HomeMy WebLinkAbout4900 Peconic Bay Blvd
Date: 09/19/03
Transaction(s):
1 Permits
Check#: 2028
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
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Receipt#:
Total Paid:
2028
Subtotal
$45.00
$45.00
InternallD: 82182
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
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FileNo.
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APPLICATlONIPERMIT FOR HIGHWAY EXCA V ATlON AND REPAIR
Ref.#Tl00317110
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 oftbe Code of the 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 of the
job site.
Print or TVDe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 4900 Pecon;c Bav Blvd.. Laurel
Name of Owner of Premises
Address
3) Peconic Bav Blvd. ~ bellhole e/s oaved area aoorOl. 600' slo Birch Drive. Laurel. to installl!as 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 Trade's License No.
Signature of Applicant
09-16-03
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
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:
J).39
Page 1 of3
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 $50,000 property damage.
Tl00317110
13) Security:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for applications and permits: Basic Aoolication Fee................. $25.00
AI. ~Servicc Connections excavations @ $20.00 ~ $ 20.00
No.
A2. _IAdditional Excavations same service@$10.00=$
No.
B. Excavations 18" in depth or less:
0-] 00 I.f. ~ $ 10.00
If @ $0.10~ $_
Additional
C. Excavations 18" in depth to 5' in depth:
0- 100 1.f. ~ $30.00 ~
_l.f.@$O.30=
Additional
D. Excavations 5' in depth and over:
0-100 1.f. ~ $50.00
1.f. @ $0.50 ~ $
Additional
E.
No.
Utility Repair Excavations @ $1 0.00 ~ $
Additional
Repairs same service @ $5.00 = $
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.
~iZ
Dat
Received by the Town Clerk
PermIt Issued 9'1/7/03
q 116" !D3
Date
Permit No.
C27tY'
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.
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SEP, -II' 03(THU) 14:32
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BU GAS DESIGN PATCH
TEL:516 7585136
p, 002
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