HomeMy WebLinkAbout8405 Cox Ln a
* * * RECEIPT * * *
Date: 11/25/13 Receipt#: 159753
Quantity Transactions Reference Subtotal
1 Excavation Permits 893 $170.00
Total Paid: $170.00
Notes:
Payment Type Amount Paid By
CK#8252 $170.00 Eastern, Utilities Contracting
Corp
Name: Eastern, Utilities Contracting Corp
17 Maple Ave
East Moriches, NY 11940-1342
Clerk ID: LINDAC
Internal ID:893
Permit No.
TOWN OF SOUTHOLD RECEIVEDttjr
HIGHWAY DEPARTMENT
Peconic Lane
Peconic,New York 11958 2 F `
(631)765-3140p1 fid'
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 Tore
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Name of Applicant Address of Applicant
z. a i r X75 C� L
Name of Owner of Premises \ Address of Owner
3 _—`L`j �� o•• �)�fi cyA 5tff1tC� lmnly- CDC A UAX r A f,l� n �
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.
Signature of Applicant
►� �a �3
—� 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: 11 �
8. Work Schedule: Phase _Completion Date
Excavation
Facility Installation
Backfill&Completion
Pavement Replacement
9. Under which authority is application being made: ti5 1 fU 5.$:� 01ARQQ f—
10. Estimated Cost of Proposed Work: $ t 00 .
11. Remarks:
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12. Insurance Coverage:(Attach Copy)
(a) Insurance Company: U Y15 UJGnr-,(sL
(b) Policy#:
(c)State whether policy of certification on file with the Highway Department: o o 1�
(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
Ly
Al. /Service Connections excavations @$20.00 $ aO .
No. -
A2. /Additional Excavations same service @$10.00 $
No.
B. Excavations 18"in depth or less
0-100 it=$10.00;Additional it @$0,10 $
C. Excavations 18"in depth to 5'in depth
0-100 it_$30.00;Additional it @$0.30 $
D. Excavations 5',in depth and over
0-100 i.f. $50.00;Additional is.@$0.50 $
E. `Utility Repair Excavations @$10.00 $
No.
Repairs same service @$5.00 $
Additional
TOTALS iV(70-(';;
F. Notice to public utilities proof must be provided and attached to this application prior to issuance
of permit.
xr
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.
SUPERINTENDANT OF HIGHWAYS
TOWN OF SOUTHOLD,NEW YORK
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"+ Petor W.H,ajrjs
.,• a?5,1j.3
f 'q�J�'13/� Date
Date Received by the Town Clerk
Date Permit issued Permit No. 7
NOTE: Permit expires one(1)year from date of issuance.
No work to start without 48 hour notice to Superintedant of Highways.
Permit must Wavailable for inspection.
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