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Home My WebLink AboutTR-7935ESOUTHOLD TRUSTEES Address~ THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL..: 765-1892 ~-'-' ........ Z_-_- ZZ ZZ ....... N .I James F. FAng, President Bob Ghosio, Jr., Vice-President Dave Bergen John Bredemeyer Michael J. Domino Town Hall Annex 54375Main Road P.O. Box 1179 Southold, New York 11971-0959 BOARD OFTOWNTRUSTEES TOWN OFSOUTHOLD Telephone (631) 765-1892 Fax (631) 765-6641 HURRICANE SANDY EMERGENCY APPLICATION ¥~lid thru Ju~e 1, 2015 Permanent Mailing Address: / 7~ Phone Number(s): ~/-'7~ Suffolk County Tax Map Nl~mber: 1000- ~' fO-//-/-'/~' / Agent (if applicable) Address: ~ Phone Number(s): Board of Trustee Permit Number(s): /~o f)CCc,,~'~Lc~ Will any part of this project require a Building Permit? How much fill will be required? of Trustees App, licatio~ County of Suffolk State of New York 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 THIS APPLICATION. SWORN TO BEFORE ME THIS DAY OF ~Ib'~4Y~ ~ ,20 I~ Notary Public CONNIE D. BUNCH Notary Publtc, State of New York No. 01BU6185050 Qualified in Suffolk County Commission Expires April 14, 2~,