HomeMy WebLinkAboutTR-5123
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TERMS and CONDITIONS
The Permittee
David and Ann Corieri
residing at
part of the consideration
lowing:
155 Brompton Rd., Garden City N. Y., as
fot the issuance of the Permit does undetstand and prescribe to the fol-
1. lbat the said Board of Trustees and the Town of Southold are released from any and
aU damages, or claims for damages, of suits arising directly or lndirecdy as a result of an.y oper-
ation performed pursuant to this permit, and the said Permittee will, at his or her own expense,
defend any and all such suits initiated by third patties, and the said Permittee assumes full 1Jabl1iry
with respect chereto, to the complete exclwion of the Board of Trustees nf the Town of Southold
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2. lbat this Permit is valid for a period of 24 mos. whith is considered to be the
estimated time required to complete the work involved, but should circumstances warrant, request
for an extension may be made to the Board at a later date.
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3. 111at this Permit should be retained indefinitely, or as long as the said Permittee wishes
to maintain the structUCe or project involved, to provide evidence to anyone concerned that auth.
orization was originally obtained.
4. lbat the work involved will be subject to the inspection and approval of the Board or
its agents, and non-compliance with the provisions of the originadog appUcatloo, may be canse for
revocation of this Pennit by resolution of the said Board.
5. lbat there will be no unreasonable interference with navigation as a result of the work
herein au'dlorized.
6. That there shall be no interference with the right of the public to pass and repass along
the beach between high and low water marks.
7. lbat if future operations of the Town of Soutbold require the removal and/or alterations
in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the
work shall cause unreasonable obsttuCbon to free navigation, the said Permittee wiU be requited,
upon due notice, to remove or alter this work or project herein stated without eapeoses to the Town
of Southold.
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8. lbat the said Board will be notified by the Permittee ot the completion of the work auth-
orized.
9. That the Permittee wiU obtain aU other permits and consents that may be required sap-
plemental to this permit which may be subject to revoke upon failure to obtain same.
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Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-18lJ2
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
March 9, 2000
-
Mr. Robert E. Herrmann
En-Consultants, Inc.
1329 North Sea Rd.
Southampton, NY 11968
..
Re: DAVID & ANN CORIERI
SCTM#l23-7-9.2
Dear Mr. Herrmann:
The following action was taken by the Board of Town Trustees
during its regular meeting held on February 24, 2000 regarding
the above matter:
WHEREAS, En-Consultants, Inc. on behalf of DAVID & ANN CORIERI
applied to the Southold Town Trustees for a permit under the
provisions of the Wetland Ordinance of the Town of Southold,
application dated January 31, 2000, and,
WHEREAS, said application was referred to the Southold Town
Conservation Advisory Council for their findings and
recommendations, and,
WHEREAS, a Public Hearing was held by the Town Trustees with
respect to said application on February 24, 2000 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 standard set forth in
Chapter 97 of the Southold Town Code,
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WHEREAS, the Board has determined that
will not affect the health, safety and
people of the town,
the project as proposed
general welfare of the
NOW THEREFORE BE IT,
RESOLVED, that the Board of Trustees approve the application of
DAVID & ANN CORIERI to remove and replace (inkind/inplace) (2)
+/-50' existing timber groins with vinyl groins, as shown on
survey dated August 19, 1998 and last revised January 26, 2000.
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 it is signed. Fees must be paid, if applicable,
and permit issued within six months of the date of this
notification.
Two inspections are required and the Trustees are to be notified
upon completion of said project.
Fees: None
Very truly yours,
~ 9. /&"-f'~' ~.
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/lms
cc: DEC
ACE
Dept. of State
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EN-CONSULTANTS, INC.
1329 North Sea Road
Southampton, New York 11968
631-283-6360
Fax: 631-283-6136
E-mail: encon@peconic.net
www.enconsultants.com
ENVIRONMENTAL SERVICES
Board of Trustees
Town of Southold
53095 Main Road
Southold, NY 11971
m rn @J n \L~Jn\ I
lill ~AR - 9 2000
March 7, 2000
~~~__~~_.~"a
RE: David and Ann Corieri. 412 Park Avenue. Mattituck
Members of the Board:
As requested during your regular meeting of 24 February 2000, please fmd enclosed (3) copies
of a survey depicting the existing height differential between the top of the bulkhead and each
groin to be removed and replaced (in-kind/in-place).
Although I trust this information will allow you to issue your permit, please contact me if you
require any further information.
Respectfully y
7
~/
""-
-;--,....
Robert E. Herrmann
Coastal Management Specialist
Enclosures
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DAVID AND ANN CORIERI
412 PARK AVENUE, MATITfUCK
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Figure J. uHJking west at (2) timber groin.. to be replaced (ip) with vinyl groin...
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Figure 2. Looking ea.t at (2) timber groins to be replaced (ip) with vinyl groin....
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DAVID AND ANN CORtERt
4t2 PARK AVENUE, MA1TITUCK
ill( ~N ~ :;~~
TOWN OF SOUTHOLD
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Figure 3. Looking north over newly con.\tructed vinyl groin fronting adjacent property to w01.
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NY5I7E'C Jtrlsdlctlc>1 p.rsual!; to flda
Wel:l~ ~etter of Nc>1-jIrlsdlctlc>1
No, 1-41;.(3-020;'7/ ()(X)(J7,
dated 20..LI4 1999
6 , Project locatlc>1:
1. AdJacenI; Owners:
I _ HcJrnan
2 -9teeha-J
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EN-CONSLJl1ANTS INC,
1329 NORTH SEA RD,
SOUTHAMPTON, N,Y, 11968
516-283-6360
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- - - - - - PROPOSW c:iROIN KrMOV A!- &
KrPlACfMfNi (IP) fOR DAVID & ANN
CORlfRI ON c:iKrAl PfCONIC ~AY,
MAn1111CK, SUffOlK CO" NY
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~ 1329 NORTH SEA RD.
SOUTHAMPTON, N.Y. 11968
516-283-6360
PROPOseD CAROIN i'rMOV.AJ... &
i'rPL-ACt:Mt:Nf (IP) fOR DAVID & ANN
CORnl ON CAi'rAf Pt:CONIC ~A Y,
MAf1l11JCK, 5UffOL-K CO" NY
5HEU 2 Of 2 1/12/00
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----. PROPOseD c:iROIN t<l;:MOV,AL. &
RE:PlACE:ME:Nf (IP) fOR DAVIt? & ANN
CORIE:RI ON c:it<l;:Af PE:CONIC ~AY,
MAfll11JCK, SUffOlK CO" NY
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Wetla>:Js ~ei:I'a- of Nc>1-jrl5dictlc>1
No. 1-o41,,s-020??! 0CXXJ1.
dated 20 J.J4 1999
6. Pr()ject locaI;lc>1:
1, Ma::enl; Ow,..,...:
1 - Hdmal
2 -5heeha-J
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PI.r.ONSlJLTANTS we.
] ??9 NORTH SEA RD.
S')UTHAMPTON, NY. 11968
516283.6360
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il:f 137<) NOnTH SEll RD.
S()lmW:~PTON, N~Y. 11968
51 fj~783 6360
PROPOSfD (AROIN Rt:MOV/i. &
Rt:Pl.-A(lM~N1 (IP) fOR DAVID & ANN
CORIeR! ON (ARt:Ai P~CONIC rJAY,
MAl11rucK, 5UffOl.-K CO" NY
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NY5I?E:C jtrlsdld:i", 1"T5Ua1t to -rida
Wetlands letter d' NGl1-jIrIsdlctlGn
No. H1?8-0207'7/ 0CXXJ1.
dated 20 J.Jy 1999
6, Pr()ject l<>:atl""
7, Adjacent Owners,
I - Hdman
2 -5I1eeha,
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EN-CON:-I" T M.JTS INC.
1329 NIY" ~[^ RD.
SOUTH~iMrr:)~I, NY. ]]968
516-283-63:):}
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PROPOseD c:iROIN KfMOVPJ.- &
KfPlACfMfNf (IP) fOR DAVID & ANN
CORlfRI ON c:iKfAf PfCONIC I?AY,
MAfl111JCK, SUffOlK CO" NY
SHfff I Of 2 1/12/00
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EN CONSUlTANTS INC.
J 329 NORTH SEA RD.
SOUTHAMPTON, N.Y. 11968
516-283-6360
PROPOSl;D GROIN ?iMOVIi- &
?iP~ACr:Mr:Nf (IP) fOR DAVID & ANN
CORIr:RI ON G?iAi Pr:CONIC rPAY,
MAil111JCK, SUffO~K CO" NY
51-Ui2 Of 2 1/12/00
--~ 'J-
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Telephone
(516) 765-1SC12.
Town Hall. 53095 Main Road
P.O. Box 1179
Southold. New Yark 11971
SOUTHOLD TOWN
CONSERVATION ADVISORY COUNCIL
At the meeting of the Southold Town Conservation Advisory Council held Tuesday, February
15, 2000, the following recommendation was made:
Moved by Bill McDermott, seconded by Bret Hedges, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the
Wetland Permit Application of DAVID & AJ."\IN CORIER! 123-7-9.2 to remove and replace
(inplace) (2) +/-50' existing timber groins with vinyl groins
412 Park Ave., Mattituck
Vote of Council. Ayes: All
Motion Carried
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EN- CONSULTANTS, INC.
1329 North Sea Road
Southampton, New York 11968
516-283-6360
Fax: 516-283-6136
E-mail: encon@peconic.net
ENVIRONMENTAL SERVICES
January 26, 2000
--- -,
ill[ ~:3 ~ :"J"
TOW~' ('i: C::'., :
ii~\~ \.)1 v~'.-___
Town of Southold
Board of Trustees
Post Office Box 1179
Southold, New York 11971
Attn.: Diane Herbert
Re: David & Ann Corieri
412 Park Avenue, Mattituck
SCTM #1000-123-7-9.2
Dear Ms. Herbert:
In regard to the above referenced property, enclosed are the following for the Board of Trustees review:
I. Three (3) Wetland Permit Applications,
( including Notice and Proof of Mailing to adjacent owners).
2. Three (3) Short Environmental Assessment Forms.
3. Three (3) copies of authorization & disclosure forms.
4. Three (3) work plans.
5. Three (3) copies of survey.
6. One (I) set of site photographs.
7. Application fee of$150.00.
I trust this information shall allow you to process our permit request. Should any additional information
be required, please do not hesitate to contact our office.
I
o ann
Coastal Management Specialist
/khs
Enc.
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Robert C. Sheehan and Elizabeth M. Sheehan
640 Park Avenue (at Marratooka Road)
Mattituck, New York 11952
,," _.-::-'-~"."'-1
m( ~ "z : :
TOWN OF SOUTi:,~,'
Board of Trustees
Town of Southold
Town Hall
P.O. Box 1179
Southold, New York
11971
Re: Permit Application
David and Ann Corieri
SCTM #1000-123-7-9.2
Ladies and Gentlemen:
We are writing in connection with the application submitted by David
and Ann Corieri to the Board of Trustees of the Town of South old for permission to
remove and replace two (2) timber groins with two (2) vinyl groins at their above-
referenced property. We are the adjacent property owners to the east of the Corieris.
We fully understand the Corieri's need for the replacement groins
considering the erosion that their property has suffered due to the construction of the
three (3) jetties (or groins) on the Holman property located adjacent and to the west
of the Corieri property. Thus, we have no objection to the Trustees granting ap-
proval of the Corieri application as shown on the plan dated 1/12/00 prepared by En-
Consultants Inc.
We feel it is important, however, to point out that the reconstruction
of the groins at the Corieri property will undoubtedly have a profoundly negative
effect on our property in terms of erosion, just as the construction (styled as a
reconstruction) of the jetties (or groins) at the Holman property had a negative effect
on the Corieri property - in essence, as "domino" effect. Accordingly, upon the
Corieri permit being granted, we will be in the position of having to undertake
similar construction at our property. Thus, we reiterate our support for approval of
the Corieri application on the express condition or understanding that the Trustees,
recognizing the "domino" effect, will similarly approve our forthcoming request for
comparable reconstruction of groins at our adj acent property.
.
.
.
One additional point of observation - we recognize that it is in
everyone's best interest to keep the dimensions of all jetties or groins to the minimum
necessary to accomplish their purpose so as not to exacerbate the deleterious effect
on neighboring properties. In this regard, we suggest that the Trustees might want to
verify that the jetties constructed immediately to the west ofthe Corieri property
properly conform to the dimensions earlier authorized by the Trustees - - as we will
need jetties (or groins) as long and as high as the Holmans' to retain our "fair share"
of the beach.
Very truly yours,
;/
/?,p~~ ), J;~
Elizabeth M. Sheehan
/}
/t~ t:~~~~~-
Robert C. Sheehan
309202.01-New York S4A
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GJ COUNTY OF SUFFOLK
Real Property _Tax Servic~ A~~_~cy
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Alben J. Krupski. President
John Holzapfel, Vice President
Jim King
Martin H. Garrell
Peter Wenczel
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
uffice Use Only
Coastal Erosion Permit Application
~etland Permit Application
Grandfather Permit Application
---waiver/Amendment/Cha~es
~eceived Application: 1131. D
"Recei ved Fee: $ I Sb. ,
vt:ompleted Application ,j ;"I./lf&
Incomplete .
SEQRA Classification:
Type I Type II Unlisted
Coordination:(d~sent) ----
~CAC Referral Sent: '~/~~
ate of Inspection: ~ I
Receipt of CAC Report:
Lead Agency Determination:
Technical Review:
~ublic Hearing Held:~/~a/DO
Resolution:
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UUI JAN 3 I 2000
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Name of Applicant
Address
David & Ann Corieri
~5~ Brompton Road
Garden City, NY 11530
Phone Number: (516)
742-0961
Suffolk County Tax Map Number: 1000-
123-7-9.2
Property Location:
412 Park Avenue, Mattituck
(provide LILCO Pole #, distance to cross streets, and location)
AGENT:
(If applicable)
En-Consultants, Inc.
Address:
1329 North Sea Road
Southampton, NY 1196~
Phone: 631-283-6360
FAX#: 631-283-6136
1
~d of Trustees APplicatioJlt
GENERAL DATA
Land Area (in square feet) : 57,117.45
Area Zoning: R-40
Previous use of property: Residential
Intended use of property: No Change
Prior permits/approvals for site improvements:
Agency
'Date
7/99
7/99
NYS DEC
Southold Trustees
No 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):
Remove & replace (in-place) (2) iSO' existing timber groins
with vinyl groins.
2
B~ of Trustees APplication~
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:Maintain stabilized shorefront.
Area of wetlands on lot:
o
square feet
Percent coverage of lot:
N/A
%
Closest distance between nearest existing structure and upland
edge of wetlands: N/A feet
Closest distance between nearest proposed structure and upland
edge of wetlands: N/A feet
Does the project involve excavation or filling?
x
No
Yes
If yes, how much material will be excavated? N/A
cubic yards
How much material will be filled?
N/A
cubic yards
Depth of which material will be removed or deposited: N/A
feet
Proposed slope throughout the area of operations: N/A
Manner in which material will be removed or deposited:
N/A
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):
The proposed groin replacements will maintain the stabilized
shorefront and help to reclaim some of the beachfront lost
as a result of the construction of the new vinyl groin to
the west. The project will have no adverse impacts on
Town waters; there are no vegetated wetlands present on-site.
3
14-1&-4 (2/87)-'Text 12
I' PROJECT 1.0. NUMBER
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PART I-PROJECT INFORMATION (To be completed by Applicant or Project sponsor) !~. "_I~. , :1 ,
1 . APPLICANT {SPONSOR DAVID & ANN CORIERI BY I 2. PROJECT NAME Ii '
EN-CONSULTANTS, INC. Dr! '^" '} I OMO
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3. PROJECT LOCATION:
MuniCipality MATITTUCK County SUFFOLK ".
4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map)
412 PARK AVENUE, MATTITUCK, TOWN OF SOUTHOLD, SCTM#1000-123-7-9.2; MAP PROVIDED
5. IS PROPOSED ACTION:
~New o Expansion o Modification/alteration
6. DESCRIBE PROJECT BRIEFLY:
REMOVE & REPLACE (IN-PLACE) (2) +/-50' EXISTING TIMBER GROINS WITH VINYL GROINS.
7. AMOUNT OF LAND AFFECTED:
Initially 1.31 acres Ultimately 1.31 acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
~Yes o No If No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
~ Residential o Industrial o Commercial o Agriculture o Park/Forest/Open space DOlher
Describe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING. NOW OR UL TIMATEL Y FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL.
STATE OR LOCAL)?
~Yes DNO If yes, list agency(s) and permit/approvals
DEC, COE, DOS
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
DYes ~ No If yes, list agency name and permiUapproval
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
DYes ~NO
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicanusponsor name: AtOBER'LE. mRRMANN, COASTAL MGMT. SPECIALIST Date: JAN. 26, 2000
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Signature: . ,.,l '1T ,
61 7.21
AppendiX C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS onlrr
SEQR
If the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
nVFR
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NOTICE TO ~~JACENT PROPERTY OWNER
BOARD OF TRUSTEES. TOWN OF SOUTHOLD
In the matter of
David & Ann Corieri
SCTM#1000- 123-7-9.2
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a
Permit from the Board of Trustees to: Remove & replace (in-place)
(2) ISO' existing timber groins with vinyl groins.
2. That the property which is the subject Environmental Review
is located adjacent to your property and is described as
follows: 412 Park Avenue, Mattituck
3. That the property which is subject to Environmental Review
under Chapters 32,37,or 97 of the Town Code is open to public
comment. You may contact the Trustees Office at 765-1892 or in
writing. February 23, 2000 at 7:00 p.m.
The above referenced proposal is under review of the Board of
Trustees of the Town of Southold and dose not reference any
other adjacent that might have to review same proposal.
OWNERS NAME: David & Ann Corieri
MAILING ADDRESS: 155 Brompton Road
Garden City. NY 11530
PHONE #: 516-742-0961
Ene.: Copy of sketch or plan showing proposal for your
convenience.
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PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Name:
Address:
Bud Holman
c/o Kelly Drie
101 Park Avenue
New York, NY 10178
Elizabeth Sheehan
63 West 89th Street
New York, NY 10024
STATE OF NEW YORK
COUNTY OF SUFFOLK
doing business En-Consultants, Inc.
Robert E. Herrmann , ~ at 1329 North Sea Road
Southampton, NY 11968 , being duly sworn, deposes and says
that on the 26th day of January , ~ 200,0 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 Southampton , hat said Notices
were mailed to each of said. persons by (registered)
mail.
rmann
Sworn qefore me this d c.,-h.-
day of" )(Jni'~.Q2.'o ,1'i:'~otJ{)
V~~A ""- /2'1 YzyA.
<. Notary PUblic
KIM H. STEPHENS
~ No12'Y Publlc-SlBte 0' New Vorll
Il~'r <.C''";~'''''n No. 60159~1.,
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Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1'*12
Fax (516) 765-1823
BOARD OF TRUSTEES:
BOARD OF TOWN TRUSTEES
TOWN OF SOUTH OLD
TOWN OF SOUTHOLD
In the Matter of the Applj.cation
of
Do'lJ.l.G:_ ;'_1L-M_ tQrJg..r::C _.. _ _ ____ __
COUNTY OF SUFFOLK)
STATE OF NEW YORKj
AFFIDAVIT OF POSTING
I,~1l-\ l--\E./UL<Mt"f.HJ ,re~a1n9 at G,;- ~~v\...D)-t.J~, INC. )
l]zq WDfL7rt S::~ ~, ScIJ~A.,.....-p~, ~y (1"'t6~
being duly swor.n, depose and say: .
t-- r: 2000
That on the II day of r~ , ~, I personally posted the
pr,:;,perty known i1S_~!rlZ.\L A\lfrJlif l-.l. ~mTVC-1'-
;:,y pLi,~iDg the Board of Trustees cffi'cial poster where it C.3,),;
(lasU.~" be ,':een, and that I have checked to be sure the posr:er
i1as r,~:l'ained J.E p13..:::e for seven days prior to the dat." of ~-:e... ().!f-
publi,? J;::.~~ing _ (dat.e of hearing noted thereon to bE: heJ.d rc.-u~, <<DaD
OO..DJ:..Q..WLL+- l)~OO pm .--' .
Da-ced.:
Sworn to before me this
..,1 L(./1.day of .~'-- &CV('1\- t9:9.2 (f/JV
\: '. / Lnt 01 \....j ct(~,,--
'-No~a y Public .
Kill H. STEPHENS
. Notary Publlc-S_ 0' New Y~,k
Commission N... 50159,11
Qualified In'' . C,,',:,'
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Postmark or Dale
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BO'" of Trustees APPlication...
County of Suffolk
State of New York
-~M"U (1r !P( I '"tNtv' ~r~ (lrl BEING DULY SWORN
DEPOSES AND AFFIRlI1S 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 APPLI CANT 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.
'~t~.fl<Ftkuu
SWORN TO BEFORE ME THIS
;1r-&-
DAY OF ~
,19ft
MICHAEL ClRJlm)
Nol-.y Public. State of New'lblt
No. 30-4990718
au.tffied in Nassau County. .
"1 . IIJ ......11,..-
.:2000
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BOtlf of Trustees APPlicatio~
AUTHORIZATION
Ci)( I fY I
of property)
I, -;J)~i_1l ' A rJ i\J
(pr:.m:' owner
/l1A ml7.Je [(
residing at Lf/2 P--1R/( Av; _
(mailing address)
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do hereby authorize ~^I(1~~VLl~L)
(Agent)
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
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APPLICANT
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics prohibits conflicts of
interest on the part of town officers and employees. The
ur ose of this form is to rovide information which can
alert the town of poss ble conflicts of interest and allow
it to take whatever action is necessary to avoid same.
YOUR NAHR.
.D C. u)(\o(\ .ANI\) e U')!IP((
(Last name, first name, m ddle 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.)
NATURE OP APPLICATION. (CheCk all that apply.)
Tax grievance
Variance
Change of zone
Ap'p.t;'oval Of "lat .
Exe~ption from plat or official map
Other ~ .
(If "Other," name the activity.) -r-'!"(W\\t
Do you perRonally (or through your company, Rpouse, sibling,
parent, or child) have a relationRhip with any officer or
employee of the Tovn of Southold? -RelationRhip- includeR
by blood, marriage, or business interest. -BuRiness
interest- means a business, including a partnerShip, in
which the toyn officer or employee has even a partial
ovnership of (or employment by) a corporation in Yhich
the toyn Officer 7r emplo e ovns more than 5% of the
shares.
YRS NO
If you ansyered -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)
and the town officer or employee. Either check the
appropriate line h) 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),
h) the owner of greater than 5% of the shares of the
corporate stock of the applic~nt (when the applicant
is a corporation),
B) the legal or beneficial owner of any interest in a
noncorporate'entity (when the applicant is not a
corporation),
cl an offl~~r: dfr~ctori par~~ert or cmpl~yeG of th~
applicant, or
D) the actual applicant.
DESCRIPTION OF RELhTIONSIIIP
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SUbmitte~ Of~P(k99Y(7 '"~ .~
Signatur ___ 1U li-tt-e>u/
Print name'JMvIO (1(9,(1[;(, / A..1".jParJ~(t