HomeMy WebLinkAboutGrandview 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 1 Permits
Reference Subtotal
448 $150.00
447 $150.00
446 $150.00
Check#: 317
Total Paid: $450.00
Name:
Verizon, Communications
501 N. Ocean Ave
Patchogue, NY 11772
Clerk ID: LYNDAB ~nternal ID: 448
TOWN OF SOUTHOLD
H]GHW^Y DEP,~TMENT.
Pec~ nlc Lane
peoo~c: ~[eW York 1.1958
,A~pLICA'CION/PE,R]dlT ~OR HtGHWAY.E.~CGAYAT. ION AND REPAIR
APPLIC.~TION l$ HEREBY made to.the Superintendent of Hlgh~ys ~ ~e Town
of ~ld for the is~n~ of ~ ~a~tlo~ P~it 'p~nt to Chair
~,ot · J-,,-~- ~-- *ko ~ herein do~b~- The ~pu~n~
o~l~nc~ oe ~-~,yj,~ L~ -, ~-~-~- ~ a~ ~ulafiohs, and ~ pe~
Print or Type
::Iri~m" of Own~'°f e~i:~ ^ddress ~j/~/~
Ca) Is m~c~oh I~t~ ~it~'TS [~t of ~1 we~a~m ~
&) gu d~s ~lcen~ No- pJ~ Li~o
5)' a) At.ch ~ot p~n ~1~ I~ ~'p~ ~ and
~Inlng p~l~ ~ public ' s ~ ~ or a~s, a~ gland a da~ll~
fl~ of la--'of ~vatlon.
b) A~ch ail ot~r ~es~ permi~ and li~ns~ for ~is'pmJ~t.
' c) ' ~'.~er~ by ~ appll~h ~Y ~t ~mmen~ before ~n~ of a
Highway Ex~va~ofl Pe~it ~ ~e Town Cl~k.
7) Sta~ing Date: C~p~etioh ~te
~) Work Sch~ule: -
~v~nt Replacer..
g} Und~ which au~orlty Is ~e appIl~h
lO) E=tlmated Cost of P~p0s~ ~or~: ~ -
11] Re~=r~Ls:
PaDS ! of 3
lnsurorleo Coverage: (Attach copy)
a) Insurance C~mpany;
b) Pdl~ ~
C) S~te whe~er ~l[cy of ca~J~tlon on fil~ with ~e Highway ~a~-
~ge r~u~rcd ~&~d~ ~ the Town:
B~lly tnJu~ and p~pe~y ~gc: $30O~000/$S00,000 e~ily InJu~,
and SS0,0O& pretty damage,
13~
a) Surety Bond or C~;rtlfie~l Check pr~id~ In'~e
to~l amount ~ $
b} ~lnt~e~e ~nd provide: ',Z y~rs or
14) ~ for appll~tlohs and perm~: Basic ~pIl~n
Al. J~i~ Conn~ions ~=vat~on= ~ $20.00 = ~ ..
/Addi~al E~vatlons ~me se~l~
A2.
Authorlz&tlon Is here. by grante~l to the Town Clerk of ~e To~ of ~d
IsSue a Highway Ex~vat~ Pa~it 'to:
In'a~an~ with ~is'appli~o~.
EHDENT OF HIGHWAYS
UTHOLD. N~ YORK
P, ece~ed by the Town C'erk -I6-OG
Date
p~r~;t Issued ~--~¢-0~ Permit No.
Note: P~it ~plres one (1)
Pe~'mus~ be available for Ingp~on.
VERIZON
EMERGENCY PERXMIT REQUEST
CONTACT: Karen Campagnola
R/W DEPT 687-8429
FAX// 687-8512
LOG//
PERMIT//
FRMN NAME
FRMN TEL#
FRMN BEEP#
TT# / JOB#
CENTRAL OFC
TAX DISTRICT
LOCALITY
INFORMATION REQUIRED:
DO NOT DIG BEFORE SECURING PERMIT NUMBER
1. DIRECTION OF NORTH ARROW
2. DISTANCE TO NEAREST CROSS STREET
3. OPENING IN PAVEMENT OR GRASS
4. SIZE OF OPENING
NORTH ARROW
9. t\O
~/.J
X'
CURB
EDGE OF PVMT