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HomeMy WebLinkAbout1000 Pike St Perrriit No. / 0 ® l TOWN OF SOUTHOLD ` ot,tCk HIGHWAY DEPARTMENT /4.k.' Peconic Lane92 Peconic,New York 11958 kt, (631)765-3140 0.1, 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 1. 1/1/11 L. iAt //4 e- 631- 714-036c' Name of Applicant Phone Number Address of Applicant 2. 74/4 6/210/1J) e41940 a26 101/W aril-1 71 es /°0 X19 2 E)-4.$7-Po/2-)I AP/ I 1`M/ Name of Contractor Phone Number Address of Contractor 3. i/e9- 7/laCPCa2�'".D ooi 1000 A I ; ) for7, 'ec1'c Name of Property Owner Requesting Service(if applicable) Address/� of Owner" 4. btyZP-C -IDU4K- d��-� ()Gnats :41 G/:/��9 y uro-0-d T2e-,-- I� ;.2�1� e) Work Description and Location(Street Number,Hamlet,Cross Street) }� (a) Is construction located within 75 feet of tidal wetlands? *Yes No %c *If yes,other Town permits may be required. NOTE: All information requested by this Signature of1pplicant Application/Permit Form is � //�� Required for a complete application! / lV��' l S Date 5. (a) Attached plot plan to reasonably and adequately describe the proposed work. Provide accurate schematic site plan showing the location of all proposed excavations and relationship to adjoining premises,public streets or areas,and give a detailed description of all site and pavement restoration work. (b) Attach all other necessary permits and licenses for this project. (c) Work covered by this application may not commence before issuance of a Highway Excavation Permit by the Town Clerk. 6. Tax Map No.: District 1000 , Section// __ / 4 , Block , Lot :;. 7. Starting Date: 1 f ©,� PI.tJ ��ly, My-lb Completion Date: el- 619 8. Work Schedule: Phase Completion Date Excavation Work Schedule Facility Installation Must be provided Backfill&Completion for consideration as a Pavement Replacement Complete Application. 9. Under which authority is application being made: 1-0,' 1., et,e-L`fn D wt, / Aor��i✓ /���z See Town Code Chapter 237_(E)-Provide Resolution by,or authority from,the Utility being modified.OL' F'n-t 00 r C.-]0. Estimated Cost of Proposed Work: ^^$ J ,e,IL/ 11. Remarks:411.-76-C---7702--1-1-C-- �-� /� P/�( IL/4U'is 1 A-0.-✓z-(tet Ta o 4iZ 7 LiA )4 /c cs— �d✓ QPcw£- 1 �7'���£dc,ci �r 6.71-..s: / 1 of 3 D-39 �p Pte- 62, i�(� • 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 $ 2.0 No. A2. i Additional Excavations same service @$10.00 $ No. B. Excavations 18"in depth or less 0-100 L.F.=$10.00;Additional L.F.@$0.10 $ l 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 TOTAL$ r 80°C) F. Notice to public utilities proof must be provided and Shall be 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 and subject to the"General Conditions"and"Special Conditions"of permit('f any)attached hereto. CA's-L RA- m N21 L O�� �' 1, SUPERINTE ' PENT OF HWS•YS (1/76/7/C-5 d 11/4) ifr& l2dA�. TOWN OFr Pt�, OLS W /O•,/ GAs — T65)7 1Il / L L ' Vient M. Orlan_d - //-30-i) Date Date Received by the Town Clerk 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. D-39 2 of 3 Copy Distribution: Permit# Highway Department Engineer(with page 3) Applicant Town Clerk (Original) INSPECTOR'S RECORDS 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 for Repair D-39 3 of 3 -'''-:.,-._'.;i'4“.'''''',.'',_I-':- ''''''''''':'i IC: 5f4 q:5'::::'''.$7.1r4it'7"1".•ft: :•.7:- ..-- - ."'---,i,'•'..Y` -?...4.k'.-.--,. .•.. ----l•F-1F7 7....':','-'3".--7 ;;;;. . 7.;:''',74',71.. 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[ - [. 1 , 1 ,- I ' ( I. 1.": 1 ', ' r" - 11/ It - ' I ' ' 1.' l': C.' l• r r , r 1 r, L [I, A I ' i : r; r _tgli 1111r-rU Ct< cri.; , r--- 3 i ODC7 Pi ,. ; ',..-.) i) ro 1\1m-7-Tc-I I-2 e-'1 •S t2) E ‘i,..,,y , l''''',' -,''' i • - ,- -, t'::!.',,,:`A 4... „.., ,,,,--, ,,, .,,,,, - -- 0 ,,. - .. • .7,,.'„ •.,.', 0 _ .. , v — : f2-1.egtrr D.' Vde41 „ . .:,.. . , . . ., . . . . th :•.- I CC: Z 0 1 C ...`,‘ * * * RECEIPT * * * Date: 12/01/15 • Receipt#: 194771 Quantity Transactions Reference Subtotal 1 Excavation Permits 1084 $180.00 Total Paid: $180.00 Notes: Payment Type Amount Paid By CK#2885 $180.00 American, Underground Utilities/Cablevi Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: American, Underground Utilities/Cablevision P 0 Box 900 Eastport, NY 11941 Clerk ID: CAROLH Internal III 1084