HomeMy WebLinkAbout1000-70.-4-5 O~-~1CE LOCATION:
Town Hail Annex
54375 State Route 25
(cor. Main Rd. & Youngs Ave.)
Southold, NY 11971
MAILING ADDRESS:
P.O. Box 1179
Southold, NY 11971
Telephone: 631 765-1938
Fax: 631 765-3136
LOCAL WATERFRONT REVITALIZATION PROGRAM
TOWN OF SOUTHOLD
MEMORANDUM
To:
Jill Doherty, President
Town of Southold Board of Trustees
From: Mark Terry, Principal Planner
LWRP Coordinator
Date: August 16, 2010
Re: Proposed Wetland Permit for JOHN PEARSON
SCTM# 1000-70-4-5
En-Consultants, Inc. on behalf of JOHN PEARSON requests a Wetland Permit to construct
approx. 101 If. of vinyl bulkhead in place of (and +/-6" higher than) existing timber bulkhead
and backfill with approx. 25 cy. sand to be trucked in from an upland source; construct 4'X 8'
wood walk to existing dock in place of existing walk behind bulkhead. Located: 3575 Wells
Ave., Southold. SCTM#70-4-5
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 department, as well as the records available to me, it is my
recommendation that the proposed action is CONSISTENT with the Policy Standards and
therefore is CONSISTENT with the LWRP provided the following best management practice is
required pursuant to:
§ 275-11. Construction and operation standards.
A. General. The following standards are required for all operations within the jurisdiction of
the Trustees:
(2) Erosion control. Installation of an erosion control structure is necessary during any
building, grading, landscaping or site work activity within Trustee jurisdiction. This structure
may include, but is not limited to, installation of a silt fence, hay bales, wood chip berm and silt
booms. The placement of the erosion control structure(s) shall be determined by the Trustees
or their designee. All intertidal construction and excavation requires the installation of a
silt boom that will retain all suspended sediments within the immediate project area.
Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in
preparing its written determination regarding the consistency of the proposed action.
Cc: Lori Hulse, Assistant Town Attorney
EN-CONSULTANTS, INC.
ENVIRONMENTAL CONSULTING
1319 North Sea Road
Southampton, New York 11968
631-283-6360
Fax: 631-283-6136
www, enconsultants.com
Mark Terry, LWRP Coordinator
Planning Board
Town of Southold
P.O. Box 1179
Southold, NY 11971
Re: John Pearson~ 3575 Wells Avenue~ Southold
Dear Mr. Terry:
July 19, 2010
Attached please find a copy
Wetlands Permit to replace an
location, as depicted on the
with the Board of Trustees for a Town
timber with a vinyl bulkhead in the same
prepared by , Inc., dated July 12, 2010.
?
Pu~sua~to Town Code §268-5 .of and the corresponding definitions of
"action' and "minor action" by §~ mJ the project meets the following definition
of n~or action and is thus not subject ~er ~sistency review pursuant to Chapter 268:
\"G~. Within all Town creeks, replac oj existing bulkhead on the applicant's property in
hefame location with a silt curtain de ~'pl or to and during construction.
~h[refore, I have not filed an LWRP Consistency Assessment Form with the Trustees. Should
determine the project is not exempt from waterfront consistency review, however, please let
ml~ know and I will file the form with your office immediately.
Coastal Management Specialist
cc: Lauren Standish, Board of Trustees
JUL 3 0 2010
1" =40'r ¢
AND GARA(~
DRIVEWAY
ADJ. BLKHD.
101L.F. OF
CONSTRUCTED IN
THAN) EX.
VEGETATED
REPLANTED &
AS
AHW
EX. WALK TO DOCK
BE REPLACED (IN-PLACE)
OF (AND
~i00'
_ _ _~Lw
------EX. D~CK
TO REMAIN
CREEK
El. 5.5'
ADJ. BLKHD.
E N- CONSULTANTS INC
1319 NORTH SEA RD,
SOUTHAMPTON, NY 11968
631-283-6360
rNECK
PROPO~P PLLI~.,~ I~PL,~I?./V~I~I' (IN
FOR JOHN P~/~f:ON ON JOCI~Y
~;~-!OI.P, ~LIPPOLK COUNTY, NY
Of I ?/12/10
Jill M. Doherty, President
James F. King, Vice-President
Dave Bergen
Bob Ghosio, Jr.
John Brederneyer
Town Hall, 53095 Main Rd.
P.O. Box I 179
Southold,NY 11971
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:
Received Feel
Completed Application
Incomplete
SEQRA Classification:
Type I Type II Unlisted
Coordination: (date sent)_
LWRP Consistency Assessment Form ~ ..
CAC Referral Sent:
Date of Inspection:
Receipt of CAC Report:
Lead Agency Determination:
Technical Review:
Public Hearing Held:
Resolution:
Name of Applicant JOHN PEARSON
Address 3575 WELLS AVENUE, SOUTHOLD, NY 11971
Phone Number: (631) 765-6941
Suffolk County Tax Map Number: 1000 - 70-4-5
Property Location: 3575 WELLS AVENUE, SOUTHOLD
(provide LILCO Pole #, distance to cross streets, and location)
AGENT: EN~CONSULTANTS, INC.
(If applicable)
Address: 1319 NORTH SEA ROAD, SOUTHAMPTON, NY 11968
Phone:631-283-6360
Board of Trustees Application
GENERAL DATA
Land Area (in square feet): 20,493 SQ. FT.
Area Zoning: R-40
Previous use of property: RESIDENTIAL, 1-FAMILY DWELLING
Intended use of property: NO CHANGE
Covenants and Restrictions:
If "Yes", please provide copy.
Yes X No
Does this project require a variance from the Zoning Board of Appeals
If "Yes", please provide copy of decision.
Prior permits/approvals for site improvements:
Agency Date
Yes X
No
__ No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?
X No Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
Construct approximately 101 linear feet of vinyl bulkhead in place of (and +/-6" higher than) existing timber bulkhead
and backfill with approximately 25 cubic yards sand to be trucked in from an upland source; construct 4' x 8' wood
walk to existing dock in place of existing walk behind bulkhead, all as depicted on the project plan prepared by
En-Consultants, Inc. dated July 12, 2010.
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
To maintain existing bulkheaded shoreline.
Area of wetlands on lot: 0 square feet
Percent coverage of lot: 0
Closest distance between nearest existing structure and upland
edge of wetlands: N/A feet
Closest distance between nearest proposed structure and upland
edge of wetlands: N/A feet
Does the project involve excavation or filling?
No X Yes
lfyes, how much material will be excavated? N/A
How much material will be filled? +/-25 cubic yards
Depth of which material will be removed or deposited: <2
Proposed slope throughout the area of operations: N/A
Manner in which material will be removed or deposited:
cubic yards
feet
Approximately 25 cubic yard clean sand fill will be trucked in from an upland source and dumped & graded as backfill
to be vegetated landward of new bulkhead.
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):
The project entails the ordinary and routine maintenance of a bulkheaded shoreline through the in-place replacement of an
existing treated timber bulkhead with new untreated, vinyl-sheathed bulkhead. As the existing vegetated embankment behind
the bulkhead will be restored through native plantings and maintained as a nonturf buffer, the project will have no adverse
impact on the adjacent tidal wetlands or waters of the Town.
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEESt TOWN OF SOUTHOLD
In the matter of applicant:
John Pearso~
YOU ARE HEREBY GIVEN NOTICE:
1.
SCTM# 1000-70-4-5
That it is the intention of the undersigned to request a Permit from the Board of
Trustees to:
Construct approximately 101 linear feet of vinyl bulkhead in place of(and +/-6" higher than) existing
timber bulkhead and backfill with approximately 25 cubic yards sand to be tracked in from an upland
source; construct 4' x 8' wood walk to existing dock in place of existing walk behind bulkhead, all as
depicted on the project plan prepared by En-Consultants, Inc. dated July 12, 2010.
2. That the property which is the subject of Environmental Review is located
adjacent to your property and is described as follows:
3575 Wells Avenue, Southold
3. That the project which is subject to Environmental Review under Chapters
96,111 and/or 275 of the Town Code is open to public comment on:
DATE: August 18th, 2010 ~ 6:00 P.M.
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
Southold and does not reference any other agency that might have to review same
proposal.
PROPERTY OWNERS NAME: John Pearson
MAILING ADDRESS: 3575 Wells Avenue, Southold, NY 11971
PHONE#: 631-765-6941
AGENT:
EN-CONSULTANTS, INC.
MAILING ADDRESS: 1319 NORTH SEA ROAD, SOUTHAMPTON, NY 11968
PHONE #: 631-283-6360
Enc: Copy of sketch or plan showing proposal for your convenience.
RITA & JOSEPH DeNICOLO
JOAN & TOR TORKELSON
ATHINA & STEVEN SKOPELITIS
JENNIFER & MICHAEL KOKE
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Address:
3 VALENTINE DRIVE
ALBERTSON, NY 11507
P.O. BOX 511
SOUTHOLD, NY 11971
P.O. BOX 1535
SOUTHOLD, NY 11971
P.O. BOX 1035
SOUTHOLD, NY !1971
STATE OF NEW YORK
COUNTY OF SUFFOLK
ROBERT E. HERRMANN
1319 NORTH SEA ROAD
SOUTHAMPTON, NY 11968
day of JULY
doing business at EN-CONSULTANTS, INC.
, being duly sworn, deposes and says that on the
,20 10 , deponent mailed a true copy of the Notice
set forth in the Board of Trustees Application, directed to each of the above named
persons at the addresses set opposite their respective names; that the addresses set
opposite the names of said persons are the address of said persons as shown on the current
assessment roll of the Town of Southold; that said Notices were mailed at the United States Post
Office at SOUTHAMPTON , that said Notices were Mailed to each of said persons by
(certified) IR~) mail.
ROBERT E. HERRMANN
COASTAL MANAGEMENT SPECIALIST
Sworn to before me this
day of JULY ,20 10
Notary Public
PROIECT ID NUMBER
PART I - PROJECT INFORMATION
1. APPLICANT / SPONSOR
JOHN PEARSON BY EN-CONSULTANTS, INC.
3. PROJECT LOCATION:
Mtmidpality SOUTHOLD
617.20
APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLISTED ACTIONS Only
( To be completed by ,~ olicant or Project Sponsor)
PROJECT NAME
EARSON BULKHEAD REPLACEMENT
County SUFFOLK
4. PRECISE LOCATION: Street Address and Road Intersections. Prominent landmarks etc - or provide map
SEQR
3575 WELLS AVEN1JE, TOWN OF SOUTHOLD, SCTM #1000-70-4-5
5. iS PROPOSED ACTION: [] New [--]Expansion []iVrO/f-icatim/alteratim
6. DESCRIBE PROJECT BRIEFLY:
Construct approximately 101 linear feet of vinyl bulkhead in place of (and +/-6" higher than) existing timber bulkhead and
backfill with approximately 25 cubic yards sand to be trucked in from an upland source; construct 4' x 8' wood walk to existing
dock in place of existing walk behind bulkhead, all as depicted on the project plan prepared by Eh-Consultants, Inc. dated July
12, 2010.
7. AMOUNT OF LAND AFFECTED:
Initially 0.47 acres Ul~n, ately 0.47 acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS?
~Yes ['-] No If no, describe briefly:
9. WHAT IS PRESENT LAND USE 1N VICINITY OF PROJECT? (Choose as many as apply.)
[~ Residential [] Industrial [] Commercial [~Agriculture [] Park / Forest/Open Space
---]Other(describe)
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
AGENCY (Federal, State or Local)
~Yes ["~ No If yes, list agency name and permit / approval:
DEC, COE, DOS
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
~]Yes ~7~No If yes, list agency name and permit / approval:
1~.~S A P,~.~JLT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION?
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE 1S TRUE TO THE BEST OF MY KNOWLEDGE
Applicant / Sponsor Name ROBERT E. HERRMANN, COASTAL MANAGEMENT SPECIALIST Date: JULY 16, 2010
Signature
If the action is a Coastal Area, and you are a state agency,
complete the Coastal Assessment Form before proceeding with this assessment
PART 11 - IMPACT ASSESSMENT (To be completed by Lead Agency)
A DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.47 If yes, coordinate the review process and use the FULL EAF.
[~] Yes [~No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative
declaration may besuperseded by anotherinvolved agency,
[~Yes [~No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible)
Cl. 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, other natural or cultural resources; or community or neighborhood character? Explain briefly:
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered spedes? Explain briefly:
[
C4. A commumty's existing phns or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly:
C5. Growth, subsequent development, related activities likely to be induced by the proposed action? Explain briefly:
C6. Long term, short, term, cumulative, or other effects not identified in C1- C57 Explain briefly:
C7. Other in,pacts (including changes in use of either quantity or type of energy? Explain briefly.
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL
ENVIRONMENTAL AREA (CEA)?/If yes, explain briefly:
[-']Yes [~]No
E. IS THERE, OR IS THERE LIKELY TO BEt CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain.
['"]Yes [~]No
PART lli - DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significm~t. Each
effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring: (c) dural/on, (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
),es, the determ/nafion of significance must evaluate the potential impact of the proposed action on the envirommental characteristics of the CEA.
Check th/s box if you have identified one or m~e potentially large or significant adverse/mpaOs wtdch MAY c3ccur. Th~ ~ ~y ~ the ~
EAF and/or prepare a positive declaration.
Check this box if you have determined, based on the information and analysis above and any supporting dccumentaticn, that the prolx3sed action
WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting this
determination.
Name of Lead Agency
Date
Title of Responsible Officer
Print or Type Name of Responsible Officer in Lead Agency
Signature ot Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer)
S} Town of Southold
Erosion, Sedimentation & Storm-Water Run-off ASSESSMENT FORM
PROPERTYLOCATION: S.CT.M.#: TIlE FOLLOWING ACTIONS MAY REQUIRE TIlE SUBMISSION OF A
1000 70 6 32 STORM-WATER, GRADING, DRAINAGE AMP EROSION CONTROL PLAN
Dlstrlct Section Block Lot CERTIFIED BY A DESIGN PROFESSIONAL IN THE STATE OF NEW YORK.
SCOPE OF WORK - PROPOSED CONSTRUCTION ITEM # / WORK ASSESSMENT ] Yes No
a. What is the Total Area of the Project Parcels? 1 Will this Project Retain All Storm-Water Run-Off
(include Total Area of all Parcels located within
the Scope of work for Proposed CoBstmction) 20,493 SQ. FT. Generated by a Two (2") Inch Rainfall on Site?
b, What is the Total Area of Land Clearing tS.R/Acres)) (This item will include all run-off created by site
clearing and/or construction activities as well as all --
and/or Ground Disturbance for the proposed Site improvements and the permanent creation of
construction activity? (S.R / ^cresl impervious surfaces.)
2 Does the Site Plan and/or Survey Show All Proposed
PROVIDE BRIEF PROJECT DESCRIPTION (Provide Additional Pages as Needed)) Drainage structures Indicating Size & Location? This
1251
item shall include all proposed Grade Changes and --
Construct approximately 101 linear feet ot3 vinyl bulkhead Slopes Controlling Surface Water Flow,
3DoestheSitePlanand/orSurveydescribetheerosion X ~
in place of (and +/-6" higher than) existing timber and sediment control practices that will be used to
control site erosion and storm water discharger. This
bulkhead and backfill with approximately 25 cubic yards Item nmst be maintained throughout the Entire
Construction Period.
sand to be trucked in from an upland source; construct 4' x 4 Will this Project Require any Land Filling, Grading or
Excavation where there is a change to the Natural
8' wood walk to existing dock in place of existing walk Existing Grade involving more than 200 Cubic Yards
of Material within any Parcel?
behind bulkhead, all as depicted on the project plan 5 Will this Application Require Land Disturbtug Activities ['-'"]Encompassing an Area in Excess of Five Thousand X
prepared by Eh-Consultants, Inc. dated July 12, 2010. (5,000 S.F.) Square Feet of Ground Surface?
6 is there a Natural Water Course Running through the
Site? Is this Project within the Trustees jurisdiction
General DEC S3NPPP Requireroents: or within One Hundred (100') feet of a Wetland or
Submission of a SWPPP is required for all Construction activities involving soil Beach?
disturbances of cme (1) or rrore acres: h~cluding disturba~es cfi less than o~le ac~ that 7 Will there be Site preparation on Existing Grade Slopes
are part of a larger common plan that will ultimately ~stmb one or ra2re acres of lamls; which E×ceed Plfteen (15) feet of Vertical Rise to ~ X
the DEC has determined that a S]?D~3 Per'at is required for storm water discharge~
SWPPP's Shall meet the Minimum Requirements of the gPDES General Permit 8 Will Driveways, Parking Areas or other impervious
:lorStormWaterOischargestromConstructionactivity-PermitNo. GP.O.lO.O01.) Surfaces be Sloped to Direct Storm-Water Run-Off
1. The SWPPP shall be prepared prior to the submittal of the NOI. The NOI shall be into and/or in the direction of a Town right-of-way?
submitted to the Department prior to the commencement of construction activity.
2. The SWPPP shall describe the erosion and sediment control practices and where 9 Will this Project Require the Placement of Material,
required, post<onstructlon storm water management practices that will be used and/or Removal of Vegetation and/o~ the ConstaucBon of any D X
constructed to reduce the pollutants in storm water discharges and to assure Item Within the Town Right-of-Way or Road Shoulder
compliance with the terms and conditions of this permit. In addition, the SWPPP shall
iden~fy potential sources of pollution which may reasonably be expected to affect the Area? tTId~ item will NOT include t~ ln~tallatloI, of D~l~eway Aprons,~
quality of storm water discharges. NOTE: If Any Answer to Questions One through Nine is Answered with a Check Mark
3. All SWPPPs that require the post-construction storm water management practice in a Box and the construction site disturbance is between 5,000 S.F, & 1 Acre in area,
a Storm-Water, Gradth , Drainage. & Erosion. Control. Plan is Required b)~ the. Town of,
component shall be prepared by a qualified Design Professional Licensed in New York Southo[d and Must be ~bm~tted for Rewew Prior to Issuance of Any Building Permit.
that is knowledgeable in the principles and practices of Storm Water Management (NUfl~ AChrk ~ {X) and/c* Ans~ for each (3~stion is l?o~ed for a ~ A~icati~.
STATE OF NEW YORK,
Thet I, .~(~t}~RT E. HERRMAN~ ................ being duty sworr~ deposes and says ti.at he/she is the applicant for Perrrdt,
AGENT FOR OWNER
And that he/she is the ..............................................................................................
Owner and/or representative of the Owner or Owners, and is duly authorized to perform or have performed the said work and to
make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and
that the work will be performed, in the manners set forth in the application filed herewith.
Sworn to before me this;
16TH ................. .day of, JUb~f. ................... 20 10
Notary Public
(signature of Applicant)
FORM - 06/10
Board of Trustees Application
AUTHORIZATION
(where the applicant is not the owner)
(print owner of property)
residing at..-~,~'-7 ~'- h~//,[-
(mailing address)
~e_ x~jL,t T}jw. lt c~ do hereby authorize
(Agent)
~,-~- ~ jrF ~a ~ ~ l3 to apply for permit(s) from the
So~thold Board of Town ~ruslees on my behalf.
(Owner's signature)
Board of Trustees Application
County of Suffolk
State of New York
"~ ('J 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 HIS/HER 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, 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 ~ DAY OF ]~ pM' I
,20 [ ~
Notary Public
DEBORAH L KELLY
Notary Public, b"tat~ of New York
No, 01KE60~196
Ou~fled io Suffok County .,
Comml~on Expires February 14, 20/_7
APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics r~rohibits conflicts of interest on the part of town officers and employees. The Dumose of
this form is to provide information which can alert the town of oossible conflicts of interest and allow it to take whatever action is
necessary to 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 the other
person's or company's name.)
NAME OF APPLICATION: (Check all that apply.)
lax grievance Building
Variance Trustee
Change of Zone Coastal Erosion
Approval of plat Mooring
Exemption from plat or official map Planning
Other
(lf"Other", name the activity.) ~r~._ ~/) }~t(¢ .~1.~ 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 Southold? "Relationship" includes by blood, marriage, 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% 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 Southold
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 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 OF RELATIONSHIP
Form TS 1
Submitted this ~- ~' day of i'%Q~,' t 200 [ r0
Signature ~ ~~' ~"-'"-'-
PrintName "&,l l,~l.'x IAi- ~-Jt°/AV"A ~"~