HomeMy WebLinkAbout1600 Henry StTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/04/09
* * * RECEIPT * * *
Receipt~: 42600
Transaction(s):
I 1
Permi~
Reference Subtotal
611 $170.00
Check#: 2225
Total Paid: $170,00
Name:
R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID: 611
RECEIVED
Permit No~_
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconlc Lane
Peconlc; New York 11958.
(631) 765-31~0
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Souihcl~ Town
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
Code of the Town of Southold, Suffolk County, New York· and other applicable laws,
ordinences 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~ nec&SSary inspections of the job site.
Print or Type
Name of Applicant
Name of Owner of Premises
Address
Address
Work Descriptloff and Location (Street Number,'Hamlet, Cross Street)
(a) Is censtructlo~ located wlthih 75 feet of tidal wetlands? *Yes No ~(~
*If yes, other Town permits' may be required.
~) Builder's License No.
Electricieffs.License No.
s) a)
b)
c)
6) Tax Map: Section
7) Starting Date:
s)
Plumber"s License No.
9)
10)
11)
Other Trade's License No.
I pate
Attach plot plan showing location1 o~prol~osed excavation and relationship to
adjoining premises or public'streets or areas, a~d giving a detailed descrip-
tion of layout' of excavation.
Attach all other necessary permits and licenses for this project.
Work covered by this appliceUon may not commence before issuance of a
Highway Excavation Permit 'by the Town Clerk.
· Block , Lot
Completion Date ~1~.
Comple)tlon Date
Work Schedule:
Phase
Excavation .........................................
Facility Installation .................................
Backfill S Compaction ..............................
Pavement Replacement .......... ; ...................
Under which authority is the appliCation made:
Estimated Cost of Proposed Work: $
Remarks: I~'C~G¢C C~v~ ~c~ ~ 1~-~-~,
D-39 Page I of 3
12)
Insurance Coverage: (Attach copy]7~ ot~O'~ ,~j/~ [ a) Insurance Company:
c) S~te whether ~ltcy of certi~tion on file with the Highway Depart-
ment:
d)
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
10} Fees for applications and permits: Basic Application Fee ........
Al. /Service Connections excavations Q $20.00 = $
No.
A2. /Additional Excavations same service ~ $10.00 = $.
Coverage required extended to the Town:
Bodily Injury and property damage: $300,000/$500,000 Bodily Injury,
NO.
B. Excavations 18" In depth or less:
0-100 I.f. = $10.00:
~OD I.f. e $0.~0 - $ .20,
Additional
C. Excavations 18" In depth to 5" in depth: · -I00 I.f. : $30.00
I.f. ~ $0.30 .= $
Additional
D. Excavations 5~ in'depth and over:
0-100 I.f. = $50.00
I.f. ~ $0.50; $
Additional
Eo
Additional
Utility Repair Excavations ~$~0.00 = $
Repairs same service ~ $5.00 = $
F. Notice to public 'utilitieS proof must be provided and attached to
this 'application prior to issuance of Permit.
Authorization Is hereby granted to the
issue a Highway Excavatloh Permit to:
in accordance with this application.
Town Clerk of the Town of Southold to
SU,p~r-R11fl~NDENT OF HJGHWAYS
T~W N ~7~O UT HO LD :~J~TW YORK
lieder W. Harris
Received by the Town Clerk'~'~ ~ ~
Date
Permit Issued ~-~/- O ~' Permit No. ~ ///
Date
D-39
Permit expires one (1) year from Date of Issuance.
No work to start without 08 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 SPECTORES RECORD
Inspection Date
Findings (use cede)
Applicant Notified
1st
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 -Improper backfill' (too high) (not sufficient)
HFS - Inspector holding for final settlement of exqavatlon
RFR - Ready to repair
D-39 Page 3 of 3