HomeMy WebLinkAboutTR-8153ESOUTHOLD TRUSTEES
Issued To~ Date~/_~_~~
THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF' SOUTHOLD
$OUTHOLD, N.Y. 11971
TEL.: 765-1892
YOUNG & YOUNG
400 OSTRANDER AVENUE, R(VERHEAD, NEW YORK
ALDEN W. YOUNG HOWARD W. YOUN~
SURVEY FOR:
JOAN R. CHISHOLM
LOT NO.I I 8, PART OF LOT NO.12
"MAPOF EDGEMERE PARK"
AT LAUREL GUARANTEEDTO:
LONG IGLAND NATIONAL BANK
TOW~ Or SOUTHOLD THE Tr'rLE GUARANTEE CO.
SUFFOLK CO., N.Y. BY
SCALE: I" = :50' IDATE: FEB. §, I97:5 IN°'7E,-iOi
'1
James F. King, President
Bob Ghosio, Jr., Vice-President
Dave Bergen
John Bredemeyer
Michael J. Domino
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Town Hall Annex
54375Main Road
P.O. Box 1179
Southol~ New York l1971r0959
Telephone (631) 765-1892
Fax (631) 765-6641
ECEIVE
tlAY- 9 20~3
Southold
~oard of Trustees
TROPICAL STORM SANDY EMERGENCY APPLICATION
Valid thru June 1, 2013
Phone Number(s):
Property Address:
Property Owner Name: ',,~ o t?.Jt.~
Permanent Mailing Address:
Su"olk County Tax Map Number:
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?
Project Description: ~-~r-f-~-~. ~¢¢)~~fff ~'~/~
County of Suffolk
State of New York
~-'~,q-rx/ ~, ~------~/~'lt'~/,._.~ 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.
USignat~]~ o? Property Owner'
SWORN TO BEFORE ME THIS
DAY OF
Notary Public