HomeMy WebLinkAboutTR-5480
TERMS and CONDmONS
. ""t..t .'~ '. ...
.-_.J ''''',
1ñe I'ecmittee Paul & Patricia Ahlers
residing at 1905 Gull Pond Lane, Greenport, N. y~ as
part of the coosi.deraûon for the isSuance of the Permit does uøderstaDd and prescribe to the fol-
lowing:
1. That the said Board of Trustees and the Town of Southold are released from any and
aU damages, or claims for damages, of suhs arising direà1y or inditcàfy as a rault of any ope¡:-
aûoo pedo..-l pursuant to this peøuit, and the raid ¡>.-... ¡"'"T wiIJ, at his or her own expease.
defend I11Y and aU suda suits -Wtiated by thhd parties, and the said P: . "1.-4' &5$'- full1åbl1ity
with respect thereto, to the complete exclusion of the Board of Trustees of the Town of s.-~
2. That this Permit is ...ud for a period of ? 4 mos. wbid1 is coosi<I<! ..,d to be the
estimated ûme required to comp1ete the work invol-.ed, but - iIwa1d circmi>sW>ces warraÐt, request
for 111 exteOSÍoo may be made to the Board .t . later dalE.
3. That this Permit should be tetaioed indeíanitely, or as long as the said petmittee wishes
to .....õn..;n the struCt\I<e or project involved, to provide evidence to anyone conceroed that auth-
orization was originally obtained.
4. That the wodc involved will be subject to the inspectioo and approval of the Board or
its agents, and noo-compliance with the ptovisions of the or1ginotJ..g application, may be cause for
rcvocatioo of this Permit by resolutioo of the said Board.
5. That there will be DO unreasonable interference with navigation as · rault of the work
herein authorized.
6. That there oball be no interference with the right of the public to pass and repass along
the beach between high and low water marks.
7. That if future operations of the TowD of Southold require the ftIIlOfti and/or alœraâoos
in the iocatioo of the _do: herein ...II-"M, or if, in the opûùoo of the Board of TrusteeS, the
wodc shall cause unreasonable obsttuct1OO to free navigation, the said Permittee will be required,
upoo. due notice, to remove or alter this _do: or project herein stated without ~~D'" to the Town
of Southold.
8. That the said Board will be notified by the Permittee O( 1he ~ of the work auth-
orized.
9. That the permittee wiU obtain .U other permits and conse<'t< d1at may be required sup-
plemeDtal to this permit which may be subject to revoke upoo failure to obtain woe.
.
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Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poli \\'oda
Peggy A. Dickerson
Town Hall
53095 Route 25
P.O. Box 1179
Southold. New York 11971-0959
Telephone (6311765-1892
Fax 1631.1 765-1366
BOARD OF TOWN TRUSTEES
TO\\TN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
#
0015C
Date 10/29/04
THIS CERTIFIES that the pO/lech, pitUiJ, ,~hed, !.>eecond 6.(00"- ,ldc/,¿t,¿on :to dw~lli'lg,
At 1905 GuU Pond LaJle, G,'lee,¡po,'Lt
Suffolk Couuty Tax Map #
35-4-16
Conforms to the application for a Trustees Permit heretofore filed in this office
Dated
1/3/02 pursuant to which Trustees Permit # 5480
Dated 1/23/02
Was issued, and conforms to all of the requirements and conditions of the applicable
provisions of law. The project for which this certificate is being issued
is it pO.'Lech, paM-a, ~hed, and ,~eeco,¡d-6.(0¡)."- adc/,¿t,¿oH :to dwelling
The certificate is issued to
Pau..C & Pa..tUua Ah£vw
owner of the
aforesaid property.
4I¿..,j f/ ~,(}<
Authorized Signature
Albert J. Krupski, preSident.
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
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Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Faxl631i 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.
INSPECTION SCHEDULE
Pre-construction, hay bale line
1 st day of construction
Y:z constructed
Project complete, compliance inspection. \ () 1)-'6 ¡ Ö ~
OK9()~
+
.
.
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 (6311 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
June 18,2003
Mr. & Mrs. Paul Ahlers
1905 Gull Pond Lane
Greenport, NY 11944
RE: 1905 Gull Pond Lane, Greenport
SCTM#35-4-16
Dear Mr. & Mrs. Ahlers:
The following action was taken by the Southold Town Board of Trustees at their Regular
Meeting held on Wednesday, June 18,2003
RESOLVED, that the Southold Town Board of Trustees APPROVE the Waiver to replace and
relocate the existing pool fence, with the condition that the roof drains on the house are hooked-
up.
This is not an Approval from any other agency.
If you have any questions, please call our office at (631) 765-1892.
Sincerely,
dLk.-f ? ~. 9».
Albert 1. Krupski, Jr.
President, Board of Trustees
AJK:lms
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CllLù...
TelephoDe
(631) 765-1892
Town Hall. 53095 Main Road
P.O. Box 1179
Southold, New York 11971
SOUTHOLD TOWN
CONSERVATION ADVISORY COUNCIL
At the meeting of the Southold Town Conseniation Advisory Council held Monday, June
16, 2003, the following recommendation was made:
Moved by Drew Dillingham, seconded by Bob Ghosio, it was
RESOLVED to recommend APPROVAL of the Waiver Request of PAUL & PATRICIA
AHLERS to replace and relocate the existing pool fence.
Located: 1906 Gull Pond Lane, Greenport. SCTM#35-4-16
Vote of Council: Ayes: All
Motion Carried
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
February I, 2002
Mr. & Mrs. Paul Ahlers
1905 Gull Pond Lane
Greenport,~ 11944
RE: 1905 Gull Pond Lane, Greenport, NY
SCTM#35-4-16
Dear Mr. & Mrs. Ahlers:
The following action was taken by the Board of Town Trustees during a Regular Meeting, held
on January 23, 2002, regarding the above matter.
WHEREAS, PAUL & PATRICIA AHLERS applied to the Southold Town Trustees for a
pennit under the provisions of the Wetland Ordinance of the Town of Southold, application
dated January 3, 2002
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
January 23,2002 at which time all interested persons were given an opportwlity 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 determined that the project as proposed will not affect the health,
safety and general welfare of the people of the town,
.
2
.
NOW THEREFORE BE IT.
RESOLVED, that the Board of Trustees approved the application of Paul & Patricia Ahlers for
a Wetland Permit to relocate tront entrance adding tront porch- tront bay window add 2'x12' bay
window on side of house - reconfigure rear entrance and wooden steps and increase patio area
add 12'x16' shed - reconfigure a portion of existing roof line to accommodate second floor
bedroom add drywells and gutters on creek side 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.
Fee must be paid, if applicable and permit issued within six months ofthe 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,
{l¿¿J? /~ 9v
Albert J. Krupski, Jr.
President, Board of Trustees
AJKlcjc
cc: Building Department
DEC
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TelephoDe
(631) 765-1892
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
SOUTHOLD TOWN
CONSERVATION ADVISORY COUNCIL
At the meeting of the South old Town Conservation Advisory Council held Wednesday,
January 16, 2002, the following recommendation was made:
Moved by Drew Dillingham, seconded by Scott Hilary, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the
Wetland Permit Application of PAUL & PATRICIA AHLERS to relocate front entrance
and adding 8'X 12' front porch, add by window on the front and side of the house,
reconfigure rear entrance and wooden steps and increase patio area. Add 12'X 16'
shed. Reconfigure a portion of the existing roofline to accommodate second-floor
bedroom.
Located: 1905 Gull Pond Lane, Greenport. SCTM#35-4-16
Vote of Council: Ayes: All
Motion Carried
""«:..>
12 ·In··n1 ){O~ H: 16
N'rSD:::::::
._ F.H 6.11 j¡¡,2!05 u;m Y;~E ~COLOGICAL
Ef'.!',.lRG\! p. I S F,:.x . 63.1. ",.ú.JO..::.6CI
NEW YOAK STATE DEPA'1TMENT OF ENVIRONMENTAL CONSERVA TION
De. 2001 !3:~6
P.02
~nn3
DEC PERMIT NUMS;oA
1-4738-02595/00007
FACILITY/PROGRAM NUM8ER(S)
..
PERMIT
Under the EnvIronmental
Conserv:!ltlon Law
EFFECTIVE DATE
DeCQmber 10, zOO,
EXPIRATION DATE(S)
DQCQmbé,. 10, 2004
TYPE:: OF=- PEFl:MIT . Now D Renowsl C1 MOdification .:J Permit to Construct I: PQn'Tlit to Op~re.:.t9
D Ar:¡cle ~5 T,(lg 5' Prmemlol"'l ðf WI'l!crs
c:; Artic:IÐ '17, Tme~ 7, B: SPDES
r;:J Article 27, Titl~ 9: ONYCRR 373
Ha:::!ar(j(')LJs W .JS'~Q M.Qnagemf1l'1t
::: Ar~;çle'~, Title 15 Wat~r SUDPIY
':J Ar. ell:! "ijl' Air FlOIJi.Jtlotl Centrol
o A".¡cl¡;. ~5, TltfQ 15. W.atørTr:;:¡nsport
D ArtiQI, 23. Tlt/. 27: MI/1ðd land
Reclama:io,1
o Article 34: Coastal Eros:jOI~
M«I"'Iagernarlt
o Artic!e15, Title: 1.5: l.ong !sJandWells
o ArtfcJs 15, Title 27 Wild. Sf;a~¡c and
RecrsRtrO/" al fqlvlîlrs
c= Article 24: FreshwBtsr Weflands
o Article 36: FlooClpfBln Managameht
!:J G"IJYC1=:FI 6Of:!: Water Quality C:mtlficatloo
. Artier. 25: Trd.1 W.~.n~
o Article 27, Till. 7; 6NYCRR 360:
o Artie'.", 3. 17. 19. ~7. ~7: 6NYCF<n
380: Radiðt!on Control
SOI (I Waste ManðQemel"1t
PERMIT ISSUED TO TELI?:"HONE NUME!~FI
Paul Ahlers re31J 2ðS-S516
ADDRESS 01' F>ERMITTI;E
133 Sunken Meadow Road, Fort Salonell. NY "768
CONTACT P~R$ON FOR PERMITTED WORK "ïELEPHONE NUMBE~
Land v¡:g Eoolooicl!Il Services. '575 Sound A....enuA. 8e:itiMð Hollow NY 11 733 15311 727-2dOO
NAME AND ADDR~SS OF PROJ~CT/FACIUTY
At'llers Prooertv, 1 gOS Gul: Pond Read. Graanoort
COUNTY TOWN WATE'\COURS¡¡ NYTM COOR::>INATES
E' N:
S..s!folK Southold GUll POl1d
DI!SCRII'TION C.. AUTHORIZED ACTIVITY: Remove portions of an existing aSþha/t driveway, co"struct Itn
8ddltlon to "n ....¡stin9 dwelling, It deck, end e poreh ,AU work is to be don.. in .ccordance with the plan..
stamped NYSDEC APPROVED on 1211012001.
By aGC9plsnoe 01 this permit, the permittee agrees that the permit is contingent upon slrict compliance with the ECL, all
applicable ~gurations. the General Conditions "peellled (see page 2 & 3) and any Specla' CondItIons included as pa,'t
of thiS parmlt.
F'ERM¡'T AOMINf$TFlA. 'rOA·
ADDRE;SS
RegIon 1 HeadqueJ'tørs
Bid . #40 SUNY Sten
~L
Brook. NY 11790-2358
DATE
Mark C Carrare.
AUTHORIZED SIGNATURe
Dl3'cemoer
Page 1 of 4
12/10.'01 ~ON l3~ 28
(T:VRX :-;0 75J7 ~Q02
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NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OJ:._:?OUPIQ.!J'
In the matt~r of applicant:
SC'l'MUOOO-
,.-...)
yOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a
Permit from the Board of Trustees to: . .-
,';'F-{)lf-)U~ ~ ¡.q'::_l,,=\L()'-·è-:. (~(I:'::>T \ r~(~ ('ceL- CF ,~(i:-
~""1 ---. ,',,\.\.-.-'l" ¡,\ Ci"'-; ,..=.¡\. c"L' r '·'l' . -, 'C. "r'~\' ¡::'v¡' .c)lIr-ri--<4
r v "I:::'" 1'\ _ - . '-- - "--- '-- '-...- .- '.J.-/ ,_................" - - I -- . ". \ .
2. That th9 property which is the subject of Environmental .~
.Review is located adjacent to your property -and is describea as
follows: - - '
\q c. S (-:'..' L.t.. ¡::t:t,:O L ftf\2<¿-; c LWEè:---W {'on I )J ''{- I z.'.-¡:3 - 'vc2..
~(C \:\' \ -\ c ç (CI.}11 \'~: r c./\ 0 \-< \.] é l'-~) ~ A., ~ Lc. T \ r,'. F
FC'~Þ H t·,-,·, /', ( K' c:..~
3. That the project which is subject to Environmental Review
.mder Chap':ê'? ~ 2, 37, or 97 0: ~he Town Code is open to pub;.l';
':0!!U1'.ent on: -JUI'H:- /8u?CtEfz may contact the Trustees OHlc"! ê.t
765-1852 ar Ln ~ritlnq.
The ~ove r9~e~~~ced proposal is under review of th¿ Board of
Tr'.lste~S 0;" the TO\m of Sout.hold. and does not reference ~r.}
otaer agen~l that might have to review same proposal.
OWNERS NAMEi9n-K\(I(1 'J- ~ALjL. A_\Acr:-:-r...s
MAIL¡riG ADDRESS: :'-"-j~;>' ('l.'u..~ PO~':/C I -v'1,\'"ç
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':" '_1.:1-· ~., ;. .~- I '"
PHONE :-: (á~ i '-I - '.
Ene.: Copy of sketch or plan showing proposal for'your
convenience.
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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 (63lì 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
JUt( U 2JØ
~
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
---------------------------------------------------------------
In the Matter of the Application
of
Q~\_+__eo..-m_~_~__~~l<!_~_______________
COUNTY OF SUFFOLK)
ST ATE OF NEW YORK)
1l1li
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AFFIDAVIT OF POSTING
/'7',j-'5' 0,/¿C
/-?;~/L.J ,~::~L'"
, residing at
G£f';7/{, /iíKí /II ~4 ð7f:fL
being duly sworn, depose and say: /
That on the
day of
, 200 , I personally posted the property known as
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 U»ð,¡.ll1.l\L \r a,m'2, N\ or tlÍ)a H: 1~<nPf(\.
Dated: ',1.11)12- (s¡2()() 3
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- (sigmrture)
Sworn to before me this
\ ~ day oUtN. 200~
~~~/( ;:~
1<JÔtary Public
SUSAN K TOOKER
NOTARY PUBLIC, State of New York
No. ün050n120
Qualified in Suffolk County
CommisSIOn Expires May /q t 2.00 7
2<. 1T,?4TR/(A Aßk.rS
Gu¿¿ ;:?/!/D ~/1,A/E GR¿-E?O£' /
Alb¡,rt J. K1!ki' Jresi!
James King, Vice-~reSident
Henry Smith
Artie Foster
Ken Poliwoda
.
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BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
_Coastal Erosion Permit Application
~etland Permit Application ~ Major _ Minor
_ W aiver/ Amendment/Changes
...-Received Application 1 /.31 0;)..
~eceived Fee:$ 'S1:)' .
--eompleted Application 1/3pJ-J
_Incomplete
_SEQRA Classification:
Type I~Type II~Unlisted_ :I\i:- ~,
_Coordination:(date sent)
.......CAC Referral Sent 1 L ~ ~
~ate ofInspection: 1/IIð/O ~
_Receipt ofCAC Report:
Lead Agency Determination:
Technical Review:
;1fublic Hearing Held: 1/.}3/0v.
Resolution:
Name of Applicant
Address / 'J 0 5
/f/.y: //9 yfL
.
Town Hall
53095 Route 25
P.O. Box 1179
Southold. New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
o It::. (J (J-J
PhoneNumber:( ) 63/ -<",177- 33 92-
-
Suffolk County Tax Map Number: 1000 - 035"· O,J
o 7': T}:J
Property Location: / 'lof 6¿'¿¿ R,v¿) 4~$
Cf\W'f r:¡ é'f>¡;¡ rr
1'<' AI,;. 0</ n/e /" ¿?,eo/íEIV /
. - - - ,
-if (pruvlde LILCO Pole #, distance to cross streets, and location)
AGENT
(If applicable)
Address:
Phone:
6A:"Æß4/,Po-RT-4/.1 //?~
/1/ /Co4ð
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Board of Trustees Application
GENERAL DATA
Land Area (in square feet):
2/ "l5,:}
Area Zoning: ':(j v 7 I OÐV 71 P¡J--
Previous use of property: .'//I/G/£ /"'?/l.ð7IL 7
Intended use of property: S' / AI C ¿ ¿; .~A.¡n Ii 7
VU/c.-//J,(/6
..£J ¿¿/ e- / // ;(/<5'
Prior permits/approvals for site improvements:
Agency (E n-,é/l/v i>ocJc J
t/s iJl!hy c.o~ps of' E";~/I'Je;eÞ
/
O¡Ç:C (HTEIt/Ò òoc.k )
(E.re"/Vi> '¡:>O<",(I
Bo,JtleD OP !7JWP ?'¡:-V.-nð
Æ~-' I I7QW
£) IE" C- 1f.7?'/11'v~ r"o.e
Date
ij~ /.,J
#i9'ho
f! IoJ
/~oÞ/
_ 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): ~/()C",n: Fie ""vT 4'l//iíf!/lVc.¡;,
A-tlO /100//1/6 (1':6"" >,/Í-o// p,,<:<I;e/T fi,ec /I - Add / ~&,/~q':~¿/
¡Z~ 0 0(/ T' ~/f,,?, ÚhA,/OtJv./ _ /l oJ '" ;z ~ e>d)< /2 trJI ð.ðf' U/ /UO~"'"
o~ SlOE (J'<z #ÐU::J£ - If>e.co/(/,.enó¿¡R.ff ff§/I/I" £/f/TK!f,uCjf'
,4,(,/¿? U/tJ 0,O#",u $ t£;=5 AA/t:> /,vC:I1:E/fSG ?""T/O /1"R£4
Adel' / 'J. / Y /6./ <5" ð.§ è> . ~~ tJV ,1#/6C/.R-E /f ~~;rfo'v t/~
£-y Jj'T//[/& /f'''DÞ- ~nf./.f /0 /f'ccod7 tJc/dTli :2.",uò ,Po-¿oo~ ,.b>¿;,¿J.koo/P
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Board of Trustees Application
WETLANDrrRUSTEE LANDS APPLICA nON DATA
Purpose of the proposed operations: S;AJr-. /.[Ç Oll)§ FlfJ?1J¿j LJ«JÚ/¡AJ¡C;
Area of wetlands on lot: 3, 033
sq uare feet
Percent coverage oflot:_
%
Closest distance between !1earest existing structure and upland
edge ofwetlands:_ _ - _feet
Closest distance between nearest proposed structure and upland
edge of wetlands: SO feet
Does the project involve excavation or filling?
No V Yes
rfyes, how much material will be excavated?
-'5 cubic yards
How much material will be filled?
5
cub i c yards
Depth of which material will be removed or deposited:
3
20
If.ÁA/Þ
feet
Proposed slope throughout the area of operations:
Manner in which material will be removed or deposited:
,J ~Ih Is
/~
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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):
/1/0 /!/ £
.
. .
.
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Board of Trustees Application
COASTAL EROSION APPLICATION DATA
Purposes of proposed activity:
SnUG L E F/f/J?¡L ì j)t:.{jd/ÍI(/r
Are wetlands present within 100 feet of the proposed activity?
No Y Yes
Does the project involve excavation or filling?
No
)(
Yes
¡fYes, how much material will be excavated? S
( cubic yards)
How much material will be filled?
s
(cubic yards)
Manner in which material will be removed or deposited: HA/t/6 S~j/¿¿
/~,TQ
4//let!./ ¡;>,,'<:Rvr..V
Describe the nature and extent of the environmental impacts reasonably anticipated resulting
trom implementation of the project as proposed. (Use attachments if necessary)
/f/o/!/ E
.. .
Board of Trustees
..
Application
.
Couhty of Suffolk
JAN I 5
(
State of New York
~ ~?S" BEING DULY SWORN
DEPOSES AND AFFÍRMS 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 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 CLAlMS 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.
~~
.~¿~--
Signature
SWORN TO BEFORE ME THIS
>.cC
DAY OF
~
) """œ'1
,20 C?2...
ROBERT I. SCOTT. JR.
NOlory Public. Slole of New York
Quolifiod in Suffolk CounlV
No.01SC4725089-
Term Expire. Mey 31, ~o~
.
..
.
..
l'lrPL1~II.N'l'
TRII.NSII.CTIONII.L DISCLOSURE FORM
The Town ol Soubhold's Code of Ethics prohibits contlicts or
interest on the part of town officers and emPlo,Ysis. The
purpose of this form is to provide information wh ch can
alert the town of Possible conflicts of interest and allow
it to take whatevor action is nocessary to avoid same,
tOUR "/\.HRr
.
k::;
Last name, first name, n tal, unless
you are applying in the someone else or
other entity, such ~s a company, If so, indicate
the other person's or company's name,)
NATURE or l'lrPLI~^TIONI (Check al1 that apply.)
. . .,[" .ï':,i;.. ... '."~'
,', .".~~~).; .:"." :~.
Tax grievance
Variance
Change of zone
lI.p.p'ipoval of plat,.
Exemption from plat or official map
other ~ f
(If "Other," name the activity.) R"'//c/Jl1í /¿,,e,¡n,
Do you personally (or through your co~pany, spoune, sibling,
parent, or child) have a relationship vith uny officer or
employee of the Tovn of Southoldl "Relationship" includes
by blood, marriage, or business interest_ "Dusiness
interest" MeanR a busineos, including a partnership, in
vhich the tovn officer or employee has even a partial
ovnership of (or employment by) a corporation in vhich
the tovn officer or employee ovns more than 5% of the
shares.
YES
x
NO
. ..,.
If you ansvered Ø~ES,M complete the balance Of ~hìø 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)
and the town officer or employee. Either check the
appropriate line h) through D) and/or des~ribe in the space
provided.
The town officer or employee or his or her spouss, sibling,
parent, or child is (cheek all that apply).
11.) the owner of greater than 5% of the shares of the
corporate stock of the applicant (when the applicant
is a corporation),
B) the legal or beneficial owner Of any interest in a
noncorporate'entity (when the applicant is not a
corporation) ,
C) an officer, director, partner, or employee of the
applicant, or
D) the actual applicant,
DESCRIPTION O~· RELII.TIONSIIlP
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ADJACeNT PfO.OPéRTY OWNeF/.~'
CD
EUöI:Ne: KESSLER
I 52!; GUL.L. FOND L.A.
6fO.EéNPOfO.T, NY 1\9+4-
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JOHN &If,AIPeR
5!14 MAIN fiT.
NORTH FORT, NY 117"05
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PROF05ED:
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E)('TENDiN6 E)('I~TINó +"&0 DOCK e.y 10 FT., INSTALUI'I6
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