HomeMy WebLinkAbout3475 Wells AveTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 02/24/11
* * * RECEIPT * * *
Receipt"8: 98129
Transaction(s):
1 1
Permits
Reference Subtotal
687 $180.00
Check~: 1213
Total Paid: $180.00
Name:
L, IPA
117 Doctor's Path
Riverhead, NY 11901
Clerk ID: LINDAC Internal ID: 687
LIPA Reference T101166106
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
P.O. Box 178
Peconic, New York 11958
(631)765-3140
£ CEIV D
APPLICATION / PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
XPPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southotd for the issuance of an Excavation Permit
pursuant to Chapter 83 of the Code of thc 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 make necessary inspections of the job site~
Print or Type
1. LIPA
Name of Applicant
117 Doctors Path, Riverhead, NY 11901
Address of Applicant
2. Joseph De Nicolo
Name of Owner of Premises
3475 Wells Avenue, Southold
Address of Owner
LIPA to dig a 1'×30' trench on the s/s of Wells Ay, 520' e/of Oaklawn Av,
then trenching in a west direction for 30' LIPA to set a new pole 580' e/o
Work Description and Location (Street Number, Hamlet, Cross Street) 0 a k i a w n A v,
(a) Is construction located within 75 feet of tidal wetlands? * Yes No
· If yes, other Town permits may be required.
4. Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
/~ Signature of A~plJcant
Steven AyA'ward - LIPA
2/9/11
Date
(a) Attached plot plan showing location of proposed excavation and relationship to adjoining premises or public street or areas, and
giving a detailed description 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.
6. Tax Map No.: Section _, Block , Lot
7. Starting Date: Completion Date:
8. Work Schedule: Phase Completion Date
Excavation
Facility Installation
Backfill & Completion
Pavement Replacement
9. Under which authority is application being made:
10. Estimated Cost of Proposed Work: $
I 1. Remarks:
D-39 1 of 3
12. Insurance Coverage: (Attach Copy)
, (a) ~nsurance Company!
(b) Policy #:
(c) State whether pohcy of certification on file with the Highway Deparlmemt:
(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 or Certified Check provided in the total Amount of
(b) Maintenance Bond provided: 2 years or 3 years.
14. Fees for Applications and permits:
Basic Application Fee $150.00
Al. /Service Connections excavations ~ $20.00 $
No.
A2. /Additional Excavations same service ~ $10.00 $
No.
B. Excavations 18" in depth or less
0-100 i.f. = $10.00; Additional . i.f. ~ $0.10 $
C. Excavations 18" in depth to 5' in depth
0-100 i.f. = $30.00; Additional i.f.
D. Excavations 5' in depth and over
0-100 i.f. = $50.00; Additional. i.f. ~ $0.50 $
E. Utility Repair Excavations ~ $10.00 $
No.
Repaizs same service ~ $5.00
Additional
TOTALS
' F. Notice to public utilities proof mast be provided and attached to tiffs application prior to issuance
of permit.
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permi~ to:
Dat? Received by the Town Clerk
in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TO'C~N'DF~OUTHOLD, NEW YORK
Pe~er W. Harris
Date o~,~/,..~//it/
Datk Permitlssued ~/;c/~./? PermitNo. ~ ? 7
.j
NOTE: Permit expires one (1) year from date of issuance.
No work to start without 48 hour notice to Superintendent of Highways.
Permit must be available for inspection.
D-39
2 of 3
Copy Distribution:
· Highway Department
Engineer (with page 3)
Applicant
Town Clerk (Original)
1st
2nd
3rd
4th
Inspection Date
INSPECTOR'S RECORDS
Findings (use code)
Applicant Notified
(To Permit Clerk)
CODE
lB Improper Barricades ·
IL -imp,,~pcr Lights
ST Sunken Trench or Excavation
UTM Unable to Measure (due to backfilling)
BUC Building Under Construction
WIP Work In Progress
DB Improper Baali~ll (too high, not sufficient)
HFS Inspector Holding for Final Settlement of Excavation
ILFR Ready for Repair
D-39 : 3 of 3
NOTES: WO~TI 01166106
1) UPA TO DIG A 1' X30' TRENCH ON THE SOUTH SIDE OF WELLS
AVE.,ST/~TING 520' EAST/ OF ON(LAWN AVE.THEN TEENCHING IN A WEST
DIRECTION FOR 30'
2) LIPA TO INSTALL A NEW POLE ON THE SOUTH SIDE OF WELLS AVE,580'
EAST/ OF ON(LAWN AVE.
N
0