HomeMy WebLinkAboutTR-5263
Board Of Southold Town Trustees
SOUTHOLD, NEW YORK
PERMIT NO. $JIo3"
December
DATE: ..m" ,,' ""
ISSUED TO .....m,,}ºS~I'H,lòmPQ~N:AI3¡;;NPOWS.KL ' '"
^utltorilnttou
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 P",c.~..20,.....
2000 d ' 'd t· f th f $ ISO 00 'd b
.".., an In cons! era Ion 0 e sum 0 ",. . ". pal Y
Joseph & Donna Bendowski
..........-.....
of .,." ...m.M.~ttituck N. Y. and subject to the
Terms and Conditions listed on the reverse side hereof,
of Southold Town Trustees authorizes and permits the following:
Wetland Permit to construct a first-story addition on the east
1 side of the house and deck addition, with the condition that
drywells be installed to contain additional roof run-off and that a'
row of hay bales are placed down across the landward side of'th
. all in accordance with the detailed specifications as presented in
,the originating application, . ' '.
bulkhead during construction. . ,
IN WITNESS WHEREOF, The said Board of Trustees here-
bycau'se~its COrporate Seal to be affixed, and these presents to
be subscribed by ð 'majority of the said Board as of this elate,
, . ,
..
.1..
, .
Trruiee.
~-2.-~~-.!....~__~._-.!_._~~.~.!._~._--.!-...!~~.~_._._ ~ !_ ._._.......!_!...-!.._.. ~.
TERMS and CONDITIONS
'The Pennittee
Joseph & Donna Bendowski
residing ae 3060 Park Ave.. Mattituck N. y~ as
put of the consideration for cbe issuance of the Permit does understand and prescribe Co cbe fol-
lowing :
1. That the said Board of Trustees and cbe Town of Soucbold ale released from any and
all damages, or claims for damages, of IIÚts arising directly or lncIirec:dy as a result of any opec-
atioa performed punumt to cbIs permit, and cbe said Penaittee will, at his or her own ~_,
defend any and dI sum adts 'IaItiaœd by dilid par!Ïef, and the said Pamitcee ,- full liability
with respect thereto, to the complece eu:1usion of the Board of Trusœa of the Town of Southold
2. That cbIs Penait Is ...ud for a period of 24 JDOS. which Is c>"'1s1icnd to be the
estimaeed time requUed to comp1ece the work involml, but sboald årcumstaaces wUraat, request
for an extension may be made to the Board ae a later da....
I
I
.,
3. Thae chis Permit should be retained indefinitely, or as long as the said Permi_ wisba
CO maineain ehe struccure or project involved, Co ptovide evidence Co anyone roncemed thac ouch-
orization was originally obeained.
4. That the work involved will be subject to the inspection and approval of the Board or
its agenes, and non-complianœ with the provisions of the ori¡inacing application, may be cause for
revocacion of ebis Permie by resolution of the said Board.
5. That there will be no unreasooable interference wicb navigation as a result of the work
berein au·cborized.
G. That there shall be no interference wicb tbe rigbt of the pub1ic to pass and œpass aIoag
the beach between high and low water marks.
7. Thae if future operations of the Town of Southold require the ftIDOft! andfoc aIœntioas
in the location of the work herein aacbotb.ed, or if, in the opinion of the Board of Trustees, the
wotk shall cause unreasooable obstrucnon Co free oavigatioo, the said Peœittee will be required,
upon due notice, to remove or aIeer cbIs work or project berein stared wicbouc eq>eases to the Town
of Soucbold.
8. That the said Board will be notified by tbe Permittee 01 the comp1~ of the work ouch-
orized.
9. Thae cbe Permietee will obtain all other permies and consents tbat ""y be requUed sup-
plemental co this permie which may be subject to revoke upon fai1ute Co obtain same.
Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
.
.
Town Hall
53095 Route 25
P.Q, Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SoUTHoLD
December 27,2000
Jeffrey T. Butler, P,E,
P.O, Box 634
Shoreham, NY 11786
Re: JOSEPH & DONNA BENDOWSKI
3060 Park Ave., Mattituck
SCTM#123-8-19
Dear Mr, Butler:
The following action was taken by the Board of Town Trustees during its regular meeting held
on Wednesday, December 20,2000 regarding the above matter:
WHEREAS, JetITey T, Butler on behalf of JOSEPH & DONNA BENDOWSKI applied to the
Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town
of Southold, application dated December I, 2000, 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
December 20, 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 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,
NOW THEREFORE BE IT,
RESOLVED, that the Board of Trustees approve the application of JOSEPH & DONNA
BENDOWSKI to construct a first-story addition on the east side of the house and deck addition,
with the condition that drywells be installed to contain additional roof run-off and that a row of
hay bales are placed down across the landward side of the bulkhead during construction,
BE IT FURTHER RESOLVED that this detennination should not be considered a detennination
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 trom 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: None
Very truly yours,
~~ /~~·9·
Albert 1. Krups(¡, Jr.
President, Board of Trustees
AJK/lms
cc: Building Dept.
DEC
.
.
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 Thursday, December
14.2000, the following recommendation was made
Moved by Bret Hedges, seconded by Billl\1cDermott, it was
RESOL VED to recommend to the Southold Town Board of Trustees APPROVAL WITH A
CONDITION of the Wetland Permit Application of JOSEPH & DONNA BENDOWSKI123-
8-19 to construct a first-story addition on the east side of the property and for a deck addition.
3060 Park Ave., Mattituck
"
The C AC recommends Approval with the Condition of a 10' non-turf/non-fertilization buffer.
Vote of Council Ayes: All
t\Iotion Carried
t.
..
.
-.
Albert J, Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
Telephone (516) 765-18,'12
Fax (516) 765-1823
~\) 'ðUfFOl.t ~
~'V ~
§ ~
,Q -
~.,. ~
"'ð .
Town Han
53095 Main Road
P.Q, Box 1179
Southold, New York 11971
BOARD OF TOWN TRUSTEES
TOWN OF SoUTHoLD
Office Use Only
Coastal Eros~on Permit Application
~etland Permit Application
Grandfather Permit Application
---Waive~/Amendment/Ch~n~~s
~eceived ApplicatisP: J~IIIDU
./Received Fee: $ J3:J -=;;:
~ompleted Application /~ 7ro
Incomplete
SEQRA Classification:
Type I T'Tpe II :Jnlisted DEe _ I
_coordinatl~r¡: :date se~.t~-
~AC Referral Sent: J~ I ,1)
ate of Inspection: r. ~
. Receipt of CAC Report: __
ILead Agency Deter¡ni:Jatj.(m:
¡Technical Review: ---
~P~blic Hearing Held:~CVOO
r_ReSO~Ution~
Name of Applicant .....~-;,¿~ A/V.n U/lI/I/¡Q ß~'/V:OtJÞvs It:. I
,:;dd:!:ess 306:::} ¡?~.€-J£, 1/ a
I
'.
mil 17 ,-rU(,k.
Phone Number: (S-t6) 7 "f r- ;ll¡ð
Suffolk County Tax Map Number: 1000 - I). ~ - /) ¡r - I '1
Property Location: 3060 f?~£'K /l yg.
/,/lA1717vvl:. j}PJ?LD-t Sõo ~.IQ<,' ,?t? l3,u.l6¡IJLä.J L.A/'~
(provide LILCO ~ole #1 distance to cross streets, and location)
AGENT: .;:¡- Frl'+.£tb T. ¡;u~U;A. f'.6.
(If applicable)' J
Address: ;'0, t~ 6Y/
/1¡ ~ y.
'5h'tI.£t:HI'9 A1
1/ 7ó.{.
Phone: 6"3/- 8';;./- ¡¡>¡,:s-v
FAX#: ó3/-8;)1- '7;)R7
1
· .
BO~ of Trustees Application .
GENERAL DATA
Land Area (in square feet): ;J <} , q s-R. .:; 7
56>. rr.
Area Zoning:
Previous use of property: R.s-,:> ,P~N""'>PL
Intended use of property: /2f:'"'.> 'Püvr,/J!-
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
goverrunental agency?
~
Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
;::,,e.s, Sro~ /JPi?ITlð/lJ 011/ E=.IJ..,..
P£oPÜl. ì (D~N). P,A'..o,PðSUJ 1/é-c..../£.
5 >¿)e o/'-
.AI/PI r/ÒN.
2
· .
Boat of Trustees APPlication.
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
Area of wetlands on lot:
o
(J
square feet
Percent coverage of lot:
%
Closest distance between nearest existing structure and upland
edge of wetlands: 3 A 1011 feet
Closest distance between nearest proposed structure and upland
edge of wetlands: '") S-' 0 /I feet
Does the project involve excavation or filling?
.-/
Yes
No
If yes, how much material will be excavated? ~ñ
cubic yards
How much material will be filled?
ó
cubic yards
? '0 'f
Depth of which material will be removed or deposited: ?
feet
Proposed slape throughout the area of operations, C.&-95 'f7¥,A,,¡ s-Þ::;'
Manner in which material will be removed or deposited:
:2 66ÞAP<'.{J
ð^J
S ITb
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):
3
. .
Boat of Trustees Application .
COASTAL EROSION APPLICATION DATA
Purposes of proposed activity:
Are wetlands present within 75 feet of the proposed activity?
/NO
Yes
Does the project involve excavation or filling?
No /' Yes
If Yes, how much material will be excavated? ;?r7
(cubic yards)
How much material will be filled?
6
(cubic yards)
Manner in which material will be removed or deposited:
f26r;A-AP~f)
ON
5/,~
Describe the nature and extent of the environmental impacts
reasonably anticipated resulting from implementation of the
project as proposed. (Use attachments if necessary)
A/ 0 /VE1-'
4
4IÞ ~ .
Boa. of Trustees APPlicatiO..
AUTHORIZATION
(where the applicant is not the owner)
...
I, ,,-¡;: ó- 1St<; 1I.I.cnL-</S À!./
(print owner of property)
residing at '1;>. &-1' é-"H(,~ ¿A.J)
(mailing address)
j}J"os:.<¡;/I'p6 62/./iJ. Iv-Y. (17S-8 do hereby authorize
(Agent)
....y;.r¡e-~ /. £o/U"Z, ,17.1.
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
{J:iigna~
8
,
.-
.
..
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
SCTMUOOO- f). '3 -0 <¡r-/9
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a
Permit from the Board of Trustees to:
CDNS.,..{2<J<--r h- o.vtr <5'0') ßpO,'T'o,.} 7õ &--tI":>TJ/'6
(' 't'l6 5Q. ~i,) A NO ~J( P/9/,d) t:-.\-I-""'·k, [)6<-f<- (7 I?'ð
/26S/.P6.'V(.E;
54>, ~/")
2. Tha t
Review--.is
follows:
3C16c>
the property which is the subject of Environmental
located adjacent to your property and is described as
o Il /VI /11 /10 ,,--' "... /0 D L, \
rlJtl../:. Þ'(;- ) ///A TTTTVc..k.. (I r-r:e:"J( .>u<.> c-"C; Pc-1I.J6Ihi>.J AI'f'.-J
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 on: You may contact the Trustees Office at
765-1892 or in writing.
The above referenced proposal is under review of the Board of
~rustees of the Town of Southold and does not reference any
other agency that might have to review same proposal.
O\'INERS NAME:
MAILING ADDRESS:
PHONE it:
Ene.: Copy of sketch or plan showing proposal for your
convenience.
s
617,21
Appendix C
State Environmental QuaJity Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I-PROJECT INFORMATION (Ïo be comolered by Aoolicant or Project soonsor)
H·~õ·J.,;2J'l7l_7'~x{ 12
I PROJECT i.O, ,'UMaE~
-.
..
SEC
,. APPUCANT ,SPONSOR 2. ?ROJE'::;-:- ,'IA,'.1E
VË-,..~.¿d--. ì. !lu17ÞL ;? 6, B""1/L7/J#vS,c" RG<¡;4::>ð'Ñ7_l
J. .QROJECT LOCA1"'ÖN: J
MunlcloaHly ¡?J A 7T1 TU£L C,Junry ç v ,c.,e=,A7_i
J. ?RE-::SE LOCATION (Street aaaress ana roae In{ersec:Jons. ;JromlneN lana"arkS. gte..,Jr ~rovrae :Trap!
506'0 PA~'" /114-. /J?/I~'7'Vf.,L, é-t'o g""N6.-9lOW LA/'--e'-
f--
5. IS ?GOPQSED .\.G7tCN:
I . .'Juw ~anSiOn
[J Moolfication/alteratfon
5. :JESCR!8E ?ROJEC:- 3REF~.:~:
hLSr
'7'i
Ç7b~
I!c~ I,,>rd,
¡¡pp IT"<-N
t? éc-~·
,'"
G~/~r.~
¡?:e; I'Pe-.V'-6
.
Dé-GJ:.. ApPn-7D~
'. ,'MOU.....T GF !-AND ..1..Fr=:::':::;~:J:
inlllatly
3.cres
'Jrtrmal~l" > ~ ~
3C,':S
~. '-¡IL:..JI'O?')SEJ AC-;-¡C,~ C;:MP'_':' '..nTH :::<JS7~ÑG ::~lI,'~G ':R ::;Ti-1¡:,~ ~::ST'NG "-.:..,'\C I..:S¡: ~:::.s7¡::¡[C7;C~~S:'
.:J?'Y~s 1= .'\a It 'a. <~esc~lbe :Hle~ly
, J,
.._~- ,:.It:' -~-'IT "",-.~:.; " '1IC'r'IT" -F oOC -,--'"
... """ ,~_c:. _--'..J ~__ 1,- ", ~ ~C:_,:
- - -
~ =ìesldenual _,'r.cus:naJ ~ :.Jmmerclãl
Jesc:l:¡a:
1- .:"qnC'JI!ure
- ,::!'w(J¡:::'~r'õ'suO;)en ':C3ce
~Otner
:0. JCé.S "C7!CN INVCl'/E.:.. ;)r:?,Mlï ....ppt10VAL. ,'::!=I ::;JNOING. .\lOW C.-l t..:l:-:MAÎ~L:' .;;~a,·.1 ';NY DïHER G.-::VE~NME;\7Al AGENCY 1,:::::i:ERA:....
3'jA7~''';M LQÇ;.L;? /"
:~ V~S l%o It 'o:!s, :ist agenC'{\s1 and ,:)ermlt/aocrov<lIS
11. --90ES ANY ~OF ïHE ACï!or~ HAVE A CURRE!HL':' 'lAUD PERMIT ':JR ..;pct10VAl:'
U ':''!s ~ ~ja !f ·f':!S. lisl .J.ÇlenC'( name ana ~ermJtfaccrova
-
:2. ....5..; =1ESUl:'" ûF.;;¡ P~Së:J ;.C";'lON 'NIL!.. ~<ISTrNG ?'?::?:MlïfAPPt10VAl .':¡E.JU¡RE \.IOOIF:C;.-;-rCN?
c:: 'f,!! GÃ No
I CEiìTIF''' THA, 7HE IN¡:::fJRMA ,ION ¡::¡qC'lI(~EQ ...eCVE IS "T"r:1UE -0 ;'"!-J!: 3ESï OF '.1Y ,-(NCWl'::::GE
Siynalur~:
Apclicanrls:¡cnsor lame; ~¡e:.¡r:../2.7
df~
r.
gu r/ #1"
J
J? [,
O.ue:
I )- ~. O,t)
./
-
If the ac~ion is in the C02~ta¡ .-\rea. and '{ou are a state açency, complete the
C()as~aJ ,.4.ssessmen~ Form berore ~roceeding with ~his a~~essmen!
OVSR
.
?.:.ñï
.u
, -'·I1JI-C'¡~·'-'-'· ·-'~'I-'I-
d-=;'< M 'I,,=.J........ :::'~\I'::'. I
J :~ ::~:;~~-:2= :'( ~;-:2!"'.C"
-.
_. :~3 .:..":7";,,::'. ~.(.::~:
_ 'J-!s :?-~O
":',' '~
,..:~. -.....;;-S3¡-CLJ '~I -3 'J"J':~;::. .:0:"';;7" -3~;'"_.:~
:r :¡~s. :.:crc,nar9 :~e '~y,~'N :.·CC.2S.:! a.na JSa '~e '::..:L_ ~')1,..:;
-. NIL:... .:..':7:,:::,'1 .~E·::::;'¡S :::CP.CIN...."T"~J
i'lav :Je slJ:::ersecec ::y ~ncl~er nyolvp.o
~E"lIE'N ':"S ,=Õ::C':ICE.:'
..çenc·¡.
'-,",
'.J,'IL.S"T":::J .:.,:7:C,'S N
.\n':::;R. ::IJ,';7 -3;:-.:7
./ ·~a. .1 1eç;;,r:'¡e :::ec:.lr':
1_ V~S
'_:<10
- :':UlO .:..C7:C,' :::I.E3üL7'·N "'NY ....QvE?SE ::::-=~·:7.s ...1,'::.3c;::;";"T"~:: ',VI";':.! -~= ='JL~':'N!~G_ AnS-ners ;":';a.v :e -:anc.....rr.:e:"'l. I 'e:;I::le!
:,- :"~ls!lng lLf ,:uallt·f. :)UCfaC3 Jr ;rOt.:n~wace~ :uallty :::r :t.:3.l1my. .'OJSë e·/p.IS. '!x:s:;nq ':-a:fic :a[:erns. sOlie ....as:e JrCCl:C::::;:1 Jf 115::
'Olenual for :ros.on. :ralnaçe- ùr :Ioocinq :::roclems? ¿~OlaLn :::nelly:
C:" J,¿s!nelfc. .lçr:c:..zUur'lil. lrc:-:~eol~q[c.J.l. .'IS:CflC. Jr Jr~er 1.::;,¡:.,¡rJI J[ :::':H1..:r:lI -'!!sourc~s: Jr ::::mmunl['f "Jr -:elç:H::Crnooc ':~arac:~r" ~::lalf1 ~
--,
'!eç~{a!lon .Jr :auna. ·¡Sri. ir:ellfis:1 ,Jr "lie tHe 3"ec:es. :¡c;nli:;:~rH "IaOJla!::. Jr ~nre:1ten~ :lr ~nc:.anc;er~a .;¡::ec:es..? :'~claln :r:art'/:
.-,
~ =::rnmt:nn·...-: ~xls::l'1g ;Jlans or ;cal::;.lS "Jff!c:;¡llv ;'CCCteo. :lr 1 c~ange In ~se Qr Intenslly -:or r..;se Qf ';¡oa or .Jmer na[ura¡ ~escur'::'ss7 =.~ot::n ~.
--,
3..:::"..tn. :;uoseCl,;etH ::e"'eloomen[. =r re!atea JC::"'ltle~ ';kelv :0 :::e nCl,;ceo J"( :ne :rCCO$ec aC:10117 :''t::II<lJn Jr:efly.
-".
'_:n~ :erm. :~cr~ ...!r.-:1. ::.:rT:tJlat;·le. ::r JU1er ~Ifec:~ lC¡ ce~,lr;e': n ::_":='" :"~:::!::l.Jn :r:e~!'(.
:!~~~ r.'10ac:.: tnC:.J:::r.ç ::-:anç':!s n 'Jsa :;r ~:r:1er ::t.:anmy -::r ::¡ce 'Jf ~!1erçrJ? ~t"Jlaln ::r:en'¡.
J. .3 -·-!S::-:.
:R S -:-=~2 _.~:.:;:..:, -.:; 3F_ :'::,'lï::;CVr::::-S-r
--'. -
~=;...-.. =-
::Ç7~:.
'"
~2\/S'=:~2 :::.'VI.:\C··ME~JT':'L .'.!F\C727
J ~s
_,'10
t :'~S. :!X::;laln ::r:e!!...
:);'i17 1¡¡-·-;E7=~MIN,).7ICN :::¡= .sjG,\Ir=iC;",·~C'::: .",:".J :::e ::~O!eraa Jy" .1genCï)
;NS-;-:=1UC71CNS; ,='Jr ~3C:l iiC'JerSe -;rfec: :éenllfie-o ::'Ccve. :2!ermlne .....nerner It is suCStéintiaJ, :arçe. :mccr:anr ('Ir o:~er.vlse SIç;"U r;c
;:.lC:1 :iiec': :;;10uIC :Je assesse<:: :n ::::Ir.nec~rcn ,1/1111 rs ·a¡ 5et:mg i.~. ut!::an :Jr ;,uraJ); .,1::1 .:rocaCl!it'! .Jf .Jc::=--Wç; .C: juration
.rrev~rslarlitï: 'EH ·;2cqr:='Cl1lc 5c:;ce: ana '.f) ;T'laçnlt:.;ce_ If 'ecessar.', ace 3.nac~ments ,:¡r ;ererence suoccrtrng ,ï1aCenaIS. '::::1sL:r~
~xcranallcns .;::r.tarn sur:'ic:ent :Je!3Ii (0 3i10W :nar .:;¡ ~~!e'Jant .lcverse .moac:s ,1ave oeen Icenntiec ana 3.ceCLJat::!V 3.CC:'ess¿c.
:::eçx: :nzs :CX :fQU ,ia'le :cennfiea :'ne ~r ·"7:cr:= :::otenuaíl'/ larç:= .J( siçmficant aC'J2!'sa ;~Cê.C:3 ......niC:l .'if':'"
':Jc:::Jr. -:-;'e!1 Jrcc.esc cirec:!' :C ::1e ,=:JL~ =.::..r= :inc/Qr ~re~are .3. positive" .::ec~ara!ic;'"ì.
::-:e-:;( :i1¡S :CX .r /ou ,1ave .:le~ermrnec:. ~asea ':1n :he infcrmation Ind ana!ysls .above ar.Q 3.r.y :3ucccr::i.(
':cc:...:r.-:enr3.t:cr:. :;¡a.! ::-:e :rccosea ::i.C~jCi: ·:¡Ill.. ,'JOT result :n3r.'l s¡çmficant aC'lerse -:2n'/lrcr.rT.e::[.:.! im:ac::
~NO ::rC'/IC::: ;n =.;::ac:-:men[s 3.S ,1ecessar:, :he 'S3S0ns 3ur;ccnl~g ;:nlS care:-m!na:jon:
11 _.:...0.1 ~1;t:nC'1
J',nl;' .t.,;~ ··..rn.. :;1 ~~·'~O,,\.O,~ _::...:::r " _"..0 '~""("
: .Ilc .)1 ~"oOQn\'OI<:: '..II(,(::r
;'r.:n...(L:'~ ~r ~"<CC""Q'~ ":!"(~r ,1 ."'..IC ~r.:c"ç{
;''<n.;,:.....r~ H J·":J..r~r LI _,/:::-""1 ~Jm ·..)CO""O,,, .Hr,c<!"
~
';...(e
"
,\rPJ.tCANT
TRAtlSM:'fIONI\L IHSCLOSURE FORM
.
..
The Town of Sou~hold's Code of Ethics prohibi~s conflicts o~
in~eres~ on ~he parL of ~own officers and employees. The
purpose of ~his form is to provide information which can
alert the town of possible conflicts of in~erest and allow
i~ to take wha~ever action i~ necessary to avoid same,
YOUR NAHR.
~''''~12-
Last name, first name, m ddle
you are applying in the name of someone else or
other entity, such as a company, If so, indicate
the other person's or company's name,)
. ..1,(
: ...;~.'¡~::}~'~,'
I
. ,>,~·~::l.. '.' ì.,t.;:", I",~
NATURE or APPLICATION! (Check all tha~ apply,)
Tax grievance
Variance __
change of zone___
Ap'p~p.val of plab ,
Exempbion from plat or official map
Obher
(If "Obher," name the actlviby,) 8ó/J1U>
"
or
7~~,:-~ IIpj7¿'<.A77ùJ
DO you 1'erøonally (or ~hrough your company; spouse, sibling,
parenb, or child) have a relablonshlp with any officer or
employee of tho Tovn of Southold1 -Relationship- includes
by blood. marriage. or business intereot. -Buoiness
interest- meana a b»sineoo, including a partnership, in
vhich the town officer or employee has even a partial
ovnership of (or employment by) a corporation in which
the tovn officer OL employee ovns More than 5% of the
shares.
YES
NO
~
If you answered >YES," complete the b3lance of thlg form and
date and sign whore indicated.
Name of person employed by the Town of Sou~hold
Title or position of that person
Describe the relationship bebween yourself (the applicant)
and the town officer ør employee. Ei~her 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)1
A) the owner of greater than 5% of the shares of the
corporate stock of the applicant (when the applicant
is a corporabion)/
B) the legal or beneficial owner of any in~eres~ in a
noncorporate'entity (when the applicant is no~ a
corporation) /
c) an officer, 1i~ec~or, partner, or employee of lhe
applicant, or
D) the aobual applicant,
, '
DESCRI PTION Of' tI¡¡UI'i'Jor,f;1I t p
"
. ,'. .
.-,.....-.---.....---. --
"
..-.;.____.O-;.,.~....'..;,' .' ". ..,:."... - ." ,;,..~
. - --"."-- .-"-.- --'...- ..--.-----------
~---
___"__._____.. - .._ "..____ .." -0_"'--"-'-'
.. ."
'., : '·,i::,;":...~ !c.: ";&.i'~'.ii,j¡i,';
."':" "', "I.I'-~~.
subl1lH.ted lhiy 3ø' daY t)f':"~ä:,___~" ' ;
,:::::t:::~~, ,·,7,"':.',~·:;" ,:;i;W;":,i
't' :>.' :,t,,:ií~~if !5l'i.t~~':-. 1¡;;;:;'l:¡·";-)¡'~\
.' . ..... ..¡.~:!fl~~ '" ...\~:.~ ..~',' ~ ~ )~~'. .- ';
.~....u. .. '.' ...... " '" -11\.'''' 1o!J',~
:·'...t~·:;y.