HomeMy WebLinkAbout1005 Cedar Ln Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 09/09/11 Receipt#: 114147
Transaction(s): Reference Subtotal
1 1 Permits 726 $150.00
Check#: 3388 Total Paid: $150.00
Name: R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID:726
T Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic. New York 11958
(631) 765-3140 O 1 41
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 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 excavation herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to mlake'necessary inspections of the job site.
Print or Type ``rUc>�1
1) Q 4 Z `�tSrin 671ct-Prtk:, JT yr
Name of Applicant Address
2)
Name of Owner of Premises
' 6.?-e -4
ddress X�
31� �I' OMV-- Mt ICX)5- 't6
c,6 r .?-e143
Work Description and Location (Street Number, Hamlet, Cross Street) ��+,
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*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.
C A--8 =Wsrou
A2 7��
Signat re f App lcant
ate
5) a) Attach plot plan showing location of. proposed excavation and relationship to
adjoining premises or public streets or areas, and giving a detailed descrip-
tion 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: Section , Block , Lot _
7) Starting Date:_ %3 Completion Date 3 1l
8) Work Schedule:
Phase Completion Date
Excavation........................................
RiCEi E1D Facility Installation................................
Backfill E Compaction.............................
Pavement Replacement.....................
_ 9 201 ....
`' 9) Under which authority is the application made:__ C�.6Lev ISio!n
10) Estimated Cost ofProposed Work: $y_ OO(-)
Sita ^:Id Tows r'0r 11) Remarks• MtSsiye (JA cf' (cAc- 4r0 A7U
D-39
Page 1 of 3
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Depart-
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) Security:
a) Surety Bond or Certified Check provided in the
total amount of $
b) Maintenance Bond provided: 2 years or 3 years
••• i SU.CAC)
14) Fees for applications and
permits: Basic Application Fee..... 25.00-
A i• /Service Connections excavations @ $20.00 = $
A2• No. /Additional Excavations same service @ $10.00 = $
B. Excavations 18" in depth or less:
0-100 I.f. _ $10.00 ��� Cfoa i'v
I.f. @ $0.10 - $ d
Additional �S
C. Excavations 18" in depth to 5' in depth:
0-100 I,f. _ $30.00
Additional
I.f. @ $0.30 = $
D. Excavations 5' in depth and over:
0-100 I.f. _ $50.00
Lf. @ $0.50 = $
Additiona
E. Utility Repair Excavations @$')0.00. _ $
No.
Additionai—
Repairs same service @ $5.00 = $
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
Tf,�SOUTHOLD, ,FEW YORK
Peter W. arris
ate
Received by the Town Clerk y fir'
Date
Permit Issued l Permit No.
Mite
Note: Permit expires one (1) year from Date of Issuance.
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 O R ' S R E C O R D
Inspection Date Findings (use code) Applicant Notified
1st
2nd
3rd
4th
(T) Permit Clerk)
REMARKS
CODE
IB - Improper barricades
iL - Improper lights
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 to repair
D-39 Page 3 of 3