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HomeMy WebLinkAboutVermaellen, Joseph & Kathleen Glenn Goldsmith,President ®F•S0�/ Town Hall Annex T... ®" 54375 Route 25 A.Nicholas Krupski,Vice President I�®" �® P.O.Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly CA . ,�: Telephone(631) 765-1892 Elizabeth Peeples ® y® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD July 19, 2024 Eileen A. Powers, Esq. PLLC 456 Griffing Avenue Riverhead, NY 11901 RE: JOSEPH & KATHLEEN VERMAELLEN 2020 BAY AVENUE, MATTITUCK SCTM# 1000-144-3-40.1 Dear Ms. Powers: The Southold Town Board of Trustees reviewed the survey prepared by Young &Young, last dated May 1, 2024 and determined that the proposed installation of a septic system is out 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, Glenn Goldsmith, President GG:ec °; .. "s'°,.� w �°,,c mow.�,�:a,,"<°'p°.x,' ..o o`i m c`:'nE `,;':ui �, n,��.,``�"n„•„ :,m»rP'ca m - wa �, .• .m v«w,W rn�wxs a a.. K.°a°n°uw� .,,_�.zm.: sue. ,.o�:a y.wLL.c,x '�d m }.a swc..,.s:so HEALTH DEPARTMENT USE s9e asp 400 Ostrander Avenue,Riverhead,New York INOI TEST HOLE tel.63I.1.212303 fax.631.i2fA1,44 BY M4)ONALO GEOSERVICES 1V admin®youngengtn©ering.com DATE:02/24/2023 L°p.mer\Y I) o14ii•}}EL_31 PALE GRAY 6 0.01 T\ov 5nideT',1r• +f� BROWN SILTY r9 /' I Howard W. Ycune Land Surve or(SM) Thomas O.Wolpert,Frofsional Engineer 15• I - Douglas E.Adams,Frofecsional Engineer BROWN FINE I SAND Robert O.Tast,Architect 1 (5P) Robert Stromski,Architect GW EL 12 L9' f _ A BROYM FINE _ SITE DATA SAND nOW or{o' e'�ytn i N S AREA=40,086 5Q.FT. Bo' AR"Jo OVb�e�cw. I$ VERTICAL DATUM =NAVO(1988) KSHESTEV CTED GROUND WATER I •SEE FLOOD INSURANCE RATE MAP PANEL NO.36103CO481 H LAST DATED EL-2.5 BASED ON OFFICE RECORD.SB gQ USES MONITORI46 WELL DATA i m SEPT.25,2009, LEGEND e F'rs0 CLF =CHAIN LINK FENCE CMF =CONCRETE MONUMENT FOUND CM5 =CONCRETE MONUMENT SET i a CSW CONCRETE SIDEWALK I A EOP =EDGE OF PAVEMENT OL =ON PROPERTY LINE $ I RO =ROOF OVER RCSWIF =RE I E ENAFPSET OrMelrll =WR noWor Tefi Ark f�`& WDF =WOOD FENCE c 5 S ruch WSF =WOOD STAKE FOUND She\\y I ENGINEER'S CERTIFICATION WSS =WOOD STAKE SET UTILITY POLE 'I HEREBY CERTIFY THAT THE WATER SUPPLY(S)AND/OR SEWAGE DISPOSAL • =END OF DIRECTIOWDISTANCE SY57EM(5)FOR THIS PROJECT WERE DESIGNED BY ME OR UNDER MY WETLAND FLAG NUMBER DIRECTION.BASED UPON A CAREFUL AND THOROUGH STUDY-OF THE-SOIL, ` = 8 ,/ SITE AND GROUNDWATER CONDITIONS,ALL FACIL771ES,AS PROP05E05;, u CONFORM TO THE SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES '•� ® 'WELL g CONSTRUCTION STANDARDS IN EFFECT AS OF TViS DATE.° I I n0W Veem or °,en b• \� ` £i Helen ') E Sbt� /' o I 'I I HOWARD W.YOUNG,N.Y.S.L.S.NO.45893n \ / qer 1 THOMAS L.WOLPERT,N.Y.S.P.E.NO.61483 // 1 BASE FLOOD ELEVATIONS BOUNDARY LINES SHOWN pet Mprje P c W�P'r) pTiA �� I F DOUGLAS E.ADAMS,N.Y.S.P.E.NO.80897 9 AS SCALED FROM FLOOD INSURANCE RATE 3e°11Vrv9W�h _w -�/ A5SO a ^GE 14o°�ormer1 n 3r. P SURVEYOR'S CERTIFICATION--- t E� f5&!'.•' LP Wa'1 p,0 O.e CS 5.93 ea,s 15�P \ ht IS pt pVer`O hW°Y`') #1 MS.BB' _ *WE HEREBY CERTIFY TO JEISEPH P.VER Mi4ELEN THATTHIS \ EXt°y0° .�' ` o g),U. } 1 R`9 F('OnLSI fyyts bH`90, 1 0 I r SURVEY WAS PREPARED IN ACCORDANCE WITH THE CODE OF PRACTICE FOR _ PROPOSED 12"HIGH zoµOOLF�,e 1 Lys ,• Dds, 0 i LAND SURVEYS ADOPTED BY THE NEW YORK STATE ASSOCIATION OF _ WATERPROOF CN�snE�' L%''3.7° N ,Y% (P° 15 4.� P PROFESSIONAL LAND SURVEYORS. I� 1 .e \ RETAINING WALL t. 4.03�• O 6 8 1 Q• 6.05 -q OF17277 '17ft96, �Bta, Q 15.00' 56 wss WEtLA 1 /m j _ EIC E11/ E -3.22 �TH •289 LAT+ µNST D°N�2 ..�yA.. —\I 6.�4�\ `\ HOWARD W.YOUNG,N.Y.S.L.S.N0.45893 -- Ds _ 4.74— 4.91. 1 N 00 ` SURVEY FOR IJUL 2 2024 ups^' a 1\\, r / �r-- Woo - 1 G v W 4 l N ���fff \ .5.36 ' `7.10 m JOSEPH P. VERMAELEN ! IR .)�,'1 \` - yy pRpPO'1'-° r .4.67 �g—� W� -,SWAY u4, -7.29 \ .SOU�fWId To11Yi1 E 7 �.\, // tstO�NpME'' VROppSED ,.�� N TpµEe1F3'jp0�„-- i ` �• at Mattituck,Town of Southold I B6'didofTNSb= j-'4 7 \ i / �AF ° O1��Dr _ W/ pROp0 p5 \ 7.9774 \ Suffolk County,New York 51 MIT O d b ''0 W pT1Ew AY \ 4. V,.•• t 1 / 1 W or{TD0ho\ s BUILDING PERSURIIEY °{ �A \ % ,(`•�"'>'�1�N � OSEO° - 0 r MSp.ao 0 County Tax Map 0,.t-t 1000 �j 144 81,ck 03 <0.1 40.1 FR�µD SITAR" f FIELD SURVEY COMPLETED 'x SEPT.12,2022 \ , ` MAP PREPARED (1.,, rii';o (4 SEPT.13,2022 i' pE ��R 57q AO or fDrmer \is \ 2 C,L�K' [/�}2 noW BDCO 9 "GG.. —— Ojos A• 9 �l Re.�or "bf'Revisia 8 �" ,/' ` \ ?.?• ADDED TEST HOLE MAR.09.2023 pQ Nieh (PIN / o ( ¢� REVISION n.,` ,�i:, y - DATE MAR.22,2024 GENERAL AMENDMENTS 4 MAY 01 2024 '1 zi -/ thPublic , :}x:��•,o• *in V4-4 mo3Pn �tl?. G' r J / 40 0 20 40 80 120 (DWyTUn9'AithNbbc Scale:1°= 40' \ JOB NO.202-155 DWG.2022_0155_bpr1 1 OF 3 GRAVELESS GEOTEXTILE DWELLING TO GRADE SAND FILTER -vz•VENTILATION PIPE MO SURFACE VATER VITHIN 39 IF SITE FF12.0 LOCKING COVER OCKING COVER INFILTRATOR ROWS 32RFEET LONG SCUM BAFFLE B OVERS TO GRADE /3 SLOPE MAX 3' BEYOND ATL °I �N SNimentation Cham�ER Vo1277(ga) .5'MAX ECIRCULATION Anaerobic Filtration Chamber 278 GRADE 7.0 GRADE 7,0 GRADE 6.8 TO MATCH EXISTING GRADE AIR LIFT PIRG' Aerobic Concoct Filtration Clamber 127 C/0 GRADE 6.7 _ IE6.0 4• SDR 35 IE5. DISTBOX IE5.3 © CISINFECT YLINDER(OPTI@UU Stom eChamber 63 IE5.7 IE5.4 °M ® Disinfection Chamber 4 PITCH 1/4'/FT EL4,5 ¢�• 4'INLET!RECIRCULATION •OUTLET PIPE Total Volmne 749 FUJI CENS 4' SDR 35 P .� 2'MIN ABOVE GV .'. Qsa ITCH 1/8'/F °m'°°" ' p OUNDATION MEG, 2.5 SPECIFICATIONS EL1.5 _ , �r.,w-+-ev®,.�4dv. Tarts re uLr4Na - ma•d.. -,N-a®eymn..-rr--u, - Anaerobic Media PP/PE Fllhng Rate 32% SANITARY INVERTS b FFLNENT Board Type Aerobic Media PVC/PP/PE Filli Rnm 16% BA ® AIR LIFT PUMP Aerobic Media PP/PE Filling Rate 57% NTS - SANITARY DESIGN HQDNT HACBDR IN V THICK CON(REIE BASE >� ® BI.- Malin B DWELLING VITH 4 BEDF,101S-NO GARBAFtE TRNIDt Tank PRP COVER 6' 1r a' I Prying PVC/PP/PE 4•[OVEN MM APPUCATOBN RATE FOR CATEGORY l 1126PD/SF PIPE V BAFFLE J le AIR INTAKE Access Covers Plastic/Cast Iron PLUG 2'-0' FLOW OPENING(TYP. B (THREADED) SQUARE 6' 3• REQUIRED LENGIIH OF ABSORPTION TRENCH=61 FF (CLEANING OPEMNGI Diainfamnt(OpUoaal) Chlorine Tablets -}r _ T- REQUIRED LENGTH 50'I FOR EXPANSION=TIT 6. PLAN VIEW P13LYLEK 2V SAFETY SCREE P.'•CONCRETE BASE •, I' -L a• PRPOSSED FA SP CFh 5 4 0 FORGPD 4 BEE O �L�� YM3017{20 PmTLOK 20'NO COVERSS Pit-3008�a'HEAVY COVER CLEANOtTT BOX „,,,�,,, 0 RBVS INFILTRATOR AIL fRIYVEIESS GEUT00111 ABSWTION TRENCH 32 FEET LONG=64 FT I PB RISER 20 PtL3008 SSYLOK CLEANO •SAFETY SCREEN e POLYLm(20'RISER P POLYLm(20'RISER P pLYL01(24'RISER PAN ADAPTER ,..aarNar rr.a, (ll IX.RUNS]lFILTRATLR ATL TRAVELESS f#fOEIITIIE ABSOIPTOBN 1RENCH 32 FEET L6YG=32 FT 1--, 1^ _� PB 3009-RP P�3009-RP Pt 3008 ADAPTER ADAPTER ^'� -aoun �' B' POLYLOK 20-SAFETY SC a•Mq PP 3009-SS 1SDiEETION DW OPENING 30 DEGREE FITTING ° FUJI MAC80R BLOWER UNIT CYUNOER(OPTIONAL) je"^'E" r.A• ,^•>b• DARD TYPE CGNTACT MEDIA 60 YE INFILTRATOR ATL �mm POLYLOK20'D-BOX BOXAEGEP,B 4-FOOT TRENCH DETAIL PARTNO.3017-20 GRAVY TE- ER PARTNO.017�a p GRATE- PARTNO.•3017G20 FLOW NITS eo MATERIAL-HOPE 17TALLRISER PARTNO.3009AI2 Ii_IIA 4%CONTROL PANEL O O ECIRC SEVER LINE O O P( 0.ENAN UNIT FUJI "V'1 ASSEMBILYAn� CLEANOUT DETAIL SCOND UPPLY T TD ELECTRICAL S(1PPLY MS • 22mr I II$ PRESSURE X © OO mac\y p1n�D�(Rr y p ii 4•POSTS Op for yap N9 eE I A16T 10 LM DIM 10(K VNH RISTT5 EROB[C)Rnw po ecm0e 62T�1•' g PROPOSED �-V oy\elt •.. o n t DUALL EM UUTUTS AT SNE OF/ATM VHB DUN IEYE N UM I �P�I�rrmuDE BASE FLOOD ELEVATIONS BOUNDARY LINES SHOWN Pe r ocye Vey WnteT1 ••"••'• AS SCALED FROM FLOOD INSURANCE RATE p M W;thwbT'0 t EM DISTRIBUTION BOX ERATIdN ASSEMBLY Da+eTh°B o 11'�'8EEA5 ° NTB FUJI CLEAN CONTROL SECTION A-A VIEW DO' SECTION B-B VIEW T��' p1eAy PANEL ° t+�i'pyA H $ Rl9htOfWDY I1oV'l?)Jes oe\�3r. ttl .s see•ss3 FUJI CEN-5 OWTS s P• h �p yp�Ilty�(''� 'AAQ1Igqqq �ExL 10 _ =-, fropc_T,:-�•H'9 r 9 TEST HOOF Q -•WIEFANY IACNVHJI� lT'•N" ZEE AE ICY o 4.03 3.75'': tt6' yRoOdS• ..Z�•����. Fd�Y`(. .� 19 g• �5.Do •" ••ss E�NOs 'i 6.D5 'n r MAIN ELECTRICAL PANEL PANEL MODEL C DISCHARGE PUMP 1 a � CONTROL SITE INFORMATION, f. 6 ti Q aoaNcaF CH A 1 CB 1 5 H V 7 ;, .• ''/---"� 3.0• L n aNm SC t 0 PAY AVE,NA KY. •qqj8' WARDL71NT�1N zslzz ` L fCU�W L,. SITE PLAN 1BASED ON SURVEY TIEN YORG 6 YOUNG LS DATED 5IV2024 QED �22.89 LAND W.51�oa1 tta 6A0 CB 2 4 AIR BLOWER 2.7 NSOWTS Q N� a-J 1 y �G w^®a SITE AREA 40A SF.IR 092 ACRES o �, s B O // ti tiM1a BY- - i 6 1 w•': ALL EIEVATON RETERNCR TO NAVD I DAM ' T' a+ !r 4.e]• t o "" TELEPHONE SERVICE �C.NTR.Ll Nl SURROUNINi LOTS ARE IMPROVED WITH PUBLIC VATER WITH 150'IF SITE Vim' DODs 4 a Y - ---� G NO IRANA[€STRILTUES IN SITE :#�o 22 Ole / W -5.36 T 11FRE ARE NO UNIIERG?(RIND FIFL TAWS IN SITE P ( 3 6n v fp +✓ - �O A�a��° £.D°a VETLANDS NOTED IN SITE o y c6,i1 rvA ', '; Cm MURVPYHOSET4 _ n CIRCUIT BREAKER PANEL P}(0q 1 m J3USED ELEci�crl3Plu OIPANEL �� - ~ 7'10 SPECIFICATIONS CBl - 20 AMPS 2 HIGH WATER ALARM Sr zsTCO`=°a�„ FUII�i�ITROLPANEI _6-- D DST ��° SWAY Z 7.93�•7.29 4 VERICO MO AMPS LONTROL CB3 - IS AMPS 3 AIGPOA va t .a CBORAIR _ PRC` 7.n {Orr\oa o -~ �w�o WIRING DIAGRAM 1o�p 6 F 30 q1 :1 SANITARY M RS DEDK •---- "---- - eEnp'RB PROPOSEONIERSERREI'NIN '. L.THE DVTs INSTALLER SWll1 HOLD AN TNDIRSEIFNT FROG TIE SUM COUNTY 11EPARTPPM IF HEALTH ' pR0Ra5D STATp'6 I 2 AN EIFLTIIED IPEERAIION AND MAINTENANCE CONTRACT BETWEEN THE NAINIQENANCE PROVIDER AND THE ct SHAM BE PfAMDED TO THE SCDHS c% r� 'too\os for A Sac rokoAl�1 CMP L• F��-- 4.UNSUITABLE Sma 9VTS UNIT TO BE SELF VINING-NO HOUSE TRAP INSTALLD LS SHALL BE REIM AND RIPLACED VNIN SAID AND GRAVEL,(SP OR SV)UNDER TRENCHES o o--3 o� N1ch W N,IE11'NN ^� EXTENDING DOWN INTO A HMO SU40 STRATA OF ACCEPTABLE SAND AND GRAVEL EXCAVATION DEPTH TO BE TO ELEVATION o f es6 a5 DWe0m8 D f 12' NI 110 TO ENSURE A V STRATA IF ACCEPTABLE$OILS FILL UNDER TRENCHES TO BE SW OR SP RATED VITH A r� 2 N% mz z y HIM APPLICATM RATE IF 12 GPD/SF JUL 2 2024 ' S NE CONTRACTOR SHAL NOTIFY THE DESIGN ENGDVEGt I VED(IN ADVANCE IFTHE OVTS INSTALLATIEN -�-*3 AOWoter) ^v;c e� the°b; 6,SANITARY COVERS LESS TIN 60 LBS VOL HAVE SAFTEY UD/COVER S 6 6 g yDWe14n9° 7.ELECTRIC SERVICE AND UTILITY VRES TO BE UVERNEAD Southold Town A2- ® olTLvstees \DWeNY9W'th p°blaWoteTl FUJI CENS BOUYANCY CALCULATION FUJI CLEAN Cr.-OR CEN-SERIES UNIT - ASSUME EMPTY TANK COMPLETELY SUBMERGED IN GROUNDWATER INCLUDE SOIL WEIGHT OVER CONCRETE DEADMEN V WIDE X 10'LONG NYLON STRAP DENSITY OF WATER 62.4 LBS/CF OF CONCRETE 150 LBS/CF LEGEND DENS ITY 3/8'WIRE ROPE WITH(2)3/8 CABLE CLAMP mP)\ f\f1 DENSITY OF CONCRETE IN WATER 87.6 LBS/CF LIV DENSITY OF SUBMERGED SOIL 72.6 LBS/CF G6SF IRAVELESS GDTEXTILE SAND TITER TANK VOLUME 118.18 CF 5/8'X 9- TURNBUCKLE EXGGSF-DYNSION GRAVELESS GEOTEXTILE SAND FILTER TANK DRY WEIGHT 463 LBS (TYP OF 2 MIN,PER TANK) SCDHS APPROVAL TANK BOUYANCY FORCE 5.911.55 LBS C/0-CLEANDUT CONCRETE DEADMAN 8•x1.5'x0.67'=16.00 CFI{c' Michael Mapes P.E. Ir.1Co7GYu L J CONS FILO CENS 440(p➢ CONCRETE SUBMERGED WEIGHT 1401.60 LBS 283 BI CABREP WITH LE CLAMP(TTP) "t v E N` } 163 PENINSULA PATHa VOLUME OF SOIL COLUMN OVER DEADMEN TO GRADE 120.00 CF EMBEDDED EYEMOOK .("�,� a+ DB-DISTRIBUTION BOX VOLUME OF HALF THE SOIL PRISM OVER DEADMAN 108.59 CF (TYP 6 4) r+ RIVERHEAD,N.Y 11901 00'20 ID 1 D 'D 20 30 _vx_ pR�O p WATER SERVICE CONCRETE DEADMAN SUBMERGED WEIGHT 16,595.72 LBS i */�L "' '" _ TOTAL WEIGHT OF SUBMERGED DEADMAN AND SOIL 17,997.32 LBS CONCRETE / * PHONE 631J69-2170 1U(-DUSTING SPOT UVATON TOTAL TANK BOUYANCY FORCE-11,0115.77 LBS ANCHOR 6'MIN BED OF COMPACTED GRAVEL OU0-PUDS13 SPOT ELEVATION THEREFORE TANK WILL NOT FLOAT WITH NEGATIVE BOUYANCY FORCE SIZEOPER-Z BENEATH TANKS AND ANCHORS 2020 BAY AVE FACTOR OF SAFETY 2.60 BOUYANCY X- SOD CALcS FUJI CEN5 BOUYANCY ANCHORING DETAIL TING CONTOURhp� SZE PROPOSED SANITARY PLAN A- DATE 6-2-2031 Sru r.t•.v' SHEET 1 OF 1 Glenn Goldsmith,President ®v S®U�� Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ,`®� ®�® P.O. Box 1179 Eric SepenoskiB Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples y® Fax(631) 765-6641 c®UNT`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD NON-JURISDICTION INSPECTION DATE OF INSPECTION: 711q INSPECTED BY: Ch. 275 Ch. 111 COMMENTS: PcO�rT �S F1.Dn - `�Lry%.9 •G =011% ��oaDSP�► w�c� S MGC� �`An 160o,.. EILEEN A. POWERS, Esq. PLLC ATTORNEY AT LAW 456 GRIFFING AVENUE RIVERHEAD,NEW YORK 11901 516-695-7660 eapowers,:&!ontonlin.e.net SE July 2, 20242Q24 Southold Town Trustees Southold Town Annex n54375 Main Road P.O. Box 1179 Southold,New York 11971 Re: Vermaellen-200 Bay Avenue Mattituck Dear Chairman Goldsmith: I am writing on behalf of my cousins,Joseph Vermaellen and Kathleen Vermaellen. Please accept this letter as a request for a letter of non jurisdiction over the design and placement of the septic system at 2020 Bay Ave, Mattituck for the Suffolk County Department of Health. The proposed septic system is over a hundred and thirty feet from the wetlands,which is in compliance with the Town of Southold's current regulations and satisfies your oversight. I have enclosed a copy of the lot survey which shows the proposed house and a copy of the septic system currently under review by the Suffolk County Department of Health. I will make arrangements to pick up the letter when ready. 7660. If you have any questions, please feel free to contact me directly at (516) 695- Ver .ruly yours, Eileen A. Powers EP:pI Al n, M, N-� Nz,�,� \X� w"N-', MtN�\Nl� R%, x --X'Z X3,\ �,X A nzt�, ��;l N, 'N "N' &.J R ox z 9�, W� M, Q (4) X�l .11. , "'IV "N t ;�7 0 ip No No N N \< K 0, N\1�\ C3n, 41 N X, NN C2) \v, n'- 'At NN \5 \K\R Z \M"M N'K k 4\ C�o o z "I'All X, M. q,� N� "'I" N No- vkt 4, z", V, 4" '�A R N " \\" - - ,R, M, A N 0011"IX. x� X ­0 V-\ N M N\ N, X x N, X� k N�, K �x NN N ,n,\ X- 2 L NOME SECPON COUNTY OF SUFFOLK Cc) K 2 R.9 P-1-ty Th.S-i�.Ag-y y :A G ------- Qg E B6ard of Trustees Application , I i AUTHORIZATION i (Where the applicant is not the owner) Uwe, � E . owners of the property identified as SCTM# 1000- 4#1 I889 l'ty�."3"`>�- in the town of f *j ,New York,hereby authorizes OU.P,yl A. I 1 to act as my agent and handle all i I i necessary work involved with the application process for permit(s) from the Southold Town i Board of Trustees for this property. i 01 i F k roperty O ner's Signature Pr erty Own eh Sig�+lature 1 i i - ._1____._ SWORN TO BEFORE P�IB THIS � DAY OF ; , 20__a i f i f tNotary Public i CATHERINE C.DESAPM ' Notary Public,State of New York i No.02DE5014631 Qualified in Suffolk County Commission Expires March 17,20e� i i i I I APPLIC TIAGEN7t WPRESEN'I'ATIVE TRANSACTIONAL DISCLOSURE FORM j 1 Tlic Town of Southold's Code of Ethics Prohib�s conflicts of interest on the Part of townie rcers and mptlo ecs-''hc pta- se of this form is to nrovide inforination which can the town of pmibte conflicts of metes and lor+ it to take whatever action is nee ssary to avoid sa(rtntc Q y ,^ YOUR NAME: VU +�G� `• 0+ � (Last name,first ttame,�}"die 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 n e.) i NAME OF APPLICATION: (Check all that apply.) Tax grievance I Building Variance { Trustee Change of Zone �— Coasted Erosion i Approval of plat Mooring Exemption from plat or official map Planning � Other (If"Other',name the activity.) f I Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the To ni of Southold? "Relationship"inclydes by blood,marriage,or business interest.-Busincsc rntertst"meaits a business, inciuding a partnership,in which the town offeeter or employee has event a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than S%of tlw shams. YES NO {! If you answered"YES",complete the balance of this fotin and date and sign where indicated. , I Name of person employed by the Town of Southold �i g A— A. PrnNP,tfS Title or position of that person { Describe the relationship between yourself(thejapplicantfagont/representative)and the town officer or employee.Either check the appropriate line A)through D)and/ordescrjbe in the space provided Titre town officer or employee or his or her spouse,sibling,paresit,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 iseneficial 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. i DESCRIPTION OF RELATIONSHIP •' I I Submitted tis 3 ay of�, ' ! 201f�1 5igrtntatp Print N ! Form TS 1 ���, P�c:»+►n �t I f F 1."ard of Trustees application - r� i I i i AFFIDAVIT ' - - I ro IF► elv-maelw "km Aw 15—* BEING DULY SWORN I)EPOS S AND AFFIRM9 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 BFJ IEF, 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 DAIMAGES 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 WITIi 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 0,R COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. I l I Qy�QJld ign tore Property Owner 4Siture�of Prbpeity Owner a SWORN TO BEFORE ME THIS a � DAY OF ! , 20 �y f i I C C���� i i Notary Public I CATHERINE C.DESANTO Notary Public.State of New York j No.02DE5074631 I Qualified in Suffolk County ; Commission Expires March 17,ZO 1 i I ,f I i