HomeMy WebLinkAbout2355 Village Ln (2) 12. Insurance Coverage: (Attach Copy)
(a) Insurance Company: on file at Town of Southold Building Department for Ross Construction
(b) Policy#:
(c)State whether policy of certification on file with the Highway Department:
(d)Coverage required extended to the Town:
Any Loss including Bodily injury,property or commercial injury caused by or attributable to the work performed:
$1,000,000 per Occurrence and$2,000,000 general aggregate.
13. Security:
(a)Surety Bond or Certified Check provided in the total Amount of$
(b)Maintenance Bond provided: 2 years or 3 years.
14. Fees for Road Opening Applications and permits:
Basic Application Fee for Each Project Location - $500.00
A Project Location would include each Bell Hole and/or every road opening or excavation within any
50' Radius whether or not they may be inter-connected by open trench or directional boring.
The total number of Project Locations shall be subject to the approval of the Highway Superintendent.
Al. 0 /Service Connections excavations @$50.00 $ 0.00
No.
A2. 0 /Additional Excavations same service @$20.00 $ 0.00
No.
B. Trench Excavations 18"in depth or less
Total Lineal Footage of Excavation; .5 L.F. @$10.00 $ 5.00
C. Trench Excavations 18"in depth to 5' in depth
Total Lineal Footage of Excavation; 0 L.F. @$30.00 $ 0.00
D. Trench Excavations 5' in depth and over
Total Lineal Footage of Excavation; 0 L.F. @$50.00 $ 0.00
E. 0 Utility Repair Excavations @$1,000.00/Each $ 0.00
No.
0 Additional Repairs of Same Service @$500.00/Each $ 0.00
No.
F. Official Notice to public utilities-proof must be provided and
Shall be attached to this application prior to issuance of permit.
15. Fees for New or Alteration to Curb Cut:
Basic Application Fee - $50.00
A Curb Cut would include any new or alteration of an existing driveway within the boundary of the right of way.
The configuration of such is to the conditions set forth in Chapter 237 of town code.
TOTAL$ 50.00
* * * * * * * * * * * * * *
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to:
in accordance with
this application and subject to the"General Conditions"and"Special Conditions"of permit(if any)attached hereto.
SUPEPFL(
NDENT OF HIGHWAYS
TOWOUT OLD NEW O
�L
tm*. oodwin
Da
^44
Date Received by the Town Clerk y d-I '��
Date Permit Issued 10 - 3C- p9 y Permit No.
NOTE: Permit expires one(1)year from date of issuance.
No work to start without 24 hour notice to Superintendent of Highways.
Permit must be available at all times for inspection,on site,during construction.
D-30 2 of 3
Copy Distribution: I 1 54
Permit#
Highway Department
Engineer(with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
1st
2nd
3rd
4t`
(To Permit Clerk)
REMARKS
CODE
IB Improper Barricades
IL Improper Lights
ST Sunken Trench or Excavation
UTM Unable to Measure(due to backfilling)
BUC Building Under Construction
WIP Work In Progress
DB Improper Backfill(too high,not sufficient)
HFS Inspector Holding for Final Settlement of Excavation
RFR Ready for Repair.
D-39 3 of 3