HomeMy WebLinkAbout3495 Peconic Bay Blvd
Permit NO~(,:u
File NO.~
.
TOWN OF 5:JU (HOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New' York -11958
(516) 765c31l10
Po. (601- Of:,
Ref. II T I (JOn 611 ., (J
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 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 make; necessary .Jnspections of the job site.
Print or Type
1) KEY SPAN ENERGY 44B EAST MAIN STREET
Name of Applicant
PATCHOGUE. NEW YORK.
Address
11727
2)
Name of Owner of Premises
Address
3) 3'iQt) pec.O,..l.c:. 6Ar
Work Description and Location
~\()J - LA-<--(e-r! (
(Street Number. Hamlet. Cross Street)
(al
fs construction located within 7S feet of tidal wetlands? "'Yes No
"'If yes, other~'Town permits may be required. -
4) Builder's License No.
Plumber1s License No.
Electrician's License No.
Other Trade's License No.
~.~,.
Signature f I\pplicant
.. /- ro-I
Date
S) a) Attach plot plan showing location of proposed ex.cavation and relationship to
adjoining premises or public stre,ets 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)
7)
Tax Map: Section
Block
, Lot
Completion Date
Starting Date:
8) Work Schedule:
Completion Date
Phase
Excavation.................. ..... .-....................
Facility Installation.................................
Backfill & Compaction.........:....................
Pavement Replacement........~. ~ . . . . . ... . .. . ... .. ..
9) Under which authority is the appliCation made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
,.
D-19
Paqe 1 of 3
12) Insurance Coveraqe: (Attach copy)
a) Insurance Company:
b) Policy II
c) State whether policy of cer;tification 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 Certifi ed Check
provided in the
3 years
2 years or
14)
Basic Application Fee........ $25. 00
excavations @ $20.00 ; $ dO. 00
Fees for applications and permits:
A 1. (/Service Connections
~
A2. /Additional Excavations same service @ $10.00 = $
~
B. Excavations 18" in depth c'r less:
0-100 J. f. ; $10.00
I.f. @ $0.10 -,$
Additional
C. Excavations...l811 in depth to 51 in depth:
0-100 I.f. ;.$30.00
Lf. @$0.30;$
Additional
D. Excavations 51 in depth and over:
0-100 I.f. ; $50.00
J.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.
* *
TOTAL cowr $ 'i ~ OV
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
nlW F SOUTHOLD, NEW YORK
Raymond L
1- '7 - 0/
Date
Received by the Town Clerk
Date
Permit Issued,/ - /;? - 0 (
Date
?~
Permit No.
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice -to the Sl:.Zperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
o STATE
o
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So ..,..711. U:J
FC.6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUESTED
BY
L
FOREMAN
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
DATE OF
OPENING
01 ION
APPROVED
SKETCH
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Date: 01/12/01
Transaction(s):
1 Permits
Cash#: 1106
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:
1106
Subtotal
$45.00
$45.00
InternallD: 24674