HomeMy WebLinkAbout4074 Stillwater Ave
Date: 09/16/02
Transaction(s):
Name:
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Cash#: 16706
Total Paid:
'A \\.0
~
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
16706
Subtotal
$145.00
$145.00
Intem.IID: 62494
Permit No.
~
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peeonie, New York 11958
(631) 765-3140
REVISED PERMIT
APPLICA TION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100193090
APPLICATION IS HEREBY made to the Superintendent of Highways urthe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 ortbe Code uftbe Town of Southold, Suffolk County, New York, and otber
applicable laws, ordinances or regulations for tbe 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) 4075 StiUwater Avenue, Cutchogue
Name of Owner of Premises
Address
3) Stillwater Ave. - 4 bellboles. 3 In the naved area and 1 In dirt. on tbe n/s to directional drill a .as main
narallt) under the roadway and a bellhole in the e!s 2'rass area of Track Ave. Cutcho2'ue
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S feet of tidal wetlands? *Yes
*1( yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
ignature 0 Applic
09-11-02
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 ail other necessary permits and licenses for tbls 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 whlcb authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
BU GAS DESIGN PATCH TEL:SI6 7585136
!<fYSP.'%Io/GA.r
REQUEST"i=ORSTREET OPENING PERMIT. .
o 5rATE D ~~, 00'. SOIA.71f~b .'
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P . PATE
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Page 1 of3
Tl00193090
12) Insurance Coverage: (Attach Cnpy)
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 $50,000 property damage.
13) Security:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aonlications and oermits: Basic Application Fee................. $25.00
AI. ~/Service Connections excavations @ $20.00 ~ $ 120.00
No.
A2. -"Additional Excavations same service@ $10.00 ~ $
No.
B. Excavations IS" in depth or less:
0-100 l.f. ~ $10.00
1.f.@$0.1O=$
Additional
C. Excavations IS" in depth to 5' in depth:
0-100 l.f. ~ $30.00
_1.f.@$OJO=$
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
l.f. @ $0.50 ~ $
Additional
E.
Utility Repair Excavations @ $1 0.00 ~ $
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 $145.00
Authorization is hereby granted to the Town Clerk of the Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Permit Issued q ~ / I~
q-/~-o '-
Date
- 0,)....... Permit No.
c9lb
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.
D-39
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