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Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR HIGHWAY EXCA V A TION AND REPAIR
Ref.#T1 00333300
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 fOf 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 inspedions or the
job site.
Print or TVDe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 1230 Clearview Avenue, Southold
Name of Owner of Premises
Address
3) Clearview Avenue - bellhole and a 100' trench in the n/s 2rass area approx. 37' wlo Breitstadt Ct..
Southold to install a 2as main and 2as 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.
ture of Ap
10-20-03
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
, BlQck
,Lot_
7) Starting Date:
Completion Date:
8) Work Schedule:
Phase Comnletion Date
Excavation,...,......"...."......,...".........,..,............"'.,........., ..
Facility Installation.......,....,......,........,.,...,........,..,...........,....
Backfill & Compaction.... ...,............".........,..,........,....,..,.....
Pavement Replacement....,.................,..."....n."...........,..,.....
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
T1 00333300
12) Insurance Coveraee: (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 aDohcatlons and Denmts. Basic Aoolication Fee................. $25.00
AI. ~t_/Service Connections excavations@$20.00= $20.00
A2. _I Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or iess:
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@ $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 - $75,00
Authorization is hereby granted to the Town Clerk of the Town of Southold t'J issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Peter W. Harris
/d~~
/ Da
Received by the Town Clerk '6/~" I ^1.. _
~~~
Permit Issued 1 0 ~ Pennit No.
c:QrG.
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
,
.It HI
P 002
3D GAS DESIGN PATCH TEL 516 i585136
KEYSPAWG~
REQUEST fOR STREET OPENING PERMIT ,
OCT, -20' 03IMON) 08:49
FC-6111.4
PERM
NO.,
D STATE
'APPROVED "
SKETCH
D SUFFOLK
COUNTY
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GAS CONSTII. ,.."..A 1C~DitI:JL.
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Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 10/23/03
Receipt#:
2255
1 Permits
Check#: 2255 . ;l,~51..
430 ."5
Total Paid:
Subtotal
$75.00
$75.00
Transaction(s):
=t\==- ~B~
Name:
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk ID: L YNDAB
InternallD: 83022