HomeMy WebLinkAboutTR-7951EIssued To~ Date.~A~
Address~
THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765-1892
SURVEY OF
d/Tf A
"OWN OF SC
SUFFOLK COUNTY
S.C. TAX Ho. IOOC
SCALE 1':
JUHE 7~ 2
Nath~
L~
DEC -4 2012,
TROPICAL STORM SANDY EMERGENCY APPLICATION
Valid thru June 1, 2013
Property Owner Name: iY)E~.
Permanent Mailing Address: /1~'~) j
Phone Number(s): qJq -~
Prope~y Address:
Suffoik Goun~y Tax ~ap Number: lO00-
Ag~,~ (if ~pp~i~bJ~) N~I h'~
Board of Trustee Permit Numbers):
Will any pa. of this p~ject require a Building
How much fill will be required?
Project Description: ~~5
County of Suffolk
State of New York
T~ ~ ~ ~-'0~--~' l.d~-I~(../~ ~.~. 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 T. HIS ~PP~TION.
SWORN TO BEFORE ME THIS ~ ~ DAY OF ~ 20 [ 2
p~qotary Public/j/
GAILA. GHOSIO
Notary Public. State of New York
No. 6163270
Qualified in Suffolk County
Commission Expires~ March 19,20itll,~,.~,
(print owner of property)
ALrFtlORIZATION - p~OP~T~
(where the applicant is not tho owns)
residing at ~01 ~ Il ~ ~OON (mailing address)
do hereby authorize
(Agent)
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
(Owner's signature)