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Home My WebLink AboutTR-8077ESOUTHOLD TRUSTEES No. ! ~ Issued To~ Dal:e~ Address THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765-1892 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 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES Property Owner Name: ~"/)~ Permanent Mailing Address: Phone Number(s): ~/~ - ~/ mope Addr ss: 5 oy Suffolk County Tax Map Number: 1000- Agent (if applicable) ~/~ 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? of Trustees Application County of Suffolk State of New York BEINO DULY SWORN DEPOSES AND AFFIRI~ THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(~ AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF I~ER 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 ~,~Jr~x DAYOF ~"~c,-~'x. ,20 )~ Notary Public CAROL HYDEL[ NOTARY PUBLIC - STATE OF NE1/V YORK NO. 01HY6189695 QUALIFIED IN SUFFOLK COUNTY I COMMISSION EXPIRES 0~/301204 D of Trustees Applicatlon AUTHORIZATION (where the applicant is not the owner) (print owner of property) residing at (mailing address) ~mat~vr ~ n "ironmental De~Iglt pO Box Peconic, NY 11958 do hereby authorize ~O ~D- (Agent) to apply for permit(s) fi.om the Southold Board of Town Trustees on my behalf. (Owner's signature)