HomeMy WebLinkAboutTR-5006
PO Box 415
Sound Beach, NY 11789
March 14, 2001
Town of Southold
Board of Trustees
PO Box 1179
Southold, NY 11971
tAAR \ 5
Dear Sir:
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This letter is in reference to Permit # 5006. We have completed all ofthe
approved work on our home located at 2050 North Oakwood Drive, Laurel. We have
also notified the Southold Building Department, and the D.E.C. for fmal inspections.
We would appreciate it if you could finalize our permit and indicate that it has
been completed. Thank you for your assistance in this matter.
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Robert!Dorothy Baumarm
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Board Of Southold Town Trust(~es
SOUTH OLD, NEW YORK
PERMIT NO. S-o 0 G
DATE: J.\lne 16, )999
ISSUED TO nIZq.B.ERT & DOROTHY BAUMANN
i\utf1orilatiOtt
Pursuant to the provisions of Chapter 615 of the Laws of
the State of New York, 1893; and Chapter 404 of the Laws of the
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;!'. and in accordance with the
Resolution of The Board adopted at a meeting held on . Ma'y' 26... 1 999
1999, and in consideration of the sum of $ 150.,.QO ... paid by
ROBE.R.T& DQRQTHYBAUMANNnnnn
of .. .......J...a.u.r.e.L.. ... ........... ... N. Y. and subject to the
Terms and Conditions listed on the reverse side hereof,
of Southold Town Trustees authorizes and permits the following:
Wetland Permit to raise roof, put in new windows, add siding,
an addition to garage, rear decks off first floor and move dirt fr
" f.rontol property with condition that haybales be placed 10' up
from e,Ige of rj1arsh & shpw plautipg pli\.ll tQ control phtailllJites if
the all In accordance With the detailed spllclticatrons as prelentea In
applj~.priginating application. decides to control them.
IN WITNESS WHEREOF, The said Board of Trustees ~re-
by causes its Corporate Seal to be affixed, and these presents to
be subscribed by Is . majority of the said Board as of this dat.e.
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-- . Trust..s
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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 Main Road
P.O. Box 1179
Southald, New Yark 11971
Telephone (516) 765-18'12
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTH OLD
June 16, 1999
Robert & Dorothy Baumann
P.O. Box 415
Sound Beach NY 11789
Re: SCTM #127-6-5
Dear Mr. & Mrs. Baumann,
The following action was taken by the Board of Town 'rrustees
during a Regular Meeting, held on May 26, 1999, regarding the
above matter:
WHEREAS, ROBERT & DOROTHY BAUMANN, applied to the Southold
Town Trustees for a permit under the provisions of the Wetland
Ordinance of the Town of Southold, application dated April 30,
1999 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 May 26, 1999, 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 standard set forth in
Chapter 97-18 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 approves the application of
ROBERT & DOROTHY BAUMANN to raise roof, put in new windows, add
siding, an addition to garage, rear decks off first floor and
move dirt from front of property with condition that haybales be
placed 10' up from edge of marsh, and show planting plan to
control phragmites if the applicant decides to control them.
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 proiect will expire two years
from the date it is signed. Fees must be paid, if applicable,
and permit issued within six months of the date of this
notification.
Two inspections are required and the Trustees are to be notified
upon completion of said project.
FEES: None
Very truly yours,
t2tk.J 9- /~.~.
Albert J. Krupski, Jr.
President, Board of Trustees
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Dept. of State
Building Dept.
.
.
Telephone
(516) 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 Monday, May 24,
1999 the following recommendation was made:
y ....tJ.JLJ. ~...,. ~p.ln 6-5 to raise roof, add new window, siding, addition
to garage and rear decks of the first floor. Move dirt from front of property to the rear to cover
footings of house.
2050 North Oakwood Dr., Laurel
The CAC did not make an inspection, therefore, it has no recommendation.
.
.
P.O. Box415
Sound Beach, N.Y. 11789
April 27, 1999
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LR 2 9 1909
TOWN OF SU~,'
Board of Trustees
Town ofSouthold
P.O. Box 1179
Southold, NY 11971
Dear Sir:
We are applying for a permit to do renovations to our house located at 2050 North
Oakwood Road in Laurel. The Trustees have done a pre-inspection ofthis property with
our architect, Diane Herold. She has advised us that one ofthe conditions requested
would be that the sanitary system be relocated from the rear of the house to the front.
This request represents a significant financial difference in our original plans. We have not
added any bathrooms or changed the footprint ofthe house in any way. We have owned
the house for just about one and a half years, and never had a complaint from the tenant in
reference to the septic system. We also have been advised that this will not be an easy feat
to accomplish since the front ofthe house is on a slab.
I was advised by your office that I should check with the Suffolk County Health
Services. I spoke with a Mr. Reynolds there, who told me that if a system is functioning
they would not usually request that it be replaced. He said that they might require
assurances that the existing system is adequate by an architect or a surveyor. I would very
much appreciate if you would reconsider this request. We have no problem in certiJYing
the existing system. We feel that to replace a system that is adequate and functioning
would place undue financial burdens, that were not anticipated on us.
Thank you for your consideration in this matter and we look forward to your answer.
~'~J)
Robert and Dorothy Baumann
.
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Telephone
(516) 765-1801
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, March 23,
1999 the following recommendation was made:
Moved by Richard Smith, seconded by Melvyn Morris, it was
RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the
Waiver Request of ROBERT AND DOROTHY BAUMANN 127-6-5 to repair roof, change
doors and windows, and replace the siding.
2050 North Oakwood Road, Laurel
The CAC expressed concerns regarding the possibility of a violation. The applicant has cleared
the wetlands. CAC recommends that a violation be issued and the wetlands be restored to their
pre-existing condition.
Vote of Council: Ayes: All
Motion Carried
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MAR I \999
DIANE HEROLD, ARCH IT
~~f- <;;oL/7
P.O. Box 884
Westhampton Beach, new York 11978
February 25, 1999
i
TOWN OF-S'C';iITH-;:;! pi
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Board of Town ~rustees
Town of Southold
Town Hall
53095 Main Road
Southold, New York 11971
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RE: presubmission inspection
property of Robert and Dorothy Baumann
2050 North Oakwood Road, Laurel!). 7- r;, -~-
Gentlemen:
On behalf of my
an requesting a
located at 2050 Nor
you will be able to
clients, Robert and
Dorothy
of
oa, aurel.
inspection on
Baumann, I
their property
I understand
March 17, 1999.
This property has a stop wor~ order placed upon it by the
Town of Southold Building Department. Mr. Baumann started
working on renovating the house and went beyond work that
could be done without a permit. The work that has been
performed includes the _ ~_ < _
, the and the
planned _ , _. All of this work is proposed
to be within the existing footprint of the house that was
existing on the property. At this time, the rafters are
covered with tarps, and the owners are requesting permission
to finish the roof to make the house less susceptible to the
weather. Mr. Boufis, Building Inspector, has agreed to give
them permission to install roof sheathing and roof shingles
and also to place Tyvek house wrap on the wall sheathing.
He has asked me to contact your board to obtain permission
to do this work. Therefore, I would appreciate your review
of this request.
While you are at
consideration of
proposing to do.
" .
the property, I would also appreciate your
further work that Mr. and Mrs. Baumann are
eJ:2g I
I realize
u~_
attached a s~etch of this
this wor~ will require an
-~~
proposed work.
application to be
"
.
.
Board of Town Trustees
February 25, 1999
page two
filed with your board, but I would like the board to
review this information and provide any feedback that
they feel would be appropriate.
Mr. and Mrs. Baumann and I thank you for the time you
will be spending to make this inspection and look forward
to hearing from you.
Sincerely,
illuw. I~{AJ
Diane Herold
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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 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1882
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use onlYID1 ~ @-~La. W.ts-.-
Coastal Erosion Permit APPlicatiojl ;'11 "--'-d~l
)Z:Wetland Permit A~plicat~on . UU~PR ] 01999..,../1/.'
Grandfather Perm~ t Appl~cat~on . i . i:
- Wai ver / Amendment/ Changes I,. '_" . I . -, ,
Received Application: 1(- ~ f,n:vl\' ()f:':'I~'II-;;',
Received Fee:$/~
Completed APPI~' tion . A ~! ~ I
IncomPlete~~~~LbV-~J..~ ~ ..-~'( r r
SEQRA Class~f~ca:io~ 1
Type I_Type II~Unlisted_
Coordination: (date sent)
CAC Referral sent:!::I..:...:l.'l- 7~ ~ []
Date of Inspection: ~ -1'1- .,-,. ""
Receipt of CAC Report:
Lead Agency Determination: APR 301999
Technical Review:
Public Hearing Held: S" -..t, -"
Resolution:
Name of Applicant ""1<Oe.ee-T e, T::o~~ 1Sau1/\'\O..Y\.At\
Address ?O 130")( YI'$"" I Sound B.eO.cVj N.\~
Phone Number: (S)(o) ~ 2- q 2.S"
Suffolk County Tax Map Number: 1000 - \~I O(p OS
Property Location: 2.050 Nor-\--\n ~1A.COCi Dr. LCt.\A.1^eJ; I'L 1
.
1"< \<:Ti. \/'-1. \'YI.\\Q..::oJ 0\- \><<DY1\c... 'iSlvd
(provide LILCO Pole ~, distance to cross streets, and location
AGENT:
(If applicable)
Address:
Phone:
FAX~ :
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~
Boa~ of Trustees Application ~
GENERAL DATA
Land Area (in square feet): i CO, otoo
Area Zoning: rt.s\A~cJ.
Previous use of property: ~~cJi
Intended use of property: K.<:.itL~u..t
Prior permits/approvals for site improvements:
Agency
Date
~NO prior permits/approvals for site improvements.
Has any permit/approval ever been
governmental agency?
revoked
/NO
or suspended by a
Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
'\Z~0\l0-.-\-1c:J\'j - \OH~ I t-:l<O of- \Oct- I nOll' \AJ1 yyJO\A\S ) ~ dt f'l~ j
Q~*,QY\ ot 3~-e.. CJ..iY',{)... -reDd' ~cks. eM ~
~ YS t fl OQ{ . To (Y\cu-e.. d I f'-t- froYII fro"\.+- &f-
r~ t--~m ~ N-0Jr +0 CDvcx- -foo-h "ley; ct-
Y10u s.e ,
2
Board~ Trustees Application ~
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:To I~-r<- ~ sC\-feJ~
r~ ~ ~~KYM_.
Area of wetlands on lot:
150,
S
square feet
Percent coverage of lot:
%
Closest distance between nearest existing structure and upland
edge of wetlands: <)[) feet
Closest distance between nearest proposed structure and upland
edge of wetlands: 50 feet
Does the project involve excavation or filling?
~ f'\ h<>"J..
If yes, how much material will be excavated? cubic yards
~\uc:ll" ~(,r
How much material will be filled? cubic yards
Depth of which material will be removed or deposited: ~d~atfOon~s
feet In 'recu-~o"&-L
No
/
-
Yes
Proposed slope throughout the area of operations:
5 '70
Manner in which material will be removed or deposited:
~cJL.~
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):
()O e~ OY'l weJ-\~ aAtlgftt-kc\
3
.
.
NOT1CE TO ADJACENT PROPERTY OWNER
BOARD OF TRUSTEES, TOWN OF SOUTHOLD
In the matter of applicant:
SCTM#lOOO- 1:1, 010 OS"
YOU ARE HEREBY GIVEN NOTICE:
1. That it is the intention of the undersigned to request a
Permit from the Board of Trustees to: per~t- r-c;nOvQt.o-YlS
-\-v ~o'{'"'l'-lL: Y\f..1.0 ~ I s \cLv"'-5 I \.<.) \nC\,oW~ I NeLLs Cvvtcl
:!J~'
2. That the property which is the subject of Environmental
Review is located adjacent to your property and is described as
follows: 2.050 \--lor'\-\-. c9Qicu..Yood Ra I lcL\..Lv,d
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. 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.
OWNERS NAME: 'Kokrhtceo
MA~ING ADDRESS:
~v G
PHONE 11: 51 \0 I ~
Ene.: Copy of sketch or plan showing proposal for your
convenience.
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. .
Board of Trustees Application
County of Suffolk
State of New York
\>.nlL0~ ~~y\. BEING DULY SWORN
DEPOSES ~ AFFIRMs THAT ~/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 VIRTUE OF SAID PERMIT(S), IF GRANTED. IN
COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,
THEIR AGENT ( S) OR REPRESENTATIVES ( S), TO ENTER ONTO MY PROPERTY
TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
~~
SWORN TO BEFORE ME THIS c-JC\
DAY OF~Q
,19~
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.
.
1-~.t6..\ {2fan-;~X( 12
I ?ROJECT '-D. ,WMaaR
517.21
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I-PROJECT INFORMA nON (To te comoleted by Aoplicant or ?roject saonsor)
SEe
'\Z.~~X?O \(wooct Qd
J. PROJ EC7 laC;" ileNt. _ .. \
Munic10alily LD.....uv~ County .0
4. ~~~c;:\~~a5.~~ "o~'n.~Of~'C~' O~J;V';:~ W~ crb r&rnJi L-
~ \3.\\J.6.. OV\ +~ e./ASt sul€' ofJ
'~5~.
5. IS PROPOSED AC':"ION: .L
o New n 5.xoansion ! MccHicatiCnlalteralion
6. DESCRlaE ?ROJEGT 3RIE"LY, \0 ....CA.\~ .-00\ I ('-t.,-S\
o..~oY\ ~tA~c1u.. IV\ ~rOb~
oJ~ I Y\eW\).lWt tlWS I ~OS'Q~
7. AMOUNT OF !....AND AFr=~CTED:
O~'- ~( q(1fu sr<-
Initially lc:es ~";l:imatej'l lc:as OY\
3. 'fJ~y~O?lJSE0 ..l.C7;CN C~MP'_':' 'NIT:-- Z<lS7:NG :=:-~ING ~A eTHER 2<ISTING '..AND USe .=-=.STrlIC7iCNS?
!~Yes 1-..: ~o If ~lo. :eSC:lce :lrlett',
'3. 'fJ:;:yS ?RESE!'4T :...ANC ~JS~:N '/IC:NII';' OF ::::::0.:';:.:7?
Q.~esldentiaJ n.!nausu:al = C;.;mmerc:al
Oesc~ibe:
L .:..gtlCUJture
......; ?atKJForestlOoen scace
......;Otner
.0. aOES ..:.CjION INVOLVE A ,;)~::1Mlj ":'PClC:;OV~L JR ,=:';NDlNG. .~OW OR ULTIMA7EL"f :=ROM ANY OTHER GOVERNMENTAL AGENCY iFE0ERAl,
57 A T~9il LOc.:.W?-
[SJ Yes U No If 'fes. !ist 3.qer.c~/~s\ ana :::ermitlaoDrovals
))EL..
~~O~ ~ , \1::v0N O~ sovntol...-\)
DOeS ANY A~T OF THE ACTIOU !-1AVe..l" CURA.E."jTL'f 'IAUe ?SRMIT OR .:..P?RQVAL7
o Yes' ~ No It '1l!S, list agel1C'( name and :::erm.Uaoproval
11.
12.
POSED ':'C71CN 'NlL:" :;<:57ING :!:RMIT/AP?GQV)..L iiEOUlAE .\10QIFIC':' TION?
Signature:
-TIFY THAT 7HE rNFC:;MAnC:-.t PROVIDE:J .l,eOVE IS Tr:lUe 7'0 THE =:57 OF \1'( KNCWL'::DGE
KoUv+BtW~.I.. ~
~~\
If the action is in :he C,J;Jsral ~ra3. 3nd 'Iou are a state agency, complete the
C,Jas~ai .4sseSSme!lt Fcrm jeiore proceecing 'Nlth this a~~essmem
OV:::R
PART II-ENVIRONME
A. DOES AC710N s..:.; "'::D ANY TYPE I THRESHOLD IN 6 NYCiiR, ?:"FiT 517.121
o Yes No
a. WIU.. AC7lCN R CEIVE COOAOINATED"AEVleN A.S ~ROVIOeo>c~
may be Supersede
o Ves No
C. COULD ACTION RESULT IN ANV AOVERSE EFFectl!',
C1. existing air quallly. surlaC8 or' 9raunaw'acei Quality or Quandty, noise levels.
potential for erosion, drainaQe or t100dlnq problems? ExPlain brieily:
,L ASSESSMENT (To be comoleted by Ag,
y!
j ;e~l:::lel
pro{JL:c::on ':it qls;:csi:.
Nf
C2. Aesthetic, agricuUural. arChaeological. histone, or other natural or cultural resOurces: or communIty or neignbornood cnarac:er? Scotain orie:
/Vo
C3. VeQetatlon or fauna. fish, snelUlsn or wildlUe sgecies. slgniiicanr haoilals. or :n,eateRed or ~ndanc;ered species? =..xola!n orlaily:
No
C..l. A community's existing plans or goals as otflc:ally adopted. or OJ Change in use or Intensity ot usa ot land or other natural resources? Explain one
No
cs, Growlh, subsequent development. or related ac:ivities likelY :0 be Induced ay the oroooseo ac:ion? ::cplain oriet/y,
NO
ca. Long term, snort term. ctlmulalive. or olher eifec:s not identitied in C~.CS? :xolam arieily.
NcJ
Otrler imoac:s (Inc:udlng C!1anges In use of ~Ilhef quanlily Of tYj:le :Jr :nergYI? ExOl31n orierly.
ft)oA.l~
"
'J. is,~HERE. OR /~ERE LIKELY TO 3E. CONTROVERSY ~eL-\rEa TO ,:lOTENTIAL ADV;RSE :!'4VIRONMENT"':'L ;MPAC7S?
'........! Yes rNO It Yes, ~xplalO onetly
PART III-DETERMINATION OF SIGNIFICANC:;: (To be comoleted by Agency)
INSTRUCTIONS: For each adverse effect identified above. determine wnerner it is substantial, large, imponam or Otherwise significa:
Each effect snould be assessed in connection with its (al setting (I.e. urban or rural); (b) probability of occa;=nng; (el duration;
irreverSibility; (e) geographic scope; and (f) magnitude. It necessary. add aUachments or reference supponfng materials. ensure ,t:
explanations contain sufficient detail to snow that all relevant adverse impacts have been idemitlea and adequately addressee.
o C~eck this box jf you have identified one or more ;Jotentially large or significant adverse impacts which MAY
occur. Then proceed directly to the rULL EAF 3.ndlor prepare a pOSitive- declaration. .
~ Check Ihis box if you have determined, based on the information and analysis above and any supporting
documentation, that ihe proposea action 'NILL ~~OT result in~.ny significant adverse environmental imcac~s
AND proviae on attacnmen;s as necessary, the reasons supporting this determination:
.sf} fATH41.1J
-muJ,J
""'~J l"&-e-5
.'l..",~ ." ".....IeJ -~,,~ncy
~A!.~rd~
r"l~ ,~, _-(<:)oon"OI~ 011'C~t
:i'''''''IlUU~' ':If )(esoon\lole <JUicer ,II ~C:oIQ t\.;~ncy
5,,,nd.lure ,), r'rl"~.J.t~r HI :Jurer,;nt rrom reSoon\lOlo! OfTlCen
~-I'I-f"l'
,J.uc
2
"
.
.
PROOF OF MAILING OF NOTICE
.ATTACH CERTIFIED MAIL RECEIPTS
Name:
Address:
.
STATE OF NEW YORK
COUNTY OF SUFFOLK
~VV\C.VVV"'\ ,residing at 4l GDld~rK Pc6Lf{)
V\.A1. llllii:\ ,being duly sworn, ~pose and sa':(s
t at on he \....\ day of All"" ,19-L/, deponent ma~led
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 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,~ai No 'ce were ailed at the United
States Post Office at tt , that said Notices
we,e mailed to each of said perso~)
ma~l. \
.
lic
THE.b, R. '''U"-'.f:?G;I(ORN
Notary Pub!ic, :S'iah.. ot l\h~w York
No, 4-852730
Qualified I!, Su1tol~.COUOty cf)
Commission Expl(G~ FI':'~). 10,a9
6
.
.
ArrtwAH'l'
'rnANSACTIONI\L 11ISCLOSUnR FOnH
The Town of Souhhold's Code of gbhics urohibihs
inl;eresl; on I;he
"
or
tOUR HAHR. V\
Last name, fir t name,
you are applying in the
other entity, such
the other person's
I "
NAtURI ot ArrLI(1AtIONI (Checl( a11 I;hal:. !llJlJly.)
...:> i}:~~~)!~i": :>::~;:,,:';i;Jf,\ ':;<~j(
Tax grievance
Variance
change of zone
^p'p~~al of pial; ,
Exe.ption from plat or official map
other
(If "other," name I;he activity.) 'R0v'ovo:hoVl
"
Uo you personally (ur thruIIgh yuur COMpany, n..uune, nibilng.
parent, or child) hove n relationship with any ufflcer ur
employee of the Town of Southuld1 "Relationship" includes
by blood, ..arriage, or business interen!;. "DunineslI
in!;erellt" Mean" a busine"", including a partnership, in
which the town officer or employee has even a partial
ownership of (or employment by) 11 corporation in which
the town officer or employee owns more than 5% of bhe
shares.
YBS
NU
./
-!,',;\',,,
If you answered "tRS,N, complete the batance ut ~hts tor* and
date and sign where indicated.
Name of person employed by bhe Town of Soul:.hold
Title or pos1b10n of bhab person
Describe bhe relationShip bebwsen yourself (bhe applicanb)
and bhe bown officer or employee. Ribher check the
appropriabe line A) through D) and/or describe in bhe space
provided.
The bown officer or employee or his or her spouse, sibling,
parent, or child is (cheCk all thab apply),
1\) bhe owner of greaber than 5% of bhe shares of bhe
corporate sbock of bhe applic~nb (when bhe applicanb'
ie a corporation),
B) the legal or b~neflcial owner of any Inbeteeb in a
noncorporate'entity (when the applicanb is nob a
corpora t ion),
C) an Officer, director, parbner, ur ~mployee ot bhe
applicant, or
0) bhe actual applicant.
. ,~ ,
DESCRIPTION OF I1ELATIONSIIIP
. ; . ,': :1 ;~ j
1,1,
'" I I. ,
, ", . t ~,l~.'
.., . ~ .~.y . ~ "~. '" .. h. ..... . .t. ,,, ".Ilw..",.,. . r" f.... ..iii '
",'.,
{. " ' ", - - ,.,' ;~".I.::::'''' '.;1I,..;/r,fii':;,:
:' ." 'I,t, ~'i~I(!lr1i,' _~;,t', ':\\"I~f:~'~!}
2.bI'd'~t" at ,'''h',
Subttd.l:be
It '1..' I
Sighllbur
'Prinb name
'. "';~'l'\' /; ',.~'.'. ':',~':~i~'!f~\~~)~' ;'t
j' I ~,~,'.:1,r"":(.'.';"):i..ti4t.~.,.,
. '\\ :~"
It,;. ~