Fillable 568 Planning Board Application (Incorporated Village of Sag Harbor)

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568 Planning Board Application (Incorporated Village of Sag Harbor)

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The 568 Planning Board Application (Incorporated Village of Sag Harbor) form is 33 pages long and contains:

  • 4 signatures
  • 250 check-boxes
  • 250 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Incorporated Village of Sag Harbor

BROWSE INCORPORATED VILLAGE OF SAG HARBOR (NY) FORMS

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Kathleen Mulcahy, Mayor
James L. Larocca, Trustee
Aidan Corish, Trustee
Beth M. Kamper, Clerk-Administrator
55 Main St., PO Box 660
Sag Harbor, N.Y. 11963
631-725-0222
631-725-0316 FAX
Thomas C Gardella, Deputy Mayor
Robert Plumb, Trustee
Denise R. Schoen, Village Attorney
Rhonda L. Meserole, Village Treasurer
Disclosure Affidavit
General Municipal Law §809
STATE OF NEW YORK}
} ss.:
COUNTY OF SUFFOLK}
____________________________________, being duly sworn, deposes and
says that:
1. (a) an application has been made by _______________________________
Name of applicant
to the __________________________________________________________, of the
Name of Village Agency
Village of Sag Harbor with respect to property situate at _______________________,
Street address
Sag Harbor, New York. I am the ________________________________________,
Applicant or Agent for applicant
I reside at _______________________________________.
Address of applicant or agent
(b) The shareholders, partners or members of the applicant corporation,
partnership or limited company are (if applicable):
(1) _______________ (3) _________________
(2) _______________ (4) _________________
2. (a) the landowner’s name and address are:
______________________________________________
______________________________________________
(b) The shareholders, partners or members of the landowner corporation,
partnership or limited company are (if applicable)
(1) _____________________ (3) ______________________
(2) _____________________ (4) ______________________
3. (a) the contract vendee’s name and address are (if applicable):
____________________________________________________
____________________________________________________
(b) The shareholders, partners or members of the contract vendee
corporation, partnership or limited company are (if applicable):
(1) ___________________ (3) ________________________
(2) ___________________ (4) ________________________
4. Does any officer or employee of the Village of Sag Harbor have an interest in
the applicant or in the landowner or in the contract vendee?
_______ Yes ______ No
If yes, state the name and residence of such officer or employee and the nature
and extent of such interest.
________________________________________________________
________________________________________________________
For the purpose of this disclosure, an officer or employee of the Village of
Sag Harbor shall be deemed to have an interest in the applicant or in the landowner or in
the contact vendee when he, his spouse, or their brothers, sisters, parents, children,
grandchildren, or the spouse of any of them:
(a) is the applicant or landowner or contract vendee, or
(b) is an officer, director, partner, member or employee of the applicant or
landowner or contract vendee, or
(c) legally or beneficially owns or controls stock of a corporate applicant or
landowner or contract vendee, or is a partner or member of a partnership or limited
liability company applicant or landowner or contract vendee; or
(d) is a party to an agreement with such an applicant or landowner or
contract vendee, express or implied, whereby he may receive any payment or other
benefit, whether or not for services rendered, dependent or contingent upon the favorable
approval of such application.
A person who knowingly and intentionally fails to make such disclosure shall be guilty of
a misdemeanor as provided in General Municipal Law §809.
________________________________________________________________________
________________________________________________________________________
5. Does any officer or employee of the Town of Southampton and/or East Hampton,
County of Suffolk or State of New York have an interest in the applicant or in the
landowner or in the contract vendee?
_________ Yes ___________No
If yes, state the name and residence of such officer or employee, the name of
such governmental entity (Town, County, and State) and the nature and extent of such
interest. ____________________________________________________________
For the purpose of this disclosure, an officer or employee of the Town of Southampton
and/or East Hampton shall be deemed to have an interest in the applicant or in the
landowner or in the contact vendee when he, his spouse, or their brothers, sisters, parents,
children, grandchildren, or the spouse of any of them:
(a) is the applicant or landowner or contract vendee; or
(b) is an officer, director, partner, member or employee of the applicant or
landowner or contract vendee; or
(c) legally or beneficially owns or controls stock of a corporate partnership or
limited liability company applicant or landowner or contract vendee; or
(d) Is a party to an agreement with such an applicant or landowner or contract
vendee expresses or implied, whereby he may receive any contingent upon the favorable
approval of such application.
A person who knowingly and intentionally fails to make such disclosure shall be guilty of
a misdemeanor as provided in General Municipal Law §809
___________________________________
Applicants Signature
State of New York)
) ss:
County of _____________)
On the ______ day of ___________in the year__________ before me, the undersigned,
personally appeared _______________________, personally known to me or proved to
me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are)
subscribed to the within instrument and acknowledged to me that he/she/they executed
the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the
instrument, the individual(s), or the person upon behalf of which the individual(s) acted,
executed the instrument.
______________________________________
(Notary Public)
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568 Planning Board Application (Incorporated Village of Sag Harbor)

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Completed 16 July 2020

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