HomeMy WebLinkAbout980 The Strand Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 01/29/13 Receipt#: 146092
Transaction(s): Reference Subtotal
1 1 Excavation Permits 813 $221.00
Check#: 1275 Total Paid: $221.00
Name: Long, Island Power Authority
117 Doctors Path
Riverhead, NY 11901
Clerk ID: LINDAC Internal ID: 813
Permit No.
TOWN OF SOUTHOLDg�}EF�i���
HIGHWAY DEPARTMENT RECElVd a
P.O. Box 178
Peconic, New York 11958 "d; 46
(631)765-3140 JAN 2 E
Southold Tow— `
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 Permi
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 Tyne
1. L 01Ve SsZ-A7V > Poj&,5 Yz &7 1 fool T K I l 7 .ta e iz)e� k'a�tM N r/ I
Name of Applicant Address of Applicant
2. Z-6 1 r/+�-, ,4�&A, 57A/117-/w'Os qua >;�C 6-AS/VH«1J Ash
Name of Owner of Premises Address of Owner
3. / 'Ib t: P11QC0 10,Vh- 1 i LLI/llC- U� U/�,'t�� �c�,1ti'� Ch-1-2�G
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.
Si 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 U Block y Lot 791
7. Starting Date: Completion Date:
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: S c
1 1. Remarks: l r 5 rj TEAcl rZ� Slf�!ti` /✓� �i�U/0 t v,0
v c3 S L' L �•� - - 5
D-39 1 of 3
12. Insurance Coverage: (Attach Copy)
(a) Insurance Company:
(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 $ 20, GG
No.
A2. /Additional Excavations same service @$10.00 $
No.
B. Excavations 18" in depth or less
0-100 i.f. _$10.00;Additional i.f @$0.10 $
C. Excavations 18" in depth to 5' in depth
0-100 i.f. _$30.00; Additional '7()_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
TOV SOUTHOLD,NEW YORK
4L',
Peter W. Harris
Date
Date Received by the Town Clerk
Date Permit Issued / -of 9,- Permit No. 0
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->9 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
ISt
2nd
3 rd
Ott,
(To Permit Clerk)
REMARKS
CODE
IB Improper Barricades
----
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
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ASSOCIATED ORDERS: S.O.#T101332411
PERMIT REQ'D: TOWN OF SOUTHOLD ry
TYPE W.O.: NEW BUS o °
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GRID# 106—E-61 .................
CKT# 8J-685 Sss
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TAX DIST: 1300 Usk
JOB DATA:
NAME: ZOITAS KONSTANTINOS i
ADDRESS: 980 THE STRAND J
TOWN: E MARION
ZIP: 11939
J"hry
PREPARED BY: S—MARANGONI
631-548-7045 0
DATE: 12-12-12 Jy6y. ♦i
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ASSOCIATED ORDERS: S.O.#T101332411
PERMIT REQ'D: TOWN OF SOUTHOLD
TYPE W.O.: NEW BUS Jam"i
GRID# 106-E-61 �♦
CKT#8J-685
LS65
TAX DIST: 1300 Usunk,
JOB DATA:
NAME: ZOITAS KONSTANTINOS
ADDRESS: 980 THE STRAND
TOWN: E MARION
ZIP: 11939
L J Jho
PREPARED BY: S-MARANGONI
631-548-7045
DATE: 12-12-12
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