HomeMy WebLinkAboutTR-8181ESO UTHOLD TRUSTEES
Address ,
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THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION
TOWN TRUSTEES, OFFICE.TOW,N OF SOUTHOLD
SOUTHOLD, N.Y, 11971
TEL.: 765-1892
~ECEIVE ~
TROPICAL STORM SANDY EMERGENCY APPLICATION
Valid thru June 1, 2013
Property Owner Name:
Permanent Mailing Address:
Phone Number(s):
Property Address:
Suffolk County Tax Map Number: 1000-
Agent (if applicable) ~(t~ ~n~
'
Board of Trustee Permit Number(s):.
Will any part of this project require a Buil~ling Permit?
How much fill will be required?
Project Description: ~Ok( ~.-
County of Suffolk
State of New York
~ ~/~i~L~, BEING DULY SWORN
DEPOSES AND AFFII~MS TI-~AT 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. 1N 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.
Signat~e of Prope~ Owner
SWORN TO BEFORE ME THIS
DAY OF ~.f
Notary Public, State of New York
No. 4994753
Qu31ified in Suffolk County ~/.J.,
Commission Expires May 22,202_~_
AUTHORIZATION
(where the applicant is not the owner)
residing at q(O~) LL)(~slr
(mailing address)
do hereby authorize ~q ff I~
(Agent)
to apply for permit(s) from the
Southold Board of Town Trustees on my behalf.
(Owner's signature) /~