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TOWN OF S;'U {HOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New' York -11958
II;J-} o7YJf--dJ" (516) 765emO
Po, f2,c'f- 178>
APPLICATION/PERMIT FOR HIGHW'AY 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 excavafion 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 448 EAST MAIN STREET
Name of Applicant
PATCHOGUE. NEW YORK
Address
11727
2)
Name of Owner of Premises
'i d-~ Hu tl {/);-> L-- 'f -
Work Description and Location (Street
Address
54'- ~Lp
Number I Hamlet, Cross Street)
3)
(a)
rs construction located within -75 feet of tidal wetlands? *Yes No
*If yes, other--Town permits may be required. -
4) Builder1s License No.
Plumber's License No.
Electrician1s License No.
Other Trade1s License No.
~ ~#~cant
. I") ClI
Date
5) a) Attach plot plan showing Iocation.of proposed- e:,;rcavation 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)
7)
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) Rema rks :
\
D-39
Paqe , of 3
~prr,~-":~:;~~"-"
12) Insurance Coveraqe: (Attach copy)
a) Insurance Company:
b) Policy #
c) State whether policy of ce~tiflcation 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
total amount of $
b} Maintenance Bond provided:
or Certified Check
provided in the
3 years
2 years or
14)
Fees for applications and permits:
A 1. I IService Connections
~
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ ~ (). (.) 0
A2. I /Additional Excavations same service @ $10.00 = $ /0. c.....>
~
B. Excavations 1811 in depth o"r less:
0-100 I.f. = $10.00
I.f. @ $0.10-$
Additional
C. Excavations-,,'1"81l in depth to 51 in depth:
0-100 J.f. =-$30.00
_ I. f. @ $0.30 = $
Additional
D. Excavations 5' in depth and over:
(1-100 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 attacbed to
this application prior to issuance of permit.
* . ."
SS'.I?
TOTAL CO~-T S
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
TOWN SOUTHOLD, NEW YORK
,p~
Raymond L. obs
('- 7 0/
Date
Received by the Town Clerk
Date
Permit Issued, - / - /J - 0 /
Date
PI
Permi t No.
Note:
Permit expires one (1) year fr:om Date of Issuance.
No work to start without LIS h9ur notice -to the Stlperintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
FC.6111.4
D STATE
D SUFFOLK
COUNTY
PERMIT
NO.
LOCA TION
NASSAU
COUNTY
MIS JOB
NO.
W/S 110fL-rf/N vA 1001 s./O (JUJVnu.),
SV2.VICC- t.,.tJDt.Mtbt...
FOREMAN
D
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED .
BY
APPROVED
h ~ tt:s
DEPARTMENT
GAS CONSTR. MAINT. & SERVICES
SKETCH
c; f2- (\)--1r?
[2f -(Ii. Sf/v-((..(Ol..t)
DATE
rz.. - Z~-OO
.s,. oS: aVTIUt.-O
DATE OF
OPENING 1- IS- - 0 I
DIVISION
c..Ct1 ,1.1 - 2-
DATE
IO~-Oq- n~z.
N
,>-1:
'v<v'V--
-iV.,)\.
-(v ~ 'L- ~~I'/.\/I Ci.-- ~
(2.. 'i. hI/C/i.... r2 ~G- u.L-4 -r. .z.
St~ .1L.SO "a, j~5' Hu:-ro,.)
Date: 01/12/01
Transaction(s):
1 Permits
Check#: 1103
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:
1103
Subtotal
$55.00
$55.00
Internal 10: 24658