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HomeMy WebLinkAboutTR-4878 . Board Of Southold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. L.{ 8' 1 g' DATE: ....March ISSUED TO .. RICK & . BOBETTE SUTER ^utqnri!utinn Pursuant to the provisions of Chapter b 15 of the Laws of the State of New York, 1893; and cnapter 404 of the Laws of the State of New York 1952: and the Southold Town Ordinance en- titled "REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;" and in accordance with the Resolution of The Board adopted at a meeting held on 3/25/98.. 19 9.8, and in consideration of the sum of $ 150...0.0. paid by Rick & Bobette .Suter. of Southald N. Y. and subject to the Terms and Conditions listed on the revel'$e side hereof, of South old Town Trustees authorizes and permits the following: I Wetland Permit to construct a fixed timber dock consisting of . a 4' X 30.' fixed catwalk, a 3' X 14' ramp and a 6' X 16' float ~ res heath an existing 10.2' retaining wall and maintain buffer are . landlf~rd of r",tainin.¡¡;h wall,ô t ·led 'f' t' t d ' a In accoraance WIT The e al spec I Ica Ions as presen e In the originating application. IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date, )t¡~ . 'ý.' ~~ Trrulets .. uoh ....__._... . .. . -..... -- . . Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765·1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD May 25,2001 Dr. John W. Pearson 3575 Wells Road Southold, NY 11971 RE: SCTM# 70-4-5 Permit 114878 Dear Dr. Pearson: The following action was taken at the Southold Town Board of Trustees Regular Meeting on May 24,2001. RESOLVED, that the Southold Town Board of Trustees approve the request for a Transfer of Permit #4878 from.Bobette & Rick Suter - to - John W. Pearson. [fyou have any questions, please contact our office at 765-1892. !!ll:IY:1 p. /4,~~. 9v Albert J. Krupski, J r. President, Board of Trustees AJK:cjc . -- 'iVC-hS {~. .... ~'\YV)i # r.fì[ ßrc L t Q Q~ 1-): --s v +e.v- -to t=è~ vlewL ... .... . +l.{I ~ ~a' h"1 Wr Ð M~Y I 6'w ,"':':"~' ':'~'·1j~¡~';;:-;<~;;;,;,~,-~._,;·:, 00;"'.. '0 '.' .. ..................~.,~~~~.~~.~~...... ....../ ...:,,;..;..~...~".,.:._.."--. ~ en '" w CJ) !!9~ eno:ß~ :¡ I'- I'- ~ ~ §~ z O~> ~ Q. oen"z l-ou..8:2" II.. c: 0 oz ,~~ Q ~::;J! ~I-~ o on m 5/){¡; /ûL______._ 040032 IL n :QCl1ùO (}t Addre.. .3S '}J W()(Lo Q..(J(' .da..H 17 l.ertr ondC9'cv---- ..'. -. /0- For 22011.,/) JJ.? ,-----,- DolI.r. $ AMT PAID SA.LANCE OUE /a - au..Un ~h. (' . . 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) 765·1!Mf.l Fax (516) 765·1823 TO: RTCK & BOARD OF TOWN TRUSTEES , .' RORRTTR ~?~OFSOUTHOLD Please be advised that your application. dated Feb. 11. 1998 has bee reviewed by this Board. at the requ1ar meetinq of March 25, 1998 and the followinq action was taken: ( xx) Application Approved. (see below} -) Application Denied. (see below) ) Application Tabled. (See below) - If you application is approved as noted above, a permit fee is now due. Make check or money order payable to the SQuthald Town Trustees. The fee is computed below accordinq to the schedule of rates as set forth int he sintruction sheet. The following fee must be paid within 90 days or reapplication including fees will be necessary. COMMENTS AND REMARKS: Application Fee: $150..0.0. PAID catPtJ'rATrON OF PERMIT FEES: 4' X 25' catwalk = 10.0.' X $3 = $300. 3' X 14' ramp = 42' X $3. = $126 6' X 16' float = 96' X $3'" = $288 TOTAL $714 TOTAL FEES DUE: $ 714.0.0. f1LJ.e.·1 ç. ~. 9, ~D APR - 8 1998 SIGNED: PRESIDENT. BOARD OF TRU~'J:ISJSS BY: ~~o~ &/95 - .- h_....___ . .' r . . Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Telephone (516) 765·18'2 Fax (516) 765·1823 Town Hall 53095 Main Road P.O. Box 1179 Southald, N ew York 11971 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD March 26, 1998 En-Consultants Inc. 1329 North Sea Road Southampton NY 11968 Re: RICK & BOBETTE SUTER SCTM #70-4-5 Dear Mr. Haje, The following action was taken by the Board of Town Trustees during its Regular Meeting held on March 25, 1998, regarding the above matter: WHEREAS, RICK & BOBETTE SUTER , applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated February 11, 1998 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 March 25, 1998, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standard set forth in Chapter 97-18 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, r1 .. . . NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approves the application of RICK & BOBETTE SUTER to construct a fixed timber dock consisting of a 4' X 30' fixed catwalk, a 3' X 14' ramp and a 6' X 16' float, resheath an existing 102' retaining wall and maintain buffer area landward of retaining wall. Located: 3575 Wells Ave., Southold. 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 proiect will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. __._, FEES: 4' X 25' catwalk = 100' X $3 = $300 3' X 14' ramp = 42' X $3 = $126 6 ' X 16' float = 96' X $3 = $288 TOTAL $714 Very truly yours, tlLL...t ~ /4.. lS~' 9., Albert J. Krupski, Jr. ' President, Board of Trustees AJK/djh cc . DEC ACE Dept. of State . . Telephone (516) 765·180.1 Town Hall. 53095 Main Road P.O. Box 1179 Southold, New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL The following action taken at a meeting of the Southold Town Conservation Advisory Council held Monday, March 23, 1998: No. 1548 Moved by Scott Hilary, seconded by Sharon Shine, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the Wetland Permit Application of BaBETTE GARBEN SUTER 70-4-5 to construct a fixed timber dock, consisting of a 4' x 30.' fixed catwalk; a 3' x 14' ramp; and a 6' x 16' float to be secured by two(2) eight inch (8") diameter pilings; res heath existing 102+/-' timber retaining wall and backfill with approximately fifteen (15) coy. of clean; construct a 3' wide wood walk landward of retaining wall. CAC recommends approval provided applicant maintain a non-turf buffer. 3575 Wells Avenue, Southold Vote of Council: Ayes: All Motion Carried . . 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) 765·1882 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD March II, 1998 En-Consultants Inc. Rob Herrmann 1329 North Sea Road Southampton NY 11968 RE: BOBETTE GARBEN SUTER SCTM #70-4-5 Dear Mr. Herrmann, The Southold Town Board of Trustees reviewed the survey of Bobette G. Suter, dated and received in our office on February II, 1998 and found that the proposed construction of a porch, pool and deck is out of the Wetlands jurisdiction under Chapter 97 of the Wetland Code.' However, this determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. Sincerely, Clt/.,·I ÇJ. /~'-9~ - ¿ Albert J. Krupski, Jr. President, Board of Trustees cc. Bldg. Dept. !~ r;' r.- =--::--'-~_.- - . ~ I,{r- --- .' I'I::! (1 j! FEB I I I~·B I ' , 1329 North Sea Road Southampton, New York 11968 516-283-6360 Fax: 516-283-6136 E-mail: encon@peconic.net EN- CONSULTANTS, INC. ENVIRONMENTAL SERVICES January 26, 1998 Mr. Albert Krupski Town of Southold Trustees 53095 Main Road Southold, NY 11971 RE: lUCK AND BOBEITE SUTER. JOCKEY CREEK. SOUTHOLD Dear Mr. Krupski: Enclosed please find an application by Rick and Bobette Suter for a Town Wetlands Permit to coastruct a fixed timber dock aød reaheathe an existill8 retaining wall. Please note that the Suters are also proposing to construct a porch, pool; and deck, all as indicated on the enclosed survey. As this upland work will occur more than 75' landward of town waters/wetlands, would you kindly issue a letter of non-jurisdiction for this portion ofthe project. For your reference, I have attached a separate photo sheet depicting the upland work site, Should you have any questions regarding this request, please do not hesitate to contact me at your earliest convenience. RespectfuUy yours, Robert E. He nn Coastal Management Specialist Attachment and Enclosures · I" " I' ---n--""'-'--- Ii 1,7 r;-A, I t~...., ! - '. -' ¡:. , ~ i, FEB I I 1998 /. I, ' EN- CONSULTANTs, INC'. ;' , --'- ~ .. f"'\, ~~. 1329 North Sea Road Southampton, New York 11968 516-283-6360 Fax: 516-283'6136 E·mail: encon@peconic.net ENVIRONMENTAL SERVICES February 4, 1998 Town of Southold Board of Trustees Post Office Box 1179 Southold, New York 11971 Attn.: Diane Herbert Re: Bobette Garben Suter 3575 Wells Avenue, Southold SCTM #100.0-70-4-5 Dear Ms. Herbert: In regard to the above referenced property, enclosed are the following for the Board of Trustees review: I. Three (3) Wetland Permit Applications, ( including Notice and Proof of Mailing to adjacent owners). 2. Three (3) Short Environmental Assessment Forms. 3. Three (3) copies of authorization & disclosure forms. 4. Three (3) work plans. 5, Three (3) surveys. 6. One (I) set of site photographs. 7. Application fee 01'$150.00. I trust this information shall allow you to process our request for a Wetlands Permit. Should any additional information be required, please do not hL'Sitate to contact our oftice, ~ßIY, ~E. H nn Coastal Management Specialist Ikhs Ene. I ¡ \' '\ (' 'f;Ç_ . .;;:'>:_ ~t ¡. ~-. 'ü. ~../JJ1' :\mll - I ' -~.~ - ~ cr'" / ," Z'_.,.. "j'l Ii'''''''' F:-.............-- ~ < ...," ~.. '. I - ¡; '1' ¡hi! ¡ , ,.... >. ":1'. \~"'-"~"., . \'. '\. ;'t~ .!..J . /! ¡¡iI'; .1 _. '\1 " ? .' '. r .' ~ ~ J '/ \ ,','i¡'" (! ;, ,; '}f'!" hl" -~ r" ~ ,\,,~1;, .; ,~t;'ì!.,'íê..>\I! ¡Iii: ~" I '\ ,'" -./ :ï '. \~~\:\ i.~ ~ ~:' ,....: é~f\..!\.'l ; ~ I (¡ t.. >--":' ,?\, lWJ '.'1..) I \ ,I ~8 ;. )' / ...~, .. ~\ \ \ ':..~' ;";1' f' t'..~". \..," .' t ~. ~ ...~ ( ) I' , . .',~. '; " ' , . 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Garrell Peter Wenczel ,P:~~ --~'\; ~'''' ::'~ ~':. ~.== ~~. ,:'" = ~ ..:; ~cn :;e~ ~ ~ ~~1 - -It. · ~~1 ~ BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 Office Use Only ~Codstal Erosion Permit Application ~Wetland Permit Application Grandfather Permit Application ---Waiver/Amendment/Cha~es eceived Application: '!--/. - ''''- eceived Fee:$/.!'O ompleted ApplicaÜon.!--II- 'E Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(d~sent) ---- CAC Referral Sent: Date of Inspection:- Receipt of CAC Report: Lead Agency Determination: Technical Review: ublic Hearing Held:..j-IY- 'F:: Resolution: " . , FEB I 11998 ,J j I j , ' . ". ~ 1--· - >..- - - Name of Applicant Bobette Garben Suter Address 6 Atlantic Avenue East Moriches, NY 11940. Phone Number: (516) 878-6485 Suffolk County Tax Map Number: 1000 - 70-4-5 Property Location: 3575 Wells Avenue, Southold (provide LILCO Pole #, distance to cross streets, and location) AGENT: En-Consultants, Inc. (If applicable) Address: 1329 North Sea Road, Southampton, NY 11968 Phone: 516-283-6360 FAX#: 516-283-6136 . . Board of Trustees Application GENERAL DATA Land Area (in square feet): R-40. 20.,493 Area Zoning: Previous use of property: one, one-family dwelling Intended use of property: no change Prior permits/approvals for site improvements: Agency Date x No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? X No Yes If yes, provide explanation: Project Description (use attachments if necessary): SEE ATTACHED . . PROJECT DESCRIPTION BOBETIE GARDEN SUTER SCTM #1000-70-4-5 3575 WELLS AVENUE SOUTHOLD, NEW YORK 11971 Construct a fixed timber dock, consisting of a 4' X 30' ftxed catwalk; a 3' X 14' ramp; and a 6' X 16' float to be secured by two (2) eight inch (8") diameter pilings. Resheath existing ±10.2' timber retaining wall and backtill with approximately tifteen (l5) cubic yards of dean sand to be trucked in from upland soW'ce. Construct a 3' wide wood walk landward of retaining wall. · . Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: To provide safe, private boat dockage. Area of wetlands on lot: ±60. square feet Percent coverage of lot: % Closest distance betweep nearest existing structure and upland edge of wetlands: nl a feet Closest distance between nearest proposed structure and upland edge of wetlands: n/a feet Does the project involve excavation or filling? No x Yes If yes, how much material will be excavated? n/a cubic yards How much material will be filled? 15 cubic yards Depth of which material will be removed or deposited: l' behind retaining feet wall Proposed slope throughout the area of operations: n/a Manner in which material will be removed or deposited: Fifteen (15) cubic yards clean sand fill will be trucked in from an upland source and deposited landward of retaining wall to be l' higher ~n elevation then existing. 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): The dock has been designed in conformance with the adjacent docks to the east and west. There will be no effect on the small patch of intert~dal marsh present on the site, and the only effect on t~dal waters w~ll be the temporary disturbance of the bottom caused by driving of the pilings associated with the dock. 3 61 7,21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I-PROJECT INFORMATION (To be completed by Applicant or Project sponsor) . I . 14-16~4 (2/87)-·Text 12 I PROJECT I.D. NUMBER SEQR " ,APPLICANT ¡SPONSOR ~J! 2. PROJECT NAME BOBET'l'B GARl!EN SU'.rER BY EN-CUNSULTAN S, INC. 3, PROJECT LOCATION: Municipality SOUTHOLD County SUFFOLK 4. PRECISE LOCATION (Street addr... and road Inter.ections, prominent landl'nllrk.. etc., or provide map) 3245 WELLS ROAD, SOUTHOLD, NY, SC1M #1000-70-4·5 5, IS PROPOSED ACTION: g New o Expansion o Modification/alteration 6, DESCRIBE PROJECT BRIEFL V: SEE ATTACHED 7, AMOUNT OF LAND AFFECTED: Innielly 20.,493 SQ. FT. acres Ultimately 20,493 SQ. FT, acres a. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? g V.. o No If No, describe briefly 9. WHAT IS PRESENT LAND use IN VICINITY OF PROJECT? ~ Residential o Industrial o Commercial o Agriculture o Park/ForesVOpen space o Other Describe: 10, DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR UL TlMATEL V FROM ANV OTHER GOVERNMENTAL AGENCV (FEDERAL. STATE OR LOCAL)? g V.. ONo If yes, li.t agency{s) and permitlapprova" NYS DEC, COE, & DOS 1\, DOES ANV ASPECT OF THE ACTION HAVE A CURRENTLV VALID PERMIT OR APPROVAL? OVe. ~ No If yes, list agency name and permiUapproval 12, AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? o V.. g No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MV KNOWLEDGE R.i ,~~ ~ , COASTAL MGMf, SPECIALIST FEB. 3, 1998 ApplicanUsponsor name: BER . Date: "-f:r=- ~ , IYlY~ Signature: If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER I .' - WeLLS RD ~/«, .'ð ~ , I I '~' I' r-' '! --- - , ' ·';~7 " " . 'ð---~' - 01 ~ C Ò c . Do.' .;;.~ ,,,... ""....æ ~ ~ ~ 3.6' , , .. I'LANTE11 Zfl,3' 17.r !1 'It I. I STY. F'R. -- ,r¡<>I, ~ /BoD !II Co IM~C' t= . ~'.".I!I . no.' Co£. 111 148 ,.... If¿¡, _ -- fJ!:Df' ø.cCo* prDp pore¡' proP poo! _ _ -- . ''2 --- -_ ...... o .;¡p *' ---__ ¡q!£T -l ~ \ is>' !"> ' '>. tæ' \Q ,~ 10_ I\) ~;; \ _------ - :- ~c ... 10 A~. ,\~...____ _ ";~YÞ& , - 3' euA"SlWÞ 'flÞPØS.Er>,'W/ÞE . """0£ a~~ '. ~PW,qL'" ~/srUJ 7bo BE t5 . . -,-, b~V£l> -- ~)(.-/Ol'~ETJ4 . 1"0 'NINt;, wi</Li.. ßE RESHE4T1TED W/NeW Z";<'(tJ~s 4NÐ 6'PPlLPS . - /(¿, s' ---/4 -/4 '. --.'2 I\) C - ru-IO \¡) "1 - --.,/".d!:-<v_ !5&' ",'.x30'FIJ(£D I t:ATW'At." !·...'''I·ItAMP 1 S·"'.£(TY,) .s- EllS - ¡;, 'I,: F....f) ÆX "'.III'" FL0141 f ."D_ , JOCKEY CREEK (+ 300') ~~~8At:X.¡;1'-'- -.3~ 'WMÞ()WAI./o( 6Jl.1(rr"/^,I"'~ w.u.. I!LW~O'-O" ~.s£P Z·'.'O-~ "T'o 8E'GTJ eJ'e.P HoIlJZf)NT4~Y (ÞfløPØED wA/..L "TO ðE lo..-J:50TP.O,:fEÞ /1-",,*&H6(1.. 1H¡fHJ êX''ó''1'"J6) '-1> S"t PILES' : .1.'-.' A. SECTION THRUE~.ffi'~lffi~s~,LL 1" = 10' 1329 NORTH SEA RD. SOUTHAMPTON, N.Y. 11968 516·283-6360 J t" \I. 't'~ ~ <>: ~ . >i~ § ~ C\ ~ II) . i ~ _ .1 ~ ~ ~ 1 Notes: ~ 1. Purpose: Priwte boat dockage and erosion contror 2. Datum: ALW 3. Timber to be CCA-treated 3. Existing retoining wall comprised of horizontally stacked 2' x 10·5 will be resheathed with new 2' X 10·5 and reinforced with B' pilings 4. Approxima1ely 15 cubic yords clean sand to be trucked in from uplond source and used as backfill 5. Si1e: Wells Road, Southald, NY; SCTM #1000-70-4-5 6. Ad Owners: 1) Gradowski 2)Hufe PROPOSED DOCK AND RESHEATHING OF RETAINING WALL FOR RICK AND BOBETTE SUTER ON JOCKEY CREEK, SOUTHOLD, SUFFOLK CO" NY SHEET 1 OF 1 1/20/98 'J.,. : . .. Q , , ......~ " II ~ ~ ...~ ::0:: o o o ~ II: :I: I- Z 00 ¡:::C\I 011 W. (f)~ EL,« -- .. .. {¡ .. !! !n - :t ~ ..' " Õ; It! ,. ~ ~ ... C . Ô c . !'1 -..- ~ :J. .. ., 1 ~.~ ~ v "Z - '" , ? ~ ¡: 'lt4l~ ~ ~ "! 1:1(.*.,,- ~~~ ¡---;:-:::.".,::O'_-:1 I'''' L._., "C.' , 'I~;~~ ¡E~-=~::"'- \ . ',~ l~~ I-! -r"1 I ¡ ; -.-, t'd l ---::-') ¡,~ L . .- ·1 ~ "t . ai ~ . . NOTICE TO Þ~JACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of Bobette Garben Suter SCTMUOOQ- 70.-4-5 YOU ARE HEREBY GIVEN NOTICE: 1, That it is the intention of the undersigned to request a ?~rmit from the Board of Trustees to: SEE ATTACHED 2. That the property which is the subject Environmental Review is located adjacent to your property and is described as follows: 3575 wells Road, Southold 3. That the property which is subject to Environmental Review under Chapters 32,37,or 97 of the Town Code is open to public comment, 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 dose not reference any other adjacent that might have to review same proposal. OWNERS NAME: Bobette Garben Suter MAILING ADDRESS: P.Ü, BOX j~~ East Moriches, NY 11940 PHONE~: 516-878-6485 Ene.: Copy of sketch or plan showing proposal for your convenience. · BJltd of Trustees APPlication4IÞ County of Suffolk State of New York ~t ~ s~TB12 BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE ÀPPLICANT FOR THE ABOVE DESCRIBED PERMIT ( S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/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 APPLI CANT AGREES TO HOLD THE TOWN OF SOTJTHOLD 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. SWORN TO BEFORE ME THIS /&~ r;l1j7L ~ {/ Notary Public JUOfTHCRONIN "~.VCounPulllic, State of N.Y. -- IV· No. 4897526 Cornm, EIC IÍ'M June 1, ''::; c¡ 7 B~d of Trustees APPlicatioJIÞ AUTHORIZATION (where the applicant is not I, esiding the owner) atW. ~~ ~Aq _ (mailing address j ( (print owner -\)q~T IVCØCr-M( r--JY\ ug4Qdo hereby authorize (Agent) EN 0-/ (2JNSU Llì4Nff to apply for permit(s) from the Southold Board of Town Trustees on my behalf. ~~a~ ~~~CV1ðe Fáe. tj)t>~ LL{MAN 0Al$9-J 8 . . . APPLICANT TRANSACTIONAL DISCLOSURE FORK The Town of Sou~hold's Code of E~hic8 prohibi~s conflic~s of in~eres~ on ~he par\; of ~own officers and employees. The £!!.!pose of ~his form is to provide information which can alert the ~own of possible conflic~s of interest and allow it to take whatever action is necessary to avoid same. YOUR NAHEI e.- Last name. first name, m ddle in tial, unless you are applying in the name of someone eise or other entity, such as a company. If so, indicate ~he o~her person's or company's name.) NATURE OF APPLICATION I (Check all that apply.) Tax grievance variance Change Of zone ^p.p~Dval of plat Exemption from plat or official map Other (If "Other," name the activity.) 110 you personally (or ""rough your company, spouse, sibling, parent, or child) have a relationship vith any officer or employee of the Tovn of Southold1 "Relationship" Includes by blood, marriage, or buølneøø Intereøt. "Duslneøø interest" means a busineøs, 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 ownø Blore than 5% of the shareB. YES NO x If you anBwered "YES," complete the balance of thlB 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 applican~) and the town officer or 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 that apply). A) the owner of greater than 5% of the shares of the corporate stocle of the applicant (when the applicant is a corporation), B) the legal or beneficial owner of any interest in a noncorpora~e'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 Sob."'.dL~'99Jf- Sign"",. ~ Print name ' -l!f€iZ.