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Home My WebLink AboutTR-6332A e A S®UI` John M. Bredemeyer III, President y®l Town Hall Annex Michael J.Domino,Vice-President 1� c'; .4_: A4,4 , ® : 54375 Main Road ilEf " . • P.O. Box 1179 James F. King, Trustee % ,„ , . Southold, New York 11971-0959 Dave Bergen, Trusteele" t. � ' z y \ •� Charles J. Sanders, Trustee Telephone (631) 765-1892�� Fax(631) 765-6641 .,iii X11 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD July 22, 2015 Patricia C. Moore, Esq. 51020 Main Road Southold, NY 11971 RE: 490 NORTHFIELD LANE, SOUTHOLD SCTM# 79-3-4.2 Dear Ms. Moore: The following action was taken at the Southold Town Board of Trustees regular meeting held on Wednesday, July 22, 2015: RESOLVED, that the Southold Town Board of Trustees APPROVE the request for a Transfer of Administrative Permit#6332A from Sandra Krac and Judith Perez to Regina Melly, as issued on April 19, 2006. If you have any questions, please contact our office at (631) 765-1892. Sincerely, fiY r lf6- John M. Bredemeyer III President, Board of Trustees JMB:eac John Bredemeyer, President ,,.e.oFFni Town Hall Annex Michael J. Domino, Vice-President °,��,��: �c°�$., 54375 Route 25 James F. King i y z'i P.O. Box 1179 Charles J. Sanders ' 4"$ Southold, NY 11971 Dave Bergen 'y�l ,� 1a°:,' Telephone (631) 765-1892 ' Fax (631) 765-6641 Southold Town Board of Trustees Field Inspection/Work Session Report Date/Time: zt.)5 /5 7O/1 Patricia C. Moore, Esq. on behalf of REGINA MELLY requests a Transfer of Administrative Permit #6332A, as issued on April 19, 2006. Located: 490 Northfield Lane, Southold. SCTM# 79-3-4.2 Type of area to be impacted: Saltwater Wetland Freshwater Wetland Sound _623* Distance of proposed work to edge of wetland Part of Town Code proposed work falls under: Chapt.275 Chapt. 111 other Type of Application: Wetland Coastal Erosion Amendment Administrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: Yes No Not Applicable Storm Water Management Review: Yes No Not Applicable Info needed: Modifications: Conditions: 4-yam. Present Were: `. J. Bredemeyer //1. Domino King .D. Bergen Sanders Bay Constable Other Form filled out in the field by Log I Mailed/Faxed to: Date: PATRICIA C. MOORS • Attorney at Law r 51020 Main Road L - - _-__._:. • Southold,New York 11971 Tel: (631) 765-4330 r� Fax: (631) 765-4643 • JUN 2 2 2015 www.mooreattys.com June 22, 2015 Board of Trustees Town of Southold Main Road(Town Hall Annex) Southold NY 11971 hand delivered RE: REGINA MELLY PREMISES: 490 NORTHFIELD LANE, SOUTHOLD SCTM: 1000-79-3-4.2 PERMIT NO'S: 6332A& 7319A Dear President and Board members: Please let this serve as a request to transfer the above permits to the new owner,Regina Melly. My client's check is enclosed for the transfer fee of$100.00 ($50/transfer) Thank you and please call should you have any questions. Very trul . s, rim C. Moore PCM/bp ends. • . James F. King,President /40 S0040 Town Hall Jill M. Doherty,Vice-President 0°141 53095 Route 25 P.O. Box 1179 Peggy A. Dickerson sig * ; Southold,New York 11971-0959 Dave Bergen G Bob Ghosio Jr. :' ` �O�1 Telephone(631)765-1892 Ol�►C�U �A i�0 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE #0252C Date: September 19, 2007 THIS CERTIFIES that the construction of an 8'x12' pre-fabricated shed At 490 Northfield Lane, Southold, New York Suffolk County Tax Map# 79-3-4.2 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 03-09-06 pursuant to which Trustees Permit# 6332A Dated 04/19/06. Was issued, and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the construction of an 8'x12' pre-fabricated shed. The certificate is issued to SANDRA KRAC &JUDITH PEREZ owner of the aforesaid property. /944.4w v0 Authorized Signature • _ _ 0 i : c :o'''''''''----- , Town Hall James F. King,President �� QF S�U Jill M. Doherty,Vice-President '1... . 4 : 53095 Route 25 Peggy A. DickersonP.O. Box 1179 1 Southold,New York 11971-0959 Dave Bergen ; G bic ,$ John Holzapfel :` ... '/ Telephone(631)765-1892 t. 'COUNT`I,* i Fax(631)765-6641 = BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction 1/2 constructed / /� �/ Project complete, compliance inspection.104/.a/. (V!'‹ • • James F. King,President It"%OF SOOry� - Town Hall i Jill M. Doherty,Vice-President ? $ l0 53095 Route 25 y• P.O. Box 1179 Peggy A. Dickerson # T I Southold,New York 11971-0959 Dave Bergen • G 1 John Holzapfel a 1� Telephone(631) 765-1892 o� Fax(631) 765-6641 courins BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. INSPECTION SCHEDULE Pre-construction, hay bale line 1St day of construction 1/2 constructed / v Project complete, compliance inspection. • • James F. King, President i''J�'F SOC74 Town Hall Jill M. Doherty,Vice-President � /� � � 53095 Route 25 y P.O. Box 1179 * Peggy A. Dickerson * Southold,New York 11971-0959 Dave Bergen G Q 1� . i Telephone(631) 765-1892 we A Fax(631) 765-6641 COUri BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 6332A Date of Receipt of Application: March 10, 2006 Applicant: Sandra Krac and Judith Perez SCTM#: 79-3-4.2 Project Location: 490 Northfield Lane, Southold Date of Resolution/Issuance: April 19, 2006 Date of Expiration: April 19, 2008 Reviewed by: Board of Trustees Project Description: Install an 8' x 12' pre-fabricated shed in the location drawn on the plans surveyed by Anthony Abruzzo approved 4/19/06 by the Board of Trustees. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth by the Board of Trustees. Special Conditions: Final inspection If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth by the Board of Trustees, a Wetland Permit will be required. This is not afrao determination from any other agency. 1� James F. King, Vice-President Board of Trustees �IpQ,r� gP� Sac. '�� `10 a • 40. =oaC oc P�.�T' - - S v b 31a. 1' - �_ a /1-...t. I.. 1 8 I OY J cox o� V ' ' - i \�qa 5 I .- __ .- ,... Iv ) tri ,.z N al 1e ..,,.... . r ,2., a l Q ` aca. ° , Jil., QJ "S ° _ r ° 69 / N �� ° I I N 2 r weo9 _ s� I �` N 1I p ;� da�l s II a 1 N i"�® r 1 1 2.' 3 .m�4�� p I 1- h 30o 7? I ■ ~s i t ® I H g o o 11 u ,. � mm t 0 0 N _.,!„<z< \ i APPROVED B. ,0 2¢� OF TRtJSTr� � o BOARD 3IVQ ID TOWN OF bOUTHOLD ,y \_N., DATE ��/9 0(0 ��Q��. Q,\-• k� 87 /' 14?� '� tap of Described Property 4.. .,..4.1%"14:44 oo Situated at Southold Town of Southold, Suffolk County, New York District 1000 Section 79 Block 3 Lot 4.2 MAR - 9 2006 Certified To: Sandra S. Krac ANTHONY ABRUZZO R.L.S. Judith A. Perez REGISTERED LAND SURVEYOR Fidelity National Title Insurance Co. of New York 1700 Hortons Lane Ohio Savings Bank Southold, New York 11971 x Tn� ,,,„� (631) 765-6242 'r4 , ^ SURVEYED: October 5, 2000 .- ti s�c C ”- Scale: 1" = i Fi Wo. 2465 I James F. King,President SOF SOU4 Town Hall d 9p Jill M. Doherty,Vice-President 4� l 53095 Route 25 Peggy A. Dickerson * P.O. Box 1179 Dave Bergen Southold,New York 11971-0959 John Holzapfel %We Telephone(631) 765-1892 i i� Fax(631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: 3/I `a/o C — V10 C O Name of Applicant: FT rc.e Pe re Name of Agent: `` Property Location: SCTM# & Street 79 - 3—'-t 2 `(� wsrr� {� cr (c' ( 5L.. i(a El Brief Description of proposed action: -s ( ( a s-(_f : • • , James F. King,President / * ? S00 UriyO Town Hall Jill M. Doherty,Vice-President �� ,`0 53095 Route 25 Peggy A. Dickerson ,4 P.O. Box 1179 Southold, New York 11971-0959 Dave Bergen �+ John Holzapfel � "e �� Telephone(631)765-1892 � le ' Fax(631) 765-6641 OUNT(, 011i1 roo BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: Sc‘f,.d.z k.CIA c &v.A .ta, h Cerez Please be advised that your application dated 3) It ( Ob has been reviewed by this Board at the regular meeting of y/ 19/ oC 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 Chapter 97 of the Southold Town Code. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: OD TOTAL FEES DUE: $ CO 4.) BY: James F. King, President Board of Trustees • • W ,7 h .ul :l I \ // -- — — — - : l 'z _1 a ter- NropbSrd BX0Si �I' 33110N.3M 1ill as ill.. . ,�, all III m _ .� / wa _ e i dil ' 1i TJ !tti(_ _ 31M1100IM1111M �ffa■'il WMMA'15135(I e II�� y; II Min _ MIII 1,i _ ii=1 II Iil ;un ! IIIHII _�=_}I� N„F Ill -__._. i ,____ __,,,a,_-_L-r,... I _�� / - = =-- / �ila _ an I 11' _ L �/ d _ ��. is LjlIJI;IL i 0 X 1 ill s m in as 446 IIa tiE V2. lis3 W d 1,0, l " 4 • lS � -� I E °� � 99 ! 4,.. a s n� --..,« . s A ! all A.4 A „ . ,,, . ea I ise 8 i 114WWW ;Ili lip tiiremitim oti Rr ar ammth allgatti A 11 if 1 41Racr tr. Marl 4, in ,{1 a 5 it° .; . ilifirl Hu Psi P ,-.1 1 itt gh , rah , „ , 63.5: .2 i.„ , 55 ilrli.. 5i s. ' =NT TDdt Y the ,g ,t�. VII I 1a VIII _ { FpE v ii3/4 ili i r 1 • �� SW15 yWSitI I II II Hs ” attirF74 . 4 - 4 SS -mina 9F€Hf1J -j °-a5i O I i Pik ' =3 I III 4 TN a smik II H SF ! \ O • H1 SH9 ,„ 3 .,... . ,,, Mt rotes* .. .. 3 3 3 ; 0,3 . . :r4, a 44%3 " Sit tit yggq# a 3it H�13 o lr 44 4u. ia ,i,Ail! j = 4 Hifi Alined 11111111 MIi_ I_1_I 1 I 1 __ J — • ''�ii • MAI_ G ADDRESS: PLANNING BOARD MEMBERS �� pf 50117 P.O. Box 1179 JERILYN B.WOODHOUSE �1 i& l� ; Southold, NY 11971 Chair I y 1 T 4 ; OFFICE LOCATION: WILLIAM J.CREMERS tn air N t Town Hall Annex KENNETH L.EDWARDS 14, Cc t -4e IS 54375 State Route 25 MARTIN H. SIDOR (cor.Main Rd. &YoungsAve.) GEORGE D.SOLOMON `�� COM� al°II Southold, NY Telephone: 631 765-1938 Fax: 631 765-3136 PLANNING BOARD OFFICE TOWN OF SOUTHOLD To: Town of Southold Board of Trustees MAR 2 From: Mark Terry, Senior Environmental Planner LWRP Coordinator Date: March 20, 2006 Re: Request for Wetland Permit for SANDRA KRAC & JUDITH PEREZ 490 Northfield Lane, Southold. SCTM#79-3-4.2 SANDRA KRAC & JUDITH PEREZ request an Administrative Permit to install an 8'X 12' pre-fabricated shed. The proposed action has been reviewed to Chapter 95, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the proposed action is generally CONSISTENT with the Policy Standards and therefore is CONSISTENT with the LWRP. Pursuant to Chapter 95, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. Please contact me at (631) 765-1938 if you have any questions regarding the above. • II,,.. ...i' _ • • Albert J.Krupski, President •.' %S3F S0O74 .` Town Hall James King,Vice-President r ,`O ,s 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda Southold,New York 11971-0959 Peggy A. Dickerson G @ r �rr Telephone(631)765-1992 CO(f rr r Fax(631)765-6641 ', err BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application Wetland Permit Application Administrative Permit Amendment/Transfer/Extension 41Received Applicah�,.s3((O1oG ✓Received Fee:$ completed Application 4 j (0 L _Incomplete SEQRA Classification: Type I Type II Unlisted Coordination:(date sent) � MAR - 9 2006 _LWRP Consistency Assessment Form�ril,,{� -DAC Referral tionL /Date offInspection: Receipt of CAC Report: Lead Agency Determination: Technical Review: .-PCiblic Hearing Held: I( e Resolution: Name ofApplicant 22__�ANbR c. MR VUC - 4 . `Pte-/ Address P .O. 1-�`� S'C 501 1'IMF tQ r Ny Phone Number:(3j /4)5`fib`ib Suffolk County Tax Map Number: 1000 - S ECTI Of, 1q ?I ocs 3 LD-1-4 Property Location: 41 I) 1 01/7"6bje(i /ANY—, Ski-14o K ( Lq1 ( • (provide LILCO Pole #,distance to cross streets, and location) AGENT: (If applicable) Address: Phone: — •ard of Trustees Applicat. GENERAL DATA Land Area(in square feet): IU • Area Zoning: 1' ✓t Previous use of property:_ Intended use of property: Prior permits/approvals for site improvements: Agency r2 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): _tat c Ct X I I: SIO pik-&-hic4tect N'offvicei , � qr c q o Nod( eelee Lr9 . • • PROJECT ID NUMBER 617.20 SEAR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1.APPLICANT/SPONSOR _--�\ 2.PROJECT NAME St%)/(virt-s.1124c, Aoh-al .,f3wk- Sm4Eh 3.PROJECT LOCATION: Municipality1(,t (k County Sc([6 I K 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map qqo Mril48e(4 ( tvc . - .Nikki) 64 5. IS PROPOSED ACTION: •Wt-iw j Expansion [1 Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: %tA rar P141tr 064 air g' x zl ` it lte 542tf . 7.AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? Yes u No If no,describe briefly: r99. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) C( AJ}iesraemtial J Industrial n Commercial Agriculture J Park/Forest/Open Space ri Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) nYes yes, list agency name and permit / approval: 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes If yes, list agency name and permit / approval: 12. ,AS,� A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? Elre o I CERTIFY THAT HE•IN IORMAT N PROVIDE ,...48,OVE IS TRUFr T(,/HE BEST OF MY KNOWLEDGE Applicant / Sponsor N me A4/4 K/i JuDet��( M/ TpHE Date: .('S_ Signal L r If the alt on 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) 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. Ei Yes El No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration may be superseded by another involved agency. Ei Yes El No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,if legible) Cl. Existing air quality,surface or groundwater quality or quantity,noise levels,existing traffic pattern,solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly: C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly: • • C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly: C4. A community's existing plans or goals as officially adopted,or a change in use or intensity of use of land or other natural resources?Explain briefly: C5. Growth,subsequent development,or related activities likely to be induced by the proposed action?Explain briefly: C6. Long term,short term,cumulative,or other effects not identified in C1-05? Explain briefly: Cl, Other impacts(including changes in use of either quantityor type of energy? Explain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA(CEA)? (If yes,explain briefly: nYes ❑No E. IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain: nYes n No PART III-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it is substantial,large,important or otherwise significant. Each effect should be assessed in connection with its(a)setting(i.e. urban or rural);(b)probability of occurring; (c)duration;(d)irreversibility;(e) geographic scope;and (f)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 actior WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting this determination. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer) Board of Trustees Application County of Suffolk State of New York )$Nb42 S-4C BEING DULYSWORN DEPOSES AND AFFIRMS THAT HE/ 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. /...✓�. _ 4 ls. rairea . r. et< Signature SWORN TO BEFORE ME THIS qlti DAY OF march ,20 / &M 2, Notary Publ.c MELANIE DOROSKI NOTARY PUBLIC,State of New lb* No.01D04634870 Qualified In Suffolk County Commission Expires September 30„ () t _ a 110 APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same.ame - ry/l d �n,1 /�/��/p/. YOUR NAME: J(TI4V #T -411(441-i tlbl Tiq k)... Pere (Last name,first name,,piddle , unless you are ppl}hng in the name of someone else or other entity,such as a company.If so,indicate the other 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 Mooring Exemption from plat or official map Planning Other (If"Other-,name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%o shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the 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 officer 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 shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP ft Submitted this , ..y of N7;'. r" 200 �s Signatur It Print Name \, brie. Form TS I