HomeMy WebLinkAboutTR-4383 Town Trustees
SOUTHOLD, NEW YORK
ISSUEDTO ]:)Az & STM ~O¥ ....................
Pursuant fo fh~ provisions o~ Chapter 615 o~ fha Laws o~
fha State o~ New Yo?~, 1893; an~ C~apfer 4~ o~ the L~ws o~ the
Sfa+e o~ New Yor~ 1952; en~ ~he So~fhol~ Town O?~na.ce e,-
flfle~ "RE~U~TIN~ AND THE PLACIN~ OF OBSTRUCTIONS
IN AND ON TOWN WATERS AND PUBLIC LANDS en~ f~
REMOVAL OF SAND, ~RAVEL OR OTHER MATERIALS FROM
LANDS U.NDER TOWN WATERS;" an~ ~n accordance w~fh the
Resolution o~ The Boar~ a~op+e~ afa meeting hel~ on ~.~./~.7/~.~..
19. 9~, and in conslderaflon o~ fhe sum of $140.00 paid by
Goste]]o..~ ~Go~,.. ~o~ ~AZ ~ ~..~ .....................
of S~ N.Y. and subiecf +o fha
Terms and Condlfions lis~ed on +he reverse side hereof,
of Sou+hold Town Trus+ees aufhorizes and ~ermifs ~he followlnq:
G~E~t~e~ ~e~m~t to ~e~eat~ ]50~ oEb~]~e~d, ~eb~
~]e~ sa~d. A~e~e~t ~o b~]~ a Z~~ ~e~. A ~0 Eoot'~o~-
all in accordance wifh fha derailed specifica+ions as preen+ed ~n
+he origlna~ing appllca~ion.
IN WITNESS WHEREOF, The sald Board of T~sfees here-
by causes ifs Corporafe Seal ~o be affixed, and fhese presenfs +o
be subserVE'ed by a maiorify of fhe said Board as of +his de~e.
Albert J. Kmpski. President Town Hall
Johfi Holzapfel, Vice President 53095 Main Road
William G. Albertson P.O. Box 1179
Martin H. Gan-ell Southold. New York 11971
Peter Wenczel Telephone (516) 765~1892
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Office Use Only
Coastal Erosion Permit Application
etland Permit Application
randfather Permit Application
Trustee Lands Permit Application
Waiver
A lication:
~Clerical R~viey:
~Completed ApPI~catiOn ~ % [ q
~ ncomplete ~ ~_~/T ~
SEQ~ ClasEifi~ation:
~e I ~e II Unlisted
~Coordinati0n: (date sent) --
~Date, o~,. InSpection. (date) }°/&lgq
Receip~ of: CAC Report: (date)
.Lead Agency DBte mlnatzon.
Tec~i~al Review: (date)
p~i~C; Hea~in~:
D~cisign: Approved (Y/N), (date)
Name of Applicant 5~ I ~ S I~ ~
Phone N~er: (J
Suffolk County Tax Map N~er: 1000
Property Location: ~Z~T k~
(If applicable)
Address: ~.~. ~ ~l~ / ~E~U
Phone: (~'
Bo~-~ of Trustees Application
GENERAL DATA
Land Area (in square feet):
Area Zoning: R~I ~ ~ [Ak~ )
Previous use of property:
Intended use of property:
Prior permits/approvals for site improvements:
Agency Date
No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a
governmental agency?
¢/ No Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
County of suffolk
Skate of New York
~E6~ ~, CO~TELLO! ~, BEING DULY SWORN DEPOSES AND
~FFIRMS THAT HE/SHEIS 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 WORK 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
AGREESTO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES
HARMLESS AND FREE FROM AMY AND ALL DAMAGES AN~ CLAIMS, ARISING
UNDER OR ~y VIRTUE OF SAID pERMIT{S;, IF GRANTED.
INCOMPL~TIN~THIS APPLICATI~N~ I HEREBY.AUTHORIZE THE TRUSTEES,
T~EIR iA~T~'s} OR R~PRESENTA~IVE(s), TO ENTER ONTO MY~ PROPER~
TOINSPECTTHE PREMISES IN CONJUNCTION WITH REVIEW OF THIS
APPLi~ON.
SWORN TO BEFORE ME THIS ~9 DAY OF
suggested space for location Map
THIS IS NOT A PERMIT