HomeMy WebLinkAbout1275 New Suffolk Rd
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 10/09/03
Receipt#:
2131
1 Permits
Check#: 2131
Total Paid:
Subtotal
$45.00
$45.00
Transaction{s):
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Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
Internal 10: 82769
Permit No.
;;I8?J
-
FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICA TlONIPERMIT FOR HIGHWAY EXCA V ATlON AND REPAIR
Ref.#T100322003
APPLICATION IS HEREBY made to the Superintendent of Highways orthe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 oftbe Code oftbe 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
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HlCKSVlLLE. NY 11801
Name of Applicant Address
2) 1275 New Suffolk Road. Cutcboeue
Name of Owner of Premises
Address
3) New Suffolk Road - bellhole oaved area 3oorox. 1000 % Main Road. Cutch02ue. to reoair a 2as leak at
#1275
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.
Signatur of A
10-01-03
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 tbe Town Clerk.
6) Tax Map: Sectiou
,Block
,Lot
7) Starting 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:
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Tl00322003
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 $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
0[$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Feedor aoplications and permits: Basic Auolication Fee............. .... $25.00
AI. ~/Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. ~ Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" 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 ~
_1.f.@$0.30=
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
If. @ $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
pennit.
* * *
TOT AI. 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 DELlVERY in accordance with this application.
NTENDENT OF HI
o SOUTH OLD, N
U
HWAYS
YORK
Received by the Town Clerk I~? 10 3
. ~ ;;; D~te
Permit Issued I"., 9 6.3 Permit No.
Peter W. Harris
Mh,Jtl:;
I Dale
cJ Y3
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.
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1CE'r....
DAlE:
LOCATION:
TOWN:
WORK ORDER:
!IlRFACE:
Macadam Road
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PERMIT APPLICATION SKETCH
t
10121200310:18:41 AM
1275 NEW SUFFOLK RD
ClITCHCG DE
T1 00322003
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1000'
V1LLAGE OF
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CROSS SI'REET:
Mi\IN RD
I &.eNn I
1275
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4 x 4' BellHoJ.
I
Preliminarv Pennit Sketcle. are or! v.pproximate estirrare. ofwtJere wurk i.m be Il'rfonre dand in no w,y represent factual measurement..
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