HomeMy WebLinkAboutTR-5386
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Country Club Estates
Property Owners Association Inc.
June 5, 2001
Mr. George Wieser
P.O. Box 1143
Cutchogue, NY 11935
I'm writing you on behalf of the Property Owners' Association concerning two matters which
have come to my attention. Since both involve the Covenants and Restrictions on Country Club
Estates, originally filed with the County Clerk on October 17, 1978 and since modified, 1 think
it's a good idea to make this a matter of record.
The first item involves the western boundary of your property (Lot 22), which borders the Park
and Recreation Area on the official map. Several people have pointed out to me that your back
yard improvements and landscaping extend well into the Park and Recreation Area, which is
owned by the Association. Given that the Association insures, pays taxes on and maintains this
area and assumes liability as owner, it would seem appropriate that the correct boundary line
between the two properties be established.
A second cause for concern is the fact that the New York State Department of Environmental
Conservation has visited the marsh and wetlands area behind Lot 22 and has contacted you about
their responsibilities to the wetlands. The Association has received no notice of this inquiry,
which mayor may not involve Association property. Here again, the proper lot line should be
indicated somehow.
In past years this community has always sought, and usually found, amicable solutions to
problems which arose. I'll need your help in resolving the boundary question, and in protecting
the Association from inadvertent vulnerability with respect to the DEC. Please give me a call at
your convenience at 734-2065.
Sincerely,
-_.~~
Norm McCuJlough, President
Pool Office Box 1092· CUlchogue. New York. 11935
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Telephone
(631) 765-1892
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 Tuesday,
June 12, 2001, the following recommendation was made:
Moved by Bret Hedges, seconde<; by Scott Hilary it was
RESOLVED to recommend to the Southold Town Board of Trustees DISAPPROVAL of
the Wetland Permit Application of GERALYN WIESER 109-3-2.13 to clear within 100' of
wetland. Re-vegetate cleared area, cut phragmites to 12", cut out briars, and mulch
cleared area.
1030 Country Club Dr., Cutchogue
The CAC recommends Disapproval and recommend that they allow the area to grow
back naturally.
Vote of Council: Ayes: All
Motion Carried
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NOTICE
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Police Dept. - Bay Constable
Town of Southold
Peconic, New York 11958
NOTICE OF VIOLATION
Date:
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To:
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(Owner or authorized agent of owner)
Address:
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'1Address of Owner or authorized agent of owner)
Please take notice there exists a violation of the Code of the Town of Southold, Chapter 97
Article II, Section 97-20 a prernises hereinafter described in that c:' é."¡ , '.,' =
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on or before the
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The premises to which this Notice of Violation refers are situated at:
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Town of Southold, Suffolk County, NY (Suffolk County Tax Map Designation: Dist. 1000
Section:
~
Block:
Lot: ~. / .:;' )
Failure to comply with the applicable provisions of the law may constitute an offense punishable by fine
or imprisonment or both. NOTICE: You have the right to apply for a hearing before the Board of Trustees
of the Town of Southold, provided that you file a written request with the Clerk of the Trustees within 10
days after service of the Notice of Violation. Such request shall have annexed thereto a copy of the Notice
of Violation upon which a Hearing is requested and shall set forth the reasons why such notice of viola-
tion should be rnodified or rescinded.
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Bay Constable,a"áwn of Sòuthold, NY
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Albert J. Krupski, President
James King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
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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
August 2,2001
Catherine Mesiano, Inc,
12 Mill Pond Lane'
East Moriches, NY 11940
RE: Geralyn Wieser
1030 Country Club Drive
Cutchogue, NY
SCTM#109-3-2.l3
Dear Ms. Mesiano:
The following action was taken by the Board of Town Trustees during a Regular Meeting, held
on July 25,2001, regarding the above matter.
WHEREAS, Catherine Mesiano, Inc. on behalf of GERAL YN WIESER applied to the
Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town
of South old, application dated May 31,2001
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
July 25,2001 at which time all interested persons were given an opportunity to be heard, and,
WHEREAS, the Board mernbers 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 standard set forth in Chapter 97-18 ofthe Southold
Town Code.
WHEREAS, the Board has determined that the project as proposed will not affect the health,
Safety and general welfare ofthe people of the town,
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2
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NOW THEREFORE BE IT.
RESOLVED, that the Board of Trustees approved the application of GERALYN WIESER for a
Wetland Permit to clear within 100 feet of house and the 100 feet will be allowed to revegatate
naturally no planting and no cutting or trimming phragmites just to revegatate naturally and left
alone.
BE IT JlURTHER 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 sirnilar project.
Permit to construct project will expire two years rrom the date it is signed. Fees rnust be paid, if
applicable, and permit issued within six months of the date of this notification,
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 when project is started and on
completion of said project.
FEES: NONE
Very truly yours,
~} /4-~0--
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/cjc
cc: DEC
Building Dept.
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A-1606
Town 01 Southold
Suffolk County, NY
TIle People of the Slale of New York vs.
LAST NAME (DEFENDANT) RRST NAME
W/ð'5:é'/<' GêÆAI.V-u
STREET ADDRESS
c,~o Co.,,vý,. C/uB '2~
CJv--nu, ð 6-f.I ç ~~
weENSE OR REGISTRATION NUMBER
MIOOLEINIT1AL
z;-
APT. NO.
"'
1/9&-
STATE
DATE EXPIRES
TYPE OF weENSE
OPERATOR
OWNS VEHICLE
DyES DNa
PLATE NO.
STATE
o N.Y. 0 N.J. 0 N.Y. 0 N.J. 0
PLATE TYPE
o PASS o COMM 0
0 CADILLAC
0 "'-YM
0
0 BUS 0 MCY
0 ,^N 0
o s.w.
VEHICLE MAKE
0 BUICK 0 CH'"
0 FOOD 0 O\.C$
0 TOVOTA 0 '000
BODY 0 "'" 0 <D'
Tye, 0 TRUCK 0 TRAILER
VINNUMBER
o DOOGE
o PONTIAC
PCT
SUFFO!..KCOUNTY.W
o
OTHER OFFENSE
t.t. ~-
tv,
o
FACTUAL PART (NOT FOR TVS)
THE ABove NAMED DEFENDANT DID ON THE STATED OATE. TIME AND PlACE ), J 1..1 ¡;-
~ fhf-/!"19- IN/'#, /IV :JL)IJ I IJ~.IJ wtrr¿..",';¡
~~e;:.;-Irþ:'~~"R~;;;.J~ ~~:~ ~
ThoI Fon¡gcing" o.s.d on (pe¡sonaI knowleòg.) and/Or (infomllllion &.beI~~. the IO~ I)9ing t"- om.çhe< sworn de¡;>œition(s) of
..""
PARKING SCHEDULED FINE S
CONTACT COUFlT 0
THE PERSON DESCRIBED ABOVE IS SUMMONED TO APPEAR AT
SOUTHOLO TOWN JUSTICE COURT. 530M ROUTE 25. SOUTHOLO, NY 11071
I AT
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OI.TEOF~(HOTFOlIl'\IBI
ON
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FM.SE STA~SNTS !-EtIElN ARE PUNISI-\ I&EAS A.Cl.ASS A MISDEMEANOR PURSUA.NT TO SECTION210.4S OF '!};E P_LN. V_S,
~.</",
COURT COpy
I'ATE '/ ¡,~ J"
BAOGE *
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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
~astal Erosion Permit Application
_Wetland Permit Application _ Major
_ W aiver/ Amendment/Changes
/Received Application: 5131/01
.,A{eceived Fee:$ SO'
....completed Application :51 al 1:)(
_Incomplete
_SEQRA Classification:
Type I_Type II_Unlisted_
_ Coordination:( date sent)
~AC Referral Sent:-.S]2, /t>1
;;7Date of Inspection:!alßU:j
_Receipt of CAC Report:
_Lead Agency Determination:
Technical Review:
/'Public Hearing Held:~ 0 \
Resolution:
,- Minor ":
0/13101 f·¡.
a\ \ \)J.J SO frol'í'l
~qi2. ~tönd
(¡Yow ~ad.. .
Office Use Only
MAli ,
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Address /O..J.ò
&;é3/2.I1LVAl Wle5~1L
~UrJ Inl C/cdJ ¡)L
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Namt~ of Applicant
ðJJt- 11935
Phone Number:(þ-M '
Suffolk County Tax Map Number: 1000 - I 0'1 - :3 - ,;L ,13
Property Location: /03 () (l ~ i'L --t ¡f}u~ ...e;
(_ld'L¿; Pol, d. d~,.:ri~x: .;;d I~do")
AGENT: 11TH é;2. fA} é If) 135/ If ,)J J ,/nc-
(If applicable) .
Address: / d.
in / / Poru)
Lp E. ({)OI2IC r/6
Phone: J 73- F if 51
, JJY / /91/6 cI
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4Itoard of Trustees ApPlicat~
GENERAL DATA
Land Area (in square feet): L¡ Lf 0 tf ~ ¢¡
Area Zoning: II - lfò
Previous use of property:
Intended use of property:
:5F IL
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): ¡; h..ð~! ~.
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/~ ¥/If/O), I(¿l./~É ¿- /h/7/1'~ ,~
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:¥~ f'Á'A~ h 1.2 ,~M4'7j¡;_;;';¡'7.4d
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Board 0'[ 'J:,I; U,II '"'~.... . -..,-
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WETLAND/'l'RUSTBB UoNDS APPLICATION DA'rA
the proposed operations I ¡¿ f' v' ffjl'''T:.f;' (' / eti..-v ." ¿
loU/I;; 100' o:f f.ve.f/ú-J<...d -h ¡¿e<; rj'D/I.e..
.)
l'Urpose of
Area of wetlands on lotI -; 300 ò
percent coverage of lot I ¿ .07
square feet
j
\
Closest distance between nearest existing structure and upland
edge of wetlands: 100 feet
Closest distance betweep nearest proposed structure and upland
edge of wetlands I ýÎ LA..-- feet
Does the
):
--
project involve excavation or filling?
No
Yes
If yes, how much material will be excavated?
How much material will be filled?
c1.Ù'i.c yards
c1.Ù'1c yards
Depth of which 'material' will be removed or deposited I
faet
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
~Iaters of the town that may result by reason of such proposed
operations (use attachments if appropriate):
~~. f/ '~~d/tw<4 t.udt Ó'~ ,{1þ
p~ ~/U/7L [ ;.-L fIA--'n~ /(L/Æ~,
3
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14-t6·4 (Zf87)- Text 12
I PROeECT LD. NUMBER
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617.21
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I-PROJECT INFORMATION (To be completed by Applicanl or Project sponsor)
,. 2. PROJEC7 ~E
€~ 1030 LOU~+~
SEa
3.
MuniclpaJity 0
4. PRECISE LOCATION (Street addr
Co Un I-r y
/Ø 30
County S U
s and road intersections. prominent landmark.s. ele., or proviae map)
(i ú-.:fc fu¡ d ~
(!/0b
DR...
5. IS PFWPOSEO ACTION:
[J New 0 Expansion
6. DESCRIBE PROJECT BRIEFLY:
ΠModification/alteration
(,~V¿ôJ~
(' Ý.- ~Q..y ~
t<-r ~
6Vl-~ !OtJ' o¡
ú.Jd~
7. AMOUNT OF LAND AF¡::eCTED:
Initíêllly ~ I acres Ultimately : / acres
a. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
Q-Yes 0 No If No. describe briefly
I
j 9. VJ~r IS PRESENT LAND USê IN VIC!NITY ~F PROJECT?
I l.)fF!es¡dentiaf O.!naustrial [J Commercial
Oescnbe:
o AgricuJture
U Park/Forest/Ooen space
LJ Other
10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL.
STATE Ort LOCAL)?
DYes c:fNo If yes. list agency(s) and permit/aøprovals
11. DO:S.S ANY ASPECT OF THE Acrler., HAVE A CURRENTLY VALID PERMIT OA APPROVAL?
o YI!S' ~ No If yes, list aQency name and permiUapproval
'%
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
DYes rs;¡...ò
I CERTIFY THAT THE !NFORMATlON PROVIDED ABOVE IS TRUE 70 THE 3EST OF MY KNOWLEDGE
APPlican"spo~name;!!:w~~
Signature: ~ ~A ____
/
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Dale:
5/1...3/'/
o¡v..fr- W~
If the action is in the Constal Area, and 'fou are a state agency, complete the
Coastal Assessment Form belore proceeding with this a~essment
OVER
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CATHERINE MESIANO, INC.
12 MILL POND LANE
EAST MORICHES, NEW YORK 11940
631-878-8951
May 26, 2001
Town of South old
Board of Trustees
Box 1179
Southold, NY 11971
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Re: Geralyn Wieser
1030 Country Club Dr., Cutchogue
SCTM # 1000-109-3-2.13
Gentlemen:
I am the agent for the above referenced applicant. Mrs. Wieser is seeking a
Wetlands Permit for a revegetation of an area within 100' of a Freshwater
Wetland, as depicted on the enclosed plans.
Enclosed please find the following:
1. Application for Permit.
2. EAF Short Form - Part 1.
3. 2 copies of plans.
4. Owner's authorization.
5. Transactional disclosure.
6. Affidavit.
7. Notice to Adjacent Property Owner.
8. Application fee ($50.00)
Kindly direct any requests for additional information to my attention. Thank you
for your consideration.
Very truly yours,
~-~
Catherine A. Mesiano
Enclosures
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NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
NAME:
Geralyn Wieser
SCTM # 1000-109-3-2.13
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a Permit from the Board of
Trustees to:
RE-VEGETATE CLEARED AREA WITHIN 100' OF WETLANDS.
2. That the property which is the subject of Environmental Review is located
adjacent to your property and is described as follows:
1030 COUNTRY CLUB DRIVE, CUTCHOGUE
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 June 21, 2001. You may contact the Trustees
Offic:e 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.
OWNER'S NAME:
MAILING ADDRESS:
Geralyn Wieser
1030 Country Club Drive
Cutchogue. NY 11935
OWNER'S AGENT:
Catherine Mesiano, Inc.
12 Mill Pond Lane
East Moriches, NY 11940
631-878-8951
Enc.: Copy of sketch or plan showing proposal for your convenience.
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Richard & Sandra Gannon
P.O. Box 1186
Cutchogue, NY 11935
Rita A. Power
P.O. Box 1273
Cutchogue, NY 11935
Edward & Judith Fornaser
169 Remington Road
Manhasset, NY 11030
James & Ann Connor
P.O. Box 240
Cut(:hogue, NY 11935
Domthy Hobson
P.O. Box 946
Cut<:hogue, NY 11935
Norman & Linda McCullough
P.O. Box 794
Cut<:hog ue, NY 11935
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BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In The Matter of the Application of
GERAL YN WIESER
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
¡;j N I
UNTRY CLUB DRIVE. CUTC OGUE,
/Ì
I, (~6iLA<.
residing at 1030 C
depose and say:
That on the II day of June, 2001, I personally posted the property known as
1030 COUNTR'YcLUB DRIVE, CUTCHOGUE, NY SCTM # 1000-109-3-2.13
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 June 21 ,2001.
,
NY being duly sworn,
/U¿ /1c;>Cú¡
/
Sworn to before me this // ~ay of '1./ t.J ¡1/ I::' ,2001.
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PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
!'lAME:
(
:Richard & Sandra Gannon
ADDRESS:
Rita A. Power
P.O. Box 1186, Cutchogue, NY 11'935
P.O. Box 1273, Cutchogue, NY 11935
Edward & Judith Fornaser
169 Remington Road, Manhasset, NY 11030
James & Ann Connor
P.O. Box 240, Cutchogue, NY '11935
Dorothy Hobson
P.O. Box 946, Cutchogue, NY '11935
Norman & Linda McCullough
P.O. Box 794, Cutchogue, NY '11935
STATE OF NEW YORK
COUNTY OF SUFFOLK
CATHERINE MESIANO, residing at 12 Mill Pond Lane, East Moriches, NY being duly
sworn, deposes and says that on the 14 day of June, 2001, 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 their 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 Unites States Post Office at East Moriches, that said Notices were mailed
to e.ach of said persons by certified mail.
,~}
Catherine Mesiano
SwoZ me th;, ~d'Y Of~. 2001.
~ ~~
PATRICIA GERARD
N01'ARY PUBLIC, STATE 01"' NEW ""CIIK
No. 52.4641853
C~UALIFIED IN IJU"'''OLK COUNTY 2
C.OM\.t'69tON EXPIIltEIJ MARCH 30.~J--{)(J,/
4t'ard of Trustees APPlicate
I, .
AUTHORIZATION
(where the applicant is not
G,e.vC¡,\)JJ\ Wle5@:!
(print o<mer of property)
.'
the owner)
residing at ¡0"30 C/lO"",{v''''
(mailing address) J
c.:I{ b Òý. C'[t !r:..L.C'l' L.
l1..rk,q,,' œ eqIP{~ ¡,he
do hereby authorize
(Agent)
to apply for permit(s) from the
Southold Board
on my behalf.
8
.
.
NOTICE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
NAME:
Geralyn Wieser
SCTM # 1000-109-3-2.13
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a Permit from the Board of
Trustees to:
RE-VEGETATE CLEARED AREA WITHIN 100' OF WETLANDS.
2. That the property which is the subject of Environmental Review is located
adjacent to your property and is described as follows:
1030 COUNTRY CLUB DRIVE, CUTCHOGUE
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 June 20, 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.
OWNER'S NAME:
MAILING ADDRESS:
Geralyn Wieser
1030 Country Club Drive
Cutchogue, NY 11935
OWNER'S AGENT:
Catherine Mesiano, Inc.
12 Mill Pond Lane
East Moriches, NY 11940
631-878-8951
Ene.: Copy of sketch or plan showing proposal for your convenience.
~ard of Trustees ApPlicat~
County of Suffolk
State of New York
G -e..v ¡;¡ ~ Y\ vJ I ~ e-IJ BEING DULY SWORN
DEPOSES AND IRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRIÆ TO THE BEST OF illS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK
WILL BE DONE IN THE MANNER SET FORTH IN TillS 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 TillS
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR
REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH W OF TillS APPLICATION.
V~
SWORN TO BEFORE ME TillS
DAY OF mill
f
20 01
'-
~~~~
GERARD M. LANG
Notary Public, Slate of New Yark
No. 4761673.juffolk CounIY_
'AInn Expires v,ç. :::II . :;Zool
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SURVEY FOR
GREGOR'! P. OOROSNI 6 SHARON OOROSKI
LOrNa 22. . COlJNrRY CW8 EsrArES·
AT Ct.lrCHOGUE· .
iUWN Of' SOlJrHOLD
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TRANSACTIONAL DISCLOSURE FORM
The Town of Southold's Code of ~thics prohibits conflicts of
interest on the part of town officers and employees. The
ur ose of this form is to rovide information which can
alert the town of poss ble conflicts of nterest and allow
it to take whatever action is necessary to avoid same.
.
tOUR MAHE.
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····,;';\j'r)."!r't1f."I:~,~.
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Ie.
Las ame, irst name, m dd~e
you are applying in the name of someone else or
other entity, such as a company. If so, indicate
the other person's or company's name.)
NATURE 0' APPLICATION. (Check all that apply.)
'f
Tax grievance
Variance
Change of zone
^pp1~al of plat .
Exemption from plat or Official map
other
(If ·Other,· name the activity.)
Do you personally (or through yuur CUlllpany. spbune,. nibling,
parent, or child) have a relationship vith any officer ur
employee of the Tovn of Southold? -Relationship- includes
by blood, marriage. or business interest. -Dusiness
interest- means a business, including a partnership. in
vhich the toyn officer or employee has even a partial
ovnership of (or employment by) a corp.oration in vhich
the tovn officer 7r e loyee ovns more than 5% at the
shares.
, ,
YES _ NO
~: .,'.~.' ,.
If you ansvered -TES,- complete the balance of ~his form and
date and sign vhere indicated.
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 ør 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, eibling,
parent, or child is (check all that applY)1
^) the owner of greater than 5% of the shares of the
corporate stock of the &pplicànt (when the applicant
is a corporation),
B) the legal or beneficial owner of any interest in a
noncorporate'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 ItELATI0NSI!lP
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Signatur
'Print
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