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HomeMy WebLinkAboutTR-8129 James F.King,President �p��gI1FFat-t-cpG Town Hall,53095 Maui Rd Bob.Ghosio;Jr.,Vice-President P.O.-BOX 11-79- Dave Bergen C4. Southold,NY 11971 . John Bredemeyer Michael J.Domino ��j� p!- Telephone(63I)765-1892 1 Fax(631)765-66.41 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. i INSPECTION SCHEDULE Pre-construction, hay bale line 1 st day of construction constructed Project complete, compliance insp ection pection .- Oe-'♦�, -'-.•. ,� , •♦'r'ri -- .p .. „r�i♦ ,. ,,<r rr�.. yir rrr .�a/f }lJj .: �..n`p 1'4 /}/%jr ,: ..._ V�Q J�j�r-� ,,11 }Ilj� - 'ir�111/ NI%$��..+...•er..m. "�11N1 llj�� .\y1f'f'�'1r}rjr�� H • ??xrr .? s� etter�e2�� surt � sss?a? a�ns,. r �zs z^s — , BOARD OF 5OUTHOLD TOWN TRUSTEES SOUTHOLD,NEW YORK i PERMIT NO. 8129 & 8129C DATE: APRIL 17,20.13 11 `,•f ISSUED TO: RUTH ANN BRAMSON SPOUSAL LIMITED ACCESS TRUST `}�,•,,, PROPERTY ADDRESS: 12042 ROUTE 25, EAST MARION A y ✓ SCTM#31-14-4.5 AUTHORIZATION ' Pursuant to the provisions of Chapter 275 and/or Chapter I I I of the Town Code of the Town of ` „ c Southold and in accordance with the Resolution of the Board of Trustees adopted at the meeting held on AA ril e 17,2013,and inconsideration of application fee in the sum of$500.00 paid by Costello Marine Contracting Corn•or authorized'waiver of Town.Board and;subject to the Terms and Conditions as stated in the Resolution, '�+1 the Southold Town Board of Trustees authorizes and permits the following: Wetland Permit to construct 142 of new retaining wall with 101 return at northeast end; fill void area landward with clean trucked-in fill(approximately 275 +h cubic yards); re-grade area and re-vegetate with native plantings to match existing; existing wood platform and stairs at southwest end to be modified as needed to accommodate new retaining wall; with the condition to establish and,subsequently J maintain a 101 wide non-turf buffer landward of retaining wall; and as depicted on the site plan prepared by Costello Marine Contracting Corp., last dated February 25, 2013, ' and stamped approved on April 17,2013. -' IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed, 1 � and these presents to be subscribed by a majority of the said Board as of this date. - 1 a 'a� AJ♦ � � +bt1 . 'rll li ..i�ili„+�+.'`•-... :-�..'ate.-•�::e,_, .., ..x__~'�.�.::1'+''�:.. �•r.� •r.� ,t "!r../ rv�: - ".E�/,1,,I,H. .e.�µr..w!� - TERMS AND CONDITIONS The Permittee Ruth Ann Bramson Spousal Limited Access Trust residing at 12042 Route 25 East Marion,New York as part of the consideration for the issuance of the Permit does understand and prescribe to the following: l. That the said Board of Trustees and,the Town of Southold are released from any and all damages,or claims for damages, of suits arising directly or indirectly as a result of any operation performed pursuant to this permit,and the said Permittee will,at his or her own expense,defend any and all such suits initiated by third parties,and the said Permittee assumes full liability with respect thereto, to the complete exclusion of the Board of Trustees of the Town of Southold. 2. That this Permit is valid for a period of 24 months,which is considered to be the estimated time required to complete the work involved, but should circumstances warrant,request 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 Permittee wishes to maintain the structure or project involved,to provide evidence to anyone concerned that authorization was originally 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 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 fhe work herein authorized. 6. That there shall be no interference with the right of the public to pass and repass along 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 work herein authorized,or if, in the opinion of the Board of Trustees, the work shall cause unreasonable obstruction to free navigation,the said Permittee will be required, upon due notice,to remove or alter this work project herein stated without expenses to the Town of Southold. ' 8. The Permittee is required to provide evidence that a copy of this Trustee permit has been recorded with the Suffolk County Clerk's Office as a notice covenant and deed restriction to the deed of the subject parcel. Such evidence shall be provided within ninety(90) calendar days of issuance of this permit. 9. That the said Board will be notified by the Permittee of the completion of the work authorized. 10. That the Permittee will obtain all other permits and consents that may be required supplemental to this permit,which may be subject to revoke upon failure to obtain same. James F.King,President *QF S�UTy Town Hall Annex Bob Ghosio,Jr.,Vice-President �O� Ol0 54375 Main Road P.O.Box 1179 Dave Bergen Southold,New York 11971-0959 John Bredemeyer G Michael J.Domino �� �� Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD COASTAL EROSION MANAGEMENT PERMIT COASTAL EROSION PERMIT#8129C Applicant/Agent: Costello Marine Contracting Corp. Permittee: Ruth.Ann Bramson Spousal Limited Access Trust SCTM#: 31-14-4.5 Project Location: 12042 Route 25, East Marion Date of Resolution/Issuance: April 17, 2013 Date of Expiration: April 17, 2015 Reviewed by: Board of Trustees DESCRIPTION OF ACTIVITY: To construct 142' of new retaining wall with 10' return at northeast end; fill void area landward with clean trucked-in fill (approximately 275 cubic yards); re-grade area and re-vegetate with native plantings to match existing; existing wood platform and stairs at southwest end to be modified as needed to accommodate new retaining wall; with the condition to establish and subsequently maintain a 10' wide non-turf buffer landward of retaining wall; and as depicted on the site plan prepared by Costello Marine Contracting Corp., last dated February 25, 2013, and stamped approved on April 17, 2013. INSPECTIONS: Final Inspection SPECIAL CONDITIONS: To establish and subsequently maintain a 10' wide non-turf buffer landward of retaining wall In accordance with Chapter 111-15 Erosion Protection Structures: XX A maintenance agreement is attached hereto and is a necessary special condition of this permit. D BY: James F. King, President Board of Trustees James F.King,President Qr Sol,- Town Hall Annex Bob Ghosio,Jr.,Vice-President 54375 Main Road P.O.Box 1179 Dave Bergen Southold,New York 11971-0959 John Bredemeyer G p Telephone(631)765-1892 Michael J.Domino '� a Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD 30-YEAR MAINTENANCE AGREEMENT EROSION PROTECTION STRUCTURES CHAPTER 111-15 OF THE SOUTHOLD TOWN CODE I (We) Ruth Ann Bramson Spousal Limited Access Trust The owners of record of property at: 12042 Main Road, East Marion, New York SCTM#: 1000-31-14-4.5 in applying for a Coastal Erosion Permit for an erosion protection structure do hereby agree to a 30-Year Maintenance program for a structure as described: to construct 142' of new retaining wall with 10' return at northeast end; fill void area landward with clean trucked-in fill (approximately 275 cubic wards): re-grade area and re-vegetate with native plantings to match existing: with the condition to establish and subsequently maintain a 10'wide non-turf buffer landward of retaining wall, as shown on the attached licensed survey and/or site plan for the approved structure. It is m&ur understanding that we are to maintain this structure with materials designed to endure 30 years and/or equivalent to the original approved structure. Any maintenance which involves more than 50% of the length of this structure requires approval of the Board of Trustees. We further understand that failure to maintain the structure could result in a requirement to post a bond and/or have the repairs ordered as a lien against the property upon a finding by the Board of Trustees that said lack of maintenance would risk life, property or important natural resource features. a Notarized signature" owner of record otary Public Mom`f This maintenance agreement shall only be valid upon the attachment of a licensed land survey/and or site plan made within one year of the original construction and validated to show the final approval of the administrator. tip = =: .. MAR:HA ALTA N f11As'0`-j q � MY COMM f.ISSION DD9-77.84 EXPIRES:Apri101,2014 1a?iit!M::�'DTARY Fl.Notmy MsQwu Asso,.00. James F.King,President �oF Sotjp Town Hall Annex Bob Ghosio,Jr.,Vice-President ,`O Ol0 54375 Main Road P.O.Box 1179 Dave Bergen Southold,New York 11971-0959 John Bredemeyer cn =c G p� Telephone(631) 765-1892 Michael J.Domino '� Fax(631) 765-6641 CoUN m i BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD April 17, 2013 Ms. Jane Costello Costello Marine Contracting Corp. P.O. Box 2124 Greenport, NY 11944 RE: RUTH ANN BRAMSON SPOUSAL LIMITED ACCESS TRUST 12042 ROUTE 25, EAST MARION SCTM# 31-14-4.5 Dear Ms. Costello: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, April 17, 2013 regarding the above matter: WHEREAS, Costello Marine Contracting;Corp. on behalf of RUTH ANN BRAMSON SPOUSAL LIMITED ACCESS TRUST applied to the Southold Town Trustees for a permit under the provisions of Chapter 275 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, and Chapter 111 of the Southold Town Code, Coastal Erosion Hazard Areas, application dated March 25, 2013, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator for their findings and recommendations, and, WHEREAS, the LWRP Coordinator issued a recommendation that the application be found Consistent with the Local Waterfront Revitalization Program policy standards, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on April 17, 2013, at which time all interested persons were given an opportunity to be heard, and, 2 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 275 and Chapter 111 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 have found the application to be Consistent with the Local Waterfront Revitalization Program, and, RESOLVED, that the Board of Trustees approve the application of RUTH ANN BRAMSON SPOUSAL LIMITED ACCESS TRUST to construct 142' of new retaining wall with 10' return at northeast end; fill void area landward with clean trucked-in fill (approximately 275 cubic yards); re-grade area and re-vegetate with native plantings to match existing; existing wood platform and stairs at southwest end to be modified as needed to accommodate new retaining wall; with the condition to establish and subsequently maintain a 10' wide non-turf buffer landward of retaining wall; and as depicted on the site plan prepared by Costello Marine Contracting Corp., last dated February 25, 2013, and stamped approved on April 17, 2013. 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: $0.00 VKy truly yours, James F. King President, Board of Trustees JFK/amn James F. King,President llFFO( Town Hall Annex Bob Ghosio,Jr., Vice-President �� Gy 54375 Route 25,P.O.Box 1179 Dave Bergen y Southold,NY 11971 x John Bredemeyer �y �� Telephone(631)765-1892 Michael J.Domino l � Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: CD Il Mo-y-l'Oe- a `n /CLAk 4 n (3 ahe)S6 (J6u I_ CCeSS 7VUS Please be advised that your application dated 3 2S 13 1 1 has been reviewed by this Board at the regular meeting of 1 and your application has been approved pending the completion of the following items checked off below. Revised Plans for proposed project Pre-Construction Hay Bale Line Inspection Fee ($50.00) 1 st Day of Construction ($50.00) l '/ Constructed ($50.00) ( I Final Inspection Fee ($50.00) Dock Fees ($3.00 per sq. ft.) 30-Year Maintenance Agreement Permit fees are now due. Please make check or money order payable to Town of Southold. The fee is computed below according to the schedule of rates as set forth in Chapter 275 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. You will receive your permit upon completion of the above. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $ BY: James F. King, President Board of Trustees Peter Young,Chairman H Town Hall,53095 Main Rd. Lauren Standish,Secretary P.O.Box 1179 i 'F Southold,NY 11971 Telephone(631)765-1892 Fax(631)765-6641 Conservation Advisory Council Town of Southold At the meeting of the Southold Town Conservation Advisory Council held Wed., April 10, 2013 the following recommendation was made: Moved by Doug Hardy, seconded by John Stein, it was RESOLVED to SUPPORT the application of RUTH ANN BRAMSON SPOUSAL LIMITED ACCESS TRUST to construct 142' of new retaining wall with 10' return at northeast end; fill void area with clean trucked-in fill approx. 275 cy.; regrade area and revegetate with native plantings to match existing; existing wood platform and stairs southwest.end to be modified as needed to accommodate new retaining wall. Located: 12042 Route 35, East Marion. SCTM#31-14-4.5 Inspected by: Jack McGreevy, John Stein, Derek Bossen, Doug Hardy The CAC Supports the application, however, recommends the Trustees identify the exposed pipes. It's the CAC's position that it is bad management practice to have bulkheads that are perpendicular to the littoral transport system. Vote of Council: Ayes: All Motion Carried D E C E � V A 1 5 2 PR 013 jDSouthold Town Board of T;u:a�es i s �b l3 i. �` . . .rfl/. - ,.air • �. �!, r5 _ - ,r...f�.N - _ - . ''�r '� f #�i. y•_ ' '� �.. tit" � �� +�Sol� r � , Ilk ♦ ti. .r . ' 'a wr- •pI�+�/#7 _ � �, �.:r *a?i M .,t,^4. r j it �4, R Y� 5 ,. fr . � .; .i � err� r' ♦ � a•t � � + +.�•� :�'��: + •fF.,�- '!"• - _,jC6wAL .. y. c,•Si... "— Ii�/' �' „ti 1 •�•.Y ,T � i� , .�, 4 'FJ is�T'" -� Y+."'�:f, '+ �� • ..r. . r 1...t' r' � s .1.�s. i�' .f1 -mot ✓3� .r • j '� �' r - 5.\ �,. _Ri�r-a rA;�...1�� •ri.t 0.7`•w +. • Lo!�.�s..=SGdwz� 5ov,+v,fl - . �'o ce y 9�ozr17 . r �='-- � J My � 'IaQ'�6��� • C.C. _ �Ro�ECT 1 ocs►TzoN OR IENT n�•.o ��' � d :��•���i nova ,,. 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CHARLES MOSBACK 4 • A 4 w w 34-14' f 14. -A 1,01(3D UA 147 X X 4 4 74.9 4 to 0. r 1,0 9A S.c. X_LL 112 A A tA 4 143 SOS. 10 / . 0. lip 4 crss, Sid S 0 A 15J %Sig AIL Ott& A \,, • C) X Of Ix SURVEY OF PROPERTY m 4 SITUA TED A T No A. wit EAST MARION j12. X TOWN OF SOUTHOLD 110 SUFFOLK COUNTY, NEW YORK *0 X, 00w 03. S.C. TAX No. J­ 1000-31 - 14-4.4 1000-31 - 14-4.5 SCALE 1 go=20 j I NOVEMBER 3, 1999 15.0 Y .... ........ . ............. S 2 2*27'42" W CER TIFIED 0.92 ROBERT BRAMSON RUTH BRAMSON t3 SJP- AREA DATA / / /, ��r/i /i/ S.C. TAX Me. 23.M.00 sq. 11000-31-14-4.4 0.347 ec. 1�2x X/ S.C. TAX No. 21 ASLINI sq. ft. Ak 1000-31-14-4.5 0.301 ea. M TIE UPI!) TOTAL 45.W" sq. M TIE Lain 1.0" as. V .�D �- E C E V E PREPARED IN ACCORDANCE WITH THE M"SMUM STANMR011 FOR TITLE VJRVEYS AS ESTABLISHED BY THE L. rXW A MAR 2 5 2013 0, .LS. yoo:%X ADOPTED FOR SUCH USE IMTJ STATE .AND Southold'lown 9\A A.I Boar d of Trustees------j 0 X" O 0 11L 66 (0 N.Y.S. Lic. No. 49668 UNAUTHORIZED ALTERATION OR ADDITION JoqG;*1 TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE A, , Ingegno EDUCATION US. COFTS Of THIS SURVEY MAP NOT "ING THE I" "M SURVEYORS SEAL OR Umd Surveyor EMMSSED SEAL SHALL NOT K CONSIDERED TO K A VALID TRUE COPY. CERTMATIONS INDICATED HEREON SMALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY Title Surveys Sub&Wsiww Ske Plans Construction Layout W O ON HMIS KHALF TO THE AND LENDING INSTITUTION LISTED HEREON, AND ASS04EES OF THE u5s om Rfm PHM (516)727-2090 Fax (516)722-5093 TO TUTIOTHEN. CER"WATICINS AM NOT T44AISFER*an- ABLE. OFFICES LOOM AT 94LWG ADDRESS THE EXISTENCE Of NOW Or WAYS =(%M:ff&OFM" One Urjw Square P.O. Box 1931 A"S"W, Now Yak 11931 Mywheed, Now York 11901 r sueFotk James F.King,President P.O.Box 1179 Bob Ghosio,Jr.,Vice-President ;� rd Southold,NY 11971 Dave Bergen ,Q Telephone(631 765-1892 John Bredemeyer ,+, ��„ Fax(631)765-6641 Michael J.Domino Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: 5,1'ly-✓-3 �y Costello Marine Contracting Corp. on behalf of RUTH ANN BRAMSON SPOUSAL LIMITED ACCESS TRUST requests a Wetland Permit and a Coastal Erosion Permit to construct 142' of new retaining wall with 10' return at northeast end; fill void area landward with clean trucked-in fill (approximately 275 cubic yards); re-grade area and re-vegetate with native plantings to match existing; existing wood platform and stairs southwest end to be modified as needed to accommodate new retaining wall. Located: 12042 Route 25, East Marion. SCTM# 31-14-4.5 Type of area to be impacted: �Itwater Wetland Freshwater Wetland Sound Bay Distance of propos d work to edge of wetland / U Part of Town Co proposed work falls under: �hapt.275 Chapt. 111 other Type of Application: "// Wetland _Coastal Erosion _Amendment —Administrative,—Emergency Pre-Submission Violation Info needed: Modifications: wee - OLC ����7`�l''�'rz ✓� f Conditions: /V ;� P nt Were: �J. K�,, B. Ghosio /D. Bergen, J. Bredeme er Michael Domino D. Dzenkowski other y Form filled out in the yeld bye�� Mailed/Faxed to: Date: � � � CC o u BOARD OF SOUTHOLD TOWN TRUSTEES SOUTHOLD,NEW YORK PERMIT NO.7762 & 7762C DATE: APRIL 18,2012 ISSUED TO: RUTH ANN BRAMSON C/O ROBERT BRAMSON ' PROPERTY ADDRESS: 12042 ROUTE 25,EAST MARION ` SCTM#31-144.5 AUTHORIZATION Pursuant to the provisions of Chapter 275 and/or Chapter 111 of the Town Code of the Town of Southold and in accordance with the Resolution of the Board of Trustees adopted at the meeting held on April 18 2012,and in consideration of application fee in the sum of$500.00 paid by Ruth Ann Bramson c/o Robert Bramson and subject to the Terms and Conditions as stated in the Resolution,the Southold Town Board of Trustees authorizes and permits the following: Wetland Permit to remove 44' of existing bulkhead eastern return and construct 50' of new return in-place and provide one level rock armoring at toe of new bulkhead return, approximately 1 ton per linear foot; and as depicted on the site plan prepared by Costello Marine Contracting Corp.,last dated February 23,2012 and stamped approved on April 18,2012. IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date. + w� 1A1 L .� € �1 � ye a �.�' %141� � so , / :. o /. ,�ROpogE�_ 7�MOvE SO'jClYMW12&TAlAZ-,4 S / �� r► /iv_/wA/C.d. WAZWVlMjE 0^001-YWL 01 AQ®GG Z b �� .4jotRed. iYMwr.waa 6.�viR�� .c aer 7m L0^140 S 'TZ: 4.0 PC 7pt�Ts,► ..I,v�v�1Q.aMso�.r Sao 1eo�a'�ar��•t�sON • asavo�,a3ow�raa�a�r csi t t pM 'rN�OIrCa11��, f*A$7 M-dAlON, N Y. //9W SAlfeZr .3 ear 4- Vec"&wrArf/9 i�POW-vrRJOS cc. teas•�• _ �G/QdW itrVCi./OR,?i G'O.C. Ml�/(•c/ vw, smma y` AAALrOA d=c o7"N � 4'Ev=nze OTe: cAsnN�.'D(/��lo �.e�;arG Go M�caTa`ove .dGC�G(OROw.iTiQC To l.� f.,/. a.Free.✓- ' r 7�ttls•t ,4,vry .$�,ti11oN �a ''Ro�s�aT•�Q�1.4fsO�t . L�Ak.�; -saJ T7��rI� I�I.4. O 2//'A **Z o.KiL par Z� '~"'!"'"� rMrwc.wr•. �asT/�.4,aio,./, ^01.y, UgZ9 m pt ilk xrj.ioroo-5i-t4-4.s ON.$4 �E♦s.23�zoo *.c4 `t am-i WWI ' �� / 'i -.. .�' '�_'.�,�'�.1�-�.�y',_�.•.r•,_-.' �_�s':..i'�.:�.� ':�i»=' �94r'� r_r�-w'�.r.'.y�'�~. '.•r��i._•.�?F �- ' Board Of Southold Town Trustees SOUTHOLD, NEW YORK m` PERMIT N0. ....:.4145................ DATE: .....4I..Z9.1.9........... �. ISSUED TO ...........RUTH•••BRAMSON .......... ... ........................................................................ Aut'T4vrt z ai* i ` }`o Pursuant to'the provisions of Chapter 615 of'the Laws of f the State of New York, 1893, and Chapter 444'of the Laws of the. . State of New York 1952; and the Southold 'i own -Ordinance en- 'E .. `' titled "REGULATING AND .THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and theY� . 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 .....4.12.9............. Y 4 I9.........93and.in consideration of the sum. of $ ............................ paid ,II .............................:............................................................ ........................................................................... of ............... N. Y. and Subject thei ' Terms and Conditions listed on the reverse.. side hereof,.• of.Southold Town Trustees authorizes and permits the following: Grandfather Permit to replace bulkhead inkirid/inplace. all in accordance with the detailed specifications as presented' in . f - the originating application. IN WITNESS WHEREOF, The said Board of Trustees hiere= by causes its Corporate. Seal to be affixed, and these presents to be subscribed by a majority of. th said Board as of•this date. s� ...... 3 ......... '`Y ��:� �; �"� .4t�I}a�r'�•..._�'N.. ..�.Jh•r4�`.'.'!:'.",��.. l � ... ......... :. k f g R Ol Trustees -,f� �'� _,>...�r.�,�.`�"�twt�.�..r,'.-�„'-�i,;i..:va�''iw�l''...�^�''a`�"'. w!Wi>�:C�-=# -47'.re-.".r'"a�er..ac.�yi�•.�r s7�_.�.� #`,a' � i,:, .. J , e i IVOR N07p- PO) 176 79 /`/F o . I FOpw `�����;�. l Po ar v F�qm Iaoo-3r-13-loll n PIidof Rd /- A.ff. ParKe r 2r . ® ._ Lucy%/P 084SE. 1f1 5 ' �R .LIL:G0 Pole � 277 rs r aea c h - 140 GrC F"f L I L',-Co POlt'. 2 7 7 S. fero l?S t is kip/ ,.Oce a fi'her by Ikhec d ..�_ dL stre �� . '`6 r t' e r'rtf ^ c. , re A00 °CC cP l �5A/ I<��II�/ I of filly,460 b fps /10 keQ0h GT�Pa. . 1'- /5D C� �'ds. rig P►ceded area. lofa/ /0.7gP A - 272' DlvN �2 y ,Pu-ih /1 h r7 Br"orn sara aos for,, t1g.4 02 fD$ ec TI4Y 4 s _� _... SI'��!,d: SUf-fDL K Taiddtl- FROD f p .ARC • � ys — y ti To Af �Urve a H. GEIDEMAN Oulkkaedd teen NEW Y^RAC We.- �< ea , irr9 - 3ea ch .......... .. , ...... .J. Y• S#ate Lic, L•3n Surveyor. I eA,I . 5 P%/� r Date ., .1. .._ �'.al , --- ram_ ...•. .-�. Board Of Southold Town Trustees _h SOUTHOLD, NEW YORK PERMIT NO. %5a3 S. DAT;?ctober 3.0 2000 + ISSUED TO .........RUTH ANN & ROBERT BRAMSON ........................................................................ ................................................ I r A 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 f State of New York 1952; and the Southold Town Ordinance on. titled ."REGULATING AND THE PLACING OF OBSTRUCTIONS 1 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 2000 1 and in consideration of the sum of paid by Peter E. Bullis for RUTH ANN & ROBERT BRAMSON r' I....... ... of ....•...Marbiehead, .MA..... .......... AXF, and subject to the ............. Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: Wetland Permit for the complete renovation of the -existing house including a porch addition to the south and one-story additions to the east and north, with- the condition that there be ha}r bales during construction an t e top 4.f the bank and thaf there •� all in accordance with the detaid specifications as presented m the origin'664 iipplic6tion: %at• .'F :: .fit r•r� ; i be no than a in the exi ti r e. , IN_WITNESS W9&%b9, The said Board of Trustees here- by'cau`sef'Its"Corpmrafe"Seal•to-b6' effixed,:and'th' �p resents 49 P;-t'. A be subscribedl'by-a majority of the ieid'Board-as-of Ahis:Aafe.o,••: .• '.� :•. r .. ..e.J�fyl.'l:. ., ' . . •7 .. .. 1 iC a lj.yt,.•L..'t1Y 1� � �• � cow ��_ ,:b�' • �� Henry Smith.- Absent T►wseees THE HOUSE ON THE BAY — RENOVATIONS + ADDITIONS for ROMAJ.'. + MRS. goBEIRT BP-.,,,MSON BARBARA ANN NARKSry S 17-39'30" E 1:2040 MAIN ROAD (SR 25) + 1.08 EAST MARiON L.I., NY 11935 it 1:2A C�,C-- Ur Wi�IWIT RW4.- p ELCr-4-ML USE o" -PETER F- -AP BUL-LIS. -CHITFCT 126 FRONT STREET \`•y i \\ P / MA;Z5LEHF-A0 MA 01945 (781) 631-8680 7 .,p 0 PLOT -------------------- %\ .71 PLAN 30' N70E JUGW OFI WAY- • w W 289.92' DATE SEIPTEMBEF- 2000 SCALE V SEE SEC.NQ O]1 s[EffexO OR UK ,& MgTCH U E yO MTAaTCN ee.xo SEE SEC.NO.ORR {� 0}OSW xsxoez C uATcx u MATLH 2 --- - r PCLNO. oaad —�---- FOR PCL xQ rn I 1.7A ,.� O N 'Irk! G-e1m to 1,to tt.t8. Ohs a 4?4P 9w `��P N ,•,A m awm OF lGsou,rlolu �P _ �pP d �� tt.18 i^�' 31 m n ® Bt,OP � M 10 t1P(cl�n �♦ T1P10° 0 y+g.s M1 d1. gj 0-0� py t1.15 116 d1 w �MP�2,cW w0] \3� 4 � x 1.1Nc „� 5 4 .a .5 a}a1m d ^,t,T B 8LHL0`'O ¢� "e zmt n"%n^• x x1 ts4a1 oq(c7. T ° ,3 g ,aR,-oc 4� ° B } t+.1R° m' B B Bd Any P FPS 19.8 3 Ltd§1e�15 \ .(w wdNl 3MAIN q M 4 t6 10.1 F ,1b m 0 Aw B t].� a 5.1 peel +b ' '�19 605 " i. O „12 aOgS m dm d�OF.II� x ° 4n. R 4 T' e• s 26A h� Q¢/: g8f�{I t.OT ,2n 101 ,t p �"d r g`d.•�g" � O'°�2 b ,IA(cl ].BKcI ® O C4,B-0e ,� °M1 � y�lycl �' y3A 04A1c1 s.R O %� ]z5 M1 b 9 ,SBA UFFOUN COUNTY 0ba1,\ R�usT Q- - ✓ w 5 „' 3 g M1 ca b / WATERAl1iHORRY d 5' �• ,$ ® b 7. �I FORPCLNO. C 0 IRRI—I,3 a d 1p a q It ,•., i,J OFECUUTHOID TO 4pP b 9�0 MAR/ON LAKE Be a ae o �'« .+ +b�a� 09� `-0+ '• °M1r .R ,a .,s.sAt=1 °°� o+',�/ 2��y . w S18 O R8 d•• F + a` 2.SAt 1.3 2lA c O a a b+j +Ad a 2B� d z � •zB1 $ T +�A` °o B, dz � ++b "d-0 se �+ d' gT'•�, I ¢�� b+ � a •� + � T. I a 9e M1` _b d ql MARION�LAKE ��e yab 18 FOR PLL NO. x 1A o, d 2 •�R�' d 'p' § +A 4 0 I SEE SEC.N. 1'd P B R.BA OO xaOF SOU'— :aaipeNB B „B dry'°`h ,•B r M 1.>A FORSEC.NO. M1a� , bmn .Ib 1R e N u. N B •„Q�F i u I 03D@-t]0 O 4 `d d•b '• 5` ms�oa2�xrwcirtL q'x'd ,� 1 b yF teo®4�`0 9`+i bsh d 9 k P a%: i � 3 a m A oRAx ya• °,E sd� b a b $+ h+�a,v'o g/' w sFG In ** en•'e an a 0.9$ X x NOTICE DLv;,. COUNTY OF SUFFOLK © E° of SOOT— SECTION NO o..ra..e F.r.e.nnm rtt) _ — Real Property Tax Service Agency v w� E --._ »....d..w , L , T„a°, °3, Eo< 31 N e��u.. eaeus. a m.,•r swo.nu. --,-- re.so.nu.--. — vu 'µ' x• 1a �*'^ xxx*uwrcEurtanax suety �l •� os,weu,oxovAvvwm orvrc,� sOFroucOuxsv,ueun svaa aTao eunl Gnmr wveReaaN p v. a r µl Ru '•�+ rro.nw -- r��0.bx. rsrtvwna w1x0UrvnmFx Fsxu sslwvoFTxE �� acx asx ,AnxO 1000 r-- r — nw�u¢ m 0 m a A Oaa T ���. ,Nm... ..'� __ �_ ,�,.. _ • — aOst FA®Om,ussR✓.uAc[xn. P 0T5 0e w ws PROPERTYMAP Robert Bramson 2/20/l 3 7 MMM 1A iy ig w'- d( -s�4• Y J• iw w M e ! \\ AW y T_""T ,. ,h�4. `' �- M¢r .✓.�a :'~ �"'! '�"� yr. ! ._._ }� � f 1• �1: • +. �r . a �.� •� Y 1 7�.` � t fy�.l • <l .,x >�•, �4!"�.�p � r,;S. �' �I,iy�. 1).�s,,�:r+ ����f i�! T,..�,-' f,•.. i� .6 .�.' * t J.. .a +.?�'�Z-'a".:'` y�R`.�•, ��`,7(:�" '� '.1.*.Lk' f t .�. ��• l't. •r.. ' iuul ti 3 , w. ��'�� ,yy 1./h�(/Jfr _�y�J /IJ,]+(�E °R i}r !" ' nr• � ..v' a. �� ,� F - •M{ `.tl�,l.E;!:l�t ��Y��1 r F! � Y �'� � � 'v. - J .. _. �. '• b' -. OFFICE LOCATION: ��OF SU(/r�,0 MAILING ADDRESS: Town Hall Annex h0 l0 P.O. Box 1179 54375 State Route 25 Southold, NY 11971 (cor.Main Rd. &Youngs Ave.) Southold,NY 11971 G Q Telephone: 631 765-1938 Fax: 631 765-3136 oly'rou LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD MEMORANDUM p ECEHE To: Jim King, President APR 10 2013 Town of Southold Board of Trustees From: Mark Terry, Principal Planner Southold Town LWRP Coordinator Board ofTrustees Date: April 10, 2013 Re: Proposed Wetland Permit and a Coastal Erosion Permit for RUTH ANN BRAMSON SPOUSAL LIMITED ACCESS TRUST SCTM#1000- SCTM#31-14-4.5 Costello Marine Contracting Corp. on behalf of RUTH ANN BRAMSON SPOUSAL LIMITED ACCESS TRUST requests a Wetland Permit and a Coastal Erosion Permit to construct 142' of new retaining wall with 10' return at northeast end; fill void area landward with clean trucked-in fill (approximately 275 cubic yards); re-grade area and re-vegetate with native plantings to match existing; existing wood platform and stairs at southwest end to be modified as needed to accommodate new retaining wall. Located: 12042 Route 25, East Marion. SCTM#31-14-4.5 The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed actions are CONSISTENT with the Policy Standards and therefore CONSISTENT with the LWRP. It is recommended that the Board clarify the dimensions of the stair platform. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Cc: Lori Hulse, Assistant Town Attorney //// Office Use Only oastal Erosion Permit Application Wetland Permit Application Administrative Permit Amen dmen"'rr r/Ext nsion �eceived Application: ceived Fee:$ 1� •I�eSo[uRovn Z 3�ZgD ((� L �/ VCompleted Application ?, 3 D ------ _Incomplete _SEQRA Classification: Type I Type 11 Unlisted MAR 2 5 2013 __. 00rdination:(date sent) WRP Consistency Asse sme t Form .� 3 �AC Referral Sent: ,_ Southold Town _____Date of Inspection: card of Trustees _Receipt of CAC Report: _Lead Agency Determination: Technical Review: Public Hearing Held: Resolution: Name of Applicant RUTH ANN BRAMSON SPOUSAL LIMITED ACCESS TRUST Address 139 A CHARLES STREET,PO BOX 169,BOSTON,MA 02114 Phone Number:(. ) 617.720.5473 Suffolk County Tax Map Number: 1000 - 31-144.5 Property Location:12042 RTE 25,EAST MARION (provide LILCO Pole#, distance to cross streets,and location) AGENT:COSTELLO MARINE CONTRACTING CORP. (If applicable) Address:PO BOX 2124,GREENPORT,NY 11944 Phone:631.477.1199 f�5e'�1 3 Boa of Trustees Application GENERAL DATA Land Area(in square feet): 21,835.99 SQUARE FEET Area Zoning: R40 RESIDENTIAL LOW DENSITY AA Previous use ofproperty:SINGLE FAMILY RESIDENCE Intended use of roe SAME p p rtY= Covenants and Restrictions: Yes X No If"Yes",please provide copy. Does this project require a variance from the Zoning Board of Appeals Yes X No If"Yes",please provide copy of decision. Prior permits/approvals for site improvements: Agency Date Southold Trustees Permit#7762 4/18/12 NYSDEC Permit#14738-00802/00007 12/3/12 Army Corps of Engineers Permit 3/13/12 #NAN-2012-00378-ESP No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? X No Yes If yes,provide explanation: Project Description(use attachments if necessary):Construct 142'of new retaining wall with 10'return at northeast end. Fill void area landward with clean trucked-in fill (approximatley 275 cubic yards). Regrade area and revegetate with native plantings to match existing. Existing wood platform and stairs southwest end to be modified as needed to accommodate new retaining wall. Boa of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: To construct an upper retaining wall to further protect the bluff from erosion during storm surges. Area of wetlands on lot: 0 square feet Percent coverage of lot: 0 % Closest distance between nearest existing structure and upland edge of wetlands: 0 feet Closest distance between nearest proposed structure and upland edge of wetlands: 0 feet Does the project involve excavation or filling? No X Yes If yes,how much material will be excavated? 50 cubic yards How much material will be filled? 275 cubic yards Depth of which material will be removed or deposited: 3 feet Proposed slope throughout the area of operations: 0 Manner in which material will be removed or deposited:A small excavator will be used to backfill the new retaining_wall. 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): There is no vegetative wetlands at the location. All construction debris will be contained and will not be allowed to enter the waterway. We do not expect any adverse effect on the wetlands or tidal waters of the Town. Boa; of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity:To construct an upper retaining to further protect the existing bluff from erosion during storm surges. Are wetlands present within 100 feet of the proposed activity? X No Yes Does the project involve excavation or filling? No X Yes If Yes, how much material will be excavated? 0 (cubic yards) How much material will be filled? 10 (cubic yards) Manner in which material will be removed or deposited: The backfill will be placed by hand. Describe the nature and extent of the environmental impacts to the subject property or neighboring properties reasonably anticipated resulting from implementation of the project as proposed, including erosion increase or adverse effects on natural protective features. (Use attachments if necessary) There are no negative environmental impacts expected by the construction of the upper retaining wall. This shoreline has endured strong storm surges which overtopped the existing bulkhead washing out the area behind it. The bank has a significant amount of erosion and the new retaining wall will give a second layer of protection to the toe of the bluff. 617.20 Appendix C . State,Environmental.Quality'Review SHORT ENVIRONMENTAL ASSESSMENT 'FORM For UNLISTED ACTIONS.Only. PART 1-PROJECT INFORMATION#o be coin ieted b A licant or•.Project S 6r is6r 1. APPLICANT/SPONSOR 2. PROJECT NAME Ruth Ann Bramson Spousal Limited Access Trust UPPER RETAINING WALL 3. PROJECT LOCATION: Municipality SOUTHOLD TOWN,EAST MARION County SUFFOLK 4. PRECISE LOCATION(Street address and road intersections,prominent landmarks;etc.,or.provide map) 12042 ROUTE 25,EAST MARION,NY 11939 SCTM#1000-31-14-4.5 LATILONG: N:4.1.129/w:72.331 5. PROPOSED ACTION IS: Q New Expansion Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: Construct 142'of new retaining wall with 10'return at northeast end. Fill void are landward with clean trucked-in fill(approximately 275 cubic yards). Regrade area and revegetate with native plantings to match existing. Existing wood platform and stairs,on. southwest end to be modified as needed to accommodate new retaining wall:m 7. AMOUNT OF LAND AFFECTED: Initially It acres Ultimately 0 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ❑✓ Yes No If No,describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? 0 Residential ❑ Industrial Commercial Agriculture Park/Forest/Open Space ❑ Other Describe: PRIVATERESIDENTIAL,WATERFRONT'.:.. 10. DOES ACTION INVOLVE A PERMIT APPROVAL;OR FUNDING;NOW OR ULTIMATELY FROM ANY'OTHER GOVERNMENTAL AGENCY' (FEDERAL,STATE OR LOCAL)? Yes No If Yes,list agency(s)name'and permit/approvals: NYSDEC,TOWN OF SOUTHOLD. 11. DOES ANY ASPECT OF THE ACTION HAVE•A CURRENTLY VALID PERMIT OR'APPROVAL? Yes No If Yes,list agency(s)name and pert mit/approvals: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? - Yes•.. .... ✓.No. .: .. .: I CEFPFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor �� � �jJ19s��;J Date: ::-3 � Signature: 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 1 ` Reset PART II- IMPACT ASSESSM[' TO be completed byliiad Agency) i A. DOES ACTION EXCEED ANY TYF'c i i HRESHOLD 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, potentlal 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. Long 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 brietty: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA(CEA)? Yes n go If Yes,explain briefly: E. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes M No if Yes,explain briefly: 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(f)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 If was checked yes,the determination of significance must evaluate the potential impact of 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 FUL 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 action WILL NOT result in any significant adverse environmental impacts AND provide,on attachments as necessary,the reasons supporting this determination Name-of Lead Agency Date Print or Type Name of Responsible Officer In Lead Agency T e.of Responsib a Officer Signature of Me—sponsible Officer in Lead AgencySignature of Preparer.(If different F97M responsible o ,cer) beset` PART[I'- IMPACT ASSESSMENT (To be completed by Lead Agency). A.DOES ACTION EXCEED ANY TYPE t THRESHOLD IN 6 NYCRR,PART 617:4? If yes,coordinate the review process and'use the FULL EAR ❑Yes. Q No e. 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 a 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 pattem;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 sp'edes?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. Long term,short-term.cumulative,or other effects not identified'in C1-05? Explain briefly: C7.•Othe impacts indudin 2 changes in use of either quantity or!ype of every? Explain briefs - - D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA CEA)? Jlf .es,ex lain bdefl : El Yes a No E. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? if .es a lain: a.Yes o No PART JU-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whetherit is substantial,large,important or otherwise significant. Each effect should be assessed in connection with ifs(a)setting(i.e.urban or rural);(b)probability of occurring;(c)duration;(d)irreversibility;(e) geographic scope-,and(f)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 ofsigri ficanoe mustevaluate the potential impactof the proposedaciion an(he environmental characteristics ofthe CEA Check this box if you have identfied one ormore potentially large orsignificantadverse impacts which MAY occur.Then proceed directly to the FU FAF and/or prepare a positive declaration. Check this box Ifyowhave determined,based on the information and analysis above and any supporting documentation,that the proposed aclio WILL NOT result in any significant adverse environmental impacts AND provide,on'attachments as necessary, the reasons supporting IN determination. Board of Trustees Name of Lead Agency Date f r President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Si ature of Responsible 0fficer in Le Agency Signature of Preparer(if different from responsible officer)