HomeMy WebLinkAbout435 Stony Shore Dr Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 05/31/12 Receipt#: 134252
Transaction(s): Reference Subtotal
1 1 Excavation Permits 772 $150.00
Check#: 2008 Total Paid: $150.00
Name: American, Underground Utilities/Cablevision
P O Box 900
Eastport, NY 11941
Clerk ID: LINDAC Internal ID: 772
Permit No- y`
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT • va
Peconic Lane p
Peconic: New York 1.1958 1
RECEIVED _ .(631) 765-3140
MAY ( 20� APPLICATION/PERMIT FOR HIGHWAY,EXCAVATION ANP REPAtR
Southold Town Clerk APPLICATION IS HEREBY made to.the Superintendent of
iighway g3 of theof the n
of Southold for the istuance of an ExcavatiOh Permit p
ursuant Code of the Town of Southold, Suffolk County• New York, and other applicable laws,
ordinances or regulations for the c4cavatiOh herein described. The applicant agrees
to comply with all applicable laws, ordln4nces, codes and regulations, and to pew
authorized Inspectors to make;necessary inspections of the job site•
Print or Type � )t/
,y
1) �picant
Address1`(41
�/
2)�'ama o g0wner o remises cess S
3) Q 3 �" lT /�✓ ,�t�u✓L p121 �= �-t�c � _leas-- .�
Hamlet, Gross Street) W 9y
Description ✓"LL✓' ii��etf �a—i
2US V/S✓d
c� (a) s construction located within 75 feet of tidal wethandsZ *Yes
*If yes, other` Town permits may be required.
4) Builder's ,License No.
plumber's License No.
Electrician's License No. Other Trades License No.
631- 711
Signature o p Icant
2 M,qy 2v! Z
Data.
5)" a) Attach plot plan showing location of:pr000ded.excavation and relationship*to
adjoining premises-or pubtic'streets or areas, and giving a detailed descrip=-
tion of layout of excavation.
b) Attach all other necessary permit6 and ticinses for this project.
c) • Wbrk .covered by this applicatiois tray not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
. 6) Tax Map: Section , Block __- , IAt
7) Starting Date: Completioh Date
8) Work Schedule: I �� ( au o Completloti Date
Phase
Excavation.........................................
Facility Installation.................................
Backfill'S Compaction.............................
Pavement Replacement..............................
9) Under which authority is the appllcitlon made:
10) Estimated Cost of Proposed Work: S 400 0 /
Remarks: lZo �vss 1 d L 4
11l /"r✓JJ��- t !��'
✓�� )91 1 U� 1515 Tiyc> b&rj 4-/ rl �S --
D-39 Page 1 of 3
V-
12) insurance Coverage: (Attach copy) D1J r l L(E
a) Insurance Company:
b) Polis* it
c) State whether policy of certifl.catioh on file with the Highway DWzrt-
ment:
d) Coverage required extended to the Town:
Bodily Injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000-property damage.
13) Securit :
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 pees Basic Application Fee....... 750.00
Al. /Service Connections excavations 0 $20.00 = $
No.
A2. /Additional l;xcavations same service 0 $10.00
No.
B. Excavatiotls epth-or less:
0-100
AddiUorW
C. Excavations lam in depth to 5' in depth:
0-100 1.f. = $30.'00
Addrtii;n_aI_-
D. Excavations 5' in depth and over:
0-100 Lf. _ $549.00
I.f. ® $0.30 = $
Addrtiotia
E. Utility Repair Fxcavatiohs Q"0-80L-- $
No.
Repairs same service @ $5.490 = $
Additional
F. Notice to public-utilities proof must be provided and attached to
"s'applicatio4 prior to issuance of perlsit.
Authorizatfoh Is hereby granted to the Town Clerk of the Town of Southold to
Issue a Highway Excavation Permit -to:
In-accordance with this'applicatioti.
MNTENDENTO HIGHWAYS
SO,�UTHO NEW YORK
&te W H rris
D e
Received by the Town Clerk
Date
Permit -Issued -5-^ Permit'No. ✓�`�
Date
Note: Permit expires one (1) year from Date of 133unncc.
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
Cody DistrEbution_:
Highway Department
Inspector
Applicant
Town Clerk
I N S P E C T 0 R '•5 RECORD
Inspection Date Findings (use code) Applicant Notified
1st
2nd
3rd
4th
• To Permit•Clerk)
REMARKS
CODE
iB - Improper barricades
IL --improper lights
ST - Sunken trench or excavation
UTM -- Unable to rbeasure (due to backfilling)
RUC - Eluildiny under Construction
WIP - Work in'progress
DD --improper backfill'ttoo high) (not sufficient)
HFS Inspector holding for final setthmunt of excavation
RFR - Ready to repair ,
p_39 Page 3 of 3
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