HomeMy WebLinkAboutTR-6799A James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob Ghosio, Jr.
Town HsllAnnex
54375MainRoad
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
# 0479C
Date: October 2, 2009
THIS CERTIFIES that the construction of a 12'x12' deck with gutters, leaders to
d _r~vells installed on the seaward side of the dwelling
At 53557 Main Road, Southold, New York
Suffolk County Tax Map # 61-4-10
Conforms to the applications for a Trustees Permit heretofore filed in this office
Dated 12/12/07 pursuant to which Trustees Administrative Permit # 6799A
Dated 1/23/08 was issued and conforms to all of the requirements
and conditions of the applicable provisions of law. The project for which this certificate
is being issued is for the construction ora 12'x12' deck with gutters, leaders to drywells
installed on the seaward side of the dwelling
The certificate is issued to GRETA SCHILLER owner of the
aforesaid property.
Authorized Signature
James F. King, President
Jill M. Dohesty, Vice-Presidenl
Peggy A. Dickerson
Dave Bergen
Bob Ghosio,
Town Hall, 53095 Main Rd.
P.O. Box I 179
Southol6, NY 11971
Telephone (63 l} 765-1892
Fax (63 I) 765-6641
BOARD OF TOWN TRUSTEES
' TOWN OF SOUTHOLD
1,// Ch. 275 Ch. 111
INSPECTION SCHEDULE
Pre-cQnstruction, hay bale line/silt boom/silt curtain
st day of construction
constructed
b///"Project complete, compliance inspection.
INSPECTED By: (//~...~. z~ ,~.~..-,~--,-~-~
~ ~ ~ ~~. ~'~
CERTIFICATE OF COMPLIANCE:
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 York11971-0959
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
1st day of construction
% constructed
v'/' 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.: 6799A
Date of Receipt of Application: December 12, 2007
Applicant: Greta Schiller
SCTM#: 61-4.10
Project Location: 53557 Main Road, Southold
Date of Resolution/Issuance: January 23, 2008
Date of Expiration: January 23, 2010
Reviewed by: Trustee Dave Bergen
Project Description: Construct a 12'x12' deck.
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
survey prepared by Peconic Surveyors, P.C., last revised November 26, 2007,
and received on December 12, 2007.
Special Conditions: Gutters, leaders and drywells installed along the eastern
(seaward) side of the house and in accordance with Chapter 236 of the Town
Code-Storm Water Runoff.
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.
This is not a determination from any other agency.
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
Telephone (631) 765-1892
Fax (631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
TO: Ile
Please be advised that your application dated'-~:~e,--/~2/~<~o? has
been reviewed by this Board at the regular meeting of :3~o-~ ~cz_r~ ,~ &; ~o<~f
and your application has been approved pending the completiondof 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)
__ ½ 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 Southoid 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: $. ,_~0 ~
BY: James F. King, President
Board of Trustees
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
Southold Town Board of Trustees
Field Inspection/Worksession Report
Date/Time:
Name of Applicant:
Name of Agent:
Property Location: SCTM# & Street
Br/ef Description of proposed action:
Type of area to be impacted:
__Saltwater Wetland vl~reshwater Wetland
Distance of proposed work to edge of above:
Sound Front
__Bay Front
~cchOf Town Code proposed work falls under:
apt.~ Chapt. ~ other
Itl
~ .
Type of Application: Wetland __Coastal Erosion __Amendment __Administrative
__Emergency
Info needed:
Modifications:
Present W~re: __J.King __J.Doherty__P.Dickerson
Other:
D. Bergen
Bob Ghosio, Jr.
Mailed/Faxed to: Date:
Comments of Environmental Technician: ~c~ ,{-(er
Town o~I Southold
' LWRP CONSISTENCY ASSESSMENT FORM
A. /INSTRUCTIONS
All applicants for permits* including Town of Southold agencies, shall complete this CCAF for
proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This
assessment is intended to supplement other information used by a Town of Southold agency in
making a determination of consistency. *Except minor exempt actions including Building Permits
and other ministerial permits not located within the Coastal Erosion Hazard Area.
Before answering the questions in Section C, the preparer of this form should review the exempt
minor action list, policies and explanations of each policy contained in the Town of Southold Local
Waterfront Revitalization Program. A proposed action will be evaluated as to its significant
beneficial and adverse effects upon the coastal area (which includes all of Southold Town).
If any question in Section C on this form is answered "yes" or "no", then the proposed action will
affect the achievement of the LWRP policy standards and conditions contained in the consistency
review law. Thus~ each answer must be explained in detail, listing both supporting and non-
suooorting facts. If an action cannot bc certified as consistent with the LWRP policy standards and
conditions, it shall not be undertaken.
SCTM# ~ I
PROJECT NAME
DESCRIPTION OF SITE AND PROPOSED ACTION
A copy of the LWRP is available in the following places: online at the Town of Southold ' s
website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all
local libraries and the Town Clerk's office, r
DEC 3 1 2007
The Application has been submitted to (check appropriate response):
Town Board
[] Planning Board ~ Building Dept. ~-~ Board ofTrustees ~]
Category of Town of Southold agency action (check appropriate response):
(a) Action undertaken directly by Town agency (e.g. capital
construction, planning activity, agency regulation, land transaction)
(b) Financial assistance (e.g. grant, loan, subsidy)
(c) Permit, approval, license, certification:
Nature and extent of action:
Location of action:
Site acreage:
Present land use:
Present zoning classification:
If an application for the proposed action has been filed with the Town of Southold agency, the following
information shall be provided:
(a) Name of applicant: ~U~
(b) Mailing address: ~ 0 K. "7 F~ 5
(c) Telephone number: Area Code (:").
(d) Application number, if any:.
Will the action be directly undertaken, require funding, or approval by a state or federal agency?
Yes [] No [~_ If yes, which state or federal agency?
C. Evaluate the project to the following policies by analyzing how the project will further support or
not support the policies. Provide all proposed Best Management Practices that will further each policy.
Incomplete answers will require that the form be returned for completion.
DEVELOPED COAST POLICY
Policy 1. Foster a pattern of development in the Town of Southold that enhances community character,
preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and
minimizes adverse effects of development. See LWRP Section III - Policies; Page 2 for evaluation
criteria.
[]Yes [] No [~Not Applicable
Attach additional sheets if necessary
Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See
LWRP Section III - Policies Pages 3 through 6 for evaluation criteria
Yes ~ No-~ Not Applicable
Attach additional sheets if necessary
Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See
LWRP Section III - Policies Pages 6 through 7 for evaluation criteria
~ Yes ~ No ~Not Applicable
-
Attach additional sheets if necessary
NATURAL COAST POLICIES
Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LwRP
Section III - Policies Paflles 8 through 16 for evaluation criteria
[] Yes [] No[~c--x Not Applicable
4.0
Attach additional sheets if necessary
Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III
- Policies Pages 16 through 21 for evaluation criteria
~ Yes [] No ['~ Not Applicable
Attach additional sheets if necessary
Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including
Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22
through 32 for evaluation criteria.
Attach additional sheets if necessary
Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies
Pages 32 through 34 for evaluation criteria.
~Yes ~ NoJ~Not Applicable
Attach additional sheets if necessary
Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous
substances and wastes. Sec LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria.
Yes No 2 Not Applicable
PUBLIC COAST POLICIE~
Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public
resources of the Town of Southold. See LWRP Section III - Policies; Pages 38 through 46 for evaluation
criteria.
~ Yes~ No ~N(~Not Applicable
Attach additional sheets if necessary
WORKING COAST POL~!~ES
Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in
suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria.
~-~ Yes ~ No ~-"~0t Applicable
Attach additional sheets if necessary
Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peconic
Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria.
Yes ~ No I~ Not Applicable
Attach additional sheets if necessary
Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages
62 through 65 for evaluation criteria.
Yes No VY. ot Appllcahlc
Attach additional sheets if necessary
Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP
Section III - Policies; Pages 65 through 68 for evaluation criteria.
Yes [-] No ~] Not AppUcablc
OFFICE LOCATION:
Town Hall Annex
54375 State Route 25
(cor. Main Rd. & Youngs Ave.)
Southold, NY
MAILING ADDRESS:
P.O. Box 1179
Southold, NY 11971
Telephone: 631 765-1938
Fax: 631 765-3136
LOCAL WATERFRONT REVITALIZATION PROGRAM COORDINATOR
TOWN OF SOUTHOLD
To:
MEMORANDUM
James King, President
Town of Southold Board of Trustees
Mark Terry, Principal Planner
LVfRP Coordinator
Date: January 9, 2008
JAN - 9 2008
SouthhoZd Tow~
Re:
Request for Wetland Permit for GRETA SCHILLER
SCTM# 61-4-10
GRETA SCHILLER requests a Wetland Permit to construct a 12' x 12' deck on the east
side of an existing house. Located: 625 Private Rd., Southold. SCTM# 61-4-10
The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review
of the Town of Southold Town Code and the Local Waterfront Revitalization Program
(LWRP) Policy Standards. Based upon the information provided on the LWRP
Consistency Assessment Form submitted to this department, as well as the records
available to me, it is my recommendation that the proposed action is INCONSISTENT
with the denoted following Policy Standards and therefore is INCONSISTENT with
the LWRP.
Policy 6. Protect and restore the quality and function of the Town of Southold
ecosystem.
6.3 Protect and restore tidal and freshwater wetlands.
Comply with statutory and regulatory requirements of the Southold Town
Board of Trustees laws and regulations for all Andros Patent and other
lands under their jurisdiction
1. Comply with Trustee regulations and recommendations as set
forth in Trustee permit conditions.
The distance from the edge of pond to the proposed deck is 55 feet; a
minimum setback distance of 100 feet from the wetland line is required
pursuant to Chapter 275-3. Findings; purpose; jurisdiction; setbacks. Please
require that the applicant amend the application to meet the above policy to
the ~reatest extent practicable.
If the action is approved the following best management practices (BMPs) are
recommended:
Require non-chemically treated lumber for the deck.
Require a non disturbance buffer between the wetland and the
deck.
The BMP will further Policies 5, Protect and improve water quality in the Town of
Southold and 6.3 Protect and restore tidal and freshwater wetlands, item D (below).
Provide adequate buffers between wetlands and adjacent or nearby uses and
activities in order to ensure protection of the wetland's character, quality,
values, and functions.
Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in
preparing its written determination regarding the consistency of the proposed action.
James F. King, President
Jill M. Doherty, Vice-President
Peggy A. Dickerson
Dave Bergen
Bob ~nosio, 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
Office Use Only
Coastal Erosion Permit Application/
Wetland Permit Application ..~ Administrative Permit
Amendment]Transfer/Extension
Received Application:
__,.~-~eceived Fee:$
.-~Completed Application
Incomplete
__SEQRA Classification:
Type I Type II Unlisted
Coordination:(date sent)
~'~LWRP Consistency Assessment Form ~'~__ ~
CAC Referral Sent:
~'l~ate
Inspection: I
of
Receipt of CAC Report:
Lead Agency Determination:
Technical Review:
~r~blic Hearing Held: ]/
Resolution:
Name of Applicant ~r~& ~¢ [t~ I (P~
Address
Phone Number:(~)t
Suffolk County Tax Map Number: 1000- t.]-] 3 I~ 0 q
Property Location: ~ccoSg ~ro~- ~/~:~l~ [;~olr&~]
(provide LILCO Pole #, distance to cross streets, and lbcation) t
AGENT:
(If applicable)
Address:
Phone:
of Trustees Applicatio~
Land Area (in square feet):
Area Zoning:
Previous use of property:
Intended use of property:
GENERAL DATA
Covenants and Restrictions:
If "Yes", please provide copy.
Yes ~ No
Prior permits/approvals for site improvements:
Agency Date
~/ No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspe, nded by a governmental agency?
X No Yes
If yes, provide explanation:
Project Description (use attachments if necessary):.
Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
Area of wetlands on lot: f2~ ~ - square f~et
Percent coverage of lot: 3 .~7 %
Closest distance between nearest existing structure and upland
edge of wetlands: - ¢-~. feet
Clos. est distance between nearest proposed structure and upland
edge of wetlands: 5~ feet
Does the project involve excavation or filling?
,~ No Yes
If yes, how much material wi 1 be excavated?
How ranch material will be filled?
Depth of which h~aterial will be removed or deposited:
Proposed slope tluoughout the area of operations:
Maturer in which material will be removed or deposited:
cubic yards
cubic yards
feet
Statement of the effect, if any, on the wetlands and tidal waters of the town that max result by
masOn` of su~fi pr0pos~d operatl(~n~ (use ~im~ei:tts if' ~pprop~iate}i .........
PROJECT ID NUMBER
PART 1 - PROJECT INFORMATION
1. APPLICANT / SPONSOR
3.PROJECT LOCATION:
Mu icipa,ty
6'17.20
APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLISTED ACTIONS Only
( To be completed by ,~ :,licant or Project Sponsor)
2. PROJECT NAME
County
SEQR
PRECISE LOCATION: Slreet Addess and Road Intersections, Prominent landmarks etc -or provide map
5,1S PROPOSED ACTION: ~ New ~pansion ~MoUifl~tion/alterati~n
6. DESCRIBE PROJECT BRIEFLY:
7 AMOUNT OF LAND AFFECTED:
Initially acres Ultimately acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
[~Yes [] No If no, describe briefly:
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.)
~Residential ["~lndustdal r-]Commercial E~Agriculture E~Park/Forest/OpenSpace E~Other (describe)
10.' DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
AGENCY (Federal, State or Local)
~]Yes [~JNo fl yes, list name and /
agency
permit
approval:
11.L)tJE~5 ANY ^SP~-~;I OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
E~Yes []No If yes, list agency name and permit / approval:
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION?
[~lYes r'~J No
Applicant
Signature
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
/ Spon.sorl N~me Date:
If the 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~enc¥)
IA* DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.47 Jf yes, coordinate the review process and use the FULL EAF.
E~]Yes E~No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 6f7.67 If No, a negative
declaration may be superseded by another involved agency.
r-]Yes E]No
c. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be han~lwdtten, 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:
C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly:
I
'1
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered ~l)~i~
I
C5. Growlh, subsequent development, or rel~]ted activities likely'to be induced by i~; p,:0p;~ ~t(o~
I--
Long term, short term, cumulative, or other effects n~t identified in 61.C5, Explain briefly:
C7. Other impacts (including changes in Use of either quantity er t~,~e ;~ ~ne;~¥? Expi;i~ bii;fi~,i
WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAl
ENVIRONMENTAL AREA (CEAI? Ill },es explain briefly:
E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If ~es explain:
E~Yes E~No i-
I I
PART III - Dr= I I::I<MINATION 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
~ ............ ~, ~'~ '~ ~"~' ................................. ~.; .-ho, o ,.t ~, ,ot,,.,.~ .~ f ;,h ~ C C.A
Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directiy to the FULl
EAF and/or prepare a positive declaration.
CheEl~ th~s B~x icyOL~'I~V~ de~:minedl b~sed ~h'ihe irtforrnation a~d ~haly&is ~b0ve a~d a~ ~uppo~i~ docu~ent~tio~i (~.t.~ ~r0~ ~1
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
Pdnt 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
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 I-IlS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK
WILL BE DONE IN THE MANNER SET FORTH tN THIS APPLICATION AND AS MAY
BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT
AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES
HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING
UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR
REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
Signature
SWORN TO BEFORE ME THIS I ~ DAY OF~-~gt'O/~e-~ ,20 O'~
(~otary Public
APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
TDe Town of Southold's Code of Ethics orohibits conflicts of interest on the oart of town officers and cmnloveas. The nuroosc of
dis form is to orovidc information which can alert the town of oossiblc conflicts of interest and allow it to take whatever action is
necessary lo avoid same.
(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, indicate thc 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
(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, nlarriage, 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% o~
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 applicant/agent/reprasentative) 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 applicant
(when the applicant is a corporation);
__.B) the legal or beneficial own~'r of any interest in a non.-corpomte 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 I
Submitted this Jl dayof ~)-ff_~(_. 200 '7
Signature -~.~ ( t/~ ~/ --
Prmt Name ~ ~ ~[~ ~
N
$CDHS REF. # RH055058~8
SURVEY O? PROPERTY
AT SOUTHOLD
TOWN OF SOUTHOLD
SUFFOLK COUNTY, N.Y.
1000-61-04-10
$CAL~,: 1'--40'
MA Y 12, 2005
SEPT. ;~,~, ,~005 (certificotion]
NOV. 2~, -~0(~"~ (PR~P L,~£ Oc )
CER T/FlED TO '
ANDREA IVEISS, GRETA SCHILLER AND
LISA SCHILLER
HUDSON CITY SA VINGS BANK,
WEST 80 CENTURY ROAD,
PARAMUS, NJ 07652-1473
WETLANDS COVERA6E ' $.7%
.oT ,1 s
J=MONUMENT ~j~ NO. 6812 MAY 7, 1979 .
e=P/PE ~ ~CONiC~ S~VEYORS, P.C.
ANY AL~RATION OR ADDISON m ~IS SURLY IS A ~OLA~ON (6~1) 765-5020 FAX (651) 765-1797
OF SECnON 72090F ME NEW rORK STA~ gOUC~nON L~
SAID MAP OR COPIES BEAR ~E IMPRESSED SEAL OF ~g SUR~YOR AREA=59,288 SQ. F~ SOUTHOLD, N. ~ 11971
~osg SIGNA ~RE APPEARS HEREON.