HomeMy WebLinkAbout675 Locust Ave
Date: 07/13/01
Transaction(s):
1 Permits
Check#: 1249
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
4 lid
1249
Subtotal
$45.00
$45.00
InternallD: 36692
Permit No;
.File NO'~
Ref. /I ",/ {)"{>{,:J 't ("
TOWN OF 5;,0 "HOLD
H IGHWA Y DEPARTMENT
Peconk Lane
Peconic, New' Yorl< -" 958
(516) 765c31110
Po.t2>o'l- ,78>
"
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
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 excavaUon herein described. The applicant agrees
to comply with all applicable laws, ordina_~'ces, codes and regulations, and to permit
authorized inspectors to make; necessa ry \ inspections of the job site.
Print or Type
1) KF.Y SPAN ENERGY "4R EAST MAIN STREET
Name of Applicant
11727
PATCHOGUF., NEW YORK
Address
(-h.-?:".J
'=-c..
L OC--L. S I" fltUL.t'
Owner 0 Premises Address
3) api/hIlL w/ r p~jJ A-...~ 14-<)7) I "'/t)
Work Description ana Location (Street Number, Hamlet, Cross Street)
2)
I J .
L 'rIrJ.-... ~ u"'-
~
(a)
t"s construction located withih'75 feet of tidal wetlands?
*If yes, othe,..--Town permits may be required.
*Yes No
~) Builder1s License No.
Plumber1s License No.
Electrician's License No.
Other Trade's License No.
Applicant
5) a) Attach plot plan showing locadon ,of proposed- e)(cavation and relationship to
adjoining premises or public'stre.ets or areas, and giving a detailed descrip-
tion of layout of excavation. .'
b) Attach 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
Blod<
, Lot
Completion Date
Starting 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:
\
f)-1f1
PCl<1C 1 of 3
.'
12) Insurance Coveraqe: (Attach copy):-
a) Insurance Company:
b) Policy"
c) State whether policy of cet:tiflcation on, file with the Highway Depart-
ment:
d) Coverage required extende~. to the Town:
Bodily injury and proper'ty damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security:
a) Surety Bond or Certified Check
tota I amoun t of $
b) Maintenance Bond provided: 2 yea rs or
provided in the
3 years
111)
Basic
Application Fee........ $25. 00
@ $20.00 = $ J Ch ..,
Fees for applications and permits:
A 1. --rfo:-/scrvicc Connections.
A2. IAdditional Excavations same service @ $10.00 :; $
~
excavations
B. Excavations 1811 in depth 'or less:
0-100 I. f. = $10.00 "
I.f. @ $0.10 -:$
Additional
C. Excavations...l81l in depth -toSI in depth:
0-100 I.f. = $30.00
.I.f. @ $0.30 ~'$
Additionai
O. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 ='$
Additional
E.
Utility Repair:Excavations @$10.00 = $
No.
Rcpail's same service -@ $5.00 = $
Additional
F. Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
J
, ~ '"
TOTAL CO~T ~ Y '--
. . .
Authorization is hereby granted to the Town Clerl< of the Town of Southold to
Issue a Highway Excavation Permit to:
in accordance with ~this application.
SUPERINTENDENT OF HIGHWAYS
T....O~. SOUTHOLD" NEW YORK
, cRX~
. . Raymond L. Jac~
7-!- 0/
Date
Received by the Town Clerk 7 h;;L~ D 1
. te
Permit Issued,' I It" /Dr
Da'te ./
Pcrmi t No.
~:
Permit expires one (1) year ft:om Date of Issuance.
No work to start without 110 hour notice .to the Stlperintendcnt of Highways.
Permit must be available for inspection.
Page 2 of 3
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FC-611l.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
SKETCH
-
KEYSPAN/tf'A-S
REQUEST FOR STREET OPENING PERMIT
D STATE
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D
D SUFFOLK rut
COUNTY ~
I ~ __ DEPARTMENT
1///1 -.JcilulZ- GAS CONSTR. MAl NT. & SERVICES
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