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HomeMy WebLinkAboutSchreiber, Michael & Kleinhaut, Iona Glenn Goldsmith, President ®��®f s®�rTown Hall Annex A. Nicholas Krupski,Vice President 54375 Route 25 P.O. Box 1179 Eric Sepenoski Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples �® ® �® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD October 6, 2023 Jennifer Leeds Leeds Expediting Services 28 North Country Road, Suite 101 Mt. Sinai, NY 11766 RE: MICHAEL SCHREIBER & IONA KLEINHAUT 14755 SOUNDVIEW AVENUE, SOUTHOLD SCTM#: 1000-50-3-7 Dear Ms. Leeds: The Southold Town Board of Trustees reviewed your letter received in this office on August 31, 2023 and the survey prepared by Nathan Taft Corwin, III Land Surveyor, dated May 30, 2023, and sanitary plan prepared by Labcrew Engineering, P.C., last dated June 16, 2023, and determined that the proposed construction of a two-story addition to existing single-family dwelling, a proposed gravel driveway and new sanitary system is out of the Wetland jurisdiction under Chapter 275 of the Town Wetland Code ,and Chapter 111 of the Town Code. Therefore, in accordance with the current Wetlands Code (Chapter 275) and the Coastal Erosion Hazard Area (Chapter 111) no permit is required. It is requested that the removal of hardwoods and mature hardwoods is done sparingly, as they are an important part of the local eco-system. Please be advised, however, that no clearing, no removal of vegetation, no cut or fill of land or removal of sod, no construction, sedimentation, or disturbance of any kind may take place within 100' landward from the top of the bluff, or seaward of the tidal and/or freshwater wetlands jurisdictional boundary or seaward of the coastal erosion hazard area as indicated above, without further application to, and written authorization from, the Southold Town Board of Trustees pursuant to Chapter 275 and/or Chapter 111 of the Town Code. 2 It is your responsibility to ensure that all necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdiction and Coastal Erosion Hazard Area, which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and the coastal erosion hazard area and your project or erecting a temporary,fence, barrier, or hay bale berm. This determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. Sincerely, Glenn Goldsmith, President Board of Trustees GG:dd TEST BORING EGE D: KEY MAP 5&8 0.0 MONUMENT ® GAS VALVE sOUNnvuwAVE Exr n1a luxe S- SIGN ® WATER VALVE M3 0'31 ® MANHOLE ® WATER METER v ■■ 6iT Old ® STORM MANHOLE Y GUY WIRE 48.8 9• � ELECTRIC MANHOLE X%.XX SPOT ELEVATION � O OCp EW ENG ■201N SAY ® SANITARY MANHOLE (XX,XX) PROPOSED ELEVATION SUBJECT a 2 N (CA" DI SANITARY CLEAN OUT PARCEL F —%X— CONTOUR STORM INLET z FP 33.B —KX— PROPOSED CONTOUR o '■•�■ P+ e� p CATCH BASIN —x— CHAIN LINK FENCE k ,� 1' 1 33.B 2V YyYo HYDRANT —o— STOCKADE FENCE W j z� BM■(gj ® TELEPHONE CONTROL BOXz —o— W000 FENCE _ O W 23.8 �' ® ELECTRIC CONTROL BOX(FLUSH) —S— UNDERGROUND SANITARY LINE y HKHM 06FC1FD ® TRAFFIC SIGNAL BOX —ST— UNDERGROUND STORM LINE W ? O mml■■nAToe m eL•s {r� F gyp T■E1yvAa N # LIGHT POLE —E— UNDERGROUND ELECTRIC LINE W UTILITY POLE —OH— OVERHEAD UTILITY LINE W Z O x NO WATER DCOLKIER D �] UTILITY POLE W/UGHT —T— UNDERGROUND TELEPHONE LINE Ll 10 z DWELLING 13 TRAFFIC UGHT POLE —W— UNDERGROUND WATER LINE 2� Zg ■ GAS METER SITE DATA: Q ARM,D+rnBr —GAS— UNDERGROUND CAS LINE I POOL PoBOXI004 soNxoln.n�rsal SITEAREA DIA.. 29,473.00 SOFT. O PHD 8(mi„�-s J W �' nATfl mrsa]] EXISTING BUILDING AREA(GROUND LEVEL) 1,350 SOFT. Z N 1 ``CESSPOOLPROPOSED BUILDING AREA(GROUND LEVEL) 2,365 SOFT, W // GROSS FLOOR AREA 4,412 SOFT. PROPOSED F.AR. 8.1 °b CESSPOOLS DATUM NAVD88 ZONE R-40 1 USE SINGLE FAMILY RESIDENCE THIS DRAWING,PREPARED FOR THE SPECIFIC PROJECT INDICATED IS AN INSTRUMENT OF SERVICE SANITARY CALIiULATIONS: AND THE PROPERTY OF LABCREW ENGINEERING P.C. I INFRINGEMENT OR ANY USE OF NOTES; THIS PROJECT IS PROHIBITED, UNSNTABLE SgLSMUST BE RE IM=TI ND REPLACE(WITH CLFAN SAND ANO GRAVELOSMUC HSiAAS TA OF(SP)0 WNGIROUNDTHE AN1'ALTERATION OR LEACHING STRUCTURES INroA STRATAOFTYPICAL LONOISLAND SAND AND ■ GRAVEL, REPRODUCTION OF THIS DOCUMENT ■G n -PRN ATE WEUSINUEEWITHNISD'CFSUBJECTPAFt EL IS ALSO PROHIBITED WITHOUT THE 'tl -THE RE ARE SURFACE WATERS OR WETLANDS LOCATED VATHW 20U OF SUBJECT yPROPERTY WRITTEN CONSENT OF THE -NOPROPosEOGASSERVICE. ENGINEER 9 -ALLUTLmESREONREASFOOTMINIMUMSEPARATONTOTHESEPT.SYSTEM. PROPOSE 2ERMANAG nO T7ANEN 1 PROPOSE025TORY ADDITION FOUR(q BEDROOM DWELLING=40p GPD REQUIRED. /yI4 a PROWDE: (1)HYDROACTON ANdGD•RATED CAPACITY.400 GPD,TOTAL CAPACITY:1,]38GALS. (1)PROVIDE B'G•tY EFF.;RATEDPPOOL WITH SAND WICK w(� MMIMUM LEAq 1N0 SVBTEM DESIGN ZER—CQR BEDRO-S: PROVIDE(1)YGa 1Y EFF.OEPTH LEACMWG POOL 215.96 ,ta iTE n IpgE FFMLE ]3E SIDE )W . TJME V1 N 4S• 3'20” E �Lr � ��,�' a A' C3 r Zymm]S Sa ❑ o ? e Z z o jg0.B2 STY ADDITION-- O bc� �O p J7 ND.BfiDR00h1S ' *•'G H, L"� 8®EJ co o a . ,.a...,.., ...._.. ../ .. ��SB.9 �Y YO `46v Ci O ak L c+twE/o q, //� ``cESSPOO xp Tm+V.� w yf[ AUG I 1 LO2 J �",.. `� .G}s Q °�� sy @<�"ror�• g+a e a ' (n $outh01dTown M' Board of Trustms PROJECT TITLE N % i• I s� . a ,"� ,'�1, a. '�+m°O- -1 �, •,2A'4�,}aa ' ON R ' NO. DATE REVISION axpdno,a� 1. W16123 nc — M O 2. W13123 ReucePhn(11x1 7) MAIF iBY*kA � 35'30" W 218.28' 476.86' � SURVEY PREPARED BY: Nathan Taft Corwin 111 Row of ssRLKE TIN)<5 t>�Y] [ L 3 P.O.Box ifi 11.o xl.o • D]GE of PAVER Jamesport,NY 11934 •-L•—' r m S MG (r PH:(631)727-2090 4 ■ ncorwin3@aol.com date.\ 012023 1Y SOUND VIEW AVENUE HOP'l S O 22.173 TP CIL g'tlb "`(� Flj'• =�. l] . (n ; ��c�.-.i Ill ; - MuwN ar �4�'vCIL DATE JULY 2023 c 0 60 120 ° R�Fess'c S P-1 SCALE: 1" = 60' SEAL SHEET N0.1 OF 1 oC FLAG /9 SURVEY OF PROPERTY FLAG #B SI T UA TE so, SOUTHOLD TOWN OF SOUTHOLD AL SUFFOLK COUNTY, NEW YORK S.C. TAX No. 1000-50-03-07 SCALE 1 "=30' y�"00 FLAG #7 MAY 30, 2023 & AL0CA .—\ I� AREA = 29,473 sq. ft. F� �F =o 1L 0.677 ac. 'P ASO• �� �`l 2D A FLAG /B Z? O • O oo v' N 2°°� oo� " NOTES: G41 GFSe 1. ELEVATIONS ARE REFERENCED TO N.A.V.D. 1988 DATUM EXISTING ELEVATIONS ARE SHOWN THUS:xx.x EXISTING CONTOUR LINES ARE SHOWN THUS:XX— — — — —XX FLAG #5 r.FL. - FIRST FLOOR G.FL. - GARAGE FLOOR TW. - TOP OF WALL 13N. - BOTTOM OF WALL A, AcG JIL MI6o 61.1 Sry N \ �-J• S FLAG #4 In 014 �ssAO�� \\ o°l • �Ol�tiy Gw 53.6 y o <<�o� 0 ti 1 • ��gGga� ,���� \ x 58.1 F ��"00. 4 $ 0. 1 60.0 / `6 62.3 '9 N x 59.4 J' _ X-52-23 A/ ` v 60.7 \S. �� ��0°e,61.,3 GQP.4 . SGV •. p{ a• &0.9 ' x 60.6 a , p •G�tp: ' ''•0�� /�Go eO � .. �c �'�0 61..0 �k o ,\Q j ° : 4„ x59.919 Q dj$y$� J'� , %4_ p, a. C?� ,p° ( °yt60.8 609 e•� pO 60.9 st.7 E QP` :••�(�' Y Ir0+,, �Aa . \ °t.B x 50.6/ \ °F . . � • V X 60.4 • \ / \ 60.4 • 6� of � ••��(\� ✓��'�O J /. 58.0' \ � 00 F 0 �^9�tJ� 57.4 Ai • PREPARED IN ACCORDANCE WITH THE MINIMUM °� STANDARDS FOR TITLE SURVEYS AS ESTABLISHED BY THE�y G45�e° I APPROVED AND FOR U HUSE BY YORK STATE LAND TITLE ASSOCIATIek4%1�� !/1// AFT 0 AUG 1 1 2023 = * * - = r . ^ — r • � of st es �i� tS'F, • .••046 m ••..• ` '`fjj10111 it N.Y.S. Lim. No. 50467 UNAUTHORIZED ALTERATION OR ADDITION t� n Taft Corwin III TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. Land Surveyor COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. Successor To: Stanley J. Is , Jr. L.S. CERTIFICATIONS INDICATED HEREON SHALL RUN StanleA. Ingegno aksenaksen L.S. ONLY TO THE PERSON FOR WHOM THE SURVEY Title Surveys — Subdivisions — Site Plans — Construction Layout IS PREPARED, AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND PHONE 631 727-2090 Fax (631)727-1727 LENDING INSTITUTION LISTED HEREON, AND ( ) 5Q TO THE ASSIGNEES OF THE LENDING INSTI- G�5 OFFlCES TUTION. CERTIFICATIONS ARE NOT TRANSFERABLE. LOCATED AT MAILING ADDRESS �—\ 1586 Main Road P.O. Box 16 THE EXISTENCE OF RIGHT OF WAYS Jamesport, New York 11947 Jamesport, New York 11947 AND/OR EASEMENTS OF RECORD, IF ANY, NOT SHOWN ARE NOT GUARANTEED. E—Mail: NCorwin3ftol.com f Glenn Goldsmith,President �rg so Town Hall Annex A. Nicholas Krupski,Vice President ®� ®�® 54375 Route 25 P.O. Box 1179 Eric Sepenoski8 Southold, New York 11971 Liz Gillooly Telephone(631) 765-1892 Elizabeth Peeples ® a® Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD NON-JURISDICTION INSPECTION DATE OF INSPECTION: ork6uc ( , 2_0-� INSPECTED BY: Rva" P-eepIt's Ch. 275 Ch. 111 COMMENTS: The neo n .±v Wcod-erl So vtn d n nv Air e nu e 01 S o v il- olrA LS d.e" n,o h - Uvi sJ i c,-p-A4 1 N r �H e Bo av-J o-P Tvusicc_& l+ i S r g4l)es� + ►aV -Hae_ ream unra I o V hard"o& avid ugi ure h a.rdwa o& is AMC 30CLYi 4(V cn�s I'I�ey are ave wyvr Fav+ J f e local eco-Sys . t) YD 1 Ss U F_ l tA4 fl`P n D),k— ulrl S Ai C 6 m 14755 Soundview Avenue,Southold v ��-"1 Nk ,l-r AirJkL , •�(f'' + JA I •F s fi 14755 Soundview Avenue,Southold do Y p Y 4 L 41 a r , 14755 Soundyiew Avenue,Southol• • y:} r t c,• ?C, r •t ti ' 14755 Soundview Avenue,Southold a � 0 t , r � t 7. V. ..1•*;�, ,.�y� �� Mfr Z1�.. s uaeae m lso+ - maea M.tJW m aoas ualue I.Isu mmm to»+e xsu N IS✓"- �8 r._ _ -_ Y �s�A,��P�j0 �•�pe FRO. / FOry —TRIXDWMt Nk-T A I zt i t�oi � a b '�.. P •alu s u y a as +svi ,s b a� S _ •n i J all syr Q�M� ��• !w� xr �fc) -� IIAn " POR Poi.No ah . a, A ,ar�i 4s I J aaoem A aap �b W.""bi COUNTYOFSUFFOLK © a SOu7II0lo secrwN No �� Real Properly Tax Service Agency___ —_ -- _— M050 .. . AONrr a w t:�N•• �. �� —__— •r --.-- N.r.�--rr-- a m. p rwcrw 1eN PROPERTY IMP Jennifer Leeds Leeds Expediting Services 28 North Country Road, Suite 101 Mount Sinai, New York 11766 631-509-4248 JenniferLeeds0255@gmail.com August 28, 2023 Diane Di Salvo Town of Southold Board of Trustees P.O. Box 1179 Southold,New York 11971 Re: Property: 14755 Soundview Avenue, Southold SCTM: 1000-50-3-7 Owner: Michael Schreiber and Iona Kleinhaut Dear Diane: We are requesting a letter of non jurisdiction for the above-mentioned property. The owner of this property is proposing to construct a two-story addition to their existing single-family dwelling, a proposed gravel driveway and new sanitary system. I previously sent surveys and owners affidavits/authorizations. We believe all work is proposed outside the wetland's jurisdiction of Southold. Enclosed is a check for$50 for Southold's fee. If you have any questions or concerns regarding this application, please do not hesitate to call or email me at JenniferLeeds0255@gmail.com. Very truly yours, J nifer Le d_ : - I DLs AUG 3 1 2023 Southold Town Board of Trustees AFFIDAVIT 7S REENG DULY SW,ORN7 ES TUE APPLICANT LIC.A.NT F'OR TI[E.A]30,XT-- D'E'SCR'RE'D PER IMSA ANDTHAT ALL STAT,EME�iTS Cdr V I y N r•II I-EERE,IN .A RJ--'TRUE TO THE REST OF IIISMER[CqO)WLEDGE AND,BELIEF,AND T'ITAT, A I.L WORK WILL HE DtF.NE[NN TITS,, xL4, ,.NINER SET EG' I�IN TMS PI.IC TIGl NT A,ND AS MAY HE APP R vE,-TD BY THE, SGUrIl'OLD TOWN BOARD OF TRUSTEE,vS. THE APPLICANT AGREES,TCI HOLD THE TOX17N GIE SO UTI OLD,.AND TI£E EC}'ARD OF TRUSTEES HAI AILES:S AND FREE FROIMANY AIN ,.A,LL DAMAGES AND CLAM S ARISENGT UNDER OR By VERTUE OF S.r fD PE`�f:iMrQS), IF GnRAWED. IN COMPLETING THIS.A,PPLICA,.TIGI-Ty E HEREBY AUTHORIZE TH, TRUSTEES,TE-1EIR. GE4 w(S)OR ,PR E+i lTT.i TjN7' is LNCLUM G THE CGIti1SEI$ ATSo�NX� COU rCllfl 0 f�NTER f�I�`O jiI'�p 0REL.7.`trT�TGI L'SIRECr THE g�IItSES INT CONJUNCTION WITH,T M, .AP PLTCAT,ff 3N, I1N'C.,UIIE%'G A MNAL NSFECT 0,%,,. I I+UE"TIIE R AUj,[GAUZE TIDE BOA, OF TRUSTEES,TO,ENT,ER GINTT0 1,'tY PROPERT V ANTU AS RE,QMRED TGI ENSU ' , CO2NIPLLANCE�WIf ANY cOIVDffT ONO O.,F,,,7 WE.TLA Iy G�'.R C� ".L EROSION PERNIFT FSS'UED BY TffE BOARD OF TRUSTEE S DURENG THE TERM OF THE PERMIT. Sira:€r I� ectg�(fie* rye 9i gnaW. �C �r CZ'c� .:r SWORNIT TO BEFORE kf THjS�__ _DAY OF Ayr& <- .20Z 3 CAROLINE M MACARTHUR _ Notary Public-state of New York No.01MA6384635 Qualified in Suffolk County My Commission Expires Dec 17,202 , Board of TzusteE s A:alsZi�a,�c�rn ftp e--t' n a eA± BEING DULY SXVO''�N DEPOSES AND ARFE,R THAT HFJSHE IS THE APPLICANT FOR THE ABOVE DESCRIBE IBEiD PE'T IN11T,(S)-SIF,THAT, .1-LL STATEXLENTIS CONTA MI HicRE�i T ARE TRUE TO THE BEST, OF HIS/HER f0;G ,C,L.EDGE AONTD BELIEF,AND THAT ALL.,WORK WELL HE DONE LN THE K40NNER SE's'FORTH IN THIS APP'1LIC'ATI I'ON AND AS K,411 BE APPROVE DI BY THE SOUTHOLD T,OWN BOARI)OF TRUST,EES. THE APPLICANX, AGREES TO HOLD THE TOWN OF 90tff'HOLID AND THE BOARD CDF"TRUST EES E L NILESS AND FRE E PROM ANY AND A,LE.DAMAGES AND,CEtAUNM ARISING UNDER OR BY VIRTUE OF SAIID PERMIT,(914 IF GRANTED. IN C05,IiPL,ETENG THIS APPL ICATEON,R LTEREBV AUTffCODE THE TRUSTEES,THEER AGE (S)OR REPRESENIT ATIVERS,INCLUDING THE CoNiSERVATzoav ADvIS0T,��,CEDUNCR,TO ENTER ONTO,AMS'T"ROPEEZT'Y TO, ENSPECT THE PRI�M[!S ES IN CONIJUNCTIU.N WITH TRES APPLICAT EON, Iii CLUDINIG A FINAL INSPECTION. Ei FURTi MI ER AUTHORIZE THE BOARD O Ti RUSTEES TO ENTER ONTOMY PROPERTY AND AS RE,QUIRETiF,.TO INSURE CONT-PLI CE WITH ANY CON DFETON€ F ANY WE T,LAND OR COASTAL AL EROSION PERMIT ISSUEID BY THE BOARD CDP'TRUSTEES DURING TH,ETERM OF TH,E PERCmrr. X z� uw-af LIE, SWORN 710 BEFORE SIE THIS � ID kY OF CAROLINE M MACARTHUR Notary Public-State of New York NO.01MA6384635 No P� Iac My commission sionalified in Suffolk County Expires Dec 17,2026 Boa=d of Trustees Applix'cation AUT HORIZAi TION, (Where the applicant is not the owner), Uwe o-,xmers of the property identified as SCT M1, IG001- - 3 - -7 in the tbwn of S�M A New.Yo+. ,hereby awhoHzes-J�n c-�e e' Le-ed-S to act as my agent and handle all new-3smy umck involved with the applicadan process far permit(s)from dt-Southold Tomm Boal of Trustees for this propeLty. X, 14 PM, 14,G"Imees Signatwe PtopertyOw-nee r, siggrt Lire✓ SRW TO BEFORE ME T17EE DAY OF CAROLINE M MACARTHUR Notary Public-state of New York atuy W NO.0IMA6384635 Public Qualified in Suffolk county My Commission Expires Dec 17,2026 Board. of T'rmateas Appl i.aation AUTHORMATION ave rs of the Amperty idendfied as scr,M4 16031- in the tout,of (A N'ew Park herebyautixa s „tm 1—, _ 1—hr\k VL CCS to apt as my agent and haa&e all wark involved,wide the appieratcan prawm for pmii*),ftm t1te SaudtctLciTown Heard of"E msr: far this Pm1perW. � eV er SAY OF 21,2 :►..+• CAROLINE M MACARTHUR Notary Public-state of New York No.01MA6384635 Qualified in Suffolk County Nlotazy F UrarC My Commission Expires Dec 17,2026 APPLICANTZA,GE N'TaZEPRESFNT,RTIC TRANSA CTIONAL DESCLOSSURE, FORIVI, R-=Tcvn Cyr alh�rmf JIM cmffr-rs W-a'c-,17rpl-r.of-250=and e lys fbrm ES ra 7.7ra r=--aw of w of (Last mwu-,fmstn=c -ddL-irikfaL unless-,vau a-c apptyin-gin the name of such as a company-if go,41kcal, Person'sorcampamy'saammy NAME OF APPUCATT0,N,: (Check an that appry.1 Erao-mz Vada= Tazz-e Chane of coasw E=kn Apprm,d,of prat 0daw (off cftlm Town*fSa-"fmEV- cc b2nEaz az:=. tu=ay) YES Nl=m, Gf�eaTtzged by trm C=a of Saaftid V99c aT pasEfm afd=greamn E)cscn-f=Me reEa&nsffp Eatvem youzew(tke apprw ,mv,aVaO cmXes=a&q),md dn town the ammPdi line Al theta QlaWardemita The tmvn afficer or emprayee,or his arherspaascm sihrm&parent;,or child is(cfic&an,tAac appiylt F--1 JL—LA) die cwpmmtm=ckaf the apgaz= (when,ft agplicwt is a carpmaaal; 131,the regal or knefidif ouner of any inf--reii in a non-c-aparzt:entRy(when,the appr1cwt ES not a corwradon); l_Q an affricer,dmdar.Partner:areaVove,of ffic appf x'cmt or � tfic actual app RD-1 DESCPjMGKI OF RELATIONSILIP print Nard. Fbau TS I APPLICAAMAGMANT,AMPRESE,NT ATI VE of 0 *2r of 49 mFV M41 nXC-=S 'el-IdCVVI-s.T11C rAMa=aff a ksr�rsa as tai % St1ta n=fgag gra due fp e om n e. azaca�iccj of jJ u *call arrow iR(0 aake jgt9cefog amara ds mm-ma to M. Fd Surra. h l oo— (L=aa�f=nma- rs kE-L rmfm 3r me apptk ingLm CLc name aff suss mm c(-a or other acuity.mc&as s caa zmy.rrs%i0&caft I-=other QC[S nos QL(XIMPM1J°r[S xir3 ,V-k1 OFAE.PLTCA'ff0N. (acck as t zt sp 7t,.) Qf Zone Chest�C435sA3� I ! Other of lh-,Team m ofaA3316'1 by N'OZ4 bmsi.mss ice."B=40285 iz--�mt=s a bl:gmcss, bd,& Az m pmt=s'h A an V/Wo dm hy)z02qm6= ica%tcs8 ±=(own c iw mar ala=Owns gym Efton 5'Yd aBf alae sp'aa as. YES NO @ffswaau;s=�ad-yEs;ara 7:w7 cCb--bs6m=cidasCam--AsdpC.4<3^nim'LLS- � Nm=of pmm w2poyed by the T;qwz,of soudwA _ Title Or p3s3tim raf dael P=wn tJa:4cci¢ crSaQti�frasn yes-` Rk�� 3' 'ar c�a ��z eases¢ Ore c�* c a¢¢�trxaezr�z�A�tss�.r�s g'�andfc�er�`ry atu�sga��c�vtirfc^xt_ C€ [ac n Q66`iers ar=ioeyee or his or Etcr orer.ifd FS<duufr all rime ap¢€ . I i A) of 9-.=*m$+'s eFUn Marta G -2 ODCk Of d=a Zest is ]; � �zra a�cer,dpi a tSartYt��csr�ttgr5rsc�mac't�acacll;� �� I i3��ad�fi aptsEi . DESCRE�,EON GE `MM'SUIP iy any aPrALfL-L' �Z3 Sig ' Fenn TS I APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. YOUR NAME: 2 J—P (Last name,first name,ipiddle initial,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other",name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES _F-1_ NO _Fq--_ If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): 12A)the owner of greater than 5%of the shares of the corporate stock of the apptiwt _n (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this 0 day of20�3 Signature Y Print Na a t- r t' � Form TS 1