HomeMy WebLinkAbout10575 Route 25
Date: 10/10/02
Transaction(s):
Name:
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16772
Total Paid:
r;y~1
*
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
16772
Subtotal
$45.00
$45.00
InternallD: 63414
Permit No.
f'lTOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
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FileNo.
APPLICATIONIPERMIT FOR ffiGHW AY EXCAVATION AND REPAIR
Ref.#T100208961
APPLICATION IS HEREBY made to the Superintendent of Highways or the Town of Southold for tbe issuance of
an Excavation Permit pursuant to Chapter 83 orthe Code ortbe 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 ofthe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 10575 Main Rd., East Marion
Name of Owner of Premises
Address
3) ODeD Kavleiehs Ct - bellhole w/s f!r8SS area 8oorox. 60' nlo Main Road. East Marion. to reolace a 2as service
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S feet of tidal wetlands? *Ves
*If yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other
re 0 \\pplicant
09-25-02
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 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
Tl00208961
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 or
3 years
[4) Fees for aoolications and oermits: Basic Annlication Fee ................. $25.00
AI. ~/Service Connections excavations@ $20.00 ~ $ 20,00
No.
A2. _I Additional Excavations same service @ $1 0.00 ~ $
No.
B. Excavations 18" in depth or less:
0-100 1.1. ~ $10.00
I.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.1. ~ $30.00
_l.f. @ $0.30 ~ $
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
1.1. @ $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 Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
10 - 9-d:;"
Received by the Town Clerk /0 -/0 - 0 Z-
Date /}/ a
Permit Issued / li - /0 - 0 z.- Permit No. WI I'
Date
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
KEYSPAN!C;:AS .
REQUEST FOR STREET OPENING PER~IT
~11.4
PERMIT,
NO,
LOCATION
REASON FaR
OPENING
W,OJPA
NO.
REQUESTED
.' BY
, APPROVED
o STATE '0
O SUFFOLK. ,r.7I (J
COUNTY LCI -JCJ";' T/Jd l j) ,
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V.sr MZ-~".L '"'ii /:s.Pt...U::A &-;tS
FOREMAN
~Jj DEPARTME~
....J?lfu.7Z- GAS CONSTR: L..z'.)
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