HomeMy WebLinkAboutTR-5449
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TERMS end CONDmONS
~"~c..
The Ifeómittee
Ar."hil1pc ¥. H:dri9R." 5tad:ttiari3
~
residing I( 310CCaro1e.,Rn"ñ Snnthnlñ N. Y. as
put of the consideratioo for the isSuance of the Permit does uødentaDd and pl'CSCribe to the fol-
Iowiog :
1. That the said Board of Trustees and the Town 01 Soucbold ue rdeased from Il11 and
aU damages, or claims for damages, of suits arising directly or indirecdy as . result of Il11 ope<-
.tioo performed pwsuant to this permit. and the said P-n'_ will, at his or her own ex¡-eos'.
defend Il11 and aU such IUits· nitl.-l by cbird puries, and the sùd F~i. .- fuI11iab/Jity
with respect thereto, to the comp1ete esdusion of the Board of Tmsœes oE the Town oE ~
2. That this Permit is wIid for a period of ? <1 mas. wbith is coDlide<ÞCI to be the
estimated time required to complete the work invol..ed, but Shoa1d cUèamstaoces warn.at, request
for an exϿsioo may be made to the Board at . later cbte.
3. That this Permit should be retaioed indefinitely, or as loog as the said Permittee wishes
to m.j_In the strueture or project involved, to provide evideoce to aoyooe cooœmed that aod1-
orizatioo was originally obtaioed.
4. That the work involved wi11 be subject to the in~ and approval of the Board or
its agents, and ooo-compJiance with the ptovisions oE the otigi_tl..g app1iatioo, may be caose for
ttVOCatioo of this Permit by resolution of the said Board.
5. That there wi11 be 00 unreasoo.I>le interfereoce with osvigatÏoo as . result of the wodr
bereio autborized.
6. That there shall be 00 ioterference with the right of the pubIk to pass and. repass aIoog
the beach betweeo high and low water marks.
7. That if future operations of the Town of Southold zequire !be reø1Oft1 and/OI: aIteratioas
in the locatioo of the work bereio auIhodzed, 0 r if, in the opioioo of !be Board oE Trustees, the
work shall caose uoreasooable obsttuct1oo to free osvigatWo, !be sùd Peaøittee wi11 be nquired,
upon due 001Íœ, to remove or alter this work or project hereio su.ted without e..peøscs to the Town
of Soutbold
8. Tbat the said Board will be ootified by the Permittee ot the comp1edoo of the wodr aod1.
orized.
9. Tbat the Permittee wiU obtaio .U other permits .nd c:oaseø.ts that may be required sup-
plemeotal to this permit which may be subject to revolce upon failure to obtaio woe.
Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
f
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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
November 27,2001
Achilles & Marion Stachtiaris
159 New Hyde Park Road
Garden City, NY 11530
RE: SCTM#52-2-8
310 Carole Road
Southold, NY
Dear Mr. & Mrs. Stachtiaris:
The following action was taken by the Board of Town Trustees during a Regular Meeting, held
on November 20,2001, regarding the above matter.
WHEREAS, ACHILLES & MARION STACHTIARIS applied to the Southold Town Trustees
for a pennit under the provisions ofthe Wetland Ordinance of the Town of South old, application
dated October 31, 200 I
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
November 20,2001 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 standard set forth in Chapter 97-18 of the Southold
Town Code.
WHEREAS, the Board has detennined that the project as proposed will not affect the health,
Safety and general welfare of the people of the town,
·2
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NOW THEREFORE BE IT.
RESOLVED, that the Board of Trustees appröved the application of Achilles & Marion
Stachtiaris for a Wetland Permit for a 3 foot wide by 5 foot long ramp for jet ski, with the
stipulation that the ramp be constructed of 4"x4" posts raised at least 8 feet and the rails for the
jet ski be no more greater than 4"x 4" actually 3 feet wide by 42 feet long.
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 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 the notification.
Fee 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 when project is started and on
completion of said project.
FEES: NONE
Very truly yours,
t2!tt.-I?- /~!h-
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/cjc
cc: Building Department
DEC
Telephone
(631) 765-1892.
.
TOWIt Hall. 53095 IIIain Road
P.O. Sol: U79
Southold. New York 11971
- SOUTHOLD TOWN
CONSERVA.TION ADVISORY COUNCIL
At tho meeting of the Southold Town ConselVation Advisory Council held Tuesday,
November 13, 2001, the following recommendation was made:
Moved by Sob Ghosio, seconded by Drew Dillingham, it was ,
RESOLVED to recommend to the Southcld Town Board of Trustees DI1I11IJl~'¡Al of
t~e Wetl¡indPermit Application of ACHILLES & MARION STACHTIARIS for th¡:¡
eX1stltI§-~"X ~jet.g (fråmþ,
310 Carole Rd., Southold. SCTM#52-2-8
The CAC recommends Disapproval of the application and recommends removal of the
entire struçtur.e.
Vote of Council: Ayes: All
Motion Carried
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NOTICE
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Police Dept. - Bay Constable
Town of Southold
Peconic, New York 11958
NOTICE OF VIOLATION
Date:
AugUèÒt l t :.:UO t
To:
Achilles Stdc~ltiari~
(Owner Ot authorized agent of owner)
Address:
159 ¡";ew HyJ¿ PdT!-\. F'_d., ''';-:'ll'dèG Citv, ;:.Y. i 1.5.1:1
(Address of owner or authorized agent of owner)
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 have erected ~~
jetski ramp wi.n~uut fir.~;t oDtai[ÜIL~ él per<,-¡ít [rum tiH~ S.)utholJ T..Twn
Trus[t:'e~.
You are therefore directed and ordered to comply with the following:
A?ply ror a p~r~it
EY-·lrr: ~ae Tv,.¡n :"(llstf.'t:"S. If permj t Ís deided t~:.': jet::;kl LJ.lTI.p Í!--' tv b<::.'
rpJr.cved.
on or before the
::'4
day of August
,20~.
The premises to which this Notice of Violation refers are situated at:
Jlí.J C¿lI"DJ_"". F".Jad, Southold~ ;':.Y. t19ïl
Town of Southold, Suffolk County, NY (Suffolk County Tax Map Designation: Dist. 1000
Section: 5;:
Block:
Lot:
i!
)
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 Ihe 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.
; i
~~ "5, rÎ<LÞ~
Ba Constable, To~ of South '" ' NY
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OUS-3205 (2/97) *FAlSE STATEMENTS ARE PUNISHABLE AS A CRIME. PURSUANT TO THE NEW YORK STATE PENAL LAW
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Albert J. Krupski, esident
James King, Vice-P sident
Henry Smith
Artie Foster
Ken Poliwoda
-.
. .
-'--
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Town Hall
53095 Route 25
P,O. Box 1179
Southold, New York 11971-(
Telephone (631) 765-189~
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTH OLD
Office Use Only
_Coastal Erosion Permit Applicatjon
_Wetland Permit Application ~ Major
_Waiver! AmendmentLChanges
_RtteivoJ Appli~'t~
Received Fee:$ _ I ~
_Completed Application )
_Incomplete
_ SEQRA Classification:
Type I_Type II_Unlisted_
Coordination:( date sent) ,
_CAC Referral Sent: :0 f/ff, oj
_Date ofInspection: ì J; I () I
_Receipt ofCAC Report:
_Lead Agency Determination:
Technical Review: ~
Public Hearing Held: /l ')u 0
Resolution:
Minor
Name of Applicant A~ We.s; 1 \vï If'rt1.U¡ IU S' +-11clJ ,Ap I'S;
Address J t:) ~_JV.f'I..d jJ~? f!. KA. bff'r121>E'/Û e. +j
Phone Number:( ) c; I b - '-f 3 7 'Jb /?
!T1--:2<?
Property Location: .<¡ l í) C ¡4 R- 0 I e.. l2A,
Sou:t-0n(d... "'-00 +0
(provide LILCO Pole #, distance to cross streets, and location)
IU'~ll)5Ò
Suffolk County Tax Map Number: 1000-
Sou IV Ö
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AGENT:
(If applicable)
Address:
Phone:
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Board of Trustees Application
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COASTAL EROSION APPLICATION DATA
Purposes of proposed activity: 10p;;{. LI _ '),,-t s /::., ¡'
fl?o~ -Who(! UlM-eIL ð/V 'to 2rr-mf l<\--¡-- /-I-¡'QA y,tJ'ì
Are wetlands present within 100 feet of the proposed activity?
No K 1res
Does the project involve excavation or filling?
i No 1res
If1res, how much material will be excavated?
(cubic yards)
1./ 0 ~ ~
How much material will be filled?
(cubic yards)
Manner in which material will be removed or deposited:
Af 0 ItI .J2-
Describe the nature and extent of the environmental impacts reasonably anticipated resulting
ITom implementation of the project as proposed, (Use attachments if necessary)
--¡--¡',p 14 ( is
f:A) (J f P ùro! 111<# 11;(
tJ () 'tI { p~d 0 tJ 'Th €-
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d D IIJ e ~(L.?w ,tr¿ ed 'lJ f!..
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Board of Trustees Application
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WETLANDrrRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: ,0 pú I..{ <:::'¡¿, 3" r
lÁPðN
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Q(t- WI 1"' I'r"
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¡-.I. t' ç" 'ì \ 'ö í' <; D
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5ft¡V )^1
6QúkÍ -
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Area of wetlands on lot: J D ! I X
square feet
Percent coverage oflot:
')
%
Closest distance between nearest existing structure and upland .ý,
edge of wetlands: feet 5-Q Q.. i)Rf'<"JJ '
Closest distance between nearest proposed structure and upland n. '" c¡
edge of wetlands: feet 5.u. l)"l ()..ùJL
Does the project involve excavation or filling?
X No Yes
If yes, how much material will be excavated? ,vrv&CUbiC yards
~J ð rJß'
How much material will be filled?
cubic yards
'1/
Depth of which material will be removed or deposited: t/ i,J /1
feet
Proposed slope throughout the area of operations:
Manner in which material will be removed or deposited:
r
¡!ð,Jr¿
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 ifappropriate):
-=r h 0 R. ç
ì-S..
A) J
¿F!'.f'êi- úl-) lIJd(rx-...,{,('
c=Ð-ì I D~( - t. 'Ç. ì i' fhv (!f'r u Ó<z "--',};. _ W I ''(-L øI:o
ç: 0 r, c¡12A::fS.
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Board of Trustees Application
Land Area (in square feet):
GENERAL DATA
-,-0''7--/(
Area Zoning: {fP..s. i) e J£.-f j 4 L.--
Previous use ofproperty:--Pe fI-(' A'1
Intended use of property: ¡;f' ItC ¡,
Prior permits/approvals for site improvements:
Agency
Date
L No prior permits/approvals for site improvements,
Has any permit/approval ever been revoked or suspended by a governmental agency?
-À- No_ Yes
If yes, provide explanation:
ð6'1- 5~¡,
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--F6r~(use attachments if neces$ary): ( ') ~_ (L
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NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
n" V"" Ç/hM.IIL' Si"dd, ttr¿,¿"
SCTM#lOOO-
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a
Permit from the Board of Trustees to:
A [lOU¿' ::SF+
I':) !,....OuJF¡1 ¿
'- I
ç: {(,
\~{hS:~
12/1-0\ P
S~+
L' tU
r,\ 1 /':>, ~ <. ~.l-,----,
t 'U)o",-- LC; rt-i- f_ (L -
.s j¿',
2. That the property which is the subject of Environmental
Review-is located adjacent to your property and is- described as
follows:
') C ^ I 'i.
~~, lA" h Iv : "..c¡
W j...-;; i >-(¡ '-I ~A.A..
'-¡:s <è (/~ éÁ.
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: You may contact the Trustees Office at
765-1892 or in writing.
The above referenced proposal is under review of the Board of
Trustees of the Town of Southold and does not reference any
other agency that might have to review same proposal.
OWNERS NAME: 1\1~ s......t,1dvl-,·I>A..;, .( 1+~Uu
MAILING ADDRESS: ~J>q Al4ù ~'( p/é/?¡l_
@~Oflll t-<~ ':7} ¡, >3 t.J
PHONE IF: ,S- '7 - Çhl 7
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Ene.: Copy of sketch or plan showing proposal for your
convenience.
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1.4-t6·4 f2l871- Text 12
I PROJECT I.D, NUMBER
617.21
Appendix C
State Environmental QuaJity Review
SHORTEN~RONMENTALASSESSMENTFORM
For UNLISTED ACTIONS Only
PART I-PROJECT INFORMATION (To be completed by ADplicant or Project sponsor)
APPLICANT I~PONSOR 2. PROJEC7 NAME
,'òtJ SK, I.ef .fi
PROJECT LO ATION:
Municipality '5 0 County L^-
4. PAEC:SE LOCATION (Street address ana road intersections, prominent landmarkS. etc.. oJr provlae map)
31D CttR,()le. 'KOI+-0) 50\A.:t'l1.oID (010 ~i)v€- \Ld ~
SEa
Pd.)
5. IS PROPOSED ACTION:
ØNew 0 Expansion
6. DESCRIBE PROJECT BRIEFLY:
o MOdificatlon/alteratfon
.Je-- t s0- R t'\"?1tf
Iv' 0' .Q.. [-e c..;(-o'1-:e~
.. 0 1.-0"'-'<2-"-
Ivt?O(J"~
4- K Pn'S' e.-
O .., (Lt
.sJ:(~'
ß 1'-"17lC-"'î
wed-...<..A-- .
7. AMOUNT OF LAND AFr-ECTED: '
Initially 1..-t'rJ I V I 8; I aGAeo Ultimately ¡"J ~ '\1"'" i' ~
a. IfJIU,,-FRO?IJSED ACTION CQMPL'f WITH EXISnNG ZONING OA OTHER EXISTING LAND USE ?lE5ïRrC710NS?
.~ Yes 0 No If No. describe brletly
'3. VJHAT IS ?RESENT LAI'"~ù lJSE!N VICINITY OF PROJECT?
~ReSldential [J.!noustriaJ C C.Jmmerclal
Descnbe:
o AgriCUlture
~ Pa:rK/ForesuOoen soace
L..! Other
10. DOES ACTION INVOLVE A P~RMIT APPROVAL OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL.
STATE Oñ LOCAL)?
QYes (2] No If yes. list agency(s) and permit/approvals
.':r
11. DOES ANY A~T OF THE ACTlor~ HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
DYes ).cl No If y'!!s, list agency name and permlt/aoproval
12. AS A RESULT OF OPOSED ACTION WILL .EXISTING PERMITfAPPROVAl rleOUIRE .'v100lFICAïION?
o Yes No
I CEnTIPf THAT 7HE INFORMATION PROVIDED AeOVE IS TRUE 7"0 THE 3ES7 OF MY KNOWLEDGE
Applicant/soon so, name: 7J7.at,(~ t ~Ií/'~ ..)./k~
slgna,u'e:j71(?r~A~ ~~
a o?t: W .?<J rf 1
oale:~
If the action is in the COGS tal Area, and fOU are a state agency, complete the
Coastal Assessment Form before proceeding with this a~~essment
OVE:R
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:nay oe slJcersece<:: ~y ::.nCli:er ,nvClvet] açency.
,-/
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C... Ç;:ULD .~C7¡CN .:l:ESUL7 iN .J.NY ;,Dve:::.SS: ::=~:Z':ïS ASSCC;':'T=~ ·.vlï~ :-:-:: ,:::·JLL:Ÿ'J!:-iG. :AnS"Ners :TIay:.e 'anawrnte!'1..f :eG C ~1
':1. :"':Isting llf -::uarit"(, 3urtaCg or ¥o¡,:nowster cualily :It ::;canuty. ,'OIse ,eve IS. .!xIs:Lng ::-ailic ::aE'erns. :>olia .vas:e JrOCl:c:;:::n or JIs:.::
;Jotenllal fer ~rosron. ::.ralnaçe- or 'loocing JrOClems? ¿'telaLn :!rlelly:
:f ,'~o. 3. _'eq.2.t~ve :~ç:a(:;,
tJD
C2, Aesthetic, 3~(lC:JItU(aJ. 3,(C:1seologlcal, :'IS¡OrlC, .:Ir :)(her "a[:,J(al 'Jr CUllural :esourC2S: or ~~mmun [y :Jr :"Iel~i'lccrnooo c::.arac:er? ::.xolaLn ~,
Nil
....... '/eçerauon or :auna. :I$n. .sr.eIUisn or 'NIIc1life species. 3lgmi;canr ~aCllats, or :hre3[~ned or ;!n<:ançerea :;cec:es? SClam Jr .lIly:
rJ O.
c~. ..\ c~munll'(s eXIsting ;>ia.ns or :~oals as otflq:aHy adootea. -::If a change in use or inten~ilY or use at lana or other natural resoun:es7 =.'tplsm .::r
VI)
C.5. Growth. suoseouent ::evetoomenl. ::Ir relstea ac:zvllles likelY to ":Je Inouceo ':Iy !he :;!(coosea aC:lon? :xolam :metrv.
¡J0
':3. !..ong :erm. .300(, :erm. ::.:muJauve, or tJlher '!rfec:s nOI Icentifieo in C:·,:S? :;:ò:Jl3m :'ICler!'I.
rJ0
...
s[:":'!~ :moac:.3 ,inc:..clnç :::-:anc;es In ~se of ~!ther quantity or :y~e OT =nergy¡? S:JlaLn :::rrerly,
tJJ
--.: Yes
:5 -:-¡..,E?Ë _:!'<2!..':I 7'0 3E. G:::rlï;:¡OVE?S'( ~E!..A7E:J 7'0
~,' o :f ':les. ~:xctaln :)(Ierly
?QTË:,m..:..i.. ":':::;VË.=!SE :::'IVlFìCNME:'I,;'L .,'.:P.\C73?
'J. ,5 ':'"HEiiE. :;:A
'ART III-OETE"MINATICN OF SiGNIFICANC:: \To ~e comoleted ~y ,~genc'l)
[NSíRUCTIONS~ ¡:O( ~3C:1 adverse ~rfec: identified acove, determine wnether it is sucstantial. large, [mcortanr or otherwise siç;:nific
=::ac:1 ~ifec: si10uld ~e assessed in connection wIth Its (a) setting li.e. urban or rural); (b) ;Jrobacility of occ~g: (c duration·
irreversIbility; (e, geogracnic 3coce; ana {f} magnltuoe. If necessary, add attachments or reference supporting materials, ::1sure
eXQlanations c::ntam sutfic:ent JeIa11 !o snow that all :-e!e'lant adverse impacts have been identitieo ana adeqUatelY aCC:ressec.
C:-JaCK ;his box if you have icenriiiea ene or more ;::otenrially large or significant 2.c'¡ersa imoac:s 'Nhic:l ,".1A':
OC:::.Jf. ïnen ~rcce2C direc:ly to ~ne FULL :::AF 3.na/or prepare a posirive- declaraticn.
_ C:-Jecx ~his ':ox ,f you :'ave determined, based on the information and analysis above and any $uooort:..-:c
doc:Jr.1enta[!cn. :hat :l1e :Jrocosea ac:ion WILL ,"JOT result in~(1Y significant adverse anvlrcnment.=1 imcac:::
AND ;>rovlce en 5.r:aC:1r.len(s 3S necessary, {he reasons sup coning this determInation:
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1 ) RJtk-r II f',
(Name of
ACCESS CONSENT FORM
FOR ACCESS
THROUGH PRIVATE PROPERTY
è 'y¡, A12.- ¡ () ft) ~:+ M.ÍL+ " 4/1'2..(5'
Aþplicant) (Address)
~
Print or Type:
Office use
File #:
Permit #:
Only
2 ) \..0 ü .v e..
(Name & Address of Contractor Involved)
3 ) ~ { 0 rt Cùlk-f' 'f2d
(Project Location)
Ç, IJ-v,.:t).. ð iJ
1000-
(S.C. LM. #)
4)
10 D \0 '1'
(Name of Road or Private Property Involved)
(Ham 1 et )
5)
(Name & Address of Homeowners Association / Property Owner)
6)
_e...~1l..-- S'7'+- {;/!.-<"
(Brief ob Description)
Starting Date:
Dr./...)7'
Completion Date:
7)
8)
9)
Estimated Cost of Proposed Work:
Insurance Coverage:
A. The coverage required to be extended to the Property Owner:
Bodily injury & Property Damage;
$300,000/$500,000 Bodi ly Injury & $50,000 Property Damage.
.m .- ?~
Da10 'è.-.
II) f) iLl ~
-
B. Insurance Company:
C. Insurance Agent
Name & Telephone #
D. Po 1 icy # :
E. State whether policy or certification
is on file with the Trustees Office:
(If no, Provide a copy with Application)
~,~
(Signature of Applicant)
(yes/no)
- ftr 1IiJ- 2...+4 I
(Dat e)
------------------------------------------------------------------
To be completed by the Propert~ Owner:
I/We the undersigned, fully understand the nature of the Proposed
Work referenced above and have no objection to allowing the
Applicant to cross My/Our Property to do the work.
läAile.ç c( '}hcu1Æ~ JtÆ¡~
(Signature of the Property Owner
or dul y aut hori zed represent at i ve)
v'
.
.
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
() J A,? ~6Itd
~1.t----------------~~
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
I7~ ·-,Þ4'/.Þ.Æ;;1.(~ residing at 15-9 fiù.-,) r&fÞ,/r f?!
C~DPé ~ £. , k ':1.. !t ~-iÒ
being duly sworn, dep~e a~ð séV:
'¡íW
That on the 1']1 day ofAJIV ,200 l, I p~sonally posted th); rJ
property known as 3 ¡ 0 CA4~.f: b( ("'d::. (fl~ r~,
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 O~he
~ublic hearing. Date of hearing noted thereon to be held ~-I
v-H Ø4 OJ~'7ð~fr1 '
Dated: 1/ /IL (01
'--;27/'Oc-1--rAIX' ~L¿a-/ ../to.--z::;¡-~
(signature)
Sworn to before me this
/2/'> day of 11~ 2001
f'4tL 1/ ~
Notary Public
EDYTHE V, MULLEN ,.
NOTARY PUBLIC, :3[,1\" e\ Ne'''' Yo I<
N). 4P9~19J
QualifiEd Itl :':;'ut'ì~'k counrft.Dð
Comml~sU:'n Explre5 r\1i;ty 26.
~..
...
.
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Name:
Address:
STATE OF NEW YORK
COUNTY OF SUFFOLK
/
'm ~, residing at
/J52j?,~V~~; 'l~;~ be~ duly swor~ d7Poses and says
that on the ~ day of 3/ _ ,'tIt'~, deponent
mailed a true--aopy 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 Uu,1 ~PK.. V.l. - , that
said Notices were mailed to each of saiCípersons ~y (certified)
(regi~~or~g7 mail.
L;?1~
flC-
Sworn t~ore me this d.J.
day of 'he,,~ .J.oO (
Wa~ PUb~
CAROL A, MillER
NOTARY PUBLIC, STATE OF NEW YORK
NO. 01 MI6003086
" QUALIFIED IN SUFFOLK COUNTY
OMMISSION EXPIRES FEBRUARY 23 ¿;¡OO I
'-
... ... .
Board of Trustees Application
County of Suffolk
State of New York
mlÄf.. ~ Df'\ 'S t ~ c.. h -+1 0... e ì S 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 HISIHER KNOWLEDGE AND BELIEF, AND THAT ALL WORK
WILL BE DONE IN THE MANNER SET FORTH IN TillS 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 lRUSTEES, THEIR AGENT(S) OR
REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF TillS APPLICATION.
In~J'~~J~
Signature
SWORN TO BEFORE ME THIS
;) ðl7'd DAY OF OJv0er- ,20~
~¡,a.,ny~
CAROL A. MILLER
NOTARY PUBLIC, STATE OF NEW YORK
NO. 01MI6003086
QUALIFIED IN SUFFOLK COUNTY
COMMISSION EXPIRES FEBRUARY 23. 200 I
.
.. . ' .. .
AttPLtCAN'l'
TRANSACTIONAL DISCLOSURE FOnM
......
.
The Town of Sou~ho1d's Code of Ethics 'rohibi~s cöntlic~s or
nberes~ on the part of bown off cers and employees. The
purpose of this form is to provide information which can
alert the town of possible conf1icbs of inberes~ and allow
ib to take whabevcr acbion is necessary to avoid same.
YOUR NAMB t .t-
Last name, firsb name. m ddle
you are applying in the name of someone else or
other enbity, such 'S a company. If so, indica~e
the other person's or company's name.)
, ",:
NATURE ot APPLICATION! (check all that applY·)
;.; .<~~~~:.: :/,' ¡;:;: :1~!f·' .:-:!:,¿'.
Tax grievance
Variance ~
Change of zone
^p'p~~a1 of plat ,
ExedlpHon from plat or Q,f'ficia1 map
other ~ P<;;fZJltv{
(If "o~her,' name ~he adivity,) (Kr\Thn FoR-.:r-Gl+5k.:[)\JJ~1..f. ¡'!,era:./.....
I
Do you personally (or through your COMpany; spoune, sibling,
parent, or child) have a relationship vi~h any officer or
employee of the 'I.'ovn of Southold7 "Relationship" includes
by blood, ~arriage, or business interes~. "nusiness
interest" Means a business, including a par~nership. in
vhich ~he ~ovn officer or employee has even a partial
ovnership of (or emplöyment by) a corp,oraHon in :vhich
the tovn ofricer or employee ovns more than 5% of the
shares.
, O
YBS
NO '!
. : ..~l! ..
If you ansvered -YBS,", complete the balance Of ~hlB form and
date and sign whsre indicated.
Name of person employed by ~he Town of Sou~hold
Title or position of that person
Describe the relationship be~ween yourself (the applicant)
and the town officer ør employee. Either check the
appropriate line ~) through D) and/or describe in the space
provided.
The town officer or employee 6r his or her spouse, sibling,
parent, or child is (check all ~hat apply).
~) the owner of grea~er than 5% of the shares of the
corporate stock of the app1icånt (when ~he applicant'
is a corporation)1
B) the legal or beneficial owner of any in~erest in a
noncorporate'entity (when ~he applicanb is no~ a
corporation) I
c) an officer; director, par~ner, or emplöyee of the
app1ican~ I or
D) bhe a~tua1 applicant.
, .
,',
. '
..,' .
, ..
....,,';.
DESCRIPTION O¡;' REL^TIONSIIIP
. ".
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. 'i':'~.\.:.~~:·:, r I"',,:¡. ~.'...,(.\:. t."I:.'.Y 'l.{~t,.'1)~~I. .:,.,'-, .·..:.i~'~;'~·,
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