HomeMy WebLinkAbout290 Grigonis Path
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 09/16/02
Receipt#:
16700
1 Permits
Check#: 16700
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
I
d. \)
.\f
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Internal 10: 62493
Permit No.
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FileNo.
TOWN OF SOUTHOLD
IDGHWAY DEPARTMENT
Peconic Lane
Pecooic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100201651
APPLICATION IS HEREBY made to the Superintendent of Highways of tbe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 ortbe Code ortbe Town of Southold, Suffolk County, New York, and otber
applicable Jaws, 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 Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 290 Gri.onis Path. Sonthold
Name of Owner of Premises
Address
3) ODeD hellhole e/s oaved area at the s1e1c of Peck Place to install a new I!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.
r
igoature oc. >\pplic
09-10-02
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.
h) 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: $
") Remarks:
D-39
Page 1 of3
Tl00201651
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 $50,000 property damage.
13) Securitv:
a)
b)
Surery Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for annlicatinns and nermits: Basic AooUcalioo Fee............. .... $25.00
A!. -L-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 l.f. = $10.00
l.f.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. ~ $30.00
_l.f. @ $0.30 ~ $
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
l.f. @ $0.50 ~ $
Additional
Utility Repair Excavations @ $10.00 ~ $
E.
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 South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
:;l/i ;;;
Dati
Received by the Town Clerk " - /4 - 0 2-
c:t Dare
Permit Issued . / to -0 l- Permit No.
o?J6
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 of3
AUG:-'30' 02 (FRI) 10: 03
FC-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.OJPA
NO.
REQUESTED
BY
APPROVED
SKETCH
BU GAS DESIGN PATCH
TEL:516 7585136
KEYSPAN/c:fAJ"
REQUEST FOR STREET OPENING PERMIT
D STATE
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