HomeMy WebLinkAbout6825 Nassau Pt Rd Permit No.
TOWN OF SOUTHOLDsu�Fot,�'P
HIGHWAY DEPARTMENT °°y
Peconic Lane
Peconic,New York 11958
(631)765-3140
APPLICATION/PERMIT FOR HIG14W—AY`,,EXCA'VATIO ,AN,D 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.
Pridvorlt-yve
Name of Applicant Phone Number Address of Applicant
/7 A 41a-d VY 117Z
Name of Contractor Phone Number Address of Contractor
3. � - (CSS G - - - aVO'� �s
Name of Property Owner Requesting Service(if applicable) Address of Owner /
4,. k�� Ce �. �
Wo
Description and L ation(Street Number,Hamlet,Cross S eet)
(a) Is construction located within 75 feet of tidal wetlands? *Yes_ _ No
*If yes,other Town permits may be required.
NOTE: All information requested by this ignature of Applicant X31_7(07–07-3�
Application/Permit Form is x
Required for a complete application! ,
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 L I Block ' Lot. v
7. Starting Date: ��J. _ _ _ Completion Date: /Zc
8. Work Schedule: Phase Comnletion'Date
Excavation _ �/ _ Work Schedule
Facility Installation _ 2 f Must be provided
Backfill&Completion _ _ WI for consideration as a
Pavement Replacement _ r L Complete Application.
9. Under which authority is application being made:-
See
ade:_See Town Code Chapter 237(E)-Provide Re/solution by,or authority from,the Utility being modified.
10. Estimated Cost of Proposed Work: $
11. Remarks: o�¢, -�r�S_ U+ Abj&fLZ ' ..,
D-39 1 of 3
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.
v,7
Al. / /Service Connections excavations @$20.00 $__ _ O
No.
A2. /Additional Excavations same service @$10.00 $
No.
B. Excavations 18"in depth or less
0-100 L.F.=$10.00;Additional,___2� L.F.@$0.10 $, 23o
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 @$10.00No. ---
-_ _Repairs same service @$5.00 $-
Additional
TOTAL$,
l72 .7°
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 xcavation permit to:
--in accordanc with
this application and subject to the"General Conditions"and"Special Conditions"of perm (i ny)a ch d eto.
SUPERIN F AY
TOWN O D,• YO K
--
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
i st
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
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N I�l5S�1u
o iiaue�t
CDL Utilities
PO Box 1098
Commack NY 11725
631-49-9860
Guyy Cella
-Z60- 853
C%L.J g�,alla@cdhrti�ties.�m
* * * RECEIPT * * *
Date: 08/23/17 Receipt#: 227863
Quantity Transactions ReferenceSubtotal
`{
1 Excavation Permits 1227 '' $17270
Total Paid: $172.70
•f
Notes: ;r
Payment Type Amount Paid By
CK#9939 $172.70 CDL, Utilities
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: CDL, Utilities
Att, Cablevision
Po Box 1098
Commack, NY 11725
Clerk ID: BONNIED Internal ID 1227