HomeMy WebLinkAboutTR-7977ESOUTHOLD TRU:S
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Issued To ~-.~~~..~-~~ Date ~ ~__~/._~_q
Address
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THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN.TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765.1892
/7' .
N. 78%'"'54'50' ~''
~
~o~ SURVEY OF
LOT ~'
L 0 T 79
A T NASSAU POINT
N 0 ? TOWN OF SOUTHOLD
/ '~,~ SUFFOLK COUNTY,N Y.
1000 - 1~ - 01- 07
~ ,~ Scale: 1" =40'
~' The Iocotion$ of we/is ond cesspools . .~ ..~.~-~
a ~ ~ ~. - · -. CERTIFIED TO, and or from data obloined from others. ~ ~o~N t.~.% .
~ = ~O,~OIsq. ft.to tielines c~.~ HOELZL ' / ~,~%~ "
CHle~GO TITLE INSURANCE CO.
.......................... ~'~ WAGE
~ A~ VA~ F~ T~ ~P ~ C~8 ~ ~Y F AND CONSTRUCTION OF SUBSURFACE SE SJ NC S ~/~~sY.~NO. ~9618
~_~ m C~S ~R ~ ~ ~ ~ ~ ~ ~SPOSAL SYSTEMS FOR SINGL~.FAMIL Y ~E D~ ~. ~ .... '' ~~~ .
~_~ A~R$ ~ ~ ~ffi ~Se ~y the conditions sel mrlh therein aha on /ne. PECO~C
~11 v ~n r~ v ~ e,~ , a. ~ ~ ... ~ ~ .... ~. :~ ~.~ ~o condrucl. [516) 765 -
~:~ ~' ~ ~ ~ ~' ~ ~EW~ -~ '~"~~'~-~ 1230 TRA~~
James F. King, President
Bob Ghosio, Jr., Vice-President
Dave Bergen
John Bredemeyer
Michael J. Domino
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Town Hall Annex
54375 M.in Road
P.O. Box 1179
Southold, New York 11971-0959
Telephone (831) 765-1892
Fa~ (631) 765- fro41
HURRICANE SANDY EMERGENCY APPLICATION
Valid thru June 1, 2013
Property Owner Name: v/
Permanent Mailing Address: 2/
Phone Number(s): ~'~3 /
Property Address: ~ ~ c/,~-' /~/fl.~.~CA
Suffolk County Tax Map Number: 1000-
Agent (if applicable)
Address:
Phone Number(s):
Board of Trustee Permit Number(s): Permit?
Will any part of this project require a Building
How much fill will be required? z-~ (~) .j/~./r)/~ .~
Project Description: R~ ~'~/_ ~ [~,~"-./~( _f~'-A,/~
77
Board of Trustees Application
County of Suffolk
State of New York
DEPOSES AlqD 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.
~b~gnature of Pr6pe~y bv~n~
SWORN TO BEFO ME TH S q DAYOF ,20 /3
N0~y Public
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