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Permit No.--O.-.!1
... F)le No. -/ I
Ref.
TOWN Or- S,JU.z'HOLD
H IGHWA Y DEPARTMENT
Pcconic Lane
Pcconic, New' Yorl< .11958
n --=:t:J..aoo ,;t.;tO I 3 (51 G) me 31110
'P.o.f2,o'l- ,75
;
APPLICATION/PERMIT FOR HIGHW),Y EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an Excava.tion 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 for the excavation herein described. The applicant agrees
to comply with all applicable laws. ordina)~'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 ~~R EAST MAIN STREET
Name of Applicant
PATCHOGtlF.. NEl.J YORK
Address
11727
2)
Name of Owner of Premises
Address
3)
.,.2 '-I 0 L eN <-
Work Dcs.cription and
LA
Location (Street
IfV'. II"<- ["l\ "T LA L t<
Number I Hamlet, Cross Street)
(aJ
fs construction located withih '_75 feet of tidal wetlands? ~Yes_No .p
*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.
~re~
/. 3\~\O\
Date
5) a) Attach plot plan showing location .of proposed. elkavation 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 permi,ls 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.
G)
7)
Tax Map: Section
Bloc"
, Lot
Completion Dille
Starting Dllte:
8) Worl< Schedule:
Phase
Completion Date
Excavation....................... 0_: .................
Facility Installation............:....................
Backfill & Compaction.........:....................
Pavement Replacement........ ":',~""""""""'"
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remar"s:
\
0-111
Pane 1 of 3
. 1)) Insurance Coverage: (Attach copy).
a) Insurance Company:
b) Policy"
c) State whether policy of cet: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 d,"nage.
13) Security;
aJ Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
3 years
2 years or
11,)
Basic Application Fcc........ $25. 00
excavations @ $20.00 ; $ ad. .xl
Fees for applications and permits:
A 1. IService Connections
~
A2. IAdditional EXC<lvations same service @ $10.00 ::: $
~
B. Excavations 18" in depth 'o'r: less:
0-100 1.f. ; $10.00 ..
1.f. @ $0.10 -:$
Additional
C. Excavations~'''8'' in depth 1Q51 in depth:
0-100 1. f. ; $30.00
1. f. @ $0.30 ;, $
Additional
D. Excavations 51 in depth and over:
0-100 l.f. ; $50.00
1.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~T ~ 'Ie;. t.P
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
T~O,'WN - SOUTHOLD., ,NEW YORK
~" ,.7dfe~
, Raymond L. Ja s
:3 - /2--- c)!
Date
Received by the Town Cierk
3/ /!i/~{
Date
Permit Issued,'
311t/ler
Date
Cr7
Permit No.
~:
Permit expires one (1) year fr:om Date of Issuance.
No work to start without 110 hour notice .to the Sl.:!pcrintendcnt of Highways.
Permit must be avai1"able for inspection.
Page 2 of 3
~ ""
.
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
D STATE D NASSAU D SUFFOLK ~ S; ~7A'<!I(.~
FC-6111.4 COUNTY COUNTY
PERMIT MIS JOB
NO. NO. "'-'-:000 z.-2-o 13
LOCATION ilPlE /,J 7}lr If.r .5ilM4J If.. .4 "$iA /~O ,
REASON FOR ~ ,;.; 1VI A-f'tr7 ~ u::....
OPENING
W,O.lPA FOREMAN DATE OF
NO. OPENING
REQUESTED etlt',.J .s;~1i DEPARTMENT DIV SION
BY GAS CONSTR. MAINT. & SERVICES 7Z~"'& '58'~5/~
APPROVED DATE
SKETCH tldib'# /t:JI'~' 739.3(2)
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-------~
Date: 03/14/01
Transaction(s):
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 3594
(J~
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
#- 91
Receipt#:
Total Paid:
3594
Subtotal
$45.00
$45.00
IntemallD: 28400