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NOTICE OF PUBLIC HEARING
SOUTHOLD TOWN BOARD OF APPEALS
WEDNESDAY, AUGUST 18, 1999
NOTICE IS HEREBY GIVEN, pursuant to Section 267 of the Town Law and the Code
of the Town of Southold, the following application will be held for public hearing by
the SOUTHOLD TOWN BOARD OF APPEALS at the Town Hall, 53095 Main Road, Southold,
NY 11971, on WEDNESDAY, AUGUST 18, 1999 at the time noted below (or as soon
thereafter is possible):
7:10 p.m. Appl. No. 4736 - GLENN AND TRACY DAVIS. This is a request for an
Interpretation and/or Determination reversing the July 14, 1999 Notice of Disapproval which
reads as follows:
"...accessory building and structures or other accessory uses shall be located in the
required rear yard proposed project is located on a parcel with road frontage on each
(Fairway Dr.) and on the west (Praity La.). This parcel has two front yards, proposed
placement of the pool is within one of the front yards. Please note: Pool is partially
completed at this time, a permit was issued in error (Building Permit #25835Z) based
on the information supplied with the original application. Subsequent to that time
additional information was received regarding the second front yard."
Alternatively, applicants are requesting a Variance under Article III, Section 100-33 for its
present location at 1450 Fairway Drive, Cutchogue, NY; Parcel #1000-109-5-14.8.
The Board of Appeals will at same time and place hear any and all persons or
representatives desiring to be heard in the above application or to submit written statements
before the hearing is concluded. Each hearing will not. start earlier than designated. Files are
available for review during regular Town Hall business hours (8-4 p.m.). If you have
questions, please do not hesitate to call 765-1809.
Dated: August 9, 1999. BY ORDER OF THE SOUTHOLD
TOWN BOARD OF APPEALS
GERARD P. GOEHRINGER CHAIRMAN
By L. Kowalski
FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
SOUTHOLD, N.Y.
NOTICE OF DISAPPROVAL
DATE; July 14, 1999
TO Glenn & Tracy Davis
PO Box 571
Cutchogue N.Y. 11935
Please take notice that your application dated June 22, 1999
For permit to construct an accessory inground pool at
Location of property 1450 Fairway Drive:Cutchojaue
County Tax Map No. 1000 -Section 109 Blocks Lot 14.8
Subdivision Filed Map # Lot #
Is returned herewith and disapproved on the following grounds pursuant to Article Ill Section 100-33
..In the Agricultural -Conservation District and Low -Density Residential R-80 R-120. R-200 and R-
400 Districts, accessory buildings and structures or other accessory uses shall be located in the require
rear yard.. proposed project is located on a parcel with road frontage on east Fairway Dr.) and on th4
Authorized Signature
Examined... c? 1 ?�:-.Cl ........ 19
Approved.... k(:t': ....., 10.�
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL: 765-1802
Permit No. �` � ..1a�
Disapproveda/c ..................................
(BuildingJr)
A APPLICATION FOR BUILDING PERMIT
f
INSTRUCTIONS
Date ... �r/ ir'�. , 192-7-
a.
91 ..
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector wi
3 sets of plans, accurate plot plan to scale. Fee according to schedule.
,b. Plot plan showing location of lot and of buildings, on premises, relationship to adjoining premises or public
streets or areas, and giving a detailed description of layout of property most be drawn on the diagram which is part of
this application.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d, Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such
permit shall be,kept on the premises available for inspection .throughout the work.
e. No buildingshall be occupied or used in whole or in part for any purpose whatever until a Certificate of
Orcupan y shall bave been granted by the Building Inspector.,
APPLICATION IS BERM MATE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Tam. of Southold, Suffolk Canty,, New York, and other applicable Laws, ordinancesor
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein
described. The applicant s to � "Q �.x "'x
appl• agrees comply with all applicaT3'1�,�.•gtfi�� ,,building code, housing code, and
regulations, and to admit authorized inspectors on premisgsa000'0jgiMltg","fot'4-)ecessary inspections.
To,_.. z ....................
(Signature of applicant, or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
...............4 .............................. .............................................
Name of owner of premises .�T�L'%UfU.. ...�1��' .../?til .............................................
(asonthe tax rollor latest deed)
i+.n
If applicant is a corporation, signature of duly authorized o icer^:, f,�j�
(Name and title of corporate officer)
Builders License No.......''"'
FV a
Plumbers License No . .........................
............
Electricians License No. ....- tt��,��� � 4•
Other Trade's License No. ....................
1. Location of land on which proposed work will be done............. . ; "''
✓��SCJ................'uJFF ..71111 ..................0 7G` flt?1 _
louse Number Street Hamlet
yy
County Tax Map No. 1000 .Section .....11.% Cr....... Block ....'r............ Int .... /tl S-
..........
Sl�bdivision i; -/?t J;J� MS ............. Filed Map No. Zip r4........ lot ....? .........
(Name).. .••..
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy
b. Intended use and occupancy��.'.u�'....:`?'c.Y...e�.���.!!z' _ ... .
BOARD OF
HEALTH ...............
3 SETS OF
PLANS ...............
SURVEY ........................
CHECK .........................
SEPTIC FORM ...................
NOTIFY:
MAIL
TO: ....................
Disapproveda/c ..................................
(BuildingJr)
A APPLICATION FOR BUILDING PERMIT
f
INSTRUCTIONS
Date ... �r/ ir'�. , 192-7-
a.
91 ..
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector wi
3 sets of plans, accurate plot plan to scale. Fee according to schedule.
,b. Plot plan showing location of lot and of buildings, on premises, relationship to adjoining premises or public
streets or areas, and giving a detailed description of layout of property most be drawn on the diagram which is part of
this application.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d, Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such
permit shall be,kept on the premises available for inspection .throughout the work.
e. No buildingshall be occupied or used in whole or in part for any purpose whatever until a Certificate of
Orcupan y shall bave been granted by the Building Inspector.,
APPLICATION IS BERM MATE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Tam. of Southold, Suffolk Canty,, New York, and other applicable Laws, ordinancesor
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein
described. The applicant s to � "Q �.x "'x
appl• agrees comply with all applicaT3'1�,�.•gtfi�� ,,building code, housing code, and
regulations, and to admit authorized inspectors on premisgsa000'0jgiMltg","fot'4-)ecessary inspections.
To,_.. z ....................
(Signature of applicant, or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
...............4 .............................. .............................................
Name of owner of premises .�T�L'%UfU.. ...�1��' .../?til .............................................
(asonthe tax rollor latest deed)
i+.n
If applicant is a corporation, signature of duly authorized o icer^:, f,�j�
(Name and title of corporate officer)
Builders License No.......''"'
FV a
Plumbers License No . .........................
............
Electricians License No. ....- tt��,��� � 4•
Other Trade's License No. ....................
1. Location of land on which proposed work will be done............. . ; "''
✓��SCJ................'uJFF ..71111 ..................0 7G` flt?1 _
louse Number Street Hamlet
yy
County Tax Map No. 1000 .Section .....11.% Cr....... Block ....'r............ Int .... /tl S-
..........
Sl�bdivision i; -/?t J;J� MS ............. Filed Map No. Zip r4........ lot ....? .........
(Name).. .••..
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy
b. Intended use and occupancy��.'.u�'....:`?'c.Y...e�.���.!!z' _ ... .
- h
3. Nature of cork (check whirr appli7-h e): New Building .......... Addition,l.;....... Alteration ...........
Repair ............ Removal ...... ..... Demolition ............ ,OI'luer Wor �...CN i-i:1�4�1? .'x.:�l/-�i ��`t y :.?�•Y•`
C (Description)
S . Estimated Cost ............ fee U t10
(to be paid on filing this application)
If duelling, amber of dwelling units ............ Number of dwelling units on each floor ..........
Ifgarage, number of cars ......................................
If business, coamrcial or mixed occupancy, specify nature and extent of each type of use ......................
r
Dimensions of existing structures, if any: Pront.-77........ Rear .72 ....... Depth..............
Height .,y�.l�................... limber of Stories .. %:. .............
Dimensions of same structure with alterations or additions: Front ............... Rear ...............
Depth .................... Beight .................... truer of Stories ...............
I. Dimensions of entire new construction: Front ................ Rear ............... Depth ..............
Height......................... Nirber of Stories .....................
i. Size of lot: Front Rear ...Ld".S._ � 4...... Depth.a?aje26 ........ t
10. Date of Purchase ..................... Nae of Former Owner ........................................
5i�i c V7iii�
II. Zone or use district in which promises are situated ...��. .._.... .........[� :.1.._. ..�.� .};� �.,......
12. Does. proposed construction violate any zoning lav, ordinance or regulation: .................
13. Will lot be regradedcam............. Will excess .fill be removed from premises:'^ NO
14. Names of Owner of premises4Z1W. 1:..` ...44. .!SAddressC!p..Aione No. 7.
Name of Architect .................................... Address .............................. Pham No.
Nano of Contractor ''17.4> +.� �:`.................. Address
15. Is this property within 300 feet of a tidal wetland? * YES .......... N0 .:y......
*IF YES, SOR1iM 1[IIdN TWS1EE5 PMMT MAY BE REWIRED..
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set -hack dimensions
ram property lines. Give street and block number or description according to deed, :and show street nacos and indicate
khether interior or corner lot.
"IMMEDIATELY" A pROVEU AS KOED
V a.osE pod. ro comm ro a-� 9 B P #
UPON COMPLETION DATE:
BEFORE "MTEW FEE:
(+�+ p p�+�/ (�� NOTIFY BUILDING A TENT AT
765-1802 9 AM TO 4 PM Ol.iCUPA�°1'y�C OR FOLLOWING INSPECTIONS:
FOR THE
USE IS UNLAWFUL 1 FOR POURI POUREDCONCRETE
WITHOUT` CERTIFICATE 3. INSULATION ACING &PLUMBING
OF OCCUPANCY 4. FINAL - CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OF THE N.Y.
UNDERWRITERSGEmicATE STATE CONSTRUCTION & ENERGY
REQUIRED CODES. NOT RESPONSIBLE FOR
TAIL' OF N -1t DESIGN OR CONSTRUCTION ERRORS
SS
....................being duly sworn, deposes and says that he is the applicant
Nam of individual signing contract)
have named,
e is die .......0d ��l! �!/ .................
-.(Contractor, agent, corporate officer, etc.)
f said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
pplicatimi; that all statements contained in this application are true to the best of his knowledge and belief;".and
hat the work will be performed in the manner set forth in the application filed therewith.
worn to before this
....
of 19.
Notary Publ. ....
(Signature :ofApplicant)
{�, a fKewYork
N No. 01GLA8795 S.
ouaBfed in Suffolk C
Coal mnssiom Fires Dec.81
TOWN OF SOUTHOLD, NEW YORK
APPEAL FROM DECISION OF BUILDING INSPECTOR APPEAL v:' li 73}�"�
DATE ..... R.i........
TO THE ZONING BOARD OF APPEALS, TOWN OF SOUTHOLD, N Y
1,(We, tonV" fIgSC 7%9
.. .;��.. b.r.
..........
L Nameof Appellant Street and Number
CG' `.. ....... N .........HEREBY APPEAL TO
......... P ...... .......
Mumci all State
THE ZQN1NG.BOARD OF APPEALS FROM THE DECISION OF THE BUILDINGN�,iSPECTOR ON
ECEfVE,h',
APPLICATION.; FOR PERMIT'NO„ "s.." ... . :: ............... DATED .....s ............................. .........
WHEREBY THE BUILDING INSPECTOR DENIED TO JUL '
.l�evi
,Southold�TownPO�?wt,
°.... :. ...........................t
Name of Applicant for permit } �
of �yOQ F� .rw l;wiCIK1 jatA ("
........ J ...... ....... ... .......
Street and Number Municipolity) State
( ) PERMIT TO USE
( ) PERMIT FOR OCCUPANCY
r— swa° � nQ PUO i 35k35Z ISS d, oC�;
I LOCATION OF THE PROPERTY :ILiS ... ...... ......................
.....
Street Hamlet. / Use. Distract on Zoning' Mop
District 1000 Sectionj()gBliocktj Lot14b Current Owner G1- ver, *- (l�arctc IJ�i�rS
Ma No. Lot No: Prior Owner. LvACt
2. PROVISION (S) OF THE ZONING ORDINANCE APPEALED (Indicate the Article Section, Sub-
section and Paragraph of .the Zoning Ordinance by number. Do not quote the Ordinance.)
Article � Section J00-3
3PE OF APPEAL Appeal is made herewith for (please checkappropriate box)
(
)X VARIANCE to the Zoning Ordinance or Zoning Mop
( ) A VARIANCE due to lack of access (State of New York Town Law Chap. 62 Cons. Lows
Art. 16 Sec. 280A Subsection 3
(
4. 'PREVIOUS APPEAL: A previous appeal (hos) (has not) been made with respect to this decision
of the Building Inspector or with respect to this property.
Such appeal was ( ) request for a special permit
( ) request for a variance
and was made in Appeal No.................................Doted ....................... ......... ...........
REASON FOR APPEAL
Variance to Section 280A Subsection 3
(� ( A Variance to the Zoning Ordinance Ij a i SG-PPYJ✓C,_t
\S✓C�rtj c�+Iovt .,to rx_ rR nor CZ
is requested for the reason that Wt f- G' 6w''dtry r,;. y
C iib L° -S
�L✓ oe�'
Form Q1 CL%yCj ( ontinue on othe si e f v
�k LAS C>`l:-i i1 t, CU_v- b C -G C3 wt O r
J i
1`1 -�'✓ Y? E� T �Jt-� Y�L. IAf.S'L, — x -C.. CA GC,r't-�, .
REASONS FOR AREA VARIANCE ONLY (to be completedby applican
Do not use these standards for "use variance" or "special
exception:," (Also attach sheets if necessary, with signatur
1. An_undesirable change will NOT be produced in the character of
the 1, he or a detriment to nearby properties, if granted
BECAUSE: �l V- Poch is ICS �c r'ea-r" y ,
+ wall b.- er\CAoKe k -Prop } Accu -d nc� iu Codk.
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:
{ ;S jt,+
rr
3. The amount of relief requested is not substantial BECAUSE
pool Lk R be , � `°" I b�d yc-4 r.xa--kk,re; is ria c -cuss 4u i rCJ�( LeI%k-
4. The variance will NOT have an adverse effect or impact on the
physical or:'environmental conditionsin rt^he neighborhood` or district
BECAUSE l is th �Ce�iec� Cz^Co_ a+ , y1 A, �i °~4GR9d�
``� �din� ,�., s �, �(C S+ck,, 'J was i� 11 ii
(� Pro(yi�ac7 0.i �c�Cec� trt Ot,%,r
5. Has the alleged dif iculty een self -c eat d?
( Yes.
No.
6. This is the minimum that isnecessary and adequate, and at the.
same time preserve; and protect the character of the neighborhood and
the health, safety and welfare of the community.
STATE OF NEW YORK)
COUNTY OF SUFFOLK)
Agent must attach written consent from owner.
Sworn to before me this /
txtlk/form.var/temp
day of J-U4V , 191/,
TOWN OF SOUTHOLD PROPERTY,,,R CORD CARD +
OWNER
STREET
VILLAGE
DISTT
SUB.
LOT : 11
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FORMER OWNER
N
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A R
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UCC♦ r2�c(y W lan9 419#
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TYPE OF BUILDING
RES.
SEAS.
VL.
FARM
COMM. CB.
MICS.
Mkt. Value
ry�
LAND'
IMP.
TOTAL
DATE
REMARKS
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CiAy/S#��
�c?�JO�DOD
Tillable
FRONTAGE ON WATER
Woodland
FRONTAGE ON ROAD
-
Meadowland
DEPTH
House Plot
BULKHEAD
--
Totol
COLOR /(1,q ?, ( r2 /)1_.
M
TRIM 17
Bath
y
Dinette
M. Bldg...
S�
LR.
Heat
`
DR.
Extension '
IVYX
BR.
Rooms 2nd Floor
FIN. B
Extension
rivewoy
div.Gr - 9
SMG s/da i/A
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Extension
Foundation
--
Porch
X-� 3` y y Z
; o
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Basement
Porch° `.; r
/0 } /S c ✓ d
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6 p
Ext. Walls
Breezeway
Fire Place _
' Garage
Z �/
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Type Roof —
Patio
Recreation Room
O. B.
Dormer
\ Total
77 Yf
M
TRIM 17
u�L�l\ iL� . , _;r:�;' i ✓✓ 725Y '157 .
Bath
y
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Floors
Interior Finish
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Rooms 1st Floor
BR.
Rooms 2nd Floor
FIN. B
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40' DCI 19,197a FIA
FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Hall
Southold, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
PERMIT NO. 25835 Z Date JUNE 30, 1999
Permission' -.,"is hereby granted to:
GLENN & TRACY DAVIS
PO BOX 571
CUTCHOGUE,NY 11935
for :
CONSTRUCT ACCESSORY INGROUND SWIMMING POOL WITH FENCE TO CODE IN
THE REQUIRED REAR YARD AREA AS APPLIED FOR.
at premises located at 1450 FAIRWAY DR CUTCHOGUE
County Tax Map No. 473889 Section 109 Block 0005 Lot No. 014.008
pursuant,to application dated JUNE 24 99 and approved by the
Building Inspector.
Fee $
150.00
c,v�-cam.
Authorize ignature
COPY
Rev. 2/19/98
OTTICE OT
BOARD OF APPP.CS
Southold7o1vn Hall
53095 Maus Road
Southold, .Ny 11971
765-18og Z13A tel.
765-9064 ZDA telefax.
August 9, 1999.
FACSIMILE TRANSMISSION to 298-3287
ATTN: LEGAL PUBLICATIONS
Upon receiving this request, please return an initialed recei t at the bottom of
this page to our fax at 765-9064.
Please publish the attached Legal Notice in the August 12, 1999 issue. Thank
you.
Very truly yours,
Linda Kowalski
Board Secretary
Attachment (1 page)
Received at Newspaper Office by
:4' � ]R-,�s,z�!'„r•�-s�;¢�.:,�c'3`"�';�.�+�.-wg"C� - - Mrrsaacrnm....�r,erm�wa�r...t�aer:.rcr�`-rwc a
CI -t �;rll•11��*1�
To: Town Clerk Elizabeth A. Neville
From: Jerry Goehringer, ZBA Chairman
Date: 12/06/99
Re: Refund of Appl. No. 4736 (Davis)
`t Pais wconfirm that by Resolution of the Board adopted December 1, 1999, the following
aetiariwas:.aken:
h' the Application of Glenn and Therese Davis for an
:......;SOLVED, that pp
I 'e::rprefation regarding an "as built" pool and Building Permit No. 25935Z, be
returned as requested by the applicant, and the $250 filing fee be refunded.
Please be aware that the Zoning Board of Appeals has not made a
determination as to whether or not a variance or interpretation is necessary, and it is
understood that in the event a variance is deemed necessary, that the same appeal
procedure would apply. Mrs. Davis had requested the refund for the holiday season
and would re -file if it is deemed necessary under the pending Building Permit No.
25935-Z.
The Town Clerk's original filing receipt is enclosed with Mrs. Davis' request
for a refund. Thank you.
cc: Building Department Attn: Ed Forrester
ELIZABETH A. r— ✓ILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 516-765-1800
RECEIVED
RECEIF 074713
�1 DATE 7'— � / 19_Z
44/ ---- $
i
` Glenn and Therese Davis''
Box airway Drive utc 6gue, New York
Phone 325-0203 — Home Phone 734-5779
November 16, 1999
Zoning Board of Appeals
Southold Town Hall
Main Road
Southold, New York 11971
Dear Zoning Board,
NOV 1 9
I would like to withdraw my application with the Zoning Board for a
variance to construct a pool. I would like to have the application fee of
$250.00 refunded to me as soon as possible. I look forward to hearing
from you shortly. Thank you for you attention in this matter.
Sincerely,
Therese Davis
cc: Mr. Brian Murphy
-T7A�-7 L.:7,7CY,-ly
-7WY1,--7
Lf
/C-7
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR, OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
M
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: Southold Town Zoning Board of Appeals
FROM: Elizabeth A. Neville
DATED: July 21, 1999
RE: Zoning Appeal No. 4736 - -Glenn & Therese Davis
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-6145
Telephone (516) 765-1800
Transmitted herewith is Zoning Board Of Appeals Application 4736 - Glenn
& Therese Davis. Also included are Z.B.A. Questionnaire, Notice Of
Disapproval, Application for Building Permit, copy of Building Permit
#25835, copy of Surveys, sketch of pool, copy of Property Record Card
and letter from Therese Davis, dated July 21,1999.
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FORM NO. 3
TOWN_OF SOUTHOLD
BUILDING DEPARTMENT
Town Hall
Southold, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
, COMPLETION OF THE WORK AUTHORIZED)
PERMIT NO. 25835 Z Date JUNE 30, 1999
Permission -is hereby granted to:
GLENN & TRACY DAVIS
'PO BOX 571
CUTCHOGUE,NY 11935
for
CONSTRUCT ACCESSORY INGROUND SWIMMING POOL WITH.FENCE TO CODE IN
THE REQUIRED REAR YARD AREA AS APPLIED FOR.
at premises located at 1450 FAIRWAY DR CUTCHOGUE
County.Tax Map No. 473889 Section 109 Block -0005 Lot No. 014.008
pursuant to application dated JUNE 24 99 and approved by the
Building Inspector.
Fee $
150.00
COPY
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FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Hall
Southold, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PAMISES-UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
PERMIT N0. 25835 Z Date JUNE 30, 1999
Permission is hereby granted to:
GLENN & TRACY DAVIS
EO BOX 571
CUTCHOGUE,NY 11935
for
CONSTRUCT ACCESSORY INGROUND SWIMMING POOL WITH FENCE TO CODE IN
THE REQUIRED REAR YARD AREA AS APPLIED FOR.
at premises located at 1450 FAI----
County Tax Map No. 473889 Section 109
pursuant to application dated JUNE
Building Inspector.
Fee $ 150.00
Y DR CUTCHOGUE
Block 0005 Lot No. 014.008
24 1999 and approved by the
Authoriz d Signature
ORIGINAL
Rev. 2/19/98
APPLICANT
TRANSACTIONAL DISCLOSURE FORH
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.
YOU : )) kv I's f 6–
R NAHE . ( '\R �' Lam. �-- I-Q-Lh
(Last nam4, 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.)
NATURE OF APPLICATION: (Check all that apply.)
Tax grievance �—
Variance
Change of zone
Approval -of plat
Exemption from.plat or official map
Other
(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? "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)
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
noncorporate 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 197 da ofi
. Signature
I
Print name) kR.re-WI)CLUI S
QUESTIONNAIRE
FOR FILING WITH YOUR Z.B.A. APPLICATION
A. Please disclose the names of the owner(s) and any other
individuals (and entities) having a financial interest in the
subject premises and a description of their interests:
(Separate sheet may be attached.)
B. Is the subject premises listed on the real estate market for
;.sal or being shown to prospective buyers? { } Yes
{ 0 No. (If Yes, please attach copy of "conditions" of sale.)
.C. Are there y proposals to change or.Alter land contours?
{ } Yes { No
D. 1. Are there any areas which contain wetland grasses? N c
Z. Are the wetland areas shown on the map submitted with
this application? / y ,
3. Is the property buLkheaded.be. een the wetlands area and
the upland building area? �J()
4. If your property contains wetlands or.pond areas, have
you contacted the Office of the. T wn Trus tees for its
determination of jurisdiction? IVy
E. Is there a depression or sloping elevation near the area of
:proposed ,,coQnstruction at or below five feet above mean sea
level? 1V O. (If not applicable, state "N.A.")
F. Are there any patios, concrete barriers, bulkheads or fences
which exist:an�di are not.shown on the survey map that you.are
submitting? fN 0 If none exist, please state "none.."
G. Do you have any construetrion taking place at this time
concerning your premises?, L S If yes, please submit a copy
of your building permit and map as approved by the Building
Department. If none, please state:
H. Do youo,rr any co-owner also own other land close to this
parcel? If yes, please explain where -or submit copies
of deeds.
I. Please 4st,present use or operations conducted at this
parcel fti and
proposed use
Authorized Signature and Date
3/87, 10/90Ik