HomeMy WebLinkAboutCR 48
Date: 09/24/01
Transaction(s):
1 Permits
Cash#: 1316
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 * * *
;r\
Receipt#:
Total Paid:
1316
Subtotal
$15.00
$15.00
InternallD: 40318
. File' NO'~
I vlln vr ~;..v: I"""".......
H IGHWA Y DEPARTMENT
Pcconic'Lane
Peconic, New' Yorl, '11956
Pre \-t <-I\.{7 [5-16) 765c31110
7(.,;).0 p.o.t2>oY- 176'
;1..
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
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Ref. n
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the iSSlIance of Dn ExcDva,tlon Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffoll, County, New York, and other applicable laws,
ordinances or regulations for the excnvafion herein described. The applicant agrees
to comply with all applicable laws, ordinab'ces, codes and regulations, and to permit
authorized Inspectors to make: necessary \inspectJons of the job sIte.
Print or Type
1) KIlY SPAN ENERGY I,I,R EAST MAIN STRERt
Name of Applicant
N cl rL "-'.
Name of Owner of Premises
'.
PATCIlOGUE, Nml YORK
Address
11727
2)
(Z.o~
3)
Address
S,) LA 7k~1 :J
Work Description and Location (Street. Number. Hamlet, Cross Street)
(n) rs construction lo,cated withih ~:'i5' feet of tida~ wetlands? *Yas_No ~
*If yes, other-.':(own permits may be required. r-
II) Bullder's License No.
Plumber's License No.
Electrlcian1s License No.
Other Trade1s License No.
::(.
'.. ......
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....,.
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5) aJ
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b)
c)
Attach plot plan showing locatfon .of proposed,,'e~fcavation and relationship to
adjoining premises or public'stre.cts or areas, and giving a detailed descrlp-
lion of layout or excavation. ;. ,::..,
Attach all other necessary perrn.~.ts and licenses for this project.
Work covered by this applic<'tio~. may not commence before issuance of a
Highway Excavation Permit by:'the Town Clerk.
Tax Map: Section
Blocl<
, Lot
6)
7)
OJ
Starting Date:
Worl, Schedule:
Completion Date
.',
Pha se
::.\
Completion Date
Exca va tion. . . . . . . . . . . . . . . . . . .'; . .. :., . . ~ . . . . . . . . . . . . . .
,
Facility Installation........... ~ :.. ~'.................
Backfill & Compaction.."....,,:..........,.....,.,'
Pavement Replacement........ ~':,..~...................
9] Under which authority is the application made:
16) Estimated Cost of Proposed Worl<:$'
11)
Remarks:
\'
.,.!.'.
0- ~"
Paqe 1 of 3
1"2)
Insuranca Coveraqe: (Attach copy).:
al Insurance Company:
b) Policy 1/
c) State whether policy of ccr;t.iflcation on, file with the Highway Depart-
ment:
d) Coverage required ex tende~. to the Town:
Bodily injury and prope;'ty damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security:
a) Surety Bond or .Certified Check
total amount of $
b) Maintenance Bond provided: 2 years or
provided in the
3 years
111) Fees for applications and permits: Basic Application Fec........ $25. 00
A 1. /Service Connections.'~xcavatlons @ $20.00 = $
~
A2. IAdditional Excavations same service @ $10.00 = $
~
B. Excavations 10" in depth or. less:
0-100 I.f. = $10.00..
I.f. @ $0.10 -;$
.'
Additional
C.
, .
Excavalions~."8" in depth -tt:;> '5' in depth:
0-100 I.f. = $30.00
I.f. @ $0.30 <$
D.
Addi tional
Excavations 5' in depth and over:
0-100 I.f. = $50.00,
I.f. @ $0.50 7~$
Additional
l)7
E.
I
No.
/
Additional
I()
-PSt:?
Utility Repalr;Excavations @$10.00 = $
;....
Repairs same ~ervicc .@ $5.00 = $
F.
Notice to public utilities proof must be provided
this application prior to issuance of permit.
~{, .
and attached to
* * *
TOTAl. cowr ~
~
IS:-
"Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance with ~this application.
s\:lPERINTENDENT OF HIGHWAYS
"p~ SOUTHOLD" NEW YORK
, tf? ~
. . . Raymond L~S
~--- (IN ~O/
Date
Received by the Town Clerk
9~ jtj~O(
Date
Permit Issued,. q. ~ c.f - D(
Da e
.,.:
)2lJ
Parmi t No.
~:
Permit expires one (1) year fr:om Date. of Issuance.
No work to start wit.hoUl '10 hour notice .to the S\:Jpcrintendcnl of Highways.
Permit must be available for inspection.
Page 2 of 3
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