HomeMy WebLinkAbout2600 Sigsbee Rd
Date: 10/22/02
Transaction(s):
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Cash#: 16830
If
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
Receipt#:
Total Paid:
'1--0
~
16830
Subtotal
$45.00
$45.00
IntemallD: 63618
'U"N'~ ~ 0
FileNo.
f~'
~P&
TOWN OF SOUTHOLD
ffiGHWAYDEPARTMENT
Peconic Lane
Peeonie, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100210475
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 of the Code oftbe Town of Southold, Suffolk County, New York, aDd other
applicable laws, ordinances or regulations for tbe excavation herein described. The applicant agrees to comply with all
applicable laws, ordinances, codes and regulations, and to permit authorized inspectors to make necessary inspe(tions of the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSYILLE. NY 11801
Name of Applicant Address
2) 2600 Sigsbee Road, Mattituck
Name of Owner of Premises
Address
3) Sigsbee Road - bellhole w/s paved area approx. 85' nlo Peconic Bay Blvd. to install a gas service.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*Ifyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other T e's License No.
I
Signature of A plieant
10-03-02
Date
S) 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 Town Clerk.
6) Tax Map: Sectiou
,Block
. Lot
7) Starting Date:
Completion Date:
8) Work Scbedule:
Phase Comoletion Date
Excavation ........................................... ..............................
Facility Installation............................ .............................. .....
Backfill & Compaction.........................................................
Pavement Replacement.........................................................
9) Uuder wbicb authority is tbe applicatiou made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
TI00210475
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 annlications and nermits: Basic Aoolication 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. ~
_I.f. @ $0.30 ~
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
I.f. @ $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 Town Clerk of the Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SU~E EN NT OF HIGHWAYS
TO OFSO HOLD'~E~RK
f' ~ ~ )'1" . J1J>-(
Peter W. Harris
Received by the Town Clerk / () 1<< ':/1 ()
j. ~ Date
Permit Issued / i') K. 0 t1.-.
}-
I (J - C).J--() .:<
Date
Permit No.
0~l)
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
SEP. -26' ~2(THU) 14:45
BU GAS DESIGN PATCH TEL:516 7585136
KEYSPANltfA.f .
REQUEST FOR STREeT OPENING PER",IT
P. 004
~'11'"
PERMIT
NO.
LOCATION S;~ - . ~&" ~ ~:s" ,.!.V~ ~
REASON FOR i2' .' _-""'_ .
OPENING ow;/ III IJIf.A,;; I ~e..K 7;" iIJr/.A4L
W.OJPA FOREMAN
NO.
REQUESTED
. BY
o STATE
DEPARTME~
GAS CONSTR. L.;z: . )
o ~~~~K. . ~ .fou~tJJ
DATE OJ. ,/' .
, 7 '.25,;kw:L
-..s-~
. APPROVED
SKETCH
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