HomeMy WebLinkAboutLatham LnTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/26/10
* * * RECEIPT * * *
Receipt-8: 91116
Transaction(s):
1 1
Permits
Reference Subtotal
665 $175.00
Check#: 2939
Total Paid: $175.00
Name:
R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC internal ID: 665
Permit No.~_~/'
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT.
Peconlc 'Lane
Peconlc: New York 11998:
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY, EXCAVATION AND REPAIR
APPLICATION IS HEREBY' made tothe 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, Now 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' ntak~ neceSSary inspections of the job site.
Print or ,Type
1) ~'~ ~1¢'1~---~
Name Of Applicant
2)
'Name of Owner of Premises
Work Description and Lecaflon (Street Number, Hamlet, Cross Street)
I~ ~'~'
Address ·
Address
(a) Is construction located within 75 feet of tidal wetlands? *Yes No ~
*If yes, othe~ Town permits' may be required.
4) Builder's .License No.
Plumber's License No.
Electriciaffs .License No.
Sig~a~/~ r<~ f/c~ppllcant
[ ' DaRe
5) a) Attach plot plan showing location of;,prolboSed excavation and relationship'to
adjoining premises or public 'streets or areas, and giving a detailed descrlp=
tion of layout of excavation.
b) Attach all other necessary permits and licenses for this project.
c) W~k covered by this application' may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
6) Tax Map: Section , Block , Lot
7) Starting Date: Completion Date
8) Work Schedule:
Phase Completion Date
Excavation.... ........................ . ............
Facility Installation .................................
Backfill & Compaction ..............................
Pavement Replacement ..............................
9) Under which authority is the application made: ~_L~o~o~'%
10) Estimated Cost of Proposed Work: $
11) Remarks: ~/~C~ ~'~ ~,y/~v./~'~j 0 t~l'-~.~-
D-39 Page 1 of 3
12) Insurance Coverage: {Attach copy)
a) Insurance Company: _(~'~1~ ~
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 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 ........
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
i.f.. $
or.)
Additional
C. Excavations 1
0-100 I.f. = $30.'00
I.f.
Additional
D. Excavations 5~ in depth and over:
0-100 I.f. = $50.00
I.f.
'Additi0nal
Eo
No*
Additional
Utility Repair ExcavaUons ~$~0.00
Repairs same service 0 $5.00
Fo
Notice to public 'utilities proof must be provld~._~u/,aZdta~od to
this application prior to is S ua nc~.__~ ,~- o c~'~
Authorization is hereby granted to the Town Clerk of the Town of Southold to
Issue a Highway Excavation Permit to:
in'accordance with this application.
ENDENT OF ~i~HWAYS
SOUTHOLDv~ ~4EW YORK
I~eter ~/, Harris
~ Data~
Received by the Town Clerk
Date
Permit Issued ~'~'~' ~/~) Permit No.
Date
D-3§
Permit expires one (1) year from Date of Issuance.
No work to start wl[hout 48 hour notice to the Superintendent of Highways.
Permit 'must be available for inspection.
Page 2 of 3
Copy Distribution:
· Highway Department
Inspector
Applicant
Town Clerk
IN SPECTOR~S RECORD
1st
2nd
3rd
~th
Inspection Date
Findings (use code)
Applicant Notified
(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 -'Improper backflll'(teo high) (not sufflolent)
HFS - Inspector holding for final settlement of excavation
RFR - Ready to repair
D-39 Page 3 of 3