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HomeMy WebLinkAboutTR-9600E Property width 69 feet 2 { rn i n O o I C-3 o _ - - 1 r ' Sand bag wall width I 69 feet TYPICAL SAND BAG WALL 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 sol behind sand bag wall Returns: 3 bags deep behind front wall William and Marie Austin existing grade I 230 The Strand Lane, East Marion o I j Temporary Sand Bag Wall L--J. -- TYPICAL SAND BAG to Protect Distressed Slope L Return at 12 ft_overall RETURN ELEVATION Scale:one inch=5 feet By: M. A. Kimack Dated: Nov. 18, 2019 I TEST HOLE DATA PERFORMED BY M.DONALD G£OSCICNCC EXISTING GRADE SURVEY OF er9.w ML>r tau a LOT 136 N 44' 10'E IN ' r N 3B' 09'30' E 55,00.00' erowN T¢Jr slxP f4.16' MAP OF PEBBLE BEACH FARMS eeP„x �nY AwP sc SITUATE APPROX H W.L EAST MARRION, TOWN OF SOUTHOLD SANDY erowx MLn—9 wrm to-wx c..rTL Tx BEACH SUFFOLK COUNTY, N Y BOTTOM OFF OF TTOM Or BLUFF s —1 SURVEYED FOR. 15 WILLIAM AUSTIN MARIE THERESA AUSTIN 20 3 --25 Ly ' FINISHED GRADE }.;I MIN z'udx ZONING R40 0 b JOO SF yy AREA LL TAX YAP NO ARCA 2 40 LEACHING U1 POOL J000-02J-05-06 N 42' 151-18 90 ` 3 ' ?D7 £TIE LINE TOP OF BLUFF 2' MIN GROUNDWATER CAI 515 9CM AS PER FM/ 6266 4 7 TYPICAL CESSPOOL SYSTEM SCALE Jf,924 larARFA=3!R S! LOT 137 N. i 5 07329ACRES SJ LOT 135 TOPOGRAPHICAL 5.e CREST OF DUN,- 56 UN£56 FM,' 6266 cl 55 V t FINISHED GRADE FILED JUNE 11, 1975 MIN S[1FFC11R COUN 1.0 " 5 J 7YDHPARTAffN'E OF HEALTH SERVICES 7'MAX t ' PRO [D /e•/' BY W25 ELEVATIONS/N NGVD, 1929- 3 STON P'l01MIT FORAPPROVALOF CONYMUCITON FORA •2 PATIO BINOLEFAMILYREMENCEONLY i 2 TORY 51 B'MIN TO CESSPOOL N SE aMs�-7-98 RSREP.No.R//0J-9�-0/D/o .5' ' 10 'JGl/L �an A//.Tfi,L., 900 GAL SEPTIC TANK W/ BE ROOMS 10APPROVED� -_ sv' 7 W FOR MAXIMUM OPHEDROOMS GUARANTEED TO 2 : 49 EXPIRES THREE YEARS FROM DATE OF APPROVAL TYPICAL SEPTIC TANK 4 WILLIAM AUSTIN PR POSE r MARIE THERESA AUSTIN 5E TIC O TOWN Of SOUTNOLD 19 1 •Y\ V s h SUFFOLK CO. HEALTH DEPT APPROVAL ROP 5[D e MI C55 L STONE WALL OVER H,S. NO r c 45 'g p, STATEMENT Of INTENT SM I \ 'ICl/ THE WATCH SUPPLY AND SCWAGC DISPOSAL SYSTEMS ET G FOR THIS RESIDENCE WILL CONFORM TO THE STANDARDS SURVCVCO 155EPT, '97 /I\ V \ 45. p �} .,.,,,,rte of THE SUFFOLK CO DEPT O!HEATH SERVICES S 4 57' 05" W I-- BI R=20' SURVEYED BY 25.40' J 46 J9 u BS 11 L=3.42 �' s A .ISPPp 60 ryF H4LF RqI 4. 6.�O• *) `� Gu.rnntee+Fd-,.d here en+holt un TOWN OF SOUTHOLDY FOR APPROVAL OF CONSTRUCTION ONLY ron -IY W the Per.r wh- h.wnr. STANLEY J ISAKSEN, JR { I Prepared,and m h,behalf b Ih< DATE: P.O. BOX 294 sTP bne,q-W —f 1,.m el Agency, NEW SUFFOLK, NY 11956 '4Np ending maihhGry d Lsled herein,and APPROVAL. o the r a.gnee+of the lending,moNtlon 516-754-5835 ranee.ore rear u.n,4reble to SUFFOLK CO. TAX MAP D£SlGINATION NOT ,dd,,,—t mmb,tm,o«."L,_Rnanl own.I� DIST SECT BLOCK PLL INCL BURIED IC WATELITIESR, IN STREET 10 INCLUDE PUBLIC WATER,£LfCTRIC, 1000 021 OS 06 TELEPHONE,CATV ..,M,ned enern,m.r.aa,mn b OWNER n LurveY Ti o viololian of Sedim 7709 of I 2J(COUNT)3'NIGH EVERGREENS ENCROACHMENT(WEST PROPERTY UNC) Ih.New York State Ed.=Low. WILLIAM AUSTIN& MARIE THERESA AUSTIN AS FOLLOWS 5.4'OVER LINE AT SOUTH CND rAPCRlNG TO 0'AT 183' AWAY FROM ROADWAY LICENSED LA 0 SURV 2 ELECTRIC SVC(BOX)3 1'ENCROACHMENT(WEST PROPERTY L/NF) C.fue+of Ihu w y.mp not be«mg NYS LIC NO. 49273 J. WATER VALVE ENCROACHMENT 2 1'WEST PROPERTY LINE the L-d S—y-emb..J seal 9,oN 4 ADD rOPO CREST Of DUNC,ADJ'CLCV TO TRUE DATUM 4/9/98 FIN ke cmudend to be a raW Hu 5 REKTOP OF BLUFF UNE 4/27/98 97C649 6 SHOW PROP RES 711/9@ ooly Michael J.Domino,President \\Qf sorry Town 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 '� �� Fax(631) 765-6641 COUNT`I,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No.: 9600E Date of Receipt of Application: November 21, 2019 Applicant: William & Marie Austin SCTM#: 1000-21-5-6 Project Location: 230 The Strand, East Marion Date of Issuance: November 22, 2019 Date of Expiration: 90 Days From Date of Issuance Reviewed by: Trustee John Bredemeyer Project Description: To construct a sand bag wall approximately 69 feet in width 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 21, 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 SOUTHOLD TRUSTEES No. 11600c - &ft4rwjnwpvbtp Issued Toi Date- Ilbma]19 Address a50 fit Sk�. 6%a4- 14ars'pan THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765.1892 Michael J. Domino, President ®�QSUFFO(,�C Town Hall Annex John M. Bredemeyer III,Vice-President _ 54375 Route 25 Glenn Goldsmith ro a P.O.Box 1179 A.Nicholas Krupski Southold,NY 11971 Greg Williams Telephone(631)765-1892 ®� �a Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Date/Time: Completed in field by: Michael Kimack on behalf of WILLIAM & MARIE AUSTIN requesting an Emergency Permit to construct a sand bag wall approximately 69 feet in width 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; and to remove all storm debris on beach to protect sand bags. Located: 230 The Strand, East Marion. SCTM# 1000-21-5-6 CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=� 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 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: 6111 -4 r-A l&Y' C b IUB I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: J. Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other ie c m 4 , .s a - 4 y 4 x a'" 5t M � AN- it r ' Ilk 7v /yam�r^' i'" .♦ A INN .03 i iY - < S- g c Z �. *t v `\ 25; tC Pp ♦ �� 5 Y 9 y )° A- Xi 15 G..._a'*° r �.•��'i .•. !' 2p'P,lcl `rSa`aP 7. 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M e� „roe ttt�tt ya a\ � „♦ �' ` ,^`aka �a � e • ,o ��� ry°t „ - - - _ 1 4 ; .., a Cyt°. ,•, 1 / 1- n. 1 1 � •6 o.ir— 04 • Mir- 2 io w . rn L e '�e + eta• - + � ,. 05 » w• -tar • dr, h� • )e „ It�p 016E'a eE 0. fSEE n[�-clq e t � y ' �£� ..�4-. 2� r ... ,,,v, cru,,. COUNTY OF SUFFOLK N n TICE K ,,,�„� —T- E E w��-- ¢ �— —— u —�— d.. —� •.• . Beal Property Tax Servt�c nye-cy W _ E ..�.a�.....0.'...'�~E r �. Amo .xoa . -- —-- —— — — ._ m� .,o.M n,�a, a � : i� 021 J 4 Michael J.Domino,President , �� Town Hall Annex - John M.Bredemeyer III,Vice-President 54376 Route 26 P.O'.Box 1179 Glenn Goldsmith F` Southold,New York 11971 INC A.Nicholas Krupski Telephone(631)765-1892 Greg Williams l ` Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF�SOUTHOLD / This Section For Office Use Only Emergency Permit Application Coastal Erosion Permit Application �, Wetland Permit Application !'� L4 Vf _Administrative Permit Amend ment/Transfer/Extensici Received Application• NOV 2 1 2019 Received Fee: $0 Completed Application: l Incomplete: S0010Id Tow,,n SEQRA Classification: Type I w Type II ^_ Unlisted g0 rd tlntstees Lead Agency Determination: -Coordination:(date sent): LWRP Consistency Assessment Form Sent: __CAC Referral Sent: ^Date of Inspection: Receipt of CAC Report: Technical Review: -Public Hearing Held: Resolution: Legal Name of Property Owner(s): W1 CL H I' AIIY7- I! - Mailing Address: v z f_e-.4s'T tL42, M W y !>9'3 Phone Number:. .� Suffolk County Tax Map-Number: 1000 - Property Location: 2 D TqE zr-r 5'T &ARAW (If necessary,provide LILCO Pole#, distance to cross streets, and location) AGENT(If applicable): ! /�' �C�� L_ ,lW_C14 Mailing Address: l? d. One lad-7. SN-3YZZ 9 77� Phone Number: 'hoard of Trustees Application GENERAL DATA Land Area(in square feet): ��7 Area Zoning: - Previous use of property: 0�T/AL Q,t(/� A54ly/ y Intended use of property; 1 W.IdE Covenants and Restrictions on property? _Yes X No If"Yes",please provide a copy, Will this project require a Building Permit as per Town Cour:? Yes ;�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 _ 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 No Does the structure (s) on property have aYalid Certificate of Occupancy?_xYes No Prior permits/approvals for site improvements: Agency Date 7Vf!7lVr1(Io't/cZ71,R1g�,y-z7R _No prior permits/approval;: for site improvements, Has any permit/approval ever been revoked or suspended by a governmental agency?__4 No Yes If yes, provide explanation: Project Description (use attachmf;n.ts if necessary); j" _&ZreQ0r A ,S'Ait/1J�G o(z) Ce9QP QeF �G�A� 6 icx ic�'�LCJC"�7 T S~e e�U� D vN�a�rlso�il�Ar. � /1/r,"F(,U S' ND 94G j1.,U1)Z.L "4 a O GUS ro � U' -r, "A911-1ZE /_716- e JAN, 46-r- 6 G!>4 CZ. , lrr --� - v'� -(D --A554QV-mac- e°c-7`�' --SXW0 13A = Board of Tru-St',es Applica—a WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations; _ _.,t�.'�L21c Lc�lp(� ✓a��,,� Area of wetlands on lot; Q squ,,re feet Percent coverage of lot; Closest distance between nearest existing structme and upland edge of wetlands;_NZ'4— feet Closest distance between nearest proposed strut-lure and upland edge of wetlands; V 'ate feet Does the project involve Oxcavation or filling? ,,._No X Yes If yes,how much material will be excavated? yards How much material will be filled? cubic yards Depth of which material will be removed or deposited; _ feet 9�0 Proposed slope throughout the area of operation,3;,___r— ,4.T Manner in which material will be removed or deposited; Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason,ofsuch proposed operations (use attacluntn.ts if appropriate); -Board of TrustwDs Application COASTAL EROSION APPLICATION DATA Purposes of proposed �'ey 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? —_ 4 (cubic yards) ��' How much material will bar filled? ....,, (cubic yards) UMAe—r-4e 1/NA.A-'-1 Manner in which material will be removed or deposited; Describe the nature and extent of the environmental impacts to the subject property or neighboring propel$ies c•eaaionably anticipated resulting from implementation of the project as proposed, including erosioyl increase or adverse eff,cts on natural protective features. (Use attachments if necessary) 4-1 V12 9Z- &ACr �OriJJM��iTiS'L. Loard of Trustees ApplicatiO- AFFIDAVIT WIZelg& /��� l/ ,BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE 113THE APPLICANT FOR THE ABOVE DESCRIBED PERMITS) AND THAT ALL ,>TATEMI�NTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER 101OWLEDGE AND BELIEF,AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES, THE APPLICANT AGREES TO HOLD THE;TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES,THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL,TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of Property Owner Signature of Property Owner SWORN TO BEFORE ME THIS—=—�� DAY OF Notary Public MICHAEL A.KIMACK Notary Public,State of New York No.02KI5056823 Qualified in Nassau County Commission Expires March 11,2022 i Board of Trustoes Application AUTHORIZATION (Where the applicant is not the owner) owners of the property identified as SCTM# 1000- in the town of eA17-- `I.�1, ZOW .New York,hereby authorizes to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. Property Owner's Signature Property Owner's Signature .403711 SWORN TO BEFORE ME THIS� j DAY OF_ 40 YZ 20� 9 Notary Public MICHAEL A.IGMACK Notary Public,State of New York No.02KI5W6U3 Qualified in Nassau County Commission Expires March 11,2022 A PP LI CANT/ALGENTf.REP RES;ENTATIVE TRANSACTIONAL DXSCLOSI=,FORM �o�rit dt Entitlta(d'e &cic.`ofr ihiits.prohlbit .a�ttli' net. flnt "+ I:U14d? !�f io n offia rs nn d crfialovcra 'n% t�raksa 2f this form 1840 nrovido lnfo��llpn� itich eorr nlrr4 t11fi(dip Q1 ,1115 'of lntG4p altos ft airh wlltli�Yer aCllon is 110cgc rpt to o�dfd sonic. 7 YOUR NAME; ('Lusk name,first name,middle Glllial,unloss you are applying in the name of someone else or other ontlty,such as a company.if so, indlonte the other person's or company's name,) NAME OF APPLICATION; (Check all that apply,) Tax grievance _ Building Verlance _, Trustee Change ofZone Coastal Erosion Approval of plat Mooring tixomption from plat or official map Planning : Other (If"Other",name the activity.), c? you,pomoiwlly(Qr through,yoUr,comparry,spouse,si6l1n94artsn4 o'r chil�.)'liavu a,rcltitionshfp'.wttlt any olTlecr oranipioyoc ofthe Townaf Saut#tald7 "i1.alAttoatsitip"lrialutfcsdty hloo'd,tllarri�g'a,,brbuslTress•lhton;sE F3uslrt�sinturest' trnsanSa business, Inoluding.8 pnrtnorslilp,In wtitch the town oftlpbr or employeo has evan-wpartlal ownctshfp,aP(6r nntiilayhient by)a catporatlon in whloh•dtb town officaror emplopea owns morothan��/o,of the sfrnnis, YES NO f" if ydu answered"YES",complete the balance or this form and date,and sign where indicated, Name of pcmpn employed by the Town of Southold _ Title br position of that person_ Describe the relationship between yourself(the appliconVpgenVrepresentative,)and the town o,MQer or employee. Either check the appropriate line A)through D)and/or describe In the space pro1ided. The town officer or employee or his or iter spouse,sibling,parent,sir child is(chock all that apply); �)lho ownbr of•greritor titan S°A of,tha shMs of the carporato stock of the applicant (whon tlto nlspllcant is a corporatlort), B)the legal`orbanr,`tielsil ow narrAnhy interasl in a noWcorporatc entity(whan tate appli""canbls not a-aorpbrnti;n), G)an officer,director,puriner,or-employee of•ilte npplic"t,or r D)the actual appllcant, DESCRIPTION OP RELATIONSHiP Submitted this da of /(/0 20/0 SI'gntituro�� Print Name Form TS 1 A JP P LI C AN VAG ENTfREP RES ENTATM, TRANSACTIONAL DISCLOSURE,FORM The D)YA of St+titttnld;�C�'of 1�th1c5 prnitEbits.confti� L�f�p�L�ISII��f lawn oflic�rs und.ernnloyaea l7 G.nttmoso 0� this form ls••to Zvi Q)nformutlon.lvhtoh enrr rrleP4 t144 Cnwn^nf s( k JL 111lGtffi Ji .r111o�v it to inky wlintt ver a lion ie nCCe& to nydld 5'nn1G. YOUR NAME; /¢U1 _ LI�A�I . (Last name,first name,.r�ttddle In tial,un loss you are npplying'lathe name of someone else.or other ontity,such as a company.If so, indicate tht other person's or company's name,) NAME OF APPLICATION; (Check all that apply.) Tax grievance �, Building Variance _ TrusteeC , Change ofZono Coastal Erosion Approval of plat Mooring l;xemption from plat or official map Planning Other (If"Other",name the activity.)_ Eo you-persotwlly(or through.your company,spouse,5161 ng,pmtnt,or child)'hftvc*a roltidonahlp'with any offl"r oremplcyeo of theTown-ofSoutheid7 "ltalaticnsl►ip"lrictucics by Mood,lttarrl.ogg or buslrresys Ihtoresc"Fiusincss intertst'l Matas a businesv, inaluding.a partnorxlitp,in which•thc,(own OfflIF r nr employee has rvan�a partial owna�sh'rp.of•(6r employment by)a oorporatlon in which•the town oMecr or employee owns morn than�6/o•ofthe s'hsuus, YES NO if ydu answered"YES",complete the balance of this form and date;and sign where indicated, Name orpcnpn employed by the Town of Southold _ Title or position orthat person, Describe the relationship between yourself(the applicant/agenVrepresentative)and the town officer or employee,Either check the appropriate line A)through D)and/or describe in the space prOided. The town officer or employee or his or her spouse,sibling,parent,dr child is(check all that apply): A)tho ownor of greater Mian S°�of the shnn;s of the cnrporatc stock of the:applicant (when the nppllcant,Is a c:orporatlon), B)the legal orlycnAoW owner otnhy,htlercst in a noWcorporate entity(-whop the applicanbls not a corporhtl;n), C)an oftlLer,director,ptiriner,or employee of•iho applicant;or D)the actual applicant, DESCRIPTION OF RELATIONSHIP Submftted this day of A/.0 V 2 Ll Signature. ' a Print Name_ /v1 Form TS 1 + APPLICANT/A.GENT'/REPR.EuENTATIVE TRANSACTI0NAL DISCLOSURE FORM -he ToNvh.dfSootholdtsCbd'c•.otrnnrtoFigytn,bj cfiL4.nn e�pf�) •aa 7atc.numnsa4L' lhts,foML,La prey p)nitsrtnation-w1i{alt gnn nl.rri t to .;�( t IaSs oPltttcrast•nn 11aw f�{a#tiktcwltnttvcrabllon is ncca to ovdid YOUR NAME; ~i . Ck ( tst name, first name,jplddle htiflal,unlow;you are applying In the name of someone els(,or other entity,such as a company,If so, Indlente the other person's or company's name,) NAME OF APPLICATION; (Check all that apply,) Tax grievance Aullding Varlance T Trustee Change of Zone Coastal Erosion Approval of plot Mooring Exemption from plat or official map Planning Other Of"Other",name the activity,) Co you•persoivlly(ter through.your.00mpany,spouso,sl61Ingrnaron4 o'r chitq)linvo•a,rolddonshfp°.with any ofXlmjr or onfpioycc of the Towwol`Southold? "I*.ahitionship"lrioluc{csdtyblond,Morriigp,br busltress•IhtamsC°Idusir ya•lntcr�st'+trwans•n buslnass, Inaluding,a pnrtnorslilp,Ip w'tileh tltw•towtt o�cor or ompioyeo has ovama�partla14t4rtot tttlp•af'(or a-rn loymeni kly}a•corporatibn In whloh, tb town offlear,or omployec owns Moro•(ha0%,6Pt116 e'nd's, YES NO _ If you answered"YES",complete the balance of this Form and date and sign where lndlcattd, Name of perspn employed by the Town of Southold Title br position of that person Describe the relationship between yourself(the applionnVagottVrepresentative)and the town o,lllcer or employee.Either check the approprloto line A)through D)and/or describe In the space provided, The town officer or employee or his or her spouse,sibling,parent,err child Is(check all that apply); A)the ownbr oFgrenter than S0/6 of:fhe Wares of the cerpotnto stork of the appilopnt (whun tlto npplIctutt Is a corporation); 13)(ho legal`orbendf)clat rrwner of nhyintcresl in n non<orporatc entity(when the uppll6an419 not a porporttt9(5n); O)nn otTlvor,director,Tnrtne:t,orantployee of-the applicant;or j D)the actual applicant, DESCRIPTION OF RELATIONSHIP Submitted this 1_9 Jaya A10V 20,// Slgnalture Form TS 1 Print Name G