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HomeMy WebLinkAboutTR-9596E Property width 72 feet 1 i Z - f w O cam F�` _ ' a m Sand bag wall width TYPICAL SAND BAG WALL ELEVATION existing grade estimated eroded slope Scale: one inch =5 feet Notes estimated unconsolidated loose sloughed soil i Sand bags: 36" x 36" x 40" H . First row fully buried to grade 2nd and 3rd rows staggered as shown approx.line for relocated loose soil behind sand bag wall Returns: 3 bags deep behind front wall Philip & Nancy Weber existing grade 160 The Strand, East Marion . Temporary Sand Bag Wall TYPICAL SAND BAG to Protect Distressed Slope Return at 12 ft.overall RETURN ELEVATION scale:one inch=5 feet By: M. A. Kimack Dated: Nov. 12, 2019 [ E C Er FI; j NOV 1 9 2019 Sot�U old zoom a P`11e T/TLE NO. /200520 BCafd Cf II�Si2C. THE LOCATION OF WELLS AND CESSPOOL! BNGWEE MERLON ARE FROM FIELD OBSERVATIONS AND OR FROM DATA OBTAINED IROY•077M! Q` THE WATER SUPPLY AND SEWAGE pISPOSAL SYSTEM?FOR Ems RESIDENCE. O ,�(. - WILL CONPORM TO THE STANDARD! of THE SUFFOLK COUNTY OR:Pft IE f p Of HEALTH SEgVI f! J 11 t3/ �' APPLICANT-av*inc(15 ADDRESS IX2 tcli4SoM gv So�TN.�o a1i 1" �Q �� WMIZ COMM HEALTH DWARTMP \�oa6 ti�" DATROCT 16WS H, D. mw. Phe sewage disposal and water enpply VO raoilitles for this location have been h L}\ inspected by this department and found Lo be satisfactory--ROW/!i{� Chief of C el rin �pk / Services �LF166 EL'st L NOTE \\ ZS ,D, ■:MONUMENT T.T• Hr 0 1sT SUBDIVISION MAP FILED/N THE OFF/CE OF THE CL£RKOF SUFFOLK COUNTY ON Q / Qa D�/•e si� ✓UNE//,/975 AS F/L£NO 6266 TH£R£AREND DWELL/NGS W/TH/N/00' \� / o ,moi r�' T!_lCP �B• C r OF THIS PROPERTY OTHER THAN THOSE \, K.J 'I n SHOWN HEREON Y `����1"0• 1u I o-STAKE \v, EV w c.D REVISIONS YOUNG & YOUNG -C B,/977 400 OSTRANDER AVENUE, RIVERHEAD, NEW YORK �`�� e �.O - 7'_ — _ 1074nn C.16,1977 ALDEN W.YOUNG HOWARD W.YOUNG ` VA¢YC _ � m D g30�W I'R 3,1978 PROF.!.IONAL..DINE..ANO LAND SURVEYOR `� N'ALLT�n/1 �• 76 �o a+ ;T 6,1978 LAND SURVEYOR N.Y.S.LIC.NO,12e4e N r S.LIC NO AIeB! it OF NF UNAVIVOICID AMRArIGH of Awrtgx ,,V l/V AND �~ (� {p TO THIS SJMY Is A VIOLATION of v I�.f�'� c p SURVEY FOR: '+ RDW t0 slrnoN 09 or THE Hlw YoIA sun N f✓��MA ✓�r`ARNOLD LEIS/NE Q ESTELLE LEWIVE �� } yr /DGCAII'-I LAW LOTIVO SO5 DE THIS SURVEY IMF NOT wAADEG O /37 "PEBBLE BEACH FARMS" �� G2 iHIIRLuo:ulvlros s INK®SEAL of i' R ELF 43 H N O) IMgs31U SIAL SPAM HOT Y CON,AM 10 M I%AUD TRUE CAR• 0 ,/ OUA•00 S INDICATED HALON MM MM ' AT GUARANTEED TO- OKI n,•H1 F'aISOM FOR WHOM IID FORM �✓ EU EAST MAR/ON THE TITLE GUARANTEE CO ��tk �0.45893 s nnuv,AND°n ws uNAu TO Tx, TOWN op SOUTHOLD SAV/NGS BANK MJF 1ITU COM.AHr,wvnNNIHUL AOB1Cr AND SOUTHOLD GND SUEVLSD? uNNHc INvnulloH usn0 HE"OH,AM To TPI ASas:NT1s w TH1 U,am Son. TUT 14 GIARANTUS Ale Not RAN ,,,_ SUFFOLK CO., N.Y. ar R!/Eil IO ADUPUHAI RDIIIUTIONS OR SufPIWUO DwH AS SCALE /"-40' DATE AUG 18,1975 No. 75-53/ R Michael J.Domino,President *QF So(/TTown Hall Annex John M.Bredemeyer III,Vice-President ,`O� ��� 54375 Route 25 P.O.Box 1179 Glenn Goldsmith Southold,New York 11971 A.Nicholas Krupski G Telephone(631) 765-1892 Greg Williams �O Fax(631) 765-6641 �yeouw,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No.: 9596E Date of Receipt of Application: November 19, 2019 Applicant: Philip & Nancy Weber SCTM#: 1000-21-5-7 Project Location: 160 The Strand, East Marion Date of Issuance: November 21, 2019 Date of Expiration: 90 Days From Date of Issuance Reviewed by: Trustee John Bredemeyer Project Description: To construct a sand bag wall approximately 72 feet in length to property lines with two (2) 12 foot returns; first sand bag course fully buried with two (2) courses above (staggered) for a height above grade of approximately 6 feet; relocate sloughed unconsolidated soil at base of distressed slope laterally behind new sand bag wall as material allows, to help stabilize toe and sand bag wall; and to remove all storm debris from beach to protect sand bags. Findings: The project meets the requirements for issuance of an Emergency Wetlands Permit as determined by the Board of Trustees. The issuance of an Emergency Wetlands Permit allows for the operations as indicated in the application received on November 19, 2019. Special Conditions: A full Wetland Permit must be obtained within 90 days in order to conduct any further activity on or around the bluff. This is not a determination from any other agency. Michael J. Domino, President Board of Trustees S D T-RUSTEES OUTH L rro. . ql..A Itp. F F�e. ,cy t*rr� Issued To�:��� � &keel- Addr-es' s.'/60 �e S1ro„�f.. Aacm THIS NOTICE, MUST BE-D,fSPLAYED DURING CONSTRUCTION TOWN TRUSTEES_OFFICE,TOWN OF .SOUT.HOLD: SO.UTHOLD; N.Y. 11971 '. TEL : 765.1892 Michael J. Domino, President O�QSufFQ[�COG Town Hall Annex John M. Bredemeyer III,Vice-President 54375 Route 25 Glenn Goldsmith o 'c P.O.Box 1179 C/] Z A.Nicholas Krupski T Southold,NY 11971 Greg Williams ?� ® p! Telephone(631)765-1892 Fax(63 1')765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 11.jo.1 q Completed in field by: BtC, e MCI (f Michael Kimack on behalf of PHILIP & NANCY WEBER requesting an Emergency Permit to construct a sand bag wall approximately 72 feet in length to property lines with two (2) 12 foot returns; first sand bag course'fully buried with two (2) courses above (staggered) for a height above grade of approximately 6 feet; relocate any sloughed, unconsolidated soil at base of distressed slope laterally behind new sand bag wall as material allows, to help stabilize toe and sand bag wall. Located: 160 The Strand, East Marion. SCTM# 1000-21-5-7 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=q Setback Waiver Required 1. Residence: 100 feet 2. Driveway: 50 feet 3. Sanitary Leaching Pool (cesspool): 100 feet 4. Septic Tank: 75 feet 5. Swimming Pool and related structures: 50 feet 6. Landscaping or gardening: 50 feet 7. Placement of C&D material: 100 feet TOP OF BLUFF: 1. Residence: 100 feet 2. Driveway: 100 feet 3. Sanitary leaching pool (cesspool) 100 feet: 4. Swimming pool and related structures: 100 feet Public Notice of Hearing Card Posted: Y / N Ch. 275 Ch. 111 SEQRA Type: I II Unlisted Action Type of Application: Pre-Submission /Administrative Amendment Wetland Coastal Erosion V Emergency Violation Non-Jurisdiction Survey <_ 5 years: Y/N Wetland Line by: C.E.H.A. Line Additional information/suggested modifications/conditions/need for outside review/consultant/application completeness/comments/standards: e,Cke f v , (Ze u U- C, L-0- 6 �b��1 6 IV (� k) 11)Y'e I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: _ _J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other *r. v._ gel now •r vt a J i wr t y. G F ,1 _ *! _ _; — �� _ ,•' 'ter � •��` i c4 _'"p� � �. -6rr�•;� "tet _- Y _ ll� I NOV 1 9 2019 $GUti1GIu OWf�� Boar of-i ^ s A� r+ r i M AVE. 10 p 0(� -��•fF 16�cl �i r acL �� e> f OP'M ��.' 15 i ',_ + �1 t. c j G Cr\y' 6 y2� Sn 16 0l -} ,i IMANDFaLO AD 32 23 ay � �• � t,m�t9 9� 2g1 i}9P m t_ � , 1 � e\ �� S.SA 22 rb " i 'N' mA 22 2AA WAR i \ l 19 1.4A12 12A I 1.tA$• p 1.1A "5 SUFFOLK OPEN SPACE Al $ CAUNiY - 5 9 NWTSR a '�F- •� Y � � ,-"'3 of 1?A� �� AUrlawTv ,. 15 3 17 3 6 1?A a O9 y� £ J`\ 'a 'm 1�1 1 ,p V,"m y y-O OPEN SPAOE `• tOF PCL N'J Via:, 1.OA -F• �cr`.' �NO`� 5 vt m 6-0S c �n wn a,2 i aacr 211 18 2�`'.Z A,1ti 1.3 \ .i.(..NOo a^ r ;e vNa 3 POfa. '� \' 1 �E,^,EC Na(.5i)' • - " ,T d, ".TV r . IGF' .. .i �` � �.�• _ COUNTY OF SUFFOLK © N NOTICE K oGrwc7ND loco SECTION_ sEcor r 12.140 Real Property Tax Service Agency MARJ71 "JcE.OLTEPAT""'SALE 0R Y '71— v® — W E M–MmUIION OF ANY PORTION OF 711E M � TowN OF SOUTHOLD 021 300 C.—Ane.Atl ha.4 IVY V901 SUFFOLK COUNTY T"MAP 6 PROFBRED ' rzr acixnn6.2 OF"M p ..a�:.^•�,'G%P'39in"�::.n.:.?R�.LC:A.LF?.�i:�fa�' srr. kri m iR3 1-1 s � * , s az - 7 {\ t Yy1 ,a ,PNS F1• tlPj v:.. VdaU e J s,eomvoxw wwwr«crwereouosvcw.m �'Y u e� • e , w,b.o,�ao...,r.ow i • - ie �1, a,• N 14 s? + , s2p � 04 ...0 �i:...y,•• ,µ:=:.. �,.. .o� � � "r 1 ...oroi ,1 11A �-t:. '1'. Ito • + . i \ y- • = 6 KLmN A ., •e 1 a ar. a a w COUNTY OF SUFFOLK c^ _ _ � •::^�°�a�o�.,�•. - —�,.�•,•..•. .� ., o ...�__`,'__ ..°...�_ —_ • J Itcal Pruperry Pax Survi�c ages c'•M E 021 N ...�__ .�,.._ �.• .�.,.� ,. .. , v n.., vn, s,rr«.oura�r rw.u.r,waaren ar Michael J.Domino, President i � C����,�,� �'-� Town Hall Annex John M.Bredemeyer III,Vice-President 64376 Route 26 Glenn Goldsmith �� P.G. Box 1179 Southold,New York 11971 A.Nicholas Krupski i!% Greg Williams t" • .>� Telephone (631) 766-1892 g C ( Fax (631) 766-6641 t' BOARD OF TO'INVN TRU MES TOWN OF ElOUTHOL'D Emergency Permit Appli at is ionction For Office Use Only Coastal Erasion Permit Application _Wetland Permit Application S_ , -- r--i ❑ r Administrative Permit ;; 3 ; _Administrative sio 7-` — -- r— eceived Application;• s, Received Fee; pkat ` `I NOV 9 2019 _Completed Application; ' , incomplete: { —SEQRA Classification; Type f Type II Unlisted _Lead Agency Determination; Coordination:(date sent); _ - _I,WRP Consistency Assessment Form Sent: CAC Referral Sent; Date of Inspection; _Receipt of CAC Report; - _Technical Review; -_Public Hearing Held; _ Resolutlon; Legal Name of Property Owner(s); PN«L'__J_Aa AZey_We 3�2 Mailing Address; � s7-f,�' 5�.�/ I REH-e Rj Al-Y /1768 Phone Number; Suffolk County Tax Map Number; 1000 - 21 Property Location; d Ti b Sr,Q,4 07_tjA,ICAI (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable); - Mailing Address; P. Phone Number; i 'Board of Trustees C'FENER.AL DATA Land Area (in square feet); Area Zoning; _ 40 Previous use of property; _&M,02—W7-12—A-4___V& t-,4/yXy Intended use of property; /���,/r � �nA- Covenants and Restrictions on property? __Yes X No If"Yes", please provide a copy, Will this project require a Building Permit as per Town Code? _YesNo If"Yes", be advised this application will be reviewed b,yr tl�e Buildi.Building Dept, prior to a Board of Trustee review and Elevation Plans will be required, Does this project require a variance from the Zoning Board of Appeals? Yes X No If"Yes",please provide copy of decision, Will this project require any demolition as per Town Code or as determined by the Building Dept,? Yes 'X/ .No Does the structure (s) on property have a valid Certificate of Occupancy? N/ Yes No Prior permits/approvals for site improvements; Agency Date _No prior permits/approvahs for site improvements, Has any permit/approval ever been revoked or suspended'by a governmental agency? No Yes If yes, provide explanation; Project Description (use attachments if necessary);_,CC �U�j—� ,q�D / 4PRRoX, 72 FT I;V 4AV6,7,Y TD PV45p.6gly L!1II W/TH YWo ?I 6 ,� LaCLR SY aUGl� , U�CD OLl�.4�iA s'G!L ��--i3As off' ,4S` /LlAt4 eW .4&04VS,) TD A65LR J'7-4,e/C/Z--e 70k-t: 00 -W�VD M& RG7ei 1�_ ALL S OS ® Z 0�° A9,4 01-1 ro poe®7�ffQ7-5A- A6P 'Board of Trust;(ses App:LioatsJ':Wd WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations; � -9 MO WOE 7"�M}�OIP,A JV%J_� ;P,eD 77�CT/D� 7---QD1 S'7i 'r' 6,1= 6 SLQ1�E SOL� Area of wetlands on lot; _ (� sgu•are feet Percent coverage of lot; L /o Closest distance between nearest existing structure and upland edge of wetlands; feet Closest distance between nearest proposed structure and upland edge of wetlands;109 feet Does the project involve excavation or filling? _ No —__ yes If yes, how much material will be excavated?,v �i D_cubic yards How much material will be filled? gD ._._cubic yards UAID167-6e IYV�V4161,6 ,66�lNl� Depth of which material will be removed or deposited; _feet y �,(�,qtL e` Proposed slope throughout the area of operations;,_ 6L4E Manner in which material will be removed or deposited; S?/i1D RA GS 1`7�dC1�tNt= . 7'�CN L_ KC,�.���/ �✓/�C�L�Q 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); No AZ .c~r D�v��c -Joard of Trustees. Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity; r� _� _VlJ�' ,g Are wetlands present within 100 feet of the proposed activity? No Yes Does the project involve excavation or filling? _. .No Yes If Yes, how much material will be excavated? 4o (cubic yards) How much material will be filled? (cubic yards) Manner in which material will be removed or doosited;_�1C CC Y/JT42 AMP Describe the nature and extent of the environmentell impacts to the subject property or neighboring propeities reasonably andcipated resulting fl•om implementation of the project as proposed, including erosion increase or adverse effects on natural protective features. (Use attachments if necessary) GUIlL ,giJl Aol, �d S,�IVD BAG G/� /S M, ANr 7"� A/V /A/ la/ , 5/aV �V,E/ BD P�►l 222l90V� ,Nse- AC ReaDJ PASTS tYS AAvh `�i�i/L14,� 1 .171� ,�'�'�1� '7�• A/W/3 •�� 7A X112 qWV P/sT.Q,5.s� sz eP� �. r i Board of Trusite�ea Application t F rl I]%'),A V1,T v ]YEPOSES ANMDAPPIRNIS THAT HE/SHE Jj-1 DULY SWOlt.1 ., THE APPLICANTFOR THE ABOYL DESCRIBED R-MIT(S) AND TITAT AT-L, L3'TAT'ClMTI`,'.NTS CONTAINED HEREIN ARE TRUE TO THE BEST OF J1181HER K?V0XlVLED(3E- AND BEI.IL,F,ANID THAT ALL WORK WILL BE,DONE IN THE MA.NNEI1SIFT FORTH IN THIS APPLICATION' AND ASNIAY BE APRROVED BY THH,SOUTHOLD TONvNBOARD F TR T E S, "lit, APPLIC.A.'NT AGIME�S TO IjO)-,D I-IN jK i' D () L:S E TOWN OF SO(;THOLI) AND THE BOARD OF TRUSTFj,-.8 HAMNILESSAND FREE FROM ANY AIND ALIS DA',)MAGES AND CLAIMS ARISING 1;,NDtR Or,BY vl;tITLiC GRA TED. OF SAID PER-MIT(S), IF RN CONIPLRTI.Na THIS APPIA CATION,I HMEDY A U-THORIZIE TIDE TRL'STEE-S,THF-.IR AGE,NT(8) OR RE-PRE,."iENTATIVES, fNCLIUDING THE CONSERVATION AD% I,50Ry COV CIL, -110 ENTER UN*;'rO My PROPERTYTO INSPECT THE PREN1 I'SES IN CO'jN,j UNlc;l, WMli THIS APPLICATION, INCLUDING A FI-NAL,'ETN'SPEcTjO,.,,j, TMATHER AUTRORIZE THE,BOARD OF TRt'STEES TO FNI "I'L A,0NTONIjl PROPE:M'A'14) AS REQUIRED I TO INSURE COMPLIANCE WITH ANY CONDITION 01F AINNY WETLAND OR COASTAL EROSION PER t1IT IS,3Ur,,D BY T14E BOAR.D OF TRUSTF,LiS DjLiPjN(3 -jqjr� OF THE Prl RMIT, TERIVI vrope,tv, 0 v/11er W IVAAICY -- RAYOF.- NoVanhor 9 Notary NICOLE M.FERRA101-0 Notary Public.State of New York No 01FE6074187 Oualified in Nassau County Commission Expires May 13,202?l Board of Trus t:fiiea App].icairion Ai.:MOI ZATION (Where :he applical;t is rlct the owner; owners of the property idnJiti%ed as SCI'NA,# I{i.)1). "7 in the town of d - \- CkV Fork, hereby authorizes •- —'��'�LG��,EL_r4. �[j►��_�,k--• _.._to act as rzy agent andhandle all neces;3ry work invo;<<ed the appiic�;tian from the Sou:i;otd Tcwn Board oi'Trustees for this property. Proper•:' O`,'. rs$ignatuie---- __ Awle!p I,S/ fiQ Prcp'��y,N;;er's i�tnzture �' 1IANC'Y 'S it;OP-\'`:'0 BEFORE Mc;'1,ji13 DAY OF Na tlC,vjab'�r ry NICOLE M.FERRAIOLO Notary Public,State of New York No.01FE6074167 Ouahfied in Nassau County Commission Expires May 13,20-d-21, APPLICANT/AGEr%vuRj-,,Pn,SENTATIVE TR-ANSACTION-41, DISCLOSURE FOrUNI IWLLMA�' c mk� mu=ur ek YOUR NAME- {Lust n —un name SOMWO-ne cis-,c,vhzr ooh-,,4,uc�l as a corpariv, j1):jjQ1Irz!.:bother Pcrso;;'s or c orrpany,s ,a.-T.vj ' NAN:B OF APP:,1CAT!0N. (Ute:k flN rr of apply,) Tm griev�-%cr- variants Bu td ng Change orzo,,2 Tin-swe Appjoy,.j of 181 (:D;Isl:J F---\CI1IP00A Plat or Moor..,g Otter PlsnttIg ,'If"Other",rxre the act.,,i(v You Iof>D sibling,;W0114or child)linvc a WMIGM111))with xvyoM.-arorc-im1oycc includes by!t!aca,morriligo,or busitiass imcrcsL,,Dwi,jc4s Iplorwl'? Including d pwinory,'jiS,In wijicll 1114:lVW;'offivcror c n-)loyce h-a evert u pl.-illill 0neir w ,lip or(O(.a,,,, .ct'L"t' 1110,YmeM i'-%vh' .(c�tvll Of,9cer or NO ir,,u arsm-ed"YUS",compiele tFe bd:61C-0! t-rrn 0,.d dilte:4.1d SiL-1 whale ind,!Cvej. N3rt','of pmon cmp oyed vy the Town 017SW';eld r le or Posh or.of chat Pubur, Om -.b,(�c rvl5(1cns.Np Wk wic-e6cm Vre,-,-t;sv tat:ec)and the'0-,-.-.ofroer Or employee.Bitthur 3PP(`pfl?1,--the A)through D):jj,.dQT descri"11,ill.. sr ': P.:)vj of".c P, --:'�-- se, vrurrk w child iy( ,*,eek a(j'j,,jfa El,')Pty); —4) tW66cutc; of I'll': of I'ta lippli.arE %gal 0. zw I'mr or ony n1cm-0 ill d'431-0]13111w Clalty(1.,!Iort it il r.Ot p Go-�,orAojj), ' Q 0:11-c u1-pllcar%or OF RFI,A1'IQNSj4fp Subay.nel tr.,,s —a. Signature— F*srm T9 I Print Name OLPPL•ICANT;AG.ENT/REPRESENTATIVE MANSACTIONAL DISCLOS'i;RE FORN, 2:ic" "•�i:��'S.•1•�, .'€C� rJnrCl3tf'+°c�,� , r Jtlt&.j4z"1:LE;�!o,n.[�v '`�s•rr:?.atl •.�� r--.-§-f.4.�i�.sl��?Z?.�iit-$.nu€liit:4ss�.�dLil�:SJ�GI.�i� ^.r.,c ' t ':i..,..Gli�,.,_. "< t 21}•lr,n_y;�_I{!venter 2`'. :.tx:441n hr;rt 15==-1::t�3]_:I:S�SS��� }�"•. t�4l r" r fl r?,.�il{'�.2.c�Z� t^ .e•'"� -�:�&I.�il.�.li:24t�3.(2'fn'z�.ti',i• s^,;,ci'S.L?t£,iS'.�.�:: YOUR NA�12! {Ir.:•t rarr:C 1{k'� 'tr.I,,n-c: , ,.'.----.�'"^'-_ someor.c els,ar �� s ;ou r•r al,pl,i•,g tn'_t a n{une�, 51.';11 vo. s�i iC�'7U):_rl�,I!$G,11Tt11;aiC:he UfhCr '�A1'lE 1F"..";�LICriTlp\ {C�ec;l{�I(:ha;rgpiy; 'J'r.?g:i".van _�- .}pR+CY3!4r}{St ".—•---. ..�.-- CDeall E�OS•9') '� '�' rkvrlrp'ia'1 Ni-:i Plat or or;ra'al r•�,, —""` vJC:""•iis" — O'I1-r nu cno act wy.) — Do>"ou•perro.u,;y(or through our•c _��-�� of Ihr•Teun�FScI,Il;ald'1 "! cY olDtparry,spcu5c sihlicg,•pruorrt,o•chll{J)11nvo i rolaJa, l llclsshJp",Peltsdes by Rlcc{l,!1larricge,or buslrre•ss;I;terosL"E3,Isrrrc,;„,(n r(r+rm not tvop oyvc Including g:F rtrarrhln,In s"hfch ll':'Vwrt Ortict_r or ci;1p'oyco hat,ovC a pa tf1!owic.Ship c F(Gr cr;rap'rmanJ 1ric r.c.1 bvsl loll In Which q c tca'n Pfrc;r or artiJlio;rec owns mors(!tnr,,9%ori. 't:5leas V PS _ ON _ X 1'9c',ans"scrx"Y?S",cprrp'e;C:I a 6.i t ate ut rhrs rs:, raid c:a{r add s.glt vF.er.::,olcatcd, �3�c orgcnor.crnplo;eC t+� ;ye Trsvn Pf So;;utcfd • or}ys'-in or(hat pe,•so.� bef:ver:,,y..t•s,. �! +,C 2r rap• 1: •s, li12 4�1RI;C<J1rr r.ter,. •I P A):hr;l gh J)Rs,r�t Ocs :i €: ter,..;))tsu"a:.re,ttnd"h to.vn,^:oe: , )r ''4e I f1.:space providec, orlplo,res,Elders'?IcCr, T'a ro5�r Cf i,, :r olto'ovice; ``' ,r"I he ' f S�a�USt: Sl✓11 , ,_fit -A) t,•c r'$ eF:tY?, -A}(wr Cr,she 11 )11 ant si'arCorl�r�the xhn:)s o, tlse t<r1 0,1!;YPck o"ne spp'• �,Ci)'`c:cgal er ben;ie'at oivrt it ofjjlly�t(nlerc5l i t ron•c{tt�',as;:>e a )f>J,!ico:4Is n0l'L l"st1), M 017c1;1,dfrnctor, w--Mim-r. or.,.jl ;o,cc cf tllc .p;riic:.rd u)the actual app;ICent RELATIONSFflr+ `. _ --•- -- ..�_��_� IVq .r, S9gn i�tlra bcr �On tq Form (S 1 :'Ctnr idr:;r••v��r' __� .1 APPLICANT/.AGENT'/REPRF,SENTATIVE r['RANSACTIONAL DIS FORM The TowtT#6fSau�hald GiYdc ofr �h?as.prn�rffj(I:aanfliszn. f{ntcCt g i of iawn,b(7tcrs.nndplgy �a, 1 ite nitmoSo 2( ibis farm It.(a�y(�#y�Jry'fnrtnbtttrnv�hfch enn•nCar4 tiSd toayn o'ru�z1t( �jfJ y_af.lntCtti�6nntl I�nw toinke wttnfevrr•se)jon ig ttcce`c lx to oydld snmG. YOUR NAME; -,/h.Q:� /1 I A (Last name,first name,jpIddle Gtillal,un m you are applying in the name of someone elso.or other entity,such as a company, If so, Jndlonte thb other person's or company's name,) NAME OF APPLICATION; (Check all that apply.) Tax grievance Building Varlartce Trustee ` Change ofZone Coastal Erosion Approval of plat Mooring t,xamptlon from plat or official map Planning Other (]f°Other",name the activity.), 6o yourpersotwlly(or tfsrnugh,yout;,company,spouso,slF;lingrptu�nt,o'r child)'linvo a,rclritlonshlp°.wi1lt any oMcer or eniplayco of the Town•o]'Southold7 "holationxhip"hioludos by blood,)i omi.*g'q,br busltrcas.ihtcrese°Busineysdnterust'�rnoatt5 n buslnnss Ineluding,a partnorg)4.,in Whloh lhq,;town orrjcbr or employed has rvcn•a,pardnl ownaxhip.af'(6r o�n iley�nent!]y)n•corporntlon In whloh•tha town oMcor-or amployce owns moro•titan'Mko,ol'lho Aam's, YES NO W irydu answered"YES",complete the balance or this form and date,and sign where indicated, Name orperspn employed by the Town of Southold Title br position of that person Describe the relationship between yourself(the appllcnnVagent/representative)and the town officer or employee,Either check the appropriate line A)through D)and/or describe In the space prolided. The town officer or employee or his or her spouse,sibling,parent,o'r child is(check all'that apply); A)the ownbr of•grentcr Mian 50/o orthe shims of the carporatc stock of the:applicant (when alto npplicnrtt Is a oorporation); B)Iho legal•orbendfioW trwnerVPnhyintoraal in a non4corporate entity(whop the applI"cont"is not a,corpor IT;1l); 0)nn o.Mor,director,pnrtner,or-employce of,ihe applicant;or D)the actual applicant, DESCRIPTION OF RELATIONSHIP Submitted this�l2 day ofAI V.. 201d'/9 Slgntituro _ Form TS 1 Print Name