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HomeMy WebLinkAboutElijahs Ln & Oregon Rd ' Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 01/26/12 Receipt#: 124610 Transaction(s): Reference Subtotal 1 1 Excavation Permits 745 $666.00 Check#: 1944 Total Paid: $666.00 Name: American, Underground Utilities/Cablevision P O Box 900 Eastport, NY 11941 Clerk ID: LINDAC Internal ID: 745 s Permit No_ ,- TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peconlc Lane kq�rv - APPLIcAT.ION/PERMtT Peconic. Mew York 1.1958.(631) 765-1.140 FOR HIGHWAY,F_m A"A'i:ION AND REPAIR APPLICATION IS HEREBY made to.the Superintendent of Highways of the Town of Southold for the issuance of an Excavation Petlmit 'pursuant to Chapter 83 of the Code of the Town of Southold, Suffolk County, New York, and other applieable laws, ordinances or rdgulatlons for the excavation herein described. The appllcfint agrees to camply with all applicable laws, ordinances, code's and regulatiofts, and to permit authorized Inspectors to ah"necessary inipections of the job site. Print or Type f� / ' �/ fl 1) 1 11�'��2/G/4 f�-� (lit/l�Zt/2 C� UNC Un Gf- 1� po `oC1 e of Applicant Q Address Name of Owner ot Premises maress ' 3 �A�� ���-�-C,�� c�S�ae- ��s�� S �� O✓z���.,�- Dov ork Description and Location Street ber, }tams t, Cross Street) (a) Is construction located withih-75 feet of tidal watlandsT *Yes No *If yes, other Town permits' may be required. 1 4) 13uilderls Llcense No. Plumber's Llo6nse No. �J Electrician's License No. Other Trade's License No. Signature of Ntpl[cant 631'7+0 61 t7 7kN 2012- - Date 5)' a) Attach plot pian showing location of:Prgbai ed.excavation and relationship'to adjoining premises•or public-streets or areas, and giving a detalled descrip-= t1cmi of layout of excavation. b) Attach all other necessary permits and licenses for this'project_ c) Wbrc-%covered by this applicdtiofr may not commence before is6uance of a Highway Excavation Permit by the Town Clerk. • 6) Tax Map: Section Block Lot ^y I_ b 7) Starting Date: AW Completion Date V 8) Work Schedule: BY 2 6 37+tA__ Phase CoMpletloh Date Excavation......................................... 0 t� Facility Instaliatiori................................. l / Backfill'6 Compaction.............................. �l v Pavement Replacement.............................. 9) Under which authority is the application made- 10) ade:to) Estimated Cost of Proposed Wo/r�k. $ 104 Q�•qL�- h `� ` ' ' 11) Remarks: A/e&c� �,4&t SSU/ -6 /M S(1`''�-� F-rr-Lll 7.D f L ' ? 52011 D-39 Page 1 of 3 12) Insurance Coverage: (Attach copy) a) Insurance Company: b) Polk' f on file with the Highway D"rt- c) State whether poftcy of cartiflcatioli rtlent: d) Coverage required extended to the Town: 30C0081$r,00,060 Bodily Injury. Bodily Injury and property damage: $ and $50,000•property 13) Securit provides In'the a) Surety Bond or Certified Check________ total amount of $ Z years or --.-3 Y rs . b) Malntenacfce Band provided: s o:V.. CntiOee • ...... 150.00 Feefplaotanpn 14) v, Al. /Service Connecfioris excavations 6 $20.00 - $ No. A2. /Additici'tal E .00 xcavations same service 6 $10 = $ 8. Excavatiotls 1a" in depth-or less: 0-=100 l.f. = $10.00- _ I.f. a �Addr ita—_ C. Excavations 18" in depth to 5' in depth: 0-104 f.f. _ $30.06 I.f. @ $0.30 r $ Additi�— D. Excavations 9 in depth and over: 0-100 I.f. = $56.100 A rtiotiaf E. Utility Repair Excavations 0"0.00 = $ No. Repairs Sa1pe service Add[Uonal F. Notice to Public'utillthes proof crust be provided and attached to this-appiksiU06 prior to issuance of pW"it. Authorizatloti Is hereby granted to the Town Clerk of the Town of Sduthold to Issue a Highway EXeavat" Permit-to: in-accordance with this•applicAt"- SUPERINTE ENT OF HIGHiY YRK TOWN OF HOLD, N ter w. Harris Received by the Town Clerk Permit 'Issued i--a - y ' Permit•No. / �� ate Note: Permit expires one (1) year from DaM Df I3Sr113 1 m. No work to start Without 48 hour noUas to the Superintendent of High.waYs- Permit-must be avaiishle for inipectloit. Page 2- of 3 D-39 Copy Distributloii: Highway Department Inspector Applicant Town Clerk I N S P E C T 0 R•'•$ R E C OR D Inspection Date Findings (use code) Applicant Notified ;-: tst 2nd 3rd 4th - (To Pe 'Clerk) - REMARKS CODE iB - Improper barricades IL --improper lights ST - Sunken trench or excavation UTM -- Unable to measure (due to bacldsllin§) SUC - I#uilding tender Construetio� WIP - Work its"progress DD —Improper backfig.(too high) (not sufficletit) HFS Inspector hoidln4 for finW settiemant of excavatlon RFR - Ready to repair D-39 lege 3 of 3 1 �1JsQ�gLv Gi�QTV �L���'�-L F-LOM Po1,9- t3S So,,'11-41�0 PM,Q Rb o ?U Q-� C 4.&L E CT V ,�,ff,_t c t- `7 0 0 S.sS 4 43q — z{-7 4s- 0 0 a lym e� PLP4-6- V quLT , ?-so' brzwc.r'w*t. /470' 7-Aar vGrr % U � o � V U-�?1 PAI 377135 ETS Julie Falzarano -- SURVEYOR G Oregon Rd. Jennifer Shipmant P-135 — AME r.00sg® 90' - a2oo 10 4745 Elijahs Lane 200 O Reference only M ADDRESS -I- 1 i i ? ADDITIONAL ADDRESSES i r !� r� Mattituck 10 TOWN DATE 12/30/11 ETS#157636 504 ®T 1® 105' 5 P- 6 2 U) TYPE 4895 115' r7 P-55 I ETS#240369 4745T �-( DROP LENGTH M 93 © P2�=