HomeMy WebLinkAbout220 Oaklawn Ave
Date: 06/04/03
Transaction(s):
Name:
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 1546
Total Paid:
69
d
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
1546
Subtotal
$45.00
$45.00
Internal fD: 76297
Permit No.
TOWN OF SOUTHOLD
IDGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
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FileNo.
tUSH
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 urtbe Code of the 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 urtbe
job site.
Ref.#TI00290425
Print or Tvoe
I) KEYSPAN ENERGY GAS CONSTR. DEPT.
Name of Applicant
175 E. OLD COUNTRY RD. HICKSVTLLE NY 11801
Address
2) 220 Oaklawn Avenue. Southold
Name of Owner of Premises
Address
3) Oaklawn Avenue bellhole e/s aved area a rox. 265' % Pine Neck Avenue to install a as main and as
service to house #220
Work Description and Location (Street Numbert Hamlet, Cross Street)
(a) Is construction located within 7S 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.
Signature 0 Ap
06-03-03
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 Town Clerk.
6) Tax Map: Section
,Block
. Lot
7) Starting 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: $
II) Remarks:
D-39
Page 1 of3
12) Insurance CoveraQe: (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 $50,000 property damage.
T1 00290425
13) Security:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic Application Fee............. .... $25.00
AI. -L-IService 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. ~ $10.00
!.f. @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 !.f. ~ $30.00 ~
_1.f.@$O.30=
Additional
D. Excavations 5' in depth and over:
0-100 !.f. ~ $50.00
1.1: @ $0.50 ~ $
Additional
E.
No.
Utility Repair Excavations @ $1 0.00 ~ $
Additional
Repairs same service @ $5.00 = $
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 ofSouthoJd to issue a Highway Excavation Permit to:
KEYSP AN ENERGY DELIVERY in accordance with this application.
.~
Received by the Town Clerk
Peter W. Harris
0-~-O~
Date
Permit Issued
Date
Permit No.
.;{ S?
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 2 of3
,JUN. ~02' 03 (MON) 14: 48
'~llA
PERMIT.
NO.
. ,
. .0 'STATE .
BU GAS DESIGN PATCH TEL:516 i585136
n.crar-AI'f(6'AJ'" . '
REQUEST FOR'STREer OPENING PER~IT,'
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