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HomeMy WebLinkAboutTR-6101 Albert J.Krupski,President Town Hall James King,Vice-President �QSUFF��/f'C 53095 Route 25 Artie Foster �0 �G P.O.Box 1179 Ken Poliwoda ?� Southold,New York 11971-0959 Peggy A. Dickerson y O 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 1 st day of construction Y2 constructed Project complete, compliance inspection. err - Board Of Southold Town Trustees �• SOUTHOLD, NEW YORK `.`.. April 20, 2005 A PERMIT NO. ... IO..... ........ DATE: ...._............................ e ~ ISSUED TO C&L REALTY . _................................................................................................................................... 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 State of New York 1952; and the Southold Town Ordinance en- ' titled -'`REGULATING AND THE--PLACING.OF:..OBSTRU-j- ISIS. •,� IN AND ON TOWN WATERS AND PUBLIC- LANDS and'-the REMOVAL OF SAND, GRAVEL-OR OTHER MATERIALSrFALOM LANDS _UNDER TOWN-WATERS;'.'• and in accordance with'the A ril' 20, r Resolution of The Board adopted at a meeting held on ......P...:..:... ....... 2005 , and in consideration of the sum of $ 250.00 . paid by I .. b' C&L Realty. _._ ._................................... � Southold N. Y. and. subject to:'the Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and ppermits the following: Wetland Permit to demolish westerly +/-171 'of building and 1construct new exterior wall,and make necessary interior repairs land maintenance.Add sidewalk on west side of building and ' g,and all as depicted on the site pavement for handicap parkin all in accordance with the detailed specifications as presented in •the originating application. plan prepared by Garrett A. Stran dated 'Feb. .23 2005. r IN WITNESS WHEREOF, fhe said Board of trustees here- by causes its Corporate Seal to be affixed, and these presents to be subsmibed by a majority of the said Board as of this date. g�fFO �o Y Artie ster t �• �l�Jl. l�[� - rrrurat i ' TERMS and CONDMQNS � Pern*tft C&L Realty 61600 Main Rd. , - Southold : -.. N. 'Y., As. part•of the consideration fqr the is'suulce of the Permit does understand and prescribe to the fol= 1. That the said Board of Trusters and the Town of Southold are released -from any and sec damages, or eL,&w for damages, of adu arising.dkmdy or Indirectly as a CM* of any open- . adore-pedformed..piresiiati r:_ ►: .permit,.!W-._the paid toee..�a311, !fit,fiis oe lxer own e:pease, Mad,any and all such suitf initiated:by'd4rd rattie s, and the scud Pernuttee assuoda fall Liability with respect thereto, to--tbc-opmplete emdusion of the-Board of Trustees of the Town of Southold. Z. That tiles Betfak ls'valld for a &-dod of 24'. OM whkh is &Wkk*d to be the estimated time'reequired to complete the work involved, tut-ahoald dwarWtsa es Warrant, request for an extension may be made to the Board at a -later drupe: 3. That this Permit should be retained indefinitely, or as long as the :aid Permlatie wishes to•maintain the stmcwre or project involved, to provide evidence to anyone concerned that with- .*&&don was origlnaay obtained. 4. That the work involved will be subject to the inspection and approval of the Board or its agents, and non-compliance with the provisions of the odgitia ft application, auy be cause for i- rtwoauion of this Permit by resolution of the said Board. f S. That there will be no unteasoaable interference with navigation as a result of the work herein authorized. t` 6. That there shall be no interference with the right of the pubic to pass and repass slang the beach between#;sigh and low water marks. 7. That if fumte operations of the Town of Southold tegalre theL removd and/or alterations in the location of the wodc herein-aatliodced, or If, in the opinion of•dlie.Board of Trustees, the wock..shall cause "ar+easomwe obstruction to free navigation, the said Permlaee will be required, upon-due nods,to remove or alter this wodc or project herein sated without vrpewa to the Town ` • of $wthold. 8. Thac the said Board will be notified by the Permlat a of the caompkdon-of the work *a& ; odzed. 9. That the 'Pernittee will detain all other permits and consents dW my be required sap- � elemental to this permit whkh may be subject to revoke; upon failiire to obtain saint:. •' C Albert J.Krupski,President ��oF S0�ryo Town Hall James King,Vice-President ,`O l0 53095 Route 25 Artie Foster P.O.Box 1179 Ken Poliwoda N Southold,New York 11971-0959 Peggy A.Dickerson Telephone(631)765-1892 OUNTY,Nc� Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD April 20, 2005 Mr. Garrett A. Strang 1230 Traveler St. P.O. Box 1412 Southold, NY 11971 RE: C&L REALTY 61600 MAIN RD., SOUTHOLD SCTM#56-5-3.4 Dear Mr. Strang: The Board of Town Trustees took the following action during its regular meeting held on Wed., April 20, 2005 regarding the above matter: WHEREAS, Garrett A. Strang on behalf of C&L REALTY 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 March 17, 2005 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 April 20, 2005, 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, 2 WHEREAS, the structure complies with the standards set forth in Chapter 97 of the Southold Town Code, 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 C&L REALTY to demolish westerly +/-17' of building and construct new exterior wall, and make necessary interior repairs and maintenance. Add sidewalk on west side of building and pavement for handicap parking, and all as depicted on the site plan prepared by Garrett A. Strang dated February 23, 2005. 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$50.00 per inspection. (See attached schedule.) Fees: $50.00 Very truly yours, / Albert J. Krupski, Jr., President Board of Trustees AJ K/I ms SUFFot� Albert J.Krupski, President 0�0 CD Town Hall James King,Vice-President hy` Gy 53095 Route 25 Artie Foster p P.O.Box 1179 Ken Poliwoda Southold,New York 11971-0959 Peggy A. Dickerson � Telephone(631) 765-1892 Fax(631) 7654880-&631 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: 3 �f Please be advised that your application dated has been reviewed by this Board at the regular meeting of ' o-0 6l 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: R !q L4 I OS i7ns(vc-h u,) TOTAL FEES DUE: $ , SIGNED: PRESIDENT, BOARD OF TRUSTEES ��gfilfFO�,��o a�0 Gyp Telephone p Town Hall (631)765-1892 _ W r? 53095 Route 25 P.O.Box 1179 y • �� Southold,New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Mon., April 11, 2005, the following recommendation was made: Moved by Alicia Marin, seconded by Jennifer Mannino, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A CONDITION of the Wetland Permit application of C&L REALTY to demolish westerly +/-17' of building and construct new exterior wall, and make necessary interior repairs and maintenance. Add sidewalk on west side of building and pavement for handicap parking. Located: 61600 Main Rd., Southold. SCTM#56-5-3.4 The CAC recommends Approval of the application with the Condition there are no impervious roads or parking areas within 100' of the water. Vote of Council: Ayes: All Motion Carried e.a,.Qe a s 1 e-xe-O � SEF SEL NO.eRop 12-ol - as-xs-oi �. ti 61 5 ya � - o u 'e ,o. M1s xM1] ' p0• \ ,je e 5 1, 9Gk b0 t1.t kk O ijAld < x03 \n i ,.•MAIN n \\ w \) tpLiO .. ..� '. •"„ to a N)aa\J o a. 1. UA 26sa • a• ..4 ,?M1a a a) 1•° H� O ° °\^"'\ °Nd®¢w r�A �\ \\\\C®\. �.% 17aPlcl \o, a _ ro v a' y 4 1 _sMO" •^ TOWN OF Sal]HttD f l.0itcl ° x.fiam © 12.1 �0 az ae a .e'" O Y �/ .a•. Budd's Pow 28 1D. " 2. b° 14 •.t •'� a„,26 �'� ., '.iS $�5 [xt Y)a\J a 5S s a of• s pa°PP.t, j1.., aJ° _ 35 17''a S sbt,^ O � °•Dr � yr f �� ,T's LI 221a1c, a e r• . \ a sk ,. FOR xe j0 a„ �* V SFE SEL M. -CH 9, SEE SEC.tA.066 _ — N a SECTION NO NOTicE COUNTY F SUFFOLK © SOUTHOLD .a E E (211 — • - - -- e..„..� zz .a,..a.w. sM w�m a Pro Tax Service A enc r Qz ^•� D 9 Y Coin Cen Rlvar[u N Y M1um a�z � "- - '�--=•Se.-_��-•-+-.e.�]---s es ��`3.--.1-"^'3.'�.—�_.�Lii-i=. s--cam. ._��-,—:. i-r'�,...v^. v'.....-,- _ _ -- - _ .a..IJQReciler�IU w LL a *r oS�fFO��-c Albert J. Krupski, President ��. QG Town Hall James King,Vice-President Z y� 53095 Route 25 Artie Foster ti P.O.Box 1179 Ken Poliwoda Southold,New York 11971-0959 Peggy A. Dickerson Telephone (631) 765-1892 Fax(631) 765-1-40 (a(b4 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/ xtens ion Deceived Application: 3 I Deceived Fee:$ p ' completed Application _Incomplete _SEQRA Classification: :ToAii Type I Type 11 Unlisted j Coordination:(date sent) MAR 1 5 1 'CAC Referral Sent: _safe of Inspection: _Receipt of CAC Repo : Soutllo_Lead Agency Determination: Board of Technical Review: iPublic Hearing Held: bs iW Resolution: Name of Applicant L �0/J C_ %y Address fv �, �G`2� / // /'-0. 4a' A 1-:2 5�2 T//o 7-:;::' 7 / Phone Number:( Suffolk County Tax Map Number: 1000 - a —e-:r -- e� 3 , Property Location: Dr 7— of=:�-- "i&- r T_ (provide LILCO Pole#, distance to cross streets, and location) too AGENT: �/►i2� �T��4�u C` �/� (If applicable) Address: / z 3 d 12i­i V e 6 ,9,,z- 4-1 Z JOU ZW :52&-X2 Phone: 7��5��� Board of Trustees Application GENERAL DATA Land Area(in square feet): U j 7g Area Zoning: 12� 1 — Previous use of property: C- Intended use of property: Prior permits/approvals for site improvements: Agency Date !2/ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspende y a governmental agency? No Yes If yes, provide explanation: Project Description(use attachments if necessary): t1 �� �(/!G�✓/n,5 7l ��15 fit JG% ��lit� .r Ttr�i�c p.y �Ati/J /�iri-�T.�-�vAucf. /votes /y�w�c� ef;v Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: C�/'�`«� �i5`��n�ro�. '�j�"o�i✓-ram ��i� �y T��,o -�� �-� /�41 0V Ar C�"V 7-:0-R 7.5 Area of wetlands on lot: square feet Percent coverage of lot: Z % Closest distance between nearest existing structure and upland edge of v Qflftn s: 34 ';v� �5r ` feet $�GKif�1�J Closest distance between nearest proposed structure and upland F ' �'� $` *5`1 feet edge of --�' a��u�. Q fiO�[-uf E7 v Does the project involve excavation or filling? No 1"'xc Yes If yes, how much material will be excavated? 20 cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: 3 feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: 23 G 6 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): pPR 4 2005 t Southold Town PROOF OF MAILING OF NOTICE Board of Trustees ATTACH CERTIFIED MAIL RECEIP Name: Address: SCTM#1000-56-06-2.2 Budd's Pond Marina PO Box 937 Southold, NY 11971 SCTM#1000-56-06-04* Port of Egypt Marine Main Road Southold, NY 11971 SCTM#1000-56-06-12.1 Town of Southold 53095 Main Road PO Box 1179 Southold, NY 11971 SCTM#1000-56-04,05 Mr. and Mrs. Gregory M.Power 1745 N. Parrish Drive Southold,NY 11971 *Port of Egypt is an entity of William Lieblein, applicant. No notice necessary. 4/11/05 I, GARRETT A. STRANG, residing at 1230 Traveler Street, Southold,New York, being duly sworn, deposes and say that: On the/Ah of April, 2005, deponent 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 their respective names; that the address set opposite the name of each person is the address of said person as shown on the current assessment roll of the Town of Southold; that said Notices were mailed at the United States Post Office at Southold, NY, that said Notices were mailed to each of said persons by (certified) (registered) mail. `` ignature Sworn to before me this A-th day of April, 2005. Barbara A. Strang NOTARY PUBLIC, New York No. 4730095 (Notary Public) Qualified - Suffolk County Comm. F pires July 31, _)&w 4 I oo�,��, Albert J.Krupski, President SJFF ��. QG Town Hall James King,Vice-President �� 'f'� 53095 Route 25 Artie Foster y =� P.O.Box 1179 Ken Poliwoda * Southold,New York 11971-0959 Peggy A. Dickerson �' Q� Telephone(631) 765-1892 �Ol `1►a Fax(631) 765-W68 W9J BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD nn BOARD OF TRUSTEES: TOWN OF SOUTHOLD , ® F T E V E In the Matter of the Application ppft 1 4 Z005 of ew ---- - u-F---- �s.IKL --------------------------- Soutljald Toevn COUNTY OF SUFFOLK) Board of Trustees STATE OF NEW YORK) /� �d`� S1_XA AFFIDAVIT OF POSTINGS-1—t6-6-:7 I, &/Zie'n � ��r , residing at jT� / eAyE66 2 being duly sworn, depose and say: That on the fim day of A Pelt , 2005, I personally posted the property known as by placing the-Board of Trustees official poster where it can easily be seen, and that I have checked to be sure the poster has remained in place.for eight days prior to the date of the public hearing. Date of hearing noted thereon to be held . al0, SIOX — on y) a 60u-r T06 M. Dated: /a4— (signature) Sworn to before me this lli 4 day of*&i_ 200 S otary Public Barbara A. Strang NOTARY PUBLIC, New York No. 4180095 Qualified = Suffolk Cqju my Comm. Expires July 31, pC CEo � c MAR 18 2005 Southold Town Board of Trustees LETTER OF AUTHORIZATION RE: Proposed Alterations to Former Albertson Building SCTM#1000-56-06-3.4 I WILLIAM LIEBLEIN AUTHORIZE GARRETT A. STRANG, ARCHITECT TO ACT ON MY BEHALF WHEN MAKING APPLICATION TO THE UNITED STATES OF AMERICA, STATE OF NEW YORK, SUFFOLK COUNTY, TOWN OF SOUTHOLD OR ANY OTHER GOVERNMENTAL AGENCY IN CONNECTION WITH THE ABOVE REFERENCED PROJECT. e WILLIAM LIEBLEIN, SECRETARY C&L CORPORATION Swom to before me thWb-H Day of /-/p-2 ' , 2005 Notary Public State of New York No. 4730099'. Qualified `` Board of Trustees Application County of Suffolk State of New York A. S%2 'Q j 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 IN 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 PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signature SWORN TO BEFORE ME THIS ' 7H DAY OF otary Public Barbara A. Strang NOTARY PUBLIC, New-York No. 4730095 Qualified - Suffolk County Comm. Expires July 31,Zoo= PROJECT ID NUMBER 617.20 SEAR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1.APPLICANT/SPONSOR 2.PROJECT NAME 4 - �.��� c ��G T 3.PROJECT LOCATION: Municipality County 4.PRECISE LOCATION: Street Addess and Road Intersections, Prominent landmarks etc -or provide map 5. IS PROPOSED ACTION: ❑ New ❑Expansion Modification/alteration 6.DESCRIBE PROJECT BRIEFLY: �r,_7/,7 5 eUFS 7 2---" C Co�v 5Tz v�i ��G av �X/��,�_z�a.z.. Gu,o G L � �<✓ l� z-e,e /4.0t--Z-5 1400 �jl��; �v/J L f� C3� GU0-s % O Lc.�/aS 2rca .P 7.AMOUNT OF LAND AFFECTED: Initially I., 2f-q acres Ultimately 7 acres &WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR .OTHER RESTRICTIONS? 1zYes ❑ No If no,describe briefly: 9.WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) ❑Residential ❑Industrial x Commercial El Agriculture ❑Park/Forest/Open Space Other (describe) 17714A //U 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) CYes ❑No If yes, list agency name and permit / approval: 11.DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes 141No If yes, list agency name and permit / approval: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? ❑Yes ❑No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE, Applicant / Sponsor Na Date: Signature If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART 11 - IMPACT ASSESSMENT(To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL EAF. Yes No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration may be superseded by another involved agency. ❑ Yes No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,if legible) C1. Existing air quality,surface or groundwater quality or quantity,noise levels,existing traffic pattern,solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly: C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly: C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly: C4. A community's existing plans or goals as officially adopted,or a change in use or intensity of use of land or other natural resources?Explain briefly: _....... _ ........_... C5. Growth,subsequent development,or related activities likely to be induced by the proposed action?Explain briefly. C6. Lon g term,short term,cumulative,or other effects not identified in C1-05? Explain briefly: ... . . _...... ..................: C7. Other impacts(including changes in use of either quantity or type of energy? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA(CEA)? If es,ex lain briefl : Yes No E.,IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If Xes ex lain: Yes No _..._.. ..........._. .... ...... .. ........ ED PART III-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it is substantial,large,important or otherwise significant. Each effect should be assessed in connection with its(a)setting(i.e.urban or rural);(b)probability of occurring; (c)duration;(d)irreversibility;(e) geographic scope;and (0 magnitude. If necessary,add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes,the determination of significance mustevaluate the potential impactof the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. Check this box if you have determined,based on the information and analysis above and any supporting documentation,that the proposed actin WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer) APPLICANT/AGENT/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. YOUR NAME: (Last name,first name,-middl 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 Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning 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 arcs.' 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 applicantlagent/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 Or RELATIONSHIP Submitted this 17, day of 200-f Signatures Print Name /4—Arr Form TS 1 .7 APR 12 v. 2005 /,A 5r Soo h id Tow S Roard TrIl te., 'X Lj it V-k V It -7 ',I . , 1.7A L2 LLI LU 0 3: Gi LLJ o "T- r LL- J r 0 LL, 0 L z 0 0 T Uj < 1.Al(cl L t4 I,A J SITE DATA Y, tl SITE AREA 81,473 sq. ft. (1.87 acres 3 41 TAX MAP No. 1000—56—OG —3.4 ZONING MARINE 11—(M-11) & FLOOD ZONE AE — 8 (EL. 8) ) ,�� N ? ( �� WATER SUPPLY S U r'7FOLK COUN 1Y VIATER AUTHORITY USE MARINA SERVICES AND HOTEL YL OWNER C&L REALTY INC. x iJ 61600 MAIN ROAD SOUTHOLD, NEW YORK 11971 �3 M <i I>1 o CN To e t- Cr I V-� L-I f-� ) N, N NOTE J:"� U V7 THIS SITE PLAN WAS PREPARED WITH INFORMATION TAKEN FRO'll. A SURVEY MADE 13Y PECW11-- SURVEYORS, P.C. , SOUTHOLD, NEW YORK, DATED: AUGUST 6, 2003; Ar,"iENDED: AUGUST 2e, 2003 AND SEPTEMBER 24, 2003. ED AR TITLE 1�-' (5, A GARREETT A . STRA rm I LOCATION V- 1 40• SCALE REVISED DRAWING N9 1230 Traveler Street Southold N.Y. -11971 17•-,;P t f•t- U r- DATE A- ell r 4Tf OF N01 631 765 5455 DRAWN BY PROJECT N?