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Home My WebLink AboutGreton CtRECEIVED TOWN OF SOUTHOLD HIGHWAY DEP~RTMEMT * Peconl= Lar~ Peo)nic; N. ew york 1.19S8; APpLI.GA'~ION/P£RUIT FUR HIGHWAY. Ex~;AVAT. ION AND REPAIR APPLICATION IS HEREBY made to.the Superlnte~dellt of Highways of the Town of Southold for the issuance of an Excava~lol~ Per. it 'pursuant to Ghapter 8a of the ordinances or re~.Ulauo..nS..t, or..u~._ ~__~,v.-~.~.,,.: .'-,.4e~ and re~ulaUoh~, arid to permit ~ real,Iv wJ~J~ 811 appdcame laws, uJ~,m,~-~, ~ - ?.- ... .Print or Type '. Name of Applicant Name of Ov~ner of Preml~ ~?o' Ia) I~ ~ns~fi~ I~t~ with~'75 f~ of U~I *If y~. ~ T~n ~ ~ ~ r~r~. }} Build~s LI~ No- pl~ Li¢~ No. - Ei~i~h~'~ Lj~Se No. _ Other T~dd$ 5}' · :~ignature ef .KppIicant 9-zo Date ~[nU p~-~ publlc'sJ~ or ar~s, a~ gi~ng a tl~ of la~'~ ~n. . b] A~ all ~ ~ pe~t~ and ~ns~ for ' ¢) - ~k'.~v~ by ~b applJ~ my not ~ce b~re ~n~ of a Hig~y ~vaU~ Pe~R ~ ~e T~n ~e~. · 6~ Tax Map.' ~ec~ion__ __. Block, .... Lot 7) Start~n~ Date~ ~-Z°-~G Completio~ ~. ~:~0:~ 8) Work ~h~ule = ~ p~ 9] 10,) - 11) Go~lpl~,flotl Da.t.e. Excavatioh Facility lnstallatlo~ ................................. BacERII' S Cempaction ......... , .................... Pavement Replacement .............................. Under which authority Is the appllc~tio~ reader Estimated Cost of proposed Work-' $ ~/.7~.' ~ D-3g Page. 1 of 3 Insurance Cove~J~= (Attach copy) a) ..... " b) ~1~ ~ c) S~e whir ~l~y of ~fl=t~ on fild wi~ ~e Highw~ ~,~' Courage r~quir~d ~cte~ded to th= Town: Bodily InJury nnd property damage: ~0.000/$500,000 Bodily Injury, and SsO, OOa. proparty damagn. 1;0 ~Securit~: a) Surety I~. ; .pt; CerUfii~cl Che~.k provided In'the total ~nt of ~ ' .-- b) ~ln~ ~nd p~id~: '2 y~rs ~ ~ Y~ Al. ,1~1~ ~1~s ~va~ns ~ $20.00 ~ ~, ,, .- ~ A2. /A~i~ ~a~s ~me se~i~ O ~10.00 ~ ~ , Ad~U~I E- U~J~ R~ir ~v~ofis e~o. eo ~ ~ Repair~ ra~e servica · ~5.00 = $ Additional '* Netic~ tO public'utiliti~ proof must be provided and attached to thls'applioitlob prior tO i~uance of permit.' Authorlz~lo~ Is hereby granted to the Town Clerk of the TQWll of S6uf~h~d to IsSue a Highway Excavatio~ Pemit 'to: :-~ in'accordance with this'applk~ttlc~. SUPERINTENDENT OF NIGHWAY~ ~ff~F SOU~HOU). NEW YORK Receded by the Town Clerk .... No work ~ ~ wlm~ Pem~ ~ ~ ~l~b~ for in~. ~ 2 of 3 Copy Distrtbutloh: · HiDhway Department Inspector Applicant Town Clerk I N S PE C T OR***.~,, ,R E C OR D, Inspection Date FIndin{as (use Applicant Notified 2nd ~' (To PerlmmJt 'C{erk) .REMARKS GODE lB ": Impro{:~ barricades Is.~L-'l~p$'oper li~lhts ~n ~ ~ ~on UTM - U~e to m~u~ (d~ to ~11{~} BUG - gulldi~ DB - 'lmp~ HFS ~' In~ h~d{n~ for r~l se~t of ~vat~n RFR - R~ to ~lr i~.~oUtilttte$ Plus Co~p. 99 Matinee Drive Southa~1~ton, NY 11968 · 04/10/2006 THI3 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIC~N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAOE AFFORDED BY THE POLICIES BELOW'. INSURERS AFFORDING COVERAGE ~.su~. F~rst Mercury Ins, Co. Tower 2nsurance Co. of NY El et-con Trust NAJC # REQUIR~E~, ~ OR CON~ON OF ~Y C~CT OR O~ER ~ME~ ~ ~P~CT TO ~ICH THtS CER~RCA~ ~y BE ~UED OR PERTAIN, ~ INS~CE ~FO~D BY ~E POLICIE~ DE~RIBEO HEREIN ~ SU~ECT TO ~L ~E ~S, ~C~SIONS ~D C~ND{~ONS OF SUCH ~ES. AGG~TE ~IT8 SHO~ ~Y ~ B~N REOU~O eY PAID C~IMS. ~cc~m~ ~aO0d4g9 O4/04/Z~6 04~04/2007 ~c~cua~.~ ~ l~O00t~C Z~O?O0( ~ae.~a,uw ' ~Z600OaZ 04/04/20~ 04/04/Z~7 w~~no.A.O ~6b0~0~110o106 01/Ol/2006 01/01/2007 ERTIFICATE HOLDER Town of Southo]d 75 Pecon~c Lane Pe¢on~c, NY 11958 CANCELLATION BUT FAILURE TO ~IL SUCH NOTICE aP[ALL IMPOSg NO OglJGA31~ OR LIA eUJTY ~)RD25(200~/08) FAX: (6BI)76S~i750 ©ACO~n~n~ .......