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Permit NO...d-t::i
File No. I 7
TOWN OF S;JU1'HOLD
H IGHWA Y DEPARTMENT
Peconic Lane
Peconic, New York 11958
(516) 765"31110
Po, /2>0," 176
APPLICATION/PERMIT FOR HIGHW'AY EXCAVATION AND REPAIR
Ref. I'd]- 07'fSrr'o3,0
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.nces, 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
fo.......J-e....
ark Description and Location
Address
,a..)....- ~tI.....~,L
(Street Number I Hamlet, Cross Street)
3)
(a)
'-s construction located within _75 feet of tidal wetlands? "'Yes_No
*If yes, other-Town permits may be required.
II) Builder's License No.
Plumber1s License No.
Electrician's License No.
Other Trade's License No.
YYJA, /~
Signature licant
.. tJ/ -tfS- - cI /
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 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
I Lot'
Completion Date
Starting Date:
8) Work Schedule:
Phase
Completion Date
Excavation....... ............. ... '\' ............... ..
Facility Installation............ .'....................
Backfill & Compaction..............................
Pavement Replacement........ '... . . . .. . . .. . . .. . . . .. .,
9) Under which authority is the applic-ation made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
,.
D-1q
Paf1p. 1 of 1
\
j
. -
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 di:u"!lage.
/
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:
j IService Connections
~
,
Basic Application Fee........ $25. 00
excavations @ $20.00 = $ ~ ~
/ () c.J
A1.
A2.
IAdditional Excavations same service @ $10.00 ;:: $
l'io.-
B. Excavations 18" in depth 'or less:
0-100 1. f. = $10.00
I.r. @ $0.10-$
Additional
C. Excavations-..t8" in depth to '5' in depth:
0-100 1. f. =~ $30.00
. 1. f. @ $0. 30 = $
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.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 co~ $::J y::- c/
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.
SOPE:RINTENDENT OF HIGHWAYS
TO~HOLD', NEW YORK
.. ee ,;z:~~
Raymond L. obs
/- 7-t?/
Date
Received by the Town Clerk
Date
'lot
Permit
Issued,. / - rdl-t) (
Date
Permit No.
Note:
Permit expires one (1) year fr:om Date of Issuance.
No work to start without 48 hour notice .to the Sl:Jperintendent of Highways.
Permit must be available for inspection.
n 00
Page 2 of 3
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
D STATE
D
D SUFFOLK
COUNTY
~ 1.CI. ~CAlG Il
FC.6111.4
NASSAU
COUNTY
MIS JOB
NO.
G $ U.N'i)'U.~ PA"'n-l :21S-0( s..!,
~ (lvlCL lA.~c;:.mt-
FOREMAN
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
\ 4-l MAll-its
DEPARTMENT
GAS CONSTR. MAl NT. & SERVICES
DATE
11. ... 2-2"-00
I~U. (",4.
~~vJ~~ IA
DATE OF
OPENING I - I S- - 0 I
DIVISION
&CM~'!.-?.<{
DATE
APPROVED
SKETCH
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1UBZ- Sl~VIC1...... J-
f2-'i.P~4 Cf..... (Ltb-(}..L4 '10 (L
~ .'
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: 24656