HomeMy WebLinkAbout2790 New Suffolk Ave
Permit NO;&d
File NO.-++
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Ref.
TOWN OF 5,JU.'I'HOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic;. New' York .11958
(516) 765'3\110
Po.~.y.. /7e'
,
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, ardine,hees. codes and regulations, and to permit
authorized inspectors to ma,ke; necessary .}nspections of the job site.
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN ~TREET
Name of Applicant
~ATCHOGUE. NEW YORK
Address
11727
2)
Address
Name of Owner of Premises
tv&- S'-( H#;fC-c
31
:;) 71' 0 A..J~ '-' S~ "c/",L {C
Work Description and Location (Street
'1"
Cross
'-j{l. Sr
Street)
.~ dO
Number, Hamlet,
(a) ". 1'5 construction located within '75 feet of tidal wetlands? "'Yes_No
*If yes, other-Town permits' may be required.
4) Builder's License No.
Plumberls License No.
Electrician1s License No.
Other Trade's License No.
~J~.
,. Signature 0 A 1 t
.. 1-9 - 0 I
Date
""'--
5) a) Attach plot plan showing location.of proposed "excavCltjon and relationship to
adjoini"ng premises or public 'slre.ets or areasl and giving a detailed descrip-
tion of layout of exc:ava tion.
b) Attach all other necessary perm'its and licenses for this project.
c) Work covered by thls 'application may not commence before IS.5uance of a
Highway Excavation Permit by the Town Clerk.
6)
7)
Tax Map: Section
Block
I Lot
Completion Date
Starting Date:
B) Work Schedule:
Phase
Completion Date
. \
Excavation...,................. .-.-,:"...'....""..'
Facility Installation..................................
Backfi II & Compaction..............................
Pavement RepIClcement"....., .,... ... . . ... .. ,. .. . .. ..
9) Under which euthorlty is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
\ '
["'- 20
Pace 0: 3
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-12) Insurance Coverage: (Attach copy).:
a) Insurance Company:
b) Policy #
c) State whether policy of ce'rtiflcation on. file with the Highway Depart-
ment:
d) Coverage required extende~. to the Town:
Bodily Injury and proper'ty damage: $300,000/$500,000 Bodily Injury,
and $50,000 property darj1age.
13)
S~curity :
a) Surety Bond
total amount of $
b) Maintenance Bond
or 'Certified Check
provided in the
3 years
provided.:
2 years or
14) Fees for applications and permits: . Basic Application Fee........$25.00
Al. I IService Connections:"xcavatlons @ $20.00 = $ ~O. oJ
~ '
A2. ~/Additional Excavauo,ns same service @ $10.00 = $ / ~()
B. Excavations 18" in depth 'o~ less:
0-100 I.f. = $10.00 ....
l.f. @ $0.10 - .:$
Additional
'c. Excavatlons...l'B" 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 Repai~ Excavations @$10.00 = $
No.
,....
Repairs same service'@ $5.00. = $
Additional
F.
Notice to pub/Ie utilities pro'of must be provided and attached to
this application prior to issuance of permit.
,..
* * :..:'
TOTAL COR'l'~ $ .5 S. QQ
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.
s'8PERINTENDENT OF HIGHWAYS
T,dwN SOUTHDLD, NEW YORK
/--
Date
Received by the Town Clerk
Date.
97'
Permit Issued, /- / to - 0 (
Date
Permit No.
~:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice to the Sl:Jperintendent of Highways.
Permit must be available for Inspection.
'-'-"-""C'==__.~_._,____
FC--6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
.".
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
D STATE
.. -
N~W
D
NASSAU
COUNTY
MIS JOB
NO.
D SUFFOLK
COUNTY
[Zf 1': 0 - ~O\J7110d)
DATE
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FOREMAN
~ ') - 014 c:;fs~O"1 0
\ JV J) lts
(f/Vrll" yr ')
:5,J FPOvlL-
DATE OF
OPENING
DEPARTMENT DIVISION
GAS CONSTR. MAl NT. & SERVICES Z tf
DATE
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A-CSAP
N
Date: 01/16/01
Transaction(s):
Name:
Clerk 10: L1NDAC
1 Permits
Check#: 1108
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Town Of Southord
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1108
Subtotal
$55.00
$55.00
Internal 10: 24741