HomeMy WebLinkAbout1645 Meadow Beach LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/12/08
* * * RECEIPT * * *
Receipt#: 27407
Transaction(s):
1 1
Permits
Reference Subtotal
577 $150.00
Check#: 191
Total Paid: $150.00
Name:
Verizon, Communications
501 N Ocean Ave, 1st FI
Patchogue, NY 11772
Clerk ID: LINDAC Internal ID: 577
~ 11)
TOWN OF SOUTHOLD
HIGHWAY DEP/LRTMENT ·
Peconlc Lane
p=co~c.: N. ew York 1.1958
AppLI.CA~X]ON/PERM,, !T FOP, HIGHWAY.E~CAvAT. ION AND PJcPAIR
~MaPLIC~TION l$ HEEEI~¥ made re.the ~,uperinte~de~t of Hlgh~ys ~ ~e Town
f ~ld for t~ is~n~ of ~ ~tioh P~it 'pum~nt to Chair 83 of
o ~ ....... ,~ <,,~k ~W. N~ Yo~ and ot~ appfi~e laws,
to ~mp~ wi~ all eppli~ble laws, ?~M~S, ~
~H;~ Insp~o~ ~ ~ke~ ~ry ~nsp~ons aT me jo~ ~.
Pri~e or
. '~mc of A~ll~nt Addre~
b) A~ch all ot~r ~e~ perm;~ and li~ns~ for ~is'pmJ~t. : ~ ·
' c) ' ~',~er~ by ~ apPll~h ~Y ~t ~mmen~ before ~n~ of a ~-' '
Highway Ex~va~ofl Pe~it ~ ~e Town
· 6} Tax Map: Section , Block , L~t
7) Starting Date: ~-/O C~pletio~ Da're ~
8) Work Sch~ule:
P~
_Coml~etlof~
FacJllty lnst=llet~ofl .................................
Backfill' S Comp~ctio~ ..... . · · ·. ...., ...............
Pavement Replac~'~ent ..............................
Uncl~r which au~orlt¥ Is the appIlc~t, loh reade:
E~tlmated Cost of Proposed
RECEIVZ'D
.. 2008
Page. I ot' 3
'
Insura~ee. Coverac.]e: (Attach copT)
a) insurance Company: "
¢} State wheUqer parley of certiflcatloh on file' with IJ~e Highway Depart-
el) Ceverage required extended to ~he Town:
Bodily injury =nd property damage: $30~,000/$500,000 Eodily Injury,
and $50,00b property dare=ge.
Securlt~:
a] Surety Bond or Cc~tJfie~l Che~k pro~id~cl in'the
to~l amount ~ $
b) ~lnt~a~e ~nd provide: '2 y~rs or ~ y~r~ .
for appH~tlo~s and permi~:
Al. /~i~ Conn~i~s ~vation~
/Addi~a[ Ex~vatlons ~me se~l~
A2.
B. £xcavat~o~s
$10.00 '
ExcavatioNs 18" in de, th to ~ in d~th:
Ad~[tio~
E. __Utili~ Repair ~v~ons ~$~o0 = $
Re~i~ ~me se~ice
F. Hot;~ to p~l;c'~il;~ pr~f must ~ p~id~ and a~ ~o
~ls'appli~o6 prior ~
AuthorlzatlO~ Is hereby granted to the
IsSue a Highway Excavatio~ Permit *to:
In'accordance with th%s'appllcatJoh.
Town Clerk of t~e ToW~ of S~utho~d to
SUPERINTENDENT OF HIGH'WAYS
TOW/N'~ SOUTHOLD; ~ YORK
~eter W.~rris
Rece~e~ by the Town C~erk
Da(e
~=- / z
Date
PermitNe.
D-3S
Permit c~plres one (1) yc~ar fr~m Da~e of Issuance.
No work to star~ without e,a ~ur notice to the Superlnt~d~t ~ Highways.
Pe~'mus~ be ~aiXable for Ingp~fioh.
Page 2 of 3
01/0,3 '0'6 ~'ED, 13:$7 F,*,~ 831 7~5 6115 $OL'i~OLD TOtTN CLE]RX. . -,,-~ £1ghway Dep'C ~vo:J
Cop'/ Di=trlbutlor~:
Highway Department
Inspector
Applicant
ToWn Clerk
1st
2nd
3Yd
I N S P E C T O R ',$ R E C O R D
Inspect. ion Date Findings (use
Applicant Notif;o~
(To p~rmit CIc~'K~
~F-U~RKS
CODE.
lB - Improf~er barri~dr~
IL -.laproper llght~
~ - Sun~n ~ ~ ~vetion
UTM - Unable to m~u~ (due to ~c~lling)
BUC - Bulldln~ under
WlP - Work
DB Imp~ ~111' [~ high) (~t
HFS -' I~;~r h~ding for final s~t of ~vat~n
RFR - R~ to repair
O-3g
Page 3 of 3
~QR 24 2~6 [5:36 P~GE,~