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Home My WebLink AboutMattituck F.D. Site Plan App., Applicant Affidavit, Trans. Disclosure FormSOUTHOLD PLANNING BOARD SITE PLAN APPLICATION FORM Site Plan Name and Location Mattituck Fire District Site Plan Name: Upgraded Communications Facility Application Date: 2,1 / 2–biS" Suffolk County Tax Map #1000- 140 - 3 Other SCTM#s Street Address: 100OPike Street Hamlet: —Mattituck Distance to nearest intersection: at intersection with Wickham Avenue Type of Site Plan: New X Amended Residential Zoning District HB- Hamlet Business Owners/Agent Contact Information Please list name, mading address, and phone number for the people below: Property Owner Mattituck Fire District Street PO Box 666 City Mattituck —State NY Zip 11952 Home Telephone Other 631-298-8833 Applicant Same as Owner Street City —State Zip HomeTelephone Other Applicant's Agent or Representative: Contact Person(s)* Re, Nielsen, Huber & Coughlin, LLP Street 36 N. New York Avenue City Huntington State Office Telephone 6314254100 *Unless otherwise requested, corresponds She Plan ApplIcallon !Warns ✓'1812010 NY .Zip 11743 Other will be so nt only to the contact noted here. Proposed construction type: New X Modification of Existing Structure Property total acreage or square footage: 57,052 )oWsq. ft. Site Plain build -out acreage or square footage: 100 M./sq. ft. —Agricultural __Change of use Is there an existing or proposed Sale of Development Rights on the property? Yes . No If Does the parcel(s) meet the Lot Recognition standard in Town Code §290-9 Lot Recognition? YX N If "yes", explain (and attach any necessary documentation – title report, subdivision approval, etc.) — — Building Department Notice of Disapproval Date: /0 /AZ / )� Is an application to the Southold Town Zoning Board of Appeals required? Yes No X If yes, have you submitted an application to the ZBA? Yes No If yes, attach a copy of the application packet. Show all uses proposed and existing. Indicate which building will have which use. If more then one use is proposed per building, indicate square footage of floor area per use. List all existing property uses- Fire District/ Department use, with communications facility List all proposed property uses: Fire District /Department use, with upgraded communications facility Other accessory uses: Existing lot coverage: 25.2 % Proposed lot coverage: 25.3 % Gross floor area of existing structure(s): 14,370 sq. ft. Gross floor area of proposed structure(s): 100 sq- ft - Parking Space Data-. # of existing spaces: 46 # of proposed spaces: 44 Loading Berth: Yes X No Landscaping Details: Existing landscape coverage: 12.8% Proposed landscape coverage: 12.8 % Wetlands: Is this property within 500' of a wetland area? Yes No X Maybe 1, the undersigned, certify that all the above information is true. MaoihwkFire District Signature of Preparer: BLUnA Date: 11122113 Juktl�__d- mawi444 -:L�*doj I - Print Name / Title Site Plan Application 'r. Orly? 211812010 APPLICANT'S AFFIDAVIT STATE OF NEW YORK COUNTY OF SUFFOLK being duly sworn, deposes and says that he resides at c/o 1000 Pike Street, Mattituck, NY 11952 in the State of New York, and that he is the owner of the above property, or that he is the eco rant/ of the Mattituck Fire District (Title) (Specify whether Partnership or Corp.) which is hereby making application; that there are not existing structures or improvements on the land which are not shown on the Site Plan; that the title to the entire parcel, including all rights- of-way, has been clearly established and is shown on said Plan; that no part of the Plan infringes upon any duly filed plan which has not been abandoned both as to lots and as to roads, that he has examined all rules and regulations adopted by the Planning Board for the filing of Site Plans and will comply with same; that the plans submitted, as approved, will not be alter or changed in any manner without the approval of the Planning Board; and that the actual physical improvements will be installed in strict accordance with the plan as approved by the Planning Board. Signed jnL—)l 0 .0. CFWZZ�'_ Mattituck Fire District Signed By: 1W", (Partner or Corporate Officer and Title) Sworn to me this c�Pndday of N CH -m btt— GO 13 A,, U L / � _'e '- Notary Public U EMILY A. WILSON NOTARY PUBLIC -STATE OF NEW YORK No. 01W16286377 Quallfled in Sutfolk County My Commisslon Expire: July 22, 20JI APPLICANT/OWNER TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and emnlovees. The puEgose of this form is to provide information which can alert the town of possibte conflicts of Interest and allow it to take whatever action is necessary to avoid some. YOUR NAME: Mattituck Fire District {Last name, first name, middle initial, unless you are applying In the name of someone else or other entity, such as a company. it so, indicate the other person's or company's name.) TYPE OF APPLICATION: (Check all that apply) Tax grievance Variance Change of Zone Approval of Plat Other (activity) Building Permit Trustee Permit Coastal Erosion Mooring Planning 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. a*A NO vll 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 appiicantlageottrepresentative) and the town officer or employee. Either check the appropriate Iine 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 that S% 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 Submitted this 2.2, day od—l—�O--%a— Signature Print Name Vyc.-ei��_- OFFICE LOCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave,) Southold, NY PLANNING BOARD OFFICE TOWN OF SOUTHOLD MEMORANDUM To: Accounting From: Planning Department Date; January 21, 2015 Re. Checks MAILING ADDRESS: P.O. Box 1179 Southold, NY 11971 Telephone: 631 765-1938 www.southoldtow-nny.gov Please deposit the attached check into B691: Deferred Revenue. Fee is for a Site Plan Application not yet accepted by the Planning Board. Thank you. Project Name & Type Tax Map # Amount Check Date & Number Telecommunications y # 328 Mattituck Fi"................................ . .._ Fire District 1000-140-3- $2,000.00 /21/14 - ons Facilit 11.1 1 Site Plan Application Fee Elite Tower, 1111... -- 11 11...... ---- LP 1.328 Q PNCBANK ELITE TOWERS; LP W 45 GREAT VALLEY PARKWAY, SUITE 333 '3_51310^MALVERN, PA19356 �121� I 14 ORDER OHE FE Town of Squthold $*2,000:00 P i Tft Thousand and MEMO Town of Southold II'00 1 3 2811' 1:0310000531: BP= 21563B6Sill