HomeMy WebLinkAbout58676 CR 48
.
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
~1
Receipt#:
1895
Date:
1 Permits
Check#: 1895
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
13
:+
ff
Name:
Key, Span Energy - Gas Cont Dept
175 E Oid County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
InternallD: 81538
Permit No. , '1 "!J
File No. ().;
~~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLlCA nON/PERMIT FOR HIGHWAY EXCA V A nON AND REPAIR J I
,tOO 2 ~ K4.,
Ref.#'f186I~l383
APPLICA TIQN IS HEREBY made to the Superintendent of Highways ortbe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 orthe 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 or the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - H1CKSVILLE. NY 11801
Name of Applicant Address
2) 58676 North Road. Greenoort
Name of Owner of Premises
Address
3) North Road - 4'X4' bellhole on sls North Road. aoorox 900' elo Albertson Lane to reoair a 2as leak
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 License No.
Electrician's License No.
Signature Ap
08-14-03
Date
S) 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
hy the Town Clerk.
6) Tax Map: Section
, Block
. Lot
7) Starting Date:
Completion Date:
8) Work Schednle:
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
T1 00252844
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: $300,0001$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 aoohcatlOns and permIts' Basic AODlication Fee.. .... ... .. .... . $25.00
AI. --1-IService Connections excavations @ $20.00 ~ $ 20,00
No.
A2. _/Additional Excavations same service@$10.00=$
No.
B. Excavations 18" in depth or less:
0-100 1.f. ~ $10.00
I.f.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. ~ $30.00 ~
_1.f.@$O.30=
Additional
D. Excavations 5' in depth and over:
0-100 1.f. ~ $50.00
I.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 Pennit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk 8' /cz (PJ tJ3
~ j. Date '
Permit Issued . c;2 ~ 0 P Permit No.
0273
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.
D-39
Page 2 of3
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. Date Plotted: 7/30/2003
S'cale: 1 in = 68ft
:ion on this document has been supplied
s sole use and is not to be relied on by 01
ed may not accurately reflect the actual
Center Grid: 107-36-0053
Layers Printed: Detail Gas (50')