HomeMy WebLinkAbout1350 Woodcliff Dr
Permit No, 7 7
File No. 77
Ref. /I ;2&,:;J'f;). d)
TOWN OF S;,UJHOLD
H IGHWA Y OEPARTMENT
Peconic La ne
Peconic, New' York 11958
(516) 765c31l10
Po.p->o",- t7b
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 83 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, and to permit
authorized inspectors to make: necessary ___inspections of the job site.
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name of Applicant
~ATCHOGUE, NEW YORK
Address
11727
2)
Address
Name of Owner of Premises
/357) L.)()o,JcL~ ~
Work Description and Location (Street Number,
y1.1 A' ( I /T-<C Ie.
Hamlet, Cross Street)
3)
(a)
(s construction located 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.
~~
Signature of Ap ica
I J- I go- - OJ
Date
5) a) Attach plot plan showing location of proposed. e5(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 perrnits 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)
7l
Tax Map: Section
Block
, Lot
Completion Date
Starting Date:
8) 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- 39
Paqe 1 of 3
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Depart-
ment:
d) Coverage required extende~ to the Town:
Bodily injury and property damage: $300.000/$500.000 Bodily Injury,
a~d $50,000 property damage.
13) Security:
aJ Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
3 years
2 years or
14)
Basic Application Fee........ $25. 00
excavations @ $20. 00 ~ $ ~o 6>
Fees for applications and permits:
A 1. I lService Connections
~
A2. 'Additional Excavations same service @ $1 Q. 00 ;:: $
~
8. Excavations 18" in depth 'o'r less:
0-100 I.f. ~ $10.00
I.f. @ $0.10 -.$
Additional
C. Excavations-,,1-8" in depth to 51 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 Repai~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 Y 5:- ti>
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.
SUPERINTENDENT OF HIGHWAYS
TOWN SOUTHOLD, NEW YORK
Ie? - /~ -CJC'
Date
Received by the Town Clerk
I 2./(,/44>
Date
Permit Issued\
I z-JI9/~
Date'
Permit No.
77
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice .to the St.lperintendent of Highways.
Permit must be available for inspection.
n- 'HI
Page 2 of 3
FC-6111.4
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
O 0 NASSAU 0 SUFFOLK r--I...r
STATE COUNTY COUNTY ~ ,.0. S,OV711 Ol.~
PERMIT I MIS JOB IDATE
NO. NO. Z'i~'Iz.- 03 0 n-((,,-OO
LOCATION Sf!3 L,J6IJ b C/"IFO(-" ,\>r'{. 2-1/0' tv/a w't.!.-r III \,......1 \)(2.\ M4HI.J.lJ~K:...
REASON FOR CH ..1 tP-l/1 C-L--
OPENING
W.O.lPA FOREMAN I DATE OF /-/1-00
NO. OPENING
REQUESTED DAIJ DEPARTMENT 'I DIVISION
BY h.A~'l~ GAS CONSTR. MAl NT. & SERVICES 7. i (It (; (0,.) '] - (l'v~rllur4h
APPROVED IDATE
Cr<l{JJP./O/-O"!- ,(.,')01 . '\)~~~_~_l_....
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i . ~o ____.~__L___;__ -----~
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SKETCH
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cc
110'
,
,
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L{''x L{I
8 ft,VI>J(,....
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- ____0 ____
Date: 12/19/00
Transaction(s):
1 Permits
Check#: 1089
Name:
Key, Span Energy
448 East Main Street
Patchogue. NY 11727
Clerk ID: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1089
Subtotal
$45.00
$45.00
Internal 10: 21205