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Home My WebLink AboutTR-5865 . . Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Han 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 CERTIFICATE OF COMPLIANCE # 0043C Date July 7, 2005 THIS CERTIFIES thatthe additions to dwelling, deck, and entry pergola 1\t 75 Harbor Lights Dr., Southold Suffolk County Tax Map # 71-2-7 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 1/26/04 pursuant to which Trustees Permit # 5865 Dated 2/25/04 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 additions to dwelling, deck, and entry pergola The certificate is issued to Patrick & Diane Kelly owner of the aforesaid property. Ji/,,- ~ 1/. ~. ().. 1\uthorized Signature . . 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 SOVTHOLD Board of Trustees Field Inspection Date J u. 1:J 5 I ,;200 S 15 ~l".,r L;~h..f-j p ~-fy, ( 1... cr.o r,,,, e {Gl. (L'1 Address Owner SCTM# , I -~ -1 tkv\~ \e~,",\-I- _, tJ 0-v-(eo~ f;' 0 f ~.~ l/'><>" (e 'Y'-i)ve.d V-.'><{ Inspected by Findings OvV,,"' [p.;?\s f\~~) 1...0'~ h~./Ir"'"'J~" loSe) a.....J. I}~ ~ 1'h..v'U ~ \ t-; \ . I.., A 0- l.,.iA c:z:v ,\ '( Photos taken 1 ~) . . Albert oJ. 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 June 20, 2005 Patrick and Diane Kelly 30 Cathedral Avenue Southold, NY 11971 Re: 75 HARBOR LIGHTS DRIVE, SOUTH OLD SCTM # 71-2-07 BOARD OF TRUSTEES PERMIT # 5657 Dear Mr. And Mrs. Kelly: Enclosed is a copy of the Board of Trustees Permit issued for the above referenced lot. As per your request this office inspected your property on June 8, 2005, to confirm the removal of the chain link fence in the wetlands and the fencing parallel to water. We have notified the Town Attorney's office that the fences have been removed. However, the re-building of the bulkhead was not constructed as per the Trustee Permit issued on November 20, 2002. The Permit for re-constructing the bulkhead was given with the stipulation if a ten-foot non-turf buffer landward of the water. An amendment to that permit was issued on May 1,2003, to allow for a "6' wide x 142' untreated deck landward of the newly constructed bulkhead as part of the non-turf buffer and as depicted on the site plan prepared by Costello Marine Contracting Corp. dated March 16,2003." At the June 8, 2005 site inspection this office determined that the decking landward of the bulkhead has been constructed to be 5' 3". The remaining area 4'9" landward of the walkway has been planted in turf. The Board of Trustees respectfully request that the 4'9" x 142' area of turf be removed, and replaced with one of the following non-turf materials, as per your permit: wood chips, native plantings that will not need watering or fertilizer, stone, ground oysters, or other natural, pervious material. Chapter 97 'Wetlands and Shoreline' of the Code of the Town of Southold defines NON TURF BUFFER as follows: Any pervious material allowing for percolation of surface runoff into the soil. Examples include: natural vegetation, wood chips, mulch, gravel, and sand. Decks may be allowed . . if they are level or pitched away from the water, are pervious to precipitation and are constructed of materials other than treated lumber. Any and all runoff generated by such structures must be allowed to percolate into the ground directly below the structure. Fertilizers may not be used within the non-turf buffer area. For your convenience, enclosed are: 1. A copy of Permit #5657. 2. A copy of the amendment issued on May 1, 2003. 3. A copy of the site plan prepared by Costello Marine Contracting. 4. Copies of minutes of the Nov. 20, 2002 Trustee meeting where Permit #5657 was approved. Please contact this office at the completion of the removal of the turf for a compliance inspection. Failure to comply with the requirements of your permit may result in a violation and fines up to $4000. Please contact this office with any questions. ~~ Heather Tetrault Environmental Technician Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson . . Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. flc..\lY INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction 11, constructed ........... Project complete, compliance inspection. . ~ . . . TERMS and CONDITIONS Patrick & Diane Kelly The Penaiutc cesidlag at 75 Harbor Lights Dr.. Southold N. Y.. as part of cbe coosideradOD for cbe lsSt.."", of the 1'ermit does UI1dentand and prescribe to the fal- 1owIII&: 1. That cbe aid ~ of Trustees and dle Town 01 Soutbold ue released from. any and all damages, Ot' dalms fOt' Umages, of suhs arisJng direcdy or hraclirccdy as a resuIr of any oper- ation performed pursuant to this .-mt, and dle IIid 1\. .1_ will, at his Ot' bet own ~, defend any and all ...m lUllS .lnlH..-I by third !'.roes, and cbe IIid P...Muce _ws.fa111iabllity with reSpect tbereto, to cbe GlGIPIete eoa:lu$ioo of cbe Ilclud of T_ of cbe Town of ~Id 2. That this Pemdt Is \'IIid for . ~ of 24 . IIlIlls. whidlls ~ to be cbe estimated time requited to romplete cbe work invohed, but ehoaId cit<wilsw>ces .-not, QqUest for an extenSioo may be pde to cbe J)oard at a later -- ~. That this Permit should be retained indefiDitely, or as long as d1e IIid Permittee ~es 10 m.lnuo1n cbe suuaure or project involved, to provide evidence 10 aayooe cooceroed d1at auth- orizatioo was origiaally obtaioe<l 4. That dle wod< involved will be subject to d1e iospectioo and Ipproval of d1e Board Ot' Its agents, and 000-<lOlDp1laoce widl d1e provisions of cbe originatiog application, may be cause fOt' revocatioo of this Permit by raolutioo of d1e said Board. S. I'hat cbere wII1 be 00 unreasonable interference with navigation as a result of cbe work betein aUtborlzed. . 6. That cbere sha11 be 00 interference with tbe right of cbe pub1ic to pass and repas aloag cbe beach between hip and low water marks. 7. That if fucure operations 01 cbe Town of Soutbold require d1e removal and/Ot' dterltlnas in d1e location of cbework herein ...tJ-I-l. or U, incbe opinion ofd1eBoard 'ol Tmstecs, cbe. .work sba11 cause uoreasoaable obslrUCllOG to free oavigldoo, d1e IIid ~ will be reqahed. upoo. due notice, to mnove or alter this work or project herein stated wicbour e..peascs to the Town . of Soutbold. 8. That d1e said Board will be notified by the Permittee ot cbe ~~<< d1e work auth- .orized. 9. That the Permittee wII1 obcain all ocher permits and (1VK"ft" d1at may be requited ~ p1emental 10 Ihls permit whidl _y be subject to revoke "poll failure to 1ll>Wo -- . . 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 February 25, 2004 Mark K. Schwartz, AlA P.O. Box 933 Cutchogue, NY 11935 RE: PATRICK & DIANE KELLY 75 HARBOR LIGHTS DR., SOUTH OLD SCTM#71-2-7 Dear Mr. Schwartz: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, February 25, 2004 regarding the above matter: WHEREAS, Mark K. Schwartz, AlA on behalf of PATRICK & DIANE KELLY applied to the Southold Town Trustees for a permit under the provisions of Chapter 97 of the South old Town Code, the Wetland Ordinance of the Town of Southold, application dated January 20, 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 February 25, 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, 2 . . 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 PATRICK & DIANE KELLY to construct new dormers, re-build existing deck, new windows and doors, and new entry pergola at street side, with the condition a line of hay bales is placed down along the phragmites on the northwest side of the house, before construction begins, and left in indefinitely, and as depicted on the plan prepared by Mark K. Schwartz last dated January 12, 2004. 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 $5.00 per inspection. (See attached schedule.) Fees: $5.00 Very truly yours, P/r4..f- 9- ~. ().. Albert J. Krupski, Jr. President, Board of Trustees AJKllms Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken poliwoda . . Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO:~laC\4. ~ Please be advised that your application, dated I ~ has b~~n_~~~fewed by this Board, at the regular meeting of ~~ and the following action was taken: ( .........) 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: <<S.oo -Hl'O.\ iO~fC?c:t;CX"l .f~~ TOTAL FEES DUE: $ S,CO tlac.1/'1 ,.({, ~._A: 9-, SIGNED: y. PRESIDENT, BOARD OF TRUSTEES BY: . ~ A ~ U'l ....Jtt,.fIIAoJ.. ~BOARD OF TRUSTEES 4/98 . . Telephone (631) 765-1892 Town Hall 53095 Roule 25 P.O. Box \179 Southold, New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Monday, February 23, 2004, the following recommendation was made: PATRICK & DIANE KELLY to construct new dormers, re-build existing deck, new windows and doors, and new entry pergola at street side. Located: 75 Harbor Lights Dr., Southold. SCTM#71-2-7 The CAC did not make an inspection, therefore no recommendation was made. + + + + 0 -N- ~ J . + + swr/fOll) 8/oJ' . + -.. SOUTHOLD stCTKlHNO '~._.."-- , ~oastal Erosion Permit Application _Wetland Permit Application ~ajor _Waiver/Amendment/Changes -LReceived Application: ~eived Fee:S 30mpleted Application _Incomplete _SEQRA Classification: Type I_Type Il_Unlisted_ _ Coordination:(date sent) -->-^C Referral Sent: i /# I~ ----..P"te of inspectIOn: ~,[!Il _Receipt of CAC Report: ' _Lead Agency Determination:_ Technical Review: AUblic Hearing Held: d-/:1.S J 6\f _Resolution: I . 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 TOw"N TRUSTEES TOWN OF SOUTHOLD Office Use Only Minor Southold 10wn Board of lrustees ~~ J~M~::~ Name of Applicant fn.. L I <- v<- l ,;), G-".e. ((aY~)2"%- 01 (,'1 / ILy, 1/1 CQ.j..~.e.d/c-\ A-,cnvL Cc-,c1R/'1 ell7 Phone Number:( ) 'L I "- .., L 'J L 0 0 I Address ] 0 Aj'f' //5J-=> Suffolk County Tax Map Number: 1000 - ., / - 0 L - 0 ! ~ 0....-1 v .. -L ~ t1:::. ~....'o J..v Dr I j' c::.... .I-;ruZ.. j7 ..:J.........d ~ (provide LILCO Pole #, distance to cross streets, and location)..- Property Location: /~ AGENT: ;n /"IA. (.{.. (If applicable) Address: ,Ul 0)( 90 W 0- / b, /' t... I , J-., ~-) t>)r tvL -4"":' /..Iev';',,- (.'5 A lJ /Dr, '""e. K Jc J.-., I-JD-/' ;- '-- , Arc.f-,,'f~cl- f\\~ S'-~ \\~ AlA C,-,J..L)...~'V<" --.J'~ //'13-';- . Phone: G:J / - 7 :J Y - s Yj 0 ,10 c; / '1\ gL\ . Board of Trustees . Application t: c:;. Ll.t( muSE GENERAL DATA Area Zoning: '2-0J () 00 SF ( 1240 SIIJGL.F- FA~ I LY ftF nt:/~Tl~ S-1A1,E. Land Area (in square feet): Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency Date ~o 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: Project Description (use attachments if necessary): G::w 5; ne II c...PPN {J F- ( NCfAJ0t7IVleR,.I((;-&(/(00 Il!KIS17NCI /?E:.cK.,. A/EMJ I . W/I//Ol1w./ AA/O Ot?t?tes; A/E.-w GlVrl2<; /::>eJlilG"c.A A, / Sr/leer flOe. N" EJC~/I;'/J/hll tJl" 17-Ie. e:.~/S.77A./CI FO,rl',!f:/N T IS PC.AIl/NF-O. . " I . Board of Trustees . Application ~f-lA_,V ffr; (/JE WETLANDffRVSTEE LANDS APPLICA nON DATA Purpose of the proposed operations: /111,1///;,/[- Aotl/77 a)(/ /' /f;vp / A-t.-rc d-""7' ' NJ P11A1t'1 /te-S(';?~r71h-- T7 ~f77;v~ , J'/-v~ C-~ ~,-..,F Area of wetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? V No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: j.J A- feet 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): j..I d IJ e- 9 ;f . . NOTICE TO ADJACENT PROPERTY OWNER BOARD 01<' TRUSTEES, TOWN OF SOUTHOLD In the matter of applicant: -/n,.j,-, <. /A c,_" d V, ~~ all{ SCTM# YOU ARE HEREBY GIVEN NOTICE: jooo- 7/- OL- 07 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: co,-,s-/'-VC.J- I"~--...J ?J~/~"J.), r,,--b~i/d e'< i5~'~--3 d-<.cl-<.... J d~--J-'). d0"jr.-:> nll-~ <2.-...-,.r--7 h'..L.rS"J/o.... ~I- / (e.-1 &I- c.;z..... L..-) ,...... " (/ o S-J- /~l- s.; cLe 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: 7S- j-I""-,,b..-/ L.iSAJ.> C,-ivc 5-0 v..y)..., Id 3. That the project which is subject to Environmental Review under Chapters 32, 37, and/or 97 of the Town Code is open to public comment on: . You may contact the Trustees Office at 765-1892 or in writing. The above-referenced proposal is under review of the Board of Trustees of the Town of South old and does not reference any other agency that might have to review same proposal. OWNERS NAME: rio.).-" t.LL ' ?J, o-^-<- j/...e /11 MAILING ADDRESS: 3--> r= J./...sz.drc...1 PI..- L (;oJcLt"-.J Ci11' /"'-J'y" //"J~ PHONE#: (,-,,-J 11..3- ~ <.0 ~ / Enc: Copy of sketch or plan showing proposal for your convenience. H.t5." {21871- Text 12 I PROJECT I.D. NUMBER . . 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I-PROJECT INFORMATION (To be completed by Aoplicant or Project sponsor) SEO I 2 PROJEC7 NAME 1. APPLICANT 'SPONSOA 3. PROJF.CT LOCATION: Municipality L, County S 4. PAEC:SE LOCA nON (Street address and road intersections, prominent landmarks. etc.. or proviae mapl 75 tf1t1e.13~te. U 6 fIT../" O!Z(,/€... 5tl (/n-f-p(,.e:/, tV Y. 5. IS PROPOSED ACTION: o New 0 expanSion Modification/alteration 5. DESCRIBE PROJECT BRiEFLY: CJ)AJS{12vC{Jf7iV ~/'" A/e-/OcJte.r1&/l-J, /2.C.(J(/"O E-)CI./f1AJCj IJECK./ IV~"'/ W/IlJI()Pf-v-f r f/Oo,zJ, N&o/ E.vTIe'l I"€"fl6pc...;f /t-T s!12e:.Ci..rU::>e:. NO ~P/1VS/~N of THE. te:->CI SJ7.v.4 FopTjC'!e../'l/T,''lI Pt.-1~NFa 7. AMOUNT OF LAND AF;::ECTED: Initially (!!:I acres Ultimately 0 acres 8. WILL ?RO?OSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? flJ::..es 0 No If No. describe briefly 9. ~l T IS PRESENT LAND USe IN VICiNITY OF ?ROJECT? ReSIdential O.!nCustflal 0 Cummercial Desc. be: U Agricuiture : I Park/ForesUOoen soace L.J Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY {F=DERAL. ST A T;Jn LOCALl:-' ~es U No If yes, list agency(s} and permit/approvals '5(Jvrff.,l.-t) rNAJ pZV/{F!'€-f' ~ I5trO(:, PEPT '::r- 11. DOES ANY ASPECT OF THE ACTIO'" HAVE A CURRENTLY VALID PERMIT OR APPROVAL? DYes. % No It yes. list a.gency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL S<ISTlNG PERMIT/APPROVAL ~EaUIRE ~OOlF!CATION? o Yes I No Applicant/sponsor name: ION PROVIDED AeOVE IS TRUE 70 THE 8EST OF MY KNOWLEDGE /tR..c Date; Of /(),j'/() 4- , I SlgnalUre: If the action is in the Constal Area, and ,au are a state agency, complete the Coastal Assessment Form beiore proceeding with this a'j.~essment OVER I] . . Kelly Adjacent Property Owners 71-2-6 Patrick and Diane Kelly 30 Cathedral Avenue Garden City, New York 11530 71-2-10 William Jones 200 Harbor Lights P.O. Box 521 Southold, New York 11971 71-2-11.3 Bruce and Edith Romboli 240 Windjamer Drive Southold, New York 11971 71-2-1.2 71-2-1.1 Harbor Lights Property Owner's Association C/O Nicholas Cordone 25 Brigatine Drive Southold, New York 11971 - . . 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 SOUTH OLD --------------------------------------------------------------- In the Matter of the Application of ._ _ ._!2Q:}:L~_5::.!5:__:A2~;...~:...J!!:.LC 1 COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, / CA-v,.Lr---J 6, c_ v ", residing at ~ 7'" j.{ c-1 -' "- L-<A- ~ (tv .~ C"-' I--<-}...> S _0-, r--' .-< being duly sworn, depose and say: Ir 'I ::J ') , That on the 11 day of hb -,~ '1, 200 r. 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 eight days prior to the date of the public pm hearing. Date of hearing noted thereon to be held III Q &~, a. S I a~ - en ~r ab c\.l t- I'):CO . Dated: (Sign~ Sworn to Qefore me this I day of f1M'v200 ~ ~i,!t-~~ JOYCE M. WILKINS Notary Public. State of New York i'h 4952246. Suffolk County . .r-"-','resJune12, ':2-00; FROM ,:, ,.P.fI~ ~,~L~~~.)We:~",~,,":,..j."i-il'.""_'1 - . ,. PHO"E "0. : -'472235 ,-=/-{IHE .'.:'. : iS3l":'3.:,;"::~':. . Jan. 082004 01:13PM Pi j~_n. 8::1 ;':~24 84:::;GAM (:'2 MI. r~lri('k Kell, ,iO CaLhcdrdl AyellUe Gardcn City, New York 11.r,:~O (21~) 7\l:~ 6(0) Ja.nuary 8, 20Q4 To Whom It M;;,y Concern: I. Patrick. Kclly,lWlhonze 1\1a.rk. Schwlll1z. AlA .. Architl:Ct., to act <l5 agent for l"'"'Ut ..vv1i..ai4v.... t<, Ib.: Southold T"",,, Bo:u-d nf TnJ~t...... V,.w Vork State Department of F..nvirclnmemOlI COl15erw.tlon, and the SouthaM Building Depa1"f.mcm. The proposed residelltial addition~alteration.~ cOIlStnldion j)J'Oje<:t is IIXared at 75 Harbur Lightll DJi>'C Southold New York (SCTM# LOOM 1.2.7). Sincerely, e~ k,-,C.V\ Patrick, Keny . . '\~b Mark K. Schwartz, AlA - Architect, PLLC ~~'l" ...~,~: p.o. Box 933 ...;::;;. Cutchogue, New York 11935 Phone: (631) 734 - 4185 Fax: (631) 734 - 4185 January 26, 2004 TRANSMITTAL To: Southold Town Board of Trustees 53095 Route 25 P.O. Box 1179 Southold, New York 11971 Project: Kelly House 75 Harbor Ughts Drive Southold, New York 11971 (SCTM# 1000-71-02-07) ~~J~" ~ ~ W ~ ~ . c " SOl'th,'id k'Nn Be -[fi, .,.'."~S ..-..-"- From: Mark Schwartz, AlA We transmit the following by USPS Priority mail: One original and two copies of; 1. General Data and Wetland/Trustee Lands Permit Data 2. Notice to Adjacent Property Owners 3. Short Environmental Assessment Form 4. $200 Payment for application fee 5. (5) Surveys with proposed additions and alterations 6. Letter of Authorization to act as agent for Mr. and Mrs. Kelly 7. Trustees Cover Letter . Landowner: Patrick and Diane Kelly 30 Cathedral Avenue Garden City, New York 11530 (212-723-6001) Remarks: Please review this application and call this office with any questions that you may have. KellyTrusteesApplication / ! ~oard of Trustees APPlica~n J<El-L'f }-/tJUSt.- County of Suffolk State of New York fJ1A,1..~ t<- Sc '-f L-->~ rz...-:1'""""L BEING DULY SWORN DEPOSES AND AFFIRMS THAT HElSHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF mSlHER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEm AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THI PLICATION. SWORN TO BEFORE ME THIS 3 /tel DAYOF,jJ.huu-~ ,20~ , N~cq ~ Not~ry ~~~:~:f~ 'ktato of NP,'N Yorl~ ~~ - /l'\')"'-;'r-;;-:;~3 Sd1o\k G~>,lmty.......1 ''101, T;~'r-n'~S..~~j~-~,;i De::"~;il.~~;- ~ ~ ~-~ ".t,..... '"I r / . . APPLlCANT/AGENTIREPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold 's Code of Ethics orohibits conflicts of interest on the Dart of town officers and emolovees. The DUmose of this form is to orovide information which can alert the town ofoossiblc conflicts of interest and anow it to take whatever action is necessarv to avoid same. YOUR NAME: -irj <.. :,J (Last n , first name, middle initial, 'unless you 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.) j"';'u-fh.;, Ie'. --r ~ _....... ---1'.---' ~J -4-D-'?' )-/ ~~) )- o-(~"'--"""~;> ~e'-&"/...)t-/:J c!-r-<.--I"......,~, 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, marriag~. 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% aCthe 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 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 applicant (when the applicant is a corporation); _B) the legal or beneficial owner arany interest in a non-corporate entity (when the applicant is not a corporation); _C) an officer, director. partner, Of employee afthe applicant; or _D) the actual applicant. DESCRIPTION OF RELATIONSHIP r Submitted ~ 26 day of ~" Signature (~\U c~ Print Name o...r' t I.<. lit 200 J