HomeMy WebLinkAboutTR-7964ESOUTHOLD TRUSTEES
Issued Date~
Address~
THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765-1892
LAWN
20' 0
SANIPY LOAM FILL
CCt~LOGS
~IS~ ER~E~' GP~E, AFTER ~RICANE SANDY
Revision #: Scale:
Date: 12/28/2012 , 1" = 5'
Landscape Plan: Elevation detail I Landscape Design by: David Cichanowic~_
Petty's pond Ass. / John Nickles Creative Environmental Design
N
TROPICAL STORM SANDY EMERGENCY APPLICATION
Valid thru June 1,2013
Property Owner Name: ~'-~¢i-T~_)~ ~2o~')'")
Permanent Mailing Address:
Phone Number(s): 7~2.~ ¢
Property Address: i drd;
Suffolk County Tax Map Number: 1000-
Agent (if applicable) {~-'
Address: ~. ~ ~
Phone Number(s): ~ ~-
Board of Trustee Permit Number(s):
Will any pa~ of this project roquiro
How much fill will be required?
Project Description: ~ ¢~L,~,&
~od~ L~i S,
County of Suffolk
State of New York
~ C~ bt/',,/ t (' ~ C E 2x '/ - 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. 1N COMPLETING THIS
APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR
REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE
PREMISES 1N CONJUNCTION WITH REVIEW OF THIS APPLICATION.
gnature o{ Prope~rty ~ner Y ~-'
SWORN TO BEFORE ME THIS 7 -~}X DAY OF ~ ,20 ] '~x
)~otary Public
CAROL HYDEI.t
NOTARY' PUBLIC - STATE OF NEW YORK
NO. 01HY6'189695
COc~MALIFIED IN SUFFOLK COUNTY,,
MISSION EXPIRES 06/30/20~.~
AUTHORIZATION
(where the applicant is not the owner)
residing at ~3~'~z.~ 6 77
(mailing address)
do hereby authorize
(Agent)
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
(Owneffs signature)