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Home My WebLink AboutTR-5925 Board Of Southold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. . S~~ DATE:. May2f>.Lf004 ISSUED TO .....~y.~?~.~.~....~.y.!~<:;~r:!~1\.u~R,lJ¡,:.~u.....u..u ,"Uu' Aut4nrilatintt Pursuant to the provisions of Chapter 615 of the law¡ of the State of New York, 1893; and Chapter 404 of the law¡ of the State of New York 1952; and the Southold Town Ordinance en- titled "REGULATING ANÐ''fHE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC lANDS and the REMOVAL OF SAND, 6R.oWELOR OTHER MATERIALS FROM lANDS UNDER TOWN WATERS;!'. and in accordance with the Resolution of The Board adopted at a meeting held on ...~"y'..2.6..L. ?-º-º.~., and in consideration of the sum of $u2Sº.,ºO ... paid by Rudolph & Virginia Bruer '" ..... ................................. ......·.n...·..... ... ..............,...... .........................._..........................._... of ..u~?':'t':'':'!cI..m .. .......u N. Y. and subject to the Terms and Conditions listed on the reverse sIde hereof, of Southold Town Trustees authorizes and permits the foRowing: Wetland P~rmit for the existi,?-g S'XS6: dock and two (2) moorIng pIles. of WhICh one 1:;; ¡(?-.illl~. c!9.1p.I1~n. .. . aU in accordance with the detailed specifications as presented in . the originating application. . IN WITNESS WHEREOF, The said Board Of Trustees h.ere- by causes its Cor)orat~ ~al to be a~uted, and these ~sents to be subscn'bed by a mðority of the said Board as of this date. TERMS and CONDI11ONS TÞe Permittee Rudolph & Virginia Bruer 3693 Pine Neck Rd.. Southold ~" K~u pan of cbe coasIdeørloa for !he ¡.....~ of che Pennit does uødeøtaod and prescribe to cbe fol- lowing: ~ 1. 11w the I&id Øoud of T_ and !he Town of Soooð>old ate re1c:ued from lIlY and aU damages, or claims for cIamages, of IUIa uWøg. ditecdy or Iodirecdy as a muIt of Il1'f ope<- adoa performed paauaat to ibis penult, and che laid P-nI- ·wI1J,'tIe'lJis or her own CXþeÐSC. defencl MlY and aU JUCh 1UiÞ'lnkI·wt by Ibhd.,atda, and the I&id 11 .hlt'> ,..."... fa111i1b111ty with respect tbeœto. to the ~ -1'IncIno. of the Bøarð of 1\..11 I n of the Town of ~d 24 2. That this I'eaDIt Is vaUd foe a period of mas. wbk:b Ú CIO'aIl~11[ I to be the eøI....te<J time· nquùcd lID mmp1ete the -m lawtwd, butiboaJd ~..- wutII1t, request for 111 exœasion may be made to the Ðoud at a Iaœr a.œ. 3. That Ibis PCQIIÎt sbould be IetaIned indefinitely, or as loog as cbe I&id Po ,.,~ wbbes lID . ",.¡nr.ln the _ Ot project lavolved, to provide evidaJœ lID anyone concemed Ihu tuth- orizIdon ...... origiaa11y oIvl-t. 4. That che wodc åmllvec1 will be subject to the ~ and apprcm1 of dae Boad or Ia agents, and ~n..".,. with che prooisioas of the ~-~ appIicadoa, l1li7 be couse for moocaåon of Ibis Pamit by raoludon of the said Boud. S. 11w tbeœ will be no WIftOJ()ft.Id~ latederence with ..mpdoa as a raaIt of tbe wodc baeIn auèborized. . 6. 11w tbeœ sbaU be DO iatedeuøœ with the rip of dae puhUc to pus and repus aIœg the beach betncel> hIP and low _ter muks. ' 7. 11w if fomre op-tloos of cbe Towa of SoI>tboI4 reqaiœ the -.I and/or allJe'1'tIonf In the 10-0"- of the wodc herein ...ø. 0 '- <t, or If, Ia the opI.,Im of_ Øoud of Trusœes, the . ..ark ahalI cause _-"'e obsttucaoo to free øa~ the laid 1"'" "UN will be recpIM. apao due nodce, lID remD\'C or alter ibis wodc or project baeIn stated .dtL....t eIJ*'"' f to the Town . of SouthoId. . 8. 11w tbe aid Board will be aodfied by tbe I'uAdace 01 the <'~r.L . Of the wodc aath- oti2ed. 9. That tbep...rnl.- will GbtaIo all ocher peaaia and ~o ...... 'that l1li7 be nquùcd sap. pIemon"" CO Ibis permit ~ DlR'fbe IIIbect to moire apoo faUøre CO obtúa ame. ._..'.._,,-~.- _ ~~_~_H___~_... ._""~---",,,."., .,- , ."'--.-...- . . 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 26, 2004 Mr. & Mrs, Rudolph H. Bruer 3693 Pine Neck Rd. South old ,NY 11971 RE: 3693 PINE NECK RD., SOUTHOLD SCTM#70-6·25 Dear Mr. & Mrs. Bruer: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, May 26, 2004 regarding the above matter: WHEREAS, RUDOLPH & VIRGINIA BRUER 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 April 21, 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 May 26, 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 conceming 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 nol affeGt 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 RUDOLPH & VIRGINIA BRUER for the existing 5'X 56' dock and two (2) mooring piles, of which one is a 2-pile dolphin. 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. Inspeclions are required at a fee of $50.00 per inspection, (See attached schedule.) Fees: None Very truly yours, IJ¿'· j- 1/. ~' ~ Albert J, Krups(¡, 'Jr. President, Board of Trustees AJK/lms . . Telephone (631) 765-1892 Town Hall 53095 Route 25 P,O, Box 1179 Southold. New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Tuesday, May 11, 2004, the following recommendation was made: Moved by William Cook, seconded by Don Wilder, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the Wetland Permit application of RUDOLPH & VIRGINIA BRUER for the existing 4'X 56' dock, Located: 3693 Pine Neck Rd., Southold. SCTM#70-6-25 Vote of Council: Ayes: All Motion Carried . j.ti I , I ¡ . : ~::i .~. ¡. l~, Á/I~~ ,,~, "." ;.0 '", / ! !,I! ~~~~ ~----~. ~. ¡, ';';; :,¡?" -: r.. r1~~11! i ~. ! 'I y~. "\ j"~' ~ \,~ ~ lF~,ì . . ¡ ¡ ~ (/ · "~' ~M~; ~ .1~.~~\ \ ~.~~~' 'î ~' ~j,,~~ ai : I ~..- "'o;~~. \\\ :._'0-!:~ . l ¡ I ,~! I · . ;J~I~'" J '. ,J ..ô \, \,~î' :;", < > < ~ ". -:.~. !~?I ' · ~~ . \, ~ . ~ < ;~0' --- ... !/0. 1~ í .\,~ ~ ..... ,..,'®'" ~ 1"1 19~ J\ . 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'\ \ ~\J , l'/ '::J o r IU > (~ :1 ,) l~ ~ 3 ..; ::; C\ <t o i:1 :-,¡ Ii l1J L w z ~ AJbert J, Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson . '. Town Hall 53095 Route 25 P,O, Box 1179 Southold, New York 11971-0959 ( Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Pennit Application ...-we¡land Pennit Application ~ajor - Minor - waiver/~'m;/~Îirs ~ceived Application: _~ceived Fee:$ YI ~J/"' ~HI:IH~ ~ompleted Application _Incomplete _SEQRA Classification: APR 2 1 2004 I~ Type I_Type lI_UnIisted_ Coordination:(date s~ -CAC Referral Sent: ;"'" '/;¡ Soutbo\d 10"'. ~ate oflnspecnon: '" , _Receipt of CAC Report: Board 011rustees _Lead Agency Detennination:_ _Technical Review: Sã/ m _..t'II5lic Hearing Held: - Resolution: Name of Applicant 7? wldf /.... Ii {3YlA.e'( II ¡1,' ""of' IH" c.-k- I? ¿ U' , \ 13 . '{ II>\. \~~ V"t.{:€,V Address '1 rn Or 'j ~1ouÆ¡¡ .¡()J/ f /' Suffolk County Tax Map Number: 1000- / Phone Nurnber:((:,"ð "7 t. S 2t!J ~ "1- c~ ~rJ~\i'\ Property Location: ðW fÎt\ ~ <t> ~ t' rk fL ~a Co k''4t; L'{~~ (provide LILCO Pole #, distance to cross stree ,and location) AJtJUJJ AGENT: (If applicable) Address: Phone: ~oard of Trustees ApPlica~n Area Zoning: GENERAL DATA .<)&?(? ~~~g ()~ r~ ~ ~.k1~..a¿-'l '.I, I r Land Area (in square feet): Previous use of property: Intended use of property: II Prior permits/approvals for site improvements: / ~~Mlo/ (;() Date 7/z/f-~ -~/ ff''3 #t/73 (. t.. ~4 ... r. (/ f. (' ty- t t. " _ 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: . J>roject Description (use attachments if necessary): ~ 0->\~ + gð ~ e>6- ðl~ "- p-e-~ItY\..~ t- ~~ ~(~ ÚJ,^!>h--t.{~+ e...l 19s'1-ltJht) '4 +k ~rt.1J~ I( Y' € fJðI. '.'$. d/)( k ~""'-- ,<)'fð'('Wl dß..INt~'\c2- l' 0t .;ltJð":f./tJt! S-loryv¡gqtLJ~y, v.J.tf. J. t ~ e.. off ~~Ie) ~Board of Trustees ApPlicatlbn WETLANDrrRUSTEE LANDS APPLICA nON DATA Purpose of the proposed operations: ~YrtA ~ + tè ý' ~ (' ~ý1S'A·lld.e.d. (qç~~() ~ -\'"'Æy.:L:- r 'Sd.wt..€ -t2rðVl- t?t16f- úÛ fl-le't ~ý1\..e.t 1-e " Area of wetlands on lot.S., .i~ square feet l( Percent coverage of lot % Closest distance between nearest existing structure and upland edge of wetlands: { t feet Closest distance between nearest proposed structure and upland edge of wetlands: , 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): 11./ a,^~ tlboard of Trustees ApPlica~n COASTAL EROSION APPLICATION DATA Purposes of proposed activity: PI2.v"IM.' f- +¿'\t' J-.t -t-~f4('¿' ~"(f ~I¿? fz:1 úJ UL!;-A-JuJLAj¡);. Are wetlands present within 100 feet of the proposed activity? No---L Yes 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) 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) iJt!)~ '€- PROJECT 10 NUMBER 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. PROJECT NAME . SEQR PART 1 - PROJECT INFORMATION 1. APPLICANT I SPONSOR Jo c.J,¿ ~ ~ County S:;:d::; Roa~~~~~ro~i:n~;;iet$~~7 L ~ v 4. PRECISE lOCATION' 5. IS PROPOSED ACTION: 0 New o Expansion E::}'Modification I alteration 6. DESCRiBE PROJECT BRIEFLY: Þa> c.-k r-'2-"'(W\. ~ 1- 1?5r~ð ¥- I1JLf~'f t..ð tK kv- ~(/ 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 6. Will PROPOSED ACTION COMPLY WITH EXISTING ZONiNG OR OTHER ~es 0 No If no, describe brieny: 9. WHAT is PRESENT LAND USE IN VICiNITY o Residential D Industrial D Commercial OF PROJECT? (Choose as many as apply.) DA9ncutture D Park I Forest I Open Space D Other (describe) " 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or local) [J1'Yes ONO if yes, list agency name and permit I approval: -.5'ð Gl~ r¿ -rtJW t\.. TV '<-Sf~ e <) 11. DOES ¡¡aves ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT DR APPROVAL? DNa If yes. list agency name and permit I approval: p"'.e.... ..e.)( :~..¡.. :"''i cLøJ< 12. AS A RESULT OF PROPOSED ACTION Will EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION? es DNa Applicant I CERTIFY THAT ~ 2~4MAT~~ »OVIDED ABOVE IS TRUE TO THE BEST OF I Sponsor Name ~/r~ MY KNOWlEDGE Date: 0ø/d1 Signature If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment . . PART" - IMPACT ASSESSMENT (To be completed by Lead Aaencvl A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR. PART 617.4? If yes. coordinate the review process and use the FULL EAF. o Yes ONo B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. o Yes ONO C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1 Existing air quality, surface or groundwater quality or quantity. noise levels. existing traffic pattern, solid waste production or disposal, potential for erosion. drainage or flooding problems? Explain briefly: I I C2. Aesthetic, agricultural, archaeological, historic. or other natural or cuhural resources; or community or neighborhood character? Explain briefly: I I C3. Vegetation or fauna. fish. sheltfish or wildlife species, significant habitats. or threatened or endangered species? Explain briefly: I I C4. A communiiy's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other nalural resources? Explain briefly. I I C5. Growth, subsequent development. or related activities likely to be induced by the proposed action? Explain briefly: I I C6. long term, short term, cumulative, or other effects not identified in C1-C5? Explain briefly: I I C7. Other imoacts (inCludina chanaes in use af either auantitv or tyDe of enerav1 ExDlain brieflv: I I D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? (If ves, explain briefly: I DYes 0 No I E. 'ÖH~:sE, 00 ~~ErE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Ifves explain: I PART III· DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is sUbstantial,large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (Le. urban or rural); (b) probability of occurring: (c) duration; (d) irreversibility; (e) geographic scope: and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box jf you have identified one or more potentially large or significant adverse impacts which MAYoccur. Then proceed directly to the FUl EAF and/or prepare a positive declaration. Check this box if you have determined. based on the information and analysis above and any supporting documentation, that the proposed actio WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary. the reasons supporting thi determination. Name of lead Agency Date Pnnl or Type Name of Responsible Ottlcer In Lead Agency Title of Responsible Officer Signature of Responsible Officer in lead Agency Signature of Preparer (II different from responsible officer) . . NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES. TOWN OF SOUTH OLD In the matter of applicant: d? ~ ri-- í lit' "\ ~ " i,. 11"/' t.L '41 '-Í YOU ARE HEREBY GIVEN NOTICE: SCTM# I. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: -Ç'..,... ¡þ ~ ~.Mf~r~ 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: Pc't-\..e.Io\~ l..\<:: ~cl :3t;~fdr IJY' W?7! 3. That the project which is subject to Environmental Review under Chapters 32, 37, and/or 97 of the Town Code is open to public comment on: . You may contact the Trustees Office at 765- I 892 or in writing. The above-referenced proposal is under review of the Board of Trustees of the Town of South old and does not reference any other agency that might have to review same proposaL OWNERS NAME: MAILING ADDRESS: PHONE #: Enc: Copy of sketch or plan showing proposal for your convenience. . . . PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK , residing at , being duly sworn, deposes and says that on the day of ,20-, 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 South old; that said Notices were mailed at the United States Post Office at , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to before me this Day of ,20_ Notary Public 4Itoard of Trustees ApPliCa~n County ofSutTolk State of New York J(IH(,,(~k;Œ,,~'{' J () t (I~~ Jot F ."".DV BEING DULY SWORN DEPOSE AND AFFIRMS THÆ HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HISIHER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND 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 REPRESENTATlVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH W F THI APPLICATION. Signature SWORN TO BEFORE ME THIS 1"5' DAY OF /If"'" ~ I ,:;[ JUDITH B. WURTZ Notal} Public. Statø of New Yor1t No.4787124.~kCowmy Tenn Expires March 30. ~ . Tel, (631) 765-1222 Fax: (631) 765-2752 May 13, 2004 Board of Town Trustees Town of South old Town Hall, 53095 Route 25 P.O. Box 1179 Southold, NY I 1971 Rudolph H. Bruer ATTORNEY AT LAW 55000 MAIN ROAD P.O. BOX 1466 SOUTHOLD, NEW YORK 11971 Re: Bruer, Rudolph H. and Virginia Pine Neck Road, Southold, NY Dear SirlMadam: . Email: rhbruer@hotmail.com S..¡'''1 O pleos UMOl PIO~¡nOS ~ ~ ': : ~ '~' ~ ~ In connection with the above matter, enclosed herewith please find the following: L Affidavit of Posting; 2. Affidavit of Mailing Notice; 3. Transactional Disclosure Form. Thank you for your assistance in this matter. Sincerely, ~~ . . 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 __h.utQt~J\'---~~l~~(ø.J~~Utt-- COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, Btk(flh..'IIlJ('t(~siding at &u¡.¿U It/V being duly sworn, depose and ~ay: ~'nnl.¿ck R' That on the/ð day oflftðvy ,200Ý,I personally posted the property known as by placing the Board of Trustees official poster where it can easily be seen, and that I have checked to be sure the poster has remained in place for eight days prior to the date of the public hearing. Date of hearing noted thereon to be held 01"\ Dated: 5//!}/'W S~rn to before me this f 0" ~ day of 111200 Ý ~~bl~' ~~ CAROL A. MILLER NotarY Public, State 01 New York No. 01 MI6003086 Qualified In Suffolk County 'D D 1/1 CorMIlasion expires February 23, a..... 'f' , . . ~ NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES. TOWN OF SOUTHOLD In the matter of applicant: d?~G;li ~f'\~~,\~ ~"f'¿d1'-Í YOU ARE HEREBY GIVEN NOTICE: SCTM# (000 07() ðG. ;2, I. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: -\...¥ ¡fA ~ ~ .Mf~r~ 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: 3&P9~ fr'l'\ot¿~-e L.\:::: ~"- S:o~fJ( ItJY' WI?! 3. That the project which is subject to Environmental Review under Chapters 32,37, and/or 97 of the Town Code is open to public comment on: W~ Mojac.o'!ðð'" 7 17M. 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 South old and does not reference any other agency that might have to review same proposaL OWNERS NAME: MAILING ADDRESS: PHONE #: Enc: Copy of sketch or plan showing proposal for your convenience. . . APPLICANT/AGENTIREPRESENT ATIVE TRANSACI'IONAL DISCLOSURE FORM The Town of Soutbold's Code of Ethics Drohìbits conflicts of interest on the nart arrow" officers and emnlovccs. The Dumose of this Conn is to Drovide inCormation which can alert the town ofoossible conflicts of interest and allow it to take whatever action is neces.'WV to avoid same. YOUR NAME: 12. ~ '" (11/\ N 111('0. e. Ý (Last ~th.: name, J1iddle initial. unless you are applying in the name or someone else or other entity, such as a company. Ifso. indicate the: other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Variance Change or Zone Approval of plat Exemption from plat or official map Other (If "Other", name the activity.) Building Trustee <./ Coastal Erosion Mooring Planning ~ C k 'U, If'" :,,( Do you personally (or through your company, spouse. sibling, paren~ or child) have a relationship with any officer or employee ofthe Town of Southold? "Relationship" includes by blood. marriage, or business interesl "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 S% of the shares. YES NO / (fyou ans\','ered "YES", complete the balance of this form and date and sign where indicated. Name orperson employed by the Town of Southold ~IÀ ~ (\n~ if,~::;~ Ií Title or position of that person II-' (1J ,~ 1- \ Describe the relationship between yourself (the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space providcd. The town officer or employee or his or her spouse, sibling, paren~ or child is (eheck all that apply): _A) the owner of greater than 5'10 or the shares of the corporate stock or the appliC\IDt (when the applicant is a corporation); _B) the legal or beneficial owner of any interest in a non-corporate entity (when the applieant is not a corporation); . C) an officer, director, partner, or employee of the applican~ or ~D) the actual applicant DESCRIPTION OF RELATIONSHIP ,,<)'L I (- Submitted this Signature Print Name da of 2001 Fonn TS I -ev