HomeMy WebLinkAboutGrand Ave and Wickham Ave
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Date: 10/13/00
Transaction(s):
1 Permits
Cash#: 1000
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk ID: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
fJ~ *76
1000
Subtotal
$45.00
$45.00
Internal 10: 18915
.Permi"t No. rz 0
'File No. 70
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765'-31110
P.o.l2>o1- t7t>
Ref. /I :;) 7 ~ Oe;. O.s
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, 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 m1a,ke: necessary .,inspections of the job site.
Print or Type
1) KEY SF AN ENERGY 44R EAST MAIN STREET
Name of Applicant
PATCHOGUE, NE1-! YORK
Address
11727
2)
Name of Owner of Premises
Address
3) 6ell~ t-.lL) ,IU s.t.O'-Lt,L I\-l'"" k Slv::. j....T6..'<Ll2>- r (rA."..J.... Wlc1cl....--.-
Work Descnption and Location (Street Number, Hamlet, Cross Street)
(a)
Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other-"(own permits may be required.
No
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~~
Signature of A pi nt -
/0-;) - CN
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
Tax Map: Section
Block
, Lot
6)
7)
Starting Date:
Completion Date
8) Work Schedule:
Phase
, \
Completion Date
Excavation............... ... .......................
'.
Facility Installation...........,:....................
BackfiI I & 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
;2) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy it
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
14)
Fees for applications and permits:
A 1. ( IService Connections
No.
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ ...:J..o. ~
No.
B. Excavations 18" in depth 'of: 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 cas.I:' S "(5.o..,6/>
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 H IGHWA YS
TOWN OF SOUTHOLD, NEW YORK
~~~
......., '. Raymond L. obs
/(J- /t? ~ cV
Date
Received by the Town Clerk
/tY/ltL~ '.'
ate'
Permit
IsSUed'/2../I'JO
I Date
Permit No.
1D
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice 'to the Sl:Iperintendent of Highways.
Permit must be available for inspection .
Page 2 of 3
D-39
O NASSAU 0 SUFFOLK
COUNTY COUNTY
I MIS JOB " IDATE~ / I
NO. ;21c/of-().3~ 7/3()/.:lI)~a
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.
KEYSPAN/lj-A S
REQUEST FOR STREET OPENING PERMIT
FC-6111.4
o STATE
~
s-.....~Wl
PENRO~IT~
LO~-~TI~~ uJ/~LP",r1l AilE-
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED 1/ .1' / r-:'" -r::.
BY f..t.VI{'J jt-ftWZ--
DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
APPROVED
SKETCH
M'~~ /0/-5-2.
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