HomeMy WebLinkAbout1470 Hobart LnTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/26/10
* * * RECEIPT * * *
Receipt#: 91117
Transaction(s):
1 1
Permits
Reference Subtotal
666 $270.00
Check#: 2953
Total Paid: $270.00
Name:
R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID: 666
Permit No.
'~qWN OF SOUTHOLD
-~HWAY DEPARTMENT
~-,c--nic Lane
Peconic; New York 11958.
(631) 765- 3!tI0
APPLICA'IXION/PERMIT FOR HIGHWAY~ EXCAVATION AND REPAIR
RECEIVED
20]0
APPLICATION IS HEREBY made to.the Superintendent of Highways of the Town
of Southold for the issuance ef 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 regulatiohs for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulaflot~s, and to permit
authorized inspectors to: rdake~ nec&ssary inspections of the job site.
Print or Type
Name Of Applicant
Address
2)
S)
Name of Owner of Premises Address
Description and Location (Street Number, I~amlet, Cross Street)
(a) Is construction located wlthih 75 feet of tidal wetlands? *Yes No tC
*if yes, other Town permits may be required.
Buildetas License No. Plumbelas License No.
Electrician% License No. Other Trade's License No.
' Sig.a~ture[f AppliCant
6) Tax Map: Section
7) Starting Date: Completion Date
8) Work Schedule:
Phase.
Excavation .........................................
Facility Installation .................................
Backfill S Compaction ..............................
Pavement Replacement .......... ; ...................
9) Under which authority is the appliCation made:
10)' Estimated Cost of Proposed Work: $
TI
a) Attach plot plan showing Iocatioh o~, proi~osed excavation and relationship to
adjoining premises or public'streets or areas, and giving a detailed descrip-
tion of layout'of excavatioh.
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 Excavafloh Permit 'by the Town Clerk.
· Block , Lot
Completion Date
D-39 Page I of 3
12)
Insurance Coverage: [Attach copy)
a) Insurance Company: L~/~
b) Pollcy #
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) SecurltT.:
a) Surety Bond or Certified Check provided in'the
total amount of $
b) Maintenance Bond provided: 2 years or 3 years
lq) Fees for applications and permitS: Basic Application Fee ........
Al.No~. ,/Service Connections excavations ~ $20.00 = $
/Additional Excavations same service ~ $10.00 = $
A2.
B.
Do
No.
Excavations 18" in depth or less:
O-100 I.f. = $10.00:
I.f. ~ $0.10- $
Additional' ' '
Excavations 18" In depth to 5" in depth:
0-100 I.f. = $30.00
I.f. ~ $0.30 .-- $
Additional
ExcavaUons 5~ in'depth and over:
0-100 I.f. -- $50.00
I.f. ~ $0.~o: $
Additional
E.
No.
Additional
F. Notice to public'utillti&S
this appllcatloh prior to
Utility Repair Excavations ~$~0.00 = $
Repairs same service ~ ~5.00 = $
proof must be provided and attached 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 Seuthold to
SUPERINTENDENT OF HIGHWAYS
TO~-~UTHOL:~ ~ YORK
~ F~eter W. Harris,
Received by the Town Clerk ~:~-~S'"/C~
Date
Permit Issued ~' '~ "~'d_~ Permit "o. ~ ~ ~
Date
N~e: Pemlt ~pires one (1) y~r f~ Date of Iss~n~.
' No work to s~ wither ~8 h~ notice to the Superintendent of Highways.
Pe~lt must be available for Insp~tion.
D-39 Page 2 of 3
Copy DistribUtion:
Highway Department
Inspector
Applicant
Town Clerk
i N S p E C T O R ~.S R E C O R D
Inspection Date
Findings (use code)
Applicant Notified
Ist
2nd
3rd
qth
(To Permit Clerk)
REMARKS
CODE,
lB- Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WlP - Work in'progress
DB ~ Jmproper backfill' (too high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR - Ready to repair
D-39 Page 3 of 3