HomeMy WebLinkAboutTR-208ESOUTH OLD TRUSTE. ES
No.
Issued To~~~~~t-.~ Date~
Address~
.SC.~M~ IDq- 5-Z3.3
THIS NOTICE IdUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y, 11971
TEL.: 765-1892
Scuthold Town
Board Of $outhold Town Trustees
SOUTHOLD, NEW YORK
Mooring NO. N/A
PERMIT NO.. ~.9.~. ................. DATE: (~.o..~.~...~.9.~.....~ 9 8 5
.~ iSSUED TO ......~..°....h..~....~.~...k..~........i ............
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 WATERSj" and in accordance with the
Resolution of The Board adopted at a meeting held on
19.. ~.]., and in consideration of the sum of $ ....... ~.~...0..9.._ paid by
................................ u~.;) ~i .o...k.~.m ....................................... ~ ...............................................
oJ ......~.~..h...o,.,cj..u,.,e. .................................................. N. Y. and sub?ct to the
Terms and Conditions listed on the reverse s,de hereo~,
of So-thold Town Trustees authorizes a.n.d permits .th.e .f.ollowin~:
Application approved under tne ~ranG~a~ner ~±ause
to secure a permit for a dike in West Creek,
all in accordance with the application submitted.
all in accordance with the detailed specifications as presented in
the originating application.
IN WITNESS WHEREOF, The said Board of Trustees here-
bY causes its Corporate Seal to be affixed, and these presents to
be subscribed by a majority of the said Board as of this dafs.
Trustees
Please tear off and return to the Trustee Office.
NOV 2 9 2012
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:
Agent (if applicable)
Phone Number(s):
Board of Trustee Permit Number(s):. ?_0%
Will any part of this project require a Building Permit?
How much fill will be required?
Project Description:
County of Suffolk
State of New York
?~" kX-C~o~Vt~_J~ ~_% ~ 0"~ 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 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 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 Owner
SWORN TO BEFORE ME THIS ~ ? DAY OF ]k~Jsv ,20 [ ~
Notary Public
oO. ryP ~,;~ ~:,Z.:~
AUTHORIZATION
(where the applicant is not the owner)
l, residing at.
(print owner of property) (mailing address)
do hereby authorize
(Agent)
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
(Owner's signature)