HomeMy WebLinkAbout675 Brower Rd
Date: 10/10/02
Transaction(s):
1 Permits
Check#: 16729
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
~gJ~
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
16729
Subtotal
$147.00
$147.00
InternallD: 63413
Permit No.
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
FileNo.
APPLICATlONIPERMIT FOR HIGHWAY EXCA V ATlON AND REPAIR
Ref.#Tl00205418
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 orlbe 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 inspections ortbe
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 675 Brower Road. Matitock
Name of Owner of Premises
Address
3) ODeD a hellhole and a 73' trench on the els ofWestview Drive in the 2rass area with a 4S' missile shot across
Brower Road and a 267' trench in the S/S erass area of Brower Road. Matituck
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.
(
ignature 0 Appli
09-17-02
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: Sectioo
,Block
,Lot
7) Startiog Date:
8) Work Schedole:
Completion Date:
Phase Comoletion Date
Excavation ............. .......... ..................................................
Facility Installation. ....... .............. ................................. ........
Backfill & Compaction.........................................................
Pavement Replacement...................................... ...................
9) Under which authority is the applicatioo made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
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Page 1 of3
Tl00205418
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 aoolications and oermits: Basic Application Fee.............. ... $25.00
AI. -L-)Service Connections excavations @ $20.00 ~ $ 20.00
No,
A2. _I Additional Excavations same service @ $10.00 = $
No.
B. Excavations IS" in depth or less:
0-100 l.f. ~ $10.00
I.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00
240 1.f. @ $0.30 ~ $ 72.00
Additional
D. Excavations 5' in depth and over:
0-100 1.f. ~ $50.00
I.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 $147.00
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.
Received by the Town Clerk /0 -/0 - 0 :L
Date
/6- '?-~
Date
Permit Issued /0 -/0 - 0 'L
Permit No.
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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
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SEP.-16'02(MON) 08:23
BU GAS DESIGN PATCH
TEL:516 7585136
P. 002
, REQUEST FOR PERMIT
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, ,Permit FEE. $
Perfil it Requested By: ~",.,,1. '.5Cl'lu 1L.
TO 13co Typeo Road
Work Request # '10020$4 /, b --cnarge ccount.#
. 0 D Isbursemont 'to be ~ile out ot potty cas~
,Return PernlitTo: [) 'New Business Departma t
'0 Q.N. 0 Cent. 0 W.S.
E.S.
Gas Service for
D, To be billed 0 No toe
o UnderQl'ound Lines Department
DOper. Plan. S. Cont. Center'
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