HomeMy WebLinkAboutTR-5922
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TERMS and CONDmONS
Ann Clements
"Die Prrmitœe
~ u 560 Ruch Lane, Southold . N. Y.. u
pare of the c:oosideratioa for the 1ssI""<:C of che Pumit does Uødentaod &ad prescñbe to the fol-
lowing:
1. That the said Ðoard of Trustees and the Town 01 Souchold _ relcoscd from any and
all damages. or claims for damages. of AÚØ adsiog clitecdy or Iodùec:dy as a ~ of any oper'
-atIoo performed punuant to this permit, .aad.Jheaid t> .:~ will, at his or 1Ia: ClWD ~,.
delcod eay and all -" suits ·'nl'¡ated by Ibhd.,ardes, and che said PermIttee ___ fuU liability
with respect thereto, 10 the mftIP1o:teeulusioo of the llaatdpt Trusttes of che Town of ~
2. That this PeöDIt is valid for . pedod of 24· mas. wbL:h is Ø'ir~ to be che
estimated time required to complete the wod: inwl..ed, but . should år<:umstanccs wunot, request .
for an exœosion rœy be made to the Ðoard at a later d.œ.
3. That this Pemùt should be retained indefmitely. or u 1008 as che said Petmiuee wishCs
to tnaincain the lttuCtUle or project Involved, to provide evidenœ to anyone roncemed chat anIh-
oåzatioo was originally obtained.
4. 'That che wad< inwlved will be subjtct to che iospectioo and approval of the Boa.td or
its ~ts. and DOO-compllanœ with the proWions of the nrlgina'¡,, ; applicatioo, may be canse for
œvocaâon of this Pumit by reso1\ltion of che laid Board.
S. That there will be no unreasonable Interference with navigatioo IS a cesult of the work
beteIn aûtborized.
6. That there oball be no interfereace with the right of the public to pass and repass aloag
the beach between. bigh and low water marks. .
7. That If future operatioos of the Town of Southold require che œmon1 and/or alteradoas
In the location of me wod< herein ...."">01 '\1, or If, In the opinion ol1be Ðoard 01 Tr-. che.
wodc shall cause anrt'IlOC"'h1e obsttuaJOn to free navigmoa, che said Permittee will be nqaIred,
apon due DOtiœ, to remove Or alter chis _tk or project berein stated wichout ~ to the T_
. of Southold. . .
8. That the said Board will be ootif"lCd by the Penniuee ot the 0.>"1"...w.. Of the work anIh-
ori2ed.
9. That the ..,.......;.- will obtain all other pemWs and con<eoli·Chat may be required sa;;
þIeø-"" to chis pemùt ~ rœyhe subject to revo!r.e upocI fallure to obWa aame.
'.
':;
,.
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 SOUTHOLD
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.
C\Q\,wnt)
INSPECTION SCHEDULE
Pre-construction, hay bale line
15t day of construction
Y. constructed
~project complete, compliance inspection.
.
.
Albert J. Krupski, President
James King, Vice~President
Artie Foster
Ken Poliwoda
Pegg:\' 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 SOUTHOLD
May 26, 2004
Ms. Ann Clements
345 West 13th St., #3A
New York, NY 10014-1255
RE: ANN D. CLEMENTS
560 RUCH LANE, SOUTH OLD
SCTM#52·2·25
Dear Ms. Clements:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday, May 26, 2004 regarding the above matter:
WHEREAS, ANN CLEMENTS 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 April 15, 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 May 26, 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,
NOW THEREFORE BE IT,
RESOLVED, that the Board of Trustees approve the application of ANN D. CLEMENTS
to construct a 300 sq.ft. ground-level deck, with the condition there is '/.,.. spacing
between the deck boards and a porous surface underneath the deck.
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 this notification.
Inspections are required at a fee of $50.00 per inspection. (See attached schedule.)
Fees: $50.00
Very truly yours,
dac- f 9. ~. 7f1"'J..· ~ '
Albert J. Krupski, Jr.
President, Board of Trustees
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SUFFOLK COUNTY, N.Y.
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ARSHAMOMOQUE (SQUTHOLD)
TOWN OF SOUTHOLD
SUFFOLK COUNTY, N.Y.
SURVEYED 8Y
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SURVEYED FOR: ANN OOBSON CLEMENTS PC'. e,v 294
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II) SEP ú3 J,[I[J fL[',.,,;Ti0IJS &: r~I)NTOUR5
.
.
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A, Dickerson
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
TO: r1..t'\fì ('\0 mÐ (\1-"',
Please be advised that your application dated '41 \~I (jf
reviewed by this Board at the regular meeting of
following action was taken:
has been
and the
( vi Application Approved (see below)
L-) Application Denied (see below)
L-) Application Tabled (see below)
If your application is approved as noted above, a permit fee is now due. Make check or
money order payable to the Southold Town Trustees. The fee is computed below
according to the schedule of rates as set forth in the instruction sheet.
The following fee must be paid within 90 days or re-application fees will be necessary.
COMPUTATION OF PERMIT FEES:
-$'Sl),OO--t;m\ 1f\&pl1.c-t¡()(\
.
TOTAL FEES DUE: $ SOd::;X)
SIGNED:
dI~-f 9 ~.t;.
PRESIDENT, BOARD OF TRUSTEES
.
.
Telephone
(631) 765·1892
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
CONSERVATION ADVISORY COUNCIL
TOWN OF SOUTHOLD
At the meeting of the Southold Town Conservation Advisory Council held Tuesday, May
11, 2004, the following recommendation was made:
Moved by William Cook, seconded by Don Wilder, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the
Wetland Permit application of ANN D. CLEMENTS to construct a 300 sq. ft. ground-level
deck.
Located: 560 Ruch Lane, Southold. SCTM#52-2-25
Vote of Council: Ayes: All
Motion Carried
· .
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
Letter of Non·Jurisdiction . Tidal Wetlands Act
January 30, 2004
Ann D. Clements
345 W 13'h St
New York NY 10014
Dear Ms. Clements:
Re: Clements Property, 560 Ruch Lane, Southold
SCTM: 1000-052·02·25
DEC No. 1-4738-03297/00001
Based on the information you have submitted, the New York State Department of
Environmental Conservation has determined that the property landward of the 10 feet
elevation contour, as shown on the survey prepared by Stanley J. Isaksen, Jr., dated August
17, 2000, is beyond the jurisdiction of Article 25 (Tidal Wetlands).
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 all 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,
ß7R~
George W. Hammarth
Deputy Permit Administrator
cc: Marine Habitat Protection
.
.
DEPARTMENT OF THE ARMY
NEW YORK DISTRICT, CORPS OF ENGINEERS
JACOB K. JAVITS FEDERAl BUILDING
NEW YORK, N.Y. 10278-0090
REPl Y TO
A. TTENTIQN OF
JAN 1 .? 2acl,
Eastern Pemlits Section
SUBJECT: Joint Application with New York State Department of Environmental Conservation
Ann Dobson Clements
345 West 13th St #3A.
,New York. NY 10014
Dear [\[s. Clements:
We have recently received a copy of the Joint Application for Pemlit you filed with the
New York State Department of Envirorunental Conservation (NYSDEC).
Please be advised we have reviewed the Joint Application. and based solely upon the
infOlmation provided, it appears that a Department of the Anny is not required for your proposal.
The Department ofthe Anny regulates construction activities in navigable waterways and
discharges of dredged or fill material into water of the United States. including inland and coastal
wetlands. [f your proposal would involve such work, and has not been portrayed as such in your
Joint Application, you should contact this office inunediately so that a project-specific
determination can be made as to whether a Department of the Army permit will be required.
Any inquires should be directed to the Regulator-of-the-Day at 212-264-6731.
Sincerely.
"".1 \L Q1J-
[\[ark Steven Roth
Acting Chief, Eastern Petmits Section
DEC Application No. 1-4738-03297/00001
.
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May 15, 2004
Dear Lauren,
Please find enclosed the notarized affidavit of posting pertaining to my Trustee
permit application for a deck.
This is scheduled for review on May 26 but I will be out of town attending my
daughter' wedding and will not be able to attend.
If necessary, please make the Board aware of this.
Thanks for all your help.
Best regards,
aw
~ ~ M~' ~ I '~i ~ ~
Ann Clements
Soulhold Town
Board of Trustees
345 W. 13'h Street, Suite 3A, New York, New York 10014-1207
VOX 212.807.091i19 FAX 212.807.0998 CELL 917.806.5434 email: anndclementS@aol.com
.
Aloert 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 (63li 765-1892
Fax 1631; 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
--
mee Use Only
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Southold Town
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__Coastal Erosion Permit Application
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\Val\'er· Amend[T1f'l1t..r.hn-Qes
~cei\"ed Application:_ __
....-:Received Fee:$ó1'St:>-
~ompleted Application .'1./l.$lOY...
__Incomplete_____
SEQRA Classitìcation:
Type 1__Type lI_Unlisted__
__coordlIlaüon:(dategem'
~c."'C Referral Sent t) _
---Pate of Inspection: ...~
_Receipt ofCAC Reporr:_____
__Lead Agency Ddemúnation:_
Technical Re\"iew:
-"...Public HeatIng HeW~~
Resolution:
-------
----------.---.-----
Name of Applicant M I'\V\ D. C, \ e"^, t: ~.s
Address_~ 'vJ. r~~ s,-t. if-'6A- AJ~e... lOOILill:S-
Phone Nllmber:( ) 'J l J.. f <Do '1- 0 q 'ì '1 \\~
'\ _ d'~
SllffolkCollntyTaxMapNllmber: 1000·_ S;). -~ -,,¿~ q~'j,,:~ /
Property Location: S"loo ~.hla~'L I -A ifS \\ti. \'Y\CM.tl~ Cdo~
KY... ¡JO~ KtCLc(J ~{bX. 1/,-\ \V\~l'( ~.. ~ tO~CL~
~'ide LILCO Pole #/ dis ce to cross streets, a~~n)
AGENT:
([fapplicable)
Address:
-
Phone:
.
.
Board of Trustees Application
GENERAL DATA
LandArea(inSqUarefeet)_~~'\r'L lot) 3Cû~.~.iülo¿ ~GteL
Area zoning--'yeSI'~Jf~
Previous use of property 1\ es,' c&. J"l'J-
Intended use ofproperty-3 es¡ ~L,:tt'cJL-
Prior permits/approvals for site improvements:
Agency
Date
D.t; ,c...
~\·~c{iS 1>~1.
:[(\11-., I J, looL_
.
\0 6qlecL
__ No prior pennits/approvals for site improvements
Has any permit/approval ever been revoked or susp¿n d by a governmental agency?
No Yes
- -
If yes, provide explanation:
Project Description (use attachments if necessary)-ªtP()1VO)(.. 3co ~ ~.
-§Y()jw.f l t u£-f~ e%... ) L. TIX)&.e.l-L.
I
.
.
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:-ttº~ (etJt( d~C1<.. 0 '^-
~S-i &£1A.eL-
Area of wetlands on lot
7
square feet
Percent coverage oflot:
L~%
Closest distance between nearest existing structure and upland
edge of wetlands: 70 feet
Closest distance between nearest proposed structure and upland
edge of wetlands: 80 feet
Does the project involve excavation or filling?
x
No
Yes
rfyes, how much material will be excavated?~_cubic yards
How much material will be filled?
_cubic yards
Depth of which material will be removed or deposited
feet
Proposed slope throughout the area of operations:
Manner in which material will be removed or deposited
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):
M~ ~~~ _ t~~>~
. ,-A(S~ ~~ ~o"'-c.Q
u'\J\SJ.;UflÙk- ~ Vb~ "t.e L ~cÛU(cf I-l},-Ot
.
.
Board of Trustees Application
COASTAL EROSION APPLICATION DATA
Purposes of proposed activity L0\.J-cJt~ ~ ~ [(vf d£.c{C
I
~ ~t ~:ttz~{,~,º- l'D eil<tl~ cDtrGt.~-
Are wetlands present within 100 feet of the proposed activity'
No X. Yes
Does the project involve excavation or filling'
X No Yes
If Yes, how much material will be excavated'
Jcubic yards)
How much material will be filled'
(cubic yards)
Manner in which material will be removed or deposited
Describe the nature and extent of the environmental impacts reasonably anticipated resulting
/Tom implementation of the project as proposed. (Use attachments if necessary)
ho\,\e.. uh..d""'S.ðE-\t(I¡ -
~ou"-~ le-~ ~cÆ::.. io be ~ece \0-€t7
~X"isi1~ c()ttQ.~ -
e)(\:<Çt-~ d.oJdf' c.j(kdow..s to b€- ~l4cecf
u~ k\i\.vk.. doors
.
I
.
I PROJECT ID NUMBER
PART 1· PROJECT INFORMATION
61720
APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLISTED ACTIONS Only
( To be completed by Applicant or Project Sponsor)
SEQR
1 APPLICANT I SPONSOR
Ò. C- le.1AA. eu.:t.s
2. PROJECT NAME
Municipality
S-(,D
d. County
provide map
tVõWo.-
~L.J V-
3.PROJECT LOCATION
4 PRECISE LOCATION Street Addess and Roa Intersections. Prominent
5"(,,0 Rv<..L...Lk,^-e..-
MS'^-4.Io....C>v-G...~ é.cLo"""::l
Do~ RAA-oL '/4. 1>\.;1e.
I >,
~()Jh-.b(
5 1$ PROPOSED ACTION. D New
o Expansion
Modification { alteration
6. DES~'~O~:~r l~~ wrok",-- & ~ c¥. ~ '^- D W\..O V"'e...
t)(,rti~ 'i Q.vQ» C¡OtPv~)(. 300 'trQ1' /)'
5c-Tbc;:c..K0DVDVv\ leT \,"'~ -~rvo)<'. 3
~ l:l "'-
7. AMOUNT OF LAND AFFECTED:
Initially acres Ultimately acres
8 WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
~es D No If no, describe briefly
30c
~AT IS PRESENT LAND USE IN VICINITY
~ Residential D Industrial 0 Commercial
OF PROJECT? (Choose as many as apply)
DAgricuJture D Park I Forest I Open Space
o Other (describe,
NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
D. (::; .C. SiC:Cì~
12 AS A ~T OF
Ges ~No
I CERTIFY
THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant I Sponsor Na
Signature
Dale:
if -/(j -() 'f
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 completed by Lead Agency)
A. DOES ACTIO~CEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF
o Yes No
B WILL ACTION RECEIVE GOOROINA TED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617_6? If No, a negative
declaration m~ superseded by another involved agency.
c=J Yes No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible)
C1 Existing ajr quality. surlace 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 1\.0 I
C2 Aesthetic. agricultural, archaeological, historic, or other natural or cuttural resources; or community or neighborhood character? Explain briefly.
I ho I
C3. vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly
I ho 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 bnefly
I h 0 I
C5 Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly:
I h.o I
C6 Long term, short term. cumulative, or other effects not identified in C T-CS? Explain briefly:
I h.o I
C7 Other impacts (including changes in use of either Quantity or type of energy? Explain briefly:
I h 'öVuL-- I
D WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL
ENVIRONME~AREA (CEA)? (If yes, explain briefly: I
o Yes No I
E. IS THERE. O~ERE LIKELY TO BE. CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain:
o Yes No I I
PART III - 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, !hedetermination of signIficance must evaluate the potential impact of the proposed action on the environmental charactensticsofthe CEA.
Check this box If you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FUl
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, thai 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
Print 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 r.63lJ 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOlD
---------------------------------------------------------------
In the Matter of the Application
of
...~JC\,_~"_._~~~_~__.._______....._________.
COUNTY OF SUFFOLK)
ST ATE OF NEW YORK)
AFFIDA VIT OF POSTING
I,}iV'l~ C(emtJ".s,residingat 3<fS-lJ. /31lz If 3/T4~/O[jY
being duly sworn, depose and say:
That on the 13dayof M I[ , 200'1f personally posted the property known as
~o v¿ L . ú- L-
by placing the Board of Trustees official poster where it ca 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 ()J'd·~- á(,)O~ - _.
On Or a~ f\',{).) rr-r-.
Dated:
..
·~·~lJ.
(signature)
~~
_r
Sworn to before me thjß/U
day of 2007" 7
otary Public
~ NISE E. WALLEN
ry Public, State of New VOlt!
No. 24-452761 B -
Qua!lf,ed In Kings County
COml1YSSlon expires April 30, 20Ql
.
.
PROOF OF MAILING OF NOTICE
ATTACH CERTUìED MAIL RECEIPTS
STATE OF NEW YORK
COUNTY OF SUFFOLK
A\\,^- G U'tLVl't~1~ ,residing at ~~s,- ~ \ ~ 1\ j-t, };1
, being duly sworn, deposes and says that on the
1 is day of ~' \ ,20Q.'i, deponent mailed a true copy of the Notice
set forth in the Board of stees Apphcatlon, 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 sho'l.'l1 on the current
assessment roll of the Town of South old; that said Notices were mailed at the United States Post
Office at ~h ¡ \~ -Av(~~, that said Notices were mailed to each of said persons by
(certified) (registered) mail. a~.fj Πt'-1..f/ 4-~
I
Name:
S'( ~j ':j S c ~ J Dùc':;¡-' (-l1y. e,ktP
l) Ò L-; V"'-\:c.\t\ Pkc:.z-
-ß If LÎLi\éll\ c, I ,ivj \ \ 1 (}
·V
,s20
/
,...,
IT"'
LIl
IT"'
ru
["-
IT"'
IT"'
,...,
o
o
o
o
...D
ru
ru
U.S. Postal Service",.
CERTIFIED MAIL.. RECEIPT
(Domestic Mail Only; No Insurance Coverage Provided)
" ,.: ...
I . /JV I1W> --... I
, .....?: ~"'"
Posl8ge $ 0.37 LflIT liJ: OŒA
Certified Fee " '^
Return Aeciept Fee P08lmark
(Endorsement Required, 1.'r.i He",
RestrICted Delivery Fee CIeri<:: KGWIF
(Endorsement RequIred)
Total Poslage & Fees $ 4.42 04/28/04
fTl
o øTh ~I' ~
i2 ~,~:;:§~~:-J-1·(-lt;Q:·~;;~-··~·i:~~~"::·~·n._....
ëírÿ:"šiã¡ã:zip;¡·--nnn...__nn_..n.
.
.
PROOI" Uf' MAiLli'¡-G OF NOTICE
ATTACH CERTlFIED MAIL RECEIPTS
Nan ~:
I'-
o
..D
AddI IT"
U.S. Postal Service"..
CERTIFIED MAIL,.. RECEIPT
fC?ome.stic M.ail On..'y; N,! Insuranc~ Cov'!,age Provided)
c¡ 'fuvlf ~ L l'~ {\..- 'LJ(( c¡ ~Z-.
~ 0 '1\, ?\ (Ù~Ct~{yJL.(
llct(.,tlA-~Uj OI\LS-o
~ )
n.J
I'-
IT"
IT"
o.:rr ~ ID: _
J
. ~.."
/~~"
D . >,ti".
..D Ù!rft: -u.. '""", :: .
ru ' .', unrfr'
ru ' 11
m Total Poslage & Fees $ 4.42 '... J~~!?_~:~~
o Sent To it!.' L' 'f:f!I.. .
~ ,....m..... ..f:~.~ c..· ( V ~ ..t( s-z-
~~';;::::o ·')05 'j ¡:..·~¡?4J4~T~.--··m~m:.:'mmm
.m........m.....iT.. I . Jt.ë
Ct(y. Stete, ZIP.4 /L t (~..t-:;.·~G-;~;-..~Zjf·Ô7lii'ij_.._m
'""
o
o
o
POS1ag8 $
Certified F"øe
, ..
Return Reclept Fee
(Endorsement Required)
Reslricted Delivery Fee
(Endorsement Required)
~
ST, TE OF NEW ....·ORK
CO TNTY OF SlíFFOLK
__~kk.~_ C~tlA.JiJ,) ,residing at .~~S- lJ l~~ frf. 3!Î
__ ___ . _' being duly sworn, deposes and says that on the
=:;Y_ day of ~~ , 20Q':f, deponent mailed a true copy of the Notice
set Jrth in the Board 0 Trustees ApplicatIOn, directed to each of the above named
per )ns at the addresses set opposite there respective names; that the addresses set
op~ >site the names of said persons are the address of said persons as shown on the current
ass, ;sment rQIl of the Town of South old; that said Notices were mailed at the United States Post
Of! ~e at n'~\ '\Á.~ {5.v-( ~that said Notices were mailed to each of said persons by
(co it¡"')(~gi",,"')=¡¡. ~.ì) â!et<u'~
DENISE E. \
Notary Public. St~rc .··f York
No, 24-~""7618
a,uafified i;! P':lnS3 County
Commission Expires Apni 30, 2006
.
.
Board of Trustees Application
County of Suffolk
State of New York
.' q IJ II () (1 t"t,j¿f£s\ BEING DULY SWORN
DEPOSES AND AFHRMS THAT ¡SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRUE TO THE BEST OF HISIHER 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 Tl-IE 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.
_ (¡~ IJ, {!¿ '/¿ ~.
Signature _ _)
,~
SWORN TO BEFORE ME THIS_1;,J .hDAY OF_!jt'), ):" ,2oŒ'
-'
//
(,_þ~. /1~
/~-~L<"" p>-:¿ 7---( ----4~¿,' - - .-- .
,~ (~otary Public . i /
GISLAINE AUGUSTIN
Notary Public. State of New York
No 01AU6105405
Qualified in Queens County
Commission Expires February 9. 201JS
.
.
APPLlCANT/AGENTIREPRESENT ATIVE
TRANSACTIONAL DISCLOSURE FORM
The 10\\11 of South old's Code of Ethics orohibits conflicts of interest on the Dart artoW" officers and emolovees. The DUfDOse of
this [ann is to DTOvide ¡"CDonation which can alert the town ofoossible conflicts of interest and allow it to take whatever action is
necessary to avoid same.
YOUR NAME: ~ C \tV\\-e~S A-\i\\¡\ ~.
(Last name, first name, .Q1.iddle mitiAJ, 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 APPLlCA nON: (Check all that apply.)
Tax grievance
Varianee
Change of Zone
Approval of plat
Exemption from plat or official map
Other
(If'·Other··, name the activity.)
Building
Trustee
CoastaJ Erosion
MooTing
Planning
../
Do you personally (or through your company, spouse, sibling, parent. or child) have a relationship with any officer or employee
of the Town of Southold? "Relationship" includes by blood, marriage. or business interest. '''Business interest" means a business,
including a partnership, in which the town officer or employee has even a partial ownership of(or employment by) a corporation
in which the town officer or employee owns more than 5% of the shares.
.,/
YES
~--
NO
(fyou answered "YES··. complete the balanœ of this fonn and date and sign where indicated.
Name of person employed by the To,,,,'n of South old
Title or position of that person
Describe the relationship between yourself(the applicanUagent/representative) and the town officer or employee. Either check
the appropriate line A) through D) and/or describe in the space provided.
The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply):
~A) the owner of greater than 5% of the shares of the corporate stock of the appliqmt
(when the applicant is a corporation);
~B) the legal or beneficial owner of any interest in a non-corporate entity (when the
applicant is not a corporation);
~C) an officer, director, partner, or employee of the applicant; or
_D) the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this day of 200
Signature Œ:::; Ò. C/..túdt./t,
Print Name ")fñ-Vl ò. CleMI'!MS
Fonn TS I