Loading...
HomeMy WebLinkAboutTR-5532 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 May 23,2002 Mr. Russ Meyer 6815 Soundview Ave. Southold, NY 11971 RE: 6815 Soundview Ave., Southold SCTM#59-6-1 Permit #5532 Dear Mr. Meyer The Board of Trustees reviewed your request to Amend Permit #5532 to set the second-story addition back landward 1 Y:z'. The Trustees hereby Approve the Amendment to Permit #5532 for the requested change. If you have any questions, please don't hesitate to call our office. Very truly yours, (}:¿L-I 9. /4.~' ~ Albert J. Krupski, Jr. President, Board of Trustees AJK:lms . . TERMS and CONDITIONS Russ Mey~r Tho Pem>ittee .... 6815 Sound view Ave., Southold N Y 1'C$"'.~at . .,as part' of the coasideratioo for the i""·~ of die Permit docs updentaDd aad prescribe to the foJ- 1owiøg: 1. That the said Board oi Trustees ..,.¡ the Towa oi Southold are released &om IJJ'f aad all cJama&es, Ðr claims foe cJama&es, of suits arisiog cIi1'eá1y ot incIiI:eedy as a ~ of IJJ'f oper- atioo pedom>ed piøWlt to chis pesmit, aad die said p.o.. J·t". will, at his Ðr her own apeP"". defCnd IJJ'f aDd all sUch "IS·I..IH..-I by chhd pardcs, aad the said .... . 1/1- --- taU JidIiUq with reSpect thereto, to the ~ete·exdusioa. of die Board oi Trasues oi die Town oi ~ 2. That this Permit Is' wUd f« . period of 24 mos..r.kh Is coasi>te{C~ to be the estimated üme' required to coiDpIete the ...me Ù1~I1'ed, but ibou1d CÍfàIIå5tIØCCS warøar, ~ for an exœasioø may be mode to the Board at a later daœ. 3. That this Permit sbould be retained inde£mirely. or as loog as die said r.....Juee wisbCs 10 m.;....;n the sauaure or project Ù1VoJved, to provide erideace to ...,.ooe .....ca""'¡ m.t IIJIb. orization was origiøaIly obuioed. 4. That die wodt/molved will be subject to the Ù1~ ud approval of the Board DC its agents, aad noo-œmpliaoœ with. die ptOVÍ5iODS of the origi"''¡'1g app1icaûoo, may be cause fot revocation of this Permit by resolution of die said Board. s. That there will be no _sooable Ù1terfereøœ with oavigatioo as a ~ of the wod< hereÙ1 .ùtborized. . 6. That there sball be 00 iøterfereoce with the right of the public to pass aad repas eloog the beach between high aad low _ter marks. ' 7. That if ,future operatioas of the Town of Souchøld reqaire die reII10ftl and/ot a1œradoas Ù1 the 1ocac/oø. of the wodt hereIø ..tJ-I>--\ or if. Ù1 the opiaioa oi the Board oi TrusteeS, die. work sball causeunmt"....¡,Je obsttuCÞOO to free naviguioa. the said p.-;.- will be rec¡aIæd, apoo due .oodœ, to remove or, alter chis wodt or project hereÙ1ltated wicbouc e...pe1lSf. to the Town of Souehold. 8. That the said Board will be notified by the Permittee ot die ccmp1edoo, oi die work IIJIb. orized. 9. That the Permittee win obtain all other petmia aad ___Ii mat may be required lap- pJemental 10 dais permit which may be subject to revoke upoo fallure to obcaÙ1 -. _____~IM\......IIM\..........."""'~oM\...Ø\-~~oWft~Mn~~"'!"''''''~- .. ...... "."." .". "." ...0..... '." .".,. "." "..-' .-. ,..... " " Albert J, Krupski, President . James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson . Town Hall 53095 Route 25 P,Q. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-189'2 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Apri126,2002 Mr. Russ Meyer 6815 Soundview Ave. Southo1d, NY 11971 RE: 6815 Soundview Ave., Southold SCTM#59-6-1 Dear Mr. Meyer: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, April 24, 2002 regarding the above matter: WHEREAS, RUSS MEYER applied to the Southold Town Trustees for a permit under the provisions ofthe Wetland Ordinance ofthe Town of South old, application dated March 18, 2002, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for lheir findings and recommendations, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on April 24, 2002, 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, 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 approve the application of RUSS MEYER to add a second floor to the existing residence, first and second floor decks and covered porch, with the condition that a row of staked hay bales be placed in front of the existing silt fence and that roof gutters and down spouts with drywells to catch the run-off be installed. 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 oflhis notification. Two inspections are required and the Trustees are to be notified upon completion of said project. Fees: None Very truly yours, t2:.1. I.-I r1 /&.._~. Co, , , '" Albert J. Krupski, Jr. President, Board of Trustees AJK/lms . . llMi.a. Telephone (631) 765-1892 Town Hall. 53095 Main Road P.O. Box 1179 Soutbold. New York 11971 . SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Thursday, April 18, 2002, the following recommendation was made: RUSS MEYER to add a second floor to the existing residence, first and second floor decks and covered porch. Located: 6815 Soundview Ave., Southold. SCTM#59-6-1 The CAC did not make an inspection, therefore no recommendation was made. ~ I , I I :.J t : t: . I I ! I en -I !i ~ ~ en " o CD ~ . <:> ~ g ;;;! ~ ", i i i i ~ ~I+; 9i~ dt ~~j. ~ili iij"'f u!' e '-'-i' l' , sfW! · "ilj Ihll !!~ II) ,hill! l;jj1' M.!!I iiiil u i ~ ~ iill! ii ill I " " , a!!i,lJ I"" , IIIIII J I Jill ~ 11111 1 111"1 d. nq 1I1li ~ ~ ~:3. i ~ 0r-1 ¡ n- E-.i ~ ;t: ~ c;~ 8- -. ...... ..... e..; I g 0 ~ ~ ~ ~::;:¡ >;'~,II ~ ~ ~e-;O~ 1-r-:t\I :>.. ~&)~~..C\li\i ~~~~:;j~~~~ ~fJj VJ 00 g~ :::>Oe-..~t..>_ &)~~)It~ ~ ~O ~ ~ :::> &) 109 ·to ;~ /'¡ ø<4 ,,!f / /' c:o I ,....::J q~"77[1'1 - .;J/[J/IV ,OO'(h, I 1'1 .. ¿ IIÙ\ þ. ~lt Ò~\~\ 1*" ø .R\ q~\~ ~ 'f{ ,P, Ê.'Ir~ ,0' (¡ Q' 0' (jç $).r c. ,/ ,"<~., ' " ' 'V. 1i\ Ç;) ~ 11\91 ...... :."') .......- ~.:..J Co ~ V) C..~ W a:: > I- 00 a=:: 0 Q.. a:: Q.. « « 0 <Q , s 0 -I 0 :I: I- r-! ::) 0 0 V) ---. u.. :r- 0 "I Z $ :)- 0 W l- I-- « 0 " " (J', " ~ co I ~ '" \Û \0 " 0'> " " " d ~ f') 4: \Û ~ U .>< ..... U<I: ..J Q"- VI ~ CoNIC rY p£ surFO~K ~pARK ~ ~ I C) C) f-~ L..J" WC!' a,,~, f- ~ VI ~ a,,>- "'(1\L..J<: C)..J O'>L..J :> ' ><<1:"" \OOa"..J """'f-~ f- ~. . C) ::¡ u¡:;:;of')o L..J\O, Q ~'" Q" " '. ~ ~ Q >- ;:~~ z <[ >,." CJ lJ).. . ~~ >~ ~' ;~:' -.~ ~-;i ~~f\J~~ :> -- Q(l&.J~~Q ,"-- '~~l..I ,:/,q;;;,--,,,,,,,, "- VI V1V"').~1.u :r"'2ì":t'~ I-~~Q!l¿j U'>-Vlq ~ .... .:t" "'""lw 3\1\ :tl:: Zwcv..,-_ !2:>'~1'<k~ I- Io-'-q ë;~~Q:~~ Qt---_a Q <r '"--"'"'-V'l.q: l..u W CkOWQ_W tJO'-V)~&~ .<::: t;;) a::: .q (J =:. OC\Jk!> ~ ""'''Q IX '.: -.. L..J CJ ~ ....."'-V1(k ..... ~~<:[<[QV1 1--1-- I--:z. ~w --I'--J~O Vi q:~L...JL..JqCJ >-- uCy'-:r: 2L...X:~~::s <r r] l<J ,. ~ ~ ~ \ Q ~ o tI1 '" .. -1: !:' <t . ;¡, .t < :Ii: " .... .... ~ . . \) In '" - ~ () \; . ~ > ~ ~ } \C. \('\ ..... 2: ~ ~~ o~ ~Q II II .. . Albe.rt J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application ,... Wetland Permit Application / Major _Waiver! Amendment/Changes ...£::Received Applicat'· 0 ~ ......-Received Fee:$ Âompleted Application~ _Incomplete _SEQRA Classification: Type I_Type II_Unlisled_ _c.oordination:(date ~ /CAC Referral Sent: A>ate ofInspection: I _Receipt ofCAC Report: _Lead Agency Determination: Technical Review: .....Public Hearing He~)..J Resolution: Minor MAK I C\ . Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 (}.JJJ:L u'\~fQ.<Zlo.&, Name of Applicant R. O..S.s Address G g / s- fJ... e...':::J c..r S a ù N D 1.J4C..W CL (5/1, . ~40 ,C//lq) ;1-vc... 1I?71 -- S'öut&IX /lJ,,¡ PhoneNumber() G~/- 7¡(J . 'JO,?J Suffolk County Tax Map Number: 1000 - S c¡ - 0 If' -0 I Property Location: S..t'H."'- (provide LILCO Pole #, distance to cross streets, and location) AGENT HCff-r Hc>~ ~~c5&e.¡'~. (If applicable) Address: ~ J:Þ (\.'f !!p,f>"" Phone: q 5 f - 8100 . . Board of Trustees Application GENERAL DATA Land Area (in square feet): ;u j 000 - Area Zoning: Previous use of property: SII-X,k- tA-n.'':! S, "-'1~ ~,~. Intended use of property: 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? -L No_ Yes If yes, provide explanation: -t:l ó>Jr' 12> 'f3 )t;{(,h~1 t<. "" II ~u.... 4VD ¡ Tv¡ ),,,,;¿ -ro :{:.Nc---<-<,"<- Project Description (use attachments if necessary): L¡ u,,,,, s,,~ - . . Board of Trustees Application WETLANDrrRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Ca",,,~r,-.:hc-,...) / )//9- 510.'7 I)fJD rhw . t Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing slructure and upland edge of wetlands: 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 excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout lhe 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): · . Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: C ó N~JfóJ-o- It, SIfV'jk.... f.q-,../'{ ~f.þt9-- 12//£ }h,I'~. Are wetlands present within 100 feet of the proposed activity? No ...( Yes Does the project involve excavation or filling? ---LNoL Yes If Yes, how muJh material will be excavated? (cubic yards) How much material will be filled? (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting rrom implementation of the project as proposed. (Use attachments if necessary) /771/j",??-11 ¿ cY1')/'" c...¿),~ Oc.Jf/2./ j Iö f3L C / a. n/.. ~L->r "-f D..,,/7 c..-vd- /.,......, µÐ J ~,..,.e c.v¡// N:.J t- of' {.,..ytr po lJ'tG¡ S ( PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: co ["- IT" Ul Postmark H". ,3 <l5 50 U NJit-....., 4 Uo ( $'0 u+~o /& tV 1 11'11 71~5' S'o(JJi'lvj ,"<<if/v-n Soufkold vr 1I'!7! 706S {o U 4d V i-ev fl- s;: LJ 1/ . (;7"/ OU/i(o./d W 7 /I<r? / .2 ~q5 Lri KE jJ1--- 5604 Id ( po ~oX Z.{Lf. P _." ,tv"( II C(7 ( 'I tea,,-! C'~ :4} Ll7 Lvt/<',,- PYf Sou1~c>{cllJ./'f, /1'77 ( eO Boy 5J(j ru CI CI CI ,.." l:3 ,r- CI ,.." Ul ru Sent To h'h'h'h,m ",< J1t t: I'Z.. ~~'B~t:~~;.--.u7l> -;;-~_m---0---_m-r--------__h__________h________ .CiiY.-Sfa"fe:Z1P+4-----------h-'::':Y-n----~~_~_t!.~I._~~__!1v-( 1Ji.- ha V ~ )/q i'innnmn 102 STATE OF NEW YORK COUNTY OF SUFFOLK 9--.v<5d I w V\t\ t''i fl-- , residing at , S. v/euJ vc--- S (J tv II , being duly sworn, deposes and says that on the'S f day of FE (~f(v RIL'--f , ~-2.<lO~ 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 Southoldj that sai~ Not~ces were mailed at the United States Post Office at ${)~\~ , that said Notices were mailed to each of said persons by (certified) (registered) mail. t;::::dI vJ 7; Sworn to bej:c re me this 2-5 day of Feb ,-H aood" Jt~/\/fG ~ ~ Notary Public SUSAN K TOOKER NOTARY PUBliC, State of New Yorl< No.O',T0507e120 Qualified in Suffolk Coun~ Commission Expires May I '7,7.002> 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I-PROJECT INFORMATION (To be complered by Applicant or Project sponsor) 11. ÀPPUCANT 'SPONSOR 1 '·~6·4 12I87)-'I!XI 12 I PÀOJECT I.D. NUMSEi1 . . SEa I 2. PROJEC7 NAME MunIcipality 4. PAEC:SE LOCATION (Stree( aadress ana road Intersections, prominent lanomarKS. -etc., ';¡f ,:Irovloe maD! J. PROJECT LOCATION: S \.9- County S~ ¡::-. (;¡¡F S O-Y'R. uce<-' ~ . 5. IS PROPOSED ACTION: o New Expansion 0 MOClificationl3Heration 6. DESCRISE PROJECT BRIEFLY, -4/JD 7o-.f f'l_ .¡., (;:..,Ø/,? S/..,4'£' ,....,~...-4 ~. 7. AMOUNT OF UNO AF¡::eCTED: Initially C acres Ultimatelv ð acres 3. 'JILL ;=RO?0SED ACTION COMPLY WITH EXIST!NG Z.ONING OR OTHER EXISTING ~ND USE :=IES7AIC7IGN$? ~ Yes U No It No, describe brtetry 9. 'IJHAT IS ?AESENT LAt~O !j~¡: IN VICINITY OF ?ROJECT? 2r! Residential CJ.!naustrlaJ C Cwmmerclõt lJesc~lbe: L.1 Agriculture -..J Parw./ForesuOoen space .- L..; Otner 10. DOES A.CTlON INVOLVE A PC:AMIT APPROVAL 'JR FUNDING. ,~OW OR ULlIMATEL'f FR.OM ANY OTHER GOVERNMEN7AL AGENCY (F::iJERAL. STATE Gn LOCAL)? ¡j(] Yes 0 No 1òw¡..J If yes. list açency(s) ana permit/approvals ¡JU1-'íÎ. ø;":I.9.?~ -r 11. DOES ANY ASPECT OF THE ACTlOH HAVE A CURRENTLY VALID PERMIT OR APPt:!QVAL? o Yes ~ No If Y~s. list age/"lcy name and permit/approval 12. AS A RESULT OF PFlOPQSED ACTION WilL S<I$TlNG ?EiìMIT!APPRovAL ¡:¡EOUIRE .'v10DIF!C.=..7ICN? DYes ONe I Ce¡:¡TIFY THAT THE !NFORMAT!ON pqOVIDEIJ AeOVE IS TAUE -:-0 THE 3E57 OF MY KNOWL=DGE Applicant/sponsor D.1Ie: 2h)~?..... ( L k Slgnalure: '74 If the action is in the Co"stal Area. and IOU are a state agency. complete the CoastaJ Assessment Form beiora proceeding with this a~~essment OVSR PArtT 11_~N'J!RC~IME;'Jï")" 'S..a"~'I- - ~Hc:.I,,) ':::~ r::Jr."'.::i¿~eC ::y .l.çe~c --- _,. :::CE5 .\.C:';C.\I ::'.~C:=:~:: :':-"'f . ...;r::. :'¡"'::;E3~GL.J:N oj :,,:,:;=¡:::. .:I:.'::.ï oj·ì.:;:~ :1 ï~S, :~cral!"a!'3 ::1ð '~YI~'o'I :roces:! ana 'J:5a ~r:e =:":L;.. ::')lr- :'~S ¡-.'O ::. 'N¡L~ ..:..C7"iCN :1E'::::':"= :::CP.CIN':', c;::J =1E··f!E'N..:..S ?¡::,C'JIGED =.:;::;. U~ L.ST~;) .:.:::7iCNS;:-.I oj ,\ '(Ç::.R. :J.\.¡::;. .", ~, :nay :,e sucersecec ::.y ...ncl:-:er ,nvalVee açenc'f. ,I ·~o. 3. lo!';.î!:·¡e -:~c:.?fõ. , Y'!S '0 c. Ç::ULO .;C7;CN ~E.sUL7 ~ .:.NY .\.C'IE;:;S¡: ::':=:=~·:;7S ..1..S.s':C:.:..T=;) .v17:.! -:-::' .='JL~":;\N!N:G: :,.:I.ngwers "ay:e lancwru:e'1. f ;eçlclet ':1. =-~¡stlng 3.lt -::uall['{, 5urrac::! Jr Jrocnawacer :ual,ry Jr :::canrlty, 'Olse .e'ip.ts. ~x:s:lng :~¡;¡;fic :ac:ef!1s. ~olie ....as;e jrcccc::::n Jr Jls.::: ;)Ofennal fcr ~ros¡on. ::::ramaçe or ·tOOOInQ Jroclems? =-'\01.11" ::>nefly: C::' Aestne\lc. 1ÇrzC:.Htural. 3.rC:1aeoloqlc3.l. :'!ls:onc. :Jr Jtner lat:./ral Jr C:.llfUt"J1 ;esourc::!s: .Jr ::ammumt'( :Jr .ieu;;"Iccrnooo ':~<irac:er? =--::QI,1ln ~. ....~. '/eçel3lton .:)r :auna. ·Isn. ;r.ellfisn or '1Vllema sDec:es. ~Igntlic.ant .'3.01Ial,S. :Jr :nr~3Ie~e<:I or '!ncan<;erea :>cec:es? S:cCI.Hn 7)nðll'f: c~. A ::::mmunlt.,'s ¿xLs::nq ;J!ans or ·;oaIS as oiflc:a Y aCOOtec. ar a cnange in usa or intensity CT use of lana or :Jttler natural resourcss7 =:cplaln :~ ':5. Growtn. ,;¡UDseauent :evelooment. .Jr relatec ac::vltles likelY !O :Je ,nOuceo :JY :tle :::rOOOSèO ac:¡on? ~'t;;!I,1ln Jnel!v. :5. '_cnr; :erm. mor: :ètm. ::;mULauve. or :I{ner ':!! ec:s "ot ,ce~1Ifiea ,n C:·":;S? -::';t.:J!aln Jtlef!y. :tr:~r :mcac:~ inc:....c:nC; ::,~aC1çes ,n 'JSè ot -a!tner 'Jcanuty ~r :vce aT ~ne((;' ? -=-X:Jlaln :::rlerlv. j. S -¡...-E::<E.:R;S -¡-,E?;E _:!<~:"':':-C :iE. ::::,'j :=IOVe:=s'( =!E~7-::':J 7"0 .:J0T~;'{Ï!;"L ,,:,,::v=..=!SE :::'~V\F\CNME~I,;'L ..·.:p~C73? _'~es _.'10 f ~>!s. ~XClaln Jneltv ::J"\Ri 1I1_ùET'E~MINATICN OF SiGNIF1C),NC= ¡¡"o :Je comoleted ':Jy Agency) !NS7RUC7¡ONS~ For ~3C:1 aaverse ~tfec: identJlie':1 at:cve. aetermine wnetl'1er It is sutstantíai. large. :mcartant or otherwise siçnific ~.?C;:1 ~ifec;: silould ~e assessed in c:Jnnecnon with ItS fal setting (La. urban or :ural); lb} ;:1robacl!ity of aC::::J..:..-wg; lC duration ,rre'¡ersIOllity: :e ge'JqracnJc ¿;C:Jce: ana (f) magnltuce. It necessary, add attachments .or reference 5upponing ma[enaIS. ::::1sur~ ~:xc'anaucns c::ntaln suftic:ent JeIal (0 snow that all re!e'Jant adverse impacts have been Icemifieo ano adequatelY acC:ressec:. C;¡ecx :nis :JOX :f '(QU ;'ave Identifiea one 'Jr ;TIore :::ocentiall',I larçe 0r sigm ficant aC'n;!rsa :moac:s WnlC:1 ~.1;"'·~ oc::~r. :;,en :)racesa c:irec:Jy to :ne ,=üL!... :::AF ana/or ¡::reoare a positive- c:eclararicn. C;¡ec~{ :his :::OX :r you i1ave ,je!ermined. Jasea an the information and analysis above and any suc:oortií:ç coc:J~enta(:cn. :nat :r.e Jrocosed ac:íon WILL ~JOT result in~r.,! significant acverse anvlrcnrr:enr2.[ imcac:: AND .:Jrcvlce 'In ;¡i:i..3.c:1r.1ents as neC2SSa('J. the reasons suç:;corIing thIS dete:"mlna~ion: "..",~ '1 _",..tJ ......\:I"IC"I "'''1"11 JI '1.:'" '.,rn~ JI ..:~·,;:¡on\.o\~ ~1I,,:~r n ~",...:J ~.;\:fI':·' :,tlc JI -<~'~OOtH'O'c ,jll,c~r ;1\;I"I.JU..;It' }I ~"'C:Qn\,o,!!, ':'l·'(~r.n .<::..IC .'.;<::ncy ),>:n"::.JI~ )1 ,..·..·J.Jr..'·1f ';":~'''''t .r..,m ·~~oon,.o,,. ,JII'C"" ~ ,)..11: o . . Board of Trustees Application County of Suffolk State of New York ,fu5sel/ úI 111-e"1-(Y- rt'/;('(J,J (/ Mt'C-¡-r L.-- BEING DULY SWORN DEPOSES AND AFFIRMS THAT HElSHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF IDS/HER 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 TIllS 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 F TIllS APPLICATION. ~!dv~jJqß V1f¡~ SWORN TO BEFORE ME THIS J. S DAY OF If.hf'lY;~µ~ ,20M... ;/ ~KM Notary Public . SUSAN K TOOKER NOTARY PUBLIC, State of Nsw York No 01T05078120 Q~aJj.fiGd In Suffolk County CommisSion Expires May /1 ( 2003 . . , APPLtCANT TRANSACTIONAL DISCLOSURE FORM The Town of Sou~holdts Code of ~~hics Þrohibi~s contlic~s of interest on the part of town officers and employees. The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take vhatever action is necessary to avoid same. YOUR N/\HRr R ,'" """",;."-",, .' I .," '~'\\'íV ~ ,.~f ",,~"\' $-J /'-1.<::- c.r' " , ,"'''''~':' (Las~ name, fir~t name, mldd.le init1aì.,'''''ùn1ess you are applying in the name of someone else or other entity, such ~s a company. If so, indicate the other person's or company's name.) " .: ; "..~~S:~:.:::: .¡-~~ :'i;j.:...: !:~~' NATURB or APPLICATION! (Check all ~ha~ apply.) Tax grievance Variance ~- change of zone ^p'p~~al of plat , Exemption from plat or official map Other (If "Other," name the activity.) _perMI-r ~z... Cð.NJfruc...hCSF'" Do you personally (or through your cö~pany. øpöuBe, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southoldl RRelationshipR includes by blood, marriage, or business interest. RDusiness interest" means a business. including a parhnership. in which ~he town officer or employee has even a parhial ownership of (or employment by) a corp,oratlon in which the town officer or employee owns more than 5% of the shares. ". YES NO x If you answered hYES,N, complete hhe balance of ~hls form and date and sign where indicated. ",1." Name of person employed by the Town of Souhhold Title or position of that person Describe the relationship between yourself (the applicant) and the town officer ør employee. Either check the appropriate line ~) through D) and/or des~ribe in the space provided. The town officer or employee 6r his or her spouse, sibling. parent. or child is (check all that apply). ^) the owner of greater than 5% of the aha res of the corporate stock of the applicånt (when the applicant ia a corporabion)/ B) the legal or beneficial owner of any interest in a noncorporate'entiby (when bhe aþplicanb is nob a corporabion)/ c) an officer. director, partner, or employee of bhe applicant / or D) the aptual applicant. , " ,', ,,;,,',:' DESCRIPTION 01,' REL^TIONSII1P )1," ' . r ., " '., .',. ;,:~~,:' ..., .,"" .,.~ " . . ..~. ..... .'~ ""'~I.....I·... ~._ .. _.__ 0'" J_ ,.~ sublnl.hted tl1l. Signahur$ ~~t . .:<:t~:~r