HomeMy WebLinkAbout455 Woodside Ln Permit No. ( 10 3
TOWN OF SOUTHOLD '�s
'' OFFOL4.
HIGHWAY DEPARTMENT ;'... ‘ss
Peconic Lane 3
Peconic,New York 11958 4,'
(631)765-3140 • o.A 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 each individual contiguous excavation project 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 Address of Applicant
2. 631 '/31 -T14.0 �n Gam, 63/ -260 •3k53
Name of Contractor Phone Number A ess of Contractor
3.
Name of Property Owner Requesting Service(if applicable) Address of Owner
4. /feet O/KL GC- advikk 'S-s woods, /see CatG(Attt Q9t
)
Work Description and Location(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. /� - .
I, /.i IJ
NOTE: All information requested by this if Signature of Applicant
Application/Permit Form is
Required for a complete application! jl X7(0
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 , Block , Lot
l 1 2/7/ZoF
7. Starting Date: � � 2 0�� Completion Date: (o
8. Work Schedule: Phase Completion Date
Excavation All GvoY'h CA,iU be- Work Schedule
Facility Installation Stab-fed runt coy/tied Must be provided
Backfill&Completion Sam dam.. for consideration as a
Pavement Replacement r 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: $
11. Remarks: . i221i, es atyi_el Ate,nd -0-6
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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 for Each Project Location - $150.00
A Project Location would include each Bell Hole and/or every road opening or excavation within any
50'Radius whether or not they may be inter-connected by open trench or directional boring.
The total number of Project Locations shall be subject to the approval of the Highway Superintendent.
Al. / /Service Connections excavations @$20.00 $ 240 b• CM,
No.
A2. /Additional Excavations same service @$10.00 $
No.
B. Excavations 18"in depth or less / •
0-100 L.F.=$10.00;Additional '7 L.F.@$0.10 $ 5C.e-D
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
TOTALS 2 2 6 . So
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 wi
this application and subject to the"General Conditions"and"Special Conditions"of permit(if: y)attached here f.
SUPERINTE II ' •• ill here
TOWN OF SO H•''a rf
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Vi ent . •rland()
19,
(t(_ DateDate Received by the Town Jerk 1 K�
Date Permit Issued '�9\I t Permit No. I � d
� 3 .
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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* * * RECEIPT * * *
Date: 02/02/16 Receipt#: 199575
•
Quantity Transactions Reference Subtotal
1 Excavation Permits- 1103 $226 50
Total Paid: $226 50
Notes:
Payment Type Amount Paid By
CK#8658 $226 50 C D L, Utilities
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: C D L, Utilities
Po Box 1098
Commack, NY 11725
Clerk ID: BONNIED Internal ID 1103