HomeMy WebLinkAbout1705 Lakewood Dr
. .
Date: 10/13/00
Transaction(s):
Name:
Clerk 10: L1NDAC
1 Permits
Check#: 1002
Key. Span Energy
448 East Main Street
Patchogue. NY 11727
Town Of Southold
P.O Box 1179
Southold. NY 11971
* * * RECEIPT * * *
fJ J.A/Yy.J -II-!o 9'
Receipt#:
Total Paid:
1002
Subtotal
$45.00
$45.00
InternallD: 18914
File No.
. ( (j,
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic . Lane
Peconic, New Yorl< 11958
(516) 765~ 31 1[0
P. c. t2>o~ /78>
Pe~mit. No.
~
Ref. II d)7l( 33- d 5
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways ef the Town
of Southold for the issuance of an Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffoll< County, New Yorl<, 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, NEl, YORK
Address
11727
2)
Name of Owner of Premises
Address
3) 17 0 5"" 1-A-
Worl< Description
- '- A-<--<.- ~ e
(Street Number, Hamlet, Cross Street)
(a)
I's construction located within 75. feet of tidal wetlands? *Yes No
*If yes, other~town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~/~
Signature of pi ant
/ olyl oJ
Date
5) a) Attach plot plan showing location of proposed.el("cavation and relationship to
adjoining premises or public' streets or areas, and giving a detailed descrip-
tion of layout of excavation.
b) Attach all other necessary permits and licenses for this project.
c) Worl< covered by this application may not commence before issuance of a
Highway Excavation Permit by the Town CierI<.
Tax Map: Section
Blocl<
, Lot
6)
7l
Starting Date:
Completion Date
8) Worl< Schedule:
Phase
,
. \,
Completion Date
Excavation. . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . .
Facility Installation.................................
Bacl<fiIl & Compaction......... ~ . . . . . . . . . . . . . . . . . . . .
Pavement Replacement........ .:. , . . . . . . . . . . . . . . . . . . .
9) Under which authority is the application made:
10) Estimated Cost of Proposed Worl<:$
11)
Remarl<s:
\'
D-39
Page 1 of 3
12) Insurance Coverage: (Attach copy)'
a) 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
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
2 years or
3 years
14)
Fees for applications and permits:
A 1. / /Service Connections
NCJ.""
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25.00
excavations @ $20.00 = $ ,;)O"~
No.
B. Excavations 18" in depth 'oi~ less:
0-100 I.f. = $10.00
I.f. @ $0.10 -.$
Additional
C. Excavations.ol"S" 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-- S
. .
I..l~'-.,co
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.
SUPERINTENDENT OF HIGHWAYS
TOWN OF SOUTHOLD, NEW YORK
~~O~{L.~S~
/0 ~ /0 - 0 D
Date
Received by the Town Clerk
Date
Permit Issued\'
Permit No.
Date
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hbur notice 'to the Sl:lperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
0-39
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