HomeMy WebLinkAboutTR-7988ESOUTHOLD TRUSTEES
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THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765-'1892
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TROPICAL STORM SANDY EMERGENCY APPLICATION
Valid thru June 1, 2013
Property Owner Name:
Permanent Mailing Address:
Phone Number(s):
Property Address:
Suffolk County Tax Map Number: 1000
Agent (if applicable)
Address:
Phone Number(s):
Board of Trustee Permit Number(s):
Will any part of this project require a Building Permit?
HOW much fill will be required?
Project Description: ~ ~ L
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 PROPERTY TO INSPECT THE
PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION.
Signature of Property O~ne.r/'
SWORN TO BEFORE ME THIS ,.~Z) ~ DAY OF
,20. /~
Notary Public
ROBERT A MAZZAFERRO
NOTARY PUBLIC - STATE OF NEW YORK
NO. 01MA6207376
QUALIFIED iN SUFFOLK COUNTY' /~j~
COMMISSION EXPIRES JUNE 15, 20 .,.