HomeMy WebLinkAboutTR-7982ESOUTHOLD TRUST,EES
.o. ~rr¢~
Issued To.,,~,~~~~~ Date~
Address~
· THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765-1892
I .,~, COUNI~ OF SUFFOLK ~}
111
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$0uthcld Town
TROPICAL STORM SANDY EMERGENCY APPLICATION
Valid thru June 1, 2013
Property Owner Name: i~)~ II; P,4y~
Permanent Mailing Address:
Phone Number(s):
Property Address:' 5
Suffolk County Tax Map Number: 1000-
Creative Environmental l~i~
PO Box 160
Peconic, NY 11958
Agent (if applicable)
Address:
Phone Number(s): '7"~ H - ~/~ ~-~
Board of Trustee Permit Number(s):
Will any part of this project require a Building Permit?,
01/10/2013 ~4:20 FAX 7722874084 STUART ROUSING ~001
CounT of Suffolk
State of New York
DEPOSES ~ AFFIRMS THAT I-IE/SRE 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 TRUSTI~ES. THE APPLICANT
AOREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES
HARMLESS AND Fl~l::l~ FROM ANY AND ALL DAMAGES AND CLAIMS ARISING
UNDER OR BY VIRTUE OF SAID PEILMIT(S), IF GRANTED. IN COMPLETING THIS
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, TFfEIR AGENT(S) OR
R£PKESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
Signatu~
SWORN TO BEFORE ME THIS
DAY o?Ja uCxrv
01/10/2013 14:20 FAX 7722874084 STUART HOUSING ~002
Boa~:d of T~'~'e l~:ypl~.c~£on
ALrEItoRIZATION
(where the applicant is not thc owner)
. . ~ ~ct ~ rcsid~g at~~''
(p~t o~ ozpro~ ~
_ . David ci~nowicz, Pres,
do hereby
(Agent)
~ apply for pa~i~s) ~o~ tho
Sou~old Board of To~ Tm~¢~s o~ ~Y