HomeMy WebLinkAboutWendy Dr
Date: 07/10/00
Transaction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits .=:lIS '1
Check#: 889
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Total Paid:
889
Subtotal
$120.00
$120.00
Internal 10: 14625
Permit No. S9
File No. Sf
TOWN OF SOUTHOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765~ 31110
Po. 12>01- 17 e:,
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
RECEIVED
JUl 6,
Ref. 11,;)(,.,~3o' OJ
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 m1ake: necessary "inspections of the job site.
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name of Applicant
)' ATCHOGUE, NEW YORK
Address
11727
2)
~ tf'..cJ A-LJ
'" ,eeL.
Street)
Name of Owner of Premises Address
A TtZe.-'cl. ,~ 1'-< Pt;V<Y'-'<:>;" ~.. I'-<: ed~ d,,<'
3) D,J ",c!. ~(L (., ~I.' eco,..Jcc.6 '31"',0
Work Descnption and Location (Street Number, Ha let, Cross
(a)
Is construction located within 75 feet of tidal wetlands? *Yes No P
*If yes, other-T'own permits may be required. -
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
/fhA~l /~
Signature of Ap i nt
&!2g/(JlJ
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 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:
\'
0-39
Page 1 of 3
12) Insurance Coverage: (Attach copy)
a) I nsurance Company:
b) Policy #
c) State whether policy of certification 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:
a) Surety Bond
total 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
~
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ C) 0
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--l'8" in depth to 5' in depth:
0-100 I.f. = $30.00
/ ~ LI~
J 0 ,I. f. @ $0. 30 = $ '.2. J
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 cowr,' $ / c!2o ,00
~ .
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to: "My ,Jfl&h.) ~ 1At'I
in accordance with ,this application.
SUPERINTENDENT OF HIGHWAYS
TOWN SOUTHOLD, NEW YORK
~
cobs
7../ :J-- tJ tJ
Date
Received by the Town Clerk 7- If, - [)c)
Date
Permit Issued,' 7-1/)~oo
Date
Permit No. 69
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice 'to the St:lperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
D-39
Request for
REQUEST FOR PERMIT
Permit required to open!
Permit FEE* $
1Jk
.
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71f-€ ~~~.rI
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Gas Service for
o Q.N. 0 Cent. 0 W.5.
.5.
Permit Requested By:
TD (300
Type of Road
"'.:23 f) '03<) Charge account #
Work Request #
o To be billed
o No fee
* 0 Disbursement to be made out of petty cash
New Business Department
o Underground Lines Department
FC-1145.6-SS
Return Permit To:
DOper. Plan. & Cont. Center
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