HomeMy WebLinkAbout4th St
Permit ~o'--e-;
FUe NO'-I-f-
TOWN OF 5;>U ,'HOLD
HIGHWAY DEPARTMENT
Pecanic Lane
Peconic,. New' York 11958
(515) 765"31110
Po.a.,.. /75
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref. II;; 3 -0 1'15f -036
APPliCATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an E'cavatiori Permit pursuant to Chapter B3 of the
Code .of the Town of Southold, Suffolk County, New York,. and other applicable laws,
ordinances or reguiations for the excavafion herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors ta miake: necessary, ,j,nspections of the job site.
Print Or Type
1) KEY SPAN ENERGY 448 EAST MAIN STREET
Name of Applicant
2)
PATCHOGUE N~I YORK
Address
11727
Name of Owner of Premises
3)
Address
I
/'0'1" .~
Location (Street Numb
Sr
Hamlet,
J'-'(H-0Lf(:
Cross Street)
(a) . (s construction IO$:ated Within 75 feet of tidal wetlands? *Yes No
*If yes, other-Town permits may be required. __
~
~) Builder's License No.
prumber's License No.
Electrician's License No.
Other Trade's License No.
~JJ J~~=-
Signature 0 Art
.' /-9-0/
Date
5) a) Attach plot plan showing iocation of proposed. excavation and relationship to
adjoining premises or Publicstre.ets or areas, and giVing a detailed descrip-
tion of layout of excavation. "
b) A tt'ach all other necessary permits and licenses for this project.
c) Work covered by this application may not commence before issuance of a
Highway Excavation Permit by the Town Clerk.
6)
7)
B)
Tax Map: Section
Block
, Lot
Starting Date:
Work Schedule:
Completion Date
Phase
'\
Completion Date
Excavation..........,.............,~................ .
Facility Installation...........;'............,......,.
Backfill I; Compaction.........:....................
Pavement Replacement........ ~',.. . . . , .. '" , " .. . ""
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: '$
11) Remarks:
\'
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12) Insurance Coverage: (Atta7h copy)..,
a) Insurance Company:
b) Policy #
c) State whether policy of ce'r:tiflcation on, file with the Highway Depart-
ment:
d) Coverage required extended. to the Town:
Bodily injury and propert"y damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage.
13) Security:
al Surety Bond
tota I amount of $
bl Maintenance Bond provided:
provided In the
or "j:ertified Check
3 yea rs
2 years or
14)
Fees for
Application Fee........ $25. 00
m $20.00 = $ ~O. ().J
/ !fl()
AI.
applications and permits: Basic
l IServlce Connections. e'xci!lvatlons
'"'f'tO":- '
~/Additional EXCavali.6,ns same service m $10.00 = $
Excavations 18u in depth 'o~ less:
0-100 I.f. = $10.00 ....
, l.f. @ $0.10 -::$
A2.
B.
C.
Additional
Excavatlons","8" in depth to '5' in depth:
0.100 I.f. =.$30.00
I.f. @ $0.30 .<$
D.
Additional
Excavations 5' in depth and over:
0-100 I.f. = $50.00 .
I.f. @ $0.50 ,:' $
Additional
E.
Utility Repai~ Excavations @$10.00 = $
No.
Additional
Repal rs same service'@ $5.00. = $
F.
Notice to public 'utilities prciof must be provided and attaci)ed to
this application prior to issuance of permit.
f
. .:.-,.
TOTAL COR<r-~ S .5 S. OQ
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
TO~'WN SOUTHOLD" NEW YORK
~~___., -&- ~f>
'. . Raymon L. J~s
1- '7- 0/
Date
",:
Received by the Town Clerk
Date
Permit Issued, / - I ir 0 (
Date
Permit No. 9 I
~:
Permit 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.
n..,_" ... "'~ ')
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.OJPA
NO.
REQUESTED
BY
APPROVED
o STATE
o
NASSAU
COUNTY
MIS JOB
NO.
O SUFFOLK
COUNTY
G11".o . S (iv1'l1, 1.-1)
DATE
1- 6 - d I
lw J,."IAI/c
IS Is .l- LJIS:. if-l'4.s T
~ 'i (l VIer.. V<.1'~ll4bt..--
7. J . 07'158'- 01.0 FOREMAN
fJ k p., CJ.
/60 I N!o ft.IN&-.l-r
DATE OF
OPENING
DEPARTMENT Ii DIVISION
GAS CONSTR. MAl NT. & SERVICES t 1
DATE
A S.A P
SKETCH
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Date: 01/16/01
Transaction(s):
1 Permits
Cash#: 1108
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk ID: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1108
Subtotal
$55.00
$55.00
Intem.IID: 24735