HomeMy WebLinkAboutTR-5682Albert J. Krupski, President
James King, Vice-President
.&rtie 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
November 17, 2004
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Ms. Sandra Savage
Long Island Permit Service
1814 Middle Country Rd.
Suite D
Ridge, NY 11961
RE: AUBREY& PRISCILLA MEALY
460 NOKAMIS RD., SOUTHOLD
SCTM#87-2-1
Dear Ms. Savage:
The following action was taken by the Southold Town Board of Trustees at their Regular
Meeting held on Wed., November 17, 2004:
RESOLVED that the Southold Town Board of Trustees grants a One-Year Extension to
Permit #5682, as issued on December 18, 2002.
This is not an approval from any other agency.
If you have any questions, please do not hesitate to contact this office.
Sincerely,
Albert J. Krupski, Jr.
President, Board of Trustees
AJk:lms
Albert J. Krupski, President
James King, Vice-President
Artie Faster
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
Y~ constructed
Project complete, compliance inspection.
Board Of Southold Town Trustees
SOUTHOLD, NEW YORK
ISSUED TO AUBREY & PRISCILLA MEALY
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 19B2; and the Southold Town Ordinance
titled ~"REGULATING AND THE PLACING OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS an~ the
REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM
LANDS UNDER TOWN WATERS;!~. end in accordance with the
Resolution of The Board adopted at e meeting held on ....g.~...~.~.~..
~0~..., and in consideration of the sum of $..~(~.~..(~) ..... paid by
.............................................. , .....................
of .......~ou.~}~?.].d .......................... N. Y. and subject to the
Terms end Conditions listed on the reverse side hereof,
of Southold Town Trustees authorizes and permih the followlng:
Wetland Permit to demolish the eximting house and construct a ne
house, with the condition that haybales are placed down along th
dirt driveway prior to const, and maintained throughout construe
and drywells and gutters are in. stalled .t.? c.ontain the roof run-of:
all in accordance with the dete,~ed spec,fmahons as presented m
the originating application, all as depicted on the approved
dated January 11, 2001 and last revised Peb. 11, 2003.
IN WITNESS WHEREOF, The said Board of Trustees here-
~ causes ifs Corporate Seal to be affixed, and thesepresenfs to
subscribed by a majority of the said Board as of this daf~.
Trustee~
TERMS and C. ONDmONS
~ p~m~ Aubrey & Priscilla Mealy
460 Nokamis Rd., Southold
[~'t' of the consideratioa fo~ the is~,-~ of ~he pm~m~ does un4:~'stand ~ [:n~tlbe ~o the fo~-
for an ,'-~',~on may be made to d~e ~ at a latec a_,~
3, That this Permit shoed be t,e~l,~ inde~mltdy, or as loa~ as the uid Fe,~ee ~.sbes
to maiz,~- the m-uctm'e or project involved, to pco~Jde e~dmce to anyone eonce~a~J that ~
mizatlon wts originally
4. Th~t ~e wodc involved ~ be subject to d~e in~ ~nd
its a~ents, and non-comp!i~'e ~v/th the provi~ons of the ot~ apl~cation, n~y be arose
tevoc~tlon of firs Pennlt by tesohtlon o~ the s~id
5. ~ d~ete will be no unreasonable Interfe~ence with m~adon as a result of t~e ~
hewn ~thodzed.
7. Thxt if futile opet'adom of ebe Town of .~tthold tec~ni~e t~e ten~vxl aad/oe dee~al~ans
inthe l~ation of the ~n~ herein nu~a~n~l~ or if~ in the o~nlm~ o~ I~e Board ¢~ Tmseee~ ~.
wo~t shall cause uazeasmutble obstmc~on to free navi~a~ the said l~mlttee ~ be ~
upo~ due nodce, to remove ot alter d~is wottt ot pzojec~ heteln stated wid~out ex'i~z~ to the T~
d So~d~old.
That the said Board will be notified by the Petmit~e ot the compledoa'o~ the work suth-
8.
or,ed.
That the Permittee ~ obcn~n aH other pet-mils nad coasenls ~ n~ty be tequJ~ed ~
ple~eatal to this permit wbid~ may be subject to revoke upon f~!!-~ to ol~dn ~
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
Town Hall
53096 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
February 11, 2003
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Mr. Richard Saetta
P.O. Box 2047
Greenport, NY 11944
AUBREY & PRISCILLA MEALY
460 NOKAMIS ROAD, SOUTHOLD
SCTM#87-2-1
Dear Mr. Saetta:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday, December 18, 2002 regarding the above matter:
WHEREAS, Richard Saetta on behalf of AUBREY & PRISCILLA MEALY applied to the
Southold To~vn Trustees for a permit under the provisions of Chapter 97 of the Southold Town
Code, the Wetland Ordinance of the Town of Southold, application dated October 29, 2002, and,
WHEREAS, said application was referred to the Southold Town Conservation Advisory Council
for their findings and recommendations, and,
WHEREAS, a Public Heating was held by the Toxvn Trustees with respect to said application on
December 18, 2002, 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,
2
NOW THEREFORE BE IT,
RESOLVED, that the Board of Trustees approve the application ofAUBREY & PRISCILLA
MEALY to demolish the existing house and construct a new house, with the condition that hay
bales are placed down along the dirt driveway prior to construction and mainta'med throughout
construction, and drywells and gutters are installed to contain the roof run-off, all as depicted on
the approved plan dated January 11,2001 and last revised February 11, 2003.
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 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: 10.00
Very truly yours,
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/lms
Albert J, Krupski, President
Jmnes King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1892
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Please be advised that your application, dated
has been reviewed by this Board, at the regular meeting of
/~;~/0~-~ and the following action was taken:
( &/) Application Approved (see below)
( . ) Application Denied (see below)
Application Tabled (see below)
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:
4/98
Telephone
(631) 765-1892
Tovat H',dl. 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 Monday,
November 18, 2002, the following recommendation was made:
AUBREY & PRISCILLA MEALY for the demolition of the existing house and for the '
construction of a new house.
Located: 310 Minnehaha Blvd., Southold. SCTM#87-2-1
The CAC did not make an inspection, therefore no recommendation was made.
Mr. Aubrey Mealy
460 Nakomis Road
Southold, Nexv York 11971
Henry. W. Drum
2615 E. Mill Road
M[attituck, New York 11952
631-298-5992
November 15, 2002
NOV 2 0 2OO2
Re: 310 Minnehaha Blvd.
Southold, New York
Dear Mr. Mealy:
This is to confirm our conversation this ~veek that the actual permitted extent of your
right of way over our property is the original 10 to 12 tbot driveway as shown on our
survey dated December 6, 1982, copy attached. There is no legal right to use our
property beyond that area, and we understand that you will return the driveway back to its
original location. This right of way is for a dirt driveway only, and does not include the
right to pave it, fence or landscape it, install utilities, or any other use.
The property is owned by Shirley Saland and me.
By copy of this letter, we are notifying the Southold Town Board of Trustees of the
situation regarding the driveway.
Sincerely,
cc: Southold Town Board of Trustees
( Re: Saetta 1000-87-02-01)
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES~ TOWN OF SOUTHOLD
In the matter of applicant:
RICBARDS~J~TTA SCTM#1000- ~7-07-01
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a
Permit from the Board of Trustees to:
REPLACE EXISTING HOUSE WITH ANEWMODULARHOME
2. That the property which is the subject of Environmental
Review~s located adjacent to your property and is described as
follows:
310 MINN~an~ BLVD. ADJACENT.TO ~T POLE ~26
~3. That the project which is subject to
Review
Environmental
"~nder Chapt~o~ 32., ~__or 97 of the Town Code is open to public
comment on: /~/'~w~,~D~ou 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.
OWNERS NAME: AUBKEY MEALY
MAILING ADDRESS: 460 NAKOMIS KD.
Cnllq~flT n ~ 11971
~4-0-~1~--'~': "- 765-2424
Enc.: Copy of sketch or plan showing proposal for your
convenience.
CJ ~GB~
~IH1'1 ~wNZ~S ^Ss~C~^r~'
~ ' CVA6ANT)
¸TI
Long Island Permit Service
MiddLe Country Road
Suite D
Ridge, NY l [961
Phone 631-345-6820
Fax 631-345-9429
November 5, 2004
Town of Southold
Town Trustees
North Fork Bank Building
Main Road
Southold, NY 11971
RE: Aubrey & Priscilla Mealy 1000-87-2-1
Dear Lauren,
Attached please find my check in the amount of $50. We respectfully request a one year extension to the
Trustees Permit which for the above referenced project. This permit will expire on December 18, 2004.
At this time, we have subnfitted our application for a building permit for a single family dwelling. Thank
you.
Sandra Savage '
I_I Pemfit Sen, ice
Nov ~1 O~ ll:09a Richard Saetta 8C thc 6~ ?65 4999
Aloert J. bZt'upsM, President
James [~ing, ¥ice-Preaident
Henry Smith
~'~ie Fo~ter
Ken Poiiwoda
Town Hall
5S095 Route 95
P.O. Box 11.79
Southold. New York 1.1971.-0959
Telephone (631) 765-~-89°-
Pax (O31) 7G5-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Officc Use Only
~,~tstal Erosion Permit Application
land Permit Application ~' Major
Waiver/Amendment/Cha~mes
ea:e~ieived Application'
_~-.~'Rec eived Fee:$_~[00ii00 .......
_~,Completed Application I0/~/0
Incomplete
SEQRA Classification:
Type I Type II Unlisted__
__,~oordination:(date sent) ,
~.~'CAC Referral Sent: /O/.~lq[,O
__Recetpt of C AC Repom
__Lead Agency Determination __
__Tectmical Review.
~,.~ublic Hearing l'teld,~/_~_0~
Resolution:
Minor
OCT 29
Name of Applicant Am~mi'y AND PRISCILLA ~Ar.v
Address 460 l, lo~s~l'I$ ROAD, SOUTItQID ~ 11971
Phone Number:( ) 63~1 765-2424
Suffbtk County Tax Map Numb_g/22_.i/)01~-- 87v02-01
P~opmqty Lof, a~o~ 460 NOltA~4IS ROAn, $OllTmnT.n, 31Y_ ll.~l.---
(provide LILCO Pole #, distance to cross streets, and location)
AGENT. RICHARD SAETTA
applicable)
Address: P.O. BOX 2047 GRRRIqPORT, NY 11944
Phone: 631 765-4900
O~t 30 0~ 1~:S4p
A[be:'t J kkrupskL President
d ames King, Vice-President
t4e~ry Smlti~
Art[e Fo~ter
Ken Poliwoda
R i ct~'d
Sa~tta GC inc
631 '65 4999
Town Hall
53095 Route 25
P.O. Box 1179
Sotitho[d, New York 11971-0959
Telephone !.6311, 765- 1892
F~,~ ,',621) 765-1366
'BOA]R.D OF TOWN TRUSTEES
TO~VN OF SOUTHOLD
Office Use Only
Coastal Erosion Permit Appllcafio,9~
Wetland Permit Application v- Major
Waiv er/Amendmemt/C_~ange.*'
__Recei~ved Application:~O
__Received Fees r~
__Completed Apptication~/
__incomplete
_ SEQRA Classification
Type I _Type II Unlisted__
__Coordination:(date sent)i--
CAC Referral Sent:
---Date of Inspection:~_~~v;/
-' Receipt ofCAC Repodu '
Lead Agency Determination:
Technical Review'
Public Hearing Held:_ }/
Resolution: t /
Minor
Name of Applicant A~IBRL~..ttl~ PRIi~_ILLA
Address 460 NOKAi"II$ ROAD, $Ou'£RO_LI) ~ 11971
Phone Number'( ) 63_1_ 765-2424
Suffolk County Tax Map Number: 1000 - 87-02-01
Property Location: 310 [,I][NNEBABA BLVD.
RYT POLE #26
(provide L1LCO Pole #, distance to cross streets, and location)
AGENT: RICRARD SAETTA
(if applicable)
Address. P.o. BOX 2047 GREENPORT, ~ 11944
Phone: 631 765-4900
Board of Trustees Application
GENERAL DATA
Land Area (in square feet): 34,293 sq. ft.
Area Zoning: RESIDENTIAL
Previous use of property: RESIDENTIAL
Intended use of property: RESIDgNTLnL
Prior permits/approvals for site improvements:
Agency Date
x No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?
x No Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
DI~qOLITION OF EXISTING HOUSE AND CONSTRUCTION OF NE%/ HOUSE
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: REPLACE EXISTING HOUSE WI'Il/
A NEW HOUSE
Area of wetlands on lot: 0 square feet
Percent coverage of lot: 0 %
Closest distance between nearest existing structure and upland
edge of wetlands: 65 feet
Closest distance between nearest proposed structure and upland
edge of wetlands: 15 feet
Does the project involve excavation or filling?
No x Yes
If yes, how much material will be excavated? '~60 cubic yards
How much material will be filled? 360 cubic yards
Depth of which material will be removed or deposited: 6 feet
Proposed slope throughout the area of operations: EXISTIHG
Manner in which material will be removed or deposited:
STORED OH SITE TI~,N BAL~FILLED AFTER FOUNDATION IS COMPLETE
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):
~ERY LITTLE. WE ARE REPLACING EXISTING HOUSE WITH A NEW MODULAR
HO~E WBICI{ WILL GREATLY REDUCE CONSTRUCTION DEBRIS. ALL
LANDSCAPING AND EXISTING DRIVE WAY WILL REi4AIN.
Board of Trustees Application
County of Suffolk
State of New York
RICm~JU) SA~TTA 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 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 TFfl2
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
S~gnature
SWORN TO BEFORE ME THIS
~otary Pub i~- '~
EMILY HEALY
Public, State Of New
No. 01 HE6059270
~ualified In Suffolk Coun~
~{0~ ~ire~ July 2~,~
~oard of Trustees Applica~
A~'r~ORIZATION
(where the applicant is not the owner)
(print owner of property) (mailing address)
do hereby a~thorize ~1~
(Agent)
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
/~ ] ( Owner '~sign~ ) ' '
8
617.21
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I--PROJECT INFORMATION (1'o be completed by Applicant or Project sponsor)
1. APPLICANT /SPONSOR i 2. PROJECT NAME
RICHARD SAETTA [ MEALY RESIDENCE
Mumcl0ality SO J.J~J~O][~) County S~
310 MIi BL~. ~JAC~ TO ~T PO~ {26
~ New ~ Expansion ~ Mooificatiomalteradon
SEQ
~Ras,denua~ ~.'naus:rm~ ~ Commercial
ONE FAMILY DWELLING
L~ Agriculture
DEC, SOUTnOLD TOWN BUILDING DEPARTNENT
DOES ANY ASPECT OF THE ACTICM HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
[] Yes ~NO It yes. lisl agency name and permdlaooroval
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL r~EQUIRE MOOIF~CATION?
[] Yes [~[NO ::
I CERTIFY THAT TH~ ~NFORMAT[CN PROVIOED AEOVE IS TRUE VD THE SEST OF MY KNOWLECCE
RICHAI~ SAETTA
t0/29/02
the action is ;n the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this as_~s, essment
OVER
u[~ 2 9
~ART ilI--DETERMINATICN CF SiGNiFiCANCE ~To be comoleted by Agencyl
Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliweda
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
COUNTY OFUSUFFOLK ) --
STATE OF NEW YORK)
NOV - 4
AFFIDAVIT OF POSTING
I, .~,~_~ ~, residing at ~
being duly sworn, depose and say:
That on the ~ day of ~0~ , 200~, I perso~Qlly posted the
property known as ~O ~;~.k~k.
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
public hea~ing. Date of hearing noted thereon to be held /~ ~
Dated:
Sworn to before me this
~day of r'~...(.~(,~ . 200~
No[a~y Public
UNDA J. COOPER
Nota~ Public Ststeof NewYork
No. 4~22565, Suffolk County
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Nanle;
Address:
RKI~IRy DRtII'[ & Al,10
LAHG~ING WATER PROPERTY ASSC.
AUBREY MEALY .IR. & AlqO
TAMARA & JOHlq GREEN
LAUGHING WATERS PROPERTY ASSC.
STATE OF NEW YORK
COUNTY OF SUFFOLK
2615 EAST MILL ROAD
MATTITUCK, NY 11952
P.O. BOX 20
SODTHOLD, NY 11971
460 NAKOMIS ROAD
SOUTHOLD, NY 11971
755 KENDALL AVE.
MOSS, TN 38575
P.O. BOX 20
SOUTHOLD, NY 11971
~t'~'~v'u~-m ~OJ.~ , residing at oQ t~ ~.~-~ ~.~rtv'U~ ~
C~,~ ~: gO )/ , being duly sworn, deposes and says th~ on tile
3C) day of OC...,(O b.e-4~ ,20 02.., deponent mailed a true copy of the Notice
set forth, in the Board of Trustees Application, 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 United States Post
Office at ~o2x..Oz-vx(~o ~4~ , that said Notices were mailed to each of said persons by
(certified) (registered) mail.
Swom to before me this q Ir.-6~
Day of_ [-L4.vO, ,20 C..9~ -
-~ ' Notar]Public
LINDA J. COOPER
Notary Public, State of New Yo~k
No. 4822563, Suffolk C~,utaty
'l;crm E;qz, i:~ O~ember ~1
APPblCANT
TRANSACTIONAL DISCLOSURE FoRM
The Town o~ 5~u~hold's Code of Ethics prohibits
interssb on the par% of town officers and ample se~ The
pROpose of this form is to provide information which can
alert the town of possible conflicts of ~nterest and allow
it to take whatever action is necessary to avoid same.
YOUR NAMRi
{Last name, ~trst name, m~dd.le ~nltiai, Unless
you are applying in the name of someone else or
other entity, such ~s a company. If so, indicate
the other person's or company's name.)
that apply,)
Tax grievance
Variance
Change of zone
App~pwal of pint ,
Exemption from plat or official map
other
(I~ "other," name the activity,) TRUSTEES PERMIT
Do you personally (or ~hrou~h you~
parent, or child) have e relattunsltip with any officer or
employee o~ the Town of Southoid? 'Relationship' includes
by blood, marriage, or business interest. 'Business
interest' meann a business, i~cludin
which ~he ~own officer or employee has ~ven a partial
ownership o~ (or employment by) a corporation in which
the town officer er employee owns more than 5% og the
shares.
NO .,x
If you anevernd "YES,#.complete the balanc~ o[
date and sign where indicated.
thi~ ~orm and
Name of person employed by the ToWn of Southold
Title or position of that person
Describe the relationship between yourself (the applicant)
and the town officer or employee. Either check the
appropriate line ~) through D) and/or describe in the space
provided.
The town officer or employee or his or her spouse, sibling,
parent, or child ts (check all that apply)~
A) the owner o~ greater than 5% of the shares of the
corporate stock of the applic~nt (when the applicant
is a corporation);
... B) the legal or b~neficial owner of a~y i~terest in a
noncorporate'entlty (when the appllcan~ is nob a
corporation)~
.. C) an officer~ di~sctor, part,er, or employee of the
applicant; or
.. D) the actual applicant.
DESCRIPTION OF RELATIONSIIIP
subml tied
Stg'natu~e
tht ,,ZP, '..day
'Print nam