HomeMy WebLinkAboutKimberly Ln Lot 10
Date: 07/25/00
Transaction(s):
Name:
Clerk 10: L1NDAC
1 Permits
Check#: 923
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
923
Subtotal
$269.40
$269.40
InternallD: 15585
File No. ~-
TOWN OF SOUTHOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765'-31110
P. o. /2>0r- 17 e.
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Perm;t No. ({7/
.. . I
,;).~ fc, ~7 - 0 'S
APPLICATION IS HEREBY made to the Superintendent of Highways of 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
PATCHOGUE, ~, YORK
Address
11727
2)
Name of Owner of Premises
Address
3) L4JT 10 K,.....~_l
Work Description nd
t...... ~O~ {\..~I J - r,...,. """-I ( 6-rY ,4-,'-
Location (Street Number, Hamlet, Cross Street)
(a) Is construction lo~ated withiri75 feet of tidal wetlands? *Yes---=--No 'P
*If yes, other-Iown permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~ \~ .,~-
, ' Signature of licant
,- J--o - c5D
Date
5) a) Attach plot plan showing location of proposed.e:j('cavation 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. . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . .
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
..
12) Insurance Coverage: (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) Security:
a) Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
14)
Fees for a pplications a nd perm its:
A 1. I IService Connections.
~
2 years or 3 years
Basic Application Fee...... .G5. 00)
excavations @ $20.00 = $ d6 OV
A2. IAdditional Excavations same service @ $10.00 = $
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.-u9
{{(Vir _I.f. @$0.30=$ 19<;. 4f()
Ad itional
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 Co~r:' ~ c;,) 6/1- Y ()
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 SOUTHOLD, NEW YORK
Raymond
I - ,;z c;?~Oc:7
Date
Received by the Town Clerk
l/as/CJo
Date
Permit
Issued, '7/0(0-/00
. Date '
Permit No.
(y/
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
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