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-
Board Of SoutholdTown Trustees
SOUTHOLD. NEW YORK
PERMIT NO. .
5t~1
DATE: .No-v..
ISSUED TO .........w.n.l-.1AM....&...PATRlCIABRENNEN--...-
1\ut11nrilutintt
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 PUBUC LANDS and the
REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM
LANDS UNDER TOWNWATERS('; and in ae<:ordance with the
Resolution of The Böard adopted at a meeting held on ..~.8l1.~~n 19th
. 20.0.3.... and in consideration of the sum of $....50...0.0. ... n paid by
.. William...&...Patricia...Brennen .... .. .............................................------...--
of ...~~::____~~~.ioll·--.-- .__._ ..... N. Y. and subi~t to the
Terms and Conditions listed on the reverse side hereof,
of Southold Town Trustees authorizes and permits the folawing:
Wetland Permit to construct a: 3'x35' stairway and ¡'ix:11
landing on the property down the slope to Marion Lake.
aU in ae<:ordance with the detailed specifications as presented in
. the originating appl"lCation. .
IN WITNESS WHEREOF, The said Bo.ard of Trustees \v3re-
by causes its CorfXIrat-: S~al to be aff!xed, and these p~sents to
be subscribed by a maJority of the said Bo.ard as of thIS dat.e.
'/
...
¡~..
·Ken Po~iwoda (Absent)
TNlSte<r
'..........,..,,..:7...·1.·...'.·,.-'. ..(.h.·.~'.··'.·...·I.·,.·.·'iI·..·.'.·.'.'II~.'. ..../.. '~.""" "III 'I' ,', ,",. .'~ '.'''-
TERMS and CONDmONS
The Permittee
. 1',crè
~'·Ir Pt' . ,
.1 llUd &. 1;.1. L l,-~a. DL t:;lllll:;;U
miding at leSe Ti u,uauo );.~~~ E;t"l M~l N. y~ as
part. of the coosideratioa for the I...,·...... 0 die t iIoes uødeataod and pLUCrlbe to the fol-
lowing:
1. That the Aid Board of Trustees and die Town of SoucboId ore released from any and
all danJa&es, or claims fIX danJa&es, of IUks arising cIItcctty « indirecd1 as . rauIt of any oper-
.tion perfooned pursuant to tbIs permit. and die said p.. '((\%- wi11, at his ot her own ~
defend any and .U IIich lUiu·1øidated by chItd patties, aDd the said ~ ,........., full 1iablIity
wiIh respect thereto, to the compIeteexdasioo of the Board of Trusttes vi. the Town of ~
2. That this PetmIt is mid fOr a period of 24 mos. ..mIch is coos¡da~ to be the
...,;""'ted time required 10 roinplete the 'IIOdc in~ but ihoald cirèmiIstIoces WattIJIt, request
for an exœasion may be made to the Board at . later date.
~. That this Permit should be reI:aiøed indefaoitely, or· as loag as die said Permittee wishes
to maiotùn the ottueture or project involved, to provide evideBœ to anyone rooœroed chat 1IIUh-
.oråation was origioa1l1 obtaioed.
4. That the wode/mool~ will be """joct to the inspecV9a aDd approval of the Board óI:
its agents, and non-axnpliaoœ with. the provisioDS of the orig/""tI..g applkaâoa, ma1 be cause fot
revocation of this Permit by resolution of the said Board.
5. That there will be no unreasonable interferenœ with navigadoa as . result of the wod<
bereIn ØÌthoåzed.
6. That there sbaU be no Intetference with the right of the public to pass and tq>US lloag
the beach between high and low water nwIcs.
7. That if future operatioos of the Town of South!>Id require die ranovaI and¡« akuadons
in the location of the 'IIOdc herein ...~...¡, 0 r if, in the opIøioa of the Board of TrusteeS, tbe .
work shall cause unreasoaable obstru<Þoo to free na~ the said PemlÙtee will be required,
upon due notice, to remove or liter tbIs _de or project herein stated without ~ to the Town
of Soutbold. .
8. That the Aid Board will be notified by tbe Permittee 01 the c:ompId/oo Of be work 1IIUh·
orized.
9. That the Permittee will obtain all other permits and cooseo.tS that mar be required sup-
plemental to this permit wbL:h ma1 be """ject to revoke upoa failure to obtain 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.
INSPECTION SCHEDULE
Pre-construction, hay bale line
151 day of construction
y. constructed
~ Project complete, compliance inspection.
bl~~
.
.
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
November 20th, 2003
William & Patricia Brennen
PO Box 221
East Marion, NY ll939
RE: SCTM#3l-l2-5,l
1050 Trumans Path
East Marion, NY
Dear Mr. & Mrs. Brennen:
The Board of Town Trustees took the following action during a Regular Meeting, held on
November 19th 2003 regarding the above matter.
WHEREAS, William & Patricia Brennen applied to the Southold Town Trustees for a permit
under the provisions of the Wetland Ordinance of the Town of South old, application dated
October 28, 2003
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
November 19'\ 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
concerning this application, and,
WHEREAS, the structure complies with the standard set forth in Chapter 97-18 ofthe 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 Wetland Permit for WILLIAM &
PATRICIA BRENNEN to construct a 3'x35' stairway with 6'x3' landing on the property down
the slope to Marion Lake.
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$5.00 per inspection (See attached schedule).
FEES: None
Very truly yours,
~? ~'~9<LJ..·~.
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/cjc
cc: DEC
-Building Department
·
-
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone
(631) 765-1892
CONSERV A nON ADVISORY COUNCIL
TOWN OF SOUTHOLD
At the meeting of the Southold Town Conservation Advisory Council held Monday,
November 17, 2003, the following recommendation was made:
Moved by Don Wilder, seconded by Tom Schlichter, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH
A CONDITION of the Wetland Permit application of WILLIAM & PATRICIA BRENNEN
to construct a 3'X 37' stairway with 6'X 3' landing down the slope to Marion Lake.
Located: 1050 Truman's Path, East Marion. SCTM#31-12-5.1
The CAC recommends Approval with the Condition no treated lumber is used.
Vote of Council: Ayes: All
Motion Carried
Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
.
.
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
_Coastal Erosion Permit Application
~ Wetland Permit Application _ Major
_ Waiver/ Amendmentl~h~ges
_Received Application: ID/~ó?
Received Fee:$ ..2J¡ - ',:-;-;¡
Completed Application IO/"Y1 ùð
_Incomplete
_ SEQRA Classification:
Type I_Type II_Unlisted_
Coordination:(date sent), ,
- CAC Referral SenC 101 ~ 0.2
Date ofInspection: / ( ï (( I 0 ~
_Receipt ofCAC Report:
_Lead Agency Detennination:
Technical Review: / ,
_Public Hearing Held 111/1/6-{)
f
Resolution:
/ Minor
oECE'UD
OCT 2 8 2003
Soutbold Town
Board of Trustees
Address tu Ç'O T~ullt'\ft~f p/lïtf
p, C ßO X "L'l..1
-"~ co1
qr ~~}
,0\
Name of Applicant WiL-UA,M å P^-r~lc.t" ßRE¡Vt.JGN
/î. Mrdtlû/J IV'! 11G(~q PhoneNumber() (,-~¡ - tT7-2-3C1.)
Suffolk County Tax Map Number: lOOO - 31 - \ Z. - S. \
Property Location: IOr;o ì~uMANf P^Î~
EM1' MI\(ÜO",
r~, kn...Çt·c-rr Wlît.i- C{-r 'l..$ /"'/L(U fCL(" Ff ·1 A ~ 1-r. (Í ~I ~Pi:ït.-¡'Y
(provide LILCO Pole #, distance to cross streets, and location)
AGENT:
(If applicable)
Address:
Phone:
~ard of Trustees ApPlicati~
GENERAL DATA
Land Area (in square feet):
iß j 1Cfi(. 0-1
s~ -Fl
Area Zoning:
i?çr'~H:Nïl¡\ L
Previous use of property:
FAMILY l-\uM\;
Intended use of property:
fAf'4\(..Y ,J.I.JIYtG
Prior permits/approvals for site improvements:
''" \~
Date
r..W'o\H tta,qU L
z. . ,"¡,C(
I, .1;t L- 1
1"1~
1"I~7
I '~l
Agency
Son., 71111<.1\ ~I.Ù c..... 1:
"
I, '2 l~q 3 n lB.µav\
, -4 H~-O¿C 11 /00'"'"\ ¡( \ \ 2."0\
t\M,,""Oc<D lollo\o~ Stilt / ,·-rI\UiirP
No prior permits/approvals for site improvements.
..
NYS De-C.
Has any permit/approval ever been revoked or suspe~d by a governmental agency?
,No Yes
~~
If yes, provide explanation:
Project Description (use attachments if necessary):
'bEt
N yrD t"G
L.t- T7t-12. tt rt:Y4\'\ 17
A-r1,it\4¡=-D, (,,\/C {¡.,,¡,rH IV CON.rn<lJ(.--t II 3""X]7'
s-41I1tu-J.tIv ImÎt-I Grx 3.r L.AfVDIN& ON 011 Or<.ONt1.ï'y
It) Oûw¡v -rt-lr- .Jt.../).pç TO M..1~I(\r-1
I_AI IÆ~ .
~oard of Trustees ApPlicat~
WETLAND/TRUSTEE LANDS APPLlCA nON DATA
Purpose of the proposed operations: To CeI N!;, t< \lCi A
('"1I\\\'2.wI1Y AN\.> LANO,"'C- Tn f'Ro\/1 ()Ç
..1Clt:sí '11) IVI,1rVUN t..f.\ ,o(ç
.
Area of wetlands on lot: II.J K N . '--VlJ square feet
Percent coverage oflol: %
Closest distance between nearest existing structure and upland
edge of wetlands: feet
Closest distance between nearest proposed structure and upland
edge of wetlands: feet
Does the project involve excavation or filling?
V No
Yes
rfyes, how much material will be excavated? tv (I. cubic yards
How much material will be filled?
tvA
cubic yards
Depth of which material will be removed or deposited:
~/A
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):
I
617.21
Appendix C
State Environmental QuaJity Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNlIS,ED ACTIONS Only
PART I-PROJECT INFORMATION (To be completed by ADPlicant or Projec¡ SDonson
H·~6-"\ 1218;;- Tp.)(1 12
I PROJECT '.0. ,'UM8E"
.
.
.>(
SEa
j. APPLICANT ¡SPONSOR
3. PROJECT LOCATION:
Municipality
I 2. ¡JAOJE':7" NAME
,s·'AII'!-WA
4. PAEC:SE LOCATION tS1reet aaClress ana road Inlersec:ions. prominent lanamarks. e!c., -:If ;JrOVld'3 .1"Iaol
C"unty
·v ~foLK
105"0 ·T{<vN'AN> 'P~-r('¡
,/.') C\J7C;-- 1r'7_.r
A p'/H v~ -rr 1'201\ D ·T /-\11'"1 Iv TcasHïr 1'-
{N 6 A J-t /V\,4 P-IO IV
S. IS PROPOSED ACTION:
o New 0 Excansion
5. DESCA!8E PROJECT SAIE!=L Y:
A S'---CA \IQ...WAY
l't (,,. '" 5 .~ i.-A
o MOClification/alteration
-
~ -'" J()'7 f'l"<l Nt 10 (' 0 r S <-ü f'<:
NV..I\JC:- CN 1V\A(ZlÒ¡J ~AIÆC
bó oN '0
TÒ
'. AMOUNT OF U.ND AF;=~CT~.J:
Inllially
acres
Ultimate/v
aCf'!S
:> 'I/ILL .~90?fJSEi) AC-;-¡ON CCMPL':' 'tJlTH 2;(JS,ING ¿:ONING OR OTHE;::¡ E..X!STING ~,' D USE .'::E37~IC7;CNS"
eYes 0 No It .'10. Jescnbe :Jrr~ily
3. '/~HATj.S ?RE.3ENT LAt;Q 'J::;:: IN '/IGINITY~F ?t::;OJECT?
~-3S,denlJal [J.~nous:rlal ~ C0mmerclal
'Jesc~lbe:
œIr ^ CN" S'Q.¡2..Y ( ONi;;"
eN TH~ rl'2-ur8t-r'Y
~ ..;gncUlture
~ P3.rKIFcresuOoen $cace
~Otl1er
FI\MIL')< 1-\0"""..-- if ¿COlî(;V
10. DOES ,),C':'10N INVOLVE A r>=:RtIIIT -I.PPROVAL OR FUND!r~G, NOW OR ULTlMA,EL:' !=ROM ~NY OTHER GOVE?"NMENÎAl AGENCY \F=:QE:=1AL,
STAiE GM LOCAL)?
~s DNa
NYc; pre:..
It yes. !ist agency(s! and permrtfaDProvalS
(-'¡¡-~Ml-t t*-I '471<¡{-C2-q,,?j/~'O()()
(AT/^ (dê'V)
". __DOgs ANY ASP=CT OF THE ACT10I" HAVE A CURRENTLY VALID PE:=1MIT OR ..1"poGOVAl?
[Jf«~s 0 No /I y~s. list agency name and OermJlfaporoval
-
Ç'er
LUV:;'- AØJVb
12. ...\.S,), ~ESUL-;- OF ?ACPQSEiJ ."'CTION WILl.. :;:ì:ISTING ?ERM!T/APpqQVAL FlE·JUIRE .'.10QIFICAï¡CN?
DYes DNa
I CEiì.TlF'f THAT ,HE INFORMATION PROVIDE'J ,),eCvE IS TRUE -:-0 ':"H:: 3EST OF MY r(NCWL=::GE
SiQnalure:
LJ~
L / " U....I A IVl /-1 -
~n-.. , _
,
ß (¿éNNt-tV'
Delle
,),ppJic;:¡ntfsponsar 'lame:
t-l
If the action is in the C02stal Area. and you are a state açenc'!. complete the
COaSL:ïJ .J.ssessment ;-orm oefore proce9ding with this J~~eSSmeni
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Board of Trustees Application
x
County of Suffolk
State of New York
L.v I U...l^ M l~ -13IZ€"NNI:?'I1 BEING DULY SWORN
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 illSIHER 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 ARlSING
UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR
REPRESENT A TIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
¿/~ J! ~~
.... .
Signature
SWORN TO BEFORE ME THIS '2·f
~ì
DAY OF octo~tft.... ,20 61
(!dL¿;y&
Veronica F. Cidone
Notary Public, State of New York
No: 52-4661406
Qualified in Suffolk CounW ~
Commission Expires Dec.31,~
....
v.
.
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 of the Application
of
_Wl~\\O'_ID-j:~~_!t:t(\~___~J:~_~ro!)
COUNTY OF SUFFOLK)
ST ATE OF NEW YORK)
AFFIDAVIT OF POSTING
I, (,," '-Lt,!."" f, r-':.c''VN ~N , residing at I C, <, ( IT, \¡MA.Nj
f'!'1¡..J (;,IIJ r .V\nr..,^, N r I Ie; )<;
,
being duly swom, depose and say:
That on the al day of 0(,10tJl;~ 2003, I personally posted the property known as
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 held !..f.k2j, n().b\"(\bQr ~~'"),
~n. bC"a.IJCl.l*- 1',00 ~.
Dated:
~¡~w ~ ßv,1~
signature)
Swom to before me this
31 dayofOu- 200.7
..... . .
LINDA J. (.1)0"~:O
Notary Public. 5181" of Npw Vor~
'hì. 4t'~~~r.3. Sl-~~r:':¡" r:'.'mty~
. - °ù'
';--,.. ·oc;..':;" [.".-..-.,_. _". """' ..<-- F
OCT 3 1 2003
E ~
'f:t<-¡4-¿~-Ll ~/ <.
Notary Public '
fowl
InI1l al1MIIII
.
.
William & Patricia Brennen
l050 Trumans Path
P.O. Box 221
East Marion, NY 11939
10/26/03
Board of Town Trustees
Town of Southold
Southold, NY 11971
To whom it may concern
We are requesting a Waiver from the Board in order to construct a stairway and landing to
Marion Lake , a freshwater lake, on our property (IOO0-3l-12-5.1) in East Marion. Several of our
neighbors have such stairways and landings on their property. We have have received a permit
from the New York State DEC. to proceed with the project. (Pernlit #l-4738-0293l/0000l).
When we purchased the property in 1975, a stairway and landing existed. It was a
"makeshift" structure and it deteriorated over the years. Since we have made the house on this
property our primary residence, we would enjoy having access to the lake in order to launch a
canoe or rowboat.
We would have the construction done to comply with all codes, and have gone to the
trouble and expense to have the construction plans professionally prepared. Therefore, we are
asking that The Town Board of Trustees grant permission for us to complete this project.
Very truly yours,
~ffl!l ~
William H, Brennen
~
"
-..- q.2 U-<...--C...-~.,_ ~Î~'~~,'--z·,-
Patricia Brennen
.
.
..
...
~
Erin M. Crotty
Commissioner
New York State Department of Environmental Conservation
Division of Environmental Permits, Region One
Building 40 - SUNY, Stony Brook. New York 11790-2356
Phone: (631) 444-0403 . FAX: (631) 444-0360
Webslte: www.dec.state.ny us
AMENDMENT TO PERMIT
October 10. 2003
Mr. William H. Brennen
P.O. Box 221
East Marion, NY 11939
Re: Brennen Property
1050 Trumans Path
East Marion, NY 11939
DEC# 1-4738-02931/00001
Dear Mr. Brennen:
Your recent requestto modify the above permit has been reviewed pursuantto 6NYCRR, Part 621.
It has been determined that the proposed modifications will not substantially change the scope of
the permitted actions or the existing permit conditions.
Therefore, the permit is amended to authorize:
Construct 3' x 37' stairway with 6' x 3' landing at seaward end. All work must be done In
accordance with the attached plans prepared by Eileen Wingate last revised September
10,2003 and stamped approved by NYSDEC on October 10, 2003.
This letter is an amendment to the original permit and, as such. shall be available at the job site
whenever authorized work is in progress.
The following Special Conditions are added to the permit:
9. Dock must be hand Installed. Piles must be hand driven.
10. A silt screen weighted across the bottom and suspended above the water surface shall
encircle the entire work area from shoreline to shoreline.
11. No eroded sediments may leave the work area.
All other terms and conditions remain as written in the original permit.
ve~r~~
George Hammarth
Permit Administrator
cc: BOH
.
APPLtCANT ..-
TRANSACTIONAL DISCLOSURE FORM
~
The Town of Soukhold's Code of Ethics rohibits conflicts of
nlerest; on l:ihe par\;. of town off cers and employeea. The
purpose of this forM is to provide informal ion which can
alert lhe town of possible conflicls of inlerest and allow
it lo take whatever action Is IleCeBsary to avoid same.
tOUR NIIMB.
RIÇNNE'" W ILLufM
Last name, first name, m dd~e
you are applying in the name of someone else or
other enlity, such ~B a company. If BO, indicate
the other person's or company's name.)
!o"
NATURB or APPLICATION. (Check all that applY·)
. 'h~~):J.. .,' ì-..~ .~.!;.. . '....'
Tax grievance
Variance
change of zone
Ap'p~~al of plat ~
Exemption from pial or official map
other tv AV¡ Ii:1\.--
(If "other," name the activity.)
.~
Do you perøona11r (or ~hrough toU~ cb~þanr, upuune, nlbl1nu.
parent, or child) have D. r-elntionohip vith any offic@r or
employee of the Tow" of Southold1 '"Rela.tionshIp" included
by blood, marriage, or bU9ine99 i"tere9~~ MOusiness
intereat" lleanu a buBineuu. including a partnerBhip. in
vhich ~he tovn officer or employee haB even a partial
ovneruhip of (or employment by) a corp.oration in vhich
the town of[icer or employee ovno .ore than 5% of the
shares.
YES
NO
¡/
If you answered ·YES,· complete the balance of ~hln for. and
date and sign vhere indicated.
Name of pereon employed by the Town of Southold
Tille or posi~ion of that person
Describe the relationehlp betveen yourself (the applicant)
and the ~own officer ør employee. El~her check the
appropriate line ~) through D) and/or. describe in the space
provided.
The town offIcer or ~mployee or 11IB or her spoune, sibling,
parent. or child Ie (check all that apply) I
_____^> the owner of greater than 5% of the shareg of the
corporate etock of the applicant (when the applicant
10 a corporation),
_____B) the legal or beneficial owner of any intereat In a
noncorporate'enti~y (when tile applicant in not a
corporat:.ion) ,
_____C) an officer, director, partner. or empluyse Of ths
applicant I or
_____D) the actual applicant.
....
...,'
DESCRIPTION O~ RELATIONSIIIP
I·'
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.... "~:·H~J~>~·\···~;:;~i1.>~·~· ~l·\~.t4¡~;/'.
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