HomeMy WebLinkAbout2105 Country Club Dr
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Date: 11/01/02
Transaction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16924
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
Receipt#:
Total Paid:
~
~~
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16924
Subtotal
$278.00
$278.00
InternallD: 63879
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Permit NOde?
File No. y
TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peeonie Lane
Peeonic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FORIDGHWAY EXCAVATION AND REPAIR
Ref.#T100216270
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 oetbe Town of Southold, Suffolk County, New York, and other
applicable laws, ordinances or regulations for the excavation berein described. The applicant agrees to comply with all
applicable laws, ordinances, codes and regulations, and to permit autborized inspectors to make necessary inspections of the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - mCKSVlLLE. NY 11801
Name of Applicant Address
2) 2105 Country Club Drive, Cntcbogue
Name of Owner of Premises
Address
ODen & restore trench in the n/s !!rass area of Countrv Club Drive with a missile shot
across the roadwav and a missile shot across Moores Lane to the e/s !!Tass area with a 10'
trench. 510' of main foota!!e and 5 bellholes.
Work Description and Location (Street Number, Hamlet, Cross Street)
(.> Is construction located within 7S feet of tidal wetlands? *Yes
*lfyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Otber r
Signatur of
10-18-0
Date
5) a) Attacb plot plan sbowing location of proposed excavation and relationsbip to adjoining premises or
public streets or areas, and giving a detailed description of layout of excavation.
b) Attacb all otber necessary permits and licenses for tbls project.
c) Work covered by this application may not commence before issuance of a Highway Excavation Permit
by tbe Town Clerk.
6) Tax Map: Section
. Block
,Lot
7) Starting Date:
Completion Date:
8) Work Scbedule:
-1
Pbase
Excavation .... ............ .... ...... ......... ..... .................................
Facility Installation. ....... ... ........... ...... ......... .... ..... ... ...... ........
Backfill & Compaction.... ... ... .... ...... ... ... ... ........ ....... ... ..........
Pavement Replacement..... ..... .......... ...... ... ........ ...... .... ... .......
Comoletion Date
9) Under wbicb autbority is tbe application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
Tl00216270
12) Insurance Covera.e: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Departtnent:
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 annlications and nennits: Basic Aoolicatioo Fee ................. $25.00
AI. _S--"Service Connections excavations@$20.00= 5100.00
A2. ~Additional Excavations same service@$1O.00=$
No.
B. Excavations IS" in depth or less:
0-100 1.f. = $10.00
1.f. @$0.10=$
Additional
C. Excavations IS" in depth to 5' in depth:
0-100 1.f. = $30.00
410 I.f. @ $OJO = $123.00
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
1.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
pennit.
. . .
TOTAL COST $278.00
Authorization is hereby granted to the Town Clerk aCthe Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk I() - .a/vb 2..>
/tJ ~.;>.S - O~
Date
Pennit Issued 11- / - 0 ~
Date
Permit No.
O{~tI
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
OCT. -18' 02(PRI) 13:41
BU GAS DESIGN PATCH
TEL:516 7585136
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