HomeMy WebLinkAboutTR-5606Albert J. Krupskl, President
James King, Vice-President
Artle Faster
Ken Poliwoda
Peggy A. Dickers6n
BOARD OF TOWN TRUSTEES
TOWN OF SOUTIIOLD
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
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 ~,~ c/i-~jo~.. -
st
1 dayof construction
~,~ constructed
Project complete, compliance inspection.
Board Of $outhold Town Trustees
SOUTHOLD, NEW YORK
ISSUED TO JOHN & SARAH MILLER
Authurizalion
Pursuant te the provisions of Chapter 615 of the Laws of
the State of New York, 1893; and Chapter 404 of the L~ws of fha
State of New York 1952; and the Southold 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;t': and in accordance with the
Resolution of The Board adopted at a meeting held on
.200.~.. , and in consideration of the sum of $..~.0.0..~..00 paid by
John & Sarah Miller
of .... ~]~g~ N.Y. and subject to the
Terms and Conditions listed on the reverse side hereof,
of Soufhold Town Trustees authorizes and permits the following:
Wetland Permit to enlarge a second-story bathroom and add a
deck and trellis to the dwelling wi~h the condition that hay bales
are installed prior to construction and drywells and gutters are
installed to contain the roof run-off.
all in accordance with the deteit~d specifications as presented in
the originating application.
IN WITNESS WHEREOF, The said Board of Trustees Imre-
by causes ifs Corporate Seal to be affixed, and these presents fo
be subscribed by a majority of the said Board as of this date.
TERIdS and CONDmONS
The Pe~raleme John & Sarah Miller
~ ~ 1132 Bridge Lane, Cutchogue N.Y. a~
part of the comidera~o~ fo~ the is~,~-ce of the Penait does unck~st~d and p~scdbe to the roi-
with ~ thereto, to tim complete ~,,,-,-hsioa of the Bo~d o~ T~ ~ ~ T~ ~ ~
for ~ ~on may ~ ~ to ~ ~ at a ~ ~
5. That ~ Permit should be ~ned indefinitely, or as long ~ the said F~ wlsh~
to ~ the smicture or project involved, to provide evidence to anyone concerned that auth-
orizatioo was originally obtained.
4. That ~he work involved will be subject to the inspe~io~ and approval of the ~ m
its agen~ ~ad non-comp~i:nce with the profisions of the origin~iog application, may be cau~ fo~
revocation of this Permit by x~oludon of the said Board.
5. That ~here will be no unreaso~le interfe~nce with navig~_~3,~ as · ~ of the w~k
he~ia su'thodzed.
6. That there shall be no interference with the right of the public to pass and repass alaag
the bea& between high and low ',m. ter m,.rks.
7. Th~ if future operations of the Town of So~thold requite the xzmoval and/oc alteratiom
in the location of the ~k herein ~uthocized, or if, in the oplnkm of Ihe Board of Trustee% d~e.
wo~ ~.h,l! c~use unrea~mable ob~mou to free navigation, the said Pemg~tre will be ~
upoa due nodee, to remove or alter ggs work ot project herein s~ted without expenses to tim
S. That the said Board will be notified by the Perm/me ot the completion of the work auth-
orize&
9. That the Permittee will obtain aH other permits and consents that may be requited
plemental to this permit which may be subject to revoke upon failure to olxain same.
Albert J. Krupski, President
James King, Vice-President
Artie Foster
Ken Poliwoda
Peggy A. Dickerson
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Town Hall
53095 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1892
Fax (631) 765-1366
August 23, 2002
Mr. & Mrs. John Miller
1132 Bridge Lane
Cutchogue, NY 11935
1132 Bridge Lane, Cutchogue
SCTM#118-1-18.4
Dear Mr. & Mrs. Miller:
The Board of Town Trustees took the following action during its regular meeting held on
Wednesday, August 21, 2002 regarding the above matter:
WHEREAS, JOHN & SARAH MILLER applied to the Southold Town Trustees for a permit
under the provisions of the Wetland Ordinance of the Town of Southold, application dated July
15, 2002, 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
August 21, 2002, 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,
NOW THEREFORE BE IT,
RESOLVED, that the Board of Trustees approve the application of JOItN & SARAIt MILLER
to enlarge a second-story bathroom and add a deck and trellis to the dwelling with the condition
that hay bales are installed prior to construction and drywells and gutters are installed to contain
the roof run-off.
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.
Inspections are required at a fee of $5.00 per inspection. (See attached schedule.)
Fees: $10.00
Very truly yours,
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/lms
Albert J. Krupski, President
J.a~mes King, Vice-President
Henry Smith
Artie Foster
Ken Poliwoda
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1892
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Please be advised that your application, dated
has bee~ reviewed by ~his Board· at the regular meeting of
'~/~J~O~ and the following action was taken:
( ~'~ 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.
TOTAL FEES DUE:
The following fee must be paid within 90 days or re-application
fees will be necessary.
S I GNED:
PRESIDENT, BOARD OF TRUSTEES
BY:
· BOARD OF TRUSTEES
4/98
Telephone
(631) 765-1892
Town H',fll. 53095 Main R~,d
P.O, Box 1179
,5outhold, Ne,~ York 11971
SOUTHOLD TOWN
CONSERVATION ADVISORY COUNCIL
At the meeting of the Southold Town Conse~ation Advisory Council held Tuesday,
August 20, 2002, the following recommendation was made:
Moved by Bill McDermott, seconded by Melvyn Morris it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL WITH
A STIPULATION of the Wetland Permit Application of JOHN & SARAH MILLER to
enlarge a second-story bathroom and add a deck porch and trellis to the dwelling.
Located: 1132 Bddge Lane, Cutchogue. SCTM#118-1-18.1
The CAC recommends Approval with the Stipulation that all building permits are in
place for the work that has already taken place.
Vote of Council: Ayes: All
Motion Carried
New York State Department of Environmental Conservat~on
D~visto~ et Er~koea~n~al Permits, Region One
LETT;ER OF-,NON JURISDICTiON-TIDAL
Erin M. Cro~, f
John M. M~ller
1132 Bridge Lane
Cutchogue. NY 11935
February 26, 2002
App{icsti~n #t-4738-02982/00001
Mi~ler Prope~, 1132 Bridge Lane, Cutchogue, NY
Dear Mr, Mitter;
Based on the information you have submitted, this Department has determined that:
The property landward of the 16' elevation contour, as shown on the survey prepared by
Joseph lngegno dated December 28, 2000, is beyond the jurisdiction ,of Article 25.
Therefore, in accordance witt~ the su~rrent Tidal Wet, ands Regutstior~s (6NYCRR Pa. 66~) no
vege~5on ~in Tid~ :We~ds ~uri~ion ~ich m~ resu~ ~ y~ pr~.
p~a~o~ m~y incl~ main~ini~ a~qu~fe w~k af~ ~een t~e t~ ~t~nd
~urisd~ionat bo~dafy and y~r p~Ject (i.e. a 15' to 20' w~ con~u~n ama) m ere~ing a
tempomw fence, bardeL or ba~ bay ~rm.
P~ase be. further advised tt3at this ~e~ter does net relieve you of the resportsibi~[ty ef obtaining
a~y necess~,ry permits or approYats from other age~3c~,es.
Very tfuty yours,
Mark G. Garrara
Permit Administrator
cc: BMHP
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
Office Use Only
Coastal Erosion Permit Application
,,4~qetland Permit Application ~ Major
Waiver/Amendment/Changes
e,,'Received Application: "1]1~']0~
..-Received Fee:$
.~°'ompleted Application '9 Incomplete
SEQRA Classification:
Type I Type II Unlisted
Coordination:(date sent)
...CAC Referral Sent: ~]lq[o~)
..grate of Inspection: Receipt of CAC Report:
Lead Agency Determination:__
Technical Review:
,"Public Hearing Held: ~.~/~ ~.~
Resolution:
Minor
'"',, JIJL I
Name of Applicant
Address \ \
PhoneNumber:(~) ~ "-~ O
Suffolk County Tax Map Number: 1000- l\~- C.) ~ '- [q~ , o{
(provide LILCO Pole #, distance to cross streets,°and locat~Ox{)
AGENT: ~.~
(If applicable)
Address:
hone:
Board of Trustees Application
GENERAL DATA
Land Area (in square feet):
/~.Area Zoning: res, d
Previous use of property: ~-e~ g', ~ 4, ~\
Intended use of property:
Prior permits/approvals for site improvements:
Agency
__ No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a governmental agency?
~'~o Yes
If yes, provide explanation~,~
Project Description (use attachments if necessary):
Board of Trustees Application
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations: ~'xo
Area of wetlands on lot: c~ o ~ ~ square feet
Percent coverage of lot: (~ %
Closest distance between nearest existing structure and upland
edge of wetlands: 6t ~ feet
Closest distance between nearest proposed structure and upland
edge of wetlands: c~ ~.. feet
Does the project involve excavation or filling?
J No Yes
If yes, how much material will be excavated? ~k~q cubic yards
How much material will be filled? ~ [ a_ cubic yards
Depth of which material will be removed or deposited: f~ l~ feet
Proposed slope throughout the area of operations: ~Cn
Manner in which material will be removed or deposited: ~n
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):
PR~)JECT J.D, NUMBER
617.2'~
Appendix C
State Environmental Quallty Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART J~PROJECT INFORMATION (To be completed by Applicant or Project
PR JECT NAM~
1_ APP~NT/SPONSOR 2.
SEC
5, [S PROPOSED ACTION:
[] New [] ExPansion ~ffication/alteration
6. DESCRIBE[ pROJECT BRIEFLY:
8. W~POSED ACTION COMPLY WITH ~[ST[NG ZONING OR OTHER ~ISTING ~NO US~ R~ST~ICTJONS?
~ Yes ~ No If NO, describe briefly
9. WHAT iS PRESENT I..A~¢D US;: iN VICINITY OF PROJSCT?
~e$ide~ltial [],!noustrlel ~ Commerci&l
Desc=ibe:
~J Agricuiture
L.~!~ParkJForestlOoen space L..J'O1~er
Y
DOSS ACTION INVOLVS A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL).?.~
OOSS ANY ASPECT OF THE ACTIOH HAVE A CURRSNTLY VALID PERMIT OR APPROVAL?
RESULT OF PROPOSED ACTION WILL ~ISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
I CERTi~ THAT TNB INFORMATION PROVIDED ABOVE IS TRUE TO THE ~EST OF MY KNOWLEDGE
tf the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this a~essment
OVER
I
PART III--0ETERMINATION OF S~GNIFICANCE lTo be completed by Agency)
INSTRUCTIONS: For eac.~ adverse e~fect identified a~'ove, determine wne~er it is sut~s~.~ntial, large, [mco~n[ or o~en~iSe signific
~ac2 ailed: should be ~ssessed in connection with ~ts (a} setting (i.e. urDa¢ or rural); (b} probaoility of occ~g; (c} dur~dort:
irrevermbility: {e) geographic sc=ce: and (0 magnitude. If necessa~, add altachmen~s or reference supposing m~edals. ~nsure
~ctanalions cch[pin sufficient detail (o snow that ail relevant &dver~e impacts have been identified and adequately addressed.
Check this box if you hsve identified one or more potentially large or significant zoverse imoac:s which ¢,~A'~
occur. Then proceed direc.'ly ~o :ne FULL -~AF ~nd/or prepare ~ positive-declara[icn.
Check mis box ff you nsve de,ermined, based on ~he in/ormation znd analysis above and any supportive
docume~(~[ioR. :~[ ;he proposed aczion WILL ~iOT result in.ay significant adverse environmen[&l imcac::
AND provide on ~[~cnments as necessary, [he reasons supcor[ing [~ls determination:
Allstate Insuranq~Company
Summary
NAMED INSURED(S)
John Miller
Sarah Ehrenson
1132 Bridge La Nassau Pt
Cutchogue NY 11935
POLICY NUMBER
1 03 225784 09/15
AMENDED
Deluxe Homeowners
Policy Declarations
YOUR ALLSTATE AGENT IS:
D. Siple Agy Inc
191 Forest Avenue
Locust Valley NY 11560
POLICY PERIOD
Begins on Sep 15, 2002
at 12:01 AM. standard time,
with no fixed date of expiration
LOCATION OF PROPERTY INSURED
1132 Bridge La Nassau Pt, Cutchogue, NY 11935
AIIstate
CONTACT YOUR AGENT AT:
(516) 671-6044
PREMIUM PERIOD
Sap 15, 2002 to Sap. 15, 2003
at 12:01 AM. standard time
Total Premium for the Premium Period (Your bill will be mailed separately)
Premium for Property Insured $1,290.00
TOTAL $1,290.00
Your policy change(u) ara effective as of Sup. 15, 2002
IEIlli llllllillSfl lllflllllllllllfilllllllllllllllllllllll llllllllllll
Allstate Insuran l Company
Policy Nunlbe~: 1 03 225784 09/"ff5 Your Agent: n. Siple Agy Inc (516) 671-6044
For Pre~)liun~ Period Beginning: Sep. 15, 2002
AIIstate.
Your Po/icy Documents
Your Homeowners policy consists of this Policy Declarations and the documents listed below. Please keep these together.
- Deluxe Policy form AP316 - New York Amendatofy Endorsement form AP497-1
- Amendment of Policy Provisions form AP521 - Declarations Supplement Pg (New York) form AU233d
* Domestic Workers' Comp & Emp Liability AP1105 - New York AmendatoP/Endorsement form AP1727
- Deductible for Severe Hurricanes End. form AP585-1 * Bldg. Struct. Reimb. Ext. Limits End. form AP693
Important Payment and Coverage Information
The property insurance adiustment condition applies using the Boeckh Publications Building Cost Index developed by The
American Appraisal Associates, Inc.
Please note: This is not a request for payment Any adjustments to your premium will be reflected on your next scheduled
bill which will be mailed separately.
In the meantime, if you have any outstanding or unpaid bills, please pay at least the minimum amount due to assure your
policy continues in force. If you have any questions, please contact your agent.
IN WITNESS WHEREOF, Allstate has caused this policy to be signed by two of its officers at Nodhbrook,
Illinois, and if required by state law, this policy shall not be binding unless countersigned on the Policy
Declarations by an authorized agent of Allstate.
Edward M. Liddy
President
Secretary
PROOF OF MAILING OF NOTICE
ATTACH CERTIFIED MAIL RECEIPTS
Name: Address: ] / ~5 fi'
STATE OF NEW YORK
COUNTY OF SUFFOLK
, being duly sworn, deposes and~says that on ~e
/
~ day of ,fu~ ,20~2~, deponent mailed a tree copy of the Notice ·
set forth, in the Board of Trffstees Application, directed to each of the above named
persons at the addresses set opposite there respective names; that the addresses set
opposite the names of said persons are the address of said persons as shown on the current
assessment roll of the Town of Southold; that said Notices were mailed at the United States Post
Office at 5 bat A./'c~ id
(certified) (registered) mail.
Sworn to before me this
Dayof 3.~1~ ,20 O_~__
No, mub i
, that said Notices were mailed to each of said persons by
~~o~V~
~. 4~
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
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In the Matter of the Application
of
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
I,~--~+s~¢~ ~N%'\~eT , residing at \\%7--~v~ ~
being duly sworn, dep and say:
That on the ~O day of ~v~n~, 200~ I personally posted the
property known as %~ %c'.d%~ ~ C~c~-%~c~ ~ ~%~
by placing the Board of Trustees official poster~where~ 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. Dat~_Qf hearing noted thereon to be held~~.~
Dated:
Sworn to before me this
~o day of~ 200~--
otary
Public
Board of Trustees Application
County of Suffolk
State of New York
,.~0~4t,1 4 ~a~/~ M/~¢W' BEING DULY SWORN
DEPOSES ~ ~F~S ~AT ~/S~ IS ~ ~PLIC~T FOR T~ ~O~
DESC~BED PE~T(S) ~ ~T ~L STA~NTS CONT~D ~ ~
~ TO ~ BEST OF ~S~R ~O~EDGE ~ BEL~F, ~ ~T ~L WO~
~L BE DO~ ~ T~ ~R SET FOR~ ~ ~S ~PLICATION ~ AS ~Y
BE ~PRO~D BY T~ SO--OLD TO~ BO~ OF TRUSSES. ~ ~PLIC~
AG~ES TO HOLD ~ TO~ OF SO--OLD ~ ~ TO~ TRUSTS
H~ESS ~ ~E ~OM ~ ~ ~L D~AGES ~ CL~S ~S~G
~ER OR BY ~ OF S~ PE~T(S), ~ G~ED. ~ CO~LET~G ~S
~PLICATION, I ~BY A~O~E ~ ~US~ES, ~ AGE~(S) OR
~P~SE~ATI~S(S), TO E~R O~O ~ PROPERTY TO ~SPECT ~
P~SES ~ CON~CTION ~m~W OF !~S ~PLICATIO%.. ~
[~ Siinature ._ ~
SWORN TO BEFO~ ~ T~S [ ~ DAY OF A ~ JM
( ¢)AIIb"l'dl e.
ALLSTATE
81
Print Key Output
5769SS1V4R5MO 000526 A4000077
Page 1
07/15/02 10:22:38
Display Device ..... : QPABEVOOXL
User .......... : S301275
Insured:
Address:
Home: ( 631 ) 734 - 5580
Class : 1101700
Status : ACTIVE
Premium: $1,233,00+
AAP $1.233.00+
Balancel $0 00+
Lst Bll: $0.00+
Cur Due: $0,00+
Due On :
JOHN MILLER POl No: 103225784 09/15
1132 BRIDGE LA NASSAU PT City: CUTCHOGUE State: NY
Zipcode: 11935 - 0000 Org Year: O0 Agent: 41 41248
**PROPERTY SUMMARY**
POSTINGS Clms: Y Frms: N DSc: Y
RENEWAL PREM 090701 $1.233.00+ Pay Pln: MONTHLY
CASH-DIR MAIL 090701 $~.233.00~ Nxt Due: $0.00~
CASH-DIR MAIL 100300 $1.214.00- Bll Act: FOLUP ISSRN
NB PREMIUM 091800 $1,214,00+ On: 9/21/02
ALL PERILS $500
HURRICANE DED 5.0~
Pol Type: DELUXE HOMEOWNERS - PRIMARY RESIDENCE
LIMITS PREMIUMS DEDUCTIBLES
4.000 $19.00
280.000 $1,191,00
300.000 / 1,000 $20,00
$3.00
$0,00
COVERAGES
BASIC COVERAGE
BASIC COVERAGE
INCRFASE LIABILITY AND MEDICAL
WORKER COMP-OCCASIONAL CLASS
BLDG STRUCTURES REIMB EXT LMTS
(ENTER) CONTINUE {
(Fg) VIEW BILL
} (Fl) HELP (F3) QUIT (F4) BACK SCREEN
LAST
07/15/2002 10:24 5IB6 ~099 ALLSTATE PAGE
· Print Key Output
5769SS1V4RSMO 000526 A4000077
Page 1
07/15/02 10:22:04
Display Device ..... : QPADEVOOXL
User .......... : S301275
Insured: JOHN HILLER
Home: ( 631 ) 734 - 5580
Pol. No,:
**POLICY COVERAGES**
Deluxe Policy - Primary
103225784 09/15
ACE Replacement Cost $: 278298
Dwelling Protection Limit $: 284000
Personal Property Prot. Limit $: 142000
Other Structures Limit $: 28400
Hurricane Ded: 5 %
Other Peril Deductible
$: 500
Liability Protection Limit $: 300000 Prem. Med. Prot. Limlt $: 1000
Do You wish to include any of the following:
ReimOursement Cost on Contents
Bldg Structure Extended Limits
Eliminate Off Premises Theft
(Y/N): N
(Y/N): Y
(Y/N): N
(ENTER) CONTINUE (Fi) HELP (F3) QUIT
(F6) PEND
APPliCANT
The Town o~ S~u~hold's cods of Ebhic~ prohibits
interest on the part of town officers and employees. The
purpose of this form ts %o provide information which can
alert the ~own of possible conflicts of in~sres~ and allow
it to ~ake whatever action is necessary to avoid same.
you are applying in ~he name of someone else or
o~her entity, such ~s a company.
~he other person's or company's name.)
NATURE OF APP~ATXONt (Cheuk a[~ ~ha~ apply. )
Tax grievance /
Variance 1~
Change of zone
Approval of plat ,
Ex~pSion from plat or official map
other
(I~ "other," name the activity.)
parent, or child) have e relationship with any officer or
employee of tile Town of Scuthold? "Relationship" inclndee
by blood, marriage, or business interest. "Business
interest" mean~
which ~he ~ovn o/Ricer or employee has ~ven a partial
ownership of (or employmen~ by) a corporation in which
~he town o/ricer or employee owns more than 5% oE the
shares.
YES NO
If you answered "YES,#.complete ~he balance el ~h[a Ecrm and
date and sign where indicated.
Name of person employed by the ToWn of Sou%hold
Title or position of that person
Describe the relationship between yourself (the applicant)
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 ~poua~,' e~bl{ng,
parent, or child is (check all that apply)!
__A) the owner of greater than 5% of the shares of the
corporate stock of the applic~n~ (when tbs applicant'
is a corporation)~
the legat or b~ns~tcia~ owner o~ any interest in a
noncorporate'entity (when the applicant is not a
B)
corporation)t
C) an officer, director,
applicantt or
D) the ~tual applicant.
DESCRIPTION OF RELATIONSIIIP
part,er, or employoe, o~ the
7
subtn£tted this~:~;day
Sly'nature
?
'Print name