HomeMy WebLinkAboutHarbor View Ave t T
* * * RECEIPT * * *
Date: 01/16/14 Receipt#: 161102
Quantity Transactions Reference Subtotal
1 Excavation Permits 900 $250.00
Total Paid: $250.00
Notes:
Payment Type Amount Paid By
CK#2340 $250.00 American, Underground
Utilities/Cablevi
Name: American, Underground Utilities/Cablevision
P O Box 900
Eastport, NY 11941
Clerk ID: LINDAC Internal ID:900
Permit No.
' TOWN OF SOUTHOLD RECEIVED
HIGHWAY DEPARTMENT
P.O. Box 178
Peconic, New York 11958 JANE _.: 14
(631)765-3140
Southold Town Clerk
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town 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,codes and
regulations,and to permit authorized inspectors to make necessary inspections of the job site.
Print or Type
1. AM EYZ uA40 L'iL &Luuni2-,-'7 07-1 Lr / tTc
Name of Applicant A0 c/00 1?r4S 7-ROA 7-- Address of Ap icant 1/q4 /
z. R VL mac.-c `?I,, ��9 .F' �> � ,�jd ,
Name of Owner of Premises , Address of Owner
Work Description and Location(Street Number,Hamlet,Cross Street) —
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X
*If yes,other Town permits may be required.
4_ Builder's License No. Plumber's License No.
Electrician's License No. Other Trade's License No.
Signatur of Applicant
45- 3 2 v I f
Date
5. (a) Attached plot plan showing location of proposed excavation and relationship to adjoining premises or public street or areas,and
giving a detailed description 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 No.: Section ,Block ,Lot
7. Starting Date: Completion Date:
8. Work Schedule: Phase Comaletion Date
Excavation
Facility Installation
Backfill&Completion
Pavement Replacement
9. Under which authority is application being made: �j�,n,?�c � s�y �.qt •�=� L�,��i&yds ju.�
10. Estimated Cost of Proposed Work:
11. Remarks:
D-39 1 of 3
12. Insurance Coverage: (Attach Copy)
.0 (a}- Insurance Company: ^ l-l ��-�U� S-
(b) Policy#: � f Q 10/ 4207
(c)State whether policy of certification on file with the Highway Department:
(d)Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,and$50,000 property damage.
13. Security:
(a)Surety Bond or Certified Check provided in the total Amount of$
(b)Maintenance Bond provided: 2 years or 3 years.
14. Fees for Applications and permits:
Basic Application Fee $150.00
Al. /Service Connections excavations @$20.00 $
No.
A2. /Additional Excavations same service @$10.00 $
No.
B. Excavations 18" in depth or less
0-100 if_$10.00;Additional i.f.@$0.10 $
C. Excavations 18" in depth to 5' in depth // 0 BU
0-100 i.f._$30.00;Additional�i.f.@$0.30 $ (�
D. Excavations 5' in depth and over
0-100 i.f._$50.00;Additional if @$0.50 $
E. Utility Repair Excavations @$10.00 $
No.
Repairs same service @$5.00 $
Additional �^
TOTAL$ �J
F. 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 F HI HW S
TOWN OF SOUTH D, W
/ e
!C�
7-
Date Date
Date Received by the Town Clerk -/S--
Date
S -Date Permit Issued 1-14, Permit No. �CIL-)
NOTE: Permit expires one(1)year from date of issuance.
No work to start without 48 hour notice to Superintendent of Highways.
Permit must be available for inspection.
D-39 2 of 3
Copy Distribution:
Highway Department
Engineer(with page 3)
Applicant
Town Clerk (Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
1St
2nd
3 rd
4 t
(To Permit Clerk)
REMARKS
CODE
IB Improper Barricades
IL Improper Lights
ST Sunken Trench or Excavation
UTM Unable to Measure(due to backfilling)
BUC Building Under Construction
WIP Work In Progress
DB Improper Backfill(too high, not sufficient)
HFS Inspector Holding for Final Settlement of Excavation
RFR Ready for Repair
D-39 3 of 3
did i
No 2 TC1'
-L —T4�� Y Zt�s�-��` 3v C?..t.6t��
Vs� J
c\
f a
lq
u