HomeMy WebLinkAbout625 Kenny's Rd
'permit No. ,;),;2.
File No. (L;) J
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765'- 3140
P.o, ~c1- t7B
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
d YS-S? 13
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, New York, and other applicable laws,
ordinances or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to mlake; necessary., inspections of the job site.
Print or Type
1) ()./Ui~~- vL~"" j~
-',:1ame of Appl' nt
v V f [' /J1~ Yr P U;rv--
Address U
2)
Name of Owner of Premises
~~ '-^-'l
Work Descnption and Location (Street
Address
3)
~ /"",)5
(a) I s construction lo~ated within 75 feet of tidal wetlands? *Yes
*If yes, other-Iown permits may be required.
No
~
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
5) a) Attach plot plan showing location of proposed/eXcavation and relationship to
adjoining premises or public streets or areas, and giving a detailed descrip-
tion of layout of excavation.
b) Attach all other necessary permits and licenses for this project.
c) Work covered by this application may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
Tax Map: Section
Block
, Lot
6)
7)
Starting Date:
Completion Date
8) Work Schedule:
Phase
Excavation........................................ .
Facility Installation.................................
Backfill & Compaction......... ~ . . . . . . . . . . . . . . . . . . . .
Pavement Replacement..............................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11)
Remarks:
\
D-39
Page 1 of 3
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy # \
c) State whether policy of certification on file with the Highway Depart-
ment:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300.000/$500.000 Bodily Injury.
and $50.000 property damage.
13) Security:
a) Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
2 years or
3 years
14)
Fees for applications and permits:
A 1. I /Service Connections
"""iilCi":-
A2. /Additional Excavations same service @ $10.00 = $
NO':-
Basic Application Fee........ $25. 00 v
excavations @ $20.00 = $ ~,,-
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
I. f. @ $0.10 - $
Additional
Excavations--J'8" in depth to 5'
0-100 I. f. =. $30. 00
'2,--
, . - -.' . I. f. @ $0. 30 = $
Additional
Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 = $
C.
in depth:
2)(J --
1."5 :; 0
4'
IftJ
50
D.
Additional
E.
Utility Repair Excavations @$10.00 = $
No.
Repai rs same service @ $5.00. = $
Additional
/
F. Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
* * *
Authorization is hereby granted to the
issue a Highway Excavation Permit to:
in accordance with -this application.
Town Clerk of the Town of Southold to
J3 i!ookL'UJ f/.,u,'t),(.) G.'H
ENT OF HIGHWAYS
THOLD. NEW YORK
/;<- /r- f1
. Date
Received by the Town Clerk /01 -IS. ~,
Date
Permit Issued, /02 -If., -i-9
Date
Permit No.
ci2az,
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Page 2 of 3
Copy Distribution:
\
Highway Department
Inspector
Applicant
Town Clerk
INS P E C TOR ',S
RECORD
Inspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
4th
(To Permit Clerk)
/'
REMARKS
/
CODE
IB - Improper barricades
IL - Improper -lights'.
ST - Sunken trencho~ 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 to repair
\
D-39
Page 3 of 3
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690
MARKETSPAN CORP.S. SUBSIDIARIES
PERMIT ACCOUNT 2
446 MAIN STREET
PATCHOGUE, NY 11772
j DATE.
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ELIZABETH A. NEVillE, TOWN CLERK
Town of Southard
Southard, New York 11971
Phone: 516-765-1800 DATE ~A /? 19~
RECEIVEDOF_Y7;iVtP-,/.o/,~ (]m,o ~~ .h~. $ /9GJ..,fi)
FOR4 c?cl~m#<u.Jtii.7/h-. ~,/~__
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o CASH
~CK II-- ~ 7() BY /.....,~__
RECEIPT
076529