HomeMy WebLinkAbout805 Kayleighs Ct Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 05/18/11 Receipt#: 103035
Transaction(s): Reference Subtotal
1 1 Permits 706 $200.00
Check#: 7145 Total Paid: $200.00
Name: Eastern, Utilities Contracting Corp
17 Maple Ave
East Moriches, NY 11940-1342
Clerk ID: LINDAC Internal ID:706
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TOWN OF SOUTHOLD r', 1Z IVB J Fki"��
HIGHWAY DEPARTMENT
P.O. Box 178 2011 +
Peconic, New York 11958
(631)765-3140 >,
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
1. �a Y\ t 'l�5 f Cac \ EaSi' 1 tur;rJ�Xs [V)/ 1�R�IU -
Name of Applicant t Addr ss of Applicant
Name of Owner of Premises Address of Owner
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3. dJee UIJr� f Coapt t r, ��',mk �
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Work Description and Location(Street Number, Hamlet, Cross Street No
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes,other Town permits may be required.
4. Builder's License No. ________ Plumber's License No.
Iilectrician's License No. Other Trade's License No.
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a�� - `��nSignature Applicant
&3i - -89y-toaGLA --1-1131 -
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: S a�z 11,
8. Work Schedule: Phase Completion Date
Excavation
Facility Installation
Backfill&Completion
Pavement Replacement
1
9. Under which authority is application being made:
10. L;stimated Cost of Proposed Work: $
11. Remarks:
D-39 1 of 3
I�. Insurance Coverage: (Attach Copy)
(a) Insurance Company:
(b) -- —
(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$50,000 property damage.
13. Security: provided in the total Amount of$
(a) Surety Bond or Certified Check_ ___P
(b) Maintenance Bond provided: 2 years or 3 years.
14. Dees for Applications and permits:
Basic Application Fee $150.00
Al. /Service Connections excavations @$20.00
No.
A2. /Additional Excavations same service @$10.00 $
No.
B. Excavations 18" in depth or less
0-100 i.f. _$10.00;Additional ___i.f. @$0.10 $_
C. Excavations 18" in depth to 5' in depth
0-100 i.f. _$30.00;Additional i.f. @$0.30 $ 30
D. Excavations 5' in depth and over
0-100 i.f. _$50.00;Additional_ _ i.f. @$0.50 $_
I?. Utility Repair Excavations @$10.00 $----
No. _No.
Repairs same service @$5.00 $
Additional
TOTAL$ b V u
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
TOWN OF SOUTHOLD,NEW YORK
eter W.Harris
Date
Date Received by the Town Clerk 5-/ //
Date Permit Issued % / r Permit No. --
NOTE: Permit expires one(1) year from date of issuance.
No work to start without 48 hour notice to Superintendent of Highways.
Pemrit must be available for inspection.
1-39
2 of 3
Copy Distribution:
Highway Department
Engineer (with page 3)
Applicant
Town Clerk(Original)
INSPECTOR'S RECORDS
Inspection Date Findings (use code) Applicant Notified
lSt
2nd
3rd
4th
(To Permit Clerk)
REMARKS
CODE
B Improper Barricades
L Improper Lights
;T Sunken Trench or Excavation
JTM Unable to Measure(due to backfilling)
WC Building Under Construction
VIP Work In Progress
)B Improper Backfill(too high, not sufficient)
IFS Inspector Holding for Final Settlement of Excavation
YR Ready for Repair
-39 3 of 3
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