HomeMy WebLinkAboutPERKINS, JAMESTOWN OF SOUTHOLD
BOARD OF TOWN TRUSTEES
TOWN CLERK'S OFFICE
SOUTHOLD, N, Y.
Exanfined ............................................... 1 9 ........... Applicatiou No .............................................
Approved ..................................................................................... Permii No ..............................................................................
Disapproved a c .........................................................................................................................................................................................................................................................
............................................................................................................. chapman, ~oard of Trustees
APPLICATION FOR PERMIT
I~ST~CT~O~S
A. This a~pii~at~cn ~o be completely fi~ed in by typewriter or in i~ ~d sub~tted to th~ To,~ Trustees i~ dup-
~ce~te.
~k~, etc.. ~ ~vi~g ~e~aiIe~ ~e~c~pt~on of
~s ~p~c~on.
C. ~he wor~ covere~ by t~s ~cat~on ~y =o~ be com~e~ce~ before the is~u~ce of a ~er~t.
on ~he ~remz~e~ an~ ~va~a~e for ~n~ect~o~
E. ~p~c~ ~a~l no~ffy t~e ~o~r~ e~ ~r~tee~ u~on co~e~o~ of t~e work covere~ by per.t,
AP~LICA~O~ ~ H~B~ ~ADE te the Bo~ o~ ~r~s~ee~ o~ ~he Town o~ So~thold, Suffolk Ceunty~ New Yor~,
~or t~e i~su~ce of ~ perm~ ~ur~u~ to t~e laws~ Or~ces an~ reg~a~ons go~eruing constr~c~on of: dock~,
~er~, b~e~ds, ~ettys ~ ~ed~g i~ un~er, ~d o~er t~e ~er~ of To~ of ~ont~ol~. ~e ~pp~ca~ ~gree~
~o co,~y ~h a~ ~pp~c~ble l~ws~ or~in~ce~ re.la,ions e~ conditions speoified by s~ trustees, and ~o hol~
~he ~e~ of Southo~, an~ ~ ~ow~ o~c~s ~ree ~rom ~a~ty a~d d~m~ges e~ any ~d,
H~me address ~ Other ~a~ n~cation
~reek, ~a7 er ~arbor ~ron~ing ~roperW ......... ~. ......... ~ ~ .......... /~.~-~ ..............................................................................................................
................. ................................................................................................................
Si~e of ~op, sed Work: ~e~'~ _.~ ~.~.-~ ........ wiam _~.~ .............. aeig~ ~bove ~ig~ Wa~er ...~.~ .............
.Dep~ Below ~ow Wa~er ............................ ~ver~ge gibe In ~ide ................................. Y~r~s ~o Bo ~xe~vage~ ................................
Complete ~lot plan to be dra~ on reverse side of *~s application.
STATE OF NEW YORK)
)S.S.
OOT.~TTY OF~~)
scribec~/permit,~ ~a~d that a~l statements contained herein are true to the Best of his kuowledge and belief; ~hat the
work ~ be done in the mariner set forth in the application a. nd as approved hy the Board of Trustees of the Town
of Southold, a~d the applicant agrees t:o held the Tovm df Southold and said trustees hac~mless and free from any
and all damages a~d claims arising under or by virtue of said pern~t.
Sworn to
.................................... county of