HomeMy WebLinkAboutWoodcliff Dr
Date: 04/24/00
Transaction(s):
Name:
1 Permits
Check#: 3207
Brooklyn, Union Gas
444 East Main St
Patchogue, N Y 11772
Clerk ID: L1NDAC
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
~ t{t
~/
3207
Subtotal
$45.00
$45.00
Internal 10: 9375
Permit No; L(f
File No. '-I f'
TOWN OF SOUTHOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765'-31110
Pc. t2>o~ /7f>
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
Ref. 1/ :)/:;7<,-6 - 03.
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 mlake: necessary. inspections 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
J: ~e ;A
(Street Number,
(,J<"S/J,,,,,, ~ -
Street) w<A-Tr,7<<< Ie
(a)
Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other--rown permits may be required.
No
-
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
.~ ~J__
Signature of irlJcant
Y '..J.-v - OV
Date
5) a) Attach plot plan showing location of proposed.ex'cavation 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) Tax Map: Section Block , Lot
7l Starting Date: Completion Date
.
8) Work Schedule:
Phase
Completion Date
Excavation.................. ........................
Facility Installation.................................
Backfill & Compaction..............................
Pavement Replacement..............................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11)
Remarks:
\'
0-39
Page 1 of 3
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy II
c) State whether policy of certification on file with the Highway Depart-
ment:
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) Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
14)
Fees for applications and permits:
A 1 . f /Service Connections
~
A2. /Additional Excavations same service @ $10.00 = $
2 years or 3 years
Basic Application Fee.......~
excavations @ $20.00 = $ ,,;Jo, UJ
No.
B. Excavations 18" in depth or: less:
a-lOa 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.
Repai rs same service @ $5.00- = $
Additional
.-~~.
F. Notice to public utilities proof must be provided and attacbed to
this application prior to issuance of permit.
* * ic"
TOTAL COM: $
<-IS ^-~ '
-
Authorization is hereby granted to the
issue a Highway Excavation Permit to:
in accordance with .this application.
Town Clerk of the Town of Soutliold to J
<I.2-v.....~ ~ - {.( q/~ 4c..,.",( ht/ . f"''''~
SUPERINTENDENT OF HIGHWAYS
TOWN 0 OUTHOLD, NEW YORK
/~
Raymond L. obs
tj/' 2.0 ~ 00
Date
Received by the Town Clerk *,0/-/16
Date
Permit Issued,' Lj-cb t./ - 00
Date
Permit No. <( P
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice -to the Sl:lperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
D-39
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
D STATE
KEYSPAN!if"1'{>
REQUEST FOR STREET OPENING PERMIT
D
D SUFFOLK rt7l
COUNTY LL::.J
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FOREMAN
00
DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
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