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HomeMy WebLinkAboutTR-4968 Michael J.Domino, President so jyo Town Hall Annex John M. Bredemeyer III,Vice-President �� l0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold,New York 11971 A. Nicholas Krupski • i� Telephone(631) 765-1892 Greg Williams �C4U O Fax(631) 765-6641 � NT`I,�� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 1458C Date: March 23, 2018 THIS CERTIFIES that the construction of a 4'x24' fixed dock ele.min. 4' above marsh,a 2 '/2'x16' walk-ramp &a 6'x20' float with 2 2-pile dolphins a pool at 77' as shown on survey dated 3/24/99 with condition that it include a drywell for drainage; At 8516 Main Bayview Road, Southold Suffolk.County Tax Map#1000-87-5-23.10 Conforms to the application for a Trustees Permit heretofore filed in this office Dated February 25, 1999 pursuant to which Trustees Wetland Permit#4968 Dated March 24, 1999,was issued and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the construction of a 4'x24' fixed dock, ele.min.4' above marsh a 2 '/2'x16' walk-ramp &a 6'x20' float with 2 2-pile dolphins a pool at 77' as shown on survey dated 3/24/99 with condition that it include a drywell for drainage. The certificate is issued to Marie Jones&Kevin R. Middleton owners of the aforesaid property. Authorized Signature FROM Kevin Middleton / 'ONE NO. 516 277 6765 { � 05 1999 10:33AM P1 MARCH 5, 1999 � o Re : Admendment t Permit. Number 4955 t. Dear Southold Ton Trustees Kevin Midd1 on and Marie Jones are respectfully requesting a admendment to ermit Number 4955 to include a Swimming Pool the Size of 16x32. I was not in our request earlier because we did no'r Know that we shopld have requested it then. We are sorry for any inconvenence this may have caused you_ Thank You, i Michael J. Domino, President ��0� SUUjyO Town Hall Annex John M. Bredemeyer III,Vice-President ,`O l0 54375 Route 25 P.O. Box 1179 Glenn Goldsmith Southold, New York 11971 A. Nicholas Krupski G � O Telephone(631) 765-1892 Greg Williams ' Fax(631) 765-6641 �yCOWN,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: 3 Zv K Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1St day of construction % constructed Project complete, compliance inspection. INSPECTED BY: Ak • ���Jorwi l COMIyIENTS: *'(W 00 + CERTIFICATE OF COMPLIANCE: 6c 42�re-W 5t 14 77 Ste. 973,t0 ID E C EA V E.nnnn I U A h' �. .� tib; �o�nsoC1 S_outhold Town f a 9�W� �^/.•« yam\ Si 7 l\ ir:\. JY�� �hYi%fes �� %l. ���; �^'� �..�,r.A -`„�,, ''��.. may.•t' �- '�C,'r ;Za. •�` � ; ,V -.. Board Of Southold Town Trustees Iiy SOUTHOLD, NEW YORKAl 9 ` PERMIT NO. DATE: .. 3/24/99 MARIE JONES &. KEVIN R. MIDDLETON• ' ISSUED TO ..... .ry ,Al Pursuant to the provisions of Chapter 615 of the Laws of -4the State of New York, 1893; and Chapter 404 of the Laws of the d ' ' State of New York 1952; and the Southold Town Ordinance en- �`� titled "REGULATING AND THE PLACING OF OBSTRUCTIONS s IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;". and in accordance with the Resolution of The Board adopted at a'meeting held on ...3/a4/99..... .x 00 ¢' 19 99 •759. and in consideration of the sum of .- P. aid by Marie. s &.Devin R. Middleton . .................................. ....... ��rt • z" ,� s.r e. Jox�� / of ........southgla . . . N. Y. and subject to the Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: - Wetland Permit to constr. a 4'X24' fixed dock, ele. min. 4' abo marsh, a 2 1/21X16' walk-ramp & a 61X20' float with 2 2-pile dolp � y dated 3/24/99 with condition tha ,C a pool at 77' as shown on surve ° it include a drywell for drainage & a dock application as submitte 9 *' on all in accordance with the detailed specifications as presented in G a' sheefhe originating application. 1 of 2 of application on approved pla in the dotted located at a "T" shape configuration. IN WITNESS WHEREOF, The said Board of Trustees .here- by causes its Corporate Seal to be affixed, and thesepresents to ; be subscribed by a majority of the said Board as of this date. fig" G - �e Trustees •�� / � r,. v, -.��.-_-"-___ - -��--G=7, -s.a�-- -,•-c+';r_y_r,,���c t•ra+ ;re i ,�..t��►.'soar%l:tw'=:±�.rd."�.�i:.� �'''.a8.rs s.r s ,�r e.�'�y=�L,•r �..�. , ^•, {.f'%3.i�h1'�G� �� -�y �/��j. hi',- ' � .,�jlyL�osi�• � �A Town Hall Albert J. Krupski, President 53095 Main Road James King,Vice-President '14 ;, P.O.Box 1179 Henry Smith Southold,New York 11971 Artie Foster Ken Poliwoda '�'*� �@ Telephone(516) 765-18g2 Fax(516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD March 26 , 1999 Kevin R. Middleton & Marie Jones 2393 Union Blvd. , Apt. 3A Islip NY 11751 Re : SCTM #87-5-23 . 10 Dear Mr. Middleton, The following action was taken by the Board of Town Trustees during a Regular Meeting, held on March 24 , 1999 , regarding the above matter: WHEREAS, KEVIN R. MIDDLETON & MARIE JONES . , applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated February 25, 1999 and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on March 24 , 1999 , at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standard set forth in Chapter 97-18 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, L , r RESOLVED, that the Board of Trustees approves the application of KEVIN R. MIDDLETON & MARIE JONES to construct a 4 ' X 24 ' fixed dock, elev. a min. of 4 ' above marsh, a 2 1/2 ' X 16 ' walk-ramp and a 6 ' X 20 ' float secured to two 2-pile dolphins, a pool at 77 ' as shown on survey dated 3/24/99 with condition that it include a drywell for draining, and dock application as submitted on sheet 1 of 2 of the application on approved plan in the dotted location at a "T" shape configuration. Located: 8516 Main Bayview Road, Southold. BE IT FURTHER RESOLVED that this determination should not be considered a determination made for any other Department or Agency which may also have an application pending for the same or similar project. Permit to construct and complete project will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. FEES : Catwalk: 4 ' X 12 ' = 48 ' X $3 = $144 ramp: 30" X 14 ' = 35 ' X $3 = $105 Float: 6 ' X 20 ' = 120 ' X $3 = $360 TOTAL DUE : $609 Very truly yours , �. . t Albert J. Krupski, Jr. President, Board of Trustees AJK/djh CC . DEC Dept . of State ACE Bldg. Dept. MAN SAW EYY..ROAD 27' TO EASTSIDE OF VICTORIA DR. _ e .. SCTM / 1000-8 -05-23.1 cv ADJACEW -IQYJAMES � 5. Es UGHTHOUSE RD o� • SOUTHOLD. NY 0 2 ANIHONI' pI5C1oTrA • ; 906 CAROINER OR 'FA i ®AYSFIORE, NY 11706 ' 3 CSO MMELL tWJ.AUAN D 0340 ANON 9AYY10M RD SoyrHOLO. NY 11971 100 SCALE 1'i3000' y LONG TS 25' 0' Q SOS IN °EEr VICINITY MAR' LOCATION MAP HAGSTIIOM SUFMI4 COUNTY �P 23. SECTION x R1-o2 30 x 16' RAMP Vf v �+ ,y 4` TWALK/RAMP 8�PIu NG5 COREY CREEK V DOCK O FLOOD ', . a"�1ur+6s AMLW p AMHw N61CATES WATER• IAEfTbHD . 'WETLANDS A7'rI:()VC17 -AS 1.188 TERMS = TOP .OF-BANK ANI) CONNnrI'a0A- or? PERMIT NO. 10' 20' - - SCALE 1NFEET PROJECT, PIAN 17nxT," 9 r— r PROPOSED, nFL,QATING DOCK ___--- COREY CREEK', HOG NECK , BAY PURPOSE: PROVIDE 1 BERTHING, A SOUTHOLD, SUFFOLK; .COUNTY; NY- ' APPLICANT;,KEVIN' MIDDLETON Qostello marine COO �`'I� .' 3293 UNION ®LVD.. APT. 3A 423 Fifth St.•P.O! �� I ,. Rtvrs60 ISLIP'. NY 11751 - Greenport. NY 9, jAK• �8, 1999 - SHEET 1- OF 2. 516)477.1 `- ste JUNE -18..1968, Td WdL0'20 GGGT LT •.d21 -j G` ON .3NOHd u0tatppTW ulnab{ WO8j fo R N c+ ld 30® x 16' 4' x'�4' ALUMINUM RAMP ELEVATED RAMP 2 PILE flOLPH1N, Six rb' CATWALK -r ®" K 22'.CCA PILES (2 REQUIRED) CCA FLOAT IF 4' m AMHW 2.5 0 AMLW CREEK BOTTOM ®" DIA. CCA PILE (TYPICAL) CA R1 Lk) co -NY80 EC: API't;0y,,,, _„ .-,,c TERN'S CROSS VIEW DIAGRAM AIND CON:D1T1ONS Or 3 D' 5' 10' 15' 20' J PER\1LT LSO. -��36-caol� ° SCALE IN FEET DA'x'e9 _— r I � kQ NOTE:•RAMP, ELEVATED CATWALK & FLOAT PROPOSED FLOATING DOCK m To BE CCA TREATED TIMBER COREY CREEK, HOG NECK BAY ' SOUTHOLD, SUFFOLK COUNTco Y, NY 3 d w �c APPLICANT: KEVIN MIOULETON T rgI~v�sEa 3293 UNION BLVD., APT. 3A �rav� 16, ts99 ISLIP, NY 11751 JUNE 18, 1998 SHEET 2 OF 2 D - �/ Aron oPOP ®ell �``Z. 4&, y j e�A° Eg®0 ,>00'F ��l �� 'q0 �2 y /600• 5,g9'3f �.� O jqg4!;!C 8 N, f� ho/e o - e'qs 1 � O TEST HOLE L9 0, O O Dark brown sandy loam OL 0.5' 6ge l O Z Brown loamy, SW 31 Brown coyer - Ac '00.00. 101,o a sad SC 3.8' Mapavr-p Y / /�' ��� a Wale fn brown �s'Cclayey sand /O?,q SC �S +( 7q AA(D 8, Water In brawn NOTE$ fine to medium LOT NUMBER REFER TO 'MINOR SUBDIVISIONsand sP' ' MADE FOR JAMES W. DAWSON /4' I am famillar with the STANDARDS FOR APPROVAL AND CONSTRUCTION OF SUBSURFACE SEWAGE DISPOSAL SYSTEMS FOR SINGLE FA MIL Y RESIDENCES and will abide by the conditlons set forth therein and on the permit to construct. No7-E SURVEY OF AT PROPERTY , F4OOCJ etre C00 cr Mar AYaic.,413[ b BA YVIEW Foy Ntw vsr2vcric,•.i �/2rn C�.Mv.��ry.Pe.w�a N0• 360813 00791 ELEVATIONS ARE,REFERENCED TOWN OF SOUTHOLD 'TO N.G.V.D. SUFFOLK COUNTY . N. Y. The locations of wells and cesspools 1000 — 87 — 05 — 23.10 shown hereon are from field observations SCALE 1" = 40 and or from data obtained from others. MAY 19, 1998 AREA = 1. 113 acres to tie line OF NEW I', OWN S. ME'T2c ip� ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION D —:wry Fp OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW, r , EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTIFICATIONS f+ HEREON ARE VALID FOR TMiS MAP AND COPIES THEREOF ONL Y IF n � `_ 1 SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SLUR .AIL 3 1 1998 f /!/Q � �Y LIC. NO. 49618 WHOSE SIGNATURE APPEARS HEREOM - TERM AL C. MUST BE4USEDTBY ANY AND ALL L Y WITH SSURVEYORAID LA W SEUTILIZING AT COPY BY TOWN OF SO U TH O 11 r5l 4 OF ANOTHER SURVEYOR'S MAP. TERMS SUCH AS IMPECTED'AND J6-� P O. .� BROUGHT-TO-DA TE'ARE NOT IN COMPLIANCE WITH THE LAW, 1230 STREET SOUTHOLD, N.Y. 11971 98 - 186 ' Albert J.Krupski, President �oOFFD[,re® -2own Hall James King,Vice-President �® G 53095 Main Road Henry Smith P.O.Box 1179 Artie Foster y Southold,New York 11971 Ken Poliwoda Telephone(516)765-1892 -A - Fax(516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: MARIE .TONES R, KFVTN R _ mTnnT.FTnN Please be advised that your application, dated February 25, 1999 has been reviewed by this Board, at the regular meeting of March 24, 1999 and the following action was taken: (__IX)} Application Approved (see below) ( ) Application Denied (see below) ( } Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees . The fee is computed below according to the schedule of rates as set forth in the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES : Catwalk: 4' X 12' = 48' X $3 = $144 ramp: 30" X 14' = 35' X $3 = $105 float: 6' X 20' = 120' X $3 = $360 TOTAL DUE: $609 TOTAL FEES DUE: $ 609.00 Q 3O � SIGNED: aZ116�� o 14� 9't MAR PRESIDENT, BOARD OF TRUSTEES BY: CLERK, IV RD OF TRUSTE9S 4/98 o��FFo��o s Town Hall. 53095 Main Road P.O. Box 1179 Telephone Q Southold. New York 11971 (516) 765-1801 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Tuesday, March 23, 1999 the following recommendation was made: KEVIN R.MIDDLETON AND MARIE JONES 87-5-23.1 to construct a swimming pool and floating dock. 8516 Main Bayview Road, Southold The CAC did not make an inspection, therefore no recommendation was made. FROM': Kevin Middleton NE NO. : 516 277 6765 F __• 11 1999 12:09PM P2 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION DEC PERMIT NUMBER EFFECTIVE DATE 1-4738-02019/00001 February 1 1999 FACILITY/PROGRAM NUMBERS) nPRMIT EXPIRATION DATE(S) Under the Environmental Conservation Law February 1, 2003 TYPE OF PERMIT ■ New ❑ Renewal ❑ Modification ■ Parmit to Construct ❑ Permit to Operate ■ Article 15, Title 5: Protection ■ 6NYCRR 608: Yater OuaLity ❑ Article 27, Title 7; 6NYCRR of Water& Certification 360: Solid Waste Management ❑ Article 15, Title 15: Water 13 Article 17, Titles 7, 8: SPDES ❑ Article 27, Title 9; 6MYCRR supply 373:.Haxardou3 Waste Management 13 Article 19: Air Pollution C Article 15, Title 15: Water Control ❑ Article 34: CoastaL Erosion Transport Management ❑ Article 23, Title 27: Mined Q Article 15, Title 15: Long Land Reclamation 0 Article 36: Floodplain Island Wells Management ❑ Article 24: Freshwater Wetlands 0 Article 15, Title 27: Wild, ❑ Articles 1, 3, 17, 19, 27, 37; Scenic and Recreational Rivers ■ Article 25: Tidal Wetlands 6NYCRR 380: Radiation Control PERMIT ISSUED TO TELEPHONE NUMBER Kevin Middleton and Marie Jones (516) 277-6785 ADDRESS OF PERMITTEE 2393 union Blvd. t. 3A Istip, NY 11751 CONTACT PERSON FOR PERMITTED WORK TELEPHONE NUMBER NAME AND ADDRESS OF PROJECT/FACILITY Middleton & Jones property, Main Bayview Road, Southold, NY 11971 LOCATION OF PROJECT/FACILITY SCTM 181000-87-05-23-1 COUNTY TOWN WATERCOURSE NYTM COORDINATES Suffolk Southold Corey Creek DESCRIPTION OF AUTHORIZED ACTIVITY: Construct a single family dwelling with associated sanitary system, deck, driveway, pool and catwalk, ramp and float. ALL work shall be done in accordance to plans stamped NYSDEC approved. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, the General Conditions specified (see page 2 & 3) and any Special Conditions included as part of this permit. PERMIT ADMINISTRATOR: ADDRESS Mark C. Carrara (CKw) 8ldo. *40, SUNY, Stony Brook, NY 11790-2356 AUTHORIZED SIGNATURE di / DATE Page 1 of 4 February 2, 1999 DEr.-%ATMENT OF THE ARMY U NEW YORK DISTRICT, CORPS OF ENGINEERS Off ��711 JACOB K.JAVITS FEDERAL BUILDING F Z % NEW YORK, N.Y. 10278-0090 .-- v� ... REPLY TO September 30, 1998 Tl;�r;,; � t���► ��. ATTENTION Of Eastern Permits Section SUBJECT: Application Number 98-10790-L2 by Kevin R. Middleton and Marie Jones To Whom It May Concern: The New York District, U.S. Army Corps of Engineers, has received a request for Department of the Army authorization for the following activity: APPLICANT: Kevin R. Middleton and Marie Jones 2393 Union Blvd. Apt . 3A Islip, NY 11751 ACTIVITY: Construct a 4 foot by 24 foot fixed pier, elevated a minimum of four feet above the grade of the marsh, a 2 . 5 foot by 16 foot walk-ramp, and a 6 foot by 20 foot float secured to two 2-pile dolphins . The purpose of this project is to provide mooring facility for the applicants, vessel (s) . WATERWAY: Corey Creek, Little Peconic Bay LOCATION: Town of Southold, Suffolk County, New York As this is minor in nature, authorization may be by Letter of Permission. This is in accordance with current Federal Regulations governing work in navigable waters of the United States . To accomplish the coordination required, prior to the issuance of a Letter of Permission, your review of the enclosed drawings is requested. Pursuant to Section 307 (c) of the Coastal Zone Management Act of 1972 as amended (16 U.S.C. 1465 (c) (3) (A) ) , the applicant has certified that the activity complies with and will be conducted in a manner that is consistent with the approved state coastal zone management program. To allow for the timely processing of the subject application, your comments are requested within 15 days of the date of this letter. Sincerely, a es W. Haggerty C ief, Eastern Permits Section Enclosures Q�OSVFFO(�CO Town Hall Albert J.Krupski,President h� Gy 53095 Main Road James King,Vice-President o= < P.O.Box 1179 Henry Smith cc Z Southold,New York 11971 Artie Foster o Ken Poliwoda y �� Telephone(516) 765-18,92 Q Fax(516) 76571823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use 0 Coastal Erosion Permit Applicat 3Z7-Wetland Permit Application FEB 2 5 190 Grandfather Permit Application Waiver/Amendment/Changes Received Application:- WN OF SQUTHDLD Received Fee:$ v Completed Application - S- Incomplete SEQRA Classification: Type I Type II Unlisted Coordination: (date sent) CAC Referral Sent:.3 Date of Inspection: Receipt of CAC Report: Lead Agency Determination: Technical Review: 2 5 10 Public Hearing Held: Resolution- LM Name of Applicant Aevit4 Q . Middle+b- o�d b a ✓rte ©ne s Address 2-39 :% Phone Number: ( Suffolk County Tax Map Number: 1000 - $ o :5 - z 3 . Property Location:gSl6 Malmo% (B 01.4VIetL) Raod So,_44-In[al kceoss . noel VICA-ank aA. m yl- P01407� OK +(A,. 144 NYT Po�e�7SoN r,g � (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone- FAX#: 1 Board of Trustees Applic ion GENERAL DATA Land Area ( in square feet) : Area Zoning: 9 e-61A&n4ig I Previous use of property: C,,Cw t uA Intended use of property: g, ,d&,44,6 J (.o,A,+f uct v , o� ,mw t" -� e5 -r-t 9491 J n C k- I Prior permits%approvals fol site improvements: i f x"r .' :'� •Agency Date_., ��,► P /�7 ii j •� ��Y�Y{i� C q p� Dc4- 'k No ]mor YgpY ermits/-app,rp. .als for site improvements. Has any permi /a p roval •fe er been revoked or suspended by a governmental1 agencyNo Yes ? €+ If yes, provide_.explanationcllf Project Description (use attachments if necessary) : C69•n��r�A C.t i cD h'9� Z5-0)wi vA 14 v m o , G SCJ 0,41✓s a f�e'er i 2 Board Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA r Purpose of the proposed operations: !DD«S d Cc e� h a I Cmc sIr&(4 e� A'c6.9,y,5 otd-qre S -F 1©a , deDck Q -i Area of wetlands on lot: 9-C) square feet Percent coverage of lot: o o ) % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: "7 9 feet Does the project involve excavation or filling? No //- Yes If yes, how much material will be excavated? So cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: 4/ feet Proposed slope throughout the area of operations: 152, Manner in which material willP /be removed or deposited: o CA v 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) : Q 9 r 141C7� )Aml p to sT-'L.t� 3 Board of Trustees Applic on COASTAL EROSION APPLICATION DATA Purposes of proposed activity: 44901dp,11111 Coy Are wetlands present within 75 ,feet of the proposed activity? No Yes Does the project involve excavation or filling? No / Yes If Yes, how much material will be excavated? >c, (cubic yards) How much material will be filled? rd (cubic yards) Manner in which material will be removed or deposited: 8 ,411 dozer Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) /tel f.R f d'w'l 4 MAIN BAYVIEw ROAD 27' TO EAST SIDE OF SCTM 1000- 7-05-23.1 VICTORIA DR. Ngd 0 1 04 ADJACENT OWNERS: I JAMES BITES 7:7 LIGHTHOUSE RD SOUTHOLD, NY 11971 2 ANTHONY PISCIOTrA 906 GARDINER DR IBAYSHORE. NY 11706S 3 JANICE HILLMAN C/O RUSSELL HILLMAN 8340 MAIN BAYVIEW RD SOUTHOLD, NY 11971 0 21,'- O SCALE IN FEET SCALE 1'=3000' LONG 72' 25' 0" VICINITY MAP LOCATION MAP HAGSTROM SUFFOLK COUNTY MAP 23, SECTION H 41-42 In 30" x 16' RAMP ATWALK COREY CREEK FLOATING DOC -FLOOD EBB- 14 20' ..... ........... . 14' . ....12' 12' ...... :4 . 2 PILE DOLPHIN (2 REQUIRED) : ......... ...... ... ... ... . ALTERNATE FLOAT LOCATIO� AMLW NOTE: AMHW 0 INDICATES WATER LAWETL�ANDS DEPTH, MLW=0.0' TOP OF BANK 0 lo' 20' 30, SCALE IN FEET PROJECT PLAN PROPOSED FLOATING DOCK PURPOSE: PROVIDE SHALLOW DRAFT COREY CREEK, HOG NECK BAY BERTHING FACILITY SOUTHOLD, SUFFOLK COUNTY, NY APPLICANT: KEVIN MIDDLETON 3293 UNION BLVD., APT. 3A ISLIP, NY 11751 JUNE 18, 1998 SHEET 1 OF 2 G 5;A-6, 01 Ak* \ n s '140 Q � N ', `�h � •® es moo, ,y��jy A0, t ' o• O8 ', ♦ 7 r ',� - � � J��, g's ecLl IV CIAI Ae Ae .tete /� v.,r b ,�,� '_ • � � � � , �.4��'%9 "• e v -': ,�, � hese � , y - � Ar, a 1 Ro .♦lb wQ� A N ��Q l9 '� ; OO 7EST HOL . SF'p�., lL 1, 10 Dark brow.- Jq �• �' 1 N ;`x.00,00. , ' `\ Brown far 1 ` PaA brow: 1 off far vA�r -�' �, 1� 1A�n e ' . 0/F Brown &N,- sand bh4 Mand 10A M3VY Q_&QU�A Pd* brow: .f 20 , ,,.L s , ; , ���,,-c �,- �A AND Coors* se NOTED REMOVE ALL #AFIERVWS SOIL BETON' A 3' Cf I AR water ih p NOTE' LEACHING PQO S BACKFXL brown ev LOT NUMBER REFER TO ?4kVOR SUBDIVISION' wisAND a GRAVEL Sand MADE FOR JAMES W. DA WSON 3.0 ��shed y iaae I am famAtar with the STANDARDS FOR APPROVAL �s � AND CONSTRUCTION OF SUBSURFACE SEWAGE ns �mr�F I000 gai DISPOSAL SYSTEMS FOR SINGLE FAMILY RESIDENCES Sept/� i£ 10.4-IE 9,*' L.P.(c�nfe and will obtde by the condlllons set forth therein and on the ask permit to construct. — — —191-. wo}e� �2� :piov contov�- GRADING PLAN (hi9he+t e FLOOD ZONE LINES FROM FIRM © P 3a4,'103C0166 G MAY � 1998 � - G ro eftv • SURVEY OF f FL NOT AVAILABLE A T FOUR'W CONSTRUCTION COASTAL BARRIER s8 UPSURFACE SEWAGE DISPOSAL BA YVIE ELEVATIONS ARE REFERENCED SYSTEM DESIGN BY+ JOSEPH FWETTI, P.E: TOWN OF S: TO N.G.V.D. SOOUATHOLD, N.Y. 11971 SUFFOLK CO_ (y6) 70 - ?$�4 IMA Q7 *1- g r .r - o ' b " � z m 20' 4'-1 2' „a. 12•- 0 30' x 16' 2 PILE DOLPHIN AL UMMIA RAMP 4' x 12' 4' x 12' 12" x 22'.-CCA PfLFS 6' x 20' ELEVATED— RAMP (2 REQUIRED) CCA FLOAT CATWALK 4 A)dHW 2.5' _ m AMLW i� 1 �uss�a,.rc3 Z 0 3' CREEK BOTtOM f/ 12" DIA, CCA PILE wdre.waS (TYPICAL) o� M LlC CROSS VIEW DIAGRAM 0' 5' 10' i 5' 20' SCALE IN FEET MOF '. EtEMT>:n cnnvALlc & Ftonr PROP_ G Dm PROPOSED FLOATINOCK - TO BE CCA TREAT TIMBER aCOREY CREEK, HOG NECK 8AY SOUTHOLD, SUFFOLK COUNTY, NY 3 APPLICANT: KEVIN MDDLETON 3293 UNION BLVD.. APT. 3A ` 1SUP. NY 11751 JUNE 16. 1996 SHEET 2 Oh 2 PART II—ENVIRONME 1L ASSESSMENT (To be completed by A ;y) A. DOES ACTION EXCCEEL —. TYPE I THRESHOLD IN o NYCRR, PART 617.12? It yes, coorafnate the review process ana use the FULL --AF. ❑Yes LL!No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN as NYCRR, PART 517.0? If No,a negative declaratic may be superseded y another Involved agency. ❑Yes No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or dlsposa potential for erosion,drainage or flooding problems?Explain briefly: tj (D - C2. Aesthetic, agricultural, archaeological,historic,or other natural or cultural resources;or community or neighborhood character? Explain brie /j6 Ca. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats,or threatened or endangered species? Explain briefly: O C4. A community's existing plans or goals as officially adopted,or a change in use or intensity of use of land or other natural resources?Explain brie ,A a CS. Growth, subsequent development,or related activities likely to be induced by the proposed action? Explain brieflt - - N CS. Long term,short term,cumulative,or other effects not identified in CI-CS? Explain briefly. /v CY C7. Other impacts(including changes in use of either quantity or type of energy)? Explain briefly. N) (� 0. IS THERE, OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑Yes L1'No If Yes,explain briefly PART ill—DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it is substantial,large,important or otherwise significz Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; Irreversibility; (e) geographic scope; and (f1 magnitude. If necessary, add attachments or reference supporting materials. Ensure tt explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive-declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in-:j3.r1y significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: �.une or Lead Agency Print or lype Narne of Kesponsiole miter in Lead Agency ride or Kesponsiole Officer Signature or Responsible Officer in Lead Agency Signature or Preparer tit different from responsiole orricerl Dare 2 14-1.6-4(2/87)—Text 12 PROJECT I.D. NUMBER 617.21 S EG Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I—PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT/SPONSOR yy y 2. PROJECT NAME Kc_UJ �. MtC�d I P+c9•• t AJaeI Q Tones 5. PROJECT LOCATION: Municipality V 5 1 � g1y1 o'11 V lei P,,aaLC1 County 4. PRECISE LOCATION (Street address� and road i tersecnttions, prominent landmarks, etc., or provide map) $Fjt 011✓1 C4J Vie") T 0a C' t S0 A-11C, r rov, &r/ 0 5. IS PROPOSED ACTION: 'V-New O Expansion ❑Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: r4�a1 c�0� Af eo,t-5+1" gC4to.n ca ITIJ1 V4W10 � / ©aCt 0 o1 ItA d o c 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL OPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes O No If No,describe briefly 9. WHP,7 IS PRESENT LAND USE IN VICINITY OF PROJECT? C2 Residential Drioustnal O Commercial O Agriculture L-1 Park/ForesUOcen space Ll Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, 08 FUNDING, ,VOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL, STATE 0 LOCAL)? L�Yes O No If yes, list agency(s) and permit/approvals AJ yo pec. -tom i - q-73$- 0 IC?/o©o 1 EF,(r"i Coro e er Pe r 01)k 11. DOES ANY ASPECT OF THE ACTIO14 HAVE A CURRENTLY VALID PERMIT OR APPROVAL? tires O No if yes, list agency name and permitlapproval / 01 is DeL Pe!'o"t-� � / m / I- 1-737 - (n -2011 C © 0 of,p4- o•F fef,M 14 9- 99-10-710 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE mCOIFICATION? ❑Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: �P U+✓\ li Cell(". Date. Signature: �� `T/V/vomit If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 ' Board -or Trustees Application County of Suffolk State of New York �P j 4 yk Q i 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 TOWN 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(S) , TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signature SWORN TO BEFORE ME THIS DAY OF I{ 19 f KS%REN A.HURWITZ 610TARY PUBLIC,State of Now York Notdry Public No.4881448-Suffolk County Term Expires December 22 7 Hoard of Trustees Applic _- ion Jk AUTHORIZATION (where the applicant is not the owner) I� residing at (print owner of property) (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner' s signature) 8 Print -or Type: TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Office use only PECONIC LANE File #: PECONIC, NEW YORK 11958 Permit #: o � � PERMIT & BOND APPLICATION FOR ACCESS THROUGH TOWN OWNED PROPERTY 1 ) Hi JAeb?_ _+ Mace- :3-o4nes zgj3 blvd 3,4- �Sl�� NY lt7s� (Name of Applicant ) (Address) 2) Cos-_ lv &ctoe Covt-:�7nc4P.4q C®,r12g2_3 .-E'I-i„ 5-V o.*,S . z12-Y Gcee..,poj q 119q�' (Name & Address of Contractor Involved) 3) V516 M01"n Kay vlew 404d 50,4+6011 1000-?7 (Project Location) (S.C.T.M. #) 4) `$51(o j' Ato 4,a weLi cva(J o alS e,44 o (Name of Road dr Town Property Involved) (Hamlet ) 5) •eea ide,4I I C_O,ns41' 0_4,6,A a� a. w�� tM►� mmf (Brief Job Description) 41 o se - &_ 6) Starting Date: Completion Date: 7) Estimated Cost of Proposed Work: t1_5 ,®Da:p .8) Insurance Coverage: A. The coverage required to be extended to the Town: Bodily injury & Property Damage; $300,000/$500,000 Bodily Injury & $50,000 Property Damage B. Insurance Company: C. Insurance Agent Name & Telephone # D. Policy # : E. State whether policy or certification is on file with the Highway Department : ( If no, Provide a copy with Application) (yes/no) X, Gas - 2 -��-?� (Signature of Applicant ) (Date) ------------------------------------------------------------ To be completed by the Superintendent of Highways: Bond Amount Required: (Signature) Print or Type: ACCESS CONSENT FORM Office use Only FOR ACCESS File #: THROUGH PRIVATE PROPERTY Permit #: 1 ) + Mct v l e- -J-v,ne s ,239?2 Uooe� told d -94 T LA 4 /17j-/ (Name of Applicant ) (Address) 2) (-dz5-61t& H rich c6,4 ,%ej,4e co,-e- y23 F,4t 54. P.D. Oyc212-9 GreC'vl,0 4 NY[IT y y (Name & Address of Contractor Involvred) 3) SSI,, Harv+ gay'loew �04p1000-97 - S - 23. / o (Project Location) ® (S.C.T.M. #) 4) g v& n4io S , +-i,5 - o tAa (Name of Road o Private Pr perty Involved) (Hamlet ) 5) 3g--t1° a--) n�4 Q 'e-- (Name & Address of Homeowners Association / Property Owner) 6) 4e Jt _ohS+f14C-� 'v 04— 6k S W I M as (Brief Job Descri pt i ont) / o� �t cc o� I f ., e�s 7) Starting Date: SSA Cletion Date: 8) Estimated Cost of Proposed Work:om 5 d a a 9) Insurance Coverage: A. The coverage required to be extended to the Property Owner: Bodily injury & Property Damage; $300,000/$500,000 Bodily Injury & $50,000 Property Damage. B. Insurance Company: C. Insurance Agent Name & Telephone # D. Policy # . E. State whether policy or certification is on file with the Trustees Office: ( If no, Provide a copy with Application) (yes/no) (Signature of Applicant ) (Date) ------------------------------------------------------------ To be completed by the Property Owner: I/We the undersigned, fully understand the nature of the Proposed Work referenced above and have no objection to allowing the Applicant to cross My/Our Property to do the work. (Signature of the Property Owner or duly authorized representative) I (!' %lafF0`,� U O�Q CO Town Hall Albert J. jLTjs , P�`Odet5 �ggg UUU h� �jy 53095 Main Road James Kin ,Vic e.President c t P.O.Box 1179 He 2 Southold,New York 11971 OF SOUT 0311 U p • Ken Poliwoda 4' Telephone(516) 765-1882 �! � Fax(516) 765-1823 t BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD ----------------------------------- In the Matter of the Application of &691C-- 4J-®A)CS _ 4-_ K45 _ lel (b0G6-7-0.J COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, fiM?' -1-P— residing at z 7,5 Uli l u' vl +cam 1 V r /� e ng duly- sworn, depose and says That on the ��day of /�(k vc, 199 9,, Irs nally sted the property known as Gt r� �jGt Vl lT[�z�J �C� �-L ' d�1 C pod by placing the Board of Trustees official poster where it can easily be seen, and that I have checked to be sure the poster has remained in place for seven days prior to the date of th public hearing. (date of hearing noted thereon to be held D� Dated: (signature) Swor,r� to befor me this of 0 r 1999 Notary Pu is ANGELA R.REESE - - Notary Pdit Site o1 Neer York N0.01RE607=4 QUW"b&A*CMft Ivo CWM* on Et"00WMW ao— 'J f © IS DLA TL mL CA) aA rn J► �'/it�cS J�1�—� '��� : y Wall- av 0O F J _ t ZA jry .:' '' ^ - . - AO - r--` _ l ,.`" •- ` ' � \ ��S � tet' O� 4":%�,, - - ,. 00, _ F • - -"V - .,, �, _ .ter�y��;.a;: -;,_ �"' O ;e fiIto r. �.\ Qr E` B2 - OV ' -1 15) JZ tt: O 0 4wf,:loath, ;of ny.' . _ O�0 N - ©0.00 . p00 sad`t`" x_ V' C4NT _ •OO p,_,oe "Welei-i broirn _ .clayey,sand~ e waler In brown`, ' } NOTEeu prop1/wil 10'nredluni' :LO-T.NUMBER REFER TO WINOR SUBDIVISION' ' ' sand sP MADE FOR JAMES -W. DAWS'ON - �!o'�� 14't 9:G 7 9 I am -famllldr w1th the STANDARDS FOR APPROVAL $tea =o,s r- AND CONS;,rRUCT/ON OF SUBSURFACE SEWAGE' - el & � ��a$ ` �000 gai. -F DISPOSAL-!,SYSTEMS FOR SINGLE FAMILY RES%DENCES and will 6A6_,by the condl/Ions set- forth therein and on the 6_4 perMll to construct, —� — ----1— GRADING PLAN -'-NOTE' .. vl,; SLOFECO ,QD'7NSEJRANCE NOT A.vAIGABL� SUR VEY aF RROP��'T Y • W- d�IS-TRUCTION " F� � rUn' - •A`T k NOTE BA YVIE SUBSURFACSEWAGE DISPO - = E SAL W' SYSTEMDEsIGN ELEVATO WN OF SOUTHOLI?. TIONS ARE.REFERENCED " BY• JOSEPH FISCHETTI, P.E TO N.,GV.D. =w'--• HOBART ROAD - SOUTHOLO, N.Y. 11971 _ SUF� LI� COU "The locotlons -of,,wells, a»d cesspoa1516) 765 - 2954 1000 - 87 -- 05 - MAO ' Is ..A ` „ -shown, hereon are -from-field'°observations SCALE -1 . ''= 40',' and or from dolb.,obtolned .from o/hers.: g�ptE of p MA Y 19, 19981. FIS o }o� JUNE 23,,1998 1 TOB), JUL Y i5, 1998..(prop flee,&pool AREA = 1113' acres- to =tie.:-,line g ANY ALTERATION'OR'ADDITION- TOTIUS-SURVEY.IS A VIOLATION Of NE OF SECTION 7209 OF.•THE NEW YORK STATE EDUCATION LAW, � ° Og h 1�' ���� . �,��� N 1. MF>�rO'P EXCEPT-AS'P:ER SECTION 7209-SUBDIVISION"2. ALL CERTIFICA77ONS iO 0 2 ��' BoacF� HEREON ARE,'VA'l104FOR ThKS MAP AND°.COP AES THEREOF ONLY/F FF, SAID`tiIAP.,OR'COPIES BEAR-THE IMPRESSED SEAL OF THE SURVEYOR ",,,�s�N. lam'°N0. 49618 WHOSE SIGNATURE APPEARS HEREON.' '' r' 0 IwI _ ADD/770NALL.Y TO COWLY.W/TH SA/D'LAW. THE TERM ALTERED BY -MUST BE:USED BY,ANY AND.ALL 'SURVEYORS;UTILIZfNG A;COPY,, i4_ OF,ANOTHER SURVEYOR'S MAP.' TERMS.-SUCH`AS 'MWECTEO"AND JUL, 3 11M P. =" "BROUGHT=TO-OATE',ARE NOT IN COMPIyANI'E,JY/TH-THE LAW. E`T SoUTH. wr s 71 = , {,,k_--,__ . .. „-_ - .` _ - _ ' - , -- -. - - - . :98_=•186.: . . . - .-. ' :-' a..r EL • •r. ~ +. ,'T•W ter•, '� • � .J it b 4 �� Q■tcra �(r a SIP 110 IPt «.) I t A 1.1 Dau 034 LSD� '•'�� + b �- � �{ '` •°' �� � , -_-_-T Vii/i \\r c 4e + to moi-•, •'o \ aj / d ■� SED. MD,m y .L.:c.. - �•` 1 '-w APAr ••.•r rn•••wc u m••■rw n p■� •••••• ■•��f�•!•P ■fit• Li and� Lip ar ur L� -- --= •�a�wrav_—.�—• ■■++r.�L� oy © COUNTY OF SUFFOLK wwwSOUTHOLD rD+va -- W Lw.....L.- — ■,,. Wer m " Real ProPoarty Tax Service Agcy w O87 —.. ._ L�rwar ---.•_—...rr. n+,� � "'# c..a..r... G.a.:s'Lwr _ J�—: tee.-_ ...���� _ .r+.�rr Pi) u.+..�w nw Ln W.•A:w.l.LIQ;Mie Ytrk„� NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: K e� l� Id d 1 e w a- 4{Ie- -:It:-- .o scTM#1000- b- -S - 23 . ) b YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit f rom the Board of Trustees to: J3,&%Lei a r-e,5t cle A to, SuJtrMVAtd•� � o0� A -FLoe.��nq Joc 2 . That the property which is the subject of Environmental Review is located adjacent to your property and iseFribed a folloWS:iVt'i49 T-be-tvi IN 1-k&- -t-OWO 04: 6C?LAf dJC Cau-rlycdt a44-te of 1j. �pouNl�r°C� - JeArs114 as folloris: ruv&1141 c56u+4 6y degeee5o ;,i1,4 rEC6&-A.4, Con4Uer11 I:ne. r laan I�Yurew ,2d. Rloevi LoN�^ /6 degrees 00 9w-'u+eS Oe-ak r Z30,00 C+ laed I'- o-� f�ok; I .s� ryedi��ogeLl IanW 3 ecu�sp6 + d�skanc�s e��llorlL77 deg reed OO w�rnu tes We-6+ r �oB.Oq -tee-4-: Ci) /Jor4� 6`1 Ib7 rKrN are 30. ao C31 rih!eac4 I6.a-ek--a 5au+9Aer1y I-e- a boeq h,s:n Wea�erie, �arBe}:ewn +o (A�1d vlow or rwlerl e7� /�,l��an/Y�oP4�„ 15°4-53tWt e4s�� /9�.o f'j+o s®ufGpr loot o"Iarh Qa�rdte�+Re 3. That the project 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. The above referenced proposal is under review of the Board of Trustees of the Town of Southold and does not reference any other agency that might have to review same proposal. OWNERS NAME: e�1 /�r r d! a f 1!�✓I�' ©��'r MAILING ADDRESS:23 eJt4,0!1j,, //pf 3fF- . PHONE #: / 21-77-167a75 Enc. : Copy of sketch or plan showing proposal for your convenience. s PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: Co tl-o- 7r Z 402 530 467 US Postal Service Receipt for Cel tffled MaN ��a S� �C tea, n �� No Insurance Coverage Provided. / I Do not use for International Mail See reverse Sent tX /I JJ yl Street&Number r�;.e - fir. Post Office,Ptate,&ZIP Cod Postage $ L� Y,Certified Fee Special Delivery Fee Restricted Delivery Fee LO n m Retum Receipt Whom&Date eliv d n Retum Receipt trowi to Whom Date,&Addr ee's ddress oTOTAL Post e& ees1�9 $ co residing at 2393 av>to v1 blvd A,a+-- — E Postmark orDat� ����o , being duly sworn, eposes and says bf b ,19 , deponent mailed Ice set forth n the Board of Trustees ---�'- - ito each of the above named persons at the addresses set opposite there respective .names; that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment roll of the Town of Southold; that said Notices were mailed at the United States Post Office at TS'&I k, aid Notices were mailed to each of said persons by certified (registered) mail. Sworn to bome day of KAREN A.HURVATZ N tary P --NOTARY PUBLIC,State of New York No.4881448-Suffolk County Term Expires December 22, 1 6 APPLICANT TRANSACTIONAL DISCLOSURE FORH The Town of Southold' s Code of Ethics prohibits conflicts of interest on the part 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: (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. ) NATURE OF APPLICATIOU: (Check all that apply. ) Tax grievance Z Variance Change of zone Approval of plat Exemption from plat or official map Other (If "Other , " name the activity. ) CO,4,-. aC-II 9— o� SNlz�wNi+'q ,0 041 1- 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. "j� Name of person employed by the Town of Sou hold SQR� CC, Title or position of that person PJU Describe the .relationship between yourself ( the applicant ) 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 ) : A) the owner of greater than 5% of the shares of the corporate stock of the applicant' (when the applicant* is a corporation) ; D) the legal or beneficial owner of any interest in a noncorporate ,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 � G oAane az On ffn-Lc er Submitted this day of V/ 199 S i g n a t u r e bJI a, �D=-L_ Print • name Dl Gyi 1'AW 1 «_.....-,. "' - .,.. .r .:.., --._.�y-. ri +,Y^•.. .. -... .• -' ..,.eoc.r.....r esus-.erear.-,�....... -r__...... . .... •...........�... APPLICANT } TRANSACTIONAL DISCLOSURE FORH The Town of SOuthOld 's Code of Ethics ' rohibits conflicts of interest on the par L• of town officers and employees. The purpose of this form is -to Provide information which can alert the town of possible conflicts of nterest and allow_ it to take whatever action is necessary to avoid same. YOUR NAME " ;?lti•' � � ..;. �, J .•�1 V Last name, firsU name, m dd e n t ai, unless you are applying in the name of someone else or other entity, such as a company. If not indicate the other person 's or company 's name. ) NATURE UP APPLICATION s (Check all that apply. ) �� • Tax grievance Variance change of zone App paras of plate Exe ption from plat or official map Other (if 'other, " name the activity. ) Do you personally (or through your company, spouse, sibling, parent, or child) have a 9relationstlip 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 baiancp t►� tihftl dorm and date and sign where indicated. Name of person employed by the mown of Southold Title or position of that person Describe the relationship between yourself (the applicant) 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) = 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 noneorporate 'entity (when the applicant is not a corporation) ; C) an officer, director, par applicants or tner, or employee of the D) the actual applicant . DESCRIPTION OF RELATIONS11tP 1 'J, •,�' /j�•� F:VPi'^.xp, f"{ 4r°^` V} r.da . (r`5 1 "•7�yy).. !4' • Submitted ,�Z;'Z' this,qday re h,,_. ' yam' � ,�-• ,,:; 12 e4ah'M f ns-,.�•... ..._ . _ -.... i•S'/ }:�' ♦'"h•1'zMWw, .