HomeMy WebLinkAbout470 N Moores Ln
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 12/10/02
Receipt#:
17145
Transaction(s):
1 Permits
Check#: 17145
Total Paid:
Subtotal
$45.00
$45.00
0j1
t/
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Internal 10: 64565
,
Permit No.
cJ. a/
02,01
~Ill'~
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peeonie, New York 11958
(631) 765-3140
APPLICA TIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#Tl 00231112
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuante 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, ordinances, codes and regulations, and to permit authorized inspectors to make necessary inspections orthe
job site.
Print or Tvoe
1) KEYSPAN ENERGY -GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. -HICKSVILLE. NY 11801
Name of Applicant Address
2) 470 N. Moores Lane. Greenoort
Name of Owner of Premises
Address
3) OoeD & restore a bell hole on the w/s oaved area aooro:\: 27S' nlo Homestead Wav to install a I!as service.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet oftidal wetlands? *Yes
*If yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
re of pplie nt
12-02-02
Date
S) 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 Towo Clerk.
6) Tax Map: Section
, Block
,Lot
7) Startiog Date:
Completion Date:
8) Work Scbedule:
Phase Comoletion Date
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
.page 1 of 3
Tl002311l2
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 $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic Application Fee.. ............ ... $25.00
A 1. ~/Service Connections excavations @ $20.00 = $ 20.00
No.
A2. _/ Additional Excavations same service @ $10.00 = $
No.
B. Excavations IS" in depth or less:
0-100 I.f. ~ $10.00
I.f.@ $0.10 ~ $
Additional
C. Excavations 18" 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 @ $1 0.00 ~ $
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 $45.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk /,;}- /t> - ,;z. a::>,;L.J
Permit Issued lei- -I 0 - ,il. 6 0 ;:..are Permit No. oZ.!} I
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Page2of3
~OV,25.2002 8:07PM KEYSPAN ENERGY KEYSPAN/~AJ' NO. 579 P.8
, .. REQUEST FOR STRE6TOPENING PERl!IlT .
, , . ,
o 'STATE '0 o SUFFOLK, '[gJ
FC-el11.4 COUNTY
PERMIT,
NO.
tbe.trl-,J' LA. .~. JH1A
REASON FOR &n4$~
OPENING A,
W,OJPA
NO.
REQUESTED' DEPARTMEfjT
BY' GAS CONSTR. L~.)
. APPROVED "
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