HomeMy WebLinkAbout745 Love Ln
Date: 09/04/01
Transaction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 1291
Total Paid:
,{
/:) 0(Uf' ~O
-'( ~ \
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk ID: L1NDAC
1291
Subtotal
$45.00
$45.00
Internal 10: 39603
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File
NO.! C1 ZJ
,
TOWN OF S;AJ ,'HOLD
H IGHWA Y DEPARTMENT
pcconic 'L~ne
Peconic, New' York "'950
(5.16) 7GSc31l.0
P. o. t2>o~ Oe.
"
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.
n -/iooc7f7g:!
APPLICATION 15 HEREllY made to the Superintendent of Highways of the Town
of Southold for the issu~nce of an Excav~,tiori Permit pursu~nt to Chapter 03 of the
Code of the Town of Southold, Suffoll< County, New York, and other applicable laws,
ordinances or regulations for the exc~vafion herein described. The applicant agrees
to comply with all applicable laws, ordina~'~es, codes and regulations, and to permit
authorized inspectors to make: necessary "inspections of the job site.
Print or Type
1) Km' SPAN I~NERGY !,I,R EAST MAIN STREEt
Name 0 App icant
PATcnOCllE Nm-1 YORK
Address
11727
2)
Name or Owner or Premises
Address
3)
7 Y 5 '- OlX (, A-o-<.. JV1 ,+ TT7 Tl-< c... ~
Work Description and Location (Street Number. H~lUlet, Cross Street)
(a) t"s construction IO,J:ated Withih'3s- feet of tidal wetlands? *Ves_No F
*If yes, other--!own permits may be required.
II)
Builder1s License No.
Plumber1s License No.
Electrician's License No.
Other Trade's License No.
t
5) a) Attach plot plan showing locati'on .of proposed.,-e:>(cavation and relationship to
adjoining premises or public'stre.cts or areas, and giving a detailed descrip-
lion of layoul of cxcava lion. .'
b) AU~ch all other necessary pcrrill,ts and licenses for this project.
c) Work covered by this applic..1tion may not commence before issuance of a
Highway Excavation Permit by:the Town Clerl<.
G) Tax Map: Section Blocl< Lot
" " 7) Starling Oatc: Completion Date
0) Work Schedule:
~ .' Completion Date
.: \,
Excavation... .... ........ .., ....- .\~.. ~..............
Facility Installation...........::....................
Backfill & Compaction......... ~ . . .. . . . . . . . . . . . . . .. .
Pavement Replacement........ '.':.......................
9) Under which authority Is the application made:
10) Estimatcd Cost of Proposed Worle $'
11) Remarks:
\
0-10
POClC ,. Of' T-'."" . .
L.
12) Insurance CoveraCJe: (Attach copyL
a) Insurance Company:
b) Policy"
c) State whether policy of ce~t.ificatlon on. file with the Highway Depart-
ment:
d) Coverage required extend~,~. to the Town:
Bodily injury and prope,rty damage: $300.000/$500.000 Bodily Injury.
and $50.000 property d,"nage.
13) Security:
aJ Surety llond or Certified Check
total amount of $
b) Maintenance Bond provided: 2 yea rs or
1 tl) Fees for applications and permits: Basic Application Fee........ $25. 00
A 1. ....l-/Service Connections 'excavations @ $20.00 = $ 2-0 %'
No.
A2. /Additional Excavations same service @ $10.00 = $
~
B. Excavations 10" in depth 'o'r. 'Iess:
0-100 i. r. = $10.00 ,',
l.r. @ $0.10 <$
Additionai
C.
, '
Excavations."l'Oll in depth tQ '51
0-100 I.f. = $30.00
i. r. @ $0.30 =.'$
Additional
provided in the
3 years
:i
in depth:
D. Excavations 51 in depth an~ over:
0-100 I.r. = $50.00,
i.f. @ $0.507'$
Additional
No.
Utility Repai~,:Excavations @$10.00 = $
E.
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.
';",
t.?-
. . .
TOTAl. CO~T. ~ Y s::
'Authorization is hereby granted to the Town Clerl< of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance with -this application.
Received by the Town CierI<
S?- 3 J ::O(
Date
Permit Issued,' 9- <./. or
Date
S0PERINTENOENT OF HIGHWAYS
TOWN OUTHOLO. NEW YORK
, .
p--.~ J ( ~ of
Date
Parmi t No.
/ cil ()
~:
Permit expires onc (1) YC<lr fr:om Date of Issuance.
No work to start without '18 hour notice 'to the Stlperintendent of Highways.
Permit must be ilvilifable fori~spection.
Page 2 of 3
Fe-Gll1.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.OJPA
NO.
REQUESTED
BY
APPROVED
SKETCH
KEYSPANj6-AS
REQUEST FOR STREET OPENING PERMIT
D STATE
D
NASSAU
COUNTY
D SUFFOLK
COUNTY
MIS JOB~
NO. '110o~ 79703
LDIIL LIhJl.' IL lis/Moo ,4,v~F:.
~.i, 4f:; ,oil IYJlffJi/ucK
FOREMAN
I ~ IJ ~ DEPARTMENT
VIii ..J?flttlZ- GAS CONSTR.
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DATE OF a/ /.
OPENING I /7 2.00/
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DATE
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