HomeMy WebLinkAbout1330 Skunk Ln
Date: 09/16/02
Transaction(s):
1 Permits
Cash#: 16700
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
,% d- \'\
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
16700
Subtotal
$45.00
$45.00
Intem.IID: 62492
FileNo.
-
.
Permit No.
TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATlON/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#Tl00202361
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 or the Town of South old, Suffolk County, New York, and other
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 inspedions urthe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 1330 Skunk Lane. Southold
Name of Owner of Premises
Address
3) ODen bellhole els I!rBSS area Borox. 960' nlo EUl!ene Rd. Cutchol!ue to install a new e-as service
Work Des4:ription and L04:ation (Street Number, Hamlet, Cross Street)
(a) Is construction I04:ated within 75 feet of tidal wetlands? *Ves
*Ifyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
ignature of pplica
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 an other necessary permits and Ii.enses 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 Schedule:
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
Tl00202361
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 Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oennits: Basic Application 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 1.f. ~ $10.00
l.f.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. ~ $30.00
_1.f.@$0.30~$
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
l.f. @$0.50~$
Additional
E.
Utility Repair Excavations@ $10.00 ~ $
No.
Repairs sarne 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 \'lith this application.
Received by the Town Clerk
Pennit Issued 9 - / b
Q~ /3-0oU
_ 0 )...Date
Permit No.
d,/'{
Note: Pennit 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 2of3
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AUG,-30'02(FRI) 10:03
BU GAS DESIGN PATCH
TEL:516 i585136
Fc-6111.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
, APPROVED
SKETCH
[KJ S;f,A.71I()~b
DATE
1/30 D2-
A~ D'j4/, '0 tu6't,J~ U
KEYSPAN/cfAJ'
REQUEST FOR STREET OPENING PERMIT
o STATE
D NASSAU D SUFFOLK
COUNTY COUNTY
MIS JOB~
NO. J/002o
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FOREMAN
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DEPARTMENT
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