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Home My WebLink AboutTR-5224Albert J. Kimpski, President James King, Vice-President .4xt ie Foster Ken Poliwoda Peggy. A. Dickerson BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD 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: Building Dept. Board of Trustees January 18, 2005 Robert Fox 580 Lloyds's Lane, Mattituck SCTM#99-3-4.2 The Southold Town Board of Trustees has inspected the above-referenced property and determined all permitted activities to be in compliance with Wetland Permit #5224. Please let us know if we can be of any further assistance. AJbert 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 FRobL DAT~: RE: BOARI~ OF TOWN TOWN OF SOUTHOLD Building Dept. Boarct of Trustee~ ~,~,st 27, 2003 Roloert Fox 580 Lloyd's Lane, Mattitnek SCTM#90-3-4.2 With regards to the above-referenced property, please be' advised that the Trustees svould like to be notified prior to the issuance ora t~erttt~cate of Oc.upancy so that the Board can make a compliance inspection. Thank you £',r ',.'o~,r zn~;pecatio,l. ~, :, ~'f [~ t r~' '. " INCIDENT REPORT NY ~ .~-" 4'~Orig[] ~pp ,'~'~/--5'CaseN°?. (/~ 7 R~r~a~ ~ate~ 9 R~por~ T~me ~cuff~ I0 Cdr ~I1 ~ateO~ .... I.__ I ~ ~/~12 TIme ~curr~ I~ ~y ~40at~~ ~ ~/ ~5 rm~e I I . ~.',,.~ ,..,; i,' ~"o ~.~-~ :..:.,.c -.~..~ :.:. .~ ,/ .... ,. ~ , ~ ,:I , .9{ ,~ ~ ~e . - ..... 4' ~ ~. ,...- ~ ,: -~.,,',.o~ x ~ d~ ~ / / 3205 (2/97) *FALSE STATEMENTS ARE PUNISHABLE ASACRIME, PURSUANT TO THE NEW YORK STATE PENAL LAW. 650 Lloyd's Lane Mattituck, NY 11952 January 14, 2004 Southold Town Trustees Southold Town Building Department 53095 Main Street PO Box l 179 Southold, NY 11971 Sirs, I am the owner of 650 Lloyd's Lane, in Mattituck. The lot is on the Sound, and is protected by a bulkhead and terracing, as previousty approved by the Town Trustees and D.E.C. The adjacent property to the east, owned by Mr. Robert Fox and being developed by R.E. Fox Construction, recently had terracing installed on its bluff. Due to the fact that the Fox terracing and plantings apparently were not installed per the permits issued by the DEC and Town, severe damage and erosion was caused to my bluff. Several hundred yards of soil was pushed, by machine, over the bluff edge, and as a result the terracing on my bluff shifted at several levels, from l 10 degrees against the bluff face, to 45 degrees opposite the bluff face. I am concerned about both further erosion, and a collapse. As noted, Fox's method of bluff stabilization has resulted in erosion in the area. The plantings installed apparently consisted of simply Hydro-Seeding the bluff face, rather than the installation of Rosa rugosa, etc. Furthermore, drywells were installed very close to the bluffedge, and natural vegetation near the bluff face was eliminated. Runoffwater t¥om the dry-wells is causing further damage through the bluff face. I write to request that a work session be scheduled with the Town Trustees, the Building Department, or both, to discuss and resolve this matter. Please contact me at your convenience to schedule this session. 1 can be contacted at the above address, or by teiephone during the day at 91 ?-440-2555. ['hank you for your courtesy and. cooperation in this nmtter. Sincerely, Jim 9Vlifttafi'os PATRICIA C. MOORE Attorney at Law 51020 Main Road Southold, New York 11971 Tel: (631) 765-4330 Fax: (631) 765-4643 Margaret Rutkowski · . Secretary July 15, 2003 Southold Town Trustees P.O.Box 1179 Southold Town Hall Main Road, Southold, NY 11971 By Fax & Mail Re: Robert Fox- SCTM#1000-99-3-4.~ Rochelle Reis SCTM#1000-99-3-4.3 Dear President Krupski and Board: The above owners advised me that they do not need to amend their permit. The bulkhead was installed and the bluff has been stabilized in accordance with the original permit, the plantings will be completed this month. Mr. Fox and Mrs. Reis respectfully withdraw the application. yours, ~~re cc: Mr. Fox Mrs.Rochelle Reis Telephone (63~) 7~5-1892 To~r~ Hall. 53095 Main Road P.O. Box 1179 Southold, Ne~v Yo~k 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Tuesday, July '15, 2003, the following recommendation was made: Moved by Bob Ghosio, seconded by William Cook, it was RESOLVED to recommend to the Southold Town Board of Trustees DISAPPROVAL of the Amendment application of ROBERT FOX to Amend Permit #5224 to include 500- 1500 cy. of fill, or as may be required, to restore bluff and plant. Located: 580 Lloyd's Lane, Mattituck. SCTM#99-3-4.2 The CAC recommends that all activity should be stopped and not to be started until an independent impact study is done and to be paid for by the property owner. Vote of Council: Ayes! All Motion Carried DCJS-3205 (2/97) *FALSE STATEMENTS ARE PUNISHABLE AS A CRIME, PURSUANT TO TH E NEW YORK STATE PENAL LAW 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 November 21, 2002 Mr. Robert E. Fox 5 Wigwam Path Babylon, NY 11702 RE: SCTM#99-03-4.2 Dear Mr. Fox: The following action was taken at the Southold Town Board of Trustees Regular Meeting on November 20th, 2002. RESOLVED, that the Southold Town Board of Trustees Approved the request for a Transfer of Permit #5224 dated September 20, 2000 from Rochelle & George Reis to Rob Fox. However, this determination is not a determination from any other agency. If you have any questions, please contact our office at 765-1892. Sincerely, ~ Albert J. Krupski, Jr. President, Board of Trustees AJK/cjc Albert J. Krupski, President James King, Vice-President Artie Fester Ken Poliwoda PegKY A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1.366 November 21, 2002 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Robert Fox 5 Wigwam Path Babylon, NY 11702 RE: SCTM#99-03-4.2 580 Lloyds Lane Mattituck, NY Dear Mr. Fox: The Soulhold Town Board of Trustees reviewed the survey dated June 28, 2002 and revised October 18, 2002 determined that the house to be out of the Wetland Jurisdiction under Chapter 97 of the Town Wetland Code and Chapter 37 of the Town Code, Coastal Erosion. However any activity within 100' of the Wetland line and/or seaward of the Coastal Erosion Hazard Line, would require action from this office. This determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. Sincerely, Albert J. Krupski, President, Board of Trustees AJK:cjc cc: Building Department Board of Trustees Town of Southold 53095 Route 25 PO Box 7,179 Southold NY Oct 30, :2002 Atto: Mr. A. Krupski Al, This is a follow up to my letter dated Sept, 19, 2002. I have purchased the lot ( as of 9-21-02) locamd at 580 Lloyds Lane in Mattituclg Tax Map # 1000-99-03-4.2. I am r~questing flint the existing permit # 5224 be transferred to my name. I am also s~nding in a check in the amt. of $10.00 to cover the cost ofthis transfer. Also, can you now give me a letter of non.jurisdiction so that I can submit my completed building plans to the building Dept.?. Anything that you can do to exl~dite this reque~ would be greatly appreciated. I would like to get sfac"ted on the project before it gets mu~h colder which could result in additional delays. Please let mc know if you need any additional information, tmsides what has be~n Tha]~you for your congidcratig~, R.E. FOX CONSTRUCTION, INC. Robert E. Fox / Victoria Friedman S WIGWAM PATH BABYLON, NY 11702 631-376-0145 Olll /0 - $o. NEW YORK ~ [ DEPARTMENT OF ENVIRONMENTAL CONSER~ Application For Permit Transfer and Application for Transfer of P; (In Accordance w{th Uniform Procedures, 6NYCRR Pa~t 621 I~ON ~' (tWO~) ,dinG A~icati~n NOTE: Please read ALL instructions before completing this application. Plea~ ; TYP~[tor PRINT clparl~ in i,~/ 1. LiST PERMIT NUMBER(S) AND THEIR EFFECTIVE AND EXPIRATION DATES LIST PENDING APPLICATION NUMBER(S): / t 12. NAM~..OF TRANSFEREE ~ [ If other than an individual, provide Taxpayer ID Number STREET ADDRESS, CITY, STATE, ZIP CODE TELEPHONE NUMBER (Daytime) TRANSFEREE IS A/AN: [7~Ownerj'~]Oporato~ Lessee [-'-~Applican~ Municipality/Govemme,ntal ,N3e cy (check a at apply) F 1~14 ~'~)1 I I I U I I 3. NAME OF FACILITY/PROJECT 4. FACILL~ CONTACT NAME STREET ADDRESS, CITY, STATE, ZIP CODE STREET ADDRESS, CITY. STATE, ZiP CODE 5. HAS WO.X -EGUN ON THE P.OJEC Yes ~'No [] If '.o,' proposed Startiog date: Approximate completion date: ~.~ ~ ~..~3~Z./ If there will be any modifications to the current or proposed operation or construction, tha transferee musl attach a statement spoci~ing the 6. CERTIFICATION: This certifies that the transferee seeks to be the legally responsible party for operations or projec~ daYelopmenl either authorized by the pomlits identified above or proposed in applications identified above. The transferee has a copy of the po~'mtt(s) and/or application(s) and understands and wilt comply with all conditions in the referanced permit(s) and supports the co.tent of referenced application(s). Facility operations/pro~ect scopp/discharges/e~a~sslon s will remain the same as author_ed or as proposed in pending applications. Further. I hereby affirm that under penalty of porjuly that iofe~ltJon provided on this form a,,,q,~,~l~l If ach nl en ta submitted berewffh is tree to the best of my knowledge and belief. False statements made her re ishable as a Class meanor pursuant to Section 210.45 of the Penal/aw. Pdnted Name and T itt e of Tran:Z/7~l~ (~.~ ~m~ ' ~'a~-"~ Signature of Transferee ~'~'~,~ ~ ~-'-'~: ~ Date / pART 2 - TRANSFEROR (Present m' Fonfter Ow~edOpemto~fl.essee/Al~nt) COMPLETES: BTR ET ADDRESS, CITY, STATE, IP CODE 2. NAME OF FA/CILIT~'/PRoJL~CT, If different from Facility Name in Part 1: If other than an individual, provide Taxpayer ID Number /- 3 CERTIFICATION: This certifies that the facility and/or application referenced in Part 1 of this form ~will be/~was transferred to the party identified as the new transferee (owner/operator/lesseelapplicant) on, (date). Pdnted Name and Titie of Tranj~lror C~ ~.(~ ~-~ ~ ~' ~- [~ .~ .~-~ ~-~[' ~-'~ '~'-~ : Transfer of .~, .pprov*, effective as of ~Transfer of pe~it approve, ~h the follo~ng mod~cat'o s E~See attached revised permit page(s)' ~ ~ [] Transfer of application approved. See attached for additional inform_:~ion r~d. ~ Transfer denied, new application required. Please complete the en rmit application and retum it the undersigned Regional Permit F-i Adrninistrator at the address listed on the reverse side of t~//~ 'etum 1, I~ NPaEmR~~/I~//~:~ ~'~*~ J Signature ~ ~ / DateL~ Board of Trustees Town of Southold 53095 Route 25 PO Box 1179 Southold NY 11971-0959 September 19,2002 Attn: Albert J. Krupski Al, Thank you for ),'our time yesterday. As per our conversation, I have attached a modified plan for my parcel at 580 Lloyds Lane in Mattituck, Lot # 2, Tax Map # 1000- 99-03-4.2. This is for existing Southold Trustees permit # 5224 dated 9-20-2000, which is currently in the name of Rochelle and George Reis, the sellers. George Reis has been notified of the need to request an extension on his existing permit and indicated he will act immediately. I will put in a request for the paperwork change showing new ownership shortly Some additional notes: 1. The proposed gazebo will be moved toward the front lot line and axvay from the bluff's crest and out of the Coastal erosion area. 2. The amount of fill required for the bluff restoration on Lot 2 will be 250-400 cu. Yards. Exact quantity will be determined at time the work begins and proceeds. 3. Work will be done by a qualified landscape contractor and will be done in a workmanlike manner 4. Precautions will be taken to eliminate any additional erosion cause by the required partial lot clearing. 5. Fill will be trucked in 20 cu. yard increments and dumped near the crest of the bluff. It will then be deposited throughout the bluff face as necessary by use of mechanical means as well as laborers. The need to bring equipment in to restore the bluff face will require clearing an area of the existing brush at a minimum of a 50'wide area. 6. Work will be completed by Spring of 2003 in accordance with DEC permit requirements, DEC permit # 1-4738-0274-00001 dated 10-31-00 Thank you Rob Fox /eD/C~/~L~L SUag~OLK COUNTY DEP.~J~,,T~. ENT OF HEALTH SER'I~Ii~S ~ OFF1CEOF WASTE~ATER MANAGEMENT ~ APPLICATION FOR EXTENSION, ~NEWAL OR T~NSFER OF ~XISTING P~IT TO CONSTRUCT S~WAGE DISPOSAL AND WATER SUPPLY FACILITIES FOR SINGLE FAMILY DWELLING Before completing this application rel~r to "lns~mcnons to Renew, Extend or Transfer ~ Existin~ ~e~it for Single Family Residence" on reverse sid: of this application. EXISTING ~FE~NCE NUMBER '~ l~ -~ ~ ~ {~ TAX MAP NUMBER: District NAME OF APPLICANT (If name is different from original applicant, see instmctioas for transferring a permit and complete section 6 below. I NAME OF AGENT (If not applicant) ADDRESS PHONE DATE OF ORIGINAL APPROVAL I' I~:¢~ ([fmorethan6yearsold.ancwapplicationwdibercquired.I TRANSFER OF PERMIT: I hereby transfer ail fights and interest i.,~ the abov. g referenced perm. it to t"i~ newl applicant named above. SIGNATURE OF ORIGINAL PERMIT HOLDF~P. JAGENT Application is hereby made to [ ]extend, [ ]renew, [ ]transfer a permit to construct a water supply and sewage disposal system for a single family residence in accordanp9 with the application, surveys and plans submitted. I hereby certi$" that I have examined the complete application afl, the statements therein ~ and correct, and th?t all ,york shall be done in accordance with all applicable Town.~funty, State and Fedeml/E. aws/afid Codes. "Any false statement made herein ~s punishable as a misdemean°r pursu~Zt°. ~210'45~]:~e~l'Ae Penal kaw" SIGNATURE OF APPLICANT/AGENT //~ 2- ~ DATE PRINT NAME ~'-~(.3{~97~ '~"'. ~D% TITLE If you are making substantial revisions or modifications to a project that has already received a permit to construct from the Department. or if the permit is more than six (6) years old, a new application will be rcqmrcd. Follow the instmctions as explained in 'Submission Requirements For Single Family Residences' (WW M-041 }- Renewed pcrmns are subject to any changes in standards enacted after the approval date of the original permit. DEPARTMENT USE ONLY Permit is Extended./Renewed/Transferred Until Number of Bedrooms ,\pprovcd __ Signature of Department Representative Date W\VM-104{Re~. 03.01) IL,\(iE I t)F 2 R.E.Fox Construction, Inc. Builders of Superior Quality Luxury Homes Highest Quality Materials and Craftmanshlp Babylon- Culchogue- East Hampton 631-374-1906 (ceil) 631-376-0145 (office/fax) SEP I § ~n~ Office Location; From: Rob Fox Office Location: Phone Number: 631-376-0145 (fax) CI Urgent n Reply ASAP E] Please comment Q Please Review ~Jil.-For your Information Total pages, Including cover: Comme~t~: Board of Trustees Town of Southold 53095 Route 25 PO Box ! 179 Southold NY 11971-0959 September 19, 2002 Attn: Albert J. Krupski Al, Thank you for yom' time yesterday. As per our conversation, I have attached a modified plan for my parcel at 580 Lloyds Lane in Mattituck, Lot # 2, Tax Map # 1000- 99-03-a,2. This is for existing Southold Trustees permit # 5224 dated 9-20-2000, which is currently in the name of Rochelle and George Reis. the sellers. George Reis has been notified of the need to request an extension on his existing permit and indicated he will act immediately. I will put in a request for the paperwork change showing new ownership shortly Some additional notes: 1. The proposed gazebo will be moved toward the front lot line and away from the bluff's crest and out of the Coastal erosion area. 2. The amount of fill required for the bluffrestoration on Lot 2 will be 250-400 cu. Yards. Exact quantity will be determined at time the work begins and proceeds, 3. Work will be done by a qualified landscape contractor mid will be done in a workmanlike manner 4. Precautions will be taken to eliminate any additional erosion cause by the required pa~ial lot clearing. 5. Fill will be trucked in 20 cu, yard increments and dumped near the crest of the bluff. It will then be deposited throughout the bluff face as necessary by use of mechanical means as well as laborers. The need to bring equipment in to restore the bluff face will require clearing an area of the existing brush at a minimum of a 50'wide area. 6, Work will be completed by Spring of 2003 in accordance with DEC permit requirements~ DEC permit # 1-4738-0274-00001/~ed 10-31-00 LLOYD's LANE ,,, Albert J. Krupski, President James King, Vice-President Attic 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 September 26. 2002 Patricia C, Moore, Esq. 51020 Main Road Southold, NY 11971 RE: George & Rochelle Reis Lloyd's Lane Mattituck, NY SCTM#99~3-4.024.03 Dear Ms, Moore: The/bllowing action was taken at the Southold To:rtl Board of Tr, tstees Re?lar ~'..'[eeting on September 25, 2002. RJESOLVED. that the Southold Tov. n Board of Tmste,:s starer :: ,me/ear extens~:,~ to Permit However, this determination is not a determinatien fi.om :my other agency. If you have any questions, please contact our office at 7554 892. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees PATRICIA C. MOORE Attorney at Law 51020 Main Road Southold, New York 11971-4616 Tel: (631) 765-4330 Fax: (63 l) 765-4643 September 19, 2002 BY FACSIMILE WITH HARD COPY TO FOLLOW Town of Southold Board of Town Trustees 53095 Main Road Southold, NY 11971 Attention: Charlotte Re: George & Rochelle Reis Premises: Lloyd's Lane, Mattituck, NY SCTM ~ 1000-99-3-4.02 & 4.03 Dear Charlotte: Please extend the Trustees Permit for the above premises which you advised our clients will expire Please send the extended Permit to my office. referenced tomorrow. If you have any questions, or need anything else, please do not hesitate to contact me. Thank you. Very truly yours, gatricia C. Moore PCM/mr ~ENT BY: MOORE; 12:07; 2/2 PATRICLA C. MOORE Attorney at I.aw 51020 M'ain Road Southold, New York I 1971-4616 Tel: (631) 765-4330 Fax: (631) 765-4643 september 19, 2002 BY FACSIMILE WITH PIARD COPY TO FOLLOW Town of Southold Board of Town Trustees 53095 Main Road Southold. NY 11971 ' ' SE? I g Attention: Charlotte Ce: George & ~_q~elle Reis Prcmi~e=:= Lloyd's Lane,~tuc~', N~r SCTM # 1000-99~3-4.02 & 4.03 Dear Charlotte: Please cxtmnd the Trustees Permit for the above premises which you advised our clients will expire Please send the extended Permit to my off,ce. referenced tomorrow. If you haw? any questions, or need anything else, please do not hesitate to contact me. Thank you. Very truly yours, Patricia C. Moore PCM/mr ~ENT BY: ~OOPE; 83t 765 4643; ~EP-t 02 12:07; PAGE 1/2 PATRICIA C. MOORE Attorney at [.aw 51020 Main Road Southold, New York 11971 Tel: (631) 765-4330 Fax: (631) 765-4643 FACSIMILE COVER S~{EET The pages comprisinD this facsimile transmission contain confidential information ~rom Patricia C. Moore. This information is intended sclely for use by the individual entity named as the recipient hereof, If you are not the intended recipient, be aware that any disclosure, copying, distribution, or use of the contents of 5his transmission is prohibited. If you have received this L£ansmission i.:~ errox-, please noti£y us by Lelephone i[mu~diatel¥ so we may arrange to retrieve this transmission at no cost to you. TOTAL NUMBER OF PAGES INCLUDING COVER SHEET IF TRANSMISSION IS FAULTY OR AS POSSIBLE. CLIENT NAME: OPERATOR- INCOMPLETE, PLEASE CALL BACK AS SOON Board Of $outhold Town Trustees SOU.THOLD, NEW YORK PERMIT NO. ,,5'~.'~ ,~ '~ DATE: ...S..e.p.~.....~Q.:....~..000 ISSUED TO GEORGE & ROCHELLE REIS Authorizaliou Pursuant to the provisions of Chapter 615 of the Laws of the State of New Yor~ 1893; and Chapter 40~ of the Laws _o.f. the · .State of New York 19~2~ and the Southold To~n..Ordlnanc~ en- titled ."REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and 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 ..S...e..p...t..:.....Z.~ ..... ..... .;~..0...0.g and In consideration of the sum of $..1..5.0...0.0. ......... paid by of ..~.~p.Lo~.,.., ............................................... N. Y. and. subject to the Terms and Conditions listed on the reverse side hereof, ',~J Seufholcl Town Trustees ~.~'l~n.';.*~ and ~ermits the ~oJlowJng:. by causes its Corporate. Seal to be a~xed, and these presents to be subscribed by 'a'malority of the sa,d Board as of this date. TERMS and CONDmONS The Pe~mtcte~ GEORGE & ROCHELLE REIS 580 Lloyd's Lane, Mattituck, · t~ding ,c N. Y~ ~ ~att of ~e co~ld~oa for ~e ~ of ~e P~t d~ ~d~ ~ p~ ~ ~ f~- '1. ~ ~e ~d B~ of T~ ~ ~e T~ of ~old ~ ~ f~ ~ ~ ~ ~ ~, ~ ~e ~pl~e '~ch~a of ~ ~ ~ T~ ~ ~e T~ ~ for ~on m~y~de~ ~e~t a ~ ~ ~. That tl~ Permit should be retained indeflnkely, or as long as the r~d P~mktee w~he~ tO' maintain the ~xtuctute or project involved, to ptov~cle evidence to anTone conceded that anth- 4. That the work involved will be ~bject to the inspection and ·pptov~d of the Bo~d- ot Its agents, and non-con~fl.~ce w~th the prov~ons of the orl~..el~g spplkation, may be c~se' for tevocatlon of this p,.m~lt by tesoluelon of ~ said Boat'cL 5. That there w~H be no unreasonable Interference ~ n~vigatf~on ss · remit of the work ' ~. That there dali be no interference with the ~ght of the public to pas~ and ~ along 7. That if furore opetadom of the Town of Southold zequlte the femoral and/or akeratlom . in the location of the work herein anthod:zed, or if, in the opinion of the Board of Tmstet% the. work shah cause unreasonable obstmcuon to free navigation, the said p~.~l-ee will be ~ upon due nodce, to remove or alter this work ot project herein stated withe~t ezlw. nse~ to the Town of Sout~olcL 8. That the said Board will be t~ofifled by the Permlttee ot the c~C'~leti°aiOf the work tuth- orlzecL plemental to this p~rmlt which ma;, be ~d~ject to ~evol~ upon f. th,,~, to 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 October 5, 2000 Mr. Robert Herrmann En-Consultants, Inc. 1329 North Sea Road Southampton, NY 11969 Re: George & Rochelle Reis 580 Lloyd's Lane Mattituck, NY SCTM# 99-3-4.2 Dear Mr. Herrmann: The following action was taken by the Board of Town Trustees during a Regular Meeting, held on September 20, 2000, regarding the above matter. WHEREAS, En-Consultants, Inc. on behalf of'GEORGE & ROCHELLE REISapplied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated August 31, 2000, and WHEREAS, said application was referred to the $outhold Town Conservation Advisory Council for their findings and recommendations, and WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on September 20, 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 standard set forth in Chapter 97-18 and Chapter 37 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 approved the application of GEORGE & ROCHELLE REIS to construct a +/- 126' timber wall to be constructed in conjunction with and tied into proposed Mihalios and Reis retaining wall to west and east respectively. In order to re-establish stable angle of repose and restore and stabilize the bluff approximately 250 cubic yards of clean sand fill will be trucked in from an upland source and used to fill bluff face, which will also be terraced and planted with Rosa rugosa, Myrica Pennsylvanica, Ammophila breviligulata, and Parthenocissus quinquefolia. The bluff crest will be re-graded as necessary to remove vertical lip and restore more gradual slope. Project will have one to three tons stone toe armour and will be terraced as per the plan and planted no later than June 1st. 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 project will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued witin six months of the date of this notification. 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 when project is started and on completion of said project. FEES: NONE Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/cjc cc: Department of State DEC ACE Albert J. Krupski, President James FAng, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southo]d, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD COASTAL EROSION MANAGEMENT PERMIT Permit Number: 5224 Date: October 4, 2000 Name of Applicant/Agent: En-Consultants, Inc. Name of Permittee: GEORGE & ROCHELLE REIS Address of Permittee: 900 WEST END AVENUE NEW YORK, NEW YORK 10025 Property.Location: 580 LLOYD'S LANE MATTITUCK, NY Description of Activity: to construct a +/- 126' timber wall ~o be constructed in conjunction with and tied into proposed Mihalios and Reis retaining wall to west and east respectively. In order to re-establishy stable angle of repose and restore and stabilize the bluff approximately 250 cubic yards of clean sand fill will be trucked in from an upland source and used to fill bluff face, which will also be terraced and planted with Rosa rugosa, Myrica Pennsylvanica, Ammophila breviligulata, and Parthenocissus quinquefolia. The bluff crest will be re-graded as necessary to remove vertical lip and restore more gradual slope. Project will have one to three tons stone toe armour and will be terraced as per the plan and planted no later than June 1st. Date of Permit Issuance: September 20, 2000 This permit is valid for a period of two years from the dates of issuance. SPECIAL CONDITIONS: ...... Bluff restoration through a re-vegetation agreement is a necessary special condition of this permit. A relocation agreement is attached hereto and is a necessary special condition to this permit. A maintenance agreement as attached with application and is a necessary special condition of this permit. Albert J. Krupski, Jr. President, Board of Trustees Wetland Permit to construct a +/- 126' timber wall to be constructed in conjunction with and tied into proposed Mihalios and Reis retaining wall to west and east respectively. In order to re-establish stable angle of repose and restore and stabilize the bluff approximately 250 cubic yards of clean sand fill will be trucked in from an upland source and used to fill bluff face, which will also be terraced and planted with Rosa rugosa, Myrica Pennsylvanica. Ammophila breviligulata, and Parthenocissus quinquefolia. The bluff crest will be re-graded as necessary to remove vertical lip and restore more gradual slope. Project will have one to three tons stone toe armour and will be terraced as per the plan and planted no later than June 1st. Telephoue (516) 765-18q~. Towu Hall. 53095 Main Road P.O. Box 1179 Southold. New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Tuesday, September 12, 2000, the following recommendation was made: Moved by Ken Meskill, seconded by Bill McDermott it was RESOLVED to Table the Wetland Permit & Coastal Erosion Permit application of GEORGE & ROCHELLE REIS,99-3-4.2 to construct a +/-126' timber retaining wall to be c~)hsffud{ed ih ° conjunction with and tied into proposed Mihalios and Reis retaining walls to west and east, respectively. In order to re-establish stable angle of repose and restore and stabilize the bluff, approx. 250 cy. of clean sand fill will be trucked in from an upland source and used to flu bluff face, which will also be terraced and planted with Rosa Rugosa, Myrica pensylvanica, Ammophila breviligulata, and Parthenocissus quinquefolia. The bluffcrest will be re-graded as necessary to remove vertical lip and restore more gradual slope. Entire project will be undertaken in conjunction with identical Reis project to west. 580 Lloyd's Lane, Matituck The CAC Tabled the application until the Mihalios erosion problem is resolved from above the bluff., . Vote of Council: Ayes: All Motion Carried Attn:Southold Trustees September 13, 2002 I'm scheduled to have my vacant property at 580 Lloyds lane, Mattituck, viewed by thc Southold Trustees on Wednesday Sept. 18. I would like to add a change to my original request. After meeting with Peter Sterling of Plantings by the Sea, it became clear that the Bluff'crest would need to be re-graded to try to return it to a more nature grade/angle. This is apparently required by the DEC per the existing permit # 1-4738-02741/00001, However, my concern is that by doing this, the building envelope may/will change duc to the breaking away of thc bluff crest, which will now move the building envelope back by approx. 15-20' .( My a~sumption is that this newly formed bluffline will superccde the pr~vlous Survey lines. Is this correct? ) If so, this will put the pool. which is currently within the building envelope, completely outside of it. This will occur because the new bluff line will change due to the re-grading, even though the location of the pool itself lmsn't change from my original plan. If the Trustees allow the pool to remain in what will be the g0'-100' area from the bluff, then there is no concern on my part, except for any possible delays that this request may create. If my assumptions are correct, and the Trogtees do not allow the pool within the 100' area of the bluffs crest, can I do thc following? That is, proceed as originally indicated, with both the pool and house within the allowable building envclopo and then do the bluffwork efterwards? In this way, I would be within the current set backs and be in compliance with thc existing zoning requirements. I've staked out the parcel in the following manner. Bright Green tape represents the approx, footprint, 73'W x 5g' D, of my proposed 4500' sq. ft. 2 story home and Bright Pink represents thc 20' X 40' Gunite pool. White tape represents a possible Gazebo, approx 10' x 10' If you have a~y questions and would like to contact me prior to your visit, I can be reached at the following numbers. Home Phone 631-661-4803, Office/Fax 631-376- 0145 and cell # 631-374-1906 Rob Fox 'l Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peg~' A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631 ) 765-1892 ' Fax (63D 765-~ qaa~ BOARD OF TOWN TRUSTE~I~ TOWN OF SOUTHOLD APPLICATION FOR AN AMENDMENT TO A PERMIT owNEP, ~A ADDRESS ~/~, ADDRESS 6'7~gc, PROPERTY LOCATION TAX MAP NO. PHONE Z/o y d '~ /Ooo -'qq- 3- ~. I/We ~,~ '~ request an Amendment to Permit Signed By: ,5'~"~-x''~ FPO~ : ENCONSLILTANTS, INC, Alber! J, Krupsrd, Pres]denl John Hoizap[e], Vice Preside.n( Jim King M~n H O~¢t! PHONE NO. : 5162836136 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Aug. 31 2000 10:45AM Town Hall 53095 Ma.in RoaO P.O, Bnx ![79 Southold. New Yorl< Telephone (515) 76}-1392 Fax (516) 765-[S23 Office Uze Only weOaStal Erosion Permi% Application tland Permit Application Grandfather Permit Application Waiver/.~rnendraent/C~ange$ Received Application:g/~/. Received Fee:$ --- Completed Application~rl/;%~./~ Incomplete SEQRA Clamsificanion: Type I _Type II Unlisted Coordinaticn:(date Sd~nt)! CAC Referral Sent:~/~ /-~f~- Date of Receipt of CAC Report% ' Lead AGency Determination: Technical Review: ~/~ Public Hearing Held: Resolution: Name of Applicant Address George & Rochelle Reis · 900 West End Avenue, Apt. 16B New York, NY 10025 Phone Number:(212) 749,-3~0 suffolk County Tax Map Nc~nber: 1000 .99-3-4.2 Property Location: 580 Lloyd's Lane, Mattituck Mattituck, NY (provide LILCO Pole ~, distance to cross streets, and location) AGENT: En-Consultants, Inc. ( If applicable3 1329 Noz~h Sea Road A~ress: Southamp%on, NY 11968 Phone: FglC~: 631-283-6360 FROH : ENCONSIJLTANTS, IHC, PHONE NO. : 5162836136 Aug. 31 ~0~0 10:45AM P4 PROJECT DESCRIPTION GEORGE & ROCI~LLE RI~IS S$O LLOYD'S LANE MATTITUCK, NY SC'I-M #10~0-99-3~2 Construct a +126' timber retaining wall to be constructed in conjunction with and tied into proposed Mihalios and Reis r~aining walls to west and east~ r~spectively. In order to r~stablish stable angle of repose and restore and slabillze the blufF, approximately 250 cubic y~rds of clean sand fill will be trucked in from an upland source and I~sed to fill bluff fa~e, which will also be terraced and planted with Rosa rugnsa, Myrica pensylvanica, Arnmophila breviligulata, and Parthenocissus quinquefolia. The bluff crest will be regraded as necessary to remove vertical lip and restore more gr$;d~l slope. Entire project will be unde~aken in co,unction with identical Reis projec! to east. 12000 FROM : ENCONSdLTANTS, [NC. PHONE NO. : 5162836136 Aug. 31 2000 10:44AM P2 EN-CONSULTANTS, INC, 1329 Nor'~h Sea Road Southampton. New York 11968 631-283-6360 Fax: 63~ -283-613u E-mail: encon @ peconic.net www.enconsultants corn ENVIRONMENTAL SERVICES August 30, 2000 Town of Southold Board of Trustees Post Office Box 1179 Southold, New York 11971 Attn.: Lauren Standish Re; George & Rochelle Reis 580 Lloyd's Lane~ Mattituck SCTM #1000-99-3-4.2 Dear Ms. Standish: In regard to the above referenced property, enclosed are the following for the Board of Trustees review: 3. 4. 5. 6. 7. Thre~ (3) Wetland & Coastal Erosion Permit Applications, ( including Notice and Proof of Mailing to adjacent owners). Three (3) Short Environmental Assessm~a~t Forms. Three (3) copies of authorization & disclosure forms. Three (3) work plans. Three (3) copies of survey. One (l) set of site photographs. Application fee of $200.00. I trust this information shall allow you to process our permit request. Should any additional information be required, please do not hesitate to contact our office. Sine, Ct ely, ." Rob-er~f'E.~l~mann Coastal Management Specialist /kbs Enc. ~£~oard o~ Trustees Applicant ~ENERAL DATA Land Area (in square feet): 32,010.97 Area Zoning: R-40 Previous use of property: Intended use of property: Vacant residential No Change Prior permits/approvals for site improvements: Agency Date X 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 (use atSachmenns if necessary): SEE A~ACHED PROJECT DESCRIPTION GEORGE & ROCI~IJ,E REIS 580 LLOYD'S LANE MA~I'UCK, NY SCTM #10~0-99-3-4.2 Construct a _+126' timber retaining wall to be constructed in conjunction with and tied into proposed Mihalios and Reis retaining walls to west and east, respectively. In order to reestablish stable angle of repose and restore and stabilize the bluff, approximately 250 cubic yards of clean sand fill will be trucked in fi.om an upland source and used to fill bluff face, which will also bc t~rraced and planted with Rosa rugosa, Myrica pensylvanica, Ammophila brcviligulata, and Parthenocissus quinquefolia. The bluffcrest will be regraded as necessary to remove vertical lip and restore more gradual slope. Entire project will be undertaken in conjunction with identical Reis project to east. Board of Trustees Application WE%~LAND/TRUSTEE LANDS AJPPLICATION DATA Purpose of the proposed operations: Restore & stabilize bluff. Area of wetlands on lot: Percent coverage of lot: 0 % Closest distance between nearest existing edge of wetlands: N/A feet 0 square feet structure and upland Closest distance between nearest proposed structure and upland edge of wetlands: N/A feet Does the project involve excavation or filling? No X Yes If yes, how much material will be excavated? N/A chubic yards How much material will be filled? ±250 cubic yards Depth of which material will be removed or deposited: N/A feet Proposed slope throughout the area of operations: ~1:1.5 Manner in which material will be removed or deposited: Approximately 250 cubic yards of clean sang fiY1 will be trucked in from an upland source, dumped, terraced, and planted. 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): There are no vegetated wetlands present and the pro3ect should have no significant effects on Town waters. See description of project on coastal erosion application form. Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: Restore & stabilize bluff. Are wetlands present within 75 feet cf the proposed No X Yes Does the project involve excavation or filling? No X Yes If Yes, how much_m~terial will be excavated? How much material will be filled? ±250 activity? N/A icubic yards) (cubic yards) ~.Ianner in which material will be removed or deposited: Approximately 250 cubic yards clean sand fill will be trucke~ in from an upland source, dumped, terraced, and planted. Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) The proposed project will serve to restore and stabilize the sub3ect bluff. Specifically, in order no reestablish a stable angle of repose, tl%e bluff toe will be stabilized by the proposed retaining wall; the bluff crest will be regraded as necessary to remove the existin~ vertical lip and restore a more gradual slope; and the bluff face will be terraced and Gensely planted ~ith beach grass, bayberry, Rugosa rose, and Virginia creeper. The entire project will be undertaken in conjunction with the identical pro3ec~ proposed to the west and east, and thus will have no adverse impact on adjacent bluffs. ' PROJECT I.D. NUMBER 61 7.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be completed by Applicant or Project sponsor) SEQR 1 . APPLICANT/SPONSORGEORGE & R~LLE ~IS BY I 2. PR~ECT ~ME EN-CONSULTANTS, INC. 3. PROJECT LOCATION: ~un~ci~ MATrlTUCK count~ SUFFOLK 580 LLOYD'S LANE, MATTITUCK, TOWN OF SOUTHOLD; SCTM #1000-99-3-4.2; MAP PROVIDED. 5. IS PROPOSED ACTION: [] New [] Expan,lon [] Modifica fion/alteratio~ Mikalios and Reis retaialng walls to west and east, respectively. In order to reestablish stable angle of reposo and restore and stabilize the bluff, approxiraately 250 cubic yards of clean sand fill will be ffucked in from an upland source and used to fill bluff face, which will also be terraced and planted with Rosa rugosa, Myrica pensylvaniea, Ammophila brevlligulata, and Pat~henocissos quinquefolia. The bluffcrest will be regraded as necessary to remove vertical lip and restore more gradual slope. Entire project will be undertaken con~tmction with identical Reis project to east. Initially 0.735 acre8 Ultimately 0.735 acres 8. ~LL PRO.BED ACTION COMPLY NTH EXIB~NG ZONING OR OTHER EXISTING ~ND USE RESTRICTIONS? I ~NolfNo. d~e 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT~ [] Residential [] Industrial [] Commercial Describe: [] Park/Forest~Open space [] Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? DI~ Yes L-I No If yea. lle. t agency(s) and pemlit/apflrovals )EC 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? L_JYes [~ No If yes, list agency name an~ penmPJapproval 12. AB A RESULT ~ PROPO~D ACTION WILL ~ISTING PERMIT/APPROVAL REQUIRE MODIFICATION? [].o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE COASTAL MGMT. SPECIALIST Det~: AUGUST 30, 2000 If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment NOTICE TC AJ2~JACF2fff PROPERY"f OW~NER z~.z_mJD 'DF -?RUSTEESr TOWN OF SOU%"HOLD in the matter of George & Rochelle Reis sCTM~ 1000- 99-3-4.2 YSU ARE HEREBY Gi',~mN NOTICE: _. Thaz it is the intention of the undersigned to request a >erml~ from the Board of Trusnees to: SEE ATTACHED ='~. ~_ha.~ the property whizh is the subject Environmental Re~__w'"= is located adjacent to your property and is described as follows: 580 Lloyd's £ane,. Mattituck 2. That the property whizh is subject to Environmental Review under Chapters 32,37,or 97 of the Town Code is open tc p~blic ~omment. You may contact the Trustees Office at 765-1892 or in writing. September 20, 2000 at or about 7:00 P.M. The above referenced proposal is under review of the Board of Trustees of the Town of Southold and dose not reference any other adjacent that might have to review same proposal. OWNERS NAME: George & Rochelle Reis MAILING ADDRESS: 900 West'E~d Avenue Apt. 16B, New Y6~, NY 10025 ~HONE ~:212-749-358~ Etc.: Copy of sketch or plan showing proposal for your convenience. PROJECT DESCRIPTION GEORGE & ROCHEIJ J~, REIS 580 LLOYD'S LANE MA'I-rri'tJCK, NY SCTM #1000-99-3-4.2 Construct a +126' timber retaining wall to be constructed in conjunction with and tied into proposed Mihalios and Reis retaining walls to west and east, respectively, tn order to reestablish stable angle of repose and restore and stabilize the bluff, approximately 250 cubic yards of clean sand fill will be trucked in from an upland source and used to fill bluff face, which will also be terraced and plamed with Rosa rugosa, Myrica pensylvanica, Ammophila breviligulata, and Parthefiocissus quinquefolia. The bluffcrest will be regraded as necessary to remove vertical lip and restore more gradual slope. Entire project will be undertaken in conjunction with identical Reis project to east. 1329 NORTH SEA RD. SOUTHAMPTON, K~( 11960 631-283-6360 LLOYD' S LANE ~DLINP, MA1'1111JCK, 5~J~FOLK CO,, NY E'N-CONSULTANTS lNG. 1329 NORTH SEA RD. SOUTHAMPTON, N.Y. 11968 631-283-6361) MAYYIT1J6K, 5Lifl~OLK 60,, NY 8/28/00 PROOF OF ~IAILING OF NOTICE ATTACH CERTIFIED 5tAIL RECEIPTS Ne/ne: Honeysuckle Hills Property Owners Association Address: c/o Alex Doroski, President 430 Bailie Beach Road Mattituck, NY 11952 James & Lili~na Mibalios 42-21 Frances Lewis Boulevard Bayside, NY 11361 Rochelle Reis 900 West End Avenue, Apt. 16B New York, NY 10025 STATE OF NEW YORK C017NTY OF SUFFOLK Robert E. Herrmann doing business En-Consultants, Inc. , :~sdx~ at 1329 North Sea Road .. Southampton, NY ~ duly sworn, deposes and says tha~ on the 31st day of ~ ,!m~ 200p deponent mailed a true c~py ~f the Nc~ice set forth in ~he Board of Trustees ApplicauLon, directed uo each of the above named persons a= the addresses set opposite zhere respective names; t~at r_he addresses se= opposite the names of said persons are ~he address of said persons as shown on the c=rren~ assessment roll of r_he Town of Southold; ~ha= said Notices were mailed at the United Stat~s Post Office at Southampton , t ~at said Notices were mailed to each of-said persons by (cerc~ ~ied) Ro~E. ~rmann Sworn to before me this 30th day of August , tx~ 206U Notary Public EN-CONSULTANTS, INC. 1329 North Sea Road Southampton, New York 11968 631-283-6360 Fax: 631-283-6136 E-mail: encon@ peconic.net www.enconsultants.com ENVIRONMENTAL SERVICES August 30, 2000 Town of Southold Board of Trustees Post Office Box 1179 Southold, New York 11971 Attn.: Lauren Standish Re: George & Rochelle Reis 580 Lloyd's Lane, Mattituck SCTM # 1000~99-3-4.2 SEP - 5". Dear Ms. Standish: In regard to the above referenced property, enclosed are the following for the Board of Trustees review: 3. 4. 5. 6. 7. Three (3) Wetland & Coastal Erosion Permit Applications, ( including Notice and Proof of Mailing to adjacent owners). Three (3) Short Environmental Assessmem Forms. Three (3) copies of authorization & disclosure forms, Three (3) work plans. Three (3) copies of survey. One (1) set of site photographs. Application fee of $200.00. I trust this information shall allow you to process our permit request. Should any additional information be required, please do not hesitate to contact our office. S nc~rely,., P(o'~e~"E 71~Mr.~a n n Coastal Management Specialist /kbs Eric. SEP '- ~ LLOYD' LAN E *'5000' EN-[~I~ULTA NT$ INC. 1329 NORTH ,~EA ~_r). $OUTNAMPTON, N.Y, 11968 $31-283-6360 ~I-CONStlI.I~NT~ I1~ 1329 NORTH SEA RD, SOUTHAMPTON, N.Y. 631-283-6360 U.~. ostal Serwce CERTIFIED MAIL RECEIPT ?~m~estic Mail Only; No Insurance Coverage Provided) U.S. Po~,tal Serwce CERTIFIED MAIL RECEIPT (Domestic Mail Only: No Insurance Coverage Provided) --~= Postage ru a e (Please Print Clearly) (To be corn ed by mailer) ~ Stree,~/pt. No- rPOBox~. ................................................. J~J~lillllllI [J[lJJ~l~llll! / & ~le.~,~..,--...,~.~.~jj J U.S. POsLdI Service CERTIFIED MAIL RECEIPT (Domestic Mail Only: No Insurance Coverage P~owded) SEI - rd of Trustees Applica=i~ AUTHORIZATION (print owner of property) residing at (mailing address) ~*00 uo.cfi. Si ~ do hereby authorize dR - (Agent) to apply for permit(s) from the Southoid Board of Town Trustees on my behalf. ~wn=~r' s s~gna~ure) B~rd of Trustees Applicati County of Suffolk State of New York DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT[S) AND THAT ALL STAT~a~flENTS CONTAIB~u sk~cEIN ARE TRUE TO T}IE BEST OF HIS/HER KNOWLEDGE AND BELIEF, ASTD THAT ALL WORK WILL BE DONE IN TRE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY Tn~ SOUTnOLD TOWN BOARD OF TRUSTEES. THE A~PLICANT AGREEs TO HOLD THE TOW/q OF SODTaOLD AND THE TOWN TRUSTEES HA_RMI~SS AND FREE FROM ANY AND ALL DA/~GES 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 E~'I'~ ONTO MY PROPERTY TO INSPECT THE PR~MISES IN CONJITNCTION WITH REVIEW OF THIS Signature APPLICANT TRANSACTIONAL DISCLOSURE FORH The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees. The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NANRI (Las't name, first name, middle initial, unless you are applying in the name of someone else or other entity, such aa a company. If so, indicate the other person's or company's name.) NATURE OF APPLICATION~ (check all that apply.) Tax grievance Variance Change of zone ARp~Dval of plat Exemption from plat or official map Other (If "Other," name the activity.) Do you personally (or through your company, spouse, elblieg, parent, or ehil. d) have a relatlonehip vlth any of[leer or employee or tile Town of Southold? "Relationship" includes by blood, marriage, or business interest. 'Business interest" meann a business, including a partnership, itt 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 chares. YES __ NO If you anevered "YES," complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicant) attd the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The parent, town officer or employee or }lis or her spouse, sibling, or child is (check all that apply), the owner of greater than 5% of the shares of the corporate stock of the applicant (when the applicant is a corporation)t __B) the legal or beneficial owner of any interest in a noncorporate'entity (when the applicant is not a corporation); __C) an off{~: d~.rector~ partner, ~r employee of applicant~ or D) tile actual applicant. DESCRIPTION OF RELATIONSHIP Submitted thi~ day of, 199_ Signature _~/~--~, ~