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HomeMy WebLinkAboutTR-5128Board Of $outhold Town Trustees SOUTHOLD, NEW YORK DATE: M~'ch 22,. 2000 ISSUED TO ...... ANI;!RE.W .MOORE .&. KAREN SIL'vTIEF.~ .... Pursuant to the provisions of Chapter 615 of the Laws of the State of New York, 1893: and CJnapter 404 of the Laws of the State of New York 1952; and the Southold Town Ordinance 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 .~z~.,. _22,....2000 lq-2P~,0 and in consideration of the sum of $ 1~0.0(! . . paid by .. En-Go!7~lzltants f~r ANDREW MOORE. ~...IfAltEI4...SILVIER of ... MatlLt2.ck ...... N.Y. and subject to the Terms and Conditions lis~ed '(~n'the reverse side hereof, of Southold Town Trustees authorizes and permits the following: ~et]a~d Permit to const, a fixed do¢~ 4~90~ ele~. min. of 3.5 above marsh, 3'X16' ramp, & a 6'X20' fit. secur, by (2) 2 pile dolphins, constr, a 100+' timber ret. wall to tie into exist, landwa end of returns (north side 5' return south side 21' return) and backal[ in accordance with the detailed specifications as presented in fill the originating application, with approx. 100 c.y. of clean sand from upland source. IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this dat~. Alber~ J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18q2 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD March 23, 2000 En-Consultants Inc. 1329 North Sea Road Southampton NY 11968 Re: ANDREW MOORE & KAREN SILVIERA SCTM ~106-11-21 Dear Rob, The following action was taken by the Board of Town Trustees during a Regular Meeting, held on March 22, 2000, regarding the above matter: WHEREAS, ANDREW MOORE & KAREN SILVIERA, applied to the Southold Town Trustees for a permit under, the provisions of the Wetland Ordinance of the Town of Southold, application dated February 3, 2000 and, WHEREAS, said application was Conservation Advisory Council recommendations, and referred to the Southold Town for their findings and WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on March 22, 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 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 approves the application of ANDREW MOORE & KAREN SILVIERA to construct a fixed dock, consisting of a 4' X 90' catwalk, elevated a min. of 3.5' above marsh, a 3' X 16' ramp and a 6' X 20' float secured by (2) 2 pile dolphins, and construct a 100+' timber retaining wall to be tied into existing landward end of returns (north side 5' return, south side 21' return) and backfill with approx. 100 c.y. of clean sand to be trucked in from upland source. Located: 515 South Drive, Mattituck. BE IT FURTHER RESOLVED that this determination should not be considered a determination made for any other Department or Agency which may also have an application pending for the same or similar project. Permit to construct'and complete project will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. FEES: None Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/djh cc. DEC Dept. of State ACE Albert J. Kr~pski, President James King, Vice-President Hen~, Smith Artie Foster Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application, dated~~~o~ has been reviewed by this Board, at the regular meeting /~. ~_~, '00 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. TOTAL FEES DUE: SIGNED: BY: PRESIDENT, BOARD OF TRUSTEES CL-ER~{, B./~ARD OF TRUSTEES 4/98 t owner ~ Androw Moor~ ~ ~ $11v~a, ~ Mr, Moor* m~t Mr Silv~J:~',~ ~I~l to We, Robert and Elizabeth Skinner, own property known as 615 South Drive, Mattituck, which is located south of and adjacent to that owned by Andrew Moore and Karen Silveira. We are aware of and have no objection t~Mr. Moore and Ms. Silveira's proposal to connect their proposed retaining wall to the existing bulkhead on our property, provided that the project does not undermine the integrity of our bulkhead and that Mr. Moore and Ms. Silveira assume responsibility for any damages should they occur. Robert Skfnfier OElizabeth Skinner EN- CONSULTANTS, INC. ENVIRONMENTAL SERVICES 1329 North Sea Road Southampton, New York 11968 516-283-6360 Fax: 516-283-6136 E-mail: encon @ peconic.net Susan Acke ~rman Division of Environmental Permits NYSDEC SUNY, Building 40 Stony Brook, NY 11790-2356 February l5,2000 RE: ANDREW MOORE&KARENSILVEIRA. 1-4738-02555/00001 Dear Ms. Ackerman: As the proposed retaining wall will be constructed differently than proposed on the project plan submitted with the captioned application, please find attached (4) copies of a revised plan. Specifically, the proposed retaining wall will be constructed of timber rather than vinyl sheathing, and because of the steepness and eroded condition of the subject embankment, a batter piling rather than deadman system will be employed. By copy of this letter and revised plans, I am similarly notifying the other involved regulatory agencies of these changes. Robert E. Heitiisann Coastal Management Specialist Attachments cc: Board of Trustees, TownofSouthold Kelly Rosendahl, U.S. Army Corps of Engineers, #2000-00141-L2 Coastal Resources Division, New York State Department of State TON, N.Y. PI~OPO~I~ POCK ANP WA.I. FOR ANI:?I~W MO01~ ANP r,,~N ~IL.V~IRA ON MA'rTIfl,,CK JO~.r.K, MA'r'i'ITUCK, 51~I~OI.,K CO,, NY, 5H~l~'r I ~ I ~/22/cz) 2/2/00, 2/II/O0 WM,.I. FOR ,ANPf~W MO01~ ~P r,,,N~N ~b~IP.A ON MAfqgL'K C"I~K, MA'rllTLL'K, .51~JDI..K NY, ~l~'r I CT: I ~/22/oo 2/2/00, 2/II/O0 REPLY TO ATTENTION OF Eastern Permits Section NEW YORK, N.Y. 10278-0090 May 31, 2000 DEPARTMENT OF THE ARMY NEW YORK DISTRICT, CORPS OF ENGINEERS JACOB K. JAVITS FEDERAL BUILDING SUBJECT: Application Number 2000-00141-L2 by Andrew Moore and Karen Silveira To Whom It May Concern: The New York District, U.S. Army Corps of Engineers, has received a request for Department of the Army authorization for the following activity: APPLICANT: Andrew Moore and Karen Silveira 652 Broadway, Apt. 7R New York, NY 10012 ACTIVITY: Install a 4 foot by 90 foot pier, a 3 foot by 16 foot ramp, and a 6 foot by 20 foot float secured to two pilings. The purpose of the work is to provide a mooring facility. WATERWAY: Mattituck Creek LOCATION: Mattituck, Town of Southold, Suffolk County, NY As this is minor in nature, authorization may be by Letter of Permission. This is in accordance with current Federal Regulations governing work in navigable waters of the United States. To accomplish the coordination required, prior to the issuance of a Letter of Permission, your review of the enclosed drawings is requested. Pursuant to Section 307 (c) of the Coastal Zone Management Act of 1972 as amended (16 U.S.C. 1465 (c) (3) (A)), the applicant has certified that the activity complies with and will be conducted in a manner that is consistent with the approved state coastal zone management program. To allow for the timely processing of the subject application, your comments are requested within 15 days of the date of this letter. Sincerely, ee~, W~' a sH~ner~c ~ 1 on Enclosure WM,.L FOR,q',lt;;~W MO~ ,AN~, r,,N~N 51L.~IRA ON 3~I~K, MAf111'~, F~LFPOI. K CO,, ~. ffl~l~f I ~ I 7/~/oo Albert J. Krupski, President James King, Vice-Pres/dent Henry Smith Artie Fester 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 May 25, 2000 Mr. Robert E. Herrmann En-Consultants, Inc. 1329 North Sea Road Southampton, NY 11968 RE: ANDREW MOORE & KAREN SILVEIRA SCTM#106-11-21 Dear Mr. Herrmann: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, May 24, 2000: RESOLVED, that the Southold Town Board of Trustees grant an Amendment to Permit #5128 to depict 50-100 lb. stone armor at the toe of the proposed retaining wall and Anu~ophila brelligulata plantings on the bank, as per the request of the DEC. However, this permit does not constitute any other permits from other agencies. If you have any questions, please call our office at 765-1892. Albert J. Krupski, Jr. President, Board of Trustees AJK/cjc EN-CONSULTANTS, INC. 1329 North Sea Road Southampton, New York 11968 631-283-6360 Fax: 631-283-6136 E-mail: encon@peconic.net www.enoonsultants.com ENVIRONMENTAL SERVICES Susan Ackerman Division of Environmental Permits NYSDEC SUNY, Building 40 Stony Brook, NY 11790-2356 May 17, 2000 RE: ANDREW MOORE & KAREN SILVEIRA. 1-4738-02555/00001 De~ Ms. Ackerman: As we discussed during our recent telephone conversation, please find attached (4) copies of a project plan revised to depict 50 - 100 lb. stone armor at the toe of the proposed retaining wall and ,4mmophila breviligulata plantings on the bank. By cop>' of this letter, I am requesting that the Southold Trustees amend their permit accordingly. Respectfully yo, trs, Coastal Management Specialist Attachments cc: Board of Southold Trustees '~'~'"~'"~""' MAT~TITUCK F~i: r~ r-';~"~' 1:329 NORTH SEA RD. 631-283-6360 ~OPOg~12 POCK & I~fAININ6; WALL POF. ANPI~W M001~ ANP KAF~N 51L~IP-.A ON MAtTI1'L6K CI~I~K, MAffllllCK, FLIPPOLK CO., NY, .5~-J~1' J ~ J, 2/2/oo, 3/11/oo ~/22/oo, 4/4/oo, ~/17/oo /vlAffl fliCK C~I~K ~' X 20' ~bOAf !~1.~ (I0") ODLPHN (~) 8 ~ MAT~TITUCK~ ~U~PO~.K F.O. HAF~I~U ~ #2.~ f~'~O,~F_.O, NY; ~CfM ~. WAf¢E FF. PITf5 ff.(..Ol~P ~::~I~IN~ LOW '~ ( ~:OCT'M, I0/~,/99) ~' fRLI(Z4~D IN Fti~2M AN LIq,AN~ ~ '"'!' ?~'"r? NYC. i': ?: ;' :.,' "~',tL N ¥. I]968 '-..~6 :'.2 0.'7.!'0 FROt~OS~g 120CK ,ANI2 ~I'AININ~i WALL FOR ANI::;~I~W MO01~: ANP K,AI~N f:,ILV~I~ C;N MAf1111.b'"K C'~I~K, MAfl111JCK. 5LF;COL. K ¢0,, NY, ~tf.~f I CTF [ 2/2/00, 2/II/O0 Telephoue (516)765-18qZ Town Hall. 5309.5 Ma/n Road P.O. Box i179 · qouthold. New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Tuesday, February. 15. 2000, the tbllowing recommendation was made: Moved by Bill McDermott, seconded by Richard Smith. it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A STIPU~AIION of the Wetland Permit Application of ANDREW MOORE & KA PEN SILVEIKA 106-11-21 to construct an "L" shaped fixed timber dock, consisting ofa 4'X 90' fixed catwalk (elevated a min. of 3.5' above marsh grade); 3'X 16' ramp; and a 6'X 20' float secured by (2) 2-pile 10" diameter dolphins. Construct a +/- 100' vinyl retaining wall to be tied into existing bulkheads to north and south and backfill with approx. I00 cy. of clean sand to be trucked in from an upland source. Located: 515 South Dr., Mattituck. SCTM#106-11-21 The CAC recommends Approval with the Stipulation that the length of the catwalk be shortened as much as possible. Vote ot'Council: Ayes: All Motion Carried EN- CONSULTANTS, INC. ENVIRONMENTALSERVICES 1329 North Sea Road Southampton, New York 11968 516-283-6360 Fax: 516-283-6136 E-maik encon@peconic.net February 3, 2000 Town of Southold Board of Trustees Post Office Box 1179 Southold, New York 11971 Attn.: Diane Herbert Re: Andrew Moore & Karen Silveira 515 South Drive, Mattituck SCTM # 1000-106-11-21 Dear Ms. Herbert: 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 ' Permit Applications, ( including Notice and Proof of Mailing to adjacent owners). Three (3) Short Environmental Assessment Forms. Three (3) copies of authorization & disclosure forms. Three (3) work plans. Three (3) copies of survey. One (I) set of site photographs. Application fee of $150.00 wetlands. I trust this information shall allow you to process our permit request. Should any additional information be required, please do not hesitate to contact our office. S inccT'ely' Coastal Management Specialist /kbs Eric. Albert J. Krupski, President John HoIzapfel, Vice President 2im King Martin H. Garrell Peter Wenczel Town Hall 53095 Main Road P.O. Box I179 Southold, New York 11971 Telephone (516) 765 - 1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application ~'Wetland Permit Application Grandfather Permit Application Waiver/Amendment/Changes ~,'Received Applica~o~:~~__ ~-Received Fee:$ ~ ~-'Completed Applica=ion~ Incomplete SEQP~A Classification: Type I Type II Unlisted Coordination:(date sent) ~'CAC Referral Sent:~ ~,Date of Inspection: Receipt of CAC Report: Lead Agency Determination:__ Technical Review: 7Public Hearing He~ Resolution: FEB 3 - Name of Applicant Address Andrew Moore & Karen Silveira b52 Broadway, Apt. 7R New York, NY 10012 Phone Number:(212) 673-7803 Suffolk County Tax Map Number: 1000 - 106-11 21 Property Location: 515 South Drive, Mattituck (provide LILCO Pole $, distance to cross streets, and location) AGENT: En-Consultants, Inc. (If applicable) i329 North Sea Road Address: Southampton, NY 11968 Phone: 631-283-6360 FAX$: 631-283-6136 eoard of Trustees Applicati6n Land Area (in square Area Zoning: Previous use of property: Intended use of property: GENERAL DATA feet): ~52,564 R-40 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 attachments if necessary): construct an "L" shaped fixed timber dock, consisting of a 4' x 90' fixed catwalk (elevated a minimum of 3.5' above marsh grade); 3' x 16' ramp; and 6' x 20' float secured by (2) 2-pile (10" diameter dolphins. Construct a ±100' vinyl retaining wall to De tied into existing bulkheads approximately ~00 cubic from an upland source. to north and south and backfill with yards of clean sand to be trucked in ~ard of Trustees ApplicatiO WETLAND/TRUSTEELANDS APPLICATION DATA Purpose of the proposed operations: To provide private boat dockage and staDilize eroding embankment. Area of wetlands on lot: 0 square feet Percent coverage of lot: 0 % Closes~ distance between nearest existing structure and upland edge of wetlands: N/A feet 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 cubic yards How much material will be filled? ±00 cubic yards Depth of which material will be removed or deposited: ±3' feet Proposed slope throughout the area of operations: N/A Manner in which material will be removed or deposited: Approximately ±00 cubic yards of clean sand fill will be trucked in from an upland source, dumped, and graded as backfill land- ward of the retaining wall. 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): The proposed retaining wall will be situated ±20' landward of the adjacent tidal marsh vegetation and will serve to stabilize the toe of the eroding embankment without significant adverse impact to the adjacent marsh or Town waters. The proposed dock is similar to adjacent structures and will be installed to the north of the adjacent marsh in order to avoid all impacts to the existing wetlands. 14-16-4 (?d87)--Text 12 PROJECT I.D NUMSER 61 7.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART P--PROJECT INFORMATION (To be completed by Applicant or Project sponsor) SEQR I APPLICANT/SPONSOR ANDREW MOORE & K~REN [ 2. PROJECT NAME I 5ILVEIRA BY EN-CONSULTANTS, [NC. $. PROJECT LOCATION: Municipality M~.TT [TUCK County SUFFOLK 4. PRECISE LOCATION (Street address end road intemection$, promirmnt landmarks, etc., or provide map) 515 SOUTH DRIVE, MA1TrrucK, TOWN OF SOUTItOLD; SCTM #1000-106-11-21- MAP PROVIDED 5 IS PROPOSED ACTION' [] New [] Expansion [] Modification/alteration 6. DESCRISE PROJECT SRIEFLY' ~ONSTRUCT AN "L" SHAPED FIXED TIMBER DOCK, CONSISTING OF A 4' X 90' FIXED CATWALK (ELEVATED A ~{IN1MUM OF 3.5' ABOVE MARSH GRADE); 3' X 16' RAMP; AND 6' X 20' FLOAT SECURED BY (2) 2-PILE ( I0" DIAtv~';TER) DOLPHINS. CONTRUCT A 4/-100' VINYL RETAINING WALL TO BE TIED INTO EXISTING BULKHEADS TO ~/ORTH AND SOUTH AND BACKFILL WITH APPROXIMATELY 100 CUBIC YARDS OF CLEAN SAND TO BE TRUCKED IN FROM AN UPLAND SOURCE. 7. AMOUNT OF LAND AFFECTED: Initially 1.2 acres Ultimately 1.2 acres 8. W~LL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? []Yes [] No If No, describe briefly WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? [] Residential [] Industrial [] Commercial Describe: ]Park/Forest/Open space [] Other 3EC, CUE, DOS 10 DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? [] Yes [] No If yes, list agency(s) and pernlit/approval$ r~-- ~ "~ '~--' ~, ' ~ Yes ~ NO If yes, list agency name and ~iUapproval 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 App)icanUspon$oroag'&'~ RO~TE'HERRMANN'-COASTAL MGMT' SPECIALIST Date: FEB. 3, 2000 Signature: If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER NOTICE TO ~DJACENT PROPERTY OWNER BOARD OF TRUSTEES~ TOWN OF SOUTHOLD In the matter of Andrew Moore & Karen silveira SCTM$1000-106-11-21 YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned t~ {equ~.est a · Permit from the Board of Trustees to: Construct an L -shaped fixed timber dock, consisting of a 4' x 90' fixed catwalk (eLevated a minimum of 3,5' above marsh srade); 3' x 16' ramp; and 6' x 20' float secured by (2) 2-pile (10" diameter) dolphins. Construct a il00' vinyl retaining wall to be tied into existing bulkheads to north and south and backfill with approxi- mately 100 cubic yards of clea~and to be trucked in from an upland source. 2. That the property which is the subject Environmental Review is located adjacent to your property and is described as follows: 515 South Drive, Mattituck 3. That the property which is subject to Environmental Review under Chapters 32,37,or 97 of the Town Code is open to public comment. You may contact the Trustees Office at 765-1892 or in writing. February 24, 2000 at 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. OWNEI~S NAME: Andrew Moore & Karen Silveira MAILING ADDRESs: 652 Broadwa¥~ Apt. 7R New York, NY 10012 PHONE ~: 2i2-673-7S03 Enc.: Copy of sketch or plan showing proposal for your convenience. P'ROP05~.I~ POCK FOR ANI:;~W MO01~ ANP Ig~N 51L.~IRA 01', 5LI~I~Clr, CO,, NY, .f~rl ~ i, 21210o PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: Shawn & Dawn Williams 405 South Drive Mattituck, NY 11952 Robert & Elizabeth Skinner 615 South Drive Mattituck, NY 11952 STATE OF NEW YORK COUNTY OF SUFFOLK doing business En-Consultants, Inc. Robert E. Herr~ann. , ~X~ at 1329 North Southampton, NY , being duly sworn, deposes and says that on the 3rd day of February ,~2000, 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 Southampton , that said Notices were mailed to each of said' persons by ~(erti~ied) mail. ~O~er ~. Herrmann Sworn to before me this 3rd day of February ,~ 2000 ~ Notary ~ublic 6 ~ ~_~ 218 041 528 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. DO not use for international Mail ISee reverse) Stre & Numb ~ - Po I Office State, & ZIP Co~e tO*AL Pos~go & Fees $ ~ ~ ,~ Z 218 041 529 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International ~. Street & Number P~p, st Office Stale Postage TOTAL Postage & Fees ~rd of Trustees Applicat~ AUTHORIZATION owner of properny) residing at (mailing address) do hereby authorize (Agent) to apply [or permit{s) ~rom the Southold Board of Town Trustees on my behal[. ~Owner' s sfgna~ure) ~rd of Trustees Applicati~ Coun=y of Suffolk State of New York BEING DULY SWORN DEPOSES AbFD AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATeMEnTS CONTAIR~D ~k~cEIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, A~FD '£nAT ALL WOR/~ WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY Tn~ SOD'£nOLD TOWN BOARD OF TRUSTEES. THE APPLICAbFr AGREEs TO HOLD THE TOWN OF SOU'£'aOLD 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 HE~Y AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESE~VfATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. SWOXN rO /'i gn e ~LT2~ R. ',~ItlTE Nouary Public ~o~¥ m~lz. stol. ot ~, yom Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18~2 Fax (516) 765-1823 BOARD OF TOV~N'r~USTEES TOWN OFSOUTHOLD 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, depdse and .~ay: That on the ~]~' day of ~. ,-~, I personally the property ~nown as ~ ~ ~v~ ~f.]~. ?,~ ~ posted by placin~ the Board of Trustees effJ/.iai p.)sz~r wnera it can easily be seen, and that I have checke~ to be s~ar,~ the poster has remained in place for aeven Says ~rJ_o~ t~ 5he date cf ~he public he~r~.ng,. (date Df ' ~ ' ' (signature) ~ -- Sworn to befo~re me this ~ day of ~L~t~c~,~ 1~_~/3 Noq~y/~b 1 ic - TRANSACT~ONA~ D~SCLOS~RE FO~H 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 NAMEz ]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.) NATURE 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.) Do you personally (or through your company, epoune, sibling, parent, or child) have a relntionehip with any oEElcer or employee of the Town oE Southold? 'Relationship" includes by blood, marriage, or business interest. 'Business interest" means a busineee, including a partnership, irt 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% o£ the shares. YES NO ~ If you answered "YES," complete the balance og this form and date and sign where indicated. Name of person employed by the Town of $outhold Title or position of that person Describe the relationship between yourself (the applicant) and 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 his 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); __B) the legal or beneficial owner of any interest in a noncorporate'entity (when the applicant is not a corporation)l applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSIIIP submitted this /~- day ofOc?'- 199)