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Home My WebLink AboutTR-5394 Glenn Goldsmith,President �Q�S®U�� Town Hall Annex 54375 Route 25 A.Nicholas Krupski,Vice President �O� ®�® P.O. Box 1179 Eric Sepenoski l l Southold,New York 11971 Liz Gillooly 'c Telephone(631) 765-1892 Elizabeth Peeples � �� Fax(631) 765-6641 COUM`(,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE 2084C Date: October 1, 2023 THIS CERTIFIES that the Wetlands& Coastal Erosion Permit to install an 8' long by 24"above grade, experimental groin and place 5 cy of pea gravel on each side to fill groin cell; At 960 Willow Terrace Lane, Orient Suffolk County Tax Map 41000-26-2-21 Conforms to the application for a Trustees Permit heretofore filed in this office Dated July 5, 2001 pursuant to which Trustees Wetland Permit#5394 Dated September 4, 2001 and Coastal Erosion Permit#5394C Dated September 4, 2001,was issued and conforms to all the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for Wetlands& Coastal Erosion Permit to install an 8' long by 24"above grade experimental groin and place 5 cy of pea gravel on each side to fillrg oin cell. The certificate is issued to William A. Hands, Jr. owner of the aforesaid property. Authorized Signature C 1 `,F 1 Glenn Goldsmith,President �AA��*®f SO Town Hall Annex 54375 Route 25 A. Nicholas Krupski,Vice President ® P.O. Box 1179 Eric Sepenoski Southold,New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 COUN`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: INSPECTED BY: �- Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, haybale line/silt boom/silt curtain 1st day of construction Y2 constructed Project complete, compliance inspection COMMENTS: r 9 CERTIFICATE OF COMPLIANCE: .� Board Of Southold . Town Trustees SOUTHOLD, NEW YORK PERMIT No.,j".39c¡.. Sept. 4, 2001 DATE: ......u u....u.uuu ISSUED TO ........I".~~.I:~.~~.u~.:....~~~.P.s.!.u JR. .... .u·... ..................-.......... Autqori;!uttou . Pursuant to the provisions of Chapter 615 of the Laws of the State of New York, 1893: and Chapter 404 of the Laws of the . State of New York 952~ and the Southokl ToWn Ordinance en- titled ."REGULATING AND THE PLACING OF OBSTRUCTIONS 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 .'.'.~.~.:....~.9..~u.. .?ºº\ and in consideration of the sum of $uu~~.~u:.~O.... paid by ...W~J1.i,,~u..It,..fIªn.g~.,....J!:.'.n... . .... .............. .....u...........u...uu..uuuu.........u..u... of ...mmuu9.r.i.e.:r!;~......uuu.u.u..mu..nu..uu.u..n. N. Y. and subjecl to the Terms and Conditions listed on the reverse side hereof, of Southokl Town Trustees authorizes and permits the foDowing: Wetland Permit and Coastal Erosion Permit to install an 8' long by 24" above grade, experimental groin and place 5 cy. of pea gravel on each side to fill groin cell. aU in accordance with the detailed specifications as presented in . the oñginating application. . IN WITNESS WHEREOF, The said Board of Trustees here- by causes. its CorfX'rat~ S~al to be a~xed, and these p~sents to be subscrIbed by a majority of the said Board as of thIS dam. ~~7/ý7 Trusi..s . . Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD COASTAL EROSION MANAGEMENT PERMIT Pennit #5394 Date: September 4,2001 SCTM#26-2-21 Name of Applicant/Agent: William A. Hands, Jr. Name of Permittee: William A. Hands, Jr. Address of Permittee: 960 Willow Terrace Lane, Orient, NY 11957 Property Located: 960 Willow Terrace Lane, Orient, NY 11957 DESCRIPTION OF ACTIVITY: To install an 8' long by 24" above grade, experimental groin and place 5 cy. of pea gravel on each side to fill groin cell. SPECIAL CONDITIONS: (apply if marked) _ Bluff restoration through a re-vegetation plan is a necessary special condition of this permit. _ A relocation agreement is attached hereto and is a necessary special condition of this pennit. _ A maintenance agreement is attached with application and is a necessary special condition of this permit. {k/. i. ·1 ~ /6--A~' n. ~ I '//' Albert J. Krupski, Jr. President, Board of Trustees AJKIlms cc: DEC ACE . . Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD September 4,2001 Mr. William A. Hands, Jr. 960 Willow Terrace Lane P.O. Box 334 Orient, NY 11957 RE: 960 Willow Terrace Lane, Orient SCTM#26-2-21 Dear Mr. Hands: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, August 29, 2001 regarding the above matter: WHEREAS, WILLIAM A. HANDS, JR. applied to the Southold Town Trustees for a permit under the provisions of the WetIand Ordinance of the Town of Southold, application dated July 5,2001, 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 August 29, 2001, 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 standards set forth in Chapter 97 ofthe Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare ofthe people of the town, NOW THEREFORE BE IT, 2 . . RESOLVED, that the Board of Trustees approve the application of WILLIAM A. HANDS, JR. to install an 8' long by 24" above grade, experimental groin and place 5 cy. of pea gravel on each side to fill groin cell. 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. Pennit 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: None Very truly yours, ~ ~ /4.~~'~. Albert J. Krups~, Jr. President, Board of Trustees AJKJlms DEC ACE I . . . New York State Department of Environmental Conservation Division of Environmental Permits, Region One Building 40 - SUNY, Stony Brook, New York 11790-2356 Phone: (631) 444-0365 . FAX: (631) 444-0360 Website: www.dec.state.ny.us ~ -... ~ Erin M. Crotty Commissioner August 24,2001 Mr. Albert J. Krupski, Jr. Town of South old Board of Trustees Town Hall 53095 Route 25 Southold, NY 11971-0959 RE: Lead Agency SEQRA Coordination for William Hands Timber Groin Project, East Marion DEC # 1-4738-01373/00003 Dear Mr. Krupski: Please be advised that the New York Slate Department of Environmental Conservation has received your letter of July 27, 2001 requesting the Department's position in regard to Lead Agency pursuant to SEQRA and commencing SEQRA Coordination. Please be advised that the Department has no objection to the Town of Southold assuming Lead Agency status for this application. Please note that the Department has received an application for this project and has commenced review. The Department will await the completion of the SEQRA process by the Town ofSoulhold as lead agency. ¡fyou have any questions regarding this matter, please contact Marilyn Peterson, the project manager for this application at 444-0365. Thank you. Sincerely, Q nÞ- '0< {/" 6--r ¡~:n W. Pavacic Regional Permit Administrator JWP/jp cc: Marilyn Peterson, Environmental Analyst I - rr-.-:...;o. . ..H=-:...·..;~:_;...~ _. __~ __...--.. . ! r - ......+ ~ (I ' '(\ ~ II' I I"f": : ~- '-. ~ r ' "1." ': 1t r· -, 'I.;" ~ ' . ~, ,.,,:l.'.~~~ 'lj;I~JII ",) "'. 'ØII~! " ....- ... . ~¡ ¡ l'f¡,~. ..;",.:,~ ~":l:·:·.~·.· .'.;', ¡}/.ßf'i. '~ 1\'\" .". ,~_.._ I..J ~ L':'~Y J1 -- - .-. _._._~ ---.- ---" F114t.,.·:8:"': -..- "8'2081 1'5: _H __ . 1:.1~!" , ý ~~ . . f r . "V ,."" r fl, C I I1 .:-, ) r:!? I~J ~ "1ÌJ"'t 1:- ~ 1~ t ~~ II . t ¿ :r U'~.. :~ - ... () ¡ }'} ~ ¡ ~- .- ,.~ ( ? ~ 11)':\ to r !.~ ~~ t'\ îI \' fJ:~f':-=. t.'" . '" ti t I")°nt ¡:; 1':~ r;{. J> ~ i '" t...~ { "' ;:. 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':l'~ .' ,/tie>-, . '><I.. A . . () .. tj,"~ \. ~ ,Z ~'a .' I..".'''". "" ~ "'P'. ~"". .;p ':'\ jI '" 111 < ~ 0 it1 ~ r- \. o ~ I ~~ $ )0 ~ 8 ~ &_8 ~ K\I} ':" ..:.:ot :v< ., '1 t~' _J '. .,. 1'~-1 ,(-hTI ;:<10 I 'itO :::;> j<.(l'1"\ 1\I1'f11 1-..1' '.; il In; II! N8i .~ . f ,. -t N~a ,.,..2 ...~, .. I 1_,__._ r' . . .t-.~. . lfl131 r~' ~I.~......f"". .l..r- .,....fb...: ....-..... '~lq .HFl..~f.'. ,...." rt'J~ i ,.v,l ". ~ i",' " .:' . ;!. 'l'~. I"',j jA HJ~~ :.nr:.(J.~!i.'.'.""...."i '. .. .'" '. ."",, .,<:.;~ \' ..-. l~ "" .,.. , .b " "',- ,. :-~ ..-, .'.,li i."'" 'lJ'l"" '.!' i. ..re!'" . ~ ,"'MIlO 'Zit) itli 10 liS-i. 81. <\,1: (. IS Q. ,'" r;-) 1""" .... 1-1 l'~'''f ~y i&Im itj l~rl';...I'n I:. ...1.....V\~....,..~.1....~r-..... I., . . .",. l~ -j.. .ib 11ti! It:' I~ i;~ I . j"m .~.II."I..'~: 11' . ~ r~1 G\.. . I 'h-" ~i... 'z:; ;.,. i.,l!'\ .fi!e . !..m~ . (l. ~ f'~ I J . - '''''t,. ( , . ' . i "~'.'1'*..,:Z : .. ~_'L'..~:':'-i:.....:-:.. . . Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD July 27,2001 Re: Lead Agency Coordination Request Dear Reviewer: The purpose of this request is to determine under Article 8 (State Environmental Quality Review Act-SEQRA) of the Environmental Conservation Law and 6 NYCRR Part 617 the following: 1. Your jurisdiction in the action described below; 2. Your interest in assuming the responsibilities of lead agency; and 3. Issues of concern that you believe should be evaluated. Enclosed please find a copy of the proposal and a completed Environmental Assessment Form (EAF) to assist you in your response. Project Name: William Hands Requested Action: Construct temporary 8' timber groin and fill each side with 5 cy. of pea gravel. SEQRA Classification: ( ) Type I. (X ) Unlisted Contact Person: Albert J. Krupski, Jr. (631) 765-1892 . . Page 2 Lead Agency Coordination Request The lead agency will determine the need for an environmental impact statement (EIS) on this project. Within thirty (30) days of the date of this letter, please respond in writing whether or not you have an interest in being lead agency. If no response is received from you ,it will be assumed that there is no objection to the Board of Trustees assuming lead agency status. Comments: Please feel free to contact this office for further information. Very truly yours, tkt~.1 9. /~J.,'~. Albert Krupski, Jr. President cc: Army Corp. of Engineers Dept. of State (·Maps are enclosed for your review) . '14-16-2 (9195)-7C f~ ::- . SEQR , 617.20 Appendix A State Environmental Quality Review FULL ENVIRONMENTAL ASSESSMENT FORM Purpose: The full EAF is designed to help applicants and agencies determine, in an orderly manner, whether a project or action may be significant. The question of whether an action may be significant is not always easy to answer. Frequent- ly, there are aspects of a project that are subjeclive or unmeasureable. It is also understood that those who determine significance may have little or no formal knowledge of the environment or may not be technically expert in environmental analysis. In addition, many who have knowledge in one particular area may not be aware of the broader concerns affecting the question of significance. The full EAF is intended to provide a method whereby applicants and agencies can be assured that the determination process has been orderly, comprehensive in nature, yet flexible enough to allow introduction of information to fit a project or aCtion. Full EAF Components: The full EAF is comprised of three parts: Part 1: Provides objective data and information about a given projecl and its site. By identifying basic project data, it assists a reviewer in the analysis that takes place in Parts 2 and 3. Part 2: Focuses on Identifying the range of possible impacts that may occur from a project or action. It provides guidance as to whether an Impact is likely to be considered small to moderate or whether it is a potentially- large impact. The form also identifies whether an Impact can be mitigated or reduced. Part 3: If any Impact in Part 2 is identified as potentially-large, then Part 3 is used to evaluate whether or not the impact is actually important DETERMINATION OF SIGNIFICANCE- Tyye 1 and Unlisted Actions tdentify the portions of EAF completed for this project: (!(' Part 1 0 Part 2 OPart 3 Upon review of the information recorded on this EAF (Parts 1 and 2 and 3 if appropriate), and any other supporting information, and considering both the magnitude and importanCe of each impact. it is reasonably determined by the lead ag~ that: ø' A. The project will not result In any large and important Impact(s) and. therefore. is one which will not have a significant impact on the envIronment, therefore a negative declaration will be prepared. o B. Although the project could have a significant effect on the environment, there will not be a significant effect for thIs Unlisted Action because the mItigation measures described in PART 3 have been required, therefore a CONDITIONED negative dedaratlon will be prepared.· o C. The project may result In one or more large arid Important Impacts that may have a significant impact on the environment, therefore a positive declaration will be prepared. . ^ Conditioned Negative Declaration Is only valid for Unlisted Actions Ifh.u.l/fÞ1 fi· J-I/Þf/iJS £. Name of Action Name of Lead Agency Û/Í Iv L / /1-n.. ,4. J.../.A..v~.5 k . Print or Type Na~ ~f Responsible ¡Of9cer in Lead A¡ency L/.#Æ~ ß H~·L. *- . . Signature of Responsible Officer In Lead kency Signature of Preparer (If different from responsible officer) . 7/S~/ , Date 1 ø I//UE/L Title of Responsible Officer PART 1-PROJECT INFORMATION Prepared by Project Sponsor NOTICE: This document is designed to assist in determining whether the action proposed may have a significant effect on the envirooment. Please complete the entire form, Parts A through E. Answers to these Questions will be considered as part of the application for approval and may be subject to furlher verification and public review. Provide any additional information you believe will be needed to complete Parts 2 and 3. It is expected that completion of the full EAF will .be dependent on information currently available and will not involve new studies, research or investigation. If information requiring such additional work is unavailable, so indicate and specify each instance. NAME OF ACTION NAME OF APPLlCANTISPONSOR S /J-¡rfé ~ BUSINESS TELEPHONE ( ) ADDRESS NAME OF OWNER PI dllI.....Q .5 ItM Ii Z'P CODE ClTYIPO ADDRESS Flt-t... t!tJ#S í/t.1{~ 7" EßCl!l S I¡}E /é~/tM/f"!Y ý' 1'(// /h' ~ {!¡~ð/c.. p,Nf<!3c/z'" 'G;;eO/N #NtJ YN.Þ5 tiP 1k/1 G~EL ZJP CODE ClTYIPO DESCRIPTION OF ACTION Please Complete Each Question-Indicate N.A. if not applicable A. Site Description Physical setting of overall project. both developec! tnd undevelopec! areas. 1. Present land use: DOrban Dlndustrial DCommerclal ,S'Residential (suburban) DRural (non-farm) DForest DAgriculture DOther 2. Total acreage of project area: (). '{' acres. APPROXIMATE ACREAGE PRESENTLY AFTER COMPLETION Meadow or Brushiand (Non-agricultural) acres acres Forested acres acres Agricultural (Includes orchards, cropland, pasture, etc.) acres acres Wetland (Freshwater or tidal as per Articles 24, 2S of ECl) acres acres Water Surface Area acres acres Unvegetated (Rock. earth or fill) acres acres Roads, buildings and other paved surf aces acres acres Other (Indicate type) acres acres 3. What is predominant soil type(s) on project site! a. Soil drainage: I1!1Well drained 100 "of site DModerately well drained % of site DPoorly drained " of site b. If any agricultural land Is inVolved, how many acres of soli are classified within soil group 1 through 4 of Ihe NYS land Classification System? acres. (See 1 NYCRR 370). 4. Are there bedrock outcroppings on project site! DYes øNo a. What is depth to bedrock! (In feet) 2 . . 00-10% ;( % 015% or greater 010-15% % % s. .Approximate percentage of proposed project site with slopes: 6. Is project substantially contiguous to, or contain a building. site. or district, listed on Ihe State or the National Registers of Historic Places? DYes j(fNo 7. Is project substantially contiguous to a site listed on the Register of National Natural landmarks? DYes DNo 8. What is the depth of the water table? / 9 (in feet) 9. Is site located over a prirriary, principal, or sole source aquifer? DYes DNo 10. Do hunting, fishing or shell fishing opportunities presently exist in the projeCt area? DYes .lð'No 11. Does project site contain any species of plant or animal life that is identified as threatened or endangered? DYes RfNo According to Identify each species . 12. Are Ihere any unique or unusual land forms on the project sile? (i.e., cliffs, dunes, olher geological formations) DYes ~No Describe 13. Is the project site presently used by the community or neighborhood as an open space or recreation area? DYes DilNo. If yes, explain 14. Does the present site include scenic views known to be important to the community? Øes DNo ¡I/o 15. Streams within or contiguous to project area: a. Name of Stream and name of River to which it is tributary 16. lakes, ponds. wetland areas within or contiguous to project area: a. Name "Ill é7V7 J./11¡8¿ðlL b. Size (In acres) 17. Is the site served by existing public utilities? QilÝes ~No a) If Yes, does sufficient capacity exist to allow çonnectlon? ¡;¡fes DNo b) If Yes, will improvemènts be necessary to allow connection? DYes ~o 18. Is the site located in an agricultural district certified pursuant to Agriculture and Markets law. Article 25-M. Section 303 and 304? DYes œ;No 19. Is the site located in or substantially contiguous to a Critical Environmental Area designated pursuant to Article 8 of the ECl, and 6 NYCRR 6171 BYes DNo' 20. Has the site ever been used for the disposal of solid or hazardous wastes? DYes l/INo B. Project Description 1. Physical dimensions and scale of project (fill in dimensions as appropriate) a. Total contiguous acreage owned or controlled by project sponsor b. Project acreage to be developed: acrés initially; c. Project acreage to remain undeveloped acres. d. length of project. in miles: (If appropriate) e. 'If the project Is an expansion. indicate percent of expansion proposed f. Number of off-street parking spaces existing ; proposed g. Maximum vehicular trips generated per hour . (upon' completion of project)? h. If residential: Number and type of housing units: One Family Two family Initially I Ultimately I i. Dimensions (In feet) of largest proposed structure 2.. height; If " width; j. linear feet of frontage along a public thoroughfare project will occupy Is? 3 IJ.$ acres. acres ultimately. %; Multiple Family Condominium f?' ft. length. 2. How much natural material (i.e., rock, earth. etc.) will be removed from the sitel A/OP¿ tons/cubic yards 3. Will disturbed areas be reclaimed? DYes DNo ŒIN/A a. If yes. for what intended purpose is the site being reclaimed? b. will topsoil be stockpiled for reclamation? DYes Œf'No c. Will upper subsoil be stockpiled for reclamation? DYes !(!'No 4. How many acres of vegetation (trees, shrubs, ground covers) will be removed .from site? J/tJ#é acres. 5. Will any mature forest (over 100 years old) or other locally-imporlant vegetation be removed by this project? DYes ¡No If single phase project: Anticipated period of construction 1- ÐI<"lS months, (including demolition). 6. 7. If multi-phased: a. Total number of phases anticipated --L- (number). b. Anticipated date of commencement phase 1 month c. Approximate completion date of final phase month d: Is phase 1 functionally dependent on subsequent phases! DYes 8. Will blasting occur during construction! DYes !S"No 9. Number of jobs generated: during construction . Y' 10. Number of jobs eliminated by this project 111,/11/: 11. Will project require relocation of any projects or facilities! year, (including demolition). year. UlNo ; after project is complete I/oI'VE DYes I!if'No If yes, explain 12. Is surface liquid waste disposal involved! DYes GilNo a. If yes, indicate type of waste (sewage, industrial, etc.) and amount b. Name of water body into which effluent will be discharged 13. Is subsurface liquid waste disposal involved! DYes IS'No Type 14. Will surface area of an existing water body increase or decrease by proposal? DYes DNo Explain 15. Is project or any portion of project located in a 100 year flood plain! DYes DNo 16. Will the project generate solid waste? . DYes 1'iiJN0 a. If yes, what is the amount per month tons b. If yes, will an existing ·solid waste facility be used? DYes DNo c. If yes. give name ; location d. Will any wastes not go into a sewage disposal system or into a sanitary landfill? DYes ~o e. If Yes, explain 17. Will the project involve the disposal of solid waste? a. If yes. what is the anticipated rate of disposal? b. If yes, what is the anticipated site life? DYes ßlNo tons/month. years. 18. Will project use herbicides or pesticides? DYes WNo 19. Will project routinely produce odors (more than one hour per day)! DYes ~o 20. Will project produce operating noise exceeding the local ambient noise levels! DYes ISNo 21. Will project result in an Increase in energy use! DYes li/lNo If yes . indicate type(s) 22. If water supply is from wells. indicate pumping capacity gallons/minute. . 23. Total anticipated water usage per day gallons/day. 24. Does project involve local, State or Federal funding! DYes ~o If Yes, explain 4 . ·2S. Approvals RCQuired: City, Town, Village Board I?IYe s DNo City, Town, Village Planning Board DYes DNo City. Town Zoning Board DYes DNo City, County Health Oepartment DYes DNo Other local Agencies DYes DNo Other Regional Agencies DYes DNo State Agencies ØYes DNo Federal Agencies DYes DNo . Type Submittal Date ß()II-~P () ¡:; //l.{(S7ee5 7/S-/cJI /111 jJé~ ~/~µ, C. Zoning and Planning Information 1. Does proposed action involve a planning or zoning decision? DYes DNo If Yes. indicate decision requited: Dzoning amendment Dzoning variance Dspecial use permit Dsubdivision Dsite plan Dnew/revision of master plan Dresource management plan Dother 2. What is the zoning classification(sJof the site! !l£s I n¡y..f"7/ IH- 3. What is the maximum potential development of the site if developed as permitted by the present zoning! 4. What is the proposed zoning of the site! /l.cSII)~NTdlt.- 5. What is the maximum potential development of the site if developed as permitted by the proposed zoning! 6. Is the proposed action consistent with the recommended uses in adopted local land use plans! Øes DNo 7. What are the predominant land use(s) and zoning classifications within a ~ mile radius of proposed action! dESIOE"X/7/hl-. 8. Is the proposed action compatible with adjoining/surrounding land uses within a 9. If the proposed action is the subdivision of land, how many lots are proposed! a. What is the minimum lot size proposedl 10. Will proposed action require any authorization(s) for the formation of sewer or water districtsl DYes lilNo 11. Will the proposed action create a demand for any community provided services (recreation, education, police. fire protectionJl DYes ¡m:¡o a. If yes, is existing capacity sufficient to handle projected demand! DYes DNo 12. Will the proposed action result in the generation of traffic significantly above present levelsl a. If yes, is the existing road network adequate to handle the additional traffic! DYes ~ mile! V¡J,f/ é Œi'l'es DNo DYes DNo DNo D. Informational Details Attach any additional information as may be needed to clarify your project. If there are or may be any adverse impacts associated with your proposal, please discuss such impacts and Ihe measures which you propose to mitigate or avoid them. E. Verification I certify that the information provided above is true t the best of my knowledge. Applicanl/Sponsor Name tl/1i..L /f.- ¡;¿s.J: _ Signature "ritle ð I(/A/I:~ If the action Is In the Coastal Area, and you are a state agency, complete the eoastal Assessment Form before proceeding with this assessment. Date 7/sic / 5 Part 2-PROJECT IMPACTS AND THEIR MAGNITUDE Responsibility of Lead Agency General Information (Read Carefully) · In completing the form the reviewer should be guided by the question: Have my responses and determinations been reasonable! The reviewer is not expected to be an expert environmental analyst. · The Examples provided are to assist the reviewer by showing types of impacts and wherever possible the threshold of magnitude that would trigger a response in column 2. The examples are generally applicable throughout the State and for most situations. But, for any specific project or site other examples and/or lower thresholds may be appropriate for a Potential large Impact response, thus requiring evaluation in Part 3. · The impacts of each project. on each site. in each locality. will vary. Therefore, the examples are illustrative and have been offered as guidance. They do not constitute an exhaustive list of impacts and thresholds to answer each question · The number of examples per question does not indicate the importance of each question. · In identifying impacts, cç>nsider long term, short term and cumlative effects. Instructions (Read carefully) . a. Answér each of the 20 questions In PART 2. Answer Yes if there will be any Impact. b. Maybe answers should be considered as Yes answers. . c, If answering Yes to a question then check the appropriate box (column 1 or 2) to Indicate the potential size of the Impact. If Impact threshold equals or exceeds any example provided, check column 2. If Impact will occur but threshold Is lower than example, check column 1. d. Idenilfylng that an Impact will be potentially large (column 2) does not mean that It Is also necessarily slgnltlcant. Any large Impact must be evaluated In PART 3 to determine significance. Identifying an Impact In column 2 simply asks that It be looked at further. e. If reviewer has doubt about size 01 the Impact then consider the Impact as potentially large and proceed to PART 3. f. If a potentially large Impact checked In column 2 can be mitigated by change(s) In the project to a small to moderate Impact, also check the Yes box In column 3. kNo response Indicates that such a reduction Is not possible. This must be explained In Part 3. IMPACT ON LAND 1. Will the proposed action result In a physical change to the project sitel . DNO DYES Examples that would apply to column 2 · Any construction on slopes of 15% or greater, (15 foot rise per 100 foot of length). or where the general slopes in the project area exceed 10%. · Construction on land where the depth to the water table Is less than 3 feet. · Construction of paved parking area for 1.000 or more vehicles. · Construction on land where bedrock is exposed or generally· within 3 feet of existing ground surface. · Construction that will continue for more than 1 year or involve more Ihan one phase or slage. · Excavation for mining purposes that would remove more than 1.000 tons of natural material (i.e., rock or soil) per year. · Construction Of expansion of a sanitary landfill. · Construction In a designated floodway. · Other impacts 2. Will there be an effect to any unique or unusual land forms found on the sltel (I.e., cliffs, dunes. geological formations. etc.)DNO DYES · Specific land forms:. 6 1 2 3 Small to Potential .Can Impact Be Moderate Large MItigated By Impact Impact Project Change 0 0 DYes ONo 0 0 DYes ONo 0 0 DYes ONo 0 0 DYes ONo 0 0 DYes ONo 0 0 DYes ONo 0 0 DYes ONo 0 0 DYes ONo 0 0 DYes ONo 0 0 DYes ONo .....-- . . Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 SouthoJd, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD July 30,2001 Mr. Fred Anders Coastal Geomorphologist NYS - Dept of State Division of Coastal Resources 41 State St. Albany, NY 12231 Dear Mr. Anders: The Southold Town Board of Trustees will be conducting their routine field inspection on Wednesday, August 15,2001, at 8:00 am. The Board would like to coordinate with you on the inspection for the following applications: William & Louise Segallis 1170 Willow Terrace Lane, Orient SCTM#1000-26-2-23 Re: Rock Revetment William A. Hands Jr. 960 Willow Terrace Lane, Orient SCTM#1000-26-2-21 Re: Timber Groin If you can join us on the field inspection, please contact the office at (631) 765-1892. Thank you. Very truly yours, {)( Qj.J.ÁL n ïY] ,--11D-ncWJ /¡ Lauren M. Standish, Clerk Board of Trustees . . cc: William & Louise Segallis William A. Hands, Jr. William Daley - NYS DEC Chris Arfsten - NYS DEC t/ . . Town Hall. 53095 Main Road P.O. Box 1179 Southold. New York 11971 Telepbone (631) 765-1892 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town ConserVation Advisory Council held Tuesday, July 17,2001, the following recommendation was made: WILLIAM A. HANDS JR. 26-2-21 to install.an 8' long by 24" above gtade experimentâl timber groin and place 5 cy. of pea gravel on each side to fill groin cell. 960 Willow Terrace Lane, Orient The CAC did not make an inspection, therefore no recommendation was made. ~ eg- '" ""õ :..::-c::r:: ~ Ii! --' ",- E2'~ ; ~~l~§ L.L...~.~i: o ~. '') ~it o~ '; I ---' ¡ ,i ' è ---. ---, - -' .,' . , -. /,- / ., "'. \ __ ;:;-~-",y__ ~___-".,,-- _\ ~r ;JØ\f . , ----.."------.. , ¡ , . ,,/--- .! .. \ // I ,,/ - ." '(' ~~ ~' d 1/ ~~,;~ __'- _ __J-------------/ . i· ¡,e,. .". ,,' "",. _ ~ co ".~..- Yj\ ___..------\---...---.-;;).- / . "' .--.-1..7 / z ~;H~ \ ' . / ¡- 'j' ;" "~d;' ~'"Æ;?<" .. "I ¡p"'/ ---Ì'i¡--- ... ./ - j ~ ~ ~ ! "j /' / ¡' .-' . -- .. ~. . ~ - -,/ /-< "~' \5 - /1'· ,I· .' ~ -If ~ ' " .' -' ~ \ ',,' ' '., ;" ,,~_ ,_____ \ ~ \ ../ ì./' N' .' . '\ ~~, N . .' - .-, .;" - /' . .<\." . :" :,\. ý/;~' ..' .-,\' /~ \\ .' ./.;V">~'<- Y"./ .. \ , '0 \ '" \./ ,'<-""""...A' \ "'t ," ~ ,;/~: //\/ " " \. '('/ ~/"o ". '.. 7\ Y'; "0 .5 / \ - \ "..-< .-\ 7""";' '. \ Ai;''''' \ P "1 ~., ).r-(:":. -" .;\ ;;.'< . ,~< \ ' \-" '. :~):y/o/ - l', , " ./" //" , . >,,";(;>'/:;4// '~''>-. ;>,'-.. ./# ' " : ",..7, " '. ¿''ç. .' '., '-..., //'. ~, / '"', />....~/. /'), "", ,"''-.. ' ':>' / ~ /'............v',"- ~ /'/. >~' ,~: "'. ./ . 1M' .... 0' / ÇJ /'''.. '-,.~\~~///~~- //-" ... ~~.:~ "- ;, N" '. II / ." .,...... ;" ( ~ '..... " . . . ... .... .........../ .~ .-" . \ . \ . .~/ . :\' , \ 0) '\ . chj " ----"'~.-I- -- - .~ ~ - '" , t i , MA.JORS " -, (:r . ~.~ ,\ ", ~ , " - r .. .. oS: ~ - . ' ¡p' t:t ~ '^ - . . ...,...---- . c----- " . , ~ ,. " , . ," 'ì " ~ " , '''- " col -0 ~I ~I' ; ~ ,~ I ~ 'p ~~, ,,~~ , , III i i ~ 7 ~ 7 : 1/111 ! t ! ~ ! 1; ;:' ... Ii ~ ¡pI' . . ¡ , . ¡. í ~ ... j I '-:-: , . ! ! /I ¡ I I I ~ "- " I Iii i !, ' :¡; - ~ ! ~ ~ qnjj ._1 ;_HiJ í//I /81 ' - I I . I,' II ,. - . DEPARTMENT OF STATE :2. ~~;¿ -d¡~)¿ George E. Pataki Gm'enwr Randy A. Daniels Secrerury of Scalf:' Didsioll of Coastal Resources 41 State Street Alban)', NY 12231-0001 January 23, 2002 NYSCoasts JAN 2. 8 '.,' William A. Hands 960 Willow Terrace Lane PO Box 334 Orient, NY 11957 ~ Re: F-2001-l037 U.S. Army Corps of EngineerslNew York District Permit Application #2001-01053-12 William A. Hands-Construct Temporary 8' Timber Groin Orient Harbor, Town of Southold. Suffolk County DEC #1-4738-01373/00003 Reauest for Additional Information Dear Mr. Hands: The Department of State received supporting information regarding the above matter on January 14,2002. Pursuant to 15 CFR 930.58, the following data and information is necessary to enable the Department of State to adequately assess the coastal zone effects of this proposed project: When structural solutions are used to control erosion where a natural protective feature existed, additional erosion often results. Vertical bulkheads are subject to scour at their base and are less effective in absorbing wave energy than a beach. Groins affect the littoral transport of beach materials and can thus have negative effects upon nearby properties. Policy #13 of the New York State Coastal Management Program states: "The construction or reconstruction of erosion protection structures shall be undertaken only if they have a reasonable probability of controlling erosion for at least thirty years as demonstrated in design and construction standards and/or assured maintenance or replacement programs." It would appear that the existing bulkhead was not designed or sited to meet those standards. Please submit photographs taken at the time of ML W depicting the beach and nearby properties before bulkhead construction, shortly after bulkhead construction. and at present. Recent photographs of properties to the south depict a line of bulkheads where the former section of beach above MHW has eroded. The submitted 'mapblast' and 'quad' maps indicate the property as either at or north of Rowe St. Enclosed is a copy of an aerial photograph. Please indicate the location of your property on this copy and return. Please provide a copy of the deed with a metes and bounds description and a copy of the survey. Please submit an analysis of how the beach would be affected north and south of the proposed grom. Please submit an analysis of alternatives to protect your residence from erosion. By copy of this letter, the Department of the Army is reminded of our need to conduct a full consistency review of your proposed project. \'\)i~è: 15181 -1.7-1.-6000 Fa.\.: 15ISI-l-7J-2-.t>-l- E-m:ti! .:oa~[al~1'd(\~.!.tate.ny.u<; www.dO.i..;¡;ltè.nyu~/c<;tl/c~tl\\\I."..html . . . Please provide the information requested above as soon as possible. If this necessary information and data is not provided within thirty days of the date of this letter, the Department of State may close the file regarding this proposed activity. If the Department closes the file and does not concur with the consistency certification provided for this proposed activity, the consistency provisions of the federal Coastal Zone Management Act prohibit federal agency authorization of the activity. Please call me at (518) 474-4516 (e-mail: wfeldbus@dos.state.ny.us) if you have any questions. When communicating with us regarding this matter, please refer to our file #F -2001-1037. Sincere~y, '7 ..... /1 ~ JM~~ William Feldbusen Coastal Resources Specialist Consistency Review c: COEINY District - MaryAnn Miller NYS DEC/Region I - John Pavacic Town of Southold Trustees - Albert Krupski . . . . AlbertJ. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only ~oastal Erosion Permit Application _Wetland Permit Application _ Major _ waiver/Amendmenmnges _Received Applicati n: 7 0 I _Received Fee:$ - _Completed Application b _Incomplete _SEQRA Classification: /' Type I_Type II_Un1isted~ ~Coordination:(date sell.t _ CAC Referral Sent: I _Date ofInspection: _Receipt ofCAC Report: _Lead Agency Determination: Technical Review:~ Public Hearing Held:~ _Resolution: Minor :::a-(\-r ('~U\Q.u.> ~CO.-ad., 11a-1101 , Name of Applicant tIIl/-.J-11f-1i'1 ,4. JI~ SA.. f! tJ. f3(J'f: 33t1- Address 9, (> /#, LL OUJ ~. /....If- . ~J2ICJJT PhoneNumber:() 323-:)77-9 Suffolk County Tax Map Number: 1000 - 1." - ~ ' 1.- / Property Location: CJ~O' .i.E. ()r KIM? S7 (provide LILCO Pole #, distance to cross streets, and location) Address: AGENT: S,1-111C (If applicable) Phone: . . Board of Trustees Application GENERAL DATA Land Area (in square feet): If, 0 ()C) S (; PI. Area Zoning: I2ES I /)CN7/1'ft.- ft,P,P/?o~ . Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency AlV /)Et'_ ~ , AI <./ /Jet!.- r Date II 79/f1 , r S/3()!91 _ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspe~ by ~emmental agency? No Yes If yes, provide explanation: )tl Project Description (use attachments if necessary): ;j#5711-LL i"' t 'w'? 13'1 2'1'1 /f.6dilc ~i exlVl /;fO/T.-f I- 7/~t8u ~/,.j /I#"/J Ik'+~E s eI/8/f!. Y,lht:tJS tlr /r,,;- G-/lA-vez.. ()A/ i:A-t!/f S/jJc ""To ~/U_ I?/l~/.A/ c-eu... . . , ' Board of Trustees Application WETLANDITRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: INS 7/1-(..<- 7i/lfA€ /L G/l4/,t/ -n jJ/2.lJ7€?T e-XIS 7//1/6 11tU.KH€7f:t) Area of wetlands on lot: I ~t'O square feet S % Percent coverage oflot: Closest distance between nearest existing structure and upland edge of wetlands: I") feet Closest distance between nearest proposed structure and upland edge of wetlands: 0 feet Does the project involve excavation or filling? No 'I Yes If yes, how much material will be excavated? 0 cubic yards How much material will be filled? /0 cubic yards Depth of which material will be removed or deposited: 2- feet 2 ' Proposed slope throughout the area of operations: - 0 Manner in which material will be removed or deposited: ICIr ?/Z/ItIEZ- 7d SlOE ,,;::: G/20/A/ ,BE ,c/U,EI'J C/7,#€/L By ,c/lt:lur Lo"'-#E/L , Statement of the effect, ifany, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): .5if() U. L 0 HlW C #0 70 ~UILf) EF,cEt!..7 /3EAe,tl /A/ //lM/7 ~T/lE1l TH/M/ ~? (3,u uc,f-/-Ci+j) . . Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: :tNS7/f-t... L 7/Hl3lF/L ~A.J '/() fJILo7U -r /3tI.LKffvf-iJ Are wetlands present within 100 feet of the proposed activity? No V Yes Does the project involve excavation or filling? No Y Yes If Yes, how much material will be excavated? 0 (cubic yards) How much material will be filled? /0 (cubic yards) Manner in which material will be removed or deposited: f E 11- ~~ /1fIEZ- -ro F1L.LEO E77Rt"A- S" {IJE d ~ t5M/d Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) 7/fCltiE .:5~u Lf) ISE /!/tJ ePkr!-7 . . NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: f,(/, J. M /I- n /1-. /-ht-N 0 J -- ..; ,. . SCTMiHOOO- 26-l-2-1 YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: t!.()N'57~l(e T /fN E1-(J~.(.f""cA/rl'fL 'If T/MI3€/f... G,.eD/'v ~b rll-i- €/le# 51IJE 1V/7# S- C!q~f~ Y~t)5 h~ /EIP 6'~E~ 2. That the property which is the subject of Environmental Revie~-is located adjacent to your property and is described as follows: 96b /.II1LJ..oIU /E7l/l. i.~. ~/l/~IJ7, 11/. '/ /19Si 3. That the project which is subject to Environmental Review under Chapters ;;2, ~7, or 97 of the Town Code is open to public comment on:? ~ 01 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. PHONE #: J/L OWNERS NAME: MAILING ADDRESS: Ene.: Copy of sketch or plan showing proposal for your convenience. s PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: f;C1lfE (;/t ZIt!.I!Mi tel rfl lr ~ .Jl fT'1 I:J ~ ru Ul Postage $ 0.34 Certified Fee o Return Receipt Fee ~ (Endorsement Required) o Restricted Delivery Fee Cl (Endorsement Required) 1.50 I:J I:J .Jl I:J 3.94 Total Postage & Fees $ I:J I:J I:J f'- Address: WILL&f.O faIL /..1+ /IIIIJ..J../j CruEl:. f)/l. {{Jill e7J7; .A/1- JI~S7 1l11rT7i 71(r!L., #.y fT'1 .Jl .Jl fT'1 ., u.s. Postal Service CERTIFIED MAIL RECEIPT (Domestic Me',,1 Only, No Insurance Coverage Provided) I:J ~ ru Ul 2.10 1.50 MA nrrUCK, NY 11952 Postage $ 0.34 "",' Certified Fee f'1J Return Receipt Fee flJ (Endorsement Required) I:J I:J Restricted Delivery Fee (Endorsement Required) I:J I:J .Jl CJ Name (Please'lJ;aire cog;:4ez;4;tJ'J1;t/ C St;eet~APt~-;;Jo::O-"P6-Box-No.u_.mmnnuuu--mm nnuum_mnm_______o... ~ 'aiY.'Siiii'zr1-.C2..;::;f.P.~---~1~/t/;:.---n---n Total Postage & Fees $ 3.94 !AAU/A11 I/- /--I-tl#.PS ~. , residing at 9~ ~L07d ~L$' 01 I " s"J , being duly sworn, deposes and says that on tbe day of ....rttL'I ,'UJc--1-, deponent mailed a true copy of the Notice set forth in the Board of Trustees Application, directed to each of the above named persons at the addresses set opposite there respective names; that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment roll of the Town of Southold; that said Notices~ere mailed at the United States Post Office at t'A/c-~~ AV.~ , that said Notices were mailed to each of said persons by (certified) (registered) mail. Public STANLEY DROSKO I JR. Notary Public. State of New York No. 52-1026275 Oualified in Suffolk County_ '7 """' ? Commission Expires March 30. "lll:;P''' ~ . . Board of Trustees Application County of Suffolk State of New York 11//1 ~ I!IJVI /f- ~/)S 1e. BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENT ATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. SWORN TO BEFORE ME THIS .$~~,#44(7' Signature .sfi DAY OF 20 !!.L STANLEY DROSKOSKI JR. Notary Public. State of New York No. 52.1026275 Qualified in Suffolk County Commi,,:,ion Expires March 30. ~ J Albert J. Krupski, President James King, Vice~President Henry Smith Artie Foster Ken Poliwoda . . Town Hall . 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD rr:;--~ . l~ () pr:-P.. ',;-' c' ,:"1 ~S 1'] ~\. ti \:j ~~, I~ . .' . ",. ,. . --. , \ ., :Uii JUll1200l . ( I BOARD OF TRUSTEES: TOWN OF SOUTHOLD , . l ----------------------------------- In the Matter ~~ the APPlicanion . Al~-a-~/-tJh----- COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, /j)/L..tJ/lU /I-. ~ fA., residing at 9(,0 /l}jJ./1/./) ~,(. LA . OIlIN7, /tJ. t/ being duly sworn, 'depose and say: That on the rt-#t,day oA ;{1tt..'1, 200/, Iyersonally posted the property known as ~ !l/ItU...oW 7e.7l/l. I-IT- by placing the Board of Trustees official poster where it can ea.l1y be .een, and that 1 have checked to be .ure the ~ has remained in place for eight days prior to the date t e pu~lic~;ng. Date of hearing noted thereon to be hel ~kH ( fTfl (f-./ V ~ 7 ~ (t'n . Dated: ~//j/~~/J,~. (S1gnature) STANLEY DROSKOSKI JR. Notary Public. State of New York No. 52.1026276 Qualified in Suffolk County ,vv Commission Expires March 30. ~ .' ..3 . , ... 4It ArPLt~ANt TRANSACTIONAL DISCLOSURB . FORK The Town of Southold's Code of gthics prohibits conflicts or interest on the art of town officers and em 10 ees. The ur ose of this form is to rovide information wh ch can alert the town of poss bIe conflicts of nterest and allow it to take whatever action is necessary to avoid same. tOUR NMfR. " '1" "";:"""'1 <"t, '! ;~,:,...~:\,:~r.c' i't{';fo.~.'h.l,'; .//'I~ 'T ///J' "'_A"" .....". WVv v. I'V,~/,.,..-,.rr" .,'. Last name, first name, m ddle n tal, 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.) . '.:::. ;:':;~ i:;ij,~J ,::,::~.:':i;::~' :'~LlfJ' ,.>!..~': NATURB 0' APPLI~ATIONI (CheCk all that apply.) Tax grievance Variance Change of zone Ap'p~~al of plat . Exe~ption from plat or orricial map other . / (If "other," name the activity.) /cU;tJt14~'f 7/~~ 6lttV-v Do you personally (or through your co~pany; sp6use. sibling, parent. or child) have a relationship vith any Officer or employee of the Town of Southold? -Relationship- includes by blood, marriage, or business interest. -Dusiness interest- lIeans a business; including a partnership, in vhich the tovn officer or employee has even a partial ownership of (or employment by) a corp~ration in which :::r:~~n officer or employee ovns more than 5% of the)~~~ NO V YBS ~ : :'~'l,' .. If you ansvered MYES,-. complete the balance a!' ~ht. torm and date aDd sign vhere indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationShip between yourself (the applicant) and the town officer er employee. Either cheek the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her SPOUSSi sibling, parent, or child is (check all that apply), A) the owner Of greater than 5% Of the shares Of the corporate stock of the applicant (when the applicant' is a corporation), B) the legal or beneficial owner of any interest in a noncorporate'entity (when the applicant is not a corporation), C) an officer; director, partner, or employee Of the applicant, or 0) the actual applicant. ,,~ ' '''.' " . " DESCRIPTION OF RELhTIONSlltP . , i (.' . I . ,~...'.. ;~..~'~ ';;:;~~,:',,' ,,'. " .,.. > ......."r.~.y ,. ... .'- . . ;".......,......'."..,.l..:..:..J~_. signature 'print ..j,~-;:~:'... . '. k,h'~ .,..,.~10i~,: