HomeMy WebLinkAbout20105 Elijahs Ln
Town Of Southold
PO Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 08/20/03
Receipt#:
Transaction(s):
Permits
Check#: 1860
Total Paid:
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Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
1860
Subtotal
$45.00
$45.00
Internal 10: 81174
Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconie, New York 11958
(631) 765-3140
APPLlCA TIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#TI00310052
APPLICATION [S HEREBY made to the Superintendent of Highways oftbe 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 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 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) 20105 Elijahs Lane. Mattituck
Name of Owner of Premises
Address
3) Eliiahs Lane - 4'X4' bellhole e/s oaved area aoorox. 60' nlo Main Road to install a l!as service
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 he required.
No~X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Signatur f pI" ant
o -13-03
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 Scbedule:
Phase
Excavation....................................................................... ..
Facility Installation........................................................... ....
Backfill & Compaction.... ................ .....................................
Pavement Replacement.........................................................
Comoletion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
0-39
Page I of3
Tl00310052
12) Insurance Coveral!e: (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 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 I.f. ~ $10.00
I.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00 ~
_1.f.@$0.30=
Additional
D. Excavations 5' in depth and over:
0-100 1.[ ~ $50.00
1.[ @ $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:
KEYSP AN ENERGY DELlVERY in accordance with this application.
Received by the Town Clerk
Permit Issued e!-~9 3
J'/.J b /0 3
WAYS
YORK
Date
Permit No.
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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.
0-39
Page 2 of 3
AUG,-08'03(FRI) 13:55
BJ GAS DESIGN PATCH
TEL:516 i585136
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