HomeMy WebLinkAbout240 N Riley Ave
"
Date: 10/05/00
Transaction(s):
Name:
Clerk ID: L1NDAC
1 Permits
Cash#: 989
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipl#:
Total Paid:
989
Subtotal
$45.00
$45.00
Internal 10: 18680
Permit No.. 0 F
File No.. 0Y
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Pecanic Lane
Pecanic, New Yark 11958
(516) 765'- 31110
P. D. /2>"1- I 7 E:>
. Ref. II ;)7;)1 10J
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to. the Superintendent af Highways ef the Tawn
af Sauthald far the issuance af an Excavatian Permit pursuant to. Chapter 83 af the
Cade af the Tawn af Sauthold, Suffalk Caunty, New York, and ather applicable laws,
ordinances ar regulatians far the excavatian herein described. The applicant agrees
to. camply with all applicable laws, ardinances, cades and regulatians, and to. permit
authorized inspectars to. mlake: necessary "inspectians of the job site.
Print ar Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name af Applicant
PATCHOGUE, NEW YORK
Address
11727
2)
Address
/ SJ.
. leJD c, .e 6-, d,J
(Street Number, Hamlet, Cross
Av-c,-
Street)
Name af Owner af Premises
3) c9'i 0 /lJ a~' e v I1v-c
Wark Descriptian andl Lacatian
(a) Is canstruction la9ated withih 75 feet af tidal wetlands? *Yes_Na
*If yes, ather-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 p I tit
cr. rl- d-' C5'U
Date
5) a) Attach plat plan shawing lacatio.nof prapased,elfcavatian and relatianship to.
adjaining premises ar publicstre.ets ar areas, and giving a detailed descrip-
tian af layout af excavatian.
b) Attach all ather necessary permits and licenses far this praject.
c) Wark cavered by this applicatian may nat cammence befare issuance af a
Highway Excavatian Permit by the Tawn Clerk.
Tax Map: Sectian
Black
, Lat
6)
7)
Starting Date:
Campletian Date
8) Work Schedule:
Phase
, \,
Campletian Date
Excavation.......................:................ .
Facility Installatian.................................
Backfill & Campaction......... ~ . . . . . . . . . . . . . . . . . . . .
Pavement Replacement..........,...................
9) Under which autharity is the applicatian made:
10) Estimated Cast af Prapased Wark: $
11)
Remarks:
\
0-39
Page 1 af 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 extendeCl 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. ...L-/Service Connections
No.
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ dJO. 6>
No.
B. Excavations 18" in depth 'or less:
0-100 I. f. = $10. 00
I.f. @ $0.10 -.$
Additional
C. Excavations...l'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
,5fLj
COM:: $' 5: dO
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 0 SOUTHOLD, NEW YORK
?~ ';<'6- 0=
Date
Received by the Town Clerk
9/q7s;.j)..
Date
Permit Issued, ,1~~c;J
Date
Permit No.
&,~
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice .to the S1:lperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
D-39
KEYSPAN/6ft's
REQUEST FOR STREET OPENING PERMIT
. .
FC~6111.4
D STATE
D
NASSAU
COUNTY
D SUFFOLK
COUNTY
o ~""~
APPROVED
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
SKETCH
k[}) If /6/ ~ 7-4
N
Lfj5io J
11 1)2--
~
- .
I-
""
~.
------
------ ~
~
\"