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HomeMy WebLinkAboutTR-9616E Property width: 78 feet(1230) Property width: 65 feet(1150) i cm N ^ n� Sand bag width(1230)78 feet Sand bag width(1150)65 feet ;Y PiCAL SAND BAG �] WALL ELEVATION estimated eroded slope estimated unconsolidated Notes loose sloughed soil Saud bags: 36' x 36" x 40- D First row fully buried to grade 2nd and 3rd rows staggered approx.line for relocated ggered as shown loose soil behind sand bag wall Returns: 3 bags deep behind front wall I Nick & Ekaterini Mihalios existing grade 1150 & 1230 The Strand, East Marion I Temporary Sand Bag Wall 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. 22, 2019 I Michael J.Domino,President *QF SUUl� 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 Q Telephone(631) 765-1892 Greg Williams 0 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No.: 9616E Date of Receipt of Application: December 9, 2019 Applicant: Nick & Ekaterini Mihalios SCTM#: 1000-30-2-73 & 1000-30-2-74 Project Location: 1150 & 1230 The Strand, East Marion Date of Issuance: December 16, 2019 Date of Expiration: 90 Days From Date of Issuance Reviewed by: Trustee John Bredemeyer Project Description: To construct a sand bag wall approximately 78 feet in width (1230 property width ±78ft.), and approximately 65 feet (1150 property width ±65ft.) with one (1) 12 foot return (west); 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 December 9, 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 16 oelp rn� 4+w Issued To M. Oketw j�� l�t IG Datelg Addressil:570. 012391ho S4rv4j# 'E&m+ffle:cfmq ' THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765-1892 Michael J. Domino, President O�Q CSG Town Hall Annex John M. Bredemeyer III,Vice-President �,, 54375 Route 25 a .c Glenn Goldsmith o ;_ 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: g. Completed in field by: �', RyeJ,9M''P' Michael Kimack on behalf of NICK & EKATERINI MIHALIOS requesting an Emergency Permit to construct a sand bag wall approximately 78 feet in width (1230 property width ±78ft.), and approximately 65 feet (1150 property width ±65ft.) with width one (1) 12 foot return (west); 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: 1150 & 1230 The Strand, East Marion. SCTM# 1000-30-2-73 & 1000-30-2-74 'CH. 275-3 - SETBACKS WETLAND BOUNDARY: Actual Footage or OK=4 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/comments/standards: V r/p 3 S �,4 &Yv�7'�" / �J✓1/Yl. f".✓�sy11 '�"t7�H �"c7 `r ����-���U�-�S ����Y,' �Q���'rJ. �'"�tie �r �f i� e s,��-►�� �alt1G I have read & acknowledged the foregoing Trustees comments: Agent/Owner: Present were: Bredemeyer M. Domino G. Goldsmith N. Krupski G. Williams Other "a` 'f,', gra.>-• - _ n3;'�► SN L �T V ;r y t ii i ., wlvpp' Y �.i 4y P" s r . i .,r. .... #..,Rai„�'► � .?� G r �fi , 6 p �W..���'r"i<' _ r 91 SEE SEC.NO 021 _ 90 Ksr MATCH UNE N35B082 92 b` v'. 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FOR PCL.N0. 1' �- SEE SEC.NO. 035-02.017.1 FOR PCL.NO a° e 035-02-001 SEE SEC.NO. 035-022-012 ,39�c\ +r ----- ------ --�-- ---T---U E q 19P� MAicH� uNE NJSz zB2 V SEE SEC.NO. 035 a NOTICE m1nv7 COUNTY OF SUFFOLK © K TOWN OF SOUTHOLD SECTION NO _ E MAINTENANCE,ALTERATION,SALEOR 4 Real Property Tax Service Agency Y +� DISTRIBUTION OF ANY PORTION OF THE � � Co.nry CsniSf RlYeTVILLAGE OF eetl,NY 11901 Ob W+ 30 SUFFOLK COUNTY TA)(MAP IS PROHIBITED �1" � SCALE IN FEET M VATHOUT VQTTEN PERMISSION OF THE 'v/q �1� 100 0 100 400 A DISTRICT NO 1000 REAL PROPERTY TA)(SERVICE AGENCY �W P 0>5 PROPERTY MAP CANVERS10N GATE.Apr 15,1012 ate+- � a > «« ,.x. „a nw•.. . .. i �m�r & ta; p ^^ Y A 9B e ] L to IN j tl am e r p1 n e, p n ao n n / m n O ior3 1- tl n eM � 11R i x A tot tl tl m.M taA i Y ea 11 / 1ta taet.er.c91 11] '1M Y A c ,te ea A PJ Y Y �F(�] CRESCENT ^ ^ m Ito to tm �' B /• Y .$y at �t0. a ]t tm t@ t°° P art ut � tl r1� V '@,m CFtO`•+ 19 t] " 1m I e� --Na s n t9 9EE sEc tq. to •/1] m 9 e � tm .0- tm ^ j QO s % e 4.M /• Is ° FpI PCL NO 'EP , mm.No ive.twnu+ // mSea-0t].t FOR PCL NO 9EESEC NO // m6@-011 FORa a. ¢\ / SEF SK.O. —C NO —) FOR PCL NO. ~ P etlol-0ae 01Sea-001 mem-0-01N0 \ N IMTCN Ril P[C NaeR a e ^,,, .. — — e..� -- it --•-- ^�„ v's'%,e^'ro NOTICECOUNTYOFSUFFOLK © K ff eouTNaa SECTION NO Property Tax Service Agency Y Fa Ece.nrycw,a.RN.meee,Nrnrot Y 30 N_Ir• ]+NRw au r �__� u --r—� air--.w-- ..�PP� ~r act xo P tM0 PROPERTY IMP G79f i Michael J. Domino, President {���� `p�� �, Town Hall Annex John M. Brademeyer III, Vice.President 54375 Routs 25 Glenn Goldemith t � � P,O, Box 1179 Southold, Now York 11971 A, Nicholas M upski Telephone (631) 766.1892 Greg Williams t 01% Fax(631) 765-6641 BOARD OF TC►'I;VN TRUl!3TEES TOWN OF SIOUTHOL'D Emergency Permit Appl i a is Section ForOffliee Use Only _Coastal Brosion Permit Application , Wetland Permit Application _Administrative Permit Amend ment/Transfer/Extensie>n ' ;�, ,' ?" •' r F` Received Application', _Received Fee; $-� _Completed Application; ( incomplete; -1 DEC 9 2019 __SEQRA Classification; Typed�_ Type II___ Unlisted _Lead Agency Determination; _t_Coordination:(date sent); LWRP Consistency Assessment Form Sent; �� w -_CAC Referral Sent; Date of Inspection; Recelpt of CAC Report; Technical ,Review; -Public Hearing Held; --..Resolution: Legal Name of Property Owner(s); --RICM�AZ/dS Mailing Address; ,;5' A4 N Y Phono Number;_ l Q`7 Suffolk County Tax Map Number; 1000 - - w?'IV— _ /C - 0 -�, 74 Property Location; Z LC-1 O !�Q_ l) CN.� � K (If necessary, provide LILCO Pole #, distance to cross streets, and location) AGENT(If applicable); ��� '& Mailing Address; Phone Number; Hoard o Tru; t;;3es ApF�1 iaa�:...::n GENERAL DATA Land Area(in square feet); /®,�D ' ?8.31 /ZOO -- 74�- Area Zoning; Previous use of property; P �1�LcJV i�LOAOiE� A4" y Intended'use of property; _ ,� L p_A4 F4t14y Covenants and Restrictions on property? Yes No If"Yes", please provide a copy, �— Will this project require a Sullding Permit as per.Town Code? __Yes --y—NoIf"Yes", be advised this applica.t:jon 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 —L),"o Does the structure (s) on property have a valid Certificate of Occupancy?--�/,—Yes No Prior permits/approvals for site improvements; Agency Date L1s / o Nom �e�S�/cryo No prior permits/approval,, for site improvements, Has any permit/approval ever been revoked or suspendei1 by a governmental agency?X No Yes If yes, provide explanation.: Project Description (use attachments if necessary);IN �O. /�/ �J •U l� 6CJ.fZL L �l- W/OAI,E Cl) c 7 &rveAv tU-/ 57), GIST NJ' �3.9G CoU�Psf � 7 , o roU�PS'�sAff6 Vele1J7AGC5X40) - Pel UMc AIJ-04047ZED SM- 47- 9-4125 a - .p -Pe opt </� 4Cy 560M!) R26 WKAIF,044,.466 3-0 JSP 131165' G owtl- Board of Trust:��ies App:Lica'�ivA WETLAND/TRUSTEE LANDS APPIaICATION DATA Purpose of the proposed operationsi_Z0_P..RD1ll� Area of wetlands on lot; Q square feet Percent coverage of lot; Closest:distance between nearest existing;struetur°e and upland edge of wetlands;-- ,4 ---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 /80 77V LOSS, How much material will be filled? .� 7 t �-.—cubic yards BaJ;V . . Depth of which material will be removed or deposited; _'9_feet 741 Proposed slope throughout the area of operations;,,J51A_r_ 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,of such proposed operations (use attachmei'ts if appropriate); ----------------- Board of.' Trusi,(a©s Applicat.Lva COASTAL RROSION APPLICATION DATA Purposes of proposed activity; _PQf �,¢ Are wetlands present within 100 feet of the proposed activity? _JL No Yes Does the project involve excavation or filling? _ No _ A! Yes If Yes, how much material will be excavated? � (cubic yards) How much material will be filled? _ (cubic yards) U/Y�.� RH/� G ��iS?/iVIJGI/4G G Manner in which material will be removed or deposited; Describe the nature and extent of the environmelated impacts to the subject property or neighboring properties reasonably aJYWpated resulting from imlziementation of the project as proposed, including erosion increase or adverse effects on natural protective features. (Use attachments if necessary) 407 iv eh,P,4 cT �! �1" Z "' N® '�✓,Q coN,y�T7o� Board oil Trustees AP;plication . _„__,BEING DULY SWORN DEPOSES AND A1+FIlR,NIS THAT HEVSHIr T9 THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BIES T OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BIP,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 HOLDTHE TOWN OF SOUTHOLD AND THE BOARD OF TRUS'T'EES HARMLESS ANI►FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY V71RTUE OF SAID PERMIT(S), IF GRANTED, IN COMPLETING THTIS AP.PIJICAT]ON,I HEREBY AUTHORIZE THE TRUS'T'EES,THEIR AGENT(S) OR REPR28ENTATI'VES, INCLUDING THE CONSERVATION ADVI.SORY COUNCIL,TO EN'T'ER ONTO MY PROPERTY TO INSPECT THE PRIr,MZS.ES IN CONJ'UNCT[ON WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION, I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTEI, ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDI'T'ION OF ANY WETLAND OR COASTAL £ EROSION PERMIT IS-i)UED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT, F 1 yl ii+4( 4 3 C Sig ature of Property Owner '"- ��z"` `' ' Signature of Property Owner 3 i SWORN TO BEFO,U M.3 THIS 7 U,'►Y OF_ ,20/ ko�aryublic MICHAEL A.IdMACK Notary Public,State of New York No.02KI5056823 Clualified in Nassau County Commission Expires March 11,2022 Boaxd Of T,euat:e)es Application AUTHORIZATION (Where the applica(atis not the owner) owners of the property iduntii:ted as SC'rm# 1(►0(). �.. in the town of' `-L� -----.-�_:New York, hereby authorizes �'�►���L �--����.��� to act as my agent and handle all necessary work involved with the appliogtion p"ooess for permits)from the Southold Town Board of Trustees for this property. E r f � =� Prop y O'wner's Signature f- A//Ck AY1#W2-1j7$ Property Owner's Signature SWORN TO BEFORS MJ,THIS �G! DAY OF 20_ZZO Notary U P—I is � blic MICHAEL A.MMACK Notary Public,State of New York No.02KI5056823 Qualified In Nassau County Commission Expires March 11,2022 APPLICANT/AG ei1'",f'/REPRr8BNrTAT1VE TRANSACTIONAL DISCLQS,,uR, p ORM a' a r !•• t ��;G.IS�Ilsfmt.orolr�lt„h�rtn�;rr;IO(",r:1::lllt9).6't'o r n•t u lltl. Q1hLl;i l"0 nmvid0lnf'crc�}}(ynj � „ i. ►-- hQlcnrc nri,onfal�vrn,s,7'tre ( nntq_nr 1L,1L4.'.1A._t}' .4-L{11��.!v1t� '.,Gif;�(}x.44! ► Y•oF�y. y (•1ri�r, n c:r�4�.� neC csnry,n•nv_•___•___�,Itl�'nn�, �41 j 1);� ntortis'IYnB•�.,►t;n' wlsn! v r YOUR NAME: �^ (!asl name, flr.'t name,.rp(drlle 1,11IInI,unlouvYD'u are appiyingln Lho name of 3emeonc clss cr other oniliy,such as a cornlraty, ffso,In(llonto the other Person's or company's name,) i NAME OF APPLICAT'}+)N; (Che(;k all 11;01 apply,) Tax grievance Yerlanee Dul)ding ChangeorZone Trustve Approyo,ofpla( — --- _. Cotist.il E'roslon Lsaniullnn from plat or o.rici,l mal) `-"`— frooring Other ---,_ , Pla•nhtg (lr"Other",namc the actrefty,l _ ------- -1 __.__ ——�., !3o)'ou fir onglfv(t r Il(rttlg}t.your.coulpany.SpDtt5b,slfillitRr{rrrtgk e'rchHc))linvo n,rcirttlonshlpp whll anyofilvcroFunipl4ycr• oPIHoTownvf:Sbu{hold9 "italtttl,tivhlp"iriolutlesrttyhib�d,lilan,f+lgp erbusllrgas:lli�cresc "Buslgcy�,Intorsst'+`Inoansnbuslnus.v Inaladi'rlg. n0rsfi;p,Iii w?ib)l�l;il: to'.vn:afJlcbrpr cm i4Ycu°ilfij,}Ye l u p:rtlni•o.vnct ttf oF(orArrtp'lagmdnt lfyf n,curparoCo,i In whfohd10 i0 fcl town 0'Cflcer0r 0rnploysc otivns moro•flmn.';o:afth�sl;nru5, YES NO Iryoa ons '"red"YES",c0mp1:tc the bntanee ot'thls I'0i m end cn(5 and sign whsre Indlcatod. Namo 0fpe•5on employed by the T;)tvn;rSouthold Title or position of Ihat person�� - ------.— Uescribc the rala(lonshlp n belwe<: yo• urseir(the APP llcunVngenVrerw-scn'ativ0)and tho town o,Mcer or employee,Elthcr check the appropriate line A)through D)ond/w describe h1 the spaco,provIdod, Tne Iown o(ircer or employee or his or her spouse,slbling,parent, d Is(check alf'IHnt apply); t)+tin o+vn4r 01'6rcacr then Se/,ot;th sNIM 01AIL corparr w sto rk orthe nppilc0nt (tvllon dlu,tppJJcr.nl-fx R oil)Jxr:"folf); 8 ?)ilr,lbgnl orbcn0flvirif owncr or•nivinterasl Jn it non•coq--orate enflty(vr116n Iha uppi;eont•Is not a eo;•pvm, lon); 0)ner.at?lyor;t(irrti4r,•;;mince;or alnl)loyu0 or'rho upflllcanh ur D)the e0tuel oppllcanf, DESCRIPTION OF R>rLATiONSHip _..._��_ -------------------------- Suboiitted this _ JP of Signature ] Z �,Q ! Pvrm TS i Print 1Jam X44 c�� � PPI,XCAANT/A.GRiVx'/ijri PRE SENTAMt` TRANSACTIONAL D18CT,(D8VR>✓ FORM I' L"ff rtL tlhnh o > klllalml, t r Ulttlslh�r "+ 1L�l fu�':11214J:e l nrt�J+�,t2lllt rsP•tnyin.hllTc r,nl s 1 ec.c ;,, .�• �'�'.miSsllsr�i• tin,, Y!; Q:r ' t#ILxS#:�Iit724�if�Jt�S.��CJ.>3 pfd 1 i�;�;,to• ..1Y1fc+.�k.U::t:rilntLt" YOURNAMBI . ((tisk nc me :1rsI name,. li! lc Mill ideti,i y`('u Art,al;pl},Ing"ti-EO"'M, sorneone el•;o or ofher o e of ntlty,suvh ru o uti rnhary, Ipso, hitil'a,nro Ihi3 other person's or company's namo,) NAME OP APPLICATICN: ;Check all that apply,) Tax grlevartce variance ---- Building Change of?one Tntstoe Approvolofplot - oasttJE-oslor —,____� B`011101011B`011101011from pial or cfliolal mcfrMvoI'hig Olher (Ir"Olhtr" n — —"" ame tho activity,) 110 NAt3•pS)N'pflBll}' Rr f1lt,ilf;f1 � -----`---..—.. ..... ........,--...,_,.,_.,,. . � f. ,�oui;,�on; �Y,spouso..sllrling>1}cizint;,cr ah}i�)iiirlo:tt,ro}dtJoitslNp•'w,fl}i any ot):ici;r or uittpiny:c i oJriho`Taurrr'gf Satltliald,),"[ta!•t(tort;chfht'•.ltialut:cs•I}y•I>1oo'tl,•/lipn�?tfg'q o1�bU;�ItrQbs<lhtarest'ij3.u�(nat�s•In�arrsl't s In atth*.(a,poiinor it o Ir 1,q"l,Oh,:t�ln.tU'a+g biliGt r.t3r°ctrinfoyoo hntnivcr.a purtlni atvnct,thfp,oF';8r an>yiictrriteni tS�An�cy h onlb;� Ih whlandli dc,vrnm(lloar.or yrnl3JOYa;c.o',4rlq mora•thtfr,i.fc+;,,d��f'IfIS1lrsrs5, Yl YSS i Iryo'u answered°YBS", coriple;o the bmonce ot'lhfs form and data and;Ign where Indicated, Nzma ofperson employed by(he••T, Yn or;touthold_ Title or poshlon of that person Dcscribe the relationship bctwecn nppllc AlAgoitt/repr;sent3Nve;and tho� town Moor or employee, Bl(her check me epproprloto line A)threu;h D)ond/ur doscrlbo in tllc sycea t;rnvldad, The sown officer or employee or his or her spouse,slbl1q,parent,<•i chlid Is(chock all'Ihat apply); AS Ills,olYr}Nrr u'F'•gronlc=r th'a+1::%r Qr..gjq Yifaros of lhu N-n3rord,stork of the 11PPIleow i�iPaq Nip appllet tit IN r,op••poruflen); .,,..,�II}tt•�icgnl'ortxnCileJni 1olYnrtir•pf nhyhtloro,vl 1n•n nohrcarlacntto tnlltY(•iyhhn the apj MonWy Pot a'grt;:poi"nl'!un)i t7)np dlilcar;dlieti'wr,fsnrtnt:t,ot�unsf3loycc of•Ihc nppllcnnll•ur , D)the actuel•oppllcant. DESCRIPTION Op ULATiONShIIP~ Submitted this —Lay af, �z SlgnnNur N /1 / �y ,� Form TS 1 Print 1'}tuna APPI,ICANT/AGEN'7.'l.REPRESENNATIVE TRANSACTIONAL INSCLOSUR FORM mna ro�4t;,�f•�titltold!4 Cdd�'oP;�;�h?uft.pro(rf6ltx:an),�ats���''(nf��,�r,�:t��tff iakin,olpie.�r��•nnd:orfinlovtltrg,The nl:mo55t,2(' lhis,form}'s,ta nmvldo'Inforirwnlltrn: cll enn•nlrti ilia.na '.ti t>g'i451 s(1tol�ntdre�•pnd Itfloiv tt'41nkr wl,ataverllon is YOUR NAME: (Lust name, first(lame,xpiddle InIII81,unloss you are npplying•dn tha name of someone else,or other entity,such as a company, if so, hldlonto the other person's or Company's nam0,) NAME OP APPLICATION; (Check all that apply.) Tax grievance Building Varlaneo y _��' Trusloo Change of Zone s �`' Coastal Erosion Approval of plat Mooring >;xomptlon from plat or ofriolal map Planning "" Other ------- (If"Other", -----(If"Other",name the activity,) C>o.you:perso,wlly(qr tlfrnugh.your;,00mpany,spouse,sli;l)ngrh�u.dnt,o'r phll�•)'liave n,rel i(Ionshfptwi(h any of leur orunfployco oFlho 1`own of Southald'7 "�lalatfotwtiillp"irfolu(tcs by blood)1noglq'q,orbusllroas•IhtomsL I'D usino.Wdntemst"trscaua•a buslnoss, Inaluding,a pnrtnorsli(,In•w.'Hloh•gwe,towp OM,Po pr employed hnu ovcn-wpurtlal n•corporatlon In whloh•thb'town ofllcorvor omplo,ycc owns mord than c,o�thcus;hnru , YBS NO ..�_x If you answered"YES",complete the balance ot'thls Form and diac and sign where IndloaM, Name of person employed by the'1'owvn of Southold Thle br position of that personDescribe the relationship beiweon yourae.lf(the applloanVlwgetiVrel)resentative)and the town o,Moer or employee, Either check the approprlote line A)through D)and/or describe In the space proYided, The town ofilcer or employee or hl!i or her spouse,sibling,parent,sir child Is(ch(;ck all'ihat apply); A)the ownor of gred(or Won 5%o1`11a shros of the corpornlo stock of tho appllccnt (whun 1110 nppllcnrtl Is n c,orporotion); B)the logal`orbeno'fiAl awne'r oT•nhyln(orMal In-n non4rorlrornta on(Ity(when(11e applicant.Is not n parporr,(fon); G)mi o,MMcr,dfrve,,wr,partner,or-employee of•'IhC applicarrl,or D)the actual appllcant, DESCRIPTION OF RELATIONSI HP Submitted this&_day of W •S lgna'turo. Print Name Form T5 ! '