The URL can be used to link to this page

Home My WebLink AboutTR-6048A l,e 't J. ~Tam,-~ t&ng, Vic~'-President Artie Poster Ken Poliwoda Pegg5 A. Diekerson q..v, n Hall 530.',5 Route 25 P.O. Box 1179 Sour hold, Ne,.,.' York 11971-095 Telephone ~3 l) 765-1892 Fax (631) 765:136 ] 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 '~ constructed L//Project complete, compliance inspection. Board Of $outhold Tom Trustees SOUTHOLD, NEW YORK PERMIT NO.. G.~).~...~ .... ISSUED TO ............. g..i~..fl...,~..~ J~£,:zi,.~ ............................................................................. Aut'lt.rizati. - PursuAnt to the provisions of ChApter 615 of the Laws of the State of New York. 1893~ and Chapter 404 of the · State of New Yor~ 19S2: ~nd the Southold To~n O~men~ I~ ':"~U~TING AND--~E. P~ClNG~F OBSTRU~ IN AND ON TOWN WATERS AND PUBLIC ~NDS REMOVAL OF SAND, GRAVEL.OR OTHER MATERIALS.~M ~NDS ·UNDER TOWN WA~RS:~. and in ac~an~ w~h'~e Real. ion of The Board adopted at a meeting hold on ..~.¢.¢.r..,~'~ ...... . ~..., end in consideration of the sum of $..~.5.Q.~.~.0. ........ ~ld by Riced B~ of C~cho~u~ .......... ~::.~.......;....,.~ .................. N. Y. and ~ubject to the T.~'"'"~"~'"'~a~.~ I,,~a o. th~ ~... ,~a~ .~, of ~hold To~ T~.~s authorizes and perml~ the foEo~ng:. ~ ~ ~o gt~ ~ ~0' ~ 40' gn-~o~,~ ~fl 2' above g~de,4' wid~ deck ~ poo~ p~ and depi~ed on the p~n s~veyed by S~ey J~ Is~en, ~r. and approved Janu~y 4, 2005 by the Bo~d .o~ T~te~ ~ ~ ' eE in e~de~ ~th the det~i~d s~cd~s es ~.nt~ m · ~e ~gi~flng ap~fi~, ed p~n. I~ W~S WHERe, ~e sald ~a~ Of T~ by ~u~s ~ ~af~ ~al ~o be a~xed, and ~e~se~ fo ~ s~d by h'~l~ ef ~ ~ld ~ .as of ~is dale. Richard Blai~ t~att' of the coasideradon trot the ls~ance of the l~,~h do~ unclm~?a and pt~scrfbe to d~e ~ol- t. Tlutt the sskl ~ e~ Tn~te~s and the Town of 8outhold ate tel_~_~_ from any and all n.,-,~es, o~ ,4u~ for dsma~s, of su~s etisia& ditecdy o~ indlte~y ~s · result of any o1~' udd~ respect thet-eto~ eo-~eaplete'e~lus~on of d~e l~d of T~ of ~e Town e~ 80udmM · ~. That thb Petmlt should be te~l~d l~de~inkely, ot as long go',-,~,~- the sm_~_.,,~ ot l~ect Involved, to ixovkle evMence to ~lzstlon was od~nslly ~-~uc~tlon of tb~s I)~( by teso~dea of dae raid Bou'd. ~. Tl~t there will ~ no untett~mdde intetf ~ere~e ~:..'. mvlgsden ss a result o~ dsc wo~ lenin au~aodzed. Albert J. Krupski, President dames 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 December 20, 2004 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD ALPHA CONSULTING P.O. Box 447 Greenport, NY 11944 RE: RICHARD BLAIR 900 MASON DRIVE, CUTCHOGUE SCTM# 104-07-004 Dear Mr. Angell: The Board of Town Trustees took the following action during its regular meeting held on Monday December 20, 2004, regarding the above matter: WHEREAS, Alpha Consulting on behalf of RICHARD BLAIR applied to the Southold Town 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 November 23, 2004, 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 December 20, 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, RESOLVED, that the Board of Trustees approve the application of RICHARD BLAIR to install a 20' x 40' in-ground swimming pool with 2' above grade 4' wide deck at pool perimeter and all as depicted on the plan surveyed by Stanley J. Isaksen, Jr. and approved January 4, 2005 by the Board of Trustees as per attached plan. 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 $50.00 per inspection. (See attached schedule.) This is not a determination from any other agency. Fees: $50.00 Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/hct RESOLUTION )_a. RESOLVED that the Board of Trustees of the Town of Southold hereby finds that the application of RICHARD BLAIR more fully described in the public hearing item #1~ of the Trustee agenda dated Monday December 20, 2004, is classified as a Type II Action pursuant to SEQRA Rules and Regulations, and is not subject to review under SEQRA. Albert J. Krupski, President James t'[inF, Vice President Artle Fo,~t er Ken Poliwoda P~g~U,' A. Di~kers~m To~*m Hail 53095 Ri)ute 2,~ P,O. Box 1179 Southo|d, New York 1.1971-095 Telep ~ane (63D 765-1892 F~x (6311 '/65-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: Please be advised that your application dated reviewed by this Board at the regular meeting of following action was taken: has been /~/~o / oW and the (__.__~) 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: TOTAL FEES DUE: $ .~0, OO SIGNED: PRESIDENT, BOARD OFTRUSTEES Telephoae (631) 765-1892 Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Tues., December 7, 2004, the following recommendation was made: Moved by Don Wilder, seconded by Doris McGreevy, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH A CONDITION of the Wetland Permit application of RICHARD M. BLAIR to install a 20'× 40' in-ground swimming pool with on-grade 4' wide deck at pool perimeter. Located: 900 Mason Dr., Cutchogue. SCTM#104-7-4 The CAC recommends Approval with the Condition drywells are installed to contain the pool backwash. Vote of Council: Ayes: All Motion Carried BLAIR PROJECT 900 MASON DRIVE CUTC~OGUE,NY 11935 CONSULTING,A~ent r. A .C.T . ~ ' .,, ~..U TC H L1 , "" ,, ' ., .,,:-".~,"~ ~.~'~: n: ...... % !: ,,, ,, .... ,~,. ,~, ~. . ,, ., ,.~., , , ,., .... , i" ..... .ri ., . ....... ,'" .,. ','~ '~3, . :'~'"', ,,~ '- ...... . .. '""" '~ .,'. ..... I; 't ~" J .. /:?) ' ~'" ....... ~' I' . . ~.~.\ ~,*,,,o ' ~ I I':; ....~1:) (',,' '.,,,. ¢ .. '.r,.' , %" .... il'Ik ,';¢~, '*, ' % ..... '"' I '~1"': "'~ ..i... ," ... i) .','"~', " ' "" ;" ....U"]"I ',' ' . .... "., ,,. .... .-.. ~:;'.~.%,., . ,... ~,~";.... ALPHA CONSU, ' . ..// D~IVE cH^~.. LINK , ) SouthoW Town Board of Trustees BLAIR PROJECT 900 Piason Drive Cutchogue, NY 11935 RICHARD BLAIR, Owner Alpha Consulting, Agent APPROVED BOARD OF TRUST[.: ':~ TOWN OF SOUTHOLD ?lAS 0 N / BLAIR PROJECT 900 Mason Drive Cutchogue, NY 11935 RICHARD BLAIR, Owner Alpha Consulting, Agent 5.8' BLAIR PROJECT 900 Mason Drive Cutchogue, NY 11935 RICHARD BLAIR, Owner Alpha Consulting, Agent ?iASON 9~ °~ [ s2 --38. ~'-- / \ /LO00 ZONE AE EL 8 WETLANDS D ELINEA'FfD ON MARCH 26, 2002 BLAIR PROJECT 900 Mason Drive Cutchogue, NY 11935 RICHARD BLAIR, Owner Alpha Consulting, Agent _ ~ .~. 72 z'*. I F[NCE ~ / / ~.~' .' BLAIR PROJECT 900 Mason Drive Cutchogue, NY 11935 RICHARD BLAIR, Owner Alpha Consulting, Agent · Albert J. Krupski, President James King, Vice-President Henry Smith Artie Fester Ken Po/iwoda 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 TOVVNOFSOUTHOLD Office Use Only C/oastal Erosion Permit Application -"Wetland Permit Application / Major Waiver/Amendment/Cha(~lges /Keceived Application: ~ ~ (&-3I --/Received Fee:$ o~X3D: f Completed Application ti [~$1~ Minor Incomplete SEQRA Classification: Type I Type II Unlisted__ Coordination:(date sent) 'C-AC Referral Sent: II ~.Date of Inspection: 10--[ Receipt of CAC Report: Lead Agency Determination:__ Technical Review: ~blic Hearing Held: [&~ck~ Resolution: S0uth0ld Town Boar,~ of Trustees Name of Applicant RICHARD M. BLAIR Address 900 Mason Drive, Cutchogue, NY 11935 Phone Number~ 3) 734- 7071 Suffolk County Tax Map Number: 1000 - 104-07-004 Property Location: 900 Mason Drive, Cutchogue, NY East of intersection with Haywaters Drive (provide LILCO Pole #, distance to cross streets, and location) AGENT: ALPHA CONSULTING (If applicable) Address' PO Box 447, Greenport, NY 11944 Phone: of Trustees Applica';lon GENERAL DATA Land Area (in square feet): 22,551 Area Zoning: Residential Previous use of property: Intended use of property: Residential Residential Prior permits/approvals for site improvements: Agency Date 1 No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? xx No Yes If yes, provide explanation: PrQectDescription(useattachmentsifnecessary): Install 20'x40' in-ground swimming pool with on-grade 4' wide deck at pool perimeter. of Trustees Applicatx~n WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Provide private recreational swimming at rear of residence. Area of wetlands on lot: 900 .square feet Percent coverage of lot: /4 % Closest distance between nearest existing structure and upland edge of wetlands: 155 feet Closest distance between nearest proposed structure and upland edge of wetlands: 75 feet Does the project involve excavation or filling? xx 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): No effect of any kind is anticipated on wetlands or Town waters from the proposed activity Board of Trustees Applica;lon COASTAL EROSION APPLICATION DATA Purposes of proposed activity: Private residential swimming Are wetlands present within 100 feet of the proposed activity? No XX Yes Does the project involve excavation or filling? XX No Yes If Yes, how much material will be excavated? (cubic yards) How much material will be filled? (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) No environmental impacts are anticipated from this project as proposed. PROJECT ID NUMBER PART1-PROJECTINFORMA~ON 617.20 APPENDIX C STATE ENVIRONMENTAL QUAUTY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. PROJECT NAME Bla±r Pro,ject Count/ Suffolk SEQR 1. APPLICANT / SPONSOR Richard M. Blair 3 PROJECT LOCATION: Municipality C u t c h o gue 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map 900 Mason Drive, Cutchogue NY - Intersects w/ Haywaters Drive IS PROPOSED AC%ION: [] New [] Expansion [] Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: Install 20'x40' in-ground swimming pool with 4' deck. wide perimeter 7. AMOUNT OF LAND AFFECTED: Initially -0-- acres Ultimately ' --0-- acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? ~ Yes [] NO If no, describe bdefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal. State or Local) ~'es []No If yes, list age.cy name and permit / approval: ~T¥SDEC 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? [~Yes ~]No If yes. list agency name and permit I approvat: 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE IApplicant / Sponsor Name ALPI{~A~CONSULTING~Agent Date: 11-5-04 -- / if the action i~ a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT (To be completed by' Lead Agency') A. DOES ACTION EXCEED ANY I~PE I THRESHOLD IN 6 NYCRR, PARq' 617.47 If yes, coordinate the review process and use the FULL FAF. B. W~LLA~T~~NRECEIVEc~~RD~NATEDREViEWASPR~~~DEDF~RUNL~STEDA~T~~NS~N6NYCRR~PART617~6? ttNo, anegative declamtico may be superseded by another invnived agency. r-"~ Yes []No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIA?ED WITH THE FOLLOWING: (Answers may be handwritten, il~legibla) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, exis~ng traffic pattern, sciid waste production or disposal, potential for emsico, drainage or flooding problems? Explain bdefly:. C2. Aesthetic, agricultural, amhaeciogical, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetatico or fauna, fish, shel~sh or wildlife species, signl~cant habitats, er threatened or endangered species? Explain brietly: C4, A communlly's existing plans or goals as officially adopted, or a change in use or Intsnstiy of use of land or other natural resources? Explain b~efly: C5. Growth, subseqsent development, or related activities likely to be induced by the proposed aclion? Explain briefly: C6. Long term, short term. cumulative, or other effects not identified in Cl-C57 Explain bdefly: C7. (~ther impacts (lncludin~ chanties Jn use of either ~uantit~ or t~e of energy? Explain briefly,: / D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL icFA/? ttyse, axplath briars= ..................... E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If}'es explain: r-iI--1Nol ...................................................... PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significanL Each effect should be assessed in connecfion with ils (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic s~ope; and (1~ magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient de[ail to show that all relevant adverse impacls have been identified and adequately addressed. Il=question d of part ii was checked yes, the determination of significance must evaluate the potentialimpact of the proposed action on the environmental characteristics of the CEA. Check this box if you have ldeniJged one or mom potentially large or significant adverse impacts which MAY' occur. Then proceed directly to the FULl FAF and/or prepare a positive decJamton. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed ac[io~ WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessa~, the reasons supporiing thi~ determination. Name of Lead Agency Date TiUe of Responsible Officer Pdnt or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Signature ut Preparer (If di~erent from responsible officer) ,il ALPHA III PO Box 447 · Greenport, NY 11944 (631) 477-0~ ~.~ Fax (631) 477-3933 LETTER OF AUTHORIZATION ALPHA CONSULTING IS HEREBY AUTHORIZED to represent (me) (us) in the securing of all required permits for waterfront improvements at:.900 Mason Drive~ Cutcho~ue, New York. *** In-ground swimming pool & future structural improvements *** Richard M. Blair NOTARY MONICA I. McFARLANE ~0~, ,°..~,.A¥.~~~ Notary Pu blJc, S fate of New ¥or1¢ No. 01MC6058416 Qualified in Queens County Commission Expires Ma), 7, Albert J. Kmzpski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Tmvn Hall 53095 Route 25 P.O. Box 1179 Southold~ New York 11971-0959 Telephone (6'3D 765-1892 Faa t63]_) 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 being duly sworn, depose and sa3.': That on the 7 ~day of~t.(--~004(, I personally 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. Date of hearing noted thereon to be held ~7)~Or~., t~ ¢, e2o, r~C~V -~ _ Dated: Sworn to before me this Iqotary Public ~SKI ' Neta~y Public, State Of New Yod~ No. 0~D06095328, Te~m ExpJr~ Jldy 7, 20 (signature) APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM II~e Towll of Southold'$.Code of Ethics nrohibits conflicts ofinterost on the trart of tuwn officers and emniovees. The t~ur~se of this form is tn m'ovide information which can alert the town of possible conflicts of interest and allow it to take whatever ac~ron is necessary to avoid same, YOUR NAME: RICHARD BLAIR (Last name, firat name, rgiddle initial, ualess you are applying in the name of soreeone else or other entity, aneh as a company. If~, indicate the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Tmstce Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (1 f "Other", name the activity.) SWIMHING POOL Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? "Relationship" includes by blood, marriage, or btmlness interesl. "Business interest" means a business, including a pamership, in which the town officer or employee has even a partial ownesship of(or employment by) a co~porafion in which the town officer or employee owns more than 5% of the shares. YES NO XX If you answered"YES", complete the balance of this form and date and sign where indicated. Name &person employed by the Toxin of Southold Title or position of that person Describe the relationship between yourself (the applican~dagent/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) th~ owner of greater than 5% of the shares of the corporate stock of the applicant (when the apptieant 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 eroployee of the applicant; or ___D} the actual applicant. DESCRIPTION OF RELATION SHIP Form TS 1 Submitted this ~y of , 200 Signature ~' PrintNam[ RICHARD BLAIR of Trustees Applicatio0 A~T~ORI ZATTON (where the applicant is not the owner) I, RICHARD BLAIR (print owner of property) residing at 900 MASON DRIVE (mailing address) CUTCHOGUE, NY 11935 ALPHA CONSULTING do hereby authorize (Agent) to apply for permit(s) from the Southold Board of Town Trustees on my behalf. (Owner's signature) 8 Board of Trustees Application County of Suffolk State of lqew York RICHARD BLAIR BE[NGDULY SWORN DEPOSES AND AFFIRMs T~IAT HFJSHE IS ~ APPLICANT FOR THE ABOVE DESCRIBED PEIlaMIT(S) AND THAT AI.I. STATF. aMA'NTS CONTAINED HERKIN 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 HARMI.RSS AND FRF. K FROM ANY AND All. DAMAGES AND CLAIMS ARISING UNDER. OK BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING TH/S APPLICATION, I HEREBY AUTHOR I?TF THE TRUSTEES, THEIR AGENT(S) OR RF3RESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signature SWORNTOBEFO mrmS 0Y o^roF ga/¥. ,2oa4. MONICA I. McFAR __ '%./_ _. "- -"- NO 01MO60~.qa.~ Notary Public uahfied in Queens Coon Commission Expires May 7, ~YO0? APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics ta'ohibits conflicts ofinrerest on the vart of town officers and emolovee~. The Imrpose of thi.5 form is tO provide information which can alert the town of nossible conflicts of interest and allow it to take whatever action is necessary to avoid sam.e.. YOUR NAME: Theodore Angell, Alpha Consulting (Last name, £nst name, ~alddle initial, unless you are applying in the name of someone else or other entity, such as a company. I f so, iodir, ate the other person's or company's name.) NAME OF APPLICATION: (Cheek all that apply.) Tax grievance Building XX Variance Trustee XX Change of Zone Co~tal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (if "Other', name the activity.). Do you personally (or through ]~our company, spouse, sibling, parent, or child) have a relationship with any officer or employee of the Town of Southold? ~Relationship" includes by blood, marriage, or btminess interest "Businass interest' means a business, inclffding a partnership, in which the town officer or employe~ bas even a papal ownership of (or employment by) a corporation in which the town officer or employee owns more than 5% of the shares. YES NO XX 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 person Describe the relationship between yourself(the applicantIageat/represe ntative) and the town officer or employee. Either check the appropriate linc 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): __fi,) the owner of greater than 5% of the shares of the corporate stock of the applic0n~ (when fig applicant is a corporation); __.B) the legal or beneficial owner of any interest in a non-eorpora~ entity (when the applicant is not a corporation); __.C) an officer, director, patmer, or employee of the applicant; or __D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I