HomeMy WebLinkAbout1615 Fleetwood Rd
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765~31llO
Po, (2,01- t7f:'>
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
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.' .Permit No.
File No.
. Ref. 11;;).(0 R () -j- 0 ')
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 mlake: necessary ,inspectionS of the job site.
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name of Applicant
J'A'TCHOGUE NEW YORK
Address
11727
2)
Address
Name of Owner of Premises
3)
Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other-"{own permits may be required. -
(a)
Plumber's License No.
ij) Builder's License No.
Other Trade's License No.
Electrician's License No.
(Y'A~.! bk~#fr--
. '. s.gnature of p Icant
i. <6\q\ov
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:
Completion Date
Phase
, \.
Facility Installation.................................
Backfill & Compaction..............................
Pavement Replacement........ .......................
9) Under which authority is the application made:
Excavation.................. ....... .................
\
10) Estimated Cost of Proposed Work: $
11) Remarks:
\'
~
Page 1 of 3
0-39
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12) Insurance Covera9~: (Attach copy)'
a) Insurance 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) ?ecurity_:
a) Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
"provided in the
'" Fo" fo' "ppl I~,IM' ,nd poem"" B"' Ie Appll~"nn F.o........ ,,,.00
A 1. /Service Connections excavations @ $20.00 = $ ,;26' &;
~
A2. /Additional Excavations same service @ $10.00 =
No.
B. Excavations 18" in depth o'r: less:
0-100 l.f. = $10.00
l.f. @ $0.10 -,$
2 years or
3 years
Additional
C. Excavationso,l8" in depth lOS' in depth:
0-100 \.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
Utility Repair Excavations @$10.00 = $
E.
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 CO~T-) Lf!) >... oD
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 OF UTHOLD, NEW YORK
s
Date
Received by the Town Clerk
1?'-II-lJO
Date
Permit No. 0 ~
Permit \ 'sued, '
[1-/tf-{)()
Date
Note:
-
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice 'to the Stlperintendent of Highways.
Permit must be avait'able for inspection.
Page 2 of 3
0-39
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Fe-61 \ 1.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
SKETCH
KEYSPAN(hS
REQUEST FOR STREET OPENING PERMIT
o STATE
it.!./iJo1IJ ,a , JUI~~ rn
rkvJ ~ Slier. ,560',Al/b
FOREMAN
~.
O SUFFOLK M (i ---"I
COUNTY l6 0G '-' '( /T &! t-D
'tS~5- 630
711~ {,./, s ,',.; 1!1~
C,.fSI,6A Y .b.
Itv' /,J .e11...1i
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
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Date: 08/14/00
Transaction(s):
Name:
Town Of SouthOld
P.O Box 1 H9
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 941
Total Paid:
Key, Span Energy
448 East Main Street
patchOgue, NY 1 H27
Clerk 10: LlNDAC
941
subtotal
$45.00
$45.00
Internal 10: 16488