HomeMy WebLinkAbout615 Marlene Ln
Town Of Southold
P.O Box 1179
Southold, NY 11971
Date: ~!c J
* * * RECEIPT * * *
Receipt#:
Transaction(s):
1 Permits
Check#: 1896
Total Paid:
~ ;;(1Y
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
1896
Subtotal
$45.00
$45.00
Internal 10: 81539
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Permit No.
~'''n
(II
FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCA V A nON AND REPAIR
Ref.#T100313822
APPLICATION IS HEREBY made to the Superintendent of Highways oftbe Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the 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 orthe
job site.
Print or TVDe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - H1CKSVILLE. NY 1180]
N arne of Applicant Address
2) 6]5 Marlene Lane. Mattituck
Name of Owner of Premises
Address
3) Marlene Lane - 4'X4' bellhole on e/s Daved area aDorox. 650' s/o Main Road. Mattituck. to install a e-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.
ignature App
08-21-03
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 ComDletion 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
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 $50,000 property damage.
Tl00313822
13) Securitv:
a)
b)
Surety Bond_
of$
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 18" in depth or less:
0-100 l.f. ~ $10.00
1.f.@$0.10=$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. ~ $30.00 =
_ 1.f. @ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
l.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 DELIVERY in accordance with this application.
p~
Received by the Town Clerk . (,;; t- ft .J
C" j /, Date
Permit Issued 2iJ cJ.- 7j v"7 Permit No.
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.
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D-39
Page 2 of3
AUG,-20'03(WED) 08:14
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TEL:516 i585136
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