HomeMy WebLinkAbout1600 Jockey Creek RdPermit No-~
TOWN OF ~OUTHOLD
HIGHWAY DEPARTMENT.
Peconl¢ Lane
PeconlcJ N. ew York 1.1958
ApPLICAI~ION/PERMI¥ FOR HIGHWAY. EX~:AVAT. ION AND REPAIR~
APPLICATION I$ HEREBY' made to.the Superintendent of Highways o~ the Town
of Southold for the issuance et' an Excavatioh Permit 'pursuant to Chapter 83 of the
ordinances or ulaUons. =o · ' ulafi ' to It
to comvly witharae~l applicable laWS, ordlnan .cas, .codes a,.n~, r~,_~u _..[_O~?s, and per~
author~z~J inspectors fix mlake~ r{ec~ary inspechons
Print or Type
· I~me of Applicant .... Address "' '
-- Name ef Ov~ner_of Pr_~u]~es L~y ! T-' ' Aadress
' work Description-a~ Loca'tlon (Street N~mber~ Hamlet, Cross
[s) Is ~onstructJo~ located wlthlh*75 feet of tidal
· If yes, othe~ Town permlt~ may be required.
~,) IBuilder% .LicenSe .No. plumber~ Li~se No.
EleCtric~ah's: Lic&nse No. . ...Other Tradels
Date.
5)' a) Attach plot plan showing location of:{~ro~o~ed excavation and relatioftship*to
adjoinln.~{ premises.or publlc*street~ or areas, arid giving a del;all':] descriP=
tlo~ of layout'of excavation.
b) Attach all other I~cessary permltg and Iic~nse~ for this'project.
· c) - l~ocJe..coye~d by this applicdt~of~ I~a7 IIot comme~ce before i~lnce of a
Highway Excava~o~ Permit by the Town Clerk.
· 6) Tax Map: Section , Block _ __, Lot
7) Startin_~l Date; Completioh Date
8) Work Schedule:
Phase
Excavatioh
Facility Installatloh .................................
Backfill' ~ C~mpactioh ......... , ....................
Pavement Replacement ..............................
9} Under which authority Is the applim/tior't reader
10) Estimated Cost of Proposed Work: $
C~omeletlo~ Da.t.e.
D-39
Page. 1 of 3
·
D--39
Insurance Coverac~_: {Attach copy)
a} Insurance Company:__ "
c) State whether pollq of certi~catioh on file' with the Highway Depart-
d) Coverage requlr~d extended to the Town:
Bodily Injury and property damage: $3g0. e0015500,808 Bodil~ Injury,
and $$~,00q. property damago.
_Security,:
a) Surety Bond ..... .m; Certifii~] Check provided la'the
total ~nt ~ $ . - ...-
b) ~in~ ~ p~id~: 'Z yers or
Al. I~i~ ~s ~vafi~s e $20.00 ~ $ ..... - -
~'I~ I.f. = $la. Oo '
,.,. ,,..,,-, ./$&
AddiU~
~I00 I.f. ~
I.f.
A~I'
Addifi~
Ut~ R~air ~v~o6s ~0.00 = ~
Repair~ sallie servic'~ · ~5.00 = $
Additional"
Notic~ to public 'utiliUei proof must be p~vided and attached to
thls'applioitioh pri~r to issuance of permit:
Authorlzatloh Is hereby granted to the
Isgue a Highway Exeavatiofi Pemit 'to:
in'accordance with this 'applkaitiofi.
ReceNed by the Town Clerk
Town Clerk of the Town of S~utho~d to
SUPERIJ:tW-E,NDENT OF HIGHJt/AY$
Date
Permit'No. 0~
Permit expires one (1) year from Dat~ of Issuance,
No work to s~rt wJttiout ~8 horn' notice to the Superlntendqnt of Hig~ays-
Permit 'must be available for ingpecUofi.
Page 2 of 3
2nd
i N S PE CT OR".$ ,RE,CORD
Inspection D~te Flndl~s (use
Apl~lcant Notified
.... (To perl~it 'Clerk)
RE~b~RK$
CODE
lB ~ Improt~er barricades
Page 3 of 3
ANYAUTO
WORKEp~ CO~PENeAllON
EACH OCCURRENCE
Da~: 0~2~06
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#: 22080
Transaction(s):
1 1
Permits
Reference Subtotal
460 $160.00
Check#: 22080
Total Paid: $160.00
Name:
Utilities, Plus Corp
99 Mariner Dr
Southampton, NY 11968
Clerk ID: LYNDAB Internal ID: 460