HomeMy WebLinkAboutWhite Eagle Dr * * * RECEIPT * * *
Date: 01/16/14 Receipt#: 161100
Quantity Transactions Reference Subtotal
1 Excavation Permits 898 $250.00
Total Paid: $250.00
Notes:
Payment Type Amount Paid By
CK#2342 $250.00 American, Underground
Utilities/Cablevi
Name: American, Underground Utilities/Cablevision
P O Box 900
Eastport, NY 11941
Clerk ID: LINDAC Internal ID: 898
• 'Pemit No. RECEIVED
OF SOUTHOLD
HIGHWAY DEPARTMENT
P.O. Box 178 JA�,' ? °l4
Peconic, New York 11958 'ao_
(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 perrnit authorized inspectors to make necessary inspections of the job site.
Print or Tyne
I. rt i i✓2 " -�v�lc..� �l L�T/ �lO�S 4? �—
Name of Applicant fr,> CIOC>
- ^ /V Address of Applicant
?2. /<'E-10r-#9c-G-- Fi1 , kt4?
Name
%�t Ge: 71c
of Owner of Premises
e►mises n Address of Owner
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.
Sig ture 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 ^y ,Block ,Lot
7. Starting Date: / ��[ J D�� Completion Date:
8. Work Schedule: Phase Completion Date
Excavation
Facility Installation
Backfill&Completion
Pavement Replacement
9. Under which authority is application being made:
Uv
10. Estimated Cost of Proposed Work: $ 7 0 y C.)
11. Remarks:
D-39 1 of 3
12. Insurance Coverage:(Attach Copy)
(a)' Insurance Company: ClyCJ —
(b) Policy#: 7- f P /0/ 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 i.f. =$10.00;Additional i.f.@$0.10 $
C. Excavations 18" in depth to 5' in depth go
v�J
0-100 i.f.=$30.00;Additional i.f.@$030 $
D. Excavations 5' in depth and over
0-100 i.f._$50.00;Additional i.f.@$0.50 $
E. AA Utility Repair Excavations @$10.00 $ �
No.
Repairs same service @$5.00 $
Additional
eX7
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:
inaccordance with this application.
SUPERINTENDE F HI S
TOWN OF SO D Y
Date
Date Received by the Town Clerk
Date Permit Issued / -16, -6 e 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
1st
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
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