HomeMy WebLinkAbout1325 Kimberly Ln
Date: OS/23/01
Transaction(s):
Name:
Clerk ID: L1NDAC
1 Permits
Check#: 1223
f
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:
\ Del
1223
Subtotal
$55.00
$55.00
IntemallD: 32574
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Permit No.
.'
TOWN OF' S:,(J .'HOLD
H IGHWA Y DEPARTMENT
pcconic Lane
Peconic, New' Yorl<11950
(SlG) 7GSc31110
P. O. /2>0'f- 176'
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
File No.
Ref.
o fJooo cJ.'1314
APPLICATION IS HEREBY mode to the Superintcndent of Highwoys of the Town
of Southold for the issuance of an Excava,tlon Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, New York, ond other opplicoblc lows,
ordinances or regulations for the cxcavafion herein described. The applicant agrees
to comply with all applicable laws. ordina.~'<;:es, codes and regulations, and to permit
authorized inspectors to mlake; necessary. inspections of the job site.
,
Print or Type
1) KRY SPAN ENERGY ""R EAST MAIN STREET
Name of Appllcont
PATCI10GI1F.. NE1, YORK
Address
11727
2)
3)
Name of Owner of Premises Address
/32.5 K'; IItII!Ju.l~ k. . .s~ <-47}fp IJJ J/C ~XA7J,Jz g.
Work Description and L cation {Street Number. l-lamlel.. Cross Street)
(a)
,"S construction located within ",75 feet of tidal wcthmds? tcYcs_No
*If yes, otherl~wn permits may be required.
II)
Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade1s License No.
~;,";,".1"~
5/"l-%-/D/
Date
5)
a) Attach plot plan showing locati"on .of proposcd,"e:,;(cavation and relationship to
adjoining premises or public .stre.cts or areas, and giving a detailed descrip-
tion of layout of excavation. .. .::
b) Attach all other necessary perm.l.ts and licenses for this project.
c) Work covered by this application may not commenCe before issuance of a
Highway Excavation Pc_rmit by:tho Town Clerl<.
G)
7)
Tax Map: Section
Blocl<
, Lot
Completion Date
Starting Date:
8) Work Schedule:
.' \
Completion Date
~
Excavation.... ...... ............ ....~... ........... ..
Facility Installation........... :......................
Bockfill & Compoclion.........:.....,..............
Pavement Replacement........ .':'." ., . . . ... .. . . . .. ... .
9) Under which authority is the opplicotion modc:
10) Eslimoted Cost of Proposed Worle $
11) Remorks:
"
P7Inro 1 or 3
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12) Insurance Coverage: (Attach copy):.
a) Insurance Company:
b) Policy n
c) State whether policy of ce~tiflcntion on. file with the Highway Depart-
ment:
d) Coverage required extendc:~. to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
a!1d $50,000 property damage.
13) Security:
aJ Surety Bond or 'Certified Check provided in the
total amount of $
b) Maintenance Bond provided: 2 yea rs or 3 years
111) Fees for applications and permits: Basic Application Fee........$25.00
AI. -1-/Service Connections . excavations @ $20.00 = $ ,}-O
No.
A2. L/Additional Excavations same service @ $10.00 :;; $ If), -
No. p
B. EXCilvations 18" in depth 'or less:
0-100 I.f. = $10.00 .'
I.f. @ $0.10 - '$
Additional
E.
Utility Repair,.:Excavations @$10.00 = $
No.
Rcpait-s same s'cfvice'@ $5.00 :;; $
Additional
F.
Notice to public utilities proof must be pl"ovided and attached to
this applicntion prior to issuance of permit.
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TOTAl. CO~T ~
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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.
s0PERINTENDENT OF HIGHWAYS
TOWN SOUTHOLD" NEW YORK
.
.
Received by the Town Cieri, -S 1cJ- ~/)I
Oat .
Permit Issued,' S/.c;. all)/ Permit No. / d 'I
ate I
~:
Permit expires one (1) year f~om Date of Issuance.
No work to start without /10 hour notice .to the Stlperintendent of Highways.
Permit must be available for Inspection.
PaQC 2 of 3
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
D STATE
SKETCH
120 xjJ-,J,.fe
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KEYSPAN/G-n<"s
REQUEST FOR STREET OPENING PERMIT
D NASSAU D SUFFOLK 0 ~
COUNTY COUNTY ~ - ~<..c. '17r.t9~.})
~~JOBI70(JO <t939~ DAT~J.;z.I/02ao/
~ /SBL~L[ /'N ~2).t.,~ oJ- .rs' ~A-
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FOREMAN
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
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