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HomeMy WebLinkAboutTR-5839 -. . Board Of Southold Town Trustees SOUTHOLD, NEW YORK b 3 200 Decem ,..DATE: ber. 1................................. PERMIT NO. ... .... ......:. JOHN HURTADO, JR. a s ISSUED TO ...................................................................................... ..... .:x 1 Pursuant to the provisions. of Chapter 615 of the Laws of. the State of New York, 1893; and Chapter 404 of the Laws of the t« 'x State of New York 1952, and the Southold Town Ordinance eh- " j titled ."REGULATING AND THE PLACING OF OBSTRUCTIONS f IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL-OR OTHER MATERIALS FROM LANDS UNDER TOWN-WATERS;' and in accordance with the ' � Resolution of The Board adopted at a meeting held on ....D._...e...c. ..17..._,.. -- 2003: . and in consideration of the sum of ._._30Q.,.QQ....... paid by .................... John Hurtadoa...Jr.�...................... s� it St. James ...... N. Y. and. subject to the of _...... ........................................................... 1 Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: Wetland Permit & Coastal Erosion-Permit to re-shingle the roof s' of the dwelling, replace wood siding with new wood siding, J4 ' replace windows and rebui ld. bluff stairs, and as depicted on ' the survey last dated February 6,. 2003. all in accordance with the detailed specifications as presented in F �. the originating application. " The said Board of Trustees bore- IN- WITNESS WHEREOF, by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date. — . :� trustees TERMS and CONDMfJNS Permittee John Hur.tado Jr. residing21 Astor. St. , St. James, NY 11780 N. Y., as at part of the coosideratioa for the :issuanbe of the Permit does"detstand and prescribe to-the-fol- t lowing: t + 1. That the said Board of Trustees :and the Town of Southold are released from any and i +dl damages, or claims for damages, of suits arising-directly-or indirediy.as a result of any opev ativa performed Pursuant to 'this permit, -and the raid Permits a will, at his of her awn expense, defend any and all such suits-initiated.17-third parties, and the said Pesmittee assumes full Milk with respect thereto, &.the complete rrcduuon of die Board of Tivst�es of the Town of Southold 2. That "•Penmit is'valid_for, a period of 24 _-mos. .which is considered to be;the estimated time'required to complete the•work involved, but;should warrant, Impost:. for an extension may be made to the Board at a later date. 3. That this Permit should be retained indefinitely, or as long as the said Permttee wishes to*maintain the structure or project involved, to provide evidence to anyone concerned that auth orization was originally obtained. 4. That the work-involved will be subject to the inspection and approval of the Board Or its agents, and non-aomplianoe-with.the provisions of the originating application,.may-be cause for revocation of this Permit by resolution of the said Board. 5. That there will be no unreasonable interference with navigation as a result of the work -herein authorized: 6. That there shall be no,interference with the right of the public to pass and n�epass alotag the beach between high and low water marks. 7. That if future operations of the Town of Southold,require the.removal and/or alterations in the location of the wodc herein authorized, or-if, in the opinion of the Board of Trustees, the. y work shall cause unreasonable obstrucaon .to free navigation, the said Permittee will be required, - upon due notice, to remove or alter this work or.project herein stated without expenses to the Town - Of Southold. s. That the said Board will be notified by the Permittee 01 the completion.cf the work auth- orized. I 9. That the Permittee will .obtain all other permits and consents that may be required sup- plemental to this permit which may be subject to revoke upon failure to obtain sane. �OFF01/( Albert J.Krupski,President ��. OG Town Hall James King,Vice-President �� 'y� 53095 Route 25 Artie'Foster cz COD - P.O.Box 1179 Ken Poliwoda Southold,New York 11971-0959 Peggy A. Dickerson y� Telephone(631) 765-1892 •� `� Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0002C Date August 3, 2004 THIS CERTIFIES that the single-family dwelling & bluff stairs At 19725 Soundview Ave. , Southold Suffolk County Tax Map# 51-4-1 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 11/24/03pursuant to which Trustees Permit# 5839 Dated 12/17/03 Was issued, and conforms to all of the requirements and conditions of the applicable provisions of law.The project for which this certificate is being issued is repairs to the existing dwelling and repairs to bluff stairs The certificate is issued to John Hurtado, Jr. owner of the aforesaid property. ��:[� ► i Authorized Signature Albert J.Krupski,'President Town Hall James King,Vice-President - OSQ�F�(/�'.0 53095 Route 25 Artie Foster Off► ��j P.O.Box 1179 'Z' y� Southold,New York 11971-0959 Ken Poliwoda o Peggy A.Dickerson H Z Telephone(631) 765-1892 Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction % constructed �i"Project complete, compliance inspection. Albert J.Krupski,President �,� CD Town Hall James King,Vice-President =�0 GZ� 53095 Route 25 Artie Foster o - P.O.Box 1179 Go Z Southold,New York 11971-0959 Ken Poliwoda Peggy A.Dickerson ij. ��� Telephone(631) 765-1892 Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD December 17, 2003 Mr. John Hurtado, Jr. P.O.Box 2147 St. James,NY 11780 RE: 19725 SOUNDVIEW AVE., SOUTHOLD SCTM#51-4-1 Dear Mr. Hurtado: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, December 17, 2003 regarding the above matter: WHEREAS,JOHN HURTADO,JR. applied to the Southold Town Trustees for a permit under the provisions of Chapter 97 of the Southold Town Code,the.Wetland Ordinance of the Town of Southold, application dated November 24,2003, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on December 17, 2003, at which time all interested persons were given an opportunity to be heard, and, WHEREAS,the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS,the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS,the structure complies with the standards set forth in Chapter 97 of the Southold Town Code, 2 WHEREAS,the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approve the application of JOHN HURTADO,JR.to re-shingle the roof of the dwelling,replace wood siding with new wood siding,replace windows, and re-build bluff stairs, all as depicted on the survey last dated February 6, 2003. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid,if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of$5.00 per inspection. (See attached schedule.) Fees: $5.00 Very truly yours, y� Albert J. Krupski, Jr. President, Board of Trustees AJK/lms SUFFot�r _- Albert J.Krupski,President O�� C� Town Hall James King,Vice-President �.`Z` Dy 53095 Route 25 Artie Foster o P.O.Box 1179 Ken Poliwoda y 2 Southold,New York 11971-0959 Peggy A.Dickerson �ifi� O�� Telephone(631) 765-1892 Q( •�a Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD COASTAL EROSION MANAGEMENT PERMIT Permit#5839 Date: December 17, 2003 SCTM#51-4-1 Name of Applicant/Agent: John Hurtado, Jr. Name of Permittee: John Hurtado,Jr. Address of Permittee: P.O. Box 2147, St. James,NY 11780 Property Located: 19725 Soundview Ave., Southold,NY DESCRIPTION OF ACTIVITY: Re-shingle the roof of the dwelling,replace wood siding with new wood siding, replace windows and rebuild bluff stairs, and as depicted on the survey last dated February 6, 2003. Permit to construct and complete project will expire two years from the date the permit is signed. SPECIAL CONDITIONS: (apply if marked) _Bluff restoration through a re-vegetation plan is a necessary special condition of this permit. _A relocation agreement is attached hereto and is a necessary special condition of this permit. _A maintenance agreement is attached with application and is a necessary special condition of this permit. /J �'. Albert J. Krupski, Jr. President,Board of Trustees AJK/lms Albert J.Krupski,President OSVFFO[�C Town Hall 53 Main Road James King,Vice-President �O OG y� P.O..Box 1179 Henry Smith o Southold,New York 11971 Artie Foster cc �? Ken Poliwoda O Telephone(516)765-1892 y Fax(516)765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: � � !� f�1,L t� C�nL B— --44 Please be advised that your application, dated has be n reviewed by this Board, at the regular meeting of 10 ' 17703 and the following action was taken: ( Application Approved (see below) ( ) Application Denied (see below) ( ) Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees. The fee is 'computed below according to the schedule of rates as set forth in the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION. OF PERMIT FEES: TOTAL FEES DUE: $ a SIGNED: PRESIDENT, BOARD OF TRUSTEES BY: C , BOARD OF TRUSTEES 4/98 o��SUFFDd,��oG Town Hall Telephone 53095 Route 25 H (631)765-1892 ® �fn P.O.Box 1179 col Sao Southold,New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Monday, December 8, 2003, the following recommendation was made: Moved by Don Wilder, seconded by Tom Schlichter, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH STIPULATION of the Wetland Permit and Coastal Erosion Permit applications of JOHN HURTADO, JR. to re-shingle the roof, replace wood siding with new wood siding, replace windows and re-build bluff stairs. Located: 19725 Soundview Ave., Southold. SCTM#51-4-1 The CAC recommends Approval of the applications with the Stipulation the stairs are re- built in-kind and with no treated lumber. Vote of Council: Ayes: All Motion Carried It'll O NOTICE dem COUNTY OF SUFFOL S)UTHOLO SECTION NO r MS ;m room* SOUND R. ISLAND OR— LONG Mm Ss .j L. A w iA- y. !o or Fm P- 0.466il F� (2'1) on NOTI F COUNlY OF SUFFOLK E D SECTION NO Imo. SOUTHOL c y 0 47 %lied Property Tax Service Agency es V.7.� .R ty CmtY M."rheA NY I= D M A 1---------- -Rl- 000 �—I—R.IERIY A- KIL—i Rop_ Y - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - L ONG ISLAND SOUND S 6/'3/'50„E MEAN y/Gy WA TER r DEED • '`I REA 2�/70 NSF 0 w490 //76o /•z• 710 hiioF woop BUCICN ?/ZG�j2 , EAp , CID N , N , M PLAT R M —� — U ti 01 Tlu 45-, wood wALL BGIi�FJ DEcK P[. N q S-7 v o BRicK 0_' PAT/D 3•/'E. cl w 2 12.3. -75.4• "o 32_q 0 0 N --�� - 12.3' Cp�75rAZ- F SToR-0 pLLA/? E�QD W 1— PEE Z M F/�•9 ME ti FRS N GZ/� vu O S' 24.o' 0 9.3' 4/ /3.o� CoNC. � .O 13a' Q ZA �' ~ 0 U Z q 2 /30�v ® O o Q O �I PST Cie0 N �+ W o- ce Z .1 O m p W Q11 Cl o�e V) 22.2' FD. STo,lyo,'J' \ I '�/ fO CovC. ` 94.00' N. 690 13' 40" VIA MON. o-3'S. L11 dZif lao't SOUND VIEW ( 66' WIDE ) A VENUE , $CALF_O Z � , ` v SURVEY OF DESCRIBED PROPERTY AT SOUTHOLD TOWN OF SOUTHOLD, SUFFOLK COUNTY, NEW YORK EASEMENTS AND/OR SUBSURFACE STRUCTURES. GUARANTEED T0: JONN L. NURTADD, J2 RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE THE PREMISES AT P, B,kA J. /1G/R7ADD �. -1,1F TIME OF SURVEY. If TX A4027G'Aa- Co., Z-L.e THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM GRi5E1-/Po/NT MO/17Gf1 G'E THE PROPERTY LINES TO THE STRUCTURES ARE FOR 60MM01VWEAG7fI Z41-ID T/7L,5"/NSU2A,V -5 ; A SPECIFIC PURPOSE AND USE. THEREFORE. THEY ,fOMPAIVY ARE NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES. SURVEYED:ADDITIONAL STRUCTURES OR ANY OTHER IMPROVEMENT. SCALE - / _ - 30' JULY 27, 2002 — pv, NEv TO DATE.'F�l3PlJ4 Q�� Z003 Es H��09 8Y 1-1//1EBZ'441D Z 4,v q S uQ VE OC. CC� E � � � D o 9 SUFFOLK COUNTY TAX MAP i DISTRICT SECT/ON BLOCK LOT NOV 2 4 20J3 <� �� ._; ' �! 1000 51 4 / OF HARRY P. HI L L EBRAND Southold Town Board of 7 stees - LAND SURVEYOR CHURCHILL LANE. SMI THTOWN. NEW YORK ; TEL . (63/) 543-5/39 r ' g Albert J.Krupski,President, ��,4 1IfFOI/C CO Town Hall James King,Vice-President h'Z` G�f� 53095 Route 25 Artie Foster coP.O.Box 1179 Ken Poliwoda Z Southold,New York 11971-0959 Peggy A.Dickerson Telephone(631) 765-1892 Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application ,wOVetland Permit Application Major Minor _Waiver/Amendmen C anus _Received Application: / _iKeceived Fee:$ _,,�eompleted Application (� nn _Incomplete R E C E V _SEQRA Classification: 1_ Type I Type II Unlisted j Coordination:(date sent) NOv 2 4 c,�;i (� SAC Referral Sent: 111A Hate of Inspection: / _Receipt of CAC Report: T— Southold Town Board of Trustees _Lead Agency Determination: Technical Review: _✓Public Hearing Held: Resolution: Name of Applicant J o h h /�V'40tjc) L 0�. Address Qo x L / V -7 ( ..1 l A14-0 r� A KILO-SCi ZXQ Phone Number:(of) -s—e a B I Suffolk County Tax Map Number: 1000- Property Location: Z o v K ���er.✓ d 0e 2 A0 (provide LILCO Pole#, distance to cross streets, and location) Na� AGENT: (If applicable) Address: Phone: Board of Trustees Application GENERAL DATA Land Area(in square feet): Area Zoning: Previous use of property: Sj-At s le Intended use of property: tc Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? Yes If yes, provide explanation: Project Description(use attachments if necessary): Pb - S ' ' tC; ace- woo 0/ el 9lece— wovo� / 'l .4 la .V Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICA�JTION DATA Purpose of the proposed operations: Area of wetlands on lot: square feet Percent coverage of lot: 0 .% Closest distance between n arest existing structure and upland edge of wetlands: feet Closest distance between nearest 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? / cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 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): L/ o/y Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: 4-0 i Mw m ro v 'P, e Z.�S�c`&1G � o&AP, Are wetlands present within 100 feet of the proposed activity? No Yes Does the project involve excavation or filling? \�/ep No Yes If Yes, how much material will be excavated? (cubic yards) How much material will be filled? (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES,TOWN OF SOUTHOLD In the matter of applicant: /f c �./ o hv� l7v/��a of o ✓K . SCTM# /a p O ^-57 YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: pe-oar-e- el A ce 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: 3. That the project which is subject to Environmental RevieX// e Ch ters 32, 37, and/or 97 of the Town Code is open to public comment on: � _ 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. OWNERS NAME: `l o �h L , Yu / -�OJ 0 MAILING ADDRESS: P O . /e z/Y 3 J—a s 8 PHONE#: 3 — SS — r o Enc: Copy of sketch or plan showing proposal for your convenience. 1•4-16-4(2/87)—Text 12 •� PROJECT I.D. NUMBER 617.21 SEC Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I—PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT(SPONSOR f 2. PROJECT NAM ci L . HuP+ad o tT. 3. PROJECT LOCATION: Municipality So O/ County v O K 4. PRECISE LOCATION(Street address and /Jroad intersections,prominent landmarrIks, (etc or provide ma`p) .- / 5. IS PROP D ACTION: New ❑Expansion ❑Modification/alteration 6. DESCRIBE PROJECT BRIEFLY:� r Vtc, TOOT S L �+,5 le 0. S c'mj o�wt /�tiP�4Gtrl�S G✓rr"ICrOH/f. Icl e-c,4­ o" a f 7. AMOUNT O7p�,ANO AFFE cD: Initially �C (j 170 a s Ultimately 6, 7 es B. WILL P.90,PADSED ----tlACTION COMPLY WITH EXISTING ZONING OR OTHER (STING LAND USE RESTRICTIONS? n a No If No,describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? _ esidential Dnaustrial ❑Commercial ❑agriculture i!Park/Forest/Coen space L✓Other(— Describe: 10. DOES ACTIOA INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL, STATE 5 OCAL)? Yes /❑No If yes,list agency(s)�and permit-/approvals /o/P 4 �u i f/Gt i So vT 46 [ & ' " v1 Turf f '/ s 11. DOES ANY ASPECT TOOF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes It yes, list agency name and permit/approval 12. AS A RESULT OF PRQ.I BSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? ❑Yes 9"No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE/IS TRUE T THE BEST OF MY KNOWLEDGE Applicant/sponsor am.. ti L �v ��" ✓TO Date: Signature: LW If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 11/20/03 THL' 15:54 FAX 631 7272605 LAND USE ECOLOGICAL 002/002 PART II- IMPACT ASSESSMENT ,o be corn leted by Lead en A. DOES ACTION"CEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinste the review process and use the FULL EAF.. []Yes ❑ No 9. WILL ACTION RECFIVE COORDINATED REVIEW AS PROVIDED FOR UNLJSTED ACTIONS INS NYCRR,PART 617.6? II'No,o negalve dedaratlon may be superseded by another involved urgency, Yes No C. COULD ACTION RESULT 1N ANY ADVERSE EFFECTS ASSOCIATED WITH THE;FOLLOWING:(Answers may be handwritten,if legible) 01, Existing air quality,surraw or groundwater quality or Quantity,noise levels,eAttng traffic pattern,solid waste productlon or disposal, potential for enorlon,drainage or flooding problems? Explain Wetly: C2.Aesthetic.agrialtural;srdtaeolopinl,historic,or other natural or cultureiliasources;or oommuhriy or neighbaAnood character?Explain briefly. C3.Vegetation or fauna,fish,sht flbsh or wildlife species,styrllEcant habitats,or threatened or endWorW sp%407 F6tpon Briany: C4,A WrrMdNW%ext9ang plans Or 9oai8 es offldaay aA XS or a orange in uea or Int telly of une of land or Other natural reaou Explain CS. GTow1h,subsequent development,or related acdvffl s tA® tq oe IriduW by ft pruposed action? n briefly: C6. Long term,short temi,cumulative,or outer eflbers not ed in C1-05 lain NWy. CT, Other irnalcts Lnclugrji @;enwis In use of e r Wantity orEE of ere Explain b D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABUSHMENT OF A CRITICAL ENVIRONMENTAL AREA CFJ►4 lain brtatr Yes Q No E. IS THERE.OR IS THERE LIKE9.Y TO 9F CONTROVERSY RELATED TO POTENTIALADVERSE ENVIRONMENTAL IMPACTS? I!y.a lain C]Yea L-]No PART 111-13MRMtNATION OF UGPORCANCE(To be completed by Agency) INSTRUCTIONS: For each adverse aifactidentilledabove,determinewhetherAIssubstantial,large.ImpoRantorotherwiseslgnlflcant. Each effect should be assessed In connectlon with its(a)setting(i.e.urban or rursi(b)ptol ablilty of occurring;(a)duration;(d)irm ersibillty;(a) geogreplift scope;and(f)magnitude. If necessary,add attachments or mWenoe supporting materials. Ensure that explana None contaln sufficient detail to show that all relevant adverse impacts have been identMed and adequately addressed. If queston d of part II was checked yes,the determinadonofsignifleancamustevaluate the potential Impact of the proposed 9,mlonon the environmental ehara rteristiesoftheCEA. Chadc this bw 0 you have identified are or more potentially large or signtfeant adverse impacts which MAY occur.Than proceed drecdyto the FULL OAF andior prepare a positive declaration. ChecK this box if you have detsmii led,based on the intonnatien and enalysls above and any supporting documentation,that the proposed actior WILL.NOT result in any signifiearit 4d mrse environmental irVads AND provide, on attachments as necessary,the reasans supporting thi deterrttind6on- Name of Lead Agency ate Mht or j%- me 57 VePrni;115119in 7ea—d KOVEry Title o1 Responsible Officer gnaUire es o Mcer in ea ency ' Nggna re raparer rent from responsible r7— PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK 7 0 y �-�„ }—, 0 t R. ,residing at o2 ( �t-6 !' y� ,�5� '�u e- S, . Q ,being duly sworn, deposes and says that on the day of ,2deponent 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 there 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 ,that said Notices were mailed to each of said pe ons by (certified) (registered)mail. Swom to before me this 7 �� Day of 20 ,03 PAR PA.ZA,CK Notary Public nc�i^1i� J IMI 0`7L'cr c.ZWVro,X '0.©I ZA484'9721 QUaLIFIEp I?I SUFFOLIC COUNTY COPFNUSSIOW EXPIRES JANUAHY 2U, l APPLICANUAGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM 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. �� / YOURNAME: #,/,< DO / O �y L (Last name,first narrre,middle initial,unless you 6re 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 Variance Change of Zone Approval of plat Exemption from plat or official map Other (If"Other",name the activity.) /S o•� !/'�JtS P/�wt� 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 Submitted s ? day of /vo-� 200—3 Signature Print Name L r