Fillable Wetlands Permit Application Submission Checklist INC. VILLAGE OF (Incorporated Village of Sag Harbor)

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Wetlands Permit Application Submission Checklist INC. VILLAGE OF (Incorporated Village of Sag Harbor)

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INC. VILLAGE OF SAG HARBOR CHAPTER 285: WETLANDS
55 MAIN ST. • PO BOX 660
SAG HARBOR, NY 11963
(631) 725-0224
ALL CORRESPONDENCE SUBMITTED TO THE VILLAGE SUBSEQUENT TO THIS
APPLICATION SHALL BE MADE AS (1) ORIGINAL AND (9) COPIES.
Wetlands Permit Application
Submission Checklist
The following items are required submission materials. Information about the submission materials may
be found in the “Detailed Submission Requirements.” Applications will be reviewed by the Village
Consultant before being forwarded to the Harbor Committee.
[A] (1) Original and (9) Copies of the Complete Wetlands Permit Application.
[B] Application Fee: $350.00 Escrow Fees: Residential: $1000.00, Commercial: $5000.00
[C] (10) Copies of an updated Certificate of Occupancy or a deed in the owner’s name.
[D] (1) Original and (9) Copies of the Owner’s Endorsement (if applicant is not the owner), signed &
notarized by the owner or authorized representative of the owner corporation.
[E] (1) Original and (9) Copies of the Authorization & Consent for Inspection of Property Form.
[F] (1) Original and (9) Copies of the Disclosure Affidavit.
[G] (1) Original and (9) Copies of a detailed, written project narrative.
[H] (1) Original and (9) Copies of the completed Coastal Assessment Form, if applicable.
• See Item G in the Detailed Submission Requirements for a list of when this is necessary.
[I] (10) sets of recent, dated color photographs of the project site, showing the general characteristics
of the property and the location where construction or other activities are proposed.
[J] (10) copies of all other applicable permits. Provide copies of BOTH the issued permit AND the
stamped-approved plan from that agency.
• May include NYSDEC, US Army Corps of Engineers, Southampton Town Board of
Trustees, and/or Suffolk County Department of Health Services.
[K] (1) Original and (9) Copies of the survey prepared and sealed by a NYS licensed land surveyor at
a minimum scale of 1” = 30’ (one inch equals thirty feet), or a scale appropriate to allow for
review of the proposed work.
• See the Item J Detailed Submission Requirements for required survey information.
[L] (1) Original and (9) Copies of the site plan showing the proposed conditions, at a minimum scale
of 1” = 30’, or a scale appropriate to allow for review of the proposed work.
• The site plan may be included on the abovementioned survey, or included separately. If
included separately, an existing conditions survey is still required.
• Other plans may also be required depending on the type of application. See Item K in
Detailed Submission Requirements for required site plan information
[M] Other Information, as necessary, if the project cannot meet the setback requirements of §285-9(A)
or §285-9(E). See Item L in the Detailed Submission Requirements. (1) Original and (9) Copies
of each document must be submitted. Describe other submitted items below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
INC. VILLAGE OF SAG HARBOR CHAPTER 285: WETLANDS
55 MAIN ST. • PO BOX 660
SAG HARBOR, NY 11963
(631) 725-0224
- 1 -
Wetlands Permit Application
Detailed Submission Requirements
An application fee and the following materials must be submitted to form a complete application
submission:
One (1) original and Nine (9) photocopies of the following:
A. The completed Wetlands Permit Application.
B. An updated Certificate of Occupancy or a deed in the owner’s name.
C. Owner’s Endorsement (if applicant is not the owner), signed & notarized by the
owner or authorized representative of the owner corporation.
D. Authorization & Consent for Inspection of Property Form.
E. Disclosure Affidavit.
F. A detailed written narrative describing the specifics of the proposed project.
G. The completed Coastal Assessment Form
1
, but only if the proposed project:
(1) Includes any of the items listed as a Type I Action under 6 NYCRR 617, the State
Environmental Quality Review Act (SEQRA) or Village Code Chapter 125,
Environmental Quality Review, even if another part of the project may be a Type
II Action; or
(2) Is strictly an Unlisted Action under SEQRA or Chapter 125; or
(3) Includes the construction or reconstruction of any dock, pier, wharf, or similar
structure; or
(4) Includes any work involving erosion control structures, including any and all
bulkheads, revetments, seawalls, gabions, riprap, breakwaters, groins, jetties, or
any other man-made fabrication or device (including those made of geotextile
tubes or sandbags) which is designed to reduce or prevent erosion; or
(5) Includes any other action that would require a permit from the US Army Corps of
Engineers is required.
H. Recent, dated color photographs of the project site, showing the general
characteristics of the property and the location where construction or other
activities are proposed.
I. Copies of any other permits or approvals have already been secured for the
proposed project from other agencies—NYSDEC, US Army Corps of Engineers,
Southampton Town Board of Trustees, and (if available) Suffolk County
Department of Health Services. Provide copies of BOTH the issued permit AND the
stamped-approved plan from that agency.
1
No Coastal Assessment Form will be required for any single family residence (new construction, addition, or
otherwise), unless the project also includes any of items listed under Letter G.
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Submission Requirements
- 2 -
J. Survey prepared and sealed by a NYS licensed land surveyor at a minimum scale of
1” = 30’ (one inch equals thirty feet), or a scale appropriate to allow for review of
the existing conditions and/or proposed work. The survey must provide the
following information:
(1) Basic legal data, including: current owner of record, date, north arrow, property
lines, existing lot area, adjacent streets and curblines, adjacent land ownership,
and existing zoning.
(2) Any and all easements, covenants, restrictions or other encumbrances that may
affect development on property.
(3) Topography throughout the property at 2 ft. contour intervals, referenced to the
elevation datum NAVD 1988.
(4) Landward limit of the wetlands boundary, established by field flagging by
qualified environmental consultant. Wetlands flags must be located by a licensed
surveyor. The boundary and flags must be labeled with: (a) the name of the
person or company that flagged it; and (b) the date of the wetlands flagging. Said
date should be within 2 years of submission of the Wetlands Permit Application.
(5) Crest of bluff (if applicable) established through field identification/flagging of
topographic conditions establishing the crest of the bluff.
(6) Location of Average High Water Line (AHW). (For dock applications, water
depths within the area of the proposed dock referenced to Average Low Water
(ALW)).
(7) Location of all existing structures, including (but not limited to) principal and
accessory buildings and structures, patios, decks, swimming pools and pool
equipment, fences, walls, bulkheads, docks, revetments, driveways, walkways,
etc.
(8) The setback of the existing buildings and structures from the flagged wetlands
boundary and/or the bluff crest.
(9) FEMA flood plain boundary lines and FEMA designations.
(10) FEMA first floor elevation of existing structures.
(11) Test hole meeting SCDHS requirements demonstrating soil conditions and depth
to groundwater table (if applicable). The location and data for the test hole should
be provided.
(12) Location of existing water supply and sanitary systems.
(13) Location of any existing drainage control structures on the property.
(14) Edge of existing lawn and landscaping, delineating that area on the property that
is in a natural (not landscaped or developed) condition.
(15) Footprints of structures on any adjacent properties. Adjacent properties are those
with property lines that touch the property lines of the subject property.
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Submission Requirements
- 3 -
K. A site plan showing the proposed conditions, at a minimum scale of 1” = 30’, or a
scale appropriate to allow for review of the proposed work. The site plan may be
included on the abovementioned survey, or included separately. If included
separately, an existing conditions survey is still required. The following is a list of
information that may be required, depending on the proposed project:
(1) All proposed structures. By way of illustration and not limitation, this could
include buildings; patios; decks; retaining walls; driveways (indicate whether
pervious or impervious); walkways; fences; catwalks; docks; septic system;
drainage control structures; pool equipment; pool drywell; generator; and the like,
etc.
(2) Indicate the proposed setback (in feet) from the nearest wetlands line and/or crest
of bluff for all proposed structures. This will differ based on the proposed project,
but may include (but would not be limited to) any proposed house, addition,
accessory building or structure, sanitary system, or ground disturbance.
(3) Proposed lot coverage and compliance to provisions of Village Code, Chapter
300, Zoning.
(4) Clearly label any and all buildings and/or structures that are to be demolished
and/or removed from the property.
(5) Proposed contours of fill or site grading, along with cut and/or fill volumes,
whose calculations to be prepared by NYS licensed surveyor, engineer and/or
landscape architect.
(6) Proposed sanitary system in plan view and cross-section demonstrating
conformance with groundwater separation requirements.
(7) Location of proposed drainage control structures along with the requisite
calculations and specifications demonstrating a minimum storage capacity of 2"
from all impervious surfaces.
(8) Limit of clearing of natural/native vegetation.
(9) Project Limiting Fence and Siltation Control: Location of proposed project
limiting fencing and proposed siltation control, along with specifications of the
proposed fence materials. The area (measured in square feet) to be bounded by the
project limiting fence should also be provided.
(10) For proposed retaining walls: Location of walls on plan view including top of
wall and bottom of wall elevations, cross-section details of construction, and
material to be used for wall construction. (Note: Setback from property line is
encouraged to allow for construction and landscape screening.)
(11) For swimming pools: Swimming pool shown on site plan, along with associated
patios and decks. Location and type of pool equipment proposed along with pool
enclosure fencing shall be shown. Swimming pool cross-section to be provided to
demonstrate bottom of pool structure in relation to groundwater table. Location of
swimming pool drywell.
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Submission Requirements
- 4 -
(12) Area of any proposed natural vegetated buffer in compliance with §285-9(A) to
be shown on the site plan. Where applicable, a separate buffer planting plan
should be provided, which shows specific locations, quantities, sizes/spacing and
common and scientific names of plants. It is noted that native coastal plant
materials should be sufficiently sized to ensure that once planted, the buffer zone
will be established within two years.
(13) For dock applications, plan view of the proposed construction, along with cross-
section of the dock and any associated catwalk, etc. The plan shall show the water
depths at average mean low water. Cross-sectional plans and details/specifications
for dock construction shall be provided. Note: Village of Sag Harbor encourages
the use of untreated dock materials for construction within the waters and
wetlands of the Village of Sag Harbor.
(14) Location and type of lighting to be located on coastal waterfront portion of the
property.
L. For those projects which cannot meet the setback requirements of §285-9(A) or
§285-9(E), the applicant shall submit:
(1) A plan showing proposed construction and setback lines from natural features
(wetlands, bluffs, etc.) as well as applicable zoning setback lines for the property.
(2) Information as required under §§285-9(D)(2) & (3) allowing for a practicable
alternatives analysis.
(3) Additional written narrative describing why proposed project requires relief and
why that is the minimum relief necessary.
(4) Listing of any proposed mitigation measures incorporated into the project.
NOTE: The Harbor Committee reserves the right on a project-specific basis to require
additional information, as needed.
INC. VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
55 MAIN ST. • PO BOX 660 CHAPTER 285: WETLANDS
SAG HARBOR, NY 11963
(631) 725-0224
- 1 -
APPLICANT NAME:
_________________________________________
STREET ADDRESS OF PROPOSED PROJECT:
_________________________________________
SUFFOLK COUNTY TAX MAP NUMBER:
_________ – _________ – _________– _________
FOR OFFICIAL USE ONLY:
RECEIVED: __________________________
PERMIT FEE: _________________________
FEE PAID: ___________________________
PERMIT NO.: _________________________
DATE ISSUED: ______/______/______
A. CONTACT INFORMATION (Please print or type answers. Check off who should receive correspondence.)
Applicant: _______________________________________________________________________
Mailing Address: _________________________________________________________________
Telephone Number: ( ) ______________ Email Address: ___________________________
Applicant is the: ____ Owner ____ Lessee ____ Contract Vendee
Owner(s) (if not applicant): _________________________________________________________
Mailing Address: _________________________________________________________________
Telephone Number: ( ) ______________ Email Address: ___________________________
If applicant or owner is a corporation, give name, title & contact information for corporation offices.
Applicant Corporate Officer
Name: _____________________________________
Address: ___________________________________
Telephone Number: ( ) ___________________
Property Corporate Officer
Name: ____________________________________
Address: ___________________________________
Telephone Number: ( ) ___________________
Agent (if applicable): ______________________________________________________________
Mailing Address: _________________________________________________________________
Telephone Number: ( ) ______________ Email Address: ___________________________
Attorney (if applicable): ____________________________________________________________
Mailing Address: _________________________________________________________________
Telephone Number: ( ) ______________ Email Address: ___________________________
Anyone filing an application who is not the property owner must also submit an original copy
of the Owner’s Endorsement form (included with this application), signed & notarized by the
owner or authorized representative of the owner corporation.
Surveyor: _______________________________________________________________________
Mailing Address: _________________________________________________________________
Telephone Number: ( ) ______________ Email Address: ___________________________
License Number: _______________________
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Section B: Proposed Activities
- 2 -
B. PROPOSED ACTIVITIES
1) Review the list below and check all activities that are included in the proposed project.
New
Residential
Building
New
Commercial
Building
Addition:
No Increase in
Footprint
Interior
Alteration
Renovate
Existing
Building
Reconstruct
Building
Swimming Pool. If checked, provide Cross Section for pool depth relative to groundwater elevation
Deck, Patio and/or Terrace. If checked, is the structure less than 12” above grade? Yes No
Fence: If checked, provide: Height (ft.) _______ Total Length (ft.) _______ Material ____________
Retaining Wall. If checked, is the retaining wall necessary for the septic system? Yes No
Other Accessory Building or Structure. If checked, list all proposed: ________________________
__________________________________________________________________________________
Demolition. If checked, specify what is being demolished & specify on site plan: _________________
__________________________________________________________________________________
New, Upgraded, or Expanded Private Septic System.
Placement of Fill. If checked, answer the questions below:
• Total Volume of Fill __________ cu. yds.
• Type & Purpose of Fill (Specify if fill will be used for septic & provide volume for septic fill): ________
________________________________________________________________________________
Excavation. If checked, specify: Maximum Depth (ft.) __________________________________
Avg. Existing Grade Elevation (NAVD 1988)_______________
Purpose of Excavation _________________________________
Dewatering. If checked, provide details of dewatering in separate written narrative.
Clearing of Vegetation. If checked, indicate limits of disturbance on site plan & provide area below:
• Area to be Cleared _____________ sq. ft.
• List Type(s) of Vegetation to be Cleared: ___________________________________________
Planting New Vegetation. If checked, provide a planting plan that shows types of proposed plants (with
common & scientific names), and the specific location, quantities, and sizes/spacing of those plants.
Dock. If checked, address §285-9(E)(3) and 285-9(F) in a separate written narrative.
Any work involving Erosion Control Structures (see definition under §285-3), including construction,
placement, installation, repair, reconstruction, replacement, or alteration. If checked, address §285-
9(E)(2) in separate written narrative.
Dredging. If checked, describe purpose in Question 3 below, or in a separate written narrative.
New Outdoor Lighting. If checked, address §285-9(G) in separate written narrative.
Other Activities Not Listed. If checked, describe other proposed activities in Question 3 below.
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Section B: Proposed Activities
- 3 -
2) What resource(s) may be affected by proposed activities? (Both may apply & should be indicated on
the submitted survey) Wetlands Bluff
3) Describe the proposed activities below or in a separate written narrative. (Be sure to include the
dimensions (area, length, or volume) of each proposed structure, and the setback of all proposed
activities to the wetland boundaries and property lines, if applicable.)
(If separate narrative is provided, please indicate below.)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4) Do the proposed activities comply with the Wetland Setbacks (buffer zones) required under
§285-9(A) and/or the Bluff Setbacks required under §285-9(E)(1)? ______Yes ____ No
If the answer to this question is “No,” the applicant is required to demonstrate that no practicable
alternatives exist for the proposed project. Refer to §§285-9(D)(2) & (3) for more information
on how this needs to be addressed to fulfill minimum application requirements.
5) Lot Area: _______________ sq. ft.
6) Complete the table below based on existing and proposed conditions.
Areas should add up to Lot Area provided in Question 5.
Land Use or Covertype
Existing Areas
(sq. ft.)
Proposed Areas
(sq. ft.)
Proposed Change
(sq. ft. +/–)
Buildings (Lot Coverage)
Other Impervious Surfaces
Non-Vegetated
(bare rock, earth, fill, pervious driveway)
Lawn
Meadows, Grasslands, Brushlands
Forested
Surface Water Features
(lakes, ponds, streams, etc.)
Wetlands (freshwater or tidal)
Other (describe) ___________________________
_________________________________________
7) Will the project exceed 300 gallons of water use per day? _____Yes _____No
• Approximate Water Use Per Day: ________________ gallons per day
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Section C: Zoning, Planning & Permitting Information
- 4 -
C. PROPERTY ZONING, PLANNING & PERMITTING INFORMATION
1) Zoning District: _____________
2) FEMA Flood Zone(s): _____________________________________
3) Suffolk County Groundwater Management Zone: ______________
4) Is the property in the Historic Overlay District? _____Yes _____No
5) Is the property in a Village Sewer District (see Village Code §220-1.3)? ____Yes _____No
6) Is the property connected to public water? ____Yes _____No _____N/A
7) Is the property part of a subdivision? _____Yes _____No
If Yes, provide the name of the subdivision and the lot number(s) of the property in that subdivision.
• Subdivision Name: _______________________________
• Lot Number(s): ______________
8) If there are any right-of-ways, easements, restrictive covenants, or other encumbrances on the
property, list what encumbrances exist and provide copies with your application.
If not, just write N/A
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9) Have any wetlands permits ever been issued by the Village in the past? If so, provide the date
of the permit and the name of the person that the permit was issued to. If not, just write N/A
10) Check off whether approval is required any of the below agencies.
If possible, indicate the applicable Reference Number, Approval or Filing Date. If approvals have already
been secured, provide copies of the permit AND the stamped-approved plans.
Agency
Reference Number
Approval or Filing Date
NYS Dept. of Environmental Conservation
(including Letter of Non-Jurisdiction)
Suffolk County Dept. of Health Services
NYS Dept. of State
US Army Corps of Engineers
Southampton Town Trustees
Other (specify) ___________________________
________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Section D: Site Characteristics
D. SITE CHARACTERISTICS
1) Predominant Soil Type: _______________________________________________
2) Depth to Groundwater: _____________ ft.
• Groundwater depth should be based on recent on-site test hole data. Location of test hole must be shown
on survey. Test hole data will be required for certain types of projects including, but are not limited to,
swimming pools, new septic systems, houses with basements, and any excavation.
3) Approximately What Percentage of the Property is:
• Well Drained: __________ %
• Moderately Drained: __________ %
• Poorly Drained: __________ %
4) Does the property contain any species of plant or animal life listed as rare, threatened or
endangered by the New York State, the New York State Natural Heritage Program, to the
United States of America? _____ Yes _____ No
• If yes, please identify each species and its status as classified by New York State, the New York State
Natural Heritage Program, to the United States.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
STATE OF _________________________ }
} ss.:
COUNTY OF _______________________ }
________________________________________________ (applicant print name) being duly sworn, deposes and says that
he or she is the owner or authorized agent for of the property described in the foregoing application, and that all information
provided on this form and in all attachments submitted herewith are true to the best of his or her knowledge and belief.
The undersigned hereby hold harmless and indemnify the Incorporated Village of Sag Harbor, including its agencies,
officials and employees, against any claim, cost or expense, including attorney fees, by reason of their reliance upon this
authorization.
____________________________________
Signature of Applicant
Sworn to me this _____ day of_________________, 20____
____________________________________
Notary Public
INC. VILLAGE OF SAG HARBOR
55 MAIN ST. • PO BOX 660
SAG HARBOR, NY 11963
P: (631) 725-0222 • F: (631) 725-0316
OWNER’S ENDORSEMENT
To Be Signed If Applicant Is Not The Owner
If there are multiple owners, each owner must prepare an endorsement.
STATE OF ____________________ }
} ss.:
COUNTY OF __________________ }
_________________________________________, being duly sworn, deposes and says:
I am the (check one) [ Owner in fee | Officer of the Corporation which is the owner in fee ] of the
premises located at __________________________________ with the SCTM#: _____-_____-_____-_____
and described in the foregoing; and that I have authorized _________________________________________
to make the foregoing application as described herein.
The undersigned hereby hold harmless and indemnify the Incorporated Village of Sag Harbor, including its
agencies, officials and employees, against any claim, cost or expense, including attorney fees, by reason of
their reliance upon this authorization.
Signed: _____________________________________
Print Name: __________________________________
____________________________________________
If Corporation, name of Corporation
_____________________________________
Title of Corporation Officer that is Signing
Sworn to me this _____ day of_________________, 20____
____________________________________
Notary Public
INC. VILLAGE OF SAG HARBOR
55 MAIN ST. • PO BOX 660
SAG HARBOR, NY 11963
P: (631) 725-0222 • F: (631) 725-0316
AUTHORIZATION AND CONSENT FOR INSPECTION OF PROPERTY
By signing this permission form for submission with an application for a permit(s) to the
Incorporated Village of Sag Harbor, the signer consents to inspection by Village Board
Members, staff, and/or consultants of the project site or facility for which a permit is sought.
This consent allows Village Board Members, staff, and/or consultants to enter upon and pass
through such property in order to inspect the project site or facility without prior notice.
Inspections may take place as part of the application review prior to a decision to grant or
deny the permit(s) sought. By signing this consent form, the signer agrees that this consent
remains in effect as long as the application is pending, and is effective regardless of whether
the signer, applicant or an agent is present at the time of the inspection. In the event that the
project site or facility is posted with any form of "posted" or "keep out" notices, or fenced in
with an unlocked gate, this permission form authorizes Village Board Members, staff, and/or
consultants to disregard such notices or unlocked gates at the time of inspection.
The signer further agrees that during an inspection, Village Board Members, staff, and/or
consultants may, among other things, take measurements, may analyze physical
characteristics of the site including, but not limited to, soils and vegetation (taking samples
for analysis), and may make drawings and take photographs.
Failure to grant consent for an inspection is grounds for, and may result in, denial of the
permit(s) sought by the application.
Permission is granted for inspection of property located at the following address(es):
________________________________________________________________________________
________________________________________________________________________________
By signing this form, I affirm that I am authorized to give consent to entry by Village
Board Members, staff, and/or consultants as described above.
_____________________________________ ________________________ ______________
Print Name & Title Signature Date
Kathleen Mulcahy, Mayor
James L. Larocca, Trustee
Aidan Corish, Trustee
Beth M. Kamper, Clerk-Administrator
55 Main St., PO Box 660
Sag Harbor, N.Y. 11963
631-725-0222
631-725-0316 FAX
Thomas C Gardella, Deputy Mayor
Robert Plumb, Trustee
Denise R. Schoen, Village Attorney
Rhonda L. Meserole, Village Treasurer
Disclosure Affidavit
General Municipal Law §809
STATE OF NEW YORK}
} ss.:
COUNTY OF SUFFOLK}
____________________________________, being duly sworn, deposes and
says that:
1. (a) an application has been made by _______________________________
Name of applicant
to the __________________________________________________________, of the
Name of Village Agency
Village of Sag Harbor with respect to property situate at _______________________,
Street address
Sag Harbor, New York. I am the ________________________________________,
Applicant or Agent for applicant
I reside at _______________________________________.
Address of applicant or agent
(b) The shareholders, partners or members of the applicant corporation,
partnership or limited company are (if applicable):
(1) _______________ (3) _________________
(2) _______________ (4) _________________
2. (a) the landowner’s name and address are:
______________________________________________
______________________________________________
(b) The shareholders, partners or members of the landowner corporation,
partnership or limited company are (if applicable)
(1) _____________________ (3) ______________________
(2) _____________________ (4) ______________________
3. (a) the contract vendee’s name and address are (if applicable):
____________________________________________________
____________________________________________________
(b) The shareholders, partners or members of the contract vendee
corporation, partnership or limited company are (if applicable):
(1) ___________________ (3) ________________________
(2) ___________________ (4) ________________________
4. Does any officer or employee of the Village of Sag Harbor have an interest in
the applicant or in the landowner or in the contract vendee?
_______ Yes ______ No
If yes, state the name and residence of such officer or employee and the nature
and extent of such interest.
________________________________________________________
________________________________________________________
For the purpose of this disclosure, an officer or employee of the Village of
Sag Harbor shall be deemed to have an interest in the applicant or in the landowner or in
the contact vendee when he, his spouse, or their brothers, sisters, parents, children,
grandchildren, or the spouse of any of them:
(a) is the applicant or landowner or contract vendee, or
(b) is an officer, director, partner, member or employee of the applicant or
landowner or contract vendee, or
(c) legally or beneficially owns or controls stock of a corporate applicant or
landowner or contract vendee, or is a partner or member of a partnership or limited
liability company applicant or landowner or contract vendee; or
(d) is a party to an agreement with such an applicant or landowner or
contract vendee, express or implied, whereby he may receive any payment or other
benefit, whether or not for services rendered, dependent or contingent upon the favorable
approval of such application.
A person who knowingly and intentionally fails to make such disclosure shall be guilty of
a misdemeanor as provided in General Municipal Law §809.
________________________________________________________________________
________________________________________________________________________
5. Does any officer or employee of the Town of Southampton and/or East Hampton,
County of Suffolk or State of New York have an interest in the applicant or in the
landowner or in the contract vendee?
_________ Yes ___________No
If yes, state the name and residence of such officer or employee, the name of
such governmental entity (Town, County, and State) and the nature and extent of such
interest. ____________________________________________________________
For the purpose of this disclosure, an officer or employee of the Town of Southampton
and/or East Hampton shall be deemed to have an interest in the applicant or in the
landowner or in the contact vendee when he, his spouse, or their brothers, sisters, parents,
children, grandchildren, or the spouse of any of them:
(a) is the applicant or landowner or contract vendee; or
(b) is an officer, director, partner, member or employee of the applicant or
landowner or contract vendee; or
(c) legally or beneficially owns or controls stock of a corporate partnership or
limited liability company applicant or landowner or contract vendee; or
(d) Is a party to an agreement with such an applicant or landowner or contract
vendee expresses or implied, whereby he may receive any contingent upon the favorable
approval of such application.
A person who knowingly and intentionally fails to make such disclosure shall be guilty of
a misdemeanor as provided in General Municipal Law §809
___________________________________
Applicants Signature
State of New York)
) ss:
County of _____________)
On the ______ day of ___________in the year__________ before me, the undersigned,
personally appeared _______________________, personally known to me or proved to
me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are)
subscribed to the within instrument and acknowledged to me that he/she/they executed
the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the
instrument, the individual(s), or the person upon behalf of which the individual(s) acted,
executed the instrument.
______________________________________
(Notary Public)
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Wetlands Permit Application Submission Checklist INC. VILLAGE OF (Incorporated Village of Sag Harbor)

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Completed 16 July 2020

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