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* * * RECEIPT * * *
Date: 07/16/13 Receipt#: 155906
Quantity Transactions Reference Subtotal
1 Excavation Permits 857 $300.00
Total Paid: $300.00
Notes:
Payment Type Amount Paid By
CK# $300.00 R & R, Construction
Name: R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID: 857
c, F
' Permit No. RECEIVED [y,
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENTy 1 5 2013
Peconic Lane
Pecon(6 New York 11958 r�T
(631) 765-3140
�ct� '-Id 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 Type`
1)
Name of Applicant Address
2)
NJa�me of\Owner o Premises ` Address
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.
Sign tur of Applicant
'7 f _
Date
5) a) Attach plot plan showing location of proposed excavation and relationship to
adjoining premises or public streets or areas, and giving a detailed descrip-
tion 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: Section Block , Lot
7) Starting Date: Completion Date
8) Work Schedule:
Phase Completion Date
Excavation........................................
Facility Installation................................
Backfill E Compaction.............................
PavementReplacement.............................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks
_i7w L -7i,-
D-39 Page 1 of 3
12) Insurance Coverage: (Attach copy) _ +�
a) Insurance Company:
b) Policy f
c) State whether policy of certification on file with the Highway Depart-
ment:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage. 0Prgt:
13) Securit
or Certified Check provided in the
a) Surety Bond__
total amount of $
3
2 ears or years
b) Maintenance Bond provided: Y VCU
14) Fees for applications and permits: Basic Application Fee.........$2—"
Al. /Service Connections excavations @ $20.00 = $No.
A2. /Additional Excavations same service @ $10.00
B. Excavations 18" in depth or less:
0-100 I.f. _ $10.00
I.f. @ $0.10
Addit___- ionai
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. _ $30.00
I.f. @ $0.30 = $
dditiona
D. Excavations 5' in depth and over:
0-100 I.f. _ $50.00
I.f. @ $0.50 = $
dditiona
E. Utility Repair Excavations 010.00 = $
Repairs same service @ $5.00
AdffitionaT
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:
1 in accordance with this application.
SUP RINTENDENT OF HIGHWAYS
_ T W OF SOUTH D, NEW YORK
Peter W. Harris
-- r Date
Received by the Town Clerk Date _
Permit Issued 7-14, 6 Permit No.O� 7
Date
Note: Permit expires one (1) year from Date of Issuance•
No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
D-39
12) Insurance Coverage: (Attach copy)
a) Insurance Company: y{-/ �I�=y ✓4Z4.
b) Policy r
c) State whether policy of certification on file with the Highway Depart-
ment
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
big.
14) Fees for applications and permits: Basic Application Fee.........$-25.-W
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
l.f. @ $0.10 - $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. _ $30.00
I.f. @ $0.30 = $
Additional
D. Excavations 5' in depth and over:
0-100 I.f. _ $50.00
I.f. @ $0.50 = $
Additional
E. Utility Repair Excavations 090.00 = $
No_
Repairs same service @ $5.00 = $
Additional
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:
�j ate,j in accordance with this application.
SUP RINTENDENT OF HIGHWAYS
T WI�OF SOUTH D, NEW YORK
OG
Peter W. Harris
!a- �V-- t3
Date
Received by the Town Clerk ✓y 5 l3
Date
Permit Issued `� Permit No.0�
Date
Note: Permit expires one (t) year from Date of issuance.
No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
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