HomeMy WebLinkAboutOld Shipyard Rd
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 Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
/l
t\d
1316
Subtotal
$15.00
$15.00
IntemallD: 40315
Fiie NO.P7 HiGI:IW\Y'D~PARTMENT
Pcconic Lane
Peconic, New' York ,11956
Ref. 0 r t< \.t '-jl.f 7 (SlG) 7GSC311lO
7 fe,~() P. o. t2>o~ 175'
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APPLICATION/PERMIT FOR HICHW'AY EXCAVATION AND REPAIR
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APPLICATION IS HERE!lY made to the Superintendent of Highways of the Town
of Southold for the issuance of .m Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Surfoll< County. New York. and other applicable laws.
ordinances or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordina~'~es, codes and regulations, and to permit
authorized Inspectors to make; necessary .,Inspectlons of the Job site.
Print or Type
1) KP.Y SPAN ENERGY ~~R EAST MAIN STREE1
Name of Applicant
PATC1l0CUE. NF.\I YORK
Address
11727
2)
Name of Owner of Premises
Address
3)
""J td. S'".., i\.--~l t:J
Work Descriptio nd Location (Street. Number, Ham ct, Cross Street
(3) 1's construction IO.!=Bled Withiil.:'is' feet of tidal wetlilnds1 1\Yes_No ~
*If yes, othe,...-!own permits may be required. r--
II) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Tradel s License No.
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5) aJ Attach plot plan showing locat;'oo .of proposed,'cx'covation and relationship to
adjoining premises or public'stre.ets or areas, and giving a detailed descrip-
lion of layout of excavation. .',
b) Attach all other necessary permi.ts and licenses for this project.
c) Work covered by this applicati~?l, may not commence before Issuance of it
Highway Excavation Permit by:t1:te Town Clerl<.
G)
7)
Tax Map: Section
!llocl<
. Lot
Starling Date:
Completion Date
OJ Worl< Schedulc:
,',\
Excavation. . . . .. . . . . . . . . . . . . .'. . .. "\ . . . . . . . . . . . . .,. . .
Phase
Completion Date
I'acility Installation...........;:..~'.................
Backfill & Compaction......... ~....................
Pavement Replacement........ ,':..,. . . . . .. . . . . . . . . . .. . .
9) Under which authority is the appllealion made:
10) Estimated Cost of Proposed Worl<: $'
11) Remarks:
\
..1....
',.
0-1"
Paqc 1 or 3
12) Insurance CoveraC)e: (Attach copyL
a)
b)
c)
Insurance Company:
Policy II
State whether policy of ce~tiflcallon on, file with the I-lighway Depart-
ment:
d) Coverage required extende~. to the Town:
Bodily injury and propcr'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)
Basic Application Fee........ $25. 00
~xcavations @ $20.00 = $
Fees for applications and permits:
A 1. IService Connections.
~
A2. {Additional Excavations same service @ $10.00 :; $
~
B. Excavations 1811 in depth 'o'r: less:
0-100 1. r. = $'0. 00 "
I.r. @ $0.10 -;$
,
Additional
, '
C. Excavations-..lOll in depth tQ51 in depth:
0-100 I.f. = $30.00
, I . r. @ $0. 30 <$
Additional
Excavations 51 in depth and over:
0-100 I.r. = $50.00 ,',
I.f. @ $0.50 ';'\$
Additional
D.
l)7
E.
I
No.
/
Additional
Utility Repai~:,::Excavations @$10.00 = $ /0
Repairs same ~'brvicc -@ $5.00 = $ R S vJ
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F.
Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
:r
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IS:-
'rOTA!. co~'r ~
.Authorization is hereby granted to the Town
issue a Highway Excavation Permit to:
in accordance wi lh ..this application.
CierI<: of the Town of Soulhold to
"
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,
s8PERINTENDENT OF HIGHWAYS
T,~,\'1~ F SOUTHOLD" NEW YORK
,; ~p.
" Raymon L~~ s .
<J-- ..;Uf-ol
Date
Received by the Town CierI< Cj- d 1./-0 ('
Date
Permil Issued,'
Pcrmi t No.
/~/ '1
~:
t) -tjl./-() (
Date
Permit expires one (1) year fr:om Date of Issuance.
No work to start wit.houl '10 hou,r notice -to the Sl:Jperintendenl of Highways.
Permit must be avallable for inspection.
Page 2 of 3
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DATE
No..' 0- s:.1..2X'O..._..Y
/CJtf-/7-V
1t>8-Y~;mGIIPRE~~URE GAS SERV~CEn:ECORD' .
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Town._S...Q...'L.:i.liil,.~-....:...._..........:...Tax' Dist....L,3..0_0~..Order N~..67.:-_~~IJ.~L.
Location w.Ji.Qj.,~.~'il.Ey.a&ll.\3..D/......1..-f.:~J.~L.b_/;L~l!.i~f::.....\!.!?...~--_......---~..._:...
~,<}1(6.11R.,Q Ll E~.lI E! '" " . ,'" -<: .nl"NC 10
Name="""~.J:LS.>.J,.'>l..u_c,,,.__...._...Premlses Used as..l.~..t.='l(.......'..'........_---
.. ' ~/ 1/ :i'S :J j" . 3'"
. Curb Cock ,..'f Size &: Kind of ~ain ~, 'Size of Tap.... 'X- Cover 'at Mail'! 1..- ()
Location of Main_._-1.2._..~.:._.___Ft..==......ln.!;..M..:r:~of..t!:\c;,:r..f'l3.p.1'......Line
Location of Tap.._....L!L__..~_J:t.':=::"'_In2.Q.Y..I.I::lOf.......tt,!2.E.:I.a....._..House Line
o . ' -//'1:, 3'
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KlOd of PavlOg , ..~____._..._.slze of Cuts 10 PavlOg._..... -- -.-. ...--........
, '.. '31 .1
Length of Pipe' Laid.. Main to Prop. Line.._............_~._?....__..........__..:.size._.:J..'i..,,_..._._'
Length of Pipe Laid.. Prop. Line to MeteL_.__...' ..:f...:J.:_..........__........Size_.~1..._.._.......:..._-
Regulator_n.L7....2...:J..._- E coN 0 t:I.I..'i.__._.._.__.. Vent Pipe.._..: '-::......~.._..._..-
Done By..:JS..~_L '{ O..l:L~_._._......._~..._._._Date_.-.._..'3::? .':1.:..::fD --'-""--
CC INSP, BY
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