HomeMy WebLinkAbout2560 Leslie RdTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/04/08
* * * RECEIPT * * *
Receipt~:
12859
Transaction(s):
1
Permits
Reference
543a
Subtotal
$0.00
Check~: 1712
Total Paid:
$0.00
Name:
R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LYNDAB Internal ID: 543a
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: 02/26/08
Transaction(s):
1 1
Permits
* * * RECEIPT * * *
Receipt#: 12445
Reference Subtotal
543 $179.00
Check#: 1685
Total Paid: $179.00
Name:
R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LYNDAB Internal ID: 543
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconlc 'Lane
Peconlc~ New York 11958:
(631) 765- 3!q0
APPLICAI~ION/PERMIT FOR HIGHWAY, EXCAVA'~ION AND REPAIR
9J
11)
APPLICATION IS HEREBY made to.the Superintendent of Highways of the Town
of Southold for the issuance of an Excavatloh Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, New York, and other applicable laws,
ordinances or regulatiohs for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit'
authorlzei~ Inspectors to ritake,' neceSSary In~pectlor~s of the job site.
Print or Type
Nome Of Applicant
Name of Owner of Premises
Address
Work Description and LecaUon (Street Number; Hamlet, Cross Street)
(a) Is construction located wlthih'75 feet of Udal wetlands? *Yes No
*If yes, other Town permlt~' may be required.
q) Builder's .License No. Plumber's License No.
Electrlclaffs .License No.
Other Traders License No.
Sigr~tu~e of Applicant
5) a) Attach plot plan showing IocaUon o~,,Proi~o~ed ex.cavatlon and relationship' to
adjoining premises or publlc'streets or areas, and giving a detailed descrlp~
tlon 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 of a
Highway Excavatioh Permit 'by the Town Clerk.
6) Tax Map: Section , Block , Lot
7) Starting Date: ~-~7~ ~/0 ~ Completion Date ,~9/,'JlO~r
8) Work Schedule:
Phase CompleUon Date
Excavation .................................... .. . . .
Facility Installation .................................
Backfill s Compaction ..............................
Pavement Replacament .......... : ......
Under
authority is the application made: &[~-~J~.~ic:)~q .
which
Estimated Cost of Proposed Work: $, ~
D-39
Page 1 of 3
:3)
Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Depart-
ment:
d)
Coverage required extended to the To~n:
Bodily Injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
Security:
a) Surety Bond or Certified Check
total amount of $
b) Maintenance Bond provided: 2 years or
provided in the
lq) F.~s for applications and permlt,~:
Al.
A2.
B.
NO.
Excavat ohs
s _Ut~-/~epth or less:
,.f.
Ad~di?onal
Exuvations 1~~ In dpth to ~ In d~th:
~I00 I,f. = $30.00
I.f.
~dditional
Ex~vaflons 5~ in d~th and over:
~100 I.f. = ~50.00
I,f.
Additional
3 years
B. asio Application Fee .......
/Service Connections excavations {I $20.00 = $.
.._ /Additional Excavations same service e $10,00 = $
Additional
Utility Repair Excavations e$~lO. OO = $
Repairs same service e $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 accordanca with this application.
SUPERINTENDENT OF HIGHWAYS
·
~etar W. Harris
D-39
Permit eXpires one (1) year from Date of Issuance.
No work to start without 48 hour' notice to the Superintendent of Highways.
Permit must be available for inspectioh.
Page 2 of 3
C. qpy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
1st
2nd
3rd
qth
IN SPECTOR~S RECORD
Inspection Date
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
.~ODE
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 (t~o high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR - Ready to repair ,
D-39
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