HomeMy WebLinkAbout1405 Clearview Ave
Date: 08/13/02
Transaction(s):
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16492
Total Paid:
&
~ ~O
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
16492
Subtotal
$279.60
$279.60
IntemallD: 61408
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FileNo.
TOWN OF SOUTHOLD
IDGHW A Y DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR HIGHWAY EXCA V A TION AND REPAIR
Ref.#T100188614
APPLICATION IS HEREBY made to the Superintendent of Highways ortbe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code oftbe 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 insp<<tions of the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 1405 Clearview Ave.. Southold
Name of Owner of Premises
Address
3) Breistadt Ct. & Clearview Ave. - a 422' trench south in w/s l!:rass area of Breistadt
Ct.. missile across to e/s l!:rass area: then a 20' trench in the l!:rass: then a 340' trench
east in the n/s l!:rass area of Clearview Ave. (see sketch attached)
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S feet of tidal 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 Tr
Signatnre ot !\pplic
07-26-02
Date
S) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areas, and giving a 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 Schednle:
Phase Comoletion 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
Page 1 of3
TI00188614
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 propetty damage: $300,0001$500,000 Bodily Injury, and $50,000 propetty damage.
J 3) Securitv:
a)
b)
Surety Bond
01$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic ADolication Fee.............. ... $25.00
AI. ~Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. _I Additional Excavations same service @ $10.00 ~ $
No.
B. Excavations 18" in depth or less:
0-100 I.f. ~ $10.00
I.f.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00
682 1.1. @ $0.30 ~ $204.60
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
I.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
pennit.
. . .
TOTAL COST $279.60
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
Pennit Issued if/;,J Ie -z.,
8/9/0 '-
Date
Permit No.
o? 1)(0
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
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KEYSPAN/~1lI'
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