HomeMy WebLinkAboutJackson St
Date: 11/08/01
Transaction(s):
1 Permits
Check#:3759
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * **
Receipt#:
Total Paid:
\:/f
~
3759
Subtotal
$75.00
$75.00
Internal 10: 41867
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Ref. # TlOOI01439
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TOWN OF- Si.lJJ' HOLD
H IGHWA Y DEPARTMENT
Peconic" Lane
Peconlc;, New' York ',11958
(5-16) 765'-3140
P. O. f2,oY- '76.
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APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
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APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an Excav4.iiori Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, New York, and other applicable laws,
ordlnimces or regulatloris for the excava,t10n herein described. The applicant agrees
to comply with all applicable laws, ordln.((l'ces, codes and regulatloris, and to permit
authorized Inspectors to make: necessary\:I,~spections of the job site.
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Print or Type
1) KEY SF AN ENERGY '
Name of Applicant
_ 175 E. Ol,LCountrv Rd.. Hicksville.NY llR01
Address
2) ':' ~
ame 0 ymer 0 Premises"' Address
3) 1st. St. - Bel hole w/s paved area & 50'trench north starting approx. 70' n/o Jackson St.
in New Suffolk. ",
Work Des.cription and Location (Str~~t ,Number I Hamlet. Cross Street)
(a) \ fs construction los:ated wlthlh;.75,Jeet of tidal wetlands1 .Yes No X
*tf yes. othe......'town pel"'mlts.:~a-y be required. -
4) Builder's License No.
Plumber's License No.
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Electrician's' License No.
Other. Tradels
ense No.
5) a) Attach plot plan showing locatioh ,of proposed,'elfcavatlon and relationship to
adjoining premises or public.stre,ets or areas, and 'giving a detailed descrlp-
~ tion of I~yout of excavation. '. :':'
b) Attach all other necessary permiis and licenses for this project.
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c) Work covered by this' applicati~'n. may not commence before issuance of a
Highway Excavation Permit -by .'tbe Town Clerk.
6) Tax Map: Section
BIQ~k
, Lot
7)
8)
Starting Date:
, "
, Completion Date
Work Schedule:
,.'
......
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Excavation.................. .......: i-;..................
, \,
FaciIitylnstallation........... ;...;.................
Backfill & Compaction........ .:.. ; .. '... .... . . ... ... .
,
Pavement Replacement........ ~-':\~. . . . . . . . . . . . . . . . . . . .
Completion Date
Phase
'.
9) Under which authority is the applica.tlon made:
10) Estimated Cost of Proposed Work: '''$:
11)
Remarks:
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_ 12) Insurance Coverage: [Attach copyi:::":
a) Insurance Company:
b) Policy #
c) State whether policy of ce~tJficatlon on, file with the Highway Depart-
ment:
d) Coverage required extend.;J: to the Town:
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Bodily Injury and prop~hydamage: $300,000/$500,000 Bodily InJury,
and $50,000 property darj!..ge.
13) Security: ,-
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a) Surety Bond or);:ertlfl~d Check provided In the
total amount of $ ,-
b) Maintenance Bond provided..i 2 years or 3 years
1 q) Fees for applications and permits: ,';.." Basic Application Fee........ $25. 00
AT. 1 /Servlce Connections,:r.,xcavatlons @ $20.00 = $ 2(1.00
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/Additional Excavations same service @ $10.00 = $
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B.
Excavations 18" in deptho't:: -~Iess:
0-1.00 I.f. = $10.00'"
,/ I.f. @ $0.10 .<$';,
Additional
'C.
Excavations...~1''811 in depth 't9' ~.5t in depth:
0-1001.f. =-$30.00 ,,'
SO ,I.f. @ $0.30 ,<'$ 30.00
Additional
Excavations 51 in depth a~i.i. over:
0-100 I.f. = $50.00 .,
l.f. @ $0.50 7~$
Additional
D.
E.
Utility Repair":Excavations @$10.00, = $
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No.
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Repairs same:' ~~'~jce'(I) $5.0Q..:= $
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Additional
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F.
Notice to public utilities pr~( must be provided and attached to
this application prior to is~uance of permit.
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TOTAL C09'1':~"" "
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Authorization is hereby granted to the Town
Issue a Highway Excavation Permit to:
In accordance with '-this 'application. . ,.
S!ilPERINTENDENT OF HIGHWAYS
T~'wN.91' SOUTHOLD,. NEW YORK
-\-/L~~~
aymon . a~s
/I~ l.- 0/
ate
Cle~k,.of the Town of Southold to
. er..gy ,SO/Au
Received by the Town Clerk
Permit Issued, - II / ~I
pat
1/ }%jO!
DatiL,'
/~p
..
, ,,',Permit No.
Note:
Permit expires one (1) year (r.Om Date of Issuance.
No work to start without qa h"l\r notice -to the Sttperlntendent of Highways.
Permit must be available for -Inspection.
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Page 2 of 3
TlOOI01439
FC-611;,4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REOUESTEO
BY
APPROVED
SKETCH
o
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REQUEST FOR STREET OPENING PERMIT
D STATE
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NASSAU
COUNTY
O SUFFOLK
COUNTY
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DATE
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DEPARTMENT
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