HomeMy WebLinkAbout1150 Old Main Rd
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Permit No. -;?
File No. 7 ~
TOWN OF S'JU ,'HOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic. New' York -11958
(516) 765c31110
PD. {2,0'l- /7B-
APPLICATiON/PERMIT FOR HIGHWAy EXCAVATION AND REPAIR
Ref. II .;lf8~J 03
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Southold. Suffolk County t 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, and to permit
authorized inspectors to make: necessary \inspections of the job site.
Print or Type
1) KEY SPAN ENERGY 448 EAST MAIN STREET
Name of Applicant
PATCROGUE , NEW YORK
Address
11727
2)
Name of Owne~ .of Premises
/1..50 () / ~ tVlAu'; R-!J
Work Description and Location (Street
Address
MA-T/7/lA c.1C.
Number I Hamlet, Cross Street)
3)
/"
(a) (s construction lo~ated within 75 feet of tidal wetlands? *Yes No.
*If yes, other......Town permits may be required.
4) Builder's License No..
Plumber's License No..
Electrician's License No..
Other Trade's License No..
~tuJ,~
. ( L( Lo / &-'
Date
5) a) Attach plot plan showing location -of proposed- ex'cavation and relationship to.
adjoining premises or public streets or areas, and giving a detailed descrip-
tion of layout of excavation.
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)
7)
Tax Map: Section
Block
, Lot
Completion Date
Starting Date:~
B) Work Schedule:
Phase
Completion Date
Excavation. ................ .. ..... ..... ...............
Facility Installation. ........... ."....................
Backfill & Compaction........:.....................
Pavement Replacement..............................
9) Under which authority is the appliCation made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
\
D-1Cl
Pi'lClf': 1 of 1
_ v
12) Insurance Coveraqe: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Depart-
ment:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security:
a) Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
3 years
2 years or
, 4) Fees for applications and permits: Basic Application Fee........ $25. 00
A 1. IService Connections excavations @ $20.00 ;:: $ C) () - (,JJ
~
A2. IAdditional Excavations same service @ $10.00 ;:: $
~
B. Excavations 18" in depth 'or less:
0-100 I.f. = $10.00
I.f. @ $0.10 -..$
Additional
C. Excavations....l8" in depth loS' in depth:
0-100 I.f. =-$30.00
. I. f. @ $0.30 = $
-Additional
D. Excavations 51 in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 =. $
Additional
E.
Utility Repair Excavations @$10.00 $
No.
Repairs same service -@ $5.00 <::: $
Additional
F. Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
. . .
TOTAL CO~T S 75-- (j)
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance with ..this application.
SUPERINT NDENT OF HIGHWAYS
TOWN SOUTHOLD, NEW YORK
Raymon
I;).-q~~ oP
ate
Received by the Town Clerk
IQ) d'/Oa
Date
Permit Issued, -
/dLiJ.4?/OO
ate I
7f'
Permi t No.
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without q8 hour notice 'to the Sl:lperintendent of Highways.
Permit must be available foririspection.
r'I_"')t!
Page 2 of 3
FC-6111,4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
~b~JOB J ~~g3-0JO
s,fs. OL.D I1AI~ ~b '. O~OI 10 (1'50' uJ!o
t: A-S MI'1 [.tv' .j- s: t Vl VI Gt.--
FOREMAN
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
D SUFFOLK .--J
COUNTY l.{J
D STATE
D
NASSAU
COUNTY
1.0. .s.OVnrCi/...~
DATE
l~-)O-OO
M/j,JJ flu hrr-rllvc.1C.
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES "2 t.f
Ar-J M4(l,~S
t&-{(/,J '1 ~ (llvtt!ll.41
DATE
b(U~* 101- ~- 3
N
h/tl,J (1.'0.
L.(xV'
off.,fJ'tJ (,... I~
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Date: 12/26/00
Transaction(s):
1 Permits
Check#: 1095
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1095
Subtotal
$75.00
$75.00
InternallD: 21703