HomeMy WebLinkAbout9700 Route 25
.'
.
Date: 05/15/00
Transaction(s):
1 Permits
Check#: 846
Name:
Key, Span Energy
448 East Main Street
Palchogue, NY 11727
Clerk 10: L1NDAC
Town Of Soulhold
P.OBox1179
Soulhold, NY 11971
* * * RECEIPT * * *
Receipt#:
4/s1
Total Paid:
846
Subtotal
$45.00
$45.00
IntemallD: 10570
Permit No. s<f
Ref.
1/ "L(9fo q-03 D
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic'Lane
Peconic, New York 11958
(516) 765'-31110
P o. f2,c~ /7e.
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND
File No. sf
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name of Applicant
l'ATCHOGUE, NEl-! YORK
Address
11727
escription and Loca on
2)
Name of Owner of Premises
.~ /lA- ~
(a)
I s construction located within 75 feet of tidal wetlands? *Yes
*If yes, other-T'own permits may be required.
No X
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~~ -Ja~
~d ·
. , ., Si9~f Appl'can
J-:' I () - (/lJ
Date
5) a) Attach plot plan showing location of proposed.e5('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)
7l
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:
\
D- 39
Page 1 of 3
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy 1/
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. --LlService Connections,
No.
A2. IAdditional Excavations same service @ $10.00 = $
r;ro:-
Basic Application Fee........
If'J
excavations @ $20.00 = $
)
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 COfl-~ S
'-Is: 00
Authorization is hereby granted to the Town
issue a Highway Excavation Permit to:
in accordance with .this application.
Clerk of the Town of Southold to
Ir'Ii" '1 ()/7 /J,J
DENT OF H IGHWA YS
UTHOLD, NEW YORK
Received by the Town Clerk
..s:: /.x. - ,~
Date
Permit Issued, - ,,/): /.5//)0
Date
Permi t No. ...j-1
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice -to the St:lperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
0-39
FC-G111A
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
D STATE
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i MIS JOB '[DATE .!. /
iNO. ::<57b9-03Q 5/1/d-ooCJ
, .
.a /~ mE. tv1 J;,4-I!h+ ;?-flfl4:,x. 7.;L' s ()
/11/}-ir! d. /"N /l1.4-/77/Udc
DATE OF _
OPENING .Ju.,J[ d-o~a
I DIVISI9!J
fj;.-?C}/o &//..>
IDATE
b-il::> !6/-c,7- 3
KEYSPAtY6A5
REQUEST FOR STREET OPENING PERMIT
D
NASSAU
COUNTY
D SUFFOLK
COUNTY
FOREMAN
~J/j; ~t.A-IL
DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
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