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Permit NO'-VU
File NO.U7
Ref. II T 1(; O(1() 1/5?
TOWN OF S;'U (HOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New' York -11958
(516) 765c31l10
Po. t2>c"f.. ,7E>
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 Excava.tion 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 excavati,on herein described. The applicant agrees
to comply with all applicable laws. ordiniu:,ces. codes and regulations, and to permit
authorized inspectors to make: necessary \inspections of the job site.
Print or Type
1) KEY SPAN ENERGY 44R EAST MAIN STREET
Name of Applicant
PATCROGUE. NEW YORK
Address
11727
2)
Name of Owner of Premises Address
Sf() SKu. '" t: LA- C,-,,- T L-kocS LA ("
Work Description and Location (Street Number. Hamlet, Cr Street)
3)
(aJ
Is construction located withii175 feet of tidal wetlands? *Yes No
*If yes, other--!own permits may be required. -
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
~i9:'tt:7-~ant
/:-f'ol
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 perm1,ts 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)
7l
Tax Map: Section
BlOck
. Lot
Completion Date
Starting 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
Paqe 1 of 3
I
12) Insurance Coverage: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of cer:-tification on, file with the Highway Depart-
ment:
d) Coverage required extende~ to the Town:
Bodily injury and property damage: $300.000/$500.000 Bodily Injury,
and $50.000 property damage.
13) Security:
aJ Surety Bond
total amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
3 years
2 years or
1 q)
Basic Application Fee........ $25. 00
excavations @ $20. 00 ~ $ :J-cJ. u
Fees for applications and permits:
A 1. ~/Service Connections'
No.
A2. IAdditional Excavations same service @ $10.00 = $
~
B. Excavations 18" in depth Dr iess;
0-100 I.f. ~ $10.00
I.f. @ $0.10 -,$
C.
Additional
Excavations-,"l8" in depth to 51
0-100I.f. ~.$30.00
. I. f. @ $0. 30 ~'$
in depth:
/') tJ
Additional
D. Excavations 51 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.
. . .
. _ ~9"'
TOTAL COWI~ $') . '- .
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 F SOUTHOLD. NEW YORK
,f-?;
Raymond L. cobs
/- 7' --- 0-/
Date
Received by the Town Clerk
Date
f:1
Permit
Issued,' / - /d- Of
Date
Permit No.
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice .to the Sl:Jperintendent of Highways.
Permit must be available for inspection.
n_-:tQ
Page 2 of 3
[2] ~...7Tlo Q)
DATE
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'1
f FC~6111.4
PERMIT
1 NO.
t LOCATION
1 REASON FOR
1 OPENING
; W.OJPA
I
, NO.
.I REQUESTED
BY
APPROVED
SKETCH
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
NASSAU 0 SUFFOLK
COUNTY COUNTY
MIS JOB
NO. 1/0000 liSt}
Srl/JlI! LAJlt.. . 2. 8El1./kus;J SS' /flU.J' I
775' .r: 0 mA;N IlL IAt Culb/~buL
FOREMAN
o STATE
o
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. .5t ;/14/2-
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
DATE
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Date: 01/12/01
Transaction(s):
1 Permits
Check#: 1106
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L1NDAC
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1106
Subtotal
$55.00
$55.00
Internal 10: 24672