HomeMy WebLinkAbout620 Founders Path
Date: 10/22/02
Transaction(s):
Name:
Clerk 10: L1NDAC
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16830
Total Paid:
CJ~
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
16830
Subtotal
$45.00
$45.00
Internal 10: 63619
Peront No. ~ l
File No. -&
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconi<, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCA VA TION AND REPAIR
Ref.#T100212131
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South old for the Issuance of
an Excavation Permit pursuant to Chapter 83 of the Code orthe Town of Southold, Suffolk County, New York, and other
applicable laws, ordinances or regulations for the enavation 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
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applh:ant Address
2) 620 Founders Path, Sonthold
Name of Owner of Premises
Address
3) Ooen Founders Path - bellhole w/s e-rass area 8oorox. 350' slo L'Homme Dieu Lane to tube a eas service
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located witbin 75 feet oftidal wetlands? *Yes
*lfyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
re of pplicant
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 necessary permits and licenses for this project.
c) Work covered by this application may not commence before issuance of a Highway Excavation Permit
hy 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
Tl00212131
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 $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aDDlications and Dennits: Basic Auuliealion Fee ................. $25.00
A I. ~/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 l.f. ~ $10.00
l.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. ~ $30.00
_1.f.@$0.30~$
Additional
D. Excavations S' 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 $45.00
Authorization is hereby granted to the Town Clerk of the Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk 10/02 02./0 J...-.-
permitIssuedlo/"'-o/(Jd....-- . Date ' Permit No. cl~ I
Note: Pennit 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.
10 -d-.{--d"]
Date
D-39
Page 2 of3
OCT. .02.' 02lWED) 08: 06
FC<l1l1.4
PERMIT.
. NO.
LOCATION
R~SON FOR I
OPENING '"
W,OJPA
NO.
REQUESTED
. BY
. APPROVED
SKETCH
..
BU GAS DESIGN PATCH TEL:516 i585136
. KEYSPAN.k.::AJ' '.
REqUEST FOR STREI;T OPENING PERr.,rr
o STATE
P. 002
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