HomeMy WebLinkAboutTR-3829 AMEND Board Of $outhoid Town
SOUTHOLD, NEW YORK
PERMIT NO.....3.~.g9, ................. DATE: May..2S,...19.90
ISSUED TO ~AA~[~ ~OSMY~A
Pursu~n~ ~o ~he provisions o{ Chapter 6t5 o{ ~he Laws
f~e Sfa+e o~ New York, I ~93, an~ C~ap~er 404 o{ +~e ~aws
5+afe o{ New York J952; end +he Soufhold Town Ordinance en-
titled 'REGULATING AND TH~ PLACING OF OBSTRUCTIONS
~N AND ON TOWN WATERS AND PUBLIC LANDS
REMOVAL OF SAND, GRAVEL OR OTHER MATE~IALS
LANDS UNDER TOWN WATERS;" and ~n accordance
Reso]ufion o{ The Boar~ ~op~ed afa meefing held or~ M~y Z~ ........
t~...~,0..,, and ~n c~nsiderMion o~ f~s sum o~ $ .............. paid by
o{ N.Y. and subiecf fo
Terms and CondO+ions Ils+ed on +~e reverse s~de ~reo~,
o{ Sou'rho~d Town Trusfees au+hor~zes and permits fhe
ccDstruct s t~mbar doc~ consisting o~'a ~ ~ ~0
~he or~glnM~ng application. Co~t~o~s: s 50~ vegeta~a~
along creek and installation of of ~ry W~i~ for, d:i~eway ~ road
run-off. ~N WlTNES5 WHEREOF, ~ne sam ~oar~ o~ Trus~eesh~re-
By causes ~ Corporate 5ea~ ~o ~e ~xed, and +hese
be subscrlbed by a majority o~ +he ~d Board as
Tr~ees
Albert J. Kmpski. President Town Hall
~"'3=~ :~%..~
John Holzapfel. Vice President ~[ 53095 Man goad
Jim King % %~'~ -~t~ ~ ~ P.O. BOX I179
Martin H. Gan-ell ~ ~ ~ll~' ~ Southold. New York 11971
Peter Wenczel ~' ~/¢~x%¥~? Telephone (516) 765-1892
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Onl~t~ ~ ~ -" ~-'~ v: ''
Coastal Erosion Permit Applicatior.t~]
~Wetland Permit Application ~NOV 2 -
Grandfather Permit Application
RR Waiver / Ama ndment / Chang_e,s
e~-~ved Application: //--~ ~ TOP N OF SOUT OLQ
eceived Fee: $/~-d . , - ....
Completed Application // ~ F~
Incomplete
SEQRA Classification:
Type I Type II Unlisted
Coordination: (date sent)
~ CAC Referral Sent: /~-~-TI"
--Receipt of CAC Report: ,
Technical Review:
~Public Hearing Held: Il--! r- ~ ~ ~7
--Resoiution:
Name of Applicant Martin Kosmynka
Address 1985 Pine Tree Road, Cutchogue, NY 11935
Phone Number:(516) 734-4059
Suffolk County Tax Map Number: 1000 - 98-1-11.2
Property Location: 1985 Pine Tree Road, Cutchogue
(provide LILCO Pole ~, distance to cross streets, and location)
AGENT: Eh-Consultants, Inc.
(If applicable)
Address: 1329 North Sea Road, Southampton, NY 11968
Phone: 516-283-6360
FAX~: 516-283-6136
~Ard of Trustees Applicatio~
GENERAL DATA
Land Area (in square feet): 16,306
Area Zoning: R-40
Previous use of property: Residential
Intended use of property: No Change
Prior permits/approvals for site improvements:
Agency -Date
Southold Trustees %3829 May 25, 1990
NYS DEC %1-4738-00110/00001-0 Sept. 20, 1990
USA COE %90-0149-L2 March 19, 1990
__ No prior permits/approvals for site imprevements.
Has any permit/approval ever'been revoked or suspended by a
governmental agency?
X No__ Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
Install (2) dolphins, consisting of (4) 8" diameter pilings
approximately 20' seaward of existing float for safe dockage
of owner's vessel.
Pf-~rd of Trustees Applicatior -.
WETLAND/TRUSTEELANDS APPLICATION DATA
Purpose of the proposed operations: Safe dockaqe of owner's
vessel.
Area of wetlands on lot: 656 square feet
Percent coverage of lot: 4%
closest distance between nearest existing structure and upland
edge of wetlands: n/a feet
Closest distance between nearest proposed structure and upland
edge of wetlands: n/a feet (mooring piles proposed in creek)
Does the project involve excavation or filling?
XX No Yes
If yes, how much material will be excavated? n/a cubic yards
How much material will be filled? n/a cubic yards
Depth of which material will be removed or deposited: n/a
feet
Proposed slope throughout the area of operations: n/a
Manner in which material will be removed or deposited: n/a
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):
The mooring pilings will be installed seaward of an existing
dock and will have no significant impacts on Town waters or
the adjacent tidal wetlands.
EN-CONSULTANTS I C.
1329 NORTH SE~ .
SOUTHAMPTON, N.~ 11968
5~6-283-~360
PROPOSED MOOING PILES
FOR M~TIN KOSMYN~ ON
LI~LE C~EK, CUTCH~GUE,
SUFFOLK CO.,
SHEET 1OF I
~,~ ~ ~, /~ ~/~ ~.,,~
PLOT eLAN ~. ~ /~
LOCATION SCALE I IN. ~ ~ JOB NO.
FINAL
Trustees Applicatio!'~:
Coun=y of Suffolk
St~e of New York
BEING DULY SWO
DEPOSES A1FD AFFIRMS THAT HE/~HE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PEP/~IT(S) AND THAT ALL STA~a~NTS CONTAINED ~I~EIN ARE
TRUE TO TSTE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL
WOP_K WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION
AND AS MAY BE APPROVED BY T~E SOB'~nOLD TOWN BOARD OF TRUSTEES.
THE APPLICANT AGREES TO HOLD THE TOWN OF SOB'£nOLD AND THE TOWN
ARISING UR-DER OR BY VIET~JE OF SAID PEP~MIT(S), IF GRARIki~. IN
COMPLETING TH!S APPLICATION, I HEREBY AUTHORIZE '~ TRUSTEES,
THEIR AGENT(S) OR REPFtESENTATIVES(S), TO E~'s~iR ONTO MY PROPERTY
TO INSPECT THE PRE/~ISES IN CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
Signature
Notary Public
B~-zd of Trustees Application,~
AUTHORIZATION
(where the applicant is not the owner)
I, ~_/~"~i~'~ ~. ~%~_ 'residing at/~6 ~~
(p~int owner of property) (mailing address)
~~~ ~'~ do hereby a~thorize
(Agent)
Southoid Board of Town Trustees on my behalf.
Owner ~ s signature ~
PROOF OF MAILING OF NOTICE _
ATTACH CEI{TIFIED MAIL RECEIPTS
Name: Address:
William Pishlinger 9 Madonia Court
Manhasset, NY 11030
Thomas Leviness 2015 Pine Tree Road
Cutchogue, NY 11935
STATE OF NEW
COUNTY OF SUFFOLK
doing business En-Consultants, Inc.
Robert E. Herrmann i~i~$~F~ at 1329 North Sea Road
Southampton , being duly sworn, deposes and says
that on the 29th day of October ,1998 , deponent mailed
a true copy o~ the Notice set forth in the Board of Trustees
Application, directed to each of the above named persens at the
addresses se~ opposit~ there respective names; that the
addresses set opposite the names o~ said persoris are the address
of said persons as shown on the current assessment roil of the
Town of Southold; that said Notices were mailed at the United
States Post O~fice at Southampton , that said Notices
were mailed to each o~ said persons by ~erti~ied)
Sworn to before me this 29th
day of October ,19 98
Z ~-~=~43 173 Z 514 943 ~72
US Post~J Service US Pos[~l Service
Receipt for Certified Mail Receipt for Certified Mai~
No Insurance Coverage Provided. No Insurance Coverage Provided.
Do not use for International Mail (See reverse) Do not use for Intemaflanai Mail (See reverse)
Postao. ~ $ ~2 ~. POSl~ge ~ ~
Celti§ed Fee / ~ ~:/ Ce~fled Fee /' 9 F
Spedal Delive~ Fee Speda[ Del[ve~ Fee
~- Whom &Oete Delivered ---~ // D ~ Return Receip~ /, /' ~
'~. Rett*mRe~eip~SJ~in~'l~-~:%~ .~,~ ~ Whom&D /
NOTICE TO .~DJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of
Martin Kosmynka SCTM~t000- 98-1-11.2
YOU ARE HEREBY GIVEN NOTICE:
!. That it is the intention of the undersigned to request a
Permit from the Board of Trustees to:
Install (2) dolphins, consisting of (4) 8" diameter pilings
approximatelv 20' seaward of existing float for safe dockage
of owner's vessel.
2. That the property which is the subject Environmental Review
is located adjacent to your property and is described as
follows:
1985 Pine Tree Road, Cutchogue, NY
3. That the properuy which is subject to Environmental Review
under Chapters 32,37,or 97 of the Town Code is open to public
comment. You may contact the Trustees Office at 765-1892 or in
writing.
T~he above referenced proposal is under review of the Board of
Trustees of the Town of Southold and dose not reference any
other adjacent that might have to review same proposal.
OWNEI%S NAME: Martin Kosmynka
MAILING ADDRESS: 1985 Pine Tree Road
Cutchogue, NY 11935
PHONE 0: 516-724-4059
Enc.: Copy of sketch or plan showing proposal for your
convenience.
APPLICANT
TRANSACTIONAL DISCLOSURR FORH
The Town of Southold's Cods of Ethics prohibits conflicts of
interest on the par5 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 sams.
(Last name, first name, midd.ls initi 1, unless
you are applying in the name of someone else or
otherentity, each as a company. If se, indicate.
the other person's or company's name.)
NATURE OF APPLiCATION~ (Check all that apply.)
Tax grievance
Variance
Change of Zone
Approval Of plat
E~emption from plat or official map
other
(If "Other," name ~he 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 Soathold? 'Relationship" includes
by blood, marriage, or business interest. -Buein~es
interest' meane a bueinese, including a partnerehip, in
which the town officer or employee has even a partial
ownership of (or employment b~) a corporation in which
the town officer or employee owns more than 5~ of 5he
shares. ~
YES NO
If you answered "YES," complete the balanue of this form amd
date and sign where indicated.
Name of person employed by the Town of Soutbold
Title or poeition of that person
Describe the relationship between yourself (the applicant)
and the town officer or employes. 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
noncorporate'entity (when the.applicant le not a
corporation)~
C) an officer, d!rector~ partner, or ¢mployee Of the
applicant; or
..D) the actual applicant.
DESCRIPTION OF RELATIONSIIIP
submitted this __day of 199
Town Hall
Albert J. Krupski, President 53095 Main Road
James King, Vice-President P.O. Box 1179
Henry Smith Southold, New York 11971
Artie Foster Telephone (516) 765-15~
Ken Poliwoda Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTI-IOLD
November 19, 1998
Mr. Robert Herrmann
En-Consultants, Inc.
1329 North Sea Road
Southampton, NY 11968
RE: SCTM#1000-98-1-11.2
Martin Kosmynka
Dear Mr. Hen-mann:
The following action was taken at the Southold Town Board of Trustees meeting on
November 18, 1998.
RESOLVED, that the Southold Town Board of Trustees grant the request for an
Amendment to Permit #3829 to install 2 dolphins consisting of 4-8" in diameter pilings
approx. 20' seaward of existing float for safe dockage with the condition that dock line be
removed in the winter.
However, this does not constitute approval from any other agencies.
If you have any questions, please call our office at 765-1892
Sincerely,
Albert J. Krupski, Jr.
President, Board of Trustees
AYK:lms
cc: DEC
ACE
;I :; 1329 North Sea Road
Southampton NewYork 11968
EN ~ Fax: 516-283-6136
,= E-maik encon @peconic.net
ENVIRONMENTAL SERVICES
October 29,
Town of Sou~aold
Board of Trustees
Post Ofl~c¢ Box 1179
Southold, New York 11971
Attn.: Diane Herbe~
Re: Mar~ Kosmynka
1985 Pine Tree Road, Cutdaogue
SCTM #1000-98-1-t 1.2
Dear Ms. Herbert:
In regardto the above r¢tbrenced property, enclosed are the foliow~§ for the Board of'Trustees review;
1. Three (3) W~land &~oast~t l~oii~ 1%~ Apphcations,
( includia§ Notice and Pruo~ of Maitin~ to adjace~ ownel~).
2. Three (3) Short Em/ironm~ntal Assessmem Forms.
3. Three (3) copies of authorization & disolos~e forms.
4. Thr~ (3) work plans.
5. Thr~e (3) copies of s~rvsy.
6. One (1) s~t of site photographs.
Application f~e 0f$150.00 w~lands.
I trust this information sha~l allow you to pro~e~s our p~rmit r~quost, Should any additional kfformatio~
t~ requirod, pl~aso do not ho~to to contact our office.
Coastal I~emem Specialist
Eric.
· ~ ~ ~ ~ P.O. Box 1179
Martin lq. Gan'ell ~,~ Sour. hold, New York 11971
~_,"P,~t~,~x%'v~/ Telephone (516) 765-1892
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
Coastal Erosion Per,it Application
Wetland Permit Application
'Grandfather Permit Application
Waiver/Amendment/Changes
Rec&ived Application:
Received Fee:$
Completed Application
Incomplete
SEQRA C~assific~tion:
TArpe I Type I~ Unlisted
Coordination:(date sent)
CAC Referral Sent:
Date of Inspection:
Receipt of CAC Report:
Lead Agency Determination:__
Tecknicai Review:
Public Hearing Held:
Resolution:
N~ne of Applicant Martin Kosmynka
Address 1985 Pine Tree Road, Cutchogue, NY 11935
Phone Number:(516) 734-4059
Suffolk County Tax Map Number: 1000 98-1-11.2
Property Location: 1985 Pine Tree Road, Cutchogue
(provide LZLCO Pole 9, distance to cross streets, and location)
AGEArT: Eh-COnsultants, Znc.
(If applicable)
Address: 1329 North Sea Road, Southampton, NY 11968
?hone: 516-283-6360
FAXg: 516-283-6136
Board of Trustees Application
GENERAL DATA
Land Area (in square feet): 16,306
Area Zoning: R-40
Previous use of property: Residential
intended use of property: No Change
~rier permits/approvals ~or site improvements:
Agency 'Date
Southold Trustees ~3829 May 25, 1990
NYS DEC ~1-4738-00110/00001-0 Sept. 20, 1990
USA C0E ~90-0149-L2 March 19, 1990
__ No prior perm~its/approvals for site improvements.
Has any permit/approval ever'been revoked or suspended by a
gover~menta! agency?
X No__ Yes
If yes, provide explanation:
Project Description (use attac.hments if necessa~t):
Install (2) dolphins, consisting of (4) 8" diameter pilings
approximately 20' seaward of existing float for safe dockage
of owner's vessel.
Board of Trustees Application
WET~LAND/T~UST~EELANDS A~PLtCATION DATA
Purpose of the proposed operations: Safe dockage of owner's
vessel.
Area of wetlands on lot: 656 s_~uare feet
Percent coverage of lot: 4%
Closest distance between nearest existing structure and upland
edge of wetlands: n/a feet
Closest distance between nearest proposed structure and upland
edge of wetlands: n/a feet (mooring piles proposed in creek)
Does the project involve excavation or filling?
XX No Yes
If yes, how much material will be excavated? n/a cubic yards
How much material will be filled? n/a cubic yards
Depth of which material will be removed or deposited: n/a
feet
Proposed slope throughout the area of operations: n/a
Manner in which material will be removed or deposited: n/a
Sta~e/nent 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):
The mooring pilings will be installed seaward of an existing
dock and will have no significant impacts on Town waters or
the adjacent tidal wetlands.
NOTICE TO ~JACEI~T PROPERTY. OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
in the matter of
Martin Kosmynka SC_V~4~1000_ 98-1-11.2
YOU ARE H~qEBY Gi%~_/~ NOTICE:
!. That it is the intention of the undersigned zo re~aest a
Permiz from the Board of Trustees to:
Install (2) dolphins, consisting of (4) 8" diameter pilings
apDroximatelv 20' seaward of existinq float for safe dockage
of owner's vessel.
2. That the proper~¥ which is the sllbject Environraen~al Review
is located adjacent ~o your property and is described as
follows:
1985 Pine Tree Road, Cutchogue, NY
3. That the properuy which is subject to Environmental Review
under Chapters 32,37,or 97 of the Town Code is open to D~blic
comment. You may contact the Trustees Office at 765-1892 or in
writing.
The above referenced proposal is under review of the Board of
Trustees of the Town of Southcld and dose not reference any
~ther adjacent that might have to review same proposal.
OWNEt%S NA/TE: Martin Kosmynka
~AiLING ADDt~ESS: 1985 Pine Tree Road
Cutchogue, NY 11935
PHONE ~: 516-724-4059
Eno.: Copy of sketch or plan showing proposal for ,/our
PROOF OF MAILING OF NOTICE
ATTACH CERTifieD MAIL REC~--I~TS
Name: Address:
William Fishlinger 9 Madonia Court
Manhasset, NY 11030
Thomas Leviness 2015 Pine Tree Road
Cutchogue, NY 11935
STAT~, OF NEW YORK
COURTY OF SLrFFOLK
doing business En-Consultants, Inc.
Robert E. Herrmann f4~i~ at 1329 North Sea Road
SouthamptQn , being duly sworn, deposes and says
tha~ on the 29th day of October ,1998 , deponent mailed
a ~rue c~py o~ the No~ice se~ f~r~ in the Board af Tr~aes
~plicanion, directed Zo each of ~e ~ove n~ed persons at ~he
~f said persons as shc~ on ~e c~rent asses~t roll of ~e
Town of Sou~otd; that s~d Nonces were mailed at ~e U~ted
Sta=~s Pest Office at Southampton , ~at said Nc=icss
were mailed to e~ ~f said Derso~ ~~~ ~,~)
mai! ..
Sworn to before me this 29th
day of October ,19 98
AUTHORIZATION
(where the applicant is not the owner)
(p'rin{' ownmr of property) (malllng address )
Southold Board of Town Trustees on my behalf.
County of Suffolk
S~a~e of New York
D~POSES ~ ~F~
~ ~ ~ BEST OF HIS/~
WO~ ~ BE DO~ IN ~ ~ S~ FOR~ ~ ~S ~LI~TIO~
~EIR AG~S) OR ~$~T~(S),
TO INSPECT ~E P~S~
~Li CATION.
S~gna~ure
,~ TO BEFS~ ~
NOTICE TO ~DJACENT PROPERTY. OWNER
BODLRD OF .~RUSTEES, TO~IN OF SOUTHOLD
In ~h~ matter of
Martin Kosmynka SCTM~1000- 98-1-11·2
YOU ARE HEREBY GIVEN NOTICE:
!. That it is the intention of the undersigned to re~aest a
o=__rm.~-u from the Board of Trustees to:
Install (2) dolphins, consisting of (4) 8" diameter pilings
aporoximatelv 20' seaward of existing float for safe dockage
of owner's vessel.
2. That the property which is the subject Environmental Review
is iccated adjacent uo your property and~s~ described as
follows:
1985 Pine Tree Road, Cutchogue, NY
3. That the property which is subject to Enviremmenta! Review
under Chapters 32,37,sr 97 of the Town Code is open to public
comment. You may contact the Trustees Office at 765-1892 or in
writing.
The above referenced proposal is under review of the Board of
Trustees of the Town of Southoid and dose not reference s_ny
other adjacent that might have to review same proposal.
OWNERS ND/~E: Martin Kosmynka
MAILING ADDRESS: 1985 Pine Tree Road
Cutchogue, NY 11935
PHONE ~-
7. 516-724-4059
Enc.: Copy of sketch or plan showing proposal for your
conve~e~ce.
~: PROOF OF MAILING OF NOTICE _
ATTACH cERTIFIED MAIL R~C~..S
Name: Address:
William Fishlinger 9 Madonia Court
Manhasset, NY 11030
Thomas Leviness 2015 Pine Tree Road
Cutchogue, NY 11935
STATE- OF NEW YO~K
COUNTY OF SUFFOLK
doing business En-Consultants, Inc.
Robert E. Herrmann , ~f~i<~ at 1329 North Sea Road
Southamuton , being duly sworn, deposes and says
that on the 29th day of October ,1998 , deponent mailed
a ~rue copy o~ the Notice se~ ~or~ in ~he Board of Tr~ees
Application, ~ractad to each of
ad~esses se= opposite there r~spec~ive n~es; ~a= ~e
ad,asses see opposite the n~es of s~d permo~ ~e the ad~es~
of said persons as shown on ~e c~rent assessor roll of ~e
To~ of Southoid; that s~d Notices were mailed at ~e U~=ad
States Post O~fice at Southampton that said Nctices
were mailed to each o~ said perso~ by ~ertiSiad)
mail ..
Sworn to before me t~s 29th
day of October ,19 98
Z ~19 943 173 Z 514 ~'43 1/72
US Postal Service US Postal Service
Receipt for Certified Mail Receipt for Certified Mail
NO Insurance Coverage Provided. No Insurance Coverage Provided.
Do not use for International Mall (See reverse) Donor use for International Mail (See reverse)
Board of Trustees Application
ALTT~Ot{I ZAT!ON
(where the applicant is not the owner)
i, ~-~'~l~ ~,. ~'~/'~,tfl?~'~- residing at/~ ~'~ J~
(prin~ owner cf pro~er~y) {mailing ad~ess)
( Agent
Southo!d Board of Town Trustees on my behalf.
Owner' s signa%ure~
Board o~ Trustees Application
County of Suffolk
State of New York
DEPOSES AND AFF!P~MS THAT HE/S~E IS THE APPLICANT FOR THE ABOVE
DESCRIBED PE-RMITIS) AND THAT ~LT. STATEMENTS CONTAINED ~i~EIN ARE
TRUE TO TPiE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND T~AT ALL
WORK WILL BE DONE IN THE MANNER SET FO~'i'a IN THiS APPLICATION
AND AS MAY BE APPROVED BY ~ SOb'~nOLD TOWN BOARD OF TRUST~V-S.
THE APPLICANT AGPMM$ TO HOLD THE TOWN OF SObTHOLD AND THE. TOWN
TRUSTEES HAILW~ESS AND -~P--EE ..=~_.OM .~/~Y- .~_ND .~J~L D~2~AGES ~,~ CLAIMS
ARISING UNDER OR BY VIRTUE OF SAiD PE~MIT( S), IF GRAR~'~D. IN
COMPLETING THZS APPLICATION, I HER~Y AUTHORIZE THE TRUSTEES,
THEIR AGENT I S ) OR REPP~ESENTATIVES ( S), TO E~'£~E ONTO MT
TO INSPECT THE PRSE.!!SEB IN CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
Si~nauure
Notary Pu~lic
APPLICANT
Th~ Town of Southold's Code of Ethics prohibi~s conflicta
interest on ~h~ part of ~own officers and employees. The
purpose of this form is to provide tllformatio~ which cai!
alert the ~own of possible co~%flicts of l~]terest and allow
it ~o take whatever action is necessary to avoid same.
· OU~ N~ 15 /~ &
(Las~ ~ame, [~rst .amc, m~d~.le iH~tial,
other entity, such as a company.
the other p~r~on's or company's name.)
NATURR OF APPLiCATION~ (check all that apply.)
Tax grievance
Change of zone
ARP~val O~ plat
Exe~ption from plat or offficial map
otber
(If "other," name the activity.)
by blood, marriage, or buetnese interest.
ownership of (or employment by) a corporation in which
the town officer or employee o~ne mere titan 5~ of the
eharee.
YES NO
If you answered 'YES,".complete ~he balance of this form and
date and sign wllere tndi~ated~
Name of person employed by the Town off Southold
Title or position of that person
Describe tho relationship between yourself (the applicant}
and the town officer or employee. Either check the
appropriate line A} through D) a~d/or describe in the space
provided.
The town officer or employee or his or her spouse, sibling,
parent, or child ia (check all that apply},
A) the owner of greater than ~% of the shares of the
corporate stock of the applic~nt (when the applicant
ia a corporation);
B) the legal er beneficial owser of any interest in a
nencorporate'entity (when the applioant ia not a
corporation);
C) an o~cer, dJ. ce~tor~ partn~r~ ~r ~mpl~y~ Of *.u
applicant; or
__D} the actual applicant.
EN-CONSULTANTS INg.
, 1329 NORTH SEA
3. ~m~r piles to ~ CCA-t~d
SCTM ~98-1-11.2
~- ~v,~
PROPOSED MOOING PILES
FOR M~TIN KOSMYN~ ON
LI~LE C~EK~ CUTCHOGUE~
SUFFOLK CO. NY
SHEET I OF i 10/2~/98