HomeMy WebLinkAbout8180 Peconic Bay Blvd
Town Of Southold
P.O Box 1179
Southold, NY 11971
(631) 765-1800
RECEIPT
#208
08/1612002
Key, Span Energy- Gas Cant Dept
175 E Old County Rd
Hicksville, NY 11801
Received $ 45.00 for Permits, on 08/16/2002. Thank you for stopping by the Town Clerk's office.
As always, it is our pleasure to serve you.
Elizabeth A.
Neville
Southold Town
Clerk
~ernllt No. ~ 0 f-
FileNo.
~
.
TOWN OF SOUTHOLD
mGHWAY DEPARTMENT
Peconic Lane
Peconic, N ew York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR mGHW AY EXCAVATION AND REPAIR
Ref.#T1 00195368
APPLICA
nON IS HEREBY made to the Superintendent of HIghways of the Town of Southold for the Issuance of an Excavation Permit
pursuant to Chapter 83 of the Code of the TOWD ofSoutbold, 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 slte.
Print or TVDe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - IDClGVILLE. NY 11801
Name of Applicant Address
2) 8180 Peconic Bav Blvd. Mattitnck
NameoCOwner oCPremises
Address
3) Peconlc Bav Blvd. - bellhole on the sfs Daved area aDorox. 425' eJo Brav Ave.. Mattituck. 0 fostaR a 2as
service.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet oftlda) 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 Tra 's License No.
ignature 0 Appli
08-12-02
Date
S) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areas, and giving a detalled 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 ffighway Excavation Permit
hy the Town Clerk.
6) Tax Map: Section
. Block
. Lot
7) Starting Date:
Completion Date:
8) Work Schednle:
Phase Comoletion Date
Excavation.................... ........ ......................... ....................
Facility Installation.... ... ...... ....... ..... .... ..... ... ...... ... ....... ... .......
Bacldlll & Compaction.........................................................
Pavement Replacement........... .................................... ..........
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Pagelof3
Tl00195368
(2) Insurance Cover..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 property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
13) Security:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oennils: Basic Application Fee ........... ...... $25.00
AI. --L-IService Connections excavations @ $20.00 = $ 20.00
No.
A2. _/Additional Excavations same service@$IO.OO=$
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
l.f. @$O.IO=$
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 l.f. = $50.00
l.f. @ $0.50 = $
Additional
E.
Utility Repair Excavations @$1O.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 Pennit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
NT OF HIGHWAYS
OLr:cJ. YO
Peter W. Hams
~ ~."'":"~'" J/; 10 2-
Pennit Issued q,&/o 2.- Pennit No. C;; () ~
<?-/3-d)-
Date
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
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REQUEST FOR STREET OPENING PERMIT
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