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Permit NOr37J-
File No.~
Ref.
TOWN Or- s;,(UHOLD
H IGHWA Y DEPARTMENT
pcconic Lane
Pcconic, New. Yorl< 11958
(516) 765c31110
Po f2,01- 175
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
.-
1/ 1/ 000,;1" d~ ~
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an Excavntlon Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffoll<. County, New York, and other applicable laws,
ordinances or regulations for the excavLI.tion herein described. The applicant agrees
to comply with all applicable laws, ordinarces, codes and regulations, and to permit
authorized inspectors to make: necessa ry", inspections of the job site.
Print or Type
1) KRY SPAN ENERGY o4R EAST MAIN STREF.T
Name 0 App icant
PATCROC.UF. Nml YORK
Address
] 1727
2)
Name of Owner of Premises Address
3) ~f)S.<) K A-1r I-t? \~ CT E- IY\ h>IL\ ()....-
Work Description nd LocMlon (Street Number. Hamlet, Cross Street)
,
(a)
.'
fs construction located withrn '.75 feet of tidal wetlands? "'Yes_No (
"'If yes. othcr--"'!own permits may be required.
II) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
5) a) Attach plot plan showing locati"on .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)
7l
Tax Map: Section
Blocl<:
. Lot
Completion Date
Starting Date:
8) Work Schedule:
~
Completion Date
Excavation. .. . .. . .. . . . . . . . . . ., .. ',' .. . . . . . . . . . . ... . .
Facility Installation........... .:....................
Backfill & Compaction......... ~ . . . . . . . . . . . . . . . . . . . .
Pavement Replacement........ ~:..-....................
9) Under which authority is the applica,tion made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
"
D-1t')
P:CH1C 1 of 3
~ 12) Insurance Coverage: (Attach copyL
a) Insurance Company:
b) Policy ff
c) State whether policy of certification 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
provided in the
2 years or 3 years
Basic Application Fee......~~
excavations @ $20.00 = $ ..;;JG. 00
111)
Fees for applications and permits:
A 1. LIService Connections'
No.
A2. IAdditional Excavations same service @ $10.00 :;; $
"""f.fO':-
B. Excavations 1811 in depth 'or: less:
0-100 I.f. = $10.00 .'
1.f. @ $0.10 -$
Additional
C. Excavations...le" in depth to '51 in depth:
0-100 I.f. = $30.00
.I.f. @ $0.30 =,:$
Addilional
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 s'ervice'@ $5.00 :;; $
Additional
F. Notice to public utilities proof must be provided and attached to
this application prior to issuance of permit.
* * 'Ii'
TOTAL CO~T' ~z.;5. 07)
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
St:JPERINTENDENT OF HIGHWAYS
TOWN 0 UTHOLD, NEW YORK
~
0/
Received by the Town Clerk
J../ /.2/ D(
Date
qq
Permit Issued,'
# /.3/{; (
:Permi t No.
Date
~:
Permit expires one (1) year fr:om Date of Issuance.
No work to start without 118 hour notice -to the St:Jpcrintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
.
KEYSPAN /6tls
REQUEST FOR STREET OPENING PERMIT
FC-6111.4
D STATE
D NASSAU D SUFFOLK
COUNTY COUNTY
MIS JOB
NO. riOo().2~ 252
11. .,.1 JJ" 6;NlSS AUIf I
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DATE
3/~V.:le>c/
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
KAyLl,'kll cr: ~
nlAitJ t11
S1 'n'!
FOREMAN
DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
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Date: 04/03/01
Transaction(s):
1 Permits
Check#: 1172
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk ID: L1NDAC
Town Of Southold
P,OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1172
Subtotal
$45.00
$45.00
IntemallD: 29344