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HomeMy WebLinkAboutTR-8390E • John M. Bredemeyer III,President �Ok SU�lyOlO Town Hall Annex Michael J. Domino,Vice-President 54375 Main Road P.O.Box 1179 James F. King,Trustee Southold, New York 11971-0959 Dave Bergen,Trustee G Q Telephone(631) 765-1892 Charles J.Sanders,Trustee ��'•`,oU Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No.: 8390E Date of Receipt of Application: April 30, 2014 Applicant: Marie & Eric Muntner SCTM#: 122-4-28 Project Location: 4210 Ole Jule Lane, Mattituck Date of Issuance: May 2, 2014 Date of Expiration: N/A Reviewed by: Board of Trustees Project Description: Fill and abandon existing collapsed cesspool and install new cesspool between the existing and the dwelling. 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 April 30, 2014. Special Conditions: This is not a determination from any other agency. _ John M. Bredemeyer III, President Board of Trustees TE ES No. e.Tnell r. • Issued Address. 4Z l'b Q-1cco -ZL Laney JUla� uck THIS'NOTICE MUST BE>DISPLAYED DURING CONSTRUCTION _ TOW" TRUSTEES OFFICE.TO.WN bP SOU'FHOLD SOUTHOLD, N:lf.11971 TEL.: 765.1892 n E C E-IVE D APR 3 0 2014 4� fD ou 60` o� �8 ' SURVEYED FOR:-,,=--el, LOCATED AT 1W,4 7-rl7t/G!G_ TOWN OF SUFFOLK COUNTY N.Y. LOT /5 L7�.�cR/dEp MAP OF AS SN >V,/ / J.Q , CO. CLK. NO. FILED `F r SCALE 1"-25' SUFFOLK CO. TAX MAP DATA:- ro �F //CSC�PG DIST. /000 SEC./22.00 LOT 028•GUO sf'* tier J p24-4- yr .�SuRVFy, �., 10- .Z SEAL v c; Y( �M c_ERT�F/ED To M R/C MAR/E MuIA17',vEA?- i 4 T D R /E I C—"/<f.4c5o T Te-e O t.� 71-7z-' 3 p.4�a. / "OZB/4- .L fF :4A:�GNIO f�1' Li41�i.t/o I lz 'Al 3YG 99�) F§ SURVEYED[SEC. /4, 1998 BY ' r_ RAMPART SURVEYING P.C. P/O BOX 340 APR 2 z EAST MORICHES, L.I., N.Y. 11940 FIL 0� DRAWN BY� � � � � �� � IOYYN OF J11:._ lyi •,� D _. F _ - APR 302014 oard ;.T 3 'ycsr �p 3 a � ^ z � y A Mfamu %owl IT NO Irk r 1 40 W 17 } e s P n ° +a g, n� . � x e w�t,q - '`�� .,�t •� �,.» ��1 +��z, c+q" Ems' $ Y'} ,a°•"�} � �#�sS �4r� �J,;«. q "r ,�; ,� �, �aqY+�"/a�f lea �,,, `Gy�,..a�.,,: .,,�. Z M. .8 y�y q�.,s�; 3y-X(Na",r L � `$ 9'i` �,�s;& ,;4F I I,�.t..i � e,,,: �f*� J,,yXg:: s.�/AS'• F b �'+.; : .°��aT-'`mss .r �€w :� �.. •. w , f 'u 4 d { t 3 � � k• dk ce� i' � � - FIZZ - -IWO- wmx E,._ ?4 ;p be e: Y ,. ::''x;R .,-a. ,.xs 3"., � _ -; `h; ,..:�:� :,. ,.5, ,. .d •h �,i-e ",,, .,:. ,. xq, »,X��%x -k-# .. s- ''.• ?kY... §"� S...x, rte. .n' �'' � ".:, �> 1.r,. ....,,.�8 r. u. �� .,.... .,: >,. , # ✓ 4 er ). �� �.. ", � -.c.`'� ...x...,. .,/34' x,,: x, ' ,•Y > '�.. .or,Fax �F�ot,Y O� CMG wn Hall,53095 Main Road ELIZABE M A.NEVILLE . = y� P.O.Box 1179 TOWN CLERK Z Southold,New York 11971 REGISTRA.B or VITAL STATISTICS Fax(631)765-6145 AGE OFFICER �! Telephone(631)765-1800 RECORDS MANAGEMEIIT OFFICER � �a southoldtown-northfork.net FREEDOM OF WoMdATION OFFICER OFFZcr, OF TaE TOWN CLERK TORN OF SOUTHOLD SOUTHOLD WAS'T'EWATER DISTRICT . ApPI,ICATION CONSTRUCTION or ALTERATION PERWr CESSPOOL or SE 25 Application No. Residential @ $IQ____ or Non-Residential $ permit No. -- Applzca�atName PECONIC CESSPOOL Applicant Mailing Address P. O. BOX .487 LAUREL, NEW YORK 11948 Septic Tom:- `or Cesspool__._ Brief Desm ptio of posed Co ction or Alteration Location of proposed Construction/Al Lion: IV� U Owner of Property-.— ,n Owner�Address' c v o ll 57;� Owner property Address: Nave and phone number of contact person 9 Section Tax Map No: °�°� Block Lot Cross Street NOTE; LOCATION• MAP MUST BE S���D DEP ARTME AEON. OVAL VfTrH CONSTRUCTION REQUIRES SURVEY Signature of Applicant Date Received by: John AL Bredameyea M,1readenS ���►of So(/j�r�/_ Town Hsll A=cz Micbnal J'_nar hl .Visa Areoid mt 6076 Main broad Janses F. Tr"" ixr P.O.Box 1179 Soutlxold,New York 11971.0959 .Dave Bergen,Trustee Charles J.Sanders,Trustea , Telephone(651)755. 'Ca Fax(631)166-6 1 BOARD OF TOWN TAUSIfEES TOWN OF SOUMOLD Office Use Only A _Coastal Erosion Permit Application ' _�Yetlard Permit Application Adtainisrra�ive:Permit Amendlmentrriansfer/Extension APR 3 0 2014 Received Application: _Received Fee:$ Completed Application .�.,;, ,",�ncomplbte SEQRA•Classification: Board of Twstees Type Y -Type fl-Unlisted, Coordinadow(date sent) LWRF Consistency Assessment Form _CAC Referral Sent: _Daft of Inspoodon• _Receipt of CAC Report: Lead Agency.Determinstion• Technical Review: _public Hearing Held, Resolution: Name of Applicant /►7 1 G f l C M U 1V-rjV 1~p2 Mailing Address_ Al)/3 U.1Z nJ �U n lZw/c rl A/.y 117. Phone Number:(Sli) 6 14 0 1 9 Suffolk County Tax Map Number: 1000- Property Location: 4,� 10 D L C- .7 U L.G �.Fl !U ? 7t7T I"[u[.!c, N• �/ ! l �? S (provide LILCO Pole k distance to cross streets,and location)- (� ',po � AGENT: 1!" (If applicable) Phone: o 3-ca Zt/Z8 3!Dvd -100dSS30 OIN0K)3d r95LLZ41E91 5e;61 17t6Z/8Z/179 Board of Trustees Application GXNERA,D DATA Land Area(in square feet): Area Zoning: Previous use of property: Intended use Ofproperty: ,. / Covenants and Restrictions on property? Yes l� No If"Y'es",please provide a copy, Will this project require a Building Pormit as per Town Code? ''Yes --LX/—O If"Yes",be advised this application will be revicwed by the Building Dept,prior to a Hoard of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of APPS s7 Yes �No If"Yes'°,please provide copy of decision. Will this project rcqWe any demolition as per Town,Code'or as determined by the Building Dept.? —yes No Does the structure(s)on property have a valid Certificate of Occupancy?_X—Yes No Prior permits/approvals for site improvements: Agency Date No prior permitslapprovals for site improvements_ Has any permitlapproval ever been revoied or suspended by a gover=%W agenay7_�(_No Yes If yes,provide explanation: Pro' t Description(use attachments if n essary): ZZ/E8 39Vd -UOdSS30 DIN003d b9SLLZLT£9C 50:6Z bTOZ/RZ/bA Board of Trustees Application WETLANDrrRUSTER LANDS AMICATI N DAT P osc of the proposed m'p operations: Area of wetlands on lot: - � feet . Percent coverage of lot.- Closest distauco between scar st o ds9ng,structure-and uplaiad odge of wetlands; - 0' 'feet. Closest distance between new proposed st 4ctum and uliland edge of wedands; t feet Does the project involve.excavadon or filyme No Yes If yes,how much material Wi21 be excavated?cubic yards How Much.materiel will be filled? cubic yards Depth of which material will be removed or deposite& _ feet Proposed slope througbout the area of operations NS r in w 'ch material removed or Statement ofthe effect,if any,on the wedands arid,tidal wat=of the town that may result by reason of such proposed operations(use gtscbine.,tg if appropriate)_. . ZZ/179 3E)Vd 100dSS�0 07N003d VIK/86/r0 Appendix B SJ�art ErrYxrOnmernral Assessment Form 1nstructioms for Completing INA I.project Inform'tion. The Rpplicant or project sponsor is responsible for the completion of Part 1. p,%ponsos become part of the application for approval or funding,are subject W public review,aril stay be subject to further verification. Complete Part I based on information currently available, ifadditiorlai NseStcb or inacsdgation would be needed to fully respond to any items please answer as thoroughly as possible based on current information. Complete all Items is Part I- You may also provide any additional information which you believe will be needed by or Useful to the lead agency;asseh additional pages as necessary+to rupplemeot say item. Pali I-Protect and S sor Inf rmation Name of Action or Project Prgject Location(deseribq,and amch n m Brief-Dwaiptiori of Action; Narnc of 4CpWcWt or$poh �eldphon4: _MOiL- ire citymo: Zip Code: I.Does the proposed action only involve the legislative adoption of a plan,local law,o�idinarne, NO YES administr-ative rule,or regulation? If Y'es,Rum"narrative description of rho intent of the Propostd action and.the environmental re~soureea that may be affected in the municipality and proceed to Part 2. If DO,continua to question 2. 2, 'Does the proposed wdon rGqulrc a permit,approval or fur4bs from any other gdvernmenudd Agency? YES If Yes,list agency(s)narne and permit or AppmVal: 3.0.Total WMW Ofthe site of the proposed cation? b.Total acreage to be physically disturbed? c.Total ecrea *(pmjed site and any contiguous properties)owned or controlled by the applicant or project sponsor' acrCS 4. Check all land usesihat occur on,adjoining and near the proposed lion (j Urban ❑Rural(rnm-aigrioultum) ❑Irnlustrial Q Comm,trcial eRcsidcntial(suburban) bl ores[ ©AVriculture ❑Aquatic 00ther(9pccify): ❑Parkland Page I of 4 i;t/50 3JCld ©f3dSS3� �IN0�3d V9SLLELI89I SO:6T VTOZ/8�/170 the proposed action, a_A permitted use under the zoning regulations? NO Yn N/A b-Consistent with the adopted cornprehensive plan? ❑ 6. Is the proposed action consisten with%a predominant character of the existing bails or natural Np landscape? YES 7- Is ere site ofT,he proposed action Iacatad in,or does it adjoin,a Stale listed Critical Environmental Alta? IVs] ifiiS If Ycs,identify: Will the proposed action ttsuk fn a substantial increase in tta#nC above present levels? U YES b.Are public transpqttAWOn service{s)available at or near the aitc of the proposed an iono `❑ C.Are aa►y pedfpWinn accommodatkw or bicycle routes available on QJ near site ofThe 7 %Dow the pro posed 7tcdon led or cxeced the suue energy posed action. If the proposed action will exceed riky cads tuitctaents? NO YFS requireWnts.describe design features and tecbnolegics 10. Will the proposed action consect to an existing publk/prjv,=c water supply? NO If No,describe method for providing potable watart 11.Will the proposed acdon aonneci to ex wastewater utilities? No YES If No,describe method lbrproviding Wastewater treatment;. 12. a Does the site contain a Places? Stan ttre that is listed on either the State or National Register of RaoUic 1V0 YES b.IS the proposed action located in an archeological sensitive area? 13-a.Mel any Portion Ofthe sitc of the proposed action,or lands adjoining the wetlands or Other waterbodies regulated by a federal,state or local agency? osed action,contain Q Y b.Would the proposed action physically alter,or encroach into,My existing wetland or waterbudy? If Yes,identify the wetland or waierbody and extent of alterations in squttro feet or acres: ❑ 14_ Ideadfy d1e typical habitat types#liar occur o%or are likely to be found oil she project situ. Check all Th apply: )Q Sbordine OForest Q Agricultural/grasslands Q Fy mid-sucorssional ifWetlwd r7 Urban OSuburban 15.Does the site of the proposed action contain any species of aaunal,or associated habitats,lisd by tt4a State or Medea government as Threatened or endangered? NU YES 16.Is the project site located in the 100 year flood plain? NO yS 17.Will the proposed action create storm water discharge,either from point or non- JifYes, point sattrces3 U Yl a.Will storm water discharges flow to aelaacent,properties? ,kNO OYES ❑ b.W111 storm water discharges be dirccW to established conveyance systems 1f yes,brie f3F and stern,drains)? describe: NO OYES Page 2 of 4 IOOdSS33 DINCO�Jd b9P?T.r7FgT CAA:GT ti,r07 dn7 ,.,, 18,Does The proposed action include construction or other activities that resuh in the impoundment of NO YES waxer nr eeher 5gaA&(o,g.retention pond,w wte las000,drun)? If Yes,explain purpose and size: 19.Has'the site ofthe pwposed action or an adjoining property been r]te loeatioh ofan arrive or closed NO YES solid waste management facility? 1F Yes,dasca'lre: X Has the site of the proposed action or an 4ipining property been The subject of rcmediation(ongoing or NO YES compacted)for hazardous wage? If Yes,dosrribe: ❑ A A lly THAT THE INFORMATION]FRO'VIN&D ABOVE LS TRUE AND ACCURATE TO TIM>eM OYr MY KNO'GVL DGE / Applieantlsponsorn Date: I-el Signature. part Z-Impart Assessm.nt. The Lead Agency is responsible for the completion of Port x. Answer all of the,following questions ip part 2 using the 1rifonna4on contained in Part 1.and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reaconable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may Occur occur 1_ Will;be proposed=ion create a mawlal conf c;with an adopted land use plan or zoning regulations? 2. Will the propnsad action result is a charge in the use or intensity of usa of land? 3. Will the proposed action hnpair the character or quality of the existing community? j� 4. .Will the prottuscd action have w impact on the environmental characteristics that caused the ��j"-1-�� ❑ establishmbnt of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an atdVme oh=ge in the existing level oftraffec or al?fea existing infrastructure for mass transit,biking or walkway. ti. Will the proposed aation•cause an increase in the use of energy and 4 fails to incorporate Masmbly available energy conservation or reoswable on2M o nunities? ❑. ❑ 7. Will the proposed action.impact existing: ( { ❑ a.public J private waiter supplies? L.J b.public I private wastewater uetstmcnt atilitios? El S. Will the proposed nedon impair the character or quality of important historic,arcltazologioal, ❑ architec(ural or aesthetk,revx=s? 9. Will the proposed acdon result in an adverse change to natural resources(e.g.,wetlands, � ❑ waterbodics,groundwater,air quality,flora and fauna)? Page 3 of 4 ZT/L8 3E)Vd 700dSS30 0IN003d V99LLZLTE91 S0:6T rlaz/8L/v0 No,or Moderate Stuall to larva impact impact may may occur occur 10. Will the proposed action result in an Increase in the potaMial for erosion,flooding ordra M& ❑ problems? I 1. Will The proposed action create a hazard to environmental resources or human health? E PUt 3-Datarmivatiion orsignllkance. The Lead Agency is responsible rOe The compl®tlon of P'rt 3. For every question in Part 2 that was answered"moderate To large,impact may occur",or if there is a new to explain why a PwTiculsr element of the proposed action may or will not result in a significant adverst enviro»mental impact,please complete Part 3. Part 3 should,in sufficient dera7,fdetltlfy The impact,including any measures or design elements That have been included by the project sponsor m avoid or reduce impacts_ Part 3 should also explain how the lead agency determined that the impact may or will not be signiftcanx.Each potential impact should be assessed considering its setting,probability of ooeurring, duration,irreversibility,geographic scope crud magnitude. Also consider the potential for short-term,long-Mm and ctlmttlative impacu. Check ibis box ifyou have determined,rinsed on the information acid analysis above,and awry suppor ft docwr minion, that the proposed notion may result in one or more potentially Large or significant adverse impacts and an tnvironn*ntal impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not r auh in any signif ant adverse cnvironn►cad imparts. Town of Souuwki-Boara or'rrw A*w Name of L*W Agency Date RrecgiQant Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency $ignature ofPreparer(if different from Responsible Officer) PRINT Page 4 of 4 • ZZf80 39Gd -100d5530 XMM3d S0:61 DZBi;/i3Z/ti0 Town of Southold Erosion Sedimentation & Storm-Water Run-off ASSESSMUNT FORM PAOPerrrr L=11 ft. i,C.T,e.at THE FoLL0111IN6 ACTIONS My tttE Tti�St191Ytittf.RipN OF A 't>EFreI ye–amt M&W! CA_" C¢ A_ a nG a S x QF li SCOPE OF WORK • PROPOSED CONS RUCI':[ON PaM# i WC)AX ASSESSMENT LasNo a WhOt it the Told Area of tha Project Pa=b? (Include TOW Area of ail PeMo&boated VRM 1 YWI this Prolect RoWn AN s pirl-Vvbtef RurrW as soups of Work t r Propo"d C=bucfion) Ganemled by a Two(Z")inch ReirdalI on Seta? :00 b• what is tdle Total Afsa of land Clearing -F r sass) (Thlo+tam ruin include aM n off created by s iro and/or Grand aahntrance for she pmpgaw rdeoft and1ty=nwucwn acovdin as wa as a Can30t4on aotivityn Site improvements and an P'a+nanentavafwn of PAotrinE 1i F �ALyELT �E4t3tII'TIpN tOmerk.Ad fiibnal ae��nremq Z Does the site Plan antllor%rvey$how/Ui PrCxJOSad eI Indlm Sias&Location?This ,f/ Item �Rdude so f�ropomw Grade Ching"ow 1L w VQPes COVO M G SWUm Water flow, and sediment G7rllrOiI pr&C i usad v co"aft erasion Wd sweet MW ads woes.This tkun must be maintained bKVaohoutt to Entire Canatrucbon Period. 4 WiU•Ihis PMjvA Requim any Lam FlMingm l3gwing or Ekcmdm when there is a dwse b the Natural Exi6fts Snide Involving more than=cubic Yards v Of Matpt W Within any Pwcal? 5 win fhia APPI10 tch ft Wre Land Dlaturbing ActMegg / EnOpPhpgygins an Area in Ei0Ce8s of Rve Thaveatd (/ (6,000$X.)Stare f=eet of Ground SurbW7 u B Is Thera a NatuW Water Course RurrsbV h tits $ite7 IS this Piafec!WlO Dta Tmatees� (� C�ormarai DEC avrpPP AeaAmeamann- Or Within One FfCUlde�sd(1QQ')feet Of a Wetlelid or SuUeis M of a MOP Or mquhed ler all Consbuckm and doo sal Beach? d-aMw�wnoo.of one l,ya more aereb ,y diMtwbennea drfo.�u w ono e�fha 7 vMIM ttrere be S119 preparation an 6Ciso are Part ors lergor oomCmn glen Vw wit ut =k*dawrb one ar more aria of 4rC� ng tirade 810W kKk'dlna t"iuoran b0pAw Inveh W col dMrbencn of low then one(f)acn vmtoe w Nch Exceed Ffterf(i s)feet or Vagieat FGsa ro Ina DEC has dWwmined dw s jR=WMA is r eked for mn wowdsdwgesa One Hvrxieed(10&)of Hwhonfal Glstsllee? (DWPW@ emu--tow 1Mkiko n RegeIm%bab Ore.sPM Osm Ol ronmr VWi Drtir smrm wean obohort#from co"'11%mlion Belli ft.Pena No.GP4.10-1. $ ,Pad to Arena IZ other i,rrr Run us 1 / 1,TM awnr�P&W be P*Wvd prior a ddb iubnxam a Che NOI,Tlma NOi shalt be ) k ft and/be d*d1r to Direct Stone Water R voy? submMod w the Dopomnam M&ro Mr oo„+menw,nau of wavuedmm epgvgy. into and/or lR Oio dlrt3cY,orr df$7ouret right ar-+►�y? 9.The SWPPP oh"d"mW Mro cfflo n and @MW MM eamier Pis and whams 9 %MN bvli Project Require The PWK*Ment Qf Matortat,Caviniction regwk*d,goer-mnamadgp SMm water ffmnapemaet Pmelle s Mgmt VA tw wed and0or Removal of V n aWhe teoshu1M b Will ft ow paw mml ti tfl n omvv% of Wqt 1 adaddbm.en SWPPP shad Pont Whin(tta Tam FU91VI I-W y ar m =w�moe wNy tICCe tons and ccndiiong of etCld � � v tdea*P�M sau,ae&of a oWun whldv may rbyaonatll,br expCOW w oHaaC Uw �?Mft 100 WS Nor rte««»mwbamp.a&I rte,,, gua*90dorwmwalwdhdmsegee, t1oTY; ern�yAr,.wartoar..roaaar�d„e„g„rza.i�neawr.dwid:.�fra�fe s:AM MMPPf>a VW ggykg Me"V OMM M66M sj.R,eaW hwnayemeM Pre06= Al 0 t W WW ttm omCWV;0oa ana difth ra is behmin Uft B F.i h AM io arew component shot to oMperod by a gWlbd badlpe PmtsaarW Uwrmad in New Yak a stm l-wbtwr,aradwe Drah I a DWI”Combo'Ph"It RowArod by V&Tbwo of tug leknMedpeafffeiwFapbdpimandDraomofShmpsw0tvY""WWL Southold and Wabaaubma mdfer ap,AyPrtorlotaeuaagaerAOVaWdiogPanaf tltp7l 'A pgsk Nemk(�?dpi Armm+wmrfer APP�l STATE OF NEV( TOR COUNTY'OF.............................__........SS No.01 BU6185050 Qualified in Suffolk County "I`laat Commission Expires April 14,2_[(0 °.............iio:m:or r,iwia�,�r�iynin¢ovsainiQirj.................bcing duly swam,deposes and says that he/she is die app)+cant for permit, rlrsd rYfat he/she is$a; ..,........_.............. ............. OW>)er and/or representative of the Owner or Owners,sad is duty authorized to perform Or have petfatme d the said werl;and W make and fk tl�is dppdit&d0a;chat aU stancments Contained in dzis.applicsdon are lobe W the best of his Ivnowtedge a0d b6cf;and that the work wdl be performed in the rnaasrer set forth is the application filed hommi$s. Sworn tin before me this; ...... �?........j� .-.._... ...day of. .. _...... „ ,201Y No4ary Fublir �!`�. ....-_ ... '� :�� ........._. .. , ' .,......... FORM - 06110 t '00 7("►0 ^u 2,1/60 3E)Vcl �OOdSS37 OINDD3d b9�L!iy��$gt S0 6T bZOZ/8Z/t:6 Board of Trust:eam; Application NA.gaa`' County ofd State of New York I Cf l l 14 N TIV C 2 BEING DULY SWORN DEPOSES AND AFFIRMS THAT RWSHE IS THE APPLICANT FOR TIC&ABOVE DESCRIBED PERMITS)AND THAT ALL STATEMENTS CONTAINED HEUIN ARE TRUE TO THE BEST OF HIS/HER kNOWLEDGE AND BELIEF,.AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IMTHIS 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,THM AGENT(S)OR R.EPRESENTATIVES(S),TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WIT$REVIEW OF THIS APPLICATION. Sig,aturc o roperty Owner SWORN TO BEFORE ME THIS G l DAY OF AIA I L 020 Notary pub 'c` ARYIND BALI Norery Public,S1e12 Of Ndw York No.020AWNS OubIINnainNOSSIMCOW�y r p ZI/eT 30ttd '100dSS30 07N003d V99LLZLTE9T 20%6T 7T6Z/$Z/C0 Board of Trustees3 Application A UTUORIZATYON (where the applicant is not the owner) Y (C... ��tJIVe4. > residing at 4L Av 8 V rt N �A1 L, 1U O�t C. (print owner of property) (mailing address) do hereby authorize (Agent) to apply for pem it(s)from the Southold Board of Town Trustees on my behalf (Owner's signature T/iT bbd 100dSS30 aTN003d bg5LZUZSST gA,'FT bTgT.IRTri,a t form t to vide in -– , MR- And ;i1p,11,111 jV 3222k saw. 7^'n ib 'con 'cts RIO of YOUR NA a. (Ullt Don%fret w=C64?rttlrliC inJtiak tales$y0a are Soateone else or other endty�swh as a cosrt °Rpm id the omoc of Person's or compf4y,$ ) ')`•ftso,italic tlteotltm NAME OF APPLICA7ION: (Check all tbat apply) Tax grievance Variance Building . Change o(Z ,* Trtow Approval of plat ---�— Coastal lwro3tion �� E ption from plat or official reap Mooring _ Planning Gr"Other",narpe the activipr � -) Do you Pets rwry(or through your company.Spottsc,st t+Jittg.lint;or child)!lave a relationship with aey officer or employee OF[hC'lovvll Of'SOUthold? ")tclatioutship"includes by blood,oimriags,or busiacss jntertst."$u intf�reSt's including a partnership,in which the ,off�oer or tr�ploy�has even a (or* mcam ak business, is Which the town oa;cer ar employee owns more than 5°/oftha shares, porsiad awnCaabip al eropJayme,+r by)n corpord&n 11'you snstivcred"YES".complete the halmtce Of WS Corm and dare and sign where iadiae td. Na ine ofpamn employed by the Town oFSouthold Titlo or position of that person brscribe the relationship betwccrt yuursclf(the appllcanVAMT/repre$entative)and the town Either chock officer•or cmplec. the appropriate linc A)through D)and/or describe in the$Paco provided oy The town offiGcr or employee or his or her spouse;sibling',pttrrpt,or child is(cb all T}iaT apply): _A)the owacr ofgnatcr than 5 ortlae shares orrhe corporate stool[ofthe"110atu (when the appocmt is a corporatlonr •`_B)she legal•or beneficial owner of any inwrm in a 004-corporate amity(what th,c' applioantt is not a corporation}; ,C)an of m,dircetor,par'mei,or employee of the upplacante or _�b}the eternal applicant DESCRIPTI0X Ol:RpLAIIONSHIp subntiitxci this day 0 Signature Farm TS 1 Print T�attne Aj zT�zti 3E)ad '1D0dSS30 DINOD3d t7Q��IT�7F4T 1:171'CT «Yn: ins . .,