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Home My WebLink AboutTR-5526 ,'.",... ~.....--.-!-~._...!~-_. "-..'., .. '~'-'-~" "-'-'"-!"'" .- TERMS and CONDmONS n.e Permittee Dr. Thomas Falco 945 Lighthouse Lane, Southold ~u ~~u port of !be coasideration for !be is$o"nœ of die Permit does uøcIersÞod and pœsaibe to the fol- lowing : 1. That !be said Board of TtuStees and the Town of SoutboId are released &em aD)' and all damages, Ot' claims foe damap. of suits arisiøg dhecd.y Ot' iDdåecdy as . result of aD)' OF" adoo perfomaecl punuaat to this permit. and the said }'o-. "'..... will, at his Ot' bet own apcosr. defend aD)' ud alllIich 1Uiu"/"It/'œoI by tbitd Puda. ud the said P. "t ~ ......... IallIiIW1kJ with reipect thereto, to !be ~ ...........w. of !be Board of T~ of !be Town of S .0(' !Id 2. That this PetmIt is ftIid fOI: apedod of 24 IDOS. ....r.kh is co. vim t to be the --'.eiI dme·~ 10 <OinpIete !be wod< la_heel, but·ibøaId CÙCDIiISWICa --. request for en exœasion may be made to tile Board at . 1aw: daII:. ~. That this Permit should be ret.iaed iadeCmitely, or u Ioog u !be said ~ wúbes to . "",¡_I" tile sttuaure or ptoject lavolved, to provide evidenœ to anyone <OOœØ>ed that auth- orization was origiðally obtaiaed. 4. That me wodcinvolved will be subject to !be ¡,,<pectIon ud apptonI of !be Board oe Jø ageøts, end aoa-oomp1iance with. the provisioøs of !be -;g¡-,;"g appIiatioa, may be ClOSe fOt' revocation of this Permit by resolution of !be said Board. 5. That there will be DO ....-sonabIe laterfereaœ with aavigatiøa u a result of !be wock herein aåtborized. 6. That there sbaII be DO iaterfereoce with the right of the pabIic to pass and repus a1œg the beach between high and ~ _ter marks. 7. That il future operations of the Town of Soutbo1d nqaire the ftIDOftI aod¡oe aIteratioas Ia !be Ioc:atioo of !be wod< bereia _Iboti-I. or il, Ia !be opiaIoo of !be Board of Trustees, !be wack sbaII cause unreasooobIe obslruCbOO to free aaYig>o"O'\ !be said 1'. MoI"~ will be œc¡uIred. upoa. due ootiœ, to remove or alter this wodc or project herein stated without ~~ to !be Town of Soutbolcl. 8. That the said Board will be notified by the Permittee ot 1be ( ~ of !be wodc auth- oriæd. 9. That the Permiuee will obtain all other permits and r:oaseall diu may be ~ ...... p1emeatal to this permit wbkb _y be IlUbject to revoIœ upaa failure to obtaia -. , , ,. , ',' , . ,".. , . . . . , , , , . , . , , . , , ,~.. .,. ,. ,to, , .. , ,-,~'-'--""""". 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 April 26, 2002 Dr. Thomas Falco 945 Lighthouse Lane Southold, NY 11971 RE: 945 Lighthouse Lane, South old SCTM#70-6-32 Dear Dr. Falco: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, April 24, 2002 regarding the above matter: WHEREAS, DR. THOMAS FALCO applied to the Southoid Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated March 20, 2002, 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 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 ofthe 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 DR. THOMAS FALCO to construct a 708 sq. ft. second-floor addition on the existing residence. BE IT FURTHER RESOLVED that this detennination should not be considered a detennination made for any other Department or Agency, which may also have an application pending for the same or similar project. Pennit to construct and complete project will expire two years from the date it is signed. Fees must be paid, if applicable, and pennit issued within six months ofthe 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, ~~/~~·Ú {¡ , ye, Albert J. Krups 1, Jr. President, Board of Trustees AJK/lms . . ~ Telephone (631) ï65-1892 Town Hall.. 53095 Main Road P.O. Bolt 1119 Soutbold. New York 11971 . SOUTROLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Thursday, April 18, 2002, the following recommendation was made: Moved by Nicholas Dickerson, seconded by Jason Petrucci, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the Wetland Permit Application of DR. THOMAS FALCO to construct a 708 sq.ft. second- floor addition on the existing residence. Located: 945 Lighthouse Lane, Southold. SCTM#70-6-32 Vote of Council: Ayes: All Motion Carried ~ ., j \ . . ;.1-........ f I" ~ r ',' , , ',:L - -', . I f " I ., , I· ." ~ " ! \-.' o· j. I \í'~~ ~ ,. I \ ,~ .j I .j ! [V " . T 0 H- I I (. '» -' 1 /,./ '/' '\ . ß/';% 'j ( '- , I ,\ -~ ., 'J \ --. . ~ o . ~ Or-- ~ ~ ~ g ! ~ ~ ¡ . "II II , It , ¡ II ~:t ~~.. ~ 8i -~ a~· I :;~. ~.!!I!' ¡;i!j· I ,,«, u~'ª 01 j:l:i " ,Iíll ::.- ~ i E ~ 'i¡!!¡ i!l$h \ \ ,j 1111111 'I', . I?II!!! ¡;·!1jj1 M,nl Iii Ii : ~ i ; t IIIII II I' ¡ II ,~ II I [ \1\ H¡ ! ~ H;! ¡II)IIII , ui ie!l! I Iii ,j ¡ i , ¡!el ¡ ! , .\ c~ ~~ ~. , , , , . ~~ " .. , , ' , . , , , , , -------¡ ;¡~ . ,j;:" ¡.J i:1i'! ¡'{q .~. .:,. ~.-. -,. ¡~i' ~ .~.. ., ¡~;.;. c:; r'(': I'}' .;~~ ":." ~f~.· ,í; <t'<, ~~'.:¡ I" ~ , !! ~ II ¡" o . '<:::"t" . ! 'I ' ¡IHil I,II 'l,i:1: I:! !I, :Id Illii -,,,,U"'ZQ ~ .- .' . ¡;,:" , ~. ,I' . "I' ,;:......"'...d::'" r .' ., ' .. ~ :,',1 . . ,..' . I I I I . . 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 Office Use Only Coastal Erosion Permit Application -:;7Wetland Permit Application .",.... Major Minor _ Waiver/Amendment/Changes ....Received Application: .......Received Fee:$ fj..oo- -COmpleted Application~ _Incomplete . SEQRA Classification: Type I_Type II_Unlisted_ MN{ 2 0 . Coordination:(date sent) -CAC Referral Sent:~ . ,.-vate ofInspection:~ L-- _Receipt ofCAC Report: _Lead Agency Determination: Technical Review: ~blic HearingHe~ _Resolution: Y(QX\ \..~~.- (!;J0 Name of Applicant DR.. "THoMAS F-.....L~ 0 Address--345 LIc"HT>-k:>l..I,;F_ L.A. I '""""UTI-!- Hol..J? Phone Number:(,,-,) -¡ {;,oS - c¡ <ð<14 Suffolk County Tax Map Number: 1000 - 10 - Co - :32... ~~-I ~\~ ~~ '7 Property Location: 4 45 LI6HTHOU,,;E:. LA.. 'SoU.THo' 0 . N ¥- ~1VAï£ ~ öFF ÞJHe..~ l2..oA.D EA6í of oA."-LAJ...JÑ p^..A.O_ (provide LILCO Pole #, distance to cross streets, ánd location) AGENT: ~ ~~ Fo~ ÓÄ~ÍJc>N.s ~\.-y / DR. -THo""".=> FALc.o (If applicable) , ~~- Address: 2.'9 c:c...tT1"2-AL.. .Þ>¥"E-. i-4Auf:"P~ NY Phone: ~) 2.2:4 - ßB5b . . Board of Trustees Application GENERAL DATA Land Area (in square feet): ~B.I '2. 9 ~ Area Zoning: Previous use of property: - FAIYII L¡ ~E:6Ir:>E:.Nc::.F_ Intended use of property: ~IV\~ Prior permits/approvals for site improvements: Agency ""OUTHo/.-C> P>Lc>Ä Diõ-Pï. Date .JAN., 19~"> _ 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/A Project Description (use attachments if necessary): CöN.5T/2.UGT A 70= = -So F. ,sE.?c"..h::::> FL..oð42.. Àl?DIT'ðN. oN ExI6TII-,k,:> ~""C>Er-J<:::.E - . . Board of Trustees Application WETLANDITRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: I-FAN1IL..j RESiDE.Ñc.E.- Area of wetlands on lot: o square feet Percent coverage of lot: 5 % (§XI£"INé¡ ~P""oPo:='ED) Closest distance between nearest existing structure and upland edge of wetlands: "J2. "! feet (e>",.s".... ",) Closest distance between nearest proposed structure and upland edge of wetlands: 42. feet Does the project involve excavation or filling? No -/ Yes If yes, how much material will be excavated? :.. 2. cubic yards (.3 - PiER.=;, ) How much material will be filled? <:> cubic yards Depth of which material will be removed or deposited: .3 feet Proposed slope throughout the area of operations: c:> /- ~Lope. Manner in which material will be removed or deposited: HAND DI6i61~ Fo~ Pr SI2.S 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 ¡fappropriate): N ð i=-FF&:=ï oÇZ.. I.....,p~. . . Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: /;""N~= ¡¿:;r ~<"<::>No FI rr->D ÅDDITI~ /0 ExI:ST"".J4 ~Gu:oE.N....-E._ E><'5TIN,," Are wetlands present within 100 feet of the proposed activity? (ðLl LI<HEAO) No V Yes Does the project involve excavation or filling? No V Yes If Yes, how much material will be excavated? 1- 2.. (cubic yards) How much material will be filled? o (cubic yards) Manner in which material will be removed or deposited: HANt"":> 1::>1416"..1 ......~ FoçZ. P E.J2- S Describe the nature and extent of the environmental impacts reasonably anticipated resulting ITom implementation of the project as proposed. (Use attachments ¡fnecessary) No E.NVI~TAL It-<"\pl5..Cí ÀNTIc:::IPATE.O. M ;..lol2- t:>E.¿..oNp rl..-cx:>R.. Acx::>ITloa-! To E.-'< 1ST ,''' ci g{;6DE-~E. . STEPHEN S. FONTANA, ARCHITECT 29 Central Avenue HAUPPAUGE, NEW YORK 11788 l1[3uu. @[? Uœ&U:!J@[ìYA]OUU&l1 (516) 234-8855 DATE 03/21/02 I JOB NO. ATTENTION RE: Dr. Thomas Falco 945 Lighthouse La. , Southold Tax Map # 1000-70-6-32 TO Board of Trustees, Town of Southold Town Hall 53095 Route 25, PO Box 1179 Southold, NY 11971-0959 WE ARE SENDING YOU > o Attached o Under separate cover via o Shop drawings o Copy of letter o Prints o Plans o Samples the following items: D Specifications o Change order o COPIES DATE NO. DESCRIPTION 1 03/21/02 Proof of Mailing Notice (2) Original Certified Mail Receipts MAl-< ;> ? THESE ARE TRANSMITTED as checked below: o For approval D Approved as submitted 0 Resubmit copies for approval 0 Submit copies for distribution 0 Return corrected prints o For your use o Approved as noted > D As requested D Returned for corrections o For review and comment o o FOR BIDS DUE o PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO SIGNED: Steve Fontana .'Õ' at once. . . Board of Trustees Application County of Suffolk State of New York bl2.. THot-<1A~ FAL.:::.o BEING DULY SWORN DEPOSES AND AFFIRMS THAT HElSHE IS TIIE APPLICANT FOR TIIE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO TIIE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN TIIE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY TIIE SOUTHOLD TOWN BOARD OF TRUSTEES. TIIE APPLICANT AGREES TO HOLD TIIE TOWN OF SOUTHOLD AND TIIE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTIÆ OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, TIIEIR AGENT(S) OR REPRESENTATIVES(S), TO ENŒR ONTO MY PROPERTY TO INSPECT TIIE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. iJ~J.re ~ SWORN TO BEFORE ME THIS / j- DAY OF /JJt:1v<-c/-- ,2002- DEBORAH L. KELL V No18ry NIle, S1aIt of New Volt< No.01KE603718e QuoIfted In S.- CaoIIIy CommiBBian EJqiao Feœu.y 14. 20~ f1..¿....c-L -t.. /C£Æ[) Notary Public . . pri nt or Type: 1) ACCESS CONSENT FORM FOR ACCESS THROUGH PRIVATE PROPERTY Office use Only File #: Permit #: Þ42.. THot-<1A$ FAL&¿J (Name of Applicant) (Address) 2 ) '0 ßE.. De..T~ "-~F.-::> (Name & Address of Contractor Involved) 3) 4) 5) 4' 4-5 '-I úo> HT 1-10 ll:<".E. L..At-i liE.. . (Project Location) / ~....~ 1000-70 -" - 3"2... (s.C. LM. #) L/4HTHOU:SE- ~E.. (Name of Road or Private Property Involved) (Hamlet) (Name & Address of Homeowners Association / Property Owner) 6) ¿"OÑ,s-rI2U¿:;¡- A 7 oÇ>, ~"F. 2.!"""=' Pl.-oolL Al:::>C>'lloN (Brief Job Description) 7) 8) 9) Starting Date: Ceo/ I J 0 "2- , , 11//02- , . Completion Date: 111,..,00 Estimated Cost of Proposed Work: Insurance Coverage: A. The coverage required to be extended to the Property Owner: Bodily injury & Property Damage; $300,000/$500,000 Bodily Injury & $50,000 Property Damage. B. Insurance Company: C. Insurance Agent Name & Telephone # D. Policy # : E. State whether policy or certification is on file with the Trustees Office: (If no, Provide a copy with Application) (yes/no) -I~vf~~ ---CSignature of Applicant) (Date) ------------------------------------------------------------------ To be completed by the Property Owner: I/We the undersigned, fully understand the nature of the Proposed Work referenced above and have no obj ect i on to all owi ng the Applicant to cross My/Our Property to do the work. (Signature of the Property Owner or dul y aut hori zed represent at i ve) . . Office use only File #: Permit #: TOWN OF SOUTHOLD HIGHWAY DEPARTMENT PECONIC LANE PECONIC, NEW YORK 11958 Print or Type: 1) 2) 3) 4) PERMIT & BOND APPLICATION FOR ACCESS THROUGH TOWN OWNED PROPERTY De... TH-ðr-<)AS FA1-¿. c::> q +5 1-¡61·m-k~LJ~ /....ÃÑE, "'-"" m-IoU:::> (Name of Applicant) , (Address) 10 .1?::JF_ l:::>E:jE~It4~ (Name & Address of Contractor Involved) -=:I 45 1-1 Q HTHC> U sÆ- I -Þ....~ 4->. T1"1-10'-= (Project Location) \-1 6. t-IT"I-tc:>u SE- l-ANE. (Name of Road or Town Property Involved) 1000- ÎC> - ~ - 3.'2- (S.C.T.M. #) (Hamlet) 5 ) . C-=t-J5TI2.U GT þ.. 108 :;So F_ ¿rJC> FL-o= ,l\C>c::>¡-noÑ (Brief Job Description) 6) 7) 8) Starting Date: ¿;,/ I 102- , , Completion Date: ~I .I o:L il7oC">o , Estimated Cost of Proposed Work: Insurance Coverage: A. The coverage required to be extended to the Town: Bodily injury & Property Damage; $300,000/$500,000 Bodily Injury & $50,000 Property Damage B. Insurance Company: C. Insurance Agent Name & Telephone # D. E. Policy # : State whether policy or certification is on file with the Highway Department: (If no, Provide a copy with Application) (yes/no) ------------------------------------------------------------------ (Signature of Applicant) To be completed by the Superintendent of Highways: Bond Amount Required: (Signature) ·' 14-16-4 (2187)- Text 12 I PROJECT 1.0. NUMSER .. I . 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only SEQ PART I-PROJECT INFORMATION (To be completed by Aoplicant or Project sponsor) 1. APPl.ICANT 'SPONSOA I 2. PAOJEC7 NAME bl2.- T¡'+ol'<1AS FAl-¿.o FAl...c:;.o RE-SI~c1" _ 3. PROJECT LOCATION: Municlpallly 5oUT¡.o \...D County :SuFF=l-I<. 4. PAEC:SE LOCATION (Street aadress anCl road Intersections. prominent landmarks, etc" or provlae map) 'q45 L/4HTHðU6E. ~-' ~HH<::>L-O - - 5. IS PROPOSED ACTION; o New ~panSion o Modification/alteration 6. DeSCRIBE PROJECT BRIEFLY: c:.oN6~ 708 ~..F. ::~...-~ Fl.-ool2... ADD'TIq.l 7. AMOUNT OF LAND AF~ëCTED: Initially 1.57 acres Ultimately 1.~7 acres a. \f~ ?RQ?0SED ACilON CQMPl'f WITH 8<ISï!NG ZONING OR OTHER EXISTING LAND USE MES, RIC710NS? Yes 0 No If No. descnbe bri'!fly 9. WHAT!S ?AESENT LANù u::=E IN VICINITY OF ?ROJECT? n , - AReSldentl81 Descnbe: D.!naus.rzal ....... Commercial o AgricUlture _ Park/Forest/Ocen space LJ Other 10, DOES A..C710N INVOLVE A PISRMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY ~ROM ANY OTHER GOVERNMENTAL AGENCY {F::DEAAL. STATE OR LOCAU? ...8-Ves 0 No If yes. list agency(s) and permiUaoorovals :SOLITH/"toL.O Iòu ILO¡..:Jc::¡: De,pr. .'" 11. DOES ANY ASPECT OF THE ACnOr..¡ HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? o Yes· ~o /I yl!S, list aQency name and permiUapproval 12. AS A AESULT OF PROPOSED ACTION WIL!.. S(ISTING PERMIT/APPROVAL ñEaUIRE .'w10QIFIC),'iION? o Yes ~ò I CErìTtFY THAT ïHE INFORMATION PROVIDED AeOvE IS TRUE 70 THE 3EST OF MY KNCWL~DGE ),pplican!Jspansor name: O..e' ..~/ 11/ 02- Slçnature: If the action is in the Cons tal Area, and "Iou are a state agency, complete the Coastal Assessment Form beiore proceeding with this a:jjessment OVER PA?7 !I_=N'JIRONMEZ'l7;'" ·S.MENï ,-:--:J 1;),= C::H7i:::ie~e'J :y.Açe!"1c· J .!¡. :CES ;.C7:Ç,'I S":CE=':: ':'NY , ~=. 7¡-,RE5¡-:CLJ ~N -) ·\':'C?F. ;:¡'='F.T -):7. ~::... ;1 'f'!s. ::ocrarnatl!t ::"Ie rSVII!iW =roc~s:! ;Lna 'JS't ~r.e =:":L_ =:-:A'= .-' \ ,·~~S ,'\10 =, 'NIL!.. AC71CN :=IE':::':V~ :::;CRDIN...,~J .=!.E'/IE'N.:..5 .:J~.C'J!aE~ =·:ñ '.mLS7":':J .:.C71CN$ iN 5 .'\IYÇ:='R, ~A¡;ï -)~T.37 if '~o, :!..1e-:;:it:l/e ::ec:ar2 may ::,¡e Sucersece~ ~y !.ncm~er :nl/olveO aç:enC"f, L.: Yes . So G, C':ULD ..:.C7iCN .~.E5UL7 :N ,1,NY .J.DVERSE ::=:=='·:75 ASSCC:"; ï=:J ·.vlï~ ":"":-iE :=,:)U,..;3WING: :AnS',yers :¡Jay ::.e 1ãnCWrrC!e". .f :e;:lcle! C1. =-'Iisung 31r ~ualit'I, 3urraC2 or ~rQl.:na'Nate~ cuality ~r ::=l.:anU!y, "OIse ;e'/eIS, ~x:S:lng :raific ::-ac;:er:'\S, SOlic .vas;:e ::Irocl.:c~:=n ::Ir ::lIs.::.: ;::IOlenUal fer :!rosion, :::ramaqe- or :Iooc:!inq :JrOClems? E.:~O!atn ::,¡nerly: C2. ),~sU'leUc, açric:..IItural, 1rC:'IaeoIOgu:al. :1iSianc. Jr Jtner .1at:Jral ::Ir cultural ~escurc!s: '::Ir ::ommun1ty or .1eH;¡¡Cctnood ':::;¡rac:~r? ~clail' _ c:.. 'leçelaIlon or :auna. :Isn, :3r:eilfisl'l ar 'Nlicllile $õ;~:es. :3u~míicant ~aDita(s. ~r :nre3tanea or ~nc:anc;ereQ .=cec:es? Ë.::CI'¡1f\ ::)t!elly~ c~. A c::mmunlty's existinç ;Jlans or ·10<l.ls as otflc:aJly aOOOleo. ~r a cnange In use or intenSity or use 01 land or :Jther natUral re~ourca:s7 Explain :=r cs, Growln, $uoseauent -:evelooment. ~r relatea aC:lvltles likelY !O :::Ie InduceO :JY !ne :roooseo ac:ion? ::.x::¡lalM ~t!eilv, ':5. !-cng :erm, Short :er:n. .::.:mulative. :Jr ~Iher !!ffec:s not ICenrifieo in C~~S7 =X,:lIalM 'Jrtefl'/, ::t¡:e~ Imoac:s :inc;...c;:nç :::':ançes ,n :Jse of !!tner quanmy ':lr :y¡;:e at ~nergy,? ~:Haln :;net!y, ::i. ,5 ':"t-!!:;:¡,E.':A ,S 7¡-'E~E '_:!<2::",::' ':"0 3E. ::::r¡ï;::¡OVE?5Y ::::I.E!..Aï:::~ 7'0 ¡:¡QTENÎ!;'.... "':"':IJ=~Së ~N\¡¡fìONMe7;'L ,~"'Pc..C73'? _'fes ~,~IO :f ':'es, ~xc!aln ::mellv AR, III-OE"ï",RMINAïION OF SiGNIFICANCE ¡To ~e comoleted ~y Agency) !NSïnUCiIONS: For ~3C:'l adverse 2tfec-:: identified at:cve. determine 'Nnether it is substantial. Jarge. ¡mcortan[ or orl'1erwise siGnific =,3,C:l ~ifec-: silould ~e assessed in connection with Its (a) 5etting (Le. urean or rural); (b) .Jrobacility of oc:::~g; (c} durarion' irreversIbility; ie geogracnic 3coce: ana (t) magnitude. If necessary, add aUac;,ments or reference supporting materials. ::'1~ure 2XClanations ccnralO sutfic:ent ae!all to snow that aU ~e!e'lant adverse impacts have been iaentifiec: ana adequately aCcressec, C:1ecK ~his box if 'IOU ¡1ave identifiea one Qr iTlore ::otentially larçe or significant aC'Ierse imoac:s whic:1 ~.1.;....; oc:':.Jr. ïhen 'Jrcc~~c airec:I'I :0 :ne ¡::ULL ::AF 3.naior prepare a pOSitive" dec!araticn, C;'ec:< this :Jox if you have de~ermlned. ::lased on the information and analysis above and any suOOOrtj:;c coc:.Jr.1entancn. :nat ~r.e :JroCOS2d a.c~ion ':IILL ~~OT result in..$.-ny significant adverse -=nvlrcnmentê,1 imcac:: AND .:Jroviae 'In :iitac:zments as necessary, the reasons 5upç::aning tr1lS determinarion: .....",~ 11 .0:.1<.1 ......I:I1C, ...."nl oJr '''UI: -.:..rT1p. )1 o{~'.vcn\lO'" ·...:n'c::r n ;.......¡¡ ....;...n,:-' ~II¡" "I o(,,~oon~'Olc 0lr,ç~f ;...;n"¡¡UII;!- ~l o(~~COO~IO'~ '';l:''~r '0 .coiO .....;"nc... )'1:0..:..,(1: )1 "'~"':J')'"'f ,Ir .;rr'e·"nl :rr)m 'I:.oon\'o'~ :;:'¡lIçi'rl ~ J.JtC' , Ar;lLt~I\N'r TRANSACTIONAL DISCLOSURE FORM . . The Town of S~u~hold's Code of ~thicð ørohibits conflicts 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 whatever action ie necessary to avoid same. YOUR NAMEI '. ·f: '.".{'¡"'~'\ ", . ! :'··..~:\.¡.~,...!\'t..,4J1:C~..·· FA!.-¿'o THoMAS ., ."..,.,..,. (Last name, first name, mldd.le l~ihiaì.:'·'·ùnleBB 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.) NATORE ov A;IPLI~ATIONI (Check all that apply,) ;.: ~,.;~~)!~i.·; ::~., :~~·:·~'il}l,'·:-·!~'· Tax grievance variance Change of zone Ap'p~~al of plat . Exe~ption from plat or official map other (If "other," name the activity.) A¡:;::>PIT'ON ,f' ..... Do you personally (or through your ~b~pany, epuune, aiblihg, p~rent. or ~hild) have a relationship vith any officer or employee of the 'l'ovn of Southold1 "Relationship" includes by blood, marriage, or business interest. "Ousiness interest" lIIeanA a business, including a partnership, in vhich ~he tovn officer or employee has even a partial ovnership of (or employment by) a corp.oration in vhich the tovn of ricer or employee owns more than 5% of the shares. YBS NO X ." ,.~..' .. If you ansvered aYBS,". complete the balance of ~his torm and date and sign where indicated. Name of person employed by the Town of Southold N./A., Title or position of that person Describs the relationship between yourself (the applicant) and the town officer ør employee, Either cheek the appropriate line ~) through D) and/or des~ribe in the space provided, The town officer or employee br his or her spouss, sibling, parent, or child is (check all that applY)1 h) the owner of greater than 5% of the shares of the corporate stock of the applicånt (when the applicant is a corporation), B) the legal or beneficial owner of any interest in a noncorporate'entity (when the applicant is not a corporation), c) an officer, director, p~rtner, or employee of the applicant, or D) the ~ptual applicant. : ,,' . , . ,,,;~I.r·.. ,',' . .'" DESCRIPTION OF RELATIONSII1P . II, ¡..' . . , ~ . ·n,' . 'I' "'~ .... ,y " " ow' ..' n ,.;.,.. .'., .. t.. ~.I.~II"w~~~a'_.'.. r ,'I . ,_ ,~. .~.. ~;:l~.~,' -...---," . . '. 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