HomeMy WebLinkAbout260 New Suffolk Rd
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 07/10103
Receipt#:
1670
1 Permits
Check#: 1670
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
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Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
Internal 10: 79025
permitNo,~
File No. :;. }
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICA nON/PERMIT FOR HIGHWAY EXCA V A nON AND REPAIR
Ref.#T100298567
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 ofthe Code or the Town of Southold, 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 or the
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 260 New Suffolk Road. Cutchosme (Cutchol!ue Fire Deoartment)
Name of Owner of Premises Address
3) New Suffolk Road - bellhole wls annrox. 300' slo Main Road. Cutchoi!ue. to install a 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.
Signatnre 0 i\ppl
06-27-03
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 Comnletion 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
Tl00298567
12) Insurance Covera!!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 Of
3 years
14) Fees for aDohcatlOns and Derm;ts: Basic Application Fee.. ......... ...... $25.00
A I. ~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
1.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 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
permit.
. . .
TOTAL COST $45.00
Authorization is hereby granted to the Town Clerk of the TOMl of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk '7/; 0 /03
J / Date
Permit Issued 7 / / D t).3 Permit No.
, .
rJ-07
Note: Permit expires one (I) 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
JUN, -26',03(THU) 12:00
BU GAS DESIGN PATCH
TEL:S16 iS8S136
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