HomeMy WebLinkAbout1855 Cox Ln Town of Southold
P.0 Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 05/09/12 Receipt#: 131804
Transaction(s): Reference Subtotal
1 1 Excavation Permits 768 $150.00
Check#: 1994 Total Paid: $150.00
Name: American, Underground Utilities/Cablevision
P 0 Box 900
Eastport, NY 11941
Internal ID: 768
Clerk ID: LINDAC
Permit No_
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT .
Peconic Lane
Peconic:
New York 1.1958
_ .(fi31) 765-'3140 U
APPL[CAT.ION/PERMIT FOR HIGHWAY-FIX .CAVATION AND REP�tI�'
g 2012
Southold Town Clerk
APPLICATION IS HEREBY• made to.the Superintendent of Highways of the Town
Excavation permit pursuant to Chapter 83 of the
of Southold for the is3uance of an
Code of the Town of Southold, suffdk County, New York, and other appl�ca'We I ,
ordiinances or rdgulations for the excavation herein described2pPll to permit
to comply with all applicable laws, ordinances, codes and reg�atior
authorized Inspectors to ukke,`.necessary inspections of the job sits.
Print or Type
1)A �� �d-.2 rte. L� ( Address
Name or Appal"In _
Names o Owner o remises a cess ��5�- �U�L✓9x�c�
_ /,aa e'Z-.73) 2 7�t)•z
Ao Description a Location Street ber, Hamlet, Cross Street)
(a) is construction located withiil•75 feet of tidal wetlandsZ *Yes No__
*If yes, other Town permitf spay be required.
4) Builder's Llcense No. Plumber's License No.
Electrician's License No. _ Other Trades License No.
Signature o p Icant
Date.
5) a) Attach plot plan showing location of.pr000sgd.excavation and relatioiiship•to
ad)olning promises-or public'streets or areas, acid giving a detailed descrivs_
tion of layoui of excavation.
b) Attach all other necessary permits and licenses for this project.
c) - Wbrk•.covered by this applicdtiarr may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
. 6) Tax Map: Section
7) Starting pate: CoMpletion Date
a) Work Schedule: V \/Z Completloh Date
Phase
Excavation................I........................
Facility Installatioti.................................
Backfill*& Compactioin.........I...............••••
PavementRepiacaeiment..............................
9) Under which authority is the applicitlon made:
10) Estimated Cost of Proposed Work: $
11) Remarks- N p �UUr K i f�_ A —
Lei 1 L i U U
q, -
D-39 Page 1 of 3
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12) Insurance Coverage: (Attach copy)
a) insurance Company:
• - b) Policy � -
c) State whether Polley of certification on file with the Highway DePB�
mento
d) Coverage required extended to the Town:
Bodily Injury and property damage= $300.000/$500,000 Bodily injury,
and $50,0011- property damage.
13) Securi
a) .Surety Bond _-- or Certified Check provided In'the
total amount of $ _
b) Maintenance Bond provided: v 2 years or - --3 yaqr •
14) Fees for applications and peautits: Basic Application Fee .......$150-00
Al. /Service Connections excavations 0 $20.00
- No.
A2. /Additibnai Excavations same service 0 $10-00 = $ --
P
B. Excavations le in depth-or less:
0--100 1.f. = $10.00
I.f. a $0..10 - $�
AddWo—nal _
C. Excavations 18" in depth to 51 in depth:
0-100 Lf. ^ $30.OQ
1.f. @ $0.30 = $
D. Excavations 5' in depth a-nd over:
0-100 I.f. _ $50.Do
I.f. 18 $0.30 =
Additiona
E. Utility Repair Excavations 6"0.09= $
No-
Repains saltie service ® $5.00 = $
Additional
F. Notice to public-utilities proof must be provided and attached to
this'applicatian prior to issuance of permit:
Authorfzatfof1 Is hereby granted to the Town Clerk of the Town of Sduthold to
Issue a Highway Excavation Permit-to:
In-accordance with this•application.
SUPERINTENDENT OF HICItWAYS
TO SOUTHO NEW YORK
Oil M. Harris J
C�
Da e
Received by the Town Clerk(
DatZ
e
Permit IssuedA—/!aRe L Permit-No.
D
Note: Permit expires one (1) year from Date of Issuanco.
No work to start without 48 hour notice to the Superintendent of Highways-
Permit must be available for inspection.
page 2 of 3
D-39
--_-
Cop Distribution•
Highway Department
Inspector
Applicant
Town Clerk
iNSpECT0R .S RECORD
Inspection Date Findings (use code) Applicant Notified
1st
2nd
3rd
4th
- - - 75Pernut'Clerk) -
REMARKS
CODE
IB - Improper barricades
IL --Improper lights
ST - Sunken trench or ovation
UTM - Unable to measure (due to backfilling)
SUC - Uullding under Constructiai
WIP - Work in-progress
DB --Improper backfill'(too high) (not suffidsht)
HFS Inspector holding for flnal settlement of excavation
RFR - Ready to repair
D-39 Page 3 of 3
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