HomeMy WebLinkAboutTR-5491 John M. Bredemeyer III,President ��o� SOUryQ Town Hall Annex
Michael J. Domino,Vice-President �� l� 54375 Route 25
�g �[ P.O.Box 1179
Glenn Goldsmith Southold,New York 11971
A.Nicholas Krupski � � �O� Telephone(631) 765-1892
Charles J.Sanders ol�'COU��� F�(631) 765-6641
,
BOARD OF TOWN TRUSTEES
' TOWN OF SOUTHOLD
CERTIFICATE O� COMPLIANCE '
# 1237C Date: June 20, 2016
THIS CERTIFIES that the replaced dama�ed bulkhead, with the condition that durin�
construction the existin�pilin�s be removed in order to keep the structure as tight to the old
structure as possible and that there be a 10' non-turf buffer behind the new bulkhead;
At 1165 West Road, Gutcl�o u�e
Suffolk County Tax Map#1000-110-7-2
Conforms to the application for a Trustees Permit heretofore filed in this
office Dated January 29, 2002 pursuant to which Trustees Wetland Permit#5491 Dated
Februarv 21, 2002, was issued and conform.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 replaced dama�ed bulkhead with the condition that durin�construction the existin�
pilin�s be removed in order to keep the structure as ti�ht to the old structure as possible and that
there be a 10' non-turf buffer behind the new bulkhead.
The certificate is issued to DONALD RYND &HELEN RYND owners of the
, �foresaid roperty. .
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' Authorized Signature
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`� � PERMII' h10. . ..��.g� .. DATE:Feb. Z1r..:z002 `- l:
iSSUED T4 DONALD & HELEN RXND -�.
.� � ,�ll�����`t��[�tt��C
�
Purwant fo ffie pc�vision: of Chapter 615 0� 4i�e� Lnws of
�he State of New Ycrk, 1893; and Chapter 404 c�th� Law3 0�fhe
�� State of New Yorii 195Y; and the Santhold Town 4rdinn�ce en-
t�tted"R�GUlA�'fhiG AND TME PI:ACtNG O� OBSTRUCTIONS �
' !N AND ON TOWN WA►TERS AND PUBLIC LAlJDS and t4re
R�MOVAz OF SAND, GRAYEL�aR OT�-iER MAT�RIALS WtOlr!
IANpS UNOER 1'OWN'WATERS;•`-'. and i� ascordance wrtl� the
Resolukioe of i1�e Boaed adop#ed at a mee�ing he{d on Feii. 20, .
� , ZOOZ 20Q.Q0`
. ... .., and in considerataon of the,sum of �................ ... ... paid by
Donald & Helen Rynd
• ..._.. ..................._..... . ....._....._.... ..,. ....... .................................... ....._..._...:
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• � 7erms and� Gonditions Hrted on +he revecse s�de hereo�, ,
y Wetland�'�t�towreplasce he daQmaged bulkhead�with�hg� �
� � condition that duiing construction�the existing pilings be remove �
•in order to keep the structure as tight to the oId structure as
� possible and that 'there be a IO' non-turf buffer behirid the new ,
bulkh �d.
. � a� m accordance witK the detailed ,sp�cificatwns as pretea}ed in
the orig'n►sfing appl'icetion.
.v
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by causes its Corporate Seal fo be af4ixet�� dnd t$�e�epre tenfs fo ?�
be :uiiscribed by a majority of the said 8oard as o$ this dats.
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TERMS and CONDtTIONS
.� � DONALD & fiELEN RYND
� u 1165 West Rd. , Cutchogue N. Y� �
pur of t6e comidmtion Eor the issuaua of the Pemtt doa uodauaod aod p�e to d�e fo!-
�O8°
t. Thu tLe aid Boud of Tewtea aod the Town af Sau�hoW aae rdaned ham �ny aod
.0 a.m.ga, a aaims r« a.m�e�, of ,aiCs .c�io� aiiwxlj o� Li�teody a . iealc o[ m� opec-
adon pafamed piewmt to tHs pe�mit, �ad dw �dd P�et�iMee w1U, K�s or Let ara eapppe,
a�rena .% .od su .a� ,au�iola.oea b� t�a p.iae., .a ak .�a P�i�ob .u.... [.0 u.ril�q
widt reipea tLneoo, ao ILe oosplete aclsrion of t6e Bo�d of 11�s�sees of the Towe af 8o�eLo.W
2. Y'hat dria Peceok i� �Nd foa : padod of 24 mos. wiir� is moddee�d to be the
� tlme'requiced a 000plete the wo�k 1a�oi�ed, bat shodd ai�aaea w�eeso[. aa�at
for m e�nston may be made ro the Bwrd u a laox dm.
3. Y7ne thls Pmnie thould 6e cetained iaddioitdy, or �s long as tLe said Nemittae w3�La
to maima�n tLc stnnuce oc peoject imot�ed, to pmvide e�idence oo aa�aoe 0000r�md drt ao�h-
orization vvu originait� obpdoed
4. nat ,iie .voac m.ut.ea .►iuu be ,ubj«c tu ehe Impat;oa ma .ppca.d af tbe Eaua a
� .��, ,oa � ..�n.� p�� �+u�«��a �er�.�� �r«
�a� or d� e�c ey �a� �c ax a�a s�a.
s. Yu.c there .vilt tx no uare.masble mterf«raoe .vuh aa.i�aion u . ceatc af tLe .e�k
hada �atLorccd.
6. 'i'h.e there s6.it be oo ia�fae�e .vi�h ehe r1�ht oE dK p.6Nc m p..c .oa .�a �ions
du bmch bet�veen Ligh �nd bw waoer m�]cs.
7. Y'hat if fimae opewims of the Tmm of Sauhold reqolce tLe�monl ud/« �
in the loatioa of d�e wodc Lada w�oe�eed, or if� 1n the opidm oE �e Hwod oE Tareeet, d�e
watlt thall aaase uo�soo�We o6sen�oa to fcee m�uioa, t6e nId Prtdnae wiY be fe�ed,
upoa due noda, to rmuove or dur dds woeic or pmj«e 6ercin moed wLbaat apwro eo the Tswn
oE Soudwld
i �& 'ILac d�e sata soara ..11l be aoaAea y ehe Pemaax « ,6e eoa�aMio.,of the .aadc a�h-
I 9. YLat t6e Perm&ox wrfll d�taln �Il other pemiu �od oonenb d�u mq � � �°P'
pkmenal oo dds permit whie6 mq be w�bject to ie�oloe npon I�ilm�e eo o6oda t�me.
Albert J.Krupski,Preaident • • Town Hall
James King,Vice-President -p$�FF��'C 53095 R,oute 25
Artie Foster �� 0 P.O.Box 1179
Ken Poliwoda � �� Southold,New York 11971-0959
Peggi�A. Dickerson Telephone(631) 766-1892
�y � ��� Fax(631) 765-1366
9Yp1 ,� �a
BOARD OF TOWN TR.USTEES
TOWN OF SOUTHOLD
February 21, 2002
Mr. &Mrs. Donald Rynd
1165 West Road
Cutchogue,NY 11935
RE: 1165 West Road, Cutchogue
SCTM#I 10-7-2
Deaz Mr. & Mrs. Rynd:
The Boazd of Town Trustees took the following action during its regulaz meeting held on
Wednesday,February 20, 2002 regazding the above matter:
WI-IEREAS,DONALD & HELEN RYND applied to the Southold Town Trustees for a permit
under the provisions of the Wetland Ordinance of the Town of Southold, application dated
January 29, 2002, and,
WHEREAS, said application was referred to the Southold Town Conservation Advisory Council
for their findings and recommendations, and,
WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on
February 20, 2002, at which time all interested persons were given an opportunity to be heazd,
and,
WHEREAS, the Board members have personally viewed and aze familiaz with the premises in
question and the surrounding azea, and,
WHEREAS, the Boazd has considered all the testimony and documentation submitted
concerning this application, and,
WHEREAS,the structure complies with the standazds set forth in Chapter 97 of the Southold
Town Code,
WHEREAS, the Boazd has determined that the project as proposed will not affect the health,
safety and general welfaze of the people of the town,
Z i •
NOW THEREFORE BE IT,
RESOLVED,that the Boazd of Trustees approve the application of DONALD & HELEN
RYND to replace the damaged bulkhead,with the condition that during construction the existing
pilings be removed in order to keep the structure as tight to the old structure as possible and that
there be a 10' non-turf buffer behind the new bulkhead.
BE IT F[JRTHER RESOLVED that this detemunation should not be considered a determination
made for any other Deparhnent or Agency, which may also have an application pending for the
same or similaz project.
Permit to construct and complete pmject will expire two years &om the date it is signed. Fees
must be paid, if applicable, and pemvt issued within six months of the date of this notificarion.
"Itvo inspections are required and the Trustees aze to be notified upon completion of said project.
Fees: None
Very truly yows,
��.� n /�,..;��' �
Albert J. Krupski, Jr.
President, Boazd of Trustees
AJK/lms
DEC
� • ��c�Ff 0(,(�c •
0
� =� Taw�c Hall. 53�95 Main Road
� P.O. 80: 1179
TeleQhone O,y�� �.�. Southold. New Yak L1971
(631) 765-1892 '�lQl � `��
SOUTHOLD TOWN
CONSERVATION ADVISORY GOIJNQL
At the meeting of the Southold 7own Conservation Advisory Council held Tuesday,
February 12, 2002, the following recommendation was made:
Moved by Melvyn Morris, seconded by Bill McDermott, it was '
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH
A CONDITION of the Wetland Permit Application of DONALD & HELEN RYND to
replace the damaged bulkhead.
Located: 1165 West Rd., Cutchogue. SCTM#110-7-2
The CAC recommends Approval with the Condition that the structure is constructed in-
place, and that there be a 10' non-turt buffer behind the bulkhead.
Vote of Council: Ayes: All
Motion Carried
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MAke��tG.�(�3f��Nq�11L �A�ME�ITS TO: MARIL , RECEIVER ��
RYND DONALD BROOKS �RS_UTHO ,,,�lY 11 71�2� THOLD
1165 MEST RD . °qOEND� O1 OF O1 2000-2001 'fAX NARRANT
GUTGHOGUE NY �11935 iOLL�C"0" 1 TAXESPAIDBYCHECK
�ccr.r+o. ARE SUBJECT TO CALLECTION
T"'�"'"PNO 473689 110.-7-2
�LO0A70N 1165 MEST RD
01� AY:R€S- 1.75
�f0°L°'�` 38Z - MATTITULK SGHOOL
vr+oPrv cvas
TAX S�VINOS DUE TO STAR: 3 5.bl
T�TAL TAX DUE: 9 9 5.58 12/O1/00 - 11/30/0 12/05/0 0180600
_ -_ -- _ -.�-.��..-
SUFFOLK COUNTY TAX 12�280Y 16.4T0 202.25 -3.2
NYS REAL PROP TAXLAN 12�Z80 7.484 91.�0 54.3
SOUTHOLO T9NN TAX 12,280 154.872 1.901.93 12.3
; !lATTITUGiE-S�H�OL 12,790 500.858 6,405.97 5.7
' CUTCk106UE LI6ARRY 13,500 40.563 547.60 1.4
� CUTGH06UE FIRf OIST 13�500 41.805 9d4.37 5.3
i GUTGH-NEM SUFFOIK PD 13�500 5.348 72.20 0.0
' MASTE MAiEIt-DISTHICT 13�500 .157 2.12 0.0
STHCD SOL M#STE DIST 13�500 10.914 147.34 -10.4
THIS BILL LS�-F9R INF9R ATIONAI COMBAT VET 1,220 COUNTY/70MN
aU1tPOSES ON�Y STAR-BASIG 710 SGHOOL _�_
- A
UNLESS YQU HAVE RECENT Y SATISFIED
YOUR MORTGAGE� Itl WHIG LASE YOU
ilOULD 8-E FIESRONSIBLE F R PAYMENT.
APPLY FOR THIRO
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i�_�t�1�M�NT
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UPDATL�D 28 Jan 02
Re�ised to indicate �all changes
from original survey.
1Qamely - Pr9sent ad�acent
property owners.
See attached forms :
"NO2ICES TO ADJACENT PROPERI7 OWIdERS. "
Albert J.ISrupski, President • �0$VFf�(�'C • Town Hall
James King,Vice-President �.0 �(� 53095 Route 2b
Henry Smith � � P.O.Box 1179
Artie Foeter y =
Southold,New York 11971-0959
Ken Poliwoda WOy � !� Telephone(631) 765-1892
eypl # �a0 Fax(631) 765-1366
BOAR.D OF TOWN TRUSTEES
TOWN OF SOUTHOLD ���3IU� �' ,1
O�ce Use Only �--
�jIC •
Coastal Erosion Permit Application
/f�Vetland Permit Application �Major _Minor
Waiver/Amendmen Changes
iiteceived Applicati � 0'+
,/Received Fee:$ � 0
/Completed Application�g,(Q�
Incomplete
_SEQRA Classification:
Type I_Type II_Unlisted �AN 'L 9 � --
Coordination:(date sent
�CAC Referral Sent: �
�Date of Inspection: / D� l,
_Receipt of CAC RepoR:
Lead Agency Determination:
Technical Review:
/Public Hearing Held: p�.�y,uY
.�-r
Resolution:
NameofApplicant Donald & Helen Rynd
Address 1165 West Road� Cutchogue� N.Y. 11935
PhoneNumber.( ) 631-'734-6188
Suffolk County Tax Map Number: 1000 -a73R89 110.-�-2 �
ProperryLocation: 1165 West Road, Cutchogue, N.Y. 11935 „�rl,� �\pa
Pole No. 6; End of Holden Ave.
�`y �'�
(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): 1•75 Acres t6.5,625 sq, ft. )
AreaZoning: Residential
Previous use of property: Re s id enc e
Intendeduseofproperty: Residence
Prior permits/approvals for site improvements:
Agency Daze
X No prior permits/approvals for site improvements.
Has any permiUapproval ever been revoked or suspended by a governmental agency?
X No Yes
If yes, provide explanation:
Project Description(use attachments if necessary): Replacement of
Damaged Bulkhead.
� . �
7�•!6-a�yB71—Texc i2
, , PROJECT I.D. NUM8Er7 6��•Z� S EQ
Appendis C
State Environmental Quality Review
SHORT EVVIRONMENTAL ASSESSMEiVT FORM
For UNLISTED ACTIONS Only
PART I—PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. APPLICANT/SPONSOR 2. PROJEC-NAME
Donald & Helen Rynd Replacement of damaged bulkhead.
]. PRO.lECT LOCaTION:
Munlclpality C11t,ChOgt18� SouthOld TO�►n co���v Suffolk
e. PpEC:SE LOCATION(Street aotlress ana road intersections, p�ominent IanEmarks, e[c.,ar praviae maD) _
1165 West Road - End of Holden Ave.
S. IS PROPOSED a.CTION: �
�� ❑New ❑Expanslon �MoOificatlon/altera[lon
6. OESCRIBE PflOJECT BRIEFLY: -
Replacement of damaged bulkhead.
7. AMOUNT OF N .�F�cCTED:
initiauy 1.�� Acres acres U�umata�v 1•75 Acres acres �o �FECT:
3. VI7I�LL ?AO�OSED ACTION COMPL`!•NITM cXISTiNG ZONING OR OTHER EYISTING L'+ND USc AES�aIC�IONS?
L` Yes �No I(4a.Gescr�be briefly
9. vl,yH,A7 IS 7RE3EN7 U�:u USc IN VICINITY OF ?ROJECT?
�'I RevdenUal CI•!ndustrial ❑Commercial ❑agncwture �:ParK�Foresu0oen soace L!Ocner .
Desc:i0e:
10. OOES .iCTION INVOLVE A PERMIT APPROVAL OR FUNOING. NOW OR ULTIMATELY FROM ANY OTHEA GOVEflNME4TAl AGENCY(FEOERAL,
STA'E Ga LOWUy?�
❑Yes U' No If yes,list agency(51 and permiVapo�ovals �
�S '
17. DOES ANY ASPECT OF THE AGT101� HAVE A CURFENTLY`/AllO PERMIT OR aPPROVAI?
❑Yes' �No lf yes. Iht auency n3me anC permitlappmval '
72. AS A FESULT OF PROPOSED ACTION WILL E:(�STING PERMIT/APPROVAL riEOUIRE MOOIFIC?.SION?
❑Yes �No
1 CE7TIFY THA7 TME INFORMATION PAOVI�ED .1BOVE IS TrIUE'O THE 3E5T OF MY KNOWLcOG'c
aoo�������spon c name: DOri81d & H@�.eII R IIC� Oa�e:26 JSII �2
Slgnature: `
If the action is in the Coastal Area, and •�au are a siate acency, complece the
j Coas2al Assessment Form before proceeding with this as;essment
f �
OVER
,
Albert J. Krupski, President • �gUFFO[,�c • Town Hall
James King,Vice-President .r0 �(/y .53095 Route 25
'� P.O.Box 1179
Henry Smith o ,.�Z
Artie Foater W : Southold, New York 11971-0959
Ken Poliwoda 0 � '� Telephone(631) 765-1892
'y�y�l � �.�0�' Fex(631) 766-1366
BOAR,D OF TOWN TRU3TEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
-----------------------------------
In the Matter of the Application
of
�c,a��.�__N_��e�-��nd-------
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
I , Donald Rynd , residing at 1165 west Road,
cutchogue, N.Y. 11935
being duly sworn, depose and say:
That on the 30thday of Jan , 2002, I personally posted the
property known as 1165 West Road, Cutchogue, N.Y 11935
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
ublic h ar��g� Da�te„of hearing noted thereon to be held ��{� ���
�
Dated: C// '
.�� - �\
�
(signature)
Sworn to befo e me this
� day of �ju��J200�,
� / SUSMIJA6�y
Nr�ry�DGC SMs/Iyy�l
- . N+, .I836735
, �uah5ed n Surmik,;q�
otary Publ c o+ma�s�,��yy���
NOTICE � ADJACENT PROPERTY OWNER • �
BOARD OF TRUSTEES, TOWN ()fi SOUTHOLD
In the matter of applicant:
Donald � Helen Rvnd SCTM#1000- 473889 110 -�-2
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a
Permit from the Board of Trustees to:
Replacement of damaged bulkhead.
2 . That the property which is the subject of Environmental
Review-.is located adjacent to your property and is described as
follows :
Ad�oining qour property on the WEST side.
3. That the project which is subject to Environmental Review
under Chapters 32, 37, or 97 of the Town Code is open to public
comment on: You may contact the Trustees Office at
765-1H92 or in writinq
The above refesenced proposal is under review of the Board of
Trustees of the Town of Southold and does not reference any
other aqency that miqht have to review same proposal.
OWNERS NAME: Donald � Helen nd
MAILING ADDRESS: 11 YYest Road"
utcho ue x.Y. 11935
PHONE #: - -
Enc. : Copy of sketch or plan showing proposal for your
convenience.
I have no ob�ection to the proposed work as set forth in
Number 1 above.
.�f
Pat avarone
BOARD_OF TRU3TELS� 'PDWN OF S�IPTf{OLD
In the matter of appl�nt �
Donald R Helen Rvnd SCTM#1000- 47�889 110 -�-2
YOif ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the underaiqned to request a
Permit from the Board of Trustees to:
Replaee Damaged Hulkhead.
2. That the property which is the snbject of Environmental
Revie�r-.ts located adjacent to your property and is. described as
followe:
Across the street kno�rn as West Road.
3. That the project which is subject to Environmental RevieFr
under Chapters 32, 37, or 97 of the Town Code is open to public
cosnent on: 2/20�02 You may contact the Truetees Office at
765-1892 or in writinq
The above referenced proposal is under review of the Board of
Trustees of the Town of Southold and dces not reference any
other agency that miqht have to review same proposal.
OwNERS NAME:_Do d � Helen nd
t`tl1lLItiG ADDRE33: at Road
u c o es, x.Y. 11935
PHONE i: - -
Bnc. : Copy of aketch or plan showing proposal for your
convenience.
I have no ob�ection to the proposed work as set forth in
Number 1 abore:
William ler
� �
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
Donald & Helen �mfl SCTM#1000- 473889 110 -�-2
YOU ARE HEREBY GIVEN NOTICE:
1 . That it is the intention of the undersigned to request a
Permit from the Board of Trustees to:
Replacement oP damaged bulkhead.
2 . That the property which is the subject of Environmental
Review-.,is located adjacent to your property and is described as
follows :
Ad�oining your property on the EAST side.
3 . That the project which is subject to Environmental Review
under Chapters 32 , 37 , or 97 of the Town Code is open to public
comment on: � �o d 3- You �nay7c�ntact the Trustees Office at
765-1892 or i w iting. Q'�`
The above referenced proposal is under review of the Board of
Trustees of the Town of Southold and does not reference any
other agency that might have to review same proposal .
OWNERS NAME: Donald & Helen R nd
MAILING ADDRESS: 11 5 'Nest Road�
Cutcho ue N.Y. 11935
PHONE #: - -
Enc. : Copy of sketch or plan showing proposal for your
convenience.
I have no ob�ection to the propos work as set or �n`��'L /
Number 1 above. �� /�3" �,%��/,`/ --�
G`'` "`� �/ (if� ,��6_ f«,
� /
�/
� �
. Print or Type: ACCESS CONSENT FORM Office use Only
FOR ACCESS File #:
THROUGH PRIVATE PROPERTY Permit s:
. � � _ t'.}�:ic ' .:�� wE�t Hoa3 ' •• - ,�,
�' ' _ . . . � , J
(Name of Applicant ) (Address) y
2� James H. Rambo Inc, 229 Bishops Lane, Southampton, N.Y. 11968
(Name � Address of Contractor Involved)
3� 1165 West Road� Cutchogue, N.Y. 1193� ; i000 4738�9 lln--7-a
(Project Location) (S.C.T.M. #)
4� 1165 West Road . Cutchogue, N.Y.
(Name of Road or Private Property Involved) (Hamlet )
5� Donald & Helen Rpnd, 1165 �Nest Road, Cutchogue. N.7. 11935
(Name & Address of Homeowners Association / Property Owner)
6� Replacement of damaged bulkhead
(Brief Job Description)
Upon approval
7) Starting Date: of aDnlication. Completion Date: 5 daqs thereafter.
S) Estimated Cost of Proposed Work:�20,864
9) Insurance Coverage:
A. The coverage required to be extended to the Property Owner:
Bodily injury & Property Damage;
a300,000/5500,000 Bodily Injury & �50,000 Property Damage.
8. Insurance Company:
C. Insurance Agent
Name & Telephone # :
D. Policy i� :
E. State whether policy or certification
is on file with the Trustees Office:
( If no, Provide a copy with Application) (yes/no)
(Si9nature of Applicant ) (Date)
To be completed by the Property Owner:
I/We the undersigned, fully understand the nature of the Proposed
Work referenced above and have no objection to allowing the
Applicant to cross My/Our Property o do the work.
d�t� lY� � a�� —
(Signature of the Property Owner
or duly suthorize representative)
� �
Board of Trustees Application
County of Suffolk
State of New York
Donald & Aelen Rynd BEING DIJLY SWORN
DEPOSES AND AFFIItMS THAT HE/SHE IS Tf�APPLICANT FOR TI� ABOVE
DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRUE TO TI�BEST OF HIS/f3ER KNOWLEDGE AND BELIEF, AND THAT ALL WORK
WII.,L BE DONE IN TI-IE MANNER SET FORTH IN THIS APPLICATION AND AS MAY
BE APPROVED BY TI� SOUTHOLD TOWN BOARD OF TRUSTEES. Tf� APPLICANT
AGREES TO HOLD 'I'I-IE TOWN OF SOUTHOLD AND Tf�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 TI� TRUSTEES, TI�IIt AGENT(S) OR
REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
Signature
SWORN TO BEFORE ME THIS��DAY OF ,20Q�
u �-
Notary Public
Ethkl�E M.GAR
Rc?ary Pi,61ic,54ate nf Nsn Yofk
No.COd'tSE3
Oikl'rfied in Siitolk Counly
Commiss±on Fxpire:Rugust 7 �
. . . � �rp�iC�N� � .
' � TRDNSACTIONAL DI$CLU3UR6 PORN i
The Toxn oP 3ou�hold ' s Code oP �bhics rohibibe ebnPlicbe oP �
nbereeb on bhe ar� oE town oFf cere and em 1� eee . The
ur oae of this form is to rov de information ah ch can
alert the toxn oF oae ble conFl eta oF ntereab and ailow
it to bake xhabever act on a necessarv to avo d same .
;c:,:,;�r�.�;:"rietii��',c'�;! .
� tOUR N11N6 t Dona ld 8c He len Rynd
Laet name, Eiret name, m dd•1e n E �tl , un eee
you are appiying in the name o! eomeone else or
qbher enbity , such ae a company. It eo, indicabe
bhe other pereon ' s or company ' � name. )
� �,. � „� •, ,
� �':'�•.v��+'.::::;•��i,:'c�.:,..::y..
N1�TdR8 di� rppLIC11'CION: (Check all that eppiy. )
Tax qriavanca
Varience
Chanqe o! zone
App pval of plab _ . , rp
L+xe�ption from pXat or oEficial map
Obher
( 2t °other, ° name the acbivity. ) Renlacement. of dama�ad bulkhead. .
bo you pereonail� (or 6hrough ydut ebnpehy� npbuete, bibling,
parenE, oc chiid) have a rela�ionel�ip vitl� any neticer or
empioyee o! the Tovn oF SouChoid? "Relationghip" includea
by biood, marriage, oc bueiness inberest. "Uugineed
intereeE" �neans a bueinees, including a partner�f�ip� in
vhich the tovn officer or employee has even a p�ttial
ovnerehip oF (or employmenb by) a corporation in vhict�
the tovn oEflcec ar employee ovnA more tNan 59L eF the
shares.
YB3 NU X .
�...�, ..
I! 7ou aneverad °YS3, ". complete bhe bglanc� tf! r1t�tl torm and
date and eign vhere indicabed.
Name o� pereon employed by tha Town of 3oubl�old
Tible or poeition o! thab person
Deecribe bhe relabionahip betveen yourseif ( bhe applicanb )
and the tiown offieer or employee. Eibher check the
appropriate line A) bhrough D) and/ur, describe in bhe epace
provided .
The town offScer or empioyee oY l�is or her gpou��� e�blingr
parent , or child ie (ciieck all thab apply ) r
A) the own�C oF qreater tiian 596 of the aheree o[ the
corporabe stock oF the eppllcanE (when the appiieanb
. ie a corporation) j .
B) the legal or b§neEicial owner oF any inberant in a
noncorporabe �enbiby (ahen bhe appiicant ie nob a '
corporabion) r
C) an ofEicar� director, pa.rbner, nr pmplbyee. oE tha
app7.icartb � or .
D) the actual epplicanb .