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Home My WebLink AboutTR-6328A James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall 53095 Route25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD January 23, 2008 Mr. Richard Bren 40 East 75th Street New York, NY 10021 RE: 430 WEST CREEK AVENUE, CUTCHOGUE SCTM# 103-13-3 Dear Mr. Bren: The following action was taken at the Southold Town Board of Trustees regular meeting held on Wednesday, January 23, 2008: RESOLVED, that the Southold Town Board of Trustees APPROVE the request for a Transfer of Permit #6328A from Frank Scavone to Richard Bren, as issued on March 22, 2006. If you have any questions, please contact our office at (631) 765-1892. Sincerely, President, Board of Trustees JFK:eac LOcal Criminal Cou i TOWN OF SOUTHOLD MISDEMEANOR INFORMATION ALLEGED VICTIM (RELATIONSHIP TO DEFENDANT ACC#: 07-3035 RREST #(s): STATE OF NEW YORK ~ RICHARD BREN } Defendant COUNTY OF SUFFOLKj~ DOB 10/20/30 TOWN OF SOUTHOLD Name (Complainant) Bay Constable Andrew C. Epple Jr. Shield # M-3 of Southold Town Police Department, 41405 State Route 25, Peconic New York 11958 being duly sworn, says that on or about Sunday, April 13, 0200, at about 7:56 am., at 430 WEST CREEK AVE, in the Hamlet of Cutchogue, Town of Southold, County of Suffolk, State of New York, the defendant, RICHARD BREN, DOB '10/20/30, of 430 WEST CREEK AVE CUTCHOGUE NY 11935 ~r~qgfully, intentionally, knowingly, committed the offense(s) of: Count# 2 Section 2~5 wetland permit of the Southold Town Code· Count# 2 Particulars In that: The defendant, at 430 WEST CREEK AVE, Hamlet of Cutchogue, Town of Southold, Suffolk County, New York, on or about Sunday, April 13, 0200 at about 7:56 am, in that, This complaint is based on (personal knowledge) & (information and belief), the source being the direct observation of your deponent In(a~vritten instrument, any person who makes a false statement which such person does not believe to be true has committed a crime under,he laws of the State of New York punishable as a Class A misdemeanor [PL Sect. 210.24]. A. ffir~ed under penalty of perjury this Friday, May 18, 2007 AntOne Surozenski Shield # 116 Bay Constable Andrew C. Epple Jr. Shield # M-3 ~ ~,' Complainant SIGNATURE OF OFFICIAL ADMINISTERING OATH Police Sergeant, Town of Southold TITLE Complainant Signature Page 2 of 2 'lea by Mail (NOT FOR VTL VIOLA'Ir TO PLEAD GUILTY: COMPLETE THIS FORM AND Southold Town Justice Court MAIL OR DELIVER TO: 53095 Main Road, P.O. Box 1179 Southold, NY'11971~0959 TO THE PRESIDING JUSTICE AT THE SOUTHOLD TOWN JUSTICE COURT: I, ~..J~' d~)~ 0.~ ,residing at ~3o (..fl~-~'" ~-~_,r~"~'~~'- _, have been charged with a violation of &: ~'~,~'" $ , under the Code of the Town of Southold."'l hereby elect to dispose of this matter without appearing in open court. I hereby waive arraignment in open court and the aid of counsel and understand that a plea of guilty is the equivalent to a conviction after trial. I hereby plead guilty to the offense as charged and elect and request that this charge be disposed of and a fine/penalty be fixed as agreed to below. I understand that the agreed upon penalty is contingent upon the Court's approval, and that my appearance may be required on a future date if the negotiated disposition is not accepted by the Court. Date:_ df.[I3 f~'7. Ticket/Summons #: In Satisfaction of: ~ Fine/Disposition Recommended: RPB HOLDINGS LLC om~ o~ c~ ~. 2884 DOLLARS ~ ~"~ ~oJPM°rganOPrlvate Bank J~r~org=n Ch=~ ~nk, N~.New Yor~ New Yor~ ~ ~ ~:0 8 ~0000 ~ ~: ONO0 Town of Soqthold -A' 4 7 9 7 SuffOlk County, NY COPY The People of the Stere of New York vs. VIN NUMBER COURT COPY 'A-4797 Town of Southold Suffolk County, NY The People of the State of New York vs. STATE COT. TR~' C0~¥ ~.Ty~o IS. Name (~, FI~, Middle) 36. AIl~i~nam~ai~ Name (Last, Fi~t, Middle) 37. A~rent Condition K 74. I~uirJ~ (Ch~k all that a~ly) I 7S .YS"I. M~ge NO 76. Complainant Signature 00MV D Wan~arrant ~ Scofflaw ~ ,~ OCrim. His~ ~ Stolen Pr~y ~ Other [~ J 7~ ~icesSi~ ure~cl~e Rank) , I 78 ~0 ,o -- l~. Su~rviso,'s Signature (include Rank) I 80. ID NO. OCB~ OJuv.-NoCust~y OAr~t-Juv OOffenderDead OExtrad O~hn DUn~nown ~'1 J/~' J~ Pag~ DCJS-3205 (2/97} *FALSE STATEMENTS ARE PUNISHABLE AS A CRIME, PURSUANT TO THE NEW YORK STATE PENAL LAW. 04/17/2007 21:06 FAX KBS REALTY ADVISORS 001/002 JKBSl F': ] 8 2007 Seuthh~d Town Board of Trustees FACSIMILE KBS REAL'P( ADVISORS 5~0 Madi~o~ Av~me, 26~' Floor New Y~ ~ 1~ T 212~ F 212~13~ 04/17/2007 21:07 FAX 2128 72 KBS REALTV ADVISORS 002/002 Ap~ 18, 2007 Mr. James King - prealdent Board of Town Trustees- 8oalhold Towfl Hall 53095 Route 25 P.O. Elox tl 79 Southold, New Yo~ 11971-0959 [~ar Jim: Thank you fro' meeting with me last ~'cck and spending fie Ume to ex~aln the proper procedures and maintenance with respect to my pfopmty Iocatnd at 430 West Creek Avenue, Cutct~gue, NY 11935. Per your suggestion, I am submitting this letter to you to outline my pmpossd plan r~arding the two buffer beds located at the lower end of my ptobeK¥ adjacent to the wetlands. As you know, these buffer beds were a requirement of the tmatees when the prior owner of my pmpen'¥, Frank Scavone, s~Jbmittnd his plan for pmpmly Improvements last year. His plan was approved by you and the trustees and remains in effect. My p~an is to increase the density of plants in the t~vo buffer beds in order to create evm~ mom buffet'than what is curmnify in place. The size of the beds will nof be altered, only the density of The existing plants will al remain in, act although some may be relocete~l in the beds in order to make mom for the and#inoal planting, t wOuKI like to add 16 EulNdodum Rugosom, 8 Bap~ia Hylxid, 5 Hydrangea Tardiva, 7 penmsida, 9 Miscanthus $inens~ t8 Morion/a. and 23 Geraalum. All these ~paciea hold tile soil, are n~ IiwssNe end am n~t m-seedms, which I know are the major concerns next 1.o wetlands. Only natund and ofgaalC materials will be applied and there will be no disturbance to any existing wetland plants. Between the two buffer beds, I would like to replace the e~'qJng grass walk path with a fletdato~e path (4-6 stones in total) and plant Sagina ~ubulata (irish Moss) in between the stones. I believe this stone and moss path will c~eate a much belier buffer/or the wetlands than the grass that is currently In place. Please call me any time at 917-6~-7700 if you have any questions regarding my planUng plan. I would like your bles~ing on this Ixoje=t as ~oon as possible since we have ~ much rain and the seasonal grass treatments have already cm~mencAKI. The idea Is to get these buffer beds functioning in the optimal way for wflicfl they were designed. Thank you again for all your input and guidance. Richard Bran Owner-430 West Creek Avenue ! 8 2007 ~uthhol~ ~en Board d ~$1~S 04/18/2007 10:28 FAX KBS REALTY ADVISORS ~001/002 '[KBsI FACSIMILE KBS REALTY ADVISORS 5~0 Madb~l,~ Averse, 26a Floor New York, NY t 0022 T 2'12.644.41e~ F 212..644-1372 /?-' 18 2007 $outhhOld Towa Board of Trustees 04/18/2007 10:28 FAX KBS REALTY ADYZSORS 002/002 Ap~118, 2007 Mr. James King - President Board of Tow~ Tnmteas - Southold Term Hall 53095 Route 25 p.o. Box 1179 Southold, New York 11971-0959 Dear Jim; Thank yOu for me~ng with me last ~ and spending the time to explain the proper proceclums and matntenence with respec~ to my ixoperty Iocat~ at 430 VVe~t GJ'~ Avenue, C4fl~togue, NY t1935. Per your auggeStlofl, I am sotwnit~ng tN$ Miter to you to outline my proposed plan regarding the two buffer beds ldcated at the lower end of my property ~l]acent to the wetlands. As you know, these buffer beds were a requirement of the trustees re'Mn the prior owner of my Ixopetty, FraflK Scevene, sobn~tted MS plan for property improvements last year. HIs plan was approved by you end the tru~ees and remains in effect. My plan is to incFease the density of plants In the two bulfe~ beds in order to ct'cate even more buffer than what is cunefllly in plo~e. The size of the beds will no( be ~ered, only the density of plants within. The exi~ng plants will all remain intact although some may be retocat~ ~n the beds in o~clar to make room for the add~onal planUng. I would like to add 10 Eupatoriurn Rugc~um, 8 Hylxid, 5 Hydrangea Tanfiva. 7 Penmskla, 9 Miscanthus Slbensis, 18 Monarda, and 23 Geranium. NI these species hold the aoil, are not invaslve and are not re-seedem, which I know are the major cerberus ns~ to wetlands. Only natural amd or~anl¢ matml°fs will be applied and there will be no distuthanee to any existing wetland plants. Between the two Ixf;;= beds, I would like tO replace the e~sUng Ora.ss v~lk path with a fieKistone path (4-~ stones in totol) and plant Sagine Subulalal (llish Moss) in between the stones. I believe this stone and rnes~ path will cre~e e much better buffer for the wetlands Mn the grass that la currenUy in pldce. Please call me any time at 917-658-7700 if you have asy questions regarding my planting plan. woul¢l like your M~ng on this projeGt as soon as possit4e sinoe we have ~ much rain and the seasonal grass traatmants have almacly commencm]. ~ ~ is to ge{ those buffm' beds functioning in the optimal way for which they wer~ designed. Thank you again fix all your input and guidance. Owner- 430 West Creek Avenue . CEIVE 3' ',?S 18 2007 Southhold Total Board ef Trustm~ January 11,2008 Mr. James King, President Board of Town Trustees 53095 Route 25 Southold, New York 11971 Re: Maintenance Permit Transfer and Renewal at 430 West Creek Avenue, Cutcho.que NY 11935 Dear Mr. King: I request that you transfer and renew Permit ~/~328A from Frank Scavone to Richard Bren for phragmites maintenance originally issued on March 22, 2006 to Frank Scavone. Please put this request on the February agenda or the agenda immediately following. Attached is my check for $50 to the Town Trustees of Southold. Thank you for your assistance. Sincerely, Cetl o117.4,5-g-- 77oco JAN 1~ 200,3 Southhold Town Board of Trusteel James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen John Holzapfel Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD Permit No.: 6328A Date of Receipt of Application: February 13, 2006 Applicant: Frank Scavone SCTM#: 103-13-3 Project Location: 430 West Creek Ave., Cutchogue Date of Resolution/issuance: March 22, 2006 Date of Expiration: March 22, 2008 Reviewed by: Board of Trustees Project Description: Trim Phragmites to 12" with no disturbance to other vegetation, as per plans surveyed by Joseph A. Ingegno and received Feb. 13, 2006. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth by the Board of Trustees. Special Conditions: One-year inspection. if the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth by the Board of Trustees, a Wetland Permit will be required. This is not a determination from any other agency. James F. Ki~-Preside't~ Board of Trustees James F~ King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen John Holzapfel Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (681) 765-1892 Fax (631) 765-6641 TO: BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Please be advised that your application dated reviewed by this Board at the regular meeting of following action was taken: ( Application Approved (see below) ( )Application Denied (see below) ( )Application Tabled (see below) has bean and the 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 Chapter 97 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be ne/~.~ry. COMPUTATION OF PERMIT FEES: , 4f O/',~/ TOTAL FEES DUE: $. ~;O ?¢ BY: James F. King, President Board of Trustees 'New York State Department of Environmental Conservation Division of Fish, Wildlife & Marine Resources, Region One Marine Habitat Protection Building 40 - SUNY, Stony Brook, New York 117@0-2356 Phone: (631) 444-0295 FAX: (631) 444-0297 3/23/2006 Notice of Violation Donald Macleod 430 West Creek Ave. Cutchogue, NY 11935 Denise Sheehan Commissioner Date of Violation: On or before 3/14/2006 Location of Violation: 430 West Creek Ave., Cutchogue Tax Map ID# - - - Permit # (if applicable): Dear Sir/Madam: Records of this Department indicate that you are in violation of the Environmental Conservation Law (ECL): Article 15, Protection of Navigable Waters Section 15-0505.1 6NYCRR Part 608 Article 15, Wild, Scenic and RecreatiOnal Rivers Act Section 15-2709.2 6NYCRR Part 666 Article 13, Protection of Marine Waters Section 13-0345.2 Article 17, Prohibition Against Pollution of Marine Waters Section 17-0503.2 Article 24, Freshwater Wetlands Act Section 24-0701.1 6NYCRR Part 662 Article 25, Tidal Wetlands Act Section 25-0401.1 6NYCRR Part 661 Page 1. In that you caused, or permitted to be caused: Clearing of vegetation in an area of 100'x50' adjacent to a regulated tidal wetland and installation of a plastic waterline, 100' in length in and adjacent to a New York State Regulated Tidal Wetland without me oenefit of a permit to do so. Contravention of this/these Article(s) of the ECL is a violation and/or a misdemeanor punishable by a fine of no more than $10,000 per violation. Penalties may be assessed for each day that the violation continues. Please be further advised that violations of the ECL which are not resolved may be the subject of an administrative hearing pursuant to Title 6 of the Official Compilation of Codes, Rules & Regulations of the State of New York (6NYCRR, Part 622). You are hereby advised to cease your operation at the referenced location immediately. Please contact the following office within thirB, (30) days of receipt of this letter, so that we may attempt to resolve this matter. Failure to contact this office within this time period will result in this matter being referred to the Department's Regional Attorney for further enforcement action. To schedule an appointment for a compliance conference in this matter, please contact The Compliance Unit at (631) 444-0295. Compliance conferences will be held with the Regional Manager of Marine Habitat Protection. Very truly yours, Charles T. Hamilton Regional Supervisor of Natural Resources Stony Brook CC; Jimmy King -Town of Southold Trustees Certified Mail # 7005 1820 0002 9464 1610 NOV# 06CTH95 Page 2. 103 Albe~ J. Krupski, President James King, Vice-President Artie Foster Ken F~iwoda Peggy A. Dickerson Tow~Ha]l 53095Route 25 P.O. Box 1179 Southold, NewYork 11971-0959 Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD Office Use Only Coastal Erosion Permit Application Wetland Permit Application J Administrative Pemfit Amendment/Transfer/Extension · ~'~Received Application: ~ ~Received Fee:$ ./Completed Application ..~! Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) LWRP Consistency Assessment Form CAC Referral Sent: _~'Date of Inspection: Receipt of CAC Report: Lead Agency Determination: Technical Review: ~blie Hearing Held: .~ Resolution: FEB 1 3 2006 Suffolk County Tax Map Number: 1000 - Property Location: ~-4_g ~) {~/3e~- C.x-t~ ~ ~-~r-~ (provide LILCO Pole #, distance to cross streets, and location) AGENT: (Ifapplicable) Address: Phone: rd of Trustees Applicatic GENERAL DATA Land Area (in square feet): Area Zoning: -~- ' ' Previous use of property:. Intended use of property: Prior permits/approvals for site improvements: Agency Date __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or susp?nd~d by a governmental agency? ~<. No Yes If yes, provide explanation: 'lO,c~- Project Description (use attachments if necessary): Q_Xrr ~~k=~ c~l,r c~ chr~: ~-c ~ of Trustees Applicatil WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: (~X~ ~? ~'-Oo square feet ~'~ Percent coverage of lot: ~2 o % Closest distance between nearest existing structure and upland edge of wetlands: ~ Zoc~ feet Closest distance between ne~ed structure and upland edge of wet~~'- feet Does the project involve excavation or filling? fi(' No Yes If yes, how much material will be excavated? ~ t~ cubic yards How much material will be filled? ' /~ ~ cubic yards Depth of which material will be removed or deposited: A~ feet Proposed slope throughout the area of operations: /40 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) i 617.20 PROJECT ID NUMBER 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) 1. APPLICANT / SPONSOR 2. PROJECT NAME 3.PROJ EICT LOCATION'S-' PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc .~dr provide map SEQR IS PROPOSED ACTION: [] New [] Expansion [] Modification/alteration DESCRIBE PROJECT BRIEFLY: 7 · i~a AFFECTED: Initially cres Ultimately ,~Ua~-~ acres 8. WI~.L PROPOSED ACTION COMPLY WITH EXISTING"~'O~'NG OR OTHER RESTRICTIONS? Yes [] No If no, describe briefly: £ ~H,~T IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) sidential [] Industrial [] Commercial r~Agric[JIt[~re [~ Park / Forest / Operl Space ]Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) r-~Yes /~No If yes, list agency name and permit / approval: 11 DOES ANY/~~ ANY SPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? E~]Yes o If yes, list agency name and permit / approval: 12.E~esAS AR~NoULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? /I CERTIFY THAT THEE I~.~IN RMQTION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name _~,.,/~ ?~ Date: Signature ~-'~,-------- '~ ~ ~ ~ '~ O~ If tl~e 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 A~lenc¥) A' E~ Yes [;Z~] No DOES ACTION J~CXCEED 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 ~f No, a negative declaration may superseded by another involved agency. C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be han~lwdtten, if legible) C1. Existing air quality, sun'ace or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. AesthetiC, agricultural, archaeological, historic, or other natural or cultural resoumes; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfi_sh or wildl!fe species, significant habitats, or threatened or endangered species? Explain briefly: C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, sflort term, cumulative, or other effects not identified in C1-C57 Explain briefly: C7~ Other ~mpaets (including changes in use of ether quart ~ or ype of energy? Explain b~efiy' D. WiLL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMEN E. IS THERE, OR I/THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL MPACTS? If es ex lain' PART Ill - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadVersee~ectidenti~edab~ve~detsrminewhetheritissubstantia~arge'imp~rtant~r~therwisesignlficant~ 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, the determination of significance 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 thi§ tiox i~ yoG have de[e~min~d, base~ on ihe information and analysis above and any support ng documentation, thai {he Pr0p0~ed ~cfim 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) Board of Trustees Application County of Suffolk State of New York '~ cqx~'c-~ ~--~C~)Olx-R BEING DULY SWORN DEPOSES AND AFFIRMS THAT I21E/S1)E 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 RE~~LICATION. Signature SWORN TO BEFORE ME THIS Notary Public DAY ,2o um~ ~ TAGGART Q.alif~ in ~dfolk Co.ffq.~ _ of Trustees Applicati~ where the appllcan~/~s not the owner) I, ~l~ ~~ ///residing at ~3~3 ~. C~ (print ~wne~ pr~) (mailing address) ~ ~~ /~ do hereby authorize -- / % ~e~, / ~ to apply for pe~it(s) from the Southo~~f Town Tru~~ behalf. APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Soathold's Code of Ethics orohibits conflicts of interest on the vart of town officers and emPloYees. The oumose of this form is to urovidc information which can alert the town ofoossible conflicts ofintersst and allow it to take whatever action is necessary to avoid same. (L~st name, first name, gaiddle initial, unless you are applying in the name of someone else or other entity, such as a company, lfso, 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 (I f "Other", name the activity.) ~ ,'cO ~r~O ~' r' %~c~ ,'~-,C 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" 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 ~5~ If you answered "YES", complete the balance of this form an/cV~ate 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 ao0~icant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or descr?6e in the space provided. The town officer or emp oyee or h~s or ber/~pouse, s~bhng, parent, or ch Id s (check all that apply) A) the owner of greater than (when the applicant is ;tuck of the applic~at ' of any interest in a non-corporate entity (when the __C) an officer, director, D) the actual a DESCRIPTION OF R Submitted this t5 .day of ~ b 200 (O Signature ~ Print Name ' .CS./~, L ~ft ~ ~ Form TS I SURVEY OF PROPERTY SITUA TED A T CUTCHOGUE TOWN OF $OUTHOLD SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-103-1.5-03 SCALE 1"=30' FEBRUARY 7, 200.5 JULY 22, 2005 ADDED 10' CONTOUR LINE & FLOATING DOCK AREA = 52,228.35 sq. ff. (TO TIE LINE) 0.740 ac. CERTIFIED TO: WASHINGTON TITLE INSURANCE PROFESSIONAL LAND SERVICES TITLE No. P-5118-S WASHINGTON MUTUAL BANK F/A FRANK SCAVONE COMPANY LLC Land Surveyor PHONE (631)727-2090 Fax (631)727-1727 25-20§A