HomeMy WebLinkAboutHeller/Glassman Glenn Goldsmith, President �`e�®F sioU�y Town Hall Annex
A. Nicholas Krupski,Vice President ®�V ®�® 5 Route 25
P..O.O. Box 1179
Eric Sepenoski AL Southold, New York 11971
Liz Gillooly Telephone(631) 765-1892
Elizabeth Peeples � �� Fax(631) 765-6641
c®UM,�
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
July 1, 2024
Robert Hermann
En-Consultants
1319 North Sea Road
Southampton, NY 11968
RE: TRACY HELLER & MATTHEW GLASSMAN
4995 NASSAU POINT ROAD, CUTCHOGUE
SCTM# 1000-111-9-11
Dear Mr. Hermann:
The Southold Town Board of Trustees reviewed the survey prepared by Artemis Landscape
Architects, Inc., last dated May 17, 2024 and determined that the proposed construction of a
swimming pool, patio, and accessory garage are to be situated more than 100 feet from the top
of bluff, landward of a project-limiting fence that is to be installed along the 100-foot bluff
setback which deems the structures to be of the 100 foot Wetland jurisdictional area under
Chapter 275 of the Town Wetland Code and Chapter 111 of the Town Code.
Please be advised, however, that no construction, sedimentation, or disturbance of any kind
may take place seaward of the tidal and/or freshwater wetlands jurisdictional boundary, or within
100' landward from the edge of vegetated wetlands, without further 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 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.
Sincerely,
*_84"-
Glenn Goldsmith, President
EXISTING TREES AND SHRUBS .._
PROPOSED MASONRY POOL PROPOSED 4' HT. POOL CODE CEDAR TO REMAIN ARTEMIS landscape architects, inc.
PATIO AT GRADE POST AND WIRE MESH FENCE
761 SF 4 Washington Avenue, Floor 2
PROPOSED SILT FENCE Sandy Hook,CT 06482
PROPOSED POOL BACKWASH �\ Tel. 203.683.1808 - Fax 203.683.1818
DRYWELL LOCATION \ SEDIMENTATION AND
EROSION BARRIER \ 1 1 1 1 I I , I I 1 1 1 I I I " I
LIMITS OFCONSTRUCTIbN 1 1 1 1 l ' I ' l l 1 I ' I I I I ' I I ITIMBE ► LEGEND
LOT 31 DISTURBANCE 1 1 I 1 1 1 I I 1 I W/ I t ► NI I I WAL 1 (+10)- Existing Spot Elevation
EXISTING TREE TO REMAIN Q I 1 011 ) 1 SDI I / 10/ / ' / OI 1 1 I +10 - Proposed Spot Elevation
S6 Q f O I // / I --10-- Existing Contour
6 6 1 11 11 1 1 1 / I / /� / / / // •� , 1 0 10 Proposed Contour
isQ ` \ \ I 1 1 1 t r O \ -----------------------------------------
PROPOSED POOL EQUIPMENT Q . \ I 1 1 I I ! I 1 1 I I I I 1 100 1 BC-Bottom of Curb
\ 54.8
1 1 I I LOCATION / l I I I I I I I I I I I I % I BM-Benchmark
62) \ 1 1 I 60• CONC.WALL No \ 1 1 1 1 1 1 , 1 I l i BS-Bottom of Step
\ 1 U. \ ) o 1 1 1 1 1 1 1 1 1 1 �. —,•----•••I'-'-...�"'-I BW-Bottom of Wall
TRW .8 N .f-J-•I;''1'{"T-1t• 1 1 1 1 I EJ-Expansion Joint
)� PIPE LIN / 60' �QyyylyCl4.§FJ�lS•--• 1 1 I I 1 1 \ \ \ \ 1 1 I I FF-Finished Floor
/ Po I 1 t 1 1 \ \ \ \ 1 I TC-To of Coping
y _,,,_.,..�-.._..�• III \ 1 P
\ RYWEL _..--�• 1 1 l 1 \ \ \ \ \ \ 1 \ 1 1 P
105'-5" ) � , \ 1 1 1 TOC-To of Curb
C \ sty - - - d I I I I 1 1 \ 1 1 1 I I 1 1 1 I I TS-Top of Step
•�..�• I ` •a -.. ..
\ 1 TW-Top of Wall
\ 26-4" 11 - !. F' / - / IN SIDE POOLWALL-TOP OF BLUFF ?' 1 I I I f 1 I 11 1 ► I 1 ( y
\\ WELL I /'bN � � I i 1 I I >1 I / 1 1 I 1 11 ( 11 1 I I 1 ( I I CC-Carpentry Contractor
I .r J ° 0 ` - - W`14 I \ 1 1 TOP OF BLUFF' ` h I I I 1 1 = EC- Electrical Contractor
EXIST REES REMAIN FC-Fence Contractor
PROPOSE® I � I ' I I I i / I I 1 1 � \ \ \ \ � I \ m
\ Q \ I PROPOSED PROPOSED 0 54 I I 1 1+ \ \ 1 I 1 r- GC-General Contractor
\ \ \ I \ DW'A• I I TWO-STORY 1`'772 SF1 POOL 105'-2" I ' 1 ' I 1 1 1 1 \ \ I 1 1 1 I l ( 1 1 vN, LA-Landscape Architect
PRO SED D\RYWELL I GARAGE ,GRADE_ 42'x 18' 1 1 I \ 1 \ \� I 1 I 1 I 1 I I r LC-Landscape Contractor
OCATIONS I \ I 3�'�'3®' I LEVEL INSIDE PO WALL- SEST POINT TO TOP OF BLUFF 1� \ 1 \ 1 , I I I I I 1 O MC- Mason Contractor
hI 1 1 1 I I I I I 1 1
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IN,
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PROPOSED 4HT POOL CODE CEDAR M p
PC-Pool Co ntractor
PATIO I O
POST AND MESH FENCE mvW r- TBD-To Be Determin
ed
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106-11" 1 TYP-Typical
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2 X2 X36 STAKES, 12 O.C. t \ \ PROPOSED T. POOL E CEDAR Im I I I l 1 I I ' I I I I I co \ O.C.-On Center
T RND M FENCE LO EL 52.5 I I I ' I w 1 1 I I I I \ Z CL -CenterLine
DRIVEN 16" MIN. INTO GRADE, EMBED FILTER ` �� 50-0 1 Irt° 1 1 I I I l j01 l l I t 1 1
CLOTH 6" I NTO G ROU N D 1 i 6'6, \ \ 00 1 I� \ I ► 1 I I I I I I ' ' I I�V 1 1 I 1 Max.-Maximum
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14 GAUGE 1"x 2"SQAURE GALVANIZED WIRE MESH STAPLED TO CEDAR D � V '
POST OYR) MAGNA-LATCH VERTICAL PULL LATCH
PLAN VIEW 1 x 5 CEDAR FASCIA BOARD(tYR) 5'-101/2'O,C.
5 x 5 SQUARE CLEAR CEDAR POST j�
41/2', V-6'ONSIDE POST) 41/2•, (SEE DTL 1 THIS SHEET FOR POST DETAIU JUN 18 2024
1/2' 1/2' 1/2' (1)1 x 3 HORIZONTAL CLEAR CEDAR BOARD AND(1)2 x 4 HORIZONTAL CLEAR CEDAR
41/2' 3'-7 1/2" 1/2' 3'-7 1/2" 41/2", 6'-0"HT,5 x 5 SQUARE CLEA ,11,110
R CEDAR POST 2'81/4' 2'-81/4' BACK BOARD CUT TO MATCH 1 x 3 BOARD(1YP) BAN D
4'-0"O.C. 4'-0"O.C. (fYR) � 21/2'(TY�) 21/2'(rYP) Southold Town �� p,NON
CEDAR FASCIA BOARD 2 /2'(TYR)3/4'(IYR) 1/8 STAINLESS STEEL CABLE TENSION WIRE
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REVISIONS
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1t1 I; CEDAR BACK BOARD CUT TO MATCH 1 x 3 BOARD
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14 GAUGE 1"x 2"SQAURE GALVANIZED WIRE
FOR SURVEY, REFER TO A MAP ENTITLED
7
MESH STAPLED TO CEDAR POST C 'AMENDED MAP OF NASSAU POINT' OF PROPERTY AT
I I I
16"W4000 PSI CONCRETE BASE SET N 4995 NASSAU POINT RD, SOUTHOLD, NEW YORK
I .
- ( C 3"BE BY KENNETH M.WOYCHUK LAND SURVEYING, PLLC
LOW GRADE
_ T !
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ame & Wire Mesh Gate Detail P.O. BOX 153 AQUEBOGUE, NEWYORK 11931
2"AGGREGATE
1 BASED�ed�arF
�� TEL: (631)298-1588
I
Sccale: 1/2 = 1 -0
AND DATED JUNE 3,2023 JOB # 1032
:
4 -- - S.C.T.M#DISTRICT 1000-SECTION 111-BLOCK 9-LOT 11
I 1a R _ I j I I I
SD
INCL.
DRAWN By
FRONT VIEW
ISSUE DATE 5/17/24
0 10 20 FT NORTH SHEET
2 �edar Post & Wire Mesh Fence Detail
e: 1/2" = 1'-0"
771
SCALE : 1 " = 20'-0" S-1
This drawing and the details on it, as an instrument of service, is the property of the landscape architect, and may be used only for this specific project and shall not be loaned, copied or reproduced without the written consent of ARTEMIS LANDSCAPE ARCHITECTS, INC.
S.C.T.M.# DISTRICT 1000 SECTION 111-_B,LOCK 9 LOT 11
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12•oAK DWELLINGS WITH
PUBLIC WATER
1510'
LOT COVERAGE
1
BUILDABLE LAND(LANDWARD OF TOP OF BLUFF):49,441 S.F.or 1.14 ACRES
DWELLING: 1882 S.F.
COVERED STOOP: 135 S.F.
DECK: 81 S.F. r _
I I
DECK
ELEV. 52.0 ENCLOSED PATIO: 312 S.F. I I I
BLUFF DECK: 165 S.F. I 2 STY FRM. I
MIXED SAND COTTAGE: 788 S.F. I GARAGE r J
&LOAM 21 COTTAGE DECK:644 S.F. ` I , F I V 13 r"
TOTAL: 4007 S.F. or 8.1% _ �•-� r
SIP PALE
JUEI
BROWN
FINE SAND Soumold rows
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NO WATER )7' I -�
AUG. 75, 2023 I
McDONALD GEOSERVICES 2 STY FRM• i DEC I
1
I DWELLING V__J
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FEMA MAP#36103C0164H
THE WATER SUPPLY, WELLS, DRYWELLS AND CESSPOOL
I _J LOCA77ONS SHOWN ARE FROM FIELD OBSERVA77ONS
AND OR DATA OBTAINED FROM OTHERS.
BUILDABLE LAND(LANDWARD OF TOP OF BLUFF):49,441 S.F.or 1.14 ACRES
AREA: 63,621.2 SQ.FT. or 1.46ACRES ELEVATION DATUM: NAVD88
UNAUTHORIZED ALTERATION OR ADD177ON TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF 77-IE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY
MAP NOT BEARING 7H£ LAND SURVEYOR'S EMBOSSED SEAL SHALL NOT BE CONSIDERED 70 SE A VAUD 7RUE COPY. GUARANTEES INDICATED HEREON SHALL RUN
ONLY TO TPE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE 777LE COMPANY, GOVERNMENTAL AGENCY AND LENDING INS777UTI0N
LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE.
7HE OFFSE73 OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES 70 THE STRUCTURES ARE FOR A SPECIRC PURPOSE AND USE THEREFORE THEY ARE
NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES, ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS EASEMENTS
AND/OR SU$SURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT 7HE 7WE OF SURVEY
SURVEY oF:LOTS 32&33 INCL. CERTIFIED TO: MATTHEW GLASSMAN;
MAP OF:AMENDED MAP OF NASSAU POINT TRACEY HELLER; EMINENT ABSTRACT, INC.;
FILED:AUGUST 16, 1922 No.156 WESTCOR LAND TITLE INSURANCE COMPANY,
SITUATED AT: NASSAU POINT CITIBANK, N.A. ISAOA,ATIMA;
TOWN OF.SCUTHOLD KENNETH M WOYCHUK LAND SURVEYING, PLLC
SUFFOLK COUNTY, NEW YORK Professional Land Surveying and Design
4 P.O. Box 153 Aquebogue, New York 11931
FILE # 223.84 SCALE:1"=30' DATE:JUNE 3,2023 N.Y.S. LISC. N0. 050882 PHONE (631)298-1588 FAX (631) 298-1586
r
i
Glenn Goldsmith,President so Town Hall Annex
A. Nicholas Krupski,Vice President ,`®V� ®�® 54375 Route 25
P.O. Box 1179
Eric Sepenoski Southold,New York 11971
Liz Gillooly Telephone(631) 765-1892
Elizabeth Peeples a® Fax(631) 765-6641
CouMV,��'
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
NON-JURISDICTION INSPECTION
DATE OF INSPECTION: Ad Z-1
INSPECTED BY:
V Ch. 275 Ch. 111
COMMENTS:
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K ,a„°, loon seclun..a
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EN-CONSULTANTS
D C 2 � IN E e 5, 2024
Glenn Goldsmith, President L�
Board of Trustees JUN 18
Town of Southold
P.O. Box 1179 Southold Town
Southold,NY 11971 Board of Trustees
Re: Heller and Glassman, 4995 Nassau Point Road, Cutchosue (SCTM 1000-1-11-9-11)
Dear Mr. Goldsmith:
We represent Tracy Heller and Matthew Glassman, who plan to construct a swimming pool,
patio and accessory garage on the captioned property, as depicted on the site plan prepared by
Artemis Landscape Architects, dated May 17, 2024, which is based on the topographical survey
prepared by Kenneth M. Woychuk Land Surveying, PLLC, dated June 3, 2023, copies of which
are enclosed herewith.
As these proposed structures and related site disturbance will be situated more than 100 feet from
the top of bluff, landward of a project-limiting fence to be installed along the 100-foot bluff
setback, and thus outside the jurisdiction of the Board of Trustees pursuant to Section §275-
3(C)(5) of the Town Code, I am writing to request that you prepare a Letter of Non-Jurisdiction
stating that no Town Wetlands Permit shall be required for this proposed work.
In addition to the above referenced site plans and surveys, enclosed in support of our request are
site photographs; a copy of the deed; a check payable to the Town of Southold for $100; and
authorization forms signed by the property owners allowing En-Consultants to act as agent and the
Trustees to access the subject property.
Please note that we are concurrently submitting an application for an Administrative Wetlands
Permit for the proposed pool-enclosure fencing located less than 100 feet from the bluff, which is
also depicted on the site plan.
Should you have any questions or require any additional information to process this request,please
do not hesitate to contact me at your earliest convenience. .
Resp ctfully yours,
Ro a Herrmann
Coastal Management Specialist
Enclosures
1319 North Sea Road Southampton,New York 11968 i p 631.283.6360 l f 631.283.6136 www.enconsultants.com
environmental consulting
�F� At
EN-CONSULTANTS
h
IJune 5, 2024
! JUN 1 ' 24 19
Glenn Goldsmith, Chairman I
iBoard of Trustees, Town of Southold P.O Box 1179 SOwhold lbwn
Board of Tr ustees
Southold,NY 11971
Re: Heller and Glassman, 4995 Nassau Point Road, Cutchogue (SCTM 1000-111-9-11)
Dear Mr. Goldsmith:
Please find enclosed the following two applications for work proposed on the subject property
pursuant to the site plan prepared by Artemis Landscape Architects, dated May 17, 2024, which
we would like the Board to process concurrently:
1) Letter of Wetland Non-Jurisdiction for proposed swimming pool, patio and accessory
garage located more than 100 feet from the top of bluff and landward of project-limiting
fencing proposed along the 100-foot bluff setback.
2) Administrative Wetland Permit for proposed pool-enclosure fencing located less than 100
feet from the top of bluff.
Please note that for purposes of your inspection,the locations of the 100-foot bluff setback/project-
limiting fencing and seaward corners of the proposed swimming pool and patio will be lathed out.
Should you have any questions or require any additional information in support of our applications,
please let me know.
Respe tfully yours,
Robert . errmann
Coastal Management Specialist
Enclosures
1319 North Sea Road Southampton,New York 11968 p 631.283.6360 1 f 631.283.6136 www.enconsultants.com
environmental consulting
Glenn Goldsmith,President ®F so Town Hall Annex
A. Nicholas Krupski,Vice President ®� ®�® 54375 Route 25
P.O. Box 1179
Eric Sepenoski6 Southold, New York 11971
Liz Gillooly
Elizabeth Peeples � • O Telephone(631) 765-1892
a Fax(631) 765-6641
MUM
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
NON-JURISDICTION INSPECTION
DATE OF INSPECTION:
INSPECTED BY:
X Ch. 275 Ch. 111
COMMENTS:
EN-CONSULTANTS
CSC Ell i' E
1 June 5, 2024
L JUNER0�� (�
Glenn Goldsmith, Chairman 1
Board of Trustees, Town of Southold P.O Box 1179 !----
Southold Town
- Board of Trustees
Southold,NY 11971 _-
Re: Heller and Glassman, 4995 Nassau Point Road, Cutchogue (SCTM 1000-111-9-11)
Dear Mr. Goldsmith:
Please find enclosed the following two applications for work proposed on the subject property
pursuant to the site plan prepared by Artemis Landscape Architects, dated May 17, 2024, which
we would like the Board to process concurrently:
1) Letter of Wetland Non-Jurisdiction for proposed swimming pool, patio and accessory
garage located more than 100 feet from the top of bluff and landward of project-limiting
fencing proposed along the 100-foot bluff setback.
2) Administrative Wetland Permit for proposed pool-enclosure fencing located less than 100
feet from the top of bluff.
Please note that for purposes of your inspection,the locations of the 100-foot bluff setback/project-
limiting fencing and seaward corners of the proposed swimming pool and patio will be lathed out.
Should you have any questions or require any additional information in support of our applications,
please let me know.
Respe tfully yours,
Robert errmann
Coastal Management Specialist
Enclosures
1319 North Sea Road I Southampton,New York 11968 p 631.283.6360 1 f 631.283.6136 www.enconsuItants.com
environmental consulting
Ord of Trustees ApplIcat is
AUMORIZATION
(Where the applicant is not the owner)
UWs, Matthew J. Glassman
owners of the property idenified as SC U# 1000- 111,9-11 in the town of
Southold
.New Yo&,hereby authorizes
En-Consultants
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 ibis property.
N/A
Property Owner's Signature Property Owner's Signatm
Matthew J. Glassman
SWORN TO BEFORE l ffi THIS DAY OF F' ,20
G � '
Co OF tIsw
Notary Public - �107RR a --
m
I
;` ►rd of Trustees Applicatic
AUMORIZATIOiT
(Where the applicant is not the owner)
I/We, Tracy Heller
owners of the property identified as SCTM# iflQQ- 111 = 9-1 in the town of
Southold
New York,hereby authorizes
En-Consultants
to act as my agent and handle all
necessary work involved with the application process for pennit(s)from the Southold Town
Board of Trustees for this property.
NIA
Properly er's Signature Property Owner's Signature
Tracy Heller
SWORN TO BEFORE AM TFBS DAY OF Q , ,24 `Z
CIS
CAI,
Notmy Public STATE `
G jt �Fv,
OF NEW YORK �
= s NOT_ Y
nuea In rtaw von Canrtf !c
OICH6414253 /H
'
61OIV'EXP`R�g ��.
- -'-iLrd of Trustees Appi3.catic
AFFEDAVIT
Matthew J. Glassman BEING DULY SWORN
DEPOSES AND AFFnEWS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMITS) AND THAT ALL STATEMENTS CONTAINED HEREIN
ARE TRUE TO THE BEST OF HISIHER 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 HARMILESS 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.
N/A
Signature of Property Owner Signature of Property Owner
Matthew J. Glassman
SWORN TO BEFORE lVIE THIS 3 � DAY OF -�-*PAL � .20
Notary Public `,�' STATE �X<C,
o OF NEW YORK eN
s i �OTAR gLjC 1
07CH6414263 O`
i SION'EXPIR�s���`
1rd of Trustees Applieatir
AFFEDAVIT
Tracy Holler BEING DULY SWORN
DEPOSES AND AFFIRMS THAT IMSHE IS THE APPLICANT FOR THE ABOVE
(DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN
ARE TRUE TO THE BEST OF H.ISIHER 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 PRENHSES 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 PERhNT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM
OF THE PERMIT.
NIA
Sa;na of Property Omer Signature of property Owner
Tracy Heller
SWORN TO BEFORE IV,MS DAY OF � p'tl � ,20 2u
\\1lullr�,,
C H,q ,,%
Notary Public �s' STATE �% 'e
z co OF 14sw YORK e, =
` l
APPLICAN'PIAGENTARE-PRESENTATIVE
TRANSAMONAL DISCLOSURX FORM
The Town ofSouthold's Code of Ethics prohibits conflicts o€interest on the RM oftown ofRcers and emI►Ioyees The neumse of
this f+osm is b provide infomcation which can alert the town of ssibie conflicts of interest and allow it ID tape whatever action,is
tneamay to avoid same.
YOURNAME: Glassman, Matthew J.
{] rare,ErA name.;piddle initial,sunless you are applying in the nam of
someone else or other entity,such as a compeay.Ifs%Indicate the other
person's or company's name.)
NAME OF APFUCATION: (Check all that apply.)
Tax grievance Building
Variance T:us,ee
Change of Zone Coastal Erosion X
Approval ofplat Mooring
Exemption from plat or official map Planning
Other
(If`'`Othec=,name the activity.)
Do you personally for through your company,spouse,sibling,parent.or child)have a relationship with any officer or employee
of the Town of Soudwid? "Relationships includes by blood,marriaM or business Inured."Business interest means a busines%
including a parnership,in which the town of xer or employee has even a partial ownership of(or employment by)a corporation
in which the town officer or employee owns moss than 5%of the shares.
YES NO
if you answered'YET',complete the balance of this form WO data and sign where indicated.
Name of person employed by the Town of Southold
Title or position of that person
Desen'be the relationship between yr urself(the apglk=Vagenthepw=tatrve)and the town officer or employee.Either check
the appropriate line A)through D)and/or deselrbe in the space provided.
The town officer or employee or his or her spoor,siding,parent,or child is(check all diet apply):
JJA)the owner of grader than 5%of the shares of the corporate stock of the applicant
f2 (when the applicant is a corporation);
B)the legal or beneficial owner of any interest in a no&vorporaw entity(when the
� applicant isnot a corporation};
C)an officer,director,partner,or employee of the applicant;or
8))the actual applicant.
DESCRIMON OF RELATIONSHIP
Submitted this day of 1'i l 2d3
Signature.�,�--���� �-
Print Nam Matthew J.Glassman
Form IS I
1
APPLICANVAGENTIRE-PRESENTATIn
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics owhibim conflicts of interest on the part of town officers and employpes The namose of
this foam is to tmneide information which can alert the town of aossible conflicts of interest and allow it to take whatevermflon is
ttecgM to avoid S3ltte. .
YouRNAl1E- Heller, Tracy_
(l ast name,.fastnatne,aiaiddle initial,unless you are appbft in the name of
smrcone else or other entity,such as a eampany.If so,indicate the other
person's or wmpany's name.)
NAhM OF APPLICATION: (Check all that apply.)
Tax grievance Building
Variance Trustee
Change ofzene Coastal Erosion X
Approval of plat Moodng
Exemption from plat or official map Planning
Other
of-other,name the activity.)
Do you personally for through your company,spouse.sibling,parent,or child)have a relationship with arty officer or employee
ofthe Town of Southall? "Relationship.includes by blood,marriage,or bushms interest."Business b ttmsF means a business,
including a pardtetshilx in which the town offerer or employee has even a partial ownership of(or employment by)a corporation
in which the town officer or employee owns more than 5tl•of the shares.
YES NO
Ifyou answered"YET',complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of Southold
Title or positron of that person
Describe the relationship between yourself(the ad tba town officer or employee,Either check
the aMopeiare lime A)through D)andlar describe in the space provided.
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply):
12A)the owner of greater than 50A of the shares of the corporate stock of the applicant
= (when the applicant is a corporations
B)the legal or beneficial owner ofany interest in a non-corporate entity(when the
EIapplicant is trot a corporation);
C)an officer,lin clot,partner,or empkW ee of the applicant;or
D)the actual applicant
DESCRIPTION OF RPLA77ONSHW
Submitted this day 2094
Signature
PdatName T Hel r
Form TS t