HomeMy WebLinkAbout150 Champlain Pl
Date: 11/07/01
Transaction(s):
Name:
Clerk ID: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#:3754
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Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Receipt#:
Total Paid:
* 0'1
3754
Subtotal
$45.00
$45.00
Internal 10: 41782
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HIGHWAV DEPARTMENT
Peconic ,'La;,e
Peconlc;. New' 'tark .11958
(SU) 765'-31'40
P. 0, a.y.. 17~
APPLICATION/PERMIT FOR HIGHW';i..y EXCAVATION AND REPAIR
File No,' 7
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Ref, , Tl00098124
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APPLICATION IS HEREBV made to th.~ Superintend\!lnt of Highways of th\!l Town
of Southold for the. Issuance of an Exca,,~,tion Permit' pursuant to Chapter' 83 of the
.Gode of the Town of Southold, Suffolk Cl>Unty, New Vork, and other applicable laws,
ordinances or regulations for the excavatlon 'hereln deScribed. The applicant agrees
to comply with all appllcabl\!l laws, ordiria!i~es, cedI's and regulations. and to permit
. authorized Inspectors to rriake; n\!lcessary~~:~spections of the job site.
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Print or Type
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. ot;{~COUnJtTV Rd..' H1cksvi11e.' "MY
.: " Address
11 A01
1) KEY SPAll 'BNJ!RGY . '.
Name. of Applicant
_ 175 ~.
2)
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Address
-Name of Owner of Premises
3)
150 Chamolain PI. - bell bole s/s oaved area aoorox.. 73' e/o Main SL in Greenoort
Work D\!ls.crlptlon and Location (Str~e!:. .]'lumber, Haml\!lt, Cross Street!
,'..
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(a) \Is construction 10J:llted Wlthlh'}S',feet of tidal wetlands! 'V\!lS No X
*If yes. o,the~!own permits~~a.y be required. -
4)
Builder's License No.
Plumber's License No.
.,'j.
ElectrIcian's' License No.
,. Other. Trade's License No.
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Date
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a)
Attach plot plan showing locati'pn:of. proposed,1ll(cavation and r\!llatlonshlp to
adjoining premises or public' stre.ats or ar\!l8S, and giving a detall\!ld d\!lscrip-
.. tlon of I~yout of excavatipn. :~:\:'. . .'
Atrac:'h alt other necessary permlt.s' and licenses for this project.
. ~~. .
Work CDV\!lred by this' appllcatl!>o. may not comm\!lnce before Issuance pf a
Highway Excavation Permit 'by :t~.\!l' Town Clerk.
b)
c)
,
BI~fk
, Lot'
6)
Tax Map: Section
7)
Start~ng Dat~:
'. Completion Date
8)
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Phase' :~'\ .
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E~cavatlon.................. i~~:~:~..l,\..,..,..,.,...",
Facility .Installation:.........: i.'~'.. ~:,""""""""
Backfill 6 Compaction.........:...:...................
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Pavemeht Replacement........ <.>...................
Work Schedule:
Completion Dale
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9)
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Und\!lr whJch authority is the appllCjj.tion mad\!l:
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10) Estimated Cost of Proposed Work:"i'$" .
11)
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Rema rks :
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Insurance Company:
Poll cy ,
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State whether policy of cer,tlf1catlon on, file with
inent: >:,:....
Coverage required extend~:cf.'~o' the Town:
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Bodily Injury ,and proi>~t~ydamage: $300;000/$500,000 Bodily Injury,
and $50,000 property d~')'iJge.
TlOO098124
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the Highway Depart-
d)
13)
Security:
or\;~ertiflild
Check
provided ,In the
14)
aJ Surety Bond
total amount of$ " '-,
b) ,Maintenance Bond provided"\,, ' 2 years' or 3 years
Fees for applications and permits: ;'.;.:" Basic Appllciotlori Fee........ $25.00
, . .'1...
A 1'. 1 /Servlce Connectlonsi'excavatlons 0 $20.00 = $ 20.00
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/Addltlonal Excavati,n!,s same service 0$10.00 = $
""Fl'Cl:- ,,'
B. Excavations 18" In deptho(:,ess:
0-1,00 I.f. = $10.00 , <:'
/ I.f. m $0.10 ~:,~".},'"
Additional
A2.
'C.
Excavations.--11l11 in depth. .ti;>' :51
0-100 I.f. ~$30.00 .
I.f., m $0.30 ;;~.$:
Additional
Excavations 5' In depth ai,:~" over:
0-100 I.f. = $50.00 :~,
I.f. m $0.50 ~:'$
'.
Ih depth:
D.
Additional
E.
Utility
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Repai~;:Excavatloils
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0$10.00, = $
No.
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Repairs same. ~ervlce 'I) $5.00.= $
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Additional
F.
Notice to, public 'utilities p~~t must be provided and attached ,to
this 'appliqltlori prior to I~.~'~~nce of permit.' /
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TOTAL COS'r-' ~ 45.00
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Authorization Is hereby granted to the town ,CJerk of the Town o,f Southold to
Issue a Hlgl)way Excavation Permit to: ,;", ' 'll'1.r{- Sp"'~4
In accordance wlth.thls 'application. ,'..,:,-" ,
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$~PERINTENDENT OF HICHWAYS
TQ'v/N' 0 SOUTHOLD, NEW YORK
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Date
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Received by the Town Clerk
11- d'Y:J (
Date';,'
Permit Issued, '
I t,- 7- 0 (
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,/;perml t No.
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Permit expIres one (IJ year frOm Date of Issuance.
No work to start wl~tiout 48 hi'Yr' notice .to the S..pe~lntendent of Highways.
Permlt'must be available for 4nspectlon. ' '
Page20f 3
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OCT. -29' Ot (MaN) 07 33
Fe-s,,,..
PERMIT
NO,
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUeSTED
BY
APPROVED
SKETCH
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BL GAS DESiGN PATCH
~EL5;6 758m6
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KEYSPAN/6AJ"
REQUEST FOR STREET OPENING PERMIT
o STATE
o
O SUFFOLK r:(l
COUNTY ~
FOREMAN
11/6/ :I.e...'
7. . -S'/t4
I ~ ,/ DEPARTMENT
1/'.)/1 ~CrlfulZ- GAS CONSTR. L.Z.}
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