HomeMy WebLinkAboutMILLER, WALTER FORM NO. 1
TOWN OF SOUTHOLD
BOARD OF TOWN TRUSTEES
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined . .. .. .. .. .. .. .. .. .. . . . . .. . . .. . . . 19 . .. . Application No. . .
Approved . .. . c �' . . Permit No. . . . . . .. . . ... . . . . . .. .. . . .. .. .
Disapproved a/c .U.. . . . . . . . . . .. .. ...�`. . . .. . . . . . . .. .. .. .. .. .. .. .. .. .. .. .. . .... ... . . . . .. . .. . .
•• •• •• •• .••. .. .. ... . . ... .. .. ... . . . . . . . . . .. . . . . .. .. . . . 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 streets, parks,
etc., and giving detailed description of proposed layout of project must be drawn on diagram which is part of this
application.
C. The work 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 all 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 Town 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 waters of Town of Southold. The applicant agrees
to comply with all applicable laws, ordinances, regulations and conditions specified by said trustees, and to hold the
Town of Southold, and all Town o ficials free from 1i bility and damages of any kind.
Name of Owner of Premises . . .� 1W b
Street Address of Property ...ft�r3 -CC9Tt/ J�✓i.`r°i ,l
Home Address If Other Than Location . .. . .. .. .. . ..^ j .. . . .... . . .... ..
Creek, Bay or Harbor Fronting Property vC�
Permits Requested To: . . . /41. .. . . . . .. . . . . . . . .. .,,. .,/ . .. . .. .. .. .. .. .. .... .. .. ....... . .. .. . .. . . . . . .
P g �. . .. .. . !u/aO1 !4I �. . . .. . . .
Size of Proposed Work: Length e� �Jidth eighth Above High Water
i
Depth Below Low Water .. .. .. .. . Average Rise In Tide . . . .. .. .. . Yards to Be Excavated . . . . . . . .
Width of Canal, Creek or Bay Fronting Property . .. 7`5. . .. . . .. .. . . . . .. . Depth at Low Tide,,0 ... . . .. .. . . . . .
Is This For Private or Business Use? . . !ls(/f . . . . . . . .. . . .. .. . . . . . . .. . Area Zoning
Complete plot plan to be drawn on reverse side of this application.
STATE OF NEW YORK )
)S.S.
COUNTY OF
2t � � .. . being duly sworn deposes and says that he is the applicant for the above described
permit, and that all statements contained herein are true to the best of his knowledge and belief; that the work
will be done in the manner set 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.
r
(applicant)
sue. ��.
Sworn to befor this �.. .. ` ay of
Notary public, of . .. . .
NICHOLA EONAND
Notary Pu61i , State of New York
No. 52.7495135,'Suffolk County
Term Expires March 30, 19?d
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