HomeMy WebLinkAboutGreton 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