HomeMy WebLinkAbout635 Kimberly Ln (2)Permit No. l
TOWN OF SOUTHOLD -Afiek
HIGHWAY DEPARTMENT
Peconic Lane
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 237 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, the attached "General Conditions of Permit' and "Special Conditions", if any and to permit authorized inspectors to make
necessary inspections of the job site.
Print or Type
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Name of Applicant Phone Number
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Name of Contractor Phone Number
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of Applicant
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Address of Contractor
Name of Property Owner Requesting Service (if applicable) Address of Owner
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Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? * Yes No X
*If yes, other Town permits may be required.
NOTE: All information requested by this
Application / Permit Form is
Required for a complete application!
Signature o Applicant
:22_ %��
Date
5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the
location of all proposed excavations and relationship to adjoining premises, public streets or areas, and give a detailed description of
all site and pavement restoration work.
(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.
7. Starting Date:
8. Work Schedule:
District 1000 , Section -70 Block % �j Lot
11�-Oe%P— / Completion Date:
Phase
Excavation
Facility Installation
Backfill & Completion
Pavement Replacement
Completion Date
Work Schedule
Must be provided
for consideration as a
Complete Application.
9. Under which authority is application being made:
See Town Code Chapter 237 (E) - Provide Resolution by, or authority from, the Utility being modified.
10. Estimated Cost of Proposed Work: $ coo,
11. Remarks: "7'tJ S i 9c -C- .9 `� �L4OUX tt
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12. '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:
Any Loss including Bodily injury, property or commercial injury caused by or attributable to the work performed:
$1,000,000 per Occurrence and $ 2,000,000 general aggregate.
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 @ $20.00 $
No. —
A2• / Additional Excavations same service @ $1'0.00 $
No.
B. Excavations 18" in depth or less 00
0-100 L.F. =$10.00; Additional..' U L.F. @ $0.10 $ 13
C. Excavations 18" in depth to 5' in depth
0-100 L.F. = $30.00; Additional L.F.@ $0.30 $
D. Excavations 5' in depth and over
0-100 L.F. = $50.00; Additional L.F. @ $0.50 $
E. Utility Repair Excavations @ $10.00 $
No.
Repairs same service @ $5.00 $
Additional
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F. Notice to public utilities proof must be provided and J
TOTAL$ / L�
Shall be attached to this application prior to issuance of permit. m/9✓1-� c-- O fs e
* * * * * * * * * * * * * *
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 and subject to the "General Conditions" and "Special Conditions" of permit (if any) attached hereto.
Date Received Received by the Town Clerk ate
L/-- / – -
Date Permit Issued ���(�, %� Permit No./
NOTE: Permit expires one (1) year from date of issuance.
No work to start without 24 hour notice to Superintendent of Highways.
Permit must be available at all times for inspection, on site, during construction.
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Copy Distribution:
Highway Department
Engineer (with page 3)
Applicant
Town Clerk (Original)
Inspection Date
1st
2nd
3rd
4th
INSPECTOR'S RECORDS
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 for Repair
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Findings (use code)
REMARKS
Permit #
Applicant Notified
(To Permit Clerk)
3 of 3
11080
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