HomeMy WebLinkAbout185 Pequash Ave
Pen~it Mo. 0 ,~
-File No. &, :)
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765'-31110
Po. (2,01- t7E:>
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
Ref. 1/ d..~ R G, Y, 0 1
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 448 EAST MAIN STREET
Name of Applicant
PATCHOGUE, NEW YORK
Address
11727
2)
Name of Owner of Premises
Address
3)
~IC{,. .
(Street Number, Ham
....
t, Cross Street)
(a)
Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other-lawn permits may be required.
4) Builder's License No,
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~/~~
Signature of Iicant
.. ~/9/ 6.J
Date
5) a) Attach plot plan showing location ,of proposed.e5tcavation and relationship to
adjoining premises or public' streets or areas, and giving a detailed descrip-
tion of layout of excavation. '
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. . . . . . . . . . . . . . . . . , . '. . ... . . . . . . . . . . . . . . . . .
Facil ity Insta lIation. . . . . . . . . . . . .'. . . . . . . . . . . . . . . . . . . .
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
.'
'12) Insurance Coverage: (Attach copy)
a) 1 nsurance Company:
b) Policy #
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. I /Service Connections
~
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ :;10' @
No.
B. Excavations 18" in depth or: less:
0-100 I.f. = $10.00
I.f. @ $0.10 -,$
Additional
C. Excavations.-'1'8" 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
. ~u /(f)
CO~T- S . , , 5"....U..
., '
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 OUTHOLD, NEW YORK
~/' (/ ~OtJ
Date
Received by the Town Clerk
ff- II-of::,
Date
Permit I ssued\' l? - / Lj - 00
Date
Permit No. h.3
Note:
Permit expir,es 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.
Pa ge 2 of 3
D-39
KEYSPANpAS
REQUEST FOR STREET OPENING PERMIT
FC-6111.4
o STATE
O NASSAU
COUNTY
O SUFFOLK rvlfX1
COUNTY ~
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
APPROVED
~'j)"r /0/- 4.2 -~
SKETCH
N
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~
Date: 08/14/00
Transaction(s):
Name:
1 Permits
Check#: 941
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
941
subtotal
$45.00
$45.00
IntemallD: 16489