HomeMy WebLinkAboutThird St
'.
Date: 09/24/01
Transaction(s):
1 Permits
Check#: 1316
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:
1316
Subtotal
$15.00
$15.00
Internal 10: 40319
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H ICHWA Y DEPARTMENT
Peconic Lilne
Peconic, New' Yorl< "'950
rf? \-t L.1\.f7 (516) 765C31110
7 (0;)0 Po. 12>0'1- 17b
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APPLICATION/PERMIT FOR HICHWAY EXCAVATION AND REPAIR
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APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of iln Excilvation Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffoll< County, New Vork, and other applicable laws,
ordinances or regulations for the excavation herein described. The <lpplicant agrees
to comply with all applicable laws, ordinaD'c:-es, codes and regulations, and to permit
authorized inspectors to make: necessary \inspections of the job site.
Print or Type
1) KP.Y $PAN RNRRGY l,t,R RA$T MAIN $TRlllli'
Name of Applicant
PATCHOGUll, N1l11 YORK
Address
11727
2)
Name of Owner of Premises
Address
3)
~ I v-..J s '\ 'f\J'f' L.J S - ~ /oL Ie
Work Description <lnd Localion (Street- Number. Ham et, Cross Street)
(a) (s construction I05=ated within '..;5- feet of tidal wetlands? "'Ves_No SV'
*If yes, other--"!own permits may be required. T-
II) Builder's License No.
Plumber's License No.
Elcctrician1s License No.
Other Trade's License No.
~
7 d-d _0 /
Date
5) a) Attach plot plan showing Iccnti'on ,of proposed,'''c)('cavation and relationship to
adjoining premises or public'stre.cts or areas, and giving a detailed descrip-
lion of layout of excavation. ".::
b) Attach all other necessary pcrm.~.ts ilnd licenses for this project.
c) Work covered by this applic.,tion. may not commence before issuance of a
Highway Excavation Permit by:-tl:lc Town Clerk.
6)
Tax Map: Section
Bloc!,
, Lot
7)
0)
Starling Date:
Completion Dale
Work Schedule:
Completion Date
Phase
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9)
Excavation.... .. . ...... .. .. ... ... "'~"""""""'"
Facility Installation...........::....................
Backfill & Compaction..............................
Pavement Replacement........ ~':,..~...................
Under which authority is the application made:
10) Estimated Cost of Proposed Worl<:$
, 1) Remarl<s:
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Poqc 1 or 3
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12) Insurance CoveraCJe: (Attach copyL
al Insurance Company:
b) Policy U
c) State whether policy of cca:tiflcatlon on. file with the Highway Depart-
ment:
dl Coverage required extende'~. to the Town:
Bodily injury and propei'ty 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 years or 3 years
1'l) Fees for applications and permits: Basic Application Fee........ $25. 00
A 1. IService Connections .'oxcavations @ $20.00 = $
~
A2. IAdditional Excavations same service @ $10.00 ;:: $
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B. Excavations lOll in depth 'o'r, less:
0-100 l.f. ; $10.00 "
I.f. @ $0.10 -$
Additional
,
C. Excavations...l"Ou in depth _tQ51 in depth:
0-100 I.f. ; $30.00
,I.f. @ $0.30 ;',,$
Additional
D.
Excavations 51 in depth an',d over:
0-100 I.f. ; $50.00
I.f. @ $0.50 ;'$
j)7
Additional
/0
.pSoJ
E.
I
No.
/
Additional
Utility Repai~,:Excavations @$10.00 ; $
Repairs same service'@ $5.00 = $
F.
Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
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'Authorization is hereby granted to the Town Cleric of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance with .this application.
, '
SUPERINTENDENT OF HIGHWAYS
:~n;. Yn"
;' Raymon L. J~
Date
Received by the Town Clerl<
Date
Permit Issued,'
:Permit No.
/c:;c;
Date
~:
Permit expires one (ll year fr:om Orate of Issuance.
No work to start without tlU hour notice .to the Sl:Jperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
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- HIGH PRESSURE AS SERVICE RECORD ,/'-" ,,-..'(--.
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CPR-No.
Village /y(.)", \(' ('\~/f, Tax Disl. ) 3('C, CDA No.
Location # d.;,j Sf,
Name C, IlVr-'N/ Premises Used As
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Curb Cock Size L_R_M Main Cover lr-Q r
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Main Loc. Ft. Of Line. Size &: Kind
Tap Loc. Ft. Of House Line "
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Length of Pipe Laid-Main To Prop. Line ~O Size )/"
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Length of Pipe Laid-Prop. Line To Meter 31 Size
Reg. No. Insulating Coupling - Yes No
Done By Date /9?'P
C.C. Insp. By
Date -
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