HomeMy WebLinkAbout365 Horseshoe DrTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 05/16/06
* * * RECEIPT * * *
Receipt#: 317
Transaction(s):
1 1 Permits
1 1 Permits
1 I Permits
Reference Subtotal
448 $150.00
447 $150.00
446 $150.00
Check#: 317
Total Paid: $450.00
Name:
Verizon, Communications
501N. Ocean Ave
Patchogue, NY 11772
Clerk ID: LYNDAB Internal ID: 448
TOWN OF SOUTHOLD
HIGHWAY DI:p~TMEh[T ·
pecon,~ ~ne "~~
pc~c~ ~e~ York 1.1958;
~A_FPLiCAT. iON/PE,pJ.I!T' FOR HIGHWAY. F_~GAVATION AND REPAIR.
APPLICATION IS HEREBY made re.the ~uperlnte~dent ef High~ys ~ ~e Town
of ~td for the is~nm af ~ ~tio~ P~it 'pum~nt to Chair
~ of ~ ToW~ of S~t~ld. Suf~k ~W. H~ Yo~, an8 oth~ appR~e laws.
o~l~nc~ aP ~atloBs f~ ~e ~ ~rein ~b~. The ~(l~nt
~ffz~ Insp~ors ~ mke] ~ry msp~Ons -- -. ~ ·
Print or TY~ d~~
I) .'~c ~ppll~
2~ Name of Own~ ~ p~i~ Addr~s
} gu;ld~S Ltcefl~ ~o. pJ~H LT~se
$)' a) Attach p~ot plan sho~ln~J Ioc~tio~ o~,pr~o~o~ ~x, co~'atian
~lnln~ p~ publlc'~ or
fl~ of la--'of ~vatlon. .
b) A~ch all ot~r ~e~ per~ and tJ~ns~ for ~is'pmJ~t.
' c) W~,~e~ by ~ app i~h my ~t ~mmen~ berate ~n~ of a
High~ay Ex~va~ofl Pe~lt ~ ~e Town C ~k.
. ~ Tax Map: S~I~ . BIo~
7) Sta~ing Date: ~pletio~
8) Work Sch~ule:
Fadll~ i~smlleUo~ ..................................
~v~nt Eepla~t ..............................
9) Und~ which ~u~orlty l~ ~e appIl~h ~d~:
10) Estimated Cost of Fmpos~ Work: ~ -
, 11] RemarTc~:
Page. 1 of 3
Insurafle= Coverage: {Attach ~)
a) Tn=urance Company;
Policy ~
c) State whe~er pell¢¥ of certi~catlol~ on file' with ~.he Highway I;:~oart-
d} C~age reCl~,ircd extended t~ the Town:
Bodily ~nlury end preper'ty damage: $300,000/$5g0,000 Eoclil); Injury,
and $50,001[ property damage.
Security.:
a) Surety Bond , ,.,or C~ct. lfie~ Che~k provided In'the
total amount ~ $ ' ,,,-
b) ~lnt~e~e ~nd provid~:
for appli~tlohs and permi~: Basic ~pIl~n F~ ........ ~150.00
Al. /~i~ conn~i~s ~vatlons e $20.00 = $~
A2. /Addi~al Ex~vatlons ~me se~[~ ~ 510.~0 = $
B.Ex~va~s lr' in d~.or less:
0-100 1.f. = $1a. 0g'
C. ~vatio~s I~~ in d~th to 9 in
Fo
MOo
__Utility Repair Ex~aYat~ehs a$~.e. 0o. = $
Repalr~ -,ams ~erVice · $~.OO = $
Net;c~ to publ|c'rr[ilii;e~ proof must be pro~ided and attached to
thls'appllc~oh prior to issuance of permit.'
Authorlzatlo~ Is hereby granted to the Town Clerk of the ToW~ of S~utho~d to
Is~.ue = Highway ExcaYatlo~ Permit 'to:
In'accordance with thls'applicatlol~.
SUPERINTEHDENT OF HIGHWAYS
TO~44-~F SOUTHOLD, NEW yORK
I~eter W. Harris
Date
parmlt I~ued ~--J ¢- O~ Permi[ No.
Da~e '
D-39
Permit expires one (1} ycar from Da~e of Issuance.
No work to ~ wight ~ ~uf police to the Superlnt~d~t ~ Highways-
Pe~ 'must be available for
Page 2 of 3
Office Phone:
Specify: ~ Town Road.,
~ Emergency
Notification of Request For
Emergency Permit
Eastern Suffolk, MUST fax completed form to:
Elizabeth Brady
F~x # (~31) 687-~512
'I-I' # or Job #:
Central Office:
Village:
[-'--~ State Road ~ County Road
['~ut of Service ~Temp Service
r'~Village Road
[qfgl-matlon Reauired:
1, Nearest cross street
2. Dlstanoa to neerest cross street
3. Approx. si=e of excavation
4. Excavating on: (check one) J---~ Sidewalk I~-]Road
5. Called for Tone &Mark {'-~Yes~-] No Case#
6. Exact location of splice pit ( Front of house # }
NOTE~'
For work being performed In the town of Brookhaven,
please indicete cu~torrmr~ ptoper~y line.