HomeMy WebLinkAbout205 Boisseau AveTown Of Southold
P.O Box 1179
Southold, NY 11971
Date: 03/02/06
* * * RECEIPT * * *
Receipt#: 2458
Transaction(s):
1 1
Permits
Reference Subtotal
435 $150.00
Check#: 2458
Total Paid: $150.00
Name:
North, East Communications
746 Montauk Highway
Bayport, NY 11705
Clerk ID: LYNDAB Internal ID: 435
6~/03 '06 WED 13:66 FA]: 631 765 6145
' * ' ' Perm--.
SOLrI~OLD TOM CLERK
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT.
Pe~onlc Lane
Pecorllc: I~lew York 11956
.(631)
**~ Hlghwa.~ ~] 001
APPLICAI~ION/PERMIT FOR HIGHWAY ExCAvATION AND REPAIR
APPLICATION IS HEREBY· made to.the Superintendent of Highways of the Town
of Southold for the Isguam:e of m~ Excavatioh Penalt 'p,u~nt to Chapter 83 of the
Code of the' Town of Emuthold, Suffolk Couflty, New york, end other applif~ible laws,
ordin~lces or r~ulaflofis for the e~ca~/atioh herein descril~d, The ~ppllc~nt agrees
to comply wlt~ all applicable laws, ordlri~mces, code~ and regtdafio~s, and to permit *
authoHz~:l Inspectors t~ mtake~ nec~ary in~.pectlons of tho job sit&.
Print or Type
· Name Of APplicant ' AddreSs '
~amo of Ownor ot' Premi~s
Work Des~iptio~ ar~ I~ce~ion {$~reat Number. Hamlet, Cros~ Street}
Is mnstructie~ located withih·75 feet of tidal w~tlandst *Y~$._.___~o
· If yes, other Town permlt~ may be requlrad.
~) 13uilder~s .License .No. Plumber~ Lic~lse Ho.
Electridah's LiCe~sa No. Ot~r~adds License No,
Date
9]
10)
· 11)
a) Attach plot plan showing Iocafi°n o~,p~ ex,cevatJon and relatioftship'tO
adjoining premises.or public 'streets or areas, and giving a detailed descrip=
t[o~ of layout' of excavation. ,
b) Attach all other necessary permit~ and licenses for this 'project.
' c) · Wb~l~.,~vered by this applicaUo~ may not commence before issuance of a
High~ay ExsavaUo~ Permit by the Town Clerk,
, 6) Tax Map.' Section
7) Starting Date:
8) Work Schedule:
Phase
· Block , Lot
Completim~ Date . . .
Completloh Date
Excavatioh .........................................
Facility Installatloh .................................
BecK'fill' g Cmnpaction ......... , ....................
Pavement Replacement ..............................
Under' which authority Is the appllc~tioh made.'
Estimated Cost eie Proposed Work: $
Remarks:
D-39 Pag~ 1 of 3
ql/03 '06 WED 13:56 FA][ 631 765 6145
TOWN CLERK
-*-,-, H18hw~T Dept ~]002
insurance Covera~/e: (Attach copy)
a) insurance Company:
b} Pdicy ~
c) State whether policy of certification on file' with the Highway Depart-
d) Coverage required extended to the Town:
Bodily Injury and property damage: ~300,000/$500,000 Bodily Injury,
and SsO, OOO. property danmge.
Security:
e) Surety Bo~d e~ Certified Check provided In'the
total amount of $
b) Maintenance B~nd provided: '2 years or .~ years.
Fees for applicatiohs and permit~: Basic Application Fee_ ........ $150,00
Al. ISerYic~ Connectloh$ excavations 6 $20.00; $
A2. /Additional IExcavatio~s same service ~ $16.00 -- ~
Do
Excavations 18" in depth.ur less:
0=100 I.f, = $1a. 00 '
I.f. · $0..10 - $
Additional
~vati~ I~' in d~ ~ ~ in d~h:
Ad~l'
Ex~vafl~s 5' in d~ ~d over:
hr. e~.s0=~
ED
Utility Repair Excavatiohs e$~O. oo ~ $
NO.
.Repair~ same ~ice C ~.O0 = $
~difioMI"
Notic~ to public 'utilitie~ proof must be provided and attached to
this 'applic~tloh prior to issuance of permit.'
Authorizati°n Is hereby granted to the Tmvn Clerk of the Town of S~uth~d to
IsSue a Highway Excavatlo~ Permit 'to:
In'accordance with this 'applic~floh.
Received by the Town Clerk ~31~ IO(_~
Date
t Dante
Note: Permit expires Dna {1) y~r f~m Date of [ss~n~,
' - No work to s~ Wight ~ ~f noti~ ~ the Superlnt~t of Highways.
Pem~ 'must be available for
D-39 Page 2 ~ 3