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Home My WebLink AboutTR-5982 , TERMS IInd CONDmONS ne Permittee Le.o Ot6 e.n oesI,I/"g at GILee.n/Jald. N. Y.. as pan oC the coosideraôoo lor cbe i...··n~ of «be Peanit docs IIndemaod and presaibe to the CoI- 1oMøg: 1. That the said Boatd of Trustees and «be Town of Southold ate related from "'Y and aU damages, ot claims fIX damages, of IIIks atisIø& di.œcd7 ot todindIy as a ~ of "'Y opet- .&a perfoaœcl punuaat eChls petmIt, aadtbe IIId ~ wI1I, at LIs or bet own ~. ddeod ...y and all ...œ IIIks "Inltl.f.ed by tbiM f'uda, aod the said p.....I_ __ fall IiabWty with nipect tbeteto, D·lbe IWl>f'loteadusioo of the IIøud of Trustees of «he Town of ~ 2. That chis I'eøI1It Is ~ Cot . pedocI of 24 " mos. wIûd1 Is <'ÌI'oLI.~ to be «he estimated time" required 10 mmpIete the 1iOd:; iowl1ed, but rhouId dtéaaDstaoœs wuntIt, request for ao enœsIoo may be made to «be Boatd at a later 4œ. 3. That this Peanit should be retaIøecI indefinildy. or as loog as the said Permittee wishes 10 m.;..../n the structure or project iowlved, to pnmde eridmœ to ...yooe roaœroed !bat ouch- oœ.ôoo was odgiaaIIy """'I-t. 4. ThaI «he woå imulved will be IIIbject to the I~ and approval of the Board ot III &/!COts, and tIOtH1OIIIpllo...... with «he prcmsïoøs of the orIginotløg appliadoa, may be ause fot l'C9OCatÍon of this Pamit by resoludoo of the said Boud. S. That Ibere will be DO wueasooab1e iotcrf_ with IIrfi&atiœ as a ~ of the woå beœIa ..òthodzocl. "6. That Ibere dW1 be 00 iotcrC_ with the rip of the poWc 10 pus aad repass aJoag the bead> Let"ec.. tJI&b aad -'- water matb. 7. That If f-.e opendoos of the Town of Snnt/o9&cl nc¡aIre die. ftIDOnl aad¡oc aIw.tIooIs iI1 the Io-otl.,p of the wodt heteio ...It ~ 1-\ or If, io the "(>'nIoo of die Boatd of TraIIees, the " wad: Iha11 _ _-e obsttuCÞoa 10 free aa~ the laid P-nI- will be reqaIred. apoadue aodœ, 10 remove or ... chis woå or project beœIa staœd "kL...4 erreoscl 10 the Town " . of Soucho1d. " " 8. That the aid BoucI will be ooâfIed by tbe PttmIute ot the ~Of the wodt oach- otbed. 9. That the "P-nlttee will obtaio all other petmIts and ....-,;, 6at øay be reqaItecI ...p; pJeo-nl 10 cbJs petmIr ~ may "be IIIbect to œvoIœ upotl &Dare to obtaio -. "- "" Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson . . 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 SOUl'HOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. o \-S~ INSPECTION SCHEDULE ~ Pre-construction, hay bale line 1st day of construction Yz constructed ~ Project complete, compliance inspection. . . Albert J. Krupski, President James King, Vice-President .Artie Foster Ken Poli\voda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (63l¡ 765-1892 Fax (63l¡ 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD August 18, 2004 Mr. Bryan Villanti P.O. Box 334 Wading River, NY 11792 RE: LEO OLSEN 3590 NORTH RD., GREEN PORT SCTM#35-4-28.12 Dear Mr. Villanti: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, August 18, 2004 regarding the above matter: WHEREAS, Bryan Villanti on behalf of LEO OLSEN applied to the Southold Town Trustees for a permit under the provisions of Chapter 97 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated July 28,2004, 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 18, 2004, 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 of the South old Town Code, 2 . . 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, RESOLVED, that the Board of Trustees approve the application Bryn Villanti on behalf of LEO OLSEN to construct a single-family dwelling with garage and deck, with the conditions of a hay bale line set at the bulkhead during construction, a 15' non-turf buffer landward of the bulkhead, drywells and gutters to retain roof runoff, and all as depicted on the plan surveyed by John C. Ehlers last dated September 17, 2004. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of th is notification. Inspections are required at a fee of $50.00 per inspection. (See attached schedule.) This is not a determination from any other agency. Fees: $100.00 Very truly yours, ~?~'9L Albert J. Krupski, Jr. President, Board of Trustees AJKlhct . . Telephone (631) 765-1892 Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 CONSERV A nON ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Tuesday, August 10, 2004, the following recommendation was made: Moved by William Cook, seconded by Jack McGreevy, it was RESOLVED to recommend to the Southold Town Board ofTrustees APPROVAL WITH A CONDITION of the Wetland Permit application of LEO OLSEN to construct a single- family dwelling with garage and deck. Located: 3590 North Rd., Greenport. SCTM#35-4-28.12 The CAC recommends Approval of the application with the Condition the large tree on the southwest corner of the property remains.. Vote of Council: Ayes: All Motion Carried New York State Department o"nvironmental conservatio.fl 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 Letter of Non-Jurisdiction - Tidal Wetlands Act July 9 2004 Inger Boyajian PO Box 334 Wading River NY 11792 . Dear Mr. Boyajian: Re: Boyajian Property, 3590 North Road, Greenport DEC No. 1-4736-01557/00003 Based on the information you have submitted, the New York State Department of Environmental Conservation has determined that the property that is landward of the buikhead, which is more than 100 feet in length, and existed on or before August 20,1977, as shown on the aerial photograph dated March 24, 1976, Is beyond the jurisdiction of Article 25 (Tidal Wetlands Act). Therefore, in accordance with the current Tidal Wetlands Land Use Regulations (6 NYCRR Part 661), no permit is required under the Tidal Wetlands Act. Please be advised, however, that no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundary, as indicated above, without a permit. It Is your responsibility to ensure that a~ necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within tidal wetlands jurisdiction which may result from your project. Such precautions may include maintaining an adequate work area between the tidal wetland jurisdictional boundary and your project (i.e., a 15 to 20 feet wide construction area) or erecting a temporary fence, barrier, or hay bale berm. Please be further advised that this letter does not relieve you of the responsibility of obtaining any necessary permits or approvals from other agencies. Very truly yours, ~i!~ George W. Hammarth Deputy Permit Administrator cc: Bureau of Marine Habitat Protection consultant . . .~ ~:~ DEPARTMENT OF THE ARMY NEW YORK DISTRICT, CORPS OF ENGINEERS JACOB K. JAVITS FEDERAL BUILDING NEW YORK, N.Y.1027S.o090 ~ JUN 0 8 2004 REPLY TO ATTENTION OF: Eastern Pennits Section SUBJECT: Joint Application with New York State Department of Environmental Conservation 3590 North Road, Greenport, New York 11944 Inger Boyajian P.O. Box 334 Wading River, New York 11792 Dear Ms. Bovajian: We have recently received a copy of the Joint Application for Pennit you filed with the New York State Department of Environmental Conservation (NYSDEC). Please be advised we have reviewed the Joint Application, and based solely upon the infonnation provided, it appears that a Department of the Army pennit is not required for your proposal. The Department of the Army regulates construction activities in navigable waterways and discharges of dredged or fill material into waters of the United States, including inland and coastal wetlands. If your proposal would involve such work, and has not been portrayed as such in your Joint Application, you should contact this office immediately so that a project-specific detennination can be made as to whether a Department of the Army pennit will be required. ; Any inquires should be directed to the Regulator-of-the-Day at 212-264-6731. Sincerely, !/!fit t::.:d~ Michael G. Vissichelli Acting Chief, Eastern Pennits Section Dec Application No. 1-4738-01557/00003 ~ I I '. ,!I~. ~/ \ it· }. , ~ Y" . ~ ~1,1~- 13 \ ....f- ," . "- . . . : _ ~ ~, 1 . " . r , . e / \/ I. II ..1. ¡ I ~ . I ~ . I , , ì I II: I~! I. Iii m !'Ih ¡¡Ii' ........u...z ,\ "',.. + -i'- ;n.....,..m ~ i Lí) ~ · n ~ ~ 0 ¡ i g g: 5i - i i ¡ i I ~U'~· m ~/ " ',Ú , . ~...>- ",..".- I· I; Ii. 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Iì' <{ w L }- Z L ..... ~ Iì' Z 0 LL ð Iì' w L \J 0. o ;¿ Z Iì' -' 0 LL 0 ¡:: D it: <{ w :;> L ..... \J1 Iì' ~ w 0 o \J LL Z Z Z z~ w <{cr' ftí ftí IJ)SI: u.. I- <{"<to &i ~ !j;!}- ú) D o<{ Z Z NL 0 <{ ¡:: DD <{> \J ow ¡:: 0..... w 0. ¡¡'~ ill t!j -- ~ N I, Oª I, "-.. '" I' ~o ~ Z It > U Ii ~:¡ *-11 ::J ~ ~ I( CZ):i ~ I; o csl Z <>(1 < ~I ~ ~I CZ) ;-1 ~ ~I ~ ful ~ 0<>( ""E-0"Ir--1 ~ ~..... 00 ~!8-:&:1 ~~o\ -rI:!Z\O ~ ~~~ ~ ¡¡; ~ &1 o ¡;¡~JI ~\D~~I ,--- . " .,....;¡.. ,< .' ... \ -- ú) w Iì' \J () <( I'f) r- "<t " c) Iì' o LL ú) ~ IY). o N " <{ w Iì' <{ , AILrt ~. Krupski, President James King, Vice-President· Artie Foster Ken Poliwoda Peggy A. Dickerson . . c-.. Oft" Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631ì 765-1892 Fax (631ì 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Coastal Erosion Permit Application ~tland Permit Application -"'Iajor - ~ W aiverl AmendmentJCha~~, ~eceived Applicat" n: 11;!C~ ......,Received Fee:$:2 0" ~ompleted Application _Incomplete _SEQRA Classification: Type I~Type II~Unlisted_ _COOrdinatiOn:(date~en 'CAC Referral Sent: ~Ie ofInspection: _Receipt of CAC Report: _Lead Agency Determination:_ Technical Review: "f'ÏÍblic Hearing Held:mJ OY _Resolution: Name of Applicant L-e-O 0 1 s ~ .ç ~ YL,J I L--L r;- }'t.- D I G (tr..-~.--1 V. ~ ,v.I, 1 , J Phone Number: 61 (p 1"3 \ J 7 J '3 Suffolk County Tax Map Number: 1000 - ""£, ) -- "I ~ -z,<a I 17..--- Property Location: -;:)" ~- \) µL~ ytJ) G /I-~~..J .p~ N 't -y.,~tw-W G I.) LL ~~ YL-I> ~ f.,J I~J t).ss 4 (provide LILCO Pole #, distance to cross streets, and location) ~I'L~ ~ V, LL-~ Address "'t.., \ \ 71 ~)O Office Use Only Minor DI:CI:PH~ JUl 2 \\ n4 \.::,J Southo1d 10"" Board oI1ru,!'" ~ ~ ~,,.'I AGENT: (If applicable) Address: l' Ò J ß ð'(J ~ ') '-f L....r(rO ,~ -1 '14 { ~ t-> ~. II I tV Phone: t,fb (LJ~ f- 7CfJ ~ 1- q q . . Board of Trustees Application GENERAL DATA Land Area (in square feet): 20i~Öe::, . Area Zoning: rL Lf 0 Previous use of property: V ~(.ft--...; {- Intended use ofproperty:~ r~111 te')/~~ c..cr- Prior permits/approvals for site improvements: Agency Date I'rt-~~ J f-h \J ~ J-- I 'i 1 ~ s 00 he) I D T¥lVS keJ 19 q I Sc>vf1-o I \J ß\JI<J~[J)~ / 173 4--'"1} NV--r",,- ~ I y1.. Þ e,rpr- '2-00,-/ ~ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? ~No~ Yes If yes, provide explanation: Project Description (use attachments ifnecessary):_l ~1-¡"1 ìt-~b~ C{Y w r7-L ~~ 0 4>----1) d€-CK- . . Board of Trustees Application WETLANDITRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: íÔ \'Z...~i Dr;;: ~ _1 ~lt VL-e.e,.,~~-& I w t...w~ç.-l-- D,J!kk~ square feet Area of wetlands on lot: Percent coverage oflot: o % Closest distance betweenJJ:llrest existing structure and upland edge of wetlands: -L-..') feet ~ ~ ~¡4- Closest distance between nearest propos~ structure and upland edge of wetlands: 7-- 5" feet Does the project involve excavation or filling? No rV Yes "<)"b-l.( rfyes, how much material will be excavated?~S How much material will be filled? 0 cubic yards Depth of which material will be removed or deposited: ~ .~ feet Proposed slope throughout the area of operations: &y ¡"-S-!-.)..r5 Manner in which material will be removed or deposited: ß fK:.-k-14o G- ~"> ') > '\-<-ft-1) ~ ~ ~~-.II--M \. -Ð ~ ~ t þ ú ;~ ,·_ole... ~ Statement of the effect, ¡fany, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): NOf\f6 \ . . Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: fZ-..e..Sr¡b& /1 ~,i'7 YL-e..s:øe~ / Are wetlands present within 100 feet of the proposed activity? No \hes Does the project involve excavation or filling? No VYes ~ - ...- If Yes, how much material will be excavated? 1 J ( cubic yards) How much material will be filled? 0 (cubic yards) Manner in which material will be removed or deposited:_ß,:K.K Ho& ~ ~ 'v' ~ ~_J(,1.L. ') V ~ ¡ryr-> rr ~J-, Describe the nature and extent of the environmental impacts reasonably anticipàted resulting from implementation of the project as proposed. (Use attachments if necessary) Y\)üN0 \?VL0?~IL.O! ~)..s~ ~ , o \- G u I k h ~ ì t-> S --h-rJ1 &f) I \.,....¡ I q 7 7' -\JfL-~bYL iü ì)~J I Ytf?)I~'C~+-/) rL $- &,S-tn.. ç N 0 µ 3" 1--4 ') It.--h èrJ-J tvL L~ ~ Çfw1.- 1> J &-. c..-. Yh-- I) J u~ N..(J If) ~ k.eJ ~ 0 ¡-> m" \ V 1'1-.') ~) l. .J-.'ò"'" fr L L-~ ~ {L.eLI·~ 6-0- - (;...qw__ b.G.C. De- lfc)o'l Y+-/50 Ot- ) (l..~ ~~ . . STATE 617.20 APPENDIX C ENVIRONMENTAL QUALITY SEQR I PROJECT ID NUMBER REVIEW 3.PROJECT LOCATION: SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. PROJECT NAME (') N ~h.-b u f{2õ ! it (l.,b PART 1 - PROJECT INFORMATION Municipality h...... County 4 P~~OgT~ ~ttde{ü;;;; In~OŠs:'æntt:'~~ rc~¡S)ro~ð.aD ~ VJ€,fJ- ~ ç.- vy 5) I µ~ YL-b i b VI- war..4--- f-f":-to 5. IS PROPOSED ACTION: r;¡a New o Expansion o Modification I alteration 6. DESCRIBE PROJECT BRIEFLY: \0 13 u 'I ~ ~!) ~~eJ' ) ~,)~ JJ.o-Yy¡"& LV ¡ h b~k. 7. AMOUNT OF LAND AFFECTED: Initially \ 0 acres Ultimately t «)õ acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~Yes D No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY gJ Residential D Industrial 0 Commercial OF PROJECT? (Choose as many as apply.) DAgricuJture D Park I Forest I Open Space DOther (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER, GOVERNMENTAL AGENCY (Federal, State or Local) C29-ves 0 No If yes. list agency name and permit I approval: o V iv-.o II) ß \J ~ 1 bJ}.s /;) f., 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? I .'C ~~esv go ( ~ y~.~~ nj:¡;;:e,mU:PP'baI4 f. NO;.. j v"/\ t> ,(.v-. ~ )f-' l VI'\.J 1 ~ . - S A RESULT OF P OPOSEq T ON WILL EXI riNG PERMIT I APPROVAL ONOC I CERTIFY THAT THE INFORMATION PROVIDED ABOiE IS TRUE TO THE BEST OF Applicant tv f.o-J VI ~h- ~ Signature MY KNOWLEDGEl ./ Date '1 L.-'Î () i If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment . . PART II _ IMPACT ASSESSMENT (To be eomDleled by Lead ADenev! A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR. PART 617.4? If yes, coordinate the review process and use the FULL EAF. DYes )gJ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR. PART 617.6? If No, a negative declaration may b~ superseded by another involved agency DYes ·~o C. COULD AC!-~ptJ-RssULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOllOWING: (Answers may be handwritten. if legible) C1 ExistiAg air quality, surface or groundwater quality or quantity. noise levels, existing traffic pattern. solid waste production or disposal, potential for erosion. drainage or flooding problems? Explain briefly: I µV I C2. Aesthetic, agricultural. archaeological. histonc, or other natural or cultural resources; or community or neighborhood character? Explain briefly: 1f'J Ö I C3. Vegetation or fauna. fish. shellfish or wildlife species. significant habitats, or threatened or endangered species? Explain brießy: I No I 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 brießy I 100 ] C5 Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: I ('JÙ I C6. long term, short tenn, cumulative, or other effects not identified in C1-C5? Explain briefly: I ~O I C7. Other imnacts lincludina changes in use of either auantitv or tvoe of enerov? Exolain brießv: I rI 0"" t- D WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONME~L AREA (CEA)? (If yes, explain briefly: I c=J Yes No I E. IS THERE. OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If ves exolain: c=J Yes ~NO PART 111_ DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box ¡fyou have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FUl EAF andlor prepare a positive declaration. Check this box if you have determined, based on the infonnation and analysis above and any supporting documentation, that the proposed actio WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. Name of Lead Agency Date Pnnt or Type Name of ResponsIble OffIcer In Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency SIgnature of Preparer (If different from responsible officer) . . Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (6311 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD --------------------------------------------------------------- In the Matter of the Application of ----~~__~J_~_J:1l__________________________________ COUNTY OF SUFFOLK) ST ATE OF NEW YORK) I, ,J -€ Ù () ÁS-:-J AFFIDAVIT OF POSTING , residing at .:( II 5/klc.v I Lt.. c F J (.;l\{2 De,J t-ITIr 1YJI- / f~'30 being duly sworn, depose and say: That on the;;¿~ day of J..ul...., , 20rf/. I personally posted the property known as 3190 MII\,,J RI> G(Z...~t\. pai-<:/- µ.y. 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 eight days prior to the date of the public hearing. Date of hearing noted thereon to be held JJ.XW. Q t lI!J. ,~ , d..~-i> On orat)'Ltf '1'œ ~ D,,", ?/~7Io,! ¥ (signature) Sworn to before me this ';)e>¡ dayofJ"()~OO rJ- ;l-~~ .trf(Œ M. WlUO:'....... PublIe. 5_ of ..... ~2248 Suffolk CaIIII&V .nnEllPi-'June12. ;)-00; ~oard of Trustees APPlicat~n County of Suffolk State of New York /...eo OÁ.--SeJ 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 THIS APPLICATION. CR- Signature SWORN TO BEFORE ME THIS 62. cr DAY OF ,2rf1-Y- ~ JOYCE M. WilKINS Notary Public. Slate of New York No. 4952246. Suffolk County Tlirm Expires June 12, êf.ò () J . . NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: L-Jt 0 0 ) 6-¡-! I ~ ~ ~ '5"- Ll - CZ§, Iv SCTM# (TV"'" 7 YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Pennit from the Board of Trustees to:î>Jv; If) \ f~,'h tL~~'''b~Ce-, t bee-\4¡ a~~ 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: ~ i 'l Y'Z-. ~JS, I Ì)..u ~ 3. That the project which is subject to Environmental Review und~r Ch~ters 32, 37, and/or 97 of the Town Code is open to public comment on: ~V) r t I 2ØOY . You may contact the Trustees Office at 765-1892 or in writing. The above-referenced proposal is under review of the Board of Trustees ofthe Town of South old and does not reference any other agency that might have to review same proposal. OWNERS NAME: L-eAJ b ( S trJ MþILING ADDRE~ S/'tv ~f:'" fL. \) > "p-'U)~ C-1' ~ l tr1D PHONE #: r¡ I 1.3" Enc: Copy of sketch or plan showing proposal for your convenience. . . PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK , residing at , being duly sworn, deposes and says that on the day of , 20_, deponent mailed a true copy ofthe 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 South old; that said Notices were mailed at the United States Post Office at , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to before me this Day of ,20_ Notary Public \ M .L-,~, ,. ~ ./ sad of Trustees APplicatio. AUTHORIZATION (where the applicant is not the owner) .. I, _Lu> D/)~ (print owner of property) residing at~ \ )")i-<-. \c...v,l, L It.j) (ma~ling address) G, ~r-> 0 ~ N"\ J I JJqo hereby authorize-13rv-t ~ I/d.L ~ I (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. ~ ~o- ~er's signature) 8 . . APPLICANT/AGENTIREPRESENT ATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics Drohibits conflicts of interest on the Dart DHow" officers and emnlovees. The Duroose of this form is to nrovide information which can alert the town of DOssible conflicts of interest and allow it to take whatever action is necessarY to avoid same. YOUR NAME: 0 I,)~ L-.-€"ê) (Last name, first name. .q¡iddle 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 Variance Change of Zone Approval of plat Exemption from plat or official map Other (If''Other"', name the activity.) Building Trustee CoastaJ Erosion Mooring Planning \,../. /' V Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of South old? "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 (fyou answered "YES", complete the balance afthis 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 herspouse. sibling, paren~ or child is (check aU that apply): _A) the owner of greater than 5% of the shares of the corporate stock of the appliqu¡t (when the applicanl is a corporation); _8) the legal or beneficial own~r of any interest in a non-corporate entity (when the applicant is not a corporation); _C) an officer. director, partner, or employee of the applicant; or _D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I . +1 S~bmitted thiS~ SIgnature . 1 I Print Name 0- C;; 0"' 200.:/