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TOWN OF S;JU,'HOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic,. New' York -1195 B
(516) 765'31110
Po. p->c1- /7e
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND
REPAIR
1/;)3-01'7'5f.ajo
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, ordina),'ces, 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 Appl i cant
PATCHOGUE, NEW YORK
Address
11727
2)
Address
Name of Owner of Premises
, ~ cL,.."f) ST.
Wor Description and Location
/,;lo' %
(Street Number, Ham et,
7'- Sr ,v(w SL{//TcLk
Cross Street)
3)
[a)
!'s construction located within 75 feet of tidal wetlands? *Yes No
'/Ilf yes. other-T~own permits may be required. -
----
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~J~__-
Signatu re 0 A I t
,. 1-'1-01
Date
eo--
5) aJ Attach plot plan showing location .of proposed. e"cavation and relationship to
adjoini'ng premises or public stre_ets or areas, and giving a detailed descrip-
tion of layout of excavation.
b) Attach all other necessary per~\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)
7)
Tax Map: Section
Block
. Lot
Completion Date
Starting Date:
BJ Work Schedule:
Phase
Completion Date
'\
Excavation. . . , . . . . . . . . . . . . , . . . . .- '< ' . . . . . . . . . , , . . . . .
Facility Installation.................................
Backfill s Compaction....,...................,.....
Pavement Replacement...,.... '.' '. ..... ., . .. .. ,. ... , .
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: ..$
11) Remarks:
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12) Insurance Coverage: (Attach copy).::..
a) Insurance Company:
bl Policy #
c} State whether policy of ce~.t.iflcation 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 damage.
13) Security:
a) Surety Bond
tota I amoun t of $
b) Maintenance Bond provided.,
or ~ertified Check
14)
Fees for
applications and permits:, . Basic A Ii
l IServlce Connections: e')(~avatlon5 @ $20
~ .
k/Additional Excavations same service @
Excavations 18" in depth 'o~ less:
0-100 I.r. = $10.00 ....
/ I.f. @ $0.10 -,:$
Additional
Excavatlons..."S" in depth te) '5'
0-100 I.f. =.$30.00
I. r. @ $0. 30 < $
Al.
A2,
B.
'C.
in depth:
O.
Additional
Excavations 5' in depth and over:
0-100 I.r. = $50.00 .
I.f. @ $0.50 ~'$
Additional
E.
Utility Repai~ Excavations @$10.
No.
Repairs same servlce'@ $5.00. =
Additional
F. Notice to public utilities proof must be prov!
this application prior to issuance of permit.
"
. *:.:.
Authorization is hereby granted to the Town Clerk of the
Issue a Highway Excavatlorl Permit to:
In accordance with -this application.
SOPER INTEN DENT
TQWN 0 SOUTHOL
aymon
-9
Oat
Received by the Town Clerk
Date.
Permit Issued,/- /6 -0 (
Date
Permit No.
provided in the
2 ye 5 or
3 years
tlon Fee...,.... $25. 00
o = $ ~O. fY
10.00 = $ / tfF)tJ
j ~,
$
and attacl)ed to
.5 S. 00
wn of Southold to
HICHWAYS
NEW YORK
.0/
9,
~:
Permit expires one (1) year from Date of Issuan
No work to start without qS hour notice .to the 5 erintendent of Highways.
Permit must be available for Inspection.
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KEYSPAN
REQUEST FOR STREET OPENING PERMIT
D SUFFOLK r-I -( 0, ~ G <1111 G L:~"
COUNTY ~ :JI)
FC-6111.4
D STATE
D NASSAU
COUNTY
PERMIT I ~IS JOB IDATE (- G.-Of
NO. NO.
LOCATION s./~ O(l.tHA~ S-r 1Z-6 I rs/O 1{.;1.. ~ 7 fJ2w S. vl/J(/I K...
REASON FOR 5;.2(ZvtCt--- u.t'>&r4D \:...- /
OPENING
W.O.lPA '2-3 - 071.f5"~-OJ() FOREMAN I ~ATE OF ASAP
NO. OPENING
REQUESTED UtltJ MA~J DEPARTMENT 'I DIVISION
BY GAS CONSTR. MAl NT. & SERVICES '2 V
APPROVED IDATE
~KETCH
o{2.G~f.O
G~\~~ 161-l(~-~02(
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Date: 01/16/01
Transaction(s):
1 Permits
Check#: 1108
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1108
Subtotal
$55.00
$55.00
Internal 10: 24740
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Received $ 45.00
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #145
1 - Permits on 12/10/2001.
Thank you.
Permit No. / L/ S
File No. I L.j 5'
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
APPLICATION IS HEREBY made to the Superintendent of Highways oflbe Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 oftbe Code of the Town of South old, Suffolk County, New Yor~ 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 TVDe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) Keith Morton -(New House) - Orchard Street - Orient
Name of Owner of Premises
Address
3) Ooen & restore a bell hole on the south side Dave{( area 8ooroximatelv 447 feet west of Tabor Street in
Orient.
Work DestriptloD aDd LotatloD (Street Number, Hamlet, Cross Street)
(a) Is tonstrudion louted within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No
a
re 0 ppli
12-04-01
Date
5) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areas, and giving a detailed description 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) Tax Map: Section
. Block
. Lot
7) Starting Date:
8) Work Schedule:
Completion Date:
Phase Comnletion Date
Excavation........... .............................. ....................... .........
Facility Installation.... .... ........................... ...... ..... ............. ....
Backfill & Compaction.........................................................
Pavement Replatemeot......................... ............ .... ................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
TlOOI09405
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Department:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
13) Security:
a)
b)
Surety Bond
01$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oennits: Basic Anolication Fee.............. ,.. $25.00
At. ~/Service Connections excavations@$20.00=$ 20.00
No.
A2. _/ Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 l.f. ~ $10.00
l.f. @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. ~ $30.00
l.f. @ $0.30 ~ $
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
l.f.@ $0.50 ~ $
Additional
E.
Utility Repair Excavations @ $1 0.00 ~ $
No.
Repairs same service @ $5.00 = $
Additional
F. Notice to public utilities proofrnust be provided and attached to this application prior to issuance of
pennit.
. . .
TOTAL COST $45.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Pennit to:
KEYSP AN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Permit Issued /~~" I'
/ tJ/lo!or
Date
DENT OF HIGHWAYS
UTHOLD, NEW YORK
/~-/o-
Date
Permit No.
/t.js
Note: Pennit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Page 2 of3
CEC.-O.4'~I(TUE; 0941
Fc..IllU
PEAM
NO.
~OCA TION
lEA80N FOA
OPENINlI
W.OlPA
NO.
REQUESTED
8Y
APPROVED
SKETCH
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B~ GAS DESIGN PATCH TEL.516 7585136
KEYSPAN!"A.l"
ReaUEST FOR STREET OPENING PERMIT
O 0 NASSAU 0 SUFFOLK
STATE COUNTY COUNTY
MIS JOB
NO. 1ifJo 0 /)
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DEPARTMEN A
GAS CONSTR. lllI,or. 11I"1F#D6lAL
DATe OF I
OPENING I('! ZQo2
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DATE
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