HomeMy WebLinkAboutHalls Creek DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 08/01/06
* * * RECEIPT * * *
Transaction(s):
1 1
1 1
Permits C~S//
Permits ~//~'-/~c
Reference Subtotal
453a $125.00
453 $60.00
Cash#: 22052
Total Paid: $185.00
Name;
Utilities, Plus Corp
99 Mariner Dr
Southampton, NY 11968
Clerk ID: LINDAC Internal ID: 453a
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconie Lane
Peeonic, 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.
Print or Type
1. J-t--tC,IT ~.-~
Name of Applicant Address of Applicant
of Owner of Premises Address of Owner
Wot'k Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? * Yes
· If yes, other Town permits may be required.
No
4. Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No. ~,
(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: &'~,/'~ Completion Date: / ~),~,/' ..~0-~
!
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: $
D-39
1 of 3
12. Ins~trance Coverage: (Attach
(a) Insurance Company:
(b) Policy #:
(c) State whether policy of certification on file with the Highway Depamnent:
(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 Ce~ified 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~" in depth or less ~ ~ ~ ~-~
0-100i.f.~Additional 2~0 i.f.~$0.10 2. $
C. Excavations 18" in depth to 5' in depth
0-100 i.f. = $30.00; Additional i.f. ~ $0.30 $
D. Excavations 5' in depth and over
0-100 i.f. = $50.00; Additional i.f. ~ $0.50 $
$
$
Additional
Notice to public utilities proof must be provided and attached to this application prior to issuance
Utility Repair Excavations @ $10.00
Repairs same service ~ $5.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation permit to:
in accordance with this application.
Date Received by the Town Clerk ~ - / - dg~
Date Permit Issued OD - /~) ~ Permit No.
SUPERINTENDANT OF HIGHWAYS
TOWN OF SOUTHOLD, NEW YORK
Date
NOTE:
Permit expires one (1) year from date 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
3rd
4t~
Inspection Date
INSPECTOR'S RECORDS
Findings (use code)
REMARKS
Applicant Notified
(To Permit Clerk)
CODE
lB Improper Bamcades
IL Improper Lights
ST Sunken Trench or Excavation
UTM Unable to Measure (due to backfilling)
BUC Building Under Construction
WlP 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
r ~ OF SUCH
~LyF~Y
APR-10-L:~36 15:3~ P.02/l~.
IMPORTANT
If the cart/fica~ holder is an ADDITIONAL INSURED, the Polioy(tes) mu~t be endorsed, A statemetlt
on this cerl/ficate does not Confer rights to the cott/f~Cate holder In ~eu of such endomemeot(s}.
If SUBROGATION IS WAIVED, subject to the terms ,-
require an endor~t' A statement on and COnd/Uons of the policy, certain POliCies may
holder in lieu of such endomement(s}, this car~icate d~s not confer right~ to the cert/ficate
DISCLAIMER
The Certificate of Inau~lnce on the reverse si
th~_ issuing insurer(si, aJ,~,,~.~---, - de of this form does n~
affirmatively or n~,~",::-"~"''=u represemative or producer --.* ~"-' .~.,,..~.uu.~e a conkact behveen
.... a~'"""'yamend, extend or alie. ,~.. __ -, ""u u~e cert~cato holder
.... ~.~verage affo~'ded by the Dolicle.'
TOTAL P. 02