HomeMy WebLinkAbout1435 West Creek Ave
.
Date: 05/02/00
Transaction(s):
1 Permits
Check#: 835
Name: Key, Span Energy
A1k1a/ Brooklyn Union
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
835
Subtotal
$45.00
$45.00
JnternallD: 9875
Ref.
II :J.sg-g-')Q J
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Pecenic Lane
Pecenic, New Yerk 11958
(516) 765~ 31110
PO. (2,,,, ~ 17 e,
APPLICATION/PERMIT FOR HIGHWAy EXCAVATION AND REPAIR
~
Permit No.. 0;b
File No.. -500
APPLICATION IS HEREBY made to. the Superintendent ef Highways ef the Tewn
ef Seutheld fer the issuance ef an Excavatien Permit pursuant to. Chapter 83 ef the
Cede ef the Tewn ef Seutheld, Suffelk Ceunty, New Yerk, and ether applicable laws,
erdinances er regulatiens fer the excavatil)o herein described. The applicant agrees
to. cemply with all applicable laws, erdinances, cedes and regulatiens, and to. permit
autherized inspecters to. make: necessary}nspectiens ef the jeb site.
Print er Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name ef Applicant
PATCHOGUE, NEH YORK
Address
11727
2)
Name ef Owner ef Premises
Address
C<....-- Ie ''-iJu'--<-
Number, Hamlet, Cress
Street)
3) / 'f ,~S- fA)~r C(2t'e tc Avc-"
. Werk Descriptien and Lecatien (Street
(a)
Is censtructien lecated within 75 feet
*If yes, ether-Iown permits may be
ef tidal wetlands? *Yes No.
-
req ui red.
r=
4) Builder's License No..
Plumber's License No..
Electrician's License No..
Other Trade's License No..
!~~re~~
y- l- 7'CJV
Date
5) a) Attach plet plan shewing lecationef propesed el<'cavatien and relatienship to.
adjeining premises er public streets er areas, and giving a detailed descrip-
tien ef layeut ef excavatien.
b) Attach all ether necessary perrnits and licenses fer'this preject.
c) Werk cevered by this applicatien may net cemmence befere issuance ef a
Highway Excavatien Permit by the Tewn Clerk.
Tax Map: Sectien
Bleck
, Let
6)
7)
Starting Date:
Cempletien Date
8) Werk Schedule:
\
Excavatien.................... .. .,..................
,
Phase
Cempletien Date
Facility Installatien.................................
Backfill & Cempactien.........:....................
Pavement Replacement..........,...................
9) Under which autherity is the applicatien made:
10) Estimated Cest ef Prepesed Werk: $
11) Remarks:
\'
D-39
Page 1 ef 3
#
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on. file with the Highway Depart-
ment:
d) Coverage required extendeCl 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
2 years or 3 years
Application Fee..... C$25. 0
@ $20.00 = $ do ' oJ
14)
Fees for applications and permits: Basic
A 1. /Service Connections. excavations
NO:-
A2. /Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth "a'r less:
0-100 I.f. = $10.00
I.f. @ $0.10 -$
Additional
C. Excavations.,,1'8" 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 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.
* * ie'
TOTAL CO~'I:-' $ Y 5:, 0)
. ,
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
TOW SOUTHOLD, NEW ORK
s:-/~oo
Date
Received by the Town Clerk S / - tJ 0
Date
Permit Issued,. S - 02 - tJ 0
Date
,;;-.-, ,
Permit No. '.:.J 0,{---
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice 'to the Sl:Iperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
D-39
I
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
MIS JOB
NO. 2. 5 5'8' S - 0.3 0
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