HomeMy WebLinkAbout1855 Westview Dr
Date: 10/10/02
Transaction(s):
1 Permits
Check#: 16729
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
& ;/-,,1
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
16729
Subtotal
$45.00
$45.00
InternallD: 63412
Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100205518
APPLICATION IS HEREBY made to the Superintendent of IDghways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 ortbe Code ortbe 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 inspedors to make necessary inspections orlhe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 1855 WesMew Drive. Mattituck
Name of Owner of Premises
Address
3) ODeD a bellhole on the els I!rass area aoorox. 630' DID Brower Road. Mattituck. to install a 2as service to
house #1855
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Ves
*Ifyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Signature Ap
09-17-02
Date
5) a) Attach plot plao showing location of proposed excavation and relatiouship 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 tbis application may not commence before issuance of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section
,Block
. Lot
7) Startiog 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
.'
TlOOM r:n8
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
14) Fees for aoolications and oermits: Basic Aoolication Fee................. $25.00
AI. ~Service Connections excavations @ $20.00 = $ 20.00
No.
A2. -"Additional Excavations same service @ $10.00 = $
No.
B. Excavations IS" in depth or less:
0-100 l.f. = $10.00
l.f. @ $0.10 = $
Additional
C. Excavations IS" in depth to 5' in depth:
0-100 l.f. = $30.00
_l.f.@$OJO=$
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.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 Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELWERY in accordance with this application.
Peter W. Harris
Received by the Town Clerk ./ 0 ~ /6 -0 "2..-
/ Date
Permit Issued 0 - / tv 0 2.- Permit No.
/d-9-cJJ
Date
0'2-1 7
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..-16' 02,(MON) 08:23
FC-liT11.4
PERMIT.
NO.
LOCATION
REASON FOR
OPENING
W,OJPA
NO.
REQUESTED
. BY
. APPROVED
SKETCH ~l.i.b ct /tJ/~t)~-.3
SU GAS DESIGN PATCH
TEL:516 7585136
p, 004
KEYSPAN/~AJ' '.
REQUEST FOR STREI;T OPENING PER~IT
. .
'0 NASSAU 0 SUFFOLK. 'r:?1 ()
COUNlY COUNlY ~...I .o....mtlLb .
MJSJOB~ DATE.
NO. lit:>O 2055/8 ' , lei, /J'Z .
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o STArE
DEPARTME~
GAS CONSTR: L ...z: ,)
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