HomeMy WebLinkAboutGrandview Dr (2) Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 05/12/11 Receipt#: 102601
Transaction(s): Reference Subtotal
1 1 Permits 701 $180.00
Check#: 3227 Total Paid: $180.00
Name: R & R, Construction
282 Line Rd
Manorville, NY 11949
Clerk ID: LINDAC Internal ID:701
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Permit No. �,
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TOWN OF SOUTHOLD
J ��T� -
HIGHWAY DEPARTMENT .
Peconic-Lane
Peconic: New York 1-1958
(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 nuke necessary inspections of the job site.
Print or Type
NameV I
o Applicant Address
2)
Name of`_caner o Premises / ddre7�s/s 1
3) > r is in l L rfl L/ 01 GryJ rc'J �Vt 54- Z 11.r,� Lf,
L% L Work Descrip nand Location (Street Number, Ham et,
Cross Street)
6-31-70 -,o& 4 (a) Is construction located within 75 feet of tidal wetlands? *Yes Nc
*If yes, other Town permits- may be required.
4) Builder's .License No. Plumber's License No.
6 jl /,7 7- A-l(,, Electrician's .License No. Other Trade's License No.
774- 1375' Signature of Applicant
� Date
5) a) Attach plot plan showing location Of.proOosed.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:A ,% Completion Date_AAk�1
8) Work Schedule:
Phase Completion Date
Excavation...............
..........................
Facility Installation.........
........................
Backfill E Compaction..............................
Pavement Replacement.............................
9) Under which authority is the application made:��j�
v 1S►o�
10) Estimated Cost of Proposed Work:
11) Remarks; p �
6n
D-39
Page Iof3
1
12) Insurance Coverage: (Attach copy) 1 + �
a) Insurance Company: Pr". --Ax - �yt K
b) Policy # H1�{��►(0 4$
c) State whether policy of cartinplion on file with the Highway Depart-
ment• dA b
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........0*9-9a-
A 1. /Service Connections excavations @ $20.00 = $
No.
A2. /Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 1.f. _ $10.00
.100' I.f. @ $0.10 - $ C) � ` ' 00
ditlona
C. Excavations 18" in depth to 5' in depth:
0-100 Lf. _ $30.00
_Lf. @ $0.30 = $
Additional
D. Excavations 5' in depth and over:
r� 0-100 Lf. _ $50.00
t���pZOa Lf. @ $0.50 = $
Additional
E. Utility Repair Excavations 0$10.00. _ $
No.
Repairs same service @ $5.00 = $
Additional
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
T SOUTHOLD, IEW YORK
eter W. arris
Date
Received by the Town Clerk
D to
Permit Issued
---__ '/ Permit No.
L,
at
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
INSPECTOR ' S 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 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
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