HomeMy WebLinkAboutTR-5637James F. King, President ~QF S~(/~y Town Hall
Jill M. Doherty, Vice-President ~O~ ~~~ 53095 Route 25
Peggy A. Dickerson
# ~ P.O. Box 1179
Southold, New York 11971-0959
Dave Bergen ~+ ~e
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Bob Ghosio, Jr. icn ~
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O Telephone (631) 765-1892
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BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
# 0351C Date: August 13, 2008
THIS CERTIFIES that the enclosing of the overhang on the north side new front
entrance and entry deck on the west side and the installation of gutters, leaders and drvwells on
the existing dwelling
At 360 Lakeview Terrace, East Marion, New York
Suffolk County Tax Map # 31-9-12
Conforms to the application for a Trustees Permit heretofore filed in this office
Dated 09/23/02 pursuant to which Trustees Permit # 5637 Dated 10/18/02 and
was issued, and conforms to all of the requirements and conditions of the applicable
provisions of law. The project for which this certificate is being issued
is for the enclosing of the overhang on the north side new front entrance and entry deck on the
west side and the installation of gutters leaders and drywells on the existing dwelling
The certificate is issued to WALTER GAIPA owner of the
aforesaid property.
~. - at'~.
Authorized Signature
Town Hall
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
=~O~SOFFOI,~~O~~
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BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631)765-1366
YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES
72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN
ALL BE CONS DERED A V OLATION AND POSSEBLEOREVOCATION OF HEO
PERMR.
~C~~~~
INSPECTION SCHEDULE
Pre-construction, hay bale line
15i day of construction
_ '/2 constructed
_~ Project complete, compliance inspection. ~I t(~C ~ ~~~
?~.. "'"
Board Of Southold Town Trustees
SOUTH OLD, NEW YORK
PERMIT NO. 5/~37
WALTER
ISSUED TO.. ..
DATE: .<:>ctober
& LINELL GAIPA
.........-........
!\ut~nr¡;!ntin"
Pursuant to the provisions of Chapter 615 of the laws of
the State of New York, 1893; and Chapter 404 of the laws of the
State of New York 1952: and the Southold Town Ordinance en-
titled "REGULATING AND THE PLACING OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS and the
REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM
LANDS UNDER TOWN WATERS;'.'. and in accordance with the
Resolution of The Board adopted at a meeting held on ..9.cto.þer..)6,
. 200~, and in consideration of the sum of $.50.00. . ... paid by
. . Walt",: & LinellGaip<i
of. E"st Marion .. N. Y. and subject to the
Terms and Conditions listed on the reverse side hereof,
of Southold Town Trustees authorizes and permits the foHowing:
Wetland Permit to en dose an overhang on the north side of the
residence and a new front entrance and entry deck on the west
. side of the residence, with the condition that gutters and drywe·
are installed.
all in accordance with the detailed specifications as presented in
the originating application. .
IN WITNESS WHEREOF, The said Board of Trustees here-
by causes its Corporate Seal to be affixed, and these presents to
be subscribed by a· majority of the said Board of this dat.e.
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.'" . . . . . ~~-'---!'~~~~ ~-'-' !_, ~-' . . .~ ~ . . -'- '-'-' . . '-'- '-' \ . '. ...
TERMS and CONDmONS
'Tho Petmittee
Walter & Linell Gaipa
residiag at 360 Lakeview Terrarp F..~~t M::n..'¡nn N.. Y., as
put of !be consideration for !he sa........ of die Petmit does uøderslaDd and pLIOSCribe to the fol-
1owiDg:
1. That !be said Board of Trustees and !he Town of Soo.dtoId are released from ""1 and
aU damoges, or claims f« damoges, of suia arisiøg direct1J or iødåecdy as a resuk of ""1 opec-
atioo pedom>ed pursuant to cbIs permit, and !he laid p... ¡ ~... will, at his or her own eq~ .. .
defeod ""1 and aU such taitdllltiaœd by thhd parties, &ad !be said 1'0. ¡·I..... ..- fall JiabIIky
with reipect theteto, to dte complete '-...!no. of !be Baud of Tmoœa of dte Town of ~
24
2. That dtIs Peøait is' ...nd for . pedocI of mos. wbich is aJlI'L' ·ood to be !be
estimated time· required to complete !be wod< iawhed, but should ätcamstaaces waaaat, request
for ... eEœllSÍ.OII may be made to !be Board at a Iaœr date.
3. That this Permit should be retaiaed iade£aaltdy, or as loag as the said Permittee wishes
to maim.in !be sttueture or ptoject involved, to ptovide evideace to aayoae coacemed chat aach-
orization was original1y obtaiaed.
4. That the work iawlved will be subject to the inspecÞoa and approval of the Board «
Its agents, and aon-œmpliaaœ with. the provisloas of !be origi....tI..g applicatioa, may be cause for
revocation of dtIs Permit by resolution of the said Board.
5. That there will be no uareasoaable iaterfereace with aavigatioo as a resuk of !be wod<
herein aùthorlzed.
6. That!bere shall be 110 iaterference with the right of the pubW: to pass and repass a10ag
!be beach betweea high and low water marks.
7. That if future opemioas of !he TowlI of Soudtold require the ftIIIOftI and/« aIœratioas
ia the Ioc:atioo of !be wotk herein ..~M. or If, ia the opIaioo of the Board of TrusteeS, dte
work sha11 cause uareasoaable obsttuCÞO<1 to free aaviguioa, !be said Permittee will be required,
upoa due 1IOÚce, to remove or alter dtIs work or project bereIa staœd wilbouc ....j>eII5eS to the Towu
of Souchold.
8. That the said Board will be noùfied by the Petminee ot dte uf''('kthD of dte work aatb-
orized.
9. That !he Permittee will obtaill all other permits and coasealS chat may be nquired IDp-
plemental to this permit which may be subject to revoke upon failure to obWa same.
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken poliwoda
Peggy A. Dickerson
.
Town Hall
. 53095 Route 25
.. P.O. Box 1179
Southold, New York 11971-0959
Telephone (63l) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
yOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES
72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN
APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO
SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE
PERMIT.
G- ~, p ~
INSPECTION SCHEDULE
Pre-construction, hay bale line
1st day of construction
y. constructed
~ Project complete, compliance inspection.
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
.
.
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
October 18,2002
BOARD OF TOWN TRUSTEES
TOWN OF SOUTH OLD
Mr. & Mrs. Walter Gaipa
360 Lakeview Terrace
P.O. Box 247
East Marion, NY 11939
RE: 360 Lakeview Terrace, East Marion
SCTM#31-9-12
Dear Mr. & Mrs. Gaipa:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday, October 16,2002 regarding the above matter:
WHEREAS, W ALTER & LlNELL GAlP A applied to the Southold Town Trustees for a
permit under the provisions of Chapter 97 of the Southold Town Code, the Wetland Ordinance of
the Town of South old, application dated September 23,2002, and,
WHEREAS, said application was referred to the Southold Town Conservation Advisory Council
for their findings and recommendations, and,
WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on
October 16, 2002, at which time all interested persons were given an opportunity to be heard,
and,
WHEREAS, the Board members have personally viewed and are familiar with the premises in
question and the surrounding area, and,
WHEREAS, the Board has considered all the testimony and documentation submitted
concerning this application, and,
WHEREAS, the structure complies with the standards set forth in Chapter 97 of the Southold
Town Code,
WHEREAS, the Board has determined that the project as proposed will not affect the health,
safety and general welfare of the people of the town,
2
.
.
NOW THEREFORE BE IT,
RESOLVED, that the Board of Trustees approve the application of WALTER & LINELL
GAlPA to enclose an overhang on the north side of the residence and a new front entrance and
entry deck on the west side of the residence, with the condition that gutters and drywells are
installed.
BE IT FURTHER RESOLVED that this detennination should not be considered a determination
made for any other Department or Agency, which may also have an application pending for the
same or similar project.
Pennit to construct and complete project will expire two years from the date the pennit is signed.
Fees must be paid, if applicable, and pennit issued within six months of the date of this
notification.
Inspections are required at a fee of$5.00 per inspection. (See attached schedule.)
Fees: $5.00
Very truly yours,
O_~t L' I (7. I~--;/)-~' ~
Albert J. Krup&:i, Jr.
President, Board of Trustees
AJKllms
.
.
~
Telephone
(631) 765-1892
Town Hall. 53095 Main Road
P.O. Box 1179
Southold. New York 11971
. SOUTHOLD TOWN
CONSERVATION ADVISORY COUNCIL
At the meeting of the Southold Town ConserVation Advisory Council held Monday,
October 7, 2002. the following recommendation was made:
WALTER & LlNELL GAIPA to enclose an Overhang on the north side of the residence
and a new front entrance and entry deck on the west side of the residence.
Located: 360 Lakeview Terrace, East Marion. SCTM#31-9-12
The CAC did not make an inspection therefore no recommendation was made.
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SA y A VENUE
Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
.
.
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
ct'\.J..la. L V\J) ~(tQd:
,
_Coastal Erosion Permit Application
.....wetland Permit Application _ Major ~Minor
_ W aiver/ Amendment/Changes
...-Received Application: " a31~ iJ
_--Received Fee:$ ~....
_.eompleted Application q I~/O-µ
_Incomplete
SEQRA Classification.
Type I_Type II_Unlisted_ SEP 2 3 ?cn~
_coordination:(date~ent
~AC Referral Sent: O:¡J
~ate ofInspection: 10
_Receipt ofCAC Report:
_Lead Agency Determination:
Technical Review:
-1'Ublic Hearing Held:~
Resolution:
Name of Applicant Walfer -f L,~/J a/1M
Address Po &1 d l.f 7 3fð:; ¡;, klÆw ~ ('f{ ~
Eøt f{q( iOf) ~PhoneNumber:(~' 411- 9113
Suffolk County Tax Map Number: 1000 - 3 L - c¡ - I 2-
Property Location: 3fao (J~r/itW þ((LVC. C ¡,OSJ
Jf~ &y .¡j/l'C
.
AGENT:
(If applicable)
NIA-
I '
(,oI"6
.¡ ~ q\tj1>W"'l
(provide LILCO Pole #, distance to cross streets, and location)
Address:
Phone:
· .
Board of Trustees Application
Land Area (in square feet):
GENERAL DATA
II, SLf+
Intended use of property:
1..'-\0
S'f\álc: {etm¡l1
S) Ô)';)k fQY>111
(t-t ~ )den ,h ~
(l~ tck r-- ~lJ
Area Zoning:
Previous use of property:
Prior permits/approvals for site improvements:
Agency
Date
/N' .s/ I fi . .
_ 0 pnor permit approva s or site Improvements.
Has any permit/approval ever been revoked or suspendßdDy a governmental agency?
V No Yes
--
If yes, provide explanation:
Project Description (use attachments if necessary):
(D E:.tìd ok c")I,~,-h<YV\, ~ ¿, \e~\d'lA')<:~
(i) JJ~w -tcor.--t Q,r\-t0VhG~ an.!
(-fò( fYU,.., \avnJc'l
fOr lo.vnJr't. (\.oorY">
~tÝ\iL1 ~c1 wJs-i.e" JI!/h ~e..
r~
.
Board of Trustees
.
Application
WETLANDrrRUSTEE LANDS APPLICA nON DATA
Purpose of the proposed operations:
-A\1:~(d\,~ ~J Qit~+if)'7
'1eJ \~'<.-
E-":¡('¡,IA fú..rn.\--;
. I
Area of wetlands on lot: 000 (;!'~~) square feet
Percent coverage oflot:.5 %
Closest distance between nearest existing structure and upland
edge of wetlands: .3 ð feet
Closest distance between nearest proposed structure and upland
edge of wetlands: .:; 0 feet
Does the project involve excavation or filling?
V No
Yes
If yes, how much material will be excavated?
cubic yards
How much material will be filled?
cubic yards
Depth of which material will be removed or deposited:
feet
Proposed slope throughout the area of operations:
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 attachments if appropriate):
NoNE=""
· .
Board of Trustees Application
County of Suffolk
State of New York
Wa rkr ~ú BEING DULY SWORN
DEPOSES AND AFF 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 TIllS 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 CONRINCTION ¡:;, REVIEW ;J¡ATION
([)~
Signature
SWORN TO BEFORE ME THIS /0;
DAYOF-4¡4
,200 :J-..
Þ Þ-l,G~
ot Puohc
JOYCE M. WILKINS
Notary Public, Stat ; of New York
No. 4952246, Suffolk County
Term Expi....Jun812...2{) Ò 3
1-4-t6·.l.12/8iÏ-'i!xt 12
I PROJECT I.D. NUMBER
.
.
617.21
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLlSïED ACTIONS Only
PART I-PROJECT INFORMATION (To be complered by ADplicant or Project sponsor)
,. APP~JCf,T IS'l9NSOR L \ I 2. P JEC7' NAME
VVQl\~r (nel ~ q
3. PROJECT LDCATlON, {::~ .L r' ,..LLlIL
MunIcIpality Q,{ð1 C.:>unty ~ "Tf U
4. PREC:SE LOCATION (Slreet aaClress ana road rntersee,ions, promlnenl lanamarks, ~IC_, or ;:JrovrCle map!
SEa
bioo
Lú./<.eIl)C/J- ~ C ( t.l L-c...
5. IS PROPOSED ACTION:
o New 0 Expansion MOClificationtalteratfon
6. DESCRIBE PëJ:r~1~ 0\J"t.......- 'hCVr\~ ~
é5) h~ 'v../ f' c lJI'f't Q/rfÌ' ( ðIYt l.t.,
c~ (ctvnc:!.C"Î. \,OOh-\
( f(f ((Y11if \ltllrJI"1 (DO"") -r- JeJ<..
7. AMOUNT OF UNO ~CTED: ~
Initially ~ acres Ultimate!y =::::.sz. acres
a. '1J~~?0S¡:~AC-;ïON COMPLY WITH EXJSïlNG ZONING OR OTHER E..XJSTING I-AND USE .':¡EST~IC7¡ONS?
~Yes U No If No, ClesC:lbe !Jrleily
3. 'N!-<A~?RE.3ENT ~~:'J UEC: IN '/IC¡NITY~F ~qOJECP
~esrdentral r-;'~naUS<riaJ ~ C.:¡mmerClðl
Qescrroe:
~ AgricUlture
~ ParK/Forest/Ooen space
'- Other
iO. DOES ACTION INVOþ¿VE A ::RMIT APPROVAL OR FiJNDING, ,\lOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (F::iJERAL,
STATE Crt LOCAL)?
DYes ....., 0 If yes. list agenCYIS) ana permit/approvals
·r
t1. DOES ANY ASP!; OF THE Acnor~ HAVE A CURRENTLY VALID PERMIT OR .A.PPROVAL?
o Yes No II y~s, list agency name and permrt/approval
t2. .~S A RESULT OF PROPQSEiJ ';CTI0N WIL!... ~(lSTlNG PERMIT/APPROVAL MEOUIRE .\iODIFICAdQN?
Dyes ~
).,pplicant/sponsor
I CERTIFY THAT THE INFORMAT!ON PROVIDED ~eOVE IS T~UE -0 ¡HE 3ESi OF MY KNCWL:::DGE
D",e.~ ;1
name:
Slgnalure:
If the action is in the C02,:al Area, and you are a state asency, "omplere the
Coas:al Assessment Form before proceeding with this a~~essment
OVE:R
PAñ.ï 1I_:::N'/!RC,~¡M=~~7:" ..s3~ 1E~ ï ,-J 'J-= ,-:::;r.;.:.e!='J :y ~:;e:'-c .
t .... :CE5 ...C:7;C~~ ::':~C==: ':':. 'f . ,;-=.. :-¡...,:::¿3i-:CLJ ~r~ oj .'.'~::?¡:::. :J':'F.Î 3-;.':""' f ¡es, :::JcrOlna!9 :n~ '-~"I~'N :~oce53 3.no 'Jsa :r.e =õ..;L_ ::-µ,-
I
·;""15
1_.'.0
3, '.vlL~ ,~C:-:C,~ ,:jE,::::;VS; :::CPCIN", ~J :::¡E~¡I'i2N "S .:J:::C'/IOEJ =':? 'JNL.S7=';) ,:,:::-:;:,'.5 .N :3 .~'('::='R. :J.~¡:; I ~" :;
.-nay 'Je sucersece<:: =y ~nc{:-,er :n'lOI"ea ,¡çenc·l.
.f ·~o, 3. leç;;.c'/'3 :~C:.3.;::;:
';"~S
'0
c, ::ULO .":'C:-¡CN ~ESvL:- :-.I ).NY ~CVE;:Sr:; ::':-=-::":;75 ASSCC:;",~::J .'I!7~ -'-:::. .=JL~':w!.'G. .).ns.....ers '~Qy:e HnC'Nrll:en. t .e':;IClel
:1_ ~~IS¡lng 3.lf ·::ual't'l, :;urt.ã.C2 Jr 1rc¡,;na.....a.ter ::uallf'l ·Jf -:¡,;an[ ty, .'Olse :e'I~!s. ~:es:¡ng '~a:fjc ::a.t:er~s, ~ouc .vas;e Jreca.:c:::;n Jr 'Jf3:::
?Olenllal fer ~ros on, ::r::unaça or :IOOCInQ JraQlems? ~~cla.ln 'Jnelly:
C2. .~~stheUc, 3.çnc:JLlural, 3.fC:'1:aeologlcJ.I, ,'Is,onc. Jf Jther ,a¡:..zral Jr C:.JI!ur~1 -eSOUfC2S: Jf :::JmmunIIY Jr :-:en;:10crnood ":~¡¡rac:er? ~~a!aJn
\/eç~!atlon -Jr fauna, :Isn. :¡r:ellfisn or ',.-¡iaWe $:Jec:es. sIgnIficant :-1aOllat!:õ. :lr :nre31:!ned ,:Jr ~nc.ançerea ::cec:es? S~clam Jrial!,,:
c~. ). ..:cmmunlt'(s ~xls::ng ;Hans or ·~oaIS as OIf!C:õilly acootea. ·Jf a cnange In usa or intensity r.lr usa of lana or :lther natufal resources? ::xplaln _,
,.." Growth, ~uoseouenl :::e'l13100;T'lent :,r relatea aC::'lI[les likelY !O Je Inducea ':I'f 'Me ::Jrccosea aC:lon? :X¡)laln .:meilv.
:3, '_cng :erm, :;non ·~r,õl. ;;;mUI"W'/e, :Jr ·':Ilnef '!f ec~s nOI ,cenutiea ,n C:·":5? :::.~;:¡Ialn :Jnerl'l.
:{~~r :moaC:3 Iflc:.Jc:nr; ::-:ançes ,n 'Jse :It ~~tner ~1,)anu!y .-;¡r :"f :::e .JT ~:"IerçïJ? ~~.:IIG¡n :(;elj'I,
5 -·....E~E. ~A ,5 :-i-E¡:1.Ë _:'<2::"·:':-C 3E. ::~nT.::;GvE.-5'( :<:2::......<.:J;-O ?0T:::'1'¡;,.. ~::'=:::SE :::.'IVIRCNMelï:'L ..'.:P~C:-3?
_';"es
_.'10
r ·"¿s, ~XClaln 'Jnellv
~AR7 III-OET'E?:MINAïICN OF SiGNI¡::JC~NC~ (;0 :Je camOlered JY Agency)
[NSïRUC7iONS; For ~3C:1 aaverse ~tfect :dennfie1 3ccve, cetermine wnetner It is suestantial, :arge. :mcortant or otnerNlse siçnific
::.:ac:1 ~ifect s:1ould je 3.ssessea in c::mnec:lon wltn Its (a) 3etting ¡i.2. urean or rural); (C) ;Jrobacllity of occ~-Wg; (c¡ duration
jrre'/erslbllity: leI geogr3.onrc 3c~ce: ana (I) magnItude. It necessary, add aUacnments or reference supporting materials. :::1sur~
~xc!anacrcns c~n(aln suttic:em Jelall !o snow thar all -e!e'lant adverse Imaacts ilave been identified ana adequatelY aCC:ressec_
C:ïecK :hls ~ox if '.'ou :-Jave Icentifiea 'Jne ':Ir il10re ::::otentialJ'{ la(çe J( significant 2C'Iersa :moac:s \NnIC:l .'.1':.::'
oC::.Jr. T;'en Jrccesa airec:/y ~o :he ,=iJLL ::.,,;r= :=.nC/or ;;reoare a posnive- aeclara!icn.
C:ïec:< ~tllS :::cx 'f you ,lave rje!ermlned, ~ased oJn the information 3.nd analysis above and any si.Jcoor~::-:ç
~oc:'J(:':.en[a[lcr., :ha'L :r.e Jrooosea ac:io;"l \"IIL!.. ~~OT result InJny sigmficant acver.s2 ~nvircnment.=.1 imcac::
AND JrCVlce :m ;';:!3.C;1ri1ents 3S necessar'J, (he ,'eaSQns 5UCicorung thIS dete!"mrnarion:
....","~. 11 _"...,¡ ~<;...nC"1
~r,nl.J' -co:: "'"1''''' )1 {,',,;}cn,,a,,, _I',.::~r n _,,~() '';''''(J
.- ,110:: ·JI -<.....'oon'.OIO:: '..II!,(~r
".;n...IU!C' 'I -<o::<c()n"C ~ _I:'.::.:'"r n ~"..I(] ....;o::no:"
·"l::n,,:"'I~ H r':";).H~r II ';"'¿-""I .r")m :o::~oorH'O'" Jrr".."
J...rc
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1\.PPLtC1\.NT
TRANSACTIONAL DISCLOSURE FORH
,
,
The Town of Soulhold's Code of Ethics prohibits contlicts of
inberesb on bhe parb of bown officers and employees. The
purpose of this form is to provide informabion which can
alert bhe bown of possible conflicbs of interest and allow
ib bo bake whabever action is necessary bo avoid same.
YOUR "/\.HBI
GQ\
Lasb name, firsb arne,
you are applying in the
other entity, such
bhe other person's
..'
. >..~~tit,: :.:. ;~~ ::~i!/.":.·!.~'.
N1\.TURE ot APPLICATION! (Check all that apply.)
Tax grievance
Variance
Change of zone
Ap'p~~al of plat
Exe~ption from plat or official map
other __ ~
(If "other." name bhe acHvity.) -=-1(Vól-ce~
.'
J"ì>1 nor. ~h1 vb
Do you personally (or through you~ cbMpøny, spbuøe, sibling,
pørent, or child) have ø relationship with any officer or
employee of the Tovn of Southold1 "Relationship" includes
by blood, marriage, or business interest. "Dusiness
interest" means a business, including a parhnership, in
vhich ~he hovn officer or employee has even a parhial
ovnership of (or employmenl:. by) a corporal:.ion in vhich
I:.he I:.ovn of ricer or employee ovns more I:.han 5% of I:.he
shares. . / . .
YES NO V
",1',,,
If you answered ÞYES," complel:.e hhe balance of ~hiö form and
dal:.e and sign where indicated.
Name of person employed by the Town of Southold
Tible or position of that person
Describe the relationship between yourself (the applicant)
and the town officer ør employee. Either cheek the
appropriate line ~) 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)1
1\.) 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 interest in a
noncorporate'entity (when the applicant is not a
corpora ti on) I
C) an officer, director, parther, or employee ot the
applicant/ or
D) the actual applicant.
"
DESCRIPTION 01;" ItELATI0NSII!P
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