HomeMy WebLinkAbout940 Laurelwood Dr (2) * * * RECEIPT * * *
Date: 05/29/13 Receipt#: 151260
Quantity Transactions Reference Subtotal
1 Excavation Permits 848 $150.00
Total Paid: $150.00
Notes:
Payment Type Amount Paid By
CK#4157 $150.00 R & R, Construction
Name: R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID:848
Permit No.- gSFF�ct'
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic-Lane
PeconNew York 11958
(6
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
RECEIVED
2 Q 2013 APPLICATION IS HEREBY made to-the Superintendent of Highways of the Town
of Southold uthold 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,
ordiMnces or regulations for the excavation herein described. The applicant agrees
Southold Town Clerk to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to mfake�necessary inspections of the job site.
Print or Type
t) 1?4 i? anA �ilaapr�5•� 'Tick dFs? G re t latr.�110, ► Y t
J Name of Applicant Address
2)
ame of Owner of Premises Address
'Work Description and Location (Street Number, Hamlet, Cross Street
(a) Is construction located within 75 feet of tidal wetlands? *Yes No__X
*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.� �✓'j c 'r
gnature o Applicant
5/111 13
- V D-We-
5) a) Attach plot plan showing location of,proOosedexcavation 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 , Bbck , Lot
7) Starting Date: _( i Completion Date (e 3
8) Work Schedule:
Phase Completion Date
Excavation........................................
Facility Installation................................
Backfill S Compaction..............................
Pavement Replacement..............................
9) Under which authority is the application made:_AL�tgy,^
10) Estimated Cost of Proposed Work: $
11) Remarks: ���QCr� :,a�C.Q ('AW -
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12) Insurance Cover: (Attach copy)
a) Insurance Company: eryS �
b) Policy #
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
rovided in the
total amount of $
b) Maintenance Bond provided;
2 years or 3
14) Fees for applications andPenaitBasic •.• i Ste•
sic A
pplication Fee.....
Al. �,/Service Connections excavations @ $20.00 = $
A2. No. /Additional Excavations same service @ $10.00 = $
B. Excavations 18" in depthor less:
0-100 I.f. = $10.00
dditiona
1.f. @ $0.10 - $
---------
C. Excavations 18" In depth to 5' in depth:
0-100 I.f. = $30.00
ditiona I.f. @ $0.30 = $
D. Excavations 5' in depth and over:
0-100 1.f. = $50.00
_I.f. @ $0.50 = $
ditiona -------
E. --- o
Repair Excavations @$10.00. _ $
o.
itiona Repairs same service @ $5.00 = $
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.
SUPER IN NDENT OF HIGHWAYS
TOWN F UTHO D, NEW YORK
� ti �
eter W. Harris
L11te 6
Received by the Town Clerk 4-/3
Date
Permit Issued oZ'T- i3 y�
ate
Permit No.
-
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.
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