HomeMy WebLinkAboutTR-6127 James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
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
CERTIFICATE OF COMPLIANCE
# 0388C
Date December 3, 2008
THIS CERTIFIES that the removal of the swimming pool, construction ora new 9'X 13'
covered deck, 9'X 28' wood deck, 13'X 24' semi-circular stone patio, 12'X 12' pergola, gutters
and drywells
At 420 Lakeview Terrace, East Marion
Suffolk County Tax Map #31-9-11
Conforms to the application for a Trustees Permit heretofore filed in this office
Dated 4/21/05 pursuant to which Trustees Wetland Permit 6127 Dated 5/18/05 and
Amended on 10/17/07 was
issued, 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 the removal of the swimming pool, construction ora new 9'X 13' covered deck, 9'X 28'
wood deck, 13'X 24' semi-circular stone patio, 12'X 12' pergola, gutters and drywells.
The certificate is issued to MICHAEL KEN1N owner of the
aforesaid property.
Authorized Signature
~U~V~f O~ F~O~~
~ITUATE: EAS, T MARION
'roi, fiN, .50UTHOLD
t~EVI..~P IO-22-2OO'I, IO-25-2OOq
SUFFOLK ~T( TAX #
I000- ~,1 - q- II
C, EP. TIFIED TO:
M~,,~- ,~,,,N APPROVED BY
BOARD OF TRUSTEES
TOWN OF $OUTHOLD
)ATE ///~/'~ 'Z
® PIf:~
~1~2 ~'DIA. X4'~Y~!5
~RAI:~HIC, 5~ALE I"= :20'
24' R.O.W.
210.0'
o
Lon¢ nova or
N55o47'20"E
LIMIT OF
132.12'
S55o47'20"W
191.17'
JOHN C. EHLERS LAND SURVEYOR
6 EAST MAIN S~ N.Y.S. LIC. NO. 50202
RIVERHEAD, N.Y. 11901
369-8288 Fax 369-8287 Ri~.-TIGER%PROS%99-202
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
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
October 17, 2007
Mr. William J. Lohn
Suffolk Environmental Consulting, Inc.
P.O. Box 2003
Bridgehampton, NY 11932-2003
RE:
MICHAEL KENIN
420 LAKEVIEW TERRACE, EAST MARION
SCTM# 31-9-11
Dear Mr. Lohn:
The following action was taken by the Southold Town Board of Trustees at their Regular
Meeting held on Wednesday, October 17, 2007:
RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to
Permit #6127 to construct a 9' x 13' covered deck and steps on the northern side of the
existing dwelling; 9' x 28' wood deck and steps wit.h associated planter on the eastern
side of the dwelling; 13' x 24' semi-circular stone patio on eastern side of dwelling; and
12' x 12' pergola with, bc.;~ches and associated planter on eastern side of the dwelling,
with the condition of the installation of drywells and gutters to contain roof runoff and in
accordance with Chapter 236 of the Town Code-Storm Water Runoff, a line of staked
hay bales to be installed prior to construction, and as depicted on the revised survey
prepared by John C. Ehlers Land Surveyor, last revised October 25, 2007, received on
October 31,2007.
Any other activity within 100' of the wetland boundary requires a permit from this office.
This is not a determination from any other agency.
If you have any questions, please call our office at (631) 765-1892.
Sincerely,
F. King
President, Board of Trustees
JFK:eac
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
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
Please be advised that your application dated ,Z~x q~s~z ~ ~5~ ~ 7 has
been reviewed by this Board at the regular meeting oF~ /"2~-]~b~- 17. ,P, Oo ¥
and your application has been approved pending the completion of the
followin/g,ffems checked off below.
-/V Revised Plans for proposed project For IooJr~q ~)<~,~rv~Jr/~e,~me^~--~ ;/o
'498,-/
__ Pre-Construction Hay Bale Line Inspection Fee ($50.00)
__ 1st Day of Construction ($50.00)
__ V2 Constructed ($50.00)
__ Final Inspection Fee ($50.00)
__ Dock Fees ($3.00 per sq. ft.)
Permit fees are now due. Please make check or money order payable to Town
of Southold. The fee is computed below according to the schedule of rates as
set forth in Chapter 275 of the Southold Town Code.
The following fee must be paid within 90 days or re-application fees will be
necessary, You will receive your permit upon completion of the above.
COMPUTATION'OF PERMIT FEES:
TOTAL FEES DUE:$ ~
BY: James F. King, President
Board of Trustees
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
TovmHall
53095Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone(631) 765-1892
Fax(631) 765-6641
BOARD OF TOWNTRUSTEES
TOWN OFSOUTHOLD
Southold Town Board of Trustees
Field Inspection/Work session Report
Date/Time: ~'"- l '~~ (--) '~
Suffolk Environmental Consulting, Inc. on behalf of MICHAEL KENIN requests an
Amendment to Permit #6127 to construct a 9'X 13' covered deck and steps on the
northern side of the existing dwelling; 9'X 28' wood deck and steps with associated
planter on the eastern side of the dwelling; 13'X 24' semi-circular stone patio on eastern
side of dwelling; and 12'× 12' pergola with benches and associated planter on eastern
side of the dwelling. Located: 420 Lakeview Terrace, East Marion~ SCTM#31-9-11
Type of area to be impacjied:
Saltwater Wetland t., Freshwater Wetland
Sound Bay
Distance of proposed work to edge of above:
Pa/of Town Code proposed work falls under:
\?Chapt.275 Chapt. 111 other
Type of Application: ~/Wetland __Coastal Erosion '~Amendment Administrative
__Emergency Pre,Submission Violation Planning
Info needed:
Modifications:
Conditions:
Pres~ent Were~ ~xJ//.~l. 'ng ~J/.Doherty .~Dickerson D. Bergen ~. Ghosio, Jr
v/ H. Cus~/ck x.~/D. D~-enkowski ~Mark Terry~other i--
Form filled out in the field by \~,~e~oc <- .
Mailed/Faxed to: Date:
EnvironmentalTechnician / ~ \~&~-~
Review ¢~ ~C&~ ~
Donald Wilder, Chairman
Lauren Standish, Secretary
Town Hall, 53095 Main Rd.
P.O. Box 1179
Southold, NY 11971
Telephone (631) 765-1892
Fax (631) 765-6641
Conservation Advisory Council
Town of Southold
At the meeting of the Southold Town Conservation Advisory Council held Tues.,
September 11,2007, the following recommendation was made:
Moved by Don Wilder, seconded by Chris Kempner, it was
RESOLVED to SUPPORT the application of MICHAEL KENIN to Amend Permit #6127 to
construct a 9'X 13' covered deck and steps on the northern side of the existing dwelling;
9'X 28' wood deck and steps with associated planter on the eastern side of the dwelling;
13'X 24' semi-circular stone patio on eastern side of dwelling; and 12'X 12' pergola with
benches and associated planter on eastern side of the dwelling.
Located: 420 Lakeview Terrace, East Marion. SCTM#31-9-11
Inspected by: Don Wilder, Chris Kempner
The CAC Supports the application with the Condition the deck is pervious and drywells
are installed to contain all run-off.
Vote of Council: Ayes: All
Motion Carried
Suffolk Environmental Consulting, Inc.
Newman Village, Suite E, 2322 Main Street, P.O. Box 2003, Bridgehampton, New York 11932 2003
(631) 537-5160 Fax: (631) 537-5291
Bruce Anderson, M.S., President
October 30, 2007
Ms. Lauren Standish
Southold Town Board of Trustees
P.O. Box 1179
Southold, NY 11971
R~
Sitaate:
SCTM#:
Permit #'s:
KENIN Permit Modifications
420 Lakeview Terrace; East Marion
Town of Southold, New York
1000 - 31 - 9 - 11
4984 & 6127
Dear Ms. Standish,
As you may recall, the above referenced permit modifications were conditionally
approved by the Southold Town Trustees at their regular meeting held on October 17,
2007. In order to finalize said approvals, please find the following enclosed herewith:
(1) Regarding Permit #4984, revised Dock Assembly Plans prepared by this Firm and
last dated 10/19/2007 indicating a 4' x 8' Thru-Flow® docking assembly;
(2) Regarding Permit #6127, revised Surveys of subject parcel prepared by John C.
Ehlers and last dated 10/25/2007 indicating drywells and staked hay bales/silt
fencing.
Kindly review the enclosed items and forward the requested approvals directly to
this office at your earliest opportunity. If you have any questions, please don't hesitate
to contact me. Thank you as always for your attention and consideration.
William J. Lohn
cc: M. Kevin
OFFICE LOCATION:
Town Hall Annex
54375 State Route 25
(cor. Main Rd. & Youngs Ave.)
Southold, NY
MAILING ADDRESS:
P.O. Box 1179
Southold, NY 11971
Telephone: 631 765-1938
Fax: 631 765-3136
LOCAL WATERFRONT REVITALIZATION PROGRAM COORDINATOR
TOWN OF SOUTHOLD
MEMORANDUM
James King, President
Town of Southold Board of Trustees
From: Mark Terry, Principal Planner
LWRP Coordinator
Date: September 4, 2007
Re~
Request for Wetland Permit for Michael Kenin
SCTM# 31-9-11
MICHAEL KENIN requests an Amendment to Permit #6127 to construct a 9'X 13'
covered deck and steps on the northern side of the existing dwelling; 9'X 28' wood deck
and steps with associated planter on the eastern side of the dwelling; 13'X 24' semi-
circular stone patio on eastern side of dwelling; and 12'X 12' pergola with benches and
associated planter on eastern side of the dwelling. Located: 420 Lakeview Terrace, East
Marion. SCTM#31-9-11
The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review
of the Town of Southold Town Code and the Local Waterfront Revitalization Program
(LWRP) Policy Standards. Based upon the information provided on the LWRP
Consistency Assessment Form submitted to this department, as well as the records
available to me, it is my recommendation that the proposed action is INCONSISTENT
with the denoted following Policy Standards and therefore is INCONSISTENT with
the LWRP.
Policy 6. Protect and restore the quality and function of the Town of Southold
ecosystem.
6.3 Protect and restore tidal and freshwater wetlands.
Comply with statutory and regulatory requirements of the Southold Town
Board of Trustees laws and regulations for all Andros Patent and other
lands under their jurisdiction
Comply with Trustee regulations and recommendations as set forth
in Trustee permit conditions.
The distance to the proposed stone patio from the freshwater wetland
boundary is 27 feet; the distance to the proposed covered deck and steps
from the freshwater wetland boundary is 52 feetl the distance from the
proposed pergola and planter from the freshwater wetland boundary is
57 feet[ a minimum setback distance of 100 feet from the wetland line is
required pursuant to Chapter 275-3.Findings~ purpose~ iurisdiction~
setbacks. Please require that the applicant amend the application to meet
the above policy to the greatest extent practical.
If the action is approved and to further Policy 5: Protect and Improve Water quality
in the Town of Southold:
1. Establish a non-disturbance buffer landward of the wetland
o
boundary to protect the water quality of the lake.
Require hay bales during construction.
Require gutters to drywells on the house and additions to contain
roof runoff.
Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in
preparing its written determination regarding the consistency of the proposed action.
MT/hkc
PERMIT #6127 AMENDMENT DESCRIPTION
FOR THE KEJVINPROPERTY
Situate: 420/akev/ew Terrace; East Marion; Town of Southold, NY
SCTM#: 1000- 31 - 9 ~ I1
On May 18, 2005, the Soufhold Town Trustees, via Permit #6127, approved
the following:
~ "...remove the existing in-ground swimming pool and construct an
18' x 40' deck, and as depicted on the survey received on April 21,
2005."
The owner is proposing fo amend the permit in order fo construct the
following:
* Proposed 9' x 13' covered deck and steps on the northern side of
the existing dwelling;
'~ Proposed 28' x 0' Wood deck and steps with associated Planter on
the eastern side of the existing dwelling;
* Proposed 13' x 24' semi circular stone patio on the eastern side of
the existing dwelling;
* Proposed 12' x i 2' pergola with benches and associated Planter on
the eastern side of the existing dwelling;
Please note that the swimming pool slated for removal as per the original
permit has been removed.
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
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
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In the Matter of the Application of
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
being duly sworn, depose and say: ~ - ~ ' '~ - '
That on theO~ day of ~, ,200'7, I l?ersonally posted the property known as
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 public
heating. Date of hearing noted thereon to be held {J,.lz/- ~,~,~ ,/q. dODO -
Dated:
Sworn to before me this
(fl'~ dayof.q~-. 2007
Ng('arf Public
Noter~ [~ [: ~c 0[ q~w York
Nb 0'.,~'¢6053859
Oualifi,:d ir Uuf o~k County
6omm~ss~or Expirgs Jar~uary 22, 20 I}
· Co~31~e items and.3. Also~oroplete
item 4 if Restricted Deflvery is desired.
· Print your name and address on the reverse
so that we can return the card to you.
· Attach this card to the back of the roailpiece¢%
or on the front if space permits. ~
1. Article Addressed to:
2. Article Number
(rrans fer from sen/ce/abe/)
B. Rece[vad by ( Prlntsd Name)
). Is dalive~ address different from Rem 1
If YES, enter dellvew address below:
[] No
[srCertlflad Mall [] Express Mall
[] Registered r'l Retum Receipt for Merchandise
[] Insured Mall r'l C.O.D.
4. Restricted Deliver//(Extra Fee) [] Yes
7006 '0$D'O 0006'!9915 1771
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-i540
· Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery Is desired.
· Print your name and address on the reverse
so that we can return the card to you.
· Attach this card to the back of the rnallplece,
or on the front if space permits.
2. Ar
PS F
[] Agent
It~ed/.by C. Date of Delivery
D, Is delivery [] Yes
If YES, enter delivery address below: [] No
3. ype
~[ffe~ Mall 0 Exprees Mall
[] RegLstemd [] Return Receipt for Merchandise
[] Insured Mall r"l C.O.D.
· Complete Items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
· Print your name and address on the reverse
so that we can return the card to you.
· Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
[] Agent
D. Is ~iv~y [] Ye~
If YES, enter delivery address below: [] No
2. Article Number
(l'ransferfrornservicelabel) 7006 0100 0006 9915 1788
PS Form 3811, February 2004 Domestic Return Receipt 102595-O2-M-1540/
· Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery s desired.
· Pdnt your name and address on the reverse
so that we can return the card to you.
· Attach this card to the backof the mailplece,
or on the front if space perrrits.
1. Article Addressed to:
D. Is derh~ry
If YES, enter deliver)
O ~gent
C. Date of D~lve~,
~t ~mrn Itom 17 []¥o8 [] ~o
2. Article Number
3. Se~lce 3~¢pe
[~-r~d ~rl [] ~ Maim
[] Registered [] Return Receipt for Mea=bendise
[] Insured Mail [] C.O.D.
4. Restrlctad DelNe~y? (Extra Fee) [] Yes
7006 0100 0006 9915 1986
(Transfer fr=m ~rvlce labeO
PS Form 3811, February 200~ Domestic Rstum Receipt
Town of Southold
LWRP CONSISTENCY ASSESSMENT FORM
A. INSTRUCTIONS
All applicants for permits* including Town of Southold agencies, shall complete this CCAF for
proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This
assessment is intended to supplement other information used by a Town of Southold agency in
making a determination of consistency. *Except minor exempt actions including Building Permits
and other ministerial permits not located within the Coasta! Erosion Hazard Area.
Before answering the questions in Section C, the preparer of this form should review the exempt
minor action list, policies and explanations of each policy contained in the Town of Southold Local
Waterfront Revitalization Program. A proposed action will be evaluated as to its significant
beneficial and adverse effects upon the coastal area (which includes all of Southold Town).
If any question in Section C on this form is answered "yes", then the proposed action may affect the
achievement of the LWRP policy standards and conditions contained in the consistency review law.
Thus, the action should be analyzed in more detail and, if necessary, modified prior to making a
determination that it is consistent to the maximum extent practicable with the LWRP policy
standards and conditions. If an action cannot be certified as consistent with the LWRP policy
standards and conditions, it shall not be undertaken.
A copy of the LWRP is available in the following places: online at the Town of Southold's website
(southoldtown.northfork.net), the Board of Trustees ~ local
libraries and the Town Clerk's office.
B. DESCRIPTION OF SITE AND PROPOSED
SCTM# 31 09 11 ~
The Application has been submitted to (check appropriate res
Southold lown
~oaTd o~ '~ustees
Town Board [] Planning Dept. [] Building Dept. [] Board of Trustees []
1. Category of Town of Southold agency action (check appropriate response):
(a)
Action undertaken directly by Town agency (e.g. capital
construction, planning activity, agency regulation, land transaction)
(b) Financial assistance (e.g. grant, loan, subsidy)
(c) Permit, approval, license, certification:
Nature and extent of action:
The applicant proposes to amend Permit #6127 in order to construct a 9' x 13' covered deck and
steps on the northern side of the existin,q dwelling; a 28' x 9' wood deck and steps with associated
planter on the eastern side of the existing dwelling; a 13' x 24' semi circular stone patio on the
eastern side of the existing dwelling; and a 12' x 12' pergola with benches and associated planter
on the eastern side of the existing dwelling.
Location of action:
Site acreage:
420 Lakeview Terrace; East Marion; Town of Southold
0.37 acre ±
Present land use:
residential
Present zoning classification: R-40
If an application for the proposed action has been filed with the Town of Southold agency, the following
information shall be provided:
(a) Name of applicant: Michael Kenin
(b) Mailing address: 1236 Park Avenue
New Yorlq NY 10128
(c) Telephone number: Ama Code ( 212 ) 722-5290
(d) Application number, if any: N/A
Will the action be directly undertaken, require funding, or approval by a state or federal agency?
Yes [] No [] If yes, which state or federal agency? NYSDEC
DEVELOPED COAST POLICY
Policy 1. Foster a pattern of development in the Town of Southold that enhances community character,
preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and
minimizes adverse effects of development. See LWRP Section III-Policies; Page 2 for evaluation
criteria.
[] Yes [] No [] Not Applicable
Subject proposal is consistent with the policy in that said proposal is simply an improvement of the existina
dweHinq on the Jot, in an area that has been previously disturbed by simiJar appurtenances le.a. the
previously existinq terrace and pool). The proposed improvements are similar in size to those that were
previously approved, and are substantially vertically separated from the situate wetlands. In addition, the
proposed improvements will not substantially alter the dwellinq or the site, which has existed harmoniously
with the neiqhborhood for many years. Accordinqly, we believe that this project is consistent with this
policy.
Attach additional sheets if necessary
Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See
LWRP Section Ill - Policies Pages 3 through 6 for evaluation criteria
[] Yes [] No [] Not Applicable
Policy 2 is not applicable in that subject lot and the surroundin.q neiahborhood cannot be deemed a
substantial historic and/or archaeological resource.
Attach additional sheets if necessary
Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See
LWRP Section III - Policies Pages 5 through 7 for evaluation criteria
[] Yes [] No [] Not Applicable
Subiect proposal will not adversely impact the visual quality of the surrounding1 area in that the orooosed
improvements will not substantially alter the appearance of the existina dwellina, which has existed
harmoniously with the neiqhborhood character for many years with previously existinq related
appudenances. Scenic resources, assumedly views of Marion Lake, are not at risk due to the fact that
there is an ex st nq dwe ngl at subject parcel and the proposed improvements will not result in further
obstruction of said views by the structure. Accordinglly, this propasal will comply with Palicy 3.
Attach additional sheets if necessary
NATURAL COAST POLICIES
Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP
Section III - Policies Pages 8 through 16 for evaluation criteria
[] Yes [] No [] Not Applicable
Subject proposal will fully comply with Policy 4 in that the proposed construction will in no way alter the
situate wetlands or shoreline. The existinq dwellinq has not been threatened bv floodina or damaae from
erosion. Accordinqly, this proposal will comply with Policy 4.
Attach additional sheets if necessary
Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III
- Policies Pages 16 through 21 for evaluation criteria
[] Yes [] No [] Not Applicable
Policy 5 is not applicable in that it will have no effect to the water aualitv/suDDIv within the surroundina
area.
Attach additional sheets if necessary
Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including
Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22
through 32 for evaluation criteria
[] Yes [] No [] Not Applicable
Subject proposal will maintain the quality of the surroundingj ecosystem in that the existina dweliina has
been located at subject parcel for years without adversely affectina the surroundina ecosystem. In
addition, the previously approved and constructed appurtenances resulted in no adverse effects to the
situate ecosystem. Accordinglly, this proposal will comply with Policy 6.
Attach additional sheets if necessary
Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies
Pages 32 through 34 for evaluation criteria
[] Yes [] No [] Not Applicable
Policy 7 is not applicable in that the proposal is simply to improve upon an ex st nfl dwellinq which will not
result in any form of adverse effects to air quality.. Accordin.qly, this proposal is not applicable with this
policy.
Attach additional sheets if necessary
Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous
substances and wastes. See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria.
[] Yes [] No [] Not Applicable
This policy is not applicable in that the proposal does not involve disposal and/or transportation of solid
waste, hazardous waste, toxic pollutants, petroleum products.
Attach additional sheets if necessary
PUBLIC COAST POLICIES
Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public
resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation
criteria
[] Yes [] No [] Not Applicable
Policy 9 is not applicable in that the proposal is attendant to a private property. Reaardless, this project will
not impede any access to the surface waters in and around subiect praperty and/or become detrimental
to the recreational use of the surroundinq resources.
Attach additional sheets if necessary
WORKING COAST POLICIES
Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependence uses in
suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria
[] Yes [] No [] Not Applicable
Policy 10 is not applicable in that the proposal is simply to improve upon an existin~ dwellina which is not.
and will not affect a water dependent use.
Attach additional sheets if necessary
Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic
Estuary and Town Waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria
[] Yes [] No [] Not Applicable
Policy 1 I is not apolicable in that the ProPOSal does not involve any form of marine resource manaaement
/i.e. commercial fisheries, recreational fisheries, aquaculture, etc...).
Attach additional sheets if necessary
Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages
62 through 65 for evaluation criteria.
[] Yes [] No [] Not Applieable
Policy 12 is not applicable in that the proposal does not involve aaricultural lands li.e. the conversion of
farmland, the establishment and/or maintenance of new coastal aglricultural production, etc...)
Attach additional sheets if necessary
Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP
Section III - Policies; Pages 65 through 68 for evaluation criteria.
[] Yes [] No [] Not Applicable
Policy 13 is not aDolicable in that the ProPosal does not involve the conservation of enerav resources on a
commercial level and/or the Dromation of alternative enerav sources, groDer maintenance of fuel storaae
facilities and/or the extraction of mineral extraction
Attach additional sheets if necessary
Suffolk Environmental Consulting, Inc.
Newman Village, Suite E, 2322 Main Street, P.O. Box 2003, Bridgehampton, New York I1932-2003
(631) 537-5160
Bruce Anderson, M.S., President
Fax: (631) 537-5291
August 21, 2007
Mr. James F. King; President
Southold Town Board of Trustees
P.O. Box 1179
Southold, NY 11971
Ah'n: Ms. Lauren Standish
Re:
Situate.
SCT~#:
Dear Mr. King,
KENIN Property
420 Lakeoiew Terrace; East Marion
Town of Southold, New York
I000-31 -9-11
As requested, please find the following enclosed herewith as it relates to the above
referenced property:
Permit #4984 Amendment Description prepared by this Firm pertaining to the
proposed fixed dock assembly (three [3] copies);
Dock Assembly Plan prepared
copies); by this Firm outlining the proposed work (three [3]
* Permit #6127Amendment Description prepared by this Firm pertaining to the
proposed decking and patio (three [3] copies);
· Survey of subject parcel prepared by John C. Elders and last dated 5/16/2007
showing all existing and proposed improvements thereon (three [3] copies);
* Check in the mount of $100.00 to cover both permit amendment fees.
Kindly review the enclosed items and continue processing the requested permit
amendments. If you have any questions, or require additional information, please don't
hesitate to contact me. Thank you as always for your attention and consideration.
Sincerely,
Encl.
Cc: M. Kenin
Suffolk Environmental Consulting, Inc.
Newman Village, Suite E, 2322 Main Street, P.O. Box 2003, Bridgehampton, New York 11932-2003
(631) 537-5160 Fax: (631) 53%5291
Bruce Anderson, M.S., President
May 30, 2007
Mr. James F. King; President
Southold Town Board of Trustees
P.O. Box 1179
Southold, NY 11971
Attn: Ms. Lauren Standish
R~
Situat~
SCTM#:
Previous
Permit #:
KENIN Property
420 Lakeview Terrace; East Marion
Town of Southold, New York
1000 - 31 - 9 - 11
6127
Dear Mr. King,
This Firm has been retained by Mr. Kenm, owner ot the above referenced property,
who wishes to amend the above referenced permit to reflect several changes that have
been made to the project. To that end, please find the following enclosed herewith for
your review:
· Permit Amendment Description prepared by this Firm outlining the proposed
changes (three [3] copies);
· Survey of the subject parcel indicating the proposed changes (three [3] copies).
Kindly review the enclosed items and begin processing the requested permit
amendment. If you have any questions, or require additional information, please don't
hesitate to contact me. Thank you as always for your attention and consideration.
Cc: M. Kenin
PERMIT AMENDMENT DESCRIPTION FOR
THE KEN/NPROPERTY
Situate: 420 Lakeview Terrace; East Marion; Town of Southold, NY
SCTM#: 1000 - 31 - 9 - 11
Exisfin~l Approval
On May 18, 2005, the Southoid Town Trustees, via Permit #6127, approved
the following:
"...remove the existing in-ground swimming pool and construct an
18' x 40' deck, and as depicted on the survey received on April 21,
2005."
Proposed Permit Amendment
The owner is proposing to amend the permit in order to construct the
following:
~, Proposed 9' x 13' covered deck and steps on the northern side of
the existing dwelling;
~, Proposed 28' x 9' wood deck and steps with associated planter on
the eastern side of the existing dwelling:
* Proposed 13' x 24' semi circular stone patio on the eastern side of
the existing dwelling;
~, Proposed 12' x 12' pergola with benches and associated planter on
the eastern side of the existing dwelling;
*, Praposed 6' x 12' fixed dock located at the terminus of the existing
catwalk.
Board Of $outhold Town Trustees
SOUTHOLD, NEW YORK
Fg.o5
PERMIT NO... L~ l..~' .... DATE:.· ~..
MICHAEL & KIN KENIN
ISSUED TO .................................................................................................................
Pursuant to the provisions of C:hapter 61!~ of the L~ws of
the Stale of New Yorl~, 18937 and Chapter ~ of the ,~.ws of the
State of New York 19!~2; and the Southold To*n Ordinance
titled ."REGULATING AND THE PLAC~ING OF OBSTRUO]'I~.NS
IN AND ON TOWN WATERS AND PUBLIO LANDS and the
REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS.F.~)M
LANDS UNDER TOWN WATERS;~.'. and in accordance with the
Resolution of The Board adopted at a meeting held on .M~.. L~, .......
~(~.~..., and in consideration of the sum of $ ......%i(!..O0. paid by
Michael & Kim Kenin
of .......... ~.~...~!e.~.~?~ ...................... N. V. ~nd ,,,Nect to the
Terms and (~,ondltions listed on the reverse side hereof,
of Southold Town Trustees authorizes and permits the following:
Wetland Permit to remove the existing in-ground swimming pool
and construct an 18'X 40' deck, and as depicted on the
survey received on April 2~, 2005.
all in accordance with the deta~ed specifications as presented in
· the originating appllcetlon.
IN WITNESS WHEREOF, The s~id Board of Trustees here-
by causes its Corporate Seal to be affixed, and these presents to
be subscrlbed by a 'm~jority of the ~aid Board as of this date.
TERMS and CL)NDITIONS
Michael & Kim K~nin
~ 420 Lakeview. Terr. ace, East bJa.rion . . · ..... N. Y~ ~
l?sxt, et ~be coastd~er~oa loc thc ls~usmz of eh¢ Peani~ ~ ua~emsad ami pa~ibe to the roi-
1. 'fhst the ss. id ~ of T~ snd d~e Town of 8audmld tm tele~tsed from any and
all n-,,,,,~-~ oc ~,~,~ 'fe~ d~aa~s, of suits ~ ~ et Indlrecd. y as, result of shy opec-
· ~b ~[~'ct ~bete~, to-~,nlete ex~4~don of ~e ~ of Tt~es of ttae Town of .~bo[~cl
~. 'rn~t~sl~h'vaJid~otst~..dodof, 24: inos. wbb:false0~nsa~ecltobetbe
~or an e.,.~r, don n~y be n~tde to the I~std ~t st !,~, d~
:~. Tl~t d~s p,.rmlr should be retained inclefb~tdy, or ~ long ts tl~ sdd P*rmluee sdshes
to ~,,,i~,~. the muctute o~ project involve~ to pmvlde evidence to anyone concerned that
~Izsdo~ ~.s or~tn~iy obtained.
4. That the wo~ involved ~ be subject to the ~ and a~proral of the ~ ot
its agents, ami non-4:ompUance w~tb d~e pravislons of dae orl~n~a& appHc~tioa, m~y be ~,,~ for
revocation of this Pe~nlt by resolution of the ~id Bo~ttd.
5. That there ~ be no ~le interference ~ n~i&~ioa ~ · eesult of the wade
beean s~d~ottzed. ' '
~on dee nodce~ to remove o~ alter dtls ~c or project I~'~n ~_,_~1_ ~oat inq~se~ to the To~n~
a. That the sa~d Boacd wtU be trollied by tlxe Perndttee ot d~e eampletloai0f the ~ ~
idemen~ eo ~ i~ndt va~h ..,.y'be subject to tevote upoa fdluxe to ebon same.
Albert J. Krupski, President
James King, Vice-President
.M°t ie Foster
Ken Poliwoda
Peggy A. Dickerson
Town tIall
53095 Route 25
P.O. Box 1179
Southold, NewYork 11971-0959
Telephone (631) 765-1892
Fax (631) 765-6641
May 18, 2005
BOARD OF TOWN TRUSTEES
TOWN OF SOD'THOLD
Mr. & Mrs. Michael Kenin
420 Lakeview Terrace
East Marion, NY 11939
RE: 420 LAKEVlEW TERRACE, EAST MARION
SCTM#31-9oll
Dear Mr. & Mrs. Kenin:
The Board of Town Trustees took the following action during its regular meeting held on
Wed., May 18, 2005 regarding the above matter:
WHEREAS, MICHAEL & KlM KENIN applied to the Southold Town Trustees for a
permit under the provisions of Chapter 97 of the Southold Town Code, the Wetland
Ordinance of the Town of Southold, application dated April 21,2005 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 May 18, 2005, 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 MICHAEL & KlM
KENIN to remove the existing in-ground swimming pool and construct an 18' X 40'
deck, and as depicted on the survey received on April 21,2005.
Permit to construct and complete project will expire two years from the date the permit
is signed. Fees must be paid, if applicable, and permit issued within six months of the
date of this notification.
Inspections are required at a fee of $50.00 per inspection. (See attached schedule.)
Fees: $50.00
Very truly yours,
Albert J. Krupski, Jr., President
Board of Trustees
AJKJIms
Telephone
(631) 765-1892
Foxtn Hall
53(195 Route 25
PO. Bo,t 1[79
Southold, Net[ York 11971-0959
CONSERVATION ADVISORY COUNCIL
TOWN OF SOUTHOLD
At the meeting of the Southold Town Conservation Advisory Council held Tues., May
10, 2005, the following recommendation was made:
Moved by Jack McGreevy, seconded by Jennifer Mannino, it was
RESQLVEE) to recommend to the Southold Town Board of Trustees APPROVAL of the
Wetland Permit application of ,MICHAEL & KlM KENIN to remove the existing in-ground
swimming pool and construct an 18'X 40' deck.
Located: 420 Lakeview Terrace, East Marion. SCTM#31-9-11
Vote of Council: Ayes: All
Motion Carried
Albert J. KrupskL President
James King, Vice-President
Artie Poster
Ken Po/iwoda
Peggy A. Diekerson
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Town Hall
53095 Route 25
P.O. Box 1179
Southold, NewYork 11971-0959
Telephone(631,765-lS92
Fax{631.1765-1366
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
Y~ constructed
Project complete, compliance inspection.
%lbert J. }QnJpski, President
James [<Jng, Vice-President
Artie Foster
Ken Pollwoda
Peggy A. Dickeraon
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 163 [~ 765-i*,~(~ (
Office Use Only
77, astal Erosion Pemut Application
"_Wetland Pemfit Application Administrative Pernnt
, Amendment Transf¢r Extension
~ce~ved Applicat~~
~ompletcd Appli~ ff /~qO
~Incomplete
~SEQRA Classification:
T)pc l~__rype Ii Unlisted
Coo~dination:(date sent~
~C Relkrral
.~Receipt ofCAC Repom
Lead Agency Determination:
Teclmical Review:
~lic Hearing Held:
Resolution:
Name of Applicant
Address
Phone Number:(
Suffolk County Tax Map Number: 1000 - ~ \ -- ~l - I\
Property Location: qi~6 k/~l.c~:'ot~-:~ -r~,~.~c.~ ~,~.~ co,~em,,o *0,./-
(provide LILCO Pole #, distance to cross streets, alld location)
AGENT: '~'"~,r_.J ,PA~, ~A~r~ 1~o2ou,e~,'~l
(If applicable)
Address: ::2.o~- u*o~¢c ~ ~,oe_.
Phonc:~b~' / t t~
of Trustees Application
GENERAL DATA
Land Area (in square Feet) ~it~,~c ~.-
Area Zoning:__
Previous use of property:
Intended use of property:
Prior permits/approvals ibr site improvements:
Agency Date
__ No prior permits/approvals For site improvements
Has any permit/approval ever been revoked or suspenfled by a governmental agency?
_ ~ No Yes
If'yes, provide explanation;
Project Description (use attachments if necessary);
I~' X frot
of Trustees ApplicatiOn
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
.~ea of xvetlands on lot: square feet
Percent coverage of lot' %
Closest distance between nearest existing structure and upland
edge of wetlands: feet
Closest distance between nearest proposed structure and upland
edge of wetlands: feet
Does the project involve excavation or filling?
No X" Yes
If yes, how much ~natefial will be excavated? cubic yards
How much fnaterial will be filled? cubic yards
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:
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):
PROJECT JD NUMBER
PART I - PROJECT INFORMATION
61F 20
APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
fo,' UNLISTED ACTIONS Only
I To be completed by Applicant or Project Sponsor)
SEQR
APPLICANT ¢ SPONSOR 2 PROJECT NAME
3.PROJECT LOCA FION ~
Muniopality ~0 L~ VlE~ ~ ~C0unty ~ ~¢
PRECISE t OCAFION Street Addess and Road Intersections. Prominent landmarks etc -or provide map
IS PROPOSED ACTION. [] New [] Expansion ~ Modification / alteration
DESCRIBE PROJECT BRIEFLY
7 AMOUNT OF LAND AFFECTED:
Initially acres Ultimately acres
8 WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
E~Yo$ [] No If no. describe briefly:
9 WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT'~ (Chooseasmanyasapply.)
Ii'Res,dent[al []lndds,rial [~Coml'nercial ~]Agriculture E~ Park / Forest l Open Space []Other !descr, bel
tO. DOES ACTION INVOLVE A PERrvlIT APPROVAL. OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
AGENCY (Federal. State or Local)
[~Yes ~ If yes. list agency name and permit / approval:
11 DOES AN'r ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? E~Yes [~No If yes, list agency name and permit / approval'
12 AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION'~
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
AppliCant / Sponsor Name Date
Signature____
If the action is a Costal Area, and you are a state agency,
complete the Coastal Assessment Form before proceeding with this assessment
PART II - IMPACT ASSESSMENT (To be completed by Lead Agency)
A. DOES ACTIO~',~ EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR PART 6 7 4? If yes coordinate the review process and use the FULL EAF
WtLL ACTION RECEIVE COORDINA1ED REVIEW AS PROVIDED FOR Uf4LISTED ACTIONS fN 6 NYCRR, PART 617 6? If ~lo. a nog?dye
declaration ma~, De superseded by anofl-,er involved agency
C COULD ACTIOH RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING' (Answers may be handwritten d [egiffie}
C1 Exisbng a~r quaidy, surface or groundwater quahty or quantity noise levels, ex,sting traffic pattern, solid waste producbon or dispoSal.
potential for erosion, drainage or flooding problems? Explain brielly:
C2 Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources, or community or neighborhood character? E,~plam briefly
C3. 'v'egetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened er endangered species? Explain briefly
t
C5 Orowlh, subsequent development, or related activities likely to be induced by the proposad action~ Explain briefly
C6. Long term, short term, cumulative, or other effects act identified in C t-C5? Explain briefly'
C/' Other impacts (includi~g changes in use of either quantity or type of energy~ Explain briefly:
D WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAl CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL
ENVIRONMENTAL AREA ICEA)? It! ~,~s, ex~!ain bde§¥
RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL iMPACTS?. If ¥~s e~p!~in!_ l
PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each
effect should be assessed in connection with its (a) setting (i.e. urban or rural); ('b) probability of occurring; (c) duration; (d) irreversibJlity; (e)
geographic scope; and (f) magnitude. I[ necessary, add attachments or reference supporting materials. Ensure that explanations contain
sufficient detail to show that ali relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked
yes, the determination of significance must evaluate the potential impact of Ihe proposed action on the environmental characteristics of the CEA.
Check this box it you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed d*rectly to the FULl
EAF and/or prepare a positive declaration.
Check this box if you have determined, based on the ~nformation and analysis above and any supporting documentatiofl, that the proposed acbor
WtLL NOT result in any significant adverse environmental impacts AND prowde, on attachments as necessary, the reasons supporting thi!
determination.
Name of Lead Agency
Date
Title of Responsible Officer
Print or Type Name of Responsible Officer in Lead Agency
Signature of Responsible Ohicer ~n Lead Agency Signature of Preparer (If different from responsible offlcerl
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-~,~C~ ~1
BOARD OF TOWN TRUSTEES
TO~5'N OF SOUTHOLD
BOARD OF TRUSTEES: tOWN OF SOUTHOLD
In the blattcr of the Application of
COUNTY OF SUFFOLK)
STATE OF NEW YORKI
AFFIDA\:IT OF POSTING
being duly sx~ o~. deposc and sa3':
That on the 0"4 day o f c,~'~ ,2()Q~. I personally posted the property known as
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 public
hearing. Date of hearing noted thereon to be held _ ~J,J~. ~ 15. t~71~t~ - _.
' 0,5 o~ o00~1 9:0~
Daled:
S%om to belbre me this
r~ day ot ~lr,,~ 2t/IJb
/ ~/~'~ ~ c.v~ Nota~Public, Stato of New York
~/~otary mmnc ~0 524~1408
~ Oualifiod in Suffolk Coun~ ~
Commission Ex~iros Doc.$I, ~ ~
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED M.4JL RECEIPTS
Nanle:
Address:
STATE OF NEW YORK
COUNTY OF SUFFOLK
?o Bo~ 3¥2,
, residing at elo~- B,,0sst^o ~o~_ t s:ootaolo
~q"l l\h"rl , being duly sworn, deposes and says that on the
day of ~__, 20 o_b_, deponent mailed a tree copy of the Notice
set forth in the Board of Trustees Application, directed to each of the above named
persons at the addresses set opposite there respective names; that the addresses set
opposite the names of said persons are the address of said persons as shown on the current
assessment roll of the Town of Southold; that said Notices were mailed at the United States Post
Office at ~oo'r~e~o ~"I I~. ~'1 ~ , that said Notices were mailed to each of said persons by
(certified) (re-gistered) 'mail.
Sworn to before me this 3,'~ .~
Dayof ,'mm}, 20 oo-
Notary Pu~'~c
John M. Judge
NOTARY PUBLIC, State of New York
No. 01JU6059400
Oual;fied In Suf[olk Count,/
Commission Expires May 29, 20
Board of Trustees ApDllcat~on
County of Suffolk
State of New York
DEPOSITS A~'D_ AFVIR_MS THAT HE/SIq2E IS THE .M~PLICANT FOR ~ .~OVE
DESCR!~ED PE~M!T(S) .~ND tHAT .~L STATE~NTS CONT,~D ~REIN .~.E
TKL~ TO T~ BEST OF ~S,~R KNOWLEDGE AND BELIEF, ~D T~T ~L WOrK
WILL BE DON~ ~ T~ bb~.~R SET FORTH IN T~S ~PLICATION ~ Ag MAY
~E ~FRO~D BY T~ SOUTHOLD TO~ BOARD OF TRUSSES T~ ~PL1CANT
kG~ES TO HOLD T~ TOWN OF SOUIHOLD ~ i~ TO~ TRUStEeS
t~ESS ~ FREE FROM ANY ~D ~1- D~AGES ~ CLA~K ARIS~G
[~DER OR BY VIRT/JE OF SA~ PE~IT(S). ~ G~NTE'D IN CO~LET~G
~PPLIC AT!ON, ! ~BY ~.UTHO~E T~ [RUSHES, T~ AGE~(S) OR
~P~SENTATI~S(S), TO EN~K ONTO ~ PROPERTY TO ~SPECT T~
P~MISES IN CONP~%$CTION ~qTH ~V~W OF T~S ~PLICATION.
Signature
SWORN TO BEFORE ME TitlS__.._~ 3
Notary PubliCVeroflica F. Cidone
Notary Public, State of New York
No: 52-4661406
Qualified in Suffolk County
Commission Expires Dec.31
DAY OF/]A%~.~ 0 ,20 0 c~
FfqX NO. : 76%1223
Board of Trustees AppLication
~. 14 20~5 03:lOPf4
P2
AUTHORI ZAT/ON
(where the applicant is not the owner)
'~, ~ ~o ~- ~,
(print o~er of Droperty) (mailing ad.ess)
( Agent )
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
Owner s ~£~natu=e) ' '
APPLICANT/AG ENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
~ Town of So~old's ~:ode of Ethics omhibits conflicts of interest on thc var[ of ~own pf~ccI'l and cmolowccs. Tho numose of
tbks form is to orovide i~fprmation which can ifierI the town ol'~nssible conflicts of ~u:mlLand allow it to ~akc whoever aclilm~
YOUR NAM£:
NAME OF APPLICATION: (Check Ifil that ap~ly.)
Tax grievance Building
Varianc~ 'l'rus~
Change ofZor, e Co~al Erosion
Approval of plat Mooring
Exemption from pl~ or official map P/orating
Other
(If"Other", name Ibc activin.)
Do you I~sonal]y (or through y our company, sl~um, sibling, ~nL or child) ~e a tailor.hip wi~ ~y o~r or employer
of thc Town of Southold? "R¢l~onghJp' inctudcs by blood, ~ag¢, or b.st~ss inmmgt "Bus~s~ ~[~s~" mea~g a busi~sg
Name of ~on cmployed by ~e To~ of Sou~old
Ti0e or ~si6on of that
thc appmpri~e linc A) though D) ~or ~cscfi~ in [he space ~vidcd.
.. A) ~e owner ofg~er ~hm 5% of the sh~ ~f~ ~e stock of~ apphcan(
~.g) t~ logo{ or ~ncficia[ own~ o~ mmre~ in a ~n<o~ entiff (w~n ~c
appficmt is nola
D) ~ ~ ~plicanL
DESCRIPTION OF RELATIONSHIP
Form TS I