HomeMy WebLinkAboutHolden Ave
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Date: 05/15/00
Transaction(s):
1 Permits ::Ii .5 7
Check#: 850
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk ID: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * *'RECEIPT * * *
Receipt#:
Total Paid:
850
Subtotal
$45.00
$45.00
Internal 10: 10655
Permit No. 5-;
Fil.e No. 5'7
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765'- 31110
Po. /2>0'1- /7E!>
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR RECEIVED
Ref. II lj-9?1.0]O
MAY 1 5 ?OOn
11 LIS', ()~
APPLICATION IS HEREBY made to the Superintendent of Highw<<lldlM#l1.li\8n C1el*n
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, NEW YORK
Address
11727
~
eet Number, Hamlet,
I IX:#--
X
2)
S't,o
Name of Owner of Premises
3) W J O-vc-. ~
ork Description and Location (S
(a)
Is construction located within 75. feet of tidal wetlands? *Yes No
*If yes, other--(own permits may be required. -
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
-;"vL~. I~ 6~
, C-;i;atur~ lfi'tp;icant
J-- fr- tit>
Date
5) a) Attach plot plan showing location of proposed- e5(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} 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
2 years or
3 years
14)
Fees for applications and permits:
A 1. L/Service Connections
No.
A2. IAdditional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ 20. n>
No.
B. Excavations 18" in depth or: less:
0-100 I.f. = $10.00
I.f. @ $0.10 -$
Additional
C. Excavations--.l8" in depth to 5' in depth:
0-100 I. f. =- $30.00
.I.f. @ $0.30 =:$
Additional
D. Excavations 5' in depth and over:
0-1001.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 attacbed to
this application prior to issuance of permit.
* * *
,
TOTAL COM:- $
'-I6D>
~uthoriza~ion is hereby granted ~o the T..own ~Ie k of t);1e Town of Southold to
Issue a Highway Excavation Permit to: .' ~r vff7~
in accordance with .this application. -_
SUPERINTENDENT OF HIGHWAYS
TOWN F SOUTHOLD, NEW YORK
s- jr- 00
Date
Received by the Town Clerk
Permit Issued,
Permit No.
67
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
0-39
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
SKETCH
o STATE
KEYSPAN/<fA 5
REQUEST FOR STREET OPENING PERMIT
DI'C.~5
Po ~ ..r-I
o
NASSAU
COUNTY
SUFFOLK
COUNTY
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MIS JOB q
NO. 25
000
FOREMAN
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
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