HomeMy WebLinkAbout160 Cottage Pl
Date: 08/16/02
Transaction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16579
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
Receipt#:
Total Paid:
16579
Subtotal
$45.00
$45.00
Internal 10: 61554
Permt NOcJ () /
File No.
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TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peeonie Lane
Peeonie, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR IDGHWAY EXCAVATION AND REPAIR
Ref.#T100196033
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Extavation Permit pursuant to Chapter 83 ortbe Code ortbe Town of Soutbold, 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 Decessary Inspections of tbe
job site.
PrlntorTvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - mCKSVlLLE. NY 11801
Name of AppUcant Address
2) 160 Cottaee Place. Soutbold
Name of Owner of Premises
Address
3) Cottaee Pl. - bellbole on the els paved area annrox. 250' sfo Main Rd. to install a eas service.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S feet of tidal wetlands? .Yes
.Ifyes, other Town permits may be required.
No_X_
4) Bnilder's License No.
Plumber's License No.
Electrician's License No.
Other Tr
/
Signature 0 :Appli nt
08-12-02
Date
S) a) Attach plot plan sbowlng 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 lltenses 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: Section
. Block
. Lot
7) Starting Date:
Completion Date:
8) Work Schednle:
Phase Comnletion Date
Excavadon .. ........ ....... ..................... ......... ......... .................
Facility Installation.......... .............................. .......... ... ..........
Backfill & Compaction.........................................................
Pavement Replacement......................... .... ............n..............
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
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:
Bodily injury and property damage: S300,OOO/S500,OOO Bodily Injury, and S50,OOO property damage.
Tl00196003
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 oermits: Basic AODlication Fee ................. 525.00
AI. -1-IService Connections excavations@ S20.00 ~ S 20.00
No.
A2. ~Additional Excavations same service @SIO.OO= S
No.
B. Excavations 18" in depth or less:
0-100 l.f. = SIO.OO
1.f. @SO.IO~S
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. = S30.00
_1.f. @ SOJO ~ $
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ S50.00
1.f.@S0.50~S
Additional
E.
Utility Repair Excavations @ S10.00 ~ S
No.
Repairs same service @$5.00= S
Additional
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
. . .
TOTAL COST 545.00
Authorization is hereby granted to the Town Clerk of the Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELNERY in accordance with this application.
Received by the Town Clerk 8M z.
fjL /; Date
Permit Issued ", !) z...
<j- 13-d.).
Date
Permit No. cJ D 7
~: 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 2 of3
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, ~eYSPAN/~s
REQUEST FOR STREET OPENING PERMIT
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; OPENING iil '
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