HomeMy WebLinkAboutTR-1253 i •
OSOFFO(��,
Albert J. Krupski,President ��. Q Town Hall
James King,Vice-President =� Gy� 53095 Route 25
Artie Foster P.O. Box 1179
Ken Poliwoda x Southold, New York 11971-0959
Peggy A. Dickerson
'y.�rQl �aQt Telephone
(6316 31) 92 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
April 21, 2004
Mr. Jim Neumann
101 West End Ave., Apt. 21 E
New York, NY 10023
RE: 750 EAST MILL RD., MATTITUCK
SCTM#107-1-1
Dear Mr. Neumann:
The following action was taken by the Southold Town Board of Trustees at their Regular
Meeting held on Wednesday, April 21, 2004:
RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to
Permit#1253 to extend the fixed portion of the dock 20' and install four new pilings, re-
sink pilings for floating dock 6'X 20' and a 6'X 16' ramp with two pilings, and as depicted
on the plan dated March 18, 2004.
This is not a determination from any other agency.
If you have any questions, please call our office at (631) 765-1892.
Sincerely,
- .[ L
Albert J. Krupski, Jr.
President, Board of Trustees
AJK:Ims
SUFF04CD Albert J. Krupski, President 0� Town Hall
James King,Vice-President zy� 53095 Route 25
Artie Foster o P.O.Box 1179
Ken Poliwoda W Southold, New York 11971-0959
Peggy A. Dickerson OPfi 0�� Telephone (631) 765-1892
Fax(631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
TO: -sum Yl euma nr\
Please be advised that your application dated 3 b 0 has been
reviewed by this Board at the regular meeting of and the
following action was taken:
�) Application Approved (see below)
�) Application Denied (see below)
�) Application Tabled (see below)
If your application is approved as noted above, a permit fee is now due. Make check or
money order payable to the Southold Town Trustees. The fee is computed below
according to the schedule of rates as set forth in the instruction sheet.
The following fee must be paid within 90 days or re-application fees will be necessary.
COMPUTATION OF PERMIT FEES:
4'Xdo' d�cK e.��etsia, _ $o" �► sa.��1� . � �a4o. c�a
Die 042037
51 N
W `� Received From (1`�.t J
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p rn Address�� E e
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to 0 ,� 0 For � I l
LL 0
=i m ACCOUNT ag47Y:11�� _
O
N O N AMT OF
¢ O�1 ACCOUNT I
J m Ob PMT PAID 1 CHECK 4(1/
BALANCE I I IMJfttY OflGEfl Y
DUE LPEDIi LNtG
F040
a Town Hail
Telephone 4 53095 Route 25
(631)765-1892 y.O P.O.Box 1179
t. Southold,New York 11971-0959
yea! � Sao
CONSERVATION ADVISORY COUNCIL
TOWN OF SOUTHOLD
At the meeting of the Southold Town Conservation Advisory Council held Tuesday, April
13, 2004, the following recommendation was made:
Moved by Don Wilder, seconded by William Cook, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH
A CONDITION of the application of JIM NEUMANN to Amend Permit#1253 to extend
the fixed portion of the dock 20' and install four new pilings, re-sink pilings for floating
dock 6'X 20' and a 6'X 16' ramp with two pilings.
Located: 750 East Mill Rd., Mattituck. SCTM#107-1-1
The CAC recommends Approval of the application with the Condition the ramp is 4'X
16' rather than 6'X 16'.
Vote of Council: Ayes: All
Motion Carried
T, 47xWe
p.
Environment East, Inc.
2885Indian Neck Lane
-_ P.O. Box 197
Peconic, New York 11958-0197
631-734-7474
-��-- - Fax: 631-734-581_2
po
April 5, 2004
Southold Town Trustees
P O. Box 1179 Southold NY 11971
Dear Board Members,
I would like to add this letter to the permit filed by the Neuman, Kathleen, Jim, and
(Michael for the extension to their current dock on Mattituck Inlet on the south side of
East Mill Road, Mattituck. I agree with their need to extend the dock and that they are
right in the middle of the East Mill Road run off problem. This tun off will continue to
silt in the inlet until the farms to the North practice contour farming of a sumpXput in.
I am responding as tl*owner of three properties on the north side of Mill Road.
Sincerely,
Peter R. Stoutenburgh
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03/08/04 YON 14:32 FAX 6911 86 Southold Town Accou�9 �OOS
t �oFd Tre Sta°es
SOUMOLD,NEW YOU
ddrr NO. _1: _�' DATE_o�i. 90, l9u 4
!v' .�::• .v .ir,a�aV65.Tb �!On - Coeat'. ,fai'6eihlegC`
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rof the Zws of
::7 7: ieti.::u yam :. �i�ip• DNS
Lou
yp :mind.the
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'Rise4+13at ofl}�e 11tl5�d�o'p6sd a}'a :�a;QcE..:90^= .
. ''(4' .md'a� watfdi►of:tlie:sLdi'}� :oo.' . pand
of'8eathdid ;
T �r - wbjW;.fc the
rdrti TtiRfeas �itd" aye d° ..of
004*0il doek'to dAd'4 'dpok ail.
Piapait7 iouce,a.2 tti11"ma7�i.1Sat .tYpCk, 76Px2o� dock
- 'Mt:•i 6"''r14p:and-20• x G� d!iaaV. .
al 3n occodaeea Wah.16 do%ged.sP almaga W PMWAed in
� ;•4heorfgioatfng�ppCcatioti: . ' . s
«bY yet tk CaParair '�'�e si[dof T`st`k t
die'416sddbad'by"e.sra :aF 4W ac of i
1
Plense to= of aad rotate to the Trusba¢ofam. ..
' Board Of Southold 'Town Trustees .
_ . MMOLD,NEW YOAt( .
41�;'iug Pecmit No.' �,
U3Qring Jo. .
certify that:- the-work as -
aut orize in'this permit.has Completed and is how ready
for gout inspection. Also, the mmb
is claasly visible. I £urthes understand this
on this pnot Va
unt3. 'this tear o££ sheet is returned to tho 1Yuaat a afficat vaSid
03/08/04 MON 14:31 FAX 0317 88 Southold Town Accou>o8 IM001
'TOWN OF SOUTHOLD
BOARD 0-S6UTHOLD TOWN TRUSTEES
..;fk4,�I1�FttP4.dr.Pacxno�t{�Itlr�304 � t1;3!?RQ Y'the:'Unin 'Fr,u
ft:.t<ettiAesa
dn.fge}jetliaikutiteebtflca tm5lertite:applleatiortiiumbtgiiEn,.. ...; '
. .panniYiiapiped•toclothe -77
#bllowlhg'+Kotk.:.1`g reby �_nri9 },Y,IdB&t{.p'.u4 § rxdAd?�in8•.mock-•
ran.........vyvvv.�•w:aw.•ww•N•-•_�•-.:.n_wwn_n..::nw4.�._ti%t
�.:L.'i�..'.:.r; ... . J.�i�iw.rvw..w•...aw.n.ua•
. 'Foa'1aa6 Ilab 4'i 5 of
.:.. ..Location�prgp"nCty on whigfi-awfk ko"be done
.. �..peek,"egy cr 7l^rtot frarKi atatticvck tree -
rtg.proptxry -...w�n.n._.n.._k._._.w._...:......_.....a_.....__....._....__.w.
Size of work: Length,n.-Z.$:a1�:...2A.:_._.._-........r..w..n_.....ww..w..,.n.- .n.........,._..._.....w.-. '.
width
Height Ahove High water. 3 ft. ..........w..:..
. Depth Below Low WeYr—a to 10 ..,..a �..... .
.Yw&m be Excavated._...-,.H1`_...______.........._...,„...w_. :........w...w.__n...
Yardstobe Fillad ......:n.....5/A_...w.___w..__..n
Manner in which matarial is to be ramovad or deposited ...........w.n-..•.n«_.n.w...n:...._...._...,.w_w....... . .
Intended use of property.......
Conditions if anY..__......,....w_...n...=' ....w._....n.—_..........w_n........................
Expiration Data October 12.
iQB6 ,} ..irork iuLq-.god.. gas.R#ntB�itaxd..date�...nw..n.n__
Number of Inspec[fons ftequited?=1"eeea•,pag ra„J .. xU d-pppa-thaneompletlen..af....n
the pork.
Inspection Fag. __p$_On paid .
•'Liability.Poliews in the Amount of
_.:._.w.__.n..--•n_..e.....a__............._......____w..w...._....._n....__.
The validity of#As permit is or maybe wblen to the approval-of Other governmental cf municipal
.autboridv% The Town.accepts no responsibiliV in-applying for or obtaining such approval. in the.
event dtat such approval is ne=wny,the holder of this permit shall not commence operations here-
under until such approvel,has bean obtained in wridng.The failure to Obtain such other approval whop
required shall subject this permit to imm"w a revocation by the TruStess'upon re peipt by the
Trustees• obw.itten natice from such other governmental or municipal authorities of its refusal or
\\U disapproval_ .
03/08/04 VON 14:32 PAX 6317&66 Southold Town Aaaott* IZ002
The applicant dam by the awmpmrroa of this pwralk sauma'all raspandbUky fnr operations under.: - --._
taken PumMnt to this permk,and dtci take all precautions for the prevention 6f Made in parnrons
r id property rmaritins from such operations.By each aouPmntw the applioptt almo prey to indsmni• .
fy and aqua harmiem the Town,and its offlceq'apem and employees from My and dl daises addng .
from operations'under this parmit and any anti afl-dam or omWoms of sppBean, hk agent and
.w*ovum
The applicant and the owner and occuparrts pf the premises upon Which the operatiorn mthor¢ed.by. ..
Nis pmnnft we ba(rg corduemd.der,by.ifre aaaptama of this peraft Ovvcontart to thrTown,and '
Its offlcas and ar•,�dayees m strut upon the pranbm wham much operations are bairn conducted m
nuke Wch inepoedons m the Town-may denim hooeumry to insure that such operations we being con-
. dmW In confmmlty vdth this perndt .. . .
This operation Will not subsuptiglry;
A. AdwerselyaffaetthewWends:ofthemAeL . . .
B. Came damage from erodon,turbidity orsllmtion
C. Cate rdtw4ur burusion into the f uh ester rmpurp .of the,ivwrw. ..
D. Adswidy affkf ft,drollfkh a btira bahefletel meriw asganlairr,aquetib wIBIRfe'aM vsgs
tntion or the rwmral haWmt t a=t
E. treumme the dhager of flood and aimm-tldidamepe. .
F. AdvmWy affect nsvfgsdcn on tidal uatae or the.*W flovv�cf the*W heaters of the town:.G. Chaape the course of any,ehautal or thi ni W nd mavwrnwrt orflohe oRaby v0atmm '
. H. .,Waakan or utderpune the lethal shQrperL cf adherlards In the vonky._ .
1. 01111"wlse advamly affect the health,ariety arhdwnwaf wdfare'of the people tif:fie'town.
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Board of jQthotd'Fowvn T"stees
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March 18, 2004
N.Y.S. Department of Environmental Conservation
SUNY, Bdlg. 40
Stony Brook, NY 11790-2356
Re: Amendment to Dock Permit #1-4738-01545/00001
Replacement of lost pilings and extension of fixed dock.
Dear Sir/Madam:
We wish to apply for an amendment to the above permit. The amendment is desired
because of the loss of depth at the floating dock and needed now as several pilings were
dislodged over the winter of 2003-4. Enclosed are the required copies of the sight and
cross-view plans. It is only the fixed portion of the dock, which is to be new, extending
an additional 20' providing for a 3' depth at apparent low water. The two floats and ramp
will remain the same. i4W Vm' y information:
Property Location: 75. ,J cast Mill Road, Mattituck NY 11952
Property Owners: Jain�s,`Michael, & Kathleen Neumann(tenants-in-common)
Winter/Mailing Address:
Jim Neumann
101 West End Avenue, Apt. 2 1 E
New York, NY 10023
Home: 212-874-3183 james.a.neumann@verizon.net
Work: 212-201-4843 james_neumann@hvbamericas.com
Mobile: 917-991-4166'
Please let us know if the documentation suite is complete or if there are any questions. If
a site visit is needed, it may be performed at any time that fits the DEC's schedule.
Thank you for your prompj:4Vention to this request.
Sincerely,
James A. Neumann
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APPROVED BY
aW BOARD OF TRUSTEES
TOWN OF SOUTHOLD
DATE
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Albert J. Krupski, President � Town Hall
James King,Vice-President h�O Tj' 53095 Route 25
Artie Foster o P.O.Box 1179
Ken Poliwoda W IM Southold,New York 11971-0959
Peggy A.Dickerson �f O�� Telephone(631) 765-1892
Fax(631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
_Coastal Erosion Permit Application
�llfetland P ation _Major Minor
_Waiv Amendmen ge
�lceived App tc Qy
/Rtceived Fee:$
,,Completed Application D (ram' ((� (5 IV
_Incomplete tt�b l�l tb D
_SEQRA Classification:
Type I_Type IIUnlisted,
_Coordination:(date sent) MAR 2 6 2G)4
/CAC Referral ti nt:y��
✓Efate of Inspection: Southold Town
_Receipt of CAC Report: Board of Trustees
_Lead Agency Determination:
Technical Review:
�ublic Hearing He ¢
Resolution:
Name of Applicant l t\;f tc'I ,IN Af
Address I l WL EN \ rlvcJuC i APT gtL nJ ' 1v Yekk
t l K 10023 Phone Number:(;L 12,) B-1 Li - 3 t f w.•-k z- 2 c i - K 4 3
Suffolk County Tax Map Number: 1000 - t o } - 0 0 1 - 0 C I �.
Property Location: S e [ as } YI: 11 '1'o A C+
(provide LILCO Pole#, distance to cross streets, and location)
AGENT:
(If applicable)
Address:
Phone:
Board of Trustees Application
GENERAL DATA
Land Area(in square feet): %
Area Zoning: �1 r e
Previous use of property:
Intended use of property:
Prior permits/approvals for site improvements:
Agency Date
n
Z)" K ' e�.�„l_ di 12 S t o go r5 S
nf . Y S . I)fL 1 -13e - c occ �
No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?
No Yes
If yes, provide explanation:
Project Description(use attachments if necessary):
/ z Le., F yt 4 Eo Oee � ,,M1«
l al,' 1 nEW 'Pl li+l riS rPa rt, 11
K � zo � 41 ) C. r,M? L�� `x 61
J. oeT— L/
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: h k,, d ��, k 1< ( < p -Z r
W c, lei E S 11 k (( Z ' C�- P 4-L' 1 o i �
rtln . 0 }-OM PN k f2J1,tCf 1-01- f1c14 � .
t�
Area of wetlands 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 Yes
If yes, how much material will be excavated? cubic yards
How much material will be filled? cubic yards
Depth of which material will be removed or deposited: feet
Proposed slope throughout the area of operations:
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):
n�I(� CL
Albert J. Kru ski, President OgOFfU(,�
D Town Hall
James King,Vice-President h`t` G.y 53095 Route 25
Artie Foster p P.O. Box 1179
Ken Poliwoda y Z Southold, New York 11971-0959
W
Peggy A. Dickerson Telephone(631) 765-1892
Fax(631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOLD---------------------------------------------------------------
In the Matter of the Application ly D
of ppR 19 2004
----------------------------- so
COUNTY Off) NEw '/Or,f loe"t att Ims
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
I, J 4_*+tS New,ary� residing at 101 wr, t 'E qd 4",4 2 i E —
Nsv Yw Ic A7Y 1( S cL —
being duly sworn, depose and say:
That on the 4*-day of Vv t , 2004, 1 personally posted the property known as
}SO Eaa4 M , ll Raa4 M0. N , 440c r A/Y 11 ';s'L
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 ( 0
On a.UU+ 0;0D m,
Dated: nn
(sign re)
Sworn to before me this
12 day of 4 f,-( 200 4
Notary Public
CATFAMIIIONNA
VOTARY PUBLIC,State of New York
No.01ME6021196
Ouavied in Newlbrk
Commission Expires p9 o6/05
0
PROJECT ID NUMBER SEAR
APPPENDIENDI X C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLISTED ACTIONS Only
PART 1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor)
1.APPLICANT/SPONSOR 2.PROJECT NAME
I . F �
gnEs A hz:w ,+ Nti/
3.PROJECT LOCATION:
Municipality ha k+ : k" K N t 1 q S ')_ County
4.PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map
150 E'os 1 ll boa 2
5.IS PROPOSED ACTION: New Expansion odfflcation/alteration
6.DESCRIBE PROJECT BRIEFLY:
7.AMOUNT OF LAND AFFECTED:
Initially acres Ultimately acres
6.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
EyYes ❑ No If no,describe briefly:
9.WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.)
Residential1:1 Industrial ❑Commercial ❑Agriculture ❑Park/Forest/Open Space Other (describe)
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
AGEN Y (Federal, State or Local)
Yes No If yes, list agency name and permit / approval: / o S )
Sew +k. lZ T0-+.� Tr.s LcLs �t'-. # 12s3 \ I �30
11,.—D—OEES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
l .,1*es nNo If yes, list agency name and permit / approval:
u S zz a. 6ovz
1,2�.,�� A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION?
L�,JYas ❑No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant / Sponsor Name 71 Date: 1 I i{; I 0 Y
Signature L(
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 ACTION EED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL FAF.
❑Yes WNo
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.67 If No.a negative
declaration may b uperseded by another involved agency.
❑ Ye DINO
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,if legible)
C1. Existing air quality,surface or groundwater quality or quantity,wise levels,existing traffic pattern,solid waste production or disposal,
potential for erosion,drainage or flooding problems? Explain briefly:
V
C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly:
hC
C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly:
tV c
C4. A oommunity's existing plans or goals as officially adopted,or a change in use or intensity of use of land or other natural resources?Explain briefly:
h �
C5. Growth,subsequent development,or related activities likely to be Induced by the proposed action?Explain briefly:
No
C6. Long tens,short term,cumulative,or other effects not identified in C1-05? Explain briefly:
I NO
C7. Other impacts(Including changes in use of either quantity or type of energy? Ex lain briefl :
ti�e
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL
ENVIRONMENTA AREA(CEA)? If es,explain briefly:
El Yes No
E. IS THERE,OR IS HERE LIKELY TO BE CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes"plain
Yes No
E- I
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)irreversibility;(a)
geographic scope;and(f)magnitude. If necessary,add attachments or reference supporting materials. Ensure that explanations contain
sufficient detail to show that all 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 the proposed action on the environmental characteristics of the CEA.
Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur.Then proceed directly to the FULL
EAF and/or prepare a positive declaration.
Check this box if you have determined,based on the information and analysis above and any supporting documentation,that the proposed actin
WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi
determination.
Name of Lead Agency Date
Print or Type Nam of Responsible Officer in ea gency Title of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from responsible officer)
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Name: Address:
[If.tn U1c:�h ,ruylsn 10'1 L IA h"aa r, Av.e .
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STATE OF NEW YORK
COUNTY OF Ki1/6111 Ya,-Vk
J I m residing at l o l wes� E n d A w.wy,
Al, r Yerr k , N Y 10,011 ,being duly sworn,deposes and says.that on the
.2 day of At- t ,20 e 4 ,deponent mailed a true copy of the Notice
set forth in the Board of Trustees Application,directed to each of the above named
persons at the addresses set opposite there respective names; that the addresses set
opposite the names of said persons 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 c.s 1w. 6, Ot My, N Y ,that said Notices were mailed to each of said persons by
(certified) (registered)mail. nn
Sworn to before me this 2
Day of 4 f, 1 2064
tary Public
CATE
NNA
NOTARY PUB CMS aie o0f New York
Oualif ed in New York County
Commission Expires
Board of Trustees Application
ryFuJ gOrk
County of 9415W]i
State of New York
�CSMtc A , nj;.�innn,� BEING DULY SWORN
DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK
WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY
BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT
AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES
HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING
UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR
REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
Si ature
SWORN TO BEFORE ME THIS tid DAY OF ///0'ye y ,200`/
Notary Publi
CATEp1NA10LCFWMA
WITARYPUBLM,State f Now York
ooalffied in New York
Commission Expires 091561
APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics prohibits conflicts of interest on the pan 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 NAME: N L U M A WV D A M E S
(Last name,first name,middle initial,unless you are applying in the name of
someone else or other entity,such as a company. If so,indicate the other
person's or company's name.)
NAME OF APPLICATION: (Check all that apply.)
Tax grievance
Variance
Change of Zone
Approval of plat
Exemption from plat or official map
Other
(If"Other",name the activity.) 17 or tier M. 31 Wa 3 A me,. d M4, l-
Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee
of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business,
including a partnership, in which the town officer or employee has even a partial ownership of(or employment by)a corporation
in which the town officer or employee owns more than 5%of the shares.
YES NO
If you answered"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/agent/representative)and the town officer or employee. Either check
the appropriate line A)through D)and/or describe in the space provided.
The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply):
A)the owner of greater than 5%of the shares of the corporate stock of the applicant
(when the applicant is a corporation);
__B)the legal or beneficial owner of any interest in a non-corporate entity(when the
applicant is not a corporation);
C)an officer,director,partner,or employee of the applicant;or
D)the actual applicant.
DESCRIPTION OF RELATIONSHIP
Submitted this I b' day of M a. c h 200 `i
Signature
Print Name SaMcr A.
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