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Home My WebLink AboutTR-6146A . . 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 CERTIFICATE OF COMPLIANCE # 0206C Date: June 6, 2007 THIS CERTIFIES that the construction of a second-floor dormer and deck over the existing porch roof at the southwest comer of the dwelling with gutters and drvwells. At 730 Bavview Drive, East Marion, New York Suffolk County Tax Map # 37-5-5 Conforms to the application for a Trustees Permit heretofore filed in this office Dated OS/27/05 pursuant to which Trustees Permit # 6146A Dated 06/22/05. 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 a second-floor dormer and deck over the existing porch roof at the southwest comer of the dwelling with gutters and drvwells. The certificate is issued to John J. Gallagher owner of the f:.U';7j, Authorized Signature Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson . . 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 SOUTH OLD 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 11~IOlG ~cJW, of-- , 1 st day of construction % constructed / Project complete, compliance inspection. f1~"1 /I.6-t ~ ~pi~ wc'Vk CdhJ,~ ofJ ~. 0xAa ~~~ +0 ~~~~ ~~ G/5/o1 {)K-/~ ~ . . Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Soutbold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 6146A Date of Receipt of Application: May 27,2005 Applicant: John J. Gallagher SCTM#: 37-5-5 Project Location: 730 Bayview Dr., East Marion Date of Resolution/Issuance: June 22, 2005 Date of Expiration: June 22, 2007 Reviewed by: Board of Trustees Project Description: To construct a second-floor dormer and deck over the existing porch roof at the southwest corner of the dwelling. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 97 of the Southold Town Code. The issuance of the Administrative Permit allows for the operations as indicated on the survey amended by John Gallagher and received in the office on July 20, 2005. Special Conditions: Hay bales must be placed down along the 8' contour before any activity begins and gutters and drywells installed to contain the roof run-off. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 97 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. bJ.~ 9. .~. ff- Albert J. Krupski, Jr., President Board of Trustees . ~ Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson 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 TO: ,\ () ~ ~ 60..1... \.Cl~ hQ yo- Please be advised that your application dated reviewed by this Board at the regular meeting of following action was taken: j/,}') II) r (l) ~I ()r- has been and the ( v) 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 South old Town Trustees. The fee is computed below according to the schedule of rates as set forth in the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: ~ hY\J.\ 1-f1'S~Ciim fell -. ~SO,m - 1)QD(~d fl\o..\'I da~\L-\,(\~ a. drqwe.L\ l:J (O<\'\o.:~ roof run-oft', TOTAL FEES DUE: $ 5D, 00 SIGNED: ~-j 9. 47QtJ-i'~. PRESIDENT, BOARD OF TRUSTEES . n ..---..--.-....-.4...... , I . ...~._-_.. < . . a D~ B 0 CD ., /. \ , , oj r-- . -- ~L.t.. , . APPEALS BOARD MEMBERS Ruth D. Oliva, Chairwoman Gerard P. Goehringer Vincent Orlando James Dinizio, Jr. Michael A. Simon http://southoldtown.northfork.net . Southold Town Hall 53095 Main Road. P.O. Box 1179 Southold, NY 11971-0959 Office Location: Town Annex IFirst Floor, North Fork Bank 54375 Main Road (at Youngs Avenue) Southold, NY 11971 BOARD OF APPEALS TOWN OF SOUTH OLD Tel. (631) 765-1809. Fax (631) 765-9064 FINDINGS, DELIBERATIONS AND DETERMINATION MEETING OF APRIL 14, 2005 ZB Ref. 5682 - JOHN and JOY GALLAGHER Property Location: 730 Bayview Drive, East Marion; CTM 37-5-5. SEQRA DETERMINATION: The Zoning Board of Appeals has visited the property under consideration in this application and determines that this review falls under the Type II category of the State's List of Actions, without an adverse effect on the environment if the project is implemented as planned. PROPERTY FACTS/DESCRIPTION: The applicant's 8,592 sq. ft. parcel has 52.63 feet along the south side of Bayview Drive, and is improved with a two-story, single-family dwelling as shown on the May 12, 2002 survey prepared by Joseph A. Ingegno, L.S. BASIS OF APPLICATION: Building Department's January 21, 2005 Notice of Disapproval, citing Sections 100-242A and 100-244 in its denial of a building permit application for new additions. The reason stated in the disapproval is that the new construction will increase the degree of nonconformance when located (a) less than 10 feet on a single side, and (b) less than 25 feet for the combined side yards. FINDINGS OF FACT The Zoning Board of Appeals held a public hearing on this application on March 31, 2005 at which time written and oral evidence were presented. Based upon all testimony, documentation, personal inspection of the property, and other evidence, the Zoning Board finds the following facts to be true and relevant: AREA VARIANCE RELIEF REQUESTED: The applicant wishes to construct a second-floor dormer and deck over the existing porch roof at the southwest corner of the dwelling. The setback from the westerly side (right-of-way/walking path) is seven (7) feet, as shown on the copy of a survey prepared 5/10/05 by Mark Kevin Schwartz, R.A. REASONS FOR BOARD ACTION: On the basis of testimony presented, materials submitted and personal inspections, the Board makes the following findings: 1. Grant of the variance will not produce an undesirable change in the character of the neighborhood or a detriment to nearby properties. There will be no change in the footprint, and the existing footprint conforms to the streetscape. Page 2 - April 14, 2005 ZB Ref. 5682 - John and Joy Gallagher elM 10: 37-5-5 . . , 2. The benefit sought by the applicant cannot be achieved by any method feasible for the applicant to pursue other than through an area variance. The room to be enlarged is the only second-floor bedroom and is on the side of the house with an existing setback of less than 10 feet. 3. The amount of relief requested is not substantial; the addition does not raise the height of the roof ridge of existing of the house. 4. The difficulty was not self-created. 5. The variance in this community of private homes will not have an adverse impact on the physical or environmental conditions in the neighborhood. The house will remain a 1-Y:. story structure. Grant of this variance relief is the minimum action necessary and adequate to enable the applicant to enjoy the benefit of an addition, while preserving and protecting the character of the neighborhood and the health, safety and welfare of the community. BOARD RESOLUTION: On the basis of testimony presented, materials submitted and personal inspections, the Board makes the following findings: NOW, therefore, on motion by Member Simon, seconded by Member Orlando, it was RESOLVED, to GRANT the variance, as applied for and shown on the drawings prepared 5/10/05 by Mark Schwartz, Architect, and the May 31, 2002 survey prepared by Joseph A. Ingegno, Land Surveyor. Vote of the Board: Ayes: Members Oliva (Chairwoman), Orlando, Goehringer, Dinizio, and Simon. This Resolution was duly adopted (5-0). GLw)~.&~ Ruth D. Oliva, Chairwoman 5/6/05 Approved for Filing I I i I I I,; Ilill -'1~ -+~ , o ~ "' I ce> Z _c_~--- I - Q - , i " ,~ i Ii , ! i , j , I I , i , , i i I' I -\ 8 ~ ~ tt" ~. ~ ~' ~ ~ Q. u c .' II ::l ., " , O! ~~ , I~ -+ I -il_~ I r" , , ! .' . MAIliNG ADDRESS: P.O. Box 1179 Southold, NY 11971 OFFICE WCATION: Town Hall Annex 54375 State Route 25 (cor. Main Rd. & Youngs Ave.) Southold, NY Telephone: 631 765-1938 Fax: 631 765-3136 PLANNING BOARD MEMBERS JERILYN B. WOODHOUSE Chair WILLIAM J. CREMERS KENNETH L. EDWARDS MARTIN H. SIDOR GEORGE D. SOLOMON PLANNING BOARD OFFICE TOWN OF SOUTHOLD To: Town of South old Board of Trustees From: Mark Terry, Senior Environmental Planner ~ L WRP Coordinator Date: June 20, 2005 Re: Request for Administrative Permit for John J Gallagher SCTM#1000-37-5-5 The proposed action involves the construction of a second floor dormer and deck over existing porch roof at the southwest comer of the dwelling. The proposed action has been reviewed to Chapter 95, Waterfront Consistency Review of the Town of South old Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the L WRP 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 provided that the following standard best management practices are implemented. 1. In the event that soil is disturbed, employ erosion and sediment controls (haybales, silt fencing) to protect the wetland system. 2. Employ water quality protection measures for areas generating runoff (gutters, downspouts and dry wells). Pursuant to Chapter 95, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency ofthe proposed action. Please contact me at (631) 765-1938 if you have any questions regarding the above. . . Albert J. Krupski, President James King, Vice-President Artie Foster Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-~'''101J1 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only ~ Coastal Erosion Pennit Applicat% ~ Wetland Permit Application _ Administrative Permit Amendment/Transfer/Extension ~~ceived Application:....s.)dQlQ...~ REceived Fee:$ ~S1)' .....eompleted Application 51 dl) I~ ~~~ lE ~ WJ ~!ij ~Incomplete ~SEQRA Classification: Type I_Type II_ Unlisted - 20[ Ii ' ~ Coordination:(date sent) MAY 2 7 10 ~AC Referral Sent: (\ \0: --'EYate of Inspection:--4l1 I ~i'J\ S(;:!t!~<i:d Town ~Receipt ofCAC Report: Bn,1id of Trustees ~ Lead Agency Detennination:~ Technical Review: .Aliblic Hearing Held:~ Resolution: G cdl 0-- ~ ~ f t~ r 0 b-t-{ 1.'2. '1 Jv-~v'c... (Cc$+ ,MH10"'-, fJ./. Phone Number:(b~) 4- 7 7 - ~ ~ q q .-- Suffolk County Tax Map Number: 1000 - '3 } ,) - ') Property Location: GC<.r~Il'\{r'" ~"I C5~~ !-.of- Fv-ow- l~o{c<....- d r'ilJ't /-[ I- C 0 (provide LILCO Pole #, distance to cross streets, and location) Name of Applicant Address 130 IIq~1 ~ h VlT. I~"\I Viev.' r/ 9.) ~Lv:l 1/2- Pole C AGENT: (If applicable) Address: Phone: 4Itoard of Trustees APPlicat~n GENERAL DATA Area Zoning: f})~z..-.d-7 ~+-r ~ ~+I"( /2et; I ~f-t~l Land Area (in square feet): Previous use of property: Intended use of property: Prior permits/approvals for site improvements: , Agency Sov\-"-.t>Iv' lV'v'7~5 Date t./ /70/ 0 ~ _ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or susp~~ by a governmental agency? No Yes If yes, provide explanation: Project Description (use attachments if necessary): (:Oll\::'>..\.-I-- V &}, ~ o ~ t.\... S'e{{),,\v^ Floc;...- ch.,..W\ C'r-- a-v.oI ohcl( Over +k. e1/s+,''''j fov-e-l rooP C\~ Sov+\-...v-e'1t CRl'rVlflV- of ~ c-Il.0ell,'^). .s<<.... q +t- o..c-i- e ~ p Icv.-v\ . 4Iloard of Trustees APPlicat~n WETLAND/TRUSTEE LANDS APPLICA nON DATA Purpose of the proposed operations:_r .b'V\'7 +rc/cJ.'GM- (') r 0..-. 5e('Gl1J f;:/vor J..e>V'w-er'" a-vJ th-e)" Over ~ (DD ~ cd- +eo.( So utk IA) f' ~ t CeJn'l ev- eY. i~ +, ''''-J o.p f-< fhrcL kel/,.~ Area of wetlands on lot: square feet Percent coverage oflot: % Closest distance between,ejlfest existing structure and upland edge of wetlands: . b feet Closest distance between nearest proposed structure and upland edge of wetlands: 0 C feet Does the project involve excavation or filling? /" No Yes If yes, how 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, ifany, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): S\'" <<- ~ ~'7} i"Uvh~,\ 01,1""'- fl,e- e~l~h~ otwell I'''\.) , T Jo V\or ey.fepj- 'T- ev I \ \ ~Cl.J e ~y h) r-.\.4r I M f~ eN\.. tc eM v~~o\'\. w.-eJ 4Itoard of Trustees ApPlica~n COASTAL EROSION APPLICA nON DATA Purposes of proposed activity: ~ '7 tv- "i' ~ I L'-'- O.f ~ 5R.t' RJv\ t! l./roy- ct>f\M{V" ~ ~I'lf olioV' ~ (}<I'j~l'^j for"L (lJ<-F Are wetlands present within 100 feet of the proposed activity? No Yes Does the project involve excavation or filling? / No Yes If Yes, how much material will be excavated? o (cubic yards) How much material will be filled? o (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) S- 1\1\ v e. -tt- ~ s _tk- (' ,-" 'S' +'\ h :; e')( f-eC/1- r r W I _I Vv\ p~+ OV\ UM "> -t-v-vd (~ ~cll,'=s) rr ~ v10T II ~ Gtve G./v...y PVV' ~ tL-<- ~ VI',r 0 V\ \It1 e IA. f-- . (::, aveV'" PART 1 - PROJECT INFORMATION I- 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only (To be completed by Applicant or Project Sponsor) - SEQR I PROJECT 10 NUMBER 3.PROJECT LOCATION: 2. PROJECT NAME 1. APPLICANT I SPONSOR ~ ---- J oh", d- Municipality ou.(..i.\() ). County ~ersections, Prominent J) rl 'it.- 1.>~ 8.1 ~ Fo/I< 4. PRECISE LOCATION: Street Addess and Road 770 r'!:>fAY 11'((<0 Wl-\.ll k, II NY. 5. IS PROPOSED ACTION: ~ew landmarks ate - or provide map ~ificatjOn I alteration 6. DESCRIBE PROJECT BRIEFLY: ~'7 r-V-v' v ~ 'U'^-. Over- tfr.c e'f 1'7 h~ (j;Y'I/Ier 0 F tt'-<- uP "'- S' e-t-O...1 API {)o r roo ~ t\...l- olcrWlf.... ,,^^,CJ M t4- S' ou f!.-, (.0 ( 7 +- , po rd,,- oL-oe tl\'oI\ S 8. WILL PROPOSED ACTION COMPLY p's D No Ultimately )J l+ acres WITH EXISTING ZONING OR OTHER RESTRICTIONS? 7. AMOUNT OF LAND AFFECTED: Initially acres If no, describe briefly: IS PRESENT LAND USE IN VICINITY D Industrial D Commercial OF PROJECT? (Choose as many as apply.) OAgriculture D Park I Forest I Open Space D Other (describe) Ho"'^~ W I f1.-- cloG-v. 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, ,State or Local) D Yes ~ If yes, list agency name and permit I approval: ". DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? DYes? If yes, list agency name and permit I approval: 12. AS A RES OF PROPOSED ACTION WILL EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION? []yes No I CERTIFY THAT ROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Si nature :ro\A~ -:r G'tll~t. ~~ 5/:2-7/0{' Applicant I Sponsor Name 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 b Lead Agenc ) A. DOES ACTION E 0 ANY TYPE t THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. D Yes No B. WILL ACTIO RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be erseded by another involved agency. c=J Ves 0 C. COULD AC ION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surtace or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, rte~~: erosion, drainage or flooding problems? Explain briefly: I C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: I )v'U I C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: I /Vu I 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: I ;Vo I C5. rowt~b~quent development, or related activities likely to be induced by the proposed action? Explain briefly: I C6. rng ~s:ort term, cumulative, or other effects not identified in C1-C5? Explain briefly: I C7. Other im acts (including chan es in use of either uanti or t e of ener ? Ex lain briefly: o D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONME~REA (CEA)? (If yes, explain briefly: DYes )Ll No I E IOH;:sE' pT LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If yes explain PART III - DETERMINATION OF SIGNIFICANCE (To be campleled 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 impactofthe 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 FUL 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 actio 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 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) 4Itoard of Trustees APPlicat~n County of Suffolk State of New York tr ,') ,^vV C od I "'-- "J k e V' BEING DULY SWORN 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 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. ~s~ SWORN TO BEFORE ME THIS P-- 7'" DAYOF /iA'(] ,202.5 KIERAN M. CORCORAN Notary Public. Stale of New'1l>rlI ~NO. 02C06119838 in SUlfuIk CountY 0"-' , Elq);IllS December 6, ZIl...:,.. I) . . APPLICANT/AGENTIREPRESENT ATIVE TRANSACTIONAL DISCLOSURE FORM The Town of South old's Code of Ethics nrohibits conflicts of interest on the Dart of town officers and emo]ovees. The nuroose of this Conn is to nrovide information which can alert the town of nossible conflicts of interest and allow it to take whatever action is necessarY to avoid same. YOUR NAME: (Las~~r~ name~dle~~l~~-;:I, h::' 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.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Variance Change of Zone Approval of plat Exemption from plat or official map Other (If "Other", name the activity.) /' Building Trustee Coastal Erosion Mooring Planning 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 busmess 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% of the 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) andlor descrihe in the space provided. The town officer or employee or his or her spouse, sihling, parent, or child is (check all that apply): -^) the owner of greater than 5% of the shares of the corporate stock of the applic~nt (when the applicant is a corporation); _B) the legal or heneficial 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 S~bmitte~Of~ 200~ SIgnature . . Print Name "" R~ Form TS I /"" ~ . ~ ... (, " t,__-._* .-. 't- ~ . / I o. <b ." , . . ~ ~z % ~~ Jll~ ~ 00 ~I ~ ~ tv .'/ -,......., ~ ~ . p~ ~- ~ ~-/ '" 0 ~ 0 ," ~ ~ - . ... 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