HomeMy WebLinkAbout435 Pine Neck Rd
Date: 08/16/02
Transaction(s):
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16579
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Receipt#:
Total Paid:
V1
I
,
16579
Subtotal
$45.00
$45.00
Internal 10: 61556
pernlltNo,~O 7
File No.
,.
~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLlCATIONIPERMIT FOR HIGHW AY EXCAVATION AND REPAIR
Ref.#T100196126
APPLlCA
TION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of an Excavation Permit
pursuant to Chapter 83 oftbe CodeoCtbe 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) 435 Pine Neek Rd.. Sonthold
Name of Owner of Premises
Address
3) Pine Neek Rd. - hellhole on the sfs oaved area annrox. 165' wlo Gardlners La. Southold. to lostall a 2as
service.
Work Description and Location (Street Number, Hamlet, Cross Street)
<a> Is construction located witbln 75 feet of tidal wetlands? *Yes
*Ifyes, otber Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
T
Slgnatur of Ap
08-12-02
Date
5) a) Attach plot plan showing location of proposed excavatioo aod relatiouship to adjoining premises or
puhllc streets or areas, and giving a detailed description of layout of excavatioo.
h) Attach all other necessary permits and IIceoses for this project.
c) Work covered by this application may not commence before issuance of a Highway Excavation Permit
hy the Town Clerk.
6) Tax Map: Sectiou
. Block
. Lot
7) Starting Date:
Completloo Date:
8) Work Schedule:
Phase Comoletion Date
Excavation.. ................. ............................ ......... ......... ........
FacUity Installation.. .................... ....... ............................. .....
Backfill & Compactlon.........................................................
Pavement Replacement.... ...... ... ....... ........ .... ...... ... ...... ... .......
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: S
11) Remarks:
0-39
Page 1 of3
Tl00196126
12) Insurance Covers.e: (Attach Copy)
a) Insurance Company:
b) Policy#
c) State whether policy of cettilication on file with the Highway Depattment:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
13) Security:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certilied Check
provided in the total amount
2 years or
3 years
14) Fees for annlications and nennits: Basic ADDlicatioD 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 l.f. ~ $10.00
l.f. @ $0.10 ~ $
Additional
C. Excavations IS" 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 l.f. ~ $50.00
1.1. @ $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
pennit.
. . .
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.
Peter W. Harris
"""~.".,~"". ~i>j; L
. ~ Date
PennitIssued 0 0 2-- Pennit No.
t
~: Pennit 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.
r;-I3-o.J-
Date
-vOf
D-39
Page 20f3
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KEYSPAN/t1AJ'
REQUEST FOR STREET OPENING PERMIT
Fc.a111,4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.OJPA
NO.
REQUESTED
BY
. APPROVED
D STATE
D SUFFOLK I./l
COUNTY l.tJ
, (""'" ,j _ DEPARTMENT
1/,1/1 ..Je:.-nu.1Z- GAS CONSTR. L ,%,)
SKETCH
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