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HomeMy WebLinkAboutWood Way & Fairway Dr * * * RECEIPT * * * Date: 01/16/14 Receipt#: 161101 Quantity Transactions Reference Subtotal 1 Excavation Permits 899 $250.00 Total Paid: $250.00 Notes: Payment Type Amount Paid By CK#2341 $250.00 American, Underground Utilities/Cablevi Name: American, Underground Utilities/Cablevision P O Box 900 Eastport, NY 11941 Clerk ID: LINDAC Internal ID:899 Permit No. TOWN OF SOUTHOLD RECEIVED HIGHWAY DEPARTMENT +� P.O. Box 178 JA N 1 5 L Peconic, New York 11958 ' (631)765-3140 Southold Town C' 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 AM E Name of Applicant P© `1100r4S�✓�C�'t lV' Address of Applica 2. j6P L AC— & —7—V C74 6 L Cr- F--Lo, Name of Owner of Premises dJ Address of Owner 3. A�� wJ/ 2Ly4 'U L/r; O CrJ9 . ��4i Work Description and Location(Street Number,Hamlet,Cross Street) (a) Is construction located within 75 feet of tidal wetlands? * Yes No *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. e Signa a of Applicant 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 Completion Date Excavation Facility Installation Backfill&Completion Pavement Replacement 9. Under which authority is application being made: "A< i7 10. Estimated Cost of Proposed Work: $ 11, Remarks: D-39 1 of 3 12. Insurance Coverage:(Attach Copy) ti (a) Insurance Company: �Tk (b) Policy#: `fi 1 1 110-7 (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 i.f. _$WO;Additional l.f.@$0.10 $ Ale C. Excavations 18" in depth to 5' in de th �V 0-10011=$30.00;Additional _1.f.@$0.30 $ an D. Excavations 5' in depth and over 0-100 11_$50.00;Additional l.f.@$0.50 $ o vc' E. I Utility Repair Excavations @$10.00 $ No. Repairs same service @$5.00 $ Additional ' l J TOTAL$ (/ 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 ac ordance with this application. SUPERINTENDE OF IGH TOWN OF SOU T OL EW _ Date Date Received by the Town Clerk Date Permit Issued / —/(0 - '/V Permit No. 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 1 st 2nd 3rd 4th (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 ,x t , k i Y � pi � I ,` � �( ��i✓!lzi 4Y �n1L'� VI/A`/ I ( It p i Z1 Ilkl �l � o � V i J I � s I q WON