HomeMy WebLinkAbout4725 New Suffolk Ln
Date: 11/01/02
Transaction(s):
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16943
Total Paid:
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Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
16943
Subtotal
$109.50
$109.50
Internal 10: 63880
FileNo.
~d-';
-
Permit No.
TOWN OF SOUTHOLD
ffiGHW AY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLlCATIONIPERMlT FOR ffiGHW AY EXCAVATION AND REPAIR
Ref.#T1 00219523
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 oftbe Code urtbe Town or Sonthold, 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, rodes 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. - H1CKSVlLLE. NY 11801
Name of Applicant Address
2) 4725 New Suffolk Lane. Mattituck
Name of Owner of Premises
Address
3) New Suffolk Lane - bellhole and a 145' trench in the n/s 2rass area aDDrox. 685' c/o
Marratooka Road to install a 2as service
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S 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.
e of Ap
10-24-02
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 Towo Clerk.
6) Tax Map: Section
,Block
. Lot
7) Startiog Date:
Completion Date:
8) Work Schedule:
Phase Comoletion Date
Excavation........... ............ .............................. ......... ...........
Facility Installation..................................... ......... ............. ....
Backfill & Compaction.........................................................
Pavement Replacement.. .......................................................
9) Uoder which aothority is the applicatioo made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
Tl 00219523
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 applications and permits: Basic Application Fee ................. $25.00
A 1. ~Service Connections excavations @ $20.00 = $ 20.00
No.
A2. ~Additional Excavations same service@$IO.OO=$
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00
l.f. @$O.IO=$
Additional
C. Excavations 18" in depth to 5' in depth:
0- 100 l.f. = $30.00
ill l.f. @ $0.30 = $34.50 Additional
D. Excavations 5' in depth and over:
0- 100 l.f. = $50.00
l.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 $109.50
Authorization is hereby granted to the Town Clerk ofthe TO\\i1l of SouthaM to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk /6 I.:J 1/ t> ~
t>ate
Permit Issued 11- / - t) Z Permit No. c? ~ a
/tf'- c!h- Od
Date
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.
D-39
Page 2 of3
OCT, :24' 02(THU) 09:42
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NO.
, Lll!CATI,ON
IEASoN FOR
: OPENING
BU GAS DESIGN PATCH TEL:516 7585136
KEYSPAN/e;:u
REQUEST FOR STREET OPENING PERMIT
p, 005
o STATE
O SUFFOLK r::i1
COUNTY ~'
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