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Home My WebLink AboutTR-5897 James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD October 15, 2008 Mr. Gerard Gralton 45 Steding Rd. Cutchogue, NY 11935 RE: 5710 SKUNK LANE, CUTCHOGUE SCTM#138-2-34 Dear Mr. Gralton: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wed., October 15, 2008: RESOLVED, that the Southold Town Board of Trustees APPROVES the Amendment to Wetland Permit #5897 to lower the decking on the existing catwalk 1.5', with the condition the timber decking is replaced with an open-grated catwalk. This is not a determination from any other agency. Sincerely, - /,~,. J.~M~ Doherty,~nt ..~oard of Trustees v JMD:lms Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD August24,2005 Mr. Gerard Gralton 45 Sterling Rd. Cutchogue, NY 11935 RE: 45 STERLING RD., CUTCHOGUE SCTM#138-2-34 Dear Mr. Gralton: The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, August 24, 2005: RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to Permit #5897 to construct a 3' high hand-rail onto the existing catwalk. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765-1892. Sincerely, Vice-President, Board of Trustees JKiims Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hail 53095 Rout? 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 April 29, 2004 Mr. John A. Wieland NYSDEC Bldg. ~40, SUNY Stony Brook, NY 11790-2356 RE: GERARD GRALTON 5710 SKUNK LANE, CUTCHOGUE SCTM#138-2-34 Dear Mr. Wieland: The purpose of this letter is to support a permit modification submitted by Gerard Gralton to shorten the catwalk he has applied for in Mud Creek. The Southold Town Board of Trustees strive to keep catwalks accessing the waterfront as short as possible so as not to impede navigation or monopolize the public lands, yet provide the property owner reasonable access. We have granted a Wetland Permit to Mr. Gralton for a 3'X 30' catwalk with a tie-off pole 24' seaward. This is in keeping with the character of the area and is consistent with the existing pier line of adjoining waterfront property owners. If you have any questions, please don't hesitate to contact our office. Very truly yours, i President Board of Trustees JK:lms Board Of $outhold Town Trustees SOUTHOLD, NEW YORK GERARD GRALTON ISSUED TO ............................................ ~ .......................................................................................... Aut'horizali Pursuant to the provisions of C~hapfer 615 of the Laws of the State of New York, 1893: and C~apfer 404 of the Laws of the State of New York 1952: and the Southold ToWn Ordinance en- fltled ."REGULATING AND THE PLAC;ING OF OBSTRUC~TIONS IN AND ON TOWN WATERS AND PUBUC LANDS and the REIdOVAL OF SAND, GRAVEL' OR OTHER IdATERIALS FROM LANDS UNDER TOWN WATERS:~?. and in acco~lance w'dh the Resolution of The Boerd adopted at a meeting held on ...A.P.~....2-1..'-- .20.~J...., and in consideration of the sum of $....2.5.0-.'..(~ ....... Paid by Gerard Gra]ton ........................ of Cutchogue ......................... N. Y. and subject fo the Te~;'"~'""'~'~i~i~'""~ed on the ~e"' ,ide he~o~, of Southold Town' Trustees authorizes and permits the folowlng: Wetland Permit to construct a 3')2 ~0' catwalk and install one 8" diameter piling 24' offshore of the catwalk for use with the pulley system, and as depicted on the survey prepared by John T. Metzger dated Dec. 11, 2002. all in accordance with the deta~'d specifications as presouted in .the originating appr~aflon. IN WITNESS WHEREOF,.The to. tmbsoribed by a malority ot the sam m~era a~ u, .,,,,- Albert J. Krupski, Jr'(abstained - · TERldS and C~)NDmONS Gerard Gralton . 7. Th~ If furze operaflom of d~ T~vn of .~mthold req~ d~ ~m~d ~md/~ ~la~t~lo~ Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Rou~e 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 April 21, 2004 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Gerard Gralton 45 Steding Rd. Cutchogue, NY 11935 RE: 5710 SKUNK LANE, CUTCHOGUE SCTM#138-2-34 Dear Mr. Gralton: The Board of Town Trustees took the following action dudng its regular meeting held on Wednesday, April 21,2004 regarding the above matter: WHEREAS, GERARD GRALTON 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 March 22, 2004, 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 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 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 GERARD GRALTON to construct a 3'X 30' catwalk and install one 8" diameter piling 24' offshore of the catwalk for use with the pulley system, and as depicted on the survey prepared by John T. Metzger dated December 11,2002. 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:S198.00 Very truly yours, JaYmes King, V~'e President Board of Trustees JK/Ims PROPOSED CA TWALK NO SCALE / 50.09' LOT ~ LOT NUMBERS REFER TO ' MAP OF NASSAU FARMS' FILED MAR, 28~ 1955 IN THE OFFICE OF THE SUFFOLK COUNTY CLERK'S AS MAP NO, 1179 SURVEY OF PROPERTY A T PECONIC TOWN OF SOUTHOLD SUFFOLK COUNTY, N Y. 1000 138 - 02- 34 SCALE: 1"= 10' DEC. 11, 2002 · (631) 76'. ~ P. O. BOX ~ I:Z30 TRAVELER STREET SO U THOL D~ NO, 49618 765 - 1797 N.Y. 11971 98 - 346 (34) 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 P ease be advised that your app cation dated ~Io~ bY reviewed by this Board at the regu ar meeting of c~ I;I ~ 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: "5',r50' ('~'tcuO.~: 5.~,r~)' ,5c~oc~ i ~'' "" --/'~' ~ ~:~c~\~. :~ Iq~.O0 TOTAL FEES DUE: $ I q 2, 00 w~ PRESIDENT, BOARD OF TRUSTEES 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 Tuesday, April 13, 2004, the following recommendation was made: Moved by Don Wilder, seconded by William Cook, it was RESOLVED to recommend to the Southold Town Board of Trustees DISAPPROVAL of the Wetland Permit application of GERARD GRALTON to construct a 4'X 52' catwalk and install one 8-inch diameter piling 20' offshore of the catwalk for use with the pulley system. Located: 5710 Skunk Lane, Cutchogue. SCTM#138-2-34 The CAC recommends Disapproval of the application because the proposed dock construction includes CCA materials. Vote of Council: Ayes: All Motion Carried DEPARTMENT OF THE ARMY NEW YORK DISTRICT, CORPS OF ENGINEERS ,JACOB K. JAVlT$ FEDERAl. BUILDING NEW YORK, N.Y. 10278-0090 REPLY TO ATTENTION OF: Eastern Permits Section October 24, 2003 SUBJECT: Application No. 2003-01024-L2 by Gerard Gralton The New York District, U.S. Army Corps of Engineers, has received a request for Department of the Army authorization for the following activity: APPLICANT: Gerard Gralton -- 45 Sterling Road '~ ~1~~'/ Cutchogue, NY 11935 ACTIVITY: Install a pier assembly consist g fixed timber pier with one 8-i ~ch~~,~l~l~n~g 20 feet off shore to be used purpose of this project is to create a private mooring facility. WATERWAY: Mud Creek, Little Peconic Bay LOCATION: Cutchogue, Town of Southold, Suffolk County, NY As this is minor in nature, authorization may be by Letter of Permission. This is in accordance with current Federal Regulations governing work in navigable waters of the United States. To accomplish the coordination required, prior to the issuance of a Letter of Permission, your review of the enclosed drawings is requested. Pursuant to Section 307 (c) of the Coastal Zone Management Act of 1972 as amended (16 U.S.C. 1465 (c) (3) (A)), the applicant has certified that the activity complies with and will be conducted in a manner that is consistent with the approved state coastal zone management program. To allow for the timely processing of the subject application, your comments are requested within 20 days of the date of this letter. Sincerely, ~_~ Marc Helman Chief, Eastern Permits Section Enclosure 11958 5 ~1~/07/2083 19:19 Plan View 6312985 J:KOWALSKI ::: N PAGE 02 Cross Section 4' x'52' (...m, In...S' ~1::~,. cjr3 I~c:d (I) pile 20 off mi[h pu]l~ Line ~ ' Bay II1¢' ~aldwin A~ ................................ Creek bLtm. CCA o.t c~ ~e~'~'ork State Department of Environmental Conservation Division of Environmental Permits, Region One Building 40 - SUNY, Stony Brook, New York 11790-2356 Phone: (631)444-0365 · FAX: (631)~??.-0360 Website: www.dec.state.ny.us Erin M. Crotty CommLssioner Request for Additional Information May 23, 2003 Mr. John Kowalski Permits & Drafting Unlimited P.O. Box 743 Mattituck NY 11952 NYSDEC #1-4738-03164/00001 Gralton Property 5710 Bay Avenue Cutchogue NY SCTM #1000-138-2-34 Dear Mr. Kowalski: The Depathnent's technical staff field inspected the project site and provided the following comments. ~'he Department objects to the project as proposed. A depth of.5-feet below apparent low water exists at the seaward end of the proposed dock. The depth is inadequate for mooring a vessel at the proposed location since the vessel would contact the benthic habitat causing unnecessary disturbance. The support piling size (8" diameter) is excessive for a shallow water dock. Therefore, the Department requests the following revisions to the plans and proposal. Please revise the plans by reducing the support pilings for the dock to be a maximum of 4-inch by 4-inch posts.'"ln order to reach a more suitable depth for mooting a small vessel, please revise the plans by lengthening the proposed dock an additional 24-feet seaward. Please eliminate one of the offshore pilings and relocate the single 12-inch diameter piling 20-feet seaward of the lengthened dock. The revised proposal would then consist of a 3-foot by 52-foot dock supported by 4-inch by 4-inch posts, one (1) 12-inch diameter piling placed 20-feet off shore of the lengthened dock, and the pulley system in between the dock and piling. Please note, the Department can approve a maximum 4-foot wide dock as opposed to the currently proposed 3-foot wide dock if the applicant so chooses (show on plans). Please provide 4 copies of the revised plans showing the requested changes. Thank you. sg? Ma~tt~ew R. Pe~ski ' CC: G. Gralton File P lan View N SC, ALE I"= ,a, pplicont: ®erord H. G Purpose: P,"ivot. e l"Joor'incj Loi'.itude: N 41-OO-5~- Loncjitude: ~ Tide Ronge: 2'+/- Ootum: AL.IN. Cposs ;iOlq ~^,E ,-: ,o,! Proposed Timber E>ock (min. D' obv. (2) piles 24' oFF ~il'h Baldwin Creek Rood Line Bay Avenue Rolaer ~ FoxI~ on OI-04-OD ISEA LEVEL MAPPING S~eet I OF I H0. 50197 ~ ~ ' *~T- TO-DA~ ARE~T~C~ ~mt~ m~ ~ PROPOSED CATWALK ~ ~ 5o.O~' ~ SURVEY OF PROPERTY ~ A T PECONIC _ ~ooo - o c. ,, NO. 49618 m NASSAU FARMS" FILED MAR. ~8~ 1935 ~ IN THE OFFICE OF THE SUFFOLK COUNTY 1~30 TRAVELER STREET ~ CLERK'S AS MAP NO. 1179 SOUTHOLD~ N.Y. 119~1 98 - 346 ( 34 ) Albert 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 AUG 2 2 2005 Southo~d Board of Trustees APPLICATION FOR AN AMENDMENT TO A PERMIT AGENT PHONE ADDRESS PROPERTY LOCATION TAX MAP NO. VWe _~--~r ~ rd request an Amendment to Permit # Albert J. KrupsYA, President JAmes King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application ..-W~tland Permit Application ,~.~Major __ Minor Waiver/Amendment/Changes ,.-Received Applica~i,~/~ ~~_ .,,,'Received Fee:$~ ~.,Completed Appli~n In~mplete -- ' SEQ~ Classification: Type I Type n Unlisted~ C~rdination:(date sent)~ ~AC Refe~al Sent: Dme of Inspe~ion: Receipt of CAC Repoa: Lind Agency Detemination: Tec~ical Review: Public He~ing Held: Resolution: Name of Applicant ~'e~rarrt Address Phone Number:( Suffolk County Tax Map Number: Property Location: ~e~ ~a~ ~ '6*er I'm5 f,~.) (provide LILCO Pole #, distance to cross streets, and location) AGENT: ~.~ ~n~."} (If applicable) Address: ~ Phone: Board of Trustees Application GENERAL DATA Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property: Prior permits/approvals for site improvements: it/ 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: do tO e. Project Description (use attachments if necessary): "~1 o. a5¢ s~ a~ar~eat. SHEET 1-A REVISED 9-26-03 PROJECT DESCRIPTION APPLICANTS/OWNERS: GERARD AND MARY GRALTON DEC Ref. #1-4738-03164/00001 ACE Ref. #2003-01024-L2 NYe DOS Approval Letter #Ff-2003-0733 Local Agency (to be filed by owner) SITE LOCATION: 5710 Bay Avenue (a/k/a Skunk La.), Cutchogue, Town of Southold, Suffolk County, NY 11935; LILCO Pole #15; 1000-138-2-34 BODY OF WATER: Els Mud Creek (a/k/a Baldwin Creek) PROPOSED ACTIVITIES: Applicants-landowners propose to construct new 4' wide x52' I.f. fixed timber dock with (10) 4'x4" CCA posts, and with one 8" dia. pulley pile 20' off with pulley, as revised on the enclosed diagram. PURPOSE: Mooring facility for owners' private use in conjunction with their residence across Bay Avenue adjacent to this site, at 45 Sterling Road. MATERIAL LIST: Piles: (10) 4"x4" CCA posts Pulley pile: (1) 8" dia. All lumber and piles shall be Southern yellow pine CCA pressure treated to 1.5 Ibs.lcu ft. maximum retention. Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: Ou)ngr r~%% mf_.r~SS ~ Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: /) ~ ,5' feet Closest distance between nearest proposed structure and upland edge of wetlands: ~- ,~f feet Does the project involve excavation or filling? t// No Yes If yes, how much material will be excavated? No n~cubic yards How much material will be filled? ,0 ~, ,a e_ cubic yards Depth of which material will be removed or deposited: r4//:l feet Proposed slope throughout the area of operations: O- It) ~]o Manner in which material will be removed or deposited:~ Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: ~0~+~ , , Are wetlands present within 1 O0 feet of the proposed activity? No ~'/ Yes Does the project involve excavation or filling? t~ No Yes If Yes, how much material will be excavated? How much material will be filled? Manner in which material will be removed or deposited: _(cubic yards) .(cubic yards) Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) · O ' t 817.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be completed by Applicant or Project sponsor) SEQ 3. PROJECT LOCATION: PROJECT NAME 5. IS PROPOSED ACTION: '~ New [] Exbansfon [] Moaificaflonialteration 5. DESCRIBE PROJECT BRIEFLY: ,. *MOU.T OF, Ne AFFECTED, Inilially j~ ~ ~'e~''Il ~ acres Ultimately WILL PROPOSED ACTION COMPLY WITH F-XISTING ZONING OR OTHER E~ISTING LAND USE RESTRICTIONS? ~Yes [] NO If NO, describe briefly 10. DOES ACTION INVOLVE A PERMIT APPROVAL~ OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCALI? ~ Yes [] No If yes. Iisi agency(s) and permit/aogrovals 11. OOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUO PERMIT OR APPROVAL? ~Yes' ~ ~ No I~ yes. list agen~ name and ~e~itlaDDroval t2. AS A .ESULT OP PROPOSED ^CTIO. WILL ~,STt.G .ER.,T,A.P.OVAL REOUIRE MOD,P1OAT,ON? [ CERTI~ THAT THE INFORMATION PROVIDED ABOVE IS TRU~ TO THE 9EST OF MY KNOWLEDGE If the action is in the Coastal Area, and you are a state agency, complete the Coastsl Assessment Form before proceeding with this as?sessment OVER I PART ii_¢NViRONME..'..iTA'i~SES.~MENT_. ~To be n~m~,e,v_-' ,='~ ay Agaric' ~ PART iII--OETE~MINATION OF SIGNIFICANCE (To ~e comoleted by Agency) INSTRUCTIONS: For each adverse effect idemilied at:ove. ~etermine wnet~er it is substantial, large. [mco~n[ or o~e~ise signific ChecX ;Mis box if you have idendfieo one or more ootendal[y large or significant adverse [moac:s which MA',' occur. Then oroceed direc:l'/ ~o :rte FULL EAF ~nolor prepare e positive' declaraticn. ChecX This box if you ,~eve determined, based on the information end analysis above and any sucoortinc_ documenta[~cn. :,hal ;P.e ~rooosed ~c:ion WILL ,'lOT result in_~?ny significant adverse environmental Jmcac:: AND provide on z(t&c.nmen~s ~s necessary, (he reasons suocor[ing [rds determination: PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Address: ~'~; ......................... r ............................ , residing at _ , being duly swo~ deposes ~d sa~ ~at on ~e ~y of ,20~, d~onent m~led a ~e copy of~e Notice set fo~. ~ the Bo~d of Trustees ~plicafion, dkected to e~h of ~e above n~ed pemons at ~e ad~esses set opposite ~ere resp~tive nines; that the ad~esses set opposite the n~es ofs~d pemo~ ~e ~e ad.ess ofs~d pemons ~ sho~ on ~e c~ent ~sessment roll of ~e To~ of Sou~old; ~at said Notices were m~l~ at ~e Unit~ States Post Office at., ~at s~d Notices were m~l~ to each of s~d persons by ~(registered) mail. Sworn t~efore me this Day of [, ~_~ ,20~--~ BARBARA ANN RUDDER Notary Public, State of New York No. 485~05 Qualified in SuftoJk County~,~....-, ~. Com mllsion Expffe$ April 14, ~ '~' 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, , residing at being duly sworn, depose and say: That on the day of ,200 , I personally posted the property known as 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 eigl3.t days prior to the date of the public hearing. Date of hearing noted thereon to be held [00~. ~.~[ e~: ~ ° · Dated: S~oru to l~fore me this q'~day of ~,-~200H~ Notary Public BARBARA ANN RUDDER Notary Poblto, State of New York No. 4855805 Qualified in Suffolk Oounty.q~. Oommt#lon Expi~l April 14, ,~ Board of Trustees Application County of Suffolk State of New York e,rr r& O ca I 4- tO BEING DU- Y SWOP, DEPOSES ~ ~F~S ~i ~/S~ IS ~ ~PLIC~ FOR T~ ~O~ DESC~ED PE~T(S) ~ ~T ~L STATE~S CO~D ~ ~ ~ TO ~ BEST OF ~S~R ~O~EDGE ~ BEL~F, ~ ~T ~L WO~ ~L BE DO~ ~ ~ ~R SET FORTH ~ T~S ~PLICATION ~ AS MAY BE ~PRO~D BY T~ SOU~OLD TO~ BO~ OF TRUSSES. ~ ~PLIC~ AG~ES TO HOLD ~ TO~ OF SO--OLD ~ ~ TO~ TRUSSES ~ESS ~ ~E ~OM ~Y ~ ~L D~AGES ~ CL~S ~S~G ~ER OR BY ~ OF S~ PE~T(S), ~ G~ED. ~ CO~LET~G ~S ~PLICATION, I ~BY AU~O~ T~ ~US~ES, T~ AGENT(S) OR ~P~SENTATI~S(S), TO EN~R O~O ~ PROPERTY TO ~SPECT T~ P~SES ~ CON~CTION ~ ~W OF ~S ~PLICATION. ~ignature SWORN TO BEFORE ME THIS BARBARA ANN RUDDER Notary Public, State of New York No. 4855805 Notary Public APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics orohibits conflicts of interest on the oart of town officers and cmolovees. The ~uroose of this form is to orovide information which can alert thc town of nossible conflicts of interest and allow it to take whatever action is to avoid am~. (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, indicete 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 Mooting Exemption from plat or official map Planning Other (If"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 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 coq)or, ion in which the town officer or employee owns more than 5% oftbe shares. YES ~ NO 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 applicanffagenl/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): __rio the owner of greater than 5% of the shares of the corporate stock of the.applicunt (when the applicant is a corporation); __B) the legal or beneficial owner of any interest in a non.-co~oorate 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 thi~. ~ {~ day o~ ~ Signature 'gl ,~-x .,,,/,~,~' /~,t. .~4, ~ PrintN~ .... t "'/ ' --- APPblCANT The Town o~ S~u~hold's Code of ~thic~ prohibits con~licta interest on the part of town officers and employees. .The purpose of this form is to provide information which can alert the town of possible it to take whatever action NATURE OF APPblCATIONs conflicts of interest and allow is necessary to avoid same. (bast name, first name, midd.l~ initial, unites you are applying in the name cE someone else or other entity, such ~s a company. I~ ac, indicate the other person's or ~ompany's name.) (Check all ~ha~ apply.) Tax grievance .. Variance Change of zone Appel>vel of plat . Exetption ~rom plat r other ~~[lcial,map (If "other," name the activity,) . . . .~ . ~,.,. , . DO you personally (or through your compaoy~ spouse, sibling, parent, or child) have a relationship with any officer or employee o[ the Town of Seuthold? "Relationship' includes by blood, marriage, or business interest. "Dusiness interest# means a business, including a partnership, in which 2he town o~£icer or employee has even a partial ownership o~ (or employment by) a corporation in which the town officer or employee owns more than 5~ o~ the shares. NO If you answered aYES,#, complete the balance oE ~hi~ ~orm and date and sign where indicated. Name cE person employed by the ToWn of Southold Title or position of that person Describe the relationship between yoursel~ (the applicant) and the town officer or employee. Either check the appropriate line A) ~hrough D) and/or describe in the space provided. The town officer or employee o~ his or he~ gpouse~' Sibling, parent, or child is (check all that apply)~ __.A) the owner o~ greater than 5% of the shares of the corporate stock o~ the applic~nt (when the applicant' is a corporation)~ the legal or b&ne~icial owner cE a~y ~ntereek in s noncorporate'entity (when the applicant is not a e) corporation)~ C) an officer; director, applicant~ or __D) the a~tual applicant. DESCRIPTION OF ~ELATIONSIIIP ~M~ . ' or employee o~ the