HomeMy WebLinkAboutTR-8124ESOUTHOLD TRUS'
No. ~
ssued TO~ Date~
Address ~- ---' --- --;--:--.-:- -
THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE.TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765-1892
8ROADVtATER$ COVE
TROPICAL STORM SANDY EMERGENCY A
Valid thru June 1,2013
ECEIVE
APR 2 5 2013
Prope~yAddress: ~ ~ ~',~ ~'1 ~ Y
Suffolk County Tax Map Number: 1000 - l o N. - ~ ~ 9. ~
Property Owner Name:
Permanent Mailing Address:
Address: ~,~\ ~-\¢~ Y"¢""'~,~' '~"-',,~
Phone Number(s): (~ ~ t - 7~ ~- ~ ~
Board of Trustee Permit Number(s): ~/~ ~
o~7
Will any part of this project require a Building Permit?
How much fill will be required?
Project Description: ~ ~,vt
County of Suflblk
State of New York
'-T~ o ~-~ ~ ~ Y-d. CWo r 6 ~. II, ~r e ~', 2 ~ ~ ~ t 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.
Signature of Property Owner
SWORN TO BEFORE ME THIS :).'9£ ~. DAY OF &f'l I ,20 jT~
Notary Public
CONNIE D. BUNCH
Notap/Public, State of New York
No. 01 BU6185050
Queiified in Suffo k County
Commission Expires April 14, 2_~_~
AUTHORIZATION
(where the applicant is not the owner)
(print owner of property)
residing at ~ ~ ~ ~ '~ ~ '~ (mailing address)
do hereby authorize "'[~owo-.~ lC/_. ~_~ c,~ co~ [\
(Agent)
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
(Owner's signature)