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Home My WebLink AboutBertani, Linda James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD December 5, 2006 Mrs. Linda Bertani 1380 Oakwood Dr. Southold, NY 11971 RE: 1380 OAKWOOD DR., SOUTHOLD SCTM#70-12-32 Dear Mrs. Bertani: The Southold Town Board of Trustees reviewed the survey prepared by John T. Metzger last dated July 5, 2006 and determined the proposed construction of a screened porch on the existing deck to be out of the Wetland jurisdiction under Chapter 275 of the Town Wetland Code and Chapter 111 of the Town Code. Therefore, in accordance with the current Tidal Wetlands Code (Chapter 275) and the Coastal Erosion Hazard Area (Chapter 111) no permit is required. Please be advised, however, that no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundary or seaward of the coastal erosion hazard area as indicated above, or within 100' landward from the top of the bluff, without further authorization from the Southold Town Board of Trustees pursuant to Chapter 275 and/or Chapter 111 of the Town Code. It is your responsibility to ensure that all necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdiction and Coastal Erosion Hazard Area, which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional - bounda.-y-aoo the-BGastal-erosion ha~rd area-and your project or erecting a temporary fence, barrier, or hay bale berm. This determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. 2 Sincerely, Jameh:: p:;d17 Board of Trustees JFK:lms 1380 Oakwood Drive Southold, NY 11971 November 29, 2006 SCTM# 1000-70-12-32 Mr. James King, President Board of Town Trustees Town of Southold P.O. Box 1179 SouthoId, NY 11971 Dear Mr. King, Last yea- we requested permission to construct an enclosed saeened porch over an existing deck attached to our home at the above address. The porch size was shown on the survey by John T. Metzger dated November 28, 2005 at 17' x 11' and would not extend over the existing deck with the closest point to our bulkhead shown as 124'. The porch size was incorrect and should have been 17' x 14'. Enclosed is a copy of the amended survey dated July 5, 2006 showing the correct porch measurements and still being 124' to the closest point to our bulkhead. You had sent us a letter dated Deoember 6, 2005 stating that we did not need a permit from you. understand that that is still the case, however, the "no permit required" letter needs to be amended. Thank you. Sincerely, du-<lc-~,I3~ Linda D. Bertani c:~, -.... L,__/1 OAKWOOD DRIVE N 83.05'30. E t.AJJDSCAI'E TE' ~ Q.I,€,. J o. ~l 110,00' fnc/ moo. ...ell./'O ,ods '-0 '0 o It) ..... l\J ;rEf-I. . ..,.~ """1T..~y BB BB APRON 11.(;' . ~".8 . l\J ~ " .. .. ~ .. 1.9' I~ UY fJ 'INlOW q .... .. Z1.4' .. Z STY. ~R. HSE. .. ;;;" , GARAGe ~. UY 58.0 ' IIlCIOW 3Z.4' a <:( 0 0: ~ l.L.J - > >- <:( CD ::I: t- o: l<J 0 : 0 Z ,.., - <I' It) 0 \D <n BAY INlOW ... o! .,. ~ l.> l<J ..... LL ..J :~ 0 ~ 0 ,.., . <1'. LL It) "- 0 0 \D "- Z Z ai' 36.0' + orop 11" 5cr<:.e0e.::L- rn por"t:.-.... ~fI S.T. 0'" e-,;/yl. ~. deck. ,. , 8:)- ry., CJ ~ D<<K ARF -\ - 30,306 sq.tt. to lie line LOT COVEriAGE = 13% AFTER CON,) TF; '. "'-'-;')N ~ IJ""~ r. -.~ Ul.:...l. - "'-11.1 ' \ 0 \ 'Y' 001 o'?) ., .,ei .,'?:>. : ~IO/~ I \~-r. c,~ (;\0 Od' ~ SURVEY FOR JOHN BERT ANI AT SOUTHOLD TOWN OF SOUTHOLD SUFFOLK COUNTY I N ,Yo 1000 - 70 - /2 32 SCALE I" = 40' JUNE 9, /986 OCT. 16, 2003 I/XCI< tOe. J r-..rT /l 0nn~, r ....,1~iti"n"l\ "~ ~~ + Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD December 6, 2005 Mrs. Linda Bertani 1380 Oakwood Dr. Southold, NY 11971 RE: 1380 OAK~NOOD DR., SOUTHOLD SCTM#70-12.32 Dear Mrs. Bertani: The Southold Town Board of Trustees reviewed the survey prepared by John T. Metzger last dated November 28, 2005 and determined the proposed screened porch on the existing deck to be out of the Wetland jurisdiction under Chapter 97 of the Town Wetland Code and Chapter 37 of the Town Code. Therefore, in accordance with the current Tidal Wetlands Code (Chapter 97) and the Coastal Erosion Hazard Area (Chapter 37) no permit is required. Please be advised, however, that no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundary or seaward of the coastal erosion hazard area as indicated above, or within 25' landward from the top of the bluff, without further authorization from the Southold Town Board of Trustees pursuant to Chapter 97 and/or Chapter 37 of the Town Code. It is your responsibility to ensure that all necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdiction and Coastal Erosion Hazard Area, which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and the coastal erosion hazard area and your project or erecting a temporary fence, barrier, or hay bale berm. However, any activity within 100' of a Wetland line or seaward of the Coastal Erosion Hazard Area would require permits from this office. This determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. Sincerely, Albert J. Krupski, Jr., President Board of Trustees AJK:lms OAKWOOD DRIVE N 8~°05'30" E STY. F"R, H~". I10.00' 0 SURVEY FOR JOHN BERTANI AT SOUTHOLD TOWN OF SOUTHOLD SUFFOLK COUNTY , N,Y. IQ00 - 70 - 12 32 SCALE I"= 40' JUNE 9, 198 6 OCT. 16, ,~003 OCT. 4, 2005 (additionol) P__o~ ~ox 1:~30 TRAVELE~ET SOUTHOLD, N.Y, 11971 86 - !63 A Alber~ J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route25 P.O. Box 1179 $outhold, New York 11971-0959 Telephone(631) 765-1892 Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Omce Use Only __Coastal Erosion Permit Application Wetland Permit Application Amendment/Transfer/Extension __Received Application: __Received Fee:$ __Completed Application __Incomplete __SEQRA Classification: Type I Type II Unlisted __Coordination:(date sent) __LWRP Consistency Assessment Form CAC Referral Sent: __Date of Inspection: __Receipt of CAC Report: __lead Agency Determination:__ __Technical Review: __Public Hearing Held: __Resolution: Adminis~ative permtt Name of Applicant Address (provide LILCO Pole #, distance to cross streets, and location) AGENT: (If applicable) Address: Phone: PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIP~ DEC - 5 2005 ~ ,. Address: I~>~00oa~u,.,xzx~-tZ)cive_ ,~.x~'tqqo~d Hq'Il STATE OF NEW YORK COUNTY OF SUFFOLK Mt-/ II'i'll , being duly sworn, deposes and says that on the ,~'~-~ . day of~ 20d.~ 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 them respective names; that the addresses set opposite the names of said persons are thc ~ldreas of said l~rsons as shown on the cummt assessment ro~l of the Town of Southold; that said Notices were mailed at the United States Post O/ffu~ ~OuTl~ J~ , that said Notices were mailed to each of said persons by ~_~ (registered) mail. Sworix_~before me this ~ ~ D~y of~-~., 20- ~-~ Board of Trustees Application County of Suffolk State of New York hn &._ O- BErNGDUrY SWO DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VlRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE ~ TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. Signature SWORN TO BEFORE ME THIS LYNDA M BOHN NOTNIY PUffi. IC, Stats of Hew York NO. 01806020932. Suffolk County Board of Trustees Application Land Area (in square feet): Area Zoning: Previous use of property: Intended use of property: GENERAL DATA 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 go/vernmental agency? No ~/ Yes If yes, provide explanation: Project Description (use attachments if necessary): Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose ofthe proposed operations: ~n,r{--cuo~+ 6.4L ti '~'17 t d'c-/~taex~-I~ d Area of wetlands on lot: square ~et Percent coverage of lot: 0 % Closest distance between nearest existing structure and upland edgeof'~/ia~ts: ! 10._ ~ feet b~t~.-~.,,~ Closest distance between nearest proposed structure and upland edge ofv~tarats: I$.~ ! feet Does the project involve excavation or filling? V/ No Yes If yes, hoxv much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): 6 PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 1. APPLICANT / SPONSOR 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) ~ ~C_~ ~2. PROJECT NAME SEQR 3.PROJECT LOCATION: Municipality ~(~l~l~0 ~.-- I~/~ 4. PRECISE LOCATION: Street Addes$ and Road Intersections, Prominent landmarks etc - or ~rovide ma~ 5 IS PROPOSED ACTION · ~ New ~ Expansion ~ Modification / alte~flon 6. DESCRIBE PROJECT BRIEFLY: c_>lll 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? r~Yes [] No If no, descdbe briefly: 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (ChoOse as many as apply.) ~-~-'~Residential E~lndustdal [~]Commercial ~]Agriculture r~ParklForestlOpenSpace E~Other (descdbe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) [-'~Yes r--~ No If yes, list agency name and permit / approval: /~ (.~ l~. ~.,/ 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? j-'--~Yes ~;INo If yes, list agency name and permit / approval: 12. AS A OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? R~ULT [~Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE iS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name Date: If the action Is 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/I A. DOES ACTION EXCEED ANY TYPE I THRESHOLD iN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF ['~ Yes E~No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 If No, a negative declaratmon may be superseded by another involved agency i--lYes E3No C COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C 1. Existing air quality, surface or groundwater quality or quantity, noise levels, exisling traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: cz Aesthetic. ag~cu~tura~, archaeoio~i~, hist3h[i'or othe~'n~tur~l or cottum~ resources: or community or neigbbor,oed oha~et~ Explain b~efiv: C3 Veg~tabon or fauna fish shellfish or w~ldl~[e species, s~gnificant habdats, or threatened or endangered species7 E×plam briefly C4. ^ ¢ommunity'~ ~×i*ting ~lan$ or goai~ ~$ off~i~ily'adoptedl or a change in u~e or intensiiy o~ use o~ land or other natural re$oumo$? ~xplaln bnofly C5. Grey'h, subsequent devel~>pment, or roland activitie~ Ii}~ely to bo induced by the proposed action. Explain briefly: C6. Long term, short terml cumuiativel ~r othereffect~ not ~dentified in C~-C57 Explain bdefly: C7 Other impacts (includin~ chan~losih I}'so of eiiher c~u~iit~(~r t~pe of energy? Exp!ain bdefl~: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA {CEA~? {If ),es, explain briefl},: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If },es explain: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: F~reachadveraeeffectidenti~edab~ve~determinewhetheritissubstantia~'~arge~imp~rtant~r~therwisesignificant~ Each e~fect should be assessed in connection with its (a) setting (i.e. urban or rural); (bi probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (fi magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULl EAF and/or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed sctiol WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi~ determination. Name of Lead Agency Date Title of Responsible Officer Pdnt or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. Before ansxvering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its significant beneficial and adverse effects upon the coastal area (which includes all of Southold Town). If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail~ listing both supporting and non- supnorfin~ facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions, it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold ' s website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION The Application has been submitted to (check appropriate response): Town Board [] Planning Board [] Building Dept. ~ Board of Trustees Category of Town of Southold agency action (check appropriate response): (a) Action undertaken directly by Town agency (e.g. capital construction, planning activity, agency regulation, land transaction) 00) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nature and extent of action: Location of action: Site acreage: Present land use: Present zoning classification: If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing address: (c) Telephone number: Area Code (d) Application number, if any: Will the action be directly undertaken, require funding, or approval by a state or federal agency? Yes ~ No[-~ Ifyes, which state or federal agency? ]/dC]~ ~.~ C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 10 Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LWRP Section III - Policies; Page 2 for evaluation criteria. Yes ~ No [~ Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LVOIP Section III - Policies Pages 3 through 6 for evaluation criteria ~ Yes [~ No [] Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III - Policies Pages 6 through 7 for evaluation criteria Yes [] No ~ Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III - Policies Pages 8 through 16 for evaluation criteria ~ Yes ~ No ~ Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of Southold. See LWRP Section III - Policies Pages 16 through 21 for evaluation criteria ~ Yes ~ No [] Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III - Policies; Pages 22 through 32 for evaluation criteria. Yes No Not Applicable Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III - Policies Pages 32 through 34 for evaluation criteria. V~ Yes ~ No [] Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III - Policies; Pages 34 through 38 for evaluation criteria. [] Yes ~ No [] Not Applicable ..Ce_e_ o..--~o.e_k~& a h.re_.Y' PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section IH - Policies; Pages 38 through 46 for evaluation criteria. ~ Yes~ No ~ Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III - Policies; Pages 47 through 56 for evaluation criteria. [] Yes ~ No ~ Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of living marine resources in Long Island Sound, the Peeonie Estuary and Town waters. See LWRP Section III - Policies; Pages 57 through 62 for evaluation criteria. ~fi~ Yes ~ No [~ Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III - Policies; Pages 62 through 65 for evaluation criteria. [] Yes ~ No ~ Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III - Policies; Pages 65 through 68 for evaluation criteria. [] Yes ~ No ~ Not Applicable TITLE OGO/x~-*- DATE ATTACHMENT TO LWRP APPLICATION FOR BERTANI 6. 7. 8. 9. 10. 11. 13. The application seeks to build an 11' x 17' screened-in pomh (no heat) on top of an existing deck, which is attached to an existing home. The porch will not extend over the existing deck. This preserves the community character of Southold Town as this is a residential area already and we seek to construct on an already existing structure. In this way we are preserving open space, minimizing the adverse effects of development and not changing the use of this coastal location. The present structure is not historical and there are no archeological resources in the area. The application will not impact the visual quality and protects the resources throughout Southold Town in that the porch it is going to be constructed over an already existing structure. The application will not impact loss of life, structures and natural resources from flooding and erosion as the porch is going to be constructed over an already existing structure. The application improves water quality in Southold Town as the runoffwill be going into an already existing drywell adjacent to the proposed porch. See It 5 The construction of this porch will not protect or improve the air quality, however, it will not impair either. The application will not environmentally degrade Southold Town from solid waste and ha:mrdous substances or waste. The application will not provide for public access to and recreational use of coastal waters as it is not on public land. The application is not applicable to maintaining or protecting Southold Town's water dependent uses as it is only for construction of a porch. See It 5 The porch is being built on an already existing deck and therefore will protect agricultural lands. The application promotes appropriate use and development of energy as there will be no heat in this pomh and will be compliant with local building codes. APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM Tl~ T0w0 of Southold's Code of Ethics nrohibits conflicts of intcreat on the hart of town officers and cmolovccs. The ouroose of this form is to nrovide information which can alit the town of ~ossible conflic~ of interest and allow it to take whatever action is aneessarv to avoid same. YOUR NAME:Q/"I ,{/x~ ~.- . . (Last name, first name, middle initial, unless you am applying in me name ot someone else or other entity, such as a company. If so, indicate the olher person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building Variance Trustee Change of Zone Coastal Erosion Approval of plat Moodng Exemption from plat or official map Planning Other (I f "Other", name the activity.) Do you personally (or through your company, spouse, sibling, parent, or child) have a relationship with any officer or employee off the Town of Southold? "Relationship" includes by blood, marriage, or business interest. "Business interest" means a business, including a partnership, in which the town officer or employee has even a partial ownership off(or employment by) a corporation in which the town officer or employee owns more than 5% of the shams. YES NO ~ Iff you answered "YES", complete the balance &this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of thai person Descrihe the relationship between yourself (the applicant/agent/representative) and the town officer or employee. Either check the appropriate line A) through D) and/or describe in the space provided. The town o ffflcer or employee or his or her spouse, sibling, parent, or child is (check all that apply): __.A) the owner of greater than 5% of the shams of the corporate stock of the applicant (when the applicant is a corporation); B) the legal or beneficial ownqr of any interest in a non-corporste entity (when the applicant is not a coqsorstion); __.C) an officer, director, parmei', or employee of the applicant; or __.D) the actual applicant. DESCRIPTION OF RELATIONSHIP Form TS I Submitted this ~_day of~ d 200 Signature Print N~e