HomeMy WebLinkAboutNarrow River Properties/Armstrong, Jeremy & Rivera, Maria Glenn Goldsmith, President ®F S®�lr� Town Hall Annex
01 A. Nicholas Krupski,Vice President ®� ®I® P.O. Route 25
P.O. Box 1179
Eric Sepenoski l�i Southold,New York'11971
Liz Gillooly @ Telephone(631) 765-1892
Elizabeth Peeples Fax(631) 765-6641
Comm
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
June 10, 2025
Robert Herrmann
En-Consultants
North Sea Road
.Southampton, NY 11968
RE: NARROW RIVER PROPERTIES/JEREMY ARMSTRONG & MARIA RIVERA
5615 SOUNDVIEW AVENUE, SOUTHOLD
SCTM# 1000-58-1-2.1 & 2.2
Dear Mr. Herrmann:
The Southold Town Board of Trustees reviewed the survey prepared by Young Associates, last
dated March 12, 2025 and determined that the proposed installation of a driveway, relocation of
electric service, and associated ground disturbance on the landward side of the project limiting
fence lies outside of the 100 foot Wetland jurisdictional area under Chapter 275 of the Town
Wetland Code of the Town Code at 216.9' minimum. If the scope or location of the project
changes, please submit revised plans to the Trustees Office for review.
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 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 withini 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,
,4ZA1-
Glenn Goldsmith, President
i ` J
g�FFO��-
Glenn Goldsmith,President 0�0 COG Town Hall Annex
A.Nicholas Krupski,Vice President `� �,�, 54375 Route 25
Eric Sepenoski y P.O.Box 1179
Liz Gillooly 7 Southold,NY 11971
Elizabeth Peeples 41, p!, . Telephone(631)765-1892
Fax(631)765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
NON-JURISDICTION INSPECTION
DATE OF INSPECTION: &IN-e 1, 2y2S
INSPECTED BY: a tZA, CA\ Qf-tb ltS
275 Ch. 111
COMMENTS:
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1 UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW.(2)DISTANCES SHOWN HEREON FROM PROPERTY LINES TO EXISTING STRUCTURES ARE FOR A SPECIFIC PURPOSE AND ARE NOT TO BE USED TO ESTABLISH PROPERTY LINES OR FOR ERECTION OF FENCES.(3)COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY.(4)CERTIFICATION INDICATED
() HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY,GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON,AND TO THE ASSIGNEES OF THE LENDING INSTITUTION.CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT OWNERS. (5)THE LOCATION OF WELLS(W),SEPTIC TANKS(ST)A CESSPOOLS(CP)SHOWN HEREON ARE FROM FIELD OBSERVATIONS AND OR DATA OBTAINED FROM OTHERS.
400 Ostrander Avenue, Riverhead, New York IIQOI
tel. 631.727.2505 fax. 631.121.0144
Odmin®youngengineering.com
Howard kN. Young, Land Surveyor
Thomas 0. Wolpert, Professional Engineer
Douglas E. Adams, Professional Engineer
S
o ; s ( Daniel A. Weaver, Land Surveyor
o Lot 2 Lot 1
Q 6.1548 AC 2.9004 AC !I'; API 1 4 2025 � � igaw ate
-� SITE DATA
r AREA = 9.0552 ACRES
o ---------------------------------------------------------- 3,e,,
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SUBDIVISION-"TIMOTHY SCOTT GRAY"FILED IN THE OFFICE OF THE CLERK
e
EXISTING OF SUFFOLK COUNTY ON JAN.17,1990 AS FILE NO.8883.
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* ZONING USE DISTRICT = R-80
0
z o * VERTICAL DATUM =NAVD(1988)
e
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o *BASE FLOOD ELEVATIONS BOUNDARY LINES SHOWN AS SCALED FROM
e
FLOOD INSURANCE RATE MAP PANEL NO.36103CO154 6 36103CO162 H LAST
o DATED SEPT.25,2009.
PLANNING BO?�RD GERTIPIG�4TION * AREA OF WETLANDS = 38,704 SF OR 0.8885 AC
* AREA SEAWARD OF CEHA LINE =65,551 SF OR 1.5048 AC
/ Lot 1 Lot 2 g nuka�d4fm
IJ 7.2183 AC 1.8369 AC
THI5 15 TO CERTIFY THAT TH15 LOT LINE MODIFICATION HAS BEEN
APPROVED A5 PROVIDED BY ARTICLE 16 OF THE TOWN LAW. CERTAIN AREAS
KEY MAP
nn.
gmmq atisonales PROPOSED DATE OF APPROVAL _____________
SCALE:1"=600'
5Y: LOT 1 TOTAL BUILDABLE
KEY MAP CHAIRPER50N AREA PRIOR TO MODIFICATION =2.9004 AC =2.9004 AC
pis °'' AREA OF TRANSFER =4.3178 AC
C/
AREA AFTER MODIFICATION =7.2183 AC =4.8250 AC
LOT 2
AREA PRIOR TO MODIFICATION =6.1548 AC =3.7615 AC
Z AREA OF TRANSFER =-4.3178AC
6 / / / a°P�� AREA AFTER MODIFICATION =1.8369 AC =1.8369 AC
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' 411, / \ \ / l I 1 5�e 5`° � /% // ij/ // / / / /l // l I , _ ENGINEER 5 CERTIFICATION
/ / / /////S/ ) - / ' I HEREBY CERTIFY THAT THE WATER SUPPLY(S)AND/OR SEWAGE DISPOSAL
3�9 SYSTEM(5)FOR THIS PROJECT WERE DESIGNED BY ME OR UNDER MY
f - ws g //// / fop. /S42°33 1 / DIRECTION.BASED UPON A CAREFUL AND THOROUGH STUDY-OF.X#E-SOIL,
\ - a114 // / � / � - - /. - O"F / I I �- SITE AND GROUNDWATER CONDITIONS,ALL FACILI . 6-A$ ROPQSEp,
/ I ` - /0 29 PROJECT LIMITING FENCE / CONFORM TO THE SUFFOLK COUNTY DEPARTMENT A15ALtH StRVICES
/ I �� . l / / / l / / / / �°/ // I \+ // / / CH J,� / 09 , PROPOSED LOT LINE
/ wss (I / / \ \ / /i / ( l / 0 36�: / / 6 \ CONSTRUCTION STANDARDS IN EFFECT AS OF S;D
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/ \ 1 GROUND DISTURBANCE 12,586 SF c "°"- :'; � •�.
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�3 °O „ 1 Y / \ \ / / N I I �/ / / 23 PROPOSED RELOCATED ELECTRIC / HOWARD W.YO �Z,1'N.Y.S.L.S.NO.45893n
e z ti -\ \ // I / lid i 39 THOMAS C.WOLPERT,N.Y.S.P.E.NO. i
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i 7 13 \ \ I (/ I I / / / 1 \\ ` ` \ / SERVICE TO LOT 1 ��FF \.j!
( c > / TH W TER / N DOUGLAS E. ADAMS,N.Y.S.P.E.N0.80897 SSIOt
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\ \ \ \ \ \ J \ e--- E�� e 83' \ / 4 WE HEREBY CERTIFY TO E R E MY A R PA sTR o N t; THAT THIS SURVEY
e / \ j / WAS PREPARED IN ACCORDANCE WITH THE CODE OF PRACTICE FOR LAND
i \ \�'\ \ \ / \ / / CMF // /�' �\ \ c` \ UNDERGROUND '� I \ - - - - \ \\ \ / / 1 6��>4' F •= -" � /�° SURVEYS ADOPTED BY THE NEW YORK STATE ASSOCIATI
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E$ HOLED nt o \ _ _ _ ` - \ / L DANIEL A.WEAVER,N. . .L.5.NO. 771 '\�AND SO
gmmg agnates L/th0/ CMF fi
PERFORMED BY:McDONALD GEOSERVICES \ \ \ a� _ - - - 2 44-
DATE:4/25/2023 \ \ J \\ `^ _ - - _ 46- 1 ` I / t''+-
\ // r� SUBDIVISION
EL=24.0 0.0' EXISTING LOT LINE �tr y JEREMY ARMSTRONG
DARK BROWN \ �s�\ `�� �A�\ I I / LOTS 1 & 2 "TIMOTHY SCOTT GRAY"
LOAM(OL) \ � / w k �
BROWN 05 \\\ \ \ � / / v q at Southold Town of Southold
s SANDY
\ \ \ \ \ 1 1 / / ' ,, Suffolk County, New York
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GW EL=15.4 WATER IN 8'6' JI County Tax Map District 1000 Section 58 Block 01 Lot 2.2
2 PALE BROWN
SAND z / FIELD SURVEY COMPLETED MAR.01,2023
a Q / MAP PREPARED SEP.11,2023
(SP) J
9.0' Record of Revisions
�e REVISION DATE
LEGEND GENERAL SEP.03.2024
WATER IN �° / / "` ADDRESSED SCDHS NOICA#1 FEB.07.2025
goung associates BROWN F, h
CH =CHIMNEY SANDY SILT, N / / o GENERAL AMENDMENTS MAR.12,2025
CID =CONCRETE PAVEMENT SILT&CLAY /
(ML,MH,CH) a
CMF =CONCRETE MONUMENT FOUND / o
CMS =CONCRETE MONUMENT SET
EOP =EDGE OF PAVEMENT
OL =ON PROPERTY LINE 51.0'
WATER IN
RO =ROOF OVER B OWN FINE
WSF =WOOD STAKE FOUND TO MEDIUM 60 0 30 60 90 120
W55 =WOOD STAKE SET SAND(SP)
9 =WELL 58.0' Scale: 1" = 60'
• =END OF DIRECTION/DISTANCE HIGHEST EXPECTED GROUND WATER EL=16.0
JOB NO.2023-0028
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OR4d14 CRES S \ O'+ ON THE LAMBERT CONFORMAL CONIC PROJECTION FOR !r?I
Contacted w,tha, Sara uuund:: G,4n5,4U1:u S.r. ur J%Oh• a_res. IIEW YOP,It STATE,LONG'SLANU 'ONE NAD 27 •i
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SUBSURFACE CONDITIONS NOT SHOWN. i I
3. THIS SURV.Y IS SUBJECT TO ANY EASEMENTS OF RECORD e y
qz % \ —, / APtn+)THF.P ENr•JMERANGES VJHIFH A FULL TITLr. SEARCH 11
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ti \ a<ahwnc Es `•` / TO BE ACQUIRED BY
TOWN OF SOUTHOLD
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FOR 1j
OPEN SPACE ACQUISITION
\ �• I, r8 % 1 �h SITUATED AT
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SUFFOLK COUNTY, N;Y,.
t ( SEPTEMBER 28, 2Q07� �.
OWNER: MOELLER/THIJ REALTY INC:
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TOWN OF SOUTHOLD Hr,I
COUNTY OF'SUFFOLK
U.S. NATI 1J '0 AL OCEANIC
L�i1�T A T ' ATMOSPHF HIC A[%IINIS'I HA110N
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PROPERTY MAP
OfRSL&TETF W E
ll��ir JJ�C April 10, 2025
Glenn Goldsmith, President APO 1 4 2025
Board of Trustees
Town of Southold
P.O. Box 1179 Southold Town (
Southold,NY 11971 Board of Trustees
Re: 5615 Soundview Avenue,Southold: Narrow River Properties LLC(1000-58-1-2.1)and
Jeremy Armstrong&Maria Rivera-(1000-58-1-2.2)
Dear Mr. Goldsmith:
We represent the owners of the two above referenced properties,which include a 6.1548-acre vacant
waterfront parcel identified by Suffolk County Tax Map Number 1000-58-1-2.2(also known as Lot 2 of the
1990 subdivision of Timothy Scott Gray)and the adjacent 2.9004-acre improved roadfront parcel identified
by Suffolk County Tax Map Number 1000-58-1-2.1 (also known as Lot 1 of the 1990 subdivision of
Timothy Scott Gray). The owners of the two properties are proposing to modify the property line separating
the parcels in a manner that would transfer 4.3178 acres from Lot 2.2 to 2.1,thereby creating a 7.2183-acre
improved waterfront parcel known as"Proposed Lot 1"and a 1.8369-acre vacant roadfront parcel known as
"Proposed Lot 2." Also proposed is the installation of a new/modified driveway and the partial relocation of
buried electric service to the existing dwelling.
Because lot line modifications are not regulated by Chapter 275,and the proposed driveway installation,
relocation of electric service,and associated site disturbance would occur landward of a project-limiting
fence erected well more than 100 feet landward of both the top of bank and nearest freshwater wetland area
located to the north of the existing dwelling on Lot 2.2, I am writing to request that you kindly prepare a
Letter of Non-Jurisdiction stating that pursuant to Town Code Section §275-3(C)(5),no Town Wetlands
Permit is required for the proposed lot line modification or construction activities depicted on the
topographical survey/lot line modification plan prepared by Young Associates, last dated March 12, 2025,
two (2)copies of which are enclosed herewith.
Also enclosed in support of our request are site photographs; copies of the property deeds; a check payable to
the Town of Southold for$50; and authorization forms signed by the property owners allowing En-
Consultants to act as agent and the Trustees to access the subject property.
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.
Re pectfully yours,
Robe errmann
Coastal Management Specialist
w Enclosures
1319 North Sea Road Southampton,New York 11968 p 631.283.6360 f 631.283.6136 www.enconsultants.com
environmental consulting
--oard of Trustees Applicati
AUTHORIZATION
(Where the applicant is not the owner)
Jeremy Armstrong
As Member of Narrow River Properties LLC
I/We, and as Individual Property Owner ,
owners of the property identified as SCTM# 1000-_58-1-2.1 & 2.2_ --- - __ 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 permit(s)from the Southold Town
Board of Trustees for this property.
�.✓� N/A
Prope&Owner's Signature Property Owner's Signature
Jeremy Armstrong
As Member of Narrow River Properties LLC
and as Individual Property Owner
SWORN TO BEFORE ME THIS_ DAY OF Gem r 20ZS
STATE •'•�
OF NEW YORK
Notary Public -
NOTARY PUBLic N
Qualified in o c
a`, Kings County
:4; OIAR6082685
R,
.' adaareee,oe,'+Q6t APR 1 4 2025
Southold Town
Board of Trustees
4
oard of Trustees Applicati'_..;)
AUTHORIZATION
(Where the applicant is not the owner)
I/We, Maria Rivera
owners of the property identified as SCTM# I000-_58-1-2.2 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 permit(s) from the Southold Town
Board of Trustees for this property.
Property Owner's Signature Property Owner's Signature
Maria Rivera
SWORN TO BEFORE ME THIS_ DAY OF ,.20. S
NL AR
' g(AIS
Notary Public ; OFNEWPORK N"
V
Q�aCfie�n Y '
/oN�Xp� •'•� APR 14 2025
Southold Town
Board of Trustees
f
�,..--,Ioard of Trustees Applicat"-_
AFFIDAVIT
Jeremy Armstrong
As Member of Narrow River Properties LLC
and as Individual Property Owner BEING DULY SWORN
DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMITS)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.
N/A
Sign ure of Pro erty Owner Signature of Property Owner
Jeremy Armstrong
As Member of Narrow River Properties LLC
and as Individual Property Owner
SWORN TO BEFORE ME THIS �� DAY OF ��� ,20 ZS
Cam:•' SSA��pRK
Notary Public
sa N= APR 1 2025
�,,,�.��••.__ - ;���.' Southold Town
SS/OK Board of Trustees
''°°°eeeaeesoe :e9°j°
Board of Trustees Applicat:'-
AFFIDAVIT
Maria Rivera 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.
N/A
Signature of Property Owner Signature of Property Owner
Maria Rivera
��
SWORN TO BEFORE ME THIS 3 DAY OF �G 20 ZQ
• ••6fATE U
__ r :•OF NE`N ORK lJ
Notary Public = NOTAF� N
�c Qualified in N
Kings County %^= APR 14 2025
01AR6082685
'''.,S��N E�P��;•°` Southold Town
'►►►4 ue a U,e,
Board of Trustees
APPLICANT/AGENT/REPRESENTATWE
TRANSACTIONAL DISCLOSURE FORM
The Town ofSouthold's Code of Ethics prohibits'conflicts ofinterest,on-the part of town>offcers andemolovees.The purpose of
,this form isto provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is
necessary to avoid same, Jeremy Armstrong
As Member of Narrow River Properties LLC
YOUR NAME: and as Individual PropertV Owner
(Last name,first name,ipiddle 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 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 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 employce has even.a partial ownership of(or employment by)a corporation
in which the town officer or employee owns more than.5 ofthe shares.
YES F-1 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/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):
f,A)the owner of greater 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 non-corporate entity(when'the
applicant is not a corporation); f
14D)
C)an officer,director,partner,or employee of the applicant;or ® V the actual applicant.
DESCRIPTION OF RELATIONSHIP APR 1 4 2�25
Southold Town
Board of Trustees
Submitted this 31 day of /q � 20 2�
Signature
Print Name Jerem A strop
Form TS 1 As Member"of Narrow River r—f'opee lies LLC
and as Individual Property Owner
APPLICANVAGENPREPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town ofSouthold's Code of Ethics prohibits conflicts of interest on the nartoftown 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.whateveraction is.
necessary to avoid same.
YOUR NAME: Rivera,Maria
(Last name,first name,•piddle 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 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 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 F-1 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/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):
_nA)the owner of greater than 5%of the shares of the corporate stock of the applicant
(when the applicant is a corporation);f1B)the legal or beneficial
C �}�]
ficial owner of any interest in a non-corporate entity(when the V
-Rapplicant is not a corporation);
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant. APR 1-4 2025
DESCRIPTION OF RELATIONSHIP
Southold Town
Board of Trustees
Submitted this-3 ay of, Y20?J
Signature ..,_ � ►,�..._ _
Print Name Maria Rivera
Fortn TS I
APPLICANT/OWNER
TRANSACTIONAL AL DISCLOSURE PORE
The Town of Southold's Code of Ethics prohibits conflicts of interest on the nart 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 same.
YOUR NAME: Herrmann Robert E
(Last name,first name,middle 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 name.)
TYPE OF APPLICATION: (Check all that apply)
Tax grievance Building Permit
Variance 'Trustee Permit XXX
Change of Zone Coastal Erosion
Approval of Plat Mooring
Other(activity) Planning
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 X
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 ID) 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 that 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
1D)the actual applicant
(DESCRIPTION OF RELATIONSHIP
Submitted this th ay ofApril ,2025
Signature
Print Name Robert E. Herrmann ® E C E
APR 1 4 2025
Southold Town •
Board of Trustees