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Home My WebLink AboutTR-6063 James F. King, President . Jill M. Doherty, Vice. President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Telephone (631) 765-1892 Fax (631) 765-6641 Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 BOARD OF TOWN TRUSTEES TOWN OF SOUTH OLD CERTIFICATE OF COMPLIANCE # m02C Date: March 24, 2008 THIS CERTIFIES that the demolition of existing residence and reconstruct further back from the wetlands with new sanitary, gutters, leaders and drvwells At 275 West Road, Cutchogue, New York Suffolk County Tax Map # I 10-7-1 I.! Conforms to the application for a Trustees Permit heretofore filed in this office Dated 12/09/04 pursuant to which Trustees Permit # 6063 Dated 01119/05. Was issued, and conforms to all of the requirements and conditions ofthe applicable provisions of law. The project for which this certificate is being issued is for the demolition of existing residence and reconstruct further back from the wetlands with new sanitary, gutters, leaders and drvwells The certificate is issued to BOB T APP & NICK ELLIS owner of the aforesaid property. rc7?'~ Authorized Signature Albert ,Allpski, President James ~ ~'ice.President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 South old, New York 1197 Telephone (e3l) 765-11 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEE~ 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 181 day of construction 110 cOnstructed V Project complete, compliance inspection. '3/1 ~6~ d Albert tpSki, PresIdent TQwn Hall James ng, Vice-President 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda Southold, New York 1197 Peggy A. Dickerson Telephone (@31) 765·1: Fax (631) 76ðc 1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEE~ 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 _ 181 day of construction - Yo ccinstructed t/' Project complete, compliance inspection. Board Of Southold . Town Trustees SOUTHOLD, NEW YORK PERMIT NO. ...!>º.§.~m ..m' DATE: ...~"::l1...19..!...Z.005 ISSUED TO _.._~2~._:!.~~~...~.~.~~9~....¡¡.T:.~~.~._........... ....._............ ............. 1\ut1}nrti!tdtnn . .... .-. Pursuant to the provisions of Chapter 616 of the Laws of the State of New yon. 1893: and Chapter 404 of the Laws of the . State of New YorIc 1962: and the Soùthold ToWn Ordinance en- ·tttIed.''ftEEiULA11N& ÁNOTHE PLACING OF OBSTR..~ IN AND ON TOWN WATERS AND PUBLIC lANDS. . REMOVAL OF SAND, GRAVEL· OR OTHER MATERIA~ LANDS UNDER TOWNWATERS;r. and in acçordance w ·the Resolution of The Boarcladopted at ð meeting held on ....,!.ilJ).....Í;.9_... .20º.~..., and in c(lnsideration of the sum of $......f.5.Q...QQ.... paid by .. ._.._.~.?~..~~~.?..._&....!I.!-_c k..~.~.~.~~. ..._..........-..................__.__....__....,..___...,.._... T~~·_··~~J~·~¿;¡~~nn..f.ri~d..···~~···~ ~v~ S:'¡!¡-: ~ of Southold Town' T rusfees authorizes and permits the foloWlng:. WeUand Permit to demolish the exisUng residence and reoonstruct further back from the weUands with a new sanitary system, with the condition drywells and guile", are Inslaned to conlaln the roof run-off, hay bales are placed down along the top of the bluff during construCUon. and all as depicted on the slle plan prepared by Thomas C. Samuels dated January 31, 2005. alln aCcordance with the detal\ecl specifications as presented In . the originating application. . IN WITNESS WHEReof, The said Board Of Trustees hare- by CIIusa. Its Corporate Seal to be affixed, and these ~sents to be su'*ribed bye' majority of the said Board as of Is date. . . . . . . . '. . 1."J~ TERMS and CONDn1QNS 'DIe .........Ittc Bob Tapp & Nick Ellis ..... 275 West Rd., Cutchogue ".- .. It y.. .... c.: che c:oasIdeødœ lor the 10...._ 01 tho PCamk docs """,,",,"" UcIl'~trcrJœ 10 the 101· .. 1. 'I1IIc the ..w JIoud _ TI\IIfetI I0Il Ibo ~ _ Soollbolcl ale 1daIed.fram IAJ I0Il ~ ...~ CIC claims foe"'''''' _ . ~ dIøcdJ CIC 1IIdInc:dJ .. . .. -IAJ opor- ~,..l. -'f r~)þI1 ",.M..MI!I.:\1ø Mffn ~~.~~ 1II&0£'1Ier OW!' apeoIe, defeMuy aað III'" "'-"",,,---, 1,·Ibhd.,1ida, aað!be..w p OJ 10- ØIIII!* &II u.wuq wIch Ieipoá IbeIeco.Iit 1III!11~ .~"" of tho IIøud 01. Trasua 01. the Tø!na cl ~ . a. That ebb I'emIIt "ftIId 10c . fOdod of . 24'· -. wbkh Is ð'Ip~"'" 110 be the ~--' time.. nquItocI to .~ the wotk fawlwcl, bIt·ihoaJd ~....... wunar, ~ . for .. --..loa -7 lie ... 10 !be load It a ..., .. . . " That ebb I'eQaIt IIIøaId lie roiaIøod Jadoflalllely, or II 1008 as che øIcI p.o., """... wbbCI . 10 . ...01_1.. the ~ O£ fð!Ject hmlYOd, to prcmcIe nideaœ CIO UIJOGO __ that mIb- .~~í,&ea WIt ......&'..." ~~ . 4. That the w«k IInoIYCd will lie lUbJect to the ~ aað appron1 of che IIoaI'd ex III &pili, aað _1"'1"10_ wkh the f'lø.1sIoøs _tho ~n.".. appUcatioa, may lie _ fex m-don of this PamIt by ""'~ of the said Boatd. S. That cben will lie 110 _-"'0 laced_ wIIh anfaIdoa as a ~ _ the wcIIk IIenJa .."""~. . : . '6. That cben åI1 lie 110 Ù1IeI:f_ wIIh the dþ of die p¡bIJc 10 pus aað .. ~ die bead. Ioot.._ fII&b' I0Il low waœr CIOItb. . 7. That If f-. ."...-.. _ the Towa. of SoøcÞpIiI nqake cb6 -.1 aað/CIC aIcendoas Ia. !be lore""" _-tho WIIIk bmJa AtIILIfI"'1, or If, fa che e>pIt>IolI cf..BoatiI cf on-. die. wcIIk.&ú1 _ __hie obiUaaIoø 10 freo aøIpIoa, die ..w po-I- will h ... .,._ aotIœ, 10.- ex eker ebb wo«k or proJect IIenJa IIaIIOII "~ør \lKI to the TowIr . cf SCIIICboIcl' . :. . . L That che aid IIoaI'd will h aodfiec1 ..,. tbe I'eaaItue or che i f'e/'M: Of cbo -" mIb- cxW. .. II. That the .p.¡....~.'W will døJa aU O!her pamks aod cldH~6Ic..., 110 no¡ahecIm¡ï; i" 117 ..1 CIO ibis pe,rmIt ~ may'lIo sabject to __ IIpatI fIIIaœ to obcaJa -. - ~ . .;'~ :....: .. .. . . . Albert J. Krupski. President Town Hall James King, Vice-President 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda Southold, New York 11971-.0959 Peggy A. Dickerson Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD January 19, 2005 Samuels and Steelman Architects 25235 Main Road Cutchogue, NY 11935 Re: BOB TAPP AND NICK ELLIS 275 WEST ROAD, CUTCHOGUE SCTM# 110-070-11.1 Dear Mr. Samuels, The Board of Town Trustees took the following action during its regular meeting held on Wednesday January 19, 2005 regarding the above matter: WHEREAS, Thomas Samuels as agent for BOB TAPP AND NICK ELLIS applied to the South old 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 December 9, 2004, 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 January 19, 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 ofTrustees approve the application of BOB TAPP AND NICK ELLIS to demolish the existing residence and reconstruct further back from the wetlands with a new sanitary system, with the condition drywells and gutters are installed to contain the roof run-off, hay bales are placed down along the top of the bluff during construction, and all as depicted on the site plan prepared by Thomas C. Samuels dated January 31,2005. 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: $100.00 Very truly yours, J:::l~%-p,",~.", Board of Trustees JKlht . · " Albert J. Krupski, President Town Hall James King, Vice-President 53.095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda ,.¿ Southold, New York 11971-.0959 Peggy A. Dickerson Telephone (631) 765·1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: 'Îhb>'"Y'-¡;;'~ 5' t"rt\ \,A(. \J rc: 1501 TCLpr .......J... jJtck ¿ II ¡' l' Please be advised that your application dated I;). Iq/o'-{ has been reviewed by this Board at the regular meeting of I/¡q/v> and the following action was taken: ~ Application Approved (see below) L-) Application Denied (see below) L-) 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: ~'1 k,{ e fiN... rl c; (r,sre. c-f,ow 0 hilA I í"'>f-<'c-f,. rJ ' 5D TOTAL FEES DUE: $ IDD ~ SIGNED: IÛ~·~ '1 ~'9-. PRESIDENT, BOARD OF TRUSTEES I ~ -. . . . . . ~ Telephone Town Hall (631) 765-1892 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 . -. ~ .. CONSERVATION ADVISORY OOUNCIL TOWN OF SOUTHOLD TO: Southold Town Board of Trustees " FROM: Southold Town Conservation Advisory Council DATE: January 11, 2005 RE: Recommendations A meeting of the Southold Town Conservation Advisory Council was held Tues., January 11, 2005. The following recommendations were made: DISCUSSION AND RECOMMENDATION OF WETLAND PERMIT & COASTAL EROSION PERMIT APPLICATIONS Moved by Jack McGreevy, seconded by Tom Schlichter, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A CONDITION of the Wetland Permit application of BOB TAPP & NICK ELLIS to demolish the existing residence and reconstruct further back from the wetlands with a new sanitary system. Located: 275 West Rd., Cutchogue. SCTM#110-7-11.1 The CAC recommends Approval of the application with the Condition hay bales are placed down at the top of the bluff before construction begins and drywells are installed to contain the roof run-off. Vote of Council: Ayes: All Motion Carried - , . Ii ~- + ------ +~ + Q ~ § . ~~ . . ... I ........"'.. j, . % ~~ , . . II !, ! II, , \, I 5 Ii ~ ,; f j "! - m !. 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I :a ¡ ::> .... , è!i , ~ I ~I a> '" I "',~ .. -",1 ~ il !I . ,. z ~i~ 0"'.... lit >:~z o....~ ! ~~ I :iz~ ù.1~ 1m I o~'" !d I ....0 2~1 ",,,, III I 0"'''' I '" "" I ~~VI ,i III \ I ",,,,,, \ I W '" Z ...HI) ::¡ ~; :J~ ...z ~ . f~~1 !110'" ~ ~i ;:::::> ",",,0 ",>!ž "jo .~ ~_ fll ,"" CJ oct ","'U \ I-J: zoo . . ~¡¡ 2zz ';(~¡::: II H I \,' ~ I~~~ .~~ ~I ~~t 'I " ~ .......... ... ~/ ! ~g~ ê '", \ 0 \ o~~ 'd. , ,:z&'> ~, --- ~"' , \J , &' "' , .. , \ \ \\ .. " .. \ \ \ \ ; ~ ! I¡~I~ ~ æ j~~ ~ '01 ~ \ ~ It -= ~ ~ ~ ;;;- J~ ~ c: ~ lilt ~(~ IrP \ ;¡ 0.... ~ i r '0 , - ë3 ~ OJ z\ ~I ~ ~ \J 0:: -J VI ~o . ¡: 'f rllll I , I LoJ Z L.r..~ II ~ ~ ~ z ~ ~ ~ 5\ ~~ iì'~ I Ii " 0.; ~ i mO <.> '" ... Q::>Z Q:: 0 I.&J:::! ~ ~I' . õ, II (- o-J . I/') in ~ oON ~ Þ-. . \ . ~ ~ m,· ,...:·~<,;::':·1 . » ~ " . .; ~ f . . Albert J. Krupski, President Town Hall James King, Vice·President 53095 Route 25 Henry Smith P.O. Box 1179 Artie Foster Southold, New York 11971-.0959 Ken Poliwoda Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application ...-w-etland Permit Application ..,¿Major Minor - _Waiver! Amendment/Changes _..Received Application: ':J-~ ,III Or- _..ReceivedFee:$ ¡)rD W,OJ ~~fd. I --eompleted Application I d-/ C( I _Incomplete ~~Ð~C ~ ~~ ~ _ SEQRA Classification: Type I_Type II _Unlisted Coordination:(date sent) ~C Referral Sent:· fì/ ~I Ct( ! --Pate ofInspection: I., ~ _Receipt ofCAC Report: Soulhold Town _Lead Agency Determination: Board of Trustees _Technical Review: . . A'úblic Hearing Held: ¡j I "I /0:;- -Resolution: " NameofApplicant.J]oØ 7Ä.rp ~ Mck flLI8 Address P.O. {jot. !()f,!f. tf..U. rt!.H06I Ill": N.¥ 1/1"ßtð . . Phone Number:( ) 734- I.flol Suffolk County Tax Map Number: 1000- 110 - o'l~ Ii.! Property Location: :l7? {)JG.ST ÆM.P,- CUrt!.H~60f;; JtXJtfl 8/0t ()~ RDlrþJ 2(,5 p(. wrsT ðf PR~{)ASIf .4LIe. (provide LILCO Pole #, distance to cross streets, and location) ~~ AGENT: 11fotnA8 a. 8A-1'J1()ê7-S, 8AHt(JfT¿~'; S~ IfrCfI. (If applicable) cþ ffl-T 1hð(:J¿Ç; GrtP;/ I/,ft A/ ~OAD"I ðð-e;rHo¿P c.1 ,'b";/ ,~ Address: .2tJZ?ß MAE/I þA/) (I~ l"eHo6CE , Phone: 73'1-<í t{ð~ . . Board of Trustees Application GENERAL DATA Land Area (in square feet): 14 crtt./, 1r SF Area Zoning: 1<-4D Previous use of property: 1! (¡S(.f)E"t1J714-L Intended use of property: !2~/Pf1l/TtÆL Prior permits/approvals for site improvements: Agency Date ..GevrlloLt> 2 riA IÐ/1/er{. _ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspe?ed by a governmental agency? _No_Yes If yes, provide explanation: Project Description (use attachments if necessary): Pf"JltOllSlI (:XlstltV~ ~tfXPfJt?:£ r$ 'e~þ.lcr FliR.rfl~ ~A~K F1èOtI1 lII€~,9(Vþs:.. PVIf?lO E:Wl'ufA'( Sf.~Nm. . . Board of Trustees Application WETLANDffRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: fj?£coAJ~~UCï t:XIS71Nt!¡ at~lF l,flllf£-1 i:FSI{)fNcG"· Area of wetlands on lot: 0 square feet - ß6"A-CH fteotVT Percent coverage oflot: - % Closest distance between nearest existing structure and upland edge of wetlands: '5 feet Closest distance between nearest proposed structure and upland edge of wetlands:)"f feet Does the project involve excavation or filling? No I Yes If yes, how much material will be excavated? 50 cubic yards How much material will be filled? - cubic yards Depth of which material will be removed er ¡~I^'~¡rtd: ~ feet IrT !bœllt>lJ-l1 tW O"'"'-'! Proposed slope throughout the area of operations: ElClStlNJtJô ~etflA(N Manner in which material will be removed or deposited: IKEl'J.HIftV leAl. fXa4vA-í(cW 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); AtWe - . . " . Albert J. Krupski, President Town Hall James King, Vice-President 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda Southo}d, New York 11971-.0959 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 o.fthe Applicatio.n o.f mOOé_1ø.Q~_j-_.--ß!ç-~-.£J..~------- COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, ¡2, ù 8 ~ /{£vc.. ,residing at he./Ù 0Ar<. () te-I V?- C-u.. ("C (+0 G L.t~, /... /Y. 1/93 ) being duly swam, depo.se and say: That an the 1 day 0.£1__ , 20os; I perso.nally po.sted the property kno.wn as by placing the Bo.ard o.f Trustees o.fficial paster where it can easily be seen, and that I have. checked to. be sure the paster has remained in place far eight days prio.r to. the date o.fthe public hearing. Date o.fhearing no.ted thereo.n to. be held 1JJ~t1.. ~I", ~.~ ~ On. Ò- O\)l).,J:t 1')',00 In. Dated: tJ910r V I!(P c:;::;> (signature) Swam to. befo.re me this Jq TIayò(j~2~ Ül~ PATRICIA RICHARDS No.tary Public Notary Public, State of New York No. 01 RI6042467 Qualified in Suffolk County Commlealon Explr.. May 30, ~ \.0 > . -- 1tJ10 . i <J121? PROOF OF MAILING OF NOTICE ATI'ACHCERTIFIED MAIL RECEIPTS . ~ame: Address: M""W ç"st 'V,O "'")'-,,5> Cc4iu4 1I93õ J-~a.1aJ. fd..v-\~ì).1> «ç~ p\. í) . I\.J'-{ 11'-3/ c.. ~ Vv\~ 5Lf8'D I-teYWI~(~¿J Píø\f\e-VlUL, ö~ 17'13] '7 e\M-DD^-. fU.-é- ÜJS e) ò W~ K-NyîJl; ") \ ~?~ it.. (vi a. if,f..¡J: /JLf l)fS~ STATE OF NEW YORK COUNTY OF SUFFOLK ~Û~ residing at ~D (,..r4~ : being duly sworn, deposes an says that on the dayof~ . 20ðÇ';" 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 f the Town of Southold; that said ~otices were mailed at the United States Post Office at that said ~otices were mailCd to each of said persons by (certified) (registered) ail. ~Ol~ Sworn to before me this / ~.fh.. . LISA K. GLuCI<- Dayof~UCtrj .20~ NOTARY PUBLIC· STATE OF NEW YORK NO 01·Gl.8052340 QUAliFIED IN SUFFOLK COUNTY oY~ If. ~ MY CQMI,4IS~ION EXPIRES 12-11-200~ ~otary Public . . '4--11-4 (12II7)-Q SEQR rROJECT ID NUMBER I .,7.20 APPENDIX C STATE INYlAONMEH1"AL QUAUTY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNUSTED ACTIONS (lnly PART I-PROJEc:1'olNFORMATION (To be CDmpleted by Applicant or Project Sponsor) 1. APPUCANT~PONSOR 2. PROJECT NAME ~ ^ Q. -~ TßPp/ ecuJ' (l~rlJntlr.J-. , 3. PROJECT LOCATION: Mun'o;..,,,, ./tL>1 'l'rf/Ol.1) ~ COu.... ¿!;c./ ¡,...- 4. PRECISE LOCATION: (51tHt addrna and road imerøcttOftl, ørominent landmark.. 1tC.. or proYJde map) 2-7 ;- ~ «J~r æoIH>" fld;ó flier t(/~t &F f'G!fJrJ,Æ'H INtlV01i 011 ~()Ttf tftc/)e OF I?ÐrlP (9IV ct.UTOKOr9CJ!? t'It9IeßoK 5. IS PROPOSED ACTION: ~Odifcaton/.It.l'1IItlon a New o Exaan~on 5. DESCRIBE PROJECT BRIEFL't. -Pt9'I;f::;u,w ~.rrFIV6f ~ RóSll¥Ñ(ß ~eT Al"el(J Fie1H1G ~/)wcç · &W1rARCf úr~7!l ' I ,. AMOUNT OF LAND AFl'ECTED: Intdatty Vq - Ultimately V4 OCIU I 8. WILL. PROPOS~CT10N COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND uSE RESTRICTIONS? ! OI-Ì<1~ ;;;;;"";;;; 1<ß!ê()lteP, M4) GUvtlD (S8? 6ŸCLDSFD) ¡ 9. W;P¡T IS PRESENT LAND USE IN VICINITY OF PROJECT? Iloo_ a ,_ a Com_ e AgricuIIurw a Pottc/FonsIIOpo..... a OIJ'I... o.cliÞe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING. NOW OR ULTI....YUY FROM ANY OTHER GOVERNMENTAL AGENCY (F_. S.... '" LocoI)? alNo a YoI ".... 'IoI_CI) one! potrnill_ t t. ~S ANY ASPECT OF THE ACTION HAVE A CURREHTI.Y VAUD PERMIT OR APPROVAL1 Yes 0 No It yes. list agency name MCI permitlaøpraval vAlZAkCE ~o/l1 óoutrtCr..¡; z..ßA 12. AS A RESULT~ PROPOSED ACTION WILL. EXISTING PERMIT/APPROVAL REOUlRE MODIFICATION? C V.I No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWI£DGE AgphcantlSpansor Name 1710~ o. r;f 41ft va {ï; Dale 12/1/0 r¡ Signalur. 'fuw~' 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 . . Bob Tapp and Nick Ellis PO Box 1064 Cutchogue, NY 11935 December 7, 2004 We hereby authorize Thomas C. Samuels of Samuels and Steelman Architects or 25235 Main Road, Cutchogue, NY, to apply for all required permits from Southold Town, Suffolk County and New York State, for our project at 215 West Road, Cutchogue, NY. 7 {¡J. 7~ Sincerely, ~h~. ~<:- Bob Tapp Nick Ellis . . . Board of Trustees Application County of Suffolk State of New York _"&\\0 T~ ~ ~ 'e.X. £11 i ~ BEING DULY SWORN DEPOSES MFIRMS THAT HElSHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF illS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN TIllS 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 TIllS APPLICATION. I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENT ATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF TIllS APPLICATION. ~/~7" Signature SWORN TO BEFORE ME TillS 7 DAY OF "J"q\tXVty- .20 Ùb ~ Notary Public PATRICIA RICHARDS Notary Public, State of New York No. 01 "'6042467 Qualified In Suffolk County Commlulon expires May 30, 2002-0(¿, .. . . AI'PLtt!ANT TRANSACTIONAL DISCLOSURE FORM , " The Town of S~U~hold'e Code of Ebhice þfohibibe conflicbo ot intereot on the part of town officers and employses. The pUrpose of this form is to provide informabion which can alert the town of ossible conflicts of interesb and allow it. t.o t.ake what.ever act on is necessary ,,"0 avo d same. .. 'UJ TOUR HIIME. Laøt. name, f tat. name, m d.le you a~e applying in the name of 80meone els9 or other entity, ouch ~s a company. If so, indicote the other perRohls or company's name.) .. i . '{I¡$....'" '.~ . 1.- . .' _ ,-."'E,. 'IO<.I.!/ .~ . ".. .: :~. ': . ' .'. ;,.' '., -,". . NATURE OP APPLICATION. (Check all that spplY.) Tax grt-vancs Variancs Changs of I:ons AP'p~p#al of plat _____ ..~ Exe ption from plat .or official map other ""Uh~ JlEðIIlr (If "Other," nams ths activity.) Do rOd p.r.on.~lr (or through four cb.pany, .pöu.., ølbllng. parent, or child) haTe a relationehip with any ofticer or employee of the Town of Southold1 -Relationship· includes by blood, Marriage, or business interest. -Du..iness interest" means a business, including a partnership, in which ~he town officer or employee has even a partial ownership of (or employment by) a corp.oration in which the town officer O~ eMployee owns More than 5% of the sh'areø .. YBS - No-L .~.-... < .. If yOd anBwered ·YBS,".co.plete the baiBnce of ihi. tor. and da~e and sign .here indicated. NamB of pBrBon empioYBd by thB Town of Southold Ti~lB or pOBition of ~hab pBrson De.crib. ~h. relation.hip betv.en yourBslf (theappUcant) and ~he ~oyn ot~lcer ør employee. Either check the appropriate lin. AI through D) ønd/or. describe in the space providBd. The town off icer or employsø Dr hib or her apouslI dbUng, parent, or child is (check all bhat apply). _A) the owner of greatBr than 5% of ths oharBB of the . corporate stock of the applicånt (when the applicant is a corporation), S) bhs lsgBl or benBficial owner of any intereat in a - noncorporate'enbity (when the applicant is not a corporation), p.rt~er, or ..plbyee.of the c) an officer, director, - applicant, or ~D) the actual' applicant. '" ·.:;~:!·w . ....:..... DBSCR1PTION 01.' RBLATIONSIIIP t..l· . . " . ".:. ; -;;:~,. ... .. ....... ." '-"1'~-- - .........~M..'M -. T'" -...-" -, sublftt H..d Sigh.tUre 'pr lnto name .,.,,;.?:·,~~~~tkï· ··í...·,- '.. ;l.t,..·., ~ ;r . \: ,IÌ~.~·. . ~. I.ï. -'.,' .~ 1t. "'; .' . .;;..., .... . ~ . II - S A M U E L S & December 7,2004 S T E E L M A N . . . . . . . . South old Town Board of Trustees Town Hall Main Road Southold, NY 11971 RE: TAPP / ELLIS RESIDENCE 275 West Road Cutchogue, NY 11935 TAX MAP # 1000-110-07-11.1 Dear Sir/Madam: We request a Permit for the above reference project. For your review we are submitting the following documents: 1. Application 2. Short Environmental Assessment Form 3. Application Affidavit 4. Three SITE PLANs prepared by Samuels & Steelman Architects 5. Current Survey 6. Letter of authorization from Owner 7. Check for $200. Please call us with any questions or concerns. Sincerely, SAMUELS & STEELMAN ARCHITECTS ~. pa¡S6IlIO pliO¡ MOl Ploq¡6OS @ ;oœ 6 - ~3G ~ Thomas C. Samuels, Principal Architect G ~f,,~~\~I~ 9,. ene. ARCHITECTS 2S235 MAIN ROAD CUTCHOGUE, NEW YORK 11935 16311 :-'3-1.-6405 FAX 1631 ¡ 7)...·640:"