HomeMy WebLinkAbout10230 New Suffolk AveDate: 06/27/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt'8: 7309
Transaction(s):
1 1
Permits
Reference Subtotal
389 $150.00
Check#: 7309
Total Paid: $150.00
Name:
R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID: 389
RECEIVED
JIJ~l 2 7 2005
Southold Town Cleric
Per.~l~o. HO~
¢ TOWN OF SOUT
HIGHWAY DEPARTMENT
. Poconlc Lane
Peconic: New York 11958:
(631) 765- 31 q0
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the To~n
of Southold for the issuance of an Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, New York, and other applicable laws,
ordinances or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws· ordinances, cedes and regulations, and to permR
authorized inspectors to niake~ necessary inspections of the job site.
Print or Type
Name of Applicant
Name of Owner of'premises
Work Description and Location (Street Number, HAmlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes__
*If yes, other Town permits may be required.
q) Builder's License No. Plumber's License No.
Electrlclaffs License No. Other Trade's License No.
~~Sig~cant
¢ ~ate
' Addres§
Addres~ w '
No ~
5) a)
b)
c)
6) Tax Map: Section
1) Starting Date:
8) Work Schedule:
Phase
9)
10)
11)
Attach plot plan showing location of prol~osed ex.cavation and relationship to
adjoining premises or public streets or areas, and giving a detailed descrip-
tion of layout of excavation.
Attach all other necessary permits and licenses for this project.
Work covered by this application may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
· Block , Lot
Completion Date
Completion Date
Excavation .........................................
Facility Installation
Backfill S Compaction ..............................
Pavement Replacement
Under which authority is the application made:
Estimated Cost of Proposed Work: $
D-39 Paae 1 of 3
12)
Insurance Coverage: (Attach copy) ~/~,~_j
a) Insurance Company: ~
c) S~te wheth~ ~licY of ~ertifi~tion on fl~ wi the High ay~ep~- ..
d) Cove~ge r~ulred ~tend~ to the Town:
B~ily Inju~ and p~perty da~ge: ~300,000/$500,000 B~IIy tnju~,
and $50,000 property damage.
13) Security,:
a) Surety Bond or Certified Check ~rovided in the
total amount of $
b) Maintenance Bond provided: 2 years or 3 years
lq) Fees for applications and permits: Basic Application Fee ........
Al. /Service Connections excavations ~ $20.00 = $
Ho.
/Additional Excavations same service & $10.00 = $
A2.
Excavations
0-100 I.f. =
18" in depth or less:
$10.00
I.f. & $0.10 - $
Additional
Co Excavations 1~~ In depth to 5' in depth:
0-100 l.f. = $30.00
I.f. ~ $0.30 = $
Additional
D. Excavations S~ tn depth and over:
0-100 I.f. = $50.00
I.f. & $O.50 = $
Additional
E. Utility Repair Excavations e$~0.00
Ho.
Repairs same service ~ $5.00 = $
Additional
Notice to public utilities proof must be provided and attached to
this appliCation prior to issuance of Permit.
Received by the Town Clerk
Permit Issued
Date
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
In accordance with this application.
SUP~R-t~I~IDENT OF HIGHWAYS
T UT~D,; NE ORK
-~ D~a-l:e -
C
Date
Permit No.
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without q8 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
Paae 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
iN SPECTORtS RECORD
inspection Date
Findings (use code)
Applicant Notified
1st
2nd
3rd
4th
-- (To Penait Clerk)
REMARKS
CODE
lB - Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WlP - Work in progress
DB - Improper backf'lll'(too high) {not sufficient)
HFS - Inspector holding for final settlement of exqavation
RFR - Ready to repair
,*- --** Paae 3 of 3