HomeMy WebLinkAboutBridge LnTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 07/27/06
* * * RECEIPT * * *
Transaction(s):
1 1
Permits
Reference
452-n/c
Subtotal
$0.00
Cash
Total Paid:
$0.00
Name:
Suffolk, County Water Authority
4060 Sunrise Hwy.
Oakdale, NY 11769
Clerk ID: LINDAC Internal ID: 452-n/c
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
P.O. Box 178
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.
Print or Type
1. Suffolk County Water Authority
Name of Applicant
4060 Sunrise Hwy., Oakdale, NY 11769
Address of Applicant
Name of Owner of Prem/ses Address of Owner
Work DeScription and Locatioh {Street Number, Hamlet, Cross Street)
fa) Is construction located within 75 feet of tidal wetlands? * Yes
· If yes, other Town permits may be required.
4. Builder's LicenseNo. N/A Plumber's License No. N/A
Electrician's License No. N/A
Signature of Applicant
Date
fa) Attached plot plan showing location of proposed excavation and relationship to adjoining premises or public s~-eet 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.: S~ction N/A ,Block N/A , Lot N/A
7. Starting Date:
As soon as possible
Completion Date: As soon as possible
8. Work Schedule: Phase Completion Date
Excavation
Facility Installation
Backfill & Completion
Pavement Replacement
9. Under which authority is application being made:
N/A
10. Estimated Cost of Proposed Work: $
N/A
l l. Remarks:
D-39 1 of 3
12. Insurance Coverage: (Attach Copy)
(a) Insurance Company:
N/A
(b) Policy #: N/A
(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 N/A or Certified Check N/A
(b) Maintenance Bond provided: N/A 2 years or
14. Fees for Applicatinns and permits:
Basic Application Fee
Al. /Service Connections excavations @ $20.00
No.
A2. / Additional Excavations same service @ $10.00
No.
B. Excavations 18" in depth or less
0-100 i.f. = $10.00; Additional i.f. ~ $0.10
provided in the total Amount of $
N/A 3 years.
$150.00
$ N/A
$ N/A
$ N/A
$ N/A
$ N/A
$ N/A
$ N/A
N/A
Excavations 18" in depth to 5' in depth
0-100 i.f. = $30.00; Additional
i.f. @ $0.30
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:
Date Received by the Town Clerk
Date Permit Issued
NOTE:
in accordance with this application.
Permit No.
SUPERINTENDENT OF HIGHWAYS
T° 'T7?
Permit expires one (1) year from date of issuance.
No work to start without 48 hour notice to Superintendent 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
4th
Inspection Date
INSPECTOR'S RECORDS
Findings (use code)
Applicant Notified
(To Permit Clerk)
CODE
IB Improper Barricades
IL Improper Lights
ST Sunken Trench or Excavation
UTM Unable to Measure (due to backfilling)
BUC Building Under Consixuction
WIP Work In Progress
DB Improper Backfill (too high, not sufficient)
HFS Inspector Holding for Final Settlement of Excavation
P~FR Ready for Repair
D-39 3 of 3