HomeMy WebLinkAbout4550 Wunneweta RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 11/14/08
* * * RECEIPT * * *
Receipt#: 30549
Transaction(s):
1
Permits
Reference Subtotal
593 $339.00
Check#: 1107
Total Paid: $339.00
Name:
L, IPA
117 Doctor's Path
Riverhead, NY 11901
Clerk ID: LINDAC Internal ID: 593
T100898339
4550 Wunneweta Road,
Southold
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
P.O. Box 178
Peconic, New York 11958
(631)765-3140
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 Code 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 authorized inspectors to make necessary inspections of the job site.
Print or Type
I. LIPA - 117 Doctors Path, Riverhead, NY 11901
'Name of Applicant Address of Applicant
2. Stephen Jacobsen - 4550 Wunnewata Rd, Southold
LIPA
Name of Owner of Prenfises Address of Owner
to dig a 2' X 415' trench on the west side of Wunneweta Road trench to start
3.630' s/of Little Peconic Bay Rd, then trenching in a south direction for 415'
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet &tidal wetlands? * Yes No
·If yes, other Town permits may be required.
4. Builder's License No.
Plumber's License No.
Electrician's License No.
Other Tmde's License No.
~-~-l~a ~~a nag e r
Date
(a) Attached plot plan showing location of proposed excavation and relationship to adjoining premises or public street or areas, and
giving a detailed description 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 ora Highway Excavation Permit by the Town Clerk.
6. Tax Map No.: Section , Block , Lot
7. Starting Date: Completion Date:
8. Work Schedule: Phase Completion Date
Excavation
Facility Installation
Backfill & Completion
Pavement Replacement
9. Under which authority is application being made:
I0. Estinmted Cost of Proposed Work: $
I I. Remarks:
D-39 1 of 3
12~ Insurance Coverage: (Attach Copy)
(a) Insurance Company: .ff.,~p-~7. t~.d/~-z,' ,~.~_ t~.-.~
(b) Policy#:
(c) State whether policy of certification on file with the Highway Department:
(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:
14. Fees for Applications and permits:
2 years or 3 years.
Basic Application Fee
$150~00
Al.
A2.
B.
/Service Com~ections excavations @ $20.00
No.
/ Additional Excavations same service @ $ I 0.00
No.
Excavations 18" ha depth or less
0-100 i.f. = $10~00; Additional i.£ @ $0.10
$
$
$
$
Excavations 18" in depth to 5' in del)th
0-100 i.f. = $30.00; Additional
Excavations 5' in depth and over
0-100 i.f. = $50.00; Additional
:.f. @ $0.30
i.f. @ $0.50
No.
Additional
Utility Repair Excavations @ $I0.00
Repairs same service @ $5.00
$
$
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.
Date Received by the Town Clerk / / -
Date Permit Issued / / - / '40 oc'' Permit No.
SUPERINTENDENT OF HIGHWAYS
TOW~UTHOLD,K~-~J2,~'~ ~NEW YORK
Peter W. Harris
Date
NOTE:
Permit expires one (1) year from date of issuance.
No work to start without 48 hour notice to Superintendent of Highways.
Permit must be available for inspection.
D-39 2 of 3
· Copy Distribution:
Highway Department
Engineer (with page 3)
Applicant
Town Clerk (Original)
2na
3ra
4th
Inspection Date
INSPECTOR'S RECORDS
Findings (use code)
REMARKS
Applicant Notified
(To Permit Clerk)
CODE
lB Improper Barricades
IL Improper Lights
ST Sunken Trench or Excavation
UTM Unable to Measure (due to backfilling)
BUC Building Under Construction
WIP Work In Progress
DB Improper Backfill (too high, not sufficient)
HFS Inspector Holding for Final Settlement of Excavation
RFR Ready for Repair
D-39 3 of 3