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Permit NO;~
File NO.~
Ref.
/1:>3- o7'tHoJ0
TOWN OF S;,u. {HOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New' York -11958
(S16) 76Sc 31'10
Po. (ho'f- ,7f>
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APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent af Highways of the Town
af Sauthald 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, ordina~-ces, codes and regulations, and to permit
authorized inspectors to make: necessary \inspections of the job site.
Print or Type
1) KEY SPAN ENERGY 44A EAST MAIN STREET
Name of Applicant
PATCHOGUE. NEW YORK
Address
11727
2)
Name of Owner of Premises
IV
Address
S IJ - i\..-. L ,g
Hamlet, Cross Street)
3)
() I C-~
Location (Street Number.
(a)
fs construction located within 75, feet of tidal wetlands? *Yes_No
*If yes. other--Town permits. may be required.
4) Builder's License No.
Plumber's License No.
Electrician' s License No.
Other Trade's License No.
~~tur~
I'S:-'~/
. Dat '
5) a) Attach plot plan showing location .of proposed- e:)'{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)
7l
Tax Map: Section
Block
, Lot
Completion Date
Starting Date:
B) 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-39~
Paqe 1 of 3
12) Insurance Coverage: (Attach copy),
a) Insurance Company:
b) Policy #
c) State whether policy of ce17tification 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:
a) Surety Bond
tota I amount of $
b) Maintenance Bond provided:
or Certified Check
provided in the
3 years
2 years or
14)
Fees for
applications and permits:
( IService Connections
~
I
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ 2--0 ?J
A1.
A2.
I Additional Excavations same service @ $10.00 :;; $ I ()
~
e-/
B. Excavations 1811 in depth 'o'r less:
0-100 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.
Repairs same service'@ $5.00-:;; $
Additional
F. Notice to public utilities pro'of must be provided and attached to
this application prior to issuance of permit.
. . .
TOTAL CO~1C $ 5' S-, 9'
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
'~""'" '" ""
, Raymo~.~
/__ 9- 0/
Date
Received by the Town Clerk
Date
Permit Issued, /- /02. - 0/
Date
f3
Permit No.
Note:
Permit expires one (1) year from Date of Issuance.
No work to start without 48 hour notice .to the Stlperintendent of Highways.
Permit must be available for inspection.
n-':l()
Page 2 of 3
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
o -(..0. So.AL q /J
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O.lPA
NO.
REQUBElTED \ w MAft,lt~
APPROVED
SKETCH
o STATE 0 NASSAU 0 SUFFOLK
COUNTY COUNTY
MIS JOB
NO.
W/$, 134'1Vlt,.W ~~ ')VO' .slo M4lJV'
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FOREMAN
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(ltPt.A(c, (Ll.-G-v..14 ..,,1<.
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DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
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DATE
p.- z.t-o 0
,?t) j,u !~oJJ
DATE OF
OPENING (- / t> -0 I
DIVISION
C C 114::' - z. 'I
DATE
N
t\.-(c:rll\(. tWf~ ~ d)~,57
Date: 01/12/01
Transaction(s):
Name:
Clerk 10: L1NDAC
1 Permits
Cash#: 1103
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
1103
Subtotal
$55.00
$55.00
Internal 10: 24660