HomeMy WebLinkAbout11500 Sound Ave
~
Date: 10/19/00
Transaction(s):
1 Permits
Check#: 1016
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1016
Subtotal
$45.00
$45.00
Internal 10: 19135
File No.
TOWN OF SOlJTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765~31llO
PD. (2,oy- /7b
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
7/
1/
Permit No.
, Ref. /I d-.75SL/- 03
APPLICATION IS HEREBY made to the Superintendent of Highways af 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 excavation 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
PATCHOGUE, NEW YORK
Address
11727
2)
Name of Owner of Premises
Address
3)
/1,1)OD SO<-(,,,,~ ~
Work Description and Location (Street
- /VI A-T/I /4 L K.
Number, Hamlet, Cross Street)
(a)
Is construction located within 75, feet of tidal wetlands? *Yes No
*If yes, other-town permits may be required.
11) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
Signature 0 Ap
/c)/!c.. / ~
Date
5) a) Attach plot plan showing location ,of proposed,e5:'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 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
6) Tax Map: Section Block , Lot
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:
\
D-39
Page 1 of 3
12) Insurance Coverage : (Attach copy) ,
aj Insurance Company:
b) -Policy #
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 or Certified Check provided in the
total amount of $
b) Maintenance Bond provided: 2 yea rs or 3 years
A1.
applications and permits:
-L-IService Connections,
No.
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ BOo ~
14)
Fees for
No.
B. Excavations 18" in depth 'Ol~ less:
0-100 I.f. = $10.00
I.f. @ $0.10 -,$
Additional
C. Excavations.,-1'8" 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 CO~T: $0/5'-- OJ
Authorization is hereby granted,to the Town
issue a Highway Excavation Permit to:
in accordance with .this application.
Clerk of the Town of Southold to
SUPERINTENDENT OF HIGHWAYS
TOWN OF SOUTHOLD, NEW YORK
k~~;{'L~~
/tfJ / (7 --- a:)
Date
Received by the Town Clerk /0/;101)'
ate
Permit Issued,'
/oh~(ocJ
'Dat
Permit No, 7/
Note:
Permit expires one (1) year fr,om Date of Issuance.
No work to start without 48 hour notice -to the Sl:lperintendent of Highways.
Permit must - be available for inspection.
Page 2 of 3
D-39
KEYSPAN/&AS
REQUEST FOR STREET OPENING PERMIT
D STATE D NASSAU D SUFFOLK [2]
FC.6111.4 COUNTY COUNTY
PERMIT MIS JOB
NO. NO. 2 7S5cJ -630
LOCATION ..s:; 5,'f ,;V ~VEd ,4~~ ~t?b /L
REASON FOR 1/.1 /YJ Ar'17';'~,e
OPENING t/~L
W.O./PA
NO.
REQUESTED ~ II 1/'1 J;lIu 1i DEPARTMENT
BY GAS CONSTR. MAINT. & SERVICES
APPROVED
SKETCH
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