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HomeMy WebLinkAboutTR-6117Albert J. ,Krupski, President James King, 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 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 ½ constructed Project complete, compliance inspection. Board Of $outhold Town Trustees SOUTHOLD, NEW YORK ISSUED TO .....~7.~ w~_~ _ .......................... Pursuant to the provisions of Chapter 615 of ~e the Sta~ of New Yor~, 1893, and ~apter ~ of ~e ~ of the State of New York 19~21 end ~e So.hold To~n t~ed ."R~TIN~ ~D ~E~P~CIN~ OF OB~RUG~S IN AND ON TOWN WATERS AND PUBU~ ~DS RE~OVAL OF SAND, ~VEL. OR OTHER ~NDS .UNDER TOWN WA~RS:~, and in acc~an~ w~h 'the Resol~ion of ~e Board ~dopted et e meeting he~ on .2~.~..., ~nd in c~nslder~fi~ of the sum of ~......~.~,9~.99..... peld by ~ete~ ~a~ of ................ ~.~.~.~. ........................ ~........~ ................... N, Y. ~nd *ubieet ~o the Terms end ~ndlflom listed on ~e ~ve~e side ~of .of ~thdd To~' T~es e~horlzes end ~mlN ~ fo~owin9: ex~t~ ~oot~t, ~t6 C~e co~t~on ~els a~d gutters ate Juj~. 28, 20~5. ·_ ag m a~orda~e ~th f~ defa~d Sp~fions · ~e ~gi~flng appfi~fi~. IN W~S WHERe, %e ~Id B~rd Of T~dees ~re- by ~s ~ ~rate ~al to be a~xed, and ~e~ ~senh to be su~ed by ~'~j~ of ~ sald ~rd .as of thh darn. o iwoa -' T~ees TERIdS ,nd CONDITIONS Peter Warns ~nt 8740 Peconic Bay Blvd., Laurel.. , ,, · ......... N. Y~ ~ L That Ihe said .]Bo~ ~ T~ ~ ~e T~ ~ ~d ~ ~ f~ ~ ~ odzed. ~ m rigs t~n~t v~ nay-I~ Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Seuthold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 April 20, 2005 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Willam C. Goggins, Esq. 13105 Main Rd. P.O. Box 65 Mattituck, NY 11952 RE: PETER WARNS 8740 PECONIC BAY BLVD., LAUREL SCTM#126-5-2.1 Dear Mr. Goggins: The Board of Town Trustees took the following action during its regular meeting held on Wed., April 20, 2005 regarding the above matter: WHEREAS, William C. Goggins, Esq. on behalf of PETER WARNS 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 Mamh 9, 2005 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 April 20, 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, 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 PETER WARNS to renovate the existing dwelling on the existing footprint, with the condition drywells and gutters are installed to contain the roof run-off, and all as depicted on the survey prepared by Daniel P. Jedlicka received in our office on July 28, 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: $50.00 Very truly yours, Albert J. Krupski, Jr., President Board of Trustees AJK/Ims Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poiiwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: Please be advised that your application dated reviewed by this Board at the regular meeting of following action was taken: has been and the ( v'~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: $. h'm,Ob SIGNED: PRESIDENT, BOARD OF TRUSTEES F/LE NO. 1000 ~ t26 ~ 5- 2.. 1 SCALE,. 1" = 20' DA TE..'7 / (631) 472-4243 DANIEL p. JEDLIOKA ~OFE$$/ONA£ LAND SURVEy N. y. 3. L/C. NO. 50098 Telephone (631) 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 Mon., April 11, 200§, the following recommendation was made: Moved by Don Wilder, seconded by Jack McGreevy, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH CONDITIONS of the Wetland Permit application of PETER WARNS to renovate the existing dwelling. Located: 8740 Peconic Bay Blvd., Laurel. SCTM#126-5-2.1 The CAC recommends Approval of the application with the Condition there is no change to the existing footprint, and gutters and drywells are installed to contain the roof run-off. Vote of Council: Ayes: All Motion Carried 12/09/2@04 13:16 63129E WILLIAN C GOGGOPC PAGE 01 WILLIAM C. GOGGI.NS~ P.C. AT-_FORNEY AND COUNSELOR AT LAW i3105 Main Road P,O, Box 65 Mat~mck, Hew York 11952 Phone: (631) 29~1200 Fax: (631) 298-4214 Via Fax 765-6641 December 9, 2004 Board of Trustees of the 'town of Southold 53095 main Road Southold, New York 11971 Peter Warns; SCTM No. 1000-126.00-05.00-002.001 8740 Peconic Bay Blvd, Laurel, New York Dear Sir/Madam: Please be advised that this firm represents Peter Warns in the renovation of his above referenced property. The proposed construction ig 64 feet from the bulkhead and 100 feet from the mean high tide level. Pursuant to section 97-12 (c), the construction is outside of the jurisdiction of the Trustees. Enclosed please find a survey and the Notice of Disapproval from the Building Department. We seek a letter confirming the Board's lack of jurisdiction. Please advise. Thank you. WCG/dmp enclosures WILLIAM C. C~OlNS _.12/09/2804 13:16 63129 WILLIAM C GOGG~c FOILM NO. 3 NOTICE OF DISAPPROVAL DATE: September 20, 2004 PAGE 02 TO: East End Desigll Associates A/~C Peter Warns// 5130 Main Bayvicw Road \ Southold, NY 11971 Please take notice that your application dated September 15~ 2043 For permit for additions and a!teratio~_ns to an ex_i_sting sintle familv dwellin~ at Location of property 8740 PeconicBav Blvd.~Laurel County Tax Map No. 1000 - Section 126 Block5 Lot 2-,1 Is returned herewith and disapproved on the following grounds: The nrot>osed construction, on this non-conf_o~rmimt 31.450 sauaret'oot lot. in the R-40 District. is not ~rmitted ~ursuant to Article XXIV Section 100-242A which states: "Nothinz in this article shallbe deemed~o vrcvent the remodeling~reconstmction or enlargement ofa non~onformim, builxlinz contai~in~ a con£ormitl~ use. nrovided that such action does not create ant new non-conformance or incre~e the dc~,mc of non-conformance with re*,',~l to the regulations p~rtainin~gto suchbuildings." The cxistine sin~le-fanxilv dw~ing has a.sin~le side yard~sethaek of+/- 3..5. feet. Followin~ the ~rono~ed addition, the sinp_/e-familv dwelline wall maintain that sethack. Pursuant to the intcror¢tation in Walz (g5309% 8ueh~dditions and alteration, will thus constitute an increase in the degree of non-conformance. Thercfore~the ore_dosed ooustmction ~is not vcrmitted Oumuant to Article XXIV. Secti~n100-244, which states that non-conformi~ lots. measurinz between 20.000 square feet anf139,999 scluare feet in ~otal size. reauire a minimum single side yard setback o[15 fe~t. In addition, the oroo. osed constx_action is not vermitted oursuant to A~icle XXIll Section 100-239.4B which stateg "All buildings locatgll on lots unon which a bulkhead, concrete wall. rivral~ or similar..stmcture exists~nd which are adiacent to tidal water bodies other than ~punds shall be set back.not less than seventh-five (75~ feet from the bulkhead."  ~s.~t!'u_ction remesen~ +/- 64 foot setback from the existing wood bulkhead. Damon R~allt~( Exanfiner O,_ z ~ LOT I /--- .~.~' 4A~' 374'DEED ~ 364.8D' F.M_ CERTIFIED TO: PETER WARNS DANfEL P. JEDUCKA FILE NO. 1000 - 126 - 5 - 2.1 SCALE: 1"= 20' DATE:7/15198 (631) 472-4243 N. Y.S. LIC. NO. 50098 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, NewYork 11971-0959 Telephone (63I) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD January 11, 2005 Mr. William Goggins, P.C. 13105 Main Road P.O. Box 65 Mattituck, NY 11952 Re: 8740 Peconic Bay Blvd, Laurel SCTM# 126-5-2.001 Dear Mr. Goggins, The Trustees are in receipt of your request for no jurisdiction concerning the above referenced property. As per field inspection we have found the house to be approximately 85' to mean high water, which is within our 100' from mean high water jurisdiction. Renovation of the existing house will require a permit from the Board of Trustees. Very Truly Yours, President, Board of Trustees AJK/hct 11/15/04 Field Inspection 11/15/04 Field Inspection 11/15/04 Field Inspection EX~STING HOUSE PLAN OVERLAYED ON NEW FIRST FLOOR L~N~ O~ A~OmON TO / PROPERI~ SETBACK ~S~ S,DE O~ UOUS~ FRONT (ROAD SIDE) ELEVATION PROPERTY SETBACK LINE OF ADDITION TO EAST SIDE OF HOUSE REAR (WATER SIDE) ELEVATION 75' PROPERTY SETBACK LINE LEFT ELEVATION 75' PROPER?( SETBACK LINE AREA NOT IN QUESTION AREA NOT IN QUEET[OM AREA NOT IN QUESTION EXISTINGAREA ~ ' - ~ RIGHT ELEVATION IT PROPE 'IRTY5 'SETJ~AC K IT IS ]~IE CONTRACTOR~ RESPONSIBU]'( TO HAVE AN ENGINEER INSPECT AND CERTIFY THAT THE CONDITION OF THE FOUNDATION WILL MEET OR EXCEED ALL STATE AND LOCAL BUILDING CODE REQUIREMENTS OR IF IT WILL REQUIRE THE FOUNDATION TO BE REPAIRED OR REPLACED. FIRST FLOOR PLAN 15: S]~COHD FLOOR PLAN W~ILLIAM C. GOGGINS, P.C. A TTORNEY AND COUNSELOR AT LAW 13105 Main Road P.O. Box 65 Mattituck, New York 11952 Phone: (631) 2984200 Fax: (631) 298-4214 WILLIAM C. GOGGINS July 28, 2005 DONNA M. PALMER Paralegal Board of Trustees of the Town of Southold P.O. Box 1179 Southold, New York 11971 Re: Peter Warns Premises: 8740 Peconic Bay Boulevard, Laurel, New York 1000-126.00-05.00-002.001 ~.~ Dear Sir/Madam: ~ Enclosed please find the su~4reflect~, g the location of the dry wells and the $50.00 fee for iss~the penmt. If you have any qu~, please do not hesitate to contact the undersigned.  ~ Very truly yours, WCG/dmp {~)~-dL 0~,%~__3 ,JUL 2 8 ~ Southold Town I~oard of Trustees GOGGINS & PALUMBO ATTORNEYS AND COUNSELORS AT LAW 13105 Main Road P.O. Box 65 Mattituck, New York 11952 Phone: (631) 298-4200 Fax: (631) 298-4214 WILLIAM C, GOGGINS ANTHONY H. PALUMBO March 8, 2005 ~~ Board of Trustees of the Town of Southold P.O. Box ~79 I11 tll aot~ , n ~,~ Ill 1, Southold, New York 11971 [ ~l~d Re: Peter W~s ~ ~e~ses: 8740 Peco~c Bay Bo~ev~d~a~el~ew ~ 1000-126.00-05.00-002.001 ELMER Dear Sir/Madam: Enclosed please find the $50.00 fee for issuance of the permit. If you have any questions, please do not hesitate to contact the undersigned. WC~dmp 0~282~ Dollars $ ~._~: 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) BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD __Coastal Erosion Permit Application ~"Wetland Permit Application Amendment/Tran~ fer/Extension ~Rece~vved Application: .~]C~ ~.~---aXeceived Fee:S_ f~ ~0-~ ~ompleted Application_ ~!Q ~lncomplete __SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) ~AC Referral Sent: ~_~Date of Inspect/on:~%- __Receipt of CAC Report: __Lead Agency Deterrmnation: __Technical Review: Resolution: Office Use Only _ Administrative Permit Name of Applicant Peter Warns Address 8740 Peconic Bay Blvd., Laurel, New York Phone Number:( ) c/o 631-298-4200 Suffolk County Tax MapNumb~: 1000- 126.00-05.00-002.001 Prope~yLocation: 8740 Peconic Bay Blvd., Laurel, New York (provide LILCO Pole #, distance to cross s~eets, and location) AGENT: William C. Goggins, Esq. (If applicablO Address: P.O. Box 65, 13105 Main Road Mattituck, New York 11952 Phone:_ 631-298-4200 Board of Trustees Applicgion Land Area (in square feet):. Area Zoning: R-40 GENERAL DATA 30,940 Previous use of property: Intended use of property: One Family Residential One Family Residential Prior permits/approvals for site improvements: Agency Date 0~¢.~ x Not. prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? x No Yes If yes, provide explanation: Project Description (use attachments if necessary): Renovation of Existing Structure 64.357 feet from the existing bulkhead and 104.00 feet from mean high tide. Board of Trustees Ap~ .on WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: co expand living space no closer than the existing structure Area of wetlands on lot: 0 square feet Percent coverage of lot: 15 % Closest distance between nearest existing structure and upland edge of wetlands: 25 feet Closest distance between nearest proposed structure and upland edge of wetlands: 100 feet Does the project involve excavation or filling? x No Yes If yes, how much material will be excavated? ID cubic yards How much material will be filled? O cubic yards Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: 6i'5 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): NONE Board of Trustees Applicglon County of Suffolk State of New York WILLIAM C. GOGGINS BEINGDULY SWORN DEPOSES AND AFFIRiVIS 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), 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 OK.THIS APPLICATION. Signature/~ SWORN tO BEFORE ME THIS DAY OF 'l~e,'~l~ia~ _,20 0L4' Notary Public OONNA M. PALMER NotaW Public, State of New York 1 PA5069978, Suffolk Ooant~1 No. 0 "- 9 "'/3 / / r~©mm!ss on Ex oires December PROJECT ID NUMBER 617,20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 - PROJECT INFORMATION ( To be completed by Applicant or Project Sponsor) I APPLICANT/SPONSOR (2. PROJECT NAME PETER WARNS 3 PROJECT LOCATION: SOUTHOLD County SUFFOLK 4 PRECISE LOCATION: Street Addess and Road Inlerseclions, Prominent landmarks etc -or provide map 8470 Peconic Bay Blvd., Laurel, NEw YOrk 5 IS PROPOSED ACTION: [~ New ~-]Expansion~Modificalion/alteration 6. DESCRIEE PROJECT BRIEFLY: SEQR Renovation of single family dwelling 7. AMOUNT OF LAND AFFECTED: Initially , 7.~ acres Ultimately . 75 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? []Yes [] No If no, describe briefly: ZBA Application pending 9 WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) [-~Residential [~lndustrial ~]Commercial DAgriculture []ParklForest/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: Aoning Board of Appeals 11, DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? []Yes J'~No If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION W,LL EXISTING PERMIT/ APPROVAL REQU,RE MODIFICATION? [~]Yes [~No I CERTIJ~Y ~'HAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Spons~r/~SignatureI /~ ~_ te~lliam_Ii C. Goggins, Date: 3/8/05 If the action I~lVa 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 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, sudace or groundwater quality or quantity, noise levers, existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain bdetly: C2 Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: 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 briefly: , C6. Long term, short term, cumulative, or other effects not identified in C1-C57 Explain briefly: C7, Other impacts (including chan~es in use of either (juantib//or t},pe of energy/? Exjplain bdefl¥: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRO film E NTAL ARF~ ~CEAI? Ill }ras, explain briefly/: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? if ~'es explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadvemee~ectidenti~edabeve~determinewhetheritissubst~ntiaI~~arge~imp~rtant~r~therwisesigni~cent- Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b} probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, th e determination of significa ncc must evaluate the potential impact of the proposed action on the environ mental 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 FULI~ 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 actlo, 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 Title of Responsible Officer Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from responsible officer) F'C F'GGE ~ AFFIDAVIT Re · Peter Warns 1000-126.00-05.00-002.001 8740 Peconic Bay Blvd., Laurel, New York STATE OF NEW YORK ) )SS: COUNTY OF SUFFOI,K) PETER WARNS, being duly sworn, deposes and says: 1. I am the owner of the above referenced property, and I hereby authorize William. C. Goggins, Esq. to act as my agent and to handle all necessary work involved in the renovation and construction of my house including an application before the Zoning Board of Appeals, Board of Trustees and the Health Department. PETER WARNS Sw. gyn to before me this day of December, 2004 //~IL~'~., ,~. ~/>L~,~ /''1 ' ' NOTAR/f ~UBLIC NOi'ARY I~iUC OF N~W Commt~ion Expl~e~ APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold'~ Code of Ethics nrohibits conflicts of interest on the oart of town officers and emolovees. The ouroose of thi~; form i~ to provide information which can alert the town of~ossible conflicts of interest and allow it to take whatever action is necessary to avoid same, YOUR NAME: I,/ARNS, PETER (Last name, first name,~iddle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate the other pemon'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 Mooting Exemption from plat or official map ' Planning Other (lf"Other", name the activity.) 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 intere~ "Bttsiness interest'? means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by) a coq~orafion in which the town officer or employee owns more than 5% of the shares. YES NO ~', lfyou 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 applicanffagen~representative) and the ~own 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 ofgreator than 5% of the shares of the corporole stock of the applic0nt (when the applicant is a corporation); B) the legal or beneficial own,r of any interest in a non-corporate entity (when the applicant is not a corporation); __C) an officer, director, parmer, or employee of the applicant; or __I)) the actual applicant. DESCRIPTION OF RELATIONSHIP OWILLIAM C. GOGGINS, P.C. ATTORNEY AND COUNSELOR AT LAW 13105 Main Road P.O. Box 65 Mattituck, New York 11952 Phone: (631) 298-4200 Fax: (631) 2984214 WILLIAM C, GOC, GINS March 8, 2005 DONNA M. PALMER Paralegal Board of Trustees of the Town of Southold P.O. Box 1179 Southold, New York 11971 Re.' Peter Warns Premises: 8740 Peconic Bay Boulevard, Laurel, 1000-126.00-05.00-002.001 Dear S/r/Madam: Please be advised that this firm represents Peter Warns in connection with the renovation of his above referenced residence. Enclosed please find the following: Application; Short Environmental Assessment Form; Authorization to act; Copy of drawings reflecting the proposed construction; A check in the amount of $250.00 If you have any questions, please do not hesitate to contact the undersigned. WCG/dmp