HomeMy WebLinkAboutCox LnTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 07/20/10
* * * RECEIPT * * *
Receipt#: 88049
Transaction(s):
Permits
Reference Subtotal
657 $213.12
Check#:2875
Total Paid: $213.12
Name:
R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID: 657
RECEIVED
Permit No. ~'c~'7
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Pesonic Lane
Pesonlc; New York 11958.
(631) 765- 31 q0
APPLICATION/PERMIT FOR HIGHWAYI EXCAVATION AND REPAIR
JUL 2 0 20]O
$ou~h01d Town Clerk
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
Cede of the 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
authorlzecl Inspectors to rdake~ nec&ssary Inspections of the job site.
Print or ,Type
Name Of Applicant
'Name of Owner of Premises
Address
Address
Wo~:k Descrlption~ahd Location (Street Number, Hamlet, Cross Sefeet)
(a) Is construction located within 75 feet of tidal wetlands? *Yes Ho /~
*If yes, othe~ Town permits' may be required. - -
4) Builder's License No.
Electrician's License No.
Plumber's License No.
, Other Traders License No.
~~'-S. 't ~~-~-
Applicant
5)' a) Attach plot plan showing location o~.pr~[~x~ed excavation and relationship to
adjoining premises or publlc'streets or areas, and giving a detailed descrip
tion of layout of excavation.
b) Attach all other necessary permits and licenses for this project.
c) WOrk covered by this appJlcation may not commence before issuance of
Highway Excavation Permit by the Town Clerk.
6) Tax Map: Section , Block , Lot
7} Starting Date: Completion Date
8) Work Schedule:
Phase Completion Date
Facility Installation .................................
Backfill g Compaction ..............................
Pavement Replacement ..............................
9) Under which authority ', the application made:
10) Estimated Cost of Proposed Work: $
D-39 Page I of 3
12) Insurance Coverage: (Attach copy)
a) Insurance Company: (~)~, '~ ~'_
b) Policy #
c) State whether policy of certification on file with the Highway Depart-
ment:
d) Coverage requlreid 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
lq) Fees for applications and permits: Basic Application Fee ........
Al. /'Service Connections excavations ~1 $20.00 = $
No.
/Additional Excavations same service 0 $10.00 = $
A2.
B.
No,
Excavatlor~s 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
I.f. 0 $0,30 .= $
Additional
Excavations 5~ In depth and over:
0-100 I.f. = $50,00
I,f, ~ ~0.S0 = $
'Additional
NO*
Additional
Utility Repair Excavations 05~0.00 = $
Repairs same service ~ $5,00 = $
F. Notice to publlc'utilitieS proof must be provided and attached to
this 'application prior to Issuance of Permit.
Authorization Is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavatloh Permit 'to:
in accordance with this 'aPplication.
Received by the Town Clerk
Permit Issued 7 - ~
Date
Note:
D-39
SUPERINTENDENT OF HIGHWAYS
I~eters W, Harris
Date
Permit No.
Permit expires one (1) year from Date of Issuance.
No work to start without 08 hou~ notice to the Superintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
C. qpy Distribution:
· Highway Department
Inspector
Applicant
Town Clerk
1st
2nd
3rd
qth
IN SPECTOR~S RECORD
Inspection Date
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
lB - Improper barrlcade~
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'(too high) (not sufficient)
HFS -' Inspector holding for final settlement of ex~.avatlon
RFR - Ready to repair
D-39 Page 3 of 3