HomeMy WebLinkAbout620 Sigsbee Rd
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Date: 10/27/00
Transaction(s):
1 Permits
Check#: 1031
Name:
Key, Span Energy
448 East Main Street
Patchogue. NY 11727
Clerk 10: L1NDAC
Town Of South old
P,OBox1179
Southold, NY 11971
if 1-3
* * * RECEIPT * * *
Receipt#:
Total Paid:
1031
Subtotal
$45.00
$45,00
InternallD: 19359
Perrjlit No. 7 3
File No, 7 J
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic 'Lane
Peconic, New York 11958
(516) 765~31l10
PO.l2>o1- t7B
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
, Ref. I/:J. 77 11- o.s
APPLICATION IS HEREBY made to the Superintendent of Highways ef 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 excavat.ion herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to mlake: necessary ,inspections of the job site.
,
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name of Applicant
J' ATCHOGUE, NEl-l YORK
Address
11727
2)
Name of Owner of Premises
Address
3)
/V1 .4 7'TiI<A c..
Location (Street Number, Hamlet, Cross Street)
(a)
fs construction located withih75 feet of tidal wetlands? *Yes No
*If yes, other-Iown permits may be required.
L1) Builder's License No,
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~~I~'~o--
Signature of p 'cant
'. ' I {) /;;',lIZ)j tf'J
Date
5) a) Attach plot plan showing location ,of proposed.ex'cavation and relationship to
adjoining premises or publicstre,ets 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 Cleric
Tax Map: Section
Block
, Lot
6)
7)
Starting Date:
Completion 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:
\'
0-39
Page 1 of 3
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy II
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
b) Maintenance
or Certified Check provided in the
of $
Bond provided:. 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee....... .$25.00
A 1. /Service Connections. excavations @ $20.00 = $ Be>, ().)
~
A2. /Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth 'of: less:
0-100 I.f. = $10.00
I.f. @ $0.10 -$
Additional
C. Excavations.,.l'8" in depth to 5' in depth:
0-100 I.f. =.$30.00
.I.f. @ $0.30 =;~
Additional
D. Excavations 5' 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 COST.: $ '-/S-~
Authorization is hereby granted- to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to: MI.::Y ..5PBll
in accordance with ,this application. '
SUPERINTENDENT OF HIGHWAYS
TOWN SOUTHOLD, NEW YORK
7-
Raymond L.
~ 2k - c;I)
Date
Received by the Town Clerk /c3/.z.e.I'~
Date.
Permit ISSUed\')i / 1~/rJO Permit No. "1--3
te
~:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice 'to the Sl:lperintendent of Highways.
Permit must be available for inspection.
Pa ge 2 of 3
D-39
.
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
SKETCH
KEYSPAN/6A.5
REQUEST FOR STREET OPENING PERMIT
D D NASSAU D SUFFOLK I </'1 .C---O ".-; ~":\
STATE COUNTY COUNTY I'- o~ ~(rro '"
IMISJOB . IDATE /- _j
NO. Z 77// - 0 30 /t)/.15/.5laoo
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FOREMAN
v/,J ~rll.-i.?z.
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
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