HomeMy WebLinkAbout1795 Old Main Rd
Date: 10/26/01
Transaction(s}:
1 Permits
,.castT#:3745
C~(UL /I
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
?
Receipt#:
Total Paid:
/
$ \:9v{
3745
Subtotal
$45.00
$45.00
IntemallD: 41551
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TOWN 01" S;>U,'HOLD
HIGHWAY DEPARTMENT
Peconic. Lane
Peconic; New' York .~ 1958
(5-16) 765'-3140
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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 Excav~.tiori 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 excavaf!on herein described. The applicant agrees
to comply with all applicable laws, ordinii,t\'~es, codes and regulations, and to permit
aut~orlzed inspectors to make; necessary~/nspections of the job site.
Print or Type
'.'
1) KEY SPAN ENERGY
Name of Applicant
175 E. Old.Country Rd.. Hicksvi11e. NY IlR01
Address
2)
3)
(a) \t"s construction located within.is', feet of tidal wetlands? *Yes_No X
*If yes, other'!own permits may be required.
4) Builder's License No.
Plumber's License No.
.,,'
Electrician's License No.
Other. Trade1s License No.
5) a) Attach plot plan showing locatfoh .of - proposed,-"e":cavation and relationship to
adjoining premises or public'stre.ets or areas, and giving a detailed descrip-
~ tion of layout of excavation. ".
b) Attach all other necessary perm~~'sand licenses for this project.
c) Work covered by this applicatio'~. may not commence before issuance of a
Highway Excavation Permit by:'t':e Town Clerk.
6)
7)
Tax Map:
Section ~
jI /;1/01
I ,
Block
, Lot. - ~
Date /~/;/fhv
I I
Starting Date:
, Completion
8) Work Schedule:
Completion Date
Phase
Excavation. .. . .. . ... .. . . . . . . .:-'.:~ ..-~ . .. . . . .... ... .,. . .
\
Fadl ity -Insta lIation. . . . . . . . . . ; ;':. . '; . . . . . . . . . . . . . . . . .
Backfill & Compaction.........'...... '. . . . . . . . . . . . . . .
Pavement Replacement........ ~ . . . . . . . . . . . . . . . . . . .
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: "$'
11)
Remarks:
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12) Insurance Coverage: (Attach copy):(~:...
a) Insurance Company:
b) Policy #
c) State whether policy of ce~tJflcatlon on, file with the Highway Depart-
ment:
d) Coverage required extend~.cf" to. the Town:
".1,..'
Bodily Injury and prop~hydamage: $300,000/$500,000 Bodily Injury,
and $50,000 property da,p""ge.
13) Security:
a) Surety Bond
total amount of $
b) Maintenance Bond provided,:
or"Fertifl~d Check
provldoo in the
3 years
.2 years or
14)
Fees for aPjCations and permits: ';,,:: ", Basic Application Fee........ $25. 00
A I'. -..:..-/Servlce Connections','excavatlons @ $20.00 = $~O. f) CJ
No. '
A2. /Addltional Excavatic)os same service @ $10.00 = $
""N'O:-
B. Excavations 18" in depth~o't:: '~Jess:
0-1.00 I.f. = $10.00 ..,
./ I.f. @ $0.10 "7-'~$':<
Additional
. C. Excavatlons--..t1J1l in depth. tQ:.s' 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 Repalr)"xcavations @$10.00, = $
: ~. ,....
No.
.'.....
Repairs same. ~~rvlce ,@ $5.00..= $
.'"
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Additional
F. Notice to public 'utilities proof must be provided and attacl)edto
this 'application prior to IS",uance of permit.'
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TOTAL COST-' $' , '.'...-
Authorization is hereby granted to the To-;'n
Issue a Hlgl1way Excavation Permit'to:
in accordance with ,-this 'application.
Clerk of the Town of Southold to
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SOPERINTENDENT OF HIGHWAYS
T~?,WN OUTHOLD, NEW YORK
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Date
Received by the Town Clerk
Issued,' J 3 i
Date
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Permit
')':Permit No.
Note:
Permit expires one (1) year fr.om, Date of Issuance.
No work to start wit,hout 48 hQ~r notice 'to the Sl:Iperlntendent of Highways.
Permit must be available for ,Inspection.
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Page 2 of 3
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OCT. - 20' O! (SAT)- 15 55
Fe-e",..
PERMIT
NO,
BU GAS DESIGN PATCH TEL:516 7585136
KEYSPAN/~A.r
REQUEST FOR STREET OPENING PERMIT
o STATE
NASSAU
COUNTY
O SUFFOLK
COUNTY
o
LOCATION on> M ',.,\
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCt1
~ jJ DEPARTMENT
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