HomeMy WebLinkAbout6190 Peconic Bay Blvd
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 05/05/00
Receipt#:
837
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
1 Permits
Check#: 837
#C .5-.3
1t qJ::,-U'i'-o36
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
InternallD: 10013
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765'- 31110
Po.P-><'1- ,76
RECEIVED
t$t/506
MAY 2000
Permit No. 6.3
File No. '-- ~-.3
Ref.
112S'8Y~ -blo
APPLICATION/PERMIT FOR HIGHWAY EXCAVA~~~~
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, ordinances, codes and regulations, and to permit
authorized inspectors to make: necessary "Inspections of the job site.
Print or Type
1) KEY SPAN ENERGY 448 EAST MAIN STREET PATCHOGUE, NEW YORK 11727
Name of Applicant Address
2) t,/?O ILCIJNtC.- /.Jlft, /It..Vt) l1t9nr U~
Name of Owner of Premises"" Address )
3) 't'/..L/ O[.u.../'-J(o...L IN ~IfVt.')A~~A SVo I Ell' /J)tcH Av
Work Description and Location (Street Number, Hamlet, Cr ss Street)
(a)
Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other-lawn permits may be required. -
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~~/$r~
" ignature Applicant
J-'" / - /Jt)
Date
5) a) Attach plot plan showing location of proposed,elfcavation and relationship to
adjoining premises or publicstre"ets 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:
\"
D-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
tota I 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. IService Connections.
~
A2. IAdditional Excavations same service @ $10.00 = $
Basic Application Fee........ $25. 00
excavations @ $20.00 = $
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 CO~ S "
Authorization is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
in accordance with ,this application.
SUPERINTENDENT OF HIGHWAYS
Td..W.;;F SOUTHOLD., NEW YORK
. ~~-d--/
aymond L. cobs
S' - Y --- C7t
Date
Received by the Town Clerk
6" /6'/?Jd
Date
Permit Issued\
<S/6-!oQ
'Da1:e
Permit No.
03
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice .to the Sl:Iperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
D-39
KEYSPAN/GrlS
REQUEST FOR STREET OPENING PERMIT
FC-6111.4
o STATE
O SUFFOLK
COUNTY
[EJ
O NASSAU
COUNTY
MIS JOB
NO. 5 'if "31- 0 3 0
(/.' Xv ;3H( 'oLE flt 71If 5/5 e.t"
LOCATION 'E:Cn /C [.4 6LI/D;;/ 11ft. t1;J/,f); IiIC'DI AY/KM( 5</.0' Ii 0 ;3/'uY/ /f//L /AI /lbU7-'/U
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED ~,I ~
BY iu iN Jeff/A /2-
PERMIT
NO.
FOREMAN
DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
APPROVED
SKETCH
N
<Y~
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