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Home My WebLink AboutTR-1155 Glenn Goldsmith, President af so U ®� Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly CO2Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD September 15, 2022 Martin D. Finnegan, Esq. Finnegan Law, P.C. P.O. Box 1452 Mattituck, NY 11952 RE: DEBRA A. ROTH 2012 FAMILY TRUST c/o WILLIAM M. ROTH, TRUSTEE _ 570 MASON DRIVE, CUTCHOGUE SCTM# 1000-104-7-2 Dear Mr. Finnegan: The following action was taken at the Southold Town Board of Trustees regular meeting held on Wednesday, September 14, 2022: RESOLVED, that the Southold Town Board of Trustees APPROVE the request for a Transfer of Wetland Permit #1155 from Henry D. Wong to Debra A. Roth 2012 Family Trust c/o William M. Roth, Trustee, as issued on June 7, 1976. Any other activity within 100' of the wetland boundary requires a permit from this office. This is not a determination from any other agency. If you have any questions, please contact our office at (631) 765-1892. Sincerely, Glenn Goldsmith, President Board of Trustees GG/dd Glenn Gdlasmith,President ~�o�OS�FFO(,��oGy�'� Town Hall Annex A.Nicholas Krupski,Vice President 54375 Route 25 Co Eric Sepenoski P.O.Box 1179 Liz Gillooly �y • �� Southold,NY 11971 Elizabeth Peeples � �a Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: ILT At Completed in field by: Martin D. Finnegan on behalf of DEBRA A. ROTH 2012 FAMILY TRUST c/o WILLIAM M. ROTH, TRUSTEE requests a Transfer of Wetland Permit#1155 from Henry D. Wong to Debra A. Roth 2012 Family Trust c/o William M. Roth, Trustee, as issued on June 7, 1976. Located: 570 Mason Drive, Cutchogue. SCTM#: 1000-104-7-2 Type of area to be impacted: Tye Saltwater Wetland Freshwater Wetland Sound Bay Part of Town Code proposed work falls under: Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No ' Not Applicable Info needed/Modifications/Conditions/Etc.: Present Were: G. Goldsmith J N. Krupski. E. Sepenoski L. Gillooly E. Peeples FINNEGAN LAW, P.C. 13250 MAIN ROAD P.O. BOX 1452 MATTITUCK,NEW YORK 11952 (631) 315-6070 MARTIN D. FINNEGAN, ESQ. MFINNEGAN@NORTHFORK.LAW Via USPS Regular Mail E E 15 D August 2, 2022 )its '"a Town of Southold Board of Trustees Southold TOWA 54375 Route 25 � Board of Trust®Ds Post Office Box 1179 ! Southold, NY 11971 Attn: Glenn Goldsmith, President Re: Transfer of Trustees Permits 570 Mason Drive, Cutchogue SCTM 1000-104.00-07.00-002.000 Permit Nos. 1921C; 0083C/5530; 10-88-104-7-2; 1898; 1155 z Dear Trustee Goldsmith: Please consider this letter a request to transfer the referenced permits from Geoffroy Penny and Henry and Ann Wong to the Debra A. Roth 2012 Family Trust, as they are the new owner of the subject parcel effective July 14th,'2022. . I have enclosed a copy of the executed deed for your records, along with an executed Affidavit, Owner's Authorization, Owner's Transactional Disclosure Form, Agent's Transactional Disclosure Form, and an attorney escrow check payable to the Town of Southold in the amount of$250.00 for the required transfer fees for all five (5) permits. J Kindly advise our office if you require anything further to process this request. Very y o .rs, Martin D. Finnegan MDF/as Encl. cc: William M. Roth i Board of Trustees 1 `aication AFFIDAVIT WILLIAM M. ROTH, AS TRUSTEE OF THE DEBRA A. ROTH 2012 FAMILY TRUST 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 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 z OF THE PERMIT. Signature of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS 14TH DAY OF JULY , 20 22 Notary Public MARTIN D. FINNEGAN Notary Public, State of New York No. 01 F16056707 Qualified in Suffolk Coun Commission Expires March 26, 022 Board of Trustees A Lication AUTHORIZATION (Where the applicant is not the owner) WILLIAM M. ROTH, AS TRUSTEE OF THE I/We, DEBRA A. ROTH 2012 FAMILY TRUST } owners of the property identified as SCTM# 1000- 104.00-07.00-002.000 in the town of SOUTHOLD ,New York,hereby authorizes MARTIN D. FINNEGAN, ESQ. to act as my agent and handle all necessary work involved with the application process for permit(s)from the Southold Town Board of Trustees for this property. Property Owner's Signa a Property Owner's Signature SWORN TO BEFORE ME THIS 14TH DAY OF JULY 92022 Notary Public MARTIN D. FINNEGAN Notary Public, State of New York No. OVI6056707 Qualified in Suffolk County Commission Expires March 26,20 APPLICANT/AGENT/RLA-PRESENT A.TIVE TRANSACTIONAL DISCLOSUU FORM The Town of$outhold's Code of Ethics lyoliibits conflicts of interest on-the.Dart oftown officers and employees.The'ourpose'of this form is to provide inforinfition which can alert the town of possible conflicts of interost aoil'a11ow it to take wliatevcr action is ncbcm2q to avoid same. WILLIAM M. ROTH,AS TRUSTEE OF THE YOURNAME: DEBRA A. ROTH 2012 FAMILY TRUST (Last name,first name,iriddle initial,unless you are applyingiii 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 X 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 f,rough your'company,spouse,sililirig;paeent,or child)have a reladogsh'ip.with any officer or employee of the Town of S.outliold? "Rehitionship"includes by blood,plarriage-or business iittcresL"13tisiii ss iirteresC'means a busiiicst. including a partnership,in which the town officer or employee has even a partial ownersltip.of(or employment by)a corporation in which the'towii officer or employee owns marc than 5%of the shares. YES NO Xr 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 applicantYagept/repeesentative)and the town officer or employee.Either check the appropriate line A)through D)find/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 carporation); C)an officer,director,partnei,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP ' 2022 Submitted this 14 d y o LY 260- Signature ' Print Name WILLIAM M. ROTH,AS TRUSTEE OF THE Form TS I D�EBRA A. ROTH 2012 FAMILY TRUST APPLICANT/AGENT/REPRESENT.A TIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold'§Code of Ethics prohibits conflict;of intorest o►r-tlie nart.of town;;Ricers and.emnjovecs:'1'iie-titmoseof tliis form is to provide inforinatioit Which can alert the town of possible conflicts of interest and tillow it to take whatever action is neccssaq to avoid"same. YOURNAME: MARTIN D. FINNEGAN (Last name,first name,jriddle initial,unless you are applying iii 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 V Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) tao.yau•personally(or through your;campany,spouse,sibling,parent,or child)have a relationship with uny.officer or employee of the"Town of Soiitliold? "ReiAtionship"inclrtiles by blood,�rlarriagc;or business iitteresk"Business interest'meaits°a business,. iricludirign,partnershij).,in which the town officer-or nmployce has e4en aparti4l owricisttip of(or employment by a corporationin which the town officer-or employee owns mdic than 5%bftile shares.- YES NO V i f 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 bo(ween yourself(the opplieant/agondrepresentative)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)"tlta owner ofgreater 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 L4th d JULY gee 2022 Signature Print Name MA D.F144EGAN Form TS I THIS INDENTURE..madc[lie (im oi,JUIV in lite year 2022 BETWEEN Geoffro w York. 1193-5 y L. Penny.residing at 570 Mason Drive,Cutchogue.Ne party i4the firm limi,and % William M.Roth,as Trustee of the Debra A.Roth 2012 FandlvTrusfj ! a2A-r 3�?,? eA,1-Tb- P14ckl, IJAPIes, FI- 3'floKS 111111%of thuwCond pall. 11'riNE,ssFT11,(hitt the party tit the first pall,ill colvideralioll of"I"...11 Dollars and other paid by the party tirtho second part.title.;,hereby grant mul rdcaic tilt.)tire Inuiv ol'the mccoed part.tire heirs or,.ukxcssov,and amsigilk vi' tile.party of'the sevolld Part lorevcr- ALLthan ceitain plot,piece or P..mM of land,with tile illiplovellient,ilrewonvr"ted,Nittuitv,lying and tvinl;ill the Hamlet of Culchogue,Towu of Southold,Counkv orSuffolk and State of New York,and more particularlv deNcribedat Schedule A attached hereto and made a part hercof. llrcniisys: 570 Mason Drive,Cutchogue,New York 1193i. Town Southolddes Board Of TOGETtim4 w.ub aft rigor.till,and miae.st.it:1111v.111,11le parry of first pact ol.in alld ill mly sweets and roads abutting OIr atlovv,dc%crillcll prclniwIII the cellicr filics T(.)(;I,-Fi1LI4 with the and all ific e�ullc and lights of[lie 11111IN of the firm put ill and to said jlretni.w,,:1*0 HAVE.ANfi.)To nmi)the pl-c-lilke,licrt:ill zramcd Unto the parry t'I'llic second pan,(Ile livil"of and a-ignN ol'the parl-,of'the secturd pitt Fmner. AND the jraiiy ofihc fir',(Intir CoNemillIN Illn(the rNoly of lbs.fil,t pall No;not done I,,,<trff-red an)ihiiq,,wlictetly the s;Ild pil-Iniso have been owumbewd in ally%la.v%%halever,v"Cept:1,ill ore"ai(L AND Ow parq of the 11im pn,in compliatict:with Seviton 13 orilic Lief/Law.C,n'coallts Illat tile parl\ofthefirt'i ilarl x0l rcceivi'the con,ik-raion I'm thk coolc%aoev:md will hold the riyfil mroc;ive ;I,a frum ILlild to be ajlpli�.d first for the pko,l)o,,of paying,ific Cost of the Improvement and will appIN the saitic first(,,the payment of the k'ost of the itriprovcniviv MOW a>ing any P.M Ili OW 101:11 01'111C sank Im ally other purpose, The%kord"priv-,hall be,onstnied as i1'it "patio"wilenewt.the wli.,c of till,ludelitille ml tetloires. IN WITNESS WHEREOF the partly of the first part has duly elcciricd dik deed tire day and year 1-irst above%vnuen. IN ........---....... ............... ......................................................--.................................... ....................... ....................... ................ FIDELITY NATIONAL TITLE INSURANCE COMPANY TITLE NO.7404-014383 SCHEDULE A-1 (Description of the Land) For Tax Map 1D(s): 1000-104.00-07.00-002.000 AMENDED 7/13/2022 ALL that certain plot,piece or parcel of land.situate,lying and being at Bayview,in the Town of Southold.County of Suffolk and State of New York,bounded and described as follows: BEGINNING at a found concrete monument on the Southerly line of Mason Drive said monument being distant 678.06 feet Westerly from the intersection formed by the Westerly line of said Broadwaters Drive and the Southerly line of Mason Drive: THENCE South 12 degrees 08 minutes 10 seconds East 326.50 feet to tie One along mean high water mark of Haywaters Cove: THENCE Southwesterly along said high water mark of Haywaters Cove along two(2)tie lines: 1. South 72 degrees 16 minutes 52 seconds West 42.75 feet: 2. South 63 degrees 32 minutes 56 seconds West 12154 feet to lands now or formerly of Patrick Sweeney: THENCE,along said lands,North 8 degrees 05 minutes 30 seconds West 337.03 feet to the Southerly line of Mason Drive; RUNNING THENCE along said Southerly line of Mason Drive the following two(3)courses and distances: 1.North 62 degrees 24 minutes 30 seconds East 65.76 feet; 2.North 72 degrees 24 minutes 30 seconds East 73.49 feet to the point and place of BEGINNING. THE POLICY TO BE ISSUED under this commitment will insure the title to such buildings and improvements on the premises which by law constitute real property. FOR CONVEYANCING ONLY: Together with all the right,title and interest of the party of the first part,of in and to the land lying in the street in front of and adjoining said premises END OF SCHEDULE A Commimentfor'ide Insurance Pnmed 07 13 22 03 02 PM "SchWule A-1 De=Aon - NY-FT--'RVH-G!030 431004-SPS-1-22-7404-014383 State ofNew Vork.County ur Suffolk }ss.: staw or New Vork.County orSuffolk 77x On tile lfl day ofjUly in lite vear2022 on tile day of in the year before,me.the undersigned.riersonally aplicared before me.the undersigned.Personally appeared Geoffroy L.Penviv personally known to nw or proved to me on tire basis of satisfactory rier-ainally known to site or proved to nit!on the basis of satisfactory evidence to be the individual(s)whose unniets)is(arc)subscribed to the evidence to he the individual(%)Mime numeW is(are)subscribed to the within instrument and acknowledgLil to me that bJ-.%W-they executed within instrument and acknowledged in me fluit he/slichlicy executed the same in hiMierAlwir capacity(iLs). and that by liivltcr/(hcir tile same in his/her/their capacityfics). and that by biAwAlicir signa lefs)!%%ll;g unify).or tile fler.-A)"upon -;ignaturuts)oil the instrument.the individual(s).or the person upon behal of which executed lite inswuntern. behairor which the individual(s)wed.executed lite instrument. NOTARY PUBLIC. 13 IC,STATE OF NEW YORK Regts No.b2.1A&0525Is QuaGtied in Suff. County rf Commission Expires February 13, A c jLvoujxjjr,.%1F-%7 FoJut FOR USE 1WHIN NEWYORK STAIE'MIX.- 1-*OR U-9.'00"VIDE'NEW YoRK Sri IT., IN"Ir Y"JASIllnerildlig 11411m.,Arin...Wkyurni jot(forkaf—,)1`wmp)Gotrial A,knw./n/Vt1lorl 0.11ifiraft I ';late ofNew York.Couniv of ss.: .................................................. 104,rplae Vraur u-411.5rale.("'Imin.P-rtmv to Mod,11whil., Oil the day ol' in lite year before me.the undersigned.personally apKtrcd Ort IIU-- day of in the year * be lbre:lite.lite unden4ywd.personally apivarcd the subscribing witness to lite forceiling instrument.withwholl,I ant personally aciluainwd.who.beingbeingby tile duly swam.did depose and fierwrially known tome or proved to me till the hasis of satisfactory hay that lie/she/they residels)in evidence to to lite individual(,.-)whose nallw(s)is(tire)subscribed to tile within instrunwrit and acknowledged to lite that heAlletilicy executed tie same in Iiis/K-r/dwirCapaCity(iUN).dint by Ili.-Ater/theirsignaturcisi, ifam-.thereeft that licklicidwy i4iow(%) on tie instrument.the individual(s).orthe per%on upoubehall'ol'which the individual(s)acted.executed lite instrument.and that such individual to he the individual described in and who executed tile forepliq made such apiwaxatwx below the untlersigned in the in%trumcne.that said subscribing whn;:%%was present:rod saw said execute the same.and that said witness at the-,anic time subscribed Mixei't the vin-or other prolilit-filstAlivixion and rhe state sir t-womy rij- hiAicr/their name(.%,)is a witness-11wrelo. tither plave. the i I u-bunt-leilkillen,was Luken). B,%R(;Al%'&SAix.Min) %V1 In(41TS AGMMI CR%V1111i M IN D14.'nelm'100 swi-lok.129.00 i3l.oCK 01.00 urr 006.000 COUNTY Ult 170WN Suffolk 'ht kl•COkAIiB,t 1'X1•:(11 7:51 OF Fidelity National rifle lusuratwe Company RDFLI,ry NATIONAI,Trri,F INS('ItA.NCI-*COMPANY A,AidefiV w 0 0 Ic 0 LL0 LU tt0 11 W U) U) at U) ta cc Board Of Southold Town Trustees SOUTHOLD, NEW YORK PERMIT NO ...... 1...1..55 ................. DATE: ..J. uzze....?.,.....:J9 76 ISSUED TO ....................... Henny.....D ...... W. ong ................................................................... Pursuanf fo fhe provisions of Chaplet 615 of fhe Laws of fhe Sfafe of New York, 1893; and C,hapfer 404 of fhe Laws of ~he Sfafe of New York 1952; and fhe Sou~rhold Town Ordinance en- fiflecl "REC=ULATINC= AND THE PLACINC= OF OBSTRUCTIONS IN AND .ON TOWN WATERS AND PUBLIC LANDS and fhe REMOVAL OF SAND, ®RAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;" and in accordance wifh 'the Resolufion of The Board adopfed afa meefing held on ,.,Tt~e:_-7.., ..... 19.:.'Z.6 .... and in cons~derafion of fhe sum of $......16.,.]50. ....... paid by · ................................... Hen~y....:D ....... .lg. ong .................................................................................... of Mason Drive_ C.u~cho.gue~..._N,..Y .................................... :. N. Y. and subjecf fo fhe Terms and Conditions lisfed on +he reverse side hereof, of Soufhold Town 'Trusfees :aufhorlzes and permifs fhe following: permission to place ramp, £loat, and 2 pilings Haywater property at Cove, directly in front of applicant's on Mason Drive, Cutohogue. all in accordance wlfh the derailed specificafions as presenfed in fhe orlginafing application. IN WITNESS WHEREOF, The said Board of Trusfees here- by causes ifs Corporafe Seal fo be affixed, and fhese presenfs fo be subscribed by a majorlfy of fhe said Board as ..of/f~.s dale. ............... BOARD OF TOWN TRUSTEES Town of $outhold Main Road Southold, New York 11971 P/1 Rev/6/~2 To: ........... .Henry...i~,....~ong~.._Mas om.. 1~. m~ze.,...C.u.C.al'~og~e 9.. N.-.Y ....... .J..l 9.35 .................... 1. Your application, dated ............. ~...a.y.....2.3.,...J.9~..~. ......................... ' ..... has been reviewed by this Board, at a meeting of the Trustees held on .......... .~.'bl~0..e....~....1.~).7..~. ...................................................... and resulting in the action, as indicated below: ( ............ ) ( ............ ) Application approved. Application denied. Application tabled. 2. Comments and remarks: PLEASE REMIT BALANCE OF FEE AT YOUR EARLIEST CONVENIENCE. ramp ,2½' X 10'= 25sq. ft. @ 10¢ per sq. float 6' x 20'=120sq. ft. @ 10¢ per sq. 2 pilings @ ~1.00 = 3. If your application is approved above, A Permit Fee is now due, arid should be made payable to the order of the Board of Southold Town Trustees. This fee is computed below according to the Schedule of Rates as set forth in the Instruction Sheet (Form I/1). If the Permit Fee is paid in person to the Secretary of the Board, The Permit will be obtainable at the same time. If the 'fee is paid by mail, the permit will be mailed in reply. Computation of Permit Fee: ft. = $ 2.50 ft. ~ 12.00 2.00 $ 16.50 less ~5.00 filing fee paid ,~ .... .~.~.00~ ' (. Total Fee for this application .............$.'1.6,.:,q0 ............................... ¢,$ ......... $.J.I~,9.0AM0.U~..DU Signed .....AL.'q'AH..~ .... GOLD~M~T~,....C[HAI~AN Chm. Board of Southold Town Trustees. by ..... ....... '-' BOARD OF SOU?HOLD TO'.~,~ TRUS.'TEES APPLICATION FOR FIXED and/or FLbATING DOCKS Applicant's name & address:~___~__p~6~ .... Con~ractor's name & address:__~~/~/~ Briefly explain thepurpose of this application: A/2 ~*e~/72.. After issuance of a Permit~ I expect to: (mark by an X) (a) Commence work ..... AT ONCE~'; ASAP UNKNOWN (b) Complete work in~IDAY ; iMO~; tYRo__; FUTURE__. Secure the correct Area Map from the Secretary of this Board,and by using an X ~JiTH!N A CIRCLE indicate as closely as possible the location of this dock~ On the reverse side of this map~ provide a SCALE DRAWING which will show Ordinary High Water Mark~ the shape and size of the dock and any supplemental pilings which are needed to hold a floating dock or tie~up a boat~ Give all dimensions necessary to determLne the area of the dock surface which extends offshore from the OoH~W~M. Will any nortion of this construction extend offshore into To~ Waters beyond an imaginary line or boundary formed by other similar structures along the area~s shoreline? ~or NO. If it does extend beyond this so~caited dock line indicate by how far ~approximately, ft. Provide the following documents: (a) A Licensed Engineer's Survey of the property invo!ved. (b) A copy of the Contractor's Plans & Specifications~ Will this construction require the Filling of any land offshore of the Ordinary High Water Mark or the Dredging of any material from Town Lands under water? ~ or NO. If it does~ Form A/4 (Application for Dredging/Filling) must be completed and a~tached as part of this appiication~ In rehuesting approval of this application~ I s~bmit that: the info~mation presented herein is true and correct to the best of my knowledge and belief~ i am the person accountable for the performance of the work in accordance with the plans and spec- ifications attached ; I have read or am familiar with the pro~ visions ~f any Southold Town Ordinance pertinent to the work invo!ved; and further~l intend to a44here~.to and abide by the Terms and Conditions of the Per~it,/~hen and ~f is sued to me~ - ..... , Accepted by: ~ Dated:~j2 . 0v¢ OOV¢ × /o~ / / / / / / ? TOWN OF $OUTHOLD