HomeMy WebLinkAbout3495 Albertson Ln
Date: 12/10/02
Transaction(s):
Name:
Clerk ID: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 17085
Total Paid:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
17085
Subtotal
$381.00
$381.00
InternallD: 64562
Permit No.
c1 ;;( f
r1()tf
.
~
FileNo.
TOWN OF SOUTHOLD
ffiGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATlONIPERMlT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#Tl00225119
APPLICA TIQN IS HEREBY made to the Superintendent of Highways of the Town of Southold for tbe issuance of
an Excavation Permit pursuant to Chapter 83 or the Code urthe Town of South old, 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 of 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) 3495 Albertsoo Laoe. Southold
Name of Owner of Premises
Address
3) Albertson Lane- bellhole w/s oaved area at vo North Road and a 1120' trench in the w/s 2rass area to install
a 2as senice and extend the 285 main.
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.
Signa ure of plica
11-13-02
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 Town Clerk.
6) Tax Map: Sectiou
,Block
,Lot
7) Startiug Date:
Completioo Date:
8) Work Schedule:
Phase Comoletion Date
Excavation. ................ .............................. ..........................
Facility Installation.. ..................... .................................... ....
Backfill & Compaction.........................................................
Pavement Replacement.. ..... .... ..... ... .... ..... ......... ....................
9) Uoder which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D.39
Page 1 of3
TI00225119
12) Insurance Covera..: (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 oermits: Basic Application 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 less:
0-100 I.f. ~ $10.00
I.f.@$O.IO=$
Additional
C. Excavations IS" in depth to 5' in depth:
0-100 1.f. ~ $30.00
1.020 I.f. @ $0.30 = $306.00
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
1.f. @ $0.50 ~ $
Additional
Utility Repair Excavations@ $10.00 ~ $
E.
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 $381.00
Authorization is hereby granted to the Town Clerk of the To\VTI of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Peter W. Hams
Received by the Town Clerk /c2 -/0 - 020() .:LJ
Date
Permitlssued/,;! -/0 -~ 6o~ Permit No.
/c2-t:Jd- (}d-...
Date
~O?g/
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 2 of3
NOV,-13'02(WED) 08:26
BU GAS DESIGN PATCH TEL:516 i585136
K.cT:st'AN,/~;{..l
REQUEST FOR STREET OPENING PERMIT
p, 006
Fc.811U
P
NO.
~OCAT10N AUtL'!?D
o STATE
D SUFFOLK ~.
COUNTY ~
DEPARTM A
GAS CONSTR. 'b,Ur. 11I1tIit>iJlJL
#"~t-'75X-SN.o '.
DATE
. 67&lJ-# /D 7 -Zi!>' 2:+.lo"
APPROVED
SKETCH
N
t. ,f.. it ..J.e;'
( a.Jd< ddn{
u)
'J'r,
-
I,
I
I
I
f;-\
';:h.
r--.
~
"""
L:\\
1::1
~
'1
~
~
t:
I
I
I
I
I !;:-- SYe;:'! / ~f 2
I
~
I
I
A 1/
,NOV.: U' 02 (WED) 08: 26
BU GAS DESIGN PATCH
TEL:516 7585136
A
SJ.l~e-r z. .f 2.
1'".1. t
r--
:l>
~
i'"
A
P. 007