HomeMy WebLinkAbout3rd St
Permit No;~
File No. \T \C7
TOWN OF S,oU ,'HOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New' York 11958
(516) 765c31110
PO. ~o..' /7&
Ref. !1;)3-0/'iSf'o]O
,
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an Excavation Permit purwant 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 compiy with all applicable laws, ordin"hces, codes and regulations, and to permit
authorized inspectors to make; necessarY...inspectlons of thll job site.
Print Or Type
I) KEY SPAN ENERGY 448 EAST MAIN StREEt
Name 0 Applicant
,
2)
v'
PATCHOGUE
I! 727
Name 0
3)
~
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- ~..s <-<"c,c",,-OC
T
Work Description and Location (Street Number,
,q. ( :. s. r-
Cross Street)
(a) . (5 construction lo~ated within 7S feet of tidal wet
*If yes, other-Town permits mElY be required.
lIrYes No
LI) Builderls License No.
Plumber's Ll nse No.
Electrician's License No.
Other Trade's LI nse No.
5)
a)
Attach plot plan showing locatiO;f1 of proposed,
adjoining premises or PUblic'stre,ets or areas,
tien of layout of excavation,
A tt'ach all other necessary permits and licenses for
Work covered by this applicatlori may not commence
Highway Excavation Permit by the Town Clerk.
5 project.
ore issuance of a
On and relationship to
,;ng a detailed descrip-
b)
c)
6)
7)
8)
Tax Map; Section
Block
. Lot
Starting Date:
Work Schedule:
Completion Date
~
\,
m let ion Date
Excavation.,."...".""",..,.. '\,......"...",...
Facility Installation",...,.".;',.,......,....."....
Backfli I & Compaction......... ~ . . . . .. . .. . . . . .. . .. ..
Pavement Replacement..".,.. ~'.,;.......,....,......
9) Under which authority is the applic~tion made:
10) Estimated Cost of Proposed Work: $
11) Remarks;
\ '
f'-~r
i
.t.
"
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of ce'r,tiflcation on_ file with the Highway Depart-
ment:
d) Coverage required extende~'. to the Town:
Bodily Injury and propeity damage: $300,000/$500.000 Bodily Injury,
and $50.000 property darj1,:,ge.
13) Security:
aJ Surety Bond
total amount of $
b) Maintenance Bond provided;
or certified Check
provided ,in the
.,
.
2 ye s or
3 yea rs
Basic
A Ii
@ $20
tlon Fee........ $25. 00
o = $ ~O. oJ
10.00 = $ I tJ!1()
14)
Fees for
applications and permits:
i IService Connections e"xcavations
~
k-/Additional Excavations same service @
f
I
1
I
Al.
Al.
B.
Excavations
0- 1 00 I. f. =
1811 in depth '0''-: less;
$10.00
I.f. @ $0.10 -,$
Additional
C.
Excavatlons-.."S" in depth to' '51
0-100 I.f. =$30.00
I.f. @ $0.30=' $
in depth:
D.
Additional
Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f. @ $0.50 7'$
Additional
'f!
E.
Utility Repai~ Excavations @$10.ilII = $
No.
Additional
Repairs same service -@ $5. OQ. =
F. Notice to public utilities proof must be provi
this application prior to issuance of permit.
;"
and attached to
* *:.:.
TAL CO,qr- s
5S 00
Authorization is hereby granted to the Town Clerk of the wn of Southold to
Issue a Highway Excavation Permit to:
In accordance with ~this application. J
H ICHWA YS
NEW YORK
9' cP
Oat
Received by the Town Clerk
Date
Paqe ~ cf ~
Permit Issued, .j_iJ._ ()/
~te
Permit No.
Note:
Permit expires one (1) year from Date of Issuan
No work to st.rt without 48 hour notice 'to the erintendent of Highways.
Permit must be available for inspection.
FC-6111.4 .
PERMIT
NO,
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
APPROVED
SKETCH
.'
M41,J
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
O 0 NASSAU 0 SUFFOLK r-Y' ~ (j C\ I ~
STATE COUNTY COUNTY ~ -r.o .~tfvr",o......
~~JOB DATE f- 6- 01
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FOREMAN
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.
MAIN s....,
DATE OF
OPENING
DEPARTMENT u DIVISION
GAS CONSTR. MAl NT. & SERVICES l-,
DATE
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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 10: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1108
Subtotal
$55.00
$55.00
Internal ID: 24730