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TERMS and CONDITIONS
The Permittee
Ralph & Terrell Kaplan
residing at
patt of the
lowing:
1657 Meadow Beach Lane, Mattituck N. y~ as
consideration for the issuance of the Permit does understand and prescribe to the fol-
1. That the said Board of Trustees and the Town of Southold are released from any and
aU damages, or claims for damages, of suits arising directly or indirecdy II a reosu.1t of any oper-
atinn performed punuant to this permit, and the said Permittee will, at his or her oom expense,
defend any and all such suits· initiaœd by third parties, and the said Permittee a__ full liability
with respect thereto, to the complete exclusion of the Board of Trusœes of the Toom of Soathold
2. That this Permit is ttlid for a period of 24 mos. ..hid>. is a>naideted to be the
estimated time required to complete the work invol\'ed, but should åtcumstances warrant, request
for an extension may be made to the Board at a later date.
3. That this Permit should be retained indefinitely, or IS long II the said Permittee wishes
10 maintain the strucmre or project involved, to provide evidence to anyone concerned that auth.
orization WIS originally obtained.
4. That the work involved will be subject to the inspection and approval <>f the Eoa.td or
its agents, and non<Olt1pliance with the provisions of the originating appücatÏon, may be cause for
revocation of this Permit by resolution of the said Board.
5. That there will be no unreasonable interfereace wid1 nAvigatioo as .. result of the work
herein aùthorized.
6. That there shall be no interference with the right oi the püblk to !",SS and repa.s .long
the beach between high and low water marks.
7. That if future operations of the Town of Southold require the removal and/or alteratioas
in the locarinn of the work herein authorlzed, or if, in the opinioa of the Board of TrusteeS, the.
work sha11 cause unreasonable obstructton to free navigaâon, the said Permittee will be requJred,
apon due notice, to remove or alter this work or project herein stated without ezpenses to the Town
of Southold
8. That the said Board will be notified by the Permittee ot the mmpledoø of the work auth.
orized.
9. That the Permittee will obtain all other permits and consenll that may be required sap-
plemenral 10 this permit which may be subject to 'revoke upon fa11ure to obtain lime.
.
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) 765-18f2
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
February 25, 2000
Mrs. Catherine Mesiano
12 Mill Pond Lane
East Moriches, NY 11940
Re: RALPH & TERRELL KAPLAN
SCTM#1l6-4-15
Dear Mrs. Mesiano:
The following action was taken by the Board of Town Trustees
during its regular meeting held on February 24, 2000 regarding
the above matter:
WHEREAS, Catherine Mesiano on behalf of RAPLH & TERRELL KAPLAN
applied to the Southold Town Trustees for a permit under the
provisions of the Wetland Ordinance of the Town of Southold,
application dated December 29, 1999, 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 February 24, 2000 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 of the Southold Town Code,
.
.
WHEREAS, the Board has determined that
will not affect the health, safety and
people of the town,
the project as proposed
general welfare of the
NOW THEREFORE BE IT,
RESOLVED, that the Board of Trustees approve the application of
RALPH & TERRELL KAPLAN to construct a 4'X 24' timber walk, to be
elevated a min. of 3.5' above grade, and 4'X 8' steps.
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.
Permit to construct and complete project will expire two years
from the date it is signed. Fees must be paid, if applicable,
and permit issued within six months of the date of this
notification.
Two inspections are required and the Trustees are to be notified
upon completion of said project.
Fees: $240.00
Very truly yours,
/].p A ./ ()
~/'
Albert J. Krupski, Jr.
President, Board of Trustees
/~~. !h.
AJK/lms
cc: DEC
ACE
Dept. of State
-
Albert J. Krupski, President
James King, Vice~President
Henry Smith
Artie Foster
Ken Poliwoda
.
.
Town Han
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1892
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
TO: rfJQ Lp Iv hop locru
Please be advised
has been reviewed
r-1/d'-//CO
.
(~) Application Approved
k;J.--!QJ9 J 79
by this Board, at the regular meeting of
and the following action was taken:
that your application, dated
(____) Application Denied
(see below)
(see bèlow)
(see below)
(____) Application Tabled
If your application is approved as noted above, a permit fee is
now due. Make check or money order payable to the Southold Town
Trustees. The fee is computed below according to the schedule
of rates as set forth in the instruction sheet.
The following fee must be paid within 90 days or re-application
fees will be necessary.
COMPUTATION OF PERMIT FEES: <!! .$ DO
j.}/'f. 'f '~k. ::. 1S')( <3 .0. I</;¡
1-/ V $-'I....¿)~ ~ ZJd' X' 3 =- <.J5;16 q,o
$ difO ~
, .)\~\cP
oci·::>
.\
TOTAL FEES DUE:
SIGNED:
tla c.' I t). 14.. 1'..1..' 9 i
PRESIDENT, BOARD OF TRUSTEES
BY:
~Cù.u ß,n ~tV~ to
R , BOARD OF TRUSTEES
4/98
Telephone
(516) 765-1SCii.
.
,
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 Tuesday, January 18,
2000, the following recommendation was made:
Moved by Bill McDermott, seconded by Scott Hilary, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A
STIPULATION of the Wetland Permit Application of RALPH & TERRELL KAPLAN 116-
4-15 to install a fixed timber walk 4'X 24' to be elevated a min. of3.5' above grade; 3'X 14'
ramp; 8'X 16' float on 6" diameter low-profile piles. Access to dock proposed is 6' wide wood
chip path, 25' long.
1657 Meadow Beach Lane, Mattituck
The CAC recommends Approval with the Stipulation that the structure be minimized for
required water depth.
Vote of Council: Ayes: All
Motion Carried
·
CATHERINE MESIANO, INe.
Licensed Real Estate Broker
Real Estate Consultant
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1-.:01 DEe 2 9199g
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.,
December 14, 1999
Town of Southold
Board of Trustees
53095 Main Road
Southold, NY 11971
Re: Ralph & Terrel Kaplan
1657 Meadow Beach Lane, Mattituck SCTM # 1000-116-4-15
Gentlemen:
The enclosed application for a Trustee Lands Permit is being submitted on behalf
of Ralph and Terrel Kaplan, owners of the above referenced property. The
applicants propose to construct a 4' x 24' fixed timber walk, 3' x 14' ramp and 8' x
16' float on low profile piles to be accessed by a 6' x 25' wood chip.
Enclosed please find the following:
1. Application for WetlandlTrustee Lands Permit.
2. EAF Short Form - Part 1.
3. Copy of survey last dated 3/9/99.
4. 4 copies of dock plans.
5. Owner's authorization.
6. Site photographs.
7. The Kaplan's check in the amount of $150.00 for payment of the
application fee.
8. Transactional Disclosure.
Please contact me if any additional information is required. Thank you for your
attention to this matter.
Very truly yours,
(þ~-~
I
Catherine A. Mesiano, President
Enclosures
12 Mill Pond Lane . East Moriches, New York 11940 . 516.878.8951
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Albert J. Krupski. President
John Holzapfel. Vice President
Jim King
Martin H. Garrell
Peter Wenczel
Town Hall
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
ùffice Use Onl:Y
¡ í ~ ["2 rr~, ¡
Coastal Erosion Permit APPlicatifi'Jijr."
~Wet1and Permit Application in Ii
_Grandfather Permit Application LlJi DEe 291999
_Waiver/Amendment/Changes ¡
Received APplication:~' 1__,.' ....
Received Fee: $/ ~ 0 _ .. [J.~è._. . '''..., . j
Completed Appll.cation /~ .~ '.4 ---
Incomplete
SEQRA Classifica;t0n:
Type I Type II Unlisted
Coordination:{date sent) ----
CAC Referral Sent:/Ql-ðl~ ~
Date of Inspection:: I-,z,. þo ~ 0
Receipt of CAC Report:
Lead Agency Determination: DEC 2 9 jDrY>
Technical Review: J~
Public Hearing Held: /-dZ,(ø- 00
Resolution:
Name of APPlicant_~ALPI-\ t{:. 1" IS I2.\tEl-L V A P LA N
Address~r)' ( 7::':11
(\"iliO¡:'OF..l',..)'!1IC¡3<; Phone Number: ( )
Suffolk County Tax Map Number: 1000 - ,\ L., - 4 - \ c;
Property Location: \(,., 51 t'0PAÒD\A.1 bSAC.t+ L.... MA"'''ì'\:.UC.K
{provide LILCO Pole #, distance to cross
AGENT: C p,.,. \-\ Ek¡ t.J F \0\ EStA No
(If applicable)
Address: \') )\I\'tL \?oJ()~ LA-
EN\()R..\t+lE..<, ,N" \\C1Ÿ-o
streets, and location)
Phone: y, 7 '6 - 'r{ C) 5 j
FAX#: ""C-rf'~
1
BO'" of Trustees Application 4IÞ
GENERAL DATA
Land Area (in square feet): 3,. Of <1 rjJ
Area Zoning:
Previous use of property: S\í\,?\\e +o.m,\' èL)~\11f\1
Intended use of property: 511'\3\<."' ,Ç'a.."",\~ rltv,,-I/'It'lq
Prior permits/approvals for site improvements:
Agency
~,:,IA I~ ~ Y"ÁO'Y\'I~ :lS)(5'" --r{ofS.,,"O<-b
~\'\5 bEG
_I,) ¡Date
~9'1
--Æ.uJ"'1 0,1t!;+,.~); Î!'I...!,.(hous~
No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a
governmental agency?
~
, ..
No
Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
b+o.\k-\-\ó", ~ fIxed -hmbu ~.ùcJ~-4'¡C::l4
3. 5' "\-"Vf' 3Yr.ó.,.. j 3')(. \4-' YC\..m f') 'ð' ¡C \ l,'
\ ('¡LU OÇ!YO.ç"\ It' çJ' \ es- P\ C-c-e 5<; +6 ci. OC I<
\N·lde.1Å)Ooc\. ch"r (Ja::Ir-) c1.5' \()r\J'
~ b,,- de vo,J-ed TV:'''''
+' II .
lo",--t. <,>r\ to dilL
. I
~HO po S e.J lS (0
2
Boa.of Trustees Application .
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: i t'ì."t c. \1¡¡Îi~" 0{ CG....tl.lo..\ \¿. r""""p
,,"ö .ç'"o..-r -1-0 prov;dp 0.("1'<"55 ~aJls \-\D-...(bo(
Percent coverage of lot:
'1.:LSD
Iì
square feet
Area of wetlands on lot:
%
Closest distance between nearest existing structure and upland
edge of wetlands: q '5 feet
Closest distance between nearest proposed structure and upland
edge of wetlands: feet
Does the project involve excavation or filling?
)(
,
No
Yes
How much material will be filled?
n\ (L
,
r {(Ã cubic yards
cubic yards
If yes, how much material will be excavated?
Depth of which material will be removed or deposited: (\,) C.
feet
Proposed slope throughout the area of operations: G.5 jJre.5eJ\4-\" e¡<lsis
,
Manner in which material will be removed or deposited: (1\4
Statement of the effect, if any, on the wetlands and tidal
waters of the town that may result by reason of such proposed
operations (use attachments if appropriate):
~L) ,."·\g",,,.ç,r·r.;1 e..çç:~c--t ..\-0 wd \c."J~ 0( +,d~ \ l.Jni,,_<ö
,<, ~ ,,-\.ie-;Pc.1--c-cV a.S \i1()çOserJ 0.<:-+10" í~GI,;y'es fit) e.'l:fc..vtA,~"
\J . .
(' .j ~ cu " ""-"\ (') ( ~ i c..J ì,^ "¡ 0. ",-6 1'\ () (\) VI - c> -If' QßY'-d \ ~ 1';V\ Lù \ , \
\..e QH,Je-J bl. +-h~ \Y\.5+Gd~C0Tt~ 01' --+n~ rr<i')05~J dcd',
3
.
.
14·16-4 (12/97)-q
-
rROJECT 115 NUMBER
617.20
APPENDIX C
STATE ENVIRONMENTAL OUALlTY REVIEW
SEaR
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLISTED ACTIONS Only
PART I-PROJECT INFORMATION (To be completed by Applicant or Project Sponsor)
1. PUCANT/SPONSOR 2. PROJECT NAME
LPf+ á:1~ (UeLL ¡¿:, PLI'N
3. PROJECT LOCATION:
\)ow bE"
<::
Munici ali TT \ T (.) c.... Coun F
4. PRECISE LOCATION: (Street address and road intersections, prominent landmarks, etc., or provide map)
S~e
",-+I "'-./O. ,. '€ d yvo "--P
5. IS P. OPOSEO ACTION:
New 0 Ex ansion
6. ESCRIBE PROJECT BRIEFLY:
\1\5\,,\\ '" 4'~24-'
(, '. 01 ¡.... \ 0 "-'
o Modification/alteration
.f",,¿ +,,,,,,be, w....tk¡ 3'¡C!"¡'Yc'_"^-f "'-"-" ~'¡Clc,,'
n A I I'Y2.5'wood
P(O+"'~ f','I<5. CCe5S<^'¿ \'Jy U
flc«A 0>0.
ch;p p<L't:J..
7. AMOUNT OF LAND AFFECTED:
Initially . .¡{5 acres Ultimately . K 5 acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
;tJ Yes 0 No If no, describe briefly
9. I(tj;IAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
ß Residential 0 Industrial 0 Commercial 0 Agriculture
Describe:
o Park/Forest/Open Space.
o Other
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, Stale or
Local)?
).1' Yes 0 No If yes, list agency(s) and permit/approvals
N~.5 DEe ACC;E
~
"Ío",,~ of' S"U,HOL1) \ fi-U.5í€Es
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
o Yes ~No If yes, list agency name and permit/approval
12. AS A RESULT OF PROPOSED ACTION Will EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
DYes 'NO
ERTlFY THAT THE INF9rrMATION PROVIDED ABOVE IS TRUE TO THE BEST
. '1ft .
F MY KNOWLEDGE
Date !I/¿?/9~
/ ,
If the action Is In the Coastal Area, and you are a state agency,
complete the Coastal Assessment Form before proceeding with thIs Bssessment
OVER
..
-
A. DOES ACTION ExceED ANY TYPE I THRESHOLD IN 6 NYCRR PART 617.4? ,
DYes o No If ves, coordinate the review process and use the FULL EAF.
e. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRA PART 617.6?
DYes 0 No If no, a neQative declaration may be superseded by another involved 8Qency.
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible)
C1. Existing air quality, surface or groundwater Quality or quantity, noise levels, existing traffic patterns. solid waste production or disposal; potential for erosion,
drainage or flooding problems? Explain briefly:
C2. Aesthetic, agricultural, archaeological, historic. or other natural or cultural resources; or community or neighborhood character? Explain briefly: \
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly:
C5. Growth, subsequent development, .;.;r related activities likely to be induced by the proposed action? Explain briefly:
I C6. Long term, short term, cumulative, or other effects not identified in C1-C5? Explain briefly:
C7. Other impacts (including changes in use of either Quantity or type of energy)? Explain briefly:
D. Will THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA?
DYes o No
E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
DYes o No If yes. explain briefly
. .
PART II-ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
PART II-DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial. large, important or otherwise significant. Each effect should be
assessed In connection with tts (a) setting (i.e., urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope;
and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that
all relevant adverse Impacts have been Identified and adequately addressed. If Question D 01 Part II was checked yes, the determination and sig-
nificance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA.
o Check this box if you have identified one or more potentially large and significant adverse impacts which may occur. Then
proceed directly to the FULL EAF and/or prepare a positive declaration.
o Check this box if you have determined, based on the information and analysis above and any supporting documentation,
that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments
as necessary, the reasons supporting this determination:
Name of Lead Agency
Print or Type Name of Responsible Officer in Lead Agency
Title of Responsible Officer
Signature of Responsible Officer in Lead Agency
Signature of Preparer (If different from responsible officer)
Date
.
.
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
_gjL~P.fL:±__-r.~.Æ.£liÁ~___MftlJ AJ
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF ~OSTING
I ,Ca::cI-lUI~'. \\{\e.s1r...¡c~ ,residing at \ 'J... ý\\ ,I \ Pcr"-c! L".
t Pr5f' ~Y\ Oi I c..ke 5. tJ ,(
being duly sworn, depose and say:
:1-000
That on the \~ day of .j"",,,,-,-,,¥ ~ , I I?ersonally posted the
property known as \051 ylJ\e.Cl.-dow q)",,-c.l-- L... (\¡\".J::ttt-~ "Je N t
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 seven days prior to the date of the
puþlic hearing. (date of hearing noted thereon to be held 'V'1/N. c1'/¡"ð()()
Q~ oL IJ 1!fJ().7 7: I ~-I' /11 .
Dated: //J.t/~DOO
Sworn to before me this
.) r,.. day of j.o.- r9"9ø1ðC<::>
~0
otar ~~\~~~
.:.íM, I
ll()~df r\lbIIC, Sta,t-; ~
No. 01 SY50344~3
OIJahtied in Suffolk (;.Junl.¡ I, II
Commission Expires Oct. 11.j18t-~
.
.
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
RALPH & TERRELL KAPLAN
SCTM # 1000·116-4-15
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a Pennit ftom the Board of
Trustees to:
CONSTRUCT AND INSTALL A 4' X 24' FIXED TIMBER WALK, 3' X 14' RAMP
AND 8' X 16' FLOAT ON 6" DIAMETER LOW PROFILE PILES.
2. That the property which is the subject of Environmental Review IS located
adjacent to your property and is described as follows:
1657 MEADOW BEACH LANE, MATTITUCK
A .85 ACRE LOT PRESENTLY IMPROVED WITH A SINGLE F AMIL Y
DWELLING WITH ATTACHED GARAGE AND DECK LOCATED ON THE EAST
SIDE OF THE PRIVATE RIGHT-OF-WAY OFF THE SOUTHERLY TERMINUS OF
MEADOW BEACH LANE
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.
OWNER'S NAME:
MAILING ADDRESS:
Ralph & Terrell Kaplan
Box 731
Mattituck, NY 11952
OWNER'S AGENT:
Catherine Mesiano, Inc.
12 Mill Pond Lane
East Moriches, NY 11940
631·878·8951
Enc.: Copy of sketch or plan showing proposal for your convenience.
Boa~of Trustees Application 4IÞ
County of Suffolk
State of New York
1\«1""'-'
~Cfl~
BEING DULY SWORN
CCç4,\
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 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 CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
{l~
Signature
SWORN TO BEFORE ME THIS/:J~
DAY OF~~
19 9 9'
'-
~O/Vc~!{~- ¡.¡,~
otary Publïc
SUSAN GARRISON HICKEY
Notary Public. Soot. 01 N.., "'"
No 31-4n1727
OueUfieó in New Yott ~
CerlificolO Filoø in Nry y~ ~
.,. 11I1.n &pi,.. /6! :J 1/ () 0
7
.
.
^ttttLt~AN'1'
TRANSACTIONAL DISCLOSURR FORH
The Town of Southold's Code of gthics þtohibits conflicts of
in~eres~ on ~he þarb of ~own officers and em 10 ees. The
ur ose of ~his form is to rovide information wh ch can
alert the town of ass ble confl cts of nterest and allow
i~ ~o take wha~ever action is necessary bo avo d same.
tOUR NAHRt
~
Last name. first name,
you are applying in the
other entity, such as a company. It so, indicate
the other person's or company's name.)
;' ,
.
NATURE O~ APPLI~^TtONt (Chsck all that apply.)
"
'I~ _t¡ ,:' " ;'" .c. ':··~';!'I·' .,;} .'
.;: <, i;;".";~~1Yh.. ,.:,:.: ¡;."~:' ~,I . I' l;1:':~';,,'
,,' ·'-'r,-:';·' ,,' " . _, v .,
Tax grievance
Variance
Change of zone
Aþ'Pt~al of plat
Exe~ption from~lat or Official map
(~~e~other /" hBme ths act! id by. ) /¡ R\J5íe P.s . L-ANÞ.Veo f2-M IT
Do you perBonä11y (or through your CO.pROy, epoune, elblthØ.
parent. or chl1d) have R re1atlonBhlp with any orflcer or
employee of the "ovn of Southold1 wRelationshipw includes
by blood, marriage, or buslnes8 interest. -Ou8ine8s
interest" means a bU8ineo8, including a partnership, in
which the tovn officer or employee has even a partial
ovnernhip of (or employment by) a corp.oratlon in which
the tovn officer or employee ovnn more than 5% or I;he
shares.
YES
NuL
¡ ;~·A·I"
If you ansvered "YRS/· complel;e the balance ot this lor. and
date and Bign vhere indicated.
Name of person employed by the Town Of Southold
Title or position of that person
Describe the relationship bstween yourself (the applicant)
and the town officer or employee. Either check the
appropriate line h) through D) and/or describs in the npace
provided.
The town officer or employee or his or her spouse/ siblinø,
parent, or child is (check all that apply),
h) the owner of greater than 5% of the shares of the
corporate stock of ths applic~nt (when the applicant
is a corporation),
B) the le~al Or beneficial owner ot any in~eresl; in a
noncorporate'entity (when the applicant i8 not a
corporation),
C) an officer, director, partner/ ör employee öt the
applicant I or
D) the actual applicant.
"
..
DESCRtÞTlON OF ItELATtONSlltÞ
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submitted thh':~dItYÖ~-:·. . .
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C . .... ...'..",. ""..,,,....'.,..; t ()
'Þtlhb h8mu':"',;.,, " '~:,!,- .'!!;.l ''..~. ~/:\'.;'i.:,,\i-,.¡.'t'!''¡'¡·';1:f': ",/,/1 rft;JI., I,
.,/: .'.. ...' ·"·"f>IÏ'I:II¡",,,U,. .. "i·"··:t:,·". .. ~ ')J/)"Ii'\¡~'
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. . <r.:,l:;~::.' ·:·;'·::":"Î"·rl~;;1!...'Jl ~w\'Î tìt,~,.;,..:~::r~t,;r~;:~~Hk- '111: ,:'; ':,,)~~~\iJ'~"~