HomeMy WebLinkAbout205 Gull Pond Ln
Date: 09/16/02
Transaction(s):
Name:
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16701
Total Paid:
'* ;f,r--
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
16701
Subtotal
$45.00
$45.00
IntemallD: 62490
Pernnt No. c1 \ ~
FileNo.
f~'
":.~
TOWN OF SOUTHOLD
ffiGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLlCATIONIPERMlT FOR ffiGHW AY EXCAVATION AND REPAIR
Ref.#Tl00199135
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 oftbe Code orthe 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 of the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVlLLE. NY 11801
Name of Applicant Address
2) 205 Gull Pond Lane. GreenDort
Name of Owner of Premises
Address
3) ODeD & restore a bell hole on the cIs of Gull Pond Lane 175' slo Main Road. Greeooort
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction 10cJlted within 75 feet of tidal wetlands? *Yes
*lfyes, other Town permits may be required.
No_X_
4) Builder's License No./
Plnmber's License No.
Electrician's License No.
re of plica
08-23-02
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 layont 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 & Compaction.........................................................
Pavement Replacement. .... ..... .... ... ..... ... .... ... ..... ....................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
Tl00199135
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 $50,000 property damage.
13) SecurilV:
a) 'Surety Bond or Certified Check
of$
b) Maintenance Bonded provided: 2 years or
provided in the total amount
3 years
14) Fees for aDDlications and Dermits: Basic Application Fee.. ............... $25.00
AI. ~Service Connections excavations@ $20.00 = $ 20.00
No.
A2. ~Additional Excavations same service @ $10.00 = $
No.
B. Excavations IS" in depth or less:
0-100 1.f. = $10.00
1.f.@$0.1O=$
Additional
C. Excavations IS" in depth to 5' in depth:
0-100 1.f. ~ $30.00
_ 1.f. @$0.30=$
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.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
permit.
. . .
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.
P~Z;
~ De
Received by the Town Clerk
Permit Issued If! I ~ f 0 L
9)/3)62.-
'Date
Permit No.
~(.,L
Note: Pennit 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
AUG,-20'02(TUE) 14:49
BU GAS DESIGN PATCH
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PERMIT
NO.
LOCATION
REASON FOR
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TEL:516 7585136
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