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Home My WebLink AboutTR-4969 . Board Of Southold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. Ljr¡" DATE: .3/24/99 ISSUED TO . ........ J01'I C ..KERBS l\utqnri1!utintt Pursuant to the provisions of Chapter 615 of the Laws of the State of New York, 1893: and CI1apter 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 3/24/99 19 99, and in consideration of the sum of $ 150.0P. paid by JON C.KERBS.. of Southgld N. y, and subject to the Terms and Conditions listed on the reverse side hereof, of South old Town Trustees authorizes and permits the following: Wetland Permit to clear property at 60' setback from the edge 0'. wetlands and maintain a non -turf, non-fertilized, no-disturbance buffer area within that 60' and place a row of hay bales on the downward side of clearina line during construction of hou,sl' - all in accordance with t~e detailed specifications as presented In' the originating application. IN WITNESS WHEREOF, The said Board of Trustees I¥!re- by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date. ..¡J;'~"'l.. _.~.... '/' . . 't: --.~_)..:L X .' ... .. ........ ,:/'/t¿t¿ .. iJ..u..JL..L:w;74 Trusttts . . 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 SOUTH OLD April 1, 2004 Mr. & Mrs. Paul Stuckart P.O. Box 614 South old ,NY 11971 RE: 550 RENE DR., SOUTHOLD SCTM#54-6-4.5 Dear Mr. & Mrs. Stuckart: The Southold Town Board of Trustees reviewed the survey prepared by Anthony W. Lewandowski last dated February 19, 2001 and determined the proposed breezeway and screened porch to be out of the Wetrand jurisdiction under Chapter 97 of the Town Wetland Code and Chapter 37 of the Town Code. Therefore, in accordance with the current Tidal Wetlands Code (Chapter 97) and the Coastal Erosion Hazard Area (Chapter 37) no permit is required. Please be advised, however, that no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundary or seaward of the coastal erosion hazard area as indicated above, without a permit. It is your responsibility to ensure that all necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdiction and Coastal Erosion Hazard Area, which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and the coastal erosion hazard area and your project or erecting a temporary fence, barrier, or hay bale berm. However, any activity within 100' of a Wetland line or seaward of the Coastal Erosion Hazard Area would require permits from this office. This determination is not a determination from any other agency. . 2 . If you have any further questions, please do not hesitate to call. Sincerely, Jt~..f 9· ~.f}- Albert J. Krupski, Jr., President Board of Trustees AJK:lms 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 August 24, 2000 Mr. & Mrs. Paul Stuckart 12 Stand ford Court Sag Harbor, NY 11963 RE: 550 Rene's Dr., Southold SCTM#54-6-4.5 Dear Mr. & Mrs. Stuckart: The following action was taken at the Southold Town Board of Trustees Regular Meeting on August 23, 2000: RESOLVED, that the Southold Town Board of Trustees approve the request for a Transfer of Permit #4969 from Jon C, Kerbs to Paul & Kathleen Stuckart. If you have any questions, please contact our office at 765-1892. Sincerely, ~ ~ /~~'}h, Albert J. Krupski, Jr. President, Board of Trustees AJK/lms . . /erM/1 -# r9¿ 9vok /<{e¡-Þ-s.iD ?cùJ t- )(a.l-IJlee/J SJueÆ(u-r I~~~ Ä~.o-I-!l~ 1.2u%.oLJ~c/~~·. . (,,2/) 7"$ ,3"'''3 .Y""'A j",-,- 1;2 ;)!-alìr£rcf- Cf S~ (V"alb<:n. mlll~J Cmrq.ed.~ , . AUG IT . . Albert J. Krupski, President James King, Vice·President Henry Smith Artie Foster Ken Poliwoda .1l~uffO~ i,r~\;.c::;: -. ,N~ ~'\ 1 Q ="'.~ ~ "" :ad! .~~ J:!d "'........ ,<"'. 'S ~ ~~v.f¡ ~ 'O.¡ . ""+-~.,}~ ~ 'L1- '~# Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-18't2 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD March 29, 1999 Jon C. Kerbs 440 Riley Ave Mattituck NY 11952 Re: SCTM #54-6-4,5 Dear Mr. Kerbs, The following action was taken by the Board of Town Trustees during a Regular Meeting, held on March 24, 1999, regarding the above matter: WHEREAS, JON C. KERBS, applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated March 3, 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 March 24, 1999, 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 of the Southold Town Code, ~C-f~~_ 3 7· WHEREAS, the Boãr~ ha~ 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 approves the application of . . Telephone (516) 765-1801 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, March 23, 1999 the following recommendation was made: Moved by Scott Hilary, seconded by Ken Meskill to TABLE the Wetland Permit Application of JON C. KERBS 54-6-4.s'Ío construct a single family home with 80' setback rrom wetland for construction and 60' setback from wetlands for clearing. 550 Rene's Drive, Southold No survey was available at the time of inspection CAC will re-inspect when the survey is available. Vote of Council: Ayes: All Motion Carried Vincent Carnagie 11085 Soundview Ave Southold N.Y. 11971 . r¡] Œ Œ Œ 0 W Œ ! ~ ~U MAR I T Iæ) ¡æ.J TOWN OF SOUTHOLD . 15 March 1999 Jean W. Cochran,Supervisor P.O. Box 1179,53095 Main Rd. Southold N.Y. 11971 Ref. SCTM # 54.-5-38 C!') SCTM # 54.-6-4.4 (~ ) Dear Ms. Cochran My home at 11085 Soundview Ave. (Ref A) is directly South of a proposed home to be built at 400 Rene Dr. Rene Drive was recently upgraded, widened, and drainage pipes installed. The redirected water runoff from tthe wetlands and higher areas accessed through Rene Dr.has resulted in an imeasureable increase in the water in the rear of my property. This alteration was done without regard to the impact on neighboring properties (37,38, and 39 of TM 1000) on the North side of Soundview Ave. However, 1 am more concerned about two potential problems: *1 draw my drinking,cooking,and household water from a well located at the front of my house and t fear that waste water and salvage the proposed home and others in the locale of the wetlands will contaminate my well * The overflow tank located in the rear of my property fills up due to increased water accmulation in that area. 1 urge the Board of Trustees cause a review to be made of the changes to the natural preexisting environment before considering requests for building homes on the referenced property. R ¡:; f(þ) r truly Yours --& «~nagi~ ",rk State DepartmenAr Envu-ollD1ental Conservati. .,.g.() - SUNY, Stony Brook, NY 1l~1356 ...pllone: (516) ~0275 1'ac:sI01ilo: (516) ~0297 ~ ..... ~ d~,?i~~~~1I 22 October 1997 Ion Kerbs 440 Riley Avenue Mattituck, NY 11952 RE: DEC#: J- t!-7,~R-(jnR3 )H-HJ1 , Dear Mr. 'Kc::rbs,' In response to your requcst for a freshwater wetlands determination for the property identified bc10w, the New York State Department of Environmental Conservation has determined that the parcel is more than 100 feet from regulated freshwater wetlands. Therefore, no permit is required under the Freshwater Wetlands Act (Article 24 of the New York State Environmental Conservation Law). Location: Rene's Drive Town: South01d Tax Map Number: 1000-54-06-4.1, 4.2,4.4, and 4.5 This dctcrmination may be considered permanent and should, therefore, be retained along with other documents related to this property. If future actions by this Department result in any change in jurisdiction, you or any subsequent owner will be so notified in writing. Please be advised that this letter does not relieve you of the responsibility of obtaining any necessary permits or approvals from other agencies. Very truly yours, ~~IJ~ Permit Administrator '--- /\ );IV V\&'\ ~ ~~/I l Q,yT , \ cc: Bureau of Habitat . . - ...--- .. _ .._____¥~. ··v .....-r- ~ ~ t ' Q~~ s:I ~ ~'~ ;, ~ \ §~, ~ ~ ~ ~: ~ ~~~~ . 1\)- !II ' ~'I ~ tv~ . ~~~~~ ~ III . "). '\\ \ ~ ~;¡: ~ ~'1<) ~~~ g Iò . §~"t' \. , ~~~~~ ~ ~ . ~ ~ ~ ~ ~ \ ~ ~ \ ,. ~ ~ ~ :\\. ~ ~ . ~~ ~ ~ "\ . { *~~~ ì"--- '(\ ),~~ ~ (j[) .~/·r; " . ~"(t~ j¥..t?1,Z9o '7{i. Cl/'lf7(?{.. ~ ~ - ##1;1 ~~~ ~ .?f?¡¥;?/lþ' ,J., ')Iø'~ Ý tyf"o" , ".ø·¡; ,rl'9~ -b.. .....<s> ~ ~ ~ ~~ ;'( ~. ~ \ ~ :1 ~ ~., ~ '\\ 7'-'(11. ~ .o!"1Q.<:Þ . I CJC1'!f/'F ~ ~ .Y,.c:v, ,""þ~ \) ItJ ~JI:~K,,- . Q I O:Ji1£ ~ {1 ~ ... ~ ..,'\,' ~!I\ ~~ 'I!~ ~ It\' "::t- ~ ~ ~ iii ~ \ ~ 'c\ 'J I\J , It " ~ ~ ~ ~ , . \ 0 ;I" ~ . '" ~~ ~ ~ ~ 0. ..... q, \ ¡ ,L~ '6/2 ;;>"Q/,Ç;t:?~h '\ (.L 1Y6::>6'¡1 ) LC'7 " "- i ~ \.J '2 o 1 ~\ ~ ~- '-" c--" " 'Q ~ ./ / /Y/ ð' /,)r' ,;f' /V ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ < '" .0____.__, .J. '11,,7£ ç ¡y1"O", P'P.f'¡:P ,17'9~ , 6~ ',*1'>-;;> ~ ).. ~ ~ ~ '\ ;.. ~ ~ \., ¡..,. ~ '\. C'"O 0-J C.!J = ~ . , .1 ...,.d ... ~ m . ~/I ... .;?'~"iY.d ~ ,:9;' í I . o " "L~'6/2 M,.~c>.c:7~ø~,.7ý I(- 't\ ~ f ~ ~"'''' .... ""'..-..; ~ ~ 'Ill -~ .. ....~ , Y"\ .:?,.O'/,I!?P.."h '2 (..t lY6?tY¡1 ) LQ7 ~ :\\ ~ ' ~ ì-. \::: ~Ù~" \\\S~~~~ \~, ,,\;) ... '~ IÌ\ IÌ\ ~ t ~ ~ ~ ~ ~ tj-.!\J ~ ~ ~ ~ 't\ , ~ ~ ~ } ~ ~ ~ ~ ~ ~ ~ ~ ~ .;¡I'~ /¡If"C?!''Z 90 *)(j .9P¡V.:?I't" #31/. ..-"'t- (J1'If1C?ç.. ~A.. --;." :;¡.> Q. .:;¡. ~ ./ / /y/ ;y I',;r' #' /V \ ~ I¡\ ~ ~ ~ ~ ~ ~ ~ ~ t...J '\ . ~ ~ ~ ~ ~ ~ ~ ~ I j I I.t. Utblln' I,. '1A 1 . il··:fIL IIIIJ· I .-1 hI!)'1i .., Iii! !f~! .~II~I·IIJ'I á'lo~",! I < . . , f ;£.g-; ~ID I ~9J . -~_9 . :'\1 ".11 §~ ~l. ìit· i \1~ g Iò ti ~ ~c1~ ~ I ~ Ifj~ ).: ~~~~ ~~~ It ~""'~l~ ,,~~ ~ ~~~ ~ .....-r... ~ t ~ , ~ ~, , ~ ~ ~ !) , ~ . IIJ a ~ to¡ ~ ~~ \\J ~ . I'\¡ ). \ !Ii '" ~I( ~~ , ~ ~ ~ \Q ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~ ~ ~~ ~ ~ ~ ~ ~ I\j~ ~ ~ . \;j'l .. ~ ~ ~~~~ ~ '\\ ~ § ~~~ ~ c1/'1f7C?Ç "H~ i~ ~. ~I\.~.. ~ ~ t~~~ " '/1 ;;/~")~ Ý ¡y1,,(), '(7'94 , , ó'? '*b:? , ~ @ M",C?c>,ç~..,?þ,Ç . "'" ~ , -< ~ ).. ~ ~~ ~, ~ , ~ . ~ ~ '\ ~ ~ ~ ~ 4~ '<\ ~ ~ Ì¡) 11 ~ ~ ,0-", , , ~ ~ '0 J'" ~ #flJJ'.J ,¿~ '6/Z "" t-. ~ > \.¡ (.L" /Y6?tY/1 ) '2 L97 ~ ~ ~ ~ ~ ~~ ì..... ~~ ~~. '(\ "0 \ t~ ~ "- 'Ii) '\J ;) / /'V/ ;Y /,?/ ;f/Ý \ :::? I¡\ IIJ l\¡ ~ ~ ~ *' ~ ~.-."'--'-- c:::::::.:;"''Þ r·::-' ._~. . ~ , ~ § .î ~ I\J "- . ~ ~ .~ ~ ~ ~ ~ ~ = .< "'-1 '. ~ "'-1 @§J 0:: I· ~ : ~ . I: ~~ ~ ~ ~ ~ \. .~ ~ ~ , .. ~ '" Jì¡ U { ~ i }~\\~ ¡ ~ <:,~ , ,\)~ ~~ ~~ '" ~ \! ~ ~ SI~ ~~ ì;¡§ );.~ ~t ~ '~ ~~ ~~ Boa. of Trustees APPlication. WETLAND/TRUSTEE LANDS APPLICAT1 DpA " T"" Æ the proposed operation.. ~ut/ ::>\",~l -ee,l II t~ -:ç~J~ Area of wetlands on lot: "-\~Ò Ö *- - square feet Percent coverage of lot: ~ % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between ne~est proposed structure and upland edge of wetlands: ~ feet Does the project involve excavation or filling? (' . _ I _ I No I- Yes '€. Htûll<-\'~~ ~. /iu..jJ" \ ,u.... -\ St' r\ c >~·")It~ If yes, how much material will be excavated? \}OOcubic yards How much material will be filled? cubic yards ¿, y\'ð c~v~ Manner in which material will be removed or deposited: ~(t V\G\LP Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: 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): \f\~ 3 U-16-4121871-íI!X! 12 "I PROJECT 1.0. ~UM8E." . . 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 SEC 1. APPLlCANT~ONSOR I 2.?R ;cr."^Mlò~ ~-')'-( -ro ._l.f. S- J. PROJECT LOCATION: 1 c- Municipality Sv v \.0.1 County "'::>0 4. PRE5:~C"'Tp~s~:~~na roao ,n[orsections, prom'nent lanamarks. !to.. or ,reyoae mao) S6~\,º- ~;:--\ _ \l11 ( S. IS Pfj8POSEO ACTION: G New 0 Expansion 0 Moaificatlonlalteration 6. DESCR[8~JIW'EFLYS\~l --t-;?~"",- ~ L'í R.e ':> t.... I s'"""þ- '-L 7. AMOUNT OF LAND AFFëCT'iD: Initially ! acres Ultimately \ acres 3. WILL F'~O?OSED ACTION COMPL'f 'NITH EXISTING ZONING OR OTHER EXISTING '..AND USE ::¡ES7~IC7ICNS? ,ec Yes 0 No It ,"10, deSCribe bnefly 9. VIHAT IS ?RESENT LA/":ù US¡: IN VIC:NiTY OF ?ROJECT? ~ ResIdential D.!naustrrar C CQmmercial Desc:lbe: o AgricUlture ~ Park/Forest/Oeen space '--..j Other 10. DOES ACTION INVOLVE A P'=.RMIT APPROVAL OR FUNDING. NOW OR ULTIMAíELY FROM ANY OTHER GOVEMNME~TAL AGENCY (F::iJERAL. STATE OM LOCAL)? 'ðYes DNo If yes. list agency(s) and permillaeprovals I Ç",~'-\l.L~ ~'-'"'.- \,^,:>b-_~ .:. 11. DOES ANY ASPECT OF THE ACTlOf., HAVE A CURRENTLY VALJD PERMIT OR APPROVAL? Dyes· .ß::1No If y~s. list agef'lcy name and permlllapproval 12. AS A RESUL";'" OF PROPOSED ACTION WILL S<ISTlNG PERMIT/APPROVAL FlEOUIRE .\.1QDIF!CAïION? DYes Ø" Nø" Applicant/seonsor 1ame Ddte SIgnature: If the action is in the Co"stal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this a'1.~essment OVER 1 PART II-=NVIRONMENTAL ASS- MENT (To be com Dieted oy Agenc!) ,),. DOES ,.1.C710N E}9I!ED ANY TYPE ¡ " DYes ŒNo 8. WILL ACTION RECEIVE COORDINATED FlEVlew AS PROVIOED '=OA UNLISTED ACTIONS IN ò NVCRR. .cART 05i7.ê? may tie superseded by another Involved agency. DYes oNO C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING; (Answers may be nandwntten. If legIble) C1. EXLsIlng air QUality, surface or grounCJwater quality or Quantity. nOise levels. eXisting !ralfic patterns. SOUd waste proauc:ion pOlenual lor erOSIon. drainage or flooding problems? ExPlain briefly: SHOLD IN 6 ~YC¡::¡FI. ~:"MT 617.12? It ¡Ets. cooramate the review ;rocess ana use me FULL E'AF, II No. 3. negative dec:aratlc or dlscosa V\ö C2. Aesthetic. agricuttural, 3rc~aeological. histonc. or other natural or cultural resources; or community or nelgnbornood crlaracter? S:plain tHlel V\,ù C3. Vegetation or fauna, fIsh. shellfish or wIldlife specIes, sIgnIficant haoitats, or threatene<J or endangered specIes? Exolaln brIefly: V\ù C4. A community's existing plans or goals as officially aCopted. or a change in use or Intensity of use ot land or other natural resources? Explain orle ~\ ò cs. Grow!h, subsequent development. or relalee! aCtlvilles likely 10 be Induced oy the proposea action? EJ:plam Orle/ly. y\O -:5. Long term, snort term, cumulative, or other erfects not Identified in C'·CS? S:Plam t)(Jefly. Ii' 0 ....,. Other impacts lincludlng changes In use of el!her Quantity or type of energy)? ExPlaLn briefly. ~() i ~ C). IS THERE. OR IS THERE LIKELY TO BE, CONTROVERSY RELATEQ TO POTENTIAL ADVERSE :'NVIAONMENT;'L :MPAC7S? :1 Yes Ø'NO If Yes. explain briefly PART III-DETERMINATION OF SIGNIFICANCE (To be comoleted by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whetl1er It is substantial, large. impol1ant or otherwise significðl Each effect sl10uld be assessed in connection with its (a) setting (Le. urban or rural); (b) prObacility of occ~g; (cI duration: irreversIbility; (el geographic scope; and (f) magnitude. If necessary, add aUachments or reference supponlng materials. Ensure th explanations contain sufficient detail to snow that all relevant adverse impacts have been identified and adequately addressed. CJ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF 3nd/or prepare a positive·declaration. S Check this box if you have determined, based on the information and analysis above and any supporting documenratlon, that :he proposea action WILL NOT result in~ny significant adverse environmental impacrs AND ;Jrovlde on attacnments as necessary. the reasons supporting this determination: '\..,"~ n! LC,H.J ......~n(V ""lnt or ~p~ '\:.Hnf" or '¡{"\pon~'ol~ ullJC~r .n LeolO -\t.:cncv r ,Ut! 01 ¡{....~oon\,oh~ ùrllCer ;;"n.lIU(C ')1 ¡.(escon\IOJe ù/l'c{"r In Lt!dQ ....a.:t!ncv )1a.;n.,¡IU(e.;lr ¡'>rt"poI(er Ilr {j,rfe'~nl rrom .~scons'ot! ')lllco?rl O..¡\e 2 B9IÞP of Trustees APPlication4IÞ fZ- County of Suffolk State of New York ...--c- fJ (\ C-, ~ vb S DEPOSES AND AFFIRMS THAT E SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) ~ T ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEstr" OF IS HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN E 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. BEING DULY SWORN SWORN TO BEFORE ME THIS .3 DAY OF Me¡ V0 h ,19!l§ )/~ry-~- Notary Public MElANIE V,IIROWN Ncúry NIle, SI8 01 NcIW YIIIII No, 4801712 Cam=~c;n¡fl1 7 APPLt(!AN'l' TRANSACTIONAL DISCLOSURB FORH . . . The Town of Sou~hold's Code of E~hic8 Þrohibi~8 conllic~s of in~eres~ on ~he part of town officers and em 10 ees. The ur ose of this form is to rovide informa~ion wh ch can alert the town of oss ble conflic~s of n~erest and allow it to take whatever action. is. ?ecessary to avo d~. a.~e\. YOUR NAME, J ð"- t ~{J)v;¡ J, "':;P'~::'!~J!jI, (Last name, first name, middle initiai:"~nless 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.) NATURB OF APPLICATIONr (CheCk all tha~ apply.) '>'_~':.>...~. ··:~'ljf¡:-·t3>( Tax grievance Variance Change of Itone Ap'p~~al of plat . Exe~ption from plat or official map . n~e~other," nam' the activHy.) Tw>~> 'Y-tJl,\I\.'l-r- Do you personally (or through your cOMpany, spouse, sibling, parent, Or child) have a relationship with any officer or employee of the Tovn of Southold1 -Relationship- includes by blood, marriage, or business interest. -Business interest- means a business, including a partnership, in vhich the town officer or employee has even a partial ownership of (or employment by) a corporation in which the town officer or employee ovns more than 5% of the shares. YES NO L If you answered ·YBS,- complete the balance ot this tor. and date and sign where indicated. Name of person employed by ~he Town of Sou~hold Title or position of that person Describe the relationship between yourself (~he applicant) 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 oE the corporate stock of the applicant (when the applicant is a corporation), B) the legal or beneficial owner of any in~erest in a noncorporats'entity (when the applicant is not a corporation) , C) an officer, director, partner, or employee oE ~he applicant, or D) the actual applicant. . "