HomeMy WebLinkAboutCAREY, JOSEPH JDear ~r. C~rey;
croau~nt on ~he c~nei. I ~ r~turning
FORH NO, 1
TOWN OF SOUTHOLD
BOARD OF TOWN TRUSTEES
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined .............................. 19 ...... Application No ..................
Approved .................... :~ .............. ~ ..... ~ r~,~/ .... ~-~,Pe'qnit No .............................
INSTRUCTIONS
A. This application ro be completely [illed in by typewriter 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, etc.. 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 before the issuance of a permit.
D. Upon approval of this application. Town Trustees will. issue a permit to applicant. Such permit shall be kept
on the premises and available for inspect/on at all times.
E. Applicant shall notify the Board of Trustees upon completion of the ~vork covered by permit.
APPLICATION IS HEREBY MADE to the Board of Trustees of the Town of Southold, Suffolk County, New
York. for the issuance of a permit pursuant to the laws, Ordinances and regulations governing construction of: docks,
piers, bulkheads, jettys and dredging in, under, and over the waters of Town of Southold. The applicant a~ees
ro comply with all applicable laws. ordinances, re~Iations and conditions specified by said trustees, and to hold
the Town of Southo!d, and all Town officials free from liability and damages of any kind.
Name of owner o~ premises ....~.~. ~,~ ~e~ .... ~.~..~~. ..................................~.~ ~ ~ .........
..... .... ...........
c~¢~, ~z o~ ~o~ ~o~ ~r .~.~ ......~: ..................... , ....
z~ z~ ~o~ ~i~t¢ o~ ~i~ ~ ....... ~.~ ........... A~ zo~i~ ..........................
STATE OF NEW YORK )
)S.S.
COUNTY OF )
................................ being duly sworn deposes and says that he is the applicant for the above
scribed permit, and that ail 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 ro hold the Town of Southold and said trustees harmless and free from any
and all damages and claims arising under or by virtue of said p~fi'tVit, i~,~.~~~~,
Sworn to before me this .............. day of .................. 19 .......
Notary public ...................... county of ...................