HomeMy WebLinkAbout2450 Jackson St
Date: 09/10/03
Transaction(s):
Name:
Clerk ID: L1NDAC
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Cash#: 1923
Total Paid:
1~
1<'}
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
1923
Subtotal
$45.00
$45.00
InternallD: 81892
FileNo.
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Permit No.
TOWN OF SOUTH OLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100314959
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 orthe Code orthe Town of South old, Suffolk County, New York, and other
applicable laws, ordinances or I'egulations 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. - HlCKSVILLE. NY 11801
Name of Applicant Address
2) 2450 Jackson Street. New Suffolk
Name of Owner of Premises
Address
3) Jackson Street - 4'X4' bellhole on w/s 2nd Street. 25' slo Jackson Street. New Suffolk. to install a l!:as senrice
Work Description and Location (Street Number, Hamlet. Cross Street)
(a) Is construction Incated 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 of pli nt
08-26- 3
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:
to) Estimated Cost of Proposed Work: $
11) Remarks:
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Page 1 of3
Tl00314959
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 ..
AI. ~Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. _/Additional Excavations same service@$10.00=$
No.
......... $25.00
B. Excavations 18" in depth or less:
0-100 1.[ ~ $10.00
Lf. @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 Lf. ~ $30.00 ~
_Lf,@$O.30=
Additional
D. Excavations 5' in depth and over:
0-100 1.[ ~ $50.00
I.f.@ $0.50 ~ $
Additional
E.
Utility Repair Excavations@$IO.OO=$
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 $45.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Permit Issued q It 0103
'I/f/b3
SUPERINTENDENT OF HIGHWAYS
TO~:;Z;Z;:;
iW/rn
Date
Date
Permit No.
c:}7S
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Pennit must be available for inspection.
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Page 20f3
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EnergyDelvery
PERMIT APPLICATION. SKETCH
GAS SERV'C.~
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D SUFFOLK
COUNTY
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DATE 'isb.s(03
LOCATION 'J,.IjSD "S~'-!ao~ ..,.
TOWN "JEw SuFFGL\<.
WORK ORDER TI003\l./ 9$"'1
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