HomeMy WebLinkAbout11225 Peconic Bay Blvd
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 06/17/03
Transaction(s):
Permits
Check#: 1586
'* ~~~
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
Receipt#:
Total Paid:
1586
Subtotal
$45.00
$45.00
Internal 10: 77086
Permit No.
r~'
~
FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATlONIPERMIT FOR HIGHWAY EXCA V ATlON AND REPAIR
Ref.#T100291383
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of South old, 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.- HICKSYILLE. NY 11801
Name of Applicant Address
2) 11225 Peconic Bav Blvd. Mattituck
Name of Owner of Premises
Address
3) Peconic Bav Blvd - bellhole s/s l!rass area aoorox. 365' elo Marlene Lane. Mattituck. to install a l!as service.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? "'Yes
*Uyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Tra 's License No.
Signatnr of App
06-11-03
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 tbe Towu Clerk.
6) Tax Map: Section
,Block
, Lot
7) Starting Date:
Completion Date:
8) Work Scbedule:
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
T1 00291383
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:
Bndily 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 "ermits: Basic Application Fee................. $25.00
AI. ~/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.[ ~ $10.00
1.[@$0.1O~$
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 1.[ ~ $50.00
I.[@ $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 Southald to issue a Highway Excavation Permit to:
KEYSP AN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk 0 - / 7 - 0 3
Date
Permit Issued 0 - / 7 - 0 ~ Permit No.
c2&.,3
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 fOf inspection.
P-39
Page 2 of 3
JUN,-06'03(FRI113:56
BU GAS DESIGN PATCH
TEL:516 i585136
p, 002
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