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Issued T,
Dal:e~
Address~
THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL,: 765-1892 ·
meters 100
COUNTY OFSU~FOLK
James F. K/ns, President
Bob Ghosio, Jr., Vice-President
Dave Bergen
John Bredemeyer
Michael J. Domino
Tel
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Town Hall Annex
54375 Main R°ad
P.O. Box 1179
Southold, New York 11971-0959
HURRICANE SANDY EMERGENCY APPLICATION
Valid thru June 1, 2013
Property Owner Name:
Pe~anent Mailin~ Address:~
Phone Numbers):
SulTolk Coun~ Tax Map Number:
Agent (if applicable)
Phone Number(s): ')/-I; ,Ct ~/~
Board of Trustee Permit Number(s):
Will any part of this project require a Building Permit?
How much fill will be required?
Project Description: (~
Board of Trustees Application
County of Suffolk
State of New York
.DEPOSES ~,~S ~T ~S~ IS ~ ~P~IC~ FOR ~ ~0~
DESC~ED PE~(S)
~ TO'~ BEST'OF ~R ~O~EDGE
~L-BE DO~.~ T~ ~ SET FOR~.~'T~S ~PLIC~TION ~ ~,~Y
BE ~PRO~D BY ~ SO.HOLD TO~ BO~ OF ~US~ES. ~.~PLIC~
AG~ES TO HOLD T~ TO~ OF SO--OLD ~ ~ TO~ ~US~S
~ESS~ ~E ~OM ~ ~. ~L D~GES ~ CE~ .~S~G
'~ER OR BY ~ OF
~PLICATION, I ~BY A~~ ~ ~US~ES, ~ AGE~(S) OR
~P~SE~ATI~S(S)~ TO E~R O~O
'P~SES ~'CON~CTION ~H ~W OF ~S ~PLICATION.
Signature
SWORN TO BEFORE ME THiS
)AYOF - M , ,20/