HomeMy WebLinkAboutKELLY, THOMAS TRUSTEES
John M. Bredemeyer, III, President
Henry P. Sm/th, Vice President
Albert I. Kmpsk/, Jr.
John L. Bednoski, Jr.
John B. Tuthill
Telephone (516) 765-1892
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
SI/PERVISOR
SCOTT L. HARRIS
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
COASTAL EROSION MANAGEMENT PERMIT APPLICATION
TOWN WETLANDS PERMIT APPLICATION
TRUSTEE LANDS PERMIT APPLICATION
Office Use Only:
oastal Erosion Permit Application
I~Wetland Permit Application
t~rustee Lands Permit Application
Grandfather
]0mpleted Apps. Date:
;ariance Required,
Neighbors notified Date:
~ Coord. Review-opt.,~a~.¢
~Insp. comp./date:3?~
SEQRA Determin./da~
Public Hearing/date:
Finaings:
Permit Vote: (Y/N):
Special Conditions:
{also see file)
Application Number; SC574 al000-
Project Name (If any)
Date Prepared:
Appl icant :__~ ,
In~erest: (owner, consultant,lessee,etc.
Owner of Property:
Subject Property Location:
location map)
THIS IS NOT A PE~IT
Yds. to be excavated: --' Yds. to be filled:
Manner in which material will be r~meved or d~posited:
Width of canal, creek or bay fronting property:
Depth at low tide: F Aver. rise in tide: 2
Distance to nearest c~annel: ~ ~ Distance project
extends beyond similar projects in area:
Area zoning: ~. Land area in acres: '~
Is project for p~ivate or business use:
Intended use of property: ~~TIA~- ' '-
Describe known pr~or operations conducted on premises:
Has any prior license or permit been issued to erecu surucuures,
dredge, or deposit fill on said premises: ~-~- -~)~-'; ~.~ ~% l~/
Has any license or permit ever been revoked or suspended by a
Governmental Agency: ~
Projecq Description
The project description must also include plans for reclamation
of land disturbed during construction of the principle and
accessory surucTures and underground surucnures (~.e., pipeline
· , ~ ~C~
Authorization (Where the applican~ is not the owner)
I ~ A~~ ~rresiding at
(Print-owner of subject property) (Mailing address-phone)
do hereby authorize to apply for
Coastal Erosion permit(s; from the Southold Town Trustees~
Signature
THIS IS NOT A PERMIT
County of Suffolk )
State of New York )
~~ ~, ~[~ BEING DULY SWORN DEPOSES AND
AFFIRMS THAT H~/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 WOtAK 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 TO%fN TRUSTEES
HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING
UNDER ORBY VIRTUE OF SAID PERMIT(S), IF GRANTED.
IN COMPLETING THIS APPLICATION, I HEREBY AU~YHORIZE THE TRUSTEES,
THEIR AGENT(s) OR REPRESENTATIVE[s), TO ENTER ONTO MY PROPERTY
TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
SWORN TO BEFORE ME THIS _/.0 DAY OF ~ ,19 ?~
JOYCE M. WILKINS
No. 4952Z , ~r~
Suggested space for location Map
THIS IS NOT A PERMIT
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