HomeMy WebLinkAboutRT 25 and Laurel Ave
,
Date: 09/21/00
Transaction(s):
Permits
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of Southoid
P.O Box 1179
Southoid, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
o
Subtotal
$303.60
$303.60
lnternallD: 18134
, Pen;'t No. '0'S
Fil~ NO: (P5
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic 'Lane
Peconic, New York 11958
(516) 765'-31110
PO, f2,oy- 176
Ref. 1/ d7/ Vf.:,-o..f
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 make: necessary _"inspections of the job site.
Print or Type
1) KEY SPAN ENERGY 4411 EAST MAIN STREET
Name of Applicant
PATCHOGUE, Nm. YORK
Address
11727
2)
Name of Owner of Premises
Address
3) IlIJ Ie.." ~<"'C n 0- J /... s{l- a-5 --- Lf'r-t........ d L~ .. L 11 ",-l(-e' L
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction lo}:ated withih75, feet of tidal wetlands? *Yes No
*If yes, other-Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~A~--l, ~
' Signature of Api ant
',. q ~ \ K-''' 0\)
Date
5) a) Attach plot plan showing location ,of proposed.ex'cavation and relationship to
adjoining premises or public' streets or areas, and giving a detailed descrip-
tion of layout of excava tion.
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 Clerk.
Tax Map: Section
Block
, Lot
6)
7)
Starting Date:
Completion Date
8) Work Schedule:
Phase
,
'\
Completion Date
Excavation.... ..........,... .'. ...,......... ........
\
Facility Installation............ .'"...,.,............
Backfill & 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
121 fnsurance Coverage: (Attach copy)
a) I nsurance 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
tota I 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. /Service Connections
No.
. Basic Application Fee........ $25. 00
excavations @ $20.00 = $ ;:) D _6)...-
A2. /Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth 'o'r less:
0-100 I.f. = $10.00
I.f. @ $0.10 -$
Additional
C. Excavations."l8" in depth to 5' in depth:
0-100 I.f. =-$30.00
7~ 9. ,I. f. @ $0. 30 =$ .()~lr - (., 0
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 attaCl1ed to
this application prior to issuance of permit.
* *- *
1:.
TOTAL CO~T> 303-.. "0
Authorization is hereby granted,to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to: -t""i1d Sf'Jf}4
in accordance with "this application. ,,' '. I
SUPERINTENDENT OF HIGHWAYS
TOWN 0 OUTHOLD, NEW YORK
c:w
Received by the Town Clerk Q - rOJO- 00
Date
Permit Issued,' 9-02/- /)0
Date
Permit No.
05
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice 'to the Sl:lperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
D-39
,
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
IN SPECTOR'S
RECORD
I nspection Date.
Findings .(use code)
1st
2nd
3rd
4th
.-.~-"
D-39
REMARKS
CODE
Applicant Notified
(To Permit Clerk)
..~.-
I B - Improper barri~ades
IL - Improper -lights\
ST - Sunken trench .or, excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Construction
WIP - Work in. progress
DB -Improper backfill. (too high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR Ready to repair
\
Page 3 of 3
-
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
FG-6111.4
o STATE
o
SUFFOLK
COUNTY
~
PERMIT
NO.
LOCATION
t:V i.J S; ;/...:Ii-
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
APPROVED
SKETCH
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