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Permit No. Jt') ~
r _
" File No. /0.3
TOWN OF S;JU ,'HOLD
H IGI-IWA Y DEPARTMENT
Pcconic L~ne
Peconic, New. Yorl<11956
(5.1G) 7G5~31110
P.o, J2,01- Of>
Ref. OT J()~. C{~ ")(.,.,
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 no Excavation Permit pursuant to Chapter 83 of the
Code of the Town of southold. Suffoll< County. New Yorl<. and other applicable laws.
ordinances or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordioc1.i.t'ces, codes and regulations, and to permit
authorized inspectors to make; necessary \inspections of the job site.
Print or Type
1) KF.Y SPAN ENERGY ~~R EAST MAIN STREET
Name of Applicant
PATCHOGUE. Nm~ YORK
Address
11727
2)
Name
of Owner of Premises Address
'f'(f!-ji' Si - ~-r-c-(,.."")""-<--
Description and Location (Street Numbe~ Hamlet, Cross
Street)
3)50
Worl<
(al
Is construction located within "75 feet of tidal wetlands'? "'Yes No
"'If yes, other".~own permits 'may be required. -
4) Builder1s License No.
Plumber1s License No.
Electrician's License No.
Other Trade1s License No.
5./)' 0/
Date
s) a) Attach plot plan showing locadon .of proposed- ex."cavation and relationship to
adjoining premises or public .stre,ets or areas, and giving a detailed descrip-
tion of layout of excava tion. .
b) Attach all other necessary permi.ts and licenses for this project.
c) Work covered by this appliCiJtion may not commence before issuance of a
Highway Excavation Permit by .the Town Clerl~.
G)
7)
Tax Map: Section
Block
, Lot
Completion Date
Starting Date:
0) Work Schedule:
~
Completion Date
Excavation. ........ ........... ... '.,~" ......... ......
Facility Installation............:....................
Backfill & Compaction..............................
Pavement Replacement........ '.',.,.....................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Wor!<: $
11)
Remarks:
\
f)-1fl
Paqc 1 of 3
'12) Insurance Coverage: (Attach copy)" -r- ) tJ D() yt:. ,'(" 1
a) Insurance Company:
b) Policy U
c) State whether policy of certification on. file with the I-lighway 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:
aJ Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certi fi ed Check
provided in the
3 years
2 years or
Fees for
Basic Application Fee........ $25. 00
excavations @ $20.00 ; $ ,9 (I. () <l
",)
applications and permits:
I IService Connections
N'O:-
A2. IAdditional Excavations same service @ $1 Q. 00 ::;: $
"""NO":-
AI.
B. Excavations 16" in depth .o"r: less:
0-100 I.f. ; $10.00
I.f. @ $0.10 -:$
Additional
C. Excavations...lan in depth tQ S' in depth:
0-100 I.f. ; $30.00
,I.f. @$0.30",$
Addi tional
D. Excavations S' in depth and over:
0-100 I.f. ; $50.00
I.f. @ $0.50 ;'$
Additional
E.
Utility Repair Excavations @$lO.OO ; $
"
No.
Repairs same s~rvicc -@ $5.00 = $
Additional
F. Notice to public .utilities proof must be provided and attached to
this application prior to issuance of permit.
'" '" *'
TOTAl. CO~T ~ ,y 5: . 0 0
Authorization is hereby granted to the Town Clcrl< of the Town of Southold to
Issue a Highway Excavation Permit to:
in accordance with ~this application.
SUPERINTENDENT OF HIGHWAYS
TOWN SOUTHOLD, NEW YORK
,
,
Received by the Town Clerk
0--17-"01
Date
Permit Issued,' 0-/7 -0 f
Date
:Permit No.
/03
Note:
Permit expires one (1) year fr:om Date of Issuance.
No work to start wit.hout fl8 hour notice 'to the Sl:lperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
~ ""
KEYSPAN/6-;09S
REQUEST FOR STREET OPENING PERMIT
FC.6111.4,
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
D STATE
D
D SUFFOLK I.;l .:-
COUNTY lLU .....JD ",,7#o!..7.l
lOa ' ;I/o
OOt) 4l:, 7 t"
;5U11k/t ~SS"" hf'lu
FOREMAN
DATE OF
OPENING 6
DIV ION
~~ ?Stf-S/-,4
DATE
n
DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
SKETCH
6ttt'i:J:# /D/~ ~2. I
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Date: 05/17/01
Transaction(s):
Name:
Clerk 10: L1NDAC
1 Permits
Check#: 1219
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
-# 103
Total Paid:
1219
Subtotal
$45.00
$45.00
IntemallD: 32222