HomeMy WebLinkAboutTR-8185ESOUTHOLD
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TR'USTEES
SJSS_F-~~a'c~ne
Issued To_J~I~.C_L'zS~]~ Date-~~
Address '_ e. ' old
sc.'r~ ~-~/p-I-15 ' '
THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES OFFICE,TOWN OF SOUTHOLD
SOUTHOLD, N.Y. 11971
TEL.: 765-1892
PI~IVATE ROAD
'EC .E i V E ~
Seuth0ld Town
I~rd of Truste~l
TROPICAL STORM SANDY EMERGENCY APPLICATION
Valid thru June 1,201:]
Property Owner Name:, . ~/~' . ~/~,/. ,~'
Permanent Mailing Address: .~!
P~pedy Address: ~
Agent(if applicable) ~'~,
phone Number(s): ~ ~5 /
Board of Trustee Permit Number(s):
Will any pa~t of this project require a Building Permit?
How much fill will be required? '
Project Description: .~'~_~ VA L
£98S8~66£~ : 'CN XD~
sIqqAHd+~Blad SNNIqD OMi : WO~d
State o f l',,l~rk
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
BI~ APPROVED BY THE SOUTI-IOLD TOWN BOARD OF TRUSTI.~ES. THE APPIJCANT
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 TRUSIEES, THEIR AGENT(S) OR
REPRESENTATIYES(S), TO ENTER ONTO MY PROPERTY TO INSPECT TIlE
PREMISES IN CONJUNCTION W'ITH REVIE~ THIS APPLICATION.
--- ~g~a~re ofl~perty ~Dwner
SWORN TO BEFORE ME THIS d/23a~ DAYOF .]q~a~_ ,20. J?x
Notary Public
TARA L. TU~KEI~ J
~B NWl£:60 £~02 [£ 'ReN £98S8P66£2 : 'ON XW] SI]gAHd+~BIB~ SNNBD OMI :
AUTHORIZATION
(where the appfieant is not the owner)
(~t owner of property)
.~c,F~ot.O #5I I1~..?1
residingat ~1 q,f' L t TT~ Lg 1°lff 6 °tt ! e t3 ,~ y Ltl#,ff
(mailing address)
, _ao n~-e~y.uthoa~_.fft/,.;~VU tva ~
(Agent)
to apply for permit(s) from the
Southold oard of Town Trustees on my behalf.
(Owner's ~ignature)
Pd WUB£:GO £I02 I£ '~eN £98S8P66£2 : 'ON ×UA SI99AHd+~B£Bd SN~]D OMi : WOW~