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HomeMy WebLinkAboutTR-9597E ( Property width 132 feet ___-- J am r j >( O N co .................................. C� ~ I C/7 O'• i 1=� Sand bag wall width 132 feet TYPICAL SAND BAG MSALL ELEVATION existing grade estimated eroded slope Scale: one inch = 5 feet � I estimated unconsolidated Notes loose sloughed soil Sand bags: 36" x 36" X 40" H First row fully buried to grade approx.line for relocated 2nd and 3rd rows staggered as shown loose soil behind sand bag wall Returns: 3 bags deep behind front wall 1 , - C Stella Lagudis existing grade 760 The Strand Lane, East Marion Temporary Sand Bag Wall TYPICAL SAND BAG to Protect Distressed-Slope �I L Return at 12 ft.overall 6 RETURN ELEVATION Scale:one inch=5 feet By: M. A. Kimack Dated: Nov. 14, 2019 Michael J.Domino,President rjF SO&P Town Hall Annex John M.Bredemeyer III,Vice-President ,`O� Old 54375 Route 25 P.O.Box 1179 Glenn Goldsmith J�[ Southold,New York 11971 A.Nicholas Krupski G Q Telephone (631) 765-1892 Greg Williams '� �� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit-No.: 9597E Date of Receipt of Application: November 18, 2019 Applicant: Stella Lagudis SCTM#: 1000-30-2-84.1 Project Location: 760 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 132 feet in length to property lines with one (1) 12 foot return on east side; 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 18, 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 SOUTH,OLD. , ..TR,U-ST. ElES 1Vo: lssued' T Da- te Address-160 Zc Shr � THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION -TOWN :TRUSTEES OFFICE,TOWN OF-,-'SO. UTHOLD $OUTHOLD, N Y. 119T1 TEL.:" .765-1892: Michael J. Domino, President O�QSVFFU(,f-CO Town Hall Annex John M. Bredemeyer III,Vice-President ,�� ��r, 54375 Route 25 Glenn Goldsmith y P.O.Box 1179 A.Nicholas Krupski 0 Southold,-NY 11971 Greg Williams Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: 'S ��_I s Completed in field by: D f����� der Michael Kimack on behalf of STELLA LAGUDIS requesting an Emergency Permit to construct a sand bag wall approximately 132 feet in length to property lines with one (1) 12 foot return on east side; first sand bag course fully buried with two (2) courses above (staggered) for a height 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: 760 The Strand, East Marion. SCTM# 1000-30-2-84.1 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: 1 II Unlisted Action Type of Application: Pre-Submission Administrative Amendment Wetland Coastal Erosion 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/comCments-/-sltandards: 41#T reP4 l r� ,S - off 5Se�7c e Cyyl g-" iz»L`1 r0 pair /7 cc r 0'j 0 ej-F T b4j, b,A b-ig�� _F4 a r e- I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: V1 J. Bredemeyer M.-Domino G. Goldsmith N. Krupski G. Williams Other a O ob S �` d' O° R' Ire. 10 A4) �v lz A lb lb AZ � C) 4- 7•�� 4-v %Ci S 76 2 / ��`Q, lb,/ // /� aj �o Q�° •,Oa �.��A 1.60 00 hi '0,, / h0/ '04., FC" 00a $ / o aa ., /5/;� S�, / / lS r 3��\ \� x ? \ \\ h X 0 '9 ° 1_ / 0D, \� �7 �4• 1 I fie'° 1 �// 00 X0 -ly 2 �;,... O\ 0 �o o - SURX, all VEY 00kkoF o LOTS 128 8 129 00 00 "a oo" oo oo MAP OF0o°� o� � � s 3LA�I 'A � SoaPEBBLE o FILE No. 6266 FILED JUNE 11, 1975 SI T UA TED A T 4 EAST MARION . ... ...... ... :. ...: ..:. .. . . � \ \ / a� .; / i h ,. 3�' o^ �� TOWN OF SOUTHOLD X o 6,� 1 \ X 6� :; .,.: / /9• C-) SUFFOLK COUNTY, NEW YORK hV \ \ X b /. ? EXIS ING WA,k / S.C. TAX No. 1000-30-02-84. 1 .4 SCALE, 1 "-20' CISIT �6x / APRIL 9, 1998 X %I I X AUGUST 18, 1998 UPDATED SURVEY & ADDED PROPOSED ADDITIONS 01 y�\ .� X�� ?�vo� ;T Q�� \ .�° �� LOT AREA DATA h° b J °4 1 a � ! 0 s ss. i \ PS`s ° 4I e�,T _ ° a F� (TO TIE LINES) �r `e 60 `� .�,�e •° •� e �' 4 LOT 128 21,871.91 sq. ft. 0.502 ac. CERTIFIED T0: a •. °d d ° • ° n r ��� 4sA r b I LOT 129 22,119.09 sq. ft. CHICAGO TITLE INSURANCE COMPANY \ \ • . x J sr. ° k I M . ., II 0.508 ac. WEBSTER BANK \ \ \ ` ° rA' r (\ I • • �' ° '• . I ° TOTAL 43,991.00 sq. ft. RENE VANGUESTAINE 1.010 ac. STELLA VANGUESTAINE • .� s`�Q�h Q°JPO ° '6V CIO \ \ \ n I •\ aai NOTES. 1. ELEVATIONS ARE REFERENCED TO N.G.V.D. 1929 DATUM ��v EXISTING ELEVATIONS ARE SHOWN THUS:�Q ,� EXISTING CONTOUR LINES ARE SHOWN THUS: — — — —5— -- — — S� • • F.FL. - FIRST FLOOR U THISSURVEY ALTERATION IS A VIOLATION ADDITION , OF per PROPOSED CONTOUR LINES ARE SHOWN THUS: 2SECTION 7209 OF THE NEW YORK STATE I • EDUCATION LAW. 2. FLOOD ZONE INFORMATION TAKEN FROM: FLOOD INSURANCE RATE MAP COMMUNITY—PANEL No. 360813 0056 E COPIES OF THIS SURVEY MAP NOT BEARING h� �O ° •n THE LAND SURVEYOR'S INKED SEAL OR X • • ZONE V9 (EL.15): AREAS OF 100-YEAR COASTAL FLOOD WITH VELOCITY EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. � Q Gj `�• (WAVE ACTION); BASE FLOOD ELEVATIONS AND FLOOD HAZARD FACTORS DETERMINED. CERTIFICATIONS INDICATED -HEREON SHALL RUN / /J ZONE C: AREAS OF MINIMAL FLOODING. ONLY TO THE PERSON FOR WHOM THE SURVEY , ;,� • OQ • c • ° \ IS PREPARED, AND ON HIS BEHALF TO THE 3. SANITARY SYSTEM LOCATION BY OTHERS. LTITLE ENDING COMPANY, NSTITUTION LSTED HEREON"rANOND ° 4. MINIMUM SEPTIC TANK CAPACITIES FOR A 1 TO 4 BEDROOM HOUSE IS 1 ,000 GALLONS. TO THE ASSIGNEES OF THE LENDING NSFER TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. 1 TANK; 8' LONG, 4'-3" WIDE, 6'-7" DEEP 1 ° °° • X 5. MINIMUM LEACHING SYSTEM FOR A 1 TO 4 BEDROOM HOUSE IS 300 sq ft SIDEWALL AREA. THE EXISTANCE OF RIGHT OF WAYS 4 • 1 POOL; 12' DEEP, 8' dia. ANY/NOT SEM NTS OFNRECORD, OT IFTEED. • ° a • • 4 •. d PREPARED IN ACCORDANCE WITH THE MINIMUM ° BY THEL. D STANDARDS SI.A.L.S. APPRFOR TITLE OVED ESTABLISHED AS ED AND ADOPTED • FOR SUCH USE BY THE NEWT YORK STATE LAND a!" � �G■ Incre a� i TITLE ASSOCIATION. / 6p1,ANDs Land Sures%For fi �QiA A.r Fc9`cr ..� 0 Title Surveys — Subdivisions — Site Plans — Construction Layout PHONE (516)727-2090 Fox (516)722-5093 4 ��OQk OFFICES LOCATED AT MAILING ADDRESSPN E N.Y.S. Lic. No. 49668 One Union Square P.O. Box 1931 Aquebogue, New York 11931 Riverhead, New York 11901 98-220B li �. ,,. c� t Ai 14 s y°� 10 f IL. R.. .1-7 dpwft 9 ,i 74 i w .V sem"° •ir _��` �� -�'��'�`. NOV 1 8 2019 9 K b � r . South wrM ar ct lr slues s f 1 -- y a i % .+� -"r slue� � i• � r M_ a n 3xA9 --- SEE SEC NO. " A I M DxtdS9A t v /,es e+ 3 a e 112 9� O *� a xs O a ee t / e, t� tat ! ^• se ex �. t tx ns �.�♦ et !�� eab Q2 r. nr � _ ne CRESCENT F SFC�NO. Iv Q ]r b A 2 to � a 0 � � o FOR PCL.NO. a . ME sfc.No I � oasaxd,e, FOR PCL NO, SEE SEC.NO. FOR PCI.NO —11 \ x j FOR PCL NO, POR PCL NO. SFE SEC.NO SEE BEC.NO SEE SEC NO Ol69xd131 fdl PCL.NO P : C1a91dM WSOx-0Bt SERE S�ECC.z O ' O�\ ^ _ _--_—_------�------------------ --�------ ---Z__ —Z--— --- ---UNE MAiCN e . � .IE>r�N9 c "�� _�_ " �_1� —_2—" m� rvoncE COUNTY OF SUFFOLK © e « aoumoln secrroN No —� Real PFOPerty Tax Serv'ce Agency M >o u,ea 30 N P rxic,rva tecta PROPERTY MAP Michael J. Domino, President ,� 4l�U�y Town Hall Annex John M.Bredeme er III Vice-President 54376 Route 26 Y !1 Q P.O. Box 1179 Glenn Goldsmith Southold,New York 11971 A. Nicholas Krupski C Telephone (631) 766-1892 Greg Williams u Iq� �a` Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF klOUTHOLD This Section For Office Use Only Emergency Permit Application Coastal Erosion Permit Application .-Wetland Permit Application -Administrative Permit �Amend ment/Transfer/Extesiva _Received ,Application; 1 l5r ) 3 _Received Fee; $ Completed Application; l r. r•_ Incomplete; ; ! SEQRA Classification; Type I Type lI ^M Unlisted i —Lead Agency Determination; —Coordination;(date sent): NOV 1 8 2019 LWRP 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); Mailing Address; 16B _s`T,P��/. L4 .451T &4 /ONSAl x99 Phone Number; 6 X647 Suffolk County Tax Map Number; 1000 - _?®— Z -e?4- Property Location; X60 7`�,ESER �(/_�Li4 -_ S'Ti�—l�,plO�/ (If necessary, provide LILCO Pole#, distance to cross strt:ets, and location) AG�,NT(If applicable); /Cy q " </�/A C L Mailing Address; pK Q l'Z� S' , IV //?7/ Phone Number; `/6 Hoard of Trus t;ees Appliaat:"`��; GENE&kL DATA Land Area(in square feet): __427' , 9 Area Zoning; _ Lf 4 Previous use of property: / M!1 F4I�ILY 9&Ej AE'AlrML Intended use of property; Ez4PZ&TIAL Covenants and Restrictions on property? __Yes No If"Yes", please provide a copy, Will this project require a Building Permit as per Town Cade? __Yes X No If"Yes", be advised this application will be reviewed by the 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? _Yes No Prior permits/approvals for site improvements: Agency Date SP _No prior permits/approval; for site improvements, Has any permit/approval ever been revoked or suspendedby a governmental agency? X No Yes If yes, provide explanation; Project Description (use attachments if necessary); TO CO (/cy' �¢ ,¢,vp A946LL ,41'VX6k. le-z jcT IN 4&V67H Ta PRO PeR Y 1ANE-s W171.1 aN,& V i2�r.P'L-1 ' AA37- SZA 7�S wI - ( 2�V2052 ,4�3d _G EED 0� ��/G,�,l;�yF.4PpTax 6 ,ANY S014 .4 r AASe _DF /SML D (LOPE /A/D W,6W SAWA $Alm iO.AZI . ArrJ A7j6R/AL ,441-OWS` TD h/,l1pSTAB/e/ZE TUB ¢` J-AND -6/46 L!>•aLL x`1011 ,�iL STV eA_/ ��--$yrs tC:A01-1 9FA OY 7 C' PR6 74C 7-JAIVD �',�s - 'Board of Trustoes Applioativu" WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations; /N�'LL ,4 Pzi�id.t� �y i S�1LU�oA/ /S Area of wetlands on lot-, .. 0square feet Percent coverage of lot; Closest distance between nearest existing structure and upland edge of wetlands; feet Closest distance between nearest proposed structure and upland edge of wetlands; feet Does the project involve excavation or filling? _ No Yes If yes,how much material will be excavated? �—cubic yards How much material will be filled? cubic yards (I I, N'416� .g.�i�/A�IJ LUr�LG Depth of which material will be removed or deposited; _feet (/— Proposed slope throughout the area of operations;,__i_5 �_ Manner in which material will be removed or deposited; .s' /) j�,� ,S l�LL &C IL eA / 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); __='Ioard of Trustoes COASTAL EROSION APPLICATION DATA Purposes of proposed activity; --1-T—rRc_1//D- .ZQ,�,t� / 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? _ (cubic yards) How much material will be filled? -' �D� _-ice . (cubic yards) U ✓ ,FAV//VP W'4 Manner in which material will be removed or depasited; V14 A/11 A Z?0� Describe the nature and extent of the environrnelltal impacts to the subject property or neighboring propelties reasonably anticipated resulting from implementation of the project as proposed, including erosion increase or adverse effects on natural protective features. (Use attachments if necessary) go- -- B�i�I/Ll4,� i`?I l7l.E�,?���r2G .7_� �.� /�-1is� � .1��►/ r�✓, i,� o 11V �isT.Q . sz�P�s f Board of Trust:ees APPlication t i i i AFF.IIa LY—IT 4 p4 i t t d DEPOSES AND AFFIRMS THAT I-IE/SHE I1 THE APPLICANT FOR THE ABOVE .. BEING DULY SWORN DESCRIBED PERMITS) AND THAT AL!-STATEMENTS CONTAINED HEREIN _ ARE TRUE TO THE BiEST OF HIS/TIER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH I,N THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES, f THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND IR.EE FROM ANY AND ALL DAMAGES AND 4:LAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED, IN COMPLETING THIS APPI,I CATION, I HEREBY AUTHORIZE THE TRUSTEES,THEIR A+(xCNT(S) OR REPRE8ENTAT)'VES, INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJ'UNCTI'ON WITH THIS APPLICATION, INCLUDING A FINAL INSPECTIO11, I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTEI. ONTO MY PROPERTY AND AS REQUIRED TO INSURE � COMPLIANCE WITH.ANY CONDITION 04F ANY WETLAND OR COASTAL EROSJON PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. } f S ature of Property"Oz ` Signature of Property Owner SWORN TO BEFORE NfI THIS�5-0 DA.Y OF Nota ry Pu mior,,,—_. MICHAEL&IGMACK Notary Public,State c„ , _ Notary Public,State of New York No.021<15056823 No.02KI5056823 Qualified in Nassau Cour'- Qualified in Nassau County Commission Expires 1- Commission Expires March 11,2022 B(Dard of Truax�;Eaes A13P1ication AUTHG WIZATI ON (Where Lhe applicnant is not the owner) i owners of the property idrnti fled as SC"rm# 10(.)0- U- -- — 2 `�• in the town of I New Yore, hereby authorizes _to act as my agent and handle all necessary work involved with the application pr(1c;es, for pc,rmit(s) from the Southold Town Board of Trustees for this property. ' 3 f 4 � r 1 f p 1'y perty Owner's Signatuv; Propc'trty Owner's Signature 7 SWORN TO BEFORE MI; THISs L'AY OF Al G Y. ,20 _ Notary Public�� MICHAEL A.KIMACK Notary Public,State of New York No.02KI5056823 Qualified in Nassau County Commission Expires P��• MICHAEL A.IaMACK Notary Public,State of New York No.02KI5056823 Qualified in Nassau County Commission Expires March 11,2022 i i i r ! i els I'P LICA NT/AGLikr;i'/KL£PR+u ENtATIYE TRANSACTIONAL IISCLCIS�1 ,FOR�z i !!ll9(4g11.I,..a �� c �•�-Q4111)l�L7�,�IIl1rL�"'.211,`(ij�.Jll[L!of tos,in bill � i 'ac C�In ovo'd cn,�, �•�•�`�-ILz1111�Cs�]�aCJ?Sf,�alL'.!.4,S�pfjLcs,'�4 ���" >?1SZY.�cs + r �,�.a1' 4 •� =•uus.ti!�OtY,�t 1Q iniia W)t�'^1 Ct'BCIIon I� YOUR Nage` gr �11 �/S E (Lull name, rrst nitld ,ry,' o�are a»!so eone elor cthar If It],,] Y I )Ing In the r,arne or ! ,sutlm,1141 acornpan:,, ifso, Indlonto Ihbo;her Person's or company's name) NAME OF APPLICATION; (Cheek all that applv,) Tttx gnovvico Variance ••----.�_..-, Dullcl,g `---�—� i Change ol'Zonc _—• Tnw—xa --p-1 Appro I'll lofplat ---- ____ Coa+taJEresion e-einpilar from plat or OMcial mal, — Mcorta -- Ulher Flan,l;g --- 01her",name the activity,), ` �Ya'-'Pursoi�al!y (or through ynW tout ,:nom_ p' Yr spousal,Iblh!g,pnr.r.t,or r.hilo)!laveOfilln rolntlonshlp w!Itt any ofT]ccr or ontplaycc Including Town of Soulhpld7 "ltelnllo tshyt"Includes,ty hfno'd,[flan lugs ur bus'Itrcas Ihtarost."E3us!rtryy•Jnlurasl'r Inctuding o parinnrthlp,In r OfIlh•llt ,to+vtt offiper or cn,plvyt o hay 4vcn u pttrtlnl otrncrs!ill,,of(or omp'ln1vrkWl I! !a,vl!loh 11tS lawn ofPcar or employee o,vns mora thnr•36o,of'i!tc;";otos, menna n tsl�aae, y)n curp�ruNon Y75 NID Ifycu ar,sw::red"`(eS complete the bnlan;e of tnls%c•m and date and sign where Indicated, f Na^e of rtr'son employed by the Town OfSouthold T,tic or pasllion of lhaf perso r, Jc,.rtbo the relations)I' etween yourself(;he cap!ropriatc!Inc A)tnro�gh D)ar CVQf oescri:x:n tits space pre nppl!cun tngenVrepresent"tive)and the town o tlaer or employee,Either caecc i Jed, TI,r town otitcer or employee or his or her spovsc,srbilrt,;,parent,o 011c.!s(ehook all•Ihai apply): `—A)fw`wnvi or'vFg eatcr!f,un 5%or l the shnros+:;'!to car tori!;stoc;0Cthe appltoon; Pl cunt IV n co;pprvtion): D)iIv,Ignl orbcncfrclni otvnar url:hy lntororl In n non•co'po•atc 1,111ty(whon the OwIlcanl Is not a Gnrpornllun); G7 nn 0111oor,dimtor,pnrint r,or untployco of the appllonnt,nr D)the actual opp!icanl, (:c"5 c IfTION OF REL AT(ONSNIF' — Subtnittod this(1� dny Slgnnittroy-- pc^,:TS I pmt lin,,e APPLICANT/AGEN7'l.R Y,PRESENTATIVE TRANSACTIONAL DISCL0SURE FORM a• ' dfSotitbald�d Circlt;`aP.�lti]gs;pralribith:ao�jJ' ° n ' �tu")+•�l.:lf]��J2.1�a�flk'�t�?Ll�ficl;�a,•g11S1';S1I�.t�R9yr,v Tl e.nrimasa 4f Ihis•Corm fs�,te nrouidaln'fart,atlan_r�j�ic]L� n rf il�e�'na+m'•of"t2ta��1(�1�.�1i ,•af jnRcrerr�Jid aflaw•II latakr wttnfavrradlbn le ae ]x,tn nycild s'nmc. • YOUR NAME; HW C21 "IW 61— A� (Last name, Clrst name,r/t ddle Initlal,unless you are applying in the name of someone else or other entity,such as a company. If so, Indlonto the other person's or company's name,) NAME OF APPLICATION; (Check all that apply.) Tax grievance Aullcling Varlance _ Trace Change ofZone Coastal Erosion Apprevol of plat Mooring Exemption from plat or ofricial map Planning Other (If"Other",name the activity.) C> you:personully(Qr ftough,your:,company,spouse,sibling;pU4nt,o'r 0114)'havo•a,relddonshi'p'vith any ol'Tlccr oromployeo oflho Town'of.Southold7 "Ike Iattonship"Iricludos by blood,iiltsttria9%orbusitrar;s:IhtorvsL IMuslrr*s-Intomst"mcans•a bust nos s, Inaludlnb,a partnorsiil}?,In w.'ttlah•Nte•town oFt'ir;br pr employee hair evan•a purtlnl ownaship.oP(or ont�iloyn7eni Eiy)a•corporatlon In whloh0b town of,car•or employee owns more.than M/a,ol'thc,'>'har"s. YES NO Ifyou answered"YES",complete the balance or this form and date;and sign where indleattd, Name of perspn employed by the Town of Southold Title br position of that person_ Dcscrlbe the relationship between yourself(the applicant/ogotiVrei)resentative)and the town o,filcer or employee. Either check the appropriate line A)through D)and/or describe In the spaco pro•11ded. The town officer or employee or his or tier spouse,sibling,parent,i r child is(chock all that apply); tho owner of grantor than 50/6 oPthe shnres of the corporuto stock of the applicant (whan the npplicnrtt Is a corporation); B)Iho logal'orbenAc:1 ii owner or,nhylnieresl in a inowcorporatc entity(whbn the applibonbls not n corpbrh6n); G)an o,fftoor,director,partner,or-employee af•ihc applicani;or D)the actual applicant, DESCRIPTION OF RELATIONSHIP Submitted this �ay of A10V20 � Signature Print Name Form TS i