HomeMy WebLinkAbout800 Crown Land LnTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/31/11
* * * RECEIPT * * *
Receipt#: 99848
Transaction(s):
1 1
Permits
Reference Subtotal
692 $150.00
Check~: 711
Total Paid: $150.00
Name:
On-line, Securi~ Ltd
P OBox 132
Medrol, NY 11763
Clerk ID: LINDAC Internal ID: 692
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Pcconic Lane
Peconic, New York 11958
(63 I)765-3140
APPLICATION / PERMIT FOR HIGHWAY F. YC&VATION AND REPAII~
APPLICATION IS HERliBY made to the ' '
pumuant to Chapter 83 of tl~ Code of thc Sup~mtendent of Highways of tho Town of Southold for the issuance of an Excavation Perm/t
Town of Southold, Suffolk County, New York, and other applicable Iowa, ordinances or
regulations for the excavation herein described. The applicant agrees to comply with all applicable laws, ordinances, codez and
regulations, and to permit authorized inSPectors to make n~cessary inmpecfions of the job site.
Name of Applicant
Name of Owne~ of ~,ex~es
Work D~iplion and Location (Street Number, Hamlet, Crozs Stme0
(a) Is construction located within 75 f~t of tidal wetlands?
*If yes, other Town permits may be required.
4. Builder's License No.
E!ectrician's License No.
Address of Applicant
Address of Owner
* Yes. No /
Plumber's License No.
Other Trade's Ljcanse No. /
Date
5. (a) Attached plot plan showing location of proposed excavation mad relation~hlp to adjoining premises or public street or areas, and
giving a dets/led description of layout of cxcavation.
(b) Attach all other necessar~ permits and lic, e~scs for this project
(c) Work covered by tfiis application may not commence before issuance of a Highway Excavation Permit bythe Town Clerk
6. Tax Map No.: Section , Block
,Ph, ase
Excavation
Facili~ Imtallet/on
Backfill & Completion
Pavement Replacement
, Lot
Completion Date: ~/~r/~r
7. Starting Date:
8. Work Schedule:
9, Under which authority is application being made:
I0. P~tlmated Cost of Proposed Work: $ ~
11. Renoarks:
Completion Date
D-39 1 of 3
12. Imurance Coverage: (At~ach Copy) ~ ·
(c) S~ w~ po~cy of cc~fica~un on ~e wi~ ~ Highway Dep~nr ~
(d) Cov~ge ~q~ed e~e~ m ~e To~: /
Bodily inj~ ~ pm~ ~ge: $3~,~0 / $500,0~ B~ly ~j~, ~ $50,~0 pm~ ~ge.
13. ~:
(a) S~ Bond ar ~ ~eck
(b) Maintenance Bond provided:
14. Fees for Applicatiom and permits:
2 years ar
Basic Application Fee
Al.
A2.
B.
NO.
NO.
Bxcavaton~ 18" in depth or less
0-100 i.f. = $10.00; Additional
Excavations 18" in depth to 5' in depth
0-100 i.f. ~ $30.00; Additional
Excavations 5' in depth and over
0-100 i,f. --- $50.00; Additional
NO.
AddifionaI
__/Service Connections excavations ~ $20.00
__/Additional Excavations same sexvice (~ $10.00
i.f. @ $0.I0
i.f. @ $0.30
i.f. ~ $0.50
Utility Repair Excavatiom @ $10.00
Repairs same service ~ $$.00
provided in the total Amount orS
3 years.
$
$
$
$
$
$
$
TOTALS f~'~ ·
Nolice to public utilities proof must be provided and attached to this application prior to isau~ce
of permit.
Authorization is hereby g~anted to the Tovn~ Clerk of the Town of Southold W ism~ a Highway Excavation permit to:
Date Received by the Town Clerk
Dato Perm/t hsued
in accordance w/th this application.
SUPERIN't E~DANT OF I-~GHWAYS
TO SO .O
NOTE:
Permit expires one (1) year from date of issuance.
No work to stur~ without 48 hour notice to Supcfintedant of Highways.
Permit rrmst be available for inspection.
D-39 2 of 3
Copy Distribution:
Highway l parUn nt
Engineer (with page 3)
Applicant
Town Clerk (Original)
]st
3~
Inspection Date
INSPECTOR'S RECORDS
Findings (use code)
REMARKS
Applicant Notified
(To Permit Clerk)
CODE
lB Improper Barricades
tL Improper Light~
ST Sunken Trench o~r Excavation
UTM Unable to Measure (due to bacl~illing)
BUC Building Under Const~xwtion
WIP Work In Progress
DB Inpropor Baekf'fll (too high, not sufficient)
I':iFS Impeetor Holding for Final Settlement of Excavatrion
RFR Ready for Repair
D-39 3 of 3
31/03 '11 'rltU 13:55 FAX 631 765 6145 SOIYI'IIOLI) TOWN CLERK ~001
*** TX REPORT
TRANSMISSION OK
TX/RX NO
CONNECTION TEL
CONNECTION ID
ST. TIME
USAGE T
PGS. SENT
RESULT
1544
31/03 13:53
01'44
4
OK
6548208
?ermit No.
TOtArN OF SOUTHOLD
HIGHWAY DEPARTMLrNT
Peconic Lan~
Pe~.onic, New York 1 I958
(631)765-3140
Work De~,iptloa a~l Location (Su'ect Number, Hsml~, Cro~ S~reet)
(a) Is a~nslruc~ioa locaI~l ~,ith!n 75 f~et of tidal wefla~ls?
.*If y~s, od~r To'a~ p,m~s maybe m. xluired.
APPLICATION ! PERMIT FOR HIGID~Ay EXCAVATION AND S~,EPAm
APPLICATION L~ HEREBY r~j~ ~o t1~ Superintendent of itigh'.~ay~ of the To~ of Sou~oM for ~ i~e of ~ Exca~on P~
p~u~t m C~p~ 83 of ~ C~ of ~ To~ of So~ol~ S~ ~, N~w Y~k, ~ o~r a~plicab~ ~w~, ~s or
re~ous f~ ~ e~on ~ des~& ~ ~H~ ~s ~ ~o~ly w~ a~ a~able la~ ~d~-ces, c~ ~
~o~, a~ to ~t aut~ ~cctom to ~ ~c~ ~o~ of ~e job ~.
~ o~ ~ ........... ~~ ...........
N~ ofO~ of~ ~
4. B~ld~r'$ lice. use A!o.
£]~Iriciau's Licea~c No.
* Yes No
5, (a) A?~chcd~t~an~h~wi~g~cat/~n~fpr~p~scdcaicava~nand~c~a~`~adj~;"~prt~r~s~~
giving a dciail~l description o~ layout o£~xcavation.
Co) Attach all offer necessary permits and llc~mea for this projert
(c) Work covered by this applicatio~ may not cotr,m~e berate issuance of a Flighway Bxcavalion P~uai by t~c Town Clerk.
6. Tax Map No.: Section , , Block , , Lot