. TABLE P M �C Y ❑ U ❑Indian ❑Asian C]Unk ❑Non-Hispanic []Medium C]Other tAQ 48 Height 49 Weight 50 z Hair 51 Eyes 52 Glasses 53 Build 54 Employer/School 55 Address N [-] Yes❑ Contacts []Small ❑Large ft in 'ABLE t} TAhLf P ❑No ❑Medium y V1 kn 56 Scars/Marks/Tattoos(Describe) 57 Misc 1 S 58 Victim or Property Property Quantity/ Make or ❑ Su ct N Status Type Measure DrugType Model Serial No Description Value _ 2 TABLES TABLET TABLE TA`:LEV 9 F- 4 IX 59 Vehicle 60 License Plate No Full❑ 61 State 62 Exp Yr 63 Plate Type 64 Value ut�I O Status0. A 3l£W Partial❑ 5❑ IYw a V 65 Veh Yr 66 Make 67 Model 68 Style 69 VIN ❑ = 6 W > 70 Color(s) 71 Towed By 72 Vehicle Notes 7❑ i To 73. ❑ 9 Gam r ��„�r ¢ r ..,.'}"' v`'if'�`,�r...; .��C `•"i ,G9%-a's� r �..�" C1r� `�t W F- 11 1701 •- d (- W Q 12 z 13 1 oral Lu 74 Inquiries(Check all that apply) 75 NYSPIN Message No 76 Complainant Signature B > ❑ DMV ❑ Want/Warrant ❑ Scofflaw t— ❑Crim.History ❑Stolen Property ❑ Other use cover Q sheet 77 Re rtm Officer Signature(inc ludeRank) e 78 ID No 79 F- po g: f Supervisor's Signature(Include Rank) 80 ID No 84 -- ' n �^'•81 Status ❑r OpensE]Closed(If Closed,check box below) ❑Unfounded 82 Status Date 83 Notified/T07 (of O ❑Vict Refused to Coop ❑Arrest ❑Pros Declined ❑Warrant Adviseda` Kr E]CBI ❑Juv -No Custody ❑Arrest-Juv C]Offender Dead ❑Extrad Declin C]Unknown 1 7 I� � I- Pages f DCJS-3205 (2/97) -FALSE STATEMENTS ARE PUNISHABLE AS A CRIME,PURSUANT TO THE NEW YORK STATE PENAL LAW. -AF fW INFORMATION FOR VICTIMS OF CRIMES AS A CRIME VICTIM YOU ARE ENTITLED TO THE FOLLOWING ASSISTANCE: 1. INJURED VICTIMS OF CRIMES, OR THEIR DEPENDENTS,MAY RECOVER COSTS OF MEDICAL TREATMENT AND REIMBURSEMENTS FOR LOSS OF WAGES. 2. IF DEATH RESULTS FROM A CRIMINAL ACT, THE VICTIM'S FUNERAL EXPENSES MAY BE PAID FOR BY THE STATE. 3. YOUR LOCAL LAW ENFORCEMENT AGENCY HAS BROCHURES APPLICATIONS AVAILABLE FOR YOU TO APPLY FOR THESE BENEFITS. COMPLETED APPLICATIONS ARE TO BE FORWARDED TO THE NEAREST CRIME VICTIM'S BOARD, WHICH ARE LISTED BELOW. LISTED BELOW ARE THE VARIOUS LOCATIONS FOR THE CRIME VICTIM'S BOARDS THROUGHOUT NEW YORK STATE Crime Victim's Board Crime Victim's Board 845 Central Avenue, Room 107 270 Broadway, Room 200 Albany, New York 12206-1588 New York, New York 10007-5160 (518) 457-8727 (212) 587-5160 Crime Victim's Board 65 Court St., Room 408 Buffalo, New York 14202-3408 (716) 847-7992 d Aen I De o5 aD 8 6 01ov Oi .+ \ SFE err N0.1x5 �•} sEE scc w OD�0 Y4TCM INE 6 uA'. EpE �- --�– EA'E u4ra 11 OD 1V 0 5 50N PCL NO Oy0 l '� fOR P0.x0 f011 PLI.No -x2 00 „ p EE SEG V o.otst sa NOx121 \\ 1xs--09Erot 35 A 1 S At.) o,y Q 21 q'iE w i h OS $ — •y"1 ��'S O 1.x41e1 _ un�c$e' 1 iN u, —A ]9i r ]4 1x a lb Ah _ iia 10,16 ,,'4. 154 1St • t w a,� / �1 r o fO 9�F +, OHO w � p C�°O� w •'+' a'J" r'+ate""u Paa xl o O A 'EE SEC ° xe-01.001 ^ M1 ' n. S�1a� 1y ^n �• 9 ^� Y� W L – E —zz— Pe 1211 O ] 1Mpi:Q NOTICE ns COUNTY OF SUFFOLK © E SOUTNDLD K Iom a =IECTIOTI�N.e µ-- . —_ _ __ e wM L uRw m suE 0P ,Real Property Tax Service Agency Y on, .0'.1P� Nsuvfuxmooruxtma wu®rm °d+ NN Calnty Center Wverhe NY 119%p r^uc Aa w ] —__— ____ aSDpx OrT1N4 ' rFE1�srPvac.awr g - p oe,�rw 1000 ens Dns _ — io az ao i James F. King,President •�*0 So�ryo Town Hall Jill M. Doherty,Vice-President 53095 Route 25 Peggy A. Dickerson P.O. Box 1179Southold,New York 11971-0959 Dave Bergen G Bob Griosio, Jr. Telephone(631)765-1892 `,oUNN,� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Applicatio __ _Wetland Permit Application Administrative Permit Amendment/Transfer/E tension Xteceived Application: d-710-7 Received Fee:$ " L� b _Completed Application �1 _Incomplete � _SEQRA Classification: 4 APpi 2 ] 2007 Type I Type II Unlisted —Coordination:(date sent) —LVW Consistency Assessment Form 5o Tows _CAC Referral Sent: boarrdd oof d f Trustees _Date of Inspection: _Receipt of CAC Report: _Lead Agency Determination: _Technical Review: _Public Hearing Held: Resolution: Name of Applicant GU(�EJV M Q"�' Address 19 IV l i j>bLc ---r;51a'n6L 54LVD, Phone Number:(631) 73 Y– 6 V& e2- C.4– 3-T C `© f Suffolk County Tax Map Number:: -1`000 - , M 7 - - , o c)3 Property Location: 3 bO N' `� • L-,0..� (provide LILCO Pole#, distance to cross streets, and location) AGEN . (If applicab Address: Phone: rd of Trustees Applicatic GENERAL DATA Land Area(in square feet): C. ,p pRa}L%MA-,'-eL-% x Area Zoning: RES i 1jEA)7T1,¢ Previous use of property: e&S i b ErJT/ 1L Intended use of property: R E 5 i D CAJr)kL- Covenants and Restrictions: Yes X No If"Yes", please provide copy. Prior permits/approvals for site improvements: Agency Date )C 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): M 0 l,[) 'P f�R Tf� m�-y--�S J P�AO✓T� ��7, �t W��`"Lr�-!✓� Lrd of Trustees Applicati WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: L UT f1l�{{"In% TSS a0 PMRA6n'I� ��s Area of wetlands on lot:PePRW• /60b square feet Percent coverage of lot: % (THREt P,fR CEJUr) • Closest distance between nearest existing structure and upland edge of wetlands:AFAAy.. 8 6 feet Closest distance between nearest proposed structure and upland edge of wetlands: feet 71oT 1qp pL i C 14 8 L Does the project involve excavation or filling? X No Yes If yes,how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: `X Manner in which material will be removed or deposited: jv 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): 617.20 PROJECT ID NUMBER APPENDIX C SEQR STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1.APPLICANT/SPONSOR 2.PROJECT NAME U 6-EJue I►'l 6 3 PROJECT LOCATION 360 NoR-ry oflir"mob RD - Municipality zit/ eI— n/- County ;51)FFJ L-l< 4 PRECISE LOCATION. Street Addess and Road Intersections, Prominent landmarks etc -or provide map 36d pJ6127-H v,49-&W oD IRD. 4_+ L)JeC-4-- 11 TG, AD JDIR 1 V E Waff AN R 16rW Nd 7V 6r— F, gU;r_ 464-Y. . 5 IS PROPOSED ACTION ❑ New ❑Expansion rX Modification/alteration 6 DESCRIBE PROJECT BRIEFLY CuT/in6 k) PHRRG(yjrT-F5 7 AMOUNT OF LAND AFFECTED �+�PROX�Ml9�C'`� � x '75.7 Initially acres Ultimately acres 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS9 rw Yes ❑ No If no,describe briefly. 9 WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply) Residential ❑Industrial ❑Commercial ❑Agriculture ❑Park/Forest/Open Space ❑Other (describe) 10 DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ❑Yes N No If yes, list agency name and permit / approval CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes IK No If yes, list agency name and permit / approval- 12 AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? ❑Yes M No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Date. Signature � —d,7.. If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT(To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL EAF. E]Yes 0 No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration may be superseded by another involved agency Yes E] No C COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING-(Answers may be handwritten,if legible) C1 Existing air quality,surface or groundwater quality or quantity,noise levels,existing traffic pattern,solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly: C2 Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources,or community or neighborhood character?Explain briefly: C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly. C4 A community's existing plans or goals as officially adopted,ora change in use or intensity of use of land or other natural resources?Explain briefly C5 Growth,subsequent development,or related activities likely to be induced by the proposed action?Explain briefly C6 Long term,short term,cumulative,or other effects not identified in C1-05? Explain briefly: C7 Other impacts(including changes in use of either quantity or type of energy? Explain briefly. D WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA(CEA)? if es,ex Iain briefl E] Yes �No E IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain FlYes F]No PART 111-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it is substantial,large,important or otherwise significant Each effect should be assessed In connection with its(a)setting(i e urban or rural); (b)probability of occurring,(c)duration;(d)irreversibility;(e) geographic scope;and (0 magnitude. If necessary, add attachments or reference supporting materials Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked --des;the-determination-of-signifisaaE 4nustevaluate-the-poteRtiaHmpacteMe-prepesed-aetien on tine envtir maul haracteristiesofthe Check this this box if you have identified one or more potentially large or significant adverse impacts which MAY occur Then proceed directly to the FULL EAF and/or prepare a positive declaration --- --- - --o-- - — -- Ctieck this box if you have determined,based on the information and analysis above acid any- supporting documentation-- ---------- ,-th-a–- t the—pr-ops-ed--actio- WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. Name of Lead Agency Date 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) Board of Trustees Application County of Suffolk State of New York • - I BEING DULY SWORN DEPOSES OM 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/DER 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 TOWN 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(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION Signature SWORN TO BEFORE ME THIS DAY OF 20© UNDA SAAh "� rn� Notary AN �Noic,State of Now yolk Notary Public "`���VVV Qualrfied Suffolk, � ^�/ and of Trustees AppLicat A ORIZATION (where the app ' cant is not the owner) I, residing at (print owner of property) (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner' s signature) 8 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./� I ,� YOUR NAME: � "EA E M O' ' (Last name,first name,.rpiddle 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 (, CTL/ys1/p (If"Other",name the activity.) C(J ' "In J eJ �l-f�ft6/►'i�rt 5 'P a ' N�6 d C 6-6¢ss 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 X 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 g," 200 Signature ( f Print Names v, p 6 a.T Form TS ]