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Telephone
(631)765-1892 ~ N Z 5 09 Route 25
D ~ .tC P.O. Box 1179
'yifJOl ~ Southold, New York 11971-0959
CONSERVATION ADVISORY COUNCIL
TOWN OF SOUTHOLD
At the meeting of the Southold Town Conservation Advisory Council held Tuesday, July
13, 2004, the following recommendation was made:
Moved by Don Wilder, seconded by Bill Cook, it was
RESOLVED to recommend to the Southold Town Board of Trustees DISAPPROVAL of
the Wetland Permit application of THEODORE LAOUDIS to construct a 252' retaining
wall within 18" in front of existing retaining wall using C-Loc 4500 vinyl sheathing, 9"
diameter pilirig, and 6'X6' stringers; place 45 to 50 cy. of clean trucked in fill between
existing and new retaining walls; place 1500 to 1800 Ib. boulders in front of new
retaining wall; reconstruct existing 5.5'X 20' stairs; construct a new set of 5..5'X 20' stairs
on the south side of the property; remove and dispose of a total of 107' of bulkhead and
construct a total of 107' of bulkhead using C-Loc 4500 vinyl sheathing; remove and
dispose of the most seaward 20' section of existing jetty and construct a new 20' section
of jetty using C-Loc 4500 vinyl sheathing; remove and dispose of a 35' section of
bulkhead and construct a new 35' section of bulkhead using C-Loc 4500 vinyl
sheathing.
Located: 405 Kimberly Lane, Southold. SCTM#70-13-20.3&20.4
The CAC recommends Disapproval of the application because the survey did not match
the property.
Vote of Council: Ayes: All
Motion Carried
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Theodore Laoudis • Agent: ~ ~ ~ ~ ~
405 Kimberly Lane Costello Marine Contractin Q:~ L~
Southold, NY ] 1937 P. O. Box 2124
Photos taken July 2003 Greenport, NY 11944 JUN 2 g c~tJ4 ~ ,
Southold Town f
Bnard of Trustees
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Theodore Laoudis - Agent:
405 Kimberly Lane Costello Marine Contracting Corp.
Southold, NY 1193'I P. O. Box 2124
Photos taken July 200; Greenport, NY 1 1944
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Theodore Laoudis -Agent:
405 Kimberly Lane Costello Marine Contracting Corp.
Southold, NY 1 1937 P. O. Box 2124
Photos taken July 2003 (ireenport. NY 1 1944
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Theodore Laoudis `a ~ Agent:
405 Kimberly Lane ~ f Costello Marine Contracting Corp.
Southold, NY 11937 P O. Box 2124
Photos taken July 2003 Greenport. NY 1 1944
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Theodore Laoudis agent
405 Kimberly Lane Costello Marine Contracting Corp
Southold, NY 1193 ~ O. Box 2124
Photos taken .Iuly 2003 Greenport, NY 11944
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Theodore Laoudis Agent:
405 Kimberly Lane Costello Marine Contracting Corp.
Southold, NY 11937 P. O. Box 2124
Photos taken 7ul_y 2003 Greenport, NY 11944
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Board Of Southold Town Trustees
SOUTHOLD, NEW YORK
" _
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600 I °
PERMIT NO......_ DATE: _Sep~,....2,2,-...2A04 ~t.
.X
.s
THEODORE LAOUDIS
• ISSUED TO
~1~t~~~t~~tj~Yt
C
Pursuant to the provisions of Chapter 615 of the Laws of
the State of New York, 1893; end Chapter 404 of the Laws of the
State of New York 1952; and the Southold Town Ordinance en-
title~d ."RfGU!AitNG AND ~E FJ~,CING.-OF~BSIRUCIIC~61S _
IN AND ON TOWN WATERS AND PUBLIC LANDS end the
REMOYAL OF SAND, GRAYEL OR OTHER MATERIALS•F~OM
LANDS .UNDER TOWN WATERS;'. and in accordance with 'the
Resolution of The Board adopted et a meeting held on _Sep~~,...~?.....
2004 : ~ and in consideration of the sum of x_250,.00_.,._.... paid by
Theodaae Laoudi.~
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of,.~...Sout~4Q.:Kd N. .Y. and, subject to the
Termz and Conditions listed on they reverse side hereof,
~qf Southold Town Trustees authorizes anr3 permits the fogowing:
WetleM Pemil t0 constlud a 252'relalmnp wall wsmin 76' In hone M exlatln0 retelNnp wan usilp GLac 1500 NnN slroa101np, e'tllemeler I
rapers: place 6510 50 ry. of dean W cketl In fln Eetween etlslinp entl new relalNlp walls; place 150010 i8001b. t .
pillnp, 8r1tl 6' x 6' sM ~
ooultlers In hon1IN new relalNnp well; rec0nswd edstlnp 5.5'%20' Storrs; consWCl anew sal o155'X 20' slalrs on IHe soulb sltla M me
property; relfpve aM depose W e brat 01107' of bulkheatl ono rnnsWC1 a total of 107' 01 bulkheatl using C-lac 6500 NnN sHeaminp; ~ ~ '
remove entl tllspose W Ne mml SbWertl 20'sedian of ertstlrp Jetty aM mnaWd a new 20'sedlon M ~Stty using C-LOC 1500 Nnyt
dreaualro; remove entl tlrepose of a 35' eedbn of HNIeleatl aM c0nstmd a crew 35' eectlan d bulkheetl using PLx 4500 Nnyl aHeeWnp, k;
wi0l th o0ndtlm IN a 16 fool nanoxf Eu6x alOnp Hre bulldiea0 entl th lop wiN be rarovetl from Ore JeHY• entl as tlepldetl on tl1a qan
prsparso by Costello Marine Caltradetl a1W lest tleletl AprR 20, 2004. -
IN WITNESS WHEREOF, The said Board of Trustees here- t
by causes its Corporate Seal to be affixed, and these presents to
. be subscribed by a majority of the said Board .as of this dots.
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T~i„tc p.,a r•.taNniTl(~NS
~ papa Theodone L~aoudi~,
ac SouthoCd N. Y., as .
of the coasIdetadan for the lssuaaoe of the Permit does uaderspmd rand presaffie to the fol-
~8t
i. Thu the acid Hoard of Trustees and the Town of Soudtoid ate released from a~ mod
all dapuges, oc claims for damages, ~ snks atlsigg. ditecdj a /ndlrectly as a «mk of nay open-
-adoa-performed-puewant~ildt.~atdt, ~uxl the .aid Pamitcee_+g1g_u litr__or ~.ow_n_a~}±mse._ .
tkfead any and dL sadt sults'btidated by thitd~atda,.aad the aid ~ttee aswmw Ettll Ba6illty
wkh respect thereto, ~o-theyoorPptete'etcduslon of the Aaard of Trustees of the roan d Soathold
2. That dds PetYnlt h! slid for a Qeriod of 24 tans. athidt 8 dO4nidetbd to be the
estimated time requited m oompkte the work iavotved, but'iheuld dMwartanta wartarx, tognsst
for w eon array tx made to the Board at a !acct tltte:
3. That this Permit should 6e tetllacd indefiaitdy, or as leag as the aid Permiaec whha
m ais.,tain the sttucmte or pr4jea htvolved, to pn~side evIdeaa m anyone concerned that artdt-
pdrxdon was orlgiaaBy obtained. i
` 4. That the trodc lavolved wlB 6e aubjea to `'the iotpeaion and approval of the Bard «
Its agents, and uon-aompliaaae wkh the prarisiom of dre odgitiadog apPliadoq may 6c cease fx
revocation of t61s Permit 6y resohtdoa of the aid Board.
S. Thae there moll! be ao uarnscaahle iataEereoa molds aavlgatloa as a aewtt of the wait
hexda autlwdttd.
6. That there shall 6e to iatetfetetroe with the eight of +dte pa6Bc m pau and tejass tdoa~
the beach 6etwan fiiglt atd kw warn maths.
7. That If fnarce apendoos of the Iowa of SoudtgW require thn removd ao~a alasadaas
is the beation of the wadc fieteia ttathodred, or IE, 1a the opidoa af~dae Soad of Tutasea, tine.
wtwic shall arise mreasoaabk obanuwaa m free tsavigadon, the aid ltamlttee will 6e requited, _
ttpoa clue aotioe, m mmove trr alter thh wetk a ptojac beteio stated wBhax s:pea+a m the t'own'
• . of Southold. ~ .
a Thu the aid Boas moll! be rodfied by the Petmiaee a the eomptaiea._oE dte wtdc aath•
«laed.
9. That the •P~,iaee will abada all trdser petmiu and tnmeate •e>k mg 6e regairod tap
plemeaal m this permit which may •be tadsjea w trwelm upon lydiaae a abada awe.
Og~FFO(,~
Albert J. Krupski, President CQ Town Hall
James King, Vice-President TY~ 53095 Route 25
Artie Foster ON - P.O. Box 1179
Ken Poliwoda ~ • ~ Southold, New York 11971-0959
Peggy Dickerson J,~O a~~ Telephone 1631') 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
September 22, 2004
Costello Marine Contracting Corp.
P.O. Box 2124
Greenport, NY 11944
RE: THEODORE LAOUDIS
405 KIMBERLY LANE, SOUTHOLD
SCTM# TO-13-20.3,20.4
Dear Mr. Costello:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday September 22, 2004, regarding the above matter:
WHEREAS, John Costello as agent for THEODORE LAOUDIS 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 June 29,
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 September 22, 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
concerning this application, and,
WHEREAS, the structure complies with the standards set forth in Chapter 97 of the
Southold Town Code,
z • •
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,
RESOLVED, that the Board of Trustees approve the application of John Costello as
agent for THEODORE L.AOUDIS to construct a 252' retaining wall within 18" in front of
existing retaining wall using C-Loc 4500 vinyl sheathing, 9"diameter piling, and 6' x 6'
stringers; place 45 to 50 cy. of clean trucked in fill between existing and new retaining
walls; place 1500 to 1800 Ib. boulders in front of new retaining wall; reconstruct existing
5.5'X 20' stairs; construct a new set of 5.5'X 20' stairs on the south side of the property;
remove and dispose of a total of 107' of bulkhead and construct a total of 107' of
bulkhead using C-Loc 4500 vinyl sheathing; remove and dispose of the most seaward
20' section of existing jetty and construct a new 20' section of jetty using C-Loc 4500
vinyl sheathing; remove and dispose of a 35' section of bulkhead and construct a new
35' section of bulkhead using C-Loc 4500 vinyl sheathing, with the condition of a 15 foot
nonturt buffer along the bulkhead and the top will be removed from the jetty, and as
depicted on the plan prepared by Costello Marine Contracted and last dated April 20,
2004.
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.
Inspections are required at a fee of $50.00 per inspection. (See attached schedule.)
This is not a determination from any other agency.
Fees: $50.00
Very truly yours,
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/hct
Albert J. Krupeki, Preaident~ • Town Hall
James King, Vice-President `Q$VFf~(A'C 53096 Route 26
Artie Foster ~~0~ ~ P.O. Box 1179
Ken Poliwoda ~ Southold, New York 11971-0959
Peggy A. Dickerson Z Telephone (631) 766-1892
'i0 ~ Fax (631) 766-1366
BOARD OF TOWN TRU$TEE$
TOWN OF SOU'PHOLD
YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES
72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN
APPOINTMENT FOR APRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO
SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE
PERMIT.
~Ct Oc1 cK~ S
INSPECTION SCHEDULE
Pre-construction, hay bale line
_ 1$` day of construction
'/z constructed
Project complete, compliance inspection.
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Vlclnlty map Locatlo n Map
® Applicant Adjacent Property Owners
I " = 8001 ~ ~ I "=300'
SGTM# 1000-70- 13-20.35, 20.36 4 20.4 1000-70- 13-20.2 1000-70- 13-20.5
Theodore Laoudig Ryck Koke Jay P. Mandelbaum ti Lauren Gordon
23 Van Buren Court 245 Kimberly lane 1088 park Avenue -Apt 9-D
Cresskill, NJ 07626 Southold, NY I 1937 New York, NY I O 128
(405 Kimberly Lane, Southold, NY I 1937) (825 Kimberly Lane, Southold, NY I 1937
Project Description:
•Construct a 252' retaining wall within 18" in front of existing retaining wall
using C-LOC 4500 vinyl sheathing, 9" diameter piling, and 6" X 6" stringers.
•Place 45 to 50 cubic yards of clean trucked in fell betwee and
new retammg walls. D ~ ~ ~ D lln 2
•Place 1500 to 1800 Ib boulders in front of new retalnin U lS D,
JUN 2 g 2u04
•Reconstruct existing 5.5' X 20' stairs.
Southold iown
•Construct a new set of 5.5' X 20' stairs on the south sl .trustees
•Remove and dispose of a total of 107' of bulkhead. Construct a total of
107' of new bulkhead using C-LOC 4500 vinyl sheathing.
•Remove and dispose of the most Seaward 20' section of existing betty.
Construct a new 20' section of betty using C-LOC 4500 vinyl sheathing.
•Remove and dispose of a 35' section of bulkhead. Construct a new 35'
section of bulkhead using C-LOC 4500 vinyl sheathing.
Theodore l~oudis
Prepared by: SCTM# 1000-70- 13-20.35,
Costello Manne Contracting Corp. 20.36 t 20.4
P.O. Box 2 124 Grccnport, NY I 1944 Prepared 04-20-04
Ph. 63 I -477- 1199 Sheet I of 6
~~~'1E ~~LA~~T - ~
Kimberly Lane
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eka~' ~cu'o
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Frame
i 500 to house Existing Conc. Wall to remaln
o
~de s / xlsting 252' Retalning Wall to
r-~r.-rrrr. .Trsrss.-s .:.T.- remaln
Proposed Proposed 2~2' Retalning
5.5' X 20' wall w/m 18" of Existing nsting 5.5' x 20'
- Stairs - Stairs to be
Reconstructed
Scale
®
I -~5 See Pa e 3 Southold Bay
9
For Deta I I Theodore Laoud~s
Prepared by: BCiMN 1000-70- 13-20.35,
Castello Manne Contracting Corp. 20.36 t 20.4
P.O. Box 21 24 Greenport, NY I 1944 Prepared 04-20-04
Ph. 63 I -477- 1199 Sheet 2 of 6
DETAIL, ®F SITE PLAN
1
Frame
douse
xlsting onc.
all to remain Exlsting 252' Retaining
Wall to Remain
Wood Bulkhead
0 0 0 0 0-0 0 0 0 o s~ 0 0 0 0 0 0 0 0~ o 0 0 0 0~
t 1500 to 1800 Ib. ~ Proposed 252' Retalning
t-Boulders lard against Exlslting 5.5' X 20' Wall w/ln 18" of Exlsting
Proposed Retalning Wall Stairs to be
5.5' X 20' Stairs Reconstructed
45 to 50 Cubic Yards
of Clean F111 between
_ Exlsting E New Wall
~isting Wood Docks-~
A°~s
Replace Exlsting 35' Section of
Bulkhead: In-Place. C-LOC 4500,
9" Dia., 6" X 6" Stringers Replace Existing 107' of
•New Retalning Wafl: Bulkhead: In-Place, C-LOC
In-Place C-LOC 4500 4500, 9" Dia., Y¢ hne along Apparen[ nigh
9" Dia. 6" X 6" Stringers ~ 6" X 6" Stringers Wacer nn,rk on Dec. ~ s, os'
• -~--~~~r~D BY 68' 1
fSTEES ~ 20'
p'v-. E.~~
1 . ~..~T~OLD
Tt_i . _ _ R\
` ~ E:clstmg 20' of Jetty
Scale DA7~~ ~ Z' / ~ Y to be Removed t
- Replaced
I 45' - ~
Theodore Laoud~s
Prepared by: SGTMX 1000-70- i 3-20.35,
Costello Mannc Contracting Corp. 20.36E 20.4
P.O. Box 21 24 Greenport, NY I 1944 Prepared 04-20-04
Ph. 63 I -477-) ! 99 Sheet 3 of 6
Scale
I" = 1.5'
New Jetty to be
constructed to
replace most
seaward 20' section
of existing betty.
Notes:
- C-LOC 4500
- 9" dla. pilings C-Loc 4500
2 0'
9"
Theodore laoudis
Prepared by: BCTMA 1000-70- 13-20.35,
Costello Marine Contracting Corp. 20.36 t 20.4
P.O. Box 2 124 Greenport, NY 11944 Prepared 04-20-04
Ph. 63 I -477- i t 99 Sheet 4 of 6
D~TA~ ~U~1 ~JLy
TOP VIEW OF BULKHEAD
Proposed "C-LOC" interlocking vinyl
sheathing 14' long X 4.5" wide
penetration 4' below grade 10' Piling 6" X 6"
6.O.C. Strangers
Scale 6" O.C.
I 2'
Total of 142' of Bulkhead
to be removed and replaced ,
Scale CROSS-SECTION OF BULKHEAD
I~~_
3® z"x I2..
Cap
Existing
1 Grade
4" X 6" 4" X 6"
Clamp Clamp
6" X 6" ~ 9" X 16'
Stringer
orizontal
3/4" X I D' Deadman
Tie Rod
9" X 16'
Beach ~-Vertical
I O" Pile, Deadman
14' long,
6' O.C.
Proposed "C-LOC" interlocking vinyl Theodore laoudis
Prepared by: SCTMk 1000-70- 13-20.35,
Costello Manne Contracting Corp. sheathing 14' long X 4.5" wide 20.36 t 20.4
P.O. Box 21 24 Greenport. NY I 1944 penetration 4' below grade Prepared 04-20-04
Ph. 63 I -477- 1199 Sheet 5 of 6
~~®S~V~]E ~~C1~~S
Scale
0' 3'
20'
Top of Bank
Min. depth
of 3'
Bttm. of Bank
Theodore laoudis
Prepared by: BCiMM 1000-70- 13-20.35,
Costello Manne Contracting Corp. 20.36 ~ 20.a
P.O. Box 2 124 6reenport, NY I 1944 Prepared 04-20A4
Ph. 63 I -477- 1199 Sheet 6 of 6
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O-~~O
W~ NO
Albert J. Krupslti, Presldent` ~$UFFOt,~ • Town Hell
c
James 1Sing, Vice-President ~ 0~ 53096 Route 26
Henry Smith ~ ~ P.O. Sox 1179
Artie Foster ~ Southold, New York 11971.0959
Ken Potiwoda G ~
Telephone (631) 765-1892
'~'bpl ~ Fax (631) 76b-1366
BOARD OF TOWN TKU3TEE3
TOWN OF SOUTHOLD ~ ~t,oiCS
Office Use Only ~ S ~ rph-'-p,«F
Co~sstal Erosion Permit Applicat~p b~,t{--4-eR-
!''Wedand Permit Application ,Major Minor
Waiver/Amendment/Changes
=-1C'eceived Application: a19__
/Olf
^RE'c'eived Fee:$
t3oRpleted Application p
_Incomptete D ~ ~ ~ U U
_SEQ1tA Classification: D
Type I,_Type II~Unlisted dUN 2 9 [u~14
_Coordination:(date sent)
iCAC Referral Sent: ~0
~e of Inspection: 1 Y soumoid Towe
Board of Trustees
Receipt of CAC Report.
Lead Agency Determination:
Technical Review:
?liiblic Hearing Held: !
Resolution:
Name of Applicant f1 y?~ ,~f `
c /~11 ~'~I ~ ~~?~aE
Address t~ lY1~Q a,~Gi tY~t ~tkSrUl~
1 ~9~~
a7~3 Phone Number.( )
Suffolk County Tax Map Number: ]000 - 'gyp ~ 13 ~e~~•
3~
Property Location: ~Q5 j~h~r~t ~ju{{~ j/( ~
~q~~
(provide LILCO Pole distance to cross streets, and location)
AGENT: l lT7[C 1 ~ l Y!f(L (~l' ttt10 [.df~
(lf applicable) t
Address: ~
; t1;~~'4 ~ IJII~Y7', ~Y 1 ~~91
~ p
Phone:'-t1~] ~~~97
• Board of Trustees Application
G/I~~E((~~NQQERAL DATA
Land Area (in square feet): ~
~ ~`17~ , l~
Area Zoning:- ' SId~1~C FO.wi?[~I~,.~pJn fr,Q.
Previous use of property: l7rIVQ~ ~ ~j('lj
Intended use of property: 1
Prior permits approvals for site improvements:
Agency Date
LI.InY,nowIY1 U,alc~eW h
No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or sus ded by a governmental agency?
No Yes
If yes, provide explanation:
Projec-t~Dyescription (use a"tt~a~c~h~m~e~n~ts if necessary):
Y~I~P SEt° Ut~l~l
Laoudis Property
Project description:
? Construct a 252' retaining within 18" in front of existing retaining wall
using C-LOC 4500 vinyl sheathing, 9"diameter piling, and 6'x6' stringers.
? Place 45 to 50 cubic yards of clean trucked in fill between existing and
new retaining walls.
? Place 1500 to 1800 Ib boulders in front of new retaining wall.
? Reconstruct existing 5.5' x 20' stairs.
? Construct a new set of 5.5' x 20' stairs on the south side of property.
? Remove and dispose of a total of 107' of bulkhead. Construct a total of
107' of bulkhead using C-LOC 4500 vinyl sheathing.
? Remove and dispose of the most seaward 20' section of existing jetty.
Construct a new 20' section of jetty using C-LOC 4500 vinyl sheathing.
? Remove and dispose of a 35' section of bulkhead. Construct a new 35'
section of bulkhead using C-LOC 4500 vinyl sheathing.
• Board of Trustees Application
WETLAND/TRU~STE~E
LANDS APPLICATION DATA
Purpose of the proposed operations: / o It~mr t f?rtl_~
a~ Yl5
Area of wetlands on lot:.~7~_square feet -
Percent coverage of lot:_pn?(~
Closest distance between nearost eXisting structure and upland
edge of wetlands: ~ feet
Closest distance between nearest proposed structure and upland
edge of wetlands: feet
Does the project involve excavation or filling?
No_ ~ Yes
If yes, how much material will be excavated? (°pD cubic yards
How much material will be filled? Oa cubic yards
Depth of which material wil! be removed or deposited: ~0 feet
Proposed slope throughout the area of operations. ~/AIf IQ,S .
Manner in which material will be removed or deposited:
clam ~4/sfll u~~ ~ ~aac,~Gtor
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):
~rr will b rn ~~,~2YPf
feC,~ ~fh~~~/~~~5
~rl exr5fih0
' • 817.20 •
' Appendix C -
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM -
For UNLISTED ACTIONS Only
PART I -PROJECT INFORMATION o bo com leted b Iicant or P act 3 onsor
1. APPLICANT/SPONSOR 2. PROJECT NAME
COSTELLO MARINE CONTRACTING CORP. (CMCC) THEODORE LAOUDIS
3. PROJECT LOCATION:
MunkJpelity SOUTHOLD County SUFFOLK
4. PRECISE LOCATION (Street eddreas antl road hte,sedbne, pmminent lentlmedta, etc., or provitle map)
405 KIIvfERLY LANE SOUTHOLD, NY 11971
SCTM 1000-70-13-20.3 & 20.4
5. PROPOSED ACTION IS:
New ~ E~enabn ? ModHicstloNelteretlon
6. DESCRIBE PROJECT BRIEFLY:
SEE ATTACHED
7. AMOUNT OF LAND AFFECTED:
InlCely - saes Uromatey - acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONST
Yes ~ No If No, tlssodbe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
Resldentlel ~ Intlwmel ~ Commerdel ~ AOdculture ~ PerklFareeVOpen Specs ~ Other
Deaaibe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY
(FEDERAL, STATE OR LOCAL)?
, Yes ~ No If Yes, Ikt e0ency(e) name antl petmiVepprovals:
ACOE, DOS, DEC, SOUTHOLD TOWN
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
Yea ~ No If Yea, list e0eney(s) name antl petmlVUpprovels:
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATIONT
Yes ? No
i CERTIFY THA7 THE INFORMATION PROVIDED ABOVE 13 TRUE TO THE BEST OF MY KNOWLEDGE
,4pplicanVeponsor ne ANE CO W PERMIT MANAGER CMCC Date:
Sgnewre:
I e action is In the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceedin wRh this assessment
OVER
1
Laoudis Property
Project description:
? Construct a 252' retaining within 18" in front of existing retaining wall
using C-LOC 4500 vinyl sheathing, 9"diameter piling, and 6'x6' stringers.
? Place 45 to 50 cubic yards of clean trucked in ftll between existing and
new retaining walls.
? Place 1500 to 1800 Ib boulders in front of new retaining wall.
? Reconstruct existing 5.5' x 20' stairs.
? Construct a new set of 5.5' x 20' stairs on the south side of property.
? Remove and dispose of a total of 107' of bulkhead. Construct a total of
107' of bulkhead using C-LOC 4500 vinyl sheathing.
? Remove and dispose of the most seaward 20' section of existing jetty.
Construct a new 20' section of jetty using C-LOC 4500 vinyl sheathing.
? Remove and dispose of a 35' section of bulkhead. Construct a new 35'
section of bulkhead using C-LOC 4500 vinyl sheathing.
PART II • IMPACT ASSESSMENT To be eom Isbd b Laad A ene
A DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 8 NYCRR, PART 817.x7 If yea, coordinate the rsNew process and we the FULL F.AF.
Ysa No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN B NYCRR, PART 817.87 If No, a nsgatlve
tlederetbn ma be euperaeded 6y another InvoNad epenq.
Yee ~ No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Anewere maybe handwritten, H leglbb)
C1. Existing arc quality, suAaee or groundwater quality or quantlry, noise lewla, exbtlnp tnlflc pattern, solid waste productlon or disposal,
pobntlal for erosion, dreinags or flooding problams7 Explain bdefly:
C2. AesUietk, epdculturel, eroheeobgiGl, histode, or other natural or cultural resources; tX eommuniry or neighborhootl dtareobR Explnln brefly:
C3. Vegeretlon or fauna, fish, shellfish or wIWIHe spades, algnHlcant habitats, or Mrestened or endengerod epecbs7 Explain Ddefly:
Ca. A communirys existlnq plans ar goals ss oMUally Woptetl, or a tlunge in use ar intanslry d uw of bntl or oMsr natural resourcas7 Explain bnefly:
C5. OrowN, subsequent devebpment, or related acflNtlea Likely to be Induced by the proposed actlon7 Explain briefly:
C8. Long term, short term, emulative, or other effects not klenttflad m C1-C87 Expain briefly:
C7. Other Impede (InUUdinq changes in use of eltlter quantlty or typo of enspy)7 Explain bdefly:
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL
ENVIRONMENTAL AREA (CEA)7
Yes ~ No If Yes, explain brefly:
E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
® Yea ~ No If Yea, explain btlefly: 1 ~)ip ~ r
olc(eSS 611 R O.yJ•~ [,a•rtShuc~~
he ~ ~ t.Je~-
• ~ PART 111 • DETERMINATION OF EIONIFICANCE (TO bs complalstl by Agsnq)
INSTRUCTIONS: For each atlwrce eft~ctldMtlflsd ebow, daMrmine whatherlt la subWntlal, large,important oroMarwise slgni}ICant. Each
effect should bs esseesed in donnectlon with Ib (a) settlrtp (I.s. urban or rural); (b) probability of occuMng; (c) duration; (d) Irrevenibility; (e)
geogrephic snipe; and (f) magnitude. H necessary, add alhehmsnn or rsbrenes supportlnp materials. Ensure that explanations contain
suffldent detail to show that all relewnt adverw Impacts haw been IdentMsd and adegwbly addressed. If questbn D of Pert II was checked
yes, the dstsrminatlon of signHicanee must swluste the potential Impad of the propoestl eGlon on the environmental charederlstlca of the CEA.
Check Mii box H you have identlflad one or more pobntlely largo or aignMCant adverse Impacts whkh MAY occur. Then proceed directly to the FUL
EAF entllor prepare a poeitWe detlsretlon.
Chedcthls box Hyou have determined, based ontM lnfamatlon and analytlsebow and anysupportlng dooumenntlon, thatUe proposed action WlL
NOT result in any signMcant atlverse environmental knpacta AND provkle, on attachments es naceasery, the reasons supportlnq this determineWn
Name o Le racy ate
t or ype ame o eepons car ~ ency espon car
naNre o espone r n ea envy nature reparer rent m reepona b car
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
Theodore Laoudia SCTM$ 1000-70-13-20.36 6 20.4
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request
a Permit from the Board of Trustees to:
~ Construct a 252' retaining wall rithin 1B" in front of
existing retaining rail.
eo Place 1500 to 1800 lb boulders in front of new retaining
Mall.
•s Reconstruct existing 5.5' a 20' stairs
6• Construct a ner set of 5.5'x20' stairs on the south aide
of property.
C' Remove and dispose of a total of 107' bulkhead. Construct
a total of 107' of ner bulkhead using C-IAC 4500 vinyl
sheathing.
d• Remove and dispose of the moat aearard 20' section of
existing jetty. Construct a ner 20' section of jetty.
r3 Remove and dispose of a 35' section of bulkhead.
Construct a ner 35' section of bulkhead.
2. That the property which is the subject of
Environmental Review is located adjacent to your property
and is described as follows:
405 Kimberly Lane, Southold, NY 11971
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 Wednesday, September 22, 2004 on
or about 7:00 pm. 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.
OWNERS NAME: Theodore Laoudie
MAILING ADDRESS: 23 Van Buren Court,
Cresskill, NJ 07626
Enc.: Copy of sketch or plan showing proposal for your
convenience.
• ~
Pine Neck Rd. ~ m I
4 Lane
~o
~ ~ ~ 5~te O i O
3
O
>Z
Z Southold Bay cJ. Ite
Southold Bay
Vicinity map Location Ma
® Applicant Adjacent Property Owners
- 800 ~ ~ I -300
SGTMX 1000-70- 13-20.35, 20.36E 20.4 1000-70-13-20:2 1000-70- 13-20.5
Theodore Laoudle Ryck Koko Jay P. Mandelbaum < Lauren Gordon
23 Van Buren Court 245 14mberly Lane 1086 park Avenue -Apt 9-D
Cres~ktll, NJ 07626 Southold, NY 119 1 New York, NY 101 28
(405 Kimberly lane, Southold, NY I 1971) (825 14mbcrly Lane, Southold, NY 119T'f~
Project Description:
.Construct a 252' retaining wall within 18" In front of existing retaining wall
using C-LOC 4500 vinyl sheathing, 9" diameter piling, and 6" X 6x stringers.
.Place 45 to 50 cubic yards of clean trucked In fell between existing and
new retaining walls.
.Place 1500 to 1800 Ib boulders In front of new retaining wall.
.Reconstruct existing 5.5' X 20' stairs.
.Construct a new set of 5.5' X 20' stairs on the south side of property.
.Remove and dispose of a total of 107' of bulkhead. Construct a total of
107' of new bulkhead using C-LOC 4500 vinyl sheathing.
.Remove and dispose of the most seaward 20' section of existing betty.
Construct a new 20' section of betty using C-LOC 4500 vinyl sheathing.
.Remove and dispose of a 35' section of bulkhead. Construct a new 35'
section of bulkhead using C-LOC 4500 vinyl sheathing.
Theodore LiOUCh~
repared by: SCTMY 1000-70-13-20.35.
ostello Manne Contracting Cap. 20.36 4 20.4
.O. Box 2 124 Greenport, NY I 1944 Prepared 04-20-Oa
i. 63 1 A77- 1199 Sheet I of 7
I
Kimberly Lane
gs/'ha/t ~ ~
~ (0 J
n~~wdy ~
~ Cl
°0 0
Frame
1500 ~ house Exlsting Conc. Wall to
1800 fb ~remam: Top of Bank
boulders Isting 252' Retalnmg Wall to
r?r.r R n r.:.T remain: Toe of Hank
Proposed Proposed 2~2' Retaming - - -
s.s' x 20' wall w/m 18" of Exlstmg asting 5.5' x 20~
- Stabs - Stalre to be
Reconstructed
35' Section of - -
Bulkhead to Replace Existing
be Replaced 107' of Bulkhead
kale
r Existing 20' of Jetty , Y
to be Removed E
7 5' Repbced
See Page 3 Southold Bay
For Detail Theodore ~oua,
repared by: SCiM+Y 1000-70- 13-20.35,
'oytidlo Manne Contracting Cap. 20.36 < 20.4
0. Box 2124 Greenport, NY 11944 Prepared 04-20.04
h. 631.477-I I99 Sheet 2 of 7
Frame
Clouse
cis ing one.
II r rruin gcisting 252' Retaining
Wall to Remain
ood bulkhead
0 0 0 0 0 o e o ~e o
e o e o 0 0 0 0 0 0 0 0 0 o
e-
t 1500 to 1800 Ib. ~ Proposed 252' Rctaimng
Prop~sed Bouldero Uid against f_xisiting 5.5' X 20' Wall w/in 18' of Existing
5.5' X 20' Staire Retaining Wall $talrs to be
45 to 50 Cubic Yards Reconstructed
of Clean Fill between
Existing € Ncw Wall 1
~-Existing Wood Do>~
~t
c`
Replace gcisGng 35' SecGOn of
Bulkh~d: In-Place. C-LOC 4500,
9` Dia.. 6' X 6" Stnngers Replace gusting 107' of
•New Retaining Wall: Bulkhead: In-Place, C-LOC
In-Place C-LOC 4500 ~ 4500, 9' Dia., Tm i,z aarg nppnent nqn
9" Dia. 6" X 6" Stnngero 6" X 6' Stnngers M'a[er Mao or Dec. i 6. v3
68' l
`C R\~ 2OI
Existmg 20' of .lefty
to be Removed €
Replaced
scale
50'
Theodore IBOUdre
repared by. SCTMk 1000-70- 13-20.35,
ostello Manne Contracting Corp. 20.36 < 20 4
0. F3o, 2 i 24 Grccnport, NY 1 1944 Prepared 04-20-04
63 1.477- 1199 5ncct 3 of
'/~~1/~~
~ - ~iM.oV / 1o
is !Y~ ~tfi1ye~ JaIT /a .TY
• - IJVT~VTT /f/VO ~"fFOst ~S~MI. aQ~CINj~Nt7' y1f -~%aSrMC)
/,6~C! •N yKf./NO K/aVYJ W/flV N1IV J~f?Y JCr7r Te
I ausM/A 9 •p O/.1. /II/i /Nal, f:
J<b "ss-f~FVS>/R.s .ll~wN /N
I <Wq "C-LIG" ?AVYL Sr/~fITN/.v64• /~t/GE
Q1(lS7: /a'Cfs ~ II~~ ASK. ! ~ '
~~~I i
~I I I ~
Sk G~ 1 '
x ~i-,~wvhlacs ~ 3 i
~I S'.e'e.e. ~Ya! s~Posan Nary x
t I 7'p /vcl3 Q
7~LIN
`YC~STMb ~it~G°INTW~~F IX~STw~.tS
-6KST/.r/ ~'AOwryt~t4 Jr 7~~/M//N
sat-yO1MOV~Q -
a«aw d -
i
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17~.-siri'»^,rw~ ZETA o/r~E7TY
~ wMO«/
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tt rwylr sw~wviw~
.47eAG. ~G~IT
TytppeRt G4evo~5
.T~CT..O /4. 2b r4N /l~/eaav Ga/ISr
C~K1LG.,.N..J. •7617
L~Qlt~.ifiVifdl L.Y LINf, Soter/o~oN•y //I7/)
7~Q4pu~t/O •Y.• laT..N. Aoeo•)e.n.se.RI,RO.RL, te.a
(-'OsT~• • M~~MA~ C~~P!'7S/CT/NA ~'~ws~!
~t0. /DOY~ Z/2Q- AQItv,~lgt~•• My. J71Ry. O 07. O¢
(G3/) 477- /i~~J /~i?, oa•?o.o4
Ss~/GET 4. 9~ 7
TOP VIEW OF BULKHEAD
Proposed 'G-LOC' interlocking virryl
sheathing I4'long X 4.5` wide
penetration 4' below grade I O' Pilirg 6' X 6'
6' O.C. Stringers
Scale 6" O.C.
I 2'
Total of 142' of Bulkhead
to be removed and replaced
Scale CROSS-SECTION OF BULKI~AD
~ u =
3® 2' X 12'
Cap
Existing
Grade
4' X 6'
Clamp
AHW-'------------
6' X 6' ~ 9' X 16'
Stringe orizontal
3/4' X I O' Deadman
Tie Rod
ALW--------------
9' X 16'
Beach Vertical
I O' Pile, Deadman
14' long,
6' O.C.
Proposed 'C-LOC' interlocking viryl Theodore uouc4s
'reparcd b7: sheathing 14' long X 4.5' wide SCTMk 1000-70-13-20.35,
'oste0o Ma""` ~O""aGhf~ ~Orp~ enetration 4' bCIOW fddC 20.36 F 20.4
'.O. Box 2124 Greenport. NY I 1944 p g Prepared 04-20-04
'h. 63 I <}77- 1 199 Shoe[ 5 of 7
- . ~ ~~~s~vv s~~~s
Scale
O' 3'
_xlstmg Concrete Wall
20'
Top of Bank
Min. depth
of 3'
Existing Retammg Wall Propo ed 1500
to 1800 Ib
New Retaining Wall Boulders
18" in Front
Toe of Bank
Theodore laoudis
'reparedby: SCTMit 1000-70-13-20.35,
:ostello Manne Contracting Corp. 20.36 < 20.4
'.O. Box 2124 Greenport, NY 11944 Prepared 04.20-04
T. 63 I-477- 1199 Sheet 6 of 7
- , ROSS-SECTION
RETAINING WALL
Proposed Retaming
Wall 18' in front of
6nsting
2' X 12~ Existing
Cap R' X 6' Grade
Clamp
6' x 6'
Strange
~nsting
grade ~I Existing Retaining Wall
Proposed 1500 to
1800 Ib boulders m
front of Retaning Wall
9` Pile,
14' long,
6' O.C.
Proposed 'C-LOC' mterlocbng hrryl
sheathing 14' long X 4.5' wide
penetration 4'below grade
Scale
I 3'
Theodore t~oudis
'repared fry: SCTMY 1000-70-13-20.35,
;ostdlo Manne ContracGny Carp. 20.36 < 20.4
'.O. flax 21 24 Greenport, N1' 11944 Prepared 04-20-04
'h. 63 1 X177- 1199 Sheet 7 of 7
gOFFO(,~
A16ert.J. Krupski, Pryaident 0~~ L'0 Town Hall
James King, Vice-PresidenC ~`Z` ~ 63095 Route 25
Artie Foater ~ ~ P.O. Box 1179
Ken Poliwoda W ~ Southold, New York 11971.0959
Peggy A. Dickerson ~ O`er Telephone (631) 765-1892
~j y ~`a Fax (631) 766-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In the Matter of the Application
of
__'_?__he~ic~r_Q_c
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
1 AFFIDAVIT OF POSTING
I, ,Jouy A ~ ~'o9-rab',(L~ ,residing at 121 o n( o,a„-,-,,~ p
~Q~~ po ~"f" l N• Y I I R H y
being duly sworn, depose and say:
That on the 3'~ay of S~pr' , 200 I personally posted the property known as
YO 5 K f n~ ~ ~C a L.s,~ ~ S O kTl}o t.il
by placing the Boazd 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 ~ .eta ~ C1~ ~
on ~rab ~ ,
Dated: ~ ,
signature)
Sw rn to before me s
y ofSe fk200~
Notazy Pub
Ellilnr ~
IbINy Public, Stete Ot Ne~N 1~bAt
No. 01 HE6059270urgy
dOtMdpion lExptra July li, 90~
• g~FFO(,f •
Albert J. Krupaki, President O~ C~ Town Hall
James King, Vice-President ~`Z` ~ 53095 Route 25
Artie Foster p ~ P.O. Box 1179
Ken Poliwoda W ~ Southold, New York 11971-0959
Peggy A. Dickerson ~,j, ~ Telephone (631) 765-1892
~Ol ~ ~a~ Fax (631) 765-1366
BOARD OF TOWN TRUSTEES D E
TOWN OF SOUTHOLD D
AUG - 92004
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
B
~uth~l7 T-~~.~
In the Matter of the Application , . ~5
of
---~1t
~o~'~
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF~P~OSTING
I,1~'~,~ .0 r ,residing at /o ~5`ov~as~e2s ~,t./ic_
being duly sworn, depose and say:
That~on the 2 day of f~u~i • , 200J~I personally posted the property known as
S /~M~S~GY LAS S'o~~oc~OrN.~ /937
y placing the Boazd of Tmstees official poster where it can easily be een, and that I have
checked to be sure the poster has remained in place for eight days prior to the date of the public
heazing. Date of hearing noted thereon to be held
ono apta,,~t ;00 ~1,
Dated: ~ • y~
signature)
S rn to b fore me tlvs
a y of <
otary Public V@rOrtlCa F. Cldon@
Notary Public, State of New York
No: 52-4661406
Qualified in Suffolk County
Commission Expires Dec.31,~
COSTELLO MARINE CONTRACTING CORPORATION
DOCK BUILDING • JETTIES • BULKHEADING • STEEL & WOOD PILING • FLOATS
423 FIFTH STREET • P.O. BOX 2124 • OREENPORT, NEW YORK 11944 • (831) 477-1199 / 477-1393 / 477-0882 • FAX (631) 477-000;
~I1~NORiZA1TON FORM
T/r~~~d~-C ~,./4~~d~Sownerof ~J~! (a3~ ~~y
Busir?ess/Pn Name.
located"at ~L~f 63:~ ~~.6~ds~ ~,,a,dc~ s6w~a
do hereby give Costello Marine Contracting Corp. the authority to act ss agent in my
behalf in applying for all of the necxssaty permits for work to be completed at my above
refereaxd property.
d V
ate Sigoahae
• Board of Trustees Application
County of Suffolk
State of New York
IL BEING DULY SWORN
DEPOSES AFFIRMS THA HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRUE TO THE BEST OF HIS/IiER 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.
r
Signature
SWORN TO BEFORE ME THIS o?I DAY OF JU,tJt; ,20 0~
I
ota ublic
MF3SCY T. flJ~".A
Nomry Rd~ w'.?M of tdliilYpk
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i •
APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics prohibits conflicts of interest on the rat of town officers and emolovees The of
this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is
necessarv to avoid same./ ~
YOUR NAME: hKODUIS ~~/~0/~e.
(Last name, fast name, middle initial, unless you are applying in the name of
someone else or other entity, such as a tympany. Tf so, vrdicate the other
person's or wmpany's narrte.)
NAME OF APPLICATION: (Check all that apply.)
Tax grievance
Variance
Change of Zone
Approval of plat
Exemption from plat or official ma~p/~~~
Other ry.)Y~~-~~Q~~~
If "Other", name the ac[ivi
Do you personally (or through your comparry, spouse, sibling, parent, or child) have a relationship with any officer or employee
of the Town of Southold? "Relationship" includes by blood, macrisge, or business interest. "Business interest" means a business,
including a partnership, th 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 5°A of the shares.
YES NO X
if you answered "YI~j, complete the balance of this 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 applicmtdagmdrepresentative) and the [own officer or employee. Either check
the appropriate line A) through D) and/or describe in the Mace provided.
The town officer or employee or his or her spouse, sibling, perm[, or child is (check all that apply):
_A) the owner of greater than 5% of the shares of the corporate stock of the applicant
(when the applicant is a corporation);
B) the legal or beneficial owner of any interest in anon-corpomte entity (when the
applicant is not a corporation);
C) an officer, director, paMer, or employee of the applicant or
D) the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this ,t/R~t 200 t~'
Signature
Print N
. • .
APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics prohibits conflicts of interest on the Dart of town officets and ettmlovees The purpose of
this form is to provide infomration which can alert the town of possible conflicts of interest and allow it to take whatever action is
necessary to avoid same. M ~ ~ ,
YOUR NAME: ~~I t~ t IIA! ~nQ ~V~. f f U~IMII ~~IZ I~
(Last name, fast name, middle initial, unless you appl ' yr the name of
someone else or other entity, such as a company. If so, ihdicate the other
person's or conyrany's name.)
NAME OF APPLICATION: (Check all that apply.)
Tax grievance
Variance
Change of Zone
Approval of plat
Exemption from plat or official map
Other ~pL~'A ~ Y
(If "Other", name the activity.) GTI~~l~ r~
Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee
of the Town of SoutholdT "Relationship" includes by blood, marriage, or business interest. "Business interest" means a business,
including a partnership, in which the town officer or etr~loyee has evrn a partial ownership of (or employrtant by) a corporation
in which the town officer or employee owns more than 5% of the shares.
YES NO
[f you answered "Y~', wtrrplete the balance of this form and date and sign where indicated.
r
Name of person employed by the Town of Southold
Title or position of that person
Describe the relationship betwern yourself (the applicanUagrnNrepresrntative) and the town officer or employee. Either check
the appropriaze 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 S% of the shares of the cerporete stock of the applicant
(whrn the applicant is a wipomtion);
B) the legal or brneficial owner of any interest in a noncorpotate 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
Submitted this 2 day of 2009"
Signature
Print Name