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HomeMy WebLinkAboutFlecken, Leo Glenn Goldsmith, President ®��®� S0lug ®� Town Hall Annex A. Nicholas Krupski,Vice President ® 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly G � Telephone (631) 765-1892 Elizabeth Peeples ® `r® Fax(631) 765-6641 C®Uf�`8,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD December 7, 2022 Hailey Jackson Islandwide Engineering & Land Surveying 751 Coates Avenue, Suite 22 Holbrook, NY 11741 RE: LEO & MICHELLE FLECKEN 555 GRAND VIEW ROAD, ORIENT SCTM#: 1000-14-2-3.28 Dear Ms. Jackson: The Southold Town Board of Trustees reviewed your letter dated November 18, 2022 along with the survey prepared by John Gerd Heidecker, NYS Land Surveyor, dated April 12, 2022, and site plan of Islandwide.Engineering & Land Surveying, D.P.C., last dated November 1, 2022 and determined that the proposed construction of one story single family dwelling on the captioned property is out of the Wetland jurisdiction under Chapter 275 of the Town Wetland Code and Chapter 111 of the Town Code. 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 is your responsibility to ensure that all necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdiction and Coastal Erosion Hazard Area, which may result from your project. Such precautions may include maintaining adequate work area z 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, Glenn Goldsmith, President Board of Trustees GG:dd Unauthorized alteration or addition to this survey is a violation of section 7209, subdivision 2, of the New York State Education Law. Copies of this survey map not bearing the land surveyor's inked or HEIDECKER LAND SURVEYING embossed seal shall not be 7 considered to be a valid copy. fl, s rEC ees 00M C: ORAND VIEW ®RIVE a ' I I DISTRICT 1000 DISTRICT 1000 SECTION 014.00-BLOCK 02.00-TAX LOT 003.026 SECTION 014.00-BLOCK 02.00-TAX LOT 003.027 N/F MCPIKE FAMILY TRUST N/F JED & HEATHER FINN LIBER 12924-PAGE 526 LIBER 12596-PAGE 77 7083-LOT 23 FILED MAP N0. 7083-LOT 22 FILED MAP N0. W O WELL 0 I TREE/BRUSH LINE (C) I �a u 10" a- Z N 82°10'40" E 7(5) 6„ �. '° �- r-- _ 387.86' C z z cS. 14" >>• 10" TREE/BRUSH LINE 12 — C MEIER� W i0 J _ �-\ 6„ �° � 10„ WD POST n?� D N 9 0 \ \ 16„ 6„ O 9„ � 14" � 1 1 „ \ 7 6 10" �1 \ \ DISTRICT 1000 \ N o \ SECT ON 014.00- OCK 02.00- X LOT 003. 8 7 Z ®/ \ o N/F LEO 8c MICHELLE FIL CKEN \ O _ \ LIBER 131,39 PAGE 214 �- �ILED MAP N0. 7083-LOT 2 \ \ o. 9,. Q Z / 10" O AREA- (Z \ Cp- Z 000 IRRIGATION POND O Q, (P WATER SURFACE=1.2' (4/5/22) 55,495— S-O-. 12"FT. \ \ o O R \ 0 1 .274 ACRE \ F_ � W � o o „ \ o CD ' D oz o (D V5 112" 17" Ld O EUw I O i O 1 C Q „ \ cs 07 N � 12" 10" 15 � r1___ z 0 (!) U ZO TRANSFORMER Q S 82°10' 0" ti \ 6" 11" CV 12" � 7" 352.07' w I q TREE/BRUSH UNE gR�SH UNE POINT O F BEGINNING TREE/ U 1 Z I( O U DISTRICT 1000 SECTION 014.00-BLOCK 02.00-TAX LOT 003.029 N/F SALVATORE CHIARELLI FAMILY TRUST LIBER 12960-PAGE 152 FILED MAP NO. 7083-LOT 25 I � 1 NOTES MAP REFERENCE 1. FIELD WORK WAS CONDUCTED APRIL, 2022 BY HEIDECKER LAND SURVEYING, PLLC MAP ENTITLED "SUBDIVISION MAP OF GRAND VIEW ESTATES AT ORIENT", FILED WITH THE AND ALL MEASUREMENTS WERE TAKEN ON THE GROUND. SUFFOLK COUNTY CERK ON JUNE 6, 1982 AS MAP NUMBER 7083. 2. PROPERTY LINES ARE BASED UPON DEED FILED WITH THE SUFFOLK COUNTY CLERK IN LIBER 13139—PAGE 214. 0 10 20 30 � 3. UNDERGROUND UTILITY LINES ARE NOT SHOWN. PRIOR TO CONSTRUCTION THE C, Z CONTRACTOR SHALL CALL 'DIG SAFELY NEW YORK" AT 811 AND HAVE ALL UTILITY METERS O 1'1�� LOCATIONS MARKED ON THE GROUND.FEET ', 11� 2Z4 4. ELEVATIONS REFER TO THE NORTH AMERICAN VERTICAL DATUM OF 1988 (NAVD 88) AND ARE BASED UPON GPS OBSERVATIONS PERFORMED BY HEIDECKER LAND SURVEYING, 0 20 40 60 80 JOH GERD HEIDECKER N.Y. STATE LAND SURVEYOR LIC. # 050719 DATE: SHEET N0. l /I � °- 751 COATES AVENUE APRIL 12, 2022 TOPOGRAPHIC BOUNDARY SURVEY 1 of 1 PLLc. GRAPHIC SCALE 1" = 20' i�F�/s �' X5011 ��,� SUITE 22 DRAWN B, B.M. SECTION 14—BLOCK 2—TAX LOT 3.28 pROJ. N0. F� LAND S�� (631)—HOLBROOK, 72 NEW YORK 11741 GRAND VIEW DRIVE 22HLS31 (631)-772-9604 CHK BY: J.H. ORIENT-TOWN OF SOUTHOLD CAD FILE: jheidecker®heideckerls.com SCALE: 1"= 20771 SUFFOLK COUNTY NEW YORK 22HLS31FP.DWG DISTRICT 1000 WELL SECTION 01N/F JBLOCK HEATHER TAX LOT 003.026 DISTRICT 1000 ll N/F JED&HEATHER FlNN SECTION 074.00-BLOCK 02.00-TAX LOT 003.027 � USER 12596-PAGE 77 RESIDENCEIWELL N/F MCPIKE FAMILY TRUST \ FILED MAP NO.7083-LOT 22 WATER I USER 12924-PAGE 526 169.8'TO FILED MAP NO.7083-LOT 23 4J 0 ( LEACHING RESIDENCEIWELL \� \ C GALLEY WATER a m \`j N 82"10'40" E \ °' 387.86 I Z z to W 1 � — — — — — 1 WD POST N O z - \ PRWELLED� I ; ROOF DRAIN \ " �-- - O PROPOSED Lo ELECTRIC \ 163.00'TO 1 LEACHING — — — GALLEY o _ _ I \ \ PROPOSED I STORY ✓ c7 \ BINDLE FAMILY DWELLING(6 BED) �Q d � BASEMENT=2556 SF (a AG = 622 SIF SOIL BOR ING ` DISTRICT 1000 �STFLE 2659 SF ROY K. REISSII SECTION 014,00-BLOCK 02.00-TAX LOT 003.028 FF.ELEV.=11.6 � G N/F LEO & MICHELLE FLECKEN \ `b 1LIBER 13139-PAGE 214 � MAY 14, 2022 $ FILED MAP NO. 7083-LOT 24 9, \ELEV 10.0 ROOF DRAIN f I I N.T.S. oY IRRIGATION POND u PT TOPSOIL o�N WATER SURFACE=1.2- (4/5/22) -, � OV ' � � n- SOIL BORING BROWN 0.3 � T T ELEV.10.0' omg PROPOSEDw SM SILTY 8� 1 (�� AREA 55 495 SF FENLOT 24 CE HO L 8-PROPOSED 9� SAND o 1.274ACRtzS \ D-BOX LEACHING W I 2.5' GALLEYS 2X4 \ Q HIGHEST PORCH /71 G'ORn of EXPECTED BROWN j__j GROUND SAND & , 0 0 I � TO PIL 14 WATER � AVE2 ELEV 4.05 I---- ,__ 10'MIN I � I I IT N ; W � ROOF DRAIN '`"1'-_r 1-'�'j FRESHWATER 50%FUTURE SP -O ` \ WETLAND 10'MIN EXPANSION \us O GRO U N D d OFFSET LINE WATER ELEV 1.0 ct TO PIL I l WET BROWN 1 ROOF DRAIN SAN I _ 3 SP 14.0' �/ \A DISTRICT 100-T I Ursa ' BECTON 014.00-BLOCK 02.00-TAX LOT 003.029 1 3 5 2.0 7' SUFFOLK COUNTY WELL DATA 82'10 .1 0\\L \ N/F SALVATORE CHIARELU FAMILY1152TRUST HYDRO ACTION AN !/) LIBER 12960-PAGE 152 FILED MAP NO,7083-4LOT 25 TREATMENT UNIT WI INTEGRAL ' HIGHEST G.W.EL.= 6.92(04119/2010) ca�J VACWNT VENT&CONTROL PANEL Ix I G.W.EL.CLOSEST TO TEST BORE=3.87(4/18122) I POINT OF BEGINNING DIFFERENCE IN ELEVATION=3.05 ELECTRIC FOR G.W.EL.TEST BORE= 10:0-9'=1.0=2.3' (5114122) TREATMENT UNIT I o ESTIMATED HIGH G.W.EL.=4.05' L, NOTES: I I 1. ELEVATION DATA BASED ON NAVD 1988 ULATIONS I I 2. NO NEIGHBORING WELL WITHIN 150'OF D �� M1� ^ � ,I ��P��A} I I PROPOSED SANITARY SYSTEM :. e 550 AI*AY l 1.5 i�. U.4Y )=307 SP 3675F/' L' 7 UNITS REGUI. 1= tb5 LOT 24 \�F NEwr NOV 2 2 r�hy�jrjPROJl. 53ALS P M. HqN �� MAP OF GRANDVIEW ESTATES \���� SITUATE SITE PL N Souftld Town ORIENT TOWN OF SOUTHOLD ' ISLAND WIDE ENGINEERING & sheet: 1 01 3 SUFFOLK COUNTY, NEW YORK 'A ti ��`` LAND SURVEYING, D.P.C. scale: 1i7 = 322 F ° 09B6g � CIVIL ENGINEERING-- SITE PLANNING -SURVEYING Date tNo. 22011 FILED: JUNE 8,'1982 p Date 0512612022 MAP No: 7083 i Drawn By EMH SCTM#. '1000-14-23.28 SIGNATURE-ERIC HANNINEN 751 COATES AVE, SUITE 22 Cl: (631) 487-5290 Revisions n ,110,12 2z SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES NYS LIC.4 098693 HOLBROOK, NY 11741 C2: (612) 245-4064 POLYLOK 20" HD COVER 054.2500 024.5010 06 0 POLYLOK RISER AS REQUIRED 024.e750 0730000 032,5000 024575 76 024.5010 FRONT/SIDE VIEW TOP VIEW CUT AWAY VIEW POLYLOK 20" D–BOX PART NO. 3017-20 PROVIDE ENDCAP 051.2500 076.0000 070.0000 MATERIAL – HDPE LEVELING DEVICES 0572500 DATE: 8/12/04 ON ALL OUTLETS 132 PROVIDE SECONDARY POLYLOK D—BOX DETAIL PROVIDE SECONDARY G Lc CONTROL PANEL SAFETY COVER W/HP80 COMPRESSOR SAFETY COVER N.T.S. Fi D—D3 E I HYDROACTION TREATMENT UNIT INLET r W L e OUTLET MAIN DWELLING ELEC PANEL CB 1 DP1_,____ _________O DOSING PUMP J B 104 F-1QUICK CB 2 RPI------ ------–--0 RECIRCULATION PUMP K F 09A DISCONNECT CB 3 MPI---______—__ _-0 MIXER PUMP SWITCH MIDWEST P065P CB 4 C1 AIR AIR HOSE 64 C—C 629643 PUMP TO DIFFUSER CB 5 A 6 t1 RECIRC TIMER ENABLED 24 PANETO ONTROL 0 -------- _ 66 325000 ISMO C-____________ __ HIGHWATER ALARM 47.5000 CIRCUIT BREAKER SPECIFICATIONS BILL OF MATERIALS ITEM PIN DESCRIPTION QTY: CB A - 30 AMP HA•180056 TANK,AN500 245 NITROGEN REDUCTION 1 CB 1 — 20 AMP ------- FIELD WIRING A 180055 TANK,AN500 245 PRETREATMENT 1 MANUFACTURER WIRING CB 2 — 20 AMP GROUND B 100118 COUPLING, 4' SCH 35 PVC SXS 1 CB 3 — 20 AMP C 240018 FO CONNECTING PANEL 24XIS 2 CB 4 — 10 AMP _____________ PNEUMATIC HOSE (FIELD INSTALL) C1 160028 ADHESIVE, CARTRIDGE 1 CB 5 — 10 AMP C2 240031 SCREW, 1- #10 SELF TAP PPH ZINC 2 D 760066 FASTENER, 3/8-16 X 3 3/4' AT HHCS 1 WIRING SKETCH D1 200013 NUT, 6 3 D2 200006 WASHERER,, 3/3/8-1616 SS 4 D3 200034 WASHER, SS 3/8' LDCKWASHER 1 E 100110 ASSEMBLY,RE-CIRCULATION 245 COMPLETE 1 F AP600-P AP600 ATU W1 PLATFORM COMPLETE 1 6 ECSO-30-LIOO-PLC EC50.30-L-100-PLC 1 H 100023 PIPE, 4' PVC SCH35 (1) 16' LONG I 100023 PIPE, 4' PVC SCH35 (1) 28' LONG 1 0 11 TEE, STRAIGHT 4' SCH35 1 10 23 PIPE, 4' PVC SCH35 (1) 10' LONG TYPICA RO ACTION AN500 DETAIL OF NEW NOV 2 2 2022 N.T.S. DE AIL S HEETSouthold Town ISLAND WIDE ENGINEERING & Sheet: 2 or 3 /1/ z� LAND SURVEYING, D.P.C. Sale: N.T.S. F °' 09869 ��' CIVIL ENGINEERING—SITE PLANNING ^- SURVEYING Project No. 22011 Date 0512612022 Drawn By EMH SIGNATURE-ERIC HANNINEN 751 COATES AVE, SUITE 22 Cl: (631) 487-5290 R vBons 11ro11202Y SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES NYS LIC.#098693 HOLBROOK, NY 11741 C2: (612) 245-4064 PROP. RES. GROUND ELEVATION 9.50 EL. 10.6 PROVIDE INLET "T" F.F. EL. 11.5 GROUND ELEVATION 10.0 GROUND ELEVATION 11.07 i INV. EL. 9.15 12" MIN. + INV. EL. 8,00 ` C/0 INV. EL. 8.85 TOP SLAB EL. 9.6 ELEV. 9.1 6' 10' 2.0' LEACHING GALLEY __ ___j HYDRO ACTION AN500 D-BOX 2 ROWS — 4 EACH INV. EL. 7.75 TREATMENT TANK INV. EL. 8,7 ELEV. 7.1 4" Tr 7'-10" (BUOYANCY KIT REQUIRED) INV. EL. 7,65 z 8'-6" 18" DIA. PIPE KNOCKOUT TOP VIEW N HIGHEST EXPECTED GROUNDWATER EL. 4,05 (EACH SIDE) t—V-10"I BOT. EL. 2.40 r®®_ ®®� SANITARY SYSTEM PROFILE ® ® ®\ / ® I V iV N.T.S. 10" 6" LEACHING HOLE, TIP. TYP DUMMY CUP, TYP. SIDE VIEW . • gib: RUBBER 3 LEACHING GALLEY DETAIL GA VANIZEDATED CABLE INCH N.T.S. NOTES: BUOYANCY CALCULATIONS w� 1. CONCRETE 4,000 PSI @ 28 DAYS WEIGHT OF AN600 TANK= 1000 LBS 2. REBAR TO BE ASTM A-615 GRADE 60 WEIGHT OF BUOYANCY KIT=3,600 LBS 3. WELDED WIRE FABRIC ASTM A-185 (2 x 12'x 1.5'x 0.67'X 150) RUBBER COATED INCH 18" 18" 4. DESIGNED FOR AASHTO HS-20 LOADING WEIGHT OF SATURATED SOIL ABOVE BUOYANCY KIT=3,880 LBS GALVANIZED CABLE 5. TOP SLAB AND WALL ARE MONOLITHIC (2 x 12'x 1.6'x 0.98 x 110) aO INTERNAL DRAIN WALL INTERNAL VOLUME DRAIN OPENINGS WEIGHT WEIGHT OF SOIL ABOVE BUOYANCY KIT ABOVE HIGHEST EXP.=11,664 LBS WALL HGT. AREA (SF) CF GAL. TOTAL SIZE I ANGLE (Lb.) (2 x 12'x 1.5'x 3.60'x 90) 4'-0" 68.0 128 957 48 3/4" X 6" 14 DEG. 1 7,675 TOTAL=20,144 LBS 3'-6" 59.5 112 838 40 3/4" X 6" 14 DEG. 6,500 BUOYANCY FORCE ON SEPTIC&TREATMENT TANK ASSUMING TANK (2)—CONCRETE DEADMAN 18"W X 8"H X 12'L AN500 2'-0" 34.0 sa 475 20 3/4" x s" 1a DEc. 5,325 IS EMPTY AND GROUND WATER IS UP TO HIGHEST EXPECTED GROUNDWATER WITH (2)—#4 REBAR CONTINUOUS EA. TANK V-6" 25.5 48 359 16 3/4" X 6" 14 DEG. 4,730 USE 57.25"DIA AND 73"DIA BASINS ANTI-BUOYANCY DETAIL 1'-0" 17.0 32 239 12 3/4" X 6" 14 DEG. 4,150 (17.88+29.07)S.F.X 1.65'=80 X 62.4=4,992 LBS N.T.S. 20,144 LBS SEPTIC TANK>4,992 LBS(4.03 FACTOR) LEACHING GALLEY DATA a)ECEVE DD NOV 2 2 2022 souttlold Town OF N E w y Board of Trustees DETAIL SHEET ISLAND WIDE ENGINEERING & sheet: 3 of 3 I 1/0. LAND SURVEYING, D.P.C. scale: N.T.S. 0986CIVIL ENGINEERING — SITE PLANNING — SURVEYING Project No. 22011 Date 0512612022 Drawn By Erm Ck SIGNATURE-ERIC HANNINEN 751 COATES AVE, SUITE 22 Cl: (631) 487-5290 Revisions 11/01/2022 SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES NYS LIC.#099693 HOLBROOK, NY 11741 C2: (612) 245-4064 Glenn Goldsmith,President A�®F so Town Hall Annex N ® 54375 Route 25 A. Nicholas Krupski, Vice President P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly Elizabeth Peeples � ® � Telephone(631) 765-1892 Fax(631) 765-6641 C®UNT`i,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD NON-JURISDICTION INSPECTION DATE OF INSPECTION: �1. G. ZO-77- INSPECTED BY: k' �Ch. 275 Ch. 111 COMMENTS: l ENGINEERING& ISLANDWIDE I LAND SURVEYING 751 Coates Ave-Suite 22, Holbrook, NY 11741 November 18,2022 Town of Southold Trustees D Town Hall Annex Building 54375 Rte.25 NOV 2 22022 P.O.Box 1179 Southold,New York 11971 Southold'fawn RE: LEO&MICHELLE FLECKEN Board of 555 GRANDVIEw RD.-ORIENT SUM No.1000-14-2-3.028 APPLICATION FOR LETTER OF NON-JURISDICTION Dear Trustees: We hereby submit one(1)original copy of the proposed plans,one(1)copy of the existing survey,agent authorization, affidavit from the homeowner,and check for issuance of a letter of non jurisdiction due to the location of proposed work being outside the 100'trustee jurisdiction limits for the above referenced project. If you have any additional questions or comments, please don't hesitate to contact our office,or email me directly at hailey@islandwideengineering.com. Very truly yours, Hailey Jackson 751 Coates Ave—Suite 22 Holbrook,NY 11741 Board of Trustees Application AUTHOMATION (Where the applicant is not the owner) I/We, Leo and Michelle Flecken owners of the property identified as SCTM# 1000- 14-2-.0,28 in the town of Southold ,New York,hereby authorizes_ Islandwide Engineering & Land Surveying 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 Signature Property Owner's Signature SWORN TO BEFORE ME THIS DAY OF �a,��v►n,�4�1— ; 202 Z JEFFREY J. PATANJO NOTARY PUBLIC-STATE OF NEW YORK _ No.01PA6418869 Notary P blic Qualified in Suffolk County My Commission Expires 06-21-2025 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code o.f Ethics prohibits conflicts of interest on-the part of town of kers and employees.The purpose of this fonn 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. YOUR NAME: Flecken,Michelle and Leo (Last name,first name,.giiddle initial,unless you are applying in the name of someone else or otherentity,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 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 D NO W] 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): -O_A)the owner of greater than 5%of the shares of the corporate stock of the applicont F-1 (when the applicant is a corporation); 13)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 a of 19 2024 Signature Print Name ta Fotm TS 1 Board of Trustees Application AFFIDAVIT Leo & Michelle Flecken 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 OF THE PERMIT. Signature of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS � f—�—I DAY OF D VeR ,20 2 Z ------- !� NotaryPublic SET=Jan3�2026 Notary Public 0State of Qualified inlk County My Commissio APPLICANUAGENTBEPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold"s Code.of Ethics'prohibits-conflicts-of interest:on-.the.par[of;town.,�ffrcers and employees.The numose of this`farm is 6-provide information which can-.alert_thelown_of possible,cotiffit.ofihi&est and allow into take-ovhate'vef acfion is; necessaryto avoid saiiie. . YOUR.NAME: Jeffrey Patanjo .(Last name,first name,.griddle initial,unless yo"u are applying-in the name of someone else or otherentity,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 ofZone 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 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 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/agrrnt/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): LiA)the owner of greater than 5%of the shares of the corporate stock of the applicant EL (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 USA day fA) " 202 Signatij, Print Name Form TSI RevlsbR3 13.iSBx w.xiea asses o1.xBa1 m.zwt to-tsa ttmaz oe-taw toa as 16Z3-0B - tb1613 A P.D.55 _�u ��• 6z zA F� t (=) t:µA m v+Md 9� 310 SSW m w SW0 V O 3 iMlq V � itAp(q SW=) '" J31 Y�J. Ji< n h sOUNa �6•\ ,w y w \ .Haat 1;10 O i 3 \ SONS 2 FO pg R PCL NO. IE-N= ESES 'N. mol MEN.t wcv 4.• J3J °O t 6 AWc) 1O - u �" nitx a mnw ta&lcica'�s'3B3 o-11 w 390 R +339 n .4 n FO OLTA(C) FOR PCL NO. FORPCL NO. RPCI..NO.•3 / ra ,f 13 to �zl n 302 SEE SEC.NO SEE SEC NO. SEE SEC.NO 1.1 1s " a3A as Ru.� a ,t>N Btsa3atu alBozatat moatasts �x SBNfcI 1.BAR1 '° MAINOLD +a tB.bNcl Jat z+ MAIN ur s7 10 t1 6 SEESEC.NO.OtB 4 maw. SEE SEC.NO.O1B ,0 3 11.1 S.R.25 fssy CL � f E °" (2,) �'° °Oi__ � __.__ war ° NOTICE COUNTY OF SUFFOLK © E tJB v SOUTHOLD SECTION NO G __ __ __ __ 7, , Real Property Tex Service Agency v E . Cowrcmravva�a.nrttBet v 014 U._.�. v w. �xt�u "w m ___ pomv. --•-- oma..--m-- Z,,,Yy~f' w P OtB cr xo 1000 PROPERTY MAP