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Home My WebLink AboutTR-6898AJames F. King, President ~QF ~QUry Town Hall Jill M. Doherty, Vice-President h0~ ~~ 53095 Route 25 Peggy A. Dickerson P.O. Box 1179 Southold, New York 11971-0959 Dave Bergen B b Gh i v+ Q ~ p Telephone (631) 766-1892 o os o, Jr. ~ O ~yC ~ ~~, Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0354C Date: August 13, 2008 THIS CERTIFIES that theng riding down of all stumps, planting Leyland Cypress trees along the seaward side of the water-main easement, and the removal of the entire fence alone the wetland area At 1380 North Bayview Road, Southold, New York Suffolk County Tax Map # 70-12-33.2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 05/15/08 pursuant to which Trustees Permit # 6898A Dated 06/18/08 and 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 thegnnding down of all stumps, planting Le}_land Cypress trees along the seaward side of the water-main easement, and the removal of the entire fence along the wetland area The certificate is issued to MICHAEL CARBONS owner of the aforesaid property. ~-- a~ Authorized Signature James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. ~o~~pF SOUryo~ • ~~0,~ ~~y00UNfV ,~"~'" BOARD OF TOWN TRUSTEES Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631)765-6641 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 APRE-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 '/2 constructed Project complete, compliance inspection. 9~~~I~$• (~k~~r . . 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 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 sl 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.: 6898A Date of Receipt of Application: May 15, 2008 Applicant: Michael Carbone SCTM#: 70-12-33.2 Project Location: 1380 North Bayview Road, Southold Date of Resolution/Issuance: June 18, 2008 Date of Expiration: June 18, 2010 Reviewed by: Board of Trustees Project Description: Grind down all stumps and plant Leyland Cypress trees along the seaward side of the water main easement. 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 project plan prepared by Michael Carbone, received on May 15, 2008. Special Conditions: All stumps are not to be removed, they may be ground down only; removal the entire fence along the wetland area. 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 {Y},'cbael (1A.rtn()p~ TO: Please be advised that your application dated mag IS, ~ 8'" __ h5ls been reviewed by this Board at the regular meeting ::r--ur>~ I~ ~r 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) y, 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: 00 TOTAL FEES DUE: $ So <-- BY: James F. King, President Board of Trustees ~ ~ ~ \J J ~ ~ j --ow~;<JJ . . James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. P.O. Box 1179 Southold, NY 11971 Telephone (631) 765-1892 Fax (631) 765-6641 Southold Town Board of Trustees Field Inspection/Worksession Report 61 ! 0 <1:.-1_ fr---- DatelTime: { r( ( 0 () '- \U MICHAEL CARBONE requests an Administrative Permit to remove all stumps and plant Leyland Cypress trees along the seaward side of the water main easement. Located: 1380 North Bayview Rd., Southold. SCTM#70-12-33.2 Type of area to be impacted: +:Saltwater Wetland _Freshwater Wetland Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: t:chapt.275 _Chapt. 111 _other _Sound _Bay "2..S--k~ r Type of Application: _ Wetland _Coastal Erosion _Amendment i:::Administrative_Emergency _Pre-Submission Violation Info needed: 0 / o ~ ~..... c::.- Go. ~ Mod ifications: l'~...e.. Q-_e-,. - = C::J ~.. +~ <e-iv~ Conditions: Present Were: hKing lJ:oohert~.Dickerson .xD. Bergen_ B.Ghosio, 'A--- D. Dzenkowski _Mark Terry_other Form filled out in the field by qJ. C\~j~"" Mailed/Faxed to: Date: Environmental Technician Review- . . A 4133 Town 01 Southold Sullolk County, NY The People of the State of New York .s. CA~AI" (DE~lmAN1) "RST NAME / .,DDLE INITIAL ~(}:flft:511J f:r m)i?A.IJ.~ STR/~~S I!J'll t5t} vleuJ ,fd AnNO ~~t>JI.o!d ~ATE //1""1/ UCENse OR REGISTRAnON NUMBER ltlE OPERA-TOO OR REGISTERED OVv'NER OFVEH1CLE DESCRIBED BELOW DATE EXPIRES PLATE NO. STATE o N.Y. o N.J. o N.Y. o N.J. 0 PLATE1YPE DPASS OCOMM 0 VEHICLE MAKE o BUICK o FORD o TOYOTA o o o BOO' fiFE o BUS o '''"' o Mev o o s.w. THE PERSON DESCRIBED ABOVE IS CHARGED AS FOlLOWS PLACE OF OCCUARENC~ 1Y~1L1f, 0.... TE OF OFFENSE IN VIOlATION OF SEC1lON ~~ECIFY) o SPEEDING MPHINA FACTUAl PART jNOT FOR TVB) d J T~ NAMED DEFENDANT DID ON TIlE STATED DATE, ..E ,,",0 PCACE J ~~f ~ 'f;kjS I~ /~ 1JI f/f IV (/'. -?-IP~JJ-' The Foregoing is L on (personal ~nowledge) "ndlo,! ,;""'- ~ '.\..0, ,\1>~""/vr PARKING SCHEDULED FINE $ ~.!.me50urooIb9lngth9l1\taChed~mllf,~rof do'" 'i/I'J/li CONTACT COURT 0 \ THE PERSON DESCRIBED ABOVE IS SUMMONED TO APPEAR AT SOUTHOl.O TOWN JUSTICE COURT, 53095 ROUTE 25, SOUTHOLD, NY 111il11 \AT% e. 57::X;T;;e"'" ON FALSE STATEMENTS HEREIN ARE PUNISK/<6LE AS ACl,..I\SS A MISDEMEANOR PUF\SUANTTO SECTION 210.45 OF THE P,LN.Y.S. APR 2 1 ?'--;(',o ,--u,,-,J 'A' 4135 Town of Southold Suffolk County, NY MIDDLE INITIAL APT. NO. THE OPERATOR OR REGISTeRED OWNER OF VEHiClE DESCRIBED BELOW DATE EXPIRES PLATE NO STATE PLATET'l'PE o N.Y. o N.J. ON,Y. o N.J. D o PASS OCOMM D VEHICLE MAKE D DOOGE D BUICK CADIu.AC D PONTIAC D 'ORD PLYM D TOYOTA BODY D .DR D 'U' D MCY D S.W. D TflAlLER D "" D I) \ tOLA N OF SECTION OO~'FY) o SPEEDING MPHINA TH vd/ p, --, -' . TOOFO.'O~O.5"-.:"'~:/O<I-_'.O&~'."'OO~~~"'OO_"'~~~ r', a;U ~>Yr "., ~<;< .lC> PARKING SCHEDULED FIN CONTACT CQURT 0 THE PERSON OESCRIBED ABOVE IS SUMMONED TO APPEAR AT SOUTHOU) TOWN JUSTICE COURT, 63095 ROUTE 25, SQUTHOLD, NY 11011 ON AT 73J & "'" FALSE STATEMENTS HEl'lEIN ARE. PVNlSHAllLE AS A ClASS A MISDEMEANOR PURSUANT TO SEC1lON 2\0..45 OF THE P.LN.Y.S. CO, DA~ 'I ~ COMPW/1 4/2 / BADGE # r??_/ Town of Southold Suffolk County, NY ~''''EF'NDANT) The People o!the Slate 01 New York v.. ~JC/,(J &i7:4/" ?VNAM' S fer ADDRESS _ ' ~ "./.tIp / "rI ~1:b /7U(9 _~ f/~ STATE UCENSEORREG ~ 'STRAlION NUMBER 'A'4134 ~INITlAL APT, NO. PlATE NO. TYPE OF LICENSE DATE EXPIRES STATE o N.Y. o N.J. o N.Y. o N.J. 0 VEHICLE MAKE o BUICK o FORO o TOYOTA PLATE TYPE DPASS DCOMM 0 D G' PDNnAC CADI BODY NP' ,US VAN o MCY D o s.w. PeT 7' MPHZONE FACTUAL PART (NOT FOR TVe OVE NAMED DEFENDANT DID ON THE STATEODA ) _1) &~lt/~:2:~~::U ..... PARKING SCHEDULED FINE $ THE PERSON OESC CONTACT COURT 0 SOUTHOLO TOWN JUSTl~B~~~ IS SUMMONED TOAPPEAR AT , 530$5 ROUTE 25 SOUTH ?J;;"A7- " Ol.D,NY11871 .------ ~ 93U ''''''ESTATE""""",,",,,,, . 0- PUNlSH.\BLE AS A a.ASS A MISOEMSANOR ;C~d2 / --j:fi?;"" ON , . . Proposal MOTI'8 Tree 8ervice (9 Landscapi118. Inc. "We also buy and Jell Cedars, Blue Spruce, JapaneJe MapleJ, Sbade or Evergreens" 1490 ~kunk Lane · Cutcho8ue. New York 11935 (631) 734-5569 WAYNE MOTT P~~SALSUBMI~DTO ~r/e... ~ ~ bo'1 ( STREET II (] (rl S ~O ,J , ~- 't""V\ &. 'v fO I 6 y CITY, STAT:~CO(E N. 'P (,. ) J LANDSCAPE ARCHITECT DATE OF PLANS PHONE SITE7'S- HOME: WORK: 1. VI> I DATE .Zo-"(/ <=t/7~ JOB LOCATION 273 (,S" 'I' LANDSCAPE TREE WORK START DATE COMPo DATE We hereby submit specifi~tions and estimates for: J{ __ L /0 - 1"2- zS' ~"C- c -.J\t~ ,. ~ , ., /) - No trees or "'rubs will be gusranteed unless customer hooks up automatic aprlnkler system. Price does not indude state and local taxes unless specified. This proposal is subject 10 general condilionsprinted on the reverse side. We PropOJe hereby to furnish material and _labor - complete in accordance with above specifications, for the sum of: PlIYf'*'IllO be m8de u follows: 22-50 i- f, -J..-r/l dollars ($ ) materl IS 9 10 as IpltCI 10 com 81 In a wor man I e manner according to standard Pl1lcticel. Any allermien or deviation from above specifications involving extra costI will be executed only upon written ordet1, and will become an ~ra charge OV8f and above tht, mlmet.. A1llgl'Mmenta contingent uponllrik... accidents or delays beyond our control. Owner 10 carry fire. tcmadO and Olh. necessary Insurance. Our workers are fully covered by Workmen's COfTC)8nsation Insurance. Authorized Signature NOTE: This proposal may be w~hdrawn by us if not accepted within days. Acceptance of Probosa!-Tha above prices, specificaiions and condi, /.. -', lions are satisfadory an~ are hereby accepted. You are authorized to do workC'Signature as specified. Payment will be made as outlined above. Date of Acceptance Signature , ~ "" ~Eb ,.; ;L,"^~:_ ...- '<'ff.~ . Im"12"H2 Carbone. Michael 13BON BayviewRd I~ He. """ ~ ....I e III :i ~UU_ A~"" ..,x'. .""m~.'.m...""" 1> ..=J.!: ~ .:;:[ File Edit View T oolbar Win Aclive RIS,l Re. vac land IVIlrll School: Soulhold School LandA'1i 100 Tota1AV:100 First Name: IMichael MI: Jr" Sr, ete: I Zip Code: 110022- ~ . i"startl ~ Jlo ,'.." "15:2-08152754 ~Inbox - Microsoft Outl."lI![JMAVINSP - Microsoft." HeRP5 Version 4 - [0... ::.!f~Rijb:cl" 3:27' ~, I ---, ~'~ ~,~w~\.,.,,-~"~., ::~' ._"'T,,"~!~~"""\ ~., '~~,. 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'-1'_ ~"O .-,'"' "-"-0' "H"" ".'0'01 ,.J-.I 1 1 . ~ )+~'l"c:~'l\ James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob linusio, Jr. Town Hall . 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 .BQARD QF TQWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application _Wetland Permit Application :;/Administrative Permit _ Amendment/Transfer/Extension Received Application: ../R:eceived Fee:$ I 00 ~ a.. ~t ~ompleted Application t)/1\S}O!: _Incomplete _SEQRA Classification: Type I_Type II_UnIisted_ _ Coordination:(date sent) _ L WRP Consistency Assessment Form CAC Referral Sent: ~ate of Inspection: It; III (Ot' _Receipt of CAC Report: _Lead Agency Determination:_ Technical Review: ~ublic Hearing Held:~1 {'(lof( Resolution: '!A'I - II'! I 2 2008 [G (~ [ ,- ~i \,1 r~:::" L L', :-> ',",\ MAY 1 5 2008 Name of Applicant M,cl/f/eL- ~d"", ,r$' 60 131 rI.;,w Tt{ 6iJ+f.,/t;; j. it?q I i!Y. Bdf II Vf Phone Number: ) 7{,s-,}..'/'O'j c/JR Bo lJe , I 1- I i I l,....~. ;J' ,. ',.':" r. ': Tr::' Suffolk County Tax Map Number: 1000 -le '-/).- AO\ / ~ ..-, t '3~,;U loW J .' Property Location: /'ii:fJo Afe-M,VILu.J 1U7 jc,'..+/~ (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: ~d of Trustees APPlicatio~ GENERAL DATA Land Area (in squarefeet): .if; {((U. t, 9 <# Area Zoning: Previous use of property: Intended use of property: Covenants and Restrictions: If "Yes", please provide copy. Yes No Prior pem1its/approvals for site improvements: Agency Date ~o prior pennits/approvals for site improvements. Has any pennit/approval ever been revoked or suspended by a governmental agency? v/No_ Yes If yes, provide explanation: Project Description (use attaclm1ents if necessary): fuwkLcj 1 ~~ f/lflJl.t.J/- -PtJY.t.?ftL-f'1 J '2 ~.- Pt1f~ ("", w"",-Jc a.. H~, ~f 1U.A.AAJa.,,_J ~ ,'_0-. 0(, W CD -I-.IL. ft-u....... 0 ~~ . 1IIfd of Trustees APPlicati~ WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed ~perations: <~ ~ o...~ -+ (\.ej!. D llLIN- fA (j$U~) (J + lt1x I Area of wetlands on lot:( square feet Percent coverage of lot: ~ ..:;, % Closest distance between nearest existing structure and upland edge ofwetlands:"h tilu feet Closest distance between \learest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? / Yes No If yes, how much material will be excavated? 5.j I dJ cubic yards How much material will be filled? ~. ~ ti J cubic yards , Depth of which material will be removed or deposited: :1_/1; feet Proposed slope throughout the area of operations: 'i,~i 11 .J Manner in which material will be removed or deposi~~d:L/.;l.L cl:. ,w Statement of the effect, if any, on the wetlands and tidal waters ofthe town thatma)' result by reason of such proposed operations (use attacIurlents if appropnate): . . _unu . ... FECT 10 NUMBER . I . 617.20 APPENDIX C STATE ENVIRONMENTAL DUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only (To be completed by Applicant or Project Sponsor) SEQR PART 1 - PROJECT INFORMATION 1. APPLICANT I SPONSOR 2. PROJECT NAME Ill, 'c~/f)eL n ' Cf.l R Bo,'J{ 3.PROJECT LOCATION: ?,~~ V, , , RJ, 15fil6 N~ p,A I~D- ~Cl FFoL IL- Municipality SD u. ' 11 L - j) County 4. PRE~:rf4~d+1 a(n~qr~;e;;~rt~s ete -or provide map 5. IS PROPOSED ACTION: 0 New D Expansion ~Odiflcation I alteration 6. DESCRIBE PROJECT BRIEFLY: 1Lz/1I,f ~ t~ plt4- r I fh~ h"1 'f ~~/1 ruM ~ 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? [Xl Yes D No If no, describe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) [)2r Residential D Industrial o Commercial DAgriculture D Park I Forest I Open Space o Other (describe) 10.' DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) DYes [Xl No If yes, list agency name and permit / approval: 1,. DOES ANY A""eC I 01- I He ACTtDWBAVE 'A CURRENTLY VALID PERMIT'OR APPROVAL? -- DYes 5(] No If yes, list agency name and permit / approval: ,-- - - 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT / APPROVAL REQUIRE MODIFICATION? []yes DNo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Na~_ (LflUU DateS -II. -c'6 '~' ) Signature -. . ( 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 ITo be comDleted bv Lead Agencv) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? Jf yes, coordinate the review process and use the FULL EAF. OVes ONo B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NVCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. DVes ONO C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be hani!written, il 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 ~. H..n ..-. . . J 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: t . ~ . mm 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: L I C5. Gro'Nlh, sUb;equent development, or related activities likely to be induced by the proposed action? Explain briefly: I .. I C6. Long.t~~;;;,~h'ort term,-~um~i~tive, or other effects not identified in C1-C5? Explain briefly' [ I Cl. Olher im~acls (including changes in use of either quanllty or type 01 ene'gy? Explain briefly: I [ . . . D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)7 . III yes, explain briefly I DYes D No I E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ilxesexplain DYes DNo r I . .. ~ . PART 11I- DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determinewhelher it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (Le. 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 ---.y.es,theGletefmi-t=latieR-Gf-sigRifIGaRCe m8st 8'/all:latethe potentialtffil*l6lQf thefH"-€lf36see-a-etieA on the GR. iranmefflatel=taf8etefj3tiu oftl,5 CCA-:- --- --- 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. CheckfhTs-boxTfyouhiive-determmed", based-on -the Information and-analysis-above and-any supporting documenta-tlon,-ihaiihe-prop-osed acUo 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 Print or Type Name of Responsible Officer In Lead Agency Title of Responsible Officer 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 M "or A/[L A-----Dt 2 P,o tJ t. 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 BISIBER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WilL BE DONE IN THE MANNER SET FORTH IN TBIS 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 HARlvlLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING TBIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENT ATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES rN CONJUNCTION WITH REVIEW OF TBIS APPLICATION. _.--L.}!~ ignature - SWORN TO BEFORE ME THIS ;(9 A.. DAY OF /ITJ...4 __,200 y- ~OJJ...JJ. 1'1 '-1Yl, -J.i.g rd<</Jh' otary Public NotaWu~;~ M, S.!AND"~ No OlSsta.. Of New York Q~alified in J~M~O~ Commls$Jon Expires April 9~~~_1L . . APPLICANT/AGENTnREPRESENTATlVE TRANSACTIONAL DISCLOSURE FORM The Town of South old's Code of Ethics orohibits conflicts of interest on the Dart of town officers and emolovees. The nurnose of this fonn is to orovide information which can alert the town of oossible conflicts of interest and allow it to take whatever action is necessarv to avoid same, ' C'fJl2 80Nt YOUR NAME: /i!'CI-//NFL \ A, (Last name, first name, J1liddle initial, unless you are applying in the name of someone else or other entity, such as a company. If so, indicate,theother person's or company's name.) . NAME OF APPLICATION: (Check all that apply.) Building Trustee Coastal Erosion Mooring Planning Tax grievance Variance Change of Zone Approval of plat Exemption from plat or official map 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 South old? "Relationship" includes by blood, marriage, or bus'iness 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% of the 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 apptic{lnt (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 or RELATIONSHIP Submitted this d~f A r;: -Ie Sig~h.::.-:z~ - Print Name AAr<.i./14&"L Jj., (jJR~ol..!~ 200& Form TS 1 .., SURVEY OF PROPERTY SITUA TE SOUTHOLD TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK ., S.C. n-nAX No. 1000-70-12-33.1 &: 3 SCALE 1 "=20' JANUARY 24, 2000 OAKWOOD DRIVE VI o Gl U' .., III o . rBJ~(G~~W .co mJ MAY 1 5 2008 C l:J t Ii '" " .... ~ i b ~ o. Southold Town Board ot Trustees AREA = 4,991.69 sq. ft. (TO TIE LINE) 0.114 oe. z o ~ ~ \fJ 7~ / ,,~ ~~ ~, CERTIFIED TO: CHRIS LEMENDOLA COMMONWEALTH LAND TITLE INSURANCE COM} o o o ~ /204lJ ~ ~ ~ ~~ ~C \c\'C~ ~ ~. s," "'C~ ~ APPROVED BY BOARD OF TRUSTEES TOWN OF SOUTHOlD DATE t/ '/7 <:78 U~fl~1!;RA-.,iIMllIl__ TO lHI5 ,$ A'"01.,illlllnlF St:CTl1ifj 1l!I511t THE: .... _ n.. roI!l'IA'" OFlHI5__lIIIJ_ ~,~'S_$fM.,l/!l _~IlOTIlI!_ BE A \IAlIl' 1A\l!' COP\'. -- I~...~,..,' . MOT .'at." ~lKnlJ' . ,wm<.THE_ fOR'. .4' ~'=~~~~ ~.. .'U6f:~ni"~~1riM, Joseph A. .".... Land ~.. " '- -,~ . .' .. ~ Titie SUfVf11' - Sub<JNisiiJns - SIt. PIons - ~1ioI\ N.r.S. lie. No. 4e6lIll PHONE (51l)727-~ OI'FlCESLOC41ED AT One Union Squore ................. _...... "'-If tt&'I1 Fox(ll~ ..... . P.~.~' -m ~- ...... "