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HomeMy WebLinkAboutEagle Nest Court �f TOWN OF SOUTHOLD �J ,��, 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 0 /� I. L �1 �l S/t9 6� A 2 an Ic�4�� (tel t l���L(�f2l�C>x�✓J (� ?`L!7`/ 1J3 Name of Applicant Phone Number Address of Applicant Name of Contractors � Phone Number Address of Contractor 3. Name of Property Owner Requesting Service(if applicable)) Address of Owner 4. V53.T-00 �rl[ ?4,t-t'Utitc'f� /o 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. / �/��• �l �, NOTE: All information requested by this Signature of App ant Application/Permit Form is n^0 l Required for a complete application! ,� HIL7 �E1 " 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: 60?`&Ly-c-a/op7'(fir- ��2�"Z �' Completion Date: 8. Work Schedule: Phase Completion Date Excavation Work Schedule Facility Installation Must be provided Backfill&Completion for consideration as a Pavement Replacement Complete Application. r� 9. Under which authority is application being made: �� C,�1�/�/O 4--l" L See Town Code Chapter 237(E)-Provide Resolution by,or authority from,the Utility being modified. VP� ©v 10. Estimated Cost of Proposed Work: $ 13 Do 11. Remarks: [ 0-Er L�Id U"cam Be IL-6-— N p �;o/t,.< [Q—, �-'uc9/J W.•Q.../ D-39 1 of 3 W- ,urance Coverage: (Attach Copy) (a) Insurance Company: v WG��`� ✓��./ �� '`� (b) Policy#: VfAlk Ai`'"�'� A7:6&v t (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$2,000,000 general aggregate. 13. Security: (a)Surety Bon VI-UOQ/or Certified Check provided in the total Amount of$ (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 $ ;514V g No. A2. 'Additional Excavations same service @$10.00 $ No. _3 4!;Vw` r— B. Excavations 18"in depth or less�`j'' I C 0-100 L.F.=$10.00;Additional a 43 L.F.@$0.10 $ -f° A-o 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$ __ --- 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: ATH with this application and subject to the"General Conditions"and"Special Conditions"of permre SUPERINTETOWN OF S V ncen . Orlando ( Date Date Received by the Town Cl �j ( / 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 * * * RECEIPT * * * Date: 06/14/17 Receipt#: 222281 Quantity Transactions Reference Subtotal 1 Excavation Permits 1215 $20450 Total Paid: $204.50 Notes: Payment Type Amount Paid By CK#35100523 $204.50 American, Underground Utilities/Cablevi Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: American, Underground Utilities/Cablevision P O Box 900 Eastport, NY 11941 Clerk ID: BONNIED Internal ID• 1215