HomeMy WebLinkAbout2675 Peconic Ln (2) Town of Southold
z P.O Box 1179
' Southold, NY 11971
* * * RECEIPT * * *
Date: 02/22/12 Receipt#: 126426
Transaction(s): Reference Subtotal
1 1 Excavation Permits 753 $180.00
Check#: 1959 Total Paid: $180.00
Name: American, Underground Utilities/Cablevision
P O Box 900
Eastport, NY 11941
Clerk ID: LINDAC Internal ID: 753
LAI
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Permit No- . ,
` TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT .
Peconic Lane G
Peconlc. tiew York 1-19S8 ;
_ .(631)
ApPLICATION/PERMIT FOR HIGHWAY,EXCAVATION AND REPAIR
21011
of
IS HEREBY made to.the Superintendent of Highways of the Town
of Southold for the is3uance of an Excavat)oh 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 e0travation herein described. The applicant agrees
T,.,,.. to comply with all applicable laws. ordinances, crudes and reg%Aatiohs, and to permit
authorized Inspectors to make,nec6iigary inspections of the job site.
Print or Type
1) M
Name o�Applicant Address
z)��1A�Lo V/s/QA/
ner o wises Aaaress
3) 7g PaCOAI,c�L ,gvt 1 tC�N`C� -Son �f✓�rJL� 1�✓�
War* Description a Location treat bar, Hamlet, Cross Street)
(a) Is construction located within75 feet of tidal wetlands
*If yes, other Town permits roay be reguir6d.
q) Builder's .License No. Plumber's License No.
Electrician's License No. Other Traders License No.
_
71
Signature o p icant
17 2 O/ 2-
Date
5)- a) Attach plot plan showing location of.prolbodad.excavation and relatioikship't�o
adjoining premises•or public"streets or areas, and giving a detalW descrils:-
tion of layout of excavation.
b) Attach all other necessary permits and ticenses for this"project.
c) Vork•.covered by this application way not commence before issuance of a
Highway Excavation Permit ley the Town Clerk.
. 6) Tax Map: Section Block Lot
7) Starting Date: Date
8) Work Schedule:
Phase Completlori- Date
Excavation.........................................
Facility installation.................................
Backfills Compaction.........I....................
PavementReplacement.............................. f
9) Under which authority is the application made:I�b2�f�/�
ou
io) Estimated Cost of Proposed Work: $ r7 S-0
11) Remarks: '<'/ EJLL� E dJ / /LU4<3 901t-el / pp�.2it/Cc'
A�;L S ✓L�/r c.E %p T��%�G t� LSC- b
D-39 Page 1 of 3
- t
12) Insurance Coverage: (Attach copy)
a) Insurance Company:TL e-i+A/ L OCA Y =ids C
b) Policy
c) State whether policy of certification on file with the Highway Depart
went.
d) Coverage required extended to the Town:
Bodily Injury and property damage: $300.000/$500,000 Bodily Injury,
and $50,009 property damage.
13) §qVrItY
a) .Surety Bond __ or Certified Check provided ln'the
total amount of $
b) Maintenance t3bnd provided: v 2 years or 3 yrs .
14) Fees for applications and permits: Basic Application Fee........$150,00
Al. /Service Connections excavations 4 $20.00
No. -
A2. /Additional Excavations same service 0 $10.00 = $ —
i�o.
B. Excavatio6s le in depth•or less:
0-100 1.f. = $10.00 -
t.f. a $0.10 - $ •
-1tional
C. Excavations 1r in depth to 5' in depth:
o-100 1.f. = $30:00
Additions
D. Excavations 5' in depth and over:
0-100 1_f. = $5Q.00
Lf. a $0.30 =
Additiottia
E. Utility Repair Excavatio6s ti�-f' 0.09= $
No.
Repairs saltie service 0 $5.00 = $
Additional
F. Notice to public-utilities proof must be provided and attached to
tbis'application prior to issuance of pemit.
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.
SUA NDENT OF HIGI+WAYS
TO OF UTHOLD, N YORK
ter W. Harris
Date
Received by the Town Clerk
Date
Permit 'lesued chi � � Pertait'No.
Datd
Note: permit expires one (1) year from Date of lssuonco.
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
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
I N S P E C T 0 R*'•S R E C O R D
Inspection Date Findings (use code) Applicant Notified
tst
2nd
3rd
4th
" --- - To Permit-'Clerk)
REMARKS
CODE
IB - improper barric2des
1L --improper fights
ST - Sunken trench or excavation
UTM -- Unable to measure (due to bacidillinb)
BUC - Elulldiny under Constructioh
WIP - Work in-progress
DB --Improper bacMi'(too high) (not suffldent)
HFS Inspector holding for final settlement of excavation
RFR - Ready to repair ,
D-39 page 3 of 3
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