HomeMy WebLinkAbout9512 Bayview RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 01/06/05
Transaction(s):
1 Permits
Permits
Receipt~:
7019
Subtotal
$190.00
$190.00
Check#: 7019
Total Paid:
$380.00
Name:
& R, Construction R
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID: 104794
TOWN OF SOUTHOI
HIGHWAY DEPARTMENT
Peconic Lane
Peconic: Now York 11958:
(631) 765-31~10
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance ef an Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, Now York, and other appliCable laws,
ordin&nces or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to rdake~ nec&ssa~-y inspections of the job site.
Print or Type
Name
(a) Is construction located withih 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
4) Buiider=s License No. Plumber's LiCense No.
Electriciants License No. Other Traders License No.
S i ~2tsU_~ad)ie~.~P P I I ce n t
of Applicant Address
of Owne~ of Pre~nises Addr&ss
Description and Location (Street Number, Hamlet, Cross Street)
No 2(.
s)
a) Attach plot plan showing location of prot~ed ex. cavaflon and relationship to
adjoining premises or public streets or areas, and giving a detailod descrip-
tion of layout of excavation.
b} Attach all other necessary permits and licenses for this project.
c) Work covered by this application may not commence before issuance of a
Highway Excavation Permit 'by the Town Clerk.
6) Tax Map: Section , Block , Lot
7) Starting Date: Completion Date
8) ~/ork Schedule:
Phase
Excavation .........................................
Facility Installation .................................
Backfill S Compaction ..............................
Pavement Replacement ..............................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks: ~)OC ~_ I':~ ~P-~' ~,~ C~C)(~ ~::~ ~-
Completion Date
D-39 Paqe 1 of 3
Insurance Coverage: (Attach copy)
a) insurance Company: ~,r~rc~ ~r~ ~
bi Policy ~
c) S~te whether policy of certlfl~tion on file with the Highway Depen-
d) Cove~ge r~ulred ~tend~ to the Town:
B~il7 Inju~ and p~pe~7 damage: ~300,000/~500,000 B~ily
and $50,000 p~pe~y damage.
S~urlty:
a) Sure~ Bond o~ Certtfl~ Ch~k provld~ in the
to~l amount of $
b) Maintenance Bond pr~ld~: 2 y~rs or J~3 ~rs
Fees for applications and ~mitS: Basic Appli~tion F~
Al. ~ /~ice Conn~tions ~vations e $20.00 =
No.
A2. /Additional Ex~vatlons ~me se~tce ~ $10.00 =
B. Ex~vations 1~~ In d~th or less:
~100 I.f. = $10.00
I.f. e $0.10 - $
Additional
C. Ex,rations 1~' in d~th to 5~ in depth:
~100 I.f. =
I.f. e $0.30 ~ $
Additional
D. Ex~vattons 5~ in d~th and over:
~100 I.f. =
Additional
No.
Additional
Utility Repair Excavations e$~0.00 = $
Repairs same service ~ $5.00 = $
Notice to public utilities proof must be provided and attached to
this application prior to issuance of Permit.
*** #
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.
SUPERINTENDENT OF HIGHWAYS
I~eter W. Harris
Received by the Town Clerk
Date
Permit Issued / -~ J D~' Permit No.
Date
Date
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without a8 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
IN SPECTOR~S RECORD
Inspection Date
Ftndings (use code)
Applicant Notified
1st
2nd
3rd
qth
(To Permit 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 backfill (too high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR - Ready to repair
D-39 Page 3 of 3
N 1 ~SHLD
JAN-05-05 IZ:SZ~ FROM- T-I$1 P 02/02 F-Z58
p. o. ~ Z448
2~2 LAue P.d.
IN~URE. RS AFFORDING COVERAGE
i~,~n~ ^: ,IGUc~,~f.D J~/'RZ ZJ/BETR,&J~ CO.
:OVERAGES
TrlE pOLICIeS OF iNSURANC~ LISTED ~*ELOW PU~V~ ~EN ISSUED TO Trl~ IN°at.J~.D K4G4ED ABOVE F~R THE pOLiCY PTr~RIOD INDICATEO
INFORMATION
~ CERTIFICATE
Igl. EXTEND OR
29~82
BI; r~ OR
03/33/2004 03/31/2005 ;~J~occum~Nc~
300000
10000
100000
20000
ACORD 26(2001/08!