HomeMy WebLinkAbout3610 Wickham Ave
;
Date: 07/22/03
Transaction(s):
1 Permits
Check#: 1745
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
Or
J ;); If
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
1745
Subtotal
$45.00
$45.00
InternallD: 79719
permitNo,~
File No. J.
fllI""~
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T1 00252837
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 of the Code of the Town of South old, 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 of the
job site.
Print or Tvne
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSYILLE. NY 11801
Name of Applicant Address
2) 3610 Wickham Avenue. Mattituck
Name of Owner of Premises
Address
3) Wickham Avenue - 4'X4' bellhole in front of house #3610.200' wlo Marv's Road. in order to renair a 2as
leak
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S 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.
Other Tr
ignature 0 App
07-15-03
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 Comoletion Date
Excavation....................................................................... ..
Facility Installation........................................................... ....
Backfill & Compactinn......................................... ........... .....
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
0-39
Page I of3
Tl00252837
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 Celtified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic Aoolication Fee. ............ .... $25.00
AI. --L-/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. ~ $10.00
l.f. @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. ~ $30.00 ~
_1.f.@$O.30=
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
I. 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
pennit.
. . .
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 7/ cf2. ~//) 3
/ ) Date
Permit Issued 7/ 02..>02... ll,~ Permit No.
&t9
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
Page 2 of 3
.
REPORTING
REPORTED BY
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RECEIVED BY
~SSIGNED Tt<:
,EPAIRS COMPLETED BY:
RESOURCE
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DATE
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(76-81)
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PRIORITY
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TIME
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PRE STREET
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INSPECTION DATE EMPLOYEE NO.
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ONE CALL CASE #
BARRICADES LEFT ON JOB 0
CONTRACTOR DAM{lGE 0
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1l GAS DESIGN & CONSTRUCTION JOB ORDER
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JOB ORDER NO.
M 153469
-
o INSPECTION
1 0 SERV 2 0 MAIN
JOB CODE
AREA
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LATE
FINISH
DATE
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