HomeMy WebLinkAbout340 Kirkup LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 11/19/07
* * * RECEIPT * * *
ReceiptS: 1572
Transaction(s):
1 1
Permits
Reference Subtotal
53O $152.00
Check~: 1572
Total Paid: $152.00
Name:
R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID: 530
RECEIVED
Permit No.~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT.
Peconlc 'Lane
Peconic: New York 11958
(631) 765- 31~0
APPLICATION/PERMiT FOR HIGHWAY, EXCAVATION AND REPAIR
Clerk
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,
ordln&nces 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' mlake] necessary inspections of the job site.
Print or Type
Name of Applicant
Name of Owner of Premises
Address
Addrdss
Work Description an ocaflon (Street Number, Ham et, Cross Street)
(a) Is construction located wlthih 75 feet of tidal wetlands7 *Yes No ~X.
*If yes, other To~n permits may be required. ' '
Zl) Bulldetas .License No. Plumber's License No.
Electriciaffs License No.
Other Traders License No.
5) a) Attach plot plan showing location o~.Pro[~osed ex. cavation and relationship to
adjoining premises or public 'streets or areas, and giving a detailed descriP-
tion 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 Excavation Permit 'by the Town Clerk.
6) Tax Map: Section , Block , Lot
7) Starting Date: It/J~ Completion Date-
8} Work Schedule:
Phase Completion Date
Excavation .........................................
Facility Installation .................................
Backfill & Compaction ....................... ,, .....
Pavement Replacement .......... ~ ...................
9) Under which authority is the application made:
J
10] Estimated Cost of Proposed Work:
D-39
Page 1 of 3
12)Insurance Coverage: (Attach copy)
a) ,nsu.nc. Comp.ny:
b) PolIc~ ~
c)ment:S~te whether ~11~ ~i~tion on file with the Hlghwa~ Depen-
d) Cove~ge r~ulr~ ~tend~ to the
B~lly Inju~ and p~y ~ge: ~300,000/~500,000 B~lly Inju~,
and ~50,000 p~pe~y damage.
13) S~urlt7:
a) Surety Bond or Certlfl~ Ch~k p~vld~ in the
to~l amount of ~
b) Maintenance Bond p~vld~: 2 y~rs or .3 y~rs
lq) F~s for appIl~tlons and ~mits: Basic Appll~t~n F~ ........ ~ /~-
Al. /~rvice Conn~t~ns ~vatlons
No.
A2. /Additional Ex~vatlons ~me se~lce
No.
B. Excavations 18" in depth or less:
0-100 I.f. = (;10.00
;20' (;0.10-, 5,00
Additional
C. Excavations 18" In depth to 5" in depth:
0-100 I.f. -- $30.00
I,f. e $0.30; $
Additional
D. ExcavaUons 5~ in depth and over:
0-100 I.f. : (;50.00
I.f, O GO.SO = (;
'Additional
No.
Additional
Utility Repair Excavations e$~O. O0. = $
Repairs same service e $5.00 = $
F. 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 Pemlt to:
in*accordance with this 'application.
SUPERINTENDENT OF H~qWAYS
I~eter W. Harris
' / Dat~
Received by the Town Clerk //-/
Date
Permit Issued ,~/~/~-~7 7 Permit NO. "L~'~-~
Date
I~ote: Permit expires one {1) year from Date of Issuance.
NO work to start without ~8 hour; notice to the Superintendent of Highways.
Permit 'must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
IN SPECTOR~S RECORD
1st
2nd
3rd
~th
Inspection Date
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
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 backflll'(too high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR - Ready to repair
D-39 Page 3 of 3