HomeMy WebLinkAbout3420 New Suffolk Ave
,
Date: 05/15/00
Transaction(s):
1 Permits
Check#: 846
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk ID: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
-# 5.j-
Total Paid:
846
Subtotal
$45.00
$45.00
lnternallD: 10572
Permit No. --5"0
, cr
'File No. ~ v
TOWN OF SOUTHOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765~ 31/10
Po. t2>o~ /7f>
Ref. 1/ l J9 ~ V -6 J {)
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIRMAY 1 2 2000
ill %,~~
Southold Town ClerIC
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,
ordinimces or regulations for the excavafion herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to ma,ke: necessary .Jnspections of the job site.
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET PATCHOGUE, NEH YORK 11727
Name of Applicant Address
2) 3Y2.IJ'.N.JA..J~~ At/<- ~~
Name of O~ner of Premis.es'. [JJ.ddress I L
~~S ~ ~~ n'
ork Location ( reet Number, Hamlet, t
(a)
Is construction located within 75 feet of tidal wetlan
*If yes, other-"rown permits may be required.
No
-
)(
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
. ~.,~~p","1 r-
.. ~ -(t)- o-u
Date
5) a) Attach plot plan showing location of proposed. el<"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. LIService Connections.
No.
A2. IAdditional Excavations same service @ $10.00 = $
Basic
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:
0-100 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 COfl'r: S
L/~ 00
~ .
Authorization is hereby granted to the Town
issue a Highway Excavation Permit to:~. ... /
in accordance with "this application. .
Clerk of the Town
S O"'ql )
, -
of Southold to
SUPERINTENDENT OF HIGHWAYS
TOWN 0 SOUTHOLD, NEW YORK
L--
L acobs
S"- / 2.~cN>
Date
Received by the Town Clerk ..5-/;;l- ,po
Date
Permit Issued, 5-/5""-oc.
Date
Permit No. ..s-s
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
D-39
\ '
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
KEYSPAN;?rJ-S
REQUEST FOR STREET OPENING PERMIT
o STATE
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;t:f 31).0
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NASSAU
COUNTY
O SUFFOLK
COUNTY
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FOREMAN
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
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