HomeMy WebLinkAbout550 Mt Beulah AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 10/21/08
* * * RECEIPT * * *
Receipt#: 29969
Transaction(s):
1 1
Permits
Reference Subtotal
589 $150.00
Check~:210
Total Paid: $150.00
Name:
Verizon, Communications
501 N. Ocean Ave, 1st Fi
Patchogue, NY 11772
Clerk ID: LINDAC Internal ID: 589
'Parallt No.~_~ '
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT*
Peco nit Lane
pcmr~c' ~ew York 1.1958
,A~pL[.CA-EiON/p£RM!T FOR HIGHWAY. F_XGAVA~IOH AND REPAIR--
O I$ HEEEBY made re.the ~uperintende~t ef H ghays d' ~e Town
~PLI~TI N .... ~ ~', '--~nt to :hair
to ~mp~ wi~ all sppli~ble Isw~, or~Mn~s, ~ a~ ~ula~ohe, and ~ pe~
~Hz~ I~sp~ors ~ ~ke~ ~ry insp~ions ef ~a j~b ~.
Print or
. '~mc of ApplJ~nt " '
Other T~d~s Li~n~
$)'
· $19nature~l' Applicant
a) Attach p/or plan sho~lr~g Iocatlm~ ~.j~o~o~iecl ~x.cavatJan ~ r~a~o~ip'm
~lnTn9 p~l~ ~ publlc's~ or
~ of la--'of ~vatlon. .
b) A~ch all ot~r ~es~ per~ and li~ns~ far ~is'pmJ~t.
' c} · ~'.~ee~ by ~ aPPN~h ~Y ~t ~mm~ before ~J~n~ of a
Highway Extra,oh Pe~it ~ ~e Town Cl~k.
. 6] Tax Map: <:ectlon , Block ., Lot
7) Starting Date: ~.-~d~ CeetpletiO~ D~te ~ -
8~ Work Sch~ule:
P~
lO)
.11)
~p~U. on
Fadlity Insmllet~oh .................................
Backfill' s Compzctio~ ...... , .......................
Pavement Replac~'e e~t ..............................
Undo' which authority la ~he appllc~T~oh ~ada:
Estimated Cost of Frop0secl florl<: ~
Pag~ ! ~f 3
MAR 24 20~6 15:3~ PQGE.~4
Insuratqce CoYote.cie.- (Attach copy)
a) ~n~ur~nca Company:
b) Pdlcy f
c) State wheU'~er parley of certiflc~tlo~l on file' with *,~e H;ghwa¥
d) C~r~ge recluircd ~xtended to [he Town:
BeclJiy injury end property clamag=: $3Q0,000/$SO0,0D0 fl,odil~ Injury,
and $50,0gE pr~erty damage.
Secur;t~:
a) Surety Bond or Gcrtlfie~l Check pro¥1d~ Jn'l~e
total amount of $
b) Malnte~ar~e B~nd provided: '2 years or ~ years,
Fe~s for appllr, atlohs and permitS_': Basic Application Fee: ....... $150,00
Al. IServic~ Connections ex~avatlons e $20.00 =
/Additib~a! Excavations same service ~ 510.00 -- $
0-t0a I.f. = $10.00'
C. Excavatlo~s 1~' in d~th to ~ in d~th:
I_f. ~ ~.~ ~ ~
D. EX~S 5' In d~ a~d ov~r:
AddTtioh~
Bo
__Utility Rcpalr Excavations
Repalr~ -.-~me 5ervlce I)
Not;c~ to publlc'utititie-~ proof must be provid.d and attached to
thls'appllc=itloA prior to i~uen~e of permit,
Author|zatlo~ Is here. by grant~] to t~e Town Clerk of the ToWn of 54atho~d to
Isiu¢ = Highway Exc~vatio~ permit 'to:
tn'acoordance with thls'applicatJoh.
SUPERINTENDENT OF HIGh'WAYS
TO,~Rq~a,F SOUTHOLD, .N~EW YORK
I~eter W. Herr;s
nato ~
Date
P~rm;t Issued /~/~//O ec>~ Permit
Date
Note:
Permit ~xplres one (1) ycar fr~m Date of Issuance.
No work to st~r~ without ~8 hour notice to the Superintendent of Highways-
Permit-'taus! be available for Ingpect~on.
Page 2 of 3
9.I-/03 "0~ WED'*'13:57 FAX 831 785 6145
SOLr/"E[OLD TOWN CLERIC
Copy Di~trlbu~-Ioh:
Highway Department
Applicant
I H S P E C T O R '.S R E C O R D
Findings (use code)
Applicant- Noti~od
2nd
~rd
--(T~Per~it ClerK}
R.F.M~RKS
(;ODE
lB - Improi3er barri~..ndr.=
UTM - Unable to m~u~ (due to ~c~lllng)
BUC - Bulldln~ und~ ~n~
WIP - Work
HFS -.l~sp~r b~din~ for final s~t of ~vat~n
RFR - R~ to repair
Page 3 of 3
M~R 24 20~6 15:36 PAGE.~6