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HomeMy WebLinkAbout1000-58.-2-5 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 F~x: 631 766-3136 LOCAL WATERFRONT REVITALIZATION PROGRAM COORDINATOR TOWN OF SOUTHOLD MEMORANDUM To: Gerard Goehringer, Chair Town of Southold Zoning Board of Appeals~ From: Mark Terry, Principal Planner LWRP Coordinator Date: October 2, 2008 Re: Coastal Consistency Review ZBA# 6218 (Geitz) SCTM# 1000-58.-2-5 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 dap~, hnent, 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. PoHc¥ Standards 4.1 Minimize losses of human life and structures from flooding and erosion hazards. The following management measures to minimize losses of human life and structures fi.om flooding and erosion hazards are suggested: Minimize potential loss and damage by locating development and structures away from flooding and erosion hazards. 1. Avoid development other than water-dependent uses in coastal hazard areas. Locate new development which is not water-dependent as far away from coastal hazard areas as practical. b. Avoid hazards by siting structures to maximize the distance fi.om Coastal Erosion Hazard Areas. The proposed action "as built deck" is not a "water dependent use". It is recommended that the Structure be located as far away from the CEHA area aa practical to maximize the distance from the "haTard area" and minimize the potential of future structural loss. Move existing development and structures as far away from flooding and erosion hazards as practical. Maintaining existing development and structures in hazard areas may be warranted for: a. structures which functionally require a location on the coast or in coastal waters. b. water-dependent uses which cannot avoid exposure to hazards. sites in areas with extensive public investment, public infrastructure, or major public facilities. sites where r~location of an existing structure is not practical. The proposed action does not meet the above reasons to warrant "malotainino existino development" within this area. The distance from the as built deck to the ordinary high water mark is 35'~ a minimnm separation distance of 100 feet is required pursuant to Chapter § 280-116. Bnildin~o setback equlrements adlacent to water bodies and wetlands which states: A. Lots adjacent to Long lsland Sound, Fishers lsland Sound and Block lsland Sound. (2) Except as otherwise provided in Subsection .4(1) hereof, all buildings or structures located on lots adjacent to sounds shall be set back not less than lOO feet from the ordinary high-water mark of said sound. It is recommended that the Board amend the application to meet and/or further the above ooHc¥ to the greatest extent practicable and minimlz,~ the potential of future structural los~ Pursuant to Chapter 268, the Southold Town Zoning Board of Appeals shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Kieran Corcoran, Assistant Town Attorney APPEALS BOARD MEMBERS Gerard P. Goehringer, Chairman Ruth D. O[iva James Dinizio, Jr. Michael A. Simon Leslie Kanes Weisman http://southoldtown.northfork.net ZONING BOARD OF APPEALS TOWN OF SOUTHOLD Tel. (631) 765-1809 · Fax (631) 765-9064 Mailing Address: Southold Town Hall 53095 Main Road · P.O. Box 1179 Southold, NY 11971-0959 Office Location: Town Annex/First Floor, North Fork Bank 54375 Main Road (at Youngs Avenue) Southold, NY 11971 September 16, 2008 Mark Terry, Senior Environmental Planner LWRP Coordinator Planning Board Office Town of Southold Town Hall Annex Southold, NY 11971 Re: ZBA File Ref. No. 6218 (Geitz) Dear Mark: We have received an application for construction of as built deck, as detailed on the enclosed map. A copy of the Building Inspector's Notice of Disapproval under Chapter 280 (Zoning Code), and survey map, project description form, are attached for your reference. - t~ May we ask for your written evaluation with recommendations for this proposal,x~sx~', required under the Code procedures of LWRP Section 268-5D. Thank you. ~v x,~r,.~ Very truly yours, Gerard P. Goehringer Chairman Encls. FORM NO. 3 NOTICE OF DISAPPROVAL DATE: June 10, 2008 TO: Charles and Susan Geitz 1580 Leeton Drive Southold, NY 11971 Please take notice that your amendment dated April 22, 2008 For permit for an as built deck reconstruction at Location of property: 1580 Leeton Drive, Southold, NY Count5' Tax Map No. 1000 - Section 5~8 Block2 Lot5 ls returned herewith and disapproved on the following grounds: The proposed construction, on this nonconforming 12,434 square foot lot in the R-40 District is not permitted pursuant to Article XXI1 Section 280-116 A (2), which states; "Except as otherwise provided in Subsection A(I ) hereof, all buildings or structures located on lots adjacent to sounds shall be set back not less than 100 feet from the ordinary high-water mark or said sound." The as built deck is noted as being +/- 35 feet from the ordinary high water mark.~ pprovaas written based John C. Ehlers, LS, dated 12/10/3. on a survey by 'x~'q~ i b~ignature Note to Applicant: Any change or deviation to the above referenced application, may require further review by the Southold Town Building Department. CC: file, Z.B.A. APPLICATION TO THE SOUTHOLD TOWN BOARD OF APPEALS Office Notes: -- Filed By: For Office Use Only Date Assigned/Assignment No. HouseNo.~Street ]d~-4IDVX ~)4'~'~J°-- Hamlet SCTM 1000 Section~ Block ~t~ Lot(s)~Lot Size Zone I (WE) APPEAL THE WRITTEN DETERMINATION OF THE BUILDING INSPECTOR DATED ~ .q~B..~ED ON MAP DATED I ~ - ! Eg-- O...~ Applicant(s)/Owner(s): [~eS ~ ~l 1~ NOTE: In addition to the abovE, please complete below if application is signed by applicant's attorney, agent, archil¢ct, builder, contract vendee, etc. and name of person who agent represents: Name of Representative: ~ for ( ) Owner, or ( ) Other: Agent's Address: Telephone Fax #: Emaih Please check box to specify who you wish correspondence to be mailed to, from the above names: ~Applicant/Owner(s), [] Authorized [] Other Name/Address below: or Representative, or WHEREBY THE BUll. DING INSPECTOR REVIEWED MAP DATED AN APPLICATION DATED FOR: [] Building Permit [] Certificate of Occupancy i3 Pre-Certificate of Occupancy [] Change of Use ~Permit for As-Built Construction []Other: and DENIED Provision of the Zoning Ordinance Appealed. (Indicate Article, Section, Subsection of Zoning Ordinance by numbers. Do not quote tile code.) Article~t~JL~ Secfion280- r~{:3 ~ ~2~ Subsection Type of Appeal. An Appeal is made for: ,~A Variance to the Zoning Code or Zoning Map. [] A Variance due to lack of access required by New York Town Law-Section 280-A. [] Interpretation of the Town Code, Article Section [] Reversal or Other A prior appeal [3 has, ~has not been made at any time with respect to this propert¥~ UNDER Appeal No. Year __. (Please be sure to research before completing this question or call our office for assistance.) Name of Owner: ZBA File # REASONS FOR APPEAL {additional sheets may be used with preparer's signature}: AREA VARIANCE REASONS: (1) An nndesirable change will not be prodnced in the CHARACTER of the neighborhood ora detriment to nearby properties if granted, because: ,~", I_U.~ ~C ['~ t~,~ (2) The benefit sought by the applicant CANNOT be achieved by some method feasible for the applicant to pursue, other than an area variance, because: (3) The amount of relief requested is not substantial because: (4) The variance will NOT have an adverse effect or impact on the physical or environmental conditions in the neighborhood or district because: (5) Has the alleged difficulty been self-created? J~Yes, or ( )No. Are there Covenants and Restrictions concerning this land: [] No. [] Yes (vlease furnish covvI. ~ [A~*t.4~ This is the MINIMUM that is necessary and adequate, and at the same time preserve and protect the character of the neighborhood and the health, safety, and welfare of the community. Check this box ( ) IF A USE VARIANCE IS BEING REQUESTED, AND PLEASE COMPLETE THE ATTACHED USE VARIANCE SHEET: (Please be sure to. consult your attorqqy.) Signature of Appellant or AuthlMized Agent Swornttq0 ~'~O~ (Agen! must submit written Authorization from Owner) before me this ~ay of~ 20~? . ~ta~l~ ~ MELANIE DOROS~ ~T~Y PUBLIC, State of N~ No. 01D04~4870 ~ualif[ed in Suffolk Coun~ C~on ~ir~ Septemb~ 3~, ~ ~ 0 Applicant: APPLICANT'S PROJECT DESCRIPTION (For ZBA Reference) C (('~ O,-~'" (~.~ ~.,' J{'7~ Date Prepared: I. For Demolition of Existing Building Areas Please describe areas being removed: II. New Construction Areas (New Dwelling or New Additions/Extensions): Dtmens~ons of first floor extension: ~ (~ ~ ~, Dimensions of new second floor: Dimensions of floor above second level: Height (from finished ground to top of ridge): Is basement or lowest floor area being constructed? If yes, please provide height (above ground) measured from natural existing grade to first floor: III. Proposed Construction Description (Alterations or Structural Changes) (attach extra sheet if necessary) - Please describe building areas: Number of Floors and General Characteristics BEFORE Alterations: Number of Floors and Changes WITH Alterations: IV. Calculations of building areas and lot coverage (from surveyor): Existing square footage of buildings on your property: Proposed increase of building coverage: (~ Square footage of your lot: [ ~'-"[(o'7, ,k~ Percentage of coverage of your lot by building area: V. Purpose of New Construction: ~)~ 'iff ~ t~C'_~. ~ O-~ VI. Please describe the land contours (flat, slope %, heavily wooded, marsh area, etc.) on your land and how it r_.~elates to th difficult in meeting the code requirement(s): Please submit seven (7) photos, labeled to show different angles of yard areas after staking corners for new construction), and photos of building area to be altered with yard view. 7/2002; 2/2005; 1/2007 Page 3 of 3 - Appeal Application Pall B: REASONS FOR USE VARIANCE (if requestecO: For Each and Every Permitted Use under the Zoning Regulations for the Particular District Where the Project is Located (please consult your attorney before completing): 1. Applicant cannot realize a reasonable return for each and every permilfed use under the zoning regulations for the particular district where the property is located, demonstrated by competent financial evidence. The applicant CANNOT realize a REASONABLE RETURN because: (describe on a separate sheet). 2. The alleged hardship relating to the property is unique because: 3. The alleged hardship does not apply to a substantial portion of the district or neighborhood because: ~j~_ ~ .~t_~_. S (3..~. ~C~-~. ~ ~~ ~ 4, The request will not alter the essential character of the neighborhood because: 5. The alleged hardship has not been self-created because: 6. This Is the minimum relief necessary, while at the same time preserving and protecting the character o! the neighborhood, and the health, safety and welfare of the community. (Please explain on a separate sheet il necessary.) 7, The spirit al the ordinance will be observed, public safety and welfare will be secured, and substantial ]usflce will be done because: (Please explain on a separate sheet if necessary.) ( ) Check this box and complete PART A, Questions on previous page to apply. AREA VARIANCE STANDARDS, (Please consult your attorney.) Otherwise, please proceed to the sl.qnature and notary area below. Signature of Appellant or Auth' 'orlzed Agent  rn to beltore mefhls (Agent must submit Authorization from Owner) av ...... 2oo . ~.~'~' L'~/~(~'~] ~ ME~NIE DOROS~ NOTARY PUBLIC, St~e of New ~ v- (N otaw P~llc) -- N0. 01D04634870 ZBA ,~pp ~o~on ~es ~eptember 30, ~ QUESTIONNAIRE FOR FILING ~/lr['H YOUR Z.B.A. APPLICATION A. Is the subject premises listed on the real estate market for sale? [] Yes 2~No Are there any proposals to change or alter land contours? ~qo [] Yes, please explain on attached sheet. 1) Are there areas that contain sand or wetland grasses? ~ ~ (2[ ~ 2) Are these areas shown on the map submitted with this application? 3) Is the propK .r!7 bulkheaded between the wetlands area and the upland building area? 4) If your property contains wetlands or pond areas, have }*o~u contacted the office of the Town Trustees for its determination of juris~i{tion? ~Please confirm status of your inquiry or application with the Trustees: {,O t---t~,_.4-~ct - and if issued, please attach copies of permit with conditions and approved map. D. Is there a depression or sloping elevation near the area of proposed construction at or below five feet above mean sea level? 1'~ O - E. Are there any patios, concrete barriers, bulkheads or fences that exist and are not shown on the survey map that you are submitting? ]~.~c.9~/e~- (Please show area of these stmctures on a diagram if any exist. Or state "none" on the above line, if applicable.) F. Do you have any construction taking place at this time concerning your premises? If yes, please submit a copy of your buitdjng permit and map as aplproved by the Building Department and describe: ~ .t 42ac ~O~L -~,r- t~- 1~9~.~. G. Do you or any co-owner also own other land close lo this parcel? ~['-~O If yes, please label the proximity of your lands on your map with this application. H. Please list present use or operations conducted at this parce] ~ ( ~,. O {'~_~ ~ ~Cs~:~l~. ,' I\,]- and proposed use (er~,h~examples: existing: single-family; proposed: same with garage or pool, or other description.) Authorized Signature ancl0Date 2/05;1/07 Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS All applicants for pem~its* including Town of Sonthold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review La;v. This assessment is intended to supplement other iifformation used by a Town of Southold agency in making a determination of consistency. *Exce£t minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion H~tzard 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 contaiued 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 (wlfich includes all of Southold Town). If any question in Section C on this form is answered "yes", then the proposed action may affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, the action should be analyzed in more detail and, if necessary, modified prior to making a determination that it is consistent to the maximum extent practicable with the LWRP policy standards and conditions. If an action cmmot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town ofSouthold's website (southoldtown.northfork.net), the Board of Trustees Office, the Plmming Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION scm. 3-g 9..- The Application has been submitted to (check appropriate response): TownBoard ~ Planning Board [~ Building Dept. [~ BoardofTrustees [] 1. 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) (~)- P~ff, approval, c~, certification! -~] Nature and extent of action: Site acreage: Present zonbtg classification: If an application for the proposed action has been filed with the Town of Sonthold agency, the following information shall be provided: (a) Name of applicant: C (CX__O~(~L ~ (b) Mailing address: IS~_O_ /~O-~JCC~ 0arX~d~- ~.~t-,~O ~. ~'~ (c) Telephone number: Area Code ( ) (tO 3 [- ?~X,q'-'~&5>/I (d) Application number, if any: Will the action be directly nndertaken, require funding, or approval by a state or federal agency? Yes ~] No [~ if yes, which state or federal agency?_ C. 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 infrastructnre, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section Ill - Policies; Page 2 for evaluation criteria. {--]Yes [~ No ~ Not Applicable Attach additional sheets if necessary Pohcy'~2: P~0tec~aBd~re~rqe liislo~[¢ a~d arcliaeo ologFc~l resources of [he oT6wn bf S~oiithold[ See LWRP Section III - Policies Pages 3 through 6 for evaluation criteria [--q Yes [~] No [~ Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources thr0nghout the Town Of South01d. 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 front flooding and erosion. See LWRP Section III - Policies Pages 8 through 16 for evaluation criteria ~] Yes [-~ No [~ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Sonthold. See LWRP Section Ill - Policies Pages 16 through 21 for evaluation criteria Yes [~ No [~Not Applicable At~ach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Siguificaut Coastal Fish and Wildlife Habfita_[s..and wetlands. See LWRP Section III - Policie_s_~ Pages 22 thr~iigh 32 (~ ~l~ation ~eria. 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 [-~ ]No [~, Not Applicable Attach additional sheets if necessary Policy 8. Minimize enviromnental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. [] Xes [~ No ~ Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. Sce LWRP Section Ill - Policies; Pages 38 through 46 for evaluation criteria. Yes [] ]No [~ Not Applicable Attach additional sheets ifnecessmy WORKING COAST POI,ICIES Policy 10. Protect Sonthold'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 [~Nbt 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. Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town' of Sonthold. See LWRP Section III - Policies; Pages 62 through 65 for evaluation criteria. ['-] Yes [-~ No ~]~ Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See L~,VRP Section III - Policies; Pages 65 through 68 for evaluation criteria. Yes [] No ~. Not Applicable Created on 5/25/05 11.'20 AM 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL A~SESSMENT FORM For UNLISTED ACTIONS Only PART I - Projecl kLformation (To be complete by Applicant or Project sponsor) t. Applicant / Sponsor 2. Project Name 3. Project location: Municipality County 4. Precise location (Street address and road inter'sec'dons, prominent landmarks, etc. or provide map) 5. Is proposed action: NEW ( ) EXPANSION ( ) MODIFICATION IALTERATION,/I~ j_ koo o-. 6. Descdbe project bdefiy: 7. Amount of land affected: Ultimately: i(0,/. &.,¢/ acres 8. Will proposed action comply wth existing or other e:qsting land use resbictions.'(~ YES ( ) NO If No, descdbe bdefly: 9. What is present land use in vicinity of project: (describe): (~,~Residential ( ) Industrial ( ) Commercial ( )Agncultural ( ) Park/Forest/Open Space ( ) Other 10. Does action involve a parfait approval or funding, now or ultimately from any other Governmental agency,(Federal, State or Local) ? (~NO If Yes, list agency(s) and permil/approvals: ( ) YES t 1. Does any aspect of the acl~on have a currently valid permit or approval? ~*~ YES ( ) NO If Yes, list agenRw(s) and pl~rmit/approCpls: 12. As a result of proposed action, mil e~sting pe~Wapproval require modlfi~don? ( ) YES ( ) NO If Yes, list agency(s) and pe~iEapprovals: I codify that the information provided above is true to the best of my kn, owledge If the action is in the Coastal Area, and yo~are a state agency, complete the Coastal Assessment Form before proceeding with this assessment I'RAI~SACTIONAL DISCLOSURE FORM APPLICABLE TO OWNER, CONTRACT VENDEE AND AGENT: The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of Town officers and employees. The purpose of this form is to provide information, which can alert the Town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. t name, first name, ~ initial, unles~oyou are applying in the nam other entity, such as a corn an If so i ' ,h~ e of someone else or P Y , nd~cate ....other person or company name.) NATURE OF APPLICATION: (Check all that apply.) Variance Special Exception -- *Other Approval or Exemption from plat or official map Change of Zone Tax Grievance *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? "Relation~ip~ bl°°d~Lnama~nterest. "Business_interest" means a busine~~a ~which the Town officer~e~e has even a L>anial emplo~ent by~corporation in which the ]'own officer or em lo ee owns more than 5% ~ __ _ shams ~- __ VE -- NO If you answered "YES", complete the balance of this form attd date attd sign where indicatecL Name °f perso employed by the To n of,So uthol4: Title or position of that person: ~k~_~J~2~~'~ ;~,0,_~,~.` __ Describe that relationship be~wveen yourself (the applicant, agent or contrac~ vendee) and the Town officer or elnployee. Either check the appropriate l/ne A through 1) (below) and/or describe the relationship in the rpace proxfided. The Town officer or employee or his or her. spouse, sibling, parenL 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 cmporati0n); ~ B) the legal or beneficial owner of any interest in a non-corporate enlity (when the applicant is not a corporation); C) an officer, director, partner, or employee of the applicant; or D) the actual applicant. DESCRIPTION OP RELATIONSHIP sS~bmitted this~ ~ay o£~"~ Z~-~ . 0 p BOARD OF SOUTHOLD TOWN TRUSTEES SOUTHOLD, NEW YORK PERMIT NO. 6460 DATE: September 20~ 2006 ISSUED TO: CHARLES GEITZ PROPERTY ADDRESS: 1580 LEETON DR.~ SOUTHOLD SCTM#58-2-5 AUTHORIZATION Pursuant to the provisions of Chapter 275 and/or Chapter 111 of the Town Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted at the meeting held on September 20, 2006, and in consideration of application fee in the stun of $250.00 paid by Charles Geitz, and subject to the Terms and Conditions as stated in the Resolution, the Southold Town Board of Trustees authorize., and permits the following: Wetland Permit to raise the existing dwelling and construct a cellar, raising the house 5; decking to be removed and replaced after house is raised; and remove the existing shed, with the condition drywells and gutters are installed to contain the roof run-off and a line of staked hay bales is installed prior to any activity, and as depicted on the plan prepared by Joseph Fischetti, Jr. dated January 3, 2006. IN WITNESS WHEREOF, the said Board of Trustees hereby causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date. ACCOUNTING & FINANCE DEPT. John A. Cushman, Town Comptroller Telephone (631 ) 765-4333 Fax (631) 765-1366 E-mail: accounting @ town.southold.ny.us TOWN HALL ANNEX 54375 Main Road P.O. Box 1179 Southold, NY 11971-0959 http://southoldtown.north fork.net/ TOWN OF SOUTHOLD OFFICE OF THE SUPERVISOR To: Employee's eligible for Health Insurance buyout From: John Cushman ./~ ~ Date: November 18, 2008 Re: Health Insurance Buyout Option for 2009 Enclosed please find a Health Insurance Buyout Option Agreement, which you should complete, sign and return to this office by December 1, 2008 if you wish to decline medical coverage for 2009 and receive a cash payment instead. Please contact me if you have any questions about this program. S:~Acceunting\ComptrollerWly Documents\Word Processing Documents\Health Insurance Buyout cover memo.doc TOWN OF SOUTHOLD HEALTH INSURANCE BUYOUT OPTION AGREEMENT Name' . / Address ' \'~- ~,~-~\ct:3 . as a/l'own of Southoid Employee eligible for health Social Security Number insurance coverage, in consideration for the sum equal to 50% of the premium equivalent as established by the Town in taxable income paid to me by the Town, do hereby voluntarily cancel my health insurance coverage for my (self) (family). I understand that my cancellation of coverage, in whole or in part, shall be for the period of January 1,2009 to December 31, 2009. I understand that I may not request reinstatement of coverage for that fiscal year except in the event of an emergency caused by the loss of health insurance coverage through another source, as described below. Any change in my election shall be consistent with the terms of the Town Flexible Benefits Plan, CSEA Collective Bargaining Agreement and applicable law. Verification of this loss of coverage is required by the Town. Reinstatement of coverage for the succeeding year shall be made in writing to the Town no later than November 30 to be effective January 1 of the succeeding fiscal year. I further understand that the consideration payment to me shall be subject to all usual payroll deductions and shall be paid to me on or about December 15 of the year for which the election is made. If reinstatement to health insurance coverage occurs during the waived year due to emergency, or I cease to be eligible for health insurance coverage, by termination of employment or other reason, I agree to repay to the Town, pro rata, any amount already paid to me as an unused portion of this agreement. I understand that: * Prior to the first day of each plan year, I will be required to complete a new benefit Election Form. My election is effective for the plan year and S:~Accounting\Comptroller~My Documents\Word Processing Documents\Health Insurance Buyout Election-Town Plan,DOC may be changed during the year only for changes in family status (e..q., marriage or divorce, death of spouse or dependent, adoption or birth of child, or certain changes in spouse's employment that affect health coverage) that cause the loss of health insurance. This agreement is subject to the terms of the Town's Flexible Benefit Plan, as may be amended by the Town from time to time, and shall be governed by and construed in accordance with that plan, CSE^ Collective Bargaining Agreement and applicable laws. By signing below, I agree to the terms of this Agreement. I will indemnify and hold the Town harmless against any and all claims and/or liabilities, including fees, that arise out of or by reason of action taken or not taken by the Town for the purpose of complying with this agreement and applicable law. Health Insurance Declination Cash In accordance with my rights under the plan and this agreement, and pursuant to the terms of the Collective Bargaining Agreement, I elect cash payment for reduci/~ or withdrawing from health coverage as follows (select one): / Family coverage to no coverage Family coverage to individual coverage Individual coverage to no coverage Accepted and agreed to by: /,,~///ol / E.a~te Town's Authorized Representative Signature Date S:~Accounting\ComptrolleAMy Documents\Word Processing Documents\Health Insurance Buy. ut Election-Town Plan,DOC SUP-.Vt='T' OF P~OPF:~Th" 51TUATE~ PEC, ONIC, TOI~ .' 5~90THOLD SUFFOLK COUNTY', SURV'E'r't=D 12-10-O~, FLOOD ZONE PdE¥1SlON O8,-11-2OO~ UP'Al'ED SUFFOLK GOUNT'¢ TAX ~: IOOO-58,-2-5 C]E~'Jt'~-'EtF. Z~ '~'O: Susan C~i~z N W E S NOTES: · MONUMENT FOUND 0 PIPE FOUND At:;~EA = 12,494 5F or' 0.2q c~cr'~.~ C, OASTAL EP, O~ION HAZARD' LINE AS ANNOTATED FP-.OM At:~EA MAP NO..56-F::,66-8~:~ SHEET 8~ OF ®t:~.APHI C, ~CALIE I"= JOHN C. EHLERS LAND SURVEYOR 6 EAST MAIN STREET N.Y.S. LIC. NO. 50202 RIVERHEAD, N.Y. 11901 369-8288 Fax 369-8287 REF.\\Compaqserver\pros\03\03-312 update 06-24-200: