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Permit NO'1 I
. File No, / 'J--/
/ I
Ref. 117/00() 7;;11,)]
TOWN OF S;)U.,'HOLD
H IGHWA Y DEPARTMENT
Pcconic Lane
Peconic, New. York -11956
(516) 765c31110
P.O, {2,<1- ,7e,.
,
APPLICATION/PERMIT FOR HIGHW),Y EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the iSSUilncc of nn ExcuvaUon Permit pursuant to Chapter 83 of the
Code of the Town of Southold. Suffolk County, New York, and other applicable lilWS,
ordinances or regulations for the excavafion herein described. The applicant agrees
to comply with all applicable laws, ordina:rlces, codes and regulations, and to permit
authorized inspectors to make; necessary./nspcctions of the job site.
Print or Type
1) KRY SPAN ENERGY 44R EAST MAIN STREET
Name of Applicant
11727
PATGHOGUE. Nm~ YORK
Address
2)
Address
1'1 ~\C.-L.-e "'-
Hamlet, Cross Street)
Name of Owner of Premises
\J ST
work' ~s~ri;ti~ ~nd Location {lle~t
." (Z\e
~
,oJ \
1'-'1 cJ
Number,
3)
(a)
1's construction located withiil'75 feet of tidal wetlands? "'Yes No ",0
"" f yes, other"""Town permits may be requi red.
II) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
nt
5) a) Attach plot plan showing location ,of proposed. ex'cavation and relationship to
adjoining premises or public'stre,cts or areas, and giving a detailed descrip-
tion of layout of excava tion. .
b) AtrDch all other necessary perml.ts 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.
6)
7)
Tax Map: Section
Blocl<
, Lot
Completion Date
Starting Date:
3) Worl< Schedule:
~
Completion Date
,\
Excavation. ... .................. ..: .................
Facility Installation............:....................
Backfill & Compaction.........:....................
Pavement Replacement........ '.:......................
9) Under which authority is the appli~'ation made:
10) Estimated Cost of Proposed War Ie $
11)
Remarks:
"
0-111
Paqe 1 of 3
12) Insurance Coveraqe: (Attach copy).
a) Insurance Company:
b) Policy ff
c) State whether policy of ce~tification on. file with the Highway Depart-
ment:
d) Coverage required extende~ to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security:
oj Surety Bond or Certified Check
total amount of $
b) Maintenance Bond provided: 2 years or
provided in the
3 years
II,)
Fees for applications and permits:
A 1. -L-IScrvicc Connections
No.
Basic Application Fee........ $25. 00
, ~
excavations @ $20.00 = $ ? d
A2. IAdditional Excavations same service @ $10.00 = $
--;:ro.-
B. Excavations 1811 in depth o'r: less:
0-100 I. f. = $10.00 "
I.f. @$0.10-;$
Additional
C. Excavations...l811 in depth -tc:;>51 in depth:
0-100 1.f. = $30.00
, 1. f. @ $0.30 =',$
Additional
D. Excavations 51 in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 ='$
Additional
E.
Utility Repair :Excavations @$10.00 = $
No.
Rcpc:lirs same scrvicc@ $5.00 = $
Additional
F.
Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
'.~,. .-
. . .
~
TOTAL CO~T' ~ y:;:
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance wi th ~this application.
ENT OF HIGHWAYS
UTHOLO, NEW YORK
aymo d L.
8-~ 3~OI
Date
Received by the Town Clerk
Rj 3 /0.1
Ollte
Permit Issued,'
0/" III (
Opte
Permit No.
J) V
. ,
~:
Permit expires one (1) year f~6m Date of Issuance.
No work to start without tll) hour notice .to the Sl:.Iperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
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FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
KEYSPAN/G-4S
REQUEST FOR STREET OPENING PERMIT
D STATE
D
NASSAU
COUNTY
D SUFFOLK
COUNTY
W .sa U/ -r#cLdJ
DATEr/3/ZtDOO
~ ~',if/O /i&kllu
I ~ ,I __ DEPARTMENT
1///1 ..Jc.-/fU/2- GAS CONSTR. MAINT. & SERVICES
6~'u rrj I t/. - 2.13 - 4
N
Date: 08/06/01
Transaction(s):
1 Permits
Cash#: 1271
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1271
Subtotal
$45.00
$45.00
Internal 10: 38052