HomeMy WebLinkAboutCASBOR INC
FOR~ NO. 1
TOWN OF SOUTHOLD
BOARD OF TOWN TRUSTEES
TOWN CLERK'S OFF CE
SOUTHOLD, N. Y.
Examined .............................. 19 ...... Application No ..................
Approved ........................................... Permit No .............................
Disapproved a/e .............................................................................................
...................................................... chairman, Board of Trustees
APPUCAT ON FOR PERMIT
INSTRUCTIONS
A. This application ro be completely filled in by type~vriter or in ink and submitted to the Town Trustees in dup-
licate.
B. Plot plan showing location of lot and buildings on premises, relation to adjoining premises, public streets,
parks, ere., and giving detailed description of proposed layout of project must be drawn on diagram which is part
of this application.
C. The work covered by this application may not be commenced be£ore the issuance of a permit.
D. Upon approval of this application. Town Trustees will issue s permit zo applicant. Such permit shall be kept
on the premises and available for inspection ar all times.
E. Applicant shall notify the Board of Trustees upon completion of the work covered by permit.
APPLICATION IS HEREBY MADE ro the Board of Trustees of the Town of Southold, Suffolk County, New
'fork, for the issuance of a permit pursuant zo the laws. Ordinances and regulations governing construction of: docks,
piers, bulkheads, jettys and dredging in. under, and over the waters of Town of Southo!d. The applicant agrees
co comply with ali applicable laws. ordinances, regulations and conditions specified by said trustees, and to hold
the Town of Southo!d, and al! Town officials free from liability and damages of any kind.
Name of owner of premises ...... :%..CU. .................................................
Home address ri Other Than Local~on .... ~.~..~..~ .... ~%~. ~95~ ..............
Creek, Bay or Harbor Frontmg Property ..... ~e CoO '~ ~.~.~.~. ...............................
Permit Reques*ed To' ~&o~
Size of Proposed Work: Len~h..~.T.~.g~.f~ridth.
Depth Below Low Water...~Z;7. ~..Average Rise In TiJf.. ~.7~ .~..Y~rds ~o $~ E~cavated. Z~.~...
Wi4th of Canal, Creek or Bay Fronting Propert[..~.~.7~.~..~, .... Depth at Low Tide ../. Z .~...~ .......
}s ~his For P~, or Business Use? ... ~.~.~.~1.~7 .............. Area Zoning ..........................
~?~pIe'te plot plan zo be dravcn on reverse side of this application.
STATE OF NEW YORK )
)s.s.
COUNTY OF )
............................... being duly sworn deposes and says that he is the applicant for the above de-
scribed permit, and that all statements contained herein are true to the best of his knowledge and belief; that the
work will be done in the manner set forth in the application and as approved by the Board of Trustees of the Town
of Southold. and the applicant agrees to hold the Town of Southold and said trustees harmless and free from any
and ail damages and claims arising under or by virtue of said per, mit
/ ~appli~nt)
Sworn to before me thls .... ',,~..~. ..... day of .....fi,.e..~... / 19.(~.~.
' Notary public.. ,county/ of...$, .c/.~.~'..o././.~ _i~,~4 ~
Ncmry~aotie, State oE
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