HomeMy WebLinkAboutTR-5944
Board Of Southold . Town Trustees
SOUTH OLD, NEW YORK
PERMIT NO. .. 5.90/'1
CHARLOTTE MULLEN
ISSUED TO mn..n..n..n...
DATE: n!une 24, 2004
... .................-........
1\utlfnrh:atintt
Pursuant to the provisions of Chapter 615 of the LaW$ 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 OBSTRUC.IIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS and the
REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS.fS-OM
lANDS UNDER TOWN WATERS:!'. and in accordance with the
Resolution of The Board adopted at a meeting held on J':'n.:"'?~.'n
..~~~.~ and in consideration of the sum of $ 25Q...00 ... paid by
Charlotte Mullen
..···......mm........... .............._h. ...... ......................................._............_.....
of nn~()':':~~()~cln N. Y. and lubject to the
Terms end Conditions listed on the reverse side hereof,
of Southold Town Trustees authorizes and permits the following:
Wetland Permit to construct a 4'X 20' level dock leading tö a
1 32"X 16' ramp and ending ~ith a &'X 20' floating dock secured
by three (3) one-pile dolphins, and all as depicted on the plan
'. preparl"'d by Costello Marine Contracting last dated July 2,2004.
aU in accordance with the detailed specifications as presented in
. the originating application. .
IN WITNESS WHEREOf, The said Board of Trustees here-
by causes its Col"f>Ol'at~ ~al to be a~xed, and thele P!'esents to
be subscn"bed by a malority of the said Board as of this dat.e,
TERMS and CONDmONS
"Die Permitœe
Charlotte Mullen
~ at 1775 Mill Creek Dr., Southold . N. Y.. u
part of the coosideraâon for the isso··""" of che Pemùt does uødeøtaod and pœscribe 10 the fol·
lowing:
1. That the saidJloard of Trustees and the Town 01 SouthoId _ reløsed from my and
aU damages, or claims for damages. of suits adsiog dúecdy or tødirecdy as a a-esuk of an-¡ oper'
atIoopedotmedl"'_t~..tbis.peaalt, aaclJbe.Aklj)II~"-mu.~~ or.~ ~,~.
delead ...y and all -" sults'lnltl·ted by Ibhd.,ardes, and the said PctmIttee __ fuU I10bIlIcr
with respect thereto, 10 ·~exdusiOQ of the &ud of Tcasœes of the TO'RD of ~
2. That this I'eaDIt is ~ for . pedod of 2 4 mas. wbkh is ~ to be che
estimated time· requùed to axnplete the wod: inwl..ed, but ihoald rircumstaDccs wunot, reqaat
for an exœosion ,rœy be made 10 the Ðoard u a bier d.œ. .
3. That this PCfIIIÎt should be retaioed indefmitely, or as 1008 as the said Pemùttee 1I'IsbCs
10 . maintai.. the lUUCQlre Ot project Involved, to provide evidence to anyone œncemed chat auth-
!)tization ...... originally nt- ~
4. That Ihe wod: inwlved will be subject to the ~ aacI approval of 1be Board or
its ~ts. and ooo.-œmpllaoœ with the proWions 01 the orI&''''''''<Ig applicatioa, may be CIUSC for
œvocaâon of chis Petmit by resollation of the laid Board.
S. That there will be no UItttaIOIIable Interf_ with oavigatioo IS a result of the wad<
berein aUthorized. . .
. 6. That there oball be 00 interfereoœ with the right of die puLIJc to pass aacI repass aloag
the beach between IIIsh aacI low water marks. .
7. Thu if future opentioos of the Town of South9Id m¡uIre che œmon1 aacl/or alW'JItioas
In the Jocaâoo of the wotk herein..,d.o.i-1. or If. In che opIaIoa ol6e Board 01 TIusteeI, che.
wodc shall cause anreasooabIe obstnJdlOO 10 free øavigmoa, che said p.-.I~ will be reqaIæd,
apoodue ootiœ, 10 remove or alter this wotk or project berein staœcI wkbouc eqcIISCI to the Town
. . . of Souchold. . .
8. Thu the said Board will be ootifIed by the I'ctmiuee at the ~ Of the work aath-
orbed.
9. That the ·¡>erml.- will GbtaIn all other permits aod -.. 'Chat may be required sa;;
ti_tsl to chis permit ~ may·be subject to 1'mIIre apoo faIJuœ CO obcaIn 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 (631) 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.
fYL..I I I ~ '"'
INSPECTION SCHEDULE
Pre-construction, hay bale line
1 st day of construction
Yz constructed
¡./' Project complete, compliance inspection.
.
.
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
Town Halt
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone 1631) 765-1892
Faxi631ì 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
June 24, 2004
Mr. John Costello
Costello Marine Contracting Corp.
P.O. Box 2124
Greenport, NY 11944
RE: CHARLOTTE MULLEN
1775 MILL CREEK DR., SOUTH OLD
sCTM#51-6·33
Dear Mr. Costello:
The Board of Town Trustees took the following action during its regular meeting held on
Thursday, June 24, 2004 regarding the above matter:
WHEREAS, Costello Marine Contracting Corp. on behalf of CHARLOTTE MULLEN
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 Southold,
application dated May 14, 2004, 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 June 24, 2004, 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,
.-r
.
.
Al!>ert J. Krupski, President
James King, Vice· President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
BOARD OF TOWN TRUSTEES
TO\VN OF SOUTHOLD
TO: -.Own otizz.. mullDlî
Please be advised that your application dated 0/ J.3~tJ{
reviewed by this Board at the regular meeting of 6 { ~ CiI-
following action was taken:
.
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax 1631., 765-1366
has been
and the
( vi'~PPlication Approved (see below)
L-) Application Denied (see below)
L-) 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:
$5D.cu- r-ìM-l..'1:n&ptL-!\ð"I ~
::::e.~ ~tto(....'\ ~ 'l'K'S clod ~ 1'60,00
@ ..!?i'())\~.fI. 3J"K Ib' ro.lI\f "'¡/~O.OO
h'l ð.o' -A1:U.1 ::.t 3JðO ,00
TOTAL FEES DUE: $ '7/0,(;ú
SIGNED:
æt~.$ 9· ~.~.
PRESIDENT, BOARD OF TRUSTEES
J
.
.
Telephone
(631) 765-1892
TQwn Hatl
53095 Route 25
P.O. Box 1179
Southold. New York 11971-0959
CONSERV A nON ADVISORY COUNCIL
TOWN OF SOUTHOLD
At the meeting of the Southold Town Conservation Advisory Council held Tuesday,
June 15, 2004, the following recommendation was made:
Moved by Doris McGreevy, seconded by Don Wilder, it was
RESOLVED to recommend to the Southold Town Board of Trustees DISAPPROVAL of
the Wetland Permit application of RICHARD MULLEN to construct a 4'X 35' level dock
leading to a 32"X 12' ramp and ending with a 6'X 20' floating dock, secured by (3) 1-pile
dolphins.
Located: 1775 Mill Creek Dr., Southold. SCTM#51-6-33
The CAC recommends Disapproval of the application because the docking facility
exceeds 1/3 the width of the creek and should be in line with the neighboring docks.
Vote of Council: Ayes: All
Motion Carried
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COSTELLO MARINE CONTRACTING CORPORATION
DOCK BUILDING' JETTIES' BULKHEADING . STEEL & WOOD PILING· FLOATS
423 FIFTH STREET . P.O. BOX2124 . GREENPORT,NEWYORK11944' (631)477-1199/477-1393/477·0682. FAX (631)477-0005
July 8, 2004
~~ ~l~1 : :o~ ~
sout"old TDwn
Board 0\1rust...
Southold Town Trustees
P. O. Box 1179
Southold, NY 11971
ATTN: Lauren
RE: Mullen Project
1775 Mill Creek Drive, Southold, NY
Dear Lauren:
Enclosed please find three copies of revised plans showing a 4'x20' level dock
leading to a 32"x16' ramp and ending with a 6'x20' floating dock secured by (3)
1-pile dolphins.
If you have any questions regarding this matter, please do not hesitate to
contact me.
Yours truly,
/~Œ~:
y ~~~~it Manager
Enclosure
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LONG
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VICINITY MAP
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ADJACENT PROpeltTY OWt.JëR5··
CD AUDREY e.AKER ® L-INDA PRICE
120 CL-INTON Ave, (ø7 HUO.sON RD.
M INEOL.A...NY I"L.OItAL. PAR.K, NY
11~01- ~87", 11001
(1('~.5 M/L.L- C~EEK DR,} (18"5 MIL.L CREed" DIE.)
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APPLICANT'
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(1775 MIL.L. CReEK DR.)
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MAR. 15, -.003
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Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
AlbertJ. Krupski, presiden_
James King, Viea·President
Henry Smith
Artie Foster
Ken Poliwoda
.
~
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
_Coastal Erosion Permit Applicat~ Minor
~etland Permit Application ~ Major -
_ Waiver/Amendment/Changes
---1teceived Application:
,--Received Fee:$ .J\D r
_Completed Application , l U "'-...~ rI r
_Incomplete ~~a:I!:~U TI
SEQRA Classification:
Type I_Type II_Unlisted_
_Coordination:(date sent) JUN 2 3 2004
~ CAC Referral Sent:
_Date of Inspection: ~.[Iv. { IY{
_Receipt ofCAC Report: Southold Town
_Lead Agency Determination: Board of Truste.s
Technical Review:
~Public Hearing Held: Cr/JY/O<f
_Resolution:
Name of APPlicant~ ~
Address -:PO.
bl/~lö.-í fJ.
cia IL CCLT
bæ(LJO'-
I'D'""" 'S~ I
Phone Number:( )..1ðJ. 7"5 -{ D q 70
Suffolk County Tax Map Number: 1000 - J21 -l. - ~
Property Location: 7
ql(
(provide LILCO Po!e #, distance to cross streets, and loc.:ation)
Address:
AGENT:
(If applicable)
Phone:
4Itoard of Trustees ApPlicattlt
GENERAL DATA
Area Zoning:
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?
~No_Yes
I f yes, provide explanation:
Project Description (use attachments if necessary):
4Ikoard of Trustees ApPlicattlt
WETLANDffRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
~t.
Area of wetlands on lot:~square feet
Percent coverage of lot: q %
Closest distance between nearest existing structure and upland
edge ofwetlands:--.JO feet
Closest distance between nearest proposed structure and upland
edge of wetlands: JD feet
Does the project involve excavation or filling?
X No Yes
If yes, how much material will be excavated?-+-CUbiC yards
How much material will be filled?.JJ1 A cubic yards
I
Depth of which material will be removed or deposited:..lIIJ II\.
J
Proposed slope throughout the area of operations: N/ A
I
Manner in which material will be removed or deposited:
feet
N/A
I
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 app'ropriate):
tItoard of Trustees APPlicaJltn
County of Suffolk
State of New York
. hWl, eD~_Ullrn BEING DULY SWORN
DEPOSES AND AFFIRMS THAT HElSHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRUE TO THE BEST OF HISIHER KNOWLEDGE AND BELIEF, AND THAT ALL WORK
WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MA Y
BE APPROVED BY THE SOUTIiOLD 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 THI S
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR
REPRESENTATlVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
~.. .,-.
- /..
{¡~ / ..
,.,~ ,.'.... .
. ,-~,~. Agj. d h
._:~ Signature
!j DAY OF mar
,
.20Cf!
SWORN TO BEFORE ME THIS
~. a¡;ä~dllt(cä
otary Public
REBECCA A. VILARDI
NOTARY PUBLIC, STATE OF NEW YORK
QUALIFIED IN SUFFOlK COUNTY
NO: 01W06039106
COMMISSION EXPIRES MARCH z¡,¿Ç)Cé.;'Ç'j
-
.
Albert J. Krupski, President
J ames 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 SOUTH OLD
_Coastal Erosion Permit Application
.....-wetland Permit Application ..- Major
Waiver/Amendment/Changes
....-Received Application: SJIIf)
-""Received Fee:$ (,) ,.
-€ðmpleted Application
_Incomplete
_ SEQRA Classification:
Type I_Type "_Unlisted_
Coordination:(date sent)
-C-AC Referral Sent: ~/'IIOL{
-f)ate .of Inspection: ~ ,I I "V OIJ
_ReceIpt ofCAC Report:
_Lead Agency Determination:
Technical Review:
wfI'líólic Hearing Held: f4/.J1/ 101{
_Resolution:
Minor
01/10 a¡.¡ r S.
Li(t\<, (ui ba(! t
I
do Iì Oi ~~
Office Use Only
[5), ~ (C ~ ~ ~E.i
lfù MAY 1 4 ~
¡'C -~
~~. !-..¡,
,
-- ¡¡
I '
, I
J
Southold Town
Board of Trustee,
Name of APPlicant~mrc\ ;t1..Y.lj: V\
Address ~.O. fX)x l.:tn8 I ~11.fuQld--r_btLJ ¡q 11
Phone Number:( ) -1ð\ lID fj. I a q 1 0
~
9~,,1'}
Suffolk County Tax Map Number: 1000 - ~I n -.3 ~
Property Location:-1]ì 5 Mill Crft~ Drlv'r I ),1A1h1k:l-N Y II q 7 J
(provide 1ILCO Po!e #, distance to cross streets, and lo~ation)
AGENT flJsi:e.ilo.....Mo v' I \'1f-. ~ Cn~þ·
(If applicable)
Address_:E..DJ).J)( JIJ4 ! 8X'ffV\I(ðA, t-\y JlC}14
Phone:~~n - IIqL_
~
.
.
Board of Trustees Application
GENERAL DATA
Land Area (in square feet):~ f).
Area Zoning: JIO Oý'R klYWly (QSYÌIl\'lŒ.,
Previous use of property: S~1e ~V\l.14 1'e~I~
Intended use of property: ,<1 «'e..
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
¡fyes, provide explanation:
Project Description (use attachments if necessary):
3:1" X I;¡' rn.Wlp a.v1d ev4(,t1é( WÛ1:La.J 0 I X ~n'
~C(k c.fJ(ured.JJ4 (~) Lp',1t do[pV¡Ù'lS
------
· .
Board of Trustees Application
Purpose of the proposed operations:
WETLANDffRUSTEE LANDS APPLlCA TION DATA
î6 ~yoyúe, dcäwq -fOr
J. 'jvwuUooJ-
Area of wetlands on lot: If) 1 c:¡ square feet
Percent coverage oflot: q %
Closest distance between nearest existing structure and upland
edge ofwetlands:--.J1J feet
Closest distance between nearest proposed structure and upland
edge of wetlands: 10 feet
Does the project involve excavation or filling?
;< No Yes
Jfyes, how much material will be excavated?~cubiC yards
How much material will be filled?4-CUbiC yards
Depth of which material will be removed or deposited:~ feet
Proposed slope throughout the area ofoperations:~¡ I'r
Manner in which material will be removed or deposited:~ A
Statement of the effect, ifany, on the wetlands and tidal waters of the town that may result by
reason of such proposed operations (use attachments ifappropriate):
'Sw:rf, wltl œ' ~(ea.stU Vf,CS£- ;««1<, 10 4he.
.
.
Board of Trustees App11cation
Counry ofSufTolk
State of New York
hvt ~o")w,\lWa~h BEING DUL Y SWORN
DEPOSES AND AFFIRMS THAT HE/SHE [S THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ..\RE
TRUE TO THE BEST OF I-llS/HER KNOWLEDGE AND BELIEF, AND THAT ALl WOKI'.
WILL BE DONE IN THE MANNER SET FORTH IN TI-llS APPLICATION AND AS 1\1.-\ Y
BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLlC-\I'\1
AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES
H.-\RMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING
UNDER OR BY VIRTUE OF SAID PERMIT(S), [F GRANTED IN COMPLETING THI ~
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR
REPRESENTATIVES(S), TO ENTER ONTO ¡viY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
..-,'-
/;;</ -,
L //~/Í' . J )}
Signature - ,
, " "Ú-~)~·
SWORN TO BEFORE ME THIS
1-f DA Y OF )Y)¿¿1
.20c/
-) .. I, . .
..c;h,- ... :;{{ Lé¿e.Ä-¿¡/~¿(¿~(é-'¿( .
¿--::-Notary Public
REBECCA A. VILARDI
NOTARY PUBLIC, STATE OF NEW YORK
QUALIFIED IN SUFFOLK COUNTY
NO: Q1 W060391 06
COMMISSION EXPIRES MARCH 27,,3 tZ/V;
.
.
--....0_
COSTELLO MARINE CONTRACTING CORPORATION
DOCK BUILDING' JETTIES· BULKHEADING . STEEL & WOOD PILING· FLOATS
423 FIFTH STREET· P.O. BOX 2124 . GREENPORT, NEW YORK 11944 . (631) 477·1199/ 477·1393/ 477·0682 . FAX (631) 477-0005
. "',I
AUTHORIZATION FORM
')
!, ('l]fJýlðff~ /viI< II~^I owner of ~"-:IIA~"', hr.""'.....
Business/Property Name
!ocatedatC775" \'1~\1 ('...""""~ Î'.r. (.Il 6(),,-tt,~tdl MY 1/17/,
do hereby give Costello Marine Contracting Corp. the authority to act as agent in my
behalf in applying for all of the necessary permits for work to be completed at my above
referenced property.
X¡¿.'/():J-
; ate
(lli'/Ltt~~77:: ~Ltþ1"/'.?~,-
Signature·
-------
..
.
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
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
------------------.--------------------------------------------
In the Matter ofthe Application
of
.._~Jl~~~___~~~_~____.____.__..___._______
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
/ AFFIDAVIT OF POSTING
I, ~~ J' iÆ/,.1t~ ,residing at /C:' ~"-/~-,,z.~..,4/~ t<,ßj,'-:h.~ Æ~kJr
A/..-z......- .~/,,~/C
being duly sworn, depose and say: /
That on the l,s-day of ~'""I6 ,2004,-1 personally posted the property known as
/ 7 7S- .Á./j ,,:-'- C.";Z6.<:'7c..D/~,v-<2ii. ~"r74C>l-O ..v. 'I. //"'"17/
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 eight days prior to the date of the public
hearing. Date of hearing noted thereon to be heldTh~'l .).,},t\4.. .;)~ '
01'\ or ~b 1M'" V)'~ p~,
Dated: .~ /S- ,;)-dZ; i.,t/
,
,
I
/
,
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7- ...:...., ~~
/' ·(signature)
Veronica F. Cidone
Notary Public. State of New York
No: 52·4661406
Qualified in Suffolk Coun~ _ .-----
Commission Expires Dec.31, é70úS
.
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Posting Notice
Richard Mullen
1775 Mill Creek Road
Southold, NY 11971
6-15-04
-
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7001 0360 0001 0522 1529
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STATE OF NEW YORK
COUNTY OF SUFFOLK
.
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
AddreE 7001 0360 0001 0522 1536
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C¡..,-j,D ed ~",,(llt ~y II7&)
, residing at 1(,0 ~L I -"'"1 \
, being duly sworn, deposes and says
that on the I"') day of .Ju.~ ,,tÐ~, deponent
mailed a true copy of the Notice set forth in the Board of
Trustees Application, directed to each of tne 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 curr nt assessment
roll of the Town of Southold¡ tha said No c w re mailed at
the United States Post Office at , that
said Notices were mailed to each y (certified)
(registered) mail. ~.. ~
12 i;He (/ "'l Ú ,
Sworn tOJ before
day 17 IAI.)(S
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me this jl
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Public ./.....- ".'-;0
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APPLICANT/AGENTIREPRESENT A TIVE
TRANSACTIONAL DISCLOSURE FORM
The Town of Southald's Code of Ethics Drohibits conflicts of interest on the Dart o£to\\'I1 officers and emvlovees. The Dumose of
this fonn is to provide jnformation which can alert the town ofoossible conflicts of interest and allow it to take whatever action is
necessary to avoid same.
YOUR NAME:
I=-/
(Last name, first name, middle initial, unless you are applying in the ame 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
Variance
Change of Zone
Approval of plat
Exemption from plat or official map _
Other
(If "Other", name the activity.)
----
\i\;i'HùYlr1~
Ap~\ll:a..t(( n
Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee
of the Town of South old? "Relationship" includes by blood, marriage, or business interest. "Business interest" means a business.
including a partnership, in which the to\\'I1 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
x
NO
If you answered "YES", complete the balance of this form and date and sign where indicated.
Name of person employed by the Town of South old
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):
_A) the owner of greater than 5% of the shares afthe corporate stock of the applicant
(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 oftìcer, director, partner, or employee of the applicant; or
__D) the actual applicant.
DESCRIPTION OF RELATIONSHIP
¡;~~~~"" ~
--