HomeMy WebLinkAbout1400 4th St
Permit No;
f/v
File No.
TOWN OF 5;JU.,' HOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic;, New' York -11958
(5H) 765'31/10
Po. f.,o"- /78-
Ref. II;) 3 -0" 'f5i'0](,
;',
APPLICATION 15 HEREBY made to the Superintendent of Highways of the Town
of SouthoJd for the issuance of ,m 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.:hces, codes and regulations, and to permit
authorized inspectors to ma"ke; necessary,}:nspectlons 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
3)
I ~ 0 0 l..f 7'- .s T - J <,'{)"
Work Description and Location (Street
/J /0
Num ber ,
t'" (--'~ S r _Ne.... S~ l'/vl.-lC
Ha~(et. eross Street)
(a) ". !'s construction located withih '75 feet of tidal wetlands? *Yes No ~
*If yes, other-T~wn permits' may be required.
4) Builder's License No.
Plumberls License No.
Electriclan1s License No.
Other Trade1s License No.
~J~-
Signature 0 A I t
... 1-9. 0 I
. Date
a--
5) a) Attach plot plan showing location ,of proposed. e:5i(c'lv'ltion and relationship to
adjoining premises or public' stre,ets or areas, and givi n9 a detailed descrip-
tion of layout of excavation.
b) Attach all other necessary permits and licenses for this project.
c) Work covered by this 'applicatio~ 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:
8) Work S chedu Ie:
Pha se
Completion Date
.\
Excavation. .. . . . . . . . . . . . . . . . . . . .' '.,: . . , . . . . . . . . . . . . . .
Facility Installation...,....,... ......................
Backfill & Compaction.........;................,...
Pavement Replacement........ ~',." .,. . . ... .. .. .. . .. ..
9) Under which euthority is the applieation made:
10) Estimated Cost of Proposed Work: '$
, 1) Remarks:
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12) Insurance Coveraqe: (Attach copy).:.';.
a) Insurance Company:
b) Policy #
c) State whether policy of ce~t,jflcation 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 da~age.
13) Security:
a) Surety Bond
tota I amoun t of $
b) Maintenance Bond provided,'
or "f:ertified Check
provided in the
3 yea 1"'5
2 years 01'"
14) Fees for appIlcations and permits:' " Basic Application Fee........$2S.00
A 1. -k-/servlce Connections: ..cavatlon. @ $20.00 = $ ~O. oJ
A2. ~/Additional E.cavati.~ns same service @ $10.00 = $ / lFl()
B. Excavations 1811 in depth or: less:
0-100 l.f. = $10.00 ....
/" 1.f. @ $0.'0-)
Additional
'c. Excavatlons...l'S" in depth to '5' in depth:
0-100 I.f. =.$30.00
I. f. @ $0. 30 .c" $
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 ,:,' $
Additional
E.
Utility Repair..excavatlons @$10.00 = $
No.
Additional
Repairs same service ,@ $5.00. = $
F.
Notice to public 'utilities proof must be provided and attached to
this application prior to issuance of permit.
f
* *:*>
TOTAL CO~'l" $
55.00
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.
S0PERINTENDENT OF HICHWAYS
Ti.QWN SOUTHOLD" NEW YORK
/- '1- 0/
Date
Received by the Town Clerk
Date
9;2./
Permit Issued,'
/-/(P-o(
Date
Permit No.
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without qB hour notice .to the Superintendent of Highways,
Permit must be available for Inspection.
0,.,,..... ., nf 1
.
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
-
FC-6111.4
D STATE
D
NASSAU
COUNTY
MIS JOB
NO.
D SUFFOLK
COUNTY
[2f -1. 0 . S (iv1'I1't..'l>
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
DATE
1- 6-pl
It-/ j",IAI/c
/ 6 0 I NIo /t../NC-..!-r
DATE OF
OPENING
DEPARTMENT Ii DIVISION
GAS CONSTR. MAl NT. & SERVICES 7. 7
DATE
A -S.A P
SKETCH
GJ1(D~ IO/-I.{l:, - ~017
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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 South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1108
Subtotal
$55.00
$55.00
IntemallD: 24739