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Home My WebLink AboutTR-5616Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, NewYork 11971-0959 Telephone (631} 765-1892 Fax {6311 765-1366 August 18, 2004 BOARD OF TOWN TRUSTEES TOWN OF $OUTHOLD Mr. FrankJacobsen 330 Shore Lane Peconic, NY 11958 RE: 330 SHORE LANE, PECONIC SCTM#86.1-4.12 Dear Mr. Jacobsen: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, August 16, 2004: RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to Permit #5616 to construct a 12'X 22' tool shed, and to Transfer Permit #5616 from Schembri Homes to Frank Jacobsen. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765-1892. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees AJK:lms .SHORE :LANE' ( sc~,~ looo 8~- o/- ,~.z0 · 0 0 .00' L=105.07' Albert J. Krupski, President James King, Vice-President Artie Poster 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 TO: FROM: DATE: RE: BOARD OF TOVfN TRUSTEES TOWN OF SOUTHOLD Building Department Board of Trustees February 3, 2003 Schembri Homes, Inc. SCTM#86-1-4.10, 4.11 &4.12 Please notify our office prior to issuance of a Certificate of Occupancy for each of the above-referenced so that we can make a final/compliance inspection. Thank you for your cooperation. Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dicksrson 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. ID._. INSPECTION SCHEDULE Pre-construction, ~ ~ c ~ 1st day of construction ¼ constructed Project complete, compliance inspection. TERI',4S and CONDITIONS Schembri Homes, Inc. ~ai.g ax 10 Sandpiper Dr., Riverheadt NY 1~90~ N. %'. as part of the comk~-atioa loc the issuance of ~e r~..-~t does umtexstami a~l pa~s~d~e to the fo1- I. Th~ the said Board of T~_~'~ and the Town for an ~on may be u~de to ~. That this 'Permit should be t~-t~fined iadeirmltely, or as ia~t~ as the ~Jd l~'m~ee wishes to maintain the structure ot project involved, to provide evidence to tnyone concerned dmt ~ odzatio~ was ofiginall? obtained. 4. That ~he work involved will he subject to the ;-,mectioa and approval of the Board z~ its agents, and non-compliance with the provisions of the otiginat/ng app/ication, may be _~-~. for t'evocaxion of thi¢ Permit by resolution of the said Boazd. 5. That there will be no unteasontble interference with navigation as a result o~ the w~k herein authorized. 6. That there shah be no interference with the tight of the pul~c m ~ and repass aloog the beach between high and low wtter ma~ks. 7. That if future olgntiom of the Tovm of ~o~thold t~paite the zemovsl and/m- in the location of the work herein authorized, or its in the opinle~ of the Boaxd o~ Trustee% the WOt~ ~h~H cause mu~asonable obstrucnon to free navlgaxioo, the said Petmlttee will be vequi~ upon due notice, to remove or alter this work or project herein stated without eq~emes to the To~ 8. That the said Board will be notified by the Permittee ot ~he complefio~ of the w~c aud~ otized. That the Permittee will obtain all other permits and co,series d~t may be requited ~ plemental to this pem~it which may be subject to revoke upon failure to olxaln san~ 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 10, 2002 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Ms. Catherine Mesinao Catherine Mesiano, Inc. 12 Mill Pond Lane East Moriches, NY 11940 SCHEMBRI HOMES, INC. E/s SHORE LANE, PECONIC SCTM#86q-4.12 Dear Ms. Mesiano: The Board of Toxvn Trustees took the following action during its regular meeting held on Wednesday, August 21, 2002 regarding the above matter: WHEREAS, Catherine Mesiano on behalf of SCHEMBRI HOMES, INC. applied to the Southold Tox~m 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 July 30, 2002, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on August 2 l, 2002, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standards set forth in Chapter 97 of the Southold Town Code, 2 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 SCIlEMBRI HOMES, INC. for clearing and grading required for the construction ora 59'X 75' single-family dwelling with attached garage, driveway, and on-site sewage disposal system, with the condition of a non- disturbance buffer 50' from the edge of the wetlands and a split-rail fence installed at the 50' line, and a 25'non-turf buffer on the west side of the fence, all as depicted on the survey dated January 13, 2000 and last revised August 28, 2002. Documentary proof that the reserved areas indicated on the survey has been transferred to a homeowners association "tax-exempt organization" or that all necessary steps and approvals have been obtained to transfer the reserved areas indicated on the above survey to a homeowners association "tax-exempt organization" or the Town of Southold, must be provided. BE IT FURTHER RESOLVED that this determination should not be considered a determination made for any other Department or Agency, xvhich 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 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 $5.00 per inspection. (See attached schedule.) Fees: $10.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/lms cc: Building Dept. Health Dept. NYSDEC PROKOP & PROKOP ! 31 ROLrFE 2,~,A ROCKY POINT, NY I ! 778 Septeraber 6, 2002 Lauren Standish Southold Board of Trustees P.O. Box 1179 Southold, NY 11971 Re: Richmond Shores Schembri Homes, Inc. Permit Application for Lots 4.10, 4.11 and 4.12 Dear Ms. Standish: We are counsel to Schembri Homes, Inc. ("Schembri"). We have been advised that the trustees have requested information regarding the reserved areas (District 1000, Section 86, Block 1, and Lots 4.25, 4.27, 4.28 and 4.29) the development at Richmond Shores in Peconic, New York. for Please be advised that we have been retained to form a not for profit association for the purpose of taking title to the reserved areas at Richmond Shores and that the association will initially be managed by the Schembri and then management shall be turned over to the lot owners. Please contact the undersigned if any additional information is needed. David~,t.') Prckop Telephone Town H'~. 5309,5 M~,in Road P.O. Box 1179 Southold. New Yo~k 11971 SOrJTI~OLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town ConserVation Advisory Council held Tuesday, August 20, 2002, the following recommendation was made: Moved by Bob Ghosio, seconded by Jason Petrucci, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A STIPULATION of the Wetland Permit Application of SCHEMBRI HOMES, INC. for clearing and grading required for the construction of a 59'X 75' single-family dwelling with attached garage, driveway and on-site sewage disposal system. Located: Els Shore Lane, Peconic. SCTM#86-1-4.12 The CAC recommends Approval of the application with the Stipulation of a 75' non- disturbance buffer. Vote of Council: Ayes: All Motion Carried Albert J. Krupski, President James King, Vice-President Attic Foster Ken Poliwoda Peggs' 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 APPLICATION FOR AN AMENDMENT TO UTL- 8 OWNER ADDRESS AGENT ADDRESS PHONE PROPERTYLOCATION .~2-?'d) ..fi"dO/-~' d,e,~.e ,/2~,_ o ,,;. lA.l); UWe ,~,// ~(c'~o"e~ request an Amendment to Permit Signed By: Albert J Krupsk~, President James King, Vice-President Arfie Foster Ken Pohwoda Peggy A. Diekerson Tvwn }tall 53095 Route 25 P@.Box 1179 Southold, New Yolk 11971-0959 Telephone ~ 631'~ 766 1892 Fax ~631.1 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office (!se Only __ Coastal Eroston Pcrrmt Application __Wetland penrat Application .... M'ajor ___Waiver, Amcndmenl/Changes __Receive~ Application:__ Minor Completed Application ---~lncomplctc ___SEQRA Classification: Type I,,, Type II ,Unlisted __Coordinafion:(date sent). ___CAC Referral Sent: _ _Date of Lnspection: _ _Receipt of CAC Report: ___Lead Agency Determination: __ _T~chnical Review' .___Public Hearing Held- ___Resolution: ............ NameofApplicam /--fa ~ /[ Phone Numbcr:(~.~. 7.3 ~-/ - 2 ~/~' ~ Suflblk CoantyWax Map Number: 1000-_ff.~ - 0 / - L]./__~ ' Property Location: 7-7. ~ ~ ~ of'~' /r.' t~ ~ /g;7.~ rc~ t ~ (provide LILCO Pole it, distanl/e to cros~ ltreets, and location) AGENT: (If applicable) Address: Phone: County of Suffolk State of New York Board of Trustees Application fr ~ ,~/t' d-'~ ~-oB_c.e~ BE~N~ Dray swo~ DEPOSES ~ ~F~S THAT ~/S~ IS T~ ~PLIC~T FOR T~ ~O~ DESC~BED PE~IT(S) ~ t~t ~L STATE~NTS CONWED ~ ~ TR~ TO t~ BEST OF HIS~R ~OWLEDGE ~ BEL~F, ~ THAT ~L WO~ WILL BE DO~ ~ t~ M~R SET. FORTH ~ T~S ~PLICATION ~ AS MAY BE ~PRO~D BY t~ SOUTHOLD tO~ BO~ OF TRUSTEES. t~ ~PLIC~T AG~ES TO HOLD t~ tO~ OF SOUTHOLD ~ t~ tO~ TRUSTEES H~ESS ~D F~E FROM ~ ~ ~L D~AGES ~ CL~S ~S~G ~ER OR BY ~T~ OF S~ PE~T(S), ~ G~D. ~ CO~LET~G ~S ~PLICA~0N, I ~Y AU~O~ ~ ~US~, ~ A~ ~ ~.~s~.~,~s(~>, ~o ~N~ o~o ~ ~o.~. ~o ~c~ ~ - -- Signature // 7 Notary Public PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAlL RECEIPTS ///,? STATE OF NEW YORK COUNTY OF SUFFOLK , , being duly sworn, depose~ and says that on the /69 day of a'o'fo,,-c/-' ,200~, deponent mailed a true copy of the Notice set forth in the Board ol'Tmstees Application, directed to each oft_he above named persona at the addresses set opposite there respective names; that the addresses set opposite thc names of sa/d persons are the address of said persons as shown on the currcat assessment roll of the Town of Southold; that said Notices were mailed at the United States Bost Office at /')~ fi' o ~, ' ¢ /I/~/ , that sa/d Notices wcrc ma/led tg~ach of said persons by (certified) (registered) mail. Sworn to, before me this Day of ~22._, 20~'~ ~Or~al~e LaRva ARY PUBLIC, State of ~ ~. 01LA6059257 ~arnmlffied II1 Suffolk County isslon Expires May 29, Telephone (631 ) 765-1892 Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Tuesday, August 10, 2004, the following recommendation was made: Moved by William Cook, seconded by Jack McGreevy, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the Amendment application of FRANK JACOBSEN to Amend Permit #5616 to construct a 12'X 22' tool shed. Located: 330 Shore Lane, Peconic. SCTM#86-1-4.12 Vote of Council: Ayes: All Motion Carried APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics orohibits conflicts of interest on the Dart of town officeri~ ired etnpJoyce~;, The puq~nse of this form is to nrovide information which can alert the town of~ossible conflicts of interest and allow it to lak, whatever action is necessar~ to avoid same. (Last name, flint name, middle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indinate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance ~ Trustee Change of Zone Coastal Erosion Ar.~rev~-! ef p!nt Mooring E~mOt[on from plat or official map Planning Other (If"Other", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee oftbe Town of Southold? "Relationship" includes by blood, marriage, or business interes~ "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of (or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO If you unswered "YES", complete the balance of this form and date and sign wbem indicated. Name of porson employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/ngent/representative) and the town officer or employee. Either check the appropriate 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 ofgrea~r than 5% of the shams of the corporate stock of the applicont (when the applicant is a corporation); __B) the legal or'henefieial owner of any interest in a non-corporate entity (when the applicant is not a corporation); __C) an officer, director, pmocr, or employee of tho applicent; or __D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I Name of Applicant: Address: Phone Number: SCHEMBRI HOMES, INC 10 SANDPIPER DRIVE, RIVERHEAD, NY 11901 631-727-4127 Suffolk County Tax Map Number: 1000-86-1-4.12 Property Location: E/S SHORE LANE, 532.74' S/RICHMOND LANE, PECONIC AGENT-. CATHERINE MESIANO, INC. 12 MILL POND LANE EAST MORICHES, NY 11940 PHONE /FAX: (63t) 878-8951 Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: -0- .square feet Percent coverage of lot: -0- % Closest distance between nearest existing structure and upland edge of wetlands: N/A feet Closest distance between nearest proposed structure and upland edge of wetlands: 100.9 feet Does the project involve excavation or filling? No X Yes If yes, how much material will be excavated? APPROX. 900 cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: 11 feet Proposed slope throughout the area of operations: AS PR£SENTLY EXISTS Manner in which material will be removed or deposited: EXCAVATION AS REQUIRED FOR CONSTRUCTION OF FOUNDATION. EXCESS MATERIAL WILL BE USED TO BACKFILL SITE. NO ADDITIONAL FILL IS PROPOSED TO BE BROUGHT ONTO THE SITE. 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): NO EFFECT ON THE WETLANDS OR TIDAL WATERS IS ANTICIPATED AS A RESULT OF THE PROPOSED ACTIVITY. · IMPROVEMENTS WILL BE SETBACK >100' FROM THE LANDWARD EDGE OF THE WETLAND. · DRYWELLS FOR CONTAINMENT OF ROOF RUN-OFF WILL BE UTILIZED. · A 50' BUFFER AREA WILL BE MAINTAINED LANDWARD OF THE EDGE OF WETLAND. NOTICE TO ADJACENT PROPERTY OWNER BOARD Of TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: SCHEMBRI HOMES, INC YOU ARE HEREBY GIVEN NOTICE: 1. SCTM # 1000-86-1-4.12 That it is the intention of the undersigned to request a Permit from the Board of Trustees to: CLEAR AND GRADE AS REQUIRED FOR CONSTRUCTION OF RESIDENTIAL IMPROVEMENTS. PROPOSED IMPROVEMENTS ARE BEYOND THE LIMITS OF JURISDICTION. HOWEVER, DISTURBANCE WILL OCCUR WITHIN THE AREA SEAWARD OF THE PROPOSED IMPROVEMENTS, WITHIN 100' OF THE WETLAND. 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: ElS SHORE LANE, 532.74' S/RICHMOND LANE, PECONIC 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 August 21, 2002. 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. OWNER'S NAME: MAILING ADDRESS: SCHEMBRI HOMES, INC 10 SANDPIPER DRIVE RIVERHEAD, NY 11901 OWNER'S AGENT: Catherine Mesiano, Inc. 12 Mill Pond Lane East Moriches, NY 11940 631-878-8951 Enc.: Copy of sketch or plan showing proposal for your convenience. PROJECT ID NUMBER PARTI-PROJECTiNFORMATION I. APPLICA. NT/SPONSOR SCHEMBRIHOMES, INC. 3.PROJECT LOCATION: PECONIC Mu~ci~l~ 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. PROJECT NAME RICHMOND SHORES LOT#12 SUFFOLK County 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or orovide map E/S SHORE LANE, 532.74' S/RICHMOND LANE SEQR PROPOSED ACTtON: [] New [~]Expansion [---I Modification / alteration 6. DESCRIBE PROJECT BRrEFLY: CLEARING AND GRADING AS REQUIRED FOR CONSTRUCTrON OF REIDENTIAL IMPROVEMENTS BEYOND THE LIMITS OF TRUSTEE JURISDICTION 7. AMOUNT OF LAND AFFECTED: Initially .574 acles Ultimately .574 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS'~ []Yes [] No If no, describebtiefly: g. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Chooes as many es apply.) []Residential r-[Industrial ["--~Cornmercia, ~---]Agriculture r--lPark/Forest/OpenSpace ~] Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) ]Yes r~No If yes, list agency name and permit / approval: SCHD (APPROVED) NYSDEC (NJ) SOUTHOLD BLDG.DEPT. (BLDG. PERMIT) 11 DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? []Yes [~]No If yes, fist agency name a~:l pen~t / approval: SCHD NYSDEC i1,~.,AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I~lYes M No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE iS TRUE TO THE BEST OF MY KNOWLEDGE ~op,ican, / s.esx.~- N~me CATHE~E MESIANO.~NC for SCHEMBRI HOMES. INC, Date; July 29, 2002 If the action is a Costal Area, and you am s state agency, complete the Coastal Assessment Form before proceeding with this assessment FROM :C ~ESIRNO If,lC., FAK NO. :612-878-8951 25 2082 02:56PM P4 County of Suffolk State ,~ New York PETER SCHEMBRI, VP., SCH~MBRI HOMES, INC, BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/ SHE IS THE APPLI'CANT FOR THE ABOVE DESCRIBED PERMIT AND THAT ALL STATtEMENTS· CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER 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 HARblLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARRISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVE(S) , TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. DONNA FIREN'ZE' Notary Public. State of New YoI~ No. 4785585 CountyOf Suffolk Commission Expir .~ FlqOM :C !qESIAHO IHC~ FAK HO. : Schembri Homes Map of Richmond Shores Lots #10, 11 &12 Peconic STATE OF NEW YORK) COUNTY OF SUFFOLK) Peter $.chembri , being duly sworn, dei~oses and says: reside a[ 76 Overlook Drive, WadJna River In the County of Suffolk and the State of NeW Y~rk, Anti I am the officer of tl~e Corooration whictl i~ ~ Qwner in fee of the premises describecl in the foregoing application and that I have authorized C~NC. to~/ake the foregoing application as described herein. Peter Schembrl, Vice President ' Schembrl Homes, Inc. Sworn before me thi~ day of~ )~/ ,20.~ NO~ Ptlblic ~ ~ DONNA FIRENZE Notary Publio. State of New No. 4785585; County Of Suffolk Commission Expirea,.6el:~-I~ FA~ NO, :63~-678-8951 Jul. APPLICANT ?RANIACTIOflAL DI~cmo~URE FORM r.-,~J hie cor~lcts of I~termt end allow It to take whatever action is nece~,~w to avoid same, YOUR NAME: PETER SCHEMBRI NATURE OF APPLICATION: (Check all thai al;~ly.) Tax gri,evance Varlanc:e Change of ~ Apf~:~al of Ida.__ Exempt~n fr~m prat or official map. Olher (ti "Other," name ~e a~lvlty) Do you per.nelly (or through your coml~lly, with any offl~er or employee of t~e Tow~ of ~uthold? or I~J~ qe~ Interest. "l~ainese interact" town o~flcer or emffeyee has e~en a partial ownership of (or employment which t~e town office' or eml~ee m~'n$ moe~ t~an 5% of the ~arel. YES NO If y~l ;~nswafed "YES," ~o~111~8 Me balat~c~ of tl~lt form an(I ~ a~l ~lgn where Indlcate~l. Name of per~ eml~oyed by tile Towfl of So~thbld, Title or pcelti~ of that person Descritm the relatlonetti, p belween youmetf (the applicant) anti the tow officer Either check the al~ line A) through O) and/or deecfihe In the ~ 1~3vtde~L Tile town officer or eml~oyee or his or her spouse, sibling, pilrlmt or child ts (Check mml that a~bly): A) the owner of greater tha~l 8% of the shame of the ~ ~k of Ihe el~licellt (wfle~ the eppllcem le · corporation); the legal ~ ba~!~:icial own~ of ar~ interest in a entity (w~en the al~lioant I~ not · ~x~omtion); an officer, dlreca3r, pad. mr, or employee of tine £)) the ac~a( DESCRIF~TION OF RELATIONSHIP NO~ Pubic.: ~,ew York NO. 4785E8~ · , F~lk J~m isslell Ex, -~ ~oard of Trustees APPlica~ GENERAL DATA Land Area (in square feet): 24.855.57 SQ.FT. Area Zoning: R-40 Previous use of property: VACANT Intended use of property: CONSTRUCT SINGLE FAMILY DWELLING Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? X No Yes If yes, provide explanation: Project Description: CLEARING AND GRADING REQUIRED FOR CONSTRUCTION OF 59' X 75' SINGLE FAMILY DWELLING WITH ATTACHED GARAGE, DRIVEWAY AND ON-SITE SEWAGE DISPOSAL SYSTEM. PROPOSED IMPROVEMENTS ARE BEYOND THE LIMITS OF JURISDICTION. HOWEVER, DISTURBANCE WILL OCCUR WITHIN THE AREA SEAWARD OF THE PROPOSED IMPROVEMENTS WITHIN 100' OF THE WETLAND. . -b~ -1-' ~ I ~~. I 0; f .1 ~\. e ! , , f'l i , !il , u....'i' / f' i,' / ~ -t---.7---.ul'lf ......,,,..... I i . <.0 ~ <Xl g O. ~ i I ~ ' " , .. . , ' i i I I ~):; ~'~-+i "1" 0' 'II 1'> ~ '1"11 ~ 1i:1~ 'if! ~l!l i~ t lil:1 h11~ !!~ml Il!lm 1;ljjjJ M.lII i ii!! l11i1 i Ii II I"'" ,I!I!! ii iii i ! ~ ! ~ ~ ! 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