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Home My WebLink AboutTR-6758A ""'" '-' ..:> James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghos io, J r. 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 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 1 st day of construction Y, constructed ~ Project complete, compliance inspection. ,.- '- ""'" -' 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 Permit No.: 6758A Date of Receipt of Application: November 5, 2007 Applicant: Betty Rugg SCTM#: 51-6-32 Project Location: 1695 West Mill Creek Drive, Southold Date of Resolution/Issuance: November 14, 2007 Date of Expiration: November 14, 2009 Reviewed by: Board of Trustees Project Description: Replacement of most existing windows and doors in the heated part of the main house, some salvaged windows to be installed in the unheated areas, such as the attic in the east elevation and the garage in the north and east elevations; upgrade insulation in the attic and basement; extend the existing front brick stoop and replace with wood deck; install new wood steps at new living room door on the south elevation. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by Frank Uellendahl, Architect, last dated November 5,2007, and received on November 5,2007. Special Conditions: None. Inspections: Final inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. y:.:O;:,?'"OO from '"y othoc '9'"0>. James F. King, President Board of Trustees JFK:eac -,.""..,"'_.---,",- ,....... '-' .~ 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 Telephoue (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: ~-\-\--'j "KUZ1~ Please be advised that your application dated AJclVl"a~~'f<fo7has been reviewed by this Board at the regular meeting of ~7 and your application has been approved pending the completion of the following items checked off below. Revised Plans for proposed project Pre-Construction Hay Bale Line Inspection Fee ($50.00) 1st Day of Construction ($50.00) % Constructed ($50.00) / Final Inspection Fee ($50.00) Dock Fees ($3.00 per sq. ft.) Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION.OF PERMIT FEES: TOTAL FEES DUE: $ 5'()~ @/z..<e,67 BY: James F. King, President Board of Trustees _.--~_._--"..' .___,,,,__,"_'.~__c______'w_,,.-.._.'._~_' New York State DepQment of Environmental CorOrvation Division of Environmental Permits, Region One SUNY @ Stony Brook, 50 Circle Road, Stony Brook, NY 11790 - 3409 Phone: (631) 444-0365 . FAX: (631) 444-0360 Webslte: www.dec.state.ny.us . .. .... ~ LETTER OF NON-JURISDICTION-ARTICLE 25 June 14,2007 Betty Rugg & Phyllis Sousa 1695 West Mill Creek Dr. Southold, NY 11971 Re: Application #1-4738-03726/00001 1695 West Mill Creek Dr., Southold SClM# I 000-51-06-32 Dear Permittees: Based on the infonnation you have submitted the Department of Environmental Conservation has determined that: The property landward of the 10' elevation contour on a gradual, natural slope as shown on the survey prepared by Joseph A.lngegno, last revised 4/6/07, is beyond Tidal WetlandsAct(Article 25) jurisdiction. Therefore, in accordance with the current Tidal Wetlands Land Use Regulations (6NYCRR Part 661) no permit is required. Be advised, no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal wetlands jurisdictional bouudary, as indicated above, without a permit. It is your responsibility to ensure that all precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Article 25 jurisdiction which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and your project (i.e. a 15' to 20' wide construction area) or erecting a temporary fence, barrier, or hale bay berm. Please note that this letter does not relieve you of the re permits or approvals from other agencies or local m . in cc: MHP Frank Uellendahl file I o \"'--------_/ ~ "..,"','" a ~ " ~ \ \ . I 'I \ ( \\ ) \ ) Q 5 '" , ..." i "'" l , , 1 i , ?i , ~ 4- l Tm I .-< > l[)' 01 i . . , , I a> ! > ~. T' ,> ! ~ ~ i , , '''''" ~~.. :II... \ \\ 8"" ~i ~.~: ~~I'> . 15.2 ~ , >-t!~ ~g.J ".., u~l ~~. ~ ") *" ~~ c,',,' <?;> V ::f'" G 7 0~ ~~ , . .'~ ~~-- i! ;".)) L [L N,~,,:~\::~: ~ PREPARED IN ACCORDANCE WiTH THE MINIMUM STANDARDS FOR TITLE SURVEYS AS ESTABUSHEO BY THE 1.l.A.LS. AND APPROVED AND ADOPTED FOR SUCH USE BY THE NEW YORK STATE LAND nTLE ASSOCIATION. ~ "'..p <'0 + ?>.?> - .;pO ~ + +v <'<, <1>+ N.Y.S. Lie. No. 49668 UNAUTHORIZED AlTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VAUD TRUE COPY. CERTIFICATIONS INDICATED HEREON SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHAlF TO n-rE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION USTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTJ- TUTION. CERTIFlCATlONS ARE NOT TRANSFERABLE. Joseph A. Ingegno land Surveyor Title Surveys - Subdivisions ~ Site Plans - Construction Layout 'HONE (631)727-2090 OFFICES LOCATED AT 322 ROANOKE AVENUE IrRl-lrAn l\I""w y.....rv 11on1 Fax (631)727-1727 MAIUNG ADDRESS P.O. Box 1931 O;"..rh..."..-1 "I".., Y...r(, 110n1 f\nc<;. THE EXISTENCE OF RIGHTS OF WAY AND/OR EASEMENTS OF RECORD. If ."., .,.......- .....,'....."., ."'.. .......~ "".........,...,.......... "V-0 <1-6 Olp (~ -<'V -0 SURVEY OF PROPERTY SITUA TED AT ARSHAMOMAQUE TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK s.c. TAX No. 1000-51 -06-32 SCALE 1 "=30' NOVEMBER 2, 2005 AREA = 18,975.95 sq. ft. (TO TIE LINE) 0.436 ac. "'~ v "'<P. "'+<1> + ~"'o "'.,<)~ .?> "'c>~ f- <'<, ~ "'A <::~. <' '" '.;f> CERTIFIED TO. PHYLLIS SOUSA BETTY RUGG PECONIC ABSTRACT, INC. FIRST AMERICAN TITLE INSURANCE COMPANY OF NEW Y J. P. MORGAN CHASE BANK, N. A. ~o ~, " '\ ^".. Of' S 54'11 '53" W :0\) 70'13'45,,1:12' # 10 3099' //~~ 1>'{-.1 s 49' /~/ ~~ ~~ 3/4'75" //...~O G .47' W ~/ ~~p, ~G AsY> lVO ~ ~ -, n r - "'''-", I \ilj l~ I ryq i I I II' [rD. "'"')' iG ~ lE [j ,', ..----"- '\1'>1 ,r", ,i: ': i' NOV - 5 2C07 ,,,I , --.....- , I ,~, PROPOSED WOOD DECK I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .............. .:.:.:-:-:.:.:.:- EXISTING '.' .....:.:.:.:-:-:.:.:.:.:. I::::::::::::::::. G~~~L .D~~E:~A~.:.:.::::.:.: . ..... ... . ... ... ... ....... ...... . ..... ... . ..................... ... ........ . ........ .. ........ ............ ...... . - ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~:: ~ ~ ~ ~ ~ ~ ~ ~ ~ ~: ~ ~ ~ ~ ~ ~ ~ ~: ~: ~: ~ ~: ~:: ~:: ~ ~: ~ ~: ~ ~: :: ~: ~: i i: ~ i;:;:::; ~ ~: ~: ~ ~ ~ i ~:;: ~::: i: ~::: i::;:; i: i: ~: ~:::;:;: WOOD DECK .....1.6.:. , , , " :i u-, ~ ..-; - ~ , , " ARSHAMOMAQUE POND 11.5' I D PROPOSED CONSTRUCTION SURVEY BY JOSEPH A. INGEGNO, P.C. DATED: 11/02/2005 NORTH ElEVATIOM ~ ~ WEST ElEVATIOM EXISTING SOUTH ElEVATlIN EAST ElEVATKIN NORTH ElEVATIOM WEST ElEVATIOM PROPOSED WINDOW REPLACEMENTS ~ SCALE: 1/16" =1'-0" SITEPLAN SCTMI = 1000-51-06-32 TOWN OF SOUTHOLD TRUSTEES SUFFOLK COUNlY, NEW YORK PERMIT APPLICATION ! ALTERATION TO THE ~ 12 i d o ~ SOUSA i RUGa ~ RESIDENCE i SOUTHOLD, NY ~ 1695 WEST Mill CREEK OR ~ ~ ~ 12 ~ ~ ~ OWNERS I PHYlUSSOUSA & BETTY RUGG 162-01 POWElJS coo: B1.\U .. WHrrESTON~ NY 11357 lE~ 917-864-4751 ~ lE~ 718-747-3717 ~ lE~ 631-765-6071 I ~ ~ !li! ~ j ~ ~ ;;1 ~ ! I ~ !5 -<~ ~~ ~ ~ DAlE: 11 /05/2007 ~ '" SCAlE: 1/16' = 1'-0' ..~ ~ ; SITE PLAN ~ ~ ~ IlWG. NAME ~~ A - 1 9;;1 1lWG. NC ARCHITECT FRANK UELlENDAHl P.O.BOX 316 GREENPORT, NY 11944 ~ 631-477 8624 FAX: 631-477 2997 I C ~I~ I/!I ~~~ I~I ~~ ~ !H!~ ~-~ 00 _ - _ 0 . . Page 1 of 1 Cantrell, Elizabeth From: frank uellendahl [fuellend@optonline.net] Sent: Tuesday, November 20, 2007 2:52 PM To: Cantrell, Elizabeth Subject: [NEWS ENDER] - Rugg Sousa application - Message is from an unknown sender Dear Elizabeth, As per your request I updated the project description for the Rugg Sousa application as follows: - replacement of most existing windows and doors in the heated part of the main house, some salvaged windows to be installed in unheated areas, such as the attic (east elevation), and the garage (north and east elevations) - upgrade insulation in attic and basement - extend existing front brick stoop and replace with wood deck - install new wood steps at new living room door (south elevation) Happy Thanksgiving! Frank ~EH: ~::E 0 Frank Wolfgang Uellendahl, Architect PO Box 316 Greenport, NY 11944 Soull1huld T/)w8 Boanl of Trustees 11/20/2007 . . James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob LThosio, 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 _Coastal Erosion Permit APPlica~ _Wetland Permit Application Administrative Permit _ AmendmentlTranslfrfl,;xtension _4ceived Application:, 111,j IrJJ .....-Received Fee:$ 6\)- 2 ;~ _--etlmpleted Application I I 1 _Incomplete _SEQRA Classification: Type I_Type II_Unlisted_ _ Coordination:( date sent) _ L WRP Consistency Assessment Form CAC Referral Sent: .....oate oflnspection: II/v In J _Receipt ofCAC Report: _Lead Agency Determination:_ _Technical Review: ~lic Hearing Held: 11f/I.fJO I _Resolution: Office Use Only ~ lE ~ J~JJL!J~ , I' ~V - 5::J! L----c- Soutnoid Town Board of Trustees Name of Applicant ~~'("'k' b:.":f(t:'U;9,'9/~ r;o/u,.n~rr- I=?JJ2 13bilY I2.V~ 1"2 - 01 'Pc;LVc=.u'6 C.OVl:: /::D / tlrtl:s.TtX.JS o'JUIy' 11369- Address ,Q9~ .3/~., ~L!:&~r4't3r:, ,'77- //"J<t<{ Phone Number:( ) /ir3/) 4- -;;.?- ~_s?4. <3J:1., e6f.-~~1 Suffolk County Tax Map Number: 1000 - g / - 0 h - 62 Property Location: /G,<3t? tzI~r hll./ C:/~G(~ TJP. ....::: LI. ~ /6Al (provide LILCO Pole #, distance to cro s streets, and location) -1.- /oi2- PT FieOH Ro~O AGENT: rl2~UK- UEU&-Vt?,q~c .qP/',i.,//~ / (If applicable) Address: 6Ge- 4.a7t/G fo ~y: 310 I Grepr.~ Phone: ~oard of Trustees APPlicJllbn GENERAL DATA Land Area (in square feet): /E/.qr1-~ SF /.2 ~ 4D /2~~/ 061Jl? RC .PEFS> 1~/Jf7 ,qL Area Zoning: Previous use of property: Intended use of property: Covenants and Restrictions:_ Yes No If "Yes", please provide copy. Prior permits/approvals for site improvements: Agency Date /' No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspen~d by a governmental agency? V No Yes -- If yes, provide explanation: Project Description (use attachments if necessary): -I2ePt.-qa::J4~ CJF ~~ IAJ/A..Jt.:JaJS f D?/.7,?6 - UP?1240~ /~t-R17l9v IV J:JttN:: ;q.vP B~T -~ G:tcr~ t1?/JVf Bp-I/.-e 6T~OP ,A-iJD P~PL-,qa:::;; l-/ f77..I tvOCJO 1J~i,/ . Board of Trustees APPliCeon WETLANDITRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: UP t:;;l?AV~ / A../6U~t:7LJ t3'PG;;>er'k ~€ hVD IHP,lU:JU~ h~ TO ~ur 007R- Area of wetlands on lot: o square feet Percent coverage oflot: g. <d8 % Closest distance between nearest existing structure and upland edge of wetlands: 42,8 feet Closest distance between nearest proposed structure and upland edge of wetlands: IV (;,"1- feet 77/ PI2P~V ~t:::. Does the project involve excavation or filling? No A es 17//2.. .3 R?t7T7Mb6 If yes, how much material will be excavated? cubic yards How much material will be filled? CJ..2Gi cubic yards Depth of which material will be removed or deposited: g, feet Proposed slope throughout the area of operations: R-,qr L.q)(/D Manner in which material will be removed or deposited: ,e,~ /!77X../p Statement of the effect, if any, on the wetlands and tidalwaters of the town thatl11a)'fes~1tby reason of such proposed operations (use attachments if appropriate): ,czz67Pt?sev ~t'J.? 0;u_ tUor Gff"t?C-( 0! /;;Tl.t:r,( )O~ 617.20 . PROJECT ID NUMBER APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1. PROJECT INFORMATION (Ta be campleted by Applicant ar Project Sponsar) SEQR 1. APPLICANT I SPONSOR 2. PROJECT NAME / J2u~G e~SrZ7t:!!5VCG County .::50 ~c. 4. PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks ete - or provide map /&?@~ W~ h/d- ~..o.e - OV IiRGII-;QI7.!JH/7aoG P~)'/D Off ,erorc --?-t;:::r,/ c:snu1:fl3J e.tCJIl-'lt!JVO.eo &I2otE 5. IS PROPOSED ACTION: 0 New D Expansion 0 Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: .J2E1L?t:rl/er e>tr~ C3/Z./ce .:57l?p6 .hUD ze;~~ Lvi WFJD ~pp'r;Q;;". .7.?JUO ~~ "1l t7ZJO VECk:..- 4'-T 'R2lJVT oooe RRHP 7. AMOUNT OF LAND AFFECTED: /....:;1 Initially acres Ultimately acres:;/ e 61= 8. WILL ROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? o No If no, describe briefly: !!!fj;1IS PRESENT LAND USE IN VICINITY l.!1"Residential D Industrial D Commercial OF PROJECT? (Choose as many as apply.) DAgriculture D Park I Forest I Open Space DOther (describe) 10.' DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL ~~y (Federal, State or local) L0"'es ONO If yes. lis' agency name and permit I approval:~ ~.' eec.eit/cO alleFe:f-t</pu~ . - 13UIt-O/Vb ~ -loCO -ANYASPECTOF-IHI:: ACIION HAV!:: A CUHHENILY VALID PERMIT OR APPROVAL? es ~NO If yes, list agency name and permit I approval: ,DGc. C&Py ;iq?7RcHeD PROPOSED ACTION WILL EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION? FORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant Date: Signature Ifthe action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment . . PARTII. IMPACT ASSESSMENT ITa be comDleted bv Lead Agencv) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? Jfyes, coordinate the review process and use the FULL EAF. DYes DNo B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superse'd by another involved agency. DYes D No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: I - ^ ^ ^~^ - ^ -. I C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: I .. I C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: I I 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: I .. II C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly: L ... .....-- _... 1 C6. Long leon, short term, cumulative, or other effects not identified in C1-C5? Explain briefly: I I C7. Other impact~ (inclu~ing _~hanges in use of ei_ther ~~a~~ityortx?e_~f ~~ergC Explain briefly: I .. ....... . ........ .... . ......1 D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL DI~~:MED~~rA(CEA)? (If yes, explain briefly 1 E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? II yes explain: DYes DNo l. . ...................... .. . ............1 PART 11I- DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. 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, t~9 dstermiRation ofsignific3AGe-fA\:l-5t-ev-a1uate--tAe--peteA-tial-im[:}8et--ef-tI:te I3roposed aetiofl OR tl=l(; (;flvimnfl,(;ntal challietcri~ticsofthe OCA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FUL EAF and/or prepare a positive declaration. Che6-k-ifils.box-lfyo"LJ-have-delermmec( basedon.flie liiformalion and analysis -above and-any supporting do-cument~ition'- fhaftheproposed 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 Pnnt or Type Name of Responsible Officer In Lead Agency Title of Responsible Officer Signature of Responsible Officer 10 Lead Agency Signature of Preparer (If different from responsible officer) . Board of Trustees . Application County of Suffolk State of New York ~JV I:::. v/~I(/O,q-llL BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTHIN 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 REPRESENT ATIVES(S), TO ENTER ONT MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH RE OF THIS APPLICATION. Signature SWORN TO BEFORE ME THIS 1Jltl DAY OF --'J tJ7} ,2oH VERONICA F. C1~ 'ak NalIIy PublicJdlll1o& No.O. ~'''''''k~ Qualified in ........ . Commission EIpIres Ole. 31. " ~ Board of Trustees APP~lIJion AUTHORIZATION (where the applicant is not the owner) ~ I, ~* (print 0 ner $c, ~o\JJ I (~'i \Adk~~o. -eX residing atMSrJ~~Gui y\ (maLling ~dreSS) ~ authorize \:-- ~ ty) do hereby (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. 8 . ... APPLICANT/AGENTnREPRESENtATlVE TRANSACTIONAL DISCLOSURE. FORM The Town of South oJ d's Code of Ethics nrohibits conflicts of interest on the Dart of town officers and emolovees. The nuroose of this ronn is to orovide information which can alert the town of oossible conflicts of interest and allow it to take whatever action is necessarY to avoid same. . YOUR NAME: f=E.q,ue Ug.lF,UVIN/L (Last name, first name, .qtiddle initial, unless yo"u are applying in the name of someone else or other entity, such as a company. If so, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Variance Change of Zone Approval of plat Exemption from plat or official map Other (If''Other'', name the activity.) OI=!("J Building Trustee Coastal Erosion Mooring Planning ../ ../ Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of South old? "Relationship" includes by blood, marriage, or business interesl "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% o.9he shares. YES NO ~ If you answered "YES", complete the balance of this form and date and sign where indicated. Name ofpers()n employed by the Town of South old Title or position of that person Describe the relationship between yourself(the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town officer or employee or his or her spouse, sibling, parent, or child is (check all that apply): _A) the owner of greater than 5% of the shares of the corporate stock of the applic~nt (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, partner, or employee of the applicant; or _D) the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this 5"~ d Signature Print Name 200;}- UGAJ77/1tk.. Form TS 1