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Permit No, LII-A /
F.le No, / U fY--../
,
TOWN OF 5;,(.1 ,'HOLD
H IGHWA Y DEPARTMENT
Pcconic Lane
Peconic. New' Yorl< -11958
(S16) 76sc31l10
P.o, /2>0,," ,7E>
APPLICATION/PERMIT FOR HIGHWiW EXCAVATION AND REPAIR
Ref. nil 00032'101
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.
ordinances or regulations for the excavation herein described. The applicant agrees
to comply with all applicable laws, ordinEs'.i:"'ces, codes and regulations, and to permit
authorized inspectors to make; necessary. inspections of the job site.
,
Print or Type
I) KY.Y SPAN ENERGY ~~R EAST MAIN STREET
Name of Applicant
PATCHOGllE, NEW YORK
Address
11727
2)
Name of Owner of Premises
Address
31
fL,oo 61~
Work Description and
~
~~t." t.....
Location (Street Number,
lI'V\ A- Tl I I<....< c Ie
Hamlet, Cross Street)
(a)
t's construction located within '"is feet of tidal wetl;::mds? ....Yes_No
"'If yes, other"".T~wn permits may be required.
II) Builder's License No.
Plumber's License No.
Electrician1s License No.
Other Trade's License No.
~~Si~~ur~~.
. Y-Y'O(
Date
s) a) Attach plot plan showing locadon .of proposed.cx: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 perml.ts 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.
6)
7)
Tax Map: Section
Blocl<
, Lot
Completion Date
Starting Date:
01 Worl< Schedule:
Completion Date
~
Excavation......................-.. .................
..
Facility Installation............:....................
Backfill & Compaction..............................
Pavement Replaccment........ ~.... .. . ... .. . . . . . . ..,
9) Under which authority is the application made:
10) Estimated Cost of Proposed Worle $
11)
Remarks:
,.
D-ltl
Paqc 1 of 3
".'.
12) Insurance Coveraqe: (A ttach copy).
a) Insurance Company:
b) Policy 1/
c) State whether policy of cer:tification 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.
1 3) Secu rity:
a) Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
3 years
2 years or
tll)
Fees for applications and permits:
A 1. '/Service Connections
~
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ d (J. VJ
A2. IAdditional Excavations same service @ $10.00 ;:: $
~
B. Excavations 1011 in depth .or less:
0-100 I. f. = $10.00
I.f. @ $0.10 - :$
Additional
C. Excavations...lOIl in depth t<;> '51 in depth:
0-100 I.f. = $30.00
Ii) Lf. @ $0.30 ~',$ :1 ,t>~
Additional
D. Excavations 51 in depth and over:
0-100 1.f. = $50.00
1.f. @ $0.50 ='$
Additional
E.
Utility Repair :Excavations @$10.00 = $
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.
',".
<Y
* * *
TOTAl. CO~T ~ '7;'-
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance wi th ~this application.
ENDENT OF HIGHWAYS
SOUTHOLD. NEW YORK
Raymond L. obs
~~ f- 01
Date
Received by the Town Clerk
J/- 9-01
Date
/iJ 02./
Permit Issued,' Lj~/D -0 I
Date
Permi t No.
~:
Permit expires one (1) year fr:om Date of Issuance.
No work to start without 110 hour notice .to the Sl.:Iperintendcnt of Highways.
Permit must be available for inspection.
Page 2 of 3
" ,n
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
,
D STATE
D NASSAU
COUNTY
D SUFFOLK
COUNTY
c:z[ 1:0. ~(7(/(HOl..-ih
Fe-5111.'1
PERMIT I MIS JOB IDATE
NO. NO. .n 000 J) "10 I 1.(- 5-01
LOCATION //01 --r{l.,;vCI1 0/'1 rils. au:. JUL'i...- LA' 5'10' "10 {,501 .s/o fJi-w svf/1f/( A
REASON FOR eu M4I,.J -l- S'z-fLvl (L /VJ4"1V Tc.{Clc....
OPENING
W.OJPA FOREMAN I DATE OF
NO. OPENING 5-If-o/
REQUESTED 0A iJ MAr2-(C2 DEPARTMENTTDIVISION
BY GAS CONSTR. MAINT. & SERVICES ZL{
APPROVED IDATE
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SKETCH
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Date: 04/10/01
Transaction{s):
Name:
Clerk 10: L1NDAC
1 Permits
Check#: 1185
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:
1185
Subtotal
$78.00
$78.00
Internal 10: 29768