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Permit NO.4/-
File NO.-/.-'12-
Ref. IITJotJQ,;;}Oo5r
TOWN OF S;)U ,'HOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New- York -11958
(516) 765c 3140
Po, (6<,<- t7f>
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
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 .}nspections of the job site.
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name of Applicant
PATCHOGUE. NEW YORK
Address
11727
2)
Name of Owner of Premises
Address
rJe", S-- di-IC
Number, Hamlet, Cross Street)
3)
(a)
1"s construction located within 75 feet of tidal wetlands? *Yes_No
*If yes, other-fawn permits'may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~ret}:+i
3/'7 /0 J
Date '
5) a) Attach plot plan showing location ,of proposed-e,fcavation 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.
6)
7l
Tax Map: Section
Block
, Lot
Completion Date
Starting Date:
8) Work Schedule:
Completion Date
Phase
. \,
Excavation....................... .-.... ..............
,
Facility Insta lIation.. . . . . .. . . . ~ .' . . . . . . . .. . .. . .. . . .. .
Backfill & Compaction..............................
Pavement Replacement........ ":'," . . .. . . ... . .. . . . .. ..
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
\'
D- 39
Paqe 1 of 3
.
~ 12) Insurance Coveraqe: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of cer,tification 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
3 years
2 years or
1ij)
Fees for applications and permits:
A 1. -L/Service Connections
No.
Basic Application Fee........ $25. 00
excavations @ $20.00 ; $ d () V
A2. IAdditional Excavations same service @ $10.00 ;:: $
~
B. Excavations 18" in depth 'or less:
0-100 I.f. ; $10.00
I.f. @ $0.10 -,$
Additional
C. Excavations--...lS" in depth to oS' in depth:
0-100 I.f. ;.$30.00
.I.f. @ $0.30 ;:$
Additional
D. Excavations 51 in depth and over:
(}-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.
. . .
Y S:-. (j)
TOTAL CO~T- $
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
TOWN SOUTHOLD. NEW YORK
3- 7-0/"
Date
Received by the Town Clerk 3 / ? If) (
3/010 ( Date
Permit Issued, ' oft. Permit No. 9 b
Dafe
Note:
Permit expires one (1) year fr:om Date of Issuance.
No work to start without 4B hour notice -to the Stlperintendent of Highways.
Permit must be available foririspection.
n-~Q
Page 2 of 3
KEYSPAN/6A'S
REQUEST FOR STREET O~ENING PERMIT
FC.6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
D STATE
D
NASSAU D SUFFOLK I./l .--
COUNTY COUNTY LLJ ...)t:l,,",- 7J(()(.ZJ
MIS JOB
NO. liooo ;J.OD 5e. 3 ~ ~oOI
ff eP6€ J' 4wAJ&-",r ~ ,',JIY~ ~
Su~M:'
Sf~S/~
#. IAl6- ,&- l3t.IL
I nE.}> /L /,J
FOREMAN
DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
APPROVED
~
SKETCH I ~'b 10[- 45.
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500
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Date: 03/08/01
Transaction(s):
1 Permits
Cash#:3590
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
,/1 96
yJ~ 'TW-
Receipt#:
Total Paid:
3590
Subtotal
$45.00
$45.00
Internal 10: 28135