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HomeMy WebLinkAboutTR-5035 ~ . ,. '.;r .. ._" h' ..'t- ,'),'" ì Tîustecs Ò¡,';" ,Þ ,.. _.,~! .-¡ ~)'- J _' , :r-'. '-','.- _"'J' .. i .. _ i .~ ~ .-';'..;), : PERMIT NO. ISSUED TO ~'"-- ~",,:".J '":'. ~ .",;) (/ '.) '.'. O¡'.T(: . 7.f¿1I99 WlJ,LJ:\r: S, I: r-:I·[,Y i, ~;i\;inRA SIKORSKI ... " f . < . }' .,,'. . ."...,., ......, ..~. \ J, t ~ _~ ~ ~~ -. _~ ~'/:c ~ i J. ~ ': . ~:~ \ Pursuant to the F·."':'·"~~S d Chc:'icr 615 of th~ Laws of the State of New Yx~, '~77; ",1 C':.,:" Ie:" -104 (If the L.n·s of the Sfate of New York 1957; ",wi th" ~"'Jtfdd Town Ordinance en- titled "REGULATit<G þJ:D T! i" rV,C'·i':; C¡: orS-r~UCTIONS IN AND ON TOV/¡~ V;'Aï ¡:RS :\: H.' f',.il;~ìC LI\:ms and the REMOVAL Or: SAt·!D, G:lAVr:L Oft C"f!'!EP- ~.1ATFP.II.'"S FROM LANDS UNDFR TOV/i·j \'¡r'.T':~::;" "i ¡" ,.:C'Or·:!1i1c'.! v"th the Resolution of The 90¿Fd '--·~f~':"F:-o...J;:,1:) n;"~fi!;'; Ldd ('il 7/~~.IrJC~.. 19 99, and in çon'idccati~n of tl", ",:n 'J;" ~ I "O.,eO p~id by WiHiam S. Kdl{ t of Soutlwlcl Terms lIOd Con¿i:¡cr,; ~.>L:1,J;.::.. Sii.()J·~~,j ¡: - : .".! ~ ii. Y. c.ld 5'J!)¡.)d to the ;~:. r·;\·'~:·"'\:; 5i.-:'e horcof, ,.. . . '. . .., " r _~.,~>-.~, t . .i.. ;" I".·n . Albert J. Krupski, President James I(ing, Vkl·f'n:sidelìt Henry Smith Artie Foster Ken Poliwoda ) :~!¡ TO',"n lI,lll iJ10nS I\!a:n TIoad p .(1. fk'x 1179 Sl.kithold. r~P\"" YOi'k 11071 r;<~,·:t~::~~::·~. - ,""/ .,~~. .~ r~ro:: .~",¡. ~" " ",,~"" .~ '~ - 1,1 ¡' ,IJ T.....le-phane (516) 765·1892 Fax (G16) 765-1823 DOl\.flD (}C T(;~i ."7·-l ,..{_~tùSTl~ES 'iOW~¡ OF SülTTHOLD July 21, 199 William S. Kelly & Sandr~ Sikorski P.O. Box 1680 Southold NY 11971 Re: SCTM #79-4-24 Dear Mr. Kelly & Ms. Slhcrski, The following action was lakga hI ~h2 ß03J~ of Tawn Trustees during a Regular Me8ting, 1:eld on ,hi__., .;I.'" IJ99, regarding the above matter: WHEREAS, WILLIA¡"¡ S. ¡æV,y & S;1;1:)[';, é; TY'JRS?;.r appLied to the Southold Tm-m TrusteE:s [or a pCGIllt \.0:1<301: the provisions of the Wetland Ordinance of the TOvm of Sopt.bold.. application dated June 8, 1999 and, WHEREAS, said applicaticn ~~s rcfer~cd to the Southold Town Conservation Advisory CCI:;y;il .cOi: theé:: Undlngf3 and recommendations, and WHEREAS, a Public He¡n-L;¡g Wll': h·?ld. by the 'I'ovm Trustees with respect to said application on July 21, 1999, at which time all interested persons were given an o~0ortunity to be heard, and, WHEREAS, the Board membe,-s have personRlly vie,,¡ed and are familiar with the premis0-s jn (ì;Hj~:ti{'1''1 ¿~nd the surrounding area, and, WHEREAS, the Board ha3 cü;,~' i,'):' t"",·J ,.1.1 U", testiraony anc! documentatlcn submi tted C(,!ì^;C, L'l) iDe ~.h:; ,,: a;',[-.1.i::ation, and, WHEREAS, the structure cc:"\pJleo \'"L~-h th::-: stanùùrd set forth in Chapter 97-18 of the f;outl1cld Tr.'l'n Co,.~;e, WHEREAS, the Board has c!cteçmined t.héJt the project as proposed will not affect tIle h8~lth, s~fety and gen~ral welfare of the people of the town, NOW THEREFORE BE IT, ~ . . RESOLVED, thaI: the BOÐYd ,.'< '1'1: 'c" ,) .. ,.'.,- ....,'. tJ~e "'-pplication of WILLIAM S. KELLY & SU'\ìFi\ ~;;'..C;'..,:".i. ~"~ '_.j,l._:t.J ,":t a single f-::mily dwelling with a trellis, w~ll, sal,lt~ry syst0m, and picket fence in front yard, subject to rlÐcir,C! ¡,üy'c.'ale.'3 G·t the 35 foot non-disturbance area durin.:J CC¡"¡:J,.cucti''=":1, as indicated on nevi survey approved at the P1"~.~;_5.n¡J' f·C'(;at.E~d: IB':lO Brigantino Drive I Southold. BE IT FURTHER RESOLVED that t~is d~t0~~ination should net be considered a determin2tio:1 rrxLJ for a,;y other Department or Agency which may also h~ve an ~p~ljc~t'on pending for the same or similar project. Permit to con3truct a'",d c,~.'·pl,'t.·? "::,)J~c", yilL§..xpire two years from the date it is signed. Fees Wll~:t be paid, if applicable, and permit issued ,·¡ithin six mont_he; (,f the date cf this notification. Two inspections are req'l.i rc":i and l:~" 1'1."\'3 teas are to he noti f ied upon completion of said project. FEES: None Very truly yours, tla..e..-/ ª /&-,~ß¿ {? Albert J. Krupski, J/. . President, Board of Tru~le£a AJK/djh cc. DEC Dept. of State Heal th Dept. . . Telephone (516) 765,1801 Town Hal!, 53095 Main Road P .0, Box 1179 Southold, New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting ofthe Southold Tov.m Conservation Advisory Council held Monday, July 19, 1999, the following recommendation was made: Moved by Richard Smith, seconded by Ken Meskill, it was RESOL VED to recommend to the Southold Town Board of Trustees APPROVAL WITH A STIPULATION of the Wetland Permit Application of WILLIAM S. KELLY & SANDRA SIKORSKI 79-4-24 to construct a single-family dwelling with a 1250 s.f footprint. Construct trelace (open) attached to house, install private well, install on-site sanitary system, and install picket fence in front yard. 1840 Brigantine Dr., Southold The CAC recommends Approval as per the survey received in the Trustee's Office dated June 8, 1999, with the stipulation that haybales be placed along the construction site Vote of Council: Ayes: All Motion Carried ¡P! i '¡; "i'(l I: II ':'J.. I: I pn lip . ¡: . ~ i ~ I ~ íj' , ! I ",i "Ö II ! '~p I ~ ~ J ~ ~ ~ ! ! -ii'f 11111 IIIII ~ . , < illl í IIII II III n,!! i ~ \ I I I I ~ ~ ; "III IIIII ~ !¡¡¡p! I m~: ¡H¡H' llr;; k~~H ~~!:H ~ . "; ç:¡ ;~ ~ i!~ ~ ~¡H~ ~ M "~Ë "I" ~i ~ ." , e , , ¡¡' . c , n_ ra~ ,~t ~~ ~ ~~V1 L~~ %0,-, ,œ 0 _r ':<0;><;: ~~ n ~ -<....,"" ~ "._-, " .~ u........~..' "..' ! '~I-- ,. 'C·" " , f~ :f" :h , . . , ". . . 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Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Main Road P,O, Box 1179 Southold, New York 11971 Telephone (516) 765·18'12 Fax (516! 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use ° Œ ® Œ ~ W Œlr~1 JUN - 8 1999 !i:' , I ;--.. J . , ,_...J ; T.OWN OF SOUTH:t-:; 1 """', Jew - 8 1999 Name of Applicant-.JilrU TA.kA 5. 1/.s.11 t-I ¿ <~Di!A (Cn~ AddressYO. Rot I~~ ~.Jrl-V'r f"\ Nt.( Coastal Erosion Permit Applicati ~etland Permit Application ___Grandfather Permit Application Waiver/Amendment/Chan9~s eceived Application: hl'JI'Itl Received Fee:$/!'V ' _ _Completed Appli¡ation _ . Incomplete_~~; ~(10"~ SEQRA Classificat:i/ðñ: () . Type I_Type II..:&-unlisted_ Coordination:(date sent) CAC Referral Sent: I:. - It - '1"- Date of Inspection: 7-1«- 9 <; Receipt of CAC Report: Lead Agency Determination: Technical Review: Public Hearing Held: 7-rl/- f? Resolution: IÆO C· Phone Number: ( ) 785 - 312:..-1 \\(\\ I) Suffolk County Tax Map Number: 1000 - 1<1 - CY-i - Z4 Property Location:Jl.A~ L.rC:H'7S ¡;S-rIr1f:..,~ LDT -¡fS7 7Gb FT. J./ a: IE. (provide LILCO Pole ,distance to cross streets, and location) AGENT: NA (If applicable) Address: AlA- Phone: FAX#: I Boan.:, ;"us;.~-: ,'" . ·cct j,on . t¡Fl:ER!\.f-, Di\Tl\ Land Area (in square feet): _Hf:¿, 2..~.'1 Area Zoning: f..- L.j D Previous use of property:~~~l-r Intended use of property:,_6I"tJ(¿,Þ FÅI".!,J.LL/ OOf-/l.T,JÚ. Prior permits/approvals for site improvements: ~ / /' Agency )( No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? -Á-- No Yes If ye rovide explanation: -- -------------- pr~criPtion (use attachments ---- 'f ~) l' necessary: CalSí{l L 'L-:T Sa,¡CU. r-l:Wý/ rJ QJJþ,L-TAY: 'iJVH- iJ. /Z~ S,F. QDr W~ (c::NS-rIWL-r lPþ I Ni;:~í0Pf:¿))_ATI~ TD /-là)::f- INSTALL Ye.LV4~V--Lf;;l,L 1lJS -rALL Ul-'fSìTL HJJr:r!l~t!f2"ú;,,^ .mSîALL FtrY¡::T F0J(r;;- 1~ F~T '-IAZ{) 2 Boarèe[ ',-_ ~ ~_~...~,I::~~· <.--; /.'....~-·r'.'. ..(::iLlcil . WETLAND/TRUST¡;;~ IJ,NDS Þ.Pi'r~le;ŒION DA'~A Purpose of the proposed op~ratio~s:__e!¿;;jL[¿F~~ Area of wetlands on lot: ~ Z?-(:{;:; Percent coverage of lot:~¿I.:S square feet OJ. u Closest distance between nearest existing structure and upland edge of wetlands:~UI£. feet Closest distance between nearest proposed structure and upland edge of wetlands: </2- feet Does the project involve excavation or filling? No )( Yes If yes, how much material will be excavated? .3(;:C:) cubic yards How much material will be filled? ~ cubic yards Depth of which material will b2 removed or deposited:~ TO 2- feet Proposed slope throughout the area of operations: In~FT ~ ~ / Manner in which material will be removed or deposited: l1tfEE r:s À M!:il\l(f) AT ELEVi1IJ:mJ /7. 5 T{) &:u-fDc£D TO 12-(; V41Jkhl IS" TD 12-' L TO ßE (J:;:f--:LAs f~ t-ILL IÎPtv.JO f.- S atement of the effect, if waters of the town that may operations (use attachments any, on the wetlands and result by reason of such if appropri2t.e): tidal proposed NO EFT£Lí I !M-ûUlt4ß/CÁ,{¡ Fe£>tJ.. VJ£:r LAtJO 35' liD ~ ¥:i.JfIiL 3 . . 14·16-4 ~"'95J- r-<:Ixt 12 I PROJECT '-D. NUMBER 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I-PROJECT INFORMATION (To be completed by Applicant or Project sponsor) SEaR 3 PROJECT LOCATION: 2. PROJECT NAME H 5I Municipality County ~ 4 ~TML1fATrõæ;~ 7Ge:s~o:d~iisec"ons, prominent landmarks. etc., or provide map) ~ ~ NO(2..ï14 ~Î ~ CF i)g,r"MlTß.JE u:.4'SQ..L~"Œ p:t;~æ uJ 5. IS PROPOSED ACTION: New 0 Expansion o Modification/alteration 6 DESCRIBE PROJECT BAIEFL Y: z.. 6TC$! 5rN4L£ ~ D.LJç/ / TNt¡ ¥JP"~ 'lJr=u- ~ ~~t..( S-Pít=M. 7 AMOUNT OF LAND AFFECTED: Initially .40 acres Ultimately . 1..[0 acres 8. W3 PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? þ(.I Yes 0 No If No. describe bnefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ~ReSidenlia¡ Dlndustrrl,1 0 Commercial 0 Agriculture Desc';be ll'£e ý tt fZ- AC2.ft. ~L£ FAMJ.L'f' o Park/Forest/Open space ~ o Other 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY ¡FEDERAL. STATE OR LOCAL)~ DYes IpLNo If yes, list agency(s) and permit/approvals " DOES ANY ~CT OF THE ACTION HAVE A CURRENTLY VALlD PERMIT OR APPROVAL? DYes }ð\NO If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? o Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Appllcanllsponsor Dale 4 - Z 7 - 'î 'Î Signature: If the action Is In the Coastal Area, and you are a stâte agèncy, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 . . Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18f 2 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD ----------------------------------- In the Matter of the Application of WtY.J.:_J{..EL~_'f-__"r__.$.lU::Lbß!t S (/(0 ¡¿~K ( COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, eJtU £.1t1 -5 µu c.-f, residing at 2'23"'5 ~ ¥ t::t2.- be~¿[i':2!;[Jd~~ and say: That on the '[ day of 0u....:9!~ 19~" I pers9n¡¡,1~ EOf;ted" !-hEh. property known as !0L1.0 ~~)7:f:,.J~ ~ .'t::15J....>7#ClL1J~ by placing the Board of Trustees official poster where it can easily be seen, and that I have checked to be sure the poster has remained in place for seven days prior to the date of the public hearing. (date of hearing noted thereon to be held nL'-I' øt~ If?f ()AJ off I'1lJoU.,. 7: I r¡ø"" T Dated: Swor~ to before me this :&~ay of ~~ 1999 0~/fl ~ Notary Public ' HELENE D. HORNE Notary Public, State 01 N_ York No. 4951364 Qualified In Suffolk County Commission Expires Mey 22. ~ ðd ( . . Form 3800, April 1995 PS Form 3800. April 1995 f ., .. Jn~ f 0 aZ:Dc g · o 0 CD en ~ " ~ .. ~5"n" "- i!. Q ~ 3 !: 2.~CD~ c . ilU ~ ~ ~ a -.S' "- . · (J) :3 "C - N ~. . N · _n _en " Q CD ....~ LU ~ LU 5" (') 0 -. . . .z; CD ~ .., £ .r 3 !!¡ (") ..... ..... ,," _<0 ft) õ' (D :¡, lr1 lrl ~ 31-· 0> <It 0> ~ ~ =: OJ OJ alõ.:(t) = ~ Co ..... + ~Î ..... c/). s: f\J ~ ..... ..... ~ III ~ ¡¡¡ - LU U~ D \J) ;§ ¡;¡ ~ :II f ¡¡ ;J f ., OZJJC . o0(þ(/) . ~ " " 3. . o. ¡¡; :::J 5" (') "'tI " .. i!. Q "- i!. !2. ê CD g i!. c . C N . if ~ ~ ~ ~ -.S' c f N . ·~¡(g,Cñ · . LU " " :. ~.....~ .r .. LU ~ _. :::J 0 0 õ' · ..... . .r · (\ m<""'t<tJ ..... 3~(") ~"" lr1 =-.~ CD lr1 " '::1. '" "-. ru <It 0> -- , ~/ 0_. OJ a: CD ~Co ..... ..... N c/). s: ..... If¡ ..... (\i ~ .r N (t. ~ ª' ~ OJ ¡¡¡ 10 Ü \}. C) 1 ;§ ¡;¡ ~ . . PS Form 3800. Apnl , 995 ,- u> a Z:DC <'II 0 0 (I) en ""s" g, CJ 0 c c . CJ @ -.S' m:::::l""C - _n_CI> o CD_(D 3-QO ~. ëij<-'C'C 3 ~ (") " " _<0 - õ' (f :s. ~ ~_. ;: ~ ::!': ~a.:(þ = ~ 0- f¡>' s: ~ æ. ~ - ~ ~ ~~ '\ !is c-:> - -,,{:: . .-:'"..:.~ 'ì'l \J> , N LU .z; ..... lr1 0> OJ ..... ..... o BO~ of Trustees Application 4IÞ County of Suffolk State of New York VJr u.L1v..A <5, Y ¡;. ; , L--( BEING DULY SWORN DEPOSES AND AFFIRMS ~/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE 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 TOWN 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 ( S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. " ¡fI1 SWORN TO BEFORE ME THIS DAY OF ~Y1 q ,19 S9 ef~m~L otary Public LYNDA M. BOHN NOTARY PUBUC, State of New York No. 01 B06020932 Qualified In Suffolk County Term Expires March 8, 20 ru 7 . . PART II_ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EEl'~ED ANY TYPE I THRESHOLD IN 6 NVCAA, PART 617.4? If yes, coordinate the review process and use the FULL EAF o Yes No B WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACT!ONS IN 6 NYCRR. PART 617.6? If No. a negative declaration may tie supersef;1",bY another Involved agency. o Yes No C COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOllOWING: (AnSwers may be handwritten, If legible) C1. EXisting air quality. surface or groundwater quality or quantity. noise ]eveI5. eXisting traffic palterns, solid waste production or disposal. potentIal for erosion. drainage or flooding problems? Explain briefly 1J0 , . -. C2. AeSlhatic, agricultural, archaeological, historic, or other natural or cultura\ resources; or community or neighborhood character? ExplaIn briefly: No . .. , .. C3. Vegetalion or fauna, fish. shellfish or wildlife species. significant habitats. or threatened or endangered species? Explain bnefly: . -' . N 0 C4. A communlty's existing plans or goals as officially adopted, or a change In use or Intensity of use of lanû or other natural resources? Explain bnefly N 0 C5. Growth. subsequent development, or related activities likely to be induced by the proEosed action? Explain bnefl'l pJÖ C6. Long term. short term. cumulative, or other effects not identified in C1·C5? Explain briefly rJ d C7. Other ,mpacts ~including changes In use of either quantity or type of energy)? Explain briefly ,j d D. WILL THE PROJ~(HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? DYes 0 . E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? DYes 1NO If Yes. explain bneflY PART III-DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it IS substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural): (b) probability of occurring; (c) duration; I.d) irreversibility; (e) geographic scope: and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been idenlified and adequately addressed. If question D of Part II was checked yes. the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. SfP rL tHO ÙJ ~ D Check this box If you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF andlor prepare a positive declaration. "¢ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: -rr;W¡J (JOftR'o ð+ -¡¡¿uJ 76:-e-s;. N.lme ot l!"".:JJ .I,>;:ent, 'tl ~~ I >:r~. 12/'(. I:$ft) êAl"7' ,(er In L<:'.ld TLtle 01 Re,pùn~Lble Drllcer .,eI \0,;.'''''' -·--';0'-t,;;-;-.~,~rMI. r,.."t :r"I" r,"~',.,rl"blt' --- ';1\;n.ltLJr"()IR,·,p ",n...." .m2..::- L r.¡ -_ tu9_ ¡J,-¡,. 2 APPr.t~^N'l' TRANSACTIONAL DISCLOSURE PORH . . The Town of Southold's Code of E~hics Þtohibihs conllic~s or in~ereB~ on ~he ar~ of ~own officers and em 10 ees. The ur OBe of ~his form is ~o rovide informa~ion wh ch can alert the town of poss ble conflicts of n~etest and allow it ~o take whatever action is necessary ~o avoid same. tOUR NAHR. '" .,- ;I'~i.·.:t~~ ',,1,. .,.-,.,,'¡..,','..,...., . ,,' , . ,:.'.~'4-. -,..~'"'l· '. . . Last name, first name, m ddle you are applying in the name of someone else or other entity, such as a company. It so, indicate the other person's or company's name.) " . ~'....., """~"'';''''''' .;. ,,',. . ..:.,:,' 4<~, ft!'4~t~> ~f{f. ".... ,'" . NATURE 0' APPLI~^TIONI (Check all ~ha~ apply.) Tax grievance Variance Change of zone ^p'p~~al of plat , ExedipHon fr0ll'nJ!.l...JI,t. ~I\-...0Ws;¡.i~.t map other ~~ (If "other," name ~he activi~y.) Do you personally (or through your company, spouse, s bl ng, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, marriage, or business interest. MOusiness interest" means a business, including a partnetship, 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 NoL If you answered ·f8S,·. complete the balance øf this fotm and date and sign where indicated. -..J'" Name of person employed by ~he Town of Sou~hold Title or position of that person Describe the relationship between yourself (the applicant) 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), AI the owner of grea~er than 5% of the shares at the corporate stock of the applicånt (when the applicant' is a corporation), B) the legal or beneficial owner of any Interest in a noncorporate'entity (when the applicant is not a corporation), c) an officer, director, partner, or employee ot the applicant, or D) the actual applicant. 'i , DESCRIPTION OF ItELATIONS!I1P . . .~'~"',~ .' " . .. , . "oj ~ ~ . .,. . ¡I'. " .... , , -, .- .: _ . ,.,__ ...... .-!t".~....W..... a'A '"."~-t ... ....:,:~ ;;:~~~: Siønatur 'print , .~ ...<;....."~.,..,."'~........,... ...'J'~~.~:~~. .' rJ J- ~l_ v' :·;_:~r.~:~·. ~~..:~._-::~~<~' .~ 1~, ....:;:~t~.:.~·~I~'~. ."_ ~~.::~._~::-. '. ,~\'~. '~';"'J,f;¡,iJ,: . ::.. "" ::!> ~ >- ;.¡, , '" ; 1r'~~~ i ~ I-~- ,¡'i1 -.;~; ; '~-"'"-".., I '''1--'--- , ....", ~M..-:;-,-- ¡ . ,'i . , . I ! 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