HomeMy WebLinkAboutHorton LnAPPLICATJONIPERM[T ~::IR HIGHWAY, EXGAVA'~JON AND REPAIK,
.A. PPUCATIDN IS Hr:-REB~ made re.th= Superlntende~t of Hlgh~y= ~ ~e Town
C~ of ~' Town ef S~t~ld~ surfak ~n~; N~ Y~k~ and ~ ~pl;~e laws,
Print o~
Naae of Own~ P~i~ ' Addm~
'~ ~55' OE open t~ench~n9 ~n 9:ass shou'l~e~ a~ea be~. Poles
WOrk ~Jptlan a~' ~g~oR~eet ~, Hamlet, C~' ~t~t)
[a) IS mnst~O~ I~t~ Wlth~'75 f~t of Udal WeUa~ ~ No X
Elc~i~h~'s ~se No. N/A , Other Trades Li~n~ No. N/A
Re~. ~T100566670 3/21/06
work sketch previously mailed
~nln~ p~lses'~ pu~l:'st~ or a~s, and ~vln~ a do~l[~
ti~ of b~' of ~va~n,
A~ch all ot~ n~e~ ~it~ and II~nS~ for this'pmJ~t.
Highly Ex~va~ Pe~;t ~ ~e Town
. 63 Ta~ M~; S~t~n 055 . B~ 1 ~t
7) S~rtln~ Oate; .... C~pletlo6 Da~ ,, ,
~] ~rk S~ule:
Repla~ent .................... ,,.,
Pa~ent ...........
3) Und~ which ~u~rlt~ Is ~a appll~:lu~
10] Esfl~t~ Cost ~ P~posed Work:
· 11) R~arks:
NY 11901
29 & 31
Horton's Lane
ZDO[~ 'rUE 12:07
· o~ Wb'D 13."S~ F,~ 6~1 765 ~145
SOUT~0LD TOWN CLERK
002/003
12]
1:0
Iq)
d~
Coverage requireCl extended t~ thc Town:
B~ily InJury and property damage: ~500,000/$500,060 Bodily; Injury',
and ~50, 00~. property' damage.
Security.:
a) Surety Bond, o~ Cert~li~l Check ~r~;d~ ln'~e
b) ~int~e ~nd p~[d~: 'Z y~rs or 3 7~ .
for a~li~h~ a~ ~: Basic ~pl~t~O~ ....... $150.00
I.f. I ~,.11 - $
C.~;~ti~ 1~ in d~th to ; in d~h:
~1o. l.f, = $30.'0g
155 Lt. e~.~;s 46.50
D. i~s S' In d~ nd over;
Authorl~don I~ hereby granted to the Town Clerk of the Town of Sduthdd to
lsgue a Highway Exmvaibfi Pe~it '~: LIPA
In'a~ance wit~
SUPERINTENDENT OF HIGHWAYS
E~'' by 'e TOWn Clerk
NoEe: Pe~t ~pir~ one (1) y~r f~m Da:e
No work xo ~ w~t ~ hOUr'
Pe~ 'must ~ aveil~bl~ for
D-39 Page 2 of
1./2008 TUE 12:07 FAX ~}003/003
'0~R~:D~I~:ST_ FAX 63! 765 $~45 $oUTIIOLD TOWN CLERK , ~003
Copy Di~tributlo6 t
· 14jgh~ray Department
Inspector
Applicant
T~n Clerk
I[ ,N $ p E CT 0 I~'*-S ~ E C O R l)
I I~c'cl~n Date
Findings
Applicant Nc~iflecl
2nd
[~O Penflt'Clerk}
.REMARKS
CODE
lB '~ Improper barricad~
IL -'Improper I1ght.-
S:T - Sunken U'enr~ or eaccavat]on
UTM - Urmble to ~e~sure (~ue %0 ba~kfillin~J
BUC - Building u~der Construc'ci.o~
WlP - Work I~'p~xj~e$~
D~ - 'Improper backf~l' [too high) [not sufflcJeht)
HFS -. Inc~pecter hddln~ for ri~al settlement of excavation
RFR - Ready to repair
D-3g Page $ of 3
ELIZABETH A. NEVILLE .
TOWN CLERK
Date,REGISTRAR OF ViTAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Transaction(s):
1 1 Permits
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Receipt~ (631}1}~.6145
Telephone (631) 765-1800
southoldtown.northfork.net
Reference Subtotal
442 $226.50
,or ~xC~ O~ li-l~ 'l'Owr~ ~,Le,r,~btaI Paid:
TOWN OFSOUTHOLD
$226.50
Name:
L, IPA
117 Doctor's Path
Riverhead, NY 11901
Clerk ID: