HomeMy WebLinkAboutJACKSON'S LANDINGPrint .or Type:
IOffi. ce use only
File ~:
Permit ~:
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
PECONIC LANE
PECONIC, NEW YORK 1195@
PERMIT & BOND APPLICATION
FOR ACCESS THROUGH TOWN OWNED PROPERTY
1 ).
2)
(Name of Applicant) (Address)
3)
ooo-//3 - /
(S.C.T.M. ~)
(Name & Address of Contractor Involved)
(Project Location)
(Name of Road or Town Property Involved) (Hamlet)
(Brief Job Description)
5)
7)
.8)
Starting Date:
Completion Date:
Estimated Cost of Proposed Work:
Insurance Coverage:
A, The' coverage required to be extended to the Town:
Bodily injury & Property Damage;
$300,000/$500,000 Bodily Injury & $50,000 Property Damage
Insurance Company:
Insurance Agent
Name & Telephone # :
O. Policy
E.
State whether policy or certification
is on file with the Highway Department:
(if no, Provide a copy with Application)
(yes/no)
(Signature of Applicant) (Date)
To be completed by the Superintendent of Highways:
Bond Amount
Required:
(Si gnature)
Print or Type:
1)
ACCESS CONSENT FORM
FOR ACCESS
THROUGH PRIVATE PROPERTY,
IOffice use Only
File ¢:
Permit #:
2)
(Name of Applicant) (Address)
3)
4)
5)
(Project Location) (S,C.T.M, ~)
(Name of Road or Private Property Involved) (Hamlet)
(N~me & Address of Homeowners As'soci~tion / Property Owner)
(Brief Job Description)
7)
8)
g)
Starting Date:
Completion Date:
Estimated Cost of Proposed Work:
Insurance Coverage:
A. The coverage required to be extended to the Property Owner:
Bodily injury & Property Damage;
$300,000/$500,000 Bodily Injury & $50,000 Property Damage.
B, Insurance Company:
C, Insurance Agent
Name & Telephone ~
:= .... D. Policy ~ :
E,
State whether policy or certification
is on file with the Trustees Office:
(If no, Provide a copy with Application)
(yes/no)
(Signature of Applicant) (Date)
To be completed by the Property Owner:
I/We the undersigned, fully understand the nature of the Proposed
Work referenced above and have no objection to .allowing the
Applicant to cross My/Our Property to do the w~rk./
--
(Signature of the Property Owner
ordulyauthorizedrepresenta~ive)
Albert J, Krupski. President
John Holzapfel, Vice President
Jim King
Martin H. Garrell
Peter Wenczel
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Town Hall
53095 Main Road
P.O. Box 1179
Southold. New York 11971
Telephone (516) 765-1892
Fax (516) 765-1823
Office Use Only
Cgastai Erosion Permit Appl!cat~h
.L~et!and Perm!t A.ppllcatlon Di~jF
Grandfather Pe~!t Application
' Waive r / ~en~ent / Change s
Received Application:
~eceived Fee: $ --
SEQ~ Classification: '
~.~e I ~e II Unlisted
Coordination: (date sent)
CAC Referral Sent:
Date of Inspection:
Receipt of CAC Report:
Lead Agency Determination:
Technical Review:
P~iic Hearing Held:
Resolution:
Name of Applicant,~_~..~~_.
Address
Phone Number: (
Suffolk County Tax Map Number: 1000
Property Location: 'V//~A~,-,C~[~ ~Jg>/~"~
)
/13 - -/o
(provide LILCO Pole ~, distance to cross streets, and location)
(If applicable)
Address:
Phone:
FAX%:
~ ~rd of Trustees Applicatic
GENERAL DATA
Land Area (in square feet):
Area Zoning: ...~~
Previous use of property:
Intended use of property:
Prior permits/approvals for site improvements:
Agency r Date
/
·
No prior permits/approvals for site ~provements.
Has any permit/apProval ever been revoked or suspended by a
governmental agency?
v No Yes
If yes, provide explanation:
Project Description (use attachments if necessary):
Be~ '"d of Trustees Applicatiom.'
WETLAND/TRUSTEE LANDS APPLICATION DATA
Purpose of the proposed operations:
Area of wetlands on lot:
Percent coverage of lot:
~0 square feet
ZO
Closest distance between ~aK~est existing structure and upland
edge of wetlands: ~Jl~ feet
Closest distance between nearest proposed structure-and upland
edge of wetlands: feet
Does the project involve excavation or filling?
/
%/ No Yes
If yes, how much material will be excavated?
How much material will be filled? ~ ~ ~ cubic yards
Depth of which material will be removed or deposited:
feet
Proposed slope throughout the area of operations: /
Manner in which material will be removed or deposited: ~//~
- (f> ards
Statement of the effect, if any, on the wetlands and tidal
waters of the town that may result by reason, of such proposed
operations (use attac.hments if appropriate):
~' 'rd of Trustees Applicatio~~
COASTAL EROSION APPLICATION DATA
Purposes of proposed activity: ~/~/~ ~
Are wetlands present within 75 feet of the proposed activity?
No ~/~ Yes
Does the project involve excavation or filling?
~<~ No Yes
If Yes, how much material will be excavated?~G/D~ (c~hic yards
How much material will be filled? ~A)~ (c~bic y~rds)
Manner in which material will be removed or deposited:
Describe the nature and extent of the environmental impacts
reasonably anticipated resulting from implementation of the
project as proposed. (Use attachments if necessary)