HomeMy WebLinkAbout440 Shipyard LnDate: 08/07/06
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt~: 22054
Transaction(s):
1 1
Permits
Reference Subtotal
455 $160.00
Checl~: 22054
Total Paid: $160.00
Name:
Utilities, Plus Corp
99 Mariner Dr
Southampton, NY 11968
Clerk ID: LINDAC Internal ID: 455
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631)765-3140
APPLICATION / PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
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, ordinances 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 make necessary inspections of the job site.
Utilities Plus Corp.
Print or Type 99 Maflner Dr.
Southampton, NY 11968
Name of Applicant
2. C~c~t/~,to,,,/ or~
Address of Applicant
Name of Owner of Premises Address of Owner
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands?
*If yes, other Town permits may be required.
* Yes No ~
4. Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
Date
(a) Attached plot plan showing location of proposed excavation and relationship to adjoining premises or public street or areas, and
giving a detailed description 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 No.: Section Block _, Lot
7. Starting Date: '~7~t ~'I~-{ ~ {.~ ~ Completion Date.'~t I:~-~./ 1~ ~ ~
8. Work Schedule: Phase Completion Date
Excavation
Facility Installation
Backfill & Completion
Pavement Replacement
9. Under which authority is application being made:
10. Estimated Cost of Proposed Work: $
11. Remarks:
D-39 1 of 3
12. Insuran,ce Coverage: (Attach Copy) ill
'(a) Insurance Company: /q~tys,--., ~c.~/) -7/
(b) Policy #:
(c) State whether policy of certification on file with the Highway Department:
(d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000 / $500,000 Bodily Injury, and $50,000 property damage.
13. Security:
(a) Surety Bond
or Certified Check
provided in the total Amount of $
(b) Maintenance Bond provided:
2 years or 3 years.
14. Fees for Applications and permits:
Basic Application Fee
Al. __/Service Connections excavations ~ $20.00
No.
A2. /Additional Excavations same service @ $10.00
No.
B. Excavations l~depth or less
0-100 i.f. =~ddifional i.f. ~ $0.10
C. Excavations 18" in depth to 5' in depth
0-100 i.f. = $30.00; Additional i.f. ~ $0.30
$ I0o°
$
Excavations 5' in depth and over
0-100 i.f. = $50.00; Additional
i.f. @ $0.50
NO.
Additional
Utility Repair Excavations @ $10.00
Repairs same service ~ $5.00
TOTAL $
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:
U'F ~ ~. ! "v~ ~ '~ ~,l..q ~ O'4' et~ in accordance with tiffs application.
Date Received by the Town Clerk o(2/7~
Date Permit Issued ~'/7/0 ~ Permit No.
SUPERINTENDANT OF HIGHWAYS
TOWN ~UTHO~LD, NEW Y RK
ate
NOTE:
Permit expires one (1) year from chte of issuance.
No work to start without 48 hour notice to Superintedant of Highways.
Permit must be available for inspection.
D-39 2 of 3
,Copy Distribution:
Highway Department
Engineer (with page 3)
Applicant
Town Clerk (Original)
1st
2nd
3,-,~
4th
Inspection Date
INSPECTOR'S RECORDS
Findings (use code)
Applicant Notified
(To Permit Clerk)
CODE
lB Improper Barricades
IL Improper Lights
ST Sunken Trench or Excavation
UTM Unable to Measure (due to backfilling)
BUC Building Under Construction
WIP Work In Progress
DB Inproper Backfill (too high, not sufficient)
HFS Inspector Holding for Final Settlement of Excavatrion
RFR Ready for Repair
D-39 3 of 3
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