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Home My WebLink AboutTR-5505Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickers~on Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 April 25, 2002 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Mr. Martin Kosmynka 1985 Pine Tree Rd. Cutchogue, NY 11935 RE: 1985 Pine Tree Rd., Cutchogue SCTM#98-1-11.2 Dear Mr. Kosmynka: The ibllowing action was taken by the Southold Toxvn Board of Trustees at their Regular Meeting held on Wednesday, April 24, 2002: RESOLVED, that the Southold Toxvn Board of Trustees APPROVE the Amendlnent to Permit #5505 to move the previously approved sunroom with an above-ground pool, in line with the existing ramp. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765- 1892. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees AJK:lms cc: Bldg. Dept. ABPJ~ALS, ]~0ARD MEMBERS Gerard R Goehringer, Chairman Lydia A. Tortora George Homing Ruth D. Oliva Vincent Orlando BOARD OF APPEALS TOWN OF SOUTHOLD April 11, 2002 Mr. Martin Kosmynka 1985 Pine Tree Road Cutchogue, NY 11935 Re: Appl. No. 5104 - Variance Request Southold Town Hall 53095 Main Road EO. Box 1179 Southold, New York 11971-0959 ZBA Fax (63l) 765-9064 Telephone (631) 765-1809 http://southoldtown.northfork.net Dear Mr. Kosmynka: Enclosed please find a copy of the determination with grant of alternative relief issued by the Board of Appeals. You may wish to contact the Building Department as to the next step in the building permit review process, and submit revised plans to conform to the conditions of the variance, for this new construction area, and any other agency that may have jurisdiction. The Building Department personnel may be reached between 8 and 3 p.m. at 765-1802. Please feel free to call our office if you have any questions regarding this determination. Very truly yours, Enclosure Copy of Decision to: Building Department /...~l-owfi Trustees (Attn: Charlotte) Gerard P. Goehringer Chairman APPEALS. BOARD MEMBERS Gerard E Goehringer, Chairman Lydia A. Tortora George Homing Ruth D. Oliva Vincent Orlando BOARD OF APPEALS TOWN OF SOUTHOLD Southold Tov,'n Hall 53095 Main Road EO. Box 1179 Southold, New York 11971-0959 ZBA Fax (631) 765-9064 Telephone (631) 765-1809 http://southoldtown.northfork.net FINDINGS, DELIBERATIONS AND DETERMINATION MEETING OF MARCH 28, 2002 Appl. No. 5104 - MARTIN KOSMYNKA Parcel: 98.-1-11.2. BASIS OF APPEAL: Building Department's Notice of Disapproval dated February 20, 2002, denying a permit for an addition with in-ground swimming pool, for the reason that Section 100-244B of the Zoning Code requires a setback of 10 feet on one side yard and 15 feet on the other side yard, for a minimum total side yard area of 25 feet. AREA VARIANCE REQUESTED: Applicant wishes to construct a new swimming pool attached to the dwelling with a setback of three feet on the west side of the house instead of the code requirements. The total side yards are proposed at seven feet. FINDINGS OF FACT The Zoning Board of Appeals held a public hearing on this application on March 21, 2002, at which time written and oral evidence was presented. Based upon all testimony, documentation, personal inspection of the property, and other evidence, the Zoning Board finds the following facts to be true and relevant: PROPERTY FACTS: Applicant's property contains 16,306 sq. ft. in area and is located on the easterly side (House #1985) Pine Tree Road in Cutchogue. The property is improved with a single-family dwelling and structures as shown on the survey prepared by Kenneth H. Beckman, revised January 11, 2002. REASONS FOR BOARD ACTION: IN ACCORDANCE WITH THE REVIEW STANDARDS SET FORTH IN TOWN LAW 267B-3 "AREA VARIANCES," THE BOARD HAS CONSIDERED THE BENEFIT TO THE APPLICANT IF THE VARIANCE IS GRANTED, AS WEIGHED AGAINST THE DETRIMENT TO THE HEALTH, SAFETY AND WELFARE OF THE NEIGHBORHOOD AND COMMUNITY BY SUCH GRANT, AND DETERMINES THAT: 1. Grant of the area variance as requested will produce an undesirable change in the character of the neighborhood or detriment to nearby properties. The proposed addition would extend toward the adjacent lot leaving a setback of three feet. 2. The benefit sought by the applicant cannot be achieved by some method, feasible for the applicant to pursue, other than an area variance, because the applicant desires a pool area due to the medical need requiring constant physical activity. Page 2 March 28, 2002 Appl. No. 5104- M. Kosmynka Parcel 98.-1-11.2 at Cutchogue 3. The variance requested is substantial and represents a seven-foot reduction in the code requirement of 10 feet, and total reduction of a combined side yard setbacks. 4. The variance granted will not have an adverse effect or impact on the physical or environmental conditions in the neighborhood or district. No evidence has been submitted to suggest that this variance will have an adverse impact on physical or environmental conditions in the neighborhood. The applicant has agreed to accept alternative relief with conditions. 5. Grant of the requested variance is the minimum action necessary and adequate to enable applicant to enjoy the benefit of a swimming pool attached to the dwelling, while preserving and protecting the character of the neighborhood and the health, safety, and welfare of the community. BOARD RESOLUTION ACTION OF THE BOARD: In considering all of the above factors, and applying the balancing test under New York Town Law, motion was offered by Member Orlando, seconded by Chairman Goehringer, and duly carried, to: DENY the application as applied for, and GRANT alternative relief for setbacks from the easterly side property line at six (6) feet at its closest point and nine (+/-) feet at the opposite point, SUBJECT to the following CONDITION: That the walkway, if placed, shall be located only on the south side and extended from front to rear. This action does not authorize or condone any current or future use, setback or other feature of the subject property that violates the Zoning Code, other than such uses, setbacks and other features as are expressly addressed in this action. Vote of the Board: Ayes: Members Goehringer (Chairman), Tortora, Oliva, and Orlando. (Member Horning of Fishers Island was absent as authorized.) This Resolution was duly adopted (4-0). "' -" ,¢.~J--.'"~'~'~ ' ~ - Gerard P. Goehringer, Chairr~an Albert J. Krupski, President James King, Vice-President Attic 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 $OUTHOLD March 22, 2002 Mr. Martin Kosmynka 1985 Pine Tree Road Cutchogue, NY 11935 RE: SCTM#98-1-11.2 Dear Mr. Kosmynka: The following action as taken by the Board of Town Trustees during a Regular Meeting, held on March 20, 2002, regarding the above matter. WHEREAS, MARTINKOSMYNKA applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated February 20, 2002 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 20, 2002 at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viexved 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. 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 lT. 2 RESOLVED, that the Board of Trustees approved the application of Martin Kosmynka for a Wetland Permit to add sun room14'x29-1/4' with above ground fiberglass pool 7.8'x13' 48 inches deep above ground with ch'ywells. 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. Fee 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 when project is started and on completion of said project. FEES: NONE Very truly yours, Albert J. Krupski, Jr. President, Board o f Trustees A~K/cjc Cc DEC Building Department Board Of $outhold Town Trustees SOUTHOLD, NEW YORK PER.,T ^TE: March MARTIN KOSMYNKA ISSUED TO ...................................................................................................... ~Xnl'l~urizutinn Pursuant fo the provisions of Chapter 615 of the Laws of the State of New YorE, 1893; end Chapter q04 of the Laws of the State of New York 1952; and the Southeld 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 WATERSide. and in accordance with the Resolution of The Bbard adopted at a meeting held on ....~'~....~.' 2002 and In consideration of the sum of $ 200.00 paid by .... Max.tin......Kos myn ka ......................................................... . ..................... of Cutchogue, N.Y. and subject fo the Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes end permits the following: Wetland Permit to add sun room 14'x29-1/4' with above ground fibreglass pool 7.8'x13' 48 inches deep above ground with drywells. all in accordance with the detailed specifications as pre~ented in the originating application. IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be eft?ed, end these presents to be subscribed by e majority of the said Board as of this dat~. .Artie Foster (Absent) Trm~ees TERIMS end CONDmONS TbeP~ Martin Kosmynka ~esidin~ at 1985 Pine Tree .,Road, GCtchogu~. lq. ¥~ ss part' of the comider~tlon fo~ the ~ of the Pe~lt doe~ trade,rand tnd p~qbe to the roi- 1. 'r'mu the said Board of Tnu~es and the Town o~ Southold ate telatsed f~0m any nad all ~ m ~,~,~ for dan~,es, of suits arising dkecdy ot lndh~dy ts · result of my o1~- 2. That this 1~-,,i~ is wild fo~ a l~iod of 24 mo~. qthkh Is coasldeml to be dae ~mated dme'requlred to complete the wotic involved, b~t'should ~ warrant. for an ex,','~on may be made to ~e 13o~d at a is~e~ dat~ 5. That this Permit should be t~lned indei~mltely, or as loog as the _~,t Petmktee withes to' maintain the structure or project involved, to provide evidence to anyone concerned that amh- 4. That the work involved will be subject to the ~ and approval of the ~ ot lis agents, and non-comp~l.,~e with. the ptavL~ions of the otlglnsgng spl~c~Imh may be ,'-.'---~ fo~ ~evocstlo~ of this P~it by tesolutlon of the said Board. 5. That there will be no um~ason~le interference with mviga~m ~s a teak of the w~k he.tn a~thodzed. 6. That there shah he no interference with the right of ~e publk to p~tss and t~p~tss along the beach between hlgh and low water m~rks. 7. That if future operattom ol~ the Town of Southold requite the femoral and/of alterations tnthe location of the wotic herein sutho~ or If, in the oplnlon ~ the Board o~ Trustees, t~e. wock ~h~,ll CI~L.~ un~-zsom~le obstt'uc~on to free navignt~ the sa~d Pe~'m!~'ee ~ be ~ upon due notice, to remove or alter dais work or project he~eln uated without ezl~nses to the Town 8. That the said Board will be notified by the Permit'tee ot the c0nlpledon 0~ t~e wot'k s~lh- orized. That the Petmlttee will obtaln aH othet petmks and coosents ~ may be tequlted sup- plemental to this pex'mlt wbi,-h may be subject to revoke upoa fdlute to olxaia same. Telephone (631) 765-1892 Town Hall. 5.'1095 Main Road P.O. Box 11"/9 ,~lahold. Ne~ Y~'k 11971 SOUTHOLD TOWN CONSEHVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Monday, Mamh 18, 2002, the following recommendation was made: Moved by Bill McDermott, seconded by Bret Hedges, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the Wetland Permit Application of MARTIN KOSMYNKA to add a sunmom 14'X 29' with above ground pool 7.8'X 13'. The pool is fiberglass and 48" in depth. Located: 1985 Pine Tree Rd., Cutchogue. SCTM#98-1-11.2 Vote of Council: Ayes: All Motion Carried EUGENE & ANN BURGER 2215 Pine Tree Road Cutchogue, NY 11935 March 19, 2001 Southold Town Trustees/ZBA Main Road Southold, NY 1197l RE: MARTIN KOSMYNKA - LAP POOL To Whom It May Concern: This letter is written in reference to the proposal for the construction of an indoor lap pool addition to the home of Martin Kosmynka on Pine Tree Road in Cutchogue. As you may know Mr. Kosmynka has a heart condition and is paralyzed from the waste down. Every day he must overcome many hardships, which we, easily mobile and transportable persons, take for, granted. Simple movable acts such as "getting out of bed" each morning requires patience, time and extreme physical concentration. These feats are not only physically taxing but mentally also. His request for a small addition surrounding a pool, in which to aid blood circulation and slow down the muscle degeneration in his legs is very important to his well-being. Any opposing Feedback should be considered insignificant in light of the reality of the situation - he is a victim of an unfortunate physical handicap. A small addition, although close to the property line, shielded with the correct vegetation, will have minimal impact of both the environment and the neighborhood. His home is presently one of the more aesthetically pleasing and well maintained homes in our neighbothood. Sincerely, Eugene and Ann Burger Dear Sir, This is a letter of medical necessity for Martin Kosmynka to have an indoor lap pool. Aquatic therapy would positively impact in his reaching and maintaining his maximum physical potential. His independent mobility is limited to trunk and upper extremity use secondary to a spinal cord injury that is permanent. The ability to exemise his body in water on a regular basis could be key to his survival, as swimming exercises his heart and lungs as no other exemise that he is capable of performing could. It would allow him to remain a productive taxpayer and member of society. Sincerely, -~a'dndra J. Pe~ P.T.~ 1: 2 7 North Fo k Family Practice Associates Dr. Richard Cappello Dr. I.uigl Buono P.O. Box 153 7905 Main Road Mattltuok, NY 11952 (831) 298-2030 February 26, 2002 Southold Town Zoning Board Route 25 Southold, N.Y. 11971 To whom it may concern: L My patient has paraplegia and is wheelchair confined. He has CAD disease, high blood pressure, Cardiac Arrhythmia and CABG X 2. He requires daily exercise to maintain his cardiovascular health. Due to his physical limitations an indoor exercise pool is medically required. Richard CappeHo, D.O. RC:cdk rs OF' RECORD IF' ARE NOT ,c'LE~'7- /~'IARK["7- CORP ~TION OR ADDITION T-,~V'~' '7-17'/._~ II~/..~URAA./C~ OF rio LATION OF' Albert J. Krupski, President James' King, Vice-President Henry Smith Attic Poster Ken Poliwoda Town Hall 53095Route 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 UseOnly Coastal Erosion Permit Applicatiofi Wetland Permit Application ~' Major Waiver/Amendme_n~/C hatnges Received Application: 'Y! Received Fee:$ ,'~2t~-'v ~ ! - Completed Application ~/?!/0 Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(date sen~.._,~q~.~ CAC Referral Sent: _~,"v~'/ Date of Inspection: _~ ~f/~/O Receipt ofCAC Rep~{'t: Lead Agency Determination:__ Technical Review: t Public Hearing Held: ,.~/~)-O/6 9-- Resolution: / -- Minor Name of Applicant ff~]/L~ Address /~ ~' Suffolk County Tax Map Number: 1000 - ~] ~- Phone Number:( ) 7 ? y-- - / Property Location: ~ ~I~'~/~''/ ~ (provide LILCO P~le #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: Board of Trustees Application Land Area (in square feet): Area Zoning:. ~ GENERAL DATA 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 suspende~y a governmental agency? ~'~ No Yes If yes, provide explanation: Project Description (use attachments ir necessary): Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: /~) ~ t~ ! ~J Area of wetlands on lot: Percent coverage of lot: Closest distance between/pe.~a~est edge of wetlands:. ~J Closest distance between.9~'est edge of wetlands: /tS square feet existing structure and upland feet proposed structure and upland feet Does the project involve excavation or filling? ~//No Yes If yes, how much material will be excavated? How much material will be filled? Depth of which material will be removed or deposited: Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: cubic yards cubic yards feet 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): PR0,~ECT 1.0. NUMBER 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) SEQ 1. LJC ~b_ISPONSO 2. PROJECT NAME 3. PROJE~ LOCATION: ~ IS PROPOSED ACTIO ' [] New ~ansion [] Moc~ificadontallerat[on 6. DESCR[BE PROJECT BRIEFLY: 7. AMQUNT OF I.J, ND AFFEC ED: r~OES ACTION INVOLVE A PERMIT APPROVAL OR PUNDIr~G. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FBDERAL, STATE O~ LOCAL)? ~ Yes ~No If yes. frs! agency(s) and permitla¢orova~s 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID RERMIT OR APPROVAL? [] Yes' ,~ NO ~ yes. list ager~cy name and DermHlaD~rova ~2. AS A RESULT OF PROPOSED ACTION WILL EX[STING PERMIT/APPROVAL REQUIRE MODIFICATION? [] ¥~s [] No If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this as__s, essment OVER I ~ART II]--OETEP, MINATION OF SIGNIFICANCE tTo 0e comoleted ~y Agency) INSTRUCTIONS; Foe _=3c.~ ~overse e~fe¢*, iden~tie~ ~-Eove. ceterrnine wneti~er ~t is Suos~3ntial, large. [mcortsn[ or otllec.wse $iGnific =_3c.~ eifec: snoulcl 3e issessed in connection ,mi/3 ,ts (~) setting ti.~- urban or rural); (b) ~¢obel3ilit'! of occ:3-'-'~g; Lc) durs[iort' irreversd3Hi{y; ~et geogrsmnic ~coce; ano (0 magm{uoe, if necessary, aod attac.qmen~s or reference supporting maIerlsl$. =nsure Board of Trustees Application County of Suffolk State of New York /*7/0 ~/'-//t/ ~OSr~ y/t/?~ .~__. BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/Sim 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. SWORN TO BEFORE ME THIS Signature //dA DAY OF l~otary Public PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Name; Address: 19.o. STATE OF NEW YORK COUNTY OF SUFFOLK C ~' T~ I4o~u~r' . , residing at / _, bein. g duly sworn, deposes and says that on the ,200_~_~ deponent mailed a true copy of thc 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 O~Ho~./Lj ., that said Notices were mailed to each of said persons by (certified) (registered) mail. ~ Sworn to before me this // Day of p'l?f c . , 20 ro '~ ' Notary Pt~blic - LINDA I', KOWAL$KI I;otary Public, ~tate of N~¥o~ No. 52-4524771 C!:[a!i,.'ied in ~uffolk ~ ~'c. "' ' - ,'%v. 30. l~O~OO ~_ PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Nan~e: Address: STATE OF NEW YORK COUNTY OF SUFFOLK , , residing at [ q~;~" f//¢/f ~"tq/¢2r~ , being duly sworn, deposes and says that on the ,20 ¢~.,_deponent mailed a true copy of the Notice ) ~ day of pl ta ~e¢ ~4 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 ff,.,rc-lqor),Jt-~ , that said Notices were mailed to each of said persons by (certified) (registered) mail. Sworn to before me this Dayof /l~qfC// 20 Notary Public L PROOF OF MAll ,ING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS Nallle.' Address: STATE OF NEW YORK COUNTY OF SUFFOLK ff//0t~T//c, ~/O~7t,/~,,,~- , residing at /gJ~'f f?/v'~r ~A'~d c~ Fc~q~ , being duly sworn, d~oses ~d sa~ that on the ~ ~ dayof ~ ,2~deponentmail~a~ecopyof~eNofice · set foah. in the Bo~d of Trustees Application, dk~ted to each of~e above nmed persom at the ad~esses set op~site ~ere resp~tive roes; ~at ~e ad&esses set op~site the nines ofs~d persons m the ad.ess of said pe~o~ ~ shorn on ~e c~ent ~sessment roll of the Tom of Southold; ~at said Notices were m~l~ at the U~ted States Post Office at ~ u ~U~ , that s~d Notices were m~led to each ofs~d pemons by (ce~ified) (re~stered) m~l. ~ 'v ~~. . .CA Sworn to before me this /'/ Day of ~Q PC,~ , 2~ ~. Notary Public APP~X~NT TRANSACTIONAL DISCLOSURE FORM The ToWn o~ S~u~hold's Code of Ethics p=ohibits con[licts,,o~ interest on the part of town officers and,.emplo ees. ,The purpose of this form is to provide, information which_gan alert the town of possible conflicts of inter,st and allow it to take whatever action is necessary to avoid same. (bast name, first name, middle initial, onless you are applying in tho name of someone else or other entity, such 9s a company. If so, indicate the other person's or company's name.) NATURE OF APPLICATIoN~ (Check ali that apply.) Tax grievance Variance , ~ Change of zone Approval of plat '. Exe~ption from plat or official map other (If "other," name the activity.) parent, or child) have a relationship with any officer or employee OE the Town og Southold? 'Relationship' includes interest" means a business, including a partnership, in ~hich ~he to~n officer or employee has even a pattie! ownership of (or employment by) a corporation in ~hich the town officer or employee owns more than 5~ o£ the shares. NO date and s~gn where indicated. thin ~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 o~ricer or employee. Either check the appropriate line k) through D) and/or describe in the space provided. The parent, A) town officer or employee or his or her spouse, sibling, or child is (cl~eck all that apply)~ the owner of greater than 5% of the shares of the corporate stock of the applic~nt (when the applicant' ia a corporation)~ B) the legal or b&neficial owner o~ any interest in a noncorporate'entity (when the applicant is not a corporation)~ .C) an o~icer, director, partner, or employes o~ the applicsntl or D) the a:tual applicant. DESCRIPTION OF RELATIONSIIIP L';' submitted · Print name