HomeMy WebLinkAboutWilmarth Ave
.,.
Date: 10/09/03
Transaction(s):
1 Permits
Check#: 2136
J
Name:
Keyspan, Energy - Gas Cant Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
. '}/
/-\ CJ (
rJ-l
L/
2136
Subtotal
$45.00
$45.00
IntemallD: 82768
~
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
-
FileNo.
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100325395
APPLICATION IS HEREBY made to the Superintendent of Highways orthe Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 ortbe Code or the 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 or the
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - H1CKSVILLE. NY U801
Name of Applicant Address
2) Wilmarth Avenue. Greenoort
Name of Owner of Premises
Address
3) Wilmarth Ave - bellhole s/s oaved area 30Drox. 175' wlo Main Street. Greenoort. to installeas service
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's Liceuse No.
Electrician's License No.
Ignatnre of A
09-30-03
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 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) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
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 $50,000 property damage.
Tl00325395
13) Securitv:
a)
b)
Surety Bond.
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aDDlications and Dermits: Basic Avvlication 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. ~ $30.00 ~
_1.f.@$O.30=
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
1.[ @ $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
permit.
. . .
TOTAL COST $45.00
Authorization is hereby granted to the To\Vl1 Clerk of the Town of South old to issue a Highway Excavation Permit to:
KEYSP AN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk / i9 /0..3
/ .Iz Date
Permit Issued Ii!) 9 1) .3 Pennit No.
, ,
SU~TENDENT OF HIGH.W A YS
T 0 SOUT~, N~RK
\~ .'W
..... Peter W. Harris
/6 jq/d 2-,
I r:fate
oZrlOL..
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 2of3
SEI',-30'03ITUZI08:47
8U GAS DESIGN PATCH
TEL:515 7585135
p, 002
, "
, "
, FD-llI, I.A
"
SKETcH
-, '~i.)1:J'~ /tJ J~, ~9';'2.
",- N
It
,
,
~
/Jew Hous,- I
I
" I
IH
I":"
I "
?
1_,
, ,
I
I
,
" ~
1-'
tr)/L MI9J2.7}( I~ I/VL I t.~
C'"
t '7 ,r+i 2'SrL
}7 5" ~ I", ~
I ,
,
-,
~
1"-
-,
(..
~