HomeMy WebLinkAboutMaple Ln
Date: 09/24/01
Transaction(s):
1 Perrpits
Cash#: 1316
Name:
Key, Span Energy
448 East Main Street
Patchogue. NY 11727
Clerk ID: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
k (J-'-i
1316
Subtotal
$15.00
$15.00
IntemallD: 40311
File No.
/l1tf
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Ref. n
I VII., VI" ..r..."" I ""..........
H IGHWA Y DEPARiMENT
Pcconic . Lane
Peconic, New' York '11950
rf? \~ '--1'17 (5.16) 76Sc31110
7(0;).0 P.o. f2,o'f- /7fY
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APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southald for the issuance of Dn Excnvation 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 excnvation herein described. The ilpplicant agrees
to comply with all applicable laws, ordini(~'~es, codes and regulations, and to permit
authorized inspectors to make: necessary )nspectlons of the Job site.
Print or Type
1) KRY SPAN RNRRGY ..R FAST MAIN STRRR~
Name of Applicant
PATCHOGUR, NEll YORK
Address
11727
2)
3)
Name of Owner of Premises Address
WO~~c~I~&on ~^:Ca:;-n (Stre~t Numbe/H~,Set ~~o~s Street)
(a) t"s construction lo~aled withih )5', feet of tidal wetlands? *Ycs_No ~
*If yes, other"'"!own permits may be required. --t---
II) Builder's License No.
Plumber's License No.
Electrician1s License No.
Other Tradc1s License No.
,'.
11___
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Date
S) aJ Attach plot plan showing locat;.o;, .of proposed,..",tcavation and relationship to
adjoining premises or public 'stre.cts or areas, and giving a detailco descrip-
tion of layout of cxctlvation. ;. .:~:
b) Attach all other necessary pcr~.i..ts rmd licenses for this project.
c) Work covered by this applicatlo~, may not commence before issuance of a
Highway Excavation Permit by:'tbe Town Clerk.
6)
7)
Tax Map: Section
Blocl,
, Lot
Starling Date:
Completion Date
0) Worl, Schedule:
~
.....
.":.\
Completion Date
Exca va tion. . . . . . . . . . . . . . . . . . .'; . .. ..{ . . -. . . . . . . . . . . . . . .
r-acility Installation...........~.:......................
Backfill & Compaction........ ..~....................
Pavement Replacement........ "'::"~""""""""'"
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: .$.
11) Remarks:
\.
..
[)-1"
PaCTe 1 of 3
12) Insurance CoveraCJc: (Attach copy).:
0)
b)
c)
Insurance Company:
Policy /I
State whether policy of cer;tiflcntlon on, file with the Highway Depart-
ment:
d) Coverage required ex tende'~. to the Town:
Bodily injury and propei'ly damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security:
0) Surety Bond or c:;ertified Check provided in the
total amount of $
b) Maintenance Bond provided: 2 yea rs or 3 years
"1)
Application Fee........ $25. 00
@ $20.00 = $
Fees for applications and permits: Basic
A 1. IService Conncctions.:cxcavatlons
""Nci:-
A2. IAdditional Excavations same service @ $10.00 :;; $
""Nci:-
B. Excavations 1811 in depth 'o'r: 'Iess:
0-100 I.f. = $10.00'"
I.f. @ $0.10 -;$
Additional
.'
C.
, .
Excavations~.l81l in depth tQ' "SI
0-100 I.f. = $30.00
I. f. @ $0.30 =:.$
. . .
in depth:
Additional
D.
Excavations 5' in depth and over:
0-1001.f. =$50.00 .:
I. f. @ $0.50 ,;,'$
Additional
oJ
E.
t
No.
t
Additional
Utility Repair,.::Excavations @$10.00 = $ /0
fZlSvJ
Repairs same sc'rvicc'@ $5.00:;; $ ..",.
F.
Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
',.',
* * *
'1~OT^I. co~'t ~
VJ
./ s:-
'Authorization is hereby granted to the Town
Issue a Highway Excavation Permit to:
in accordance with .this application.
CierI< of the Town of Southold to
,
s\:lPERINTENDENT OF HIGHWAYS
T'OWN SOUTHOLD,. NEW YORK
'.
0./
Received by the Town Clerl<
9- i Lj:; 01
ate.
Permit Issued,' q - ~ 1/-("') I
Date
. Permit No. / eX V
Note:
Permit expires one (1) year fr:om Date. of Issuance.
No work to start wit.hout flD hour notice -to the Sl:Iperintendcnt of Highways.
Permit must be available for inspection.
~ ""
Page 2 of 3
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HIGH PRESSURE GAS SERVICE RECORD
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, ,t;)' "":""'" . - . CPR-No. '-! _ -,'!
; 1:>,--', ,_/11 (J, -?rakist. /:;'/)() CDA No.
).) \" ,." r fo_
, .
(')(1" i- (l ~ Premises Used As
4
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-
Cas-2083 Li
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Village
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Location #
Na~e V;'~ (' P f\1 t-
.
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-../'.
Curb Cock Size.
L_R_M
, Main Cover
Main Loc.
Ft.
Of
Line. Size & Kind
"
1
Tap Loc.
Ft.
Of
House Line
/
'/5'
'/6'
Size
3..</
. >
.
,
Yy
..
Length of Pipe Laid-Main To Prop. Line
I
Length of Pipe Laid-Prop. Line To Meter
Size
Reg. No.
Insulating Coupling - Yes
No
~
. -
Date /tj/ ~R
I I=I=I-I=E
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Done By
C.C. Insp. By
Date
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