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HomeMy WebLinkAboutTR-5950Albert J. Krupski, Presideni James King, Vice-President Artie Foster Ken Poliwoda . Peggy A. Dickerson BOARD OF 'POWN 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 ¼ constructed V/Project complete, compliance inspection. Board Of $outhold 'Town Trustees SOUTHOLD, NEW YORK ROBERT WHITE ISSUED TO ............................................ ......................................................................................... ut'l nri ati u Pursuant fo the provisions of Chapter 615 of ~he laws of tho Sfa~e of New York, 1893; end CJaapfer 404 of Se ,~.ws of tho · State of New York 1952; and the Southold ToWn Ordmenoe eh- filled ."REOULATING AND THE PLACING OF OBSTRUCIlQNS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL.O,R, OTHER IdATERIALS~.F.,$~.~.M LANDS UNDER TOWN WATERS:J. and in accordance wffh the Resolution of The Board adopted efa meeting held o~ ...~.}~.1.~...~.~..,.... ~0.g.~..2, and in consideration of the sum of $_..~.g.0...:...0.? ...... paid by Robert White of Mattituck N.Y. and subject to tho T.r~;'"'"~'~"""~'a'i~i'~;'""'li~;~'"'"g~'"tho reYer~ side homo{. of Southold Town' Trustees authorizes and permih tho fo~owlng: Wetland Permit for the existing 'as-built .stockade fence running on the property'line on the sout.hwest side of the house, with the condition a 3' section is removed from the- sea,erda. ~n eccofaancesid~ of the, onooertwwmt meaeta~ma' Specifications es presented in .~he odg~.~fi.9 epl~fio". IN WITNESS WHEREOF, The sald Board Of Trustees here- ~ ~,~, ~, C,o,~at: ~a~ ~o. ~e am,ed, and ~o~..~,~,~ ~o subsa'ibed by ~ 'malodty of tho said Board .as, of fhls dat~. Ken Poliwoda TE~S end CONDITIONS  ~ Pc~mtttee Robert White. · te~llngat 2400 Ole Jule Lane, Mattituck i~ all damages, o~ ctaims to~ ~ o~ ~ ~ ~ O~n~!!I ~ Albert J. Krupski, president James Kingl 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 July 21,2004 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Robert White 2400 Ole Jule Lane Mattituck, NY 11952 RE: 2400 OLE JULE LANE, MATTITUCK SCTM#122-4-11 Dear Mr. White: The Board of Town Trustees took the following action during its regular meeting held on Thursday, July 21,2004 regarding the above matter: WHEREAS, ROBERT WHITE 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 June 21,2004, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and, WHEREAS, a Public Headng was held by the Town Trustees with respect to said application on July 21, 2004, 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.~s pro.p.osed 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 ROBERT WHITE for the existing as-built stockade fence running on the property line on the southwest side of the house, with the condition a 3' section is removed from the seaward side of the property. 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: $50.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/Ims Albert J. Krupski, President ~arnes King, Vic~-Preside~t 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 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: Please be advised that your application dated ~ i~l ~ reviewed by this Board at the regular meeting of "/jb~l O~ following action was taken: has been and the Application Approved (see below) Application Denied (see below) Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees. The fee is computed below according to the schedule of rates as set forth in the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: SIGNED: PRESIDENT, BOARD OF TRUSTEES 7/15/04 Field Inspection Z~4oo o~ ~ L,~ Telephone (63D 765-1892 Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Tuesday, July 13, 2004, the following recommendation was made: Moved by Doris McGreevy, seconded by Bill Cook, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the Wetland Permit application of ROBERT WHITE to install a 6' stockade fence running on property line 101'4" on the southwest side of the house. Located: 2400 Ole Jule Lane, Mattituck. SCTM#122-4-11 Vote of Council: Ayes: All Motion Carried d NOTICE Police Dept. - Bay Constable Town of Southold Peconic, New York 11958 NOTICE' OF VIOLATION Date: (Owner or authorized agent of owner) Address: ?4(:) 0!d Jtl.le l.ane, Mattituck, >:.f. 11952 (Address of owner or authorized agent of owner) Please take notice there e~sts a violation of the Code of the Town of Southold, Chapter 97 ~ticle II, Section 97-20 a premises herein~ter described in that y,~u are co[i~ucting activity within lO0 feet ot a 'de~[mlds wirh,,ut - ..... ~ [~st obtr, ining ~ You are therefore directed and ordered to comply with the following: <:~:~ se ali further work on ~:ence withi,~ I00 ~mt .~ ~e~:la:~d~. Appl;~ [c:r >i qrustee on or before the :' day of APrL~l , 20 0~,, The premises to which this Notice of Violation refers are situated at: Town of Southold, Suffolk County, NY (Suffolk County Tax Map Designation: Dist. 1000 Section: i'~ Block: 4 Lot: 1 t ) Failure to comply with the applicable provisions of the law may constitute an offense punishable by fine or imprisonment or both: NOTICE: You have the right to apply for a hearing before the Board of Trustees of the Town of Southold, provided that you file a written request with the Clerk of the Trustees within 10 days after service of the Notice of Violation. Such request shall have annexed thereto a copy of the Notice of Violation upon which a Hearing is requested and shall set forth the reasons why such notice of viola- tion should be modified or rescinded. Bay/Constable, Towl~ of Southold,/NY Town of Southold A' 16 2 4 Surfak County, NY lhe P~ople of the 8tat~ of N~t York VIN NUMBER COT. I'R'~ COPY Albert J. Krupski, President James K~ng, Vice-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 Office Use Only et aStal Erosion Permit Application land Permit Application Major Waiver/Amendment/Changes ~eceived Application: --~eceived Fee:$ ~'~ ~ompleted Application __Incomplete __SEQRA Classification: Type I Type II Unlisted Coordination:(date sent~ ~AC Referral Sent: ~D.~t~/,~ ~fte of Inspection: '~]/1~/ __Receipt of CAC Report: Lead Agency Determination: Technical Review: Hearing Held: Resolution: Minor JUN 21 2(04 Soutlmid Town Board of Truste~ Name of Applicant ~ O De c Address 2qlD~ Old b3 ?'/. II q 52 Phone Number:( Suffolk County Tax Map Number: 1000 - t~ 7 2 ¥ .' ?' Property Location: i~[9¢CC'Z. Io0'(r , og Oic} ~T~,le, t.a,~e o,~cl Kceu-$ t~cl. (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: Board of Trustees A~plication Land Area (in square feet): Area Zoning: ~ I Previous use of property: Intended use of property: GENERAL DATA Prior permits/approvals for site improvements: Agency Date 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): i~'~q oi'q" (on 4he S/ es+ Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: ~¢' r ITl i ~- ~C'T ~3 ~- c)(: ko~ ~. fe n ~-e Area of wetlands on lot: ~ ~' square feet Percent coverage of lot: ~ % Closest distance between nearest existing structure and upland edge of wetlands: '30 ' feet Closest distance between nearest proposed structure and upland edge of wetlands: i I ' feet Does the project involve excavation or filling? v/ No Yes If yes, how much material will be excavated? ~ How much material will be filled? ~z~ Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: cubic yards cubic yards 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): Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: Are wetlands present within 100 feet of the proposed activity? No ~' Yes Does the project involve excavation or filling? v,/ No Yes If Yes, how much material will be excavated? (cubic yards) How much material will be filled? (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) PROJECT ID NUMBER PART t - PROJECT INFORMATION 1. APPLICANT / SPONSOR 3.PROJECT LQCATION: M,,.icipa,, . I"OUoC hotd 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by A:~plicant or Project Sponsor) 2, PROJECT NAME County I L 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc - or provide map 5. IS PROPOSED ACTION: [~]~New [] Expansion [] Modification / alteration SEQR DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially iOl'q ~ acres Ultimately IO~'c~ '; acres 8 WiLL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? [---]Yes [5~No Ifno, describe briefly: ¢.~lolor-ovel Is neede(l ~co~ ~o~n cO 9. WHAT IS PRESENT ~ND USE IN VICINI~ OF PROJECT? (Choose as many as apply) ~Residential ~lndustrial ~Com~rcial ~Agriculture ~Park/Forest/OpenSpace ~Other (describe) 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 name and permit/ approval: --~0~'~ J~'oJ~J To~Ji3 -'i~Co.~-ee3 11 DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ]Yes r-~No If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? ~Yes o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Signature ' '~z~'~'~ ' ~, If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 If yes, coordinate the review process and use the FULL EAF. J-]Yes [~No B. WiLL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR. PART 617.67 If No. a negative declaration may be superseded by another involved agency, C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, ,otential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natumr or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, sign~cant habitats, or threatened or end'angered species? Explain bdefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly C5 Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain bdefly: C6. Long term, short term, cumulative, or other effects not identified in C1~;57 Explain bdefly: C7~ Other impacts (including changes in use of either quantity or type of energy? Explain edefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? (If yes, explain bdefly: E, IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: F--'] Yes F"--~ No PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadversee~ectident~~edab~ve~determinewhetheritissubstantia~~~arge~imp~rtant~r~therwisesigni~cant~ Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duratbn; (d) irreversibility; (e) geographic scope; and (t) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that a~l relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significence must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed acbor WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi.. determination Name of Lead Agency Date Pdnt or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: 1. W~r~. ~ ....... Annie Croon 2500 Ole Oule Lane, Mattituck NY 11952 [athleen D. O'To~le U.S. Postal ServiceT~ m~ CERTIFIED MAIL,M RECEIPT p. P- (Domestic Mail Only; No Insurance Coverage Provtded) and 55 Locust Street, Floral Park NY 11001 4175 Ole Jule Lane, Mattituck NY 11952 [gat 2400 Ole Jule Lane. l~atttt,,el* tuly sworn, deposes and says that on the d~onent mailed a true copy of the Notice 11952 ~uthold; that said Notices were mailed at the United States Post ,, that said Notices were mailed to each of said persons by '?~';~-~'~':~-~_J:~-.'"'i'~'~'3-~ ........................... ~on, directed to each of the above named ~'"'~' '"~ address of said sho~ ~e c~t p~o~ on r$ 4.uo Oestinat~on: 1100~ Weight: O,70oz P~f~n~ Tvne: PVI (ce~ified) ~e~) mail. Sworn to before me this Day of 3uly ,20 04 RICHARD F. LARK 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 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, Robert White , residing at 2400 Ole Jule Lane, Mattituck NY 11952 being duly sworn, depose and say: That on theqO~-day of July ,200 4, I personally posted the property known as 2400 Ole Jule Lane, Mattituck, New York 11952 by placing the Board of Trustees official poster where it can easily be seen, and that I have checked to be sure the poster has remained in place for eight days prior to the date of the public heating. Date of hearing noted thereon to be held {j It~l.~,~ u.u4 Dated: July~ , 2004 mgnature) bert~ WI~i t ~- Sworn to before me this ~ ~'day of JulY200 4 N~ary Public NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: (~ O be~' ~r bO ¼, ~-~_. SCTM# YOU ARE HEREBY GWEN NOTICE: 1. Iooo-laz-oq-I~ 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: That the project which is subject to Environmental Review under Chapters 32, 37, and/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: MA1LING ADDRESS: r~H t~ck- PHONE#: Enc: Copy of sketch or plan showing proposal for your convenience. NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: ~0 bec ~r {.k) h ~ J-e_ SCTM# YOU ARE HEREBY GiVEN NOTICE: io00- t2_2.-oq- Il 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: That the project which is subject to Enviromnental Review under Chapters 32, 37, and/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: 65 L. oc~o~t ~T, PHONE#: Enc: Copy of sketch or plan showing proposal for your convenience. PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name~ ~ c~n~ue end Ud.~rrer~ C) Toole Address: STATE OF NEW YORK COUNTY OF SUFFOLK ~ob¢-r/- vt~¼~[c: , residing at 2qoo ©lc ~-ule Le imfll+~cIc- ~-',/· , being duly sworn, deposes and says that on the day of ,206q-, 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 , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to before me this Day of ,20__ Notary Public Board of Trustees Application County of Suffolk State of New York .-, __ .~ 0 ~x2(% ~-~ }3 1 '~-~._ BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE 1N 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. Signature SWORN TO BEFORE ME THIS [ ~' DAY ,20~'/-7/ Notary Public No 01DI4835190 - 8ul~ C,o~ ~ ~ims ~. 31, ~ · ' Boar~)f Trustees Application AUTHORI ZA~ION (where the applicant is not the owner) ROBERT WHITE (print owner of property) Mattituck, New York 11952 residing at 2400 01e Jule Lane, (mailing address) do hereby authorize Richard F. Lark (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. Robert White 8 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics orohibits conflicts of interest on the part of town officers and employees. The purpose of this form is to I~rovide information which can alert the town of ~ossible conflicts of intarest and allow it to take whateve~ action is neeessarv to avoid same. YOURNAME: Richard F. Lark (Last name, first name, middle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Cheek all that apply.) Variance Change of Zone Approval of plat Exemption from plat or official map Other (If "Other", name the activity.) Permit from Board of Trustees Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, marriage, or business interest. "Business interest" mea~s a business, including a partnership, in which the town officer or employee has even a partial ownership of(ur employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO X If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicantTagent/represantative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): A) the owner of grenter than 5% of the shares of the corporate stock of the applicant (when the applicant is a coq~oration); B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a colporafion); __.C) an officer, director, pa.-mcr, or employee of the applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSHIP SubmiRed this ~y of July Signature PrintName~/ Richard F. Lark 200 4 Board of Trustees Application County of Suffolk State of New York ~©1o(:'¢ [ [.~13 i~ ~. BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), 1]? 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. Signature SWORN TO BEFOREME THIS / ¢' DAY ,20 t:~ Notary Public APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics t~rohibits conflicts of interest on the Dart of town officers and emvlovees. The purvose of this form is to vrovide information which can alert the town of vossible conflicts of interest and allow it to take whatever action is necessar~ to avoid same. (Last name, first name, .middle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zune Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (lf "Other', name the activity.) Do you personally (or through yoar comgxany, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, marriage, or business interest "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of (or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO L/// If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicant/agenffrepresentative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): A) the owner of greater than 5% of the shares of the corporate stock of the applicoat (when the applicant is a corporation); ~B) the legal or beneficial owr~r of any interest in a non-corporate entity (when the applicant is not a corporation); C) an officer, director, partner, or employee of the applicant: or __D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 Submitted tlfls-q l ~' ,day. of. ~ _200 ~ ~/ Signature.~?~ ~' . PrintName_ ~0 ~Dq r'~ -~'J~xl APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and emolovees. The ours~se of this form is to omvide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. (Last name, first name, middle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If "Other'L name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) bare a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, marriage, or business interest. "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of (or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO ~ iff If you answered "YES", complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applican~/ngent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): __.A) the owner of greater than 5% oftbe shares of the corporate stock of the applicant (when the applicant is a corporation); B) the legal or beneficial owner of any interest in a non-corporate entity (when the applicant is not a corporation); __C) an officer, diroc~r, parlner, or employee of the applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS 1 tint amc 200_ p'