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HomeMy WebLinkAboutTR-7617E Jill M. Doherty, President Bob Ghosio, Jr., Vice-President James F. King Dave Bergen John Bredemeyer Town Hall Annex 54375 Main Road P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD EMERGENCY WETLANDS PERMIT Permit No,: 7617E Date of Receipt of Application: September 6, 2011 Applicant: Pat lavarone SCTM#: 110-7-3 Project Location: 995 West Road, Cutchogue Date of Issuance: September 7, 2011 Date of Expiration: N/A Reviewed by: Board of Trustees Project Description: Temporarily place plywood onto wall of existing bulkhead and place sandbags against plywood for added support. Measure is proposed as a temporary stop-gap until all regulatory approvals can be obtained to construct vinyl bulkhead in place of damaged structure. Findings: The project meets the requirements for issuance of an Emergency Wetlands Permit as determined by the Board of Trustees. The issuance of an Emergency Wetlands Permit allows for the operations as indicated in the application received on September 6, 2011. Special Conditions: A full Wetland Permit must be obtained in order to conduct any further activity on the bulkhead. This is not a determination from any other agency. I~M. Dohert~nt Board of Trustees SOUTHOLD TRUS No. ~ ISsued To~ Date~ Address~ THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765-1892 NEW YORK STATE DEPARTMI~OF ENVIRONMENTAL CONSERVATI Fat~tity DEC ID 1-4738-03813 PERMIT Under the Environmental Conservation Law (ECL) Permittee and Facility Information Permit lssued To: PAT IAVARONE 6 SUTTON PL MANHASSET, NY 11030 Facility: IAVARONE PROPERTY 995 WEST RDISCTM# 1000-110-7-3 CUTCHOGUE, NY 11935 Facility Application Contact: GARY MOSES 2 WHALENECK DR MERRICK, NY 11566-5300 (516) 546-3479 Facility Location: in SOUTHOLD in SUFFOLK COUNTY Village: Cutcho Facility Principal Reference Point: NYTM-E: 712.9 NYTM-N: 4542.3 Latitude: 41°00'14.8'' Longitude: 72028'06.6'' Project Location: 995 West Road - Watercourse - Cutchogue Harbor Authorized Activity: In-place replacement of approximately 112 linear feet of ekisting functional bulkheading and backfill. Replacement of existing returns and the construction of two new six foot long bulkhead returns. Reconstruct existing parallel capping boardwalk landward of bulkhead. All authorized activities shall be done in strict conformance prepared by Bulkhead Permits by Gary, 7/7/11 with the attached plans stamped "NYSDEC Approved" on 7/19/11. SAP# 1-08-010 Permit Authorizations Tidal Wetlands - Under Article 25 Permit ID 1-4738-03813/00002 New Permit Effective Date: 7/26/2011 Expiration Date: 7/25/2016 Excavation & Fill in Navigable Waters - Under Article 15, Title 5 Permit ID 1 ~4738-03813/00003 New Permit Effective Date: 7/26/2011 Expiration Date: 7/25/2016 Water Quality Certification - Under Section 401 - Clean Water Act Permit ID 1-4738-03813/00004 New Permit Effective Date: 7/26/2011 NYSDEC Approval Expiration Date: 7/25/2016 By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, ali applicable regulations, and ali conditions included as part of this permit. Permit Administrator: SUSAN ACKERMAN, Deputy Regional Permit Administrator Page 1 of 6 NEW YORK STATE DEPARTMI Facility DEC In 1-4738-03813 OF ENVIRONMENTAL CONSERVATIO Address: NYSDEC REGION 1 HEADQUARTERS SUNY ~STONY BROOKI50 CIRCLE RD Authorized Signature: ST /cv],.._ O~0ONY'~BR OKI NY 1179 / Date ~) /~.(, Distribution List GARY MOSES Habitat - TW SUSAN ACKERMAN Permit Components NATURAL RESOURCE PERMIT CONDITIONS WATER QUALITY CERTIFICATION SPECIFIC CONDITION GENERAL CONDITIONS, APPLY TO ALL AUTHORIZED PERMITS NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS NATURAL RESOURCE PERMIT CONDITIONS - Apply to the FollOwing Permits: TIDAL WETLANDS; EXCAVATION & FILL IN NAVIGABLE WATERS; WATER QUALITY CERTIFICATION 1. Regulated Activities Authorized By This Permit This permit ONLY authorizes those regulated activities / structures identified under the section titled "SAP Authorized Activity". The Department does not issue after-the-fact or as-built permits. This permit does not authorize activities, or legitimize the existence of structures, which would have required a permit but for which no permit or other authorization has been granted by the Department. 2. Conformance With Plans All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or applicant's agent as part of the permit application. Such approved plans were prepared by Bulkhead Permits by Gary, 7/7/11 with the attached plans stamped "NYSDEC Approved" on 7/19/11. 3. Notice of Commencement At least 48 hours prior to commencement of the project, the permittee and contractor shall sign and return the top portion of the enclosed notification form certifying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion of project, the bottom portion of the form must also be signed and returned, along with photographs of the completed work. 4. No Disturbance to Vegetated Tidal Wetlands There shall be no disturbance to vegetated tidal wetlands or protected buffer areas as a result of the permitted activities. Page 2 of 6 New York State Department of Environmental Conservation Division of Environmental Permits, Region One SUNY @ Stony Brook, 50 Circle Road, Stony Brook, NY 11790-3409 Phone: (631)444-0357 Fax: (631)444-0360 Website: www.dec.ny.qov Joe Martens Commissioner Pat lavarone 6 Sutton Place Manhasset, NY 11030 Re: Permit No.: 1-4738-03813/00002 July 21,2011 Dear Permittee: In conformance with the requirements of the State Uniform Procedures Act (Article 70, ECL) and its implementing regulations (6NYCRR, Part 621 ) we are enclosing your permit. Please carefully read all permit conditions and special permit conditions contained in the permit to ensure compliance dudng the term of the permit. If you are unable to comply with any conditions please contact us at the above address. Also enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather. n V. Ackerman it Administrator SVNIs NEW YORK STATE DEPARTMI Facility DEC ID 1-4738-03813 OF ENVIRONMENTAL CONSERVATI~ 5. No Construction Debris in Wetland or Adjacent Area Any debris or excess material from construction of this project shall be completely removed from the adjacent area (upland) and removed to an approved upland area for disposal. No debris is permitted in wetlands and/or protected buffer areas. 6. No Seaward Extension of Bulkhead The new bulkhead shall be constructed in place of the existing bulkhead with no seaward extension of the outermost bulkhead face. 7. Excavation for Bulkhead/Structure Prior to any construction or removal of bulkheads and other shoreline stabilization structures all backfill shall be excavated landward of the structure and retained so as not to enter the waterway, tidal wetland or protected buffer area. 8. Replacement Bulkhead Maximum Height The top elevation of the replacement bulkhead shall be no more than 18 inches higher than the existing bulkhead. 9. Use of Treated Wood The use of wood treated with creosote, pentachlorophenol or other wood treatment not specifically approved by the department for use in wetlands and/or marine waters, is strictly prohibited in the construction of structures that will be in contact with tidal waters. 10. Jet-in Bulkhead Bulkheads constructed directly adjacent to vegetated tidal wetlands shall be hand driven or jetted in with no disturbance to the tidal wetland. Trenching is strictly prohibited. 11. Clean Fill Only All fill shall consist of clean sand, gravel, or soil (not asphalt, slag, flyash, broken concrete or demolition debris). 12. No Beach Excavation For Fill No excavation of the beach is authorized for the purpose of obtaining fill or stone materials. 13. Backf'flling The installation of the approved replacement bulkhead shall be completed prior to the placement of any fill material behind the structure. 14. No Dredging or Excavation No dredging, excavating or other alteration of shoreline or underwater areas is authorized by this permit, nor shall issuance of this permit be construed to suggest that the Deparhnent will issue a permit for such activities in the future. 15. No Runoff Over or Through Bulkhead or into Wetland Upon completion of the bulkhead replacement authorized herein, there shall be no discharge of runoff or other effluent over or through the structure or into any tidal wetland or protected buffer area. 16. Parallel Capping Boardwalk The width 0fthe parallel capping boardwalk shall not exceed six (6) feet. No portion of the boardwalk shall extend seaward of the most seaward face of the bulkhead sheathing. 17. No Structures on Reconstructed Bulkhead or Pilings No structures, other than structures specifically authorized by this permit, shall be constructed on the reconstructed bulkhead or pilings without further authorization from the Department (new pem~it, modified pcm~it). 18. Storage of Equipment,, Materials The storage of construction equipment and materials shall be confined to the upland area landward of the bulkhead or on a barge. 19. Seeding Disturbed Areas All areas of soil disturbance resulting from the approved project shall be Page 3 of 6 NEW YORK STATE DEPARTM~OF ENVIRONMENTAL CONSERVATI~ Facility DEC ID 1-4738-03813 -- stabilized with appropriate vegetation (grasses, etc.) immediately following project completion or prior to permit expiration, whichever comes first. If the project site remains inactive for more than 48 hours or planting is impractical due to the season, then the area shall be stabilized with straw or hay mulch or jute matting until weather conditions favor germination. 20. Temporary Mulch, Final Seeding If seeding is impracticable due to the time of year, a temporary mulch shall be applied and final seeding shall be performed at the earliest opportunity when weather conditions favor germination and growth but not more than six months after project completion. 21. No Interference With Navigation There shall be no umeasonable interference with navigation by the work herein authorized. 22. State May Order Removal or Alteration of Work If future operations by the State of New York require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural resources of the State, the owner may be ordered by the Department to remove or alter the structural work, obstructions, or hazards caused thereby without expense to the State, and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other modification of the watercourse hereby authorized shall not be completed, the owners, shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall be made against the State of New York on account of any such removal or alteration. 23. Precautions Against Contamination of Waters All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project. 24. State Not Liable for Damage The State of New York shall in no case be liable for any damage or injury to the structure or work herein authorized which may be caused by or result from future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no claim or right to compensation shall accrue from any such damage. 25. State May Require Site Restoration If upon the expiration or revocation of this permit, the project hereby authorized has not been completed, the applicant shall, without eXpense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may lawfully require, remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. WATER QUALITY CERTIFICATION SPECIFIC CONDITIONS I 1. Water Quality Certification The NYS Department of Environmental Conservation hereby certifies that the subject project will not conlxavene effluent limitations or other limitations or standards under Sections 301,302, 303, 306 and 307 of the Clean Water Act of 1977 (PL 95-217) provided that all of the conditions listed herein are met. Page 4 of 6 NEW YORK ST ATE DEP ARTMI~OF ENVIRONMENT AL CONSER V A Tie ~ Faollty DEC ID 1-4738-03813 GENERAL CONDITIONS - Apply to ALL Authorized Permits: 1. Facility Inspection by The Department The permitted site or facility, including relevant records, is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Department) to determine whether the permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71- 0301 and SAPA 401(3). The permittee shall provide a person to accompany the Department's representative during an inspection to the permit area when requested by the Department. A copy of this permit, including all referenced maps, drawings and special conditions, must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. 2. Relationship of this Permit to Other Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Depmhnent or any of the terms, conditions or requirements contained in such order or determination. 3. Applications For Permit Renewals, Modifications or Transfers The permittee must submit a separate written application to the Department for permit renewal, modification or transfer of this permit. Such application must include any forms or supplemental information the Department requires. Any renewal, modification or transfer granted by the Depadlnent must be in writing. Submission of applications for permit renewal, modifiqation or transfer are to be submitted to: Regional Permit Administrator NYSDEC REGION 1 HEADQUARTERS SUNY ~ STONY BROOKI50 CIRCLE RD STONY BROOK, NY11790 -3409 4. Submission of Renewal Application The permittee must submit a renewal application at least 30 days before permit expiration for the following permit authorizations: Excavation & Fill in Navigable waters, Tidal Wetlands, Water Quality Certification. 5. Permit Modifications, Suspensions and Revocations by the Department The Depa~hnent reserves the fight to exercise ali available authority to modify, suspend or revoke this p~mfit. The grounds for modification, suspension or revocation include: a. materially false or inaccurate statements in the permit application or supporting papers; b. failure by the permittee to comply with any terms or conditions of the pcmdt; c. exceeding the scope of the project as described in the permit application; Page 5 of 6 NEW YORK STATE DEPARTM~OF ENVIRONMENT AL CONSERV ATI~ Facility DEC 1D 1-4738-03813 d. newly discovered material information or a material change in environmental conditions, relevant technology or applicable law or regulations since the issuance of the existing permit; noncompliance with previously issued permit conditions, orders of the commissioner, any provisions of the Environmental Conservation Law or regulations of the Department related to the permitted activity. 6. Permit Transfer Permits are transferrable unless specifically prohibited by statute, regulation or another permit condition. Applications for permit transfer should be submitted prior to actual transfer of ownership. NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee, excepting state or federal agencies, expressly agrees to indemnify and hold harmless the Department of Environmental Conservation of thc State of New York, its representatives, employees, and agents ("DEC") for all claims, suits, actions, and damages, to the extent attributable to the permittee's acts or omissions in connection with the permittee's undertaking of activities in connection with, or operation and maintenance of, the facility or facilities authorized by the permit whether in compliance or not in compliance with the terms and conditions of the permit. This indemnification does pot extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or intentional acts or omissions, or to any claims, suits, or actions naming the DEC and arising under Article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision under federal or state laws. Item B: Permittee's Contractors to Comply with Permit The permittee is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit, including all special conditions while acting as the permittec's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee. Item C: Permittee Responsible for Obtaining Other Required Permits The permittee is responsible for obtaining any other permits, approvals, lands, easements and rights-of- way that may be required to carry out the activities that are authorized by this permit. Item D: No Right to Trespass or Interfere with Riparian Rights This permit does not convey to the permittee any right to ~espass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. Page 6 of 6 Applicant: Pat lavarone Project Site: 995 West Rd Cutchogue, NY 11935 Proposed: Navy bulkhead replacement in kind & place Prepared by Bulkhead Permits by Gary Inc 2 Whaleneck Dr Merrick NY 11566 Scale 1"=50' July 7, 2011 Project Plan ?~'? - 6 201i ~;, ~dh~o!d ]'own Helen M Rynd 1165 West Rd Cutchogue, NY 11935-2257 Flood _ Cutcho~ue Harbor ~idth 3200' Leonard R~din [ 805 West Rd Cutchogue NY 11935 All hardware, nails and bolts shall be hot dip galvanized, all bolt heads and nuts will be used with cut washers. All timber will be cca treated marine grade, All vinyl sheathing will be interlocking madne grade, All inland backfill will be clean soil, Cross View ~ 93' ~ 135' Not to Scalo Applicant: Pat tavamne Project Site: 995 West Rd Cutchogue, NY 11935 Proposed: Navy bulkhead replacement in kind & place Prepared by Bulkhead Permits by Gary Inc 2 Whaleneck Dr Merrick NY 11566 Scale 1"=50' July 7, 2011 Jill M. Doherty, President James F. King, Vice-President Dave Bergen Bob Ghosio, Jr. John Bredemeyer lown Hall, 53095 Main Rd. P.O. Box 1179 Southold, NY 11971 Telephone (63 I) 765-1892 Fax (63 I) 765-6641 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD J n ,~ n ,. C~f?ce Use Only C orSecc/ __Coas~l Erosion Pe~t Application ~Wetland Pemit Application Adminismfive Pemit ~endmen~r~f~Extension Received Application: 9/~[t/ Received Fee:$ .~ ~Completed Application ~Incomplete ~SEQ~ Classification: T~e I T~e II Unlisted ~Coordination:(date sent) ~L~ Consistency Assessment Fora ~CAC Refe~al Sent: ~Date of Inspection: ~Receipt ofCAC Repo~: ~Lead Agency Dete~ination:~ ~Tec~ical Review: ~ublic Hearing Held: ~Resolution: Name of Applicant Address Phone Numb~':(~l(¢ Suffolk County Tax Map Number: 1000 - I I O Property Location: ~'~f' t~ 7' ~ (provide ~ILCO Pole #~ distance to ~oss strcets~ ~nd location) AGENT: (If applicable) Address: Phone: trd of Trustees Applicati~ Land Area (in square feet): Area Zoning: GENERAL DATA Previous use of property: Intended use of property: Covenants and Restrictions: If "Yes", please provide copy. Yes No Does this project require a variance from the Zoning Board of Appeals __ If "Yes", please provide copy of decision. Prior permits/approvals for site improvements: Agency Date Yes No __ No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspende~a gov~mtal agency? -~ No Yes If yes, provide explanation: Project Description (use attachments if necessary):_ Board of Trustees Application VOgTLANDfFRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: square feet Percent coverage of lot: t~ % Closest distance between near. est existing structure and upland edge of wetlands: I :~" feet Closest distance betweennear-est proposed structure and upland edge of wetlands: /~ feet Does the project involve excavation or filling? No Yes If yes, how much material will be excavated? How much material will be filled? Depth of which material will be removed or deposited: Proposed slope ttucoughout the area of operations: Manner in which material will be removed or deposited: cubic yards cubic yards feet Statement of the effect, !f ~nY, on the wetl~ands and tidal waters_ 9f~e town that may_ r_~_sult by reason of such proposed operations (use attachments if appropriate): PROJECT ID NUMBER PART 1 - PROJECT INFORMATION 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only ( To be completed by Applicant or Project Sponsor) 2. PROJECT NAME SEQR 1. APPLICANT / SPONSOR 3 PROJECT LOCATION: 4. PRECISE LOCATION: Street Addess and Road Intersections. Prominent landmarks etc -or provide map 5. iS PROPOSED ACTION: [] New []Expansion i']MoOificationlalteration 6 DESCRIBE PROJECT BRIEFLY: 7 AMOUNT OF LAND AFFECTED: Indially acres Ultimately acres 8 WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING QR OTHER RESTRICTIONS? E~es [] No If no, describe briefly: 9. ~NR Z iS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) ~Re~identia, []Industrial ~-~Commercial [~Agriculture C~ParklForesllOpenSpace []Other (describe) 10~' DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGEN~(Federal, State or Local) L~Yes []No if yes. list agency name and permit / approval: [ ~I.t)L)L5 NY A~PE~r~'-IHE ACTION HAVE A CURRENTLY VALID ^[]No If yes, list agency name and permit / approval: PERMIT OR APPROVAL? ...... 12. AS A RES OF PROPOSED ACTION WILL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? I CERTIFY THAT T/~INFORM~'./ON PROVIDED ABOVE iS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Name //,~~ Date: Signature ~' ~ '[ ~ If t tion is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment of Trustees Applica~n County of Suffolk State of New York 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 1N 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 1 PREMISE~//JUN~ ~.~ ~ ION~r WITH [I.~PERTYJ, O INSPECT THE 7HI~WPLICATION. nature SWORN TO BEFORE ME THIS ~0g'- DAY ,20 j/ LAUREN M. STANDISH Nofarj.,Public, State of New York r~o. 01ST6164008 Qualified in Suffo k County Commission Expires Apdl 9, 20/~' AUTHORIZATION (where the applicant is not the owner) (print owner of property) residing at ~3-~c~i/~-z~ (mailing address) ~J~W ;V~ //f~do hereby authorize (Agent) to apply for permit(s) from the Southold Bo~ Trustees on my behalf. ~$ signature) APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics orohibits conflicts of interest on thc oart of town officers and emnlovecs. The ouranse of this form is to nrovide information which can alert the town ofnossible conflicts of interest and allow it to take whatever action is necessary to avoid same. (Last name, first name, middle initial, unless you are 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 Building Variance Trustee Change of Zone Co~-stal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (lf"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, incinding 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~5,ghares. YES NO 1 f 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 appropria e ne 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 thc shares of the corporate stock of the applicant (when the applicant is a corporation); __B) the legal or 'beneficial own~ 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 Form TS I Submitted this ~ day al' ~ ¢ 1~ 200 I ~- PrintNamo / ~/ ~ ~ ~,1 ~, ~