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, .
Pel"mil NO.~
File No.~
Ref. Of I 0003 5 J/~
TOWN OF S"Jll,'HOLD
H IGHWA Y DEPARTMENT
Pcconic L<lnc
Peconic, New' YorJ( -11958
(516) 765c31"0
Po. ~<'I- /75
.;
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREl3Y mode to the Superintendent of Highways of the Town
of Southold for the issuance of em Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Southold. Suffoll< County I New York, and other applicable laws,
ordinances or regulations (or the excavation herein described. The applicant agrees
to comply with all applicable laws, ordina,r\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 t,loR EAST MAIN STREET
Nome 0 Applicant
PATCHOGIlE NEW YORK
Address
11727
2)
Name of Owner of Premises
Address
oS '" <.A /kcl I ~
(Street Number I Hamlet, Cross Street)
3)
Lowe..,e I2cJA-IJ
Work Description and Location
(0)
I-s construction located within .75 feet of tidal wetlands? 'IIYes_No r
*If yes, other~'Town permits may be required.
II) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~~~~~
" _ Sig ature of Ap lican
'.l. ;! 'fl.;.~ I
Date '
5) a) Attach plot plan showing location .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 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 CIerI<..
6)
71
Tax Map: Section
l3lock
. Lot
Completion Date
Starling Date:
B) Work Schedule:
~
Completion Date
Excavation.... .......... ........ ',' ... ..............
Facility Installation.............-....................
Backfill & Compaction.........:....................
Pavement Replacement........ '....... ...............
9) Under which authority is the application mode:
10) Estimated Cost of Proposed Work: $
11)
Remarks:
\
f)-VI
Paqc 1 of 3
12) Insurance Coverage: (Attach copy).
a) Insurance Company:
b) policy<<
c) State whether policy of cer;tiflcation 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.
13) Security:
a) Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
providCd in the
3 years
2 years or
111) Fees for applications and permits: Basic Application Fee........ $25. 00
A 1. ~/Service Connections excavations @ $20.00 :;:: $ a 0 ~
No.
A2. IAdditional ExcavZltions same service @ $10.00 :;:: $
~
B. Excavations 1811 in depth o'r: 'less:
0-100 I. f. = $10.00 ,',
l.f. @ $0.10 -:$
Additional
C. Excavations...l8" in depth t<;> 5' in depth:
0-100 I.f. = $30.00
I. f. @ $0. 30 =', $
Additional
O. Excavations 51 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.
. . ."
. r..J
TOTAL CO~T ~ ~ ~.
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
, '
S0PERINTENDENT OF HIGHWAYS
~D', NEW YORK
, ~~t-
. ' Raymond L. JMobs
~~ ~- 0 J
Date I
Received by the
Town Clerk if' /110 (
Da(e
t/ / sj Of 'permit No.
Date
/cJ()
Permit Issued,'
~:
Permit expires one (1) year from Date of Issuance.
No work to start without 118 hour notice -to the St:.lperintendcnt of Highways.
Permit must be available foririspection.
Page 2 of 3
n ,...,
FC-6111.4
PERMIT
NO.
LOCATION
. ,
KEYSPAN/6A S"
REQUEST FOR STREET OPENING PERMIT
[KJ STATE
D SUFFOLK I \/ I r-
COUNTY "l.j 0 u '71-1- ( ~
IIjs 6JA.rS AU,4o.5.' Wt51t.L 1-
W.O.lPA
NO.
REQUESTED ~
BY ~oJi.J ~t. Jlw::f'L
APPROVED
SKETCH
s.l.
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
6ij]) c. log. 3. 'I
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:$I 25
(6. Itc.. J'YJA;Ji U
L''s1l- -
. .
Date: 04/05/01
Transaction(s):
1 Permits
Check#: 1179
Name:
Key, Span Energy
448 East Main Street
Patchogue. NY 11727
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1179
Subtotal
$75.00
$75.00
Internal 10: 29471