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Home My WebLink AboutTR-5397Board Of Southold Town Trustees SOUTHOLD, NEW YORK KATHRYN CAMPBELL ....... ISSUED TO ................................................................................................................ p ' -' ' 'he -rovislons of Chepter 615 of the bws .of' ursu~nT ~o · the Sfe~ of New Yo~, 1893j end ~pier ~ of ~e ~ d ~ Sfele of New Ymk 19~2: ~nd ~e ~he~ To~ Ordlne~ e~ t~ ."R~U~TIN~ AND ~E p~IN~ OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIO ~DS e~ t~ ~E~OVAL OF SAND, ~VEL' OR OTHER ~ATERIALS ~O~ ~DS UNDER TOWN'WA~RSj~b e~ in eooo~e~ ~ih ~e Res01~n of ~e ~erd edopfed el e meeting h~ on ~.~' ~.~- -. .~.g.g.~, end Jn eonsJder~fio, of ~e sum of $.....~?~.L~.~ ....... ~id by ' ~h~ g~mpbe]] ............................. ~- ....... .. ] ..................................................................... ~ ............................... 5ou~ho]d ..L ................................ N. Y. end subj~t fo fhe ~fe~'""'~'"'"~j~j~s ~d~ on the reve~ dde ~f, of ~h~ T~n' Tr~es e~hedzes ~nd ~i~ ~ fo~ng: aff'~ accmdance ~fh the defa~ s~Hicatmns as ~e~nfed in . ~e odgi~flng a~ficafion. IN WITNESS WHERe, %e said ~ of T~sf~s ~m- subserved by ~'.~1~ ot tb sa,d ~ard ,s of th~ date. TER S and CONDmONS Kathryn Campbell 570 Hippodrome Dr., Southold pa~'of the conslden~oa fo~ the is~man~ of the l~"dt do~ uadesstmxl and P~escdbe t° the f°l' 2. Thatd~isl~.~h'valldfota.pesiodof.' 24 ,~e. whkhismmtdea~tobed~e to f~.,~,.,~a, cbc s~-uccm'c oc project iavolv~ to pmv~ ev~sence to anyone 9. That the Pecmkcee ~ ~ all. othe~ [,iemea~ to d~ permit which may be ~blect to Albert J. Krupski, President James King, Vice-President Henry Smith Attic Poster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, NewYork 11971-0959 Telephone(631) 765-1892 Fsx(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD September 4, 2001 Ms. Meryl Kramer 124 Broad Street Greenport, NY 11944 KATHRYN CAMPBELL 570 Hippodrome Dr., Southold SCTM#66-2-12 Dear Ms. Kramer: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, August 29, 2001 regarding the above matter: WHEREAS, Meryl Kramer on behalf of KATHRYN CAMPBELL applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated June 15, 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 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, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approve the application of KATI:IRYN CAMPBELL to construct a first floor addition to the existing one-story residence with new two-story addition and septic system landward of the house, all with the condition that the driveway be put in before October 31st and that the driveway be put in before any construction starts. A line of hay bales must be placed down along the wetland fringe during construction of the driveway and the 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 ~vill 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. Two 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/Ims DEC Bldg. Dept. Health Dept. Telephone (631) 765-1892 P.O. Box Ii~9 Sovthokl. New Yo~k X19Ti SOUTHOLD TOWN CONSERVATION ADVISORY COUNCYr, At the meeting of the Southold Town Conservation Advisory Council held Tuesday, July 17, 2001, the following recommendation was made: KATHRYN CAMPBELL 66-2-12 for a first floor addition to the ex!sting one-story residence with new two-story addition. Any new septic work shall be landward of house. 570 Hippodrome Dr., Southold The CAC did not make an inspection, therefore no recommendation was made. 6-1~-2~1 6:IBPH FROM MKRAMERARCH 631477~826 P. 1 June 14,2001 Board of Town Trustees Town of Southold Town Hall, 53095 Main Road P.O. Box 728 Southold New York 11971 VIA FACSIMILE M £ R Y L K R A M E R a r C h J 1: e c t JUN I 5 2001 RE: Campbell Residence Tax Map # 1000-66-02-12 Dear Trustees: I am requesting a permit for the above referenced property. For your review I am submitting the following documents under separate cover: 1. Three copies of Completed Application for Permit including General Data, Wetland/Trustae Land Data, Coastal Erosion Data, Notarized Affidavit and Transactional Disclosure Form 2. Three Copies of Completed Part I of Short Environmental Assessment Form 3. Three surveys prepared by Peconic Surveyors dated May 2, 2001 4. Application fee of $200.00 5. Authorization Letter 6. Proof of Mailing of Notices to adjacent property owners If you have any questions, please do not hesitate to call me. Sincerely, Meryl Kramer Cc: Kathryn Campbell 1.24 BROAD STREET GR EENPORT, NY ~. ~.944 63 ;~ - 477.0 a 2 6 M £ R Y L K R A M a r c h i t e C t E R August 23, 2001 Board of Town Trustees Town of Southold Town Hall, 53095 Main Road P.O. Box 728 Southold New York 11971 ' ' AU6 2 3 2081 RE: Campbell Residence Tax Map # 1000-66-02-12 Dear Trustees: For your review I am submitting the additional information you requested at the July 25th hearing, It is my understanding that this application will be reviewed again at the August 29t~ hearing, Should you have any questions or comments prior to the meeting, please do not hesitate to call me. Sincerely, Cc: Kathryn Campbell 124 BROAD STREET G R EENPORT, NY 11944 631-477- 0826 Albert J. Krupski, President James King, Vice-President Henry Smith Attic Foster Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18,F2 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only astal Erosion Permit Application tland Permit Application Grandfather Permit Application ~aiver/Amendment/~h~nge~ Received App~ic~t/lon: ~][-~/0! n Received Fee.$~7~V- ~'J(~,,l~ ! Completed Application L?~! O / Incomplete SEQRA Classification: Type I__?ype II Unlisted Coordination:(date CAC Referral Sent: 0 I Date of Inspection: % !!~ ~ Receipt of CAC Report: ~ ' Lead Agency Determination:__ Technical Review: Public Hearing Held: Resolution:' -- ' Name of Applicant K~%'~"~.X~t~ ~.~~ Address ~O LL%V d MWEL , Suffolk County Tax Map N~er: 1000 Location: ~ V PropertyLILCO~ ~y/' (provide and locati (If applicable) F~#: of Trustees Applicatio~ GENERAL DATA Land Area (in square feet): ~~ Area Zoning: ~--+0 Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency Date __ 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 2 Bo~of Trustees Application Purpose of the proposed operations: Percent coverage of lot: ~0,~ % Closest distance between nearest existing structure and upland edge of wetlands: ~._~' feet Closest distance between nearest proposed structure and upland edge of wetlands: ~5' feet Does the project involve excavation or filling? No ~ Yes If yes, how much material will be excavated? How much material will be filled? ~ ~ cubic yards cubic yards Depth of which material will be removed or deposited:_~__~T 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): 3 BoO of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: '~t~"~ ~--~"~- ~-'~---~ Are wetlands present within 75 feet of the proposed activity? No ~ Yes Does the project involve excavation or filling? No ~ Yes If Yes, how much material will be excavated?5~ How much material will be filled? ~ (cubic yards) (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEESf TOWN OF SOUTHOLD In the matter of applicant: YOU ARE HEREBY GIVEN NOTICE: 1. That it is the Permit from the Board of Trustees intention of the undersigned to request a 2. That Review-is follows: the property which is the subject of Environmental located adjacent to your property and is described as %FFO RD 4P De, ,VE. 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. MAILING ADDRESS: Enc.: Copy of sketch or plan showing proposal for your convenience. 617.21 Appendix C State Environmental Quat[ty Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART l--PROJECT INFORMATION (To be comoleted by Applicant or Proiect sponsor) SE( APPLICANT/SPONSOR 2. PROJECT ,NAME PROJECT LOCATION: $. 0ESCRISE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially ' [ acres Ultimately · I ~-]~l'!n~us [rial ~ Cornrnerc:al 10. DOES ACTION INVOLVE A PC-RMIT APPROVAL OR FUNDhqG, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? eyes [] No if yes. list agency(s) and permit/approvals 11. ODES ANY ASRECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? NO CERTIFY THAT THE INFORMATION PROVIDED AEOVE IS TRUE TO THE SEST OF MY KNOWLEDGE the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this a~.~}essment OVER 1 PART II]--OETE~MINATICN OF SIGNIFICANCE ~To ~e completed by Agency) INSTRUCTIONS: For each acJverse etfect ident~fJe,5 al:ova, determine whed~er it is sul~s~antial, large. [mco~an~ or oUler, vise sign --ach -~ffect snoulcl ~e assessed in connection w~dl ~ts (a) setting [i.e. urban or rural); (bJ.probaDHit¥ Of Occ=~J,qg; (c) duratJ< irrevermbdily; (el geogreonic .~c,=ce: and (0 magmtuae. If necessary, aecl attachments or reference suoooning materiels. E~sur ~x~tanadcns ccntam sufficient de[aH Ia snow tJ~[ all re~evant ~dverse impacts have been icten~ifJec~ ~n~ adecuateiy decrease Check ;his box if you.nave identified one-or more paten(Jelly large or significant acverse imoac:s which occur. Then ?cc~eo directly !o :ne FULL E,AF anolor preoare a gositive'declaratJon. Checx :his =ox :f you nave determined, based on [he information and analysis above and any suooort: documenta:;cn. :hat ;he 2roaosea ac:Jan WILL ,',lOT result in -_~.ay significant adverse environmental inca, AND 2rovtce on a~tacmments as necessary, the reasons supcordng this determination; 2 ~OOZ ~oo~ p.:~ LETTER OF AUTHORIZATION Koth~Jn .Campbell Sullivan and Cromwell N~# Yo~, NY 10004 Febn~mS, 28, Date of Trustees Application Ab'raORIZA'r±ON (where the applicant is not the owner) (print owner of property) residing at (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) 8 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 OFTOWNTRUSTEES TOWN OFSOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application AFFIDAVIT OF POSTING I, ~/ kr~.F~ , residing at ]~ ~ ~_~ being duly sworn, ~epose and say: That on the ~ day o~l~.. 200[, I personally posted the property known as ~-~O '~~~ D~V~ by placing the Board of Tr~t~s official poster where it can easily be seen, and that I have checked to be sure the poster tothebedate of~h9 has remained in place for eight days prior to held~/ public he~rinq. Date of hearing noted thereon Dated: Sworn to before me this ~ day of ~/&~ 200~ Notary Public County of Suffolk State of New York BEING DULY SWORN DEPOSES AND AFFIRMS THAT--/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN AR~ TRUE TO THE BEST OF ~ii~/HER 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 REPRESEnTATIVES(S), TO E~TER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. SWORN TO BEFORE ME THIS /~L---DAY-- OF /~c~._/ ~OO/ ,~ Notary Public HELENE O. HORNE Not~W Public, State of New York No. 4951364 Qualified in Suffolk Countyl Commission Expires May 22, o'~ 6-0S-20~1 3:28PM FROM MKRAMERARCH 63]A770826 P. 2 The Town of Sou~ho%d's C0de of in~eresb on ~he,,parb of town o~ficers and employees. Th~ purpose of ~h~a form ts to provide lnforma~ion which can alert the bowB of possible conflicts o~ interest, and a~low ib bo bake whatever ack,on.is necessary ~o avoid same. (bast name, ~irst name, mtdd&e Initial, unlesS'" you are applying in the name of someone else or uther enhity, such as a company. Xf co, indicate the other person's or company's name.} NATURE OF APPbI~2ATIONt (Check all ~ha~' appZy. ) Tax grievance Variance ~We cha~ge of zone A~p~j;~ral of plat , ~xe~ptto. from plat or o~lciai map other (I~ "Other," name ~he activity.) .,, Do you personel~F (o= ~hroUgh Four eompnny~ npoese, sibll~9, parent, or child) hewn a relationship with any o~lcer or employee of the Town of Southold? "Relationship- includes by blood, marriage, or business interest. 'Business interest' meann e buniness, including a pn£~ner~hip, in which the town o~ficer or employee has even a partial ownership of (or employment by) a corp~£ation in which the town of£1cer or employee owns more than 5~ ef the date and sign where indicated. Name of person employed by the ToWn nE SouEhold Title or position of that pe~son Describe the relationship between yourself (She applicant) and the town officer er employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer parent, or child B) or employee or his or her spouss~ sibling, is (check all tha~ apply)~ bbs owner of grea~er than ~% o~ the shares o~ the corporate e~ock o~ the applic~n~ (when the applicank' ia a corporabion)~ the legal or bkneficial owner o~ any in~eresb in a noncorporate'entity (when the applicant is nob a corporation}l __.C) an offioer~ dirsctor~ applicant~ or D) the ee~al applicant, D~SCRIPTION OF R~LATIONSIIIP pa~bner~ or emplOyee, of the M E R Y L K R A M E R a r c h ~ t e c t August 23, 2001 Board of Town Trustees Town of Southold Town Hall, 53095 Main Road P.O. Box 728 Southold New York 11971 i 2 3200l RE: Campbell Residence Tax Map # 1000-66-02-12 Dear Trustees: For your review I am submitting the additional information you requested at the July 25th hearing, It is my understanding that this application will be reviewed again at the August 29th hearing, Should you have any questions or comments prior to the meeting, please do not hesitate to call me, Sincerely, Cc: Kathryn Campbell 124 BROAD STREET GREENPORT, NY 11944 632-477-0826 Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18.~2 Fax (516) 765-1823 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD Office Use Only __~astal Erosion Permit Application tland Permit Application Grandfather Permit Application ~--'.. ~aive r / Amendment / ~h~ng~s .. I~?]_~ Received Applic~flo~: Received Fee:$~0~ · Completed Application ~!l{~]% / /~ · Incomplete SEQRA Classification: Type I__.Type II Unlisted Coordination:(date ~e~t)_ CAC Referral Sent: (~ ! Date of Inspection: . Receipt of CAC Report:'' [~' · Lead Agency Determination: Technical Review: Public Hearing Held: Resolution: Name of Applicant Address ~ ~L~V~ NY 10004 Phone N~er: Suffolk County Tax Map N~er: 1000 - Property Location: (provide LILCO Pole eets, and locati (If applicable) F~: of Trustees Applicatio~ GENERAL DATA Area (in square feet): J~ Land Area Zoning: ~--+0 Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency Date __ 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): Bo~ of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ~D Area of wetlands on lot: Percent coverage of lot: Ii % square feet Closest distance between nearest existing structure and upland edge of wetlands: ~._~' feet Closest distance between nearest proposed structure and upland edge of wetlands: ~5' feet cubic yards Does the project involve excavation or filling? No ~ Yes If yes, how much material will be excavated? ~ How much material will be filled? -- cubic yards Depth of which material will be removed or deposited:_~___~T feet Proposed slope throughout the area of operations: ~T. 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): BoO of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: Are wetlands present within 75 feet of the proposed activity? No ~ Yes Does the project involve excavation or filling? No ~ Yes If Yes, how much material will be excavated?5~ · How much material will be filled? ~ (cubic yards) (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES~ TOWN OF SOUTHOLD In the matter of applicant: 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: ~~ 2. That the property which is the subject of Environmental Review-~s 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: 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. MAILING ADDRESS Enc.: Copy of sketch or plan showing proposal for your convenience. · ," ' PROJECT LD, NUMBER 617.21 SE( Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be comD[e[ed by Applicant or Projec[ sponsor) PROJECT LOCATION: 6. DESCRISE PROJECT BRIEFLY: Nr::N PI~'T' t=t.OolZ. ,~]:~TIoN, F~.I,Iov'A-'noN aP ~t.O-. -FiR,g]- . FLoOA., &Nb ~;r::d_.cNt:, t::LC~P-., x~:tl)t'noN 7. AMOUNT O,= LAND AFFECTED: I IAgncuit.ure 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDIr.tG. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL. STATE OR LOCAL)? *~Yes NO If yes. llst agency,s) and permit/aDoroYal$ 11. DOES ANY ASPECT OF THE ACTIOt4 HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [] No I! yes. list agency name and perm*t/aOproval 12. AS A RESULT DOFf. PROPOSED ACTION WILL E~ISTING PERMiT/APPROVAL REQUIRE MOOJFICATION? E']Yes o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE If the action is in the Coastal Area. and you are a state agency, complete the Coast.si Assessment Form before proceeding with this a~s, essment OVER 1 PART [II--DETE.RMINATICN OF SIGNIFICANCE LTo be camoleted by Agency) INSTRUCTIONS; For each aclverse affect identideo score, determine wne¢~er it is suos~antial, large, imcor~ant or otherwise signi ~:~c.~ s~fec', should be assessed in connection w~trt ~t=i (c) setting ¢.e. ufO',an or rural); (b) prooaoilit¥ of occ=?'"~g; (.cl durati~ irrevers~bHi[y: ~e) geographic scoce: an(~ (i~ magmtu(:e. If necessary, a0O attec.flments or reference sub0or~in~ materials. ~nsur ex~t&na[icns contain suffic:en~ deZall !o StlOW that all re~evant ccJverse imbec~$ h~ve been idendf|ed &no adecuateW &o~resse .~ Check ~his ~o× ~f '/ou.hcve identified one-or more oolentially large or signific:~nt c~verse imoac:s which M. occur. Then Drccae~ airec:ly [o :~e FULL EAF ~n~/or preoare a positiv~ecl~raticn. ~ Chec:< :~is ~ox f~ you have de[ermrne~. ~aseo an the information znd ~nalysis ~bove ~na ~ny ~uooort: documen[aHcn. :h~t ;~e 2roooseo cc:ion WILL NOT result in.ny signific3nt adverse enwrcnment~l imca~ 2 0]./03 '0]. 20:58 ~002 LEI[ER OF AUTHORIZATION Kothfy~ ~mpb~l Sullivan and Cromwell NewYo~ NY 10004 F'ehruar,y 29, to my m~nc~ atS?O Hiupodmme Drive, ~utholcl, Date of Trustees Application AUTHORIZATION (where the applicant is not the owner) (print owner of property) residing at (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) 8 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 OFTOWNTRUSTEES TOWN OFSOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application COUN LK STATE OF NEW YORK) AFFIDAVIT OF POSTING I, ~_/ k[~F' , residing at I~ ~ ~-~ ~ and say: being auly w , p ~e~yt~o~n~ a~aY o~¥~t~~er~a~y posted the by placing the Board of Tru~t~6s 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~hp public hegring. Date of hearing noted thereon to be held~/__~/ Dated: Sworn to before me this ~ day of ~ 200~ Notary Public sc. .,// Lrd of Trustees Applicati~ County of Suffolk State of New York BEING DULY SWORN DEPOSES AND AFFIRMS THAT ~/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STA'I'~ENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF iii~/HER 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 REPRESENTATIVES (S) , TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. swo TO BEFORE THIS OF SOO/ / Notary Public HELENE O. HORNE Notary Public, State of New Yor~ No. 4961364 Quat(Eed in Suffolk County_ Commission Exp;res May 22, ~0~ 6-8S-2001 3:28PM FROM MKRAMERARCH 631~770826 P. 2 APPliCANT The. Town of Sou~ho~d'e ~nteree~ on ~h~.part 9f town of£~cers and employees. purpose, of th~s form ia to pro.v~de ~nformat~on which can a~ert the. tow i~ ~o ~a~e wha~eYer action is necessary to avoid same. (bast name, ~iret name, middle initial, ual'ess ' you are applying in the name o~ someone else other entity, such aa a company. If go, the other pereom'g or company's name.) NATURE OF APP~I~ATION~ (Check all tha~ apply'. ) Tax grievance Variance ]W' Change of zone ARp~val of plat . Exe~ption £ro~ pXa~ o~ o~lcial map o~her (If "other," name the ac~ivity,) Do you psrsonaXXF (or ~hrough your ~ompenF, spouse, parent, or child) have a relationship wi~h any of~iuer or ~mploye~ of the Town o~ Sou~hold? *Relationship" includes by blood, marriage, or business interes~. 'Business interest* means e business, including a pa£~nerehip, in which the town of[icer or employee has even a par~lal ownership of (or employment by) a ~orporatios in which ~h~ town o~ficer or employee owns mor~ than 5~ of shar~. NO' If you answered 'YES,#.complete the baiane~ o~ ~hl~ £orm and date and sign where indicated. Hame og person employed by the ToWn or 8ouEhold Title or position cE that person . Describe the relationship between yourself (Ehe applicant) and the town officer mr employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all ~hat apply)f __~) Lhe owner o~ grea~er than 5% og ~he shares o~ Lhe corporate stock o£ ~he appllc~nh (when the applican~ ia a corporation)~ __B) the legal or b~neficial owner of any interea~ in a noncorpora~e'en~l~y (when the applicant Is no~ a corporation)~ __C) an officer~ director, · applicant~ or . D) ~he astral applicant. pe~ner, or employee o£ \ \ ,. % NOTES: SURVEY OF LOT 9 BLOCK 4 MAP OF BEIXEDON ESTATES FILE No. 1472 FILED MARCH 16, 1946 SITUA TED A T SOUTHOLD TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-66-02-12 SCALE 1"=20' FEBRUARY 15, 2001 FEBRUARY 27, 2001 ADDED PROPOSED PORCH MAY 2, 2001 REVISED PROPOSED ADDITION AREA = 10,798.79 sq. ft. (TO 11E LINE) 0.248 aC. I. ELEVATIONS ARE REFERENCED TO N,G.V.D. 1929 DATUM EXISTING ELEVATIONS ARE SHOWN THUS: lP, O 2. THE LOCATION OF WELLS AND CESSPOOLS SHOWN HEREON ARE FROM FIELD OBSERVATIONS AND/OR DATA OBTAINED FROM OTHERS. $. FLOOD ZONE INFORMATION TAKEN FROM: FLOOD INSURANCE RATE MAP No, ~6103C0158 G ZONE AR: BASE FLOOD ELEVATIONS DETERMINED ZONE X*: AREAS OF 500-YEAR FLOOD, AREAS OF 100 YEAR FLOOO WITH AVERAGE DEPTH OF LESS THAN 1 FOOT OR WITH DRNNAGE AREAS LESS THAN 1 SQUARE MILE, AND AREAS PROTECTED BY LEVEES FROM lDO-yEAR FLO00 ZONE X: AREAS DETERMINED TO BE OUI~JIDE 500-YEAR FLOODPLAIN. TEST HOLE DA TA (TEST HOLE DUG BY McDONALD GEOSCIENCE ON JANUARY 2OOl) 14' JUN ) 5 THE EXISTENCE OF RIGHTS OF WAY AND/OR EASEMENTS OF RECORD, IF Joseph A. Ingegno Land Surveyor N.Y.S. Uc, No. 4966~ PHONE (631)727-2090 Fox (631)727-1727 20-717B ~'~' EDGE OF BUILDING LE^C'~POOL*T,P~'--~ ~ ~,g, / i /__ GRADE EL. I20 -- ~AST IRON COVER TO ". \ \ ill, ~' FIN FLR ELEV 140 ' / / GRADE TYPICAL % %~ ~l~.~hfl~ J ---- -- / .¢' "~, GRADE EL. 130 GAL ~ GROU~WATER EL L4 /~~. ~%~*~,',,~ ,*~ ..--" P~¢F I t F LEACHING POOL ~~~" "~ '%'' ,'":X" '7,, *~¢< ~" 7 - -- " ~ "~ARD OF TRUSTEES ¢ ToWN OF souTHOLD , ~ ~ / YELLO~SH BROWP %ALE I' = 20' , ~' LOT INFOrmATION TAKEN FRO~ ~VE* ~REPA~EO ~* TEST HOLE