HomeMy WebLinkAbout810 Greenfields LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/13/09
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt: 57364
Reference Subtotal
634 $181.50
Check~: 2473
Total Paid: $181.50
Name:
R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID: 634
RECEIVED
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconlc Lane
Peconlc: New York 11958:
(631) 765- 3!q0
APPLICATION/PERMIT FOR HIGHWAY, EXCAVATION AND REPAIR
2009
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 regulatlofls for the excavation herein described. The applicant agrees
to.comply with all applicable laws, ordinances, codes and regulaUons, and to permit
authorized inspectors to' mlake~ neceSSary inspections of the job site.
Print or Type
of Applicant
Address I ~ c~ ~
2)
Name of Owner of Premises Address
De~ciiPLion ano Leeatlo~l (Street Numbet-, Hamlet, Cross Street)
(a) Is construcUon located wlthih 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
Builder's License No. Plumber's License No.
Electrician's License No. Other Traders License No.
No
Signpture of AppliCant
/ ! Date
5) a) Attach plot plan showing IoceUon of,,Prol§osed excavation and relationship to
adjoining premises or public'streets or areas, a~d 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 application may not commence before issuance of a
Highway Excevatioh 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:._
10)' Estimated Cost of Proposed Work: $.. /,, b'-/'~-), CiO
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12)
~3)
Insurance Coverage: (Attach copy)
b) Policy #
c) State whether policy of certification on file with the Highway Depart-
merit:
d)
Security:
b)
Fees for
Al.
A2.
Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
Surety Bond or Certified Check provided inthe
total amount of $
Maintenance Bond provided: 2 years or .,. 3 years
applications and permlt~'? Basic Application Fe~ ....... ~
"~/'0. /Service Connections excavations ~1 $20.00 = ~.
N~. /Additional Excavations same service ~ $I0.00 = ~.
B. Excavations 18'" in depth or leas:
0-100 I.f. = $10.00:
· ~ IS I.f. e $0.10 - $
Additional
C. Excavations 18" in depth to 5° in depth:
0-100 I.f.. = $30.00
I,f. ~ $0.30;
Additional
Excavations 5~ In depth and over:
0-~oo ~.f.. =
I.f. ~ ~0.s0 = ~ ....
Additional
Fe
No,
Utility Repair Excavations 95~!0.00 = ~..
Repairs same service ~ $5,00 = $
Additional ...
Notice to public '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 Excavation Permit to:
In accordance with this 'application.
SUPERI~LT.F~NDENT OF HIGHWAYS
TOWj~ ~OLD~ YORK
'
R~eiv~ by the Town Clerk '~
Date Permit No.
~ote: Pemlt ~plres one (1) y~r f~ Date of Iss~n~.
No work to s~ wither ~8 h~r' notice to the Superintendent of Highways.
Permit must be available for insp~tion.
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