HomeMy WebLinkAboutGLENN, ROBERTTOW~ O~ SOfT,OLD
BOARD OF TOWN TRUSTEES
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined .................................................. 19 ........... Applicatiou No~ .............................................
Approved .................................................................................................. Pern~it No ..............................................................................
· Disapproved a/c
............................................................................................................. chairman, Board of Trustees
APPLICATION FOR PERMIT
INSTRUCTIONS
A. This application to be comple,tely filled in by typev~'iter or in ink and submitted to, the Town Trustees i~ dup~
licate.
B. Plot plan showing location of lot and buildings on premises, relatio~ to adjoining premises, public s%reets,
parks, etc., and giving detailed description cf proposed layout of project must be drawn on dia~am which is part of
this applic~ution.
0. The work covered by this application may not be commenced before the issuance of a pe~'~r~t.
D. Upon approval of this application, Town Trustees ~,i]l issue a permit to applicant. Such permit shall be kept
on the premises and available for inspection at all times.
E. Applicant sha~ notify the Board of Trustees upon cor~pZetion of the work cove~ed by permit.
APPLICATION IS, HEREBY i~ADE to the Board of Trustees of the Town of So~thoZd, Suffolk County, New Yo~k,
for the issuance of a permi,t pursuant to the laws, 0r~_inances and regulations governing construction of: docks,
[~iers, bulkheads, jettys and dredging in; under, and over the waters of Town of Sou'~hold. The applicant agrees
to comply v~b all applicable laws, ord~nahces, reg~Zatlons and conditions specified by s~d trustees, and to hold
the Town of Snuthold, and all Town o~c~als free from liabi~.¢y and damages of any kind.
Name of.~er of premises ........ '..~?..~.~_..~...._..~...e.~C.~ .....................................................................................................................................
S~reot Address of Prope~ ....... ~_&..~.~.._~.~.~_ A ........ ~: ................ ~~.C~_._~._~.~.~. .............
Home address If Other Tha~ Location ......................
............ 7 ......... ~' ~":'~
~ ot ~o~osea ~o~: ~ ....~...~ ................ ~ ...~..~...~.~ ........ ~e~ ~o~ ~ ~e~ ....~..~..~ ............
~ ~ ~ana, ~ ~ ~ ~o~u,~ ~ ~..~.~..~.~_~...~. ...... ~ ~ ~ .~.,~ ~. ................................................
~ ~ ~o~ ~ o~ ~ainess ~? ......~..L~..~..~.~ ................... ~ca Zo,ul~ ..........................................................................
STATE~OFNEW YORK)
)s. s.
~COUNTYOF )
................................................................................. beiug duly sworn, deposes and says that he is the applican~ for the above de*
s~ibed permit, and that an statements contained he~ein are true to the best of his k~owledge and belief; that the
work wl]l be done in the man,er set forth in the application and as approved by the Board of Trustees of the Town
of Southo]d, a~d the applicant agrees to hold the Town cf Southold and said trustees harmless anal free from any
and an damages and claims arising ~mder or by virtue of said permit.
(applicant)
Sworn to before me this .............................. day of .............................. 19 ............
No~tary public .................................... county of ....................................