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Home My WebLink AboutTR-5643Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD August 24, 2005 Diane Herold, Architect P.O. Box 884 Westhampton Beach, NY 11978 RE: NANCY ROSS and others 3350 PARK AVE., MATTITUCK SCTM#123-8-22.2 Dear Ms. Herold: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, August 24, 2005: RESOLVED that the Southold Town Board of Trustees grants the last One-Year Extension to Permit #5643, as issued on October 16, 2002. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees AJK:lms Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 August18,2004 BOARD OF TOWN TRUSTEES TOWN OFSOUTHOLD Ms. Diane Herold Diane Herold, Architect P.O. Box 884 Westhampton Beach, NY 11978 RE: NANCY R. ROSS AND OTHERS 3350 PARK AVE., MATTITUCK SCTM#123-8-22.2 Dear Ms. Herold: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, August 18, 2004: RESOLVED that the Southold Town Board of Trustees grants a One-Year Extension to Permit #5643, as approved on October 16, 2002. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees AJK:lms Albert J. Krupski, President j~a~ing, Vice-President Henry Smith Attic 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 To: Please be advised that your application, dated has been reviewed by this Board, at the regular meeting of /0~/0~ 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 FE~S: Albert J. Krupski, President James King, ¥ice-President Artie Foster Ken Poliwoda Peggy A. Dickerson BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction % constructed Project complete, compliance inspection. Board Of Southold Town Trustees SOUTHOLD, NEW YORK Pursuant to the provisions of Chapter 6lB of the L~ws of the State of New York, 1893; and Chapter ~ of the I.~ws of the State of New York 19~i2; end the Southeld Town Ordinance aa- titled ?'RE-~ULATING AND THE PLACIN('= OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, C~RAVEL OR OTHER MATERIALS FROId LANDS UNDER TOWN'WATERS;~. and in accordance with the Resolution of The B6ard adopted at a meeting held on .~b.~....~.6, . 2~.~..., and in consideration of the sum of $.....~%.~O ..... paid by C. William Carmean Pennington, NJ -n~ of ][~ o ,, .~ to the Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees ~utherizes and permits the foBowing: Wetland Permit to demolish the existing house and boat shed and rebuild a two-story house with a boat shed and decks conformin to the existing non-conforming setbacks, with the condition that gutters and drywells .are. ins. tall.ed, and..hay., bales are place.d all in accordance with the deteBed s[peCltiCatlons as presented in the originating application, before the project begins. IN WITNESS WHEREOF, The said Board of Trustees I~- ~ causes ifs Corporate Seal to be affixed, and these presents to subscribed by a majority of the said Board as of this darn. Ttwstees TER~S end CONDITIONS Nancy R. Ross and others re~aln~ at 121 East Delaware Ave., Pennington, NJ 08534 ~.X~ as pa~t' of tt~ consideration fo~ ~e J.~m~ge of ~he P"rn4t doe~ undetsta~l aml pte~ri~e to th~ f~t- 5. That this 'Petmlt should be retained iadefmi~et?, or as long as the ~ld P~I~ ~ to n~n~in the stt~ma~ or project involved, to provide evidence to anyoa,e ~ that 4. That .the wod~ involved will be subject to the inspection and appt~ral o[ the Board ie; ageneg and ~liance with. the ptovisiom o~ the odglnatiag appilcatio~, may be t~ocation of this ~t I~ tesohdoa of the said Boa~L 5. That there will be no uagasoa~le iat~ference with navig~fioo_ as a remit of the wo~ herein ~khortzed. 8. That the said Boa£d will be notified by the Permit~e ot ~ e0~plet~k~°f the work ~ That the Petmittee will obtMa all other permits ~ coz~a~ ~mt may be ~ ~ plementtl to &is permit which may be subject ¢o revoke upon fdlme to obtain same. Albert J. Krupski, President James King, Vice-President Attic Foster Ken Poliweda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765~1892 Fax (631) 765-1366 October 16, 2002 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Ms. Diane Herold P.O. Box 884 Westhampton Beach, NY 11978 NANCY R. ROSS and Others 3350 PARK AVE., MATTITUCK SCTM#123-8-22.2 Dear Ms. Herold: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, October 16, 2002 regarding the above matter: WHEREAS, Diane Herold, Architect on behalf of NANCY IL ROSS and others applied to the Southold Town Trustees for a permit under the provisions of Chapter 97 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated September 11, 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 October 16, 2002, 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, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approve the application of NANCY R. ROSS and others to demolish the existing house and boat shed and rebuild a two-story house with a boat shed and decks conforming to the existing non-conforming setbacks, with the condition that gutters and drywells are installed and hay bales are placed down before the project begins. 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 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 $5.00 per inspection. (See attached schedule.) Fees: $5.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/lms Field Inspection 10/09/02 Teleph~e (631) 765-1892 Town H'.dl. 53~95 M~a Ro~l P.O. Box 11~9 Southold. New York 1197~. $OUTHOLD TO~N CONSE~VATI0~{ ADVISORY COLr~IC~L At the meeting of the Southold Town Conservation Advisory Council held Monday, October 7, 2002, the following recommendation was made: NANCY R. ROSS to demolish the existing'house and boat shed and rebuild a two-st(~ry house with a boat shed and decks conforming to the existing non-conforming setbacks. Located: 3350 Park Ave,, Mattituck. SCTM#123-8-22.2 The CAC did not make an inspection therefore no recommendation was made. TOWN OF SOUTHOLD OFFICE OF BUILDINGINSPECTOR TOWN HALL SOUTHOLD, NEW YORK CER'PIFICATE OF OCCUPANCY NON CONI;'OR MING PliEMISES I Ills IS I D CL'llTI1;'Y that the~ /~/ Land Pre C.O. ~- g14201 /X/ Building(s) Date- ye~, /? use(s) located at 2735 Park Ave. Ext. Mattituck Street Hamlet shown on County tax map as District 1000, Ssotion ~2~ , Block. Lot 022.2 , does~not)conform to the present Building Zone Code of the To~ o~ Southold for the following Insufficient total area. Insufficient front yard set back. On the basis of information presented to the Building Inspector's Office, it has been determined tbat tbs above nonconforming f~/Land /~/Building(s) /--_/Use(s) ekisted on the effective date the present Building Zone Code of the Town of Southold. and may be continued pursuant to and subject to the applt- cable provisions of said Code.' IT IS FURTHER CERTIFIED that, based upon information presented to the Building Inspector's'Office, the occupancy and use for which this Certifi- cate is issued is as follows: prspe{ty contains a one story, one family seasonal cottage with attached garage and wood deck. Property situated in the A-Residential-Agricultural Zone with access accross unopened R.O.W. to Bungalow Lane. extantion. The Certificate is issued to ROSS, FREDERICK ~. ~ BETT~ ~h of tile aforesaid bu!l'ding. Suffolk County bepartment of Health Approval N/R UNDERWRITERS CERTIFICATE NO. N/R NOTICE IS HEREBY GIVEN that the owner of the above premises HAS NOT CONSENTED TO AN INSPECTION of the premises by the Building Inspsc~ tot to determine if the premises comply With all applicable co~le;, /md ordin- ances, other than. tl{e .Building Zone.Code.~and,~eref6~e, no suc~inspee,ti,on bas been condqqted~ q~his CJ~rtlficate, therefore~'does ~ot, and i~' not'i~{edded" to certify ti%a! the p~eml's~i 6t{mpl~ ,~ith all,other applicable codes and regula- tions, Building in'ep~ c tdr PARKER WlCKHAM ~ AREA = 14,443 sq ft. or 0.3315 acre CONTOUR LINES ARE REFERENCED TO N.G.V.D. NO TE' L 0 T NUMBERS ARE REFERENCED TO · MAP OF MARRA TTOOKA POINT' FILED IN THE SUFFOLK COUNTY CLERK'S OFFICE ON MAR. 9, 1927 AS MAP NO. 351 SURVEY OF PROPERTY A T MA TTITUCK TOWN OF SOUTHOLD SUFFOLK COUNTY, N Y. 1000 - 123 - 08 - 222 SCALE.. 1" = 30' DEC. ~ tga5 JUNE 8, gO01 ' Sepf. 3, 2002 (addillons) CERTIFIED TO~ NANCY ROSS PAMELA ROSS WILLIAM CARMEAN CHARLES GA Y 85 - 402 Albert J. Krupski, President James King, Vice-President Henry Smith Artle Foster 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 Office UseOnly Coastal Erosion Permit Application Wetland Permit Application __ Major Waiver/Amendment/Changes Received Application: _ __Received Fee: $ Completed Application Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) ~. CAC Referral Sent: Date of Inspection: Receipt of CAC Report: Lead Agency Determination:__ Technical Review: Public Hearing Held: Resolution: Minor Name of Applicant Address 1'2. I Suffolk County Tax Map Number: Property Location: /O't7 ~,0 7o ~oeq~'r ~/'~7 B! 7'0 (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Board of Trustees Application Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property: 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? ~ No Yes If yes, provide explanation: Project Description (use attachments if necessary): -n:~6-tmo~4 6~cts'ctO~ Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: '~:~aO~ t'~'~l~-/'~:~ it) F-~.t~,-/'t~}6 t ~ of wetlands on lot: ~ ~ ~ ~ ~u~e feet P~nt coverage of lot: I~ % Closest distance between nearest existing structure and upland edge of wetlands: I ?c~ ~- feet Closest distance between nearest proposed structure and upland edge of wetlands: v?_o '~- feet Does the project involve excavation or filling? X No Yes If yes, how much material will be excavated? ~ cubic yards How much material will be filled? A/0D~ cubic yards Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: ~ 7o 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): Board of Trustees ApDlication COASTAL EROSION APPLICATION DATA Purposes ofproposed activity: 'x~t~ot~gR ~t$~O~ Koo$~'- 'Co Are wetlands present within 1 O0 feet of the proposed activity? .K No Yes Does the project involve excavation or filling? ~L No Yes If Yes, how much material will be excavated? How much material will be filled? --- Manner in which material will be removed or deposited: (cubic yards) (cubic yards) Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) 'lO ~ att.~ ~D6 NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: 2. That the property which is the subject of Environmental Review--is located adjacent to your property and is described as follows: 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 765-1892 or in writing. 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: MAILING ADDRESS: PHONE ~: Enc.: Copy of sketch or plan showing proposal for your convenience. Board of Trustees Application County of Suffolk State of New York 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 SOU'I~OLD 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. SWORN TO BEFORE ME THIS Signature ~J DAY OF~~ ,20 07--. NOTARY,~MY M. BEASI.EY Board of Trustees Application (where A~'r~ORIZATION the applicant is not the owner) (print owner of property) residing at I~kl· ~' ~u3~-~ (mailing address) do hereby authorize (Agent) to apply for per~it(s) from the Southold Board of Town Trustees o~my behalf. 8 PROJECT I.D. NUMBER 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT iNFORMATION (To be completed by Appifcant or Project sponsor) 1. APPLICANT/SPONSOR J 2. PROJECT NAME 3. PROJECT LOCATION: Municipality ~,~O(.~MO/---~;3 County. ~ %~,5o PA(Ere AuF.~JOf=t §. IS PROPOSED ACTION: F'~ New r'"~ Expansion [~Mocliticat ionlaltera tion WHAT IS PRESENT ~f~D ~E ~N VIC~NI~ OF PROJECT? ~Resid~ual ~4n~ustrial ~ Commercial [] Agriculture ~-J ParK/ForestJOoen sgace ~ Otl~er SEQ 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEJ~FIAL, STATE OR LOCAL)? [~[Yes [] No If yes, list agency(s) and permftla[o~rovals 11. DOES ANY ASPECT OF THE ACTtON HAVE A CURRENTLY VALID ~ERMIT OR APPROVAL? ~ Yes* ~o If yes. list agency name and permJllaooroval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION*~ [] Ye~ [] NO I CERTIFY THAT THE INFORMATION PROVIDED ABOVE I~ TRUE TO THE LEST OF MY KNOWLEDGE If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceedinG with this a.~essment OVER ! PART III--0ETERMINATION OF SIGNIFICANCE (To he com0ieted by Agency) INSTRUCTIONS; For each adverse effect identilied el:eve, determine wttetr~er it is sul~stantial, large, important or odlerwise signific. E3ch .~i~fec: should he assessed in connection with its (a) setting {i.e. url3an or rural); (b) proba0ility of occo.,%'Lng; (cl duration: irrevers~biliW; (e} geogr~onic ~coce; and {t) rnagm[u(3e. It necessaq¢, adc~ attachments or reference supporting nla~erlals. Ensure ' exotana[ions contain sufficient dexail {o snow that all relevant adverse impacts have been identifie~ eno adequately adc:reseed. Check ~his box if you have identified one or more ~otendally large or significant a~3verse imoacts which MA'; occur. Then proceeO ctirec:ly ~o :ne FULL =-'-~F anco/or prepare a positive'ciectaraticn. Chect< ~his ~ox if you have determineQ, base(~ on the information and'analysis above and any su!3oorti~ documentattcn, :~t3[ ;he proeosee ac:ion WILL NOT result in -..~.n,/ significant adverse environmen:al imcac:s AND provide on a[[sc.'3men[s as necessary. Ihe reasons supcorting trois determination: TRANSACTIONAL DI~CLOSUR~ FORM interest on the part og town officers and employees, The purpose o~ ~his ~orm ts to provide Information which can alert the town of possible conflicts si interest and i~ to ~ake ~hatever action ts necessary to avoid same. (bast name, ~irsb name, m{dd.ls you are applying tn the name of someone else or other entity~ such p~ a co~pany, If ~o~ the other perso.~s or company's NATUR~ O~ APPblCATION~ (Cheek all that apply.) Tax grievance Variance ~ change of zone ARp[~al of plat . Bxetptton from plat or official map Other ,,Other,', name the activity,) Do you personally (or through your ~o~pany~ spouse, siblihg, parent, or ohild} have a relationship with any officer or employee of tho Town of ~outhold? 'Relationship' includes by blood~ marriage, or business interest. "Business interest" mean~ a business, including a partnership, In which the town officer or employee has even a partial ownership of (or employment by) a corporation tn which the town officer or employee owns more than 5% of the shares. If you answered '~BS.#.complate the balance of thi~ form and date and sign where indicated. Name of person employed by the ToWn oF Diane Hen)Id, Architect P.O. Box 81t4 Westhampton Beach, New York 11978 August 2, 2005 Board of Town Trustees Town of Southold Town Hall P.O. Box 1179 Southold, New York 11971-0959 RE: Nancy Ross and others 3350 Park Avenue, Mattituck SCTM 123-8-22.2 AUG 3 2005 South01d Towo Board of Trustees Dear Southold Town Board of Trustees: On behalf of my client, Nancy Ross and others, I am requesting a one-year extension m Permit #5643, approved October 16, 2002, because the permit process has taken longer than expected. It was necessary to obtain a variance from Suffolk County Department of Health Services for the sanitary system. It would have been almost impossible to obtain a variance without public water because of the proximity of wells and sanita~ry systems. It took almost a year for public water to be installed in the street so the variance application was delayed until this work was done. Attached is the variance from the Suffolk County Department of Health Services dated May 25, 2005. Also attached is a letter from Eileen Cantone of that office, dated June 21, 2005, requesting a copy of the covenant be filed with their department for approval before being filed with the County Clerk. That filing was done today, but we have to wait for the approval before filing with the County Clerk. Therefore, we are requesting an extension in order that a permit may be issued from the Suffolk County Department of Health Services. All other permits that are required for submittal with a building permit application have been obtained and are currem. Thank you for your patience in the review of this request. Diane Herold Albert J. Krupski, President James IZJng, Vice-President Artie Poster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 August18,2004 BOARD OF TOWN TRUSTEES TOWN OFSOUTHOLD Ms. Diane Herold Diane Herold, Architect P.O. Box 884 Westhampton Beach, NY 11978 RE: NANCY R. ROSS AND OTHERS 3350 PARK AVE~, MATTITUCK SCTM#123-8-22.2 Dear Ms. Herold: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, August 18, 2004: RESOLVED that the Southold Town Board of Trustees grants a One-Year Extension to Permit #5643, as approved on October 16, 2002. This is not an approval from any other agency. If you have any questions, please do not hesitate to contact this office. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees AJK:lms DAVID G. GRAHAM, M.D., M.P.H. CHIEF DEPUTY COMMISSIONER June 21, 2005 Nancy Ross 121 East Delaware Avenue Pennington, NJ 08534 Re: H.D. Ref # Ri0-03-0004 Dear Ms. Ross: COUNTY OFSUFFOLK STEVE LEVY SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF HEALTH SERVICES BRIAN L. HARPER, M.D., M.P.H. COMMISSIONER ELIZABETH M. HARRINGTON, ESQ, DEPUTY COMMiSSiONER Based on the Board of Review determination, special language has been prepared for the above referenced application. Please find enclosed the special language, our instruction package, and a copy of the Board of Review decision, which must be attached to and made a part of the Covenant and Restrictions. Submit three copies of the Covenant, with one original and one copy of the Title Certification, to this office for review. Should you have any questions please feel free to contact me at 852-2100. Very truly yours, Eileen Cantone Office of Wastewater Management Enclosures · DIVISION OF ENVIRONMENTAL QUALITY · OFFICE OF W ASTEW ATE:R MANAGEMENT * RIVERHEAD COUNTY CENTER · RIVERHEAD NY 11901-3397 · Pho[~e (631) 852o2100 Fax (631) 652-2092 SUFFOLK ~UNTY DEPARTMENT OF HEALTH~RVICES DMSION OF ENVIRONMENTAL QUALITY BOARD OF REVIEW ARTICLE 2, SECTION 220, SUFFOLK COUNTY SANITARY CODE To~ Brian L. Harper, M.D., M.P.H., Commissioner From: Stephen A. Costa, P.E., Chairman, Board of Review Subject: Findings and Recommendations of the Review Board Regarding: R10-03-0004 - Residence for Ross, e/s Park Avenue, Mattituck - t/o Southold - SCTM: 1000 12300 0800 022002 Hearing Date: May 19, 2005 Statement of Problem Residential construction standards require that a subsurface sewage disposal system be placed at least ten feet fi.om a retaining wall. The applicant is proposing a septic system to serve a single-family dwelling that does not conform to departmental standards in that portions of the system are located within ten feet ora retaining wall. Residential construction standards require that a subsurface sewage disposal system be place at least ten feet fi.om a house foundation. The applicant is proposing a septic system to serve a single-family dwelling that does not conform to departmental standards in that portions of the system are located within ten feet of a house foundation. Findings and Facts 1. The applicant is proposing to remove an existing dwelling on the lot and replace it with a new single-family dwelling. The existing sewage disposal system will be removed and replaced with new facilities. 2. The project is located in Groundwater Management Zone 4. 3. Soil conditions are good with clean sand at 2 ft. below existing grade. 4. Depth to groundwater is 4.2 feet. 5. The emst~ng sewage disposal system being removed consists of a single leaching pool (cesspool) located approximately 5 feet from the existing building footprint. The proposed sewage disposal system consists of a 1,000-gallon septic tank and five 8-foot · by 2 feet deep leaching pools and an area for expansion within a retaining wall to thee north of the disposal system. The top of the waterproof retaining wall will be approximately 15 inches above existing grade. Because of the site constraints, including a traveled dirt road that runs through the middle of the lot, the leaching pools are located as close as 2 feet from the retaining wall and five feet fi.om the proposed building footprint. The building will be constructed on piles. Staff has recommended modifying the layout by Brian L. Harper, M.D.,M.P.H., Commissioner Hearing Date: May 19, 2005 Subject: Findings and Recommendations of the Review Board Regarding: R10-03-0004 - Residence for Ross, e/s Park Avenue, Mattituck - rye Southold - SCTM: 1000 12300 0800 022002 arranging the leaching pools in a more linear alignment, which will give better clearance to the wall and to the building footprint. 8. Water service is public, supplied by Suffolk County Water Authority (SCWA). 9. Wetlands permits have been issued by the state and town. Determination It was a 3 to 0 determination of the Board to grant the request for the variance for reduced separation distance, provided the following conditions are met: · The applicant shall resubmit the site plan showing a realignment of the proposed sewage disposal system to the satisfaction of the department review engineer. The applicant shall retain a licensed professional engineer to supervise, and certify the completion of the installation of the sanitary system and construction of the retaining wall. · Expansion leaching pools shall be installed at the same time as the required leaching pools. The applicant shall covenant the property, in language acceptable to the County Attorney, that the sanitary system does not comply with standards and that extensive costs may be incurred in the future if repairs or expansion are necessary. The system will be constructed to allow proper routine maintenance of the sewage system. Therefore, granting the variance will not have any adverse effect on groundwater. As per §760-609 of the Suffolk County Sanitary Code (Sanitary Code), the approval of the variance is in harmony with the general purpose and intent of the Sanitary Code to protect groundwater and drinking water supplies, surface water and other natural resources, and public health, safety and welfare. May 25, 2005 Stephen A. Costa, P.E. Chairman - Board of Review Albert J. Krupsld, President James King, Vice-President Henry Smith Artie Foster 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 Office Use Only Coastal Erosion Permit Application ~etland Permit Application fMajor Waiver/Amendment/Changes ~Received Application: J~ceived Fee:$ o~OC~ ~ ~ompleted Application Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(date sen0 fCAC Referral Sent: q/l I]0 ~-~ ~te of Inspection: Receipt of CAC Report: Lead Agency Determination:__ Technical Review: /~ublic Hearing Held: IO]l[O/O~}-~ Resolution: Minor Name of Applicant Address 1'2. I Phone Number:( ) &0~ ~ ¢5~~ Suffolk County Tax Map Number: 1000- I~ '~ Og ~ ~g.~-, Property Location: N't7 ~30 7o ~oc-~--r a/'-t7 BI 7'0 (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Phone: Board of Trustees Application Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency Date ~uo~c- 0~0. Fob X No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? M No__ Yes If yes, provide explanation: Project Description (use attachments if necessary): '~:>et~.oct~ 6)ets'rrm6 Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: -~:~_~ ~qR exit-ct06 F, DOaE g0n:~ Area of wetlands on lot: [ 500 4~ square feet Percent coverage of lot: [ t~ % Closest distance between nearest existing structure and upland edge of wetlands: I?c~ q- feet Closest distance between nearest proposed structure and upland edge of wetlands: ~o 4_ feet Does the project involve excavation or filling? X No Yes If yes. how much material will be excavated? ~ cubic yards How much material will be filled? A/O~J6 cubic yards Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: ~ 7o Manner in which material will be removed or deposited: feet 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): A.O ~ o~ ~L~ ~O~ oce~ Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes ofproposed activity: ~>~r~ot.~K 6~£srtt~6 ~,oo$ff To Are wetlands present within l O0 feet of the proposed activity? X No __ Yes Does the project involve excavation or filling? ~ No Yes If Yes, how much material will be excavated? ~ How much material will be filled? ---- Manner in which material will be removed or deposited: (cubic yards) (cubic yards) Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) Diane Herold, Architect P.O. Box 884 Westhampton Beach, New York 11978 (631) 288-5049 phone/fax Date: October 15, 2002 To: Board of Town Trustees Number of pages including cover sheet: Re: Nancy Ross and others application 3350 Park Avenue, Mattituck Attached are the following documents: Affidavit of posting Original statement signed by owner Two copies of the site plan that shows the layout of the sanitary system One copy of the preliminary floor plans and elevations ~Albert J. Krupski, President James King, Vice-President Henry Smith A~tie Foster 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 BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING · Complete items 1, 2, and 3. Also comp~te item 4 if Restdcte~ De/ivery is ctesired. · .Pff~.~t ~?O[ name and address on the mv~e ' ", Ff posted the A. Si m % . S~ ~A .r where it can ~ ~nt .ure the poster 2. Article Number ffmnsfer from ~'vk~ PS Form 38J 1, ~o~ust 2~ ~m~tlc Returo R~ei0t - ~A~ No. ~79~3 ;ice Type eft/fled Mail r-I E~press Ma~l OOO I NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: 2. That the property which is the subject of Environmental Review--is located adjacent to your property and is described as follows: 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 765-1892 or in writing. 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: A~c~ MAILING ADDRESS: PHONE ~: ~oq- Enc.: Copy of sketch or plan showing proposal for your convenience. Albert J. Krup~k~, President Jame~ K~n~, V~ce-Pres~dent Henry Smith Arcie Foster Ken Pol:Lwoda Town Hall .53095Route 25 P.O, Box 1179 Southold, NewYork 11971-0959 Telephone (631) 765-1892 Fsx (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD In the Matter of the Application of COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I,-~[~)~ ~.~O~D~:D ., residing at ~ ~0~i4__~.0_~._~ .... being duly sworn, depose and say: That on the ~%~day of~O~ 200~ I personally posted the property known as_._~.~ ~D4~ ~U~JOU~, ~%~-f-fl~uC]~ by placing the Board of Trustees official poster where it can easily b.e seen, and that I have checked to be sure the poster has remained in place for eight days prier to the date of the public hearing. Date of hearing noted thereon to be held ~o~ I~,~ Dated: Sworn to before me this /( day of ~. 200~ JOYCE M. WILKINS Notaw Public, State of New York No. 4952246, Suffolk County Term Expires June 12, ~-o O~ ( signature ) Board of Trustees Application County of Suffolk State of New York 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. SWORN TO BEFORE ME THIS Signature DAY OF ~ ~ ,20 E) ~ NOTARyAMY M. BEASLEY ~¥,.PUBUC, State of New York no. 01 BE5039767 Qualified n Suffolk County Corem ssion Expires Februaq, 27, Board of Trustees Application County of Suffolk State of New York ? ~ ~, ~sx- BEIN~D~YSWO~ DEPOSEb AND AFF~dVIS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE TRw TO ~ BES~r OF ~S~R ~OWI.~,~E ~ BEX~F, ~ TH_,,T ALX~ WO~ 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. SWORN TO BEFORE ME TI-IlS Signature DAY OF ~42t~~ ,20 0 7__ NOTARYA_MY M. BEASLEY ,~o. u~ u==o39767 comQ .ual fled in Suffo k Courav m ~lon Exio re~ F. bruar~'~,7o ~ ~, ~rd of Trustees A~p~icatio~ ~ (where AUTHORIZATION the applicant is not the owner) (print owner of property) (mailing address) do hereby authorize 3C~ (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Address: ~o~, p ~ Y~c I l~ 6 6 lto~- q lYo U.S, Postal Service CERTIFIED MAIL RECEIPT r'-t [ Postage $ ~i~ CeAIfled Fee Return Receipt F6e (Endorsement Required) [:3 Rest ri~tad D~tive~y Fee (EndoPsement Requlrec~ 8ent T~) ~-~ LYNDA M. BOHN NOTkRY PUBLIC, State of Ne~ Ye~ No. 01BO6020932 Qualified in Suffolk Coup_ Term Expires March 8, 20 ~ at ~ -Sooll4 e._ou~,r~f~-t ~ , sworn, deposes and says that on the teponent mailed a true copy of the Notice a, directed to each of the above named :spective names; that the addresses set tdress of said persons as shown on the current said Notices were mailed at the United States Post id Notices were mailed to each of said persons by KEY MAP (~) COUNTY OF SUFFOLK ~o~.~ SOUTHOLD '~. Real Property Tax Service Agency Courtly Cenler ~$TRIL'T~O. JO00 Riwrh~od, L I., N*w Yorlt 123 I PROPERTY MAP ~7388~ SOUTHOLD 123.-8-24.1 170 PARK AVE EXT = OWNER & MAILING INFO ===I=MISC ROSS DAVID ARTHUR IRS-SS 68~ DUBOIS STREET 1 DARIEN CT 06820 BANK NYSRPS ASSESSMENT INQUI~ DATE : 08/30/20 SCHOOL MATTITUCK SCHOIIE ROLL SEC TAXABLE PRCLS 260 SEASONAL RES TOTAL RES SITE TOTAL COM SITE ACCT NO 14 ======== ====== ASSESSMENT DATA =========== **CURRENT** RES PERCENT LAND 3,100 **TAXABLE** 6,200 COUNTY 6,2 **PRIOR** TOWN 6,2 LAND 3,100 SCHOOL 6,2 TOTAL 6,200 ==DIMENSIONS ===1======= SALES INF ACRES .66 IBOOK 11929 SALE ~ATE 10/31/98 IPAGE 030 PR OWNER ROSS FREDERICK A =======TOTAL EXEMPTIONS 0 =============1== TOTAL SPECIAL CODE AMOUNT PCT INIT TERM VLG HC OWN CODE UNITS PCT IFDD3O IPK071 IWWO20 ISW011 Fl=NEXT PARCEL F2=PARCEL UPDATE F3=NEXT EXEMPT/SPEC 75.10- 03-050 F6=GO TO INVENTORY F9=GO TO XREF )RMATION ================================== SALE PRICE DISTRICTS 4 ==== TYPE VALUE F4=PREV EXEMPT/SPEC F10=GO TO MENU V?~~ SOUTHOL~ 123.-8-22.5 15 PARK AVE EXT = OWNER & MAILING INFO === BASS THOMAS M JR & EVELYN 17 BUCKEYE ROAD GLEN COVE NY 11542 ==DIMENSIONS ACRES =======TOTAL NYSRPS ASSESSMENT INQUI~ SCHOOL MATTITUCK SCHOilt PRCLS 260 SEASONAL RES =MISC RS-SS 1 BANK DATE : 08/3§/20 ROLL SEC TAXABLE TOTAL RES SITE TOTAL COM SITE ACCT NO 14 I======== ====== ASSESSMENT DATA =========== I **CURRENT** RES PERCENT ILAND 1,100 **TAXABLE** ITOTAL 5,300 COUNTY 5~3 0117312 **PRIOR** TOWN ~,3 ILAND 1,100 SCHOOL 5,3 ITOTAL 5,300 ===1======= SALES INFORMATION ================================== · 40 IBOOK 11815 SALE DATE 01/18/97 SALE PRICE 241,0 IPAGE 310 PR OWNER BECHTLE EUGENE W JR & EXEMPTIONS 0 =============1== TOTAL SPECIAL DISTRICTS 4 ==== CODE AMOUNT PCT INIT TERM VLG HC OWN CODE UNITS PCT TYPE VALUE IFD030 IPKB71 IWWO20 ISWB11 Fl=NEXT PARCEL F2=PARCEL UPDATE F3=NEXT EXEMPT/SPEC F4=PREV EXEMPT/SPEC 75.10- 03-050 F6=GO TO INVENTORY F9=GO TO XREF F10=GO TO MENU 4'7 3,1, 6 q' SOUTHOL} 123.-8-22.4 3265 PARK AVE = OWNER & MAILING INFO ===I=MISC MASSAB RONALD IRS-SS 9 MAIN STREET 1 SOUTHAMPTON NY 11968 BANK NYSRPS ASSESSMENT INQUI~ DATE : 08/30/20 SCHOOL MATTITUCK SCHO~ ROLL SEC TAXABLE PRCLS 260 SEASONAL RES TOTAL RES SITE TOTAL COM SITE ACCT NO 14 I======== ====== ASSESSMENT DATA =========== I **CURRENT** RES PERCENT ILAND 1~700 **TAXABLE** ITOTAL 4,600 COUNTY 4,6 **PRIOR** TOWN 4,6 ILAND 1,700 SCHOOL 4,6 ITOTAL 4,600 ==DIMENSIONS ===1====:== SALES INFORMATION ================================== ACRES .50 IBOOK 12093 SALE DATE 01/21/00 SALE PRICE 240,0 IPAGE 105 PR OWNER MOTTOLA PHILIP =======TOTAL EXEMPTIONS 0 =============1== TOTAL SPECIAL DISTRICTS 4 ==== CODE AMOUNT PCT INIT TERM VLG HC OWN CODE UNITS PCT TYPE VALUE IFD030 IPKO71 IWwo2a ISW011 Fl=NEXT PARCEL F2=PARCEL UPDATE F3=NEXT EXEMPT/SPEC F4=PREV EXEMPT/SPEC 75.10- 03-050 F6=GO TO INVENTORY F9=GO TO XREF F10=GO TO MENU 4-738~9~ SOUTHOLD 123.-8-21 3340 PARK AVE = OWNER & MAILING INFO ===I=MISC POLLOCK DOUGLAS WILLIAM & IRS-SS POLLOCK MARCIA GLEN 1 36 MITCHELL RD BANK PORT WASHINGTON NY 110S0-4140 NYSRPS ASSESSMENT INQUI~ DATE : 08/30/20 SCHOOL MATTITUCK SCHOIIIE ROLL SEC TAXABLE PRCLS 260 SEASONAL RES TOTAL RES SITE TOTAL COM SITE ACCT NO 14 ~======== ====== ASSESSMENT DATA =========== I **CURRENT** RES PERCENT ILAND 1,300 **TAXABLE** ITOTAL 5,600 COUNTY 5,6 **PRIOR** TOWN S,6 ~LAND 1,300 SCHOOL S,6 ITOTAL ~,6g0 ==DIMENSIONS ===1======= SALES INFORMATION ================================== ACRES .22 IBOOK 1169S SALE DATE 09/16/94 SALE PRICE 280,0 IPAGE 707 PR OWNER WUTTKE HELEN B =======TOTAL EXEMPTIONS 0 =============1== TOTAL SPECIAL DISTRICTS 4 ==== CODE AMOUNT PCT INIT TERM VLG HC OWN CODE UNITS PCT TYPE VALUE IFDO3O IPK071 IWW020 ISWO11 Fl=NEXT PARCEL F2=PARCEL UPDATE F3=NEXT EXEMPT/SPEC F4=PREV EXEMPT/SPEC 75.10- 03-050 F6=GO TO INVENTORY F9=GO TO XREF F10=GO TO MENU 4'73889 SOUTHOLD NYSRPS ASSESSMENT INQUII SCHOOL MATTITUCK S( PRCLS 210 I FAMILY RES 123.-8-20.1 3190 PARK AVE = OWNER & MAILING INFO ===I=MISC MIKELBANK JAMES & CAROL IRS-SS 3190 PARK AVENUE I 1 MATTITUCK NY 119S2 I BANK ==DIMENSIONS ACRES DATE : 08/30/20 ROLL SEC TAXABLE TOTAL RES SITE TOTAL COM SITE ACCT NO 14 I======== ====== ASSESSMENT DATA =========== **CURRENT** RES PERCENT ILAND 2,700 **TAXABLE** ITOTAL 8,200 COUNTY 0189410 **PRIOR** TOWN 8,2 I ~LAND 2,700 SCHOOL 8,2 I ITOTAL 8,~00 =======TOTAL CODE AMOUNT PCT INIT TERM VLG HC OWN CODE UNITS 418~4 1,010 99 ~FDO3O IPK071 IWWO20 ISW011 Fl=NEXT PARCEL F2=PARCEL UPDATE F3=NEXT EXEMPT/SPEC 75.10- 03-050 F6=GO TO INVENTORY F9=GO TO XREF ===~======= SALES INFORMATION ================================== · 43 IBOOK 10S06 SALE DATE 00/00/00 IPAGE 0010S PR OWNER EXEMPTIONS I =============1== TOTAL SPECIAL DISTRICTS 4 ==== PCT TYPE VALUE F4=PREV EXEMPT/SPEC F10=GO TO MENU 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR ~ 2. PROJECT NAME, 3. PROJECT LOCATION: MunicID~IRY ~-~O ("/~ ~'O/'-'~1~ County 4. PRECISE LOCATION {Street adclress and road intersections, prominent lancimark$, etc., or p~owoe map) 5. IS PROPOSED ACTION: []New E'~ Expansion ~Mo~i ficationlalt erat ion 6, OESCR[8~ PROJECT 7. AMOUNT OF ~NO AEFECTED: SEQ 10. OnES ACTION INVOLVE A PSRM[T APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FE~}ERAL, STATE OR LOCAL)? ~[Yes [] No If yes, list agency(s) and permit/aoprovals 1~. 00ES ANY ASPECT OF THE ACTION HAVE A CURRENTty VAUD 9ERMIT OR APPROVAL? ~ Yes' ~o If yes, list agency name ann 12. AS A RESULT OF PROPOSED ACTION WILL SXISTING PERMIT/APPROVAL REQUIRE MOOIFICAT]ON') [ CERTfFY THAT THE iNFORMATION PROVIOED ASOVS IS TRU'E TO THE BEST OF MY KNOWLEDGE the action is in the Coastal Area, and you are a state acency, complete the Coastal Assessment Form before proceeding with th~s a?_,s, essmem OVER I PART IIi--OETERMINATICN OF SIGNIFICANCE (To ~e completed by Agency) INSTRUCTIONS; For each ~overse effect identified aCove, determine wt~etl~er it is substantial, large, interment or otherwise signi ftc. ~c~ aJfec= saould be assessed in connection wit~ its (a) setting (i.e, urban or ~ral); (b) Gro~eoility of occ~g; (c) dur~tiort: ChecX trois box if '/ou have identified one or more potentially large or significant adverse imoacts which h~AY occur. Then 2roceed direc,'ly ~o tr~e FULL EAF and/or prepare a positive declaration. Ghee× :his =o× if you have de',ermined, based on the information and analysis 8.bore and any su~oortinc. documentation. :i~a~ the ~rooeseo ac:ion WILL ;~OT result in.~?~y significant adverse environmental [m~ac:.~ AND 2rovioe on attachments as necessary, d~e reasons supeorting trtis determination: APPb~eANT TRANSACTIONAL DISCLOSURE FORM The Town 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 sams. YOUR NAH~t (Last name, ~rs~ name~ m~dd,ls '~n~tial~ un,ess you are applying in ~he name og someone else or other entity, such ~s a company. If so, indicate the other person~s or company's name.) NATOR~ OF APPbZ~ATION~ (Check s~! that apply.) Tax grievance Variance i Change of zone A~p~>val o~ plat . , Exe~pEion from plat or o~f~c~al map other (If .Other~" name the activity. ) . -fftoS766s.. ~.t~. Do you pereofla~Zy (o= ~hrough your ~ompany~ spouse, sibling, parent, or ~hi~d) hnvo n reln~tonship v~h any o£fioer or employee og ~ho Town og Sou~ho~d? "Rela~ion~hipN includes by b~ood, marriage, or business in~oroo~. "Dueineoe in~oroeb" means a business, ineiud~ng a par~nership~ ~n vhich the ~ovn o~£ieer or employee has even a par~lai ovnerehtp o~ (or employmen~ by) a corporation tn which shares. .sO _X__ If you answered #TES,#.oompXo~o ~he balanee'O~ ~his ~orm and da~e and sign ~hero indicated. Name of person employed by the Town of Southold Title or position o~ that person _ Describe ~he relationship between yourself (the applicant) and the town officer or employee. Either check the appropriate line a) through D) and/or describe in the apace provided. The town officer or empZoyes Or his or her ~pouss~' sibling, parent, or child is (check all that apply)t .A) the owner of greater tha~ 5% of the shares of hhe corporate stock of the applicfint (when ~he applicant' is a eorporation)~ __.B) the legal or b~ne~lcial owner noncorporate'entity (when the corporaeion)~ C) an o~tcor~ director~ pa~tfler~ applicantt or '. ,.D) ~he actual applicant. DESCRIPTION OF of any in~erest in a appticant la not a or emplOyee, o~ the