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Home My WebLink AboutTR-5690Albert J. Krupski, President James K/ng, 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 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0033C Data April 18, 2005 At THIS CERTIFIES that the in-ground swimming pool and fence 360 Wiggins Lane, Greenport Suffolk CounW Tax Map # 35-4-24 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 12/18/02pursuant to which Trustees Permit # 5690 Dated 1/22/03 Was issued, and conforms to all of the requirements and conditions of the applicable provisions of lax,. The project for which this certificate is being issued is for an in-ground swimming pool and fence The certificate is issued to John & Patti Casillo oxvner of the aforesaid property. Authorized Signature Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hail 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 JOHN ~ PATTI CAS~/LLO 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. INSPECTION SCHEDULE __ Pre-construction, hay bale line I~Y~ ,,I,%[(~' __ 1st day of construction ¼ constructed x Project complete, compliance inspection. ,~,~)b~ 1/27/03 Board Of $outhold Town Trustees SOUTHOLD, NEW YORK PERMIT NO.. ~lJ f~l DATE: .#.a..nu~!7¥...~.g.,. 200.~ ISSUED TO JOHN & PATTI CASILLO Authorization Pursuant to the provisions of Chapter 615 of the Jews of the State of New York, 1893: end Chapter ~ of the Jews 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 end the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN 'WATERS:!.!. end in accordance with the Resolution of The Bbard adopted at e meeting held on ....~.~abZ..22, .2~..., and in consideration of the sum of $ . .... 200..0.0 ... peld by · ..~pecl~;7~.~Ju~ar....~ls ............................................... , ..................... of ....... Mi].l.~7...?].~.~., .......................... N. Y. and subject to the Terms end Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: Wetland Permit to install a in-ground pool 16x32 with a fence to Code with the oondi~ibns of haybales during construction betw~ the bulkhead anc~ poo'~ drywetl for pool backx~ash. ali in accordance with the detailed specifications as presented in the odginafing application. IN WITNESS WHEREOF, The said Board of Trustees here- by causes ifs Corporate Seal to be affixed, and these ~.resents to be subscribed by a'majority of the said Board as of this date. Trust~e$ TER~S and CONDmONS 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 F~x (631) 765-1366 BOARD OF TOWN T~USTEES TOWN OF SOUTHOLD JOHN & PATTI CAS'iLLO 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. x INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction ¼ constructed Project complete, compliance inspection. 1/27/03 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 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD January 27, 2003 Specht-Tacular Pools 2 Quiet Court Miller Place, NY 11764 RE: SCTM#35-4-24 John & Patti Casillo 360 Wiggins Lane, Greenport, NY Gentlemen: The Board of Town Trustees took the following action during a Regular Meeting, held on January 22, 2003 regarding the above matter. WHEREAS, Specht-Tacular Pools on behalf of John & Patti Casillo. applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated December 18th, 2002. WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and WHEREAS, a Public Heating was held by the Town Trustees with respect to said application on January 22, 2003 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 conceming this application, and, WHEREAS, the structure complies with the standard set forth in Chapter 97-18 of the Southold Town Code. 2 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. NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approved the application of John & Patti Casillo Wetland Permit to install a in-ground swimming pool 16x32 with a fence to code with the condition ofhaybales during construction between the bulkhead and pool c~ywell fro, pool backwa$.h. ' BE IT FURTHER RESOLVED that this determination 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. Fee must be paid, if applicable and permit issued within six months of the date of this notification. If inspections are required, at a fee of $5.00 per inspection (See attached schedule). FEES: $10.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/cjc cc DEC Building Department Speci t-Tacular Pools ~ Ouiet Court Miller Place. New ¥o~k I i ~ 64 696~$900 May 6, 2003 Town of Southold Board of Town Trustees Town Hall PO Box 11779 Southoid, NY 11971 Regarding: Applicant Casillo Application Dated December 18th, 2002/ Regular Meeting Dated January 22, 2003 Dear Board of Trustees, Enclosed please find a site plan created by the customer. I am suppling it to you for your review and to be placed in your records. The customer has added some landscaping and the pool is remaining in the same location. If you have any questions, please do not hesitate to contact me. Sincerely Yours, iECEi¥ UA¥ - 9 2003 Board ef Trustees Albert J. Krupski, President James King, Vice-President Henry Smith Artie Foster Ken Poliwoda Town Hail 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: $ohn & Patti Casillo Please be advised that your application, dated December 18th, has been reviewed by this Board, at the regular meeting of T ........ 77 9nn~ and the following action was taken: ( X) Application Approved (see below) 2002 (__) Application Denied (see below) (__) Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees. The fee is computed below according to the schedule of rates as set forth in the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: Two Inspections 055.00 each TOTAL FEES DUE: $ 10.~0 BY: PRESIDENT, BOARD OF TRUSTEES Telephone (631) 765-1892 Town HaIL 53095 Main Road P.O. Box 1179 Southold, New Ycrk 11971 SOI. YI'~I'OLD TOWi~I' CONSERVA.TIOI~' ADVISORY COUI~CIL At the meeting of the Southold Town Conservation Advisory Council held Wednesday, January 15, 2003, the following recommendation was made: JOHN & PATTI CASlLLO for the installation of a 16'X 32' in-ground Swimming pool with fence. Located: 360 Wiggins Lane, Greenport. SCTM#35-4-28.33 The CAC did not make an inspection, therefore no recommendation was made. By Dieter B. Specht Phone (631) 696-3900 Fax (631)924-2863 FAX COVER SHEET To:Charotte Cunningham Company: Board of Town Trustees Fax Number: Date: 1/6/03 Regarding: Casillo Hearing 1/22/03 Charotte, I hope you had a wonderful new year!! I am faxing you An approvel letter from the DEC for the Casillo project. If You would be so kind and add it to the file for the up Coming hearing, I would appreciate it. Take Care, Gretchen 4 pages sent including cover ~oo~ I~lew York State Department of Environmental Conservation Division of Environmental Permits Building 40 - SUNY, Stony Brook, NY 11790-2356 Telephone {631) 444-0365 Facsimile (631) 444-0360 Erin M. Crotty Commissianer December 19, 2002 Mr. & Mrs. John Casillo 31 Shennandoah Boulevard Coram, NY 11727 RE: 1-4738-02887/00004 Dear Permittee: In conformance with the requirements of the State Uniform Procedures Act (Article 70, ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit. Please read all conditions carefully. If you are unable to comply with any conditions, please contact us at the above address. Also enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather. SVA/ls Enclosure Sincerely, V. Ackerman Environmental Analyst ~oo~ NEW YOR DEC PERMIT NUMBER 1-4738-02887/00004 FACILITY/PROGRAM NUMBER(S) DEPARTMENT OF ENVIRONMENTAL CONSERVATION ERMIT Under the Environmental Cooservatien Law TYPE OF PERMIT · Ne-'"~-~-Renewal [] Modific~ Permit to Construct [] Pem~it t~'~ r~ Article 15, Title 5: Pretectlon of Waters [] Article 15, Title 15; Water Supply E] Altlcle 15, Tille 15: Water Transport [] A~licle 15, ~tle 15: Long Island Wells [] Article 15, Title 27: Wild. Scenic and Recrsational Rivers E] 6NYCRR 608: Water Quality Certification [] Article 17, TitJes 7, 8: SPDES [] Article [] Article 19: Air Pollution Control [] Article [3 Article 23, Title 27: Mined Land Manac Reclamation [] Article [] Article 24: Freshwater Wetlands · Article 25: Tidal Wetlands [3 Articl, 380: Ra [] Article 27, Title 7; 6NYCRR 360: AE,DRESS OF PERMITrEE ( 3__1 Shen.~nandoah Boulevard Coram, NY 11727 CONTACT PERSON FOR PERMITTED WORK S_.J)echt-Tacular Pool Inc., 2 Quiet Court,.__Miller Place, NY 11764 NAME AND ADDRESS OF PROJECT/FACILITY C.~asillo ro ert ,360Wi ins Lane, Green or[ S,~ Southold DI=-SCRIPTION OF AUTHORIZED ACTIVITY: SCTM #1000-35-. CDnstruct 32' x 16' in ground swimming pool located a maximum of 3 feet seaward of existing dwelling. All work must be done in accordance with the attached plans by SI: 7/I 1/2002 and stamped NYSDEC approved on 12/18/2002. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compli applicable regulations, the General Conditions specified (see page 2 & 3) and any Special Con of this permit, EFFECTIVE DATE 7, Title 9; 6NYCRR 373. ~us Waste Management 4: CoastaJ Erosion 6: Flooclplain Management 1, 3, 17, 19, 27, 37; 6NYCRR :liation Control EPHONENUMBER ~2 EPHONE NUMBER -28.3 'M COORDINATES ~.he front of the ;cht-Tacular Pools, Inca with the ECL, all lions included as part PERMIT ADMINISTRATOR: ALITHORIZED SIGN ADDRESS I Head, Ston DATE December 19, 2002 NY 11790-2356 Page 1 of 4 coo ~ ~9g~ P~6 ~9 ~¥~ ~:T[ ~00~/90, I0 12/12/2002 12:08 FAX 631 924 ~3 Thrifty Electronics New York State Department of Environmental Conservation Division of Environmental Permits, Region One Building 40 - SUNY, Stony Brook, New York 11790-2356 Phone: (631) 444-0365 · FAX: (631) 444-0360 Webslte: www.dec.state.ny.us Erin M. Crotty Commissioner October 23, 2002 Specht-Tacular Pools 2 Quiet Court Miller Place, NY 11764 Re: 1-4738-02887/00004 John Casillo 360 Wiggins Lane, Greenport Dear Sirs, The New York State Department of Environmental Conservation has reviewed the application listed above for a new swimming pool. The Department has no objection to the proposed pool, however, the pool must be relocated to maximize the distance from the tidal wetland. Please submit 4 copies of a revised plan which shows the landward edge of the pool located even with the most landward edge ofthe existing dwelling. ( see enclosed sketch) If you have questions concerning this matter, please contact me ,~! 1631 ) 444-0357. Sinferely' I ,/ /Susan Ac~ Environmental Analyst d iii l echf - ' acular ~l: Dieter 2 Quiet Court Miller Place, New York 1 ! 764 P# (631) 696-3900 F~ (631) 924-2863 Town of Southold Board of Trustee Town Hall 53095 Route 25 Southold, New York 11971-0959 (631) 765-1892 Re: SCTM#35-4-24 Dear Mr. Ed Forster, Letter serves to notify you that the hay bales have been placed tt } t,4o,¢~/I Am (date) as directed by permit number 5690. (Attached' please fred a copy of the permit.) Please inspect at' earliest convenience and share with us any of your thoughts. Best Regards, Gretchen Specht LOO/LO0 ~ Albert J. Krupeki, President James King, Vice-President Arkie Foster Ken Poliwocla Peggy A. Dickeraon P-O. Southold. Ne3[ Telephone Fax (63 BOARD OF TOWN TRUSTEES TOV~N OF SOUTHOLD January 27, 2003 Sp~cht-Tacular Pools 2 Quiet Court Miller Place, NY I 1764 1~: SCTM#35-4-24 John & Patti Casillo 360 Wiggins Lane, C-reenport, NY Gentlemen: The Board of Town Trustees took the following action during a Regular Meeting, held c January 22, 2003 regarding thc above ma~ter. WHEREAS. $1~echt-T-cul-r Pools on behalf of John & Patti C~sillo. applied to the Southold Town Trustees for a pemfit under the pmvisiom of the Wetland Ordinance oft of Southold, application dated D~ember 18th, 2002. WHEREAS, said application was referred to the Southold Town Conservation Adviso~ for their findings and recommendations, and WHEREAS, a Public Hearing was held by the Town Trustees with respect tO' said apph~ January 22, 2003 at which time 11 tnterested persons were g~ven an opportunity to be h, and, WHEREAS, the Board members have personally viewed and are familiar with thc prerm question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation ~ubmitted concerning this application, and, WHEREAS, the structure complies with the standard set forth in Chapter 97-18 of the Sc Town Code. tall :ute 25 '1179 · ~k 11971-0959 765-1892 Tow'il ~uncil on on d, hold 900/800~] sJosuas pue saq3).[~8 ~98~ ~'Z8 L89 ×¥J 9L'gL EOO~/LL."LL 2 WH~I~AS, the Board has determined that the project as proposed will not affect the S~fety and general welfare of the people of thc town. NOW THER~FOKE BE IT, Rt~SOLVED, that the Board of Trustees approved the apphcation of]oh~ & Wetland Permit to install a in-ground swimming pood 16x32 with a fonce to code with~ ha ale dung co st ctiori be e , the hu ead and poo BI~ IT FURTHEP. RESOLVED that this determination should riot be considered a made for any other Department or Agency, which m~y also have an application same or ~imilar project. Fee must be paid, if applicable and permit issued within six months of the date of th/s notificstion. If inspections arc requ/red, at a fee of $$.00 per ir~p~ction (See attached schedule). !ool · the FEES: $10.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AlK/cjc cc DEC Building Depm'tment Board Of Southold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. , .~..,.~ll iJ~l~.. DATE: ...,.T.~,,~,r,~,..~,.,. ISSUED TO ~OHN & PATT~ CAS~LLO u 'h riza io Pursuant to the pro¥i;ions of Chapter 61S of the . ,, , nd ~e ~uthold To~n Ordinance t~fled- R~U~TIN~ AND ~E P~CIN~ OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC ~NDS ~ t~ RE~OVAL OF SAND, ~RAVEL. OR OTHER MATERIALS FROM LANDS UNDER TOWN WA~RS?~ ~nd in ~¢c=rden¢e ~th the Resolution o~ The B6ard ~dopfed at a meeting held on ....~.~X..~. ................................................................... Y. end subject fo the Terms end Condffmns li=~'"'on' ~e re~e~e ~rde he.f, of Sodhold Town TruCes eufhor~es end permits the fol~wlng: Code wtt~ t~e ~nd~b~-~ o~ b~yb~es ~u~ co~st~=ctJon betwe. ell in accordance with t~e detal~d speclficeflons es pre~nfed · ~e orlglnafing application. IN WITNESS WHERE., ~e ~ld Board of T~sfee~ by ceu~l ~ ~orporefe Se~l to be ~zed, and fhe~e plaints fo be ~ub,eribed by ~ 'majori~ of f~ ~md ~erd es of th~s dot=. ~oo/~oo ~ Henry Smith Artie Foster Ken Poliwoda Town Hedl 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone(631) 765-1892 Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Applica.ti~ Wetland Permit Application v' Major Waiver/Amendment/Changes Received Application: 1~1S/o '~' . 1 Received Fee:$ /bO~ ~ Completed Application ['V/I~'[ CO,,/ Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(date senO~ c^c Renewal Sent: I"l Date of Inspection: I 1 Receipt of CAC Report: ~ / Lead Agency Determination: __ Technical Review: Public Hearing Held: Resolution: Minor NameofApplicant ~o,q,q a.,d f~r4', Co~5, LL.v PhoneNumber:~;~ ~/~7- lC. 2.7. Suffolk County Tax Map Number: 1000 - -~ ~'''% c/~ -~ ~. //,7-/q //qqq Property Location: ~O ¢),~a,.05 Lm~O (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: ({~ '~9 Land Area (in square feet): Area Zoning: GENERAL DATA Previous use of property: Intended use of property: Prior permits/approvals for site improvements: Agency Date 9'/, 7/,9 7.. __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? v/ No__ Yes If yes, provide explanation: Project Description (use attachments WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: i'h y /OLLc~ ~, )~ ,aV r~ t'Tt¢oe4 Ar~ of wetlands on lot: _square feet Percent coverage of lot: [ % Closest distance between nearest existing structure and upland edge of wetlands: ~-/~'~ feet Closest distance between nearest proposed structure and upland edge of wetlands: c-[~'~ feet Does the project involve excavation or filling? No j 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: 5~% ~ feet Proposed slope throughout the area of operations: AJO C[~o,pe ~ 5[-,Pff Manner in which material will be removed or deposited: /~_,,g,9oe. ~/ 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): ~ar~of Trustees Applica COASTAL EROSION APPLICATION DATA Purposes ofproposed activity: ,~n~/qZLa~n ,~/ ~ ~ ~e wetlands pre~nt ~thin 1 O0 f~t of the pro~sed aaivity? No ~ Yes Do~ the proje~ involve ex~vation or filling? No ~ Yes If Yes, how much material will be ex~vat~? ~ (cubic yards) How much ~terial will be fill~? ~ (cubic y~ds) Manner in which material will be removed or deposit~: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) Trustees Applicati~ mw AU'£~ORI ZATION (where the applicant is not the owner) (print owner of property) (mailing ad~res.~ ) do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. 8 "PROJECT i.D. NUMaER 617.21 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) 1. APPLICANT /SPONSOR SEQ ~ i ~ I' 2. PROJECTNAMEt 3. PROJECT LOCATION: / P PROPOSED ACTION: [] New ~ansion ~itlcalionlalt era tlon ~, OES IBE PROJECT SPJEFLY: ~II 7. AMOUNT O~= LAND AFFECTED: I.itla.y / 0 ¢ Z. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTR CTIONS?' g. ?,tHAT [S PRESENT LAi'~D UEE IN VICIN ]7, OF PROJECT? iI par~lForesUOoen $0ace ~--JOtner 10. DOESsTATEACTIONo;~ LOCAI.j?INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL ~GENCY (FEDERAL, 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAIJO PERMIT OR APPROVAL? I [] Yes' ~No If yes, list a@el~cy name and permit/approval bed. j.,~ ~,e,t~cL ~p/~od~L...~ n/zc ,--¢~;¥,~c.- p.~.~t ,.,~/z~.z..7. ~4~/~ ~ ~.~ ~ 12. AS A RESULT OF PROPOSED ACTION WILL ¢d(ISTING PERMITIAPPROVAL REQU RE MOO F CATION? [] Yet [~No I CERTIFY THAT THE INFORMATION PROVIDEO ABOVE IS TRUE TO THE SEST OF MY KNOWLEDGE the action'is in the Coostal Area, and you are a state agency, complete the J Coastal Assessment Form before with this I proceeding OVER I PART il-- ENVIRONM E?JTA' PART III--DETERMINATION OF SIGNIFICANCE lTd be camoleted by Agency) INSTRUCTIONS; For earn adverse effect identified score, determine wlletiqar it is substantial, large. [mgor~snt or otherwise signific. E~ch offer: Should be ~[ssessed in connection wilh its (a) setting (i.e. urt3an or rural); (b).DrobaeHity of occa?i~g; (c} duration: irrevers~bdity; {el geographic scoDe; one (t) magmtude, if necessary., add attac.~menls or reference suppor~fng materials. Ensure ' exe~anations remain sufficient de,ail to snow tha[ all re!evant adverse impacts have been identified and adequately ~CCressec. Check ~his box if you have identified one or more potentially large or significant Adverse imoac:s which MAY occur. Then Drcceed direr:fy ,'.o :he FULL --Ar And/or prepare e positive- dectarAticn. Checx =his box if you ,hsve de,.ermined, based on [he information and analysis Above And any sueoortJnc_ documentation. :hat :he proaoseo Action WILL ,'lOT result in -_~.n? significant adverse environmental imeac:a .{ TRAN~ACTIONA~ D~CLOSUEE FORH The Town o~ S~U'~hold~s Code of ~hice prohibits con£iicba oS inberes~ oh the par~ of ~own officers and employegs. .The PUrpose of, this form is ~o provide information w~lch can alsr~ ~he town of possible conflicts of interest and allow 'it ~o take whatever action is llecesaary ~o avoid same. ~OUR (Last name, first name, m~ddie initial, u.less you are applying in %he name gE someone else or other entity, a0cll ~s a compamy. IE so, indicate the other person's or company's name.) NATURE O~ APPLI~ATIONt (Check ail tha~ apply,) Tax grievance ,, Variance Change of ~one. .. App~p.val uS plat, . ~.~, gxe~p~ion from pla~ o~ official map Other (IS "Other," name the activity,) .,~p~Ja/ Do you pereenaliF (o~ through your u~mpany~ spouse, by bXood, marriage, or bueinees interest. 'Business interest# means a business, including a parEnorship~ in {hich ~he ~otn o~£icer or empXoyee has even a par~ia! o~nerehip o~ (or emp/oymenb by) a corporation in which the town officer or employee owns more than ehar~e. you answered 'YES,".compXehn hbo balanoe o~ ~hie ~orm and da~e and sign uhere indicated. Name of person employed by the ToWn oS 9ouEhoid ~ltis or position of that person . Describe ~he relationship between yourself (Bhs applicant) and the town officer er employee. Either check the appropriate tine A) through D) and/ou describe in the apace provided. The %own officer or employes Or hi~ or her epouea,' sibling, or child is (check all ~hat apply)~ ~he owne~ of grsater than 9% of the share~ of the corporate stock of ~he appiic~nb (when the applicant' is a corporation)~ the legal or bbneficial o~ner of any ihberemt in s noncotpo:ate'entity (~hen the applicant ie not a parent~ A) corporak~on)l D) the a~bual applicant. DESCRIPTION OF R~LATION$IIIP