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James F. King, President • ~~OF SO!/lyo • Town Hall Annex
Bob Ghosio, Jr., Vice-President l~ 54375 Main Road
P.O. Box 1179
Dave Bergen l~( #f Southold, New York 11971.0959
John Bredemeyer H ~e
Michael J. Domino ~ i~ Telephone (631) 765-1892
Ol~,CO~I~ Fax (631) 765-6641
BOARD OF TOWN TRUSTEES If1]
TOWN OF SOUTHOLD 11 I ~ ~ ~ I I
outhold own
f Trustg___
TROPICAL STORM SANDY EMERGENCY APPLICATIO
Valid thru June 1, 2013
Property Owner Name: R N rJ fl l)11 flG F}-
Permanent Mailing Address: ~ 23 3"Z ~ , R . 4 s c,yTt-1~l ~D~ tJ y { l 71
Phone Number(s): c~L: G•3/ `f5~3 -~S C3 N~?~: G3/ '7~5.23`f3
Property Address: 52:3"32~ c,,K. ~<.~~~-r}~,c_pbN y 1197/
Suffolk County Tax Map Number: 1000 - ! 3S
-v3~ l7. l
Agent (if applicable)
Address: -
Phone Number(s):
Board of Trustee Permit Number(s):
Will any part of this project require a Building Permits ~ -
How much fill will be required - ~ ~ ~
Project Description: o~ t~.en...~-.~A ~2.Ri,.vw.1 ~o.cm~_ ~ cam- ~L~,..-,~,
CL ,M~ ~Q~ QtQ~y, cs-aC a`h~ tn~-e_~ ~.v. ~~m~v~a~cL c~ ~ ,
A-ma_Ok'_ mze_- crzZA-~J.__ aY~ c~,Li,c~cr-nr' 1~~+-oTiR~ G,•3-a-'LA'~ o-~
--y~ ~ ~ tLw
-Q.cv+-.~..9.~z,t~.u ,~c.a~._-.. -=i ~v-Q-~... / K-~-ti ~ie~_ LaJ a ~ 2 ~i~mc~.i
w-~,~e~(- ~~~~-z.h ~ cozz- _ o-w<~ tF d~ u~ ~ c~-~,
-t1a-6- n~.aE~ 51 ~ 9~l ~a9-c.~ S~.%1~ ~ n~-~*~c~~
County of Suffolk
State of New York
1 ~ BEING DULY SWORN
DEPOSES AND AFFIRMS THAT HE HE S THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND~T.)IAT STATEMENTS CONTAINED HEREIN ARE
TRUE TO THE BEST OF H[S ER NOWLEDGE AND BELIEF, AND THAT ALL WORK
WILL BE DONE IN THE MAN~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 O.Jvner
SWORN TO BEFORE ME THIS C1 ~'Yl DAY OF~Tq(~l~l ,201
b ~u~
Notary Public
:C.Nnr,E D. Bu~~::-~
N~ta~y~ Public, 3i3t~ ai "!~~~n~ Yr=.a
No. 471 RI_ i¢, i $5f~'ii7
CF;;yftied ire ~~;{folk ; ,,Y
Ccrrrisior, -~ra.;;~.~ ~.(~I~