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Home My WebLink About10230 New Suffolk Ave (2) Permit No. t(3O TOWN OF SOUTHOLD } os1IFF04co HIGHWAY DEPARTMENT Peconic Lane 2 .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 each individual contiguous excavation project herein described. The applicantagrees 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 tk - 631-1 14--13/ct moi. 43i-7 7—f6‘7 6 Name of Applicant si Phone Number Address of Applicant i?2. ans'tf At'o - E 4 pri I,ic 2,E Lim. t1/44401\e N."1, , 1S Name of Contractor Phone Number Address of Contractor 3. Name of Property Owner Requesting Requesting Service(if applicable) Address of Owner n 8 4. •j f4et riIG�'d /0.2306'r !fir S ,t ftc,.e r QtAc - M-Mr s &put, Work Description andY.ocation(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. 2a NOTE: All information requested by this Signature of Applicant Application/Permit Form is Required for a complete application! a•-i C, 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 7. Starting Date: 5-2 3 r 1(aD Completion Date: S.-Z.3-1(v 8. Work Schedule: Phase Completion Date Excavation s---23- f6 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: See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being,modified. 10. Estimated Cost•ofPropos � ed Work: � $ 4 `s 60 • 0:S 11. Remarks: ekce vn'(�e ge) D-39 1 of 3 12. Insurance Coverage:(Attach Copy) ��}}��, it (a) Insurance Company: ➢I . 7'K-t+" s til y (b) Policy#: (c)State whether policy of certification on file with the Highway Department: (d)Coverage required extended to the Town: Any Lossnncluding"Bodily injury,property or commercial injury caused by or attributable to the work performed: $1,000,000 per Occurrence and$2,000,000 general aggregate. 13. Security: (a)Surety Bond , an or Certified Check provided in the total Amount of$ (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. t /Service Connections excavations @$20.00 $ e2t O. CO No. A2. /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 $ C. Excavations 18"in depthto5' 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 1170% CO F. Notice to public utilities proof must be prodded and Shall beattached 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: i accordance with this application and subject to the"General Conditions"and"-Special Conditions"of permit Of a , attached hereto SUPERINTEND; e Fi Aw�t • S TOWN OF SOkitIL ' 'a`�''" i' ince ty0 ]moo SI l if /dDate Date Received,by the Town Clerk fr- l f Date Permit Issued ((0 I�� Permit No. l 13 0 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(duetobackfilling) 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 �✓1 Cj l7 °Rs S-00 c-toc Cfi� f1 t c � kr 7 * * * RECEIPT * * * Date: 05/06/16 Receipt#: 204129 Quantity Transactions Reference Subtotal 1 Excavation Permits 1130 $170.00 Total Paid: $170.00 Notes: Payment Type Amount Paid By CK#5555 $170 00 R & R, Construction Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: R & R, Construction 282 Line Rd Manorville, NY 11949 Clerk ID: BONNIED Internal ID 1130