HomeMy WebLinkAbout1300 Grathwohl Rd
Date: 12/10/02
Transaction(s):
1 Permits
Check#: 17145
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3D
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Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksvilie, NY 11801
Clerk 10: L1NDAC
17145
Subtotal
$45.00
$45.00
Internal 10: 64564
Permit No.
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Cl30
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T1 00230609
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town ofSoutbold for tbe issuance of
an Excavation Permit pursuant to Chapter 83 uftbe 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 or the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSYILLE. NY 11801
Name of Applicant Address
2) 1300 Grathwahl Rd.. New Suffolk
Name of Owner of Premises
Address
3) OueD & restore a bell hole on the e/s oaved area aoorox 540' slo Geore-e Rd. to install a e-as service.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal 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.
Other Tr
re of ppli
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
hy the Town Clerk.
6) Tax Map: Sectiou
,Block
. Lot
7) Startiog Date:
Completion Date:
8) Work Schedule:
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 of3
T1 00230609
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 applications and permits: Basic Application Fee................. $25.00
AI. ~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 l.f. ~ $10.00
l.f.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. ~ $30.00
_l.f.@ $0.30 ~ $
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
l.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.
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Received by the Town Clerk
/,;}.-/O ~;?PO;U
Date
Permit Issued I,;J - /0 'Db "0 ;,...
Permit No.
023D
Note: Permit expires one (I) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
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Page 2 of3
NOY, -2f 82 (SUN) 22: 56
BU GAS SALES PATCHG TEL:516i585182
KEYSPAN/tfA.f
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