HomeMy WebLinkAbout250 Bartley Rd
.
Date: 05/15/00
Transaction(s):
Name:
Clerk ID: L1NDAC
1 Permits
Check#: 850
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipl#:
dJ-5'-
Total Paid:
850
Subtotal
$45.00
$45.00
Internal 10: 10654
Ref.
112~tJ / (,- 63 0
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Pecanic 'Lane
Pecanic, New Yark 11958
(516) 765~ 31110
PO, ~o~ 178>
. -
Permit No.. Sh
Fife No.. l ,h
,
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to. the Superintendent af Highways af the Tawn
af Sauthald far the issuance af an Excavatian Permit pursuant to. Chapter 83 af the
Cade af the Tawn af Sauthald, Suffalk Caunty, New Yark, and ather applicable laws,
ardinances ar regulatians far the excavatian herein described. The applicant agrees
to. camply with all applicable laws, ardinances, cades and regulatians, and to. permit
autharized inspectars to. make; necessary}nspectians af the jab site.
Print ar Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name af Applicant
l'ATCHOGUE, NEH YORK
Address
11727
Oc,.t... ~
ian and Laca
~~ o7C" '0
an (Street Number, Haml t, Crass
I / )
q. 'IV ,dH.
2)
z.ro
Name af Owner af Premises
(a)
Is canstructian lacated withih75 feet af tidal wetlands? *Yes No.
*If yes, ather-"(awn permits may be required. -
>(
4) Builder's License No.,
Plumber's License No..
Electrician's License No..
Other Trade's License No..
~~
tA..J
Signature pplicant
.J. - - IS- - tJ"L)
Date
5) a) Attach plat plan shawing lacationaf prapased- e5(cavatian and relatianship to.
adjaining premises ar public streets ar areas, and giving a detailed descrip-
tian af layaut af excavatian.
b) Attach all ather necessary permits and licenses far this praject.
c) Wark cavered by this applicatian may nat cammence befare issuance af a
Highway Excavatian Permit by the Tawn Clerk.
Tax Map: Sectian
Black
, Lat
6)
7)
Starting Date:
Campletian Date
8) Wark Schedule:
Phase
. \.,
Campletian Date
Excavatian. .. . ... .. . .. . .. .. .. '. .... .. . ',' .'... .. ... . . .
Facility Installatian.................................
Backfill & Campactian..............................
Pavement Replacement..........,...................
9) Under which autharity is the applicatian made:
10) Estimated Cast af Prapased Wark: $
11) Remarks:
\'
D-39
Page 1 af 3
.~
. 12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy II
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. I /Service Connections.
~
A2. /Additional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ 2 (). ~
No.
B. Excavations 18" in depth 'or 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
,I.f. @ $0.30 =~$
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 COM' S
.76:.t?o
Authorization is hereby granted to the Town ,CJ.erk of the Town of Southold to
issue a Highway Excavation Permit to: K ~O lr~
in accordance with .this application. .
SUPERINTENDENT OF HIGHWAYS
TOWN SOUTHOLD, NEW YORK
s:-- 15-0z;
Date
Received by the Town Clerk ofi:d
Permit Issued,. 6';{1.~cJ Permit No.
D te
S0
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice 'to the Sl:Iperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
D-39
6
FC-6111.4
PERMIT
NO.
KEYSPAN~19.s
REQUEST FOR STREET OtE-NING PERMIT
o STATE
o
lEJ J;u 77/0 ( l)
DATE
NASSAU 0 SUFFOLK
COUNTY COUNTY
MIS JOB
NO. .:!t-o/6.-.:>..30
~ ~ A'T;;NC. /";'T<<s~~"/ ,,/,
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LOCATION 8t-t.(~4:. _piE w/.s ./
REASON FOR ,
OPENING ~ Gfts I11A,/J
W.O.lPA
NO.
REQUESTED
BY
0,:..1 ~!lnn
APPROVED
SKETCH
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DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
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