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HomeMy WebLinkAboutTR-5393Board Of $outhold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. ~.~.~ .... ISSUED TO ANN DOBSON CLEMgNTS ........... nt'ltnri alinn Pursuant to tl~e provisions of Chapter 615 of the Laws of the State of New York, 1893; and C~apter 404 of the Laws of the State of New York 1952: and the Southold Town Ordinance en- titled · "REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GR~VEL OR OTHER MATERIALS FROM LANDS UNDER TOWN'WATERSr'~: and in accordance with the Resolution of The B~ard adopted at a meeting held on .~g.,....~.~.~... . 2~gl.., and Jn consideration of the sum of $.......~.~.~ ....paid by Ann Dobson Clements Southold of ...................................................................................... N. Y. and. subject to the Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the followlncj: Wetland Permit for a ground level: (grade) wooden patio approx. 20' square attached to existing screened~in porch o£ house. all in accordance with the detailed specifications as presented in · the originating application. IN WITNESS WHEREOF, The said Board of Trustees ~re- by causes it~ Corporate Seal to be affixed, and these present~ to be subscr~ed by a'majority of the said Board as of this date. Trustees TERMS end C. ONDITIONS Ann Dobson Elements 345 West 13th St., #3A, NYC, NY 10014 N. ¥.'a~ pazt' of the comlderafion for the ts~.~-ce__ of the Petmlt does und~stand stnd pt~'ibe to the fol- l<mlng: 3. That *h~ porm;t should be t~ained inde~rmitely, or as 1oo8 as the ~1~ p,.~r~e wishes to malntsin the m-ucmte oc project involved, to ptxwide evidence to anyone co,,~.q~ed m., ._.d,. .otlzatioa was otlgim~lly ob~t. 4. That the work involved will be subject to the inspectkm and appt~ral of the ~ its agents, and non-compliance with. the ptovislom c~ d~e or~ application, may be cause revocation of rhl, P,'*~t by resolution of the said Board. That there will be no unzeasonable interference with m~io~ ~ · ~ of the w~k 8. Tha~ the said Board wilt be notified by the Po*~ee ot d~e com~iof the wink ~ 9. That the Pexmittee ~ ~n aH other p,~mi~ and consents s~.-e m~y be tequi~ed plemeneal to this permit which may be mb~:t to revoke upo~ fallu~ to ob~l,, same_ 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 August 30, 2001 Ms. Ann Dobson Clements 345 West 13th Street, Apt. #3A New York, NY 10014 RE: 560 Ruch Lane, Southold SCTM#52-2-25 Dear Ms. Clements: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, August 29, 2001 regarding the above matter: WHEREAS, ANN DOBSON CLEMENTS applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated July 16, 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 opportuniW 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 Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approve the application of ANN DOBSON CLEMENTS for a ground level (grade) wooden patio approx. 20' square attached to existing screened4n porch of house. BE IT FURTHER RESOLVED that this determination should not be considered a determination made for any other Department or Agency, which may also have an application pending for the same or similar project. Permit to construct and complete project will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Txvo inspections are required and the Trustees are to be notified upon completion of said project. Fees: None Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/lms Bldg. Dept. DEC N ~4' 45' ~ .................. 85. 26' STORY WOOD '~'°'r S $4' 45':,'" T~( I000-052~02-2§ SUR~/~Y Of' OESCRIBED PROPER TY ARSHAMOM©OUE (SOU THOLO), TOWN OF $OUTHOLD SUFFOLK ¢OUN fY, N.Y. SURV~Y'~D I? AUGUST. 20~. 5C~££ OR SURVEYED FC..? At,.'A~ O0~JSON CLEMEN?$ SURVEYED STANLEY J. ISAKSEN, P O. BOX 294 ICE W- ,,~ OQL Telephone (631) 765-1892 Town H',~i. 53095 Ma,in Road P.O. Box 1179 Southold, New Yo~k 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Monday, August 20, 2001, the following recommendation was made: . ANN DOBSON CLEMENTS for a ground level (grade) wooden patio'approx. 20' squ~re attached to existing screened-in porch of house. 560 Ruch Lane, Southold. SCTM#52-2-25 The CAC did not make an inspection, therefore no recommendation was made. ANN DOBSON CLEA ENT$ July 12, 2001 Board of Town Trustees Town of Southold P.O. Box 117'9 Southold, NY 11971 July 12, 2001 Dear Lauren, Please find enclosed my new application for a Trustees permit for a wooden patio at my home on Ruch Lane. I am sending 2 copies of all of the application paperwork but only one copy of the stamped survey as per our conversation yesterday. Many thanks for your kind assistance. Best regards, Ann D. Clements 345 W. ~3'h Street, Suite 3.A~ Ne~, yorl'v/XJe~t, york xoot4-[zo7 ~OXz~z.8o?.o999 FA-Xz~z.8oT.o998 CELLg~7.8o6.~434 email:anndc[ements~'ao[.com Albert J. Krupski, President James King, Vice-President Henry. Smith A-.tie 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 April 30, 2001 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Ms. Ann Dobson Clements 345 West 13th Street, #3A New York City, NY 10014-1255 Re: 560 Ruch Lane, Southold SCTM#52-2-25 Dear Ms. Clements: The Board of Trustees took the following action during its regular meeting held on Wednesday, April 25, 2001 regarding the above matter: WHEREAS, ANN DOBSON CLEMENTS applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated March 27, 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 April 25,2001 at which time all interested persons xvere given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar xvith the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, NOW THEREFORE BE IT RESOLVED, that the Board of Trustees Disapprove the application of ANN DOBSON CLEMENTS to construct a ground-level wooden patio approx. 15' attached to the existing screened-in porch of the house, based on the applicants request to withdraw the application at the present time. However, the Trustees permit the applicant to re-vegetate the bank with Rosa Rugosa, or other wetland species, in order to stabilize the bluff. BE IT FURTHER RESOLVED that this deternfination 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. Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK:lms cc: Bldg. Dept. NOTICE Police Dept. - Bay Constable Town of Southold Peconic, New York 11958 NOTICE' OF VIOLATION Date: Address: (Owner or authorized agent of owner) (Address of owner or authorized agent of ov, ner) Please take notice there exists a violation of the Code of the Town of Southold, Chapter 97 Article II, Section 97-20 a premises hereinafter described in that You are therefore directed and ordered to comply with the following: on or before the day of 20 The premises to which this Notice of Violation refers are situated at: Town of Southold, Suffolk County, NY (Suffolk CounB, Tax Map Designation: Dist. 1000 Section: Block: Lot: ) Failure to comply with the applicable provisions of the law may constitute an offense punishable by fine or imprisonment or both. NOTICE: You have the right to apply for a bearing before the Board of Trustees of the Town of Southold, provided that you file a written request with the Clerk of the Trustees within 10 days after service of the Notice of Violation. Such request shall have annexed thereto a copy of the Notice of Violation upon which a Hearing is requested and shall set forth the reasons why such notice of viola- tion should be modified or rescinded. Bay i~onstable, Town of Southold., NY Town of Southold A 1660 Suffolk County, NY A 166~_ The People of the State of New York vs. COURT COPY Town of Southold Suffolk County, NY The People of the Stale of New York vs. THE PERSON DESCR;BED ABOVE IS CHARGED AS FOLLOWS cOURT COPY Telephone (631) 765-1892 Town Hall. 53095 Main Road P.O. Bo:: 1179 Southold. New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNC. H, At the meeting of the Southold Town Conservation Advisory Council held Monday, April 16, 2001, the following recommendation was made: Moved by Bob Ghosio, seconded by Bill McDermott, it was RESOLVED to recommend to the Southold Town Board of Trustees DISAPPROVAL of the Wetland Permit Application of ANN DOBSON CLEMENTS 52-2-25 for a ground- level wooden patio approx. 15' attached to existing screened-in porch of house. 560 Ruch ~_ane, Southold The CAC recommends Disapproval because the proposed deck is too close to the edge of the bluff, which would promote erosion. The CAC recommends re-vegetation of the bluff with an approved planting plan. Vote of Council: Ayes: All Motion Carried I I I /, i ii~I L ~'rl~,'o~.~ '/'-~,.o~d ,~-~ INCIDENT REPORT ~ I ] ~ U I~ian ~ A~tn 0 Unk. ~ Non-H'~nic ~ NO Commuter M,lita~ ~ H~ OUnk ~1 I I _ . r~n~ '5 L,,JS3205(2/~73 *FALSE STAYEMENTS ARE PUNISHABLE AS A CRIME. PURSUANT TO TH£ NEW YORK STATE PENAL LAW NOTICE Police Dept. - Bay Constable Town of Southold Peconic, New York 11958 NOTICE' OF VIOLATION Date: Address: :: t '. (Owner or authorized agent of owner) (Address of owoer or authorized agent of owner) Please take notice there exists a violation of the Code of the Article II, Section 97-20 a premises hereinafter described in that To~vn of Southold, Chapter 97 Yon are therefore directed and ordered to comply with the following: on or before the .da}' of · v- ,20__ The premises to which this Notice of Violation refers are situated at: Town of Southold, Suffolk Count.,,', NY (Suffolk County. Tax Map l)esignation: Dist. 1000 Section: Block: Lot: .) Failure to comply with the applicable provisions of the law may constitute an offense punishable by fine or imprisonment or both. NOTICE: You have the right to apply for a hearing before the Board of Trustees of the Town of Southold, provided that you file a written request with the Clerk of the Trustees within 10 days after sen, ice of the Notice of Viola{ion. Such request shall have annexed thereto a copy of the Notice of Violation ttpon which a Hearing is requested and shall set forth the reasons why such notice of viola- tion should be modified or rescinded. Bdy Constable, qbwn of Southold, NY Local Criminal Court VILLAGE OF TOWN OF DOCKET NO.(S) Southold STATE OF NEW YORK COUNTY OF SUFFOLK VILLAGE OF TOWN OF Southold Name (Complainant) ~OLA~ONINFORMA~ON SS } De~nd~t(~) Ann Dobson Clements B.C. Kent B. McCarthy C.C. NUMBER 02-2829 ~REST NUMBER(S) DEFENDANTS IN CUSTODY FROM DATE & HOUR of No. Southold Town Police Department~ POB 911, Peconic~ N.Y. 11958 beingdulysworn, saysthaton or about April 3, 2002 atabout at 560 Ruch Lane ~f Southold Townof I County of Suffolk, State of New York, the defendant(~) TO DATE & HOUR Ann Dobson Clements Southold DOB 11/22/50 345 West 13th St., 3A, New York, N.Y. 10014 wrong~ll~intentionally, knowingly.x~x~imimakm~g~,g~moeacommitted ~eoffense(x) of: Conduct operations within 100 feet of wetlands. No Trustee Permit pursuant to 97-20. A violation of Section 97-33A of the Southold Town Code. in that: Count #1 the defendant, at 560 Ruch Lane, Hamlet of Southold, Town of Southold, County of Suffolk, State of New York, on or about April 3, 2002, having no right to do so, did clear a bluff within 100 feet of a wetland without first obtaining a permit from the Southold Town Trustees. Therefore violating Section 97-33.A of the Southold Town Code. This complaint is based on (personal knowledge) &~ti~~ffitt31~t:{~/ttitgxt~:~R~Oi~W.~r:~xO;~t~fi~ Direct involvement of deponent. dated ] [the attached laboratory report of the dated 1'. SWORN TO BEFORE ME THIS 3 DAY OF Apri 1 Sergeant- Southold Town Police VILLAGE OF APR 2002 T(~I~ OF Soul;hold SSCS-3000b 'STR~KE OUT WORDS NOT APPUCABLE '53-240..5/91cs 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 Office Use Only Coastal Erosion Permit Application /"Wetland Permit Application __ Major Waiver/Amendment/Changes ..,Received Application: .,"Received Fee:$ ~" ,,,'Completed Application Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) -~CAC Referral Sent: .~'I~'ate of Inspection: Receipt of CAC Report: Lead Agency Determination:__ Technical Review; ~Public Hearing Held: Resolution: Minor (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone; Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: ~'F-0Ol~. le~u~ ~c]q,~ct~e,~1 Area of wetlands on lot: 3 g 0~ square feet ./ Percent cover{tge of lot: /~ % Closest distance betweep nearest existing structure and upland edge of wetlands: 6, ,~' feet Closest distance between nearest proposed structure and upland edge of wetlands: (~ 0 feet Does the project involve excavation or filling? ~ No Yes If yes, how much material will be excavated? ~-~O fcubic yards How much material will be filled? f C) ~ cubic yards Depth of which material will be removed or deposited: f O f feet Proposed slope throughout the area of operations: ~- CD ~ Manner in which material will be removed or deposited: -~ (9 ~ 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): Board of Trustees Application GENERAL DATA Area Zoning:_ Previous use of prope~y: Intended use of propeAy: Prior permits/approvals for site improvements: Agency Date prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspxe~nded by a governmental agency? ~ No Yes If yes, provide explanation: Board of Trustees Application County of Suffoflc State of Ne~v York DEPOSES'AND AFFIRMS THAI HE/SHE I$'¥HE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONIAINED HEREIN ARE TRUE TO THE BEST OF mS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN TInS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF IRUSTEES. 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. 1N COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEm AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. SWORN TO BEFORE ME THIS // DAY OF // VEE~ A. GUtATI COMMISSIONER Of DEEDS City of t4ew Yorl~, No, 1-2723 ,20 / $17.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be completed by Aoplicant or Project sponsor) SEQ 5, IS PROPOSED ACTION: 6. DESCRIBE PROJECT BRIEFLY; I [AgriculIure 11. DOES ANY ASP-~CT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ~Yes [] NO ff ,/es list aoency name and permrt/approval If ~he action is in the Coas{al Area, and you are a state agency, complete the J Coastal Assessment Form before proceeding with this as_.s, essment OVER 3ART Ill--OETE?,MINATICN OF SiGNIFiCANCE iTo 3e comole[ed by Acjenc'/) PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: I].S. 'Postal Servi'~ ~ CERTIFIED MAIL RECEIPT (Domestic Mall Only; No Insurance Coverage Provided) m NE~ YDR~__. NY Address: U.S. Postal Service CERTIFIED MAIL RECEIPT (Domestic Mail Only; No Insurance Coverage provided) m $OUTHgL[I, i~J. 971 STATE OF NEW YORK COUNTY OF ~UCLI( ~J't;~--~Ol~t ,/~D O. 0~/41(~ , residing at /%~(L~ tO~/y , being duly sworn, deposes and says that on the /j day of ~-c~J~ ,~92LO/, deponent mailed a true copy of the Notic~ 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~aid Notices were mailed at the United States Post Office at ~_~ , that said Notices were mailed to each of said persons by (certified) (registered) mail. NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEESr TOWN OF SOUTHOLD In the matter of applicant: SCTM#1000- YOU ARE HEREBY GIVEN NOTICE: That it is the intention of the undersigned to request a from the Board of Trustees to: Permi~c)/~J dc 50' D'~. ~ ~(.~/-,~-~'3~ 2. That the property which is the subject of Environmental Review-is located adjacent to your property and is described as follows: 3. That the project which is subject to Environmental Review under Chapters 32, 37, or 97 of the Town Code is open to public comment on: ~u~ozZ.~O~( You may contact the Trustees Office at 765-1892 or in writing. The above referenced proposal is under review of the Board of Trustees of the Town of Southold and does not reference any other agency that might have to review same proposal. OWNERS MAILING ADDRESS: PHONE #: Enc.: Copy of sketch er plan showing proposal for your convenience. 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 BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the. Application of COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I,~L{_~b~C~h&~ residing at ~-~. being duly sworn, depose and say: /~'~-~ That on the [2--day effigy. , 200 , I personally posted the property known as ~O ~ ~C~ 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. Dat~ of hearing noted thereon to be Dated: before me this Swor~ to of~_~200! /~-2~Cday Notary Public HELENE D. HORNE Notary Public, State of New Ymk No. 4951364 Qualified in Suffolk County Commission Expires May 22, ~.') ~nature) Albert J. Krupski, President James King, Vice-President Henry Smith Artie Poster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box I179 Southold, New York 11971-0959 Telephone 1631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application ,.~"'Wetland Permit Application __ Major __Waiver/Amendment/Changes ~-Received Application:~)~_ ¢' Received Fee:$ ~ ,.~Completed Application~ Incomplete SEQRA Classification: Type I Type II Unlisted__ Coordination:(date sent) ~CAC Referral Sent: ~ ~fite of Inspection: Receipt of CAC Report: Lead Agency Determination:__ Technical Review: ~,~dCublic Hearing Held: Resolution: ~Minor MAC: ,; , Phone Number:( )d/~- / .:t(. / - t9 9 i'! Suffolk County Tax Map Number: 1000 - Property Location: -~(., ~?u~z[, /4ilr (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: Board of Trustees Application GENERAL DATA Land A~ea (in square feet): /~(~ 5c;. ,/.~- / ~J ~///' Previous use of property: ~ ~ J ~' ~'~ t ~ ~ Intend~ use of property: ~5~ (C~ tx ~ Prior permits/approvals for site improvements: Agency Date 'v 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 if necessary): / ,, __ t J $17.21 Appendix C State Environmental QuaJJty Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS OnJy PART I--PROJECT INFORMATION (To be com¢leted Dy AepHcaet or Project SDOnSOd SE(: PROJECT }"~P~'c~N"%i,? ~o~o,, cl~'~,,~,~r~ I~' )~:o ,/~,,~,,~ 3. PROJECT LOCATION: {'~ ~ I ' L~ A(:jncu~ture 11. .3 / / / the action is Jn the Coastal Area, and you are a state ac~ency, complete the ,Coastal Assessment Form before proceeding with this as~s, essment OVER I //u //o PART III--0ETE.=,MINATICN 3F SIGNIFICANCE ~To =e comule[ed Dy A,~encT) Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations:. Area of wetlands on lot: Percent coverage of lot: square feet Closest distance between nearest existing structure and upland edge of wetlands: 30 feet Closest distance between nearest proposed structure and upland edge of wetlands: ~- feet Does the project involve excavation or filling? X.,/ No Yes If yes, how much material will be excavated7 f 0 cubic yards How much material will be filled7 f D /' cubic yards Depth of which material will be removed or deposited: ~ o -~ feet Proposed slope throughout the area of operations: Manner in xvhich 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): PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: U,S. Postal Service CERTIFIED MAIL RECEIPT (Domestic Mai/Only; No Insurance Coverage Provided) ,~ ] NLq~ *fOR(, NY 10014 - - ~ / / / ......... ~,...~,,.,,,,., I Address: U.S. Postal Service CERTIFIED MAIL RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) STATE OF NEW YORK COUNTy 0r SUFFOL __/~ '~O~)~Oh C{~/~ _, residing at _ ~IVC 10o[~(3~ , being duly sworn~ deposes and says that'on the ~ day of /~---- ,t-9'~3°f, 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 were mailed at the United States Post Office at ~, /~(~.~ , that said Notices were mailed to each of said persbns by (certified) (registered) mail. Sworn to before me this ~-~ day of ~>~ , kg~( Notary Public / VINCENT G. NOON,AN, Notazy Pub~, 8t~ Ol I~e~w Board of Trustees Application County ofSu~gt~-o~ ~,~J '~c~A&-- State of New York DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TR[FE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIE~F, 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, 1 HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signature / ~ SWORN TO BEFORE ME THIS /~wd.,.__ DAY OF J ~ ,20 0/ Notary Public VINCENT G. NOONA~I, J~. Notary Pu b{.ic, NO. 31-~O017'?B