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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.