HomeMy WebLinkAbout890 Depot Ln
Date: 06/17/03
Transaction(s):
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 1586
&
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
lJ;)J
();
Receipt#:
Total Paid:
1589
Subtotal
$45.00
$45.00
InternallD: 77085
, .
Permit NO.~ ~
File No. ();
f1~'''~
~Jl
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peeonie, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100292701
APPLICATION IS HEREBY made to the Superintendent of Highways oftbe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 ortbe Code ortbe 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 COUNTRYRD.-HICKSVILLE. NY 11801
Name of Applicant Address
2) 890 Deoot Lane. Cutchoeue
Name of Owner of Premises
Address
3) Denot La - bellhole w/s e:rass area aoorox. 1350' nlo Main Road. CutchOlme. 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
*Ifyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
7;.
Signature 0 pplieant
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 the Town Clerk.
6) Tax Map: Section
. Block
, Lot
7) Starting Date:
Completiou Date:
8) Work Schednle:
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
TI00292701
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 aDDlications and Dermits: Basic ADDlication 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 Lf. ~ $10.00
Lf. @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 Lf. ~ $30.00 ~
_Lf,@$0.30=
Additional
D. Excavations 5' in depth and over:
0-100 Lf. ~ $50.00
Lf. @$0.50~$
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 Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
0-/7- 03
SUP~.. NTOFHlGHWAYS
TOr ,~. HO D,N ORK
. I
P~WliS
G. <: ~
!fare
Permit Issued
(;,-/7-03
Date
Permit No.
02c. ~
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 20f3
JUN, -09' 03 (MON) 10: 33
EU GAS DESIGN PATCH
TEL:516 i585136
P 006
, APPROVED "
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