HomeMy WebLinkAbout2700 Fairway Dr
Permit No.
';l <6' l
a '67
(I)
FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR IDGHW AY EXCAVATION AND REPAIR
Ref.#T100331139
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 ofthe 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 inspections ofthe
job site.
Print or Tvoe
I) KEYSPAN ENERGY -GASCONSTR. DEPT. -175 E. OLD COUNTRY RD. -H1CKSVILLE. NY 11801
Name of Applicant Address
2) 2700 Fairwav Drive. CutchOi!Ue
Name of Owner of Premises
Address
3) Fairwav Drive - hellhole e/s erass area aoorox. 180' n/o Green Wav. Cutch02ue. to install a eas service to
#2700
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*Ifyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
ignature of ppl
10-16-03
Date
5) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areas, and giving a detailed description 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) Tax Map: Section
,Block
. Lot
7) Starting Date:
Completion Date:
8) Work Schednle:
Phase Comoletion Date
Excavation............................................................. ............
Facility Installation...............................................................
Backfill & Compaction................. ........................................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $.
II) Remarks:
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Page 1 of3
Tl00331139
12) Insurance Covera.e: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Department:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
13) Security:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and permits: Basic Aoolication Fee ............. .... $25.00
A I. ~Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. _I Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or Jess:
0-100 1.f. ~ $10.00
I.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. ~ $30.00 ~
_1.f.@$O.30=
Additional
D. Excavations 5' in depth and over:
0-100 1.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 COST $45.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in acconlance with this application.
Received by the Town Clerk~
~ Date
Permit Issued 10 /)3 Permit No.
~'67
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Page 20f3
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Date: 10/23/03
Transaction(s):
Name:
Clerk ID: L YNDAB
1 Permits
Check#: 2236
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
:tf d87
2236
Subtotal
$45.00
$45.00
Internal ID: 83023