HomeMy WebLinkAbout290 Pine Neck Rd
Date: 06/05/03
Transaction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 1505
Total Paid:
~o
YfdJ
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
1505
Subtotal
$45.00
$45.00
Internal 10: 76365
.
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
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FileNo.
APPLICA TIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100286576
APPLICATION IS HEREBY made to the Superintendent of Highways ortbe Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 orthe Code oftbe 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 ortbe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 3290 Pine Neck Road. Southold
Name of Owner of Premises
Address
3) Pine Neck Rd - bellhole s/s oaved area 30Drox. 300' elo Park Wav to install a 2as service
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S feet oftidal 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 Tr 's License No.
Signature 0 l\.pp
05-22-03
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
hy the Towu Clerk.
6) Tax Map: Section
,Block
.Lot
7) Startiug Date:
Completion Date:
8) Work Schedule:
Phase ComDletion 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
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TI00286576
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 $50,000 property damage.
13) Security:
a)
b)
Surety Bond_
0[$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aonlications and oermits: 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.f. @ $O.IO~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. ~ $30.00 ~
_1.f.@$O.30=
Additional
D. Excavations 5' in depth and over:
0-100 1.f. ~ $50.00
1.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
" -~-~3
Date
Permit Issued
h -.f:>--O~
Pennit No.
021..G>
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.
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EU GAS DESIGN PATCH TEL:516 7585136
KEYSPANA;A.s' '.
REQUEST FOR'STREer OPENING PERMIT .'
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