HomeMy WebLinkAboutTR-7957ESOUTHOLD TRUS
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I,sued To.~,~a~~__ Date_[~~
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THIS NOTICE MUST BE DISPLAYED DURING, CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765-1892
James F. King, President
Bob Ghosio, Jr., Vice-President
Dave Bergen
John Bredemeyer
Michael J. Domino
Town Hall Annex
54375 Main Road
P.O. Box 1179
Southold, New York 11971-0959
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Telephone (/k31) 765-1892
Fax (631) 765-6641
EMERGENCY APPLICATION
HURRICANE SANDY
Valid thru June 1, 2013
Property Owner Name:
Permanent Mailing Address:
Suffolk County Tax Map Number: 1000 -/,~ b ~ i1~/6
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:
of Trustees Appllcatlon
County of Suffolk
State of New York
'~c.o ~ 9 c,}x G-.-- 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 H1S/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK
WlLL 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 CONJ UNCTION WITH REVIEW OF THIS APPLICATION.
/Si~ature of pr~e~ty Owner
SWORN TO BEFORE ME THIS Q..0~ ,c~ DAY OF ~ 6X/V~CA~( ,20\r~
Notary Public
ALBENA MITOVA
NOTARY PUBLIC-STATE OF NEW YORK
No. 01MI6249841
Qualified In Sultolk county
My commlstlon Expires October I 1,2015