HomeMy WebLinkAboutTR-5321AllJert 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
CERTIFICATE OF COMPLIANCE
# O011C
Date 10/20/04
At
THIS CERTIFIES that the dwe~ng,~a~age, pool house & pool
240 Bria~ Lane, Southold
Suffolk CounB, Tax Map # 81 - 1 - t 6.8
Conforms to the application for a Trustees Permit heretofore filed in this office
Dated 4/5/01 pursuant to which Trustees Permit # 5321 Dated 4/25/01
Was issued, and conforms to all of the requirements and conditions of the applicable
provisions of law. The project for which this certificate is being issued
is for a dwelling, garage, pool house and pool
The certificate is issued to RonaAd & Kn~ Heyvnanee
aforesaid property.
owner of the
Authorized Signature
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy' A. Dickerson
Town Hall
53095 Route 25
P.O. Box 1179
Seuthold, 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
__ Ist day of construction
~ constructed
Project complete, compliance inspection, i o{,~ 100~
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dk:kerson
Town Hall
53095 Route 25
P.O. Box 1179
Sout~hold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
September 26. 2003
John Bertani Builder, Inc.
1380 Oakwood Drive
Southold, NY 11971
Re;
SCTM#81-l-16.8
Ronah] & Kris Hemance
240 Briar Lane
Southold. NY
Dear Mr. Benani:
The following action was taken at the Southold Town Board of Trustees Regular Meeting on
September 24, 2003.
RESOLVED that the Southold Town Board of Trustees grant a One Year Extension to
Wetland Permit #5321 dated November 15, 2001 for Ronald & Kris Hernance to construct a
55'x55' single family dwelling, pool (24xl 8) and garage/pool house (20x 15) on site sewage
disposal system, with pubic water an pervious driveway with the condition of a 50 foot non-
disturbance buffer and a staked row of hay bales during construction based upon the inspection
of Town Code Enforcement prior to construction for a hay bale line - also drywells and gutters
to retain roof run-off from all structures that there be drywells for the pool backwash. As
depicted on survey dated Dec. 11, 2000 and last revised October 26, 2001
However, this: determination is not a determination from any other agency.
If you have arty questions please contact our office at 765-1892
Albert J. Krupski, Jr.
President, Board of Trustees
AJK: cjc
Cc: DEC
Building Department
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
May 23. 2002
Mr. Tom Samuels
Samuels & Steelman Architect
25235 Main Road
Cutchogue, NY 11035
RE: SCTM#81-1-16.8
240 Briar Lane
Southold, NY
BOARD OF TOWN TRUSTEES
Tow oF souT OLr
Dear Mr. Samuels:
The following action xvas taken by the Southold Town Board of Trustees at their Regular
Meeting held on Wednesday, May 22, 2002.
RESOLVED, that the Southold Town Board of Trustees Approve an Amendment to Permit
//5321 for a house (55x60) pool (24x18) and garage/pool house (20x35) - based upon the
inspection of Town Code Enforcement prior to construction for a hay bale line - also drywells
and gutters to retain mol run-off from all structures - that there be drywells for the pool
backwash Approved the request for a Transfer of Permit #5321 dated November 16, 2001
fi.om John Dempsey to Ronald & Kris Hermance
If you have any'questions, please call our office at 765-1892.
~qincerely,
Albert J. Krupski, Jr.
President, Board of Trustees
AJK:cjc
Building Department
Town Code Enforcement
Telephone
(~3~) 765-~892
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 Monday, May
20, 2002, the following recommendation was made:
Moved by Scott Hilary, seconded by Jason Petrucci, it was
RESOLVED to recommend to the Southold Town Board of Trustees ~AI. of
the Amendment Request of RONA,k,Q & ,K/~J$ ~ to Amend ~e~r~'~ '"/f5~21 to
construct a single-family dweffing (55'X 80'), pool (2'4'× 18'), and garage/pool house
(20'X 35').
Located: 240 Briar Lane, Southold. SCTM#81-1-16.8
The CAC recommends Disapproval of the application because of the following reasons:
2.
3.
4.
A new application should be submitted.
The new structure was not staked.
A 75' non-disturbance buffer should be flagged.
The wetland delineation should be flagged.
Vote of Council: Ayes: All
Motion Carried
Board Of Southold Town Trustees
SOUTHOLD, NEW YORK
PERMIT NO.. '~'~. '~ ..
DATE: ..~97' 16.~...~(~01
ISSUED TO JOHN DEMPSEY ............................
Pursuant to the .provisions of Chapter 61~i of the Laws of
the State of New York, 1893; and Chapter 404 of the L~ws of the
State of New Yore 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 WATERS;!~. and in accordance with the
Resolution of The Board adopted at a meeting held on
2001 and in consideration of the sum of $ 200.00 Paid by
......... ................................................................ . ......................
of .................. (~.'~?h?.g?.'~ .................................. N. Y. and subject to the
Terms and Conditions listed on the reverse side hereof,
of Southoid Town Trustees authorizes and permits the following:
Wetland Permit to construct a 55'X55' single-family dwelling,
on-site sewage disposal system,with public water and pervious
driveway,with the condition of a 50' non-disturbance buffer and
a staked row of hay bales during construction,as depicted on'
all in accordance with the detailed specifications as presented in
· the origin~ting application, survey dated Dec.ll, 2000 and
last revised Oct. 26, 2001.
IN WITNESS WHEREOF, The ~aid Board of Trustees here-
by causes its Corporate Seal te be affixed, and these [~.resents to
be subscr~ed by a'maiodty of the said Board as of th~s dat~.
. H,enr.y Smith .- Absent
- ' Trustees
TERMS and CONDmONS
Tbe Permktee . John Dempse¥.
P.O. Box 5, Cutchogue
N. Y~ as
l~ZC'of d~e coaslde~t~o~ fo~ ~he ~ of ~he Peem~: do~ ~m:le~s~! ~ad pea, ca'be ~o the roi-
1. T'nat the sald Board of Trustees mgl the Town of South°Id axe released ft~n stay ~od
damages, oc ,4.I,~ fm damask, of suits acislag ~ oe ~y ss ~ muk of aay opes-
~ respect there., to the complete exclusion of tl~ ~ of Tnntees ~ ibc Town o~ ,q~tb~
2. That ghts Permit Is valid fo~ st period of 24 mos. ~ch is coasMeaxl to I~e the
es~matecl tlme'mqulmd to _-~o,plete the work involved, but should clmmsmasccs warmz, mlueSt
for an eucmn~on may be n~de to the ~ ~t a ~_~ da~e.
That this Permit sl~mld be t'etaln~d indefinitely, or as 1~ as l~e said p.~.~!u'ee
msimala the m-ucm~ oc p~o.iecc involved, to pmvkle t-~lence co anyone comemed that aud~-
odzatloo was odglnaHy
4. That d~e work b~olved wtll be subject to ~e ~ and approval of ~ Boa_rd
its %~nts, and non-mmpIiance ~4d~. d~e ptovlslons of d~e oclginattng ~pllc~tton, n~ty be _--~e_~
mvocatic~x of thls Pennk by resolution of the said B<~d.
7. That if future opel~iom of fie Town of So.hold lcequlre die mnoval smd/m altcraltoos
inthe location of d~ ~xk benin tud~lzed, or ii, in ~he opinion ~ ibe Board o[ Trustee% *he.
vto~ ~-" ~suse unresson~ble obstmcnon to free m~tlon, the said Pmnktee will be ~qulteds
upon due notlce, to remove or alter d~is work ot project het~n sta~ecl without ezpem~ to the Tosm
8. That the sald Board will be .oti[i~d by the Peanit~e ot d~e ~loao[ the wodc mah*
odzed.
9- That the Permirtee wifl obtain aH other permits and comenes that troy be requited sup-
plemental to this petmlt whic~ may be subject to revoke upon f~.,e to ol~!p same.
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
November 16, 2001
Ms. Catherine Mesiano
Catherine Mesiano, Inc.
12 Mill Pond Lane
East Moriches, NY 11940
JOHN DEMPSEY
240 Briar Lane, Southold
SCTM#81-1-16.8
Dear Ms. Mesiano:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday, April 25,2001 regarding the above matter:
WHEREAS, Catherine Mesiano, Inc. on behalf of JOHN DEMPSEY applied to the Southold
Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of
Southold, application dated April 5, 2001, 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 Town Trustees with respect to said application on
April 25, 2001, 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 of JOHN DEMPSEY to
construct a 55'X 55' single-family residence, on-site sewage disposal system, with public water
and pervious driveway, with the condition ora 50' non-disturbance buffer and a staked ru~v of
hay bales during construction, as depicted on survey dated December 11, 2000 and last revised
October 26, 2001.
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 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,
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/lms
DEC
Bldg. Dept.
Tele~hooe
(631) 765-1892
Towe H'~. 53095 ~ Road
P.O. Box 1179
Southold. New York 11971
SOL1THOLD TOWN
CONSERVATION ADVISORY COUNCIL
At the meeting of the Southold Town Conservation Advisory Council held Monday, April
16, 2001, the following recommendation was made:
Moved by Scott Hilary, seconded by Bob Ghosio, it was.
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH
A CONDITION of the Wetland Permit Application of JOHN DEMPSEY 81 ol -16.8 to
construct a 55'X 55' single-family residence, on-site sewage disposal system, with
public water and pervious driveway.
240 Briar Lane, Southold
The CAC recommends Approval with at least a 75' non-disturbance/non-fertilization
buffer.
Vote of Council: Ayes: All
Motion Carried
B .4 S £ ~V
I
llll
ll[J
Il!
SEF 1 6 £OO3
$outhold Tow.
Board o~ Trustees
J~n Bertani Builder Inc.
1380 Oakwood Drive
Southold, N.Y. 11971
(631) 765-1594
FAX (631) 765-3916
September 16, 2003
Re: SC'fM1~1-1-16.8, 240 Bdar Lane, Southold
PERMIT NO. 5321
Mr. A~bert J. Kn~pski, Jr., President
Southold Town BOard of Trustees
P.O. Box 1179
Southold, NY 11971
Dear Mr. Krupski,
We are requesting a one year permi! extension for permit # 5321 for Ronald and Kris Hermance, 240
Briar Lane, Southold, $CTtv~ 81-1-16.8 whirl3 expires on 11/16~3.
Enclosed is our chec~ for $10.00.
Thank you.
Sincerely,
$ A M U E L S &
S T E E L M A N
April 29, 2002
Albert Krupski, Jr., President
Southold Town Trustees
53095 Main Road
Southold, NY 11971
Re: PERMIT #5321
SCTM #81-1-16.8
Dear Al and Trustees,
Since the issuance of the above referenced permit to Mr. John Dempsey, the property
at 240 Briar Lane, Southold, has changed ownership, its new owners are Ronald and
Kris Hermance, of 327 McKinley Place, Ridgewood, NJ 07450. Please amend the
permit to reflect this change of ownership.
The Hermances have commissioned my firm to design a new house (55x60), pool
(24x18), and garage/pool house (20x35) for the property. Enclosed you will find three
(3) copies of a new SITE PLAN for the project, which includes these features. You will
note that the design respects the various setbacks required in the existing permit: 50'
non-disturbance zone, 75' building setback, and 100' sanitary system setback. Please
note that our design includes a masonry retaining wall along the east side of the
building envelop, which enables that portion of the site between the principal and
accessory structures to be filled. Proposed topographic elevations are noted.
Approximately 450 yards of fill material will be required to achieve these contours. The
new plan also shows stone paved terraces and a permeable driveway.
Please review the enclosed documents and get back to me with any questions or
concerns. If possible, please schedule a PUBLIC HEARING for the proposed
AMENDMENT at the next available meeting.
Enclosed you will find a check that includes $10.00 for the service~f changin .g~he name
on the original permit, and $40.00 for amending that permit. ,~X,
cc: Hermance
ARCHITECTS
25235 MAIN ROAD
CUTCHOGUE, NEW~ORK ]1935
~631 ~ 714-6405
FAX ~6311 734 6407
Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
Town Hall
· 53095 Route 25
P.O. Box 1179
Southo[d, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In the Matter of the Application
STATE OF NEW YORK)
~ AFFIDAVIT OF POSTING
' ,..~e.~t.~ing at ~.0
being duly sworn, depose and say:
T~to~~ t~o~wn~-a~aY o~,~~~200~I~/_~,_}.~_~~rsonally posted the
by placing the Board of Trustees offi~al'p0ster where it can
easily be seen, and that I have checked to be sure the poster
has remained in place for eight days prior to the date oK the
~ublic he~ariqg. Date pf hearing, noted thereon to be held~~
Dated:
Sworn to before me this
~. day of ~ 200~
Notary Public
( signature )
PATRICIA RICHARDS
Notary Public, State of New York
No. 01 RI6042467
Qualified in Suffolk County
Commission Expires May 30, 2002
Alber~ J. Krupski, President
Jameus King, Vice-President
Hem, y Smith
Artie Fester
Ken Poliwoda
Town Hall
53095 Route 25
P.O. Box 1179
Southold, NewYork 11971-0959
Telephone(631) 765-1892
Fax(631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OFSOUTHOLD
Office Use Only
Coastal Erosion Permit Application
~..-'W~tland Permit Application ~'"Major __ Minor
Waiver/Amendment/Changes
· ,-Keceived Application: qlq~ I
~teceived Fee:$ o~00
· ~'Completed Application
Incomplete
SEQRA Classification: APR
Type I , Type II Unlisted
Coordination:(date senQ~
-,~AC Referral Sent: t//tll01
~"~ate of Inspection: ~OI
Receipt of CAC Report:
Lead Agency Deterraination:__
Technical Review:
~'~ublic Hearing Held:
Resolution:
Name of Applicant -.~o~ -'~ e ~-~
Phone Number:( )~t- q hq- &os~
Suffolk Co~ty Tax ~p Number: 1000- .~ I - I- ~.~
Pmpe~Lo~tion: ~.~ ~r~ ~ ~ ~0~ ~1 ~b,~o~ ~.
(pro,de L~CO Pole'S, dist~ce to cross s~re~s, ~d location)
(If applicable)
DATA
Area (in s~uare feet)~
Zoning:. ~:~0 .~
Previous use of pro~ertys
Intende~ use o~ propertyt
frO.
Prior ~ermits/approvals for site improvements:
Agency Date
_ ~ No prior perm£ts/a~provals for site in~p:ovements.
Bas any permit/approval ever been revoked or suspended
gover~entaI agsncy?
No Yes
If yes, provide explanation~
l~roJect Description (use &t:achments if necessar¥)~. .
U --
Area of wetlands on
, s~uare feet
Pexcent coverage of lot:
~ %
Closest ~istance between nearest existing itructure and upland
edge of wetlands: ~\a_ feet
edge of wetlands: 75 feet
Does ~he project involve excavation or filling?
No.,, X Yes
If yes, how much materiel'will be excavate~?
How much material will be ~illed?
~:~pth of which material will be removed or depcsited~
Proposed slope throughout the area of operations:.
Manner in which material will be removed or deposited=
Statemenu of the effect, if any, on the wetland~ ami tidal
waters of the town that may result by reason of such pro~se~
l' O / ' '
14.1~ (l~m?)-q BEQR
PROJECT ID NUMBER APRENDIX C
SHORT ENVIRONMENTAL ASSESSMENT FORM
for UNLIIBTBD ACTION6 Only
PART I--PROJECT INFORMATION (To he completed by ADplicant or Project Sponsor)
3. ~ROJECI'~.OCATIOI~' /
Municlpal~ ,J~/~-~ [County ~..~
5. I$ PROPOSED ACTION:
7. AMOUNT OF LAND AFFECTED:
E. WILL PROPOBED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
[3 No if no. ~e~crtb~ br[e.y
9, WHAT IS PRESENT LAND UBE IN VICINITY OF PROJECT?
[] Aorlcumture i'q PmrkJFore~t/Open Epace. [] Oth~
10. DOES ACTION INVOLVE A PERMIT APfmROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER QOVERNMENTAL AGENCY (F~Pal, Eta~ or
Loc. eOT
~ Yes [] No If y~s, fist agency(a) and Dermit/al~rOvala
11, DOES ANY ASPECT OF THE ACllON NAVE A CURRENTL?"VALIO Pill[qUIT OR APPROVAL?
12. AS A RESULT OF I~:IOPOEED ACTION WILL EXISTING PERMIT/API~ROVAL REQUIRE MODIFICATION?
[] Yes [] NO
I C.E~i )~-¥ THAT THE INFORMATION PROVIDED ABOVE I$ TRUE TO THE BEST OF MY KNOWLEDGE
If tho action Is In the Coastal Area, and you ara · ~tate agency, I
complete the Coeetel Aeaeeement Form before proeeedlng with thla easesemont
I
OVER
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
NAME JOHN DEMPSEY
YOU ARE HEREBY GIVEN NOTICE:
SCTM # 1000-81-1-16.8
That it is the intention of the undersigned to request a Permit from the Board of
Trustees to:
CONSTRUCT A 55' X 55' (IREGULAR) SINGLE FAMILY DWELLING, ON-SITE SEWAGE
DISPOSAL SYSTEM WITH RETAINING WALL, AND PERVIOUS DRIVEWAY
2. That the property which is the subject of Environmental Review is located
adjacent to your property and is described as follows:
240 BRIAR LANE, SOUTHOLD
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 April 25, 2001. 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.
APPLICANT'S NAME:
MAILING ADDRESS:
John Dempsey
Box 5
Cutchogue, NY 11935
OWNER'S AGENT:
Cathedne Mesiano, lnc.
12 MillPond Lane
Ea~ Modches, NY 11940
631-878-8951
Enc.: Copy of sketch or plan showing proposal for your convenience.
~rd of T~ustee$ Applicati,
County of Suffolk
State of New York
~)~.Pos~s A~ A~mMS THAT ~SI~ ~S ~ A~PUC,~T FOR ~ ~O~
~L BE DO~ ~ T~ ~ SET FORTH ~ ~S ~PLICATION ~ ~ MAY
BE ~PRO~D BY ~ SO--OLD TO~ BO~ OF ~US~S. T~ ~PLIC~
AG~ES TO HOLD ~ TO~ OF SOU~OLD ~ T~ TO~ ~US~S
~ESS ~ FB~. FROM ~ ~ AT.I. D~AGES ~ CL~S ~S~G
~ER OR BY ~ OF S~ PE~(S), ~ G~. ~ CO~LET~O T~S
~PLICATION, I ~BY A~O~E T~ ~US~ES, T~ AGE~(S) OR
~P~SENTA~S(S), TO ~ O~O ~ PROPERTY TO ~SPE~ T~
P~SES ~ CON~C~ON ~ ~W OF ~S ~PLICA~ON.
SWO~ TO B~O~ ~ ~S ~ DAY OF ~ ~V ~, ,20~
CAROL A. MILLER
Notary Public, State of New Yo~k
No 0 ~ IV116003086
Oua,;!,ed i¢ S,,:'olk County,,~
Commismon Expires February 23, c~
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In The Matter of the Application
of
JOHN DEMPSEY
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
I, Catherine Me$ianq, residing at 12 Mill Pond Lane, East Moriches, NY being duly
sworn, depose and say:
That on the 13 day of April, 2001, I personally posted the property known as
240 BRIAR LANE, SOUTHOLD SCTM # 1000-81-1-16.8
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. Date of hearing noted thereon to be held April 25, 2001.
Dated: 4/25/01
Gather, ne Meslano
Sworn to before me this ~ day of ~
,2001.
Notary Public
SANDRA M. COOPER
NOTARY PUBLIC, State of New
No. 4801478
Qualified in Suffolk County
Comm~ssmn Expires January 31,
ia~n~nmb on the p&r~ 9f born officers end emp~oveew. The
~urpoma of bhLs form ~e bo,provide Lnfp~mi~9~ uhich cnn
other . ~ .--
Jn~eriIt" BuIn, a builness, including a pn~2uKaltip, In
the &own o~lce~ oc emptoye~ ov~. mo~e ~han 5~ or bhe
~f you answered 'TSS~' ~oap~e~e ~he ba~anoe o~ ~h~e'~ore end
da~e and sign uhe~e lnd~oa~ed,
Name of pIriOn imployed by &ho Town of Boubho~d
a~d thi to~n oeficeF or employii. El~he~ c~eok
appcopcia~o ~oe A) ehFough O) end/or deicribe In 2~e space
provided,
p~rent, o= child i~ (check a~ 2ha2
l~ a =ocpo~a~lon)~
app~i=an~; or
J
J