The URL can be used to link to this page

Home My WebLink AboutTR-7933ESOU THOLD TRUSTEES . ~~h,:7, P~,.'m~'../.... Issued To~ Date_[~~ Address ~ THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y..11971 TEL.: 765-1892 SUFFOLKTIMES.COM I NOVEMBER1,2012 I 2'1 despread destruction 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 (631) 765-1892 Fax (63~1~ ,. !. NOV -5 2012 HURRICANE SANDY EMERGENCY APPLICATION Valid thru June 1, 2013 Property Owner Name: Permanent Mailing Address: Phone Number(s): ~11'57~ Prope~y Address: ~0 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? -- Trustees Application County of Suffolk State of New York 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 ]~J O k/ ,20 t ~ Notary Public VlCKI TOTIq Notary Public,, State e,{, New No, O~TO619rj696 Qualified in Suf~o~l', County Commission Expires July 7_8 20 MAIN STREE'Ii .:,2 APPROVED BY SURVEY OF PROPERTY NEW SUFF'OLK TOWN OF SOUTHOLD SUFFOLK COUNTY, NEW YORK Nathan Taft Corwin III Land Surveyor