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HomeMy WebLinkAbout46975 Route 25 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 04/09/13 Receipt#: 148501 Transaction(s): Reference Subtotal 1 1 Excavation Permits 830 $180.00 Check#: 10679 Total Paid: $180.00 Name: J & M, Long Island Inc P O Box 2507 Southampotn, NY 11969 Clerk ID: LINDAC Internal ID: 830 T � Pcimit No. ^ RECEIVED TOWN OF SOUTHOLD gFO� HIGHWAY DEPARTMENT APR 9 2013 P.O. Box 178 Peconic, New York 11958 Southold Town Clerk (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 Type ? ( / 1 c, 1. Jr)4 LOhi rtlgny( Zk� /n0 13o+C ,' 507 u,-44r,A-/7 .A Name of Applicant Address of Applicant 2. �vrrey 1r, 4t C 4/6 �/7S ,y y5 /Z�e 19,S SOA./d "tly Name of 0&mer [[of Premises/ 1 Address /a of/Owner 3. .tAs4Sl1 rle�Ti« t VII Er 7AY' /`/ r-0*d d A/t,/y ,,.J L4. so,* oC' L/AIZ Work Description and Location( treet 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. J /0 Electrician's License No. Other Trade's License No. /79-1-&-1 0C i0/-(3/- A�'7- x/77 nature 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 S_ ,Lot /S. / /g.� 7. Starting Date: yb 3 Completion Date: 8. Work Schedule: Phase / Completion Date Excavation yJ / ? Facility Installation Backfill&Completion i Pavement Replacement n 9. Under which authority is application being made: /_ IIY2 10. Estimated Cost of Proposed Work: $ A 3 50- DU / 11. Remarks: S/ cS ror ¢%�f��� S �•Y+��P �o t �o� unrT¢r 4ve� r •rGl qT VA_ hur►�� Cr v' .ro�4A //2 R �� ? D-39 1 of 3 12. Insurance Coverage: (Attach Copy) _ (a) .insurance Company: (b) Policy#: Q 4/1?1S 9"r 006 -- (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. / /Service Connections excavations @$20.00 $ ,Z O• of No. A2. / /Additional Excavations same service @$10.00 $ / D• UG No. B. Excavations 18" in depth or less 0-100 i.f. =$10.00;Additional a @$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$ 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. SUPERINTENDENT OF HIGHWAYS TO SOUTHOLD,NEW YORK 1 0-) -4L b)�Vl I — j ete W.Harris Z ate Date Received by the Town Clerk `� g - �✓ p Date Permit Issued eV— 7j Permit No. D _ NOTE: Permit expires one(1)year from date of issuance. No work to start without 48 hour notice to Superintendent of Highways. Permit must be available for inspection. D-39 2 of 3 Copy Distribution: a ` Highway Department Engineer(with page 3) Applicant Town Clerk (Original) INSPECTOR'S RECORDS Inspection Date Findings (use code) Applicant Notified is` 2nd 3 rd 4 t (To Permit Clerk) REMARKS CODE IB 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 Improper Backfill(too high,not sufficient) HFS Inspector Holding for Final Settlement of Excavation RFR Ready for Repair D-39 3 of 3 JAM Long Island, Inc. P O Box 2507 Southampton, NY 11969 (631) 287-0580 283-5898 �UI 1214A IDr Olt) 1 LIRA /3 Q Ja c(c�AS . reg elPi'ms v P%ts A 04/02/2013 00:32 #5245_ P.001 4/2/2013 12:50 PM FROM: Quinton insurance Microsoft TO: 1-7ZT-7S 5-7851 PAGE: 002 OF 002 ✓'� - D*Te(Mfd00NYYY) AC c�,r CERTIFICATE OF LIABILITY INSURANCE O4WI:J TI9 EZT1F(CATE IS 1�$11ED:AS A IVIATTEfi OR(IgI tijaA,4TION O1�ILY AND CONFERS NO RIGHTS UPON Ti1E Cf RTIKICATE FtT3Lf3ER T>tilS ICERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED By THE POLICIES SELpW. THIS GERTIF(CATE©FINBURANdE DOES NOT CQNSTITUTE A CONTRACT BETWEEN THE 1"VING ff4SUR.ER(S),AUTHORJZED REPR>`SENTATWE OR PRODUCER,AND THE:CERTIFICATE HOLDER. - IMPORTANT: If the cettmcate holder is an ADDITIONAL iNSUx>D;the pWley(iea)Must be endorsed-.Ir SUBROGATION IS WAIVED,subject to ttie terms and conditions of the polity,certain P011cle's may requireE%mendorsemenL A sEaferrseM on this aertihtate dbes not confer.rights to the certifrcatc•holder in lieu of such endgrvwoent(� CONT PRODUCER. Me Quinton insurance.Protection Team � Wq� �$ ) 1 -- ennsi�e� customeruervice�uiotonMaurance:com 6605 pittsfocd Pplmyra Rd.,Ste W 1 rywc to--- Fatport.NY 14450 --- __�INsuR (-saFFb�o1NG cov_eRat3 _ --- Fax (55855. 35831 : )NA(ME A:_Eric Insurance C,7. Phone 58 53889530 INSURED I INS _ J&M Long Island Inc. 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