HomeMy WebLinkAboutTR-7617E Jill M. Doherty, President
Bob Ghosio, Jr., Vice-President
James F. King
Dave Bergen
John Bredemeyer
Town Hall Annex
54375 Main Road
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-6641
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
EMERGENCY WETLANDS PERMIT
Permit No,: 7617E
Date of Receipt of Application: September 6, 2011
Applicant: Pat lavarone
SCTM#: 110-7-3
Project Location: 995 West Road, Cutchogue
Date of Issuance: September 7, 2011
Date of Expiration: N/A
Reviewed by: Board of Trustees
Project Description: Temporarily place plywood onto wall of existing bulkhead
and place sandbags against plywood for added support. Measure is proposed
as a temporary stop-gap until all regulatory approvals can be obtained to
construct vinyl bulkhead in place of damaged structure.
Findings: The project meets the requirements for issuance of an Emergency
Wetlands Permit as determined by the Board of Trustees. The issuance of an
Emergency Wetlands Permit allows for the operations as indicated in the
application received on September 6, 2011.
Special Conditions: A full Wetland Permit must be obtained in order to conduct
any further activity on the bulkhead.
This is not a determination from any other agency.
I~M. Dohert~nt
Board of Trustees
SOUTHOLD TRUS
No. ~
ISsued To~ Date~
Address~
THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765-1892
NEW YORK STATE DEPARTMI~OF ENVIRONMENTAL CONSERVATI
Fat~tity DEC ID 1-4738-03813
PERMIT
Under the Environmental Conservation Law (ECL)
Permittee and Facility Information
Permit lssued To:
PAT IAVARONE
6 SUTTON PL
MANHASSET, NY 11030
Facility:
IAVARONE PROPERTY
995 WEST RDISCTM# 1000-110-7-3
CUTCHOGUE, NY 11935
Facility Application Contact:
GARY MOSES
2 WHALENECK DR
MERRICK, NY 11566-5300
(516) 546-3479
Facility Location: in SOUTHOLD in SUFFOLK COUNTY Village: Cutcho
Facility Principal Reference Point: NYTM-E: 712.9 NYTM-N: 4542.3
Latitude: 41°00'14.8'' Longitude: 72028'06.6''
Project Location: 995 West Road - Watercourse - Cutchogue Harbor
Authorized Activity: In-place replacement of approximately 112 linear feet of ekisting functional
bulkheading and backfill. Replacement of existing returns and the construction of two new six foot long
bulkhead returns. Reconstruct existing parallel capping boardwalk landward of bulkhead. All authorized
activities shall be done in strict conformance prepared by Bulkhead Permits by Gary, 7/7/11 with the
attached plans stamped "NYSDEC Approved" on 7/19/11. SAP# 1-08-010
Permit Authorizations
Tidal Wetlands - Under Article 25
Permit ID 1-4738-03813/00002
New Permit Effective Date: 7/26/2011 Expiration Date: 7/25/2016
Excavation & Fill in Navigable Waters - Under Article 15, Title 5
Permit ID 1 ~4738-03813/00003
New Permit Effective Date: 7/26/2011 Expiration Date: 7/25/2016
Water Quality Certification - Under Section 401 - Clean Water Act
Permit ID 1-4738-03813/00004
New Permit Effective Date: 7/26/2011
NYSDEC Approval
Expiration Date: 7/25/2016
By acceptance of this permit, the permittee agrees that the permit is contingent upon strict
compliance with the ECL, ali applicable regulations, and ali conditions included as part of this
permit.
Permit Administrator: SUSAN ACKERMAN, Deputy Regional Permit Administrator
Page 1 of 6
NEW YORK STATE DEPARTMI
Facility DEC In 1-4738-03813
OF ENVIRONMENTAL CONSERVATIO
Address: NYSDEC REGION 1 HEADQUARTERS
SUNY ~STONY BROOKI50 CIRCLE RD
Authorized Signature: ST /cv],.._ O~0ONY'~BR OKI NY 1179
/
Date ~) /~.(,
Distribution List
GARY MOSES
Habitat - TW
SUSAN ACKERMAN
Permit Components
NATURAL RESOURCE PERMIT CONDITIONS
WATER QUALITY CERTIFICATION SPECIFIC CONDITION
GENERAL CONDITIONS, APPLY TO ALL AUTHORIZED PERMITS
NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS
NATURAL RESOURCE PERMIT CONDITIONS - Apply to the FollOwing
Permits: TIDAL WETLANDS; EXCAVATION & FILL IN NAVIGABLE
WATERS; WATER QUALITY CERTIFICATION
1. Regulated Activities Authorized By This Permit This permit ONLY authorizes those regulated
activities / structures identified under the section titled "SAP Authorized Activity". The Department does
not issue after-the-fact or as-built permits. This permit does not authorize activities, or legitimize the
existence of structures, which would have required a permit but for which no permit or other
authorization has been granted by the Department.
2. Conformance With Plans All activities authorized by this permit must be in strict conformance
with the approved plans submitted by the applicant or applicant's agent as part of the permit application.
Such approved plans were prepared by Bulkhead Permits by Gary, 7/7/11 with the attached plans
stamped "NYSDEC Approved" on 7/19/11.
3. Notice of Commencement At least 48 hours prior to commencement of the project, the permittee
and contractor shall sign and return the top portion of the enclosed notification form certifying that they
are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion
of project, the bottom portion of the form must also be signed and returned, along with photographs of
the completed work.
4. No Disturbance to Vegetated Tidal Wetlands There shall be no disturbance to vegetated tidal
wetlands or protected buffer areas as a result of the permitted activities.
Page 2 of 6
New York State Department of Environmental Conservation
Division of Environmental Permits, Region One
SUNY @ Stony Brook, 50 Circle Road, Stony Brook, NY 11790-3409
Phone: (631)444-0357 Fax: (631)444-0360
Website: www.dec.ny.qov
Joe Martens
Commissioner
Pat lavarone
6 Sutton Place
Manhasset, NY 11030
Re: Permit No.: 1-4738-03813/00002
July 21,2011
Dear Permittee:
In conformance with the requirements of the State Uniform Procedures Act
(Article 70, ECL) and its implementing regulations (6NYCRR, Part 621 ) we are
enclosing your permit. Please carefully read all permit conditions and special permit
conditions contained in the permit to ensure compliance dudng the term of the permit.
If you are unable to comply with any conditions please contact us at the above address.
Also enclosed is a permit sign which is to be conspicuously posted at the project
site and protected from the weather.
n V. Ackerman
it Administrator
SVNIs
NEW YORK STATE DEPARTMI
Facility DEC ID 1-4738-03813
OF ENVIRONMENTAL CONSERVATI~
5. No Construction Debris in Wetland or Adjacent Area Any debris or excess material from
construction of this project shall be completely removed from the adjacent area (upland) and removed to
an approved upland area for disposal. No debris is permitted in wetlands and/or protected buffer areas.
6. No Seaward Extension of Bulkhead The new bulkhead shall be constructed in place of the existing
bulkhead with no seaward extension of the outermost bulkhead face.
7. Excavation for Bulkhead/Structure Prior to any construction or removal of bulkheads and other
shoreline stabilization structures all backfill shall be excavated landward of the structure and retained so
as not to enter the waterway, tidal wetland or protected buffer area.
8. Replacement Bulkhead Maximum Height The top elevation of the replacement bulkhead shall be
no more than 18 inches higher than the existing bulkhead.
9. Use of Treated Wood The use of wood treated with creosote, pentachlorophenol or other wood
treatment not specifically approved by the department for use in wetlands and/or marine waters, is
strictly prohibited in the construction of structures that will be in contact with tidal waters.
10. Jet-in Bulkhead Bulkheads constructed directly adjacent to vegetated tidal wetlands shall be hand
driven or jetted in with no disturbance to the tidal wetland. Trenching is strictly prohibited.
11. Clean Fill Only All fill shall consist of clean sand, gravel, or soil (not asphalt, slag, flyash, broken
concrete or demolition debris).
12. No Beach Excavation For Fill No excavation of the beach is authorized for the purpose of
obtaining fill or stone materials.
13. Backf'flling The installation of the approved replacement bulkhead shall be completed prior to the
placement of any fill material behind the structure.
14. No Dredging or Excavation No dredging, excavating or other alteration of shoreline or
underwater areas is authorized by this permit, nor shall issuance of this permit be construed to suggest
that the Deparhnent will issue a permit for such activities in the future.
15. No Runoff Over or Through Bulkhead or into Wetland Upon completion of the bulkhead
replacement authorized herein, there shall be no discharge of runoff or other effluent over or through the
structure or into any tidal wetland or protected buffer area.
16. Parallel Capping Boardwalk The width 0fthe parallel capping boardwalk shall not exceed six (6)
feet. No portion of the boardwalk shall extend seaward of the most seaward face of the bulkhead
sheathing.
17. No Structures on Reconstructed Bulkhead or Pilings No structures, other than structures
specifically authorized by this permit, shall be constructed on the reconstructed bulkhead or pilings
without further authorization from the Department (new pem~it, modified pcm~it).
18. Storage of Equipment,, Materials The storage of construction equipment and materials shall be
confined to the upland area landward of the bulkhead or on a barge.
19. Seeding Disturbed Areas All areas of soil disturbance resulting from the approved project shall be
Page 3 of 6
NEW YORK STATE DEPARTM~OF ENVIRONMENTAL CONSERVATI~
Facility DEC ID 1-4738-03813 --
stabilized with appropriate vegetation (grasses, etc.) immediately following project completion or prior
to permit expiration, whichever comes first. If the project site remains inactive for more than 48 hours
or planting is impractical due to the season, then the area shall be stabilized with straw or hay mulch or
jute matting until weather conditions favor germination.
20. Temporary Mulch, Final Seeding If seeding is impracticable due to the time of year, a temporary
mulch shall be applied and final seeding shall be performed at the earliest opportunity when weather
conditions favor germination and growth but not more than six months after project completion.
21. No Interference With Navigation There shall be no umeasonable interference with navigation by
the work herein authorized.
22. State May Order Removal or Alteration of Work If future operations by the State of New York
require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the
Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation
of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause
loss or destruction of the natural resources of the State, the owner may be ordered by the Department to
remove or alter the structural work, obstructions, or hazards caused thereby without expense to the State,
and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other
modification of the watercourse hereby authorized shall not be completed, the owners, shall, without
expense to the State, and to such extent and in such time and manner as the Department of
Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill
and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall
be made against the State of New York on account of any such removal or alteration.
23. Precautions Against Contamination of Waters All necessary precautions shall be taken to
preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents,
lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials
associated with the project.
24. State Not Liable for Damage The State of New York shall in no case be liable for any damage or
injury to the structure or work herein authorized which may be caused by or result from future operations
undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no
claim or right to compensation shall accrue from any such damage.
25. State May Require Site Restoration If upon the expiration or revocation of this permit, the
project hereby authorized has not been completed, the applicant shall, without eXpense to the State, and
to such extent and in such time and manner as the Department of Environmental Conservation may
lawfully require, remove all or any portion of the uncompleted structure or fill and restore the site to its
former condition. No claim shall be made against the State of New York on account of any such
removal or alteration.
WATER QUALITY CERTIFICATION SPECIFIC CONDITIONS I
1. Water Quality Certification The NYS Department of Environmental Conservation hereby certifies
that the subject project will not conlxavene effluent limitations or other limitations or standards under
Sections 301,302, 303, 306 and 307 of the Clean Water Act of 1977 (PL 95-217) provided that all of the
conditions listed herein are met.
Page 4 of 6
NEW YORK ST ATE DEP ARTMI~OF ENVIRONMENT AL CONSER V A Tie ~
Faollty DEC ID 1-4738-03813
GENERAL CONDITIONS - Apply to ALL Authorized Permits:
1. Facility Inspection by The Department The permitted site or facility, including relevant records, is
subject to inspection at reasonable hours and intervals by an authorized representative of the Department
of Environmental Conservation (the Department) to determine whether the permittee is complying with
this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71- 0301
and SAPA 401(3).
The permittee shall provide a person to accompany the Department's representative during an inspection
to the permit area when requested by the Department.
A copy of this permit, including all referenced maps, drawings and special conditions, must be available
for inspection by the Department at all times at the project site or facility. Failure to produce a copy of
the permit upon request by a Department representative is a violation of this permit.
2. Relationship of this Permit to Other Department Orders and Determinations Unless expressly
provided for by the Department, issuance of this permit does not modify, supersede or rescind any order
or determination previously issued by the Depmhnent or any of the terms, conditions or requirements
contained in such order or determination.
3. Applications For Permit Renewals, Modifications or Transfers The permittee must submit a
separate written application to the Department for permit renewal, modification or transfer of this
permit. Such application must include any forms or supplemental information the Department requires.
Any renewal, modification or transfer granted by the Depadlnent must be in writing. Submission of
applications for permit renewal, modifiqation or transfer are to be submitted to:
Regional Permit Administrator
NYSDEC REGION 1 HEADQUARTERS
SUNY ~ STONY BROOKI50 CIRCLE RD
STONY BROOK, NY11790 -3409
4. Submission of Renewal Application The permittee must submit a renewal application at least 30
days before permit expiration for the following permit authorizations: Excavation & Fill in Navigable
waters, Tidal Wetlands, Water Quality Certification.
5. Permit Modifications, Suspensions and Revocations by the Department The Depa~hnent
reserves the fight to exercise ali available authority to modify, suspend or revoke this p~mfit. The
grounds for modification, suspension or revocation include:
a. materially false or inaccurate statements in the permit application or supporting papers;
b. failure by the permittee to comply with any terms or conditions of the pcmdt;
c. exceeding the scope of the project as described in the permit application;
Page 5 of 6
NEW YORK STATE DEPARTM~OF ENVIRONMENT AL CONSERV ATI~
Facility DEC 1D 1-4738-03813
d. newly discovered material information or a material change in environmental conditions, relevant
technology or applicable law or regulations since the issuance of the existing permit;
noncompliance with previously issued permit conditions, orders of the commissioner, any
provisions of the Environmental Conservation Law or regulations of the Department related to
the permitted activity.
6. Permit Transfer Permits are transferrable unless specifically prohibited by statute, regulation or
another permit condition. Applications for permit transfer should be submitted prior to actual transfer of
ownership.
NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS
Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification
The permittee, excepting state or federal agencies, expressly agrees to indemnify and hold harmless the
Department of Environmental Conservation of thc State of New York, its representatives, employees,
and agents ("DEC") for all claims, suits, actions, and damages, to the extent attributable to the
permittee's acts or omissions in connection with the permittee's undertaking of activities in connection
with, or operation and maintenance of, the facility or facilities authorized by the permit whether in
compliance or not in compliance with the terms and conditions of the permit. This indemnification does
pot extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or
intentional acts or omissions, or to any claims, suits, or actions naming the DEC and arising under
Article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision
under federal or state laws.
Item B: Permittee's Contractors to Comply with Permit
The permittee is responsible for informing its independent contractors, employees, agents and assigns of
their responsibility to comply with this permit, including all special conditions while acting as the
permittec's agent with respect to the permitted activities, and such persons shall be subject to the same
sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee.
Item C: Permittee Responsible for Obtaining Other Required Permits
The permittee is responsible for obtaining any other permits, approvals, lands, easements and rights-of-
way that may be required to carry out the activities that are authorized by this permit.
Item D: No Right to Trespass or Interfere with Riparian Rights
This permit does not convey to the permittee any right to ~espass upon the lands or interfere with the
riparian rights of others in order to perform the permitted work nor does it authorize the impairment of
any rights, title, or interest in real or personal property held or vested in a person not a party to the
permit.
Page 6 of 6
Applicant: Pat lavarone
Project Site: 995 West Rd
Cutchogue, NY 11935
Proposed: Navy bulkhead replacement
in kind & place
Prepared by Bulkhead Permits
by Gary Inc
2 Whaleneck Dr
Merrick NY 11566
Scale 1"=50'
July 7, 2011
Project Plan
?~'? - 6 201i
~;, ~dh~o!d ]'own
Helen M Rynd
1165 West Rd
Cutchogue, NY 11935-2257
Flood _
Cutcho~ue Harbor
~idth 3200'
Leonard R~din [
805 West Rd
Cutchogue NY 11935
All hardware, nails and bolts shall be
hot dip galvanized, all bolt heads and nuts
will be used with cut washers. All timber will
be cca treated marine grade, All vinyl
sheathing will be interlocking madne grade, All inland
backfill will be clean soil,
Cross View
~ 93' ~
135' Not to Scalo
Applicant: Pat tavamne
Project Site: 995 West Rd
Cutchogue, NY 11935
Proposed: Navy bulkhead
replacement in kind & place
Prepared by Bulkhead Permits
by Gary Inc
2 Whaleneck Dr
Merrick NY 11566
Scale 1"=50'
July 7, 2011
Jill M. Doherty, President
James F. King, Vice-President
Dave Bergen
Bob Ghosio, Jr.
John Bredemeyer
lown Hall, 53095 Main Rd.
P.O. Box 1179
Southold, NY 11971
Telephone (63 I) 765-1892
Fax (63 I) 765-6641
BOARD OFTOWNTRUSTEES
TOWN OFSOUTHOLD
J n ,~ n ,. C~f?ce Use Only
C orSecc/
__Coas~l Erosion Pe~t Application
~Wetland Pemit Application Adminismfive Pemit
~endmen~r~f~Extension
Received Application: 9/~[t/
Received Fee:$ .~
~Completed Application
~Incomplete
~SEQ~ Classification:
T~e I T~e II Unlisted
~Coordination:(date sent)
~L~ Consistency Assessment Fora
~CAC Refe~al Sent:
~Date of Inspection:
~Receipt ofCAC Repo~:
~Lead Agency Dete~ination:~
~Tec~ical Review:
~ublic Hearing Held:
~Resolution:
Name of Applicant
Address
Phone Numb~':(~l(¢
Suffolk County Tax Map Number: 1000 - I I O
Property Location: ~'~f' t~ 7' ~
(provide ~ILCO Pole #~ distance to ~oss strcets~ ~nd location)
AGENT:
(If applicable)
Address:
Phone:
trd of Trustees Applicati~
Land Area (in square feet):
Area Zoning:
GENERAL DATA
Previous use of property:
Intended use of property:
Covenants and Restrictions:
If "Yes", please provide copy.
Yes 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
No
__ No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspende~a gov~mtal agency?
-~ No Yes
If yes, provide explanation:
Project Description (use attachments if necessary):_
Board of Trustees Application
VOgTLANDfFRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
Area of wetlands on lot: square feet
Percent coverage of lot: t~ %
Closest distance between near. est existing structure and upland
edge of wetlands: I :~" feet
Closest distance betweennear-est proposed structure and upland
edge of wetlands: /~ feet
Does the project involve excavation or filling?
No Yes
If yes, how much material will be excavated?
How much material will be filled?
Depth of which material will be removed or deposited:
Proposed slope ttucoughout the area of operations:
Manner in which material will be removed or deposited:
cubic yards
cubic yards
feet
Statement of the effect, !f ~nY, on the wetl~ands and tidal waters_ 9f~e town that may_ r_~_sult by
reason of such proposed operations (use attachments if appropriate):
PROJECT ID NUMBER
PART 1 - PROJECT INFORMATION
617.20
APPENDIX C
STATE ENVIRONMENTAL QUALITY REVIEW
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLISTED ACTIONS Only
( To be completed by Applicant or Project Sponsor)
2. PROJECT NAME
SEQR
1. APPLICANT / SPONSOR
3 PROJECT LOCATION:
4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map
5. iS PROPOSED ACTION: [] New []Expansion i']MoOificationlalteration
6 DESCRIBE PROJECT BRIEFLY:
7 AMOUNT OF LAND AFFECTED:
Indially acres Ultimately acres
8 WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING QR OTHER RESTRICTIONS?
E~es [] No If no, describe briefly:
9. ~NR Z iS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.)
~Re~identia, []Industrial ~-~Commercial [~Agriculture C~ParklForesllOpenSpace []Other (describe)
10~' DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL
AGEN~(Federal, State or Local)
L~Yes []No if yes. list agency name and permit / approval: [
~I.t)L)L5 NY A~PE~r~'-IHE ACTION HAVE A CURRENTLY VALID
^[]No If yes, list agency name and permit / approval:
PERMIT
OR
APPROVAL?
......
12. AS A RES OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION?
I CERTIFY THAT T/~INFORM~'./ON PROVIDED ABOVE iS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant / Sponsor Name //,~~ Date:
Signature ~' ~ '[ ~
If t tion is a Costal Area, and you are a state agency,
complete the Coastal Assessment Form before proceeding with this assessment
of Trustees Applica~n
County of Suffolk
State of New York
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 1N 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 1
PREMISE~//JUN~ ~.~ ~ ION~r WITH
[I.~PERTYJ, O INSPECT THE
7HI~WPLICATION.
nature
SWORN TO BEFORE ME THIS ~0g'- DAY
,20 j/
LAUREN M. STANDISH
Nofarj.,Public, State of New York
r~o. 01ST6164008
Qualified in Suffo k County
Commission Expires Apdl 9, 20/~'
AUTHORIZATION
(where the applicant is not the owner)
(print owner of property)
residing at ~3-~c~i/~-z~
(mailing address)
~J~W ;V~ //f~do hereby authorize
(Agent)
to apply for permit(s) from the
Southold Bo~ Trustees on my behalf.
~$ signature)
APPLICANT/AGENT/REPRESENTATIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of Ethics orohibits conflicts of interest on thc oart of town officers and emnlovecs. The ouranse of
this form is to nrovide information which can alert the town ofnossible 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.)
Tax grievance Building
Variance Trustee
Change of Zone Co~-stal Erosion
Approval of plat Mooring
Exemption from plat or official map Planning
Other
(lf"Other", name the activity.)
Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee
of the Town of Southold? "Relationship" includes by blood, marriage, or business interest. "Business interest" means a business,
incinding 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~5,ghares.
YES NO
1 f 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 appropria e ne 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 thc shares of the corporate stock of the applicant
(when the applicant is a corporation);
__B) the legal or 'beneficial own~ 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 I
Submitted this ~ day al' ~ ¢ 1~ 200 I ~-
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