HomeMy WebLinkAbout1610 The StrandTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 04/08/11
* * * RECEIPT * * *
Receipt~: 100165
Transaction(s):
1 1
Permits
Reference Subtotal
693 $150.00
Check#: 561
Total Paid: $150.00
Name:
On-line, Security Ltd
P O Box 132
Medford, NY 11763
Clerk ID: LYNDAR Internal ID: 693
P~ut No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Pcconic Lane
Peconic, New York 11955
(631)765-3140
APPLICATION / PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendant of Highway~ of the Town of Southold for the issuance of an Excavation Permit
pursuant to Clmptcr 83 of the Code of thc Town of Southold, Suffolk County, New York,' and otber applicable hws, orcli.~.~o~s or
regulations fear the excavation herein described. The applicant agrees to comply with all applicable laws, orrlln~nceS, codes and
regulations, and to peixnit authorized inspectors to make necessary impections of the job site,
print or Tvce
Name of Applicant
Name of O~er of Premses
Work Description and Location (Sheet Number, ~H'amlct, Cross Sheet) ~'~ --
(a) Is conslruction located within 75 feet of tidal wetlands? * Yes No
· If yes, other Town permits may be required.
Builder's License No.
Eleclrician's License No.
Plumber's License No. ~
t
//~//~~/°f A~lica~
Date
(a) Attochod plot plan showing location of proposed excavation and rchtionship to adjo~i-~ premises or public street or arca$, and
giving a detailed description of layout of excavation.
Co) Attach all other necessary permits and liee~es for this project
(c) Work covered by Us application may not commence before i~suance of a Highway Excavation Permit by the Town Clerk.
6. T~x Map No.: Section
7. Staffing Date:
Block , Lot
Completion Date: ~"--
8. Work Schedule: Phase
Excavation
Facility Installation
Backfill & Completion
Pavement Replacement
9. Under which authority is appiication being made:
Completion Date
10. Estimated Cost of Proposed Work: $ ~
D-39 1 of 3
,1~. Insurance Coverage: (Atlach Copy)
(a) llmuranee Company: ,.J if
(c) State whether policy of certification on file w/th the Highway Department/~'~/~'
(d) Coverage required extended to the Town:
/
Bodily injury and property damage: $300,000 / $500,000 Bodily Injury, and $50,000 propen'y damage.
13. Security:
(a) Surety Bond ~ or Certified Check
provided in the total Amount of $
(b) Maintenance Bond provided:
14, Fees for Applications and permits:
Basic Application Fee
Al. /Service Connections excavations ~ $20.00
No.
A2. / Additional Excavatiom same service @ $10.00
B. Excavations 18" in depth or less
0-100 i.f. = $10.00; Additional · i.f. ~ S0.10
Excavations 18" in depth to 5' in depth
0-100 i.f. = $30.00; Additional
i.f. @ $0.30
Excavations 5' in depfl~ and over
0-100 i.f. = $50.00; Additional
Lf. @ $o.5o
Additional
Utility Repak Excavations @ $10.00
Repairs same service @ $5.00
$
$
Notice to public utilities proof must be provided and attached to ~ application prior to issuance
of permit.
Date Received by the Town Clerk
Dat~ Permit Issued q-~-
Authorization is hereby granted to the Town Clerk of the Town of Southold to is~..e a Highway Bxcavation permit to:
in accordance with this application.
Permit expires one (1) year fi:om date of issuance.
No work to start without 48 hour notice to Superintedant of Highwnys.
Permit must be available for inspection.
D-39 2 of 3
Copy Distribution:
Highway Department
Engineer (with page 3)
Applicant
Town Clerk (Original)
1 st
3~
4m
Inspection Date
INSPECTOR'S RECORDS
Findings (use code)
Applicant Notified
(To Permit Clerk)
CODE
IB Improper Barricades
IL Imprope~ Lights
ST Sunken Trench or Excavation
UTM Unable to Measure (due to bacldilling)
BUC Build/ng Under Construction
wn~ Work In Progress
DB Inpropcr Backf'fll (too high, not sufficient)
HFS lmpector Holding for Final Settlement of Exc, avatfion
RFR Ready for Repair
D-39 3 of 3
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