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
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