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Home My WebLink AboutTR-5859 *pF SO(/l Michael J. Domino,President � ��lo Town Hall Annex John M.Bredemeyer III,Vice-President 54375 Route 25 P.O.Box 1179 Charles J.Sanders CA Southold,New York 11971 Glenn Goldsmith Telephone (631) 765-1892 A.Nicholas Krupski ��oUNTV,� J Fax(631) 765-6641 I BOARD OF TOWN'TRUSTEES TOWN OF SOUTHOLO DATE OF INSPECTION: `U Lk L- V Ch. 275 Ch. 111 11Wda&4 LATA"t— A-0v(5WTWA"T TAT CVVbP RT- I F- Tth5'&)U'e_WAP 961�ke_V6 INSPECTION SCH 9-c Po'g_t -7�*T K0 le ITP W 5 irrcg- 1A(9rAz-P �_D), , t co L F Lt tnJ vA-S A-PfhSw ALc-o- Pre-construction, hay bale line/silt boc, TU t M- A-i Albert J.Krupski,President Town Hall FO` James King,Vice-President OSUF �C 53095 Route 25 QG P.O.Box 1179 Artie Foster o~� Southold,New York 11971-0959 Ken Poliwoda Peggy A.Dickerson H = Telephone(631)765-1892 o � � Fax(631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF S BO MAKE AN OARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK APPOINTMENT FOR APRE-CONST ON AND POSSIBLEPRN.E-CONSLURE TO DO TRUCTION ON OF THE SHALL BE CONSIDERED A VIOLA PERMIT. Treq INSPECTION SCHEDULE Pre-construction, hay bale line 1St day of construction % constructed ,/ J complete,lete, compliance inspection. �� -�l�� c p Board Of $outhold Town Trustees SOUTHOLD, NEW YORK ISSUED TO ROBERT H. FREY Aul'harizalion Pursuant to the provisions'of Chapter 615 of the Laws of the State of New York, 1893; end Chapter 404 of the ,1~. ws of the · State of New Yore 19~12; and the Southold ToWn Ord,eence en- tiffed ."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 w'flh the Resolution of The Board adopted at a meeting held on .'~.~....~.~..,. ..... .30.0..4....., and in consideration of the sum of $...~.0..0..:.g.0 ..... paid by ..... .~?'~L..~.~....?~T.?.t: ............................................................................... : ........... : ......... of .................. ~.?..u.~.l~]d. ........................................ N. Y. and subject to the Terms and Conditions llrted on the reverse side hereof, of Southold Town' Trustees authorizes end permits the fdlowleg: Wetland Permit to repair the existing bulkhead in-place using C-Loc vinyl sheathing, with the condition of a 10~ non-turf buffer landward of the bulkhead, and as depicted on the plan. prepared by Jsznes E. Fitzgerald, Jr. dated Feb. ~3, ZO0~ ell in accordance with the deta~ecl specifications as presented ,n the odglcafing application. IN WITNESS WHEREOF, The said Board of Trustees here- by causes ifs C~porete Seal +o be affixed, and these .j~esents to be subscribed by a'majorlty of the said Board es of this dutn. A,r~e F. oster -Absent - · ~ t[~m~.' ,., Robert, It. Fre¥., 400 Windjammer Dr., Southold . IN. ¥~ ss a. Thatthisl~,,~h'valkl~s~mlof. 24. mm.q~kibcasdJ~adtobedm 9. Tht the Pmnktee will ~ot~-~o ~!1 odser p~,~a- ~dcome~sdsatsmyb gequ3x~d ~ ~ to ~ l~'mit ~ ma~, he ~ to revoke upm f~e ~o ~ ~ OIOHIflOS :lO N,~AOI S~ISNI~I ~00B¥OS A~ O~lAO~ldd¥ So~thold iown Board of Trustees ALU) SECTION Application regarding thc ~ of Robert H. Frey $CTM #1000-71-2-24 James E. Fitzoerald Jr, February 23. 2004 SECTION VIEW Application regatdiag the property of Robert II. Frey $CTM #1000-71-2-24 February 23.2004 ~am~S E. Fitzgerald. Jr. ~ ' SECTION VIEW Application regarding the property of Robert H. Frey SCTM # 1000-71-2 -24 James E. Fitzgerald. Jr. February 23. 2004 CONSULT YOUR LAWYER BEFORE SIGNING THIS INSTRUMENT -- THIS INSTRUMENT SHOULD BE USED RY LAWYERS ONLY. THIS INDENTURE, made the 24th day of february 2004 and BETWEEN GEORGE H. MABER, as surviving spouse (LEE MABER deceased 5/29/03), residing at 1795 Anchor Lane. Southold NY 11971. party of the first part, and ROBERT FREY, residing at 400 Windjammer Drive, Southold NY 11971 party of the second part. WITNESSETH, that the party of the first pan. in consideration of ten dollars and other valuable consideration paid by the party of the second part. does hereby grant and release unto the party of the second part. the heirs or successors and assigns of the party of the second part forever. ALL that certain plot. piece or parcel of land. with the buildings and improvements thereon erected, situate, lying and being in the in the Town of Southold, County of Suffolk and State of New York, bounded and described as follows: BEGINNING at a point on the westerly line of Lot 10 on Map of Harbor Lights Estates, Section 1, distant 50 feet northerly when measured along the said westerly line of Lot 10 from a point on the said westerly line of Lot 10 where the same is intersected by the northerly line of Lot 13 as shown and laid out on the above mentioned Map; RUNNING THENCE from said point of beginning, North 64 degrees 05 minutes 10 seconds West 45 feet; THENCE North 20 degrees 12 minutes 20 seconds East 25.13 feet; THENCE South 64 degrees 05 minutes 10 seconds East 47.50 feet to the westerly line of Lot 10; THENCE along the westerly line of Lot 10, South 25 degrees 54 minutes 50 seconds West 25 feet to the point or place of BEGINNING. TOGETHER with an non-exclusive 5 Foot Easement from the southeasterly comer of the descriptive parcel above described, and running southerly about 50 feet and then running easterly 180 feet to Lot No. 11, as shown on said Map. BEINGIthe same premises described in the deed to the parties in the first part herein by the deed to grantor in LIBER 9785 PAGE 121 The grantors herein being the same person (s) as the named grantees in a certain deed in LIBER 9785 PAGE 121 TOGETHER with all right, title and interest, if any. of the party of the first part. in and to any streets and roads abutting the above-described premises to the center lines thereof; TOGETHER with the appurtenances and all the estate and rights o1' the party of the first part in and to said premises; TO HAVE AND TO HOLD the premises herein granted unto the party o[" the second part, the heirs or suc~cessors and assigns of the party of the second purl forever. AND the party of the first part covenants that the party of the first part has not done or suffered anything whereby the said premises have been encumbered in any way whatever, except as aforesaid. AND the party of the first part. in compliance with Section 13 of the Lien Law. covenants that the party of the first part will receive the consideration for this conveyance and will hold the right to receive such consider- ation as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same first to the payment of the cost of the improvement before using any part of the total of the same for any other purpose. The word "party" ~hall be construed as if it read "parties" whenever the sense of this indenture so requires. IN WITNESS WHEREOF, the party of the first part has du~..e~ this deed the d'~y and year first above e'of New York, County of SUFFOLK , ss: Onthe '24 dayof Feb ,intheyear 200,~eforeme, the unclersigned, personaily appeared GEORGE H. MABER personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s) or the person upon behalf of which the individuat(s) acted, executed the instrument. N~)~ar y Public VICTORIA CHARCZtJK Notary Public, State of New York No. 4850488 Qualified in Nassau County ~;Q~r~i~sio~ Expires January 20, 20 Acknowledgement by Subscribing Witness taken in New York State State of New York, County of On the day of , in the year the undersigned, personally appeared , before me, the subscribing witness to the foregoing instrument, with whom I am personatly acquainted, who being by me duly sworn, did depose and say, that he/she/they reside(s) in that he/she/they know(s) to be the individual described in and who executed the foregoing instrument; that said subscribing witness was present and saw said execute the same; and that said witness at the same time subscribed his/her/their name(s) as a witness thereto. Title No.:_ 641-S-02392 TO Distributed by Chicago Title Insurance Company State of New York, County of , SS: On the day of , in the year the undersigned, personally appeared , before me, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(les), and that by his/her/their signature(s) on the instrument, the Individuat(s) or the person upon behalf of which the indlviduat(s) acted, executed the instrument. Acknowledgement taken outelde New York State * State of , County of · (or insert District of Columbia, Territory, Possession or Foreign Country) , SS: On the day of , in the year the undersigned, personally appeared before me, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(les), that by his/her/their signature(s) on the Instrument, the individual(s) or the person upon behalf of which the individual(s) acted, executed the instrument, and that such individual made such appearance before the undersigned in the (add the city or political subdivision and the state or country or other place the acknowledgement was taken). SECTION 71 BLOCK 2 LOT 24 COUNTY OR TOWN Southold RETURN BY MAILTO: Law O~ce of Paul A. Caminiti 53345 Main Road P.O. Box 846 Southold NY 11971 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 1st day of construction ¼ constructed /Project complete, compliance inspection. ~ ,~CY~--JC(_t¢-~ ~ C 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 February 25, 2004 Mr. Robert H. Frey 400 Windjammer Dr. Southold, NY 11971 RE: ANCHOR LANE, SOUTHOLD SCTM#71-2-24 Dear Mr. Frey: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, February 25, 2004 regarding the above matter: WHEREAS, ROBERT H. FREY applied to the Southold Town Trustees for a permit under the provisions of Chapter 97 of the Southoid Town Code, the Wetland Ordinance of the Town of Southold, application dated January 28, 2004, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and, WHEREAS, a Public Headng was held by the Town Trustees with respect to said application on February 25, 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, 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 ROBERT H. FREY to repair the existing bulkhead in-place using C-Loc vinyl sheathing, with the condition of a 10' non-turf buffer landward of the bulkhead, and as depicted on the plan prepared by James E. Fitzgerald, Jr., dated February 23, 2004. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of $5.00 per inspection. (See attached schedule.) Fees: $5.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/Ims Telephone (631 ) 765-1892 Town Hall 53095 Route 25 P.O. Box I 179 Southold, New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Monday, February 23, 2004, the following recommendation was made: Moved by William Cook, seconded by Don Wilder, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH CONDITIONS of the Wetland Permit application of ROBERT H. FREY (as contract vendee) to repair the existing bulkhead in-place with C-Loc vinyl sheathing. Located: Anchor Lane, Southold. SCTM#71-2-24 The CAC recommends Approval of the application with the Condition of a 10' non-turf buffer and no treated lumber is used. Vote of Council: Ayes: All Motion Carried Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application ~,~'efland Permit Application JMajor Waiv er/Amendm~nt/Chonlles .,,~l[eceived Applica?.n.: ~ ] ,~'R"eceived Fee:$ ~ ,.f~ympleted ApplicationIncomplete SEQRA Classification: Type I Type II Unlisted __Coordinafion:(datc sen0 FAC Referral Sent: I e'~ate of Inspection:~ Receipt of CAC Report: ~Eead Agency Determination:__ Technical Review: _~gSlic Hearing Held.'--~-~-~~ Resolution: Minor NameofApplicant ~d:T~-~'~ f'~. 1~'~2-_~ ~,a~~~p_.~_.~ Phone Number:( ) 7&~- Su o ¢ou ,T xMapNumbcr: 000- */ - - Property Location: ~tg--~rr:~4~F-l~ D~'-.~'"~ ~t~(?tl0q (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: Board of Trustees Application GENERAL DATA Land Area (in square feet):. Area Zoning: Previous use of property: Intended use of property: 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 If yes, provide explanation: Project Description (use attachments if necessary): Board of Trustees Al~plication WETLANDfrRUSTEE LANDS APPLICATION DATA Purposeoftheproposedoperstions: ~>L~,vA-//'? /.-~tsT'/~6~ L~t~t.A"d~-~> Area of wetlands on lot: square feet Percent coverage of lot: % 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? No ~/Yes If yes, how much material will be excavated? 2.o ~.~ cubic yards How much material will be filled? 7~0/rff cubic yards /--f:--:~'~, Depth of which material will be removed or deposited: 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): CONSENT Re: SCTM#1000-7 I-2-24 PREMISES: NO #, ANCHOR LANE, SOUTHOLD I, GEORGE H. MABER, owner of the above referenced property, consent to our contract vendee, ROBERT FREY, and their representative, or either of them, to make applications necessary for the approval of construction of BULKHEAD REPAIRS, including but not limited to the Toxvn of Southold, and all matters relating thereto. Dated: JANUARY 22, 2004 Sworn to me this 22nd Day of January, 2004 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 COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, ~--'~/~-~.~- /Lf /L~E~ , residing at ¥oO ~t~/~ ~ ~,q~ being duly sworn, depose and say: That on the/7 day of ~,3 ,200~, I pers6nally 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. Da~e of hearing noted thereon to be held '~ ' ~. '- _ ' . Dated: (signamre) Sworn to before me this , ~7~day of ~ 200z~ / Notary Pukka//~) C~ILLE LUCARINI Publk:, State of New No. 4910722 NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES~ TOWN OF SOUTHOLD In the matter of applicant: YOU ARE HEREBY GIVEN NOTICE: 1. SCTM# /~o--7/-Z-7--4 That it is the intention of the undersigned to request a Permit from the Board of Trustees to: 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: /?/~, tx.~/~OD,/~w~ /B/'~,~- 3. That the project which is subject to Environmental Review under Chapters 32, 37, and/or 97 of the Town Code is open to public comment on: ~ ~- - ~-~-~ a> Vt . 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. Enc: Copy of sketch or plan showing proposal for your convenience. PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIl, RECEIPTS Name: Address: STATE OF NEW YORK COUNTY OF SUFFOLK ~o~'~/c~ ~ 1~71 ,bcingdulysworn, dsposes and says that on the ~7. oc~-L-'Tday of J,~,~,~ e.,/ ,20.~ deponent mailed a true copy of the Notice · set forth, in the Board of Trustees Appli0~tion, directed to each of the 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 current assessment roll of the Town of Southold; that said Notices were mailed at the umted States Post Office at S t~ ~ F/-/t~/- ~ ~3 7t ~ ~ ~ [ , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to bef°re me this c~o~fi'~ Not~ P~blic - · JOSEPH H. GIBBONS N~a~ Public. State of New No. 524618265 Qualified in Suffolk County/~ ~ommlss~on Expires April 30~ Board of Trustees Application County of Suffolk State of New York ~'vm~-~,- ,d. ~-~/ BEe4a DULY SWO~ ~POS~S ~ mV~S ~X ~S~ tS ~ ~PUC~X VO~ ~ ~0~ DESC~ED PE~T(S) ~ ~T ~L STA~NTS CO~D ~ ~ ~ TO ~ BEST OF ~S~R ~O~DGE ~ BEL~F, ~ ~T ~L WO~ ~L BE ~ ~ ~ ~ SET FOR~ ~ ~S ~PLICATION ~ AS ~Y BE ~PRO~D BY ~ SO--OLD TO~ BO~ OF ~US~S. ~ ~PLIC~ AG~ES TO HOLD ~ TO~ OF SO~O~ ~ ~ TO~ ~US~ES ~SS ~ ~ ~OM ~ ~ ~ D~AGES ~ CL~S ~S~G ~ OR BY ~ OF S~ PE~T(S), ~ G~D. ~ CO~LE~G ~S ~PLICATION, I ~Y A~O~ ~ ~US~ES, ~ AG~(S) OR ~P~SE~ATI~S(S), TO E~R O~O ~ PROPERTY TO ~SPE~ ~ P~SES ~ CON~CTION ~ ~W OF ~S ~PLICA~ON. JOSEPH H. GIBBONS Notary Public, State of New York No. 524618265 Qualified in Suffolk County / 4:)/-.),e~ r~ C°mmlss*°n Exp'res April 30./.-~2'' I''%'/ f IPR~)JECT i.D. NUMEER I 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I--PROJECT INFORMATION (To be comf31eted by ADplicant or Project s00nsor) SEQ /y/. f/~_~/~ 2. PROJECT NAME 3. PROJECT LOCATION: Municipality County 4. PRECISE LOCATION (Street 5. IS PROPOSED ~ New ~ ~ansion ~ificatlonlalteratlon 7. AMOUNT QF ~NO AFFECTED: ~mllally acres Ultimately acres WILL RROROSED ACTION COMPLY WITH ~XJSTING ZONING OR OTHER EXISTING r..~ND USE RESTRICTIONS? [] No l! NO. describe briefly WHAT IS PRESENT L~i':D ~JEE JN VlCINtI~t' ~F PROJECT? [~Res,den[lal [],!ndustrlat ~ Commerci~ . Describe: tO. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GQVERNMENTAL AGENCY (FEDERAL, STATE Da LOCALI? [] Yes Go ~f yes. list agency(s) and oermitlar3proval$ 11. DOES ANY ASPECkSPEC~T OF THE ACTtON HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [] Yes' ·. ~o I! ye~J, list agency narne and permit/aooroval . RESULT OF P POSED ACTION WiLL S~[STING PERMIT/APPROVAL REQUIRE MODIFICATION? . If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this as_~sessment OVER 1, PART II--E~'J~RONME:'.JTA' '"5SESSME~IT ,T.~ ~e c~mc;e-~eo c'/ .-'.genc- ~ 2ART III--OETE~MINATION OF SiGNIFiCANCE ~To ~e completed by Agency) [NSTRUCTIC~NS: For each ~dverse .=~fect iclentifieo 3~o~e, ~etermine whe~iqe~ it is substantial, large, [meona~lt or otJlet-,vise signific ---~cn effec: snoutcl be ~ssessed in connection with ~ts (a) .-~etting (i.e. urOan or rural); (D) ~rooaDility of occ=3.~'~i..qg; (el duration- irrevetstb*Hl¥; le~ ~eocJraonic ~coce; eno (r) magm[ucle. If necessa~, aclcl attac,~meflts or reference sup~or~incj materials. E.q~ure ~ Chec,~ :his ~ox if '!au have idendfie~ one or more ,cotendally large ar significant aGverse imoac:s which MAY occur. Then proceeQ direc:ly ~o :ne FULL ~.F ~ne/or ;reoare ~ positJve'declaraticn. "~ Checx :,his ~ox ii' 7au ,have determined, based on ~he iniormadon and analysis above and any sucoortJnc_ documenta[~on. :na~ ~h,e :ronosa~ ac:ion WILL :~OT result in -_1.ay significant adverse envircnmen~al imoac:~ AND prov~oe on ~;:acnmen[s as necessary. [he reasons su~corting this determination: APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics nrohibits conflicts of interest on the Dart of town officers and enxolovees. The ouroose of this form is to orovide information which can alert the town of ~ossible conflicts of interest and allow it to take whatever action is necessary to avoid same. (Last name,rfirst name, middle imtial, unless you are applying in the name of someone else or other entity, such es a company. If so, indicate the other person's or company's nan'~e.) NAME OF APPLICATION: (Check all that apply.) Variance Change of Zone Approval of plat Exemption from plat or official map Other (If"Other", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southo[d? "Relationship" includes by blood, mamage, or basmess interest. "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership of(or employment by) a corporation in which the town officer or employee owns rr~re than 5% of the shares. YES 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 Southold Title or position of that pe~on 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 of the 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 officer, director, partner, or employee of the applicant; or __D) the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this/~y, of 0z:c~ o..~.,~.~_ 200 Signature I