HomeMy WebLinkAboutTR-5057
Telephone
(516) 765-1GQ2.
.
Town Hall. 53095 Main Road
P.O. BOK 1179
Southold. New York 11971
SOUTHOLD TOWN
CONSERVATION ADVISORY COUNCIL
At the meeting of the Southold Town Conservation Advisory Council held Monday, September
20, 1999, the following recommendation was made:
Moved by Scott Hilary, seconded by Bret Hedges, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A
CONDITION of the Grandfather Permit Request of ELLEN L pmL 37-4-7 for an existing
boat ramp from the basement of the house to Spring Pond, a bulkhead between the property and
Spring Pond and a retaining wall between the lawn and the flat gravel area adjacent to the
bulkhead.
2235 Cedar Lane, East Marion
The CAC recommends Approval with the Condition that a 10' non-turf buffer is placed behind
the bulkhead and that necessary documents are provided in order to meet the criteria for a
Grandfather Permit.
Vote of Council: Ayes: All
Motion Carried
..\.lbert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
.
- ---
, "\UfFO¡;c'Oc~
:I.~ ~~"\
.~ "",..
~(::). ~:
":~~Q.l + ~'ð~>'
~~.~:::~-...:-,,--
.
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 119í1
Telephone (516) 765-18'!'2
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use On
. . .. I D Œ @ ~ f7¡p---;:--..,
_Coastal Eros:-on Per~J.t ~pplJ.cat r;:,,-,",-..lL.,.ì I "
Wetland PermJ.t ApplJ.catJ.on "{¡¡"
~Gr~ndfather Permit Application AL.G 3 1/999 III},!
WaJ. ver / Amendmen t/ Çhanges I ,-j:
Received Application: ¿j--,J f- r r¡ I rO~-;:-:;-ì::--"f'~-- :
Recei ved Fee: $/ d-() - L__~_d!_~>' j n-! ~ .,
Completed Application ~-,J (-p , ..---..
Incomplete
SEQRA Classification:
Type I Type II Unlisted
Coordination: (date sent) ----
CAC Referral Sent: ¡--,J (- r 1.
Date of Inspection: '-/r-'f, fii:0. 0
Receipt of CAC Report:
Lead Agency Determination:
Technical Review: AUG 3 11999
Public Hearing Held: '1-.:1 '7 - po 9
Resolution: .
Name of Applicant ELL£IV ""'i:. R+rL
Address 2--¿';55" (l€'ÐAR.. I-flNE... , PO. Box; 2-01, El\Sj
mA~IDIÙ 10'-1 11C¡3'f Phone Number: (.51¡,) 4-'1'7-0TLB
Suffolk County Tax Map Number: 1000 - 31- 4- - 1
Property Location: 10.1 GA1t.J¡'t-\E.R.'~ ßA-\i ESïA riS,,> QIJ t:'Asr S¡¡:)E:' o~
(!e..OAR L~\..:\;;. 350FT Soun" of'" \t03T"e:.~c;E,criO\j Ol=ri=nAR.\-ü A-elO ßt.'1VIW
(provide LILCO Pole #, distance to cross streets, and location) .I>~v~
AGENT: Pf\UL \..0. \~t+L. ~<;'
(If applicable)
\31\4 V\5\.0 1J ~.
,
\ 19:2..1
Address: tp Z-S
(Y}A¡;¿IDI..' ~(
.
p, u. bo~ 'SF. €A'>.
,
Phone: -:'511..-- ~ - l'1~3
FAX# :
1
j
Boa.of Trustees Application .
GENERAL DATA
Land Area (in square feet):
\"Z....400
.
Area Zoning:
R-40
Previous use of property: 5. '" (ó'1.-E:.
Intended use of property: 5; I~GLE:"
t=""'''\I'\o1I~'1 ~c.sIj)éNCG
-FAM\ L'1 K'E£,.DC/v(£,
Prior permits/approvals for site improvements:
Agency
Date
)( No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a
governmental agency?
x
No
Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
SEE
ArT 1\<...1-1 m tS"-Jr
2
.
.
GRANDFATIIER PERMIT APPUCATION
This application contains the following:
· A completed General Data section as provided in the Board of Trustees
Application Fonn
· An authorization as provided in the Board ofTrnstees Application Fonn for cases
where the applicant is not the owner
· An Attachment 1 which describes the project covered by the Grandfather
Application and provides evidence that the structural improvements covered by the
Grandfather Application are timctional and at least 5001Ó intact
· An Attachment 2 consisting of a lot map based on a September 11, 1959 swvey to
provide evidence that the structural improvements covered by the Grandfather
Application were complete prior to enacbnent of South old's Wetlands Law which
took place on June 29, 1971
· An Attachment 3 consisting ofamarkup of the September 11, 1959 sW"Vey map to
show the location of the retaining wall which is an integral part of the structural
improvements covered by this Grandfather Application. The marlrup was prepared
in August 1999 by measw-ing the setback of the retaining wall from the outer edge
of the bulkhead and then drawing it on the sW"Vey map with the appropriate scale.
· A copy of the Notice to Adjacent Property Owner and a notarized proof of mailing
ofa true copy of the Notice set forth in the Board ofTrnstees Application
· A notarized certification of the validity of the Grandfather Application
· A Transactional Disclosure Fonn
Boaref Trustees Application .
.'
I, t;LL¿ ¡J
(print
(where the
~,
AUTHORIZATION
applicant is not the owner)
f} J4 '--
of property)
residing
at -¿ Z. :2 .:.- f:£o .II, r<. L..I\- tJ IS f
(mailing address)
authorizeJu L.
owner
f o. Pox W f. E. f11M2.JDV t 1~37 do hereby
.
(Agent)
L;) . GJ-f\ 4 e.s
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
,
6 lL <.P P ~
(OWner's signature)
8
~
~
¡¡
z
"
IJI
O!
;':¡h
jI.
-3
I
1/1
...
~
z PI
o Þ
t'I 1/1
-1
f ~ ~
of ) -I
J: 13
o -
,.. 0
.0 z
Z
~
I
1
I
I
\
¡
j
!
ì
¡
\
,
l~c 011-1(;\
ß(\ ...~_.¡::
BA~Õ-<;';C
~, ,~~ b-<
1)u ,.,¡; !l
D ß ,. Co !
-<~- ~~~.....
¡.... ",-" ~~
zf" J ~U\~t
It! ' 1: /b C
¡f ~ ,t,JJ:"'U -( t
, ,-,,--++-
~f~--'~'¡"
v' _II-:r
~ C (JJ -So ·
-( 0-'
1 ! ~(ìr
o lIIe Jl
0( 1Ð:1 -<
u 1\ &:.
. ø :1
- ....
.. II
J: b
QØ-
"
-
~----==--
.- -
-"---
o
-f
-f
o .11\ ~
~ )>
OJ ~ 1)
.( 0
_ 111 "TI
(// 0
í
() ~ )
I JI 1.
o ÇI
11
"Tt
~~iz
a....p 0
-< D'" -+-
~.... ß
:it·O ..
· ,-:-'t,r
c- '(J\O
""-t"tfb'"
-+>-'(1
¡¡_....:t
D fb _.r
~~1
r:. _,-> rr
'" :r -:i ~
.,.-+í-(
;:,,;!'ol/l
.g ,. ¡III
zUl(ìlÕ
..t:c<
<t)"'"'
"'.....~>
10 -.
...._3-(
rnr-"
. -<-n'
~~
:t c C-r
-+-$
..
-
-T..c::.-
-.-
\J
~-
.,
. :~
"
CE"DAR. '
( PViVOIT'"
N.ê.(ØoO"f'30·
W.
LA "
YOQd.)E
100.0
_.
-
í
o
....
IØ
"
'"
.
III
U
(II
o
.
~ s'oJ
I
I
I
I
,
,
í-
O·
...
~
'J
I
~
1
6'
III
.
VI
tv.
W
O.
1'1
"
,
1"30
12.9
-
01 ' -.
()";'~ "
- :', ' "
, -:
,,po:
I
T 1 ..+øv~
v.,..,
.. ko".
!
-~'-
¡f.."
~ ~~
úI
~
¡J.
-
í
I
i
t ¡ø
¡ 1 ¿f'/
;/ .,,>tl'j!
. ~ 1
e ,..... .
__ I aei 0+, 1...,(01 ~//
2!:: I -.¡-z..' / I"'Ø~""
0;;:;--- L ./I;\\...¡....."¡> .It..
,I, ...._~_..... c..r
.......y ...'" y> 0 <'
.¡
:~
"
. ~~. ~~.
. ':'.-=r
. /.
~
Spv\Y'O)
. ¡;¡ (/I
" ,) ()
--< 1 D
[) 0 -
: :I n
C
~ I or
""f) {& 0
It ::1 h"
+ -
Ij¡
1
, l.NHNIDVl.LV
· -:j .- '
· ~ .
'f.--'* . ,~~.-'-..... "
.~l·:, . ~~'..:~' .·,¡-~::~.~F ~¿. -
~i 2-.':, """·>"·".·c·-'·
~~'c w:'i -; ~~ .-
~ ..;£:.~:";' . . ...~.~~':-'" ."
': 'tf._~:_'.
~:" ;,~'~ '
· .).'
'-.: ... _ i.' .. _ '''::..', .~
.... .~. :"'-,"
·r·
¡)
... - .:¿.....
,: - ...<,..<'
; -~-'1t'
.. .
<
4,,'
.¡ .
%
.
fT(
þ
o III
11 ,of
,~~
of »
å~
r 0
.0 Z
Z
{
.
..~. ,," . ....
~'t ;.~~'~:,
'p~ ";~":;' ."
,
.' ~ ..
", - ',~ '1,"
· . .:øL ,..Q"'-i (;\.
'..-<.:~';.-'-""~ -¡:
,p.;..-. '!f''¿'''" .
· _ . " ,,_;~ ..-w
J' .: \, .:...~. ~:
-~1:(. ~
III' . - ,s:, ~ :r
.0.'" . <. ~-+-
-< ~, ø IU·~
.... ......! ~
· . r , -I(þ~~
;~. "be-+
t r}~'¡.
. JI .f-
'/-lft __Þ1"'
'fC -JIlt
i -< ~~.
< :-(ìC\
\ "0 :;
,¡; ,.. Il
o "'! -<
-( \011 e.
1.1 . ):!
~ ....
- It
"'1\
Q~
\I
\.;. .-'
o
-f
-(
o
. \ { r
c
~ ~ 0
" . ...
II 0
,(
\It "11
a úI
r -
'N )
1.
10 C7
OJ
-
C/l
()
I
o
1'1
-q
~
('IM~Z
~R :-.pO
»-\ ......1).....
<- }>. .. ~ ( Q . ~
Iì' = <:It ....
~~:..~~[
" ~ '-"-. P 1:
.,:¡ r ¡¡ ið :::3:
¡,r !lnC"!:
..\.;) ¡,.¡..::I
U\ C. _.:I IT
J ~ .4:r ~I'
r '-I- -+~..ç
£ ~:ro IÞ
6\('\ D. I'~
11 \7 1:1 ....
» . (þ(j\'"
3 oJ z, a ~
1\ - · <f)"I
1> :; 1\1.... ~ >
i"!>-.lY..:I~
co 1) ij\Jf''' ,.
: . ~~
~ ql..¡.
c !~c
,. .r.;::
:¡ .s:.
o
c-
.... ~ - .",,-..¡"
,
.'-
o'
"
-. _r~L.. J
-¿1tOAR "~Ä~E~ ,!;.(ki~
;>;>~,:),~p.y\vQ(+.. "~~-~, c': :'. .-:~!v ßE~
..' _..... _-" ''''LU cO.-.. -'. ...<' .."". .....c.....
. ø...-.: I""":'. t:........ -. _ ..~_. ~. . iÞ :'-, .... > < ',.' ~
.1.::~' :~ - . ~-
~ :~. .' ·:w;-:~ ~!fn~
~ . . :.. 't~ ~~..~(
~ .'~·./é·.·· :-..- :.~ ..-
'. ", ..:~'<~ ·~~;~~r.
." ..... ...... ;;t.
... . ·",..".Y"..
'" ,Ø;·f":;
,...." +~.
\AI ...... ~ .
",Oi . ~)-.._~
[II !.If..;,.',
.-.~. .
,-~""",,""
.,\~ . \..;.-
. . i ',.._.. -.,'
..~- -. ~ - -
...1
":-":'.'- -- - ~ .~.
- <' ~
'":"..
. . .~, .
-
"
1:
...
..
A"
\If
.
CII
~
UI
o
. .1
~ a~
ze'
130
t29
1 s1"<>v j
;:v..\+\ _ ,",0"'$&
I
i.'"
~"
'"
,-
r.
'i
. "
I
I
o
III
1+
'. .
'.
..' .
,
,'",.¡t:2·. .
.
.,..-. .
ð
. :!-¿¡I,./ .
:~. ¥~-'~':'
'-"'~~
...
.. .~~:
Sp
....G\.
y \ ..
. Gt (jI
. " ('
~ Il
<; -
0 0 ~
- :r
'1: (AI'
1J J
A 0
1) (& ,
.- :1 ..
-+
I.
t .LNill"HDVl.L V (
r
.
.
~0~1CE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
E Li..E..t-J A. Pili \- SCTMUOOO- 3'1 - 4 - L
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a
Permit from the Board of Trustees to: 'Doc.vf11£'/..J ï Ti~ltr
ßVi-14IE:-ADS, l3 Olt'r !CAmP IhJ!) J:::£rlf IN ¡..)G £VAL!..':> Ae£
LAt..\JFULv-( ~1.s·Îi¡J6 SíR:-i.'C-TLJ¡q¡.L IJ'I1pæOl/6P1~IJT5
WU/U-/ P~ÐI1T6 TN'; GfJltGTMEIJT OF TH6 TDWk,i's
W6TLfhJDS ¡....Ihv OIJ Jvt-J6 Z~. Ie'¡ '1/ (G~AµO¡::-11 TH€/t. f'¡::;R,M /"1)
2. That the property which is the subject of Environmental
Review is located adjacent to your property and is described as
follows:
LOT Izq C~I\ ;::DlrVe.IL'~
Zz....:3 '5 Œ..e:D t'l-R.. 1~1\-t.JE..
f3A.'1 Es T 11 r e:: .s
I E"'5r i'Y\,~ ~tot.J
t-J11 IIq31
3. That the project which is subject to Environmental Review
under Chapters 32, 37, or 97 of the Town Code is open to public
comment. You may contact the Trustees Office at 765-1892 or in
writing.
The above referenced proposal is under review of the Board of
Trustees of the Town of Southold and does not reference any
other agency that might have to review same proposal.
OWNERS NAME: ELLe:..... A, ~ HL
MAILING ADDRESS: P.O. Bo ( 201
-ë:.A-~T ~~e'o~, tv"1 I~!?~
PHONE #: I \p '1 " ... 0 .-,
Enc.: Copy of sketch or plan showing proposal for your
convenience,
-'
.
.
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Name:
Address:
Vê-re..t.Jot-J JAc..ol3S
P, 0, So)!. 88 EAST
,
1'9.3~
1525"4 WI L...sHIrc£
PÐn ßI2.o~€- A tJE6 .
,
¡YI,4e,o", \J'1
,
~ ~ R-o'_ k::L61 tV f" éL D
~.i ,e.c.L£. $OIJTI-I
~L 330-z.'7
~ ( 1<.. J'Y1 A 2': ~ A FEJê.A:¡
Po, Box BS:3
G /LeSe:. IV Po "C;r) "-.J \...1 \ I <1 4.-4-
STATE OF NEW YORK
COUNTY OF SUFFOLK
ßUI... \-Ù. \--J.A'iES. ,residing at (,U ßA-''i VI Eo"'" Ðrt:.
EAs-r rfll\£jÐU rJ'-\ 1\<1~;t-, being duly sworn, deposes and says
that on the day 0 AuG,J....r ,19...9.!L, deponent mailed
a true copy of the Notice set forth lñïthe:soard of Trustees
Application, directed to each of the above named persons at the
addresses set opposite there respective names; that the
addresses set opposite the names of said persons are the address
of said persons as shown on the current assessment roll of the
Town of Southold; that said Notices were mailed at the United
States Post Office at tA.sr IY\Aeita) , that said Notices
were mailed to each of said persons by (certified) (r~~i8~Qreà)
mail. ,---;¡ ~
~~ ~
Sworn to before me this
day of O«'<'f<~ 'y- ,19
G
3(
c:....
/<7
JOVœ M. WILKINS
Notary Public, State of N_ Yortc
No. 4862248, Suffollc CountY
Tenn &plr. Jun.. 12. ¿. Ó éï (,
o Complete items 1 and/or 2. lor additional services.
Complete items 3. 4a. and 4b. .
o Print your name and address on the reverse 01 this lorm so that we can return this
card to you
o Attach this form to the Iront of the ma.lpiece. or on the back II space does not
perm't
o Wnte 'Return Receipt Requested' on the mailplece below Ihe article number.
o The Return Rece'pt will show to whom the article was delivered and the dale
delivered.
3. Article Addressed to:
o Complete items 1 and/or 2 lor addlt.onal services
Complete items 3. 4a, and 4ö
o Print your name and address on Ihe reverse of this lorm so that we can return th,s
card to you.
o Attach this form to the lront of the ma,lpiece, or on the back II space does not
permit
o Wnte "Rerum ReceIpt Reqúestea" on the ma,lplece below the article number
o The Return Receipt WIll Sllow to whom II-,e article was delivered and Ihe date
delivered.
3. Article Addressed to:
.
O·
·
"
-.;
:¡¡
~
>
~
·
=
c
o
"
·
;¡
ã.
E
o
u
VI
SENDER:
Mil- ,,'u..Jo r..) b,
fo. ~Ã ~
£ rî Ae-Ioµ ,~\ \) ~.s9
J,q~~
~
~
o
>-
.!!!
o·
·
"
-.;
·
o
~
>
~
·
=
c
o
"
·
;¡
ã.
E
o
u
SENDER:
.
I also wish to receive the follow-
ing services (for an extra fee):
1. 0 Addressee's Address
2. 0 Restricted Delivery
4aA2eNï~er3ð-O 37
4b. Service Type
o Registered
o Express Mail
o Return Receipt I
~ertified
o Insured
OD
eturn Receipt
I also wish to receive the follow-
ing services (for an extra fee):
1. 0 Addressee's Address
2. 0 Restricted Delivery
o Complete Items 1 and/or 2 lor additional services.
Complele Items 3. 4a, and 4b.
o Print your name and address on the reverse 01 this lorm so that \I've can reTurn t~"s
card to you.
o Atlach this lorm 10 tile fronl otlhe mallp,ece. or on the back if space does nUT
permit.
o Write 'Return Receipt Requested" on the mallpiece belol'< the article number
o The Return Receipt will show to whom the article was delivered and tile üate
oellvered.
3. Article Addressed to:
o·
·
"
,;;
·
o
~
~
·
=
SENDER:
rYjt<: W¡C¡:: iYlAU 1\ F~l2o
f D, ßD)( <95:3
b£G£rJf'l)t::ï VI 1/144-
5. ReceIved By: (Print Name)
102!:!'I5-99-B-0223 Domestic Return Receipt
I also wish to receive the follow-
ing services (for an extra fee):
1. 0 Addressee's Address
2. 0 Restricted Delivery
4a, A1'LnT¡"e' 3 d-IJ :; 7 ~
4b. Service Type
o Registered
o Express Mail
o Relurn Receipt for Merchandise
~ertifjed
o Insured
DeOD
"
éJ......
a. Address e's Address (Only if requested and
fee is paid)
102S8S-99-B·û223 Domestic Return Receipt
,;
u
.~
·
VI
ë.
.¡
u
·
a:
E
~
;¡
a:
0>
c
,¡;
~
2
~
o
>-
~
c
m
.,
....
,;
u
;:
~
VI
ë.
"i
u
·
a:
c
5
;¡
a:
0>
c
'æ
~
.2
~
o
>-
...
c
m
.,
....
,;
u
.~
.
VI
ë.
.¡
u
.
a:
E
~
1;
a:
0>
c
,;;
~
.2
~
o
>-
...
c
m
.,
....
Boar4IÞof Trustees Application 4IÞ
County of Suffolk
State of New York
_RuL. 0, Ij~6.s
DEPOSES AND AFFIRMS THAT HE/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 APPLI CANT 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.
BEING DULY SWORN
'3/
Q~
DAY OFFob OS,
SWORN TO BEFORE ME THIS
,193...1-
~ À~,l0~JA~\
Notary Public
JOYCE M. WILKINS
~ Public:, b. of N_Yart
No. 4952248, SuffoUc eo..-
Term EllplreeJune 12. ;;)..(!o I
I
7
.
.
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) 765-1~
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
-----------------------------------
In the Matter of the Application
of
-~b~~Al__~_~_R_'_~t.. _______
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
1,-*1.1)'-- ~. W ¡''-{t.S, residing at fs;, z.:ç ß t.'1vIE.1.J '~
EA~T M A~ c .) , \j'1 \ \ q~~q
being duly sworn, depose and say:
That on the It~day of2>ëÆï , 1991, I personally posted the
property known as "2. ¿ - -- I - t\ EA - 1 ~. \J ü~ I' 'l3í
by placing the Board of Trustees 0 fici 1 poster where J.t 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 heldOAJoLAIJI¡,(r
7:'OA," f-J..2.-'O
, ,
Dated: SE('T ¿Z, '997
<::ð~J.Û.cÞ~
(signature)
Sworn to bef9re me this
"2-"2- day of J ~¡aT, 199 '7
~'¿kA t?c.::5U~
Not y Public
f!UZABETMASTA1MS
NOTARY PUBLIC; Slate of NewYM
No. 01ST60081,3, SuIroIk ~
Term ExpireaJune 8. 2CIQD
.
.
APPLICANT
TRANSACTIONAL DISCLOSURE FORH
YOUR NAHR.
The Town of Sou~hold's Code of E~hics prohibi~s cbnflic~s of
interest on the par~ of town officers and employees. The
ur ose of this form is to rovide information which can
alert the town of poss ble conflicts of nterest and allow
it to ~ake whatever action is necessary to avoid same.
ri H L. ) EL ~E'\-J -:I- ,'.. '.,' ,
(Last name. first name, mldd~e 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.)
..
NATURE OF APPLICATION! (Check all tha~ apply.)
Tax grievance
Variance
Change of zone
App~~al of plat
Exemption from plat or official map
Other)( .
(If "Other," name the activity.) GP.:!4/IJJ) ¡:f¡ r HE,¡"¿
P6Kn1! T
Do you perBonal1y (or through your company, Bpouse, sibling,
parent, or child) have a re1atlonohip with Bny officer or
employee of the Town of Southold? RRelationohipR includeo
by blood, marriage, or busineoo intereot. RDuBineBB
intereBtR meana a bUBineaB, including a partnerBhip, in
vhich ~he tovn officer or employee haB even a partial
ovnerohip of (or employment by) a corporation in which
the tovn officer or employee ovno more than 5% of the
shares.
YES
NO X.
If you answered -YES,- complete the balance of thin form and
date and sign vhere indicated.
Name of perBon employed by ~he Town of Sou~hold
Title or posi~ion of that person
Describe the relationship be~ween yourBelf (~he applicant)
and the town officer or employee. Ei~her 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 ~hat applY)1
A) the owner of greater than 5% of the shares of the
corporate stock of the applicant (when the applicant
is a corporation)
B) the legal or beneficial owner of any in~erest in a
noncorporate'entity (when the applicant is not a
corporation)
c) an officer, director, par~ner, or employee of the
applican~ or
D) the actual applicant.
DESCRIPTION OF t1ELATIONSIIIP
'
,.
. ..
._~A.u .
. . ... ~ .
. . .,,
Submi Hed thb ~daÝ ot.(-\it;,.1 ~9.~(
Signature ~.~ ~~. ~ .
Print name E::E:.~-1t\t.~ ,... ~:::.>
. ,,' . '.;'!:\j~~{~~:;;~¡.~';:-~~\.'. ··,.,~~{z:():/::...
. .'
..