HomeMy WebLinkAbout1050 King St Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 06/01/11 Receipt#: 104770
Transaction(s): Reference Subtotal
1 1 Permits 712 $200.00
Check#: 7166 Total Paid: $200.00
Name: Eastern, Utilities Contracting Corp
17 Maple Ave
East Moriches, NY 11940-1342
Clerk ID: LINDAC Internal ID:712
Penn;t No.
TOWN OF SOUTHOLD RECEIVED
IHIGHWAY DEPARTMENT
P.O. Box 178 J
Peconic, New York 11958 U� 2011 '
(631)765-3140
S®ohniu Towa Clerk
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 make necessary inspections of the job site.
Print or Type
NAQ PG- ku-p— E.Mone- Ivy 11V
Name of Applicant Address oT Applicant
2.
I�
Name of Owner of Premises Address of Owner
3. Y�Jr� �VOL— 1'�1 r)(,,, 1 T n (1 t'k l tn�` `�ol�5 pro W,(rS
Work Description and Loc n(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.
Signature of Applicant
3, rl
Date
5. (a) Attached plot plan showing location of proposed excavation and relationship to adjoining premises or public street or areas,and
giving a detailed description 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 No.: Section ------, Block--- Lot
7. Starting Date: _ Completion Date: (✓ I 1
8. Work Schedule: Phase Completion Date
Excavation
Facility Installation
Backfill&Completion
Pavement Replacement
9. Under which authority is application being made:
10. Estimated Cost of Proposed Work: $
11. Remarks:
D-39 1 of 3
121. Insurance Coverage: (Attach Copy)
(a) Insurance Company:
(b) Policy#:
(c) State whether policy of certification on file with the Highway Department:
(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.
14. Fees for Applications and permits:
Basic Application Fee $150.00
�
Al. /Service Connections excavations @ G
$20.00 $ s�o 1J
No.
A2. _/Additional Excavations same service(cry,$10.00 $
No.
B. Excavations 18" in depth or less
0-100 i.f. —$10.00;Additional i.f (a�$0.10 $
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; Additional i.f. @$0.50 $
E. _Utility Repair Excavations n$10.00 $
No.
Repairs same service(a?$5.00 $
Additional
TOTAL$ R Vy
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.
SUPV�ZIN ENDENT O HIGHWAYS
TOWNO SOUTH L ,NEW YORK
Peter W.Harris
611
)Ste
Date Received by the Town Clerk
Date Permit Issued !t li Permit No.
NOTE: Permit expires one(1)year from date of issuance.
No work to start without 48 hour notice to Superintendent of Highways.
Permit must be available for inspection.
D-39 2 of 3
Cally Distribution:
Highway Department
Engineer(with page 3)
Applicant
Town Clerk (Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
l
2110
3`1
01
(To Permit Clerk)
REMARKS
PA
1
U
CODE
113 Improper Barricades
1 L Improper Lights +�
S"f Sunken Trench or Excavation
11TM Unable to Measure(due to backfilling)
Iil V Building Under Construction
Will Work In Progress
D13 Improper Backfill(too high, not sufficient)
I IFS Inspector Holding for Final Settlement of Excavation
RFR Ready for Repair
D-39 3 of 3