Loading...
HomeMy WebLinkAboutTR-5277 `=�•'-_---"''Lry irJ�. ram.,._..-___r_ ... ...... r r�•., }�• _� .���•-._-_`--" -- �, r� .fir Ow amm °- Board Of Southold Town Trustees j SOUTHOLD, NEW YORK a.� ' DATE February 22, 20 }: PERMIT NO. ... ..5.... ... ... A h l TED DOWD ISSUEDTO .................................................................................................................................... 4orization 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- `yvy titled ."REGULATING AND THE PLACING OF OBSTRUCTIONS :... :. IN AND ON TOWN WATERS AND PUBLIC LANDS and the y Y` REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM r ��. LANDS UNDER TOWN WATERS;'.. and in accordance with the Feb 21 Resolution of The Board adopted at a meeting held on ........................ , xs , 2001.., and in consideration of the sum of ............................. pay y * Ted Dowd ............................................... k • ......................................... ........................................................................... �" of ...... Southold .... N. Y. and. subject to the Terms and Conditions listed on the reverse side hereof, >4.: permits the following: of Southold Town Trustees authorizes and p ie, ' • �� j Wetland Permit to construct an addition inside the footprint of �. the orignal home (100 sq.ft. of floor area) . �. ' ` ' all in accordance with the detailed specifications as presented in a{ the originating application. < IN WITNESS WHEREOF, The said Board of Trustees Mere- ` by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date. , : Albert J. Krupski, Jr. - Absent C= a.. c•� Artie Foster Absent Y Trustees 1:� ,t,�. .._Yam'- - -�-�.�'::�.�i3':s',��.dd:{.�rs�^.�f'i'r�`� —s��s i'..i�s�' :-��:�;�"y' •*,���si�a'f�L+�L'�' :.?� 17 { i TERMS and CONDITIONS Ted Dowd The Permittee residing at 1775 Inlet Way, Southold N. Y as parr of the consideration for the issuance of the Permit does understand and prescribe to the fol- lowing: 1. That the said Board of Trustees and the Town of Southold are released from any and all damages, or claims for damages, of suits arising directly or indirectly as a result of any oper- ation performed pursuant to this permit, and the said Permittee will, at his or her own expense, defend any and all such suits-initiated by third parties, and the said Permittee assumes full liability 1 with respect thereto, to the complete exclusion of the Board of Trustees of the Town of Southold 2. That this Permit is valid for a period of 24 mos. which is,considered to be the estimated time'required to complete the work involved, but should circumstances warrant, request for an mension may be made to the Board at a later date. 3. That this Permit should be retained indefinitely, or as long as the said Permittee wishes to maintain the structure or project involved, to provide evidence to anyone concerned that auth- orization was originally obtained 4. That .the work involved will be subject to the inspection and approval of the Board or its agents, and non-compliance with.the provisions of the originating application, may be cause for revocation of this Permit by resolution of the said Board. 5. That there will be no unreasonable interference with navigation as a result of the work herein authorized. j6. That there shall be no interference with the right of the public to pass and repass along the beach between high and low water marks. 7. That if future operations of the Town of Southold require the.removal and/or alterations . in the location of the work herein authorized, or if, in the opinion of the Board of Trustees, the. work shall cause unreasonable obstruction to free navigation, the said Permittee will be required, upon due notice, to remove or alter this work or project herein stated without expenses to the Town . of Southold 8. That the said Board will be notified by the Permittee of the completion,of the work auth- orized. 9. That the Permittee will obtain all other permits and consents that may be required sup- plemental to this permit which may be subject to revoke upon failure to obtain same. f yel i FEB 5 OF N EW yo I y,�P ONCE TL�'� F7I ( # 49 r W �� �f Cl) '! ' 032254 3 9©FESS10��` -- -- e Co + �S 21.i �3 _ s AREA = 1.1631 Acres to tie lines ul zo N S. 78°/5, 25.00 Y E. l% zN >0 m CEpq �i z ° PO�, A6vT a 55\33/ nc5 C) E EAST �� /� k e '' VA oaf .� f C! l S r°°o�vLSD�. n 0. ST„ ' cJ � �}, off• 0 o F N N a+0°DOWj a�x SQ0 9.3' S F bocc/' bQ�l cot.rf (!� •��_ wE �. ,. 2,.3, .N Z /`•_ CAI /f11 d e�g ofi ouf�t Fgn mm shorter el(o•'� J O N rgs d' e 9•{e�. �� � M �. Vl� �OG• 1 � V 4.2 ((% � i 3Q'QQ N. 9° j` Wood- S.,9`9\ N. 88'00'00' E. 90.00 ----� // ` oZecK 9 O0 \�obbpe5/onC LOT 9 = O� (�,• C% 9 17OU s I �•�y'S o A o e/ 79•38'40� E. a• � W lA e p N. 47.30 eye, k,oaa I 27.1 cU ° - d mio be opve f �\ L O T e/ G.g 6�/kheaoz {yooc� oteck =N P arcel1�0?' Q•�5� P •tih \ 95 LOT e� l 11 N. T6°/2�8 4 0•0e /65 4'55p W• :� LOT 93 / S. 71°� / 3 IV 16 NJ FEB _ 5 LOOP , SHORELINE AS PER FILED MAP SURVEY OF `--" - LITTLE PE-CONIC BAY PROPER T Y - - -- A T CEDAR BEACH CERTIFIED TO, TOWN OF SOUTHOLD EAGLE ABSTRACT CORP. SUFFOLK COUNTY, Ill. Y. C, o�N I 1000 - 92 - 01 - 08 Scale: 1" = 40' LOT NUMBERS ARE REFERENCED TO "MAP ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION Oct. 10, 1997 OF CEDAR BEACH PARK" FILED IN THE OFFICE OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW, 4' OF THE SUFFOLK COUNTY CLERK ON DEC. EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTIFICATIONS p Y.S. LIC. 'NO. 49618 /c2n- /2, /997(e/e�ia f/ors HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY /F �e 20,1927 AS MAP NO. 90 SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR WHOSE S1GNA TURF APPEARS HEREON, RS, P.C. ' (5/ 0 ADDITIONALLY TO COMPLY WITH SAND LAW.THE TERM 'ALTERED B.Y' P. 0. B 09 MUST BE USED BY ANY AND ALL SEURR�(VEYORS UTILIZWG A COPY 1230 TRAVELER STREET B OUGH�OATE-ARE NOT W COkftIANCE W TH THE LAW, AND SOUTHOLD, N.Y. 11971 1��, s 97 — 329 Albert J.Krupski,President �O$uFFO[�'CO Town Hall James King,Vice-President o�0 � 53095 Route 25 Henry Smith P.O.Box 1179 h Southold,New York 11971-0959 Artie Foster O � Ken Poliwoda `� Telephone(631) 765-1892 *A �a Fax(631) 765-1366 BOARD OF TOWN TRUSTEES February 22, 2001 TOWN OF SOUTHOLD Mr. Ted Dowd 1775 Inlet Way Southold,NY 11971 RE: 1775 Inlet Way, Southold SCTM#92-1-8 Dear Mr. Dowd: The following action was taken by the Board of Town Trustees during its regular meeting held on Wednesday,February 21,2001 regarding the above matter: WHEREAS, TED DOWD applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated February 5, 2001, and WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on February 21, 2001 at which time all interested persons were given an opportunity to be heard, and, WHEREAS,the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standards set forth in Chapter 97 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED,that the Board of Trustees approve the application of TED DOWD to construct an addition inside the footprint of the original home (100 sq.ft. of floor area). BE IT FURTHER RESOLVED that this determination should not be considered a determination made for any other Department or Agency which may also have an application pending for the same or similar project. Permit to construct and complete project will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. Fees: None Very truly yours, Albert J. Krupski, Jr. President,Board of Trustees AJK/lms cc: Building Dept. o Town Hall: 53095 Main.Road rn T P.O.-Box 1179 Telephone p� Southold.:New.York 11971 (631) 765-1892. SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Thursday, February 15, 2001, the following recommendation was made: ' F TED DOWD 92-1-8 for an addition inside the footprint of original home (100 sq.ft. of floor area). 1775 Inlet Way, Southold The proposed project was unclear, therefore the CAC has no comment. _ys 4 Ted Dowd Box 58027 St. Petersburg, FL 33715 (727) 864 1274 Phone/FAX: (727) 867 2761 January 31, 2001 Dear Lauren, Enclosed is the Trustee Permit request for a minor residential addition to my home at 1775 Inlet Way, Cedar Beach, Southold. The addition is for a 100 square foot mezzanine or viewing area in the home. However, in order to meet changing requirements of the State and Town building codes, the outside dimensions of the addition are 15' X 21'. The overall height of the home will be less than 30'. The building permit application was submitted in September 1999 but took several iterations due to changes in building department personnel and coordination with the state. The final plan was verbally approved in September 2000 pending an agreed upon revision to the engineering plan. The building department approved the plan 1/30/01 pending Trustee approval. I will be unable to attend the Trustee meeting but am available anytime or during the meeting at (727) 864 1274 or (727) 867 2761 to answer any questions. Thank you for your help with the permit process. c�rely, r FEg - 5 2001 I Al CEDAR BEACH HARBOR % Alm 'N dli X A 7­ >P z 3 N K CEDAR 5 1.2A(d 7 Z. HOG NECK BAY z PROPiRTe SECTION NO L NOTICE COUNTY OF SUFFOLK (D EK T"11 SOUTHOLD E IT.. TIE —.... —.1. - - G ————-- — •mom —TDDD,uTSUW4 WE M Real Property Tex Service Agency y VLLAGE CIF E USTZaM OF�ZTT OF M ED CoLmty Center RiverheA N Y 119I)1 m 092 9XF.1�TO—5 N P_ ��E N FEET-.,. 23 =�12.1 AIM or 12.0 .0w IRTTE. A w 1000 D 12.1 At.] RW TO MMCE"Em P PROPERTY MAP 7 01/30/01 TUE 08:44 FAX 516 765 1366 Southold Town Accounting Z 003 Albert J. .rupski,President 4 ��SVFf�(�C Town Hall James King,Vice-President 0 �(/ 53095 Route 25 �� +� P.O.Box 1179 Henry Smith y southold,New York 11971-0959 Artie Foster 2 Ken Pchwoda 0 'Telephone(631)765-1892 'ylJOl 0� Fax(631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application / r ✓1�Vetland Permit Application Major ✓ Minor U lVaiverlAmeniime h antes o<eceived Application: O�( ✓Received Fee:$ / Completed Application Incomplete _SEQRA Classification: Type I _Type IY Unlisted, - -_ Coordination:(date sent) /CAC Referral Sent: O FE — 5 2001 �� ,i Date of Inspection: _Receipt of CAC Report: . _Lead Agency Determination: _Techni cal Review: _✓Public Nearing Held: a 8A Resolution: Name of Applicant Address h111/a/ �1i' , &,0 e)s7 Phone Number:( (722) _fR 6 `/ /24 7y Suffolk Country lax Map Number: 1000- --O i+ Property Location: .5,q V41 �dlstwyice Lncxe h �� en o n 1e i w.y(provide Ll�0 Polross streets,and location) AGENT: (If applicable) Address: phone: S Jan-30-01 08:48A P_ 01 Albeit J.F+rupski,President �5UEF0t,� Town Hall James Ding,VIP_-President �4 63066 Route 26 P.O.Box 1179 l teary$faith 6authnld,New York 11971-0959 Artie Foster G Sri polievodn Telephone(631)765-1692 ��01 �aOR Fax(631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application � 1�Ietland Permit Application Major Minot ,f'U Waiver/Amendment/Changes Received Applic" D / Received Fee:$ _Completed Applicatuka / _Xnoomplete 'r SEQRA Classificarion: Type I Type 11 Unlisted JAN 3 lJ 11 _Coordination:(date Seat Ll l CAC Referral Sent. ;-06ate of Inspection: Receipt of CAC Rcp-brt= 6 l' Y,ead Agency Determination: _Technical Review: _✓Public)fearing Field: A .: 0 RcsolutoQ: Name of Applicant Address l)U T/� �ls, ��i�fs BoJr SR�.2 y -,- Z _3.7Z.E Phone Number:( Suffolk County Tax Map Number: 1000- Property Location:_ C cr,., ,8z-.d _ /7 7 4 Z �-of — IMUl i�ie_ _-,j c-F -r'llef Wzv) . (provide L1LC0 Pot #, distance to cross trss eevts, and location) AGENT: (lf appli cable) Address- _ Phone_ Z660b 8�C .� r--- 01/30/01 TUE 08:45 FAX 516 765 1366 Southold Toren Accounting Q 004 Board of Trustees Application GENERAL DATA Land Area(in square feet): t, 2 A c re s Area Zoning: Re s, d e-., i i zJ Previous use of property_. Res,J e,,i i a. I Intended use of property: Re s' ��h t a f Prior permits/approvals for site improvements: Agency Date No prior permits/approvals for site improvements_ Has any permittapproval ever been revoked or suspended by a governmental agency? _ No Yes If yes,provide explanation_ Project Description(use attachments if necessary): ( nor, -add, taot-i InsAe. -�l e Foot pint Of O N Inn homy (ICO Go Var e Feet of Floor Area)_ - See ral cviltneJ :2r•za oa, ,vr-vey and Mr-�u�L,lls en� ,hcer�s p Izn L� , 01/30/01 TUE 08:45 FAX 516 765 1366 Southold Town Accounting �005 Board of Trustees Application WE,TLANJD/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: '6 c.V F1 5 t rO(,-� a M )117 0 IIDh 114S 1!!"}�E, foe ��oo , v, t of & r 1 rh ) home , Area ofwetlands on lot: square feet Percent coverage of lot: % Closest distance between nearest existing structure and upland edge of wetlands: feet Closest distance between nearest proposed structure and upland edge of wetlands: feet Does the project involve excavation or filling? X 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,if any,on the wetlands and tidal waxers of the town that may result by reason of such proposed operations (use attachments if appropriate): N © fy Albert J.Krupski, President ��SUFF�C/f'CO Town Hall James King,Vice-President �� Gy 53095 Route 25 P.O.Box 1179 Henry Smith = Southold,New York 11971-0959 Artie Foster C4 Ken Poliwoda • `F Telephone(631) 765-1892 Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD L 4 _ - 11 3 BOARD OF TRUSTEES: TOWN OF SOUTHOLD---------------------------------- � In the Matter of the Application xsr of _ ------------------- COUNT Y OF SUFFOLK) STATE OF NEW YORK) " � AFFIDAVIT OF POSTING n � I, C OL ��' Cq 4v�eVv residing at (o (�`'� co e(L r Sou*�0 ( 6 ) l6rll being duly sworn, depose and say: That on the[Z-�day of �., 200 I I ersonally posted the property known as CI Z771 3 T "� a 6 Ia_ by placing the Board of Triustees official Oster where it can easily be seen, and that I have checked to be sure the poster has remained in place for eight days prior to the date of public earin Date of hearing noted thereon to be held .�I � �00� tn4r �tx i T-OD (gym• Dated: Z. 113 j O 1 (signature) Sworn to before me this 3 day of J,_Qr. 2001 No Public JOYCE M.WILKINS Notary Public,State of New York No.4952246,Suffolk County Term Expires June 12, 9-od) Feb-09-01 12 : 35P P _01 PLEASE DELIVER TO LAUREN TO: Board of Trustees Town Hall, Main Road Southold, NY 11971 FEB 9 an FROM: Ted Dowd 1775 Inlet Way _ Southold, NY 11971 (727) 864 1274 February 9, 2000 RE: Notice to Adjacent Property Owner and Proof of Mailing for Permit. Dear Lauren, Enclosed are the documents you requested. They are being mailed today. If a sign has to be placed on the site please contact Claire Glew. Michael Glew will post it and Claire can bring you the verification of posting. Please contact me if there are any questions. cerely, Te wd Feb-09-01 12 : 36P P _ 02 NOTICE TO ADJACENT PROPERTY OWNER BOARD OF TRUSTEES, TOWN OIL SOUTHOLD In the matter of applicant: FEB 9 r�001 Ted Dowd: SCTM#1000-92-1-8 YOU ARE HEREBY GIVEN NOTICE: 1. That it is the intention of the undersigned to request a Permit from the Board of Trustees to: Build a minor addition inside the footprint of original home(100 square feet of floor area), 2. That the property which is the subject of Environmental Review is located adjacent to your property and is described as follows: SCTM# 1000-92-:1-8 as per plan(See "Enc." below). 3, That the project which is subject to Environmental Review under Chapters 32, 37, or 97 of the Town Code is open to public comment. You may contact the Trustees Office at 765-1892 or in writing, The above referenced proposal is under review of the Board of Trustees of the Town of Southold and does not reference any other agency that might have to review same proposal, OWNERS NAME: Worth EnterD ises, Inc, (Ted Dowd) MAILING ADDRESS; Box 58027 ST PETERSBURG, FL 33715 PHONE. #; (727) 864 1274 Enc,; Copy of sketch or plan showing proposal for your convenience, (Copied from Survey)_ fFr HOUSc' M N Wtl Feb-09-01 12 : 36P P _ 03 PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS FEB -' 9 Name: Address: Re er+- Kz P-I TT+aHapiag Roslyh Fs t )Uy )1574- CERTIFIED MAIL RECEIPT U.S. Postal Seivice m m Ln nl Candied Fee � ReWm Haceip!Fee � ,_ Fire 1 yo � IEndogem�t Rayaved) a r K= Fndome d DW=Fan Q (EMo'sefnenr Regiuectl iblal pasu e i F.ee $j v�pS � Ben!To � '-' - - ••- .__ - -• -'— -- - r� � -- S&&- !.No, dr F'O-BOX Mu. 1�5-�~ ..... � � STATE OF NEW YORK G Cify bd� . � ^ J COUNTY OF SUFFOLK N\ residing at e 7 z 4 =n le't N_2 k, -- _ ./ 1, ��, being duly sworn, deposes and says that on t e —— day of �- �,,�� � deponent mailed a true copy of the Notice set forth in the Board of Trustees Application, directed to each of the above named persons at the addresses set opposites there respective names; that the addresses set opposite the names of said persons are the address of said persons as shown an the current assessment roll of the Town of Southold; that said Notices were mailed at the United States Post Office at .- — oeid , that said Notices were nailed to a of said perms b certified) (registered) mail. Sworn t_p4e ore me this day of _ Le AW 30 Notary ub is i�����Petesd•A lakrile>q * *MY CpmmisdeM CC78862A y h.,,.fir�lr6s NovenlD�0.�� 01/30/01 TUE 08:46 FAX 516 765 1366 Southold Town Accounting Q 008 Board of Trustees Application County of Suffolk State of New York BEING DULY SWORN D SES AND AFFIRMS THAT HE/S1&IS THE . LIGANT FOR TIE ABOVE DESCRIBED PERT&T(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 TINS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S)OR REPRESENTATIVES(S), TO ENTER 0�U9_MYLPRORETY_TO INSPECT THE PREMISES IN CONJUNCTION I�I REVIEW OF THIS APPbICATION_ S' SWORN TO BEFORE NE THIS DAY OFy��P 20—DL a 01 Po%Amanda D Byrum * *My Commission CC884701 Vw?Expires August 19,2003 Notary-Public 01/30/01 TUE 08:46 FAX 516 765 1366 Southold Town Accounting a 009 1.0,16-4(21971—TC:r 12 , PROJECT LD.NUMBER 59T 2[ SEQ Appeneiz C State Environmentai Duality Review SHORT ENVIRONMENTAL. ASSESSMENT FORM For UNLISTED ACTIONS Only PART I—PROJECT INFORMATION (To be completed by,applicant or Project sponsor) T. APPLICANT ISPONS40R 2. PROJECT NAME 172'd VcuV ' HI'l0 ' A 100 t U Ho+he, 3. PROJECT LOCATION= ii 1 j Municipalltr S 0 0-6 �0 1 a County A. PRECISE LOCATION(street aodre23 3no road intersectlon3.prom'lent IanomarKs,etc,or provice mao) 1?-75 to1et Wzy1 S00 "o ` AlV. -T-; ke ll1or $:3yi(ie-v Avc. o Gz.rerz / wzyAC 'riln' R( yb � +vrn (htti herd j , 13e-:;t c- c >7 10h y , Pr'o ewe d 1-, D 't-r- " S tip sigh , 1„e to v er y ,t d F r^o f f-nlzt w ), ` 5. IS PROPOSED ACTION: 0 New ❑excansion MOOificltlon/aft2ratioro f 6. DESCRIBE PROJECT BRIEFLY: M (n d r A d d D t^I� 7- AMOUNT OF LAND AFFECTED: initially PJ t) N E acres Ultimately acres a. VlILL r'40PO5Z-.j)El COMPL`"NI7H EXISTING ZONING OR OTHE;3 EXISTING LANO USE REST RIC 1QNS? L Yes^, El No It No.describe briefly 9- WHAT IS PRESENT LANE)USE IN VICINITY OF PROJECT? LLyResidentlsl r J!naustrial r Commercial Q agriculture ParWlForesvOoen space Otner 'Je9G'lae: r s In �(-e f'a., 1 y IN o YhP•f - 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING,NOW OR ULTIMATELY FROM .ANY OTHER GOVERNMENTAL AGENCY(FZOFRAL, STATE OR LOGAU? 0Yes LLZNo If yes.list agency(a1 and permittaoprava(s 11, tf��10095 ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD OE.RMtT OR APPROVAL? yet Yee No If yea Ilst aoency name and permiUawroval � t7 v y �o i � T o w YI �U, �d ,N 12. AS A R£SULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? El Yea SNo I CERTIFY THAT-f HE'INFORMATION PROVIDED A@CVE IS TRUE 7-0 TtdE 3Ea'i OF MY KNOWLEDGE Applicantrs0onSox names , �o w It Oats- � J ✓ _ r Signature: if the action is in the Coastal Area, and you are a state acency, complete the Coastal Assessment Form before proceeding with this a�sessmeni f~ O V=_R y 01/30/01 TUE 08:46 FAX 516 765 1366 Southold Town Accounting f�j010 <IPPLICANT TRANSACTIONAL DISCLOSURE PORH The Town of Southold's Code of Ethica 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 Rossible conflicts of ntereet and allow it to take whatever action is necessar to avoid same. YOUR NRM6! yC w d Last name, Eirst name, m ddle i n I t 1 al, 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. ) NATURE Of APPLICATION! (Check all that apply. ) r,. ,- r-✓T • Tax grievance variance change of zone Appiwal of plat Exemption from plat or oEricial map Other YI �L (If "other," name the activity. ) Tr., S Lem. �a� ,_ t Do you personally (or through your t:ompany, 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 the shares. YES No „ If you answered brES,•. complete the balance'of this form and date and sign where indicated. Name of parson employed by the Town of Southold Title or position of that person Describe the relationship between yourself (the applicant) 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 epouse,- sibling, parent, or child is (check all that apply)r 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 noncorporate'entity (when the applicant is not a corporation)! C) an officer, director, psrtner, or' employee. of the applicant) or D) the actual applicant. DESCRIPTION OF RELATIONSHIP . . ... • ..., .,,r:,:•.>; sE;:., ;.ems-.+. kr�. � . Submitted this-`�y.Vdny d6,6-! �Lov ' Signature _ ''' ' •Print ame . . - _�� :.::;,-;. :. •:: t y::