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Home My WebLink AboutGibbons, Brigitte James F. King,President ��OF so�jo Town Hall Jill M.Doherty,Vice-President ,`O yl0 53095 Route 25 P.O. Box 1179 Peggy A.Dickerson Southold,New York 11971-0959 Dave Bergen G Q John Holzapfel �� Telephone(631)765-1892 l�G,oU ,� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD 4ft1A iT AEVER SSV, Permit No.: 6444A Date'of Receipt of Application: August 31, 2006 Applicant: Brigitte Gibbons 'S.CTM#:,117-1-1�4 Project Location: 1380 Grathwohl Rd., N'ew,Suffolk Date of•Resolution/Issuance: September 20, 2006 Date of Expiration:-September 20, 2008 - Reviewed 'by: Jill Doherty Project Description: Trim the Phragmites to 12" with the condition that all cutting be done by hand with no machinery near the wetlands, a final inspection at the completion of the cutting, and all as depicted on the,plan as surveyed by Joseph A. Ingegno and - received September 5, 2006 by the Board of Trustees. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth by the Board of Trustees. Special Conditions: Final inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth by the Board of Trustees, a Wetland Permit will be required. NO This is not a determination from an other agency ��y ' x " ° � ` 3rY2:t '^ YS'S< ;" JY's: �� T'�.e r• ai' S _ 1 'it "�-•' •��`'--`�'i`%'ss?�z��;-�' ,'� -.'r�'r�:^�;. .- C� � = a MEAN` :FSC'"MEN, �-"�.'v^�''-�"�,��.,��g��;ti ,•,.�<«�`. ,�`x James F. King, President ri `" `+?a"'ari` ea f' Board of Trustees .x � r = +4 . p_ ,F� --K: ;5:�•.,_i >s tom:.y"ehT✓XScy,i�'``'+"3'�:-3i.^'.1LKi,i '"�'.`, c,':r_se:.-_..r.,v� _ ":' > = tiez rgy' °2_;x c e rives- �.t:k 7 �r� •��"v,�,, sw;,:`rte.--s,�..�.�., v� -Pb:. s,3 �,v`;o-uza=: ', �� Dr''"'s"" ,.`-sYTt-r4''"'t�r'"` v`r'.sir`- a "' Wiz- + 'r Srf`7`,; .i r„t°,�.a=`,�i?fr s` ,.z£ '. {,��.x,r,,., ?- �r,y �3S'`4-z.v"f�."i.. -'^ " ,,ki,4 y, `:: ; r'^sy, k ` '.'�„,,^k�-,'-".. '�' "^�n =nab,._ e..,�, �e ��F..F, �',.`.+,,_�**�,'c:S'c>ya�`.,.%,zks�r,,.'.y"`� V, ;M?M?3t _�.� . c� :;�',. >x,,�rs,a;•w�:ate>�:�„ �- �%,�''+T,-';,�"��`ds.-zi.,�� ''�s:��';"`¢-.;;s,-k"i':I y? .,^.}''T= t,;�:.°,"-t?x K' �m;....:;7t rr<• '":#=.nY„ ,,'<`, __r.-.,ss,`n,'r'yi �E�i;,.ri�i:.= James F.King,President ��®� S®!/ryo Town Hall Jill M.Doherty,Vice-President ,`O l® 53095 Route 25 P.O. Box 1179 Peggy A.Dickerson Southold,New York 11971-0959 Dave Bergen John Holzapfel ® �� Telephone(631)765-1892 l�C®U9� Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 6444A Date of Receipt of Application: August 31, 2006 Applicant: Brigitte Gibbons SCTM#: 117-1-14 Project Location: 1380 Grathwohl Rd., New Suffolk Date of Resolution/Issuance: September 20, 2006 Date of Expiration: September 20, 2008 Reviewed by: Jill Doherty Project Description: Trim the Phragmites to 12" with the condition that all cutting be done by hand with no machinery near the wetlands, a final inspection at the completion of the cutting, and all as depicted on the plan as surveyed by Joseph A. Ingegno and received September 5, 2006 by the Board of Trustees. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth by the Board of Trustees. Special Conditions: Final inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth by the Board of Trustees, a Wetland Permit will be required. This is not a determination from any other agency. C� f James F. King, President Board of Trustees James F.King,President �*oF so�ryo Town Hall Jill M. Doherty,Vice-President 53095 Route 25 Peggy A. Dickerson l P.O. Box Southold,New Yorkk 11 11971-0959 Dave Bergen John Holzapfel �� Telephone(631) 765-1892 lyComm Fax(631)765-6641 t 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. f. INSPECTION SCHEDULE Pre-construction, hay bale line 1St day of construction / % constructed `� Project complete, compliance inspection. F �4' 9002 9 ddS Ell Li� a •66, E, 9" / / AT roI ,moo' / / //N/ // ». ^�, w � // \ •„\• 71 1}g 6s 1 '/ ` I vd / N/ NIX P",4 cu N p.. a / wE'� '82g o 445 gy O h °J,_ I� � 9 M Irp .y m lSO. 00Ar O �4 APPROVE® BY BOARD OF TRUSTEL-3 (PA vx IIIA� 0 A D OLD (CHARLI�,S ROADN OF SOUTH LANE) T®'fir L') ELATE q( Lo (0b 91 / SOUTHOLD TR.USTEES No. . (p4q,4 lssuedT,. Address - 1310 �-«�w�►� RA-, 4ffellc THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE TOWN OF SOUTHOLD . SOUTHOLD, N.Y. 11971 TEL.: 765-1892 i _ SURVEY OF PROPERTY p1S � SIT UA TED AT �� I- -- - -_-- - NEW SUFFOLK ® �vA44� TOWN OF SOUTHOLD 90OZ 5 d3S SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-117-04-06 s'6�2 / I L,ti ,p(l 1000-1'17-01 -14 p.. / � s � _ � SCALE 1 =20 _ MARCH 18, 1998 JUNE 29, 1998 FOUNDATION LOCATION JUNE 9, 1999 ADDED FINAL SURVEY & TOPOGRAPHICAL SURVEY JULY 22, 1999 UPDATED DRIVEWAY LOCATION MARCH 8, 2002 ADDED WATER LINE q CERTIFIED TO: C� 'A / / / / / s33?� �'"•�,p�y,YR �� JOSEPH GIBBONS / / / / 4 O a /0 � ,�o - 2p•..a dr ,Q•Q✓� BRIGETTA GIBBONS NOTES: �_ '/ • i / ^ N N N 1. FLOOD ZONE INFORMATION TAKEN FROM: ryv� `'l 00// / / \� , o` FLOOD INSURANCE RATE MAP COMMUNITY-PANEL No. 360813 0094 D /Q7/ // / /\ \< �� \ r ' , ASO o ZONE A4 (EL 8) FLOOD OHAZA D FACCTTORSFLOOD: DETER�EEDFLOOD ELEVATIONS AND /N/ / y /7 •+1 e• ' O/` , �09s ` ers 5f8. ZONE B. AREAS BETWEEN LIMITS OF THE 100-YEAR FLOOD AND 500 YEAR FLOOD, `a' OR CERTAIN AREAS SUBJECT TO 100-YEAR FLOODING WITH AVERAGE DEPTHS LESS THAN ONE1 FOOT OR WHERE THE CONTRIBUTING DRAINAGE AREA IS / / / / `• /� // , `'rye �,, 1 „J I �S� LESS THAN ONE�1; SQUARE MILE; OR AREAS PROTECTED BY LEVEES FROM THE BASE FLOOD. %// / / a.• �' /N / .^ �,\ a/ 1 'B' you ¢gprFR i � 2. METES & BOUNDS DESCRIPTION TAKEN FROM DEED LIBER 10399 PAGER 535 \ �y c1R1c 4E I J 3. ELEVATIONS ARE REFERENCED TO N.G.V.D. 1929 DATUM /_ / \\ '� 1 e / �N EXISTING CONTOUR EXISTING NLINES ARE S ARE OSHOWN:WN S-1�0—t0--- — — v ' 4. S.C.D.H.S. REFERENCE No. R10-96-0016 9 W zAo o e w� • / �11��sg.' �pp •'y~/ :��. - o ' ��W`q4 LOT AREA DATA S C. TAX N. 0 13, 9.59asq. ft. 306 k47 wop S.C. TAX No. 1,487.82 sq. ft. 1000-117-01-14 (TO TIE UNE) 0.034 ac. r ` LIQ • +< • 0 ` t'ry TOTAL 14,837.41 sq. ff. y a� O (TO TIE LINE) 0.340 oc. 104 d1 d p Eyp jr a F � OM TO ThIS SUR NTEStAT VI DR ADD F SE nay 7299 IS A VIOLATION YORK OF LM1R ti (1-` EDUCAT rm9 of mE NEW Yblac STATE HIN LAW eb ��5)�v� lU (0� C COPIES O su7195irhSLIRVEY Yo s INKED NOTESEAL NG S� S Fl OWED SEAL SH-LL NOT BE CONSIDERED V TO BE A%MUD TRUE COPi 4 p CEKnF=nONS xOICA=HEREON SMI.RUN ® ®�//p ED pyy�/�/ p\�� 3 ONLY TO THE PERSON FOR WHOP THE wREY ® Y P P R • Y �� IS DING WED.IIJD ON 10.4 BElll{LF IO'WE LIRE COIPANY.OaIEIxNTMAl.ADENGY AND LENDING INSTITUTION FISTED N6$pN,AND TO THE ASSIGNEES OF THE LENOING x9B— NOON COMFICAnONS ARE NUT 7RANSFFTU&E � EF�q, A ppm pp � gyp+Aq FIS'I ]1 BOARD ®1 TRUSTEES THE E%ISTENCE OF ROf R OF WAY J/-�A', � AND/oR FASENEHfS OF RECORD,IF `yy py �y�p[ ANY,NOT SHOWN ARE NOT GUARANTEED. FANG ROAD)AD TOWN OF SOUTHOLD _ PRTPARMIN RDANC£WRINTHEMLW4 STANOMOS TIRE SURVEYS AS FSTAHUMM C��RLI�!'� LANe) DATE SII2,o 6b FOR CI ANDAPPROVmANOADOWED Joseph A. Ingegn® FOR ON B/THE NiW'roRx STATE IABD I. Land Surveyor LVN e A O 'I. T; SDTI'eyD—SuadMslane — Ale Ran — ComUucfbn Layoul ' a PHONE(631)727-2090 Fox (831)727-1727 41 _ OFFR>:'S LOCATED AT Af JLM ADDRESS — NYS. Uc. No 49668 1380 ROANOKE AVENUE P.O.BOX 1931 RIVERHEAD, Now York 11901 RNadxad,Now Yolk 11901-0965 98-193C James F.King,President � ; ��F sorry Town Hall Jill M. Doherty,Vice-President �' '�o� �l0 53095 Route 25 P.O. Box 1179 Peggy A.Dickerson Southold,New York 11971-0959 `Dave Bergen G Joephone(631)765- hn Ho 1 z ap f e 1 �ol�� Te1Fax(631) 765-6641 92 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 1 st day of construction / % constructed v Project complete, compliance inspection. James F. King,President �*of svUryo Town Hall Jill M.Doherty,Vice-President ,`O l0 53095 Route 25 P.O. Box 1179 Peggy A.Dickerson Southold,New York 11971-0959 Dave Bergen John Holzapfel 0 �Q Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 6444A Date of Receipt of Application: August 31, 2006 Applicant: Brigitte Gibbons SCTM#: 117-1-14 Project Location: 1380 Grathwohl Rd., New Suffolk Date of Resolution/Issuance: September 20, 2006 Date of Expiration: September 20, 2008 Reviewed by: Jill Doherty Project Description: Trim the Phragmites to 12" with the condition that all cutting be done by hand with no machinery near the wetlands, a final inspection at the completion of the cutting, and all as depicted on the plan as surveyed by Joseph A. Ingegno and received September 5, 2006 by the Board of Trustees. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth by the Board of Trustees. Special Conditions: Final inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth by the Board of Trustees, a Wetland Permit will be required. This is not a determination from any other agency. James F. King, President Board of Trustees i James F.King,President ��oF so�ryo Town Hall Jill M.Doherty,Vice-President ,`O l0 53095 Route 25 Peggy A.Dickerson l P.O. Box 1179 Southold,New York 11971-0959 Dave Bergen CA John Holzapfel a � Telephone(631)765-1892 COU Fax Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: eB r Please be advised that your application dated 031 to 6 has been reviewed by this Board at the regular meeting of 071 a-0 1 b and the following action was taken: �) Application Approved (see below) �) Application Denied (see below) �) Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees. The fee is computed below according to the schedule of rates as set forth in Chapter 97 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: l (-hs 6'j S� 9 TOTAL FEES DUE: $ 1L BY: James F. King, President Board of Trustees IJames F.King,President Town Hall ®� �� Jill M.Doherty,Vice-President .` 53095 Route 25 Peggy A.Dickerson Jx[ P.O.Box 1179 Southold,New York 11971-0959 Dave Bergen G �� Telephone(631)765-1892 John Holzapfel �� Fax(631)765-6641 �OOUM`{N i BOARD OF TO RUSTEES TOWN OF SO OLD i Southold Town Board o T stees Field Inspection/Workses io Report Date/Time: Name of Applicant: Name of Agent: Property Location. SCTM# &Street Brief Description of proposed action: it i . Type of area to be impacted: altwater Wetland Freshwater Wetland Sound Front Bay Front Distance of proposed work to edge of above: Pail o Town Code proposed work falls under: 1%Chapt.97 Chapt. 37_other Type of Application: Wetland_Coastal Erosion_Amendment_Administrative _Emergency Info needed: Modifications: Conditions: 7)W'4 0 1 0 Present Were: _J.King Doherty_P.Dicke son. D. Bergen J.Holzapfel Other: Date: Mailed/Faxed to: I i i K RD rsm ze I UTH)LL (3) I All 113 Y2. O n. 6 c ,�^ 4] i?_9• .,, ` I' 12F. '] t ? 1],cf z ]^ d K W� LL et ? 11 r' n "� Is-y f9a -: s.d '„ u 1 L0 x 6( CUTCHOGU - CUTCHOGUE HARBOR 21 27 A Ei 7 261 5T 112 d 16 1 164 11, i2x a21 N x65 x26.1 WW ppy1 36 F 2AI A 213 112 Y3 It , A.1 R 114 x.11([1 -Al'o -A P.D.go f9 Iw. 29 :S BAY PECONIC GREAT L 6w^o :� � — - -- +v E -- ---- (M G ————-- E NOTICE COUNTY SUFE66FOLK SOUTHOLD SECTION No D Al AA !Service! l A,. Red Property !� !: Agency c�lly gntx R IF I IBM 1-7 U: ' S -'Albert J.Krupski,President ��OF S0(/jTown Hall James King,Vice-President ,�O l0 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda ` N Southold,New York 11971-0959 Peggy A.Dickerson G O Telephone(631) 765-1892 Cow,��' Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application _Wetland Permit Application V Administrative Permit Amendment/Transfer/Extension -Z; eceived Fee:$c o :___� ®y //Received Fee:$�� r �� _Completed Application Incomplete _SEQRA Classification: � " �1 6 Type I Type II Unlisted _Coordination:(date sent) _LVW Consistency Assessment Form I I' AUG 3 1 2006 _CAC Referral Sent: I Bate of Inspection: _Receipt of CAC Report: _Lead Agency Determination: ` _ — Technical Review: ,Public Hearing Held: J 9 10(0 Resolution: Name of Applicant i`�l G ✓�, i G2 % �`�� / Address / 3 FV G"//e/L-Z—W wo t,4 1, /q -b d i j5 3,,->, AI'ZJZ,(� 5wf`t`vL K /�✓ l f �f 47 Phone Number: ( oa Suffolk County Tax Map Number: 1000 - Property Location:_ t �V22&x AV // �S � 11 (provide LILCO Pole#, distance to cross streets, and location) AGENT: A` 4 (If applicable) Address: Phone: Board of Trustees Appli :ion GENERAL DATA Land Area(in sq are feet): Area Zoning: Previous use of pro erty: Intended use of prop y: Prior permits/approvals or site improvements: Agency Date No prior permits/appro als for site improvements. Has any permit/approval ever b en revoked or suspended by a governmental agency? No Yes If yes,provide explanation: Project Description (use attachments ifn cessary): emm'W'71 9a. RhLt-& -�O e 4- 'Qbv� lj�ed d hac Pd) 0C P 00ded /91/ t14 01/1 Py-an"I 6/10 LJ OL 6ti n o-'I(C� 1 0& r Board of Trustees Appli ;ion WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: / ®` ' r 7 l Co IVC,[�4r� 4/vAVIAv� 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: feet Does the project involve excavation or filling? No Yes If yes,how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which mate�'al will be removed or deposited: feet Proposed slope throu out the area of operations: Manner in which mate 1 will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operation (use attachments if appropriate): PROJECT ID NUMBER 617.2:, SEAR APPENDIX C 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 3 PROJECT LOCATION Municipality Nr, County 4.PRECISE LOCATION Street Addess and Road Inter ections, Prominent I ndmarks etc -or provid�mapld=a C�`c�t � �`�:�.4 &til f�l"��:t�/C , 5.IS PROPOSED ACTION New ❑Expansion ❑Modification/alteration 6.DESCRIBE PROJECT BRIPf LY- /V LA 'If- cq G a,4-ic tv A I ed e-Lo �C' 0 V'-e- 7.AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8 WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? 19Yes ❑ 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) ElYes 9No If yes, list agency name and permit / approval 11 DOES ,ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes MINo If yes, list agency name and permit / approval 12 AS-A RE ULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? Oyes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Date: Signature If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART If - IMPACT ASSESSMENT(To be completed by Lead Agency) /v4 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. EjYes ❑ No B WILL ACTION RECEIVE COORDINAT REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617 62 If No,a negative declaration may be superseded by anothe involved agency 0 Yes 0 No C. COULD ACTION RESULT IN ANY ADVERSFFECTS ASSOCIATED WITH THE FOLLOWING (Answers may be handwritten,if legible) C1 Existing air quality,surface or groundwat quality or quantity,noise levels,existing traffic pattern,solid waste production or disposal, potential for erosion,drainage or flooding p oblems? Explain briefly. C2 Aesthetic,agricultural,archaeological,historic, r other natural or cultural resources;or community or neighborhood character?Explain briefly: C3. Vegetation or fauna,fish,shellfish or wildlife specie significant habitats,or threatened or endangered species?Explain briefly C4. A community's existing plans or goals as officially adopted,Nr a change in use or intensity of use of land or other natural resources?Explain briefly C5 Growth,subsequent development,or related activities likely o be induced by the proposed action?Explain briefly L J C6 Longterm,short term,cumulative,or other effects not identifle in C1-05? Explain briefly C7 Other impacts(including changes in use of either quantity or type ol energy? Explain briefly I—-- I'll A .... D WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CH RACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA(CEA)? If es,ex Iain briefl Yes ❑No s E. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POAFNTIAL ADVERSE ENVIRONMENTAL IMPACTS? If xes ex Iain: El Yes F-1 No PART Ill-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether i is substantial,large,important or otherwise significant. Each effect should be assessed in connection with its(a)setting(i.e.urban or rural); )probability of occurring; (c)duration;(d)irreversibility;(e) geographic scope; and (f)magnitude If necessary,add attachments or referen a supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and dequately addressed. If question d of part ii was checked yes,the determination of significance must evaluate the potential impactof the propo ed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse\onftachments which MAY occur.Then proceed directly to the FULL EAF and/or prepare a positive declaration Check this box if you have determined,based on the information and analysis above supporting documentation,that the proposed actio WILL NOT result in any significant adverse environmental impacts AND provide, as necessary, the reasons supporting thi determination. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title o esponsible 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 61qj 6-I---,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 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. a' I / l ey'4' Signature SWORN TO BEFORE ME THIS DAY OF �'LL 20 otaryoPublic JOSEPH H.GIBBONS Notary Public,State of New York No.524618265 Qualified in Suffolk County Commission Expires April 30. 1 —s r 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 n_ecessary to avoid same. YOUR NAME: (�✓63 GAYS ��I �- i C',� (Last name,first Aame,.piiddle 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 t 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 employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of t "hares. 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 applic4nt (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 thi9, ,,L � da f ,�ff�l /200 Signature11 W111__VL1 Print Name Form TS 1