HomeMy WebLinkAbout1530 Crown Land LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 06/09/08
* * * RECEIPT * * *
Receipt#: 21240
Transaction(s):
Permits
Reference Subtotal
566 $150.00
Check#: 168
Total Paid: $150.00
Name:
Verizon, Communications
501 N. Ocean Ave, 1st FI
Patchogue, NY 11772
Clerk ID: LINDAC Internal ID: 566
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT.
peconl¢ Lane
pcoor~lc: I~ew York 119S9
~__~pL. ICAT. ION/PER~.dIT FOR HIGHWAY. EXCAVATION AND REPAIR
ord ..... . -,-,- ordnances, code~ ar~l regu]aaon~, ---
to COlm?¥ W t~ e,h eppilcaoie [.wD, .....
author~zC~l Inspeclors t~ m~ake] ~e~&~-~ary ]nspm;ons ef ~e job ~.
9)
10) E~tlmated Cost of proposed ~Vortc:
· $1gn,ature ~t' ~l~}lcant
~ of la~ of ~vatlon. .
b) A~h all ot~r ~e~q permi~ and Ij~ns~ for
' c) ' ~'~e~ by ~ appli~h my ~t mmaen~ before b~n~ efa
High~ay Ex~va~ofl Pe~lt ~ ~e Town Cl~k.
T~X Map: S~l~ , BIo~ , ~t~ ,
Work SchCule:
~m~o~ Data
P~ - ·
~vatlo~ ........................ '
Fa~l]~ InsmilaUafl ..................................
Bac~ll' S C~pacti~ ......... , .... ,, ..............
t R pla~t ..............
Und~ which eu~orl[y is ~e appll~h ~do: . .-
r~
. 11] Red, arks:
Pag~ 1 of 3
1/03 ',0~ W'~13:Sg FAX 631 785 6145
Insurafle= C~'era~e: (Attach
a) Insurance Company:
b) Policy I --
c) S~te whe~er ~l[¢y of ce~i~tlon on file' with ~e Highway
d) ~ge r~uir~d ~t~d~ W the Town:
B~IIy InJu~ and p~pe~y ~gc: $3~0,00O/$Sg0,0a0 E~ily InJu~,
and $S0,0a~ pretty damage,
_Security:
a} Surety Bond or C=~tlfie~ Che~k pr~id~ ln'~e
to~l amount ~ $
b) ~lnt~e~e ~nd provld~: 2 y~rs or ~ y~rs
for appl~tlo~s and permj~: ~ ....... $150,00
Al. J~ Conn~iohs ~vat~on~ ~ $20.00; $ ,..
A2. /Addi~al Ex~vatlons ~me se~ a 510.00 = $
B. Excava'c;o~s
0-100 I.f. =
lB" in d~pth.or less:
~vatio~5 le~ in d~th to ~ ~n d~th;
Add[tioh~
E. Ut]Ii~ Repair Ex~v~ons g$~00, ~ S
Re~j~ ~me ~e~ice · $~.00 = $
F. Not~ to p~lic'~if;~ pr~f must ~ p~id~ and a~ to
Authoriz&tlon Is hereby grmnt-~ to the Town Clerk of the To~rn of S6utho~d to
IsSue = Highway Ex~vat~ p~it 'to:
In'ac~an~ with ~ts'appli~o~.
r W. Herr[s ~/
Race, ecl by the Town Clerk ~ ' ~-
Date
Date
0-39
Permit c~plres one (1))'car fr~m Dale of [ss~nca.
No work to s~ wl~: ~ ~ur ~otce to the ~uperlnt~d~t ~ Htgh~oys-
Pe~'mu=t be avaitable for In~p~Uoh.
Pa~a 2 Of 3
03/24/2005 FRI 16:28 ?'Ag
01/03 "'05 ~ [3:57 FAX 631 765 6[45 $oLrl'EOLD TO~ cLErK ~ Ei~hwa7 Dep~ ~003
Copy Di~tribuUon.:
Highway Department
Applicant
i~,S p E C T O R'.S R E C O R D
InspacUon Date Flndlngs (use code)
Applicant Notif;od
2nd
~d
--(To ?Cr~it ClerK}
REMARKS
GODE
i8 - Impro~er barri~d~
IL -.Improper
UTM - Unable to m~u~ (due to
BUC - BullS;n~ under ~n~
WIP - Work
DB - 'lmpm~ ~c~;ll' [~ high)
RFR - R~ to repair
0-39
Page 3 of 3
RPR 14 1996 15:50 FR TEl 654'7952 P.01/01
Notifirmtion of Request For
"Emergency Permit
NOTE""'
I
SPECIAL CONI)n'IONs:
TOTAL PAGE.01 **