HomeMy WebLinkAboutMILLER, WALTERTOWN OF SOUTHOLD
BOARD OF TOWN TRUSTEES
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined 19. Anplication No.
Approved ..-:. . ._~_... Permit No .............................
Disapproved a/c" ;Y ..... l' .......................... ~...fy ..... / ....
..................................................... chairman, Board of Trustees
APPLICATION FOR PERMIT
INSTRUCTIONS
A. This application to be completely filled 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 streetsl parks.
etc., and giving detailed description of proposed layout of project must be drawn on diagram which is part of thii
application.
C. The ~vork 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 inspection at ali times.
E. Applicant shall notify the Board of Trustees upon completion of the work covered by permit.
APPLICATION IS HEREBY MADE to the Board of Trustees of the To~vn 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 w~ters of Town of Southold. The applicant agrees
to comply witti all applicable laws, ordinances, regulations and conditions specified by said trustees, and to hold the
Town of Southold, and ail Town officials free from 'iigbiSty and damages of any kind.
Name of Owner of Premises....~.!~ .~ff.~.~c .J~...~.... , ....... ¢, ......... ~. ..............................
Home Address If Other Than Location ............ ~./k,~.;}.~5f ...............................................
Permits Requested To: .. ~~.~. ...................... .................................................
· ~)/ .~.;-Z¥~eighth Above High Water ...~.f ........
Size of Proposed Work: Length .../~-! ......... Width
Depth Below Low Water . ..'~..( ........ Average Rise In Tide . ..~/. ........ Yards to Be Excavated . ..D. ........
~ridth of Canal, Creek or Bay Fronting Property ....~..'~. ................. Depth at Low Tide ..........
Is This For Private or Business Use?....~...'Of~..~ ........................ Area Zoning . .~...~..
Complete pl*t plan to be drawn on reverse side of this application.
STATE OF NEW YORK )
__ )S.S.
~COUNTY 0~'/~)
permit, and that ali statements contained herein are true to the best of his knowledge and belief; that the wvork
will be done in the manner se't 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
all damages and claims arising under or by virtue of said permit /¢/
....
.~~ (applicant)
x¢-'- , ., 19..~fl..[...
Sworn to befor - this ..... .?../..-2... of ....
No. 52-74951~5, Suff0[k
Term Expires ~.arbh 30,