The URL can be used to link to this page

Home My WebLink AboutTR-4233 Z`Fvo � e .F' Board Of Southold Town Trustees 2 SOUTHOLD, NEW YORK ` b....26,.._2003 , PERMIT NO. DATE: ...Fe.... INGER BOYAJIAN ,. ISSUED TO ......... .......... ... ....._........................ ... . .... .. .. ........ .......... ... 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 26.r... - 2003 . ......... and in consideration of the sum of $..3 3o....a!.o...0 . .. paid by t. Inger Boyajian ........ . ..... ...................................I............. ..... ., of ,,...,., Wading. River N. Y. and subject to the ' Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits rho following: y' r wetland Permit to renovate the house,deck,and bulkhead within the existing footprint,with the condition that drywells and gutters are installed to contain the roof run-off,no work can be done on the jetty unless the applicant comes before the Board with an application to amend the permit and include a plan for a iow-profile jetty,the first story finished floor height elevation of the house shall not increase greater than 24"from the present elevation,and as depicted on the pian prepared by John C.Ehlers dated May 19,2003 and the survey prepared 200 by John C.Ehlers last dated June 11, 3 .. .. ....., ..._ _,..arse/] specifications as presented in the originating application. IN WITNESS WHEREOF, The said Board of Trustees hare- by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this data. in t � 7 M LOCKWOOD, KESSLER & BARTLETT, INC. ONE AERIAL WAY.SYOSSET.NEW YORK 11791 CONSULTING ENGINEERS-SINCE 1889 (516)938-0600 October 5, 1984 i I Tony Scarmato Inc. 16 West 46th Street New York, New York 10036 Attention: Tony Scarmato Gentlemen: i This will certify that photograph number 3339-53-311 at a scale of 1"=200' covering the Bay Avenue area in East Marion, New York was taken on March 28, 1978 in the normal course of our business and is a true rendition of the ground. No retouching or alterations were performed on the original negatives or resultant enlargements. Very truly yours, LOCKWOOD, KESSLER & BARTLETT, INC. SAC/pn Sylvester A. Celebrini , L.S. Director, Survey and Mapping I i D xt COMPANY l� DF SOU'�;` ._.,, A TOWN AN EQUAL OPPORTUNITY EMPLOYER r. i TEL.765-1802 p5 1p TOWN OF SOUTHOLD .� OFFICE OF BUILDING INSPECTOR o P.O.BOX 728 ' v' TOWN HALL _ SOUTHOLD,N.Y. 11971 November 8 , 1984 TO: Henry Smith, Chairman Board ofTrus ees FROM: Vic Lessard, Exec . Administrator - SUBJECT: Scarmato letter on groin �� Researching the work stated by Mr. Scarmato, I cannot find any evidence of approvals by Southold Town. Mr. Zaterain claims. his bulkhead was rebuilt and re- p.aired in place which would not need a Wetland Per- mit . There does not seem to be anything in the rec- ords to contradict this statement. Mr. Scarmato in- dicates in his letter that. no groins ; bulkheads etc . ever existed until the fall of 1982 .. Photo taken (accor,ding to Sylvester A Celebrini, L. S. ) on March 28 , 1978 seems. to indicate only .the concrete wall and no groin. -Now the Building Inspector informs ,me that a bulkhead ; forward of this existing cement retaining wall; and a "new" groin; "photos by Building Inspector. The Building Department will now wait for what-ever action the Board of Trustees would care to pursue . i j �S%FFOL��o o s L TELEPHONE (516)765-1892 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 November 9, 1984 Mr. Anthony J. Scarmato, President Tosca Realty Holding Corp. 16 West 46th Street i New York, New York 10036 Re: Zatarain groin Orient Bay I Dear Mr. Scarmato: I This is to acknowledge receipt of your letters and photographs pertaining to the groin in Orient Bay on the Zatarain property. This material was referred to the Board of Trustees from the Building Department. I have circulated copies of same to all the Board members. After their review we will forward to you, the Boards action regarding this matter. Very truly yours, I Henry P. Smith, President Board of Town Trustees Ilene Pfifferling, Secret ry jcc: Trustees Building Dept. File I FOR INSPECTION PLEASE REVIEW THIS MATERIAL. This structure is close to the proposed groin application, before the Board now, for the Tosca Realty Company. i j I i I I i I� Anthony J. Scarmato,President Tosca Realty Holding Corp. 16 West 46th Street New York, NY 10036 October 8, 1984 Mr. Bart DiMartino Regulatory Affairs Unit US Army Corps of Engineers 26 Federal Plaza New York, NY 10278-0090 Dear sirs This letter is on behalf of me and my neighbors to shed some light on a situation that has become intolerable and somewhat dangerous. Two years ago, in the Fall of 1982, Mr. Richard Zaterain, who owns the property at the foot of Bay Avenue (west side), East Marion, NY, constructed a new dock, bulkhead and groin from his existing bulk- head out into Orient Bay. Adjacent to Mr. Zaterain's west property lineisa property owned jointly by Frank (now deceased), Amy, Nicholas and Katherine Mandaro. My property is next in line. Neither I nor the Mandaros were ever advised of this construction. After the Winter 1982/Spring 1983 ravaging of our beachfronts, it was clear that this structure had cut oif the natural flow of sand that we have normally received onto our.; beaches. I immediately sent a letter to Inspector Jose Almodovar, US Army Corps of Engineers at Riverhead. A corresponding copy was simultaneously forwarded to Mr. Bob Thurber, NYS Department of Environmental Conservation at Stony Brook, Long Island accompanied by "before and after" photographs of the beachfront site in question. I was informed by Mr. Thurber that a permit was issued to Mr. Zaterain without an inspection of the area because the construction involved the rebuilding of a functional, existing structure. This was clearly not the case by any stretch of the imagination. Inspector Almodovar, responding to my letter of April 1, 1983, inspected the structure and agreed that it was not in the Mandaros' or my best interests. He said he could not do anything to help us. We later-learned--that Mr. Zaterain never applied"for-a bui7d1n$ or wetlands permit from either the US Army Corps of Engineers or the Town of Southold Board of Trustees. The Mandaros have owned their property for at least fifteen years. I have owned my property since 1972. Mr. Zaterain never had a functional, existing dock or groin on his property since the Mandaros and I have owned our respective properties until the construction in question took place in the Fall of 1982. Therefore, the "rebuilding of a functional, existing structure" has never been the case. During the past winter and spring, our beachfronts lost a total depth of over two (2) feet of sand. This caused the total rebuilding of my entire length of retaining bulkhead. Four (4) ste;)s led down to the beach last year. This year, eight (8) steps are required. The summer and fall tides have not returned any significant amount of sand. We look forward, fearfully, to another disastrous winter and spring. Now, we are asking all the agencies involved to give us some relief by 'taking some action for .the removal of this unlawful structure. I am enclosing a copy of my previous letter to the US Army Corps, dated April, 1983, and an aerial photograph of the beachfront area taken in 1978, by the engineering firm of Lockwood, Kessler and Bartlett of Syosset for the Town of Southold. It clearly shows that no functional structure existed at that time. -2- My neighbors and I have sworn before a notary that all of the above statements are true and correct to the best of our knowledge. We would appreciate an answer to this letter as soon as possible, Thank you. Sin re , nthon Scarmato Presi nt Tos Realty Holding Corp. cc: Daniel J.. Larkin, NYS DEC Harold Berger, NYS DEC Mr. Hinderman, Bldg. Dept. , Town of Southold my Mandaro Nicholas Mandaro I aggP* ' W nes,, :qed Stefhr„ �. kali f' JF NEW JERSEYarY Public,state of NF„Ya# W GIWI=ON UM WA A lllENNo.244762273 GuNllled i nppa County Oorrvnladon re IMarch 1085 Katherine Ma daro Ant y rmato s JS EH Witnessed AkfAry Public,State of New York NINA CHANEVICH 1• No. in K1n 3 c NOTARY P1131 IC.Frtr of r7ew York. �7 OYdhled to K1ngs County Nc.41 4735525 mon Expim'Maroh 30,1886 Quilifmd in Qua=..:s Ccwlty S.ommission gxyires March 30,19." I i Tony Scarmato, Inc. U.S. Army Corp of Engineers 4/1/83 518-C ��ct Majr cHr-.r,l eiverhead, N.Y. 11901 Gentlemen+ I am writing this letter after phone conversations with your office retarding the problem that has been created for me as an adjoining property owner, by the issuance of a permit to a Sandra Zatarain to erect a jetty. The immediate property owner or myself were never informed of such a project by anyone or agency to date. i I think the issuance of this permit was not a wise decision in view of what the advantages and disadvantages were, as you can see by the photographs I am forwarding. What has taken place over the winter months is just a start of the foreseeable loss and erosion that will continue to take place in the future. At least one foot of sand has built up on the Zatarain beach front, while my neighbor and I have lost at least the same amount of beach. Normal high tide is now about thirteen feet higher than before. I am requesting an inspection of the area and the problem, at this time. An answer to my letter will be appreciated and please return all pictures. Thank You. . . . . n (Copy sent too Mr. Bob Thurber S incer p ourr? D.E.C. ) ' j Stonybrook Campus - - 6West 46 Street/NewYork,N.Y.10036/869-8787 i • TOWN OF SOUTHOLD ,SUN 5 2C07 tJ BUILDING DEPARTMENT SOUTHOLD, N.Y. Southold Town NOTICE OF REVOCATION Board of Trustees DATE; June 5; 2007 TO Anthony Scarmato P.O. Box 725 East Marion NY 11939 Please take notice that your permit #6633 For permit to erect a six foot high chain link fence forty feet back from the high water mark at the southeast property line. Location of property 235 Huckleberry Hill Road, East Marion NY County Tax Map No. 1000- Section 31 _ Block 16 Lot 9 Subdivision Filed Map # Lot# Is returned herewith and revoked on the following grounds pursuant to Chapter 144 Section 144-12 C which states; § 144-12. Revocation of building permit. The Building Inspector may revoke a building permit theretofore issued and approved in the following instances: C. Where he finds that the work performed under the permit is not being prosecuted in accordance with the provisions of the a,pplication,Lplans or specifications. Location of fence does not comply with conditions noted on permit --------------- Authorized Signature cc: encl. / Cert Mail.✓ T rney Trustees v "off._ : gym �U a. r. c f ^Y• A��f'' � ��{re red ;.t � � -;,t y��<.�YWly�s2tf��iC�:d}��'�''�`'`'r�:•l��'b►tf�n�:a.sY..d.M`"..*._..rw`4ac•,..�i. ....'l.n!..�,.v .■ 9 MIN a _ w 0 0 Albert J.Krupski,President ��0� SU!/r�o Town Hall James King,Vice-President 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda Southold,New York 11971-0959 CAR Peggy A. Dickerson � Telephone(631)765-1892 COU NTI,� Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD October 19, 2005 Anthony J. Scarmato 235 Huckleberry Hill Rd., P.O. Box 725 East Marion, NY 11939 RE: 235 HUCKLEBERRY HILL RD., EAST MARION SCTM# 31-16-9 Dear Mr. Scarmato: The following action was taken by the Southold Town Board of Trustees on Wednesday October 19, 2005: RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to Permit#4233 as follows: Include the maintenance of the pre-existing ponds on the landward side of the bulkhead, as marked on the survey received Oct.7, 2005 by the Board of Trustees, with the condition that the chain link fence be removed seaward of the high water mark. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765-1892. Very Truly Yours, Albert J. Krupski, Jr. President, Board of Trustees AJK:hkc Cc: Lori Hulse-Montefusco, Town Attorney • 0 James F. King,President *OF S�(/rO Town Hall Jill M. Doherty,Vice-President �O yl0 53095 Route 25 Peggy A. Dickerson P.O.Box 1179 Dave Bergen Southold,New York 11971-0959 G Telephone(631)765-1892 Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Southold Town Board of Trustees Field Inspection/Worksession Report Date/Time: I 1 /(0/0G Name of Applicant: R 'Tl'o^ `) SC arrr``+a Name of Agent: Tl PVA C L eA(A (i fv Property Location: SCTM# & Street a 3 5 }{�n��le- xa22 Brief Description of proposed action: aks�-uss f0..,0Jr.A` oL: „Cz (lid poss;l�le neh�r• khn. QL Of �p� k-rctii rn Type of area to be impacted: _Saltwater Wetland _Freshwater Wetland _Sound Front ✓Bay Front Distance of proposed work to edge of above: Pa of Town Code proposed work falls under: ✓Chapter _Chapt. 37_other a?S Typgof-4pplication: _Wetland_Coastal Erosion_Amendment_Administrative N0ac �t� _Emergency Info needed: LOc,HU,, o1- IeP c:.k in &Los,r, deo? TU(ma ksuKirerrFS. Modifications: L t i 0 ,t -�00-f1 L6 Conditions: Present Were: J.King _J.Doherty_P.Dickerson_D. Bergen Other: Mailed/Faxed to: Date: Comments of Environmental Technician: -Ren. bLr- o ctikc CIAk rn,,\,-, (Ayl.l4 4,s 6- SSI a- Cti'1 �P_� i N le�ltiti ar 10365 CONSULT YOUR LAWYER BEFORE SIGNING THIS INSTRUMENT—THIS INSTRUMENT SHOULD BE USED BY LAWYERS ONLY. -0� . 84 1 THIS INDENTURE,made the x.0116 day of October nineteen hundred and eighty-six BETWEEN Tosca Holding & Realty Corp., a corporation organized and existing by virtue of the business corporation law of the State of New York, and in the course of its winding up pursuant to dissolution- and having an office located at 16 WEST 46th Street, New York, N.Y. party of the first parr,and Anthony Scarmato, residing at Bay Avenue, East Marion, New York, 11939 WSTRICT rSECTION '�-� BLOCK LOT __ par Mi'� ; �'('11 CE] Z (1,.,1�.".L�J I 1 26 , rho Zrhe parry of the first flrt, in consideration of Ten Dollars and other valuable consideration paid the parry of to second part,does hereby grant and release unto the party of the second part, the heirs or successors and assigns of the party of the second part forever, ALL that certain plot, piece or Parcel of land, with the buildings and imp nv enc rhe t d sic re, lying and heing WIN" at East Marion, Town of Southhold, W foe e�ouriny, `9�atA oda New York, being more particularly bounded and described as follows: BEGIOMC at a monument on the southerly side of Existing Road distance South 74 degrees 22 minutes 50 seconds West 58.88 feet when measured along the southerly side of Existing Road from a monument situate at the corner formed by the intersection of the southerly side of Existing Road with the al� I southu-sterly side of Bay Avenue, said point of beginning being where the nLL,westerly lime of the hereinafter desfribed premises and the southwesterly line of land now or formerly of Mandaro intersects said sutherly side of Existing Road; running thence South 35 degrees 35 minutes East along said southwesterly line of land now or formerly of Mandaro, 58.19 feet to a monument; thence South 16 degrees 28 minutes East and along said land now or formerly of Mandaro 42.75 feet to a monument; thence South 35 degrees 35 minutes Fast still along said land now or formerly Mandaro and passing thru a monument 115.00 feet to the oriinary high water mark of Peeonic Bay or Orient Harbor; thence southwesterly along the ordinary high water 3�� mark of Peoonic Bay or Orient Harbor on a tie line course and distance of South 42 degrees 22 minutes 00 seconds West 119.00 feet; thence North 0 0 9 b 0 45 degrees 07 minutes West along 176.83 feet to a monument on the south- easterly side of Existing Road; thence northeasterly and northerly and easterly along the southeasterly, easterly and southerly side of Existing Road the following three courses and distances: (1) North 16 degrees 10 minutes East 116.87 feet; (2) North 46 degrees 50 minutes East 30.30 feet; (3) North 72 degrees 24 minutes 50 seconds East 39.80 feet to the monument at the point or place of BEGINNING. TOGETHER with all right, title and interest, if way, of the party of the first part in and to any streets and roads abutting the above described premises to the center litres thereof;TOGETHER with the appurtenances and all the estate and rights of the party of the first parr in and to said premises; TO HAVE AND TO HOLD the premises herein granted unto the party of the second parr, the heirs or successors and assigns of the party of the second part forever. AND the party of the fust part covenants that the party of the first part has not done or suffered anything whereby the said premises have been encumbered in any way whatever,except as aforesaid. AND the parry of the first part,'in compliance with Section 13 of the Lien Law,covenants that the party of the first Part will receive the consideration for this conveyance and will hold the right to receive such consideration as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same fust rhe payment of the cost of the improvement before using any part of the total of the same for any ocher purpose. to ' The word "party"shall be construed as if it read "parties' whenever the sense of this indenture so requires. IN WITNESS WHEREOF, the party of the first part has duly executed rigs deedrhe day and year firs written. t above IN PAMENCP.OF: r �fiA'4 To y Corp. JUL I s 1987 1. Jill IMF A. K1NSF.LLA 3290 f RECORDED CAUL 15 1901: Clerk of Suffolk County Oct. 13 , 2005 Field Inspecti 7 s r p r t x r Oct. 13 , 2005 Field Inspectio M ;t ..�1 �nIM,,...r.•- y 1 r r ti• � r Oct. 115 Field Inspectio 1 ,. I ° Sept115 Field Inspecti• s t� f iT 4 +' w '413 9-53AM- �;;�, •" X54 , .,` : � 'v. " µ 4 si a , 71, 1 t , t > ,r Albert J.Krupski,President ��OF S�Ury� Town Hall James King,Vice-President ,`O l0 53095 Route 25 Artie Foster P.O. Box 1179 Ken Poliwoda y Southold,New York 11971-0959 Peggy A. Dickerson p � Telephone(631)765-1892 ^Um' Fax(631)765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD October 19, 2005 Anthony J. Scarmato 235 Huckleberry Hill Rd., P.O. Box 725 East Marion, NY 11939 RE: 235 HUCKLEBERRY HILL RD., EAST MARION SCTM# 31-16-9 Dear Mr. Scarmato: The following action was taken by the Southold Town Board of Trustees on Wednesday October 19, 2005: RESOLVED, that the Southold Town Board of Trustees APPROVE the Amendment to Permit# 4233 as follows: Include the maintenance of the pre-existing ponds on the landward side of the bulkhead, as marked on the survey received Oct.7, 2005 by the Board of Trustees, with the condition that the chain link fence be removed seaward of the high water mark. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765-1892. Very Truly Yours, d&,r� e2 , Albert J. Krupski, Jr. President, Board of Trustees AJK:hkc Cc: Lori Hulse-Montefusco, Town Attorney f .f+�Li t"�'.-��.r _ i:�-!'.�s5�- .+arc--�-w •�••��'��'�' l• ` Board Of Southold' Town Trustees ' SOUTHOLD, NEW YORK j PERMIT NO. 4233 DATE: .-... 9/30/93 4 1 ISSUED TO .. ANTHONY•.SCARMATO / � :� �u#f�u�t��t#tun a• � Pursuant to the provisions of Chapter 615 of the Laws of �y the State of New York, 1893; and Chapter 484 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 =i REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM �i► LANDS UNDER TOWN WATERS;" and in accordance with the �I `A Resolution of The Board adopted at a meeting held on 9/30/93 t \, 19 93, and in consideration of the sum of $ 250.00 paid by Anthony Scarmato• , of . East Marion N. Y. and subject to the •t; Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: Replace 124 l.f. of timber wall within 18", repair inplace 73 l.f. of easterly return, Approx. 100 c.y. of fill, 4' X 4' platforrxi 1 4' wide steps from retaining wall to beach. 't -if in accordance with the detailed specifications as presented in 1' the originating application. t +� IN WITNESS WHEREOF, The said Board of Trustees Isere- E by causes its Corporate Seal to be affixed, and these presents to ,� l ' .. be subscribed by a majority of the said Board as of this date. pr fit T Albert J.Krupski, President �C own Hall James King,Vice-President �. 53095 Route 25 Henry Smith oP.O.Box 1179 Artie Foster 0 Southold,New York 11971-0959 Ken Poliwoda Dy� ! Telephone(631)765-1892 Fax(631)766-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD October 20, 2000 Mr. Anthony Scarmato 235 Huckleberry Hill Rd. P.O. Box 725 East Marion, NY 11939 RE: 235 Huckleberry Hill Rd. East Marion, SCTM#31-16-9 Dear Mr. Scarmato: The Trustees have reviewed the survey dated September 28, 1972 and determined that your proposal to enclose the existing porch to be out of the Wetland jurisidiction, under Chapter 97 of the . Town Wetland Code. However, any activity within 100' of the Wetland line would require permits from this office. The Southold Town Board of Trustees recommend that the chain-link fence be removed immediately, from below the mean high water mark. This determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. Sincerely, e?Z� e? • ��. . - Albert J. Krupski, Jr. President, Board of Trustees AJK:lms r i N.T ri s0 Od'E• N•� c� O r 1 [ IL ' LL 50. 9 tf•S� � :V cb 6 ( 0 C+1 PprcG 6 / 0 J / � v u Q..4 ` o � of � V N �^ �a1� ♦ or O tJ t O R C7 R F A/ 7- ... - H. P E �.� MAP QF Pzopelzry /OC T _ 7 2005 SuR V�YES ��/e S00131d Town Burl of Trustees ;qOIVY- SC^RMATO , -LNG • AT SUFFoc�' Albert J. Krupski, President �� C� Town Hall James King,Vice-President h'1` Gy 53095 Route 25 Artie Foster q P.O.Box 1179 Ken Poliwoda � Southold, New York 11971-0959 Peggy A. Dickerson G A �� Telephone(631) 765-1892 F IJ 1 OCT BOARD OF TOWN TRUSTEES - 7 2005 TOWN OF SOUTHOLD Southold Town Board of Trustees APPLICATION FOR AN AMENDMENT TO A PERMIT DATE �� 7 06 OWNER /q/C�7ff�� J 'SC /�Iflla7u PHONE ADDRESS me /� / / �A 4y 2 L� AGENT PHONE ADDRESS PROPERTY LOCATION -5 7 TAX MAP NO. I/1,4e request an Amendment to Permit# �/2 3 e t�'(S'/571 AJ C�- /0 o tib O A Z _W G Signed By: 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. �J YOUR NAME: & /L o (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 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%of a 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 Submitted this a c/ 200 Signature Print Name C Y� r"0 Form TS I y