HomeMy WebLinkAbout4470 Wickham Ave
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Permit NO.~
File NO.~
Ref. # T100088626
TOWN OP S;,U,'HOLD
HIGHWAY DEPARTMENT
Peconic . Lane
Peconic, New' York -.11958
(5-16) 765~3140
Po.R>of.- /75
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APPLICATION/PERMIT FOR HIGHW).Y EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an Excay~,tjori 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 excavatJon herein described. The applicant agrees
to comply with all applicable laws, ordina:~'~s, codes and regulations, and to permit
authorized inspectors to make~ necessary .;i.,nspections of the job site.
,
Print or Type
1) KEY SPAN ENERGY
Name of Applicant
175 E. Old,Country Rd.. Hicksville. NY 11801
Address
2)
Name of Owner of Premises
Address
3)4470 Wickham Ave. - s/s grass-fiiea approx. 180' ,,/n MOl"rQ Rd. in Mattituck.
Work Des.ci'"iption and Location (Str~et- Number. Hamlet, Cross Stree )
(a) \ fs constructian la.PIted withih'}5:, feet af tidal wetlands? oliVes_No. X
*If yes, otherfawn permits may be required.
4) Builder's License No..
Plumber's License No.
5) a) Attach plot plan showing lo.cation .o.f proposed,.<e:sfcavation and relationship to.
adjo.ining premises or public'stre.ets or areas, and giving a detailed descrip-
" tion of layout of excavation. "
b) Attach all other necessary per~~~'s and licenses for this project.
c) Wark covered by this application. may nat cammence before issuance of a
Highway Excavation Permit by.-U;te Town Clerk.
6)
7)
Tax Map: Sectian
Blbck
, Lot
Completion Date
Starting Date:
8) Work Schedule:
~
,.
,
.' \,
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:
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n-1q
P;:'l1e 1 of :l
w.0.IITI00088626
12) Insurance Coveraqe: (Attach copy):
a) Insurance Company:
b) Policy #
c) State whether policy of cer;tjflcation on. file with the Highway Depart-
ment:
d) Coverage required extende~: to the Town:
Bodily Injury and prop~..ty damage: $300,000/$500,000 Bodily Injury,
and $50,000 property darjlage.
13) Security:
a) Surety Bond orj:ertlfjed Check providiod in the
total amount of $
b) Maintenance Bond provided:~ 2 years or 3 years
14) Fees for applications and permits: _." Basic Application Fee........$25.00
ALl IService Connections;'excavatlons @ $20. 00 ~ $ 20.00
--;;ro.-
A2. IAdditional Excavations same service @ $10.00 ~ $
--;;ro.-
B. Excavations 1811 in depth 'o'r:"less:
0-100 I.f. ~ $10.00 "
I.f. @ $0.10 -,$
Additional
'c. Excavations-~lall in depthtc;> ',51 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 Repai~Excavations @$10. 00 ~ $
No.
Repairs same service'@ $5.0Q..= $
Additional
.,~-
F. Notice to public utilities proof must be provided and attached .to
this application prior to iS~'uance of permit.
f.
. . .
TOTAL COM"s45.00...
Authorization is hereby granted to the Town Clerk of the Town of Southold to
Issue a Highway Excavation Permit to:;V~,t SIJt:I,V
in accordance with ~this application. "'.
S8PERIN'TENDENT OF HIGHWAYS
TOWN F SOUTHOLD" NEW YORK
acobs
/&- f.-O/
ate
Received by the Town Clerk
ID /9/0c(
. Date,:,
. '. .Permit No. f <oJ ()
Permit Issued,'
/ ti:01n(
ate'
Note:
Permit expires one (1) year fr.om Date of Issuance.
No work to start without ija hqyr notice .to the S"'perintendent of Highways.
Permit must be available for -inspection.
~ '0
Page 2 of 3
FC-l;111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.OJPA
NO.
REQUESTED
BY
APPROVED
SKETCH
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KEYSP AN/6?i$
REQUEST FOR STREET OPENING PERMIT
o STATE
NASSAU
COUNTY
O SUFFOLK
COUNTY
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AV[~
MIS JOB~
NO. I loot? 99' t. 2.1-
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FOREMAN
v/;.; ~lIu7Z-
DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
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Date: 10/10/01
Transaction(s):
1 Permits
..(Jt.sb#:3700
Checie...-
o
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Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
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Receipt#:
Total Paid:
3700
Subtotal
$45.00
$45.00
Internal 10: 40966