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HomeMy WebLinkAboutTR-5239Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0568C Date August 25, 2010 THIS CERTIFIES that the single-family dwelling with associated sanitary system, decks, pool, driveway, garage, gutters, drgwells and 50' non-disturbance buffer, At 3485 Main Bagview Rd., Southold Suffolk County Tax Map #78-2-13 Conforms to the application for a Trustees Permit heretofore filed in this office dated 10/5/00 pursuant to which Trustees Wetland Permit #5239 dated 10/30/00 was issued and Amended on 9/25/02 and on 8/18/10 and conforms to all of the requirements and Conditions of the applicable provisions of law. The project for which this certificate is being issued is for a single-family dwelling with associated sanitary system, decks, pool, driveway, ~araee, gutters, drgwells and a 50' non-disturbance buffer. The certificate is issued to ROBERT TOMAN owner of the aforesaid property. Authorized Signature Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 August18,2010 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD Mr. Robert Toman 3485 Main Bayview Rd. Southold, NY 11971 RE: 3485 MAIN BAYVIEW RD., SOUTHOLD SCTM#78-2-13 Dear Mr. Toman: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wed., August 18, 2010: RESOLVED, that the Southold Town Board of Trustees APPROVES the Amendment to Wetland Permit #5239 to reflect the dimensions of the existing deck, as depicted on the plans received on July 27, 2010 and stamped approved on August 18, 2010. This is not a determination from any other agency. Sincerely, Boar,/of Trustees JMD:lms James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dava Bergen lolm HOlZapfel Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 .... _Telephone APPLICATION FOR AN AMeNDMeNT TO A W~TLA~ P~IT DATE ~~ AGENT ~~ ~D~Ss Signed By: ~ Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Ch. 275 Ch. 111 INSPECTION SCHEDULE INSPECTED BY: COMMENTS: Pre-construction, hay bale line/silt boom/silt curtain I st day of construction ~ constructed Project complete, compliance inspection. CERTIFICATE OF COMPLIANCE: James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (631 ) 765-1892 Fax {631 ) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD DATE OF INSPECTION: Ch. 275 Ch. 111 INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 1st day of construction }5 constructed Project complete, compliance inspection. COMMENTS: CERTIFICATE OF COMPLIANCE: Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliweda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: FROM: DATE: RE: Building Dept. Board of Trustees October 19, 2005 ROBERT & SUSAN TOMAN 3480 MAIN BAYVlEW RD., SOUTHOLD SCTM#78-2-13 With regard to the above-referenced property, an inspection was made and it was determined that the single-family dwelling was constructed in compliance with Wetland Permit #5239, as issued on October 25, 2000 and amended on September 25, 2002. If you have any questions, please do not hesitate to contact us. 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 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 A PRE-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 ¼ constructed Project complete, compliance inspection. Albert J. Krupski, President James King, Vice-President Attic Foster Ken Poliwoda Peggy A. Dickersen Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 August 20 2003 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. & Mrs. Robert Toman P.O. Box 1605 Mattituck, NY 11952 RE: 3480 BAYVIEW RD., SOUTHOLD SCTM#78-2-13 Dear Mr. & Mrs. Toman: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, August 20, 2003: RESOLVED that the Southold Town Board of Trustees grants the last One-Year Extension to Wetland Permit #5239. Permit will expire October 25, 2004. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, President, Board of Trustees AIK:lms 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 September 26, 2002 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. & Mrs. Robert Toman P.O. Box 1605 Mattituck, NY 11952 RE: 3480 BAYVIEW RD., SOUTHOLD SCTM#78-2~13 Dear Mr. & Mrs. Toman: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, September 25, 2002: RESOLVED that the Southold Town Board of Trustees grants a One-Year Extension to Wetland Permit #5239. Permit will expire October 25, 2003. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees Albert J. Krupski, President James King, Vice-President Artie Fester Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Seuthold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD September 26, 2002 Susan & Robert Toman PO Box 1605 Mattituck, NY 11952 RE: SCTM#78-2-13 Dear Mr.& Mrs. Toman: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, September 25, 2002. RESOLVED, that the Southold Town Board of Trustees Approve an Amendment to Permit #5239 to change the house and garage configuration install a 20'x40' pool and decks with the stipulation that drywells and gutters for the house and garage - drywell for pool backwash - be included.as per survey dated 9/23/02. If you have any questions, please call our office at 765-1892. Sincerely, President, Board of Trustees AJK:cjc New York State Department of Environmental Conservation Division of Environmental Permits Building 40 - SUNY, Stony Brook, NY 11790-2356 Telephone {631) 444-0365 Facsimile (631) ~.~.q-0360 Erin M. Crotty Commissioner August 12, 2002 Susan & Robert Toman P.O. Box 1605 2165 Gabriella Court Mattituck, NY 11952 AUG2 RE: 1-4738-00622/00004 Dear Permittee: In conformance with the requirements of the State Uniform Procedures Act (Article 70, ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit. Please read all conditions carefully. If you are unable to comply with any conditions, please contact us at the above address. Also enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather. KPK/Is Enclosure Sincerely, Kendall P. Klett Environmental Analyst · DEC PERMIT NUMBER 1-4738-00822/00004 IFAC L 'rY/PROGRAM NUMBER(S) PERMIT Under the Environmental Conservation Law EFFECTIVE DATE August 6, 2002 EXPIRATION DATE(S) August 6, 2007 TYPE OF PERMIT · New [] Renewal [] Modification · Permit to Construct [] Permit to Operate [] Article 15, Title 5: Protection of Waters [] Article 15, Title 15: Water Supply [] Article 15, Title 15: Water Transport [] Article 15, Title 15: Long Island Wells [] Article 15, Title 27: Wild, Scenic and Recreational Rivers [] 6NYCRR 608: Water Quality Certification [] Article 17, Titles 7, 8: SPDES [] Article 19: Air Pollution Control [] Article 23, Title 27: Mined Land Reclamation [] Article 24: Freshwater Wetlands · Article 25: Tidal Wetlands [] Article 27, Title 7; 6NYCRR 360: Solid Waste Mana~]ement [] Article 27, Title 9; 6NYCRR 373: Hazardous Waste Management [] Article 34: Coastar Erosion Management [] Article 36: Floodplain Management [] Articles 1, 3, 17, 19, 27, 37; 6NYCRR 380: Radiation Control PERMIT ISSUED TO Susan and Robert Toman ADDRESS OF PERMITTEE P.O. BOX 1605, 2165 Gabriella Court, Mattituck, NY 11952 ITELEPHONE NUMBER 1631) 298-5672 CONTACT PERSON FOR PERMI'I-rED WORK TELEPHONE NUMBER NAME AND ADDRESS OF PROJECT/FACILITY Toman property, Main Bayview Road at Baywater Avenue, Bayview COUNTY ~ TOWN WATERCOURSE / Suffolk ! Southold West Creek DESCRIPTION OF AUTHORIZED ACTIVITY: SCTM #1000~78-2-13 INYTM COORDINATES Construct single family dwelling with associated septic system, deck, pool, driveway and garage. Establish 50' wide non-disturbance buffer zone. All work must be done in accordance with the attached plans stamped NYSDEC approved. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, the General Conditions specified (see page 2 & 3) and any Special Conditions included as part of this permit. PERM IT ,A~MINISTRATOR: /,~DRESS ~ // ~ J Region 1 HeadqUarters J¢~/~/V~ieland (KPK) /' I Bldg. ~40, SUN/Y, Stony Brook, NY 11790-2356 AbT~O~IZED SlGNATUR(~/ '" DATE Page 1 of 4 NEW YORK TE DEPARTMENT OF ENVIRONMENTAL CONSERVATI~ NOTIFIC~'TION OF oT'~ER PERMITTEE OBLIGATION~ Item A'.' Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee expressly agrees to indemnity and hold harmless the Department of Environmental Conservation of the State of New York, its representatives, employees, and agents ("DEC") for all claims, suits, actions, and damages, to the extent attributable to the permittee's acts or omissions in connection with the permittee's undertaking of activities in connection with, or operation and maintenance of, the facility or facilities authorized by the permit whether in compliance or not in compliance with the terms and conditions of the permit. This indemnification does not extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or intentional acts or omissions, or to any claims, suits, or actions naming the DEC and arising under article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision under federal or state laws. Item B: Permittee's Contractors to Comply with Permit The permittee is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit, including all special conditions while acting as the permittee's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee. Item C: Permittee Responsible for Obtaining Other Required Permits The permittee is responsible for obtaining any other permits, approvals, lands, easements and rights-of-way that may be required to carry out the activities that are authorized by this permit. Item D: No Right to Trespass or Interfere with Riparian Rights This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. GENERAL CONDITIONS General Condition 1: Facility Inspection by the Department The permitted site or facility, including relevant records, is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Department) to determine whether the permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71-0301 and SAPA 401(3). The permittee shall provide a person to accompany the Department's representative during an inspection to the permit area when requested by the Department. A copy of this permit, including all referenced maps, drawings and special conditions, must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. General Condition 2: Relationship of this Permit to Other Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modity, supersede or rescind any order or determination previously issued by the Department or any of the terms, conditions or requirements contained in such order or determination. General Condition 3: Applications for Permit Renewals or Modifications .The permittee must submit a separate written application to the Department for renewal, modification or transfer of this permit. Such application must include any forms or supplemental information the Department requires. Any renewal, modification or transfer granted by the Department must be in writing. The permittee must submit a renewal application at least: a) 180 days before expiration of permits for State Pollutant Discharge Elimination System (SPDES), Hazardous Waste Management Facilities (H~MVlF), major Air Pollution Control (APC) and Solid Waste Management Facilities (SWMF); and b) 30 days before expiration of all other permit types. Submission of applications for permit renewal or modification are to be submitted to: NYSDEC Regional Permit Administrator, Region 1, SUNY Bldg g40, Stony Brook NY 11790-2356 General Condition 4: Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to modify, suspend or revoke this permit in accordance with 6 NYCRR Part 621. The grounds for modification, suspension or revocation include: a) materially false or inaccurate statements in the permit application or supporting papers; b) failure by the permittee to comply with any terms or conditions of the permit; c) exceeding the scope of the project as described in the permit application; d) newly discovered material information or a material change in environmental conditions, relevant technology er applicable law or regulations since the issuance of the existing permit; e) noncompliance with previously issued permit conditions, orders of the commissioner, any provisions of the Environmental Conservation Law or regulations of the Depa,,tment related to the permitted activity. DEC PERMIT NUMBER 1-4738-00622/00004 PAGE 2 OF 4 ARTMENT OF E.~NVIRONM ENTAL ADDITIONAL GENERAL CONDITIONS FOR ARTICLES 15 {TITLE 5), 24, 25, 34~I~ND 6NYCRR PART 608 ( TIDAL WETLANDS) If future operations by the State of New York require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural resources of the State, the owner may be ordered by the Department to remove or alter the structural work, obstructions, or hazards caused thereby without expense to the State, and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other modification of the watemourse hereby authorized shall not be completed, the owners, shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall be made against the State of New York on account of any such removal or alteration. The State of New York shall in no case be liable for any damage or injury to the structure or work herein authorized which may be caused by or result from future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no claim or right to compensation shall accrue from any such damage. Granting of this permit does not relieve the applicant of the responsibility of obtaining any other permission, consent or approval from the U.S. Army Corps of Engineers, U.S. Coast Guard, New York State Office of General Services or local government which may be required. All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project. Any material dredged in the conduct of the work herein permitted shall be removed evenly, without leaving large refuse piles, ridges across the bed of a waterway or floodplain or deep holes that may have a tendency to cause damage to navigable channels or to the banks of a waterway. 6. There shall be no unreasonable interference with navigation by the work herein authorized. If upon the expiration or revocation of this permit, the project hereby authorized has not been completed, the applicant shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. If granted under 6NYCRR Part 608, the NYS Department of Environmental Conservation hereby certifies that the subject project will not contravene effluent limitations or other limitations or standards under Sections 301,302, 303, 306 and 307 of the Clean Water Act of 1977 (PL 95-217) provided that all of the conditions listed herein are met. 9. At least 48 hours prior to commencement of the project, the permittee and contractor shall sign and return the top portion of the enclosed notification form certifying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion of project, the bottom portion of the form must also be signed and returned, along with photographs of the completed work and, if required, a survey. 10. All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or his agent as part of the permit application. Such approved plans were prepared by John Metzger last revised on 7/12/02. DEC PERMIT NUMBER PAGE 3 OF 4 1-4738-00622/00004 SPECIAL CONDITIONS 1. During construction, concrete or leachate shall not escape or be discharged, nor shall washings from transit mix trucks, mixers, or other devices enter tidal wetlands and or protected buffer areas. 2. Any debris or excess material from construction of th is project shall be completely removed from the adjacent area (upland) and removed to an appreved upland area for disposal. No debris is permitted in tidal wetlands and or protected buffer areas. 3. There shall be no disturbance to vegetated tidal wetlands or protected buffer areas as a result of the permitted activity. 4. All areas of soil disturbance resulting from this project shall be stabilized immediately following project completion or prior to permit expiration, whichever comes first. The approved methodologies are as follows: a. Stabilization of the entire disturbed area with appropriate vegetation (grasses, etc.). 5. The storege of construction equipment and materials shall be confined to within the project work site and or upland areas greater than 75 linear feet from the tidal wetland boundary. 6. To protect the values of the tidal wetlands, a permanent vegetated buffer zone shall be established. There shall be no disturbance to the natural vegetation or topography within an area extending 50 linear feet landward of the tidal wetland boundary. 7. A row of staked hay bales or apprevable erosion control devices shall be placed at the landward edge of the buffer area or 50 linear feet from the tidal wetland boundary, or as per NYSDEC approved plan, at commencement of regulated activities and remain in place until project is completed and all disturbed areas stabilized with vegetation. 8. Roof runoff must be directed to drywells a minimum of 75 linear feet landward of the most landward edge of the tidal wetland boundary, and must be installed a minimum of 2 feet above seasonal high groundwater. 9. Dry wells for pool filter backwash shall be located a minimum of 100 feet landward of the tidal wetland boundary. 10. There shall be no draining of swimming pool water directly or indirectly into tidal wetlands or pretected buffer areas. 11. Driveways and parking areas shall be constructed of pervious material. 12. The permittee shall incorporate the following language as a notice covenant to the deed: "Regulated tidal wetlands associated with Goose Creek are located at Suffolk County Tax Map Number: District 1000, Section 78, Block 02, Lot 13, otherwise known as the preperties of Robert & Susan Toman and their heirs, assigns, or successors. This preperty is subject to the previsions of New York State Environmental Conservation Law (ECL) Article 25 or its successor, and the conduct of regulated activities may occur only pursuant to ECL Ar/icle 25 if prior approval is given by the New York State Department of Envirenmental Conservation (NYSDEC) or its successor. Regulated activities include, but are not limited to the erection of any structure{s); excavation; dredging grading and filling; cleadng of vegetation; and application of chemicals." This deed covenant shall be recorded with the Clerk of Suffolk County within 90 days of the issuance of this permit. A copy of the covenanted deed or other acceptable proof of record, along with the number assigned to this permit, shall be sent within one calendar year of the issuance of this permit to: NYSDEC, Regional Manager, Bureau of Marine Habitat Protection, SUNY Building 40, Stony Brook, New York 11790-2356. DEC PERMIT NUMBER PAGE 4 of 4 1-4738-00622/00004 SURVEY OF PROPERTY AT SOUTHOLD TO~N OF SOUTHO~ SUFFOLK COUNTY, NE~ YORK 1000-78-p2-13 . NOV. 6, ~0 ( oM conc. [oondofion ~ Nov. aS~ ~OOO (BofHJ Jan. 24, zO¢ I~opo.) OCT. 12~ 2~1 f ~. h¢¢. ] dULY 12, 800~ f~i~ ~r~. ~1 ) F-, r AREA ~ 55914 sq. ff. o.r', Fc. mlhc. c ,,ti-. 1:he STANDAP.3S f'DP APFRD'vAL AND CDNSTRUCIlDN DF SuBSLIRFAC£ O~ ~he OsFm~ ~0 COK~S~r'L~C~ The [ocot~c/l oF weUs ,Drnd cesspools 5r'owr F~om Fiela ¢,~secv0. t[,Dr~s and or ~nlour bes and elevations ce ref~enced lo N.G.V.Oatum CERTIFTED TO' HOUSE PAINTIN6 BY ROBERT. TOMAN INC. ~LITY ~ TI~L TITLE ~A~ F7-O0~ ZONE L~dES FR~ FIRM 56103C0166 G' MAY 4, 19~ z'~- O',;F SURV£ Y~P,S PC PATRICIA C. MOORE Attorney at Law 51020 Main Road Southold, New York 11971-4616 Tel: (63l) 765-4330 Fax: (631) 765-4643 February 2, 2001 Southold Town Trustees Southold Town Hall 53095 Route 25 P.O. Box 1179 Southold, NY 11971-0959 RE: Premises: Toman L_ Main Bayview Road, Southold, NY 11971 SCTM # 1000-78-2-13 Dear Ladies/Gentlemen: As per your request, enclosed please find two (2) prints of the survey of the above referenced premises. advise us when your Permit is ready. Thank you. revised Please PCM/mr Encls. Tetephone (631) 765-1892 To~t Hall. $3095 Ma/n Road P.O. Box 11/9 Southokl, N~w York 119~1 SOr~HOLD TOWN CONSERV~.'~IO[~ ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Tuesday, August 20, 2002, the following recommendation was made: ROBERT & SUSAN TOMAN to Amend Permit #5239 to change the house and garag'e configuration, install a 20'X 40' pool and deck. Located: 3480 Main Bayview Rd., Southold. SCTM#78-2-13 The CAC did not make an inspection, therefore no recommendation was made. Board Of Southold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. ~)'~ o~. dj DATE: C~.ff/~?b ff~ .~?..t....2000 ISSUED TO .... SUSAN. & ROBERT TOMAN ............................. Pursueut tG the provisions of C~hepter 61S of the L~ws of. the State of New York, 1893: end Che rpte '04 of the ~ws of the · Stele of New York 19521 end theSo~ ToWn Ordinance en- titled ."REGULATING AND THE PLAC;ING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBUG LANDS end the REMOVAL OF SAND, GRAVEL. OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;!~. end in accordance with the Resolution of Yhe B6erd adopted af · meeting hekl on ..O...c..~........~.~.~. ...... ~0(~...L., and in eonslderafion of the sum of $....~:.~.~..t..0...0. ...... paid by Susan & Robert Toman of ....... M~!.*.~S~ .................................. ' ..................... N. Y. ,nd ,~bi~ to the Te~a~ and Conditions I~d on ~he re¥~n~ dde he~o{, o{ SocOho~ Town Trm-~ authorizes ~nd parm~ ~t~ {ollowi~g:. Wetland Permit to construct a single-family dwelling, breezeway, and garage,sanitary system and well, with the condition of a 50t non-disturbance buffer area marked by a row of plantings an, that a. row of staked hay bales be placed down at the 50' line' · # in accordance ~ith the detai~d ~p~Hl~tlo~, as pr~ted in ~le ol~gJnaJJ~g appJ~utJo~, during ~onstruction, all in accordanl with survey dated Sept. 21, 2000 and .last revised Oct. IN WITNESS WHER[O~, The ~md Board of Tru~ ~ ~u,e~ i~ Corporate SOd to I~ affi~nd, enit ihe~ p~$enl~ . H.enry Smith - Absent - ' Trustees Albert J. Krupski, President James King, Vice-President Henry Smith Artie Pester Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone(631) 765-1892 Fax(631) 765-1366 October 30, 2000 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. & Mrs. Robert Toman P.O. Box 1605 Mattituck, NY 11952 RE: 3480 Main Bayview Rd., Southold SCTM#78-2-13 Dear Mr. & Mrs. Toman: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, October 25, 2000 regarding the above matter: WHEREAS, SUSAN & ROBERT TOMAN applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated October 5, 2000, 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 October 25, 2000, 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, 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, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approve the application of SUSAN & ROBERT TOMAN to construct a single-family dwelling, breezeway, and garage, sanitary system and well, with the condition of a 50' non-disturbance buffer area marked by a row of plantings and that a row of staked hay bales be placed down at the 50' line during construction, all in accordance with survey dated September 21, 2000 and last revised October 16, 2000. BE IT FURTHER RESOLVED that this determination should not be considered a determination made for any other Department or Agency, which may also have an application pending for the same or similar project. Permit to construct and complete project will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. Fees: None Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/lms cc: DEC Health Dept. Telephone (516) 765-18=1Z Hall. 53095 blain P~oad P.O. Box 1179 Southold, New York 1~.971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Monday, October 23, 2000, the following recommendation was made: Moved by Ken Meskill, secon~ded by Scott Hilary, it was RESOLVED to recommend to the Southold Town Board of Trustees I)ISAPPROV)~L of the Wetland Permit Application of SUSAN & ROBERT TOMAN 78-2-13 t9 coflstruct a single- family dwelling, breezeway and garage, sanitary system and well. 3480 Main Bayview Rd., Southold The CAC recommends Disapproval because they were unable to determine the distances because of the lack of stakes and where the limit of clearing would be. Vote of Council: Ayes: All Motion Carried (In Accordance with Uniform Procedures, Part 621.13) Please reed ALL instructions on bacl~ before completing this application. Please TYPE or PRINT clearly in ink. PART I--TRANSFEREE (NEW OWNERIOPERATORILESSEE) COMPLETES: 1. LzST PERMIT NUMBER(S) AND THEIR EFFECTIVE AND EXPIRATION DATES. .[ 2. NAME OF TRANSFEREE STREET ~. TRANSFEREE IS A/AN: [] Owner ~'1 Operator [] Lessee If other than an individual, provide Taxpayer ID Number TELEPHONE NUMBER STATE ZiP CODE 4. NAME OF FACiLITY/PROJECT STREET CITY STATE COUN~ TOWN 5. HAS WORK BEGUN ON THE PROJECT? ~ Yes ~ NO If no, proposed sta~ing date: Approximate completion pate; ~f there will be Any modifications ~o the current operation, the transferee must attach a statement specifying the aa[ails. ZIP CODE 6. CERTIFICATION: This certifies that the transferee is the current ownerloperatordessee of the name(3 facility, has a copy of the perm[l, unoerslands and wdl comply with all conditions in the referenced permit. Facility operatlonslproject scopetdischargeslemiss~ons will remain the same. Further, Signature and Title Date PART 2--TRANSFEROR (FORMER OWNERIOPERATORILESSEE} COMPLETES: 1. NAME Of TRANSFEROR STREET / If other than an individual provide Taxpayer iD Number TELEPHONE NUMBER ( ) CITY STATE ZIP CODE 2. NAME OF FACILITY/PROJECT, IF DIFFERENT FROM NAME IN PART 1: 3. CERTIFICATION: This certifies that the facility referenced in Part 1 of this form will be/was transferred to the party identified as the new transferee (owner/operator/lessee) on (dotal. Signature and Title Date PART 3--PERMIT TRANSFER VALIDATION SECTION--DEPARTMENT OF ENVIRONMENTAL CONSERVATION COMPLETES: [] Transfer of permit approved. Transferee subject to conditions of permit, without exception. [] Transfer of perm~I approved, with the following modifications: [] See attached reviseP permit pagefsl OCT - [] New application required. Please complele the enclosed permit application and return it to the undersigned Regional Permit Administrator, Division of Regulatory Services, at Ihe appropriate office of the Department (see map on reverse). Signature Date Heg~Onal Herm~l Administrator New York State Department of Environmental Con6ervetion Dlvi~'en of Envlronment~ Peri. tm Rnt 121, Building 40. ~UNY Stony book, New York 1179~56 Fac~mlle 1516) ~ 0~ AMlaI~TDM~M~ ~0 P~'~ J~n P, ¢~11 ~r. Roy Stakey P.O. Box 217 Aquebogue, N.Y. 11931 Date: ~,~'ch 5, 1996 Re: ~e~mi~ No. & Location: s=aKe~ pro,er=? a~ Main Bawiew Rd. and ga_vwatsr Ave. Dear Mr. Stakey; Your z-ecmnt request to extend the ahoy= ~®r~it ham ~mn rev=awed pursuant to 6NYCRR, Part 621. The expiration date is extended to_~. Your recent request to modify the above permit has been rev~.swed pursuant to ~NYC~R, Part ~2~, It h~e b.~en det~.-nin~d thaz the proposed modifications will not substantially change the scope of the permitted actions or the existing permit conditions. Therefore, the permit is amended to authorize: This letter is an amendment to the original permit and, as such, shall be available at the job site whenever authorized work ia in progress. Al! other terms an~ conditions ramat~ a~ ,~tC~n in the original permit. cc:KPK 1t48' 6505 $ DECLARATION AND COVENANT THIS DECLARATION, made the ~g ~ day of June, 1992, by ROY STAKEY and MARJORIE STAKEY, as Trustees of the Roy Stakey Defined Benefit Keogh Plan, residing at (No #) Tuthill Lane, Aquebogue, New York, hereinafter referred to as DECLARANTS, WHEREAS, DECL~{ANTS are the Owners of certain real proper~-y situate at Main Bayview Road, Southold, Town of Southold, Suffolk County, New York and identified by Suffolk County Tax Map No. 1000-078.00-02.00-013.000, and which said premises are more particularly bounded and described as set forth in Schedule A attached hereto and made a part £000 078.00 02,00 013.000 hereof, and WHEREAS, DECLARANTS had made application to the New York State Department of Environmental Conservation fnr a ~ermit to build on the said premises, and WHEREAS, the New York State Department of Environmental /~/'~21~Conservat~on had given approval for said 9~rmit provided that no orougn= To =ne pro~ec= ~lna£ gra~Ing of Environmental Conservation, that any fill plan must malntain a fifty (50') foot distance from the tidal wetland line as shown the approved survey attached to the New York State Department of Environmental Conservation application, and that there is to be no disturbance to the vegetation or topography within fifty (50') feet of the aforesaid tidal wetlands he~einbefore referred to and that a covenant to that effect is to be recorded to maintain this 1 APPLICATION FOR PERMIT TRANSFER General Instructions · Transferee (new owner/operator/lessee) must: 1. Complete Part 1 of this form. 2. Have Part 2 of this form completed by former owner/operator/lessee (Transferor). if the information requested in Part 2 cannot be obtained, the transferee must attach a statement giving the reason(s). 3. Submit completed form (Parts 1 and 2) to the Regional Permit Administrator, Division of Regulatory Services, at the appropriate office of the department (see map below). Transferee may keep the last copy of this application. Other Instructions 4. Applications by a Corporation shall be signed by the principal executive officer; a Partnership by a general partner; a Sole Proprietorship by the proprietor; a Municipality or Public Corporation by the duly authorized principal executive officer; and a State agency by a person duly designated by the commissioner or other agency head. 5. If other than the owner makes application, written consent of the owner to use the property/facility must accompany the application. 6. The transferee is responsible for obtaining any other required federal, state or local permits. Contact the Regional Permit Administrator, Division of Regulatory Services, at the appropriate office of the department, as given below, for assistance regarding any of the above requirements. Department of Environmental Conservation Regional Offices Division of Regulatory Services REGION 6--DRS State Office Building 317 Washington St. Watertown, NY 13601.3787 f315) 785-2245 SUB-OFFICE--DRS State Office Building 207 Genesee St. Utica, NY 13501-2685 (315) 793-2555 REGION 7--DRS REGION 9--DRS %'] REGION 8--DRS ' 615 Erie St. West 270 Michigan Ave. I r 6274 E. Avon-LCma Rd. / Syracuse, NY 13204-2400 Buffalo, NY 14203-2999~i Avon, NY 14414-9519 / (315} 426-7400 (716) 851-7165 ~ (716) 226-2466 ~ SUB-OFFICE--DRS SUB-OFFICE--DRS --~ 1285 Fisher Ave. 128 South St. ' Cortland, NY 13045-1090 Olean, NY 14760-3632 f607) 753-3095 (716) 372-6242 Regional Headquarters Regional Sub-Ofhce Served by Sub-office REGION 2--DRS (New York City} 1 Hunters Poir3t Plaza 47-40 21st St. Long Island City, NY 11101-5407 (718) 482-4997 REGION 5--DRS Route 86. PO Box 296 Ray Brook, NY 12977-0296 1518) 897-1234 SUB-OFFICE-- DRS County Route 40 P,O Box 220 Warrensburg, NY 12885-022 (518) 623-3(~71 REGION 4--DRS t150 North Wescott Road. Schenectady. NY 12306-26 1518~ 357-2068 SUB,OFFICE--DRS Route 10. Jefferson Rd. HCR#1, Box 3A Stamford, NY 12167-9503 (607) 652-7364 REGION 3--DRS 21 South Putt Corners Rd 1266.696 SUNY Campus Loop Rd., Building 40 Stony Brook, NY 11790-23~ (516) 444-0365 ' RIDEP. TO CONTRACT BETWEEN ROY STAKEY and~ARJORIE STAK~Y, AS TRUSTEES OF THE ROY STAKEY DEFINED BENEFIT KEOGH PLAN, SELLER and HOUSE PAINTING BY ROBERT TOMAN INC., PURCHASER DATED 2000 ALL, that certain plot, pizc~ ~r .oarr~l of lan(-', w~th the btli]digl~s on'.] i,r~prove'.~ent~ Ihereo~l erected, lying a.d bei.~ in the Town of Southold, County of Suffolk and State of New York, bounded and described as follows: BEGINNING at a point on the northerly side of Main Bayview Road on the division line between the premises herein described and lands now or formerly of McAslan; RUNNING THENCE along the northerly side of Main Bayview Road North 50 degrees 06 minutes 40 seconds West 187.32 feet to the easterly side of Main Bayview Road; RUNNING T~ENCE along the easterly Side of Main Bayview Road North 0 degrees 29 minutes 10 seconds East 171.04 feet to the southerly line of Lot 3 on Map NO. 3848; RUNNING THENCE along the division line between said Lot 3 and the premises herein described South 65 degrees 29 minutes 00 seconds East 228.63 feet to lands now or formerly of. McAslan; RUNNING THENCE along sdid lands Suu~h 18 degrees 31 minutes 00 seconds West 207.01 feet to the point or place of BEGINNING. SURVEY O? PROPERTY A T $0 UTHOLD TO~FN OF SOUTHOLD SUFFOLK COUNTY, NEfF YORK - ' ' .~.S BOAR~, TO-WN C. , ,.AOLD )ATE 1000-78-02-13 SCALE: 1"= 40' SEPT. 21, 2000 OCT. lB, 2000 (revision I ~m Comitior with the STANDARDS FOR APPROVAL AND CONSTRUCTION OF SUBSURFACE SEWAGE ~ ~,~ D]SPOSAL S~S~EMS FOR SINGLE FAMILY RESIDENCES ~ ond wiLL obide by Che conditions set Forth ~hecein and on ~he permi~ to construe%. ~he Loco~ion oC weLLs ond cesspools shown hereon ope fror, ~ield observotions ond or dolo obtoined from o%hers. [~eVO~OK~S OK e reCE, re~ced ~o N.G ~ D. ~o~m. DF SECTION 7809 OF [HE NE~ YORK STAT[ EDUCA11DN La~. GRADING PLAN NO TE' SUBSURFACE SEWAGE DISPOSAL SYSTEM DESIGN BY' JOSEPH FISCHETTI, P.E. HOBART ROAD SOUTHOLD, N. Y. 11971 (6311 765 - ~954 0 2~ TEST BORING .SANDY TOPSOIL OL LOAMY COARSE SAND SW GROUND W.4 TER ~V COARSE SAND ~,$, ~CDN~EYORS, ~63D 7~ - 5020 F D, BOX 909 tiC. ND. 49618 FAX:C631) 765-1797 Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18q2 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES · TOWN OF SOUTHOLD irt ' LETTER OF REQUEST FOR AN AMEN'DI ',. JUL 2 9 i'C",' 'C:. AGENT PHONE_/,(~! :,~c_j~,, z:o~7.,~3 / Signed ?1 Iqlo> PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Nanle: Address: STATE OF NEW YORK COUNTY OF SUFFOLK ~--~- --~r~a~ , residing at cv'~k4.'&-o c)~. ~ , being duly sworn, deposes ~d says that on ~ day~f ' ~ ,200~, deponent m~led a ~e copy of~e Notice set fo~. in the Bo~d of Trustees Application, ~rected to each of the above rimed pe~o~ at ~e ad~esses set opposite ~ere respective nines; ~at the ad~esses set opposite ~e nines ofs~d perso~ ~e the ad&ess ofs~d persons as shorn on the c~ent ~sessment roll of the To~ of Sou~61d; that s~d Notices were mailed at the U~ted States Post Office at ~,'~k Zme~ , ~at said Nff~ ~ mil~ m each of s~d persons by (ce~ified) (re~stere~ mail. Sworn to before me this -3 E> Day of 4Y't4c~' ,20 o ~- MARGARET C. RUTK'OW~KI No~y Pub~o. m~te o~ N~w Yod~ No. 4~ 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 BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I,~.~f~O3(% , residing at 0~S ~_O~i'~/L/~C~ ~_'¥' be'i~g duly'sworn, depose and say: That on the ~ day of ~ , 200~ I personally posted the property known as/ooQ-7~--O~_%~ 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 Date of hearing noted thereon to be held ~..~U~.~l~~ public hearing. .-------/~ _ Sworn to before me this ~ day of ~--~c_>/ 200~1 MARGARET C. RUTKOWSKI Notmy Publlo, ~tate c~ New No. 4982528 Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18.~2 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only 7~wOaStal Erosion Permit Application Wetland Permit Application Grandfather Permit Application /. ~aiver/Amendment/Changes ~ __~ceived Applicg~.o~:~___ ---R~eceived Fee:$ ~;-; . -'~ompleted Application~ Incomplete SEQRA Clas~ Type I Type II Unlisted Coordination:(date --'CAC Referral Sent:~ --~-D'ate of Inspection: . Receipt of CAC Report: Lead Agency Determination:__ ~pechnical Review: ~ ublic Hearing Held:]~__ Resolution: Phone Number: Suffolk County Tax Map Number: 1000 - (provide LILCO Pole #, distance to cross streets, and location) (If applicable) Address: Phone: FAX#: B~d of Trustees ApplicationO GENERAL DATA Land Area (in square feet): Area Zoning: ~- ~O Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency Dat~ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? J No__ Yes ~U~O~J~ / If yes, provide explanation: Project Description (use attachments if necessary): B~d of Trustees Applicatio~ WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: ~oo~ ~quare feet Percent coverage of lot: ,~-- % Closest distance between nearest existing structure and upland edge of wetlands: ~ feet mia Closest distance between nearest proposed structure and upland edge of wetlands: ~O feet Does the project involve excavation or filling? No J Yes If yes, how much material will be excavated? How much material will be filled? /~-O 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: /~O cubic yards cubic yards 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): Bol of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: ~C~rd~6~ Are wetlands present within 75 feet of the proposed activity? No Yes Does the project involve excavation or filling? No / Yes If Yes, how much material will be excavated? ~r~ (cubic yards) How much material will be filled? /50 (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) 4 617.21 Appendix C State Environmental Quallty Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATIQN (To be completed by ADplican~ or Project sponsor) SE( 1. APPLICANT ISPONSOR i 2. PROJECT NAME 3. PROJECT LOCATION~ 4. PREO:SE LOCATION (Street a~ress and road inters~tlons, prominent landmarks, elc., or prov~e $. IS PRO~SED ACTION: ~ New [] Expansion [] Moeificatlonlalteration 7. AMOUNT OF ~NO AFFECTED: rniualmy ecres UIt[matedy acres [] NO If NO, describe briefly in. DOES ACTION INVOLVE A PERMIT APPROVAl-, OR FUNDING, HOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE ~1 LOCAl J? ~Yes [] No If yes, llet agency(si and permit/aoprovaJ$ 11. ~ES ANY ASPECT OF THE ACTIOI,I HAVE A CURRENTLY VAUO PERMIT OR AFPROVAL? [] NO If yes, list agency name and pen~Jl/al~l~roval the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this a.~;essment OVER I PART UI--OETERMINATION OF SIGNIFICANCE (To De combleted by Agency) INSTRUCTION,S: For each adverse effect identified acove, determine whether it is substantial, large, important or otherwise signi Each effect snoulcl he assessed in connection with its (a) setting (i.e. urban or ~ural); (b).probalaility of Occ~3~'-Lng; (.c) duratJ( irrevers~bdity: (el geogr~cnic scoce; and (0 magmtucle. If necessary., aclcl attachments or reference supporting materials. [qsur explanations contain sufficient tie, ail ~o snow that all relevant aciverse impacts have been irientlfiec and adeciuately acdresse Check: :his box if you have identified one or more potentially large or significant aoverse impacts whic~ .M. occur. Then proceea c~irec:ly to :t~e FULL -~AF anc~lor prepare a positive-declaration. Chec.k :his ~ox if you have de'.ermined, =asea on :he information and analysis above and any sueeor:! Cocumenta[=on. tiaa: :~e orocosea ac:ion WILL ;lOT result in -_~.n,/ significant adverse environmental imca~ AND ~rOvlce on attachments as necessary., the reasons supporting tills determination: Alber~ J. Krupski, Presiden~ 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 (531) 765-1592 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD in the Matter of the Application of COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I,_~m~_~. ~_~ , residing at being duly sworn, depose and say: That on the ~ day~L ,.2000. I personally posted the ~roperty known as f~~{l] ~ %y pl. acing the Board 'of Trustees official p~Ster where it can ~asily De ~een, and that I have checked to be sure the poster kas remai%%ed in place for eight days prior to the dat~ cf the public ~!earin~. Da~e of hearing no'~ed thereon to be held ~~1~ OateQ: OCT- '~",, '~c,,~c-, Sworn to before me this ~74 day of 0C7% 200~ ~s~gnature) Bo~d of Trustees Application County of Suffolk State of New York ~.~ ~, ,t~/~.~_~) THAT HE/SHE IS THE APPLICANT FOR Tn~ ABOVE DESCRIBED PERMIT(S) AND THAT ALL STNI'~EI~TS CONTAINED~INARE TRUE TO THE BEST OF HIS/HERKNOWLEDGEANDBELIEF, AND'£nATALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOb'£nOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THETOWNOF SOUTHOLDAND '£n~TOWN TRUSTEES HARb~.~SS AND FREE FROM ANY AND ~r.r. DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRA~T~D. IN COMPLETING THIS APPLICATION, I HE~Y AD'£nORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO Ei~T~R ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. SWORN TO BEFORE ME THIS JOYCE M. WIll(INS ~ Publi~, State of New York No. 4952246, Suffolk County Term Expires June 12, ~o~ [ Boa~of Trustees Application A U'ruORI ZATI ON (where the applicant is not the owner) - (print' owner ~ property) (mailing address) do hereby authorize (Agent) to apply for permit(s) from the Southq~d Board 9f Town Trustees on my behalf. STATE OF NEW YORK COUNTY OF SUFFOI,Kf JO¥CE M. WILKIN$ Notary Public, State of New ~ N~o. 4952246, Suffolk" ~ ,erin E~oim~ June l~,~m~.~c~!