HomeMy WebLinkAbout565 Old Main Rd
Date: 10/22/02
Transaction(s):
1 Permits
Check#: 16832
Jf
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
d-.r
r:f
Name:
Key, Span Energy. Gas Cant Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
16832
Subtotal
$214.50
$214.50
Internal 10: 63621
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Permit No. d ;r-
File NO.-J
TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peconic Lane
Peeonie, New York 11958
(631) 765-3140
APPLICATlONIPERMIT FOR IDGHW AY EXCA V ATlON AND REPAIR
Ref.#T1 0021 0992
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for tbe 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 inspedions of the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 565 Old Main Road, Mattitnck
Name of Owner of Premises
Address
3) Old Main Road - bellhole & a 565' trench in the sls grass area e!o Bray Ave. to install a gas main and gas
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 License No.
Electrician's License No.
Signatur f Ap
10-03-02
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 net:essary 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 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
Tl00210992
12) Insurance Covera.e: (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 Of
3 years
14) Fees for aoolications and oermits: Basic ADDlication Fee.............. ". $25.00
AI. ~Service Connections excavations@ $20.00 ~ $20.00
No.
A2. _I Additional Excavations same service @ $10.00"'" $
No.
B. Excavations 18" in depth or less:
0-100 I.f. ~ $10.00
I.f. @$0.1O~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00
465 I.f. @ $0.30 ~ $139.50
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
I.f. @ $0.50 ~ $
Additional
E.
Utility Repair Excavatioos @ $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 $214.50
Authorization is hereby granted to the TO\\l11 Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Peter W. Harris
Received by the Town Clerk / t) /;(. OL/ 11 ~
.J / Date
Permit Issued / v / Q{ ol; 11 :;- Permit No.
/6 -;;) ( -02-
Date
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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
SEP.'-30' OrIMON) 08: 22
BU GAS DESIGN PATCH TEL:516 i585136
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REOUEST1:0R.STREET OPENING PERMIT.
P. 006
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