HomeMy WebLinkAboutTR-5861
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.
£",,-"~crcJc....Q.
INSPECTION SCHEDULE
Pre-construction, hay bale line
1st day of construction
Yo constructed
v Project complete, compliance inspection.
.
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TERMS ilßd CONDmONS
The Permittee Carol Santacroce
resI~'" 695 Kerwin Blvd., Greenport N Y
,- . .,.
part of the ~on lor the sa'."(' ! of che Pennit does uøderstaod and prescribe 10 the fol-
Iowiog:
1. That the said Ðoard of Trustees and the Town 01 Soucho1d _ rdeosed from my ød
aU damogt'$, or claims for tfamasa, of AÚØ arisins dúecdy 01: 1ndirecdy as a·~ of ." 01*'
atIoo petformed pwsuant 10 dds permit, and ·the said Petmi_ will, at his or her OWD GJ-IC.
delead my and aU -" lUllS ·'nltl.~ by thIrd(>arde$, and the laid p.. . hœt ...........fuU·1iabIIit1
with respect thereto, to the complete -ncIno of the Board of T_ 01 the Town ol·~
2. That this Petmk is wlid for . -petiod of 24 moa. wbIrh Is ......sidctdI to be the
estimatec1 time· reqUÏRd to com(>lete the work 1n'9Ol...ed, but Ihoald dtI;o..nc......... warraat, ~
for an exϿsIon may be made to che Board ata W. cIaI!I-
3. That this Pemùt should be retained indefinitely. or IS 1008 IS the said I'ctmittee wishes
to m.;ntain tbe structure or project involved, to provide evidence to anyone coaœrned chat anIh-
orIzation was origiaally ok,lned
4. That the wodc 1nwl1led will be subject to the ¡,,~ and approval of the J!oaIIð or
Its agents, and ooo-<OlDplisnœ with the proWions of the Ofi&inatl'lg app ~ may be cause for
œvocaåOll of this Petmit by resolution of the said 8œrd.
S. That there will be no UI>fC8SOII8ble Interfereoœ with aaYÍ l8åOll IS . result of the wed:
beteIn aûthorlzed.
6. That chere shall be no interference with the right of the public to pass and repass aloog
the beacI> between hi&b and low water marks. .
7. That If future operatioos of the Town of Souchold require the œmon1 and/or alteradoas
In the 4oøtloto of the work berein ...~. or If, in the opinion of the Board 01 T1'I1SteeS, che .
wodc shall _ _..-bIe obsttualOtl 10 free aavigmoa, the laid p...nl- will tie .~
upon due GOtiœ, to remove or alter this work or project beteIn stated ~ expeases to the Town
01 Soucho1d.
8. That the said Ðoard will be notified by the ~Ittet 01 the ~ Of the work ....
ori2ed.
9. That the .J'rrJDitœe will obtalo all other permits and conoento Chat may be required sup-
pl"'-''''' to this permit which may he subject to revoke upoo fallure 10 obtalo aame.
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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 (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
February 25, 2004
Ms. Carol Santacroce
695 Kerwin Blvd.
Greenport, NY 11944
RE: 695 KERWIN BLVD., GREENPORT
SCTM#53-3-17 .3
Dear Ms. Santacroce:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday, February 25, 2004 regarding the above matter:
WHEREAS, Joseph Santacroce on behalf of CAROL SANTACROCE 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 January
30,2004,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 February 25, 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
Southold 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 CAROL
SANTACROCE to construct a second-floor addition to the existing one-story residence
and outdoor cellar entrance, with the condition a line of staked hay bales is installed
around the construction area on the seaward side of the house prior to construction and
drywells and gutters are installed to contain the roof run-off.
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 $5.00 per inspection. (See attached schedule.)
Fees: $5.00
Very truly yours,
b~·j 'l ~'0
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/lms
.
.
Telephone
(631) 765-1892
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
CONSERVATION ADVISORY COUNCIL
TOWN OF SOUTHOLD
At the meeting of the Southold Town Conservation Advisory Council held Monday,
February 23, 2004, the following recommendation was made:
Moved by Don Wilder, seconded by William Cook, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH
A CONDITION of the Wetland Permit application of CAROL SANTACROCE to
construct a second-floor addition to the existing one-story residence. Existing footprint
would stay the same with the exception of an outdoor cellar entrance.
Located: 695 Kerwin Blvd., Greenport. SCTM#53-3-17.3
The CAC recommends Approval of the application with the Condition hay bales are
placed down during construction.
Vote of Council: Ayes: All
Motion Carried
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.
.
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
_Coastal Erosion Pennit Application
.....-wetland Pennit Application _ Major ,.- Minor
_ Waiver/Amendnw7~fges
~ceived Application: / OtJ
-.ðeceived Fee:$ JIÎ ~ 1 ~E C E 111 E r\
.......completed Application I J .JO aC¡
_Incomplete
_SEQRA Classification:
Type I_Type ll_Unlisted_ JAM 3 0 2004 ~
- Coordination:( date sent) ft/
~AC Referral Sent: I ~
~ate ofInspection: ~ 0/ Southolcl TowI
_Receipt of CAC Report: Board 01 Trustees
_Lead Agency Determioation:_
_Technical Review: ~/ 4SJ Oi/
......Public Hearing Held:
- Resolution:
Name of Applicant Cc;rð1 Sc;/IfClcroce..
Address c,C;S kerw.'1 Rlvd,
6:Unðort- ¡t,~ y. /1'1'1'1
I
Phone Number:( ) & 31 - 1-/77 - 1033
Suffolk County Tax Map Number: 1000 - OS- 3 - 03 - 017, S
PropertyLocation:L;/c"l'o¡"4¡)~7 67> ke,r..,I,., g vJ. &'....-:l'arT ,;:pJ)
ho.'.e eon"". er:.;' /("",\ Tr""h "n EeL ~ .,Jt!! "t k:i'/:...v,~ l?1"J
(provide LILCO Pole #, distance to cross streets, and location)
AGENT: JClitph Sc;/7f&¡c/Ol. ~
(If applicable)
<,O'J
C\ ~\o\
Address: / t.f s;ò .A Ib r"r ~ .fO'1L.c.1' e
t rN'",od/t ¡f/ F 1/9</'1
.
Phone: (PSi 1./77- /773
.
.
Board of Trustees Application
GENERAL DATA
Land Area (in square feet): 3.2. / '679. 9 'ð
Area Zoning: Rps)f'/7f,c./
Previous use of property: J w ~ If,- / J
Intended use of property: J we 1// ,., 5
Prior permits/approvals for site improvements:
Agencr
S('),;tl-,o J 'foeJr-l
Dat}
0-$1 N
, I
'i/3
_ No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?
~o_ Yes
If yes, provide explanation:
;11/11
Project Description (use attachments if necessary): fro f05f'd see 0'" d
S;loor "J.J,tio,fJ +r:> eXi.d-,nj O"'~ sl-orr rrs;)",,,ce
[x/if.] tootr'" + L-vovla ..r-fc.y -rtrt' sc.-"'~ "'V/'-fi,
exct>,A,,,,... f.ç} 4/1 ov4door C f' ))c.r f> .nf/Ci"'C ~.
.
.
Board of Trustees Application
WETLANDffRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: -Iv (Q.~.rf, v c·t c; SUo.., J Sfu tV 0..,
r
c.-. eX'JI-,"j 0'1" _rf~ry r('$,d" " , ". I ~ Çlvcr -!CJ bc.- vH-d by
hc.-.J;(fð r'O-Ker ;:2~\ ~ loor +.:, !.e "n') b( hf'f .5<>""~ h,J -t-!r.
Area of wetlands on lot: 1 5(. O~ I
,
square feet
Percent coverage oflot: ~ L{. 9 %
Closest distance between nearest existing structure and upland
edge of wetlands: {,..2. ç feet
Closest distance betw,¡:en nearest proposed structure and upland
edge of wetlands: b,;;)· S feet
Does the project involve excavation or filling?
./' No
Yes
If yes, 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):
1"10 eÇ'Ç'ec-f -Iv ~ we-l)c,,,Js. c"J t-,'dcl .-cJPrs 0-\ ft.é fo~-?
.$"/'0</1) (f'.rC/lf ç.'r".... -rz,'I fr"J.('cf.
Ç&; ,., r
1/..(' Q,C) +/'"" + o{ f1.e
-eXcrio'/ fo 0 C/f f;. d ~
(. f'//e;r l"År"-'c"r
s-l-r<Æ"lvrr "t/:// (f-,..c."
~
v'µ.
.
.
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Name: C c.re:> I ..sc./)f-C.C~VL-e
Address: ¿'95:' ke~wl'l1 is/vd.
b (U/lf'" t- A,/. y. 1/'7 '1'1
,
ST ATE OF NEW YORK
COUNTY OF SUFFOLK
Cc.rol ~^ic.cïoce : residing at h9.> ken.v;" BI",J. b(u",..,r1
;Vf..... Yo, k: . being duly sworn, deposes and says that on the f
day of , 20E1.. 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 rg1.l oftþç T0wr- of South old; that said Notices were mailed at the United States Post
~_ )DC/~O I d ,that said Notices were mailed to each of said persons by
~ (registered) mail.
'<... - Ç~I
""Cù,.~,- . -t.A. ~.r)f)1' ,"-
_LOUIS[ SAllTACROC£ .
_~r1:'M
..... it MIll CMIr
r " ÐIInI..... ZD, ZOQþ
.
.
Board of Trustees Application
County of Suffolk
State of New York
Cere I Sc;l"!tc.crocC 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 lllSIHER KNOWLEDGE AND BELIEF, AND THAT ALL WORK
WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY
BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT
AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES
HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING
UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR
REPRESENT A TIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
('
--) 1· -7
001 <, c.( ""-,,,I 1-~.., o~
Sig ture
SWORN TO BEFORE ME Tlllsd fM
DAY c:fu/()tJ{ i
,20 r/(/
tZ.
_UIUISf SANTACROCE
_ NIle. Stall 01 New York
II. OISA6051325
......111 SuIfoi County ...4
t IIIIR fJpim NMmIIer 20, 20~
.
.
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
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
---------------------------------------------------------------
In the Matter of the Application
of
--.-~~J___~~~~_r_C2~~____________________
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
I,_(£Am\ SJ\\\e..('f(:L~ ,residing at t:Ji'"\ 'her-W\(\ ~\\Jà.
G\"eP f\£Of-\) ~ l W{l\ ~
being duly sw m, depose and say:
That on the 'i day of ç:~ ' 200'1, I personally posted the property known as
r:oqs KeJ'W\(\ \?:¡\Ij~! G~et>.J)IX'i'"t--J tù,f, lIC,lt'l
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 1J.J(1¿. feb. ~ ¡Io, d(Xj.,¡~ Q('\ ur
ab w.+ f)'.DO \" In ,
Dated:
L·~ ~C"\ .{Jo rr:¡lhe rCAJ--
(signatur~) ,
,,~wom to befpr~R1e thi. 's
¿¡day off"lfW200-¡
J
1/ -'.
//1//
~ " .
..:-~ SANTACROCE
SIIIIt 0/ New Yolk
.Jt:JSA6051325
. '. -:.s:a~m2b
~EF: ~o'.~,~~
,
Soulhold Town
Board of TrU'iteps
.ard of Trustees APPlicati.
AUTHORIZATION
(where the applicant is not the owner)
.'-
I,
Caro I Sc. '" fc,C/o( e
(print owner of property)
residing at bC;S' ker,-"... f> Ivd.
(mailing address)
(, rU"'l"of t . NY /)9 c.¡ '-/
I '
do hereby authorize JoJ("p t.J
,
Sc;/1 f.Or C/Of('
(Agent)
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
y (~J\ ~i D ~/I\~(J tc.L
.Own r'~ signature)
8
.
.
617.21
Appendix C
State Environmental Quality Review
SHORTEN~RONMENTALASSESSMENTFORM
For UNLISTED ACTIONS Only
PART I-PROJECT INFORMATION (To be com pie red by Applicant or Project sponsor)
1. APPLICANT ISPONSOA K2. PROJEC7 ~AME
...}o.s(" h Sc..., c;.c~q S<"co...,J5.fvr
3. PROJEC LOCATI: foC¡S"
Municipality (j,hQ;yto>, ('R,..., 0' County 5(/
4. PAEC:SE LOCATION (Street address and oad in ersections. prominent lanc1marl($. e[c., or provlae map)
be¡s kert.v;", "is/vð. 0rt''''",oort /VI' 11"1'/,/, :; i:1..R hOUJ(, c,ç~f"r f!,,;/ Rc.c.iJ1rGc/çr
0,..., -¡--/-or ée.>f SJJ( 0+ kpro./'" Rivd,
1-4-t6-4 {2IB7}- Text 12
I PROJECT I.D. NUMBER
SEa
AÛI,·,,/!
k
5. IS PROPOSED ACTION:
o New ~panSion 0 Moaificationlalteration
6. DESCRIBE PROJECT BRIEFlV: rrOf0.$'-"í .+v CO/1>+r...c~ ,Co seco"à S+,,,y, f-v 4/)
e.;r,r/'''5 O/l~ slo.'y ,t'fTJe,'".-c, The: Çbof p",,-f '-</ovJó sIc-I" fi-é _fc;....,.:
Lv..·f-I. e"C'í"'""D~ -I-b t;." ov-l!;Jðf' C·",'/or t"',d;,,~(C",
7. AMOUNT OF UNO AF¡::ECTEO:
rnilially t') acres Ultimatelv ð acres
d. Vltl!.. ;:::!=IO?OSEù ..4CTION CCMPl':' 'NITH EXISÏlNG ZONING OR OTHER qlSTrNG LAND USë; ::IES7RIC710NS" \
eV,s [3";;0 ""o.d,scnb'bn,fly .:2 fc;~;lr t7....~lli~'i. IJrplooruse fð,J-,,,,,J.r"'/t!C!
rn()fí.{'f', ~..,ð Floo; V)'"J I0r Ì1u .>e>.., ......f!. hI, ~~:7' ;ok/o-t LJ pp,:ro'l[
to I,ve ,,, ho,,"C
.>r
9. v~~ ?RE.3ENT LANO LJ::¡: IN VICINITY OF ¡:IROJECT? o AgricUlture - L?OttJer
L...... iìeSldenlial [J.!ncustrlal C CvmmerClal ~ Pan</ForestlOoen $cace
DescrIbe: Th 't! f<.., 0 c.J.j·c.<......f 10 f-, crt' r~,;cJ,.",t, "'/, Ik~c,'r krr'-u" ~Ivd. to
¡..t,( /V~ -f!., aÇ' -f{.~ tea;) ~oc-<I "'/Cc~$ "5 Z..ro,,;' I;j hf b"5;""'i"'JJ
10. DOES , "CTrON INVOLVE A PERMIT , "PPAOVAL OR FUNDING. ,~OW OR ULTIMAiELY FROM ANY OTHER GOVERNMENTAL AGENCY (F::DERAL.
STATE Crt lOCAL)?
OVes ONo If yes. list agency(sJ and permit/aporovals
..~
11. DOES ANY A~T OF THE ACTlOl-1 HAVE A CURRENTLY VAUO PERMIT OR APPROVAL?
o Yes No If yes. Jisl aQel"lcy name and permlllapproval ,
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL rlEOUIRE .'-10QIFICAdCN?
DYes ONo F/.A .n
I CEr;TIFY THAT THE INFORMATION PROVIDED M~OVE IS TRUE -:-0 THE 3ESï OF MY KNCWl'::CGE
),opl!C;1nllsoonsor 'lame: JO$",,øi, Sc,/r+c,c,oc ~ D.He: J,;J -3/- 03
-<7 ., f., /J~ /
Signature: -
~
If the action is in the Co""tal Area, and IOU are a state agency, complete the
Coastal Assessment Form before proceeding with this a~~essment
OVER
"'':¡-II -""I~O'''1~''-~.S-::::-'1-'I-' -.J....p ~"""'-""'e'e"" ""J ,....o::o...c.
,...... J _=,:''J i\ L~I~ __:il.... ....J I::_.,:)IIC:: L""~ ,~....¡"~, . ~...., .....'::t-.,
.... JOE5 AC7:C;\I ::::":Ç..?'::::J :"NY . I';S. :-¡"::;E3~OLJ 'N oj .' ':'C;:::r::. .~':'ñ.ï 5:ì.:;:'
.-, ï
. ':'.-!S ~ . .'10
:1 (es. :::Jcromata :,"'Ie r!!\fJ~W :rIJC~S.s anCl 'Jsa :/'1e :='.JL_ ::"A;:'
=. 'NIL!.. .:..C7:CN .~E·::::V= :::CROINA'ë.J .=fE'IrEW AS ?RC'JIOE:J ':,=1 UNL:ST2:J ~S7iCNS iN j ;"'¡YÇ2A. ~o1.R7 ., i ;",5-:'
:TIay :>e suoersecec :.y ~nc(:':er :nvOI\lea açency.
:1 .·~o, 3. "eqJ.t:ve :::~C:3.f~
L.: y~s
i.........: No
C. C::ULD ":'C7iCN .~E5UL:- :N ANY AQVe;;:SE =':=:=:::':75 ASSCC:':' ï2J '.VIiI-! :-:-:e .=·JL~":Y'J!NG; :).ns.....ers ."<ly :e 'anawrme~. .f :eçlClet
C1. :..'usnng 3,lr ~ualit" :>urtac2 or -Jrounawarer ::ualily 'Jt :::t:anuty. .10158 ie'/elS. =xls:¡nq ::-ailic ;;1ac:erns. 30liO ,vasie :JrCCl.:c::~n Jr Jls.::c
;)Olenual rcr .UOSlon, ::ralnage or :IOOClOq Jroclems? -¿'(clam Jr1etly:
Cz. A¿S!heUc, agrzc:Jltural. :!rc:1aeOlogIC.11. :-Hsionc. ::Jr ::lIner ,1.J.[:.Hal Jr cUltural ,'esourc::!s: Jr ':;:1mmumty :]r ,1el!;;1ccrnood. .:::arac:er? ::.xclaln _,
C:. '/eçela!lon or :auna. :Isn. 3nellflsn or 'Nllcllira s~ec¡es, '>Iqmiicant :'Iacitars. ::Ir :nre3tene<! or ~ncançerea :;cec:es? :.xclaln Jriarl'f:
C..:. A .:~mmunll'l'S existing ;Hans or ;oals as otUc:ally ad.oeted. or a cnange in use or intensity or use at !and. or other natural resourC8s? Explain :.
c.::. Growln. suoseouent ::evelooment. oJr relatea ac::v¡tles likelY ~o Je ,nd.ucea Jy !ne :rccasea aC:lon? :..'(;:Ilam one/Iv.
':5. '~cng :erm, 3nort :¿rm. .::,¡mUJallve, ,::Jr 'Jlner ~Ifec:s not ,cent f;ea in C:·'::S? ::"'(;:113In :JnerJ'/.
:U':e~ .moac:s '¡nc:...¡c¡nç =:-:aO(;e5 In 'Jse of ~:tner quantHy ,Jr :yç.e or ~nerçy 7 =-'(.:::lIâlh :;rI811'{,
::i. .5 ""i!::::1E. :R:S -¡"'E?Ë _:K'=:.::':-O 5E. ':~NÎ;:¡ovE.:; S·( ~Ë:...AÎê~:-O ?DT::-lît;"L ,..:.8VC:?Së: :NVrRON,'AE~ ï;'L ..',iP~C737
_';'es
~
_.~ o
t ':'!!s. ~XCla n ::Inerty
?AR7 III-OETERMINAïION OF SiGNIFICANCE lïo oe comOleted by Agency)
INS7rtUCi¡ONS: For ~3e:1 adverse ~rfec: identlfiea accve. determine 'Nnetner it is suOstantial. large, imcartam or attlerwise signific
::3ch ~ifec~ silould be assessed in connection wilh Its fa) setting (i.~. urean or rural); (t:) ¡JrobaeiHty at oc::~-wg; (e duration
irre'/erslbllity; (el geogracnic ;:;coce: ano (F) maqOltuae. It necessary, add attac!1ments or reference supporring materials. ::1surF:!
~XClanaIlcns ccnlam sufficient ðetall to snow that all ...e!e'lant adverse impacts have been identified ana adec:uatelY aC:C::ressec.
C;'eCK ;his oox if 'fOU ;'ave idemifiea ene or iT10re ;)otemially !arçe ar significant 2C'¡erS~ jmaac:s whic:1 ,'.fA·.
OC::.Jr. ïhen :JrcceSd airec:Jy to ~he FUL!- =.-\F 3.na/or prepare a positive- ceclararicn.
- C:'ec~< ~his ~ox :f '{ou :lave de!ermjned, based on the information and analysis a.bove and any suaaort¡~(
c'oc:Jmenra[ICn, :n2i: :r.e 'Jroaosea ac~ion ',"./IL!.. ~lOT result in~ny significant adverse ~nvlrcnrr:enral imcac::
AND JrOVIGe en :i;:i:ac:1ri1ents 3S necessary, the ...easons supconing ([115 determination:
.......,~ II ~".uJ ",,,~"c'l
-'"nl.JI _1,:0: '\:..rn.. J o(~·,ccn\,olt:' ~lIlc~r n ."..0 ...~.:ncl
;'IIt:' 01 -<I.·,oon~,o t:' ,jlllcer
,,,;nJn':l~ H {11'\con\.Q,~ ·.2':".:>r ,n ~~.iO ..."",ncv
)'o,:n..:,..,,,, JI r'.·..:).Ho:r :rr ..:,1:11"",,,,( :rom '",~con\'OI~ Jrl,eln
J..II;'
o
.
.
.
APPLICANT/AGENTIREPRESENTA TIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of South old's Code of Ethics orohibits conflicts of interest on the Dart of town officers and emDlovees. The Dumose of
this form is to Drovide information which can alert the town of DOssible conflicts of interest and anow it to take whatever action is
necessary to avoid same.
YOUR NAME: 5"\ J.c.c:''''é'r ,,1..íq'0 Æ. / S&,,, fcc/v'" 6,ð/ <).
(Last name, first name, middle initÍal, unless you are applying in the name of
someone else or other entity, such as a company. If so, indicate the other
person's or company's name.)
... NAME OF APPLICATION: (Check all that apply.)
Tax grievance
Variance
Change of Zone
Approval of plat
Exemption from plat or official map
Other
(If "Other", name the actIvity.)
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
If you answered "YES", complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of South old
Title or position of that person
Describe the relationship between yourself (the applicant/agent/representative) and the town officer or employee. Either check
the appropriate line A) through D) andlor 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 applicant
(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 ~ of þ.,..c e... b u' 200-2
Signature /\~ ,.,:..(,. _
Print Name ,Jõ~~...", h c:::..-.., f-c;u_ ,.u (,.
-
TC'
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