HomeMy WebLinkAbout2075 Sigsbee Rd
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 09/10/03
Transaction(s):
1 Permits
Check#: 1924
10
~J-
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hlcksville, NY 11801
Clerk 10: L1NDAC
Receipt#:
Total Paid:
1924
Subtotal
$45.00
$45.00
InternallD: 81893
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
Permit No.
APPLICATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100314234
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 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 Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 2075 Si.sbee Road. Mattituck
Name of Owner of Premises
Address
3) Sil!sbee Road - 4'X4' hellhole on w/s Daved area aDDrox. 600' % Peconic Bav Blvd. Mattituck. to install a
I!as senrice
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
No_X~
4) Builder's License No.
Plumber's Liceose No.
Electrician's License No.
Other Tr
Signature of ppl
08-26-03
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 tbe Town Clerk.
6) Tax Map: Section
l 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
Tl00314234
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 ocnnits: 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 J.f ~ $10.00
J.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 J.f. ~ $30.00 ~
_1.f.@$0.30=
Additional
D. Excavations 5' in depth and over:
0-100 J.f. ~ $50.00
J.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 ToVvll Clerk ofthe Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
pe~
~ Dat
Received by the Town Clerk
9/L 0 II) 1
I I
Q/9~1
Date
Permit Issued
Permit No.
rJ 7 f=,
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 fOT inspection.
D-39
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AUG, -21' 0.3 (THU) 09:31
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TEL:516 i585136
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