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* * * RECEIPT
Date: 08/16/13 Receipt#: 157636
Quantity Transactions Reference Subtotal
1 Excavation Permits 861 $220.00
Total Paid: $220.00
Notes:
Payment Type Amount Paid By
CASH $220.00 Eastern, Utilities Contracting
Corp
Name: Eastern, Utilities Contracting Corp
17 Maple Ave
East Moriches, NY 11940-1342
Clerk ID: LYNDAR Internal ID: 861
Permit No. g
TOWN OF SOUTHOLD �'� ,
HIGHWAY DEPARTMENT
Peconic Lane
Peconic,New York 1.1958 `
(631)765-3140
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 Tvne
1. EaSlet� lahi,�,e� 8A \-7
Name of Applicant Address of Applicant
L
Name of Owner of Premises Address of Owner
Work'Description and Likation(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
/b 1 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: `I I hg,/! i Completion Date: L3
OL,3 `
8. Work Schedule: Phase _Completion Date
Excavation
Facility Installation
Backfill&Completion
Pavement Replacement
9. Under which authority is application being made:
10. Estimated Cost of Proposed Work: $
11. Remarks:
D-39 1 of 3
12. insurance Coverage:(Attach Copy) ,� t
(a) Insurance Company: tuts�fGM
(b) Policy#:
(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. I /Service Connections excavations @$20,00 $ cal)
No.
A2. /Additional Excavations same service @$10.00 $
No.
B. Excavations 18"in depth or less P�
0-100 i.f.=$10.00;Additional .SOO it @$0.10 $
C. Excavations 18"in depth to 5' in depth
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 i.f. @$0.50 $
E. Utility Repair Excavations @$10.00 $
No.
Repairs same service @$5.00 $
Additional /
TOTAL$ .d.o�U Glc=
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.
SUPE ANT OF HIGHWAYS
TO OF OUTHOL NEW YORK
r W.Harris
C (LIn 11 IS. DZ
Date Received by the Town Clerk P)- 5 ' 3
ate
Date Permit Issued &- I(o• 13 Permit No. 8(o
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
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
113 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 Inproper Backfill(too high,not sufficient)
HFS Inspector Holding for Final Settlement of Excavatrion
RFR Ready for Repair
3 of 3
D-39
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