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HomeMy WebLinkAboutTR-8123ESOUTHOLD. TRUSTEES I,,ued To~ Date_~~ Address ~ ----- /-- -'-.--~--- -'. :-'- - Sc'TM · ILFS-~-IL).I '~1~). Z THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD SOUTHOLD, N.Y. 11971 TEL.: 765-1892 CREEK "ROADWAY" // * LOTS J,~ THRU 18, MAP OF EDGEMERE PARK Sub] Fwd: Trees [)ate: 4/25/2013 5:37:44 P M Eastern Dayligi~t -lime Page Friday~ April 26, 2013 AOI,: GJHAINC ECEIVE APR 2 6 20t3 -, ~outhold To~m Board of Trustees TROPICAL STORM SANDY EMERGENCY APPLICATION Valid thru June 1,2013 Property Owner Name: Permanent Mailing Address: PO Phone Number(s): ~r-~ A..~r--~ .--~2~, Suffolk County Tax Map Number: 1000- Agent (if applicable) Address: 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? ]V¢/~ -- /_~-t/ET__ )Jo County of Sutlblk State of New York ~)/~ (~ ~.~T~/~ 6/~D/(~ C )~_~ 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 1N CONJUNCTION WITH REVIEW OF TH1S APPLICATION. SWORN TO BEFORE ME THIS Notary Public No, ap/PublI~-Bl~ of New York Qua ifled in ~'~m.~ ^ -~- ~ ~mmission Exoi~ lu v zS. 20 ~