HomeMy WebLinkAbout2245 Fairway Dr
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Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICA nON/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100324922
APPLICATION ]S 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 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 Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 2245 Fairwav Drive. CutchO!!'Ue
Name of Owner of Premises
Address
3) Fairwav Drive - hellhole els Daved area aDDrox. 32S' nlo Green Wav. Cutchol!ue. to installl!as service to
#2245
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S 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.
Signatnre f Ap icant
09-29-03
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: Section
, Block
, Lot
7) Starting Date:
Completion Date:
8) Work Schedule:
Phase ComDletion 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
Tl00324922
12) Insurance Coverage: (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 $50,000 property damage.
13) Securitv:
a)
Ii)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oennits: Basic ADDlication Fee........... ... $25.00
AI. ~/Service Connections excavations@$20.00=$ 20.00
No.
A2. ~/Additional Excavations same service@$1O.00=$
No.
B. Excavations 18" in depth or less:
0-100 I.f ~ $10.00
1.[ @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00 ~
_1.f.@$0.30~
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
1.[ @$0.50~$
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 Tovm Clerk of the Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk / iJ I 'f ~:3
/ / "Date'
Permit Issued /19/ /'-11 0 .1 Permit No.
.
EN DENT OF H~W A YS
S L , YORK
cl?(
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
ICETStouN
DAlE:
LOCATION:
TOWN:
WORK ORDER:
&lRFACE:
Macadam Road
I
91291:0038:42:10 AM
2245 FAlRWAY DR
CT.J'Il:::HOOUE
T1 00324922
PERMIT APPLICATION SKETCH
VILLAGE OF
CROSS SfREET:
GREEN WAY
I 'AffiWAYO'
I &.eNU I
2245
iO
II
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4 x 4' EellHole
325'
I
PreJiroinarv Permit Sketcres are on Y'P!'<OXimate estillll1es of ",,"re work is to be ",rforrredand in m way repl'e",nt factual measurements.
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Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 10/14/03
Receipt#:
2119
1 Permits
Check#: 2119
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
~ ~'6~
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
Internal 10: 82815