HomeMy WebLinkAboutBergen AveTown of Southold
P.O Box 1179
Southold, NY 11971
Date: 05/04/10
* * * RECEIPT * * *
Receipt~: 78949
Transaction(s):
1 1
Permits
Reference Subtotal
650 $150.00
Check~: 2812
Total Paid: $150.00
Name:
R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID: 650
R~CEIVED
Permit No.~ ~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Pecontc 'Lane
Peconlc~ New York 11958:
(631) 765-3140
4 ;?OlO
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR.
APPLICATION IS HEREBY made to.the Superintendent of Highways of the Town
of Southold for the Issuance of an Excavation Permit pursuant to Chapter 83 of the
e Town of Southold, Suffolk County, New York, and other applicable laws,
Code of th · .__ .~.A excavation herein described. The applicant agrees
ordinances or regulations .u/
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors ta mlake', nec&SSary inspections of the job site.
Print or Typ~e
1) ~L~nt ddress
2) ame o wrier o Pre~lsea ddress
3) ~ ' ' '~'~ ~'~ Cross Street)
(a) is construction located wlthih'7S feet of tidal wetlands? *Yes No_~3~..
*If yes, other Town permlt~' may be requir&d.
q) Builder's License HO' Plumbelas License No. ..
Other Trade~s License No.
Electrlcian~s .License No. -
~~t~nt
5) a) Attach plot plan showing location o~,Pret~osed ex. cavation and relationship to
adjoining premises or public*streets or areas, and giving a detaile~ descrip~
tion 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 Excevatioh Permit 'by the Town Clerk.
6) Tax Map: Section.T_~.r~, BI~. , Lot~
7) Starting Oate:_~'/~ ?'O Completion O~te__
8) Work Schedule: .Completion Date.
-- "Phase_
Excavation .........................................
Facility Installation .................................
Backfill ~ Compaction ..............................
Pavement Replacement ..............................
9) Under which authority is the application made: ~-~ dt~
10) Estimated Cost of proposed Work: $-,~
0-39 Page I of 3
12)
insurance Covera..~.~q~: (Attach copy)
a) Insurance Company: ~ ~:/~ ~
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) SecurltT.:
a) Surety Bond
total amount of $
b)
10) Fees for
Al.
or Certified Check
j3rovided in the
Maintenance BOnd provided:
applications and permit, s_:
/Service Connections excavations e $20.00 = $
A2. /Additional Excavations same service 0 $10,00
B, Excavations 18" In depth or less:
0-100 I,f, = $10,00
Additional
C, Excavations 18" In depth to S" In depth:
0-100 I,f, = $30,00
I.f. 0 $0,30 .= $
Additional
D, ExcavaUons 5~ In deflth and over: 0-100 I.f. = $50,00
Additional
E, Utility Repair Excavations ~$~0,00 = $
No.
Fo
2 years or .3 years
Baslc~ication Fee ........ ~'
Repairs same service e $5.00
Additional
Notice to publlc'utilltle~ proof must be provided and attached to
this application prior 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 Southold to
SU~aR4N.T. EN DENT OF H I~HWAYS
T~~THOLD; ~:RK
~l~eter W. Hair
Received by the Town Clerk
Date
Permit Issued 5- ¥ - /c~ Permit No. ~ _~d_J
Date
Note: Permit expires one (1) year from Date of Issuance.
· No work to start without ~8 hour; notice to the Superintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
D-39
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
I N S P E C T O R ~.S R E C O R D
1st
2nd
3rd
qth
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'(too high) (not sufficient)
HFS - Inspector holding for final settlement of exqavation
RFR - Ready to repair
D-39 Page 3 of 3