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HomeMy WebLinkAboutTR-5778 James F. King, President ~~~F SOVTyO Town Hall Jill M. Doherty, Vice-President l0 53095 Route 25 P.O. Box 1179 Peggy A. Dickerson Southold, New York 11971-0959 Dave Bergen G Q John Holzapfel ~ Telephone (631) 765-1592 ~~CO~~ Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: Building Dept. FROM: Board of Trustees DATE: July 7, 2006 RE: LORETTA HINDERLING 1325 SMITH DR. NORTH, SOUTHOLD SCTM#76-2-2.5 With regard to the above-referenced property, an inspection was made and it was determined that the additions to the dwelling, new garage, and decks were constructed in compliance with Wetland Permit #5778, as issued on June 18, 2003, and amended on March 22, 2006. If you have any questions, please do not hesitate to contact us. nc~~ i ~Sll,:~ Ce r~ , v~ c c~ mP ~ is nc~ ur~fi 1 tou-~ ~c~ is S~IQC~ , ~__T _ James F. King, President ~~OF S~UlyO Town Hall Jill M. Doherty, Vice-President ,~O ~ 53095 Route 25 Peggy A. Dickerson # * P.O. Box 1179 Southold, New York 11971-0959 Dave Bergen G Q John Holza fel ~ i~ Telephone (631) 765-1892 p ~~~Ct7U~ Fax (631) 766-6841 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD March 22, 2006 Ms. Loretta Hinderling 38 Pickwick Rd. Manhasset, NY 11030 RE: 1325 SMITH DR. NORTH, SOUTHOLD SCTM#76-2-2.5 Dear Ms. Hinderling: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, March 22, 2006: RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to Permit # 5778 to include the existing 10'2" x 19' deck and to install a deck landward of the bulkhead as a non-turf buffer, and as depicted on the survey prepared by John T. Metzger last revised August 7, 2003. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765-1892. Sincerely, Jamesj' o~ Presi nt, Board of T tees JFIUhkc LORETTA HINDERLING 38 Pickwick Road Manhasset N.Y. 11030 SOUTHOLD DEPT of TRUSTEES Dear Members, I would like to request an amendment to my existing permit ~k5778 which is to replace in total as existing the deck on the west side of the house at 1325 (aka 1195) Smith Dr. North, Southold. This request is being made after the fact by instructions of the building dept. as I did not realize a permit was required to replace as is my deck. Thanking you in advance for your consideration. i ~n~ y~~~~~ LORETTA HINDERLING. ~ ~ 4 20C6 Albert J. Krupski, President Town Hall James King, Vice-President ~ - p~FFO~/+'~, , 53095 Route 2b Artie Foster ~/i P.O. Box 1179 Ken Poliwoda C ~ Southold, New York 11971-0959 Peggy A. Dickerson oo = v, ~ Telephone (631) 765-1892 ~ ~ Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD 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. INSPECTION SCHEDULE Pre-construction, hay bale line 1St day of construction '/2 constructed Project complete, compliance inspection. ~~a Board Of Southold -Town Trustees SOUTHOLD, NEW YORK 0 June 18, 2003 PERMIT NO. DATE:... 1 i~' r'. LORETTA HINDERLING ISSUED TO a ~ ,~utl~nrt~tt~tnn w Pursuant to the provisions of Chapter 615 of the Lews of the State of New York, 1893; end Chapter X404 of the Lows of the ,.t 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 end 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 ..June 18, ~ 2003 and in eonsideretion of the sum of ~...~00.00 paid by Loretta Hinderlin of ............._Southold N. Y. and subject to the Terms end Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: s' Wetland Permit to construct atwo=room, two-story addition with ~ basement, a two-car garage,deck,front porch and dormer, with t . condition of a 10' non-turf buffer, gutters & drywalls are installe to contain the roof run-off, hay bales are placed down r qr to aN in accordance with the detailed specifications as presentedl m the originating application. construction, and as depicted on th survey prepared by John T. Metz er 1~ t rev sad ~o,u 7 2003. IN WITNESS WHEREOF, ~he se~~ Boar of lrus~ees riere- by causes its Corporate Seel to be affixed, and these presents to be subscribed by a majorif)r of the said Board as of this data. v"~ ~ C~fI~ ~ _ ~ Co~ - A' ~ ~ j K/1 ~ r~ Trwsteer ~ _ _ y : - - - M. 5.... i ' ` !i! l._._ TERMS end CONDITIONS Loretta Hinderling I ~ 1325 Smith Dr. , North, Southold N Y ~ part of the coosideradoo f« the icstrance of the Permit don uodnspad and prescribe to the foI- lowiog: 1. That the said Board of Trustees and the Town of Soudwld are released from any noel all damaget, « daunt f« damages, of salts arising ditecdy « indimaly as a result o[ any oper- atbn performed pursuant ro this permit, and the said Pemumee wall, at his « her o+ra erpense, defend a% and all sorb wdts'hdtlated by thud pacda, and the said Petmhtee afsumea fall liabllity with respect thereto, to the oompkte eulaslon of the Boatel of Ttutua of the Town of Southold 2. That Sus Permit h~ valkl f« a period of 24 uwa. vthkh b ooatidered ro be the estimated time required m complete the wade Involved, but theuld drduiisnoces warrant, request for an exoeadon may be made to the Board at a later date. 3. Thu ibis Permit should be retained inde£mitdy, or as long as the sold Permiuee wlsha to maiaain the structure « project involved, to provide evidence m anyone eoocaaed that wth- orizarioo wu originally obtained. ~ 4. That the work involved will be aubjea to the iaspecaon and approval of the Boatel « its agents, and non-oompliana with .the provisions of the otiginadaig applipdoa, may be case f« rev«sdon of this Permit by rewludon of dr aid hoard. 5. That there will be no unreasonable Interfermoe with navigation as a remit of the wade herein atrchoriud. 6. That there shall be oo iotaference with the right of the publk m pass and repass along the beach between high and law waxer marks. 7. That if fuatte operations of the Town of Southold ~ the remavd and/« alseratioos ie the kxxrion of the work herdn mthodred, or if, la the opldon of the Hoard of Trustees, else. wodc shall Huse unreawoable obsttucaon to free navigariea, the said Permittee will be regtdred, upon due notice, to remove or alter this woric or pmjea herdn noted without e:pmses to the Town of Southold. 8. Thar the said Bosrd will be notified by the Permittee of the oompletlon of the wroth oath- orized. 9. That the Permittee will obtain all other permits and rnostmts dot rwy be requited wp• pletneatal m this permit which may be subject to revoke open faihtre to obtain sear. Albert J. Krupski, President • - pS~fFO(,~C • Town Hall James King, Vice-President h't`~ O~~ 53095 Route 25 Artie Foster ~ P.O. Box 1179 W ~ Southold, New York 11971-0959 Ken Poliwoda Peggy A. Dickerson ~.j~ ~ O~'>E' Telephone (631) 765-1892 ~j .IL Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD June 18, 2003 Ms. Loretta Hinderling 38 Pickwick Rd. Manhasset, NY 11030 RE: 1325 SMITH DR. NORTH, SOUTHOLD SCTM#76-2-2.5 Deaz Ms. Hinderling: The Boazd of Town Trustees took the following action during its regulaz meeting held on Wednesday, June 18, 2003 regazding the above matter: WHEREAS, LORETTA HINDERLING 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 May 29, 2003, 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 June 18, 2003, at which time all interested persons were given an opportunity to be heazd, and, WHEREAS, the Boazd members have personally viewed and aze familiar with the premises in question and the surrounding area, and, WHEREAS, the Boazd has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standards set forth in Chapter 97 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfaze of the people of the town, z NOW THEREFORE BE IT, RESOLVED, that the Boazd of Trustees approve the application of LORETTA HINDERLING to construct atwo-room, two-story addition with basement, atwo-car gazage, deck, front porch and dormer, with the condition of a 10' non-turf buffer, gutters and drywells are installed to contain the roof run-off, hay bales aze placed down prior to construction, and as depicted on the survey prepazed by John T. Metzger last revised August 7, 2003. Permit to construct and complete project will expire two yeazs 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 aze required at a fee of $5.00 per inspection. (See attached schedule.) Fees: $10.00 Very truly yours, Albertsl~r./~' President, Boazd of Trustees AJK/lms Albert J. Krupski, Preaident • ~0$OFFO[,~'~o • Town Hall James King, Vice-President ~O ~j 53095 Maia Road ~ ~ P.O. Box 1179 Art~Fos~ter y ~ Southold, New York 11971 2 Ken Poliwoda O ~ Telephone (516) 785-1892 y~O! ~ ~aO~ Faz(516)765-1823 BOARD OF TOWN TRUSTEES TOVVPT GF SGUTHOLD Please be advised that your application, dated S/dA~o3 has been reviewed by this Board, at the regular meeting of /n/!R/6 ~ and the following action was taken: Application Approved (see below) ( ) Application Denied (see below) ( ) Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees. The fee is computed below according to the schedule of rates as set forth in the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FFS: L, n,:.~ ri~~,~ ^ti~.U~rj[/ !L` ~rivn-tu.i~ (4+~-b6'.',, ~aC2ycuLCC4 ~11~.~-, ~aCar TOTAL FE/ES~~D~UE: /J~ , f~C~ Q ~ S I GNED : `~:C•~rtM C/~ /~.,rO~Q•~1~.' ll , PRESIDENT, BOARD OF TRUSTEES CYJE K, BOARD OF TRUSTEES 4/98 . ~ o~o~~FFOCX~o~ c ~ Town Hall. 53095 Main Road rt+ P.O. Boz 1179 Telephone O_y,0~ ~~O<-~ Southold. New York I1971 (631) 765-1892 T~~rl SOUTHOLD TOWN CONSERVATION ADVISORY COUNCII. At the meeting of the Southold Town Conservation Advisory Council held Monday, June16, 2003, the following recommendation was made: Moved by Don Wilder, seconded by Bill McDermott, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A CONDITION of the Wetland Permit application of LORETTA HINDERLING to construct atwo-room, two-story addition with basement, atwo-car garage, deck, front porch and dormer. Located: 1325 Smith Drive North, Southold. SCTM#76-2-2.5 The recommends Approval of the application with the Condition that hay bales are placed around the project during construction and a 10' rton-turf buffer is installed. Vote of Council: Ayes: All Motion Carried Fs.~ ~I F g~ y. Sf O ~ ~ $ 1 ~F ~ \J.~ Eat[ ~ ~ E i az ~ ~ ~ ~ E `a 2 ~ • ~ ~ EI • ~ a• ~F ~ • ~ • 1 ~ 1° K• 1 4 U~ • , A " \ 4 l~ i,E~E\ 1-= - ~ e 2- ' e a ~ i i~ ,iE i. ae[iS 1. • : :ai •,~~E'. T-~, gel@~@ffa • ~ • • t7 i ~E i' , l ~ t ` i~5ia ~ e - i ~ • : ~ i EIJII~I .w° is E: J Ei e: ~s i ~i...i,, •i a,~, ay i a~ ~~•/E~ je li~l ~`a~a l~ a ° : iei i ee , ~ , ~ ~ SS I[T1! e a:a i i l ~ F ~ • ~ ° i e d :•i'• •iei 'ws ~ I :,i ie E,E 3 d : s a~ d • t l i t~ • a ~ ~ d ~IIIII ~ • e 'Weis 1.. ~i . qi : s lllll • ~ IFISF • ~ I soli! ' ~ iii ~ ; ; r.; 3p ~s.~• _ ; ~~ili i i~ sF14 - ~ ^ ,l EElii ~ ~ ~ r, rn ~ ~ ~ 2 ~ ~ 2~ ~ w ~ ~ J U~ W~ (~wa~ I ~N° gg o 2~ ~ z~ o ~ a S rr U V' ~ ~ O~CD~L''y I 181 ~ ~ ~ 'v~i~ ~".~`O.aNO ~1~1 ~ yi2~ ~ Z ~ ~ ~ ~ W ~ y~`1t~~W y2J ~F~W~ _ APPROVED BY ~~~wlx BOARD OF TRUSTEES ~~gg~ TOWN OF SOUTHOLD ~km`~~ a o DATE 12 I 3 a~~~~~ J ~4 W W ~ M.OO,OE:iS ~ ~ ~~a ~ r 1 w : ~ 4 ~ .W,.. ~ ~ ~ o t Ly - ~ ~ ° lu b : ~ ^ P GTr I ~ ~(J I c y i 0.' i/ ~i wee 1 k I p ~ ~ ~ ~ . I t 1" ~ ~ i r ~ 67.0' ~ P ~ J J I ~ i ~ r I aR' I gpp~ ~ _ ~ a - .ei - iy - I ( ~ n y tI ~ ` e \ ' v O 1 J ~O % W ~ Q W' cZ YB.B' i+,f'l ~i ~ :r ~ G R A V E i ` n I4S4 4 Y1 w ~ •~.r .F ~ 2, 'i . Z t ~ Vl ~ - R.R. 1~ LUM6ING : ' 1 i~ - s?t ~9. > : m e ~ P/0 LOT 24 0 ~ 176.09 Z ,t ~ ~ ~ N2b4'40"W j 4= ~ ~ P/O LOT 24 ~ Q~ \ ~ ~o ,s >I~49' CR~'EK RD. N I( ~ ~ F Albert J. Krupski, President ~ ~OSVFFO(~C . Town Hall James King, Vice-President h~~ OQy 53095 Route 25 Henry, Smith a ~ P.O. Box 1179 Artie Foster ti Z Southold, New York 11971-0959 Ken Poliwoda Oy ~ Telephone (631) 765-1892 '~~l ~ ~~0 Fax (631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only -Coastal Erosion Permit Application Wetland Permit Application _/Major _ Minor -Waiver/Amendment/Changes iReceived Application: .Received Fee:$ gyp' ~ Ro 2 ~ pp !completed Application .1 D t19 LS U -Incomplete D _SEQRA Classification: MAY 2 9LUU,i Type I_Type II_Unlisted _Coordination:(date sent) ~AC Referral Sent: Southold Town Board of Trustees iDate of Inspection: 0 -Receipt of CAC Report: -Lead Agency Determination: Technical Review: Public Hearing Held: 0 Resolution: Name of Applicant ~OR~E7Tf) /N b ~RL / N' Address ~ 8 CiC/~c9/ GiC ~o f} ~ /~fJ~U /~f},f,s~ 7- Nr ~ O Phone Number:( ) S~6 365' 37.29 ~3 Suffolk County Tax Map Number: 1000 - 76 - O.2 ' z . 5 Property Location: /3~s ~M/Th/ . NOR % f/ CIOUTf/D~ (i9j~i9 ~i9SSM/7`frt ~R. ~.~'T,y (provi e LILCO Pole distance to cross streets, and location) AGENT: _ (If applicable) Address: Phone: Board of Trustees Application GENERAL DATA Land Area (in square feet): a ~ ~~~j ~Q'C[~f,Q ~Ge ~ O Ic Area Zoning: ~ - Previous use of property: ~/NCI.L~ ~ ~J/.~y ~~J~ ~ Intended use of property: V /.t~G.GE ~ /t//L Y_~O Prior permits approvals for site improvements: Agency Date ~~G-<3vi~y~~L~ a/a3~9s Re~J,(,4crMe it9T No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspend d by a governmental agency? No Yes If yes, provide explanation: Project Description (use attachments if necessary): 02 12ooA2 ~ ~T©R1L 14D~~TlDh/ IA/iTh~ /~3~s~M~~% oZ C 13 R. GRRf~G~ ~~ci~ ~20NT /DofZC/~ .~a.P/Y,~:~ .Board of Trustees Applicatn WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: /o NIA/,~~ ~(~tJNI~/~2 /~O/y~ /~iO ~EIZMA,U~~vT DES/~~~tIC L' Area of wetlands on lot: 75 ~ square feet 1 Percent coverage of lot: o~ Closest distance between nearest existing structure and upland edge of wetlands: y"8 feet Closest distance between neazest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? No~_ Yes tt If yes, how much material will be excavated?_ T~ cubic yazds 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: ~ ~ S ~ aL /,{r T~ e ''eru~ Elf ~f Manner in which material will be removed or deposited: d ~aSeMeNT t7u1GOO ~ F3~/ ~/iCKtioE , Ma.~e~u-c~.L 'T~,~?~ ~ CAS ~ I eo( 11.E G r+2 MFG E A~R Ef1 io 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): t~oNE 1.1-:6~1 IZ/81-Text t2 • PROJECT I.D. NUr+IRER 61i2t SEQ Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM Far UNLISTED ACTIONS Only PART I-PROJECT INFORMATION (To be completed by Applicant or Project sponsor) t. APPLICANT JSPONSOR 2. PROJECT NAME Lo.e~'T7fI f~/.ud~RL/N4 /foyS~ ~9D~~TiOi? PROJECT LOCATION:(~ A q r Municlpallty SOUTi`fOL,d County Vt~/_~D~/~ a. PRECISE LOCATION (Street aCCress an0 road intersections. prominent IanofnarKS. ?tc., pr provipe map) /3.25' cS'~/i~``i .25.4/t~~ /?o~T/f 5. IS PROPOSED ACTION: r-~ - ? New Expansion MotlilicatlOn/alteration 6. DESCRIBE PROJECT BRIEFLY: COnSrR[7G T AG~J~f J9rL. /o ~pS~ ~/7C P ~//zG~uCCirz ~SaSemew.~ ~ RJ~oiyS , a C~rz. 9JA/LaY c , l~ccK , TaJ~ic~~o2~h , 7. AMOUNT OF LAqND AFFECTED: 7'~ J S Im rally K ~ GwBP Ultimately / O • ~~aJrae I v ILt r90P05c~D-:ACTION COMPLY 'NITH cXISTING ZONING OR OTHER ~YISTING '~:VD USE ~ESTRIC'IGNS? I~Yes ? Np If No, CeSCnpe tlneFly 9. :7H A715 PR E$E.N i L.+fJG U~E N '/ICI NITY OF ~POJ ECT? ~ReS~dentlal J?naus:nal ~ l.pm(nefC~dl L~A+]rICUltUre ~Patrt/FpreS[/OpeO space _Dlnef escaee: 10. DOES ACTION INVOLVE A PERMIT APP90VAL. OR FUNDING. VOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AG'cNCY iFEDERA I. STATE C~r7 LOCALI? Yes LJ No It yes, list ageLancy(s)/a+nC permrtlapprovals L G r 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ? Yes ~o if yes. list agency name and permit/approval ' 12. AS A RESULTp~ F/ PROPOSED ACTION 'NIL! E;(ISTING PERMITlAPPROVAL REQUIRE MODIFICATION? ? Yes J,~' No _ _ _ I CERTIF'! TTH ATpTHE INFO RMADTICN {P'~90/,VIDEO AEOVE I$ TRUE TO THE 3E3T OF MY KNCVJLEDGE Applicanu=_ppn sor name: •o/"t ~ 7T// /~~~"R ~~N~ DJIe: ~ Z~ Signawre: If the action is in the Coastal Area, and yeu are a state acency, compte[e the i CDas:al Assessment Form before proce=ding with this assessment OV.A • ~ - PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: ,-o,~ ,~A~o~,- y sue/ o P~ ~ /78c/ i~e«ccc,~ ~y, /ye/vt.~CK /?y //S66 fl ~i,/f-.Q'r ?irt ~rlgc~iv e/i t/ aZBy .~4.Ye eec,- A~ ~ UGC!/7o~ ~J~/ //.~jGr ~o~~~ ~oa~~ tl ~ ~a,~ ~ ,~~~~o~ ,may. ,,,o~ ~'ohN-+~~k~e.c~c-wAy l-ss k~no~y~ r"~,Neo1a ley l?~o! STATE OF NEW YORK COUNTY OF S~U~FFOLK .L o.e~r rr~ f>/x-ld r,PL/ti'~i ,residing at 3~ ~ ~ c K u~/cK .~c~ N~a.~`i Qs'Se. N, y ~ 03 0 ,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 aze the address of said persons as shown on the current assessment roll of the Towtt of Southold; 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 tof ~b foie me this Day of, 20~ tYmttctncomYtN / - / Notary Pu6tk, State of New Yolk No.O1CO5017S52 Qualified in Suffolk Counly _ ~ Canmkskn Expkn Spt 13, ~ J.J No ary Public ~oard of Trustees Applicat• County of Suffolk State of New York ~D~Q~TTH ~//.l-~~EP~/N~' BEING DULY SWORN DEPOSES AND AFFIIiMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/I~R 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. Signature SWORN TO BEFORE ME THIS ~ ~ DAY OF /~f ,20 PATRICIA CORWIN -'7 NabryWWi~StabdNenYak ~ ~ualN ed i Stu Wt y8~y j ~ Comm~ssmnt'xpkeaSapt,t~~j~~ '~~Z~ti. Notary Pub is • gUFFO(,~ • Albert J. Krupski, President ~0 C~ Town Hall James King, Vice-President ~`2~ Gy 53095 Route 25 Artie Foster p ~ P.O. Box 1179 Ken Poliwoda W ~ Southold, New York 11971-0959 Peggy A. Dickerson Oy~ ~ O~~ Telephone (631)765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOiJTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of --!~#ta_ l~~nd~ COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVTT OF POSTING / I, ~ ~ At 2L ~~I ,residing at 3 E3 ~r C r~w ~ C ~O( being duly sworn, depose and say: That on the (o day of ~ y1 u~1 t , 2003, I pers nally posted the property known as i3-zS ~i~rr~`7S ~Sr2r?c Nor?T/~ ~OUiho%~ by placing the Board of Trustees official poster where it can easily be seen, and at 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 ~g Fa~3 Q n Y d~lj'E '7 ~11~ P m . (signature) Swom to fore me this l J day o ~ 200 J i 7 No ary Public • APPLICANT TRANSACTIONAL bISCLO5URH PORN ~ The Town oC Southold's Code of Ethics rohibits conflicts of nterest on the par L- of town off care and em lv ees. 'P)te ur vas of this form is to rovide information wh ch can alert the town of oae ble confl cta of nterest and allox it to take whatever action a ?tecessary to avo d same. JJ r r h... YOUR NANHt f~O,~Z~ TTjg /f/i(1 L~/~L/~~~~ . ; rLaet name, E re't name, m ddle n t~al, un sae you are applying in the name of someone else or other entity, such as a company. if eo, indicate the other person's or company's name.) ~ , , n_. NATORH O>? APPLICATION: (Check all that apply.) Tax grievance Variance Change of zone App peal of plat Exe~ption from plat or official map Other / ~ (If "Other," name the activity. ) ri0llSE .~~L ~/!B /V Do you personally (or through your abnpany~ spouse, sibling. parent, or child) have a telationsl?ip vitlt any officer or employee of rite Tovn of Southvld7 "Relationship" includes by blood, marriage, or business interest. "business interest" insane a business, including a partnere)tipt in which the town officer or employee has even a partial ownership of (or employment by) a corporation in vhictt the town officer or employee owns more titan 596 of the shares. YHS NO ~ ' If you answered "YH3,".complete the balance of tltie•fvrm and date sad sign where indicated. Name of person employed by the Town of SoutFtold Title or position of that person Describe the relationship between yourself (the applicant) and the town officer or employee. Either check Ehe appropriate line A) through D) and, or. describe in the apace provided. The town officer yr employee or iris or her epouse~ sibling, parent, or child is (check all that apply)t A) the owner of greater thah 5% of the shares of the corporate stock of the applicant (when the applicant ie a corporation)t B) the legal or beneficial owner of any interest in a noncorporate~entity (when the applicant is not a corporation)t c) an officer, director, partner, or employee of the applicantt or D) the actual applicant. ~ , DESCRIPTION OP hELATI0NS11IP i~ i; . ~ i ~ r y~ rl•, ~~c } ; sir ' •7 Submitted thie.,~ ',day n k,'~ signatur ' Print name ~ ' _;)t J ,t.~~A s':, yr nt r~ e.