HomeMy WebLinkAbout2465 Crown Land LnDate: 04/17/06
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#: 1408
Transaction(s):
1 1
Permits
Reference Subtotal
440 $150.00
Check#:1408
Total Paid: $150.00
Name:
Utilities, Plus Corp
99 Mariner Dr
Southampton, NY 11968
Clerk ID: LINDAC Internal ID: 440
Permit
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT.
Peconlc Lar, e
Pe~onlc: .New York 1.1958;
APPLi.CA.T. ION/PEPJ~IIT FOR HIGHtI/AY. EX~;AVAT. ION AND REpAiR.
APPLICATION I$ HEREBY' made to.the Superintendent of Hlghvaays o~ the Town
,Print or
-- N~ of own~ ~ P~i~ ' Addre
'" WO~ ~i~ion a~ ~a~o~'~S~mt ~r, ~mlet, C~$s
Ia) Is ~nst~fi~ I~t~ wlth~'75 fat of fl~l weda~sT ~es ,.~o~
~) Build~s .Llc~ No. PI~ Li~e
El~rl~hh~s Li~se No. _ Other Trades Li~n~
~lnin~ p~l~s'~ public 'st~ or a~s, a~d ~ng a de~ll~
~ of la--'of ~n. ,
b] A~ch all ~r ~es~ p~t~ and ~ns~ for
Hig~a~ Ex~vaU~ PemR ~ ~e T~n
. $) Tax Map: Section
7) Startln~ Date; ,~,~¢~
8) Work Schedule:
P~
10)
· 11)
Fadllt7 lnstallatlob ...................................
Backfill' $ C=mpaction ......... ~ ....................
Pavement Replacement ...................................
under whi=h authority Is the appllcdtlo~ made.~:}~-/~:-//'/~/O~--/~ L~..~,
Estimated Cost of Proposed Work: $ ,~, C~-~,c~c~
/
D-39 Page. 1 of 3
Inauraflee Coverage: (Attach copy)
a) Insurance Company:__
¢)
d)
State whether policy of certl~l~atioh on t'de' with the Highway Depart-
CoVerage required extended to the Tmvn:
Bodily Injury and pro .p?ty damage: ~3Oe. OOO/~,~OO, OOO B0dil~ Injury,
and SSO, O0~ property
13) _Securit'/:
o~ Certifl~{ Check provld~l In'the
a) Surety B4m~d ..... _ __
total amount of $
b) Maintenance Bbnd provided: '2 years or 3 ymr~,
la) Fees ~or applic~ic~m and permit~_'~ laa~;{c AppIk:ation Fee .......
Al. IServic~ Cohr~-tiohs excavations e $20.00; ~;.
A2, /AddiUbnal Excavations ~ame service e ~10.00 = ~. _
ExcavaUo~,s I~' in depth.or less:
0-'100 I.f.
I.f. a ~e..10 - $
Additlo~d
ExcawUo~e~ 11" in depth to S' in depth:
0-100 I.f.
I.f.
^dditior~l'
EXCavations ~ in de~th and over:
0-100 I.f. = $51;/00
I.f.
Add~o~al
goo
Fe
Utility Repair Excavatiohs ~0.00 ~ $__
Repairg same service, la ~5. O0 a $
Additional '
Notic~ to public 'utilitieg pn~of must be l~wided and attached to
It~is 'applioit{o6 prior to i~uance of permit;
Authorlz~tlo~ Is hereby granted to the Town Clerk or' the To~m of Sduthold to
I~ue a Highway Exeavatiol~ Permit 'to:
in'ac~x)rdance with this*applic;itJoh.
$UPE~EHT OF HIG~AY$
ileter; W. K~rris
Re~e~ed by the Town Clerk
Date
N~e: P~t ~ir~ o~ (1) y~r fm ~ Df lumn~. -
.... No work m
Pa~ 2 of 3
Copy Dlstr butlp~:
. Highway Department
AppIir. ant
~'ov/n Clerk
IH sPECT OR"-$ ~E CORD
Inspection Date Findings (use
Applicant Notified
2nd
-- (To P&rlalt'Clerk)
REMARKS
CODE
x,
%
c;ERTIFIC: IFE OF LIABILITY INSU
Goeporate R~sk Associates
300 Hampton Road
Southampton, NY 1,Z968
99 Matinee Dr~ve
Southampton, NY 11968
THE POLICIES OF
G~9,tF. RAL LIABIUTy
CO~MERCI~
A~Y AUTO
P. O1/iD2.
ICE
INSURERS AFFORDING COVERAGE
Tns, Co,
INSt.~ER B;
Znsupance
:on Trust
) OR
NAIC#
~UED TO THE INSURED F
~LAIM$.
) ABOVE FOR THE PO/dc' LTED, NOT~
:' TERMS, EXr~ ~ m,* ~,~-'~-m~-r e~, I68UED OR
,-,-~,.,, ~,n,~ Mu CONDITIONs OF SUCH
F'F-R,tOM. & *Dy idd. CRy s :1 ~ 000, (~._,'
ufo
s 3 f000~OC~
E,LDISEAaE-EREM~LOyE $ 1 000
F-LOI~EA~E-POLICYLiMrr ! I 000