HomeMy WebLinkAbout1040 Founders Path
Date: 09/11/02
Transaction(s}:
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16528
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
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Receipt#:
Total Paid:
16528
Subtotal
$45.00
$45.00
Internal 10: 62370
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Permit No. 02/ /
FileNo. 6Z f (
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T1 00193660
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 or the Code of the Town orSouthold, Suffolk County, New York, and otber
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 ortbe
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 1040 Founders Path. Southold
Name of Owner of Premises
Address
3) Founders Path - bellhole wfs naved area annrox. 123' ufo Landon Lane to install a new
l!as service
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? .Yes
.If yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Tr
Signatnre App ant
08-02 -02
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 Schednle:
Phase ComDletion Date
Excavation................................ ..................n ._............. _ _. __.
Facility Installation................. ... .................. _............. ... ........
Backfill & Compaction..................................................... ..._
Pavement Replacement........... ..... ... ....... ..... ... .... ... ..... ....... ....
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
II) Remarks:
0-39
Page 1 of3
Tl00193660
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 propetty 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 oermits: Basic Application Fee................. $25.00
A I. ...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 I.f. ~ $10.00
I.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 I.f. ~ $50.00
I.f. @ $0.50 ~ $
Additional
E.
Utility Repair Excavations@ $10.00 ~ $
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 Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk q -1/ -0
Q-II-o 1.- Date
Permit Issued
2-
Pennit No.
0( J I
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 2of3
'AUG:-()j' 02(THUj 08:53
BU GAS DESIGN PATCH TEL:516 i585136
. KEYSPAN/(fAJ'
REQUEST FOR STREET OPENING PERMIT
P. 003
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PERMIT.
NO.
LOCATION
F1EASON FOR
OPENING
W,OJPA
NO.
REQUESTED
BY
APPROVED
o STATE
D
NASSAU
COUNTY
D SUFFOLK
COUNTY
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