HomeMy WebLinkAbout1160 2nd St
Date: 11/07/01
Transaction(s):
Name:
Clerk 10: L1NDAC
1 Permits
Check#: 3754
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Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
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Receipt#:
Total Paid:
3754
Subtotal
$45.00
$45.00
Internal 10: 41781
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TOWN OPS;1tl;,'HOLD
HIGHWAV DEPARTMENT
Peconic _' Lane
Peconic;. New: York'H958
(5.16) 765"3140
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APPLICATION/PERMIT FOR HIGHW).Y EXCAVATION AND REPAIR
Ref. H T1 00099635
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APPLICATION IS HEREBV made to the Superintendent of Highways of the Town
of Southold for the Issuance of an Excav~.tion Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, New Vork, and other applicable laws,
ordinances or regulations for the excavat19" -herein described. The applicant agrees
to comply with all applicable laws, ordinaj,fces, c;odes and regulations, and to permit
. aut~orlzed inspectors to make; necessary ~~,~spectlons of the job site.
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Print or Type
1) KEY SPAN ENERGY .
Name of Applicant
_ 175 E,. Ol.4..Counrtrv Rd.. H1cksv111e.-,l'lY 1] ROl
Address
2)
-;.i
Address
Name of Owner of Premises
3) 1160 2ND St.-bell hole w/s oand area aDoro:!:.. 67' nJo Kin~ St. .in New Suffolk _
Work Desd'lptlon and Location (Street. Number . Hamlet, ~o"s Street)
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(a) \Is construction 105'ated wlthln\7i(feet of tidal wetlands) .Ves No X
"'If yes, othe~"town pel"'mlts::-~ay be requIred. -
4) Builder's License No.
Plumber1s License No.
.,';'
Electrician's' License No.
Other. Tradels License No.
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5) a) Attach plot plan showing locatfo.h ,0I proposed,'el<:cavation and relationship to
adjoining premises or public'stre.ats or areas, and giving a detailed descrip-
.. tion of I~yout of excavation. ;::.':'.
b) Attach all other necessary perfulis-and licenses for this project.
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c) Work covered by this' applicati~r.. may not commence before Issuance of a
Highway Excavation Permit by :the. Town Clerk.
6) Tax Map: Section
BIQ~k
, Lot'
7)
8)
, Completion Dale
Starting Date:
Work Schedule: ;.;' .
Phase '.\ . Completion Date
ExcavatIon.................. ,;-.~:: .:,;..................
- . ,-:- \
Facility .Installation:.........; i.:,.;..,..............
Backfill & Compaction.......:.';.......:..............
Pavem~ht Replacement........ ~.~;.:.. . . . . . . . . . . . . . . . . . .
9) Under which authority Is the application made:
10) Estimated Cost of Proposed Work:'i';'$:
11)
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Remarks:
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12) Insurance Coverage: (Attach copy),i:'
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a) I nsurarice Company:
b) Policy I
c) State whether policy of cel;tJfIcatton on. file with the Highway Depart-
ment: .
Tl00099635
d)
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Coverage required extende9' to. the Town:
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Bodily injury .and prope.t~ydamage: $300,000/$500,000 Bodily Injury,
and $50,000 property darp~ge.
13)
Security:
a) Surety Bond
total amount of'$
b) Maintenance Bond provided..j
or..Fertifi~d Check
provided .in the
3 years
.2 years or
14) Fees for applications and permits: ;.:,.. '. Basic AppliCliltlon Fee........ $25. 00
A 1. 1 /Servlce Connections'\,xcavatlons e $20.00 = $ 20.00
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A2. /Additional Excavations same service e. $10.00 = $
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B. Excavatlons'1811 in depth _~;t. ':'!ess:
0-1,00 I.f. = $10.00 .t'
/ I. f .@$O. 1 0 ~.:.;~,.:.~.'" .
Additional
'C. Excavatlons-^11l" in depth 't9 :5' in depth:
0-100 I.f. =.$30.00. ^.'
, I.f.. @ $0.30 '<$
Additional . : ..
D. Excavations 51 In depth ar:a~ over:
0-100 I.f. = $50.00 -'r.
I.f. @ $0.50 ~:$
Additional
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E.
Utility Repair";Excavations @$10.00. = $
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No.
....,
Repairs same. ~i,''';'lce ,@ $5.00..= $
Additional
..---
F.
Notice to public . utilities P'rQo( must be provided and attached .to
this 'applIcation prior to I~~'~ance of permit.
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TOTAL COS'r-' $;' 45.00
Authorization is he. reby granted to the Town CI,erk of the Town
Issue a Hlgl)way Excavation Permit "to: ';",' ~'1- ~u;T)
In accordance wlth,;.thls 'application. "",''':','.-,,
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Sl:lPERINTENDENT OF HICHWAYS
-ro,",yN OUTHOLD, NEW YORK
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of Southold to
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Date
Received by the Town Clerk 11- ~''ti (
Date: .
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Permit Issued,' / f - 7 ~o (
Date
".,/:Permlt No.
Note:
Permit expires one (1.l year tr.6Jn Date of Issuance.
No work to start without 48 hCll~r' notice 'to the Sllperintendent of Highways.
Permit must be avaHable for -h'ispection.
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Page 2 of 3
OC~. -Wo! (~CN) 07 35
B~ GAS JESIGN PATCP.
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KEYSPAN/~A.r
REQUEST FOR STREET OPENING PERMIT
FC-611'.41
o STATE
o
NASSAU
COUNTY
O SUFFOLK
COUNTY
[2]
PERMIT
NO.
LOCA TION
REASON FOR
OPENING
W.O'/PA
NO.
REQUESTED
BY
APPROVED
MIS JOB~
NO. //00091635
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DEPARTMENT
GAS CONSTR.
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FOREMAN
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SKETCH
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