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HomeMy WebLinkAboutAugust Ln r l * * * RECEIPT * * * Date: 11/14/13 Receipt#: 159627 Quantity Transactions Reference Subtotal 1 Excavation Permits 888 $190.00 Total Paid: $190.00 Notes: Payment Type Amount Paid By CK#8247 $190.00 Eastern, Utilities Contracting Corp Name: Eastern, Utilities Contracting Corp 17 Maple Ave East Moriches, NY 11940-1342 Clerk ID: LINDAC Internal ID: 888 Permit No. TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peconic Lane Peconic,New York 11958 (631)765-3140b!p1 � 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 Tvoe lea n�(dsC�l n+, G©fD `�7 MULL- r� , ( �,r,t�.Q � I, Name of Applicant Address of Appl ant 2. 1) 4 A-A� AA LQ ut!IM06(� N(�ametof Owner of Premises IJ Addressb`f Owner 3. WorkDescriptionDescription and Lo tion(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 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 Dater I Completion Date: 8. Work Schedule: Phase Completion Date Excavation Facility Installation Backfill&Completion Pavement Replacement 9. Under which authority is application being made;�1AA�DL(A);5 �Tf1 10. Estimated Cost of Proposed Work: $ cl,(} O() RECEIVLO 11. Remarks: RECEIVED D-39 ' Q 1 of 3 `� Southold Town Clerk 12. Insurance Coverage:(Attach Copy) (a) Insurance Company: V 1 1 ,r`(j W kfl� (b) Policy#: (c)State whether policy of certification on file with the Highway Department 06 (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. 0� /Service Connections excavations @$20.00 $ 0•v , 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 it.@$0.50 $ E. Utility Repair Excavations @$10.00 $ No. Repairs same service @$5.00 $ Additional 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 accordance with this application. SUPERINTENDANT OF HIGHWAYS TOWN OF SOUTHOLD,NEW YORK Peter W.Harris L111,311-3 Date Date Received by the Town Clerk /�J /V 13 Date Permit Issued //—/Y—/3 Permit No. NOTE: Permit expires one(1)year from date of issuance. No work to start without 48 hour notice to Superintedant of Highways. Permit must be available for inspection. D-39 2 of 3 i. j' i In r o�- 0 r � LO i I$ i